Kate Johnson

MONTREAL — Endoanal ultrasound performed immediately postpartum can identify clinically occult anal sphincter defects, which are linked to an increased risk of anal incontinence, according to a British study.

“This technology can improve our prediction of incontinence and has the potential to be used to target postnatal follow-up to women at increased risk,” said Philip Toozs-Hobson, M.D., a consultant gynecologist at Birmingham (England) Women's Hospital.

Speaking at the annual meeting of the International Continence Society, Dr. Toozs-Hobson outlined his study, which compared findings from endoanal ultrasounds performed immediately after delivery in 198 women with anal incontinence. Questionnaires were administered at 6 weeks postpartum.

Clinical evidence of anal sphincter damage had been ruled out in all women after clinical examination by two separate assessors.

While 60% of study participants had intact external and internal anal sphincters seen on endoanal ultrasound, and 30% had an isolated external anal sphincter defect only, the remaining 10% of participants had either defects in both sphincters or such profound distortion of the sphincters that the anatomy was not interpretable.

Among this latter group, 30% of the women reported anal incontinence symptoms at 6 weeks postpartum—which was threefold the rate of the rest of the study participants.

“A severely abnormal endoanal ultrasound scan immediately postpartum increases the risk of anal incontinence three times when compared [with] women with a normal ultrasound or an isolated [external anal sphincter] defect,” Dr. Toozs-Hobson concluded.

He said the clinical absence of ultrasound-detected anal sphincter damage “confirms the concept of occult anal sphincter damage” and could prove very important on a medico-legal level in showing that anal sphincter may not have been “missed” by obstetricians but may be “genuinely occult.”

Endoanal detection of defects also could predict which women should be followed closely for symptoms of incontinence, he said.

Although participants in Dr. Toozs-Hobson's study were not managed any differently based on their endoanal ultrasound results (all had clinically intact sphincters), another recent study altered management when endoanal ultrasound revealed a defect (Obstet. Gynecol. 2005;106:6–13).

“We showed that it is very possible for any resident to be trained to diagnose these clinically occult defects by ultrasound, and that managing these defects definitely improved the outcome,” said Dr. med. Daniel Faltin, one of the authors of that study, who was present in the audience. Dr. Faltin is director of the Dianuro perineology center and consultant in obstetrics and gynecology at the Hôpitaux Universitaires in Geneva.

Dr. Faltin's study randomized 752 primiparous women to clinical and endoanal ultrasonographic examination of the anal sphincter immediately postpartum (experimental group), or clinical examination alone (control group).

In the control group, clinically detected anal sphincter tears were repaired. In the experimental group, when anal sphincter defects were detected, the anal sphincter was surgically exposed and examined, and repairs were made when a tear was identified.

The authors reported a benefit in adding endoanal ultrasonography to the standard clinical exam. At 3 months postpartum, severe incontinence was reported by 3.3% of women in the repair group, compared with 8.7% of women in the control group.

The benefit persisted at 1 year, reported the authors, with severe incontinence reported by 3.2% of the intervention group, compared with 6.7% of the control group.

But the chairman of the session, Abdul H. Sultan, M.D., questioned the value of postpartum endoanal ultrasound, dismissing the idea of occult defects as “more of a myth than anything else.”

“You can pick these defects up clinically if you are properly trained,” he said in an interview. “If you can see what you're looking for, that is the best way forward—all you need to do is improve your clinical skills.”

Dr. Sultan, who is a consultant obstetrician and gynecologist at Mayday University Hospital in Croydon, England, runs courses on the clinical recognition and repair of obstetrical anal sphincter defects.

“Even if you see a defect on ultrasound, you've still got to find it clinically. Otherwise, you cannot repair it,” he said.

Dr. Sultan pointed out that in the Faltin study, five women had an anal sphincter tear diagnosed by ultrasonography that could not be confirmed during surgical exploration of the perineum. Of these women, one reported severe incontinence at 3 months and 1 year postpartum.

MONTREAL — Endoanal ultrasound performed immediately postpartum can identify clinically occult anal sphincter defects, which are linked to an increased risk of anal incontinence, according to a British study.

“This technology can improve our prediction of incontinence and has the potential to be used to target postnatal follow-up to women at increased risk,” said Philip Toozs-Hobson, M.D., a consultant gynecologist at Birmingham (England) Women's Hospital.

Speaking at the annual meeting of the International Continence Society, Dr. Toozs-Hobson outlined his study, which compared findings from endoanal ultrasounds performed immediately after delivery in 198 women with anal incontinence. Questionnaires were administered at 6 weeks postpartum.

Clinical evidence of anal sphincter damage had been ruled out in all women after clinical examination by two separate assessors.

While 60% of study participants had intact external and internal anal sphincters seen on endoanal ultrasound, and 30% had an isolated external anal sphincter defect only, the remaining 10% of participants had either defects in both sphincters or such profound distortion of the sphincters that the anatomy was not interpretable.

Among this latter group, 30% of the women reported anal incontinence symptoms at 6 weeks postpartum—which was threefold the rate of the rest of the study participants.

“A severely abnormal endoanal ultrasound scan immediately postpartum increases the risk of anal incontinence three times when compared [with] women with a normal ultrasound or an isolated [external anal sphincter] defect,” Dr. Toozs-Hobson concluded.

He said the clinical absence of ultrasound-detected anal sphincter damage “confirms the concept of occult anal sphincter damage” and could prove very important on a medico-legal level in showing that anal sphincter may not have been “missed” by obstetricians but may be “genuinely occult.”

Endoanal detection of defects also could predict which women should be followed closely for symptoms of incontinence, he said.

Although participants in Dr. Toozs-Hobson's study were not managed any differently based on their endoanal ultrasound results (all had clinically intact sphincters), another recent study altered management when endoanal ultrasound revealed a defect (Obstet. Gynecol. 2005;106:6–13).

“We showed that it is very possible for any resident to be trained to diagnose these clinically occult defects by ultrasound, and that managing these defects definitely improved the outcome,” said Dr. med. Daniel Faltin, one of the authors of that study, who was present in the audience. Dr. Faltin is director of the Dianuro perineology center and consultant in obstetrics and gynecology at the Hôpitaux Universitaires in Geneva.

Dr. Faltin's study randomized 752 primiparous women to clinical and endoanal ultrasonographic examination of the anal sphincter immediately postpartum (experimental group), or clinical examination alone (control group).

In the control group, clinically detected anal sphincter tears were repaired. In the experimental group, when anal sphincter defects were detected, the anal sphincter was surgically exposed and examined, and repairs were made when a tear was identified.

The authors reported a benefit in adding endoanal ultrasonography to the standard clinical exam. At 3 months postpartum, severe incontinence was reported by 3.3% of women in the repair group, compared with 8.7% of women in the control group.

The benefit persisted at 1 year, reported the authors, with severe incontinence reported by 3.2% of the intervention group, compared with 6.7% of the control group.

But the chairman of the session, Abdul H. Sultan, M.D., questioned the value of postpartum endoanal ultrasound, dismissing the idea of occult defects as “more of a myth than anything else.”

“You can pick these defects up clinically if you are properly trained,” he said in an interview. “If you can see what you're looking for, that is the best way forward—all you need to do is improve your clinical skills.”

Dr. Sultan, who is a consultant obstetrician and gynecologist at Mayday University Hospital in Croydon, England, runs courses on the clinical recognition and repair of obstetrical anal sphincter defects.

“Even if you see a defect on ultrasound, you've still got to find it clinically. Otherwise, you cannot repair it,” he said.

Dr. Sultan pointed out that in the Faltin study, five women had an anal sphincter tear diagnosed by ultrasonography that could not be confirmed during surgical exploration of the perineum. Of these women, one reported severe incontinence at 3 months and 1 year postpartum.

MONTREAL — Endoanal ultrasound performed immediately postpartum can identify clinically occult anal sphincter defects, which are linked to an increased risk of anal incontinence, according to a British study.

“This technology can improve our prediction of incontinence and has the potential to be used to target postnatal follow-up to women at increased risk,” said Philip Toozs-Hobson, M.D., a consultant gynecologist at Birmingham (England) Women's Hospital.

Speaking at the annual meeting of the International Continence Society, Dr. Toozs-Hobson outlined his study, which compared findings from endoanal ultrasounds performed immediately after delivery in 198 women with anal incontinence. Questionnaires were administered at 6 weeks postpartum.

Clinical evidence of anal sphincter damage had been ruled out in all women after clinical examination by two separate assessors.

While 60% of study participants had intact external and internal anal sphincters seen on endoanal ultrasound, and 30% had an isolated external anal sphincter defect only, the remaining 10% of participants had either defects in both sphincters or such profound distortion of the sphincters that the anatomy was not interpretable.

Among this latter group, 30% of the women reported anal incontinence symptoms at 6 weeks postpartum—which was threefold the rate of the rest of the study participants.

“A severely abnormal endoanal ultrasound scan immediately postpartum increases the risk of anal incontinence three times when compared [with] women with a normal ultrasound or an isolated [external anal sphincter] defect,” Dr. Toozs-Hobson concluded.

He said the clinical absence of ultrasound-detected anal sphincter damage “confirms the concept of occult anal sphincter damage” and could prove very important on a medico-legal level in showing that anal sphincter may not have been “missed” by obstetricians but may be “genuinely occult.”

Endoanal detection of defects also could predict which women should be followed closely for symptoms of incontinence, he said.

Although participants in Dr. Toozs-Hobson's study were not managed any differently based on their endoanal ultrasound results (all had clinically intact sphincters), another recent study altered management when endoanal ultrasound revealed a defect (Obstet. Gynecol. 2005;106:6–13).

“We showed that it is very possible for any resident to be trained to diagnose these clinically occult defects by ultrasound, and that managing these defects definitely improved the outcome,” said Dr. med. Daniel Faltin, one of the authors of that study, who was present in the audience. Dr. Faltin is director of the Dianuro perineology center and consultant in obstetrics and gynecology at the Hôpitaux Universitaires in Geneva.

Dr. Faltin's study randomized 752 primiparous women to clinical and endoanal ultrasonographic examination of the anal sphincter immediately postpartum (experimental group), or clinical examination alone (control group).

In the control group, clinically detected anal sphincter tears were repaired. In the experimental group, when anal sphincter defects were detected, the anal sphincter was surgically exposed and examined, and repairs were made when a tear was identified.

The authors reported a benefit in adding endoanal ultrasonography to the standard clinical exam. At 3 months postpartum, severe incontinence was reported by 3.3% of women in the repair group, compared with 8.7% of women in the control group.

The benefit persisted at 1 year, reported the authors, with severe incontinence reported by 3.2% of the intervention group, compared with 6.7% of the control group.

But the chairman of the session, Abdul H. Sultan, M.D., questioned the value of postpartum endoanal ultrasound, dismissing the idea of occult defects as “more of a myth than anything else.”

“You can pick these defects up clinically if you are properly trained,” he said in an interview. “If you can see what you're looking for, that is the best way forward—all you need to do is improve your clinical skills.”

Dr. Sultan, who is a consultant obstetrician and gynecologist at Mayday University Hospital in Croydon, England, runs courses on the clinical recognition and repair of obstetrical anal sphincter defects.

“Even if you see a defect on ultrasound, you've still got to find it clinically. Otherwise, you cannot repair it,” he said.

Dr. Sultan pointed out that in the Faltin study, five women had an anal sphincter tear diagnosed by ultrasonography that could not be confirmed during surgical exploration of the perineum. Of these women, one reported severe incontinence at 3 months and 1 year postpartum.

MONTREAL — Vaginal delivery is associated with a near twofold increased odds of pelvic floor disorders, compared with cesarean delivery and nulliparity, according to results of a large epidemiologic study.

“This study finally gives us some numbers to hang our hat on, with respect to pelvic floor dysfunction, when we are counseling patients about vaginal versus cesarean delivery,” the study's principal investigator, Emily Lukacz, M.D., said at the annual meeting of the International Continence Society.

“A twofold increased odds of a pelvic floor disorder sounds like a lot, but surgical delivery is not without its own risks,” she said in an interview, adding that the protective effects of cesarean section must be balanced against the known risks of surgical delivery.

She cautioned that although the study shows an association between vaginal delivery and pelvic floor disorders, it does not prove causality.

“We are really still in the infancy of understanding the role of mode of delivery on the development of pelvic floor disorders until we can have a randomized, controlled trial of vaginal versus cesarean delivery, which will likely never happen,” said Dr. Lukacz of the University of California, San Diego Medical Center.

Still, she said that she suspects it's hard not to link the trauma caused by vaginal delivery to many of these disorders. “There are not many things that can cause that kind of damage,” she said. “However, not all women who deliver vaginally develop pelvic floor disorders. Therefore, future research should be aimed at identifying women at risk for developing pelvic floor disorders due to vaginal delivery.”

The Kaiser Permanente continence-associated risk epidemiology study was a population-based study of 12,200 randomly selected women between the ages of 25 and 84.

Using the validated Epidemiology of Prolapse and Incontinence Questionnaire, researchers assessed participants for symptoms and signs of stress urinary incontinence, overactive bladder (with or without leakage), and anal incontinence (leakage of solid, liquid, or gas), as well as pelvic organ prolapse.

A total of 4,103 surveys had sufficient information for analysis, and these were then categorized into three birth groups. The nulliparous group (19%) included women who had never been pregnant, or who had never delivered a baby larger than 4.5 pounds. The cesarean section group (10%) included women who had delivered only by cesarean section (with or without prior labor), or with no vaginal deliveries of more than 4.5 pounds. The vaginal delivery group (71%) included women with a history of a vaginal delivery of more than 4.5 pounds.

After adjusting for age, BMI, and parity, the vaginal delivery group had higher rates of every disorder, compared with the nulliparous and cesarean groups. (See chart.)

The study results are “highly controversial” but in line with other research, particularly the large Norwegian Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) study. That Norwegian study found vaginal delivery associated with a higher risk (odds ratio 2.2) of moderate to severe urinary incontinence compared with cesarean delivery (N. Engl. J. Med. 2003;348:900–7), Dr. Lukacz said.

Dr. Lukacz and her team also performed a subanalysis of the cesarean section group to assess the impact of cesarean sections that involved labor and those that did not; they found a significantly higher prevalence of prolapse in the group that underwent labor, as well as a trend toward a higher prevalence of stress incontinence.

The rates of overactive bladder, anal incontinence, and overall pelvic floor disorders did not differ significantly between groups in the subanalysis. “The mechanism of trauma may be different for the development of the different disorders,” she suggested.

Dr. Lukacz noted that while great efforts continue in the treatment of incontinence, a shift in focus toward prevention is crucial. “The key is being able to identify who is at risk for developing those conditions—and this is a step in that direction.”

The study was funded by the National Institute of Child Health and Human Development.

MONTREAL — Vaginal delivery is associated with a near twofold increased odds of pelvic floor disorders, compared with cesarean delivery and nulliparity, according to results of a large epidemiologic study.

“This study finally gives us some numbers to hang our hat on, with respect to pelvic floor dysfunction, when we are counseling patients about vaginal versus cesarean delivery,” the study's principal investigator, Emily Lukacz, M.D., said at the annual meeting of the International Continence Society.

“A twofold increased odds of a pelvic floor disorder sounds like a lot, but surgical delivery is not without its own risks,” she said in an interview, adding that the protective effects of cesarean section must be balanced against the known risks of surgical delivery.

She cautioned that although the study shows an association between vaginal delivery and pelvic floor disorders, it does not prove causality.

“We are really still in the infancy of understanding the role of mode of delivery on the development of pelvic floor disorders until we can have a randomized, controlled trial of vaginal versus cesarean delivery, which will likely never happen,” said Dr. Lukacz of the University of California, San Diego Medical Center.

Still, she said that she suspects it's hard not to link the trauma caused by vaginal delivery to many of these disorders. “There are not many things that can cause that kind of damage,” she said. “However, not all women who deliver vaginally develop pelvic floor disorders. Therefore, future research should be aimed at identifying women at risk for developing pelvic floor disorders due to vaginal delivery.”

The Kaiser Permanente continence-associated risk epidemiology study was a population-based study of 12,200 randomly selected women between the ages of 25 and 84.

Using the validated Epidemiology of Prolapse and Incontinence Questionnaire, researchers assessed participants for symptoms and signs of stress urinary incontinence, overactive bladder (with or without leakage), and anal incontinence (leakage of solid, liquid, or gas), as well as pelvic organ prolapse.

A total of 4,103 surveys had sufficient information for analysis, and these were then categorized into three birth groups. The nulliparous group (19%) included women who had never been pregnant, or who had never delivered a baby larger than 4.5 pounds. The cesarean section group (10%) included women who had delivered only by cesarean section (with or without prior labor), or with no vaginal deliveries of more than 4.5 pounds. The vaginal delivery group (71%) included women with a history of a vaginal delivery of more than 4.5 pounds.

After adjusting for age, BMI, and parity, the vaginal delivery group had higher rates of every disorder, compared with the nulliparous and cesarean groups. (See chart.)

The study results are “highly controversial” but in line with other research, particularly the large Norwegian Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) study. That Norwegian study found vaginal delivery associated with a higher risk (odds ratio 2.2) of moderate to severe urinary incontinence compared with cesarean delivery (N. Engl. J. Med. 2003;348:900–7), Dr. Lukacz said.

Dr. Lukacz and her team also performed a subanalysis of the cesarean section group to assess the impact of cesarean sections that involved labor and those that did not; they found a significantly higher prevalence of prolapse in the group that underwent labor, as well as a trend toward a higher prevalence of stress incontinence.

The rates of overactive bladder, anal incontinence, and overall pelvic floor disorders did not differ significantly between groups in the subanalysis. “The mechanism of trauma may be different for the development of the different disorders,” she suggested.

Dr. Lukacz noted that while great efforts continue in the treatment of incontinence, a shift in focus toward prevention is crucial. “The key is being able to identify who is at risk for developing those conditions—and this is a step in that direction.”

The study was funded by the National Institute of Child Health and Human Development.

MONTREAL — Vaginal delivery is associated with a near twofold increased odds of pelvic floor disorders, compared with cesarean delivery and nulliparity, according to results of a large epidemiologic study.

“This study finally gives us some numbers to hang our hat on, with respect to pelvic floor dysfunction, when we are counseling patients about vaginal versus cesarean delivery,” the study's principal investigator, Emily Lukacz, M.D., said at the annual meeting of the International Continence Society.

“A twofold increased odds of a pelvic floor disorder sounds like a lot, but surgical delivery is not without its own risks,” she said in an interview, adding that the protective effects of cesarean section must be balanced against the known risks of surgical delivery.

She cautioned that although the study shows an association between vaginal delivery and pelvic floor disorders, it does not prove causality.

“We are really still in the infancy of understanding the role of mode of delivery on the development of pelvic floor disorders until we can have a randomized, controlled trial of vaginal versus cesarean delivery, which will likely never happen,” said Dr. Lukacz of the University of California, San Diego Medical Center.

Still, she said that she suspects it's hard not to link the trauma caused by vaginal delivery to many of these disorders. “There are not many things that can cause that kind of damage,” she said. “However, not all women who deliver vaginally develop pelvic floor disorders. Therefore, future research should be aimed at identifying women at risk for developing pelvic floor disorders due to vaginal delivery.”

The Kaiser Permanente continence-associated risk epidemiology study was a population-based study of 12,200 randomly selected women between the ages of 25 and 84.

Using the validated Epidemiology of Prolapse and Incontinence Questionnaire, researchers assessed participants for symptoms and signs of stress urinary incontinence, overactive bladder (with or without leakage), and anal incontinence (leakage of solid, liquid, or gas), as well as pelvic organ prolapse.

A total of 4,103 surveys had sufficient information for analysis, and these were then categorized into three birth groups. The nulliparous group (19%) included women who had never been pregnant, or who had never delivered a baby larger than 4.5 pounds. The cesarean section group (10%) included women who had delivered only by cesarean section (with or without prior labor), or with no vaginal deliveries of more than 4.5 pounds. The vaginal delivery group (71%) included women with a history of a vaginal delivery of more than 4.5 pounds.

After adjusting for age, BMI, and parity, the vaginal delivery group had higher rates of every disorder, compared with the nulliparous and cesarean groups. (See chart.)

The study results are “highly controversial” but in line with other research, particularly the large Norwegian Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) study. That Norwegian study found vaginal delivery associated with a higher risk (odds ratio 2.2) of moderate to severe urinary incontinence compared with cesarean delivery (N. Engl. J. Med. 2003;348:900–7), Dr. Lukacz said.

Dr. Lukacz and her team also performed a subanalysis of the cesarean section group to assess the impact of cesarean sections that involved labor and those that did not; they found a significantly higher prevalence of prolapse in the group that underwent labor, as well as a trend toward a higher prevalence of stress incontinence.

The rates of overactive bladder, anal incontinence, and overall pelvic floor disorders did not differ significantly between groups in the subanalysis. “The mechanism of trauma may be different for the development of the different disorders,” she suggested.

Dr. Lukacz noted that while great efforts continue in the treatment of incontinence, a shift in focus toward prevention is crucial. “The key is being able to identify who is at risk for developing those conditions—and this is a step in that direction.”

The study was funded by the National Institute of Child Health and Human Development.

MONTREAL — Refeeding syndrome is a potential problem for all eating-disordered patients who are reintroducing fluids and food, but it is difficult to predict which patients are at greatest risk, Ovidio Bermudez, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

“There is something about the reintroduction of nutrients to someone who has suffered a significant nutritional insult that can cause severe metabolic imbalances, resulting in cardiovascular, pulmonary, neurological, hepatic, and even bone marrow dysfunction,” he said in an interview.

Once the body has adjusted to a state of malnourishment, refeeding will immediately signal the body to switch off compensatory mechanisms, thus unmasking nutritional deficiencies, said Dr. Bermudez, medical director of the eating disorders program at Laureate Psychiatric Clinic and Hospital in Tulsa, Okla.

The result is electrolyte and fluid imbalances, glucose intolerance, liver dysfunction, and thiamine deficiency.

“All patients who are refed will develop some degree of refeeding syndrome, but there is great variability in terms of the severity of the readjustment. Most patients fare well without any apparent clinical challenges, some patients have a moderate challenge,” and a few have severe or even fatal consequences, he said.

Although there are few predictive factors to identify patients most at risk, they tend to be those who are the most underweight and have low prealbumin levels. But these predictors should not be relied on too heavily, Dr. Bermudez said.

“The idea that a person who has had only a moderate metabolic insult is not going to develop some of these problems would be a false reassurance. The best approach we should have as physicians is to know the literature and know the group of patients at highest risk,” but to be alert for any trouble, he said.

By screening for problems prior to refeeding and then monitoring patients carefully during the refeeding, Dr. Bermudez noted, most serious consequences can be avoided.

He recommended that a comprehensive metabolic panel (including liver and renal function tests), calcium, phosphorous and magnesium levels, CBC, and a prealbumin test should be performed prior to refeeding. Any vitamin and trace mineral deficiencies, as well as electrolyte and glucose imbalances, should also be corrected at that time.

During refeeding, fluids and caloric intake should be increased gradually by 200–250 kcal every 2–3 days, and weight gain should not exceed 2–3 pounds per week, Dr. Bermudez said.

Initially, patients should have their vital signs, weight, and fluid intake and output monitored daily, with weekly assessments of CBC, electrolytes and glucose, calcium, phosphorous, magnesium, and liver and renal function. “How long to do this is not quite clear. In our setting, it is usually 2–3 weeks, but in others it can be up to 6 weeks,” he said.

MONTREAL — Refeeding syndrome is a potential problem for all eating-disordered patients who are reintroducing fluids and food, but it is difficult to predict which patients are at greatest risk, Ovidio Bermudez, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

“There is something about the reintroduction of nutrients to someone who has suffered a significant nutritional insult that can cause severe metabolic imbalances, resulting in cardiovascular, pulmonary, neurological, hepatic, and even bone marrow dysfunction,” he said in an interview.

Once the body has adjusted to a state of malnourishment, refeeding will immediately signal the body to switch off compensatory mechanisms, thus unmasking nutritional deficiencies, said Dr. Bermudez, medical director of the eating disorders program at Laureate Psychiatric Clinic and Hospital in Tulsa, Okla.

The result is electrolyte and fluid imbalances, glucose intolerance, liver dysfunction, and thiamine deficiency.

“All patients who are refed will develop some degree of refeeding syndrome, but there is great variability in terms of the severity of the readjustment. Most patients fare well without any apparent clinical challenges, some patients have a moderate challenge,” and a few have severe or even fatal consequences, he said.

Although there are few predictive factors to identify patients most at risk, they tend to be those who are the most underweight and have low prealbumin levels. But these predictors should not be relied on too heavily, Dr. Bermudez said.

“The idea that a person who has had only a moderate metabolic insult is not going to develop some of these problems would be a false reassurance. The best approach we should have as physicians is to know the literature and know the group of patients at highest risk,” but to be alert for any trouble, he said.

By screening for problems prior to refeeding and then monitoring patients carefully during the refeeding, Dr. Bermudez noted, most serious consequences can be avoided.

He recommended that a comprehensive metabolic panel (including liver and renal function tests), calcium, phosphorous and magnesium levels, CBC, and a prealbumin test should be performed prior to refeeding. Any vitamin and trace mineral deficiencies, as well as electrolyte and glucose imbalances, should also be corrected at that time.

During refeeding, fluids and caloric intake should be increased gradually by 200–250 kcal every 2–3 days, and weight gain should not exceed 2–3 pounds per week, Dr. Bermudez said.

Initially, patients should have their vital signs, weight, and fluid intake and output monitored daily, with weekly assessments of CBC, electrolytes and glucose, calcium, phosphorous, magnesium, and liver and renal function. “How long to do this is not quite clear. In our setting, it is usually 2–3 weeks, but in others it can be up to 6 weeks,” he said.

MONTREAL — Refeeding syndrome is a potential problem for all eating-disordered patients who are reintroducing fluids and food, but it is difficult to predict which patients are at greatest risk, Ovidio Bermudez, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

“There is something about the reintroduction of nutrients to someone who has suffered a significant nutritional insult that can cause severe metabolic imbalances, resulting in cardiovascular, pulmonary, neurological, hepatic, and even bone marrow dysfunction,” he said in an interview.

Once the body has adjusted to a state of malnourishment, refeeding will immediately signal the body to switch off compensatory mechanisms, thus unmasking nutritional deficiencies, said Dr. Bermudez, medical director of the eating disorders program at Laureate Psychiatric Clinic and Hospital in Tulsa, Okla.

The result is electrolyte and fluid imbalances, glucose intolerance, liver dysfunction, and thiamine deficiency.

“All patients who are refed will develop some degree of refeeding syndrome, but there is great variability in terms of the severity of the readjustment. Most patients fare well without any apparent clinical challenges, some patients have a moderate challenge,” and a few have severe or even fatal consequences, he said.

Although there are few predictive factors to identify patients most at risk, they tend to be those who are the most underweight and have low prealbumin levels. But these predictors should not be relied on too heavily, Dr. Bermudez said.

“The idea that a person who has had only a moderate metabolic insult is not going to develop some of these problems would be a false reassurance. The best approach we should have as physicians is to know the literature and know the group of patients at highest risk,” but to be alert for any trouble, he said.

By screening for problems prior to refeeding and then monitoring patients carefully during the refeeding, Dr. Bermudez noted, most serious consequences can be avoided.

He recommended that a comprehensive metabolic panel (including liver and renal function tests), calcium, phosphorous and magnesium levels, CBC, and a prealbumin test should be performed prior to refeeding. Any vitamin and trace mineral deficiencies, as well as electrolyte and glucose imbalances, should also be corrected at that time.

During refeeding, fluids and caloric intake should be increased gradually by 200–250 kcal every 2–3 days, and weight gain should not exceed 2–3 pounds per week, Dr. Bermudez said.

Initially, patients should have their vital signs, weight, and fluid intake and output monitored daily, with weekly assessments of CBC, electrolytes and glucose, calcium, phosphorous, magnesium, and liver and renal function. “How long to do this is not quite clear. In our setting, it is usually 2–3 weeks, but in others it can be up to 6 weeks,” he said.

MONTREAL — Streptococcal pharyngitis may be a very occasional trigger for anorexia nervosa and other neuropsychiatric conditions and should be investigated in patients with sudden onset of psychiatric symptoms, Mae S. Sokol, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

Identification of this cause of anorexia nervosa would not change treatment of the condition, but it would alert patients and physicians to the need for more aggressive prevention and treatment of future strep infections, said Dr. Sokol of Creighton University in Omaha, Neb.

Dr. Sokol explained that group A β-hemolytic streptococci (GABHS) have been linked with several illnesses known collectively as PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus).

In addition to anorexia, the PANDAS classification includes obsessive-compulsive disorder (OCD) and tic disorders such as Tourette's syndrome.

It is well recognized that rheumatic fever and Sydenham's chorea are streptococcus-triggered autoimmune attacks on cardiac cells and cerebral neurons, respectively. It also is believed that PANDAS might be caused by similar attacks on basal ganglia cells, noted Dr. Sokol, who is also director of the eating disorders program at Children's Hospital in Omaha.

“We hypothesize that the immune system may look at the basal ganglia cells in the brain and mistakenly attack those cells, which may cause patients to have abnormal thoughts about food and weight,” she said in an interview at the conference.

Why this damage to basal ganglia cells manifests sometimes as anorexia and other times as OCD, Tourette's, or infantile autism is not known, Dr. Sokol said.

“Since the basal ganglia are also involved with emotion, we think this area of the brain may be affected slightly differently with each condition. Another theory is that maybe we are seeing the same thing in children with PANDAS anorexia and children with PANDAS OCD—only in the PANDAS anorexia, the obsessions are about food and weight, whereas in PANDAS OCD they are about other things. What's common in all these patients is a sense of perfectionism after they become ill,” she said.

She presented her study of 21 children and adolescents with possible PANDAS anorexia. The subjects met some or all of the following criteria:

▸ Presence of anorexia meeting DSM-IV criteria.

▸ Prepubertal onset of anorexia. This was present in 10 of the 21 participants. Participants ranged in age from 10.5 to 18 years at enrollment, with symptom onset at 9.7–16 years.

▸ Acute onset/exacerbation of their anorexia symptoms. This occurred in 19 of the 21 participants.

▸ Association with GABHS infection: anorexia onset or exacerbation within 1 day to 6 months of strep infection. This occurred in all participants.

▸ Increased psychiatric symptoms, not exclusively during the strep illness. Present in all participants.

▸ Concomitant neurologic abnormalities, such as choreiform movements, motor hyperactivity, or adventitious movements. This occurred in two participants but has been reported more frequently in PANDAS OCD.

Dr. Sokol said physicians who suspect PANDAS anorexia should make an effort to confirm laboratory strep tests, although at this stage treatment recommendations would be no different for this group.

However, identification of an infection-triggered anorexia could alert physicians and patients to the need for more aggressive prevention strategies, she said.

MONTREAL — Streptococcal pharyngitis may be a very occasional trigger for anorexia nervosa and other neuropsychiatric conditions and should be investigated in patients with sudden onset of psychiatric symptoms, Mae S. Sokol, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

Identification of this cause of anorexia nervosa would not change treatment of the condition, but it would alert patients and physicians to the need for more aggressive prevention and treatment of future strep infections, said Dr. Sokol of Creighton University in Omaha, Neb.

Dr. Sokol explained that group A β-hemolytic streptococci (GABHS) have been linked with several illnesses known collectively as PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus).

In addition to anorexia, the PANDAS classification includes obsessive-compulsive disorder (OCD) and tic disorders such as Tourette's syndrome.

It is well recognized that rheumatic fever and Sydenham's chorea are streptococcus-triggered autoimmune attacks on cardiac cells and cerebral neurons, respectively. It also is believed that PANDAS might be caused by similar attacks on basal ganglia cells, noted Dr. Sokol, who is also director of the eating disorders program at Children's Hospital in Omaha.

“We hypothesize that the immune system may look at the basal ganglia cells in the brain and mistakenly attack those cells, which may cause patients to have abnormal thoughts about food and weight,” she said in an interview at the conference.

Why this damage to basal ganglia cells manifests sometimes as anorexia and other times as OCD, Tourette's, or infantile autism is not known, Dr. Sokol said.

“Since the basal ganglia are also involved with emotion, we think this area of the brain may be affected slightly differently with each condition. Another theory is that maybe we are seeing the same thing in children with PANDAS anorexia and children with PANDAS OCD—only in the PANDAS anorexia, the obsessions are about food and weight, whereas in PANDAS OCD they are about other things. What's common in all these patients is a sense of perfectionism after they become ill,” she said.

She presented her study of 21 children and adolescents with possible PANDAS anorexia. The subjects met some or all of the following criteria:

▸ Presence of anorexia meeting DSM-IV criteria.

▸ Prepubertal onset of anorexia. This was present in 10 of the 21 participants. Participants ranged in age from 10.5 to 18 years at enrollment, with symptom onset at 9.7–16 years.

▸ Acute onset/exacerbation of their anorexia symptoms. This occurred in 19 of the 21 participants.

▸ Association with GABHS infection: anorexia onset or exacerbation within 1 day to 6 months of strep infection. This occurred in all participants.

▸ Increased psychiatric symptoms, not exclusively during the strep illness. Present in all participants.

▸ Concomitant neurologic abnormalities, such as choreiform movements, motor hyperactivity, or adventitious movements. This occurred in two participants but has been reported more frequently in PANDAS OCD.

Dr. Sokol said physicians who suspect PANDAS anorexia should make an effort to confirm laboratory strep tests, although at this stage treatment recommendations would be no different for this group.

However, identification of an infection-triggered anorexia could alert physicians and patients to the need for more aggressive prevention strategies, she said.

MONTREAL — Streptococcal pharyngitis may be a very occasional trigger for anorexia nervosa and other neuropsychiatric conditions and should be investigated in patients with sudden onset of psychiatric symptoms, Mae S. Sokol, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

Identification of this cause of anorexia nervosa would not change treatment of the condition, but it would alert patients and physicians to the need for more aggressive prevention and treatment of future strep infections, said Dr. Sokol of Creighton University in Omaha, Neb.

Dr. Sokol explained that group A β-hemolytic streptococci (GABHS) have been linked with several illnesses known collectively as PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus).

In addition to anorexia, the PANDAS classification includes obsessive-compulsive disorder (OCD) and tic disorders such as Tourette's syndrome.

It is well recognized that rheumatic fever and Sydenham's chorea are streptococcus-triggered autoimmune attacks on cardiac cells and cerebral neurons, respectively. It also is believed that PANDAS might be caused by similar attacks on basal ganglia cells, noted Dr. Sokol, who is also director of the eating disorders program at Children's Hospital in Omaha.

“We hypothesize that the immune system may look at the basal ganglia cells in the brain and mistakenly attack those cells, which may cause patients to have abnormal thoughts about food and weight,” she said in an interview at the conference.

Why this damage to basal ganglia cells manifests sometimes as anorexia and other times as OCD, Tourette's, or infantile autism is not known, Dr. Sokol said.

“Since the basal ganglia are also involved with emotion, we think this area of the brain may be affected slightly differently with each condition. Another theory is that maybe we are seeing the same thing in children with PANDAS anorexia and children with PANDAS OCD—only in the PANDAS anorexia, the obsessions are about food and weight, whereas in PANDAS OCD they are about other things. What's common in all these patients is a sense of perfectionism after they become ill,” she said.

She presented her study of 21 children and adolescents with possible PANDAS anorexia. The subjects met some or all of the following criteria:

▸ Presence of anorexia meeting DSM-IV criteria.

▸ Prepubertal onset of anorexia. This was present in 10 of the 21 participants. Participants ranged in age from 10.5 to 18 years at enrollment, with symptom onset at 9.7–16 years.

▸ Acute onset/exacerbation of their anorexia symptoms. This occurred in 19 of the 21 participants.

▸ Association with GABHS infection: anorexia onset or exacerbation within 1 day to 6 months of strep infection. This occurred in all participants.

▸ Increased psychiatric symptoms, not exclusively during the strep illness. Present in all participants.

▸ Concomitant neurologic abnormalities, such as choreiform movements, motor hyperactivity, or adventitious movements. This occurred in two participants but has been reported more frequently in PANDAS OCD.

Dr. Sokol said physicians who suspect PANDAS anorexia should make an effort to confirm laboratory strep tests, although at this stage treatment recommendations would be no different for this group.

However, identification of an infection-triggered anorexia could alert physicians and patients to the need for more aggressive prevention strategies, she said.

MONTREAL — Psychotherapy for eating disorders can be delivered effectively by e-mail and can reach a segment of the population that might otherwise decline treatment, Paul Robinson, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

He recruited 97 participants with eating disorders from a university e-mail list for his study. The diagnoses of bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified all fulfilled DSM-IV criteria and were made using online questionnaires and assessments.

Roughly 80% of the cohort had received no previous treatment for their eating disorder, said Dr. Robinson, a psychiatrist with the eating disorders service of Royal Free Hospital, London.

Participants were randomized to e-mail bulimia therapy (EBT), to self-directed writing (SDW), or to a treatment waiting list, which was the control.

The EBT group (36) received 12 weeks of e-mail therapy from professionals who were experienced in the outpatient management of eating disorders. Participants were asked to write twice weekly in a food, behavior, and emotions diary, to which the therapists responded.

“We looked at the diary and annotated it with our own comments,” said Dr. Robinson. “For example, if a patient wrote that she had eaten nothing for breakfast or lunch and then binged in the evening, we might have responded by saying that eating nothing all day might be triggering the binge at night,” he said.

Participants in the SDW group (34) were asked to write about their eating disorder and e-mail their comments to Dr. Robinson twice a week, although he acknowledged the e-mails he sent did not offer specific counseling to this group.

“They knew I was reading [their comments], and they knew that if I thought they were in danger I would act, and I think that was important to them,” he said.

Participants in the control group (27) waited 12 weeks and were then randomized to either EBT or SDW.

At the 12-week assessment, the e-mail therapy and SDW groups were combined into one “e-therapy” group and compared with the control group. The results showed that, while none of the control participants lost their eating disorder diagnosis, 18.6% of the e-therapy group did.

Assessments using the Bulimic Investigatory Test, Edinburgh, (BITE) severity and symptom scores showed a mean reduction in BITE severity score of 1.2 in the e-therapy group, compared with a reduction of 0.2 in the control group. Similarly, the mean reduction in the BITE symptom score was significantly greater in the e-therapy group (2.1 versus 0.3).

When asked about their desired body mass index, participants who had completed the e-mail therapy indicated that they were more willing to accept the idea of a higher BMI than were those participants in the control group.

There was a significant correlation between the number of words a participant wrote and the degree of symptom improvements in the e-mail bulimia therapy group only, Dr. Robinson said.

“It is hard to explain the response in the self-directed writing group, although there is quite a lot in the literature about the therapeutic efficacy of writing, and how it can lower depression scores,” he noted.

Although the study found no difference in outcome between EBT and SDW, there was a trend in favor of EBT.

E-mail therapy was well accepted by the participants, with 84% saying that they would be willing to engage in further therapy either online or face to face.

MONTREAL — Psychotherapy for eating disorders can be delivered effectively by e-mail and can reach a segment of the population that might otherwise decline treatment, Paul Robinson, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

He recruited 97 participants with eating disorders from a university e-mail list for his study. The diagnoses of bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified all fulfilled DSM-IV criteria and were made using online questionnaires and assessments.

Roughly 80% of the cohort had received no previous treatment for their eating disorder, said Dr. Robinson, a psychiatrist with the eating disorders service of Royal Free Hospital, London.

Participants were randomized to e-mail bulimia therapy (EBT), to self-directed writing (SDW), or to a treatment waiting list, which was the control.

The EBT group (36) received 12 weeks of e-mail therapy from professionals who were experienced in the outpatient management of eating disorders. Participants were asked to write twice weekly in a food, behavior, and emotions diary, to which the therapists responded.

“We looked at the diary and annotated it with our own comments,” said Dr. Robinson. “For example, if a patient wrote that she had eaten nothing for breakfast or lunch and then binged in the evening, we might have responded by saying that eating nothing all day might be triggering the binge at night,” he said.

Participants in the SDW group (34) were asked to write about their eating disorder and e-mail their comments to Dr. Robinson twice a week, although he acknowledged the e-mails he sent did not offer specific counseling to this group.

“They knew I was reading [their comments], and they knew that if I thought they were in danger I would act, and I think that was important to them,” he said.

Participants in the control group (27) waited 12 weeks and were then randomized to either EBT or SDW.

At the 12-week assessment, the e-mail therapy and SDW groups were combined into one “e-therapy” group and compared with the control group. The results showed that, while none of the control participants lost their eating disorder diagnosis, 18.6% of the e-therapy group did.

Assessments using the Bulimic Investigatory Test, Edinburgh, (BITE) severity and symptom scores showed a mean reduction in BITE severity score of 1.2 in the e-therapy group, compared with a reduction of 0.2 in the control group. Similarly, the mean reduction in the BITE symptom score was significantly greater in the e-therapy group (2.1 versus 0.3).

When asked about their desired body mass index, participants who had completed the e-mail therapy indicated that they were more willing to accept the idea of a higher BMI than were those participants in the control group.

There was a significant correlation between the number of words a participant wrote and the degree of symptom improvements in the e-mail bulimia therapy group only, Dr. Robinson said.

“It is hard to explain the response in the self-directed writing group, although there is quite a lot in the literature about the therapeutic efficacy of writing, and how it can lower depression scores,” he noted.

Although the study found no difference in outcome between EBT and SDW, there was a trend in favor of EBT.

E-mail therapy was well accepted by the participants, with 84% saying that they would be willing to engage in further therapy either online or face to face.

MONTREAL — Psychotherapy for eating disorders can be delivered effectively by e-mail and can reach a segment of the population that might otherwise decline treatment, Paul Robinson, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

He recruited 97 participants with eating disorders from a university e-mail list for his study. The diagnoses of bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified all fulfilled DSM-IV criteria and were made using online questionnaires and assessments.

Roughly 80% of the cohort had received no previous treatment for their eating disorder, said Dr. Robinson, a psychiatrist with the eating disorders service of Royal Free Hospital, London.

Participants were randomized to e-mail bulimia therapy (EBT), to self-directed writing (SDW), or to a treatment waiting list, which was the control.

The EBT group (36) received 12 weeks of e-mail therapy from professionals who were experienced in the outpatient management of eating disorders. Participants were asked to write twice weekly in a food, behavior, and emotions diary, to which the therapists responded.

“We looked at the diary and annotated it with our own comments,” said Dr. Robinson. “For example, if a patient wrote that she had eaten nothing for breakfast or lunch and then binged in the evening, we might have responded by saying that eating nothing all day might be triggering the binge at night,” he said.

Participants in the SDW group (34) were asked to write about their eating disorder and e-mail their comments to Dr. Robinson twice a week, although he acknowledged the e-mails he sent did not offer specific counseling to this group.

“They knew I was reading [their comments], and they knew that if I thought they were in danger I would act, and I think that was important to them,” he said.

Participants in the control group (27) waited 12 weeks and were then randomized to either EBT or SDW.

At the 12-week assessment, the e-mail therapy and SDW groups were combined into one “e-therapy” group and compared with the control group. The results showed that, while none of the control participants lost their eating disorder diagnosis, 18.6% of the e-therapy group did.

Assessments using the Bulimic Investigatory Test, Edinburgh, (BITE) severity and symptom scores showed a mean reduction in BITE severity score of 1.2 in the e-therapy group, compared with a reduction of 0.2 in the control group. Similarly, the mean reduction in the BITE symptom score was significantly greater in the e-therapy group (2.1 versus 0.3).

When asked about their desired body mass index, participants who had completed the e-mail therapy indicated that they were more willing to accept the idea of a higher BMI than were those participants in the control group.

There was a significant correlation between the number of words a participant wrote and the degree of symptom improvements in the e-mail bulimia therapy group only, Dr. Robinson said.

“It is hard to explain the response in the self-directed writing group, although there is quite a lot in the literature about the therapeutic efficacy of writing, and how it can lower depression scores,” he noted.

Although the study found no difference in outcome between EBT and SDW, there was a trend in favor of EBT.

E-mail therapy was well accepted by the participants, with 84% saying that they would be willing to engage in further therapy either online or face to face.

SAN ANTONIO – More than 33% of patients with allergic rhinitis experience migraine headaches, compared with 3.5% of people without allergic rhinitis, according to a study by investigators in New York City.

The findings highlight a previously unrecognized potential target for migraine relief–that of histamine release in the nasal passage, said Nausika Prifti of Long Island College Hospital and one of the investigators in the study.

Oral antihistamine therapy fails to address this specific mechanism for relief of migraine pain, but nasal corticosteroids hold promise in this regard by addressing vasodilation and inflammation, she told this newspaper.

“Since there is a release of histamine in close proximity to the central nervous system, and histamine is a known releaser of nitric oxide, which is a key mediator to migraine headaches, there is more of a chance that nasal steroids might work on migraines by reducing the effects of histamines,” she said.

In a poster that she presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, Ms. Prifti and her colleagues outlined their survey of 133 patients who received care at an allergic rhinitis (AR) clinic.

A total of 76 patients met the criteria for AR and 57 did not. In the AR group, 26 patients (34%) had headaches meeting the criteria for migraines, whereas 2 patients (3.5%) in the non-AR group met these criteria.

Analysis of the data showed the risk of migraine headache was 14 times higher among patients with AR than among patients who did not have AR.

“We were surprised,” she said. “The doctors working with AR patients knew there was a trend toward migraine headaches, but they didn't expect it to be so high.”

Many patients thought they had sinus headaches and were not aware that they suffered migraines, she added.

SAN ANTONIO – More than 33% of patients with allergic rhinitis experience migraine headaches, compared with 3.5% of people without allergic rhinitis, according to a study by investigators in New York City.

The findings highlight a previously unrecognized potential target for migraine relief–that of histamine release in the nasal passage, said Nausika Prifti of Long Island College Hospital and one of the investigators in the study.

Oral antihistamine therapy fails to address this specific mechanism for relief of migraine pain, but nasal corticosteroids hold promise in this regard by addressing vasodilation and inflammation, she told this newspaper.

“Since there is a release of histamine in close proximity to the central nervous system, and histamine is a known releaser of nitric oxide, which is a key mediator to migraine headaches, there is more of a chance that nasal steroids might work on migraines by reducing the effects of histamines,” she said.

In a poster that she presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, Ms. Prifti and her colleagues outlined their survey of 133 patients who received care at an allergic rhinitis (AR) clinic.

A total of 76 patients met the criteria for AR and 57 did not. In the AR group, 26 patients (34%) had headaches meeting the criteria for migraines, whereas 2 patients (3.5%) in the non-AR group met these criteria.

Analysis of the data showed the risk of migraine headache was 14 times higher among patients with AR than among patients who did not have AR.

“We were surprised,” she said. “The doctors working with AR patients knew there was a trend toward migraine headaches, but they didn't expect it to be so high.”

Many patients thought they had sinus headaches and were not aware that they suffered migraines, she added.

SAN ANTONIO – More than 33% of patients with allergic rhinitis experience migraine headaches, compared with 3.5% of people without allergic rhinitis, according to a study by investigators in New York City.

The findings highlight a previously unrecognized potential target for migraine relief–that of histamine release in the nasal passage, said Nausika Prifti of Long Island College Hospital and one of the investigators in the study.

Oral antihistamine therapy fails to address this specific mechanism for relief of migraine pain, but nasal corticosteroids hold promise in this regard by addressing vasodilation and inflammation, she told this newspaper.

“Since there is a release of histamine in close proximity to the central nervous system, and histamine is a known releaser of nitric oxide, which is a key mediator to migraine headaches, there is more of a chance that nasal steroids might work on migraines by reducing the effects of histamines,” she said.

In a poster that she presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, Ms. Prifti and her colleagues outlined their survey of 133 patients who received care at an allergic rhinitis (AR) clinic.

A total of 76 patients met the criteria for AR and 57 did not. In the AR group, 26 patients (34%) had headaches meeting the criteria for migraines, whereas 2 patients (3.5%) in the non-AR group met these criteria.

Analysis of the data showed the risk of migraine headache was 14 times higher among patients with AR than among patients who did not have AR.

“We were surprised,” she said. “The doctors working with AR patients knew there was a trend toward migraine headaches, but they didn't expect it to be so high.”

Many patients thought they had sinus headaches and were not aware that they suffered migraines, she added.

MONTREAL — Anal incontinence is four times more prevalent than previously thought, and it affects older men and women almost equally, according to what British researchers describe as the first systematic review of the prevalence of this disorder.

“Age, not gender, is the most important factor, and obstetric trauma does not have a major effect,” Philip Toozs-Hobson, M.D., reported at the annual meeting of the International Continence Society.

The review of 29 studies with a total of 69,152 participants found an overall rate of anal incontinence of 3.5% in men and 4.5% in women across all age groups.

“It suggests that the 1% rate presumed by government agencies is an underestimate,” said Dr. Toozs-Hobson, a consultant gynecologist at Birmingham (England) Women's Hospital.

Moreover, the effects of obstetric trauma could not be seen in this data, he said.

“It has long been thought that the incidence of anal incontinence is higher in women because trauma occurs to the anal sphincter during childbirth,” he said. “However, this study does not provide evidence that women under 60 years have significantly higher rates of incontinence, when compared with men of similar age.”

When data were broken down according to age, the prevalences for men and women under age 60 years were 0.8% and 1.6%, respectively. While the rates were much higher in people over age 60 years—they remained similar across the genders, at 5.1% for men and 6.2% for women, he said.

Since anal incontinence is increasingly becoming recognized as a significant cause of physical and psychological morbidity, these data have implications for community health care providers, Dr. Toozs-Hobson said.

MONTREAL — Anal incontinence is four times more prevalent than previously thought, and it affects older men and women almost equally, according to what British researchers describe as the first systematic review of the prevalence of this disorder.

“Age, not gender, is the most important factor, and obstetric trauma does not have a major effect,” Philip Toozs-Hobson, M.D., reported at the annual meeting of the International Continence Society.

The review of 29 studies with a total of 69,152 participants found an overall rate of anal incontinence of 3.5% in men and 4.5% in women across all age groups.

“It suggests that the 1% rate presumed by government agencies is an underestimate,” said Dr. Toozs-Hobson, a consultant gynecologist at Birmingham (England) Women's Hospital.

Moreover, the effects of obstetric trauma could not be seen in this data, he said.

“It has long been thought that the incidence of anal incontinence is higher in women because trauma occurs to the anal sphincter during childbirth,” he said. “However, this study does not provide evidence that women under 60 years have significantly higher rates of incontinence, when compared with men of similar age.”

When data were broken down according to age, the prevalences for men and women under age 60 years were 0.8% and 1.6%, respectively. While the rates were much higher in people over age 60 years—they remained similar across the genders, at 5.1% for men and 6.2% for women, he said.

Since anal incontinence is increasingly becoming recognized as a significant cause of physical and psychological morbidity, these data have implications for community health care providers, Dr. Toozs-Hobson said.

MONTREAL — Anal incontinence is four times more prevalent than previously thought, and it affects older men and women almost equally, according to what British researchers describe as the first systematic review of the prevalence of this disorder.

“Age, not gender, is the most important factor, and obstetric trauma does not have a major effect,” Philip Toozs-Hobson, M.D., reported at the annual meeting of the International Continence Society.

The review of 29 studies with a total of 69,152 participants found an overall rate of anal incontinence of 3.5% in men and 4.5% in women across all age groups.

“It suggests that the 1% rate presumed by government agencies is an underestimate,” said Dr. Toozs-Hobson, a consultant gynecologist at Birmingham (England) Women's Hospital.

Moreover, the effects of obstetric trauma could not be seen in this data, he said.

“It has long been thought that the incidence of anal incontinence is higher in women because trauma occurs to the anal sphincter during childbirth,” he said. “However, this study does not provide evidence that women under 60 years have significantly higher rates of incontinence, when compared with men of similar age.”

When data were broken down according to age, the prevalences for men and women under age 60 years were 0.8% and 1.6%, respectively. While the rates were much higher in people over age 60 years—they remained similar across the genders, at 5.1% for men and 6.2% for women, he said.

Since anal incontinence is increasingly becoming recognized as a significant cause of physical and psychological morbidity, these data have implications for community health care providers, Dr. Toozs-Hobson said.

MONTREAL — Patients undergoing tension-free vaginal tape procedures for stress urinary incontinence should know that although their quality of life will likely improve after the surgery, about one-fifth of them may experience postoperative irritative bladder symptoms, according to a Dutch expert.

In a study of 307 women undergoing a tension-free vaginal tape (TVT) procedure, 19% reported irritative bladder symptoms postsurgery, said Steven Schraffordt, M.D., of the Meander Medical Centre in Amersfoort, the Netherlands.

“All patients showed an improvement in quality of life … [but] … no specific [preoperative or operative] factors could be identified for changes in irritative symptoms after TVT,” he reported at the annual meeting of the International Continence Society.

Until now, the rate of irritative bladder symptoms after TVT procedures has been difficult to determine because previous studies have not controlled for patients who have undergone concomitant surgery, said Dr. Schraffordt. His study selected women who were being treated for stress urinary incontinence (SUI) alone and who had received no previous urogynecologic surgery or medications for bladder symptoms.

The multicenter prospective study required patients to answer two questionnaires prior to surgery and again 36 months later. The Urogenital Distress Inventory (UDI-6) measures stress incontinence and irritative and obstructive discomfort, while the Incontinence Impact Questionnaire (IIQ-7) measures the implications of urinary incontinence for normal daily functioning.

Three years postsurgery, 59 of the 307 patients (19%) reported irritative symptoms in response to the question: “Do you experience, and if so, how much are you bothered by: frequent urination and leakage related to feelings of urgency?” However, no preoperative or intraoperative differences could be identified between this group and the remaining 248 (81%) patients who reported no irritative symptoms.

Even those who reported worsened irritative symptoms had significantly improved quality of life scores on the IIQ-7, with a drop from preoperative score of 50.96 to postoperative score of 23.7. Patients who did not experience irritative symptoms had a more dramatic quality of life improvement with a preoperative QII-7 score of 59.3, which dropped to a postoperative score of 10.7. A comparison of both groups found a significantly greater improvement in the nonirritative patients.

“It is impossible to predict preoperatively which patient is more at risk for developing irritative symptoms after a TVT,” he commented. “Patients should therefore be informed preoperatively about the risk of developing these symptoms.”

MONTREAL — Patients undergoing tension-free vaginal tape procedures for stress urinary incontinence should know that although their quality of life will likely improve after the surgery, about one-fifth of them may experience postoperative irritative bladder symptoms, according to a Dutch expert.

In a study of 307 women undergoing a tension-free vaginal tape (TVT) procedure, 19% reported irritative bladder symptoms postsurgery, said Steven Schraffordt, M.D., of the Meander Medical Centre in Amersfoort, the Netherlands.

“All patients showed an improvement in quality of life … [but] … no specific [preoperative or operative] factors could be identified for changes in irritative symptoms after TVT,” he reported at the annual meeting of the International Continence Society.

Until now, the rate of irritative bladder symptoms after TVT procedures has been difficult to determine because previous studies have not controlled for patients who have undergone concomitant surgery, said Dr. Schraffordt. His study selected women who were being treated for stress urinary incontinence (SUI) alone and who had received no previous urogynecologic surgery or medications for bladder symptoms.

The multicenter prospective study required patients to answer two questionnaires prior to surgery and again 36 months later. The Urogenital Distress Inventory (UDI-6) measures stress incontinence and irritative and obstructive discomfort, while the Incontinence Impact Questionnaire (IIQ-7) measures the implications of urinary incontinence for normal daily functioning.

Three years postsurgery, 59 of the 307 patients (19%) reported irritative symptoms in response to the question: “Do you experience, and if so, how much are you bothered by: frequent urination and leakage related to feelings of urgency?” However, no preoperative or intraoperative differences could be identified between this group and the remaining 248 (81%) patients who reported no irritative symptoms.

Even those who reported worsened irritative symptoms had significantly improved quality of life scores on the IIQ-7, with a drop from preoperative score of 50.96 to postoperative score of 23.7. Patients who did not experience irritative symptoms had a more dramatic quality of life improvement with a preoperative QII-7 score of 59.3, which dropped to a postoperative score of 10.7. A comparison of both groups found a significantly greater improvement in the nonirritative patients.

“It is impossible to predict preoperatively which patient is more at risk for developing irritative symptoms after a TVT,” he commented. “Patients should therefore be informed preoperatively about the risk of developing these symptoms.”

MONTREAL — Patients undergoing tension-free vaginal tape procedures for stress urinary incontinence should know that although their quality of life will likely improve after the surgery, about one-fifth of them may experience postoperative irritative bladder symptoms, according to a Dutch expert.

In a study of 307 women undergoing a tension-free vaginal tape (TVT) procedure, 19% reported irritative bladder symptoms postsurgery, said Steven Schraffordt, M.D., of the Meander Medical Centre in Amersfoort, the Netherlands.

“All patients showed an improvement in quality of life … [but] … no specific [preoperative or operative] factors could be identified for changes in irritative symptoms after TVT,” he reported at the annual meeting of the International Continence Society.

Until now, the rate of irritative bladder symptoms after TVT procedures has been difficult to determine because previous studies have not controlled for patients who have undergone concomitant surgery, said Dr. Schraffordt. His study selected women who were being treated for stress urinary incontinence (SUI) alone and who had received no previous urogynecologic surgery or medications for bladder symptoms.

The multicenter prospective study required patients to answer two questionnaires prior to surgery and again 36 months later. The Urogenital Distress Inventory (UDI-6) measures stress incontinence and irritative and obstructive discomfort, while the Incontinence Impact Questionnaire (IIQ-7) measures the implications of urinary incontinence for normal daily functioning.

Three years postsurgery, 59 of the 307 patients (19%) reported irritative symptoms in response to the question: “Do you experience, and if so, how much are you bothered by: frequent urination and leakage related to feelings of urgency?” However, no preoperative or intraoperative differences could be identified between this group and the remaining 248 (81%) patients who reported no irritative symptoms.

Even those who reported worsened irritative symptoms had significantly improved quality of life scores on the IIQ-7, with a drop from preoperative score of 50.96 to postoperative score of 23.7. Patients who did not experience irritative symptoms had a more dramatic quality of life improvement with a preoperative QII-7 score of 59.3, which dropped to a postoperative score of 10.7. A comparison of both groups found a significantly greater improvement in the nonirritative patients.

“It is impossible to predict preoperatively which patient is more at risk for developing irritative symptoms after a TVT,” he commented. “Patients should therefore be informed preoperatively about the risk of developing these symptoms.”

MONTREAL — Streptococcal pharyngitis may be a very occasional trigger for anorexia nervosa and other neuropsychiatric conditions and should be investigated in patients with sudden onset of psychiatric symptoms, Mae S. Sokol, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

Identification of this cause of anorexia nervosa would not change treatment of the condition (although this possibility is being investigated), but it would alert patients and physicians to the need for more aggressive prevention and treatment of future strep infections, said Dr. Sokol of Creighton University in Omaha, Neb.

Dr. Sokol explained that group A b-hemolytic streptococci (GABHS) have been linked with several illnesses known collectively as PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus).

In addition to anorexia, the PANDAS classification includes obsessive-compulsive disorder (OCD) and tic disorders such as Tourette's syndrome.

It is well recognized that rheumatic fever and Sydenham's chorea are streptococcus-triggered autoimmune attacks on cardiac cells and cerebral neurons, respectively. It also is believed that PANDAS might be caused by similar attacks on basal ganglia cells, noted Dr. Sokol, who is also director of the eating disorders program at Children's Hospital in Omaha.

“We hypothesize that the immune system may look at the basal ganglia cells in the brain and mistakenly attack those cells, which may cause patients to have abnormal thoughts about food and weight,” she said in an interview at the conference.

Why this damage to basal ganglia cells manifests sometimes as anorexia and other times as OCD, Tourette's, or infantile autism is not known, she said.

“Since the basal ganglia are also involved with emotion, we think this area of the brain may be affected slightly differently with each condition. Another theory is that maybe we are seeing the same thing in children with PANDAS anorexia and children with PANDAS OCD—only in the PANDAS anorexia, the obsessions are about food and weight, whereas in PANDAS OCD they are about other things.

What's common in all these patients is a sense of perfectionism after they become ill,” Dr. Sokol explained.

She presented her study of 21 children and adolescents with possible PANDAS anorexia. The subjects met some or all of the following criteria:

▸ Presence of anorexia meeting DSM-IV criteria.

▸ Prepubertal onset of anorexia. This was present in 10 of the 21 participants. Participants ranged in age from 10.5 to 18 years at enrollment, with symptom onset at 9.7 to 16 years.

▸ Acute onset/exacerbation of their anorexia symptoms. This occurred in 19 of the 21 participants.

▸ Association with GABHS infection: anorexia onset or exacerbation within 1 day to 6 months of strep infection. This occurred in all participants.

▸ Increased psychiatric symptoms, not exclusively during the strep illness. This was present in all participants.

▸ Concomitant neurologic abnormalities, such as choreiform movements, motor hyperactivity, or adventitious movements. This occurred in only two participants but has been reported more frequently in PANDAS OCD.

Dr. Sokol said physicians who suspect PANDAS anorexia should make an effort to confirm laboratory strep tests, although at this stage treatment recommendations would be no different for this group.

However, identification of an infection-induced anorexia could trigger use of prophylactic antibiotics (which is still under investigation) and to the importance of influenza vaccination, which can decrease vulnerability to strep, she said.

MONTREAL — Streptococcal pharyngitis may be a very occasional trigger for anorexia nervosa and other neuropsychiatric conditions and should be investigated in patients with sudden onset of psychiatric symptoms, Mae S. Sokol, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

Identification of this cause of anorexia nervosa would not change treatment of the condition (although this possibility is being investigated), but it would alert patients and physicians to the need for more aggressive prevention and treatment of future strep infections, said Dr. Sokol of Creighton University in Omaha, Neb.

Dr. Sokol explained that group A b-hemolytic streptococci (GABHS) have been linked with several illnesses known collectively as PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus).

In addition to anorexia, the PANDAS classification includes obsessive-compulsive disorder (OCD) and tic disorders such as Tourette's syndrome.

It is well recognized that rheumatic fever and Sydenham's chorea are streptococcus-triggered autoimmune attacks on cardiac cells and cerebral neurons, respectively. It also is believed that PANDAS might be caused by similar attacks on basal ganglia cells, noted Dr. Sokol, who is also director of the eating disorders program at Children's Hospital in Omaha.

“We hypothesize that the immune system may look at the basal ganglia cells in the brain and mistakenly attack those cells, which may cause patients to have abnormal thoughts about food and weight,” she said in an interview at the conference.

Why this damage to basal ganglia cells manifests sometimes as anorexia and other times as OCD, Tourette's, or infantile autism is not known, she said.

“Since the basal ganglia are also involved with emotion, we think this area of the brain may be affected slightly differently with each condition. Another theory is that maybe we are seeing the same thing in children with PANDAS anorexia and children with PANDAS OCD—only in the PANDAS anorexia, the obsessions are about food and weight, whereas in PANDAS OCD they are about other things.

What's common in all these patients is a sense of perfectionism after they become ill,” Dr. Sokol explained.

She presented her study of 21 children and adolescents with possible PANDAS anorexia. The subjects met some or all of the following criteria:

▸ Presence of anorexia meeting DSM-IV criteria.

▸ Prepubertal onset of anorexia. This was present in 10 of the 21 participants. Participants ranged in age from 10.5 to 18 years at enrollment, with symptom onset at 9.7 to 16 years.

▸ Acute onset/exacerbation of their anorexia symptoms. This occurred in 19 of the 21 participants.

▸ Association with GABHS infection: anorexia onset or exacerbation within 1 day to 6 months of strep infection. This occurred in all participants.

▸ Increased psychiatric symptoms, not exclusively during the strep illness. This was present in all participants.

▸ Concomitant neurologic abnormalities, such as choreiform movements, motor hyperactivity, or adventitious movements. This occurred in only two participants but has been reported more frequently in PANDAS OCD.

Dr. Sokol said physicians who suspect PANDAS anorexia should make an effort to confirm laboratory strep tests, although at this stage treatment recommendations would be no different for this group.

However, identification of an infection-induced anorexia could trigger use of prophylactic antibiotics (which is still under investigation) and to the importance of influenza vaccination, which can decrease vulnerability to strep, she said.

MONTREAL — Streptococcal pharyngitis may be a very occasional trigger for anorexia nervosa and other neuropsychiatric conditions and should be investigated in patients with sudden onset of psychiatric symptoms, Mae S. Sokol, M.D., said at an international conference sponsored by the Academy for Eating Disorders.

Identification of this cause of anorexia nervosa would not change treatment of the condition (although this possibility is being investigated), but it would alert patients and physicians to the need for more aggressive prevention and treatment of future strep infections, said Dr. Sokol of Creighton University in Omaha, Neb.

Dr. Sokol explained that group A b-hemolytic streptococci (GABHS) have been linked with several illnesses known collectively as PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcus).

In addition to anorexia, the PANDAS classification includes obsessive-compulsive disorder (OCD) and tic disorders such as Tourette's syndrome.

It is well recognized that rheumatic fever and Sydenham's chorea are streptococcus-triggered autoimmune attacks on cardiac cells and cerebral neurons, respectively. It also is believed that PANDAS might be caused by similar attacks on basal ganglia cells, noted Dr. Sokol, who is also director of the eating disorders program at Children's Hospital in Omaha.

“We hypothesize that the immune system may look at the basal ganglia cells in the brain and mistakenly attack those cells, which may cause patients to have abnormal thoughts about food and weight,” she said in an interview at the conference.

Why this damage to basal ganglia cells manifests sometimes as anorexia and other times as OCD, Tourette's, or infantile autism is not known, she said.

“Since the basal ganglia are also involved with emotion, we think this area of the brain may be affected slightly differently with each condition. Another theory is that maybe we are seeing the same thing in children with PANDAS anorexia and children with PANDAS OCD—only in the PANDAS anorexia, the obsessions are about food and weight, whereas in PANDAS OCD they are about other things.

What's common in all these patients is a sense of perfectionism after they become ill,” Dr. Sokol explained.

She presented her study of 21 children and adolescents with possible PANDAS anorexia. The subjects met some or all of the following criteria:

▸ Presence of anorexia meeting DSM-IV criteria.

▸ Prepubertal onset of anorexia. This was present in 10 of the 21 participants. Participants ranged in age from 10.5 to 18 years at enrollment, with symptom onset at 9.7 to 16 years.

▸ Acute onset/exacerbation of their anorexia symptoms. This occurred in 19 of the 21 participants.

▸ Association with GABHS infection: anorexia onset or exacerbation within 1 day to 6 months of strep infection. This occurred in all participants.

▸ Increased psychiatric symptoms, not exclusively during the strep illness. This was present in all participants.

▸ Concomitant neurologic abnormalities, such as choreiform movements, motor hyperactivity, or adventitious movements. This occurred in only two participants but has been reported more frequently in PANDAS OCD.

Dr. Sokol said physicians who suspect PANDAS anorexia should make an effort to confirm laboratory strep tests, although at this stage treatment recommendations would be no different for this group.

However, identification of an infection-induced anorexia could trigger use of prophylactic antibiotics (which is still under investigation) and to the importance of influenza vaccination, which can decrease vulnerability to strep, she said.

COPENHAGEN — While single-embryo transfer rates for in vitro fertilization procedures languish below 2% in the United States, the Europeans are hitting astonishing highs with impressive results.

Aimed at reducing the growing multiple-pregnancy rate—which was once accepted as an unavoidable side effect of invitro fertilization (IVF)—single-embryo transfer (SET) has been enthusiastically embraced across much of Europe, particularly in the Nordic countries and Belgium. Indeed, SET made up 70% of Swedish embryo transfers last year, said Anders Nyboe Andersen, M.D., at the annual meeting of the European Society of Human Reproduction and Embryology.

The latest European figures (2002) show that of all clinical pregnancies achieved using assisted reproductive technology (ART), the rate of triplet pregnancies per transfer was just over 1%, and the rate of twin pregnancies per transfer was 23.6%, he said.

According to a 2002 report from the Centers for Disease Control and Prevention, the risk of having a pregnancy involving triplets or more per ART cycle was almost 7%, and the risk of a twin pregnancy was 29%. Dr. Andersen, head of the fertility clinic at the Rigshospitalet at Copenhagen University Hospital, noted that because of reporting differences, the U.S. and European data were not directly comparable.

Many fertility experts initially regarded SET as a necessary compromise: The possibility of multiple pregnancies was decreased at the price of a decrease in pregnancy rates overall. Indeed, supporters of this theory have pointed out that the failure of the United States to adopt the widespread use of SET has worked to the advantage of the overall rate of clinical pregnancies per ART cycle in the United States, which is 34.3%, about 5% higher than the European rate.

But the recent Swedish experience has vindicated SET in this regard, reported Karin Erb, laboratory director, fertility clinic, Odense (Denmark) University Hospital.

In a review of fertility data from the Nordic countries, which she presented at the meeting, Ms. Erb reported that stricter Swedish embryo transfer legislation introduced in 2003 forced a sharp increase in SET in that country, with no decrease in the country's overall IVF success rates.

Preliminary 2004 data for Sweden is “even more exciting,” said Professor Karl Nygren of the department of obstetrics and gynecology at Sofiahemmet Hospital in Stockholm.

“The pregnancy rate per embryo transfer remained constant at around 30%, while the number of twin births plummeted to just 5%, and there were no triplet deliveries at all,” he said in a written statement.

While SET becomes the standard of care in many European countries, fertility experts in the United States continue to regard it as a rarity.

“This is amazing. I didn't even know they were doing this,” Jeffrey M. Jones, Ph.D., director of the andrology and IVF laboratory at the University of Wisconsin Medical School in Madison, commented in an interview after hearing some of the presentations at the meeting.

In 2002, SET made up just 1.2% of all IVF and intracytoplasmic sperm injection cycles in the United States, up from 0.8% in 2001. In 2004, for the first time, guidelines released by the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology recommended that SET be considered “for patients with the most favorable prognosis” (Fertil. Steril. 2004;82:773–4). The effect of those guidelines, however, will not be seen before the release of the 2005 data.

Certainly, not all centers can adopt SET without seeing at least an initial decrease in pregnancy rates—and patient selection is a key factor in this equation.

The world's first randomized trial comparing SET to double-embryo transfer (DET) in unselected patients is a case in point.

At the meeting, Aafke van Montfoort, M.D., of the Academic Hospital Maastricht (the Netherlands) reported data on 308 patients under age 41 who were randomized to SET or DET for their first IVF cycle. There were no twins in the SET group, compared with a twin rate of 21% in the DET group. The ongoing pregnancy rate was considerably lower after SET, however, at 21% vs. 40%, said Dr. van Montfoort.

But in another study presented at the meeting, patients were selected (aged less than 37, two top-quality embryos, and less than 20% embryo fragmentation), and given the choice of either SET or DET. The SET group had an ongoing clinical pregnancy rate of 39%, compared with 36% in the DET group, reported H.E. Bredkjaer, M.D., of Holbaek (Denmark) Sygehus Fertility Clinic.

According to many experts, it is important to judge SET beyond the context of the first fresh IVF cycle, because the approach often yields many frozen embryos, which can boost a patient's overall chances for pregnancy.

In Dr. van Montfoort's study of unselected patients, significantly more SET patients (52%) had excess embryos available for cryopreservation, compared with the DET patients (40%). However, even after all patients with frozen embryos underwent one subsequent frozen embryo cycle, the ongoing pregnancy rate remained considerably lower (29%) for the SET group, compared with the DET group (42%).

In Dr. Bredkjaer's study of selected patients, 93% of the SET patients had extra embryos cryopreserved, and 35% of these patients became pregnant on a subsequent frozen-embryo transfer.

Despite the promising data, Dr. Jones doesn't expect the European wave of enthusiasm for SET to catch on soon in the United States, and the main reason is financial.

“I don't think it's ever going to happen until it is mandated or there's insurance coverage for fertility treatment in the U.S.,” he said in an interview. “In the Nordic countries there is insurance for IVF, and so patients are willing to undergo several cycles with single-embryo transfer. In the U.S., it's all out of pocket, so they want to get pregnant on the first attempt.”

David K. Gardner, D.Phil., and associates at the Colorado Center for Reproductive Medicine published a study last year showing that with single-blastocyst transfer on day 5 (most European programs do single-embryo transfer on day 3), high ongoing pregnancy rates can be achieved on the first attempt (Fertil. Steril. 2004;81:551–5).

The prospective trial randomized 48 women to either single-blastocyst transfer or double-blastocyst transfer, and investigators found a comparable ongoing pregnancy rate of 61% and 76%, respectively, with a twin rate of zero in the single-blastocyst transfer group and 47% in the double-blastocyst transfer group.

“If SET can be performed with a high degree of success in appropriate patient populations, as is suggested by the current investigation, there are no financial or medical reasons not to recommend this approach,” wrote the Colorado investigators.

Patients were eligible for the study if they met the center's criteria for blastocyst transfer: a day 3 FSH level of 10 mIU/mL or less, an estradiol level of less than 80 pg/mL, a hysteroscopically normal endometrial cavity, and at least 10 follicles measuring at least 12 mm on the day of HCG administration.

The authors acknowledged their difficulty in getting patients to volunteer for SET. “This was undoubtedly due to the perception by patients that SET could result in lower pregnancy rates and that twin pregnancies are a desirable outcome,” they wrote.

Patient attitudes are undoubtedly a barrier to SET, but physicians' attitudes also can have a huge influence, said Christina Bergh, M.D., professor of obstetrics and gynecology at Sahlgrenska University Hospital in Goteborg, Sweden. A study she presented at the meeting found that physicians' attitudes toward SET in the various Nordic countries correlated strongly with the rates of SET and multiple births in those countries. “When aiming for a reduction in multiple births by introducing SET, IVF doctors are important targets,” Dr. Bergh said.

“Most patients rely on doctors for advice,” she said later in an interview. “My experience is they trust us; we are the experts.” Convincing Swedish patients to try SET was much easier than had been expected, she said.

If U.S. physicians face a tougher time convincing their patients to choose SET, some new evidence could boost their powers of persuasion. SET may actually lead to lower miscarriage rates and better neonatal outcomes, compared with singleton pregnancies resulting from the transfer of more than one embryo. It has long been recognized that singletons conceived through IVF have a much poorer outcome than spontaneously conceived singletons.

Now some researchers report that this disparity could possibly be due to the effects of multiple-embryo transfer. Just as a vanishing twin has been shown to increase complications for the surviving fetus, recent evidence suggests that the demise of at least one embryo after a multiple-embryo transfer may create a toxic environment for the implanted surviving embryo.

A study presented at the meeting by Diane De Neubourg, M.D., supports this argument. After prospectively collecting obstetrical and neonatal data on 251 IVF singletons conceived after SET and more than 53,000 singletons that were spontaneously conceived, she found both groups had comparable outcomes.

Although a higher percentage of SET babies than spontaneously conceived babies (9.2% vs. 5.4%) was born prematurely (32–37 weeks), the mean birth weights and mean gestational ages of the groups were similar.

This compares with other studies showing increased perinatal mortality, increased birth rates of small-for-gestational age infants, and increased preterm delivery and low and very low birth weight in IVF singletons (most of whom are conceived after multiple-embryo transfer), said Dr. De Neubourg, a gynecologist at the center for reproductive medicine at Middelheim Hospital in Antwerp, Belgium.

In a recent editorial on SET, Owen K. Davis, M.D., immediate past president of the Society for Assisted Reproductive Technology, noted that “in 2001, women less than 35 years of age underwent approximately 47% of the IVF cycles in the United States, and 75% of the cycles were first or second attempts. Although the proportion with 'good quality' embryos is not known, this would suggest that on the order of 30% of cycles could be considered for single-embryo transfer” (N. Engl. J. Med. 2004;351:2440–2).

Assuming acceptance of SET by U.S. physicians, he continued: “The education of patients regarding the risk of twin as well as higher-order multiple pregnancy, along with improved insurance coverage for assisted reproductive therapies, would probably enhance the acceptance of a single-embryo transfer approach for appropriate candidates.”

COPENHAGEN — While single-embryo transfer rates for in vitro fertilization procedures languish below 2% in the United States, the Europeans are hitting astonishing highs with impressive results.

Aimed at reducing the growing multiple-pregnancy rate—which was once accepted as an unavoidable side effect of invitro fertilization (IVF)—single-embryo transfer (SET) has been enthusiastically embraced across much of Europe, particularly in the Nordic countries and Belgium. Indeed, SET made up 70% of Swedish embryo transfers last year, said Anders Nyboe Andersen, M.D., at the annual meeting of the European Society of Human Reproduction and Embryology.

The latest European figures (2002) show that of all clinical pregnancies achieved using assisted reproductive technology (ART), the rate of triplet pregnancies per transfer was just over 1%, and the rate of twin pregnancies per transfer was 23.6%, he said.

According to a 2002 report from the Centers for Disease Control and Prevention, the risk of having a pregnancy involving triplets or more per ART cycle was almost 7%, and the risk of a twin pregnancy was 29%. Dr. Andersen, head of the fertility clinic at the Rigshospitalet at Copenhagen University Hospital, noted that because of reporting differences, the U.S. and European data were not directly comparable.

Many fertility experts initially regarded SET as a necessary compromise: The possibility of multiple pregnancies was decreased at the price of a decrease in pregnancy rates overall. Indeed, supporters of this theory have pointed out that the failure of the United States to adopt the widespread use of SET has worked to the advantage of the overall rate of clinical pregnancies per ART cycle in the United States, which is 34.3%, about 5% higher than the European rate.

But the recent Swedish experience has vindicated SET in this regard, reported Karin Erb, laboratory director, fertility clinic, Odense (Denmark) University Hospital.

In a review of fertility data from the Nordic countries, which she presented at the meeting, Ms. Erb reported that stricter Swedish embryo transfer legislation introduced in 2003 forced a sharp increase in SET in that country, with no decrease in the country's overall IVF success rates.

Preliminary 2004 data for Sweden is “even more exciting,” said Professor Karl Nygren of the department of obstetrics and gynecology at Sofiahemmet Hospital in Stockholm.

“The pregnancy rate per embryo transfer remained constant at around 30%, while the number of twin births plummeted to just 5%, and there were no triplet deliveries at all,” he said in a written statement.

While SET becomes the standard of care in many European countries, fertility experts in the United States continue to regard it as a rarity.

“This is amazing. I didn't even know they were doing this,” Jeffrey M. Jones, Ph.D., director of the andrology and IVF laboratory at the University of Wisconsin Medical School in Madison, commented in an interview after hearing some of the presentations at the meeting.

In 2002, SET made up just 1.2% of all IVF and intracytoplasmic sperm injection cycles in the United States, up from 0.8% in 2001. In 2004, for the first time, guidelines released by the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology recommended that SET be considered “for patients with the most favorable prognosis” (Fertil. Steril. 2004;82:773–4). The effect of those guidelines, however, will not be seen before the release of the 2005 data.

Certainly, not all centers can adopt SET without seeing at least an initial decrease in pregnancy rates—and patient selection is a key factor in this equation.

The world's first randomized trial comparing SET to double-embryo transfer (DET) in unselected patients is a case in point.

At the meeting, Aafke van Montfoort, M.D., of the Academic Hospital Maastricht (the Netherlands) reported data on 308 patients under age 41 who were randomized to SET or DET for their first IVF cycle. There were no twins in the SET group, compared with a twin rate of 21% in the DET group. The ongoing pregnancy rate was considerably lower after SET, however, at 21% vs. 40%, said Dr. van Montfoort.

But in another study presented at the meeting, patients were selected (aged less than 37, two top-quality embryos, and less than 20% embryo fragmentation), and given the choice of either SET or DET. The SET group had an ongoing clinical pregnancy rate of 39%, compared with 36% in the DET group, reported H.E. Bredkjaer, M.D., of Holbaek (Denmark) Sygehus Fertility Clinic.

According to many experts, it is important to judge SET beyond the context of the first fresh IVF cycle, because the approach often yields many frozen embryos, which can boost a patient's overall chances for pregnancy.

In Dr. van Montfoort's study of unselected patients, significantly more SET patients (52%) had excess embryos available for cryopreservation, compared with the DET patients (40%). However, even after all patients with frozen embryos underwent one subsequent frozen embryo cycle, the ongoing pregnancy rate remained considerably lower (29%) for the SET group, compared with the DET group (42%).

In Dr. Bredkjaer's study of selected patients, 93% of the SET patients had extra embryos cryopreserved, and 35% of these patients became pregnant on a subsequent frozen-embryo transfer.

Despite the promising data, Dr. Jones doesn't expect the European wave of enthusiasm for SET to catch on soon in the United States, and the main reason is financial.

“I don't think it's ever going to happen until it is mandated or there's insurance coverage for fertility treatment in the U.S.,” he said in an interview. “In the Nordic countries there is insurance for IVF, and so patients are willing to undergo several cycles with single-embryo transfer. In the U.S., it's all out of pocket, so they want to get pregnant on the first attempt.”

David K. Gardner, D.Phil., and associates at the Colorado Center for Reproductive Medicine published a study last year showing that with single-blastocyst transfer on day 5 (most European programs do single-embryo transfer on day 3), high ongoing pregnancy rates can be achieved on the first attempt (Fertil. Steril. 2004;81:551–5).

The prospective trial randomized 48 women to either single-blastocyst transfer or double-blastocyst transfer, and investigators found a comparable ongoing pregnancy rate of 61% and 76%, respectively, with a twin rate of zero in the single-blastocyst transfer group and 47% in the double-blastocyst transfer group.

“If SET can be performed with a high degree of success in appropriate patient populations, as is suggested by the current investigation, there are no financial or medical reasons not to recommend this approach,” wrote the Colorado investigators.

Patients were eligible for the study if they met the center's criteria for blastocyst transfer: a day 3 FSH level of 10 mIU/mL or less, an estradiol level of less than 80 pg/mL, a hysteroscopically normal endometrial cavity, and at least 10 follicles measuring at least 12 mm on the day of HCG administration.

The authors acknowledged their difficulty in getting patients to volunteer for SET. “This was undoubtedly due to the perception by patients that SET could result in lower pregnancy rates and that twin pregnancies are a desirable outcome,” they wrote.

Patient attitudes are undoubtedly a barrier to SET, but physicians' attitudes also can have a huge influence, said Christina Bergh, M.D., professor of obstetrics and gynecology at Sahlgrenska University Hospital in Goteborg, Sweden. A study she presented at the meeting found that physicians' attitudes toward SET in the various Nordic countries correlated strongly with the rates of SET and multiple births in those countries. “When aiming for a reduction in multiple births by introducing SET, IVF doctors are important targets,” Dr. Bergh said.

“Most patients rely on doctors for advice,” she said later in an interview. “My experience is they trust us; we are the experts.” Convincing Swedish patients to try SET was much easier than had been expected, she said.

If U.S. physicians face a tougher time convincing their patients to choose SET, some new evidence could boost their powers of persuasion. SET may actually lead to lower miscarriage rates and better neonatal outcomes, compared with singleton pregnancies resulting from the transfer of more than one embryo. It has long been recognized that singletons conceived through IVF have a much poorer outcome than spontaneously conceived singletons.

Now some researchers report that this disparity could possibly be due to the effects of multiple-embryo transfer. Just as a vanishing twin has been shown to increase complications for the surviving fetus, recent evidence suggests that the demise of at least one embryo after a multiple-embryo transfer may create a toxic environment for the implanted surviving embryo.

A study presented at the meeting by Diane De Neubourg, M.D., supports this argument. After prospectively collecting obstetrical and neonatal data on 251 IVF singletons conceived after SET and more than 53,000 singletons that were spontaneously conceived, she found both groups had comparable outcomes.

Although a higher percentage of SET babies than spontaneously conceived babies (9.2% vs. 5.4%) was born prematurely (32–37 weeks), the mean birth weights and mean gestational ages of the groups were similar.

This compares with other studies showing increased perinatal mortality, increased birth rates of small-for-gestational age infants, and increased preterm delivery and low and very low birth weight in IVF singletons (most of whom are conceived after multiple-embryo transfer), said Dr. De Neubourg, a gynecologist at the center for reproductive medicine at Middelheim Hospital in Antwerp, Belgium.

In a recent editorial on SET, Owen K. Davis, M.D., immediate past president of the Society for Assisted Reproductive Technology, noted that “in 2001, women less than 35 years of age underwent approximately 47% of the IVF cycles in the United States, and 75% of the cycles were first or second attempts. Although the proportion with 'good quality' embryos is not known, this would suggest that on the order of 30% of cycles could be considered for single-embryo transfer” (N. Engl. J. Med. 2004;351:2440–2).

Assuming acceptance of SET by U.S. physicians, he continued: “The education of patients regarding the risk of twin as well as higher-order multiple pregnancy, along with improved insurance coverage for assisted reproductive therapies, would probably enhance the acceptance of a single-embryo transfer approach for appropriate candidates.”

COPENHAGEN — While single-embryo transfer rates for in vitro fertilization procedures languish below 2% in the United States, the Europeans are hitting astonishing highs with impressive results.

Aimed at reducing the growing multiple-pregnancy rate—which was once accepted as an unavoidable side effect of invitro fertilization (IVF)—single-embryo transfer (SET) has been enthusiastically embraced across much of Europe, particularly in the Nordic countries and Belgium. Indeed, SET made up 70% of Swedish embryo transfers last year, said Anders Nyboe Andersen, M.D., at the annual meeting of the European Society of Human Reproduction and Embryology.

The latest European figures (2002) show that of all clinical pregnancies achieved using assisted reproductive technology (ART), the rate of triplet pregnancies per transfer was just over 1%, and the rate of twin pregnancies per transfer was 23.6%, he said.

According to a 2002 report from the Centers for Disease Control and Prevention, the risk of having a pregnancy involving triplets or more per ART cycle was almost 7%, and the risk of a twin pregnancy was 29%. Dr. Andersen, head of the fertility clinic at the Rigshospitalet at Copenhagen University Hospital, noted that because of reporting differences, the U.S. and European data were not directly comparable.

Many fertility experts initially regarded SET as a necessary compromise: The possibility of multiple pregnancies was decreased at the price of a decrease in pregnancy rates overall. Indeed, supporters of this theory have pointed out that the failure of the United States to adopt the widespread use of SET has worked to the advantage of the overall rate of clinical pregnancies per ART cycle in the United States, which is 34.3%, about 5% higher than the European rate.

But the recent Swedish experience has vindicated SET in this regard, reported Karin Erb, laboratory director, fertility clinic, Odense (Denmark) University Hospital.

In a review of fertility data from the Nordic countries, which she presented at the meeting, Ms. Erb reported that stricter Swedish embryo transfer legislation introduced in 2003 forced a sharp increase in SET in that country, with no decrease in the country's overall IVF success rates.

Preliminary 2004 data for Sweden is “even more exciting,” said Professor Karl Nygren of the department of obstetrics and gynecology at Sofiahemmet Hospital in Stockholm.

“The pregnancy rate per embryo transfer remained constant at around 30%, while the number of twin births plummeted to just 5%, and there were no triplet deliveries at all,” he said in a written statement.

While SET becomes the standard of care in many European countries, fertility experts in the United States continue to regard it as a rarity.

“This is amazing. I didn't even know they were doing this,” Jeffrey M. Jones, Ph.D., director of the andrology and IVF laboratory at the University of Wisconsin Medical School in Madison, commented in an interview after hearing some of the presentations at the meeting.

In 2002, SET made up just 1.2% of all IVF and intracytoplasmic sperm injection cycles in the United States, up from 0.8% in 2001. In 2004, for the first time, guidelines released by the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology recommended that SET be considered “for patients with the most favorable prognosis” (Fertil. Steril. 2004;82:773–4). The effect of those guidelines, however, will not be seen before the release of the 2005 data.

Certainly, not all centers can adopt SET without seeing at least an initial decrease in pregnancy rates—and patient selection is a key factor in this equation.

The world's first randomized trial comparing SET to double-embryo transfer (DET) in unselected patients is a case in point.

At the meeting, Aafke van Montfoort, M.D., of the Academic Hospital Maastricht (the Netherlands) reported data on 308 patients under age 41 who were randomized to SET or DET for their first IVF cycle. There were no twins in the SET group, compared with a twin rate of 21% in the DET group. The ongoing pregnancy rate was considerably lower after SET, however, at 21% vs. 40%, said Dr. van Montfoort.

But in another study presented at the meeting, patients were selected (aged less than 37, two top-quality embryos, and less than 20% embryo fragmentation), and given the choice of either SET or DET. The SET group had an ongoing clinical pregnancy rate of 39%, compared with 36% in the DET group, reported H.E. Bredkjaer, M.D., of Holbaek (Denmark) Sygehus Fertility Clinic.

According to many experts, it is important to judge SET beyond the context of the first fresh IVF cycle, because the approach often yields many frozen embryos, which can boost a patient's overall chances for pregnancy.

In Dr. van Montfoort's study of unselected patients, significantly more SET patients (52%) had excess embryos available for cryopreservation, compared with the DET patients (40%). However, even after all patients with frozen embryos underwent one subsequent frozen embryo cycle, the ongoing pregnancy rate remained considerably lower (29%) for the SET group, compared with the DET group (42%).

In Dr. Bredkjaer's study of selected patients, 93% of the SET patients had extra embryos cryopreserved, and 35% of these patients became pregnant on a subsequent frozen-embryo transfer.

Despite the promising data, Dr. Jones doesn't expect the European wave of enthusiasm for SET to catch on soon in the United States, and the main reason is financial.

“I don't think it's ever going to happen until it is mandated or there's insurance coverage for fertility treatment in the U.S.,” he said in an interview. “In the Nordic countries there is insurance for IVF, and so patients are willing to undergo several cycles with single-embryo transfer. In the U.S., it's all out of pocket, so they want to get pregnant on the first attempt.”

David K. Gardner, D.Phil., and associates at the Colorado Center for Reproductive Medicine published a study last year showing that with single-blastocyst transfer on day 5 (most European programs do single-embryo transfer on day 3), high ongoing pregnancy rates can be achieved on the first attempt (Fertil. Steril. 2004;81:551–5).

The prospective trial randomized 48 women to either single-blastocyst transfer or double-blastocyst transfer, and investigators found a comparable ongoing pregnancy rate of 61% and 76%, respectively, with a twin rate of zero in the single-blastocyst transfer group and 47% in the double-blastocyst transfer group.

“If SET can be performed with a high degree of success in appropriate patient populations, as is suggested by the current investigation, there are no financial or medical reasons not to recommend this approach,” wrote the Colorado investigators.

Patients were eligible for the study if they met the center's criteria for blastocyst transfer: a day 3 FSH level of 10 mIU/mL or less, an estradiol level of less than 80 pg/mL, a hysteroscopically normal endometrial cavity, and at least 10 follicles measuring at least 12 mm on the day of HCG administration.

The authors acknowledged their difficulty in getting patients to volunteer for SET. “This was undoubtedly due to the perception by patients that SET could result in lower pregnancy rates and that twin pregnancies are a desirable outcome,” they wrote.

Patient attitudes are undoubtedly a barrier to SET, but physicians' attitudes also can have a huge influence, said Christina Bergh, M.D., professor of obstetrics and gynecology at Sahlgrenska University Hospital in Goteborg, Sweden. A study she presented at the meeting found that physicians' attitudes toward SET in the various Nordic countries correlated strongly with the rates of SET and multiple births in those countries. “When aiming for a reduction in multiple births by introducing SET, IVF doctors are important targets,” Dr. Bergh said.

“Most patients rely on doctors for advice,” she said later in an interview. “My experience is they trust us; we are the experts.” Convincing Swedish patients to try SET was much easier than had been expected, she said.

If U.S. physicians face a tougher time convincing their patients to choose SET, some new evidence could boost their powers of persuasion. SET may actually lead to lower miscarriage rates and better neonatal outcomes, compared with singleton pregnancies resulting from the transfer of more than one embryo. It has long been recognized that singletons conceived through IVF have a much poorer outcome than spontaneously conceived singletons.

Now some researchers report that this disparity could possibly be due to the effects of multiple-embryo transfer. Just as a vanishing twin has been shown to increase complications for the surviving fetus, recent evidence suggests that the demise of at least one embryo after a multiple-embryo transfer may create a toxic environment for the implanted surviving embryo.

A study presented at the meeting by Diane De Neubourg, M.D., supports this argument. After prospectively collecting obstetrical and neonatal data on 251 IVF singletons conceived after SET and more than 53,000 singletons that were spontaneously conceived, she found both groups had comparable outcomes.

Although a higher percentage of SET babies than spontaneously conceived babies (9.2% vs. 5.4%) was born prematurely (32–37 weeks), the mean birth weights and mean gestational ages of the groups were similar.

This compares with other studies showing increased perinatal mortality, increased birth rates of small-for-gestational age infants, and increased preterm delivery and low and very low birth weight in IVF singletons (most of whom are conceived after multiple-embryo transfer), said Dr. De Neubourg, a gynecologist at the center for reproductive medicine at Middelheim Hospital in Antwerp, Belgium.

In a recent editorial on SET, Owen K. Davis, M.D., immediate past president of the Society for Assisted Reproductive Technology, noted that “in 2001, women less than 35 years of age underwent approximately 47% of the IVF cycles in the United States, and 75% of the cycles were first or second attempts. Although the proportion with 'good quality' embryos is not known, this would suggest that on the order of 30% of cycles could be considered for single-embryo transfer” (N. Engl. J. Med. 2004;351:2440–2).

Assuming acceptance of SET by U.S. physicians, he continued: “The education of patients regarding the risk of twin as well as higher-order multiple pregnancy, along with improved insurance coverage for assisted reproductive therapies, would probably enhance the acceptance of a single-embryo transfer approach for appropriate candidates.”