Susan Birk

CHICAGO — Despite a high prevalence of most bowel symptoms among women seeking urogynecologic care, few tell their physicians about their symptoms, according to a study of 463 patients.

The finding indicates that “bowel symptoms should be evaluated in all women presenting for urogynecologic care,” Dr. Fareesa Raza-Khan of Washington University, St. Louis, reported in a poster at the annual meeting of the American Urogynecologic Society. The study was conducted by researchers at Washington University and Loyola University Chicago, Maywood.

Although only 3% of patients presenting to a uro-gynecologic clinic had a bowel symptom as their primary complaint, 76% reported at least one bowel symptom on nonvalidated and validated questionnaires.

Researchers reviewed the charts of 463 consecutive new patients ranging in age from 19 to 94 years (median age, 56) with a body mass index range of 16–64 kg/m

The most frequent symptoms were difficult bowel movements (42%), flatal incontinence (34%), and fecal incontinence (19%). Dr. Raza-Khan reported that she had no conflicts of interest.

CHICAGO — Despite a high prevalence of most bowel symptoms among women seeking urogynecologic care, few tell their physicians about their symptoms, according to a study of 463 patients.

The finding indicates that “bowel symptoms should be evaluated in all women presenting for urogynecologic care,” Dr. Fareesa Raza-Khan of Washington University, St. Louis, reported in a poster at the annual meeting of the American Urogynecologic Society. The study was conducted by researchers at Washington University and Loyola University Chicago, Maywood.

Although only 3% of patients presenting to a uro-gynecologic clinic had a bowel symptom as their primary complaint, 76% reported at least one bowel symptom on nonvalidated and validated questionnaires.

Researchers reviewed the charts of 463 consecutive new patients ranging in age from 19 to 94 years (median age, 56) with a body mass index range of 16–64 kg/m

The most frequent symptoms were difficult bowel movements (42%), flatal incontinence (34%), and fecal incontinence (19%). Dr. Raza-Khan reported that she had no conflicts of interest.

CHICAGO — Despite a high prevalence of most bowel symptoms among women seeking urogynecologic care, few tell their physicians about their symptoms, according to a study of 463 patients.

The finding indicates that “bowel symptoms should be evaluated in all women presenting for urogynecologic care,” Dr. Fareesa Raza-Khan of Washington University, St. Louis, reported in a poster at the annual meeting of the American Urogynecologic Society. The study was conducted by researchers at Washington University and Loyola University Chicago, Maywood.

Although only 3% of patients presenting to a uro-gynecologic clinic had a bowel symptom as their primary complaint, 76% reported at least one bowel symptom on nonvalidated and validated questionnaires.

Researchers reviewed the charts of 463 consecutive new patients ranging in age from 19 to 94 years (median age, 56) with a body mass index range of 16–64 kg/m

The most frequent symptoms were difficult bowel movements (42%), flatal incontinence (34%), and fecal incontinence (19%). Dr. Raza-Khan reported that she had no conflicts of interest.

CHICAGO — Most adnexal tumors can be classified as benign or malignant by transvaginal gray-scale ultrasound and Doppler ultrasound based on the use of 10 simple rules, according to a prospective multicenter study of 1,938 patients.

The rules enabled less experienced ultrasound examiners to perform as well as highly experienced examiners in distinguishing benign and malignant masses, reported Dr. Dirk Timmerman at the World Congress on Ultrasound in Obstetrics and Gynecology.

The sensitivity of ultrasound pattern recognition and the simple rules was 91% and 92%, respectively, and the specificity was 96% and 96%, said Dr. Timmerman, professor of obstetrics and gynecology and clinical head of ultrasound at University Hospitals Leuven (Belgium).

“We have been looking for more objective ways to help ultrasound examiners” distinguish benign and malignant tumors, Dr. Timmerman said in an interview. “Simple rules are rather easy to learn, whereas subjective assessment [pattern recognition] takes a long time to learn and is not easily transferred to others.”

Researchers found 545 (28%) malignancies among the 1,938 patients with adnexal masses at 19 centers. The rules were applicable to 1,501 (77%) of patients and had a positive likelihood ratio of 21.29 and a negative likelihood ratio of 0.08.

The rules include five to predict malignancy (M-rules) and five to predict a benign mass (B-rules).

The M-rules are the following:

▸ Irregular solid tumor.

▸ Ascites.

▸ At least four papillary structures.

▸ Irregular multilocular-solid tumor with a largest diameter of at least 100 mm.

▸ Very high color score using color Doppler.

The B-rules are the following:

▸ Unilocular cyst.

▸ Presence of solid components, where the largest solid component is less than 7 mm in largest diameter.

▸ Acoustic shadows.

▸ Smooth multilocular tumor less than 100 mm in largest diameter.

▸ No detectable blood flow at Doppler examination.

Dr. Timmerman said that this phase II study provides additional large-scale evidence of the sensitivity and specificity of the rules, which were first published in May by the International Ovarian Tumor Analysis study group (IOTA), a consortium of European medical centers (Ultrasound Obstet. Gynecol. 2008;31:6:681-90).

In that phase I study, 1,066 patients with 1,233 adnexal tumors at nine centers underwent transvaginal gray-scale and Doppler ultrasound examination. Researchers collected 42 gray-scale ultrasound variables and six Doppler variables, and determined the variables or combinations of variables with the highest and the lowest positive predictive value for malignancy. They selected 10 rules consistent with their clinical experience that were applicable to at least 30 tumors, and tested those rules prospectively on 507 tumors in three centers.

For the phase II study, Dr. Timmerman and his colleagues assessed two additional variables (the presence of acoustic streaming and ovarian crescent sign) next to several clinical variables, such as pain during examination, he noted.

In the phase I study, the 10 rules were applicable to 76% of all tumors, in which they showed a sensitivity of 93%, a specificity of 90%, a positive likelihood ratio of 9.45, and a negative likelihood ratio of 0.08. In addition, the rules were applicable to 76% (386/507) of the prospectively tested tumors, with a sensitivity of 95%, a specificity of 91%, a positive likelihood ratio of 10.37, and a negative likelihood ratio of 0.06.

Dr. Timmerman said phase III of IOTA will test optimal second-stage tests for difficult tumors, such as ultrasound contrast agents and 3-D power Doppler examination.

CHICAGO — Most adnexal tumors can be classified as benign or malignant by transvaginal gray-scale ultrasound and Doppler ultrasound based on the use of 10 simple rules, according to a prospective multicenter study of 1,938 patients.

The rules enabled less experienced ultrasound examiners to perform as well as highly experienced examiners in distinguishing benign and malignant masses, reported Dr. Dirk Timmerman at the World Congress on Ultrasound in Obstetrics and Gynecology.

The sensitivity of ultrasound pattern recognition and the simple rules was 91% and 92%, respectively, and the specificity was 96% and 96%, said Dr. Timmerman, professor of obstetrics and gynecology and clinical head of ultrasound at University Hospitals Leuven (Belgium).

“We have been looking for more objective ways to help ultrasound examiners” distinguish benign and malignant tumors, Dr. Timmerman said in an interview. “Simple rules are rather easy to learn, whereas subjective assessment [pattern recognition] takes a long time to learn and is not easily transferred to others.”

Researchers found 545 (28%) malignancies among the 1,938 patients with adnexal masses at 19 centers. The rules were applicable to 1,501 (77%) of patients and had a positive likelihood ratio of 21.29 and a negative likelihood ratio of 0.08.

The rules include five to predict malignancy (M-rules) and five to predict a benign mass (B-rules).

The M-rules are the following:

▸ Irregular solid tumor.

▸ Ascites.

▸ At least four papillary structures.

▸ Irregular multilocular-solid tumor with a largest diameter of at least 100 mm.

▸ Very high color score using color Doppler.

The B-rules are the following:

▸ Unilocular cyst.

▸ Presence of solid components, where the largest solid component is less than 7 mm in largest diameter.

▸ Acoustic shadows.

▸ Smooth multilocular tumor less than 100 mm in largest diameter.

▸ No detectable blood flow at Doppler examination.

Dr. Timmerman said that this phase II study provides additional large-scale evidence of the sensitivity and specificity of the rules, which were first published in May by the International Ovarian Tumor Analysis study group (IOTA), a consortium of European medical centers (Ultrasound Obstet. Gynecol. 2008;31:6:681-90).

In that phase I study, 1,066 patients with 1,233 adnexal tumors at nine centers underwent transvaginal gray-scale and Doppler ultrasound examination. Researchers collected 42 gray-scale ultrasound variables and six Doppler variables, and determined the variables or combinations of variables with the highest and the lowest positive predictive value for malignancy. They selected 10 rules consistent with their clinical experience that were applicable to at least 30 tumors, and tested those rules prospectively on 507 tumors in three centers.

For the phase II study, Dr. Timmerman and his colleagues assessed two additional variables (the presence of acoustic streaming and ovarian crescent sign) next to several clinical variables, such as pain during examination, he noted.

In the phase I study, the 10 rules were applicable to 76% of all tumors, in which they showed a sensitivity of 93%, a specificity of 90%, a positive likelihood ratio of 9.45, and a negative likelihood ratio of 0.08. In addition, the rules were applicable to 76% (386/507) of the prospectively tested tumors, with a sensitivity of 95%, a specificity of 91%, a positive likelihood ratio of 10.37, and a negative likelihood ratio of 0.06.

Dr. Timmerman said phase III of IOTA will test optimal second-stage tests for difficult tumors, such as ultrasound contrast agents and 3-D power Doppler examination.

CHICAGO — Most adnexal tumors can be classified as benign or malignant by transvaginal gray-scale ultrasound and Doppler ultrasound based on the use of 10 simple rules, according to a prospective multicenter study of 1,938 patients.

The rules enabled less experienced ultrasound examiners to perform as well as highly experienced examiners in distinguishing benign and malignant masses, reported Dr. Dirk Timmerman at the World Congress on Ultrasound in Obstetrics and Gynecology.

The sensitivity of ultrasound pattern recognition and the simple rules was 91% and 92%, respectively, and the specificity was 96% and 96%, said Dr. Timmerman, professor of obstetrics and gynecology and clinical head of ultrasound at University Hospitals Leuven (Belgium).

“We have been looking for more objective ways to help ultrasound examiners” distinguish benign and malignant tumors, Dr. Timmerman said in an interview. “Simple rules are rather easy to learn, whereas subjective assessment [pattern recognition] takes a long time to learn and is not easily transferred to others.”

Researchers found 545 (28%) malignancies among the 1,938 patients with adnexal masses at 19 centers. The rules were applicable to 1,501 (77%) of patients and had a positive likelihood ratio of 21.29 and a negative likelihood ratio of 0.08.

The rules include five to predict malignancy (M-rules) and five to predict a benign mass (B-rules).

The M-rules are the following:

▸ Irregular solid tumor.

▸ Ascites.

▸ At least four papillary structures.

▸ Irregular multilocular-solid tumor with a largest diameter of at least 100 mm.

▸ Very high color score using color Doppler.

The B-rules are the following:

▸ Unilocular cyst.

▸ Presence of solid components, where the largest solid component is less than 7 mm in largest diameter.

▸ Acoustic shadows.

▸ Smooth multilocular tumor less than 100 mm in largest diameter.

▸ No detectable blood flow at Doppler examination.

Dr. Timmerman said that this phase II study provides additional large-scale evidence of the sensitivity and specificity of the rules, which were first published in May by the International Ovarian Tumor Analysis study group (IOTA), a consortium of European medical centers (Ultrasound Obstet. Gynecol. 2008;31:6:681-90).

In that phase I study, 1,066 patients with 1,233 adnexal tumors at nine centers underwent transvaginal gray-scale and Doppler ultrasound examination. Researchers collected 42 gray-scale ultrasound variables and six Doppler variables, and determined the variables or combinations of variables with the highest and the lowest positive predictive value for malignancy. They selected 10 rules consistent with their clinical experience that were applicable to at least 30 tumors, and tested those rules prospectively on 507 tumors in three centers.

For the phase II study, Dr. Timmerman and his colleagues assessed two additional variables (the presence of acoustic streaming and ovarian crescent sign) next to several clinical variables, such as pain during examination, he noted.

In the phase I study, the 10 rules were applicable to 76% of all tumors, in which they showed a sensitivity of 93%, a specificity of 90%, a positive likelihood ratio of 9.45, and a negative likelihood ratio of 0.08. In addition, the rules were applicable to 76% (386/507) of the prospectively tested tumors, with a sensitivity of 95%, a specificity of 91%, a positive likelihood ratio of 10.37, and a negative likelihood ratio of 0.06.

Dr. Timmerman said phase III of IOTA will test optimal second-stage tests for difficult tumors, such as ultrasound contrast agents and 3-D power Doppler examination.

CHICAGO — High maternal body mass index decreases the ability to detect fetal abnormalities with standard or targeted second-trimester ultrasound, a retrospective study of more than 10,000 examinations has shown.

The study found a significant decrease in detection of anomalous fetuses with increasing body mass index (BMI) with standard ultrasound and also when standard and targeted ultrasound were combined.

“Counseling may need to be modified to reflect the limitations of sonography in the setting of obesity,” Dr. Jodi S. Dashe of the University of Texas at Dallas reported at the World Congress on Ultrasound in Obstetrics and Gynecology.

“It may be harder to identify fetal anomalies in obese women because the ultrasound transducer is farther from the fetus, which limits the image resolution,” Dr. Dashe commented in an interview.

In the present study, researchers reviewed pregnancies that received standard or targeted ultrasound between 18 and 24 weeks of gestation and were delivered at the University of Texas Southwestern Medical Center between 2003 and 2007.

Standard ultrasound had been done in keeping with the criteria of the American Institute of Ultrasound in Medicine. Targeted ultrasound was performed for specific high-risk indications.

The researchers included all potentially life-threatening structural abnormalities in their analysis as well as those requiring surgery, even if detection of the anomaly would not be expected with ultrasound. Researchers used a prospectively kept database of birth defects to verify ultrasound-detected anomalies.

An anomalous fetus was considered detected if an abnormality of the relevant organ system was identified. The researchers used patients' BMIs at first prenatal visit in their analysis, categorizing BMI according to National Institutes of Health criteria: normal (less than 25 kg/m

Of 10,112 standard and 1,023 targeted ultrasound examinations, anomalies were verified in 181 infants (1.6%).

Standard ultrasound detected 66% of anomalous fetuses in women with a normal BMI, but only 49%, 48%, 42%, and 25% of anomalous fetuses in women in the overweight and class I, II, and III obesity categories, respectively.

The combined detection of anomalous fetuses was 68% in women with a normal BMI but only 55%, 49%, 47%, and 43% in women in the overweight and class I, II, and III obesity categories.

Previous research on fetal cardiac visualization and BMI also found significantly higher rates of persistent suboptimal ultrasonographic visualization (SUV) on a repeated ultrasound examination in obese women, compared with nonobese women.

SUV rates increased with increasing BMI in obese patients (J. Ultrasound Med. 2005;24:1205-9).

Dr. Dashe said she and her colleagues hope to do further research in this area. She had no financial conflicts of interest to report.

CHICAGO — High maternal body mass index decreases the ability to detect fetal abnormalities with standard or targeted second-trimester ultrasound, a retrospective study of more than 10,000 examinations has shown.

The study found a significant decrease in detection of anomalous fetuses with increasing body mass index (BMI) with standard ultrasound and also when standard and targeted ultrasound were combined.

“Counseling may need to be modified to reflect the limitations of sonography in the setting of obesity,” Dr. Jodi S. Dashe of the University of Texas at Dallas reported at the World Congress on Ultrasound in Obstetrics and Gynecology.

“It may be harder to identify fetal anomalies in obese women because the ultrasound transducer is farther from the fetus, which limits the image resolution,” Dr. Dashe commented in an interview.

In the present study, researchers reviewed pregnancies that received standard or targeted ultrasound between 18 and 24 weeks of gestation and were delivered at the University of Texas Southwestern Medical Center between 2003 and 2007.

Standard ultrasound had been done in keeping with the criteria of the American Institute of Ultrasound in Medicine. Targeted ultrasound was performed for specific high-risk indications.

The researchers included all potentially life-threatening structural abnormalities in their analysis as well as those requiring surgery, even if detection of the anomaly would not be expected with ultrasound. Researchers used a prospectively kept database of birth defects to verify ultrasound-detected anomalies.

An anomalous fetus was considered detected if an abnormality of the relevant organ system was identified. The researchers used patients' BMIs at first prenatal visit in their analysis, categorizing BMI according to National Institutes of Health criteria: normal (less than 25 kg/m

Of 10,112 standard and 1,023 targeted ultrasound examinations, anomalies were verified in 181 infants (1.6%).

Standard ultrasound detected 66% of anomalous fetuses in women with a normal BMI, but only 49%, 48%, 42%, and 25% of anomalous fetuses in women in the overweight and class I, II, and III obesity categories, respectively.

The combined detection of anomalous fetuses was 68% in women with a normal BMI but only 55%, 49%, 47%, and 43% in women in the overweight and class I, II, and III obesity categories.

Previous research on fetal cardiac visualization and BMI also found significantly higher rates of persistent suboptimal ultrasonographic visualization (SUV) on a repeated ultrasound examination in obese women, compared with nonobese women.

SUV rates increased with increasing BMI in obese patients (J. Ultrasound Med. 2005;24:1205-9).

Dr. Dashe said she and her colleagues hope to do further research in this area. She had no financial conflicts of interest to report.

CHICAGO — High maternal body mass index decreases the ability to detect fetal abnormalities with standard or targeted second-trimester ultrasound, a retrospective study of more than 10,000 examinations has shown.

The study found a significant decrease in detection of anomalous fetuses with increasing body mass index (BMI) with standard ultrasound and also when standard and targeted ultrasound were combined.

“Counseling may need to be modified to reflect the limitations of sonography in the setting of obesity,” Dr. Jodi S. Dashe of the University of Texas at Dallas reported at the World Congress on Ultrasound in Obstetrics and Gynecology.

“It may be harder to identify fetal anomalies in obese women because the ultrasound transducer is farther from the fetus, which limits the image resolution,” Dr. Dashe commented in an interview.

In the present study, researchers reviewed pregnancies that received standard or targeted ultrasound between 18 and 24 weeks of gestation and were delivered at the University of Texas Southwestern Medical Center between 2003 and 2007.

Standard ultrasound had been done in keeping with the criteria of the American Institute of Ultrasound in Medicine. Targeted ultrasound was performed for specific high-risk indications.

The researchers included all potentially life-threatening structural abnormalities in their analysis as well as those requiring surgery, even if detection of the anomaly would not be expected with ultrasound. Researchers used a prospectively kept database of birth defects to verify ultrasound-detected anomalies.

An anomalous fetus was considered detected if an abnormality of the relevant organ system was identified. The researchers used patients' BMIs at first prenatal visit in their analysis, categorizing BMI according to National Institutes of Health criteria: normal (less than 25 kg/m

Of 10,112 standard and 1,023 targeted ultrasound examinations, anomalies were verified in 181 infants (1.6%).

Standard ultrasound detected 66% of anomalous fetuses in women with a normal BMI, but only 49%, 48%, 42%, and 25% of anomalous fetuses in women in the overweight and class I, II, and III obesity categories, respectively.

The combined detection of anomalous fetuses was 68% in women with a normal BMI but only 55%, 49%, 47%, and 43% in women in the overweight and class I, II, and III obesity categories.

Previous research on fetal cardiac visualization and BMI also found significantly higher rates of persistent suboptimal ultrasonographic visualization (SUV) on a repeated ultrasound examination in obese women, compared with nonobese women.

SUV rates increased with increasing BMI in obese patients (J. Ultrasound Med. 2005;24:1205-9).

Dr. Dashe said she and her colleagues hope to do further research in this area. She had no financial conflicts of interest to report.

CHICAGO — Awareness of medical malpractice lawsuits is the first step toward protecting against them, according to an attorney familiar with medical litigation.

Even outstanding clinical skills do not guarantee protection from litigation, Patricia S. Kocour, J.D., said at the annual meeting of the Society of Obstetric Anesthesia and Perinatology. This means that obstetric anesthesiologists, and all physicians for that matter, need to develop their legal acumen. “I represent a lot of good doctors, and I also have a lot of cases, which tells you that becoming a good doctor doesn't prevent malpractice [lawsuits],” said Ms. Kocour, an attorney with Swanson, Martin, & Bell LLP, Chicago, who participated in a panel on legal issues in obstetric anesthesia.

Copanelist William B. Bower, J.D., echoed Ms. Kocour's assertion. “Simply by standing in the labor-and-delivery suite, you've put yourself in high stakes,” said Mr. Bower, who is executive director of claims and litigation at Northwestern Memorial Hospital, Chicago.

He advocated robust incident reporting and ongoing quality management aimed at reducing preventable adverse events as one of the most effective approaches for decreasing liability exposure.

Ms. Kocour said that physicians can lessen their legal exposure by focusing on the delivery of medical care consistent with or better than that of other physicians in their field, educating their patients, and documenting everything they do.

Patients sue physicians for real or perceived mismanagement, undesirable outcomes, unexpected outcomes, real or perceived inability to get answers to questions, and the need for financial resources to manage catastrophic outcomes.

To ward off litigation, she advised doctors to make sure patients understand them and ask if all of their questions have been answered; talk to patients at eye level and sit next to them when explaining a procedure or providing information about care; and make sure patients know of potential adverse outcomes. “Patients who've been informed are less likely to complain later,” she said.

Ms. Kocour stressed the importance of open communication and willingness to answer a patient's questions promptly in the event of an undesirable outcome. When patients have trouble getting answers from their physicians, they are more likely to go to an attorney to get the answers they need.

She also emphasized the value of good documentation. “My best tool is the medical record,” she said. “If the record documents who was there, what happened, and when, it makes my job much easier.”

Mr. Bower highlighted the importance of disclosure, transparency, and expectation management in the event of an adverse outcome.

Prevention is key in this regard, he said. “By the time it comes to [a lawyer], you're trying to limit exposure after the horse is out of the barn.”

A physician's willingness to meet with a patient and spend time explaining everything that happened can go a long way toward preventing litigation, he said.

Ms. Kocour touched on ways physicians may become involved in litigation other than as defendants. She encouraged physicians to serve as expert witnesses if given the opportunity. “We can't defend these cases without experts,” she said.

Involvement as a fact witness generally means the physician's care is not an issue in the lawsuit, she said. However, physicians who are asked to serve in this capacity should take their involvement seriously and contact the lawyer at their institutions to protect themselves against a future lawsuit.

CHICAGO — Awareness of medical malpractice lawsuits is the first step toward protecting against them, according to an attorney familiar with medical litigation.

Even outstanding clinical skills do not guarantee protection from litigation, Patricia S. Kocour, J.D., said at the annual meeting of the Society of Obstetric Anesthesia and Perinatology. This means that obstetric anesthesiologists, and all physicians for that matter, need to develop their legal acumen. “I represent a lot of good doctors, and I also have a lot of cases, which tells you that becoming a good doctor doesn't prevent malpractice [lawsuits],” said Ms. Kocour, an attorney with Swanson, Martin, & Bell LLP, Chicago, who participated in a panel on legal issues in obstetric anesthesia.

Copanelist William B. Bower, J.D., echoed Ms. Kocour's assertion. “Simply by standing in the labor-and-delivery suite, you've put yourself in high stakes,” said Mr. Bower, who is executive director of claims and litigation at Northwestern Memorial Hospital, Chicago.

He advocated robust incident reporting and ongoing quality management aimed at reducing preventable adverse events as one of the most effective approaches for decreasing liability exposure.

Ms. Kocour said that physicians can lessen their legal exposure by focusing on the delivery of medical care consistent with or better than that of other physicians in their field, educating their patients, and documenting everything they do.

Patients sue physicians for real or perceived mismanagement, undesirable outcomes, unexpected outcomes, real or perceived inability to get answers to questions, and the need for financial resources to manage catastrophic outcomes.

To ward off litigation, she advised doctors to make sure patients understand them and ask if all of their questions have been answered; talk to patients at eye level and sit next to them when explaining a procedure or providing information about care; and make sure patients know of potential adverse outcomes. “Patients who've been informed are less likely to complain later,” she said.

Ms. Kocour stressed the importance of open communication and willingness to answer a patient's questions promptly in the event of an undesirable outcome. When patients have trouble getting answers from their physicians, they are more likely to go to an attorney to get the answers they need.

She also emphasized the value of good documentation. “My best tool is the medical record,” she said. “If the record documents who was there, what happened, and when, it makes my job much easier.”

Mr. Bower highlighted the importance of disclosure, transparency, and expectation management in the event of an adverse outcome.

Prevention is key in this regard, he said. “By the time it comes to [a lawyer], you're trying to limit exposure after the horse is out of the barn.”

A physician's willingness to meet with a patient and spend time explaining everything that happened can go a long way toward preventing litigation, he said.

Ms. Kocour touched on ways physicians may become involved in litigation other than as defendants. She encouraged physicians to serve as expert witnesses if given the opportunity. “We can't defend these cases without experts,” she said.

Involvement as a fact witness generally means the physician's care is not an issue in the lawsuit, she said. However, physicians who are asked to serve in this capacity should take their involvement seriously and contact the lawyer at their institutions to protect themselves against a future lawsuit.

CHICAGO — Awareness of medical malpractice lawsuits is the first step toward protecting against them, according to an attorney familiar with medical litigation.

Even outstanding clinical skills do not guarantee protection from litigation, Patricia S. Kocour, J.D., said at the annual meeting of the Society of Obstetric Anesthesia and Perinatology. This means that obstetric anesthesiologists, and all physicians for that matter, need to develop their legal acumen. “I represent a lot of good doctors, and I also have a lot of cases, which tells you that becoming a good doctor doesn't prevent malpractice [lawsuits],” said Ms. Kocour, an attorney with Swanson, Martin, & Bell LLP, Chicago, who participated in a panel on legal issues in obstetric anesthesia.

Copanelist William B. Bower, J.D., echoed Ms. Kocour's assertion. “Simply by standing in the labor-and-delivery suite, you've put yourself in high stakes,” said Mr. Bower, who is executive director of claims and litigation at Northwestern Memorial Hospital, Chicago.

He advocated robust incident reporting and ongoing quality management aimed at reducing preventable adverse events as one of the most effective approaches for decreasing liability exposure.

Ms. Kocour said that physicians can lessen their legal exposure by focusing on the delivery of medical care consistent with or better than that of other physicians in their field, educating their patients, and documenting everything they do.

Patients sue physicians for real or perceived mismanagement, undesirable outcomes, unexpected outcomes, real or perceived inability to get answers to questions, and the need for financial resources to manage catastrophic outcomes.

To ward off litigation, she advised doctors to make sure patients understand them and ask if all of their questions have been answered; talk to patients at eye level and sit next to them when explaining a procedure or providing information about care; and make sure patients know of potential adverse outcomes. “Patients who've been informed are less likely to complain later,” she said.

Ms. Kocour stressed the importance of open communication and willingness to answer a patient's questions promptly in the event of an undesirable outcome. When patients have trouble getting answers from their physicians, they are more likely to go to an attorney to get the answers they need.

She also emphasized the value of good documentation. “My best tool is the medical record,” she said. “If the record documents who was there, what happened, and when, it makes my job much easier.”

Mr. Bower highlighted the importance of disclosure, transparency, and expectation management in the event of an adverse outcome.

Prevention is key in this regard, he said. “By the time it comes to [a lawyer], you're trying to limit exposure after the horse is out of the barn.”

A physician's willingness to meet with a patient and spend time explaining everything that happened can go a long way toward preventing litigation, he said.

Ms. Kocour touched on ways physicians may become involved in litigation other than as defendants. She encouraged physicians to serve as expert witnesses if given the opportunity. “We can't defend these cases without experts,” she said.

Involvement as a fact witness generally means the physician's care is not an issue in the lawsuit, she said. However, physicians who are asked to serve in this capacity should take their involvement seriously and contact the lawyer at their institutions to protect themselves against a future lawsuit.

CHICAGO — Anticipated pain, anxiety, and sensitivity to standardized audio tones can predict a woman's pain experience and narcotic requirements following cesarean section, according to a study of 118 recipients of elective C-sections.

“These findings indicate that simple questions prior to cesarean section can help providers identify patients who may be at risk for inadequate pain control and subsequent development of persistent pain and depression,” Dr. Ashley M. Tonidandel of Wake Forest University, Winston-Salem, N.C., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Previous research presented at last year's meeting indicated that pain severity following delivery is a stronger predictor of persistent pain and postpartum depression than is method of delivery.

The link between acute pain and postpartum depression, which can impair the mother's ability to attach to the infant, underscores the need for an easy method of identifying at-risk patients, Dr. Tonidandel commented.

“The Joint Commission suggests that it's both a hospital standard and a patient right to have a goal for pain scores of less than four,” she said.

To date, Dr. Tonidandel and her colleagues have collected data on 118 parturients who underwent elective C-section with subarachnoid anesthesia and spinal morphine.

Most of the patients were undergoing repeat C-sections, and the rest were undergoing primary sections for breech and other reasons.

During the preoperative anesthetic consultation, patients were asked a set of questions regarding their level of anticipated pain and anxiety.

They also rated the loudness of a series of tones with a visual analog scale.

Chart reviews provided data on actual narcotic usage in the postanesthesia care unit and 24 hours after surgery.

Assessments of resting pain, evoked pain, and satisfaction with pain control also were conducted 24 hours after surgery using the same visual analog scale.

Patient scores on anticipated pain, anxiety, and sensitivity to sound predicted levels of narcotic usage in the postanesthesia care unit and at 24 hours post surgery, as well as degree of resting and evoked pain.

Satisfaction with pain control was generally high and was not associated with patient scores.

Anticipated pain surfaced as the most significant predictor of postsurgical pain and analgesic requirements; however, audio sensitivity was an important and unique predictor of narcotic usage in the postanesthesia care unit as well.

Previous research has shown that sensitivity to heat can help predict narcotic requirements after cesarean delivery (Anesthesiology 2006;104:417–25). However, the use of audio stimuli, which were shown to be predictive in this study, provides “a nice way to get around having to use heat on parturients before C-section,” Dr. Tonidandel said.

“By asking patients [a few questions] preoperatively, I'm much less surprised by what happens later,” she added.

As more data are collected, Dr. Tonidandel and her colleagues plan to develop threshold scores to identify patients who might benefit from early intervention and the initiation of customized, multimodal pain management.

The model used in this study also may have potential applications for patients undergoing other types of surgery, they said.

CHICAGO — Anticipated pain, anxiety, and sensitivity to standardized audio tones can predict a woman's pain experience and narcotic requirements following cesarean section, according to a study of 118 recipients of elective C-sections.

“These findings indicate that simple questions prior to cesarean section can help providers identify patients who may be at risk for inadequate pain control and subsequent development of persistent pain and depression,” Dr. Ashley M. Tonidandel of Wake Forest University, Winston-Salem, N.C., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Previous research presented at last year's meeting indicated that pain severity following delivery is a stronger predictor of persistent pain and postpartum depression than is method of delivery.

The link between acute pain and postpartum depression, which can impair the mother's ability to attach to the infant, underscores the need for an easy method of identifying at-risk patients, Dr. Tonidandel commented.

“The Joint Commission suggests that it's both a hospital standard and a patient right to have a goal for pain scores of less than four,” she said.

To date, Dr. Tonidandel and her colleagues have collected data on 118 parturients who underwent elective C-section with subarachnoid anesthesia and spinal morphine.

Most of the patients were undergoing repeat C-sections, and the rest were undergoing primary sections for breech and other reasons.

During the preoperative anesthetic consultation, patients were asked a set of questions regarding their level of anticipated pain and anxiety.

They also rated the loudness of a series of tones with a visual analog scale.

Chart reviews provided data on actual narcotic usage in the postanesthesia care unit and 24 hours after surgery.

Assessments of resting pain, evoked pain, and satisfaction with pain control also were conducted 24 hours after surgery using the same visual analog scale.

Patient scores on anticipated pain, anxiety, and sensitivity to sound predicted levels of narcotic usage in the postanesthesia care unit and at 24 hours post surgery, as well as degree of resting and evoked pain.

Satisfaction with pain control was generally high and was not associated with patient scores.

Anticipated pain surfaced as the most significant predictor of postsurgical pain and analgesic requirements; however, audio sensitivity was an important and unique predictor of narcotic usage in the postanesthesia care unit as well.

Previous research has shown that sensitivity to heat can help predict narcotic requirements after cesarean delivery (Anesthesiology 2006;104:417–25). However, the use of audio stimuli, which were shown to be predictive in this study, provides “a nice way to get around having to use heat on parturients before C-section,” Dr. Tonidandel said.

“By asking patients [a few questions] preoperatively, I'm much less surprised by what happens later,” she added.

As more data are collected, Dr. Tonidandel and her colleagues plan to develop threshold scores to identify patients who might benefit from early intervention and the initiation of customized, multimodal pain management.

The model used in this study also may have potential applications for patients undergoing other types of surgery, they said.

CHICAGO — Anticipated pain, anxiety, and sensitivity to standardized audio tones can predict a woman's pain experience and narcotic requirements following cesarean section, according to a study of 118 recipients of elective C-sections.

“These findings indicate that simple questions prior to cesarean section can help providers identify patients who may be at risk for inadequate pain control and subsequent development of persistent pain and depression,” Dr. Ashley M. Tonidandel of Wake Forest University, Winston-Salem, N.C., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Previous research presented at last year's meeting indicated that pain severity following delivery is a stronger predictor of persistent pain and postpartum depression than is method of delivery.

The link between acute pain and postpartum depression, which can impair the mother's ability to attach to the infant, underscores the need for an easy method of identifying at-risk patients, Dr. Tonidandel commented.

“The Joint Commission suggests that it's both a hospital standard and a patient right to have a goal for pain scores of less than four,” she said.

To date, Dr. Tonidandel and her colleagues have collected data on 118 parturients who underwent elective C-section with subarachnoid anesthesia and spinal morphine.

Most of the patients were undergoing repeat C-sections, and the rest were undergoing primary sections for breech and other reasons.

During the preoperative anesthetic consultation, patients were asked a set of questions regarding their level of anticipated pain and anxiety.

They also rated the loudness of a series of tones with a visual analog scale.

Chart reviews provided data on actual narcotic usage in the postanesthesia care unit and 24 hours after surgery.

Assessments of resting pain, evoked pain, and satisfaction with pain control also were conducted 24 hours after surgery using the same visual analog scale.

Patient scores on anticipated pain, anxiety, and sensitivity to sound predicted levels of narcotic usage in the postanesthesia care unit and at 24 hours post surgery, as well as degree of resting and evoked pain.

Satisfaction with pain control was generally high and was not associated with patient scores.

Anticipated pain surfaced as the most significant predictor of postsurgical pain and analgesic requirements; however, audio sensitivity was an important and unique predictor of narcotic usage in the postanesthesia care unit as well.

Previous research has shown that sensitivity to heat can help predict narcotic requirements after cesarean delivery (Anesthesiology 2006;104:417–25). However, the use of audio stimuli, which were shown to be predictive in this study, provides “a nice way to get around having to use heat on parturients before C-section,” Dr. Tonidandel said.

“By asking patients [a few questions] preoperatively, I'm much less surprised by what happens later,” she added.

As more data are collected, Dr. Tonidandel and her colleagues plan to develop threshold scores to identify patients who might benefit from early intervention and the initiation of customized, multimodal pain management.

The model used in this study also may have potential applications for patients undergoing other types of surgery, they said.

CHICAGO — A prospective study of 5,300 women has provided the first biological evidence of the mechanisms underlying the statistically established association between preterm delivery and the mother's future risk of heart disease and stroke.

Low HDL cholesterol and elevated homocysteine levels surfaced as key factors associated with spontaneous preterm birth, Dr. Michael S. Kramer of McGill University reported in a plenary session at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

In addition, a significantly higher proportion of women with concentrations of homocysteine above the median showed signs of decidual vasculopathy (13.0% vs. 6.8%), Dr. Kramer said.

The study compared frozen plasma samples and fixed and stained placentas from 207 cases of spontaneous preterm birth with 444 term controls, approximately 2 per case.

Researchers analyzed homocysteine, folate, cholesterol (total, LDL, and HDL), and thrombin-antithrombin complexes and blindly assessed fixed and stained placentas for histologic evidence of infarction and decidual vasculopathy.

Both elevated homocysteine and low HDL cholesterol levels were significantly and independently associated with twice the risk of preterm birth, Dr. Kramer reported. “Similar vasculopathic risk factors may underlie preterm birth and adult coronary heart disease and stroke,” he said.

Women who delivered preterm had significantly higher plasma homocysteine (4.0 vs. 3.7 mmol/L; P = .001) and lower HDL cholesterol (1.6 vs. 1.8 mmol/L; P = .0001) levels, compared with women who delivered at term.

In addition, a higher proportion of women with high homocysteine concentrations (but not low HDL) had decidual vasculopathy (13.0% vs. 6.8%).

“The same factors that we know lead to stroke and heart disease were found to be elevated in the second trimester in mothers who subsequently gave birth preterm,” said Dr. Kramer in an interview.

The fact that their placentas showed evidence of vasculopathy on the mother's side was a major finding, because it provides a biological link with the vasculopathic plasma markers, he said.

However, “even if [these results] are robust, we still don't know whether homocysteine and HDL are pathologically involved in a biological sense with the preterm birth, or whether they're just markers of the mother's increased risk,” he said.

“In adults, when HDL and homocysteine damage blood vessels, they do it over decades,” he said. “With pregnancy, we're talking about months. How do [these factors] get translated biologically into an increased risk for preterm birth? It may be the homocysteine and HDL themselves that are acting on blood vessels in the placenta, or it may be something else that's causing the preterm birth.”

Dr. Kramer noted that the differences in HDL and homocysteine levels between the two groups were statistically significant but modest. For example, there was a less than 10% difference between the cases and controls in homocysteine (4.0 vs. 3.7 mmol/L). In addition, “the homocysteine concentrations were not high in terms of what is known or suspected to cause vascular damage, which is why we're underlining the fact that we don't know if it's the homocysteine,” he said. “These were not the sky-high levels associated with very high risks of coronary heart disease.”

The findings need to be replicated to determine whether they are robust, Dr. Kramer said. “However, I think it's unlikely that they were just a statistical fluke, because they were in the direction you'd expect,” he said.

Existing serum banks for large populations would offer a relatively easy and inexpensive method of linking pregnancy outcomes with HDL and homocysteine concentrations, he said.

CHICAGO — A prospective study of 5,300 women has provided the first biological evidence of the mechanisms underlying the statistically established association between preterm delivery and the mother's future risk of heart disease and stroke.

Low HDL cholesterol and elevated homocysteine levels surfaced as key factors associated with spontaneous preterm birth, Dr. Michael S. Kramer of McGill University reported in a plenary session at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

In addition, a significantly higher proportion of women with concentrations of homocysteine above the median showed signs of decidual vasculopathy (13.0% vs. 6.8%), Dr. Kramer said.

The study compared frozen plasma samples and fixed and stained placentas from 207 cases of spontaneous preterm birth with 444 term controls, approximately 2 per case.

Researchers analyzed homocysteine, folate, cholesterol (total, LDL, and HDL), and thrombin-antithrombin complexes and blindly assessed fixed and stained placentas for histologic evidence of infarction and decidual vasculopathy.

Both elevated homocysteine and low HDL cholesterol levels were significantly and independently associated with twice the risk of preterm birth, Dr. Kramer reported. “Similar vasculopathic risk factors may underlie preterm birth and adult coronary heart disease and stroke,” he said.

Women who delivered preterm had significantly higher plasma homocysteine (4.0 vs. 3.7 mmol/L; P = .001) and lower HDL cholesterol (1.6 vs. 1.8 mmol/L; P = .0001) levels, compared with women who delivered at term.

In addition, a higher proportion of women with high homocysteine concentrations (but not low HDL) had decidual vasculopathy (13.0% vs. 6.8%).

“The same factors that we know lead to stroke and heart disease were found to be elevated in the second trimester in mothers who subsequently gave birth preterm,” said Dr. Kramer in an interview.

The fact that their placentas showed evidence of vasculopathy on the mother's side was a major finding, because it provides a biological link with the vasculopathic plasma markers, he said.

However, “even if [these results] are robust, we still don't know whether homocysteine and HDL are pathologically involved in a biological sense with the preterm birth, or whether they're just markers of the mother's increased risk,” he said.

“In adults, when HDL and homocysteine damage blood vessels, they do it over decades,” he said. “With pregnancy, we're talking about months. How do [these factors] get translated biologically into an increased risk for preterm birth? It may be the homocysteine and HDL themselves that are acting on blood vessels in the placenta, or it may be something else that's causing the preterm birth.”

Dr. Kramer noted that the differences in HDL and homocysteine levels between the two groups were statistically significant but modest. For example, there was a less than 10% difference between the cases and controls in homocysteine (4.0 vs. 3.7 mmol/L). In addition, “the homocysteine concentrations were not high in terms of what is known or suspected to cause vascular damage, which is why we're underlining the fact that we don't know if it's the homocysteine,” he said. “These were not the sky-high levels associated with very high risks of coronary heart disease.”

The findings need to be replicated to determine whether they are robust, Dr. Kramer said. “However, I think it's unlikely that they were just a statistical fluke, because they were in the direction you'd expect,” he said.

Existing serum banks for large populations would offer a relatively easy and inexpensive method of linking pregnancy outcomes with HDL and homocysteine concentrations, he said.

CHICAGO — A prospective study of 5,300 women has provided the first biological evidence of the mechanisms underlying the statistically established association between preterm delivery and the mother's future risk of heart disease and stroke.

Low HDL cholesterol and elevated homocysteine levels surfaced as key factors associated with spontaneous preterm birth, Dr. Michael S. Kramer of McGill University reported in a plenary session at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

In addition, a significantly higher proportion of women with concentrations of homocysteine above the median showed signs of decidual vasculopathy (13.0% vs. 6.8%), Dr. Kramer said.

The study compared frozen plasma samples and fixed and stained placentas from 207 cases of spontaneous preterm birth with 444 term controls, approximately 2 per case.

Researchers analyzed homocysteine, folate, cholesterol (total, LDL, and HDL), and thrombin-antithrombin complexes and blindly assessed fixed and stained placentas for histologic evidence of infarction and decidual vasculopathy.

Both elevated homocysteine and low HDL cholesterol levels were significantly and independently associated with twice the risk of preterm birth, Dr. Kramer reported. “Similar vasculopathic risk factors may underlie preterm birth and adult coronary heart disease and stroke,” he said.

Women who delivered preterm had significantly higher plasma homocysteine (4.0 vs. 3.7 mmol/L; P = .001) and lower HDL cholesterol (1.6 vs. 1.8 mmol/L; P = .0001) levels, compared with women who delivered at term.

In addition, a higher proportion of women with high homocysteine concentrations (but not low HDL) had decidual vasculopathy (13.0% vs. 6.8%).

“The same factors that we know lead to stroke and heart disease were found to be elevated in the second trimester in mothers who subsequently gave birth preterm,” said Dr. Kramer in an interview.

The fact that their placentas showed evidence of vasculopathy on the mother's side was a major finding, because it provides a biological link with the vasculopathic plasma markers, he said.

However, “even if [these results] are robust, we still don't know whether homocysteine and HDL are pathologically involved in a biological sense with the preterm birth, or whether they're just markers of the mother's increased risk,” he said.

“In adults, when HDL and homocysteine damage blood vessels, they do it over decades,” he said. “With pregnancy, we're talking about months. How do [these factors] get translated biologically into an increased risk for preterm birth? It may be the homocysteine and HDL themselves that are acting on blood vessels in the placenta, or it may be something else that's causing the preterm birth.”

Dr. Kramer noted that the differences in HDL and homocysteine levels between the two groups were statistically significant but modest. For example, there was a less than 10% difference between the cases and controls in homocysteine (4.0 vs. 3.7 mmol/L). In addition, “the homocysteine concentrations were not high in terms of what is known or suspected to cause vascular damage, which is why we're underlining the fact that we don't know if it's the homocysteine,” he said. “These were not the sky-high levels associated with very high risks of coronary heart disease.”

The findings need to be replicated to determine whether they are robust, Dr. Kramer said. “However, I think it's unlikely that they were just a statistical fluke, because they were in the direction you'd expect,” he said.

Existing serum banks for large populations would offer a relatively easy and inexpensive method of linking pregnancy outcomes with HDL and homocysteine concentrations, he said.

CHICAGO — Careful screening for substance abuse in pregnant women and recognizing that intervention can make a difference for these patients and their offspring are two important ways to improve obstetric outcomes.

Physicians might also examine the attitudes and biases they bring to their treatment of expectant patients who are chemically dependent.

“We need to remember that addiction is a disease, not a moral failure, and that patients can change,” said Dr. Ellen Mason, an internist and attending physician in the department of obstetrics and gynecology at John H. Stroger Jr. Hospital, Chicago, in a presentation on substance abuse and psychiatric disorders among pregnant women.

“For doctors, [pregnancy and substance abuse] is not just a medical issue, it's a personal issue. In medicine, regardless of how much [physicians] think they're detached or nonjudgmental, they have a lot of trouble being nonjudgmental about [chemically dependent] women” and often view these patients as neglectful or deliberately hurting their fetuses, she said.

She stressed, however, that “treatment is ultimately more successful for women when they are not made to feel like monsters or made to feel more guilty than they already feel. Some patients, regardless of how much bravado they display … feel terrible about it.”

In her presentation, Dr. Mason cited the 2005 National Survey on Drug Use and Health (www.oas.samhsa.gov

She urged physicians to “translate ethical principals into [practices] that will serve our patients well and help them succeed.”

These practices include using the “Five A's,” the screening and behavioral counseling intervention for alcohol misuse recommended by the U.S. Preventive Services Task Force (Ann. Intern. Med. 2004;140:554–6), which asks physicians to take these steps:

▸ Assess alcohol consumption with a brief screening tool followed by clinical assessment as needed.

▸ Advise patients to reduce alcohol consumption to moderate levels.

▸ Agree on individual goals for reducing alcohol use or abstinence (if indicated).

▸ Assist patients with acquiring the motivation, self-help skills, and support needed for behavior change.

▸ Arrange follow-up support and repeated counseling, including referring dependent drinkers for specialty treatment.

CHICAGO — Careful screening for substance abuse in pregnant women and recognizing that intervention can make a difference for these patients and their offspring are two important ways to improve obstetric outcomes.

Physicians might also examine the attitudes and biases they bring to their treatment of expectant patients who are chemically dependent.

“We need to remember that addiction is a disease, not a moral failure, and that patients can change,” said Dr. Ellen Mason, an internist and attending physician in the department of obstetrics and gynecology at John H. Stroger Jr. Hospital, Chicago, in a presentation on substance abuse and psychiatric disorders among pregnant women.

“For doctors, [pregnancy and substance abuse] is not just a medical issue, it's a personal issue. In medicine, regardless of how much [physicians] think they're detached or nonjudgmental, they have a lot of trouble being nonjudgmental about [chemically dependent] women” and often view these patients as neglectful or deliberately hurting their fetuses, she said.

She stressed, however, that “treatment is ultimately more successful for women when they are not made to feel like monsters or made to feel more guilty than they already feel. Some patients, regardless of how much bravado they display … feel terrible about it.”

In her presentation, Dr. Mason cited the 2005 National Survey on Drug Use and Health (www.oas.samhsa.gov

She urged physicians to “translate ethical principals into [practices] that will serve our patients well and help them succeed.”

These practices include using the “Five A's,” the screening and behavioral counseling intervention for alcohol misuse recommended by the U.S. Preventive Services Task Force (Ann. Intern. Med. 2004;140:554–6), which asks physicians to take these steps:

▸ Assess alcohol consumption with a brief screening tool followed by clinical assessment as needed.

▸ Advise patients to reduce alcohol consumption to moderate levels.

▸ Agree on individual goals for reducing alcohol use or abstinence (if indicated).

▸ Assist patients with acquiring the motivation, self-help skills, and support needed for behavior change.

▸ Arrange follow-up support and repeated counseling, including referring dependent drinkers for specialty treatment.

CHICAGO — Careful screening for substance abuse in pregnant women and recognizing that intervention can make a difference for these patients and their offspring are two important ways to improve obstetric outcomes.

Physicians might also examine the attitudes and biases they bring to their treatment of expectant patients who are chemically dependent.

“We need to remember that addiction is a disease, not a moral failure, and that patients can change,” said Dr. Ellen Mason, an internist and attending physician in the department of obstetrics and gynecology at John H. Stroger Jr. Hospital, Chicago, in a presentation on substance abuse and psychiatric disorders among pregnant women.

“For doctors, [pregnancy and substance abuse] is not just a medical issue, it's a personal issue. In medicine, regardless of how much [physicians] think they're detached or nonjudgmental, they have a lot of trouble being nonjudgmental about [chemically dependent] women” and often view these patients as neglectful or deliberately hurting their fetuses, she said.

She stressed, however, that “treatment is ultimately more successful for women when they are not made to feel like monsters or made to feel more guilty than they already feel. Some patients, regardless of how much bravado they display … feel terrible about it.”

In her presentation, Dr. Mason cited the 2005 National Survey on Drug Use and Health (www.oas.samhsa.gov

She urged physicians to “translate ethical principals into [practices] that will serve our patients well and help them succeed.”

These practices include using the “Five A's,” the screening and behavioral counseling intervention for alcohol misuse recommended by the U.S. Preventive Services Task Force (Ann. Intern. Med. 2004;140:554–6), which asks physicians to take these steps:

▸ Assess alcohol consumption with a brief screening tool followed by clinical assessment as needed.

▸ Advise patients to reduce alcohol consumption to moderate levels.

▸ Agree on individual goals for reducing alcohol use or abstinence (if indicated).

▸ Assist patients with acquiring the motivation, self-help skills, and support needed for behavior change.

▸ Arrange follow-up support and repeated counseling, including referring dependent drinkers for specialty treatment.

CHICAGO — Proinflammatory cytokine levels escalate with normal labor but are not an underlying mechanism of epidural-related fever, according to the results of a study of 92 term parturients.

The researchers found no differences between febrile and afebrile patients in serum levels of the proinflammatory cytokine interleukin-6 during labor or post partum, Dr. Venkat Mantha reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Dr. Mantha of the University of Pittsburgh's Magee Women's Hospital and associates mapped changes in interleukin-6 levels at 4-hour intervals during labor and after delivery and measured neonatal interleukin-6 levels in umbilical cord blood samples in 92 healthy, nulliparous term parturients who went into spontaneous labor and who all received epidural analgesia.

Interleukin-6 levels rose significantly during labor in women who did not have fever as well as in those who did, he said.

The researchers drew peripheral blood and took tympanic temperatures at the time of labor epidural placement and every 4 hours until 4 hours following delivery.

Patients who, at any of the intervals, had a temperature equal to or greater than 38° C were considered febrile.

After delivery of the placenta, umbilical cord blood samples were taken, and neonatal rectal temperatures were taken within 30 minutes of birth.

The 66 afebrile patients and 26 febrile patients shared common characteristics with respect to height, weight, gestational age, and age.

In both groups, interleukin-6 was significantly higher at 8 hours and following delivery, compared with the baseline measurement, but no significant differences were found between the two groups in interleukin-6 levels at any of the measurement intervals.

In addition, while the neonates of febrile mothers had significantly higher temperatures than those of afebrile mothers (36.97° C and 36.68° C, respectively), their umbilical cord serum interleukin-6 levels were statistically the same as the afebrile group.

“We did not find any inflammatory basis for epidural-related fever,” said Dr. Mantha. “We agree with reports that suggest that maternal serum interleukin-6 levels rise in response to labor.”

The study reaffirms the generally accepted view regarding the nature of epidural-related fever, Dr. Mantha commented.

This thinking holds that epidural-related fever is the product of changes in thermoregulatory mechanisms, and that increases in proinflammatory cytokines such as interleukin-6 occur in normal pregnancy and labor.

“All of these years, it's been accepted that epidural-related fever has a physiological basis and that interleukin-6 plays a role in normal labor,” Dr. Mantha said in an interview, noting that interleukin-6's role in labor is not yet understood.

However, studies showing an increase in interleukin-6 during normal labor did not differentiate between patients who had received epidural analgesia and those who had not, he said.

“This [current study] was the first study where the primary aim was to try and find whether there is a relationship between epidural fever and increases in serum levels of interleukin-6,” Dr. Mantha said.

A catalyst for this investigation was the publication of two studies that challenged the thermoregulatory view of epidural-related fever by showing a strong relationship between epidural-related fever and increases in interleukin-6, suggesting the possibility that the fever has an inflammatory basis (Am. J. Obstet. Gynecol. 2002;187:834-8; Am. J. Obstet. Gynecol. 2003;188: 269-74).

Dr. Mantha noted that the study was limited by the fact that it did not include women who had not received labor epidural analgesia; however, performing a randomized study including these women is difficult because more than 90% of parturients at Magee request labor epidural analgesia.

CHICAGO — Proinflammatory cytokine levels escalate with normal labor but are not an underlying mechanism of epidural-related fever, according to the results of a study of 92 term parturients.

The researchers found no differences between febrile and afebrile patients in serum levels of the proinflammatory cytokine interleukin-6 during labor or post partum, Dr. Venkat Mantha reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Dr. Mantha of the University of Pittsburgh's Magee Women's Hospital and associates mapped changes in interleukin-6 levels at 4-hour intervals during labor and after delivery and measured neonatal interleukin-6 levels in umbilical cord blood samples in 92 healthy, nulliparous term parturients who went into spontaneous labor and who all received epidural analgesia.

Interleukin-6 levels rose significantly during labor in women who did not have fever as well as in those who did, he said.

The researchers drew peripheral blood and took tympanic temperatures at the time of labor epidural placement and every 4 hours until 4 hours following delivery.

Patients who, at any of the intervals, had a temperature equal to or greater than 38° C were considered febrile.

After delivery of the placenta, umbilical cord blood samples were taken, and neonatal rectal temperatures were taken within 30 minutes of birth.

The 66 afebrile patients and 26 febrile patients shared common characteristics with respect to height, weight, gestational age, and age.

In both groups, interleukin-6 was significantly higher at 8 hours and following delivery, compared with the baseline measurement, but no significant differences were found between the two groups in interleukin-6 levels at any of the measurement intervals.

In addition, while the neonates of febrile mothers had significantly higher temperatures than those of afebrile mothers (36.97° C and 36.68° C, respectively), their umbilical cord serum interleukin-6 levels were statistically the same as the afebrile group.

“We did not find any inflammatory basis for epidural-related fever,” said Dr. Mantha. “We agree with reports that suggest that maternal serum interleukin-6 levels rise in response to labor.”

The study reaffirms the generally accepted view regarding the nature of epidural-related fever, Dr. Mantha commented.

This thinking holds that epidural-related fever is the product of changes in thermoregulatory mechanisms, and that increases in proinflammatory cytokines such as interleukin-6 occur in normal pregnancy and labor.

“All of these years, it's been accepted that epidural-related fever has a physiological basis and that interleukin-6 plays a role in normal labor,” Dr. Mantha said in an interview, noting that interleukin-6's role in labor is not yet understood.

However, studies showing an increase in interleukin-6 during normal labor did not differentiate between patients who had received epidural analgesia and those who had not, he said.

“This [current study] was the first study where the primary aim was to try and find whether there is a relationship between epidural fever and increases in serum levels of interleukin-6,” Dr. Mantha said.

A catalyst for this investigation was the publication of two studies that challenged the thermoregulatory view of epidural-related fever by showing a strong relationship between epidural-related fever and increases in interleukin-6, suggesting the possibility that the fever has an inflammatory basis (Am. J. Obstet. Gynecol. 2002;187:834-8; Am. J. Obstet. Gynecol. 2003;188: 269-74).

Dr. Mantha noted that the study was limited by the fact that it did not include women who had not received labor epidural analgesia; however, performing a randomized study including these women is difficult because more than 90% of parturients at Magee request labor epidural analgesia.

CHICAGO — Proinflammatory cytokine levels escalate with normal labor but are not an underlying mechanism of epidural-related fever, according to the results of a study of 92 term parturients.

The researchers found no differences between febrile and afebrile patients in serum levels of the proinflammatory cytokine interleukin-6 during labor or post partum, Dr. Venkat Mantha reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Dr. Mantha of the University of Pittsburgh's Magee Women's Hospital and associates mapped changes in interleukin-6 levels at 4-hour intervals during labor and after delivery and measured neonatal interleukin-6 levels in umbilical cord blood samples in 92 healthy, nulliparous term parturients who went into spontaneous labor and who all received epidural analgesia.

Interleukin-6 levels rose significantly during labor in women who did not have fever as well as in those who did, he said.

The researchers drew peripheral blood and took tympanic temperatures at the time of labor epidural placement and every 4 hours until 4 hours following delivery.

Patients who, at any of the intervals, had a temperature equal to or greater than 38° C were considered febrile.

After delivery of the placenta, umbilical cord blood samples were taken, and neonatal rectal temperatures were taken within 30 minutes of birth.

The 66 afebrile patients and 26 febrile patients shared common characteristics with respect to height, weight, gestational age, and age.

In both groups, interleukin-6 was significantly higher at 8 hours and following delivery, compared with the baseline measurement, but no significant differences were found between the two groups in interleukin-6 levels at any of the measurement intervals.

In addition, while the neonates of febrile mothers had significantly higher temperatures than those of afebrile mothers (36.97° C and 36.68° C, respectively), their umbilical cord serum interleukin-6 levels were statistically the same as the afebrile group.

“We did not find any inflammatory basis for epidural-related fever,” said Dr. Mantha. “We agree with reports that suggest that maternal serum interleukin-6 levels rise in response to labor.”

The study reaffirms the generally accepted view regarding the nature of epidural-related fever, Dr. Mantha commented.

This thinking holds that epidural-related fever is the product of changes in thermoregulatory mechanisms, and that increases in proinflammatory cytokines such as interleukin-6 occur in normal pregnancy and labor.

“All of these years, it's been accepted that epidural-related fever has a physiological basis and that interleukin-6 plays a role in normal labor,” Dr. Mantha said in an interview, noting that interleukin-6's role in labor is not yet understood.

However, studies showing an increase in interleukin-6 during normal labor did not differentiate between patients who had received epidural analgesia and those who had not, he said.

“This [current study] was the first study where the primary aim was to try and find whether there is a relationship between epidural fever and increases in serum levels of interleukin-6,” Dr. Mantha said.

A catalyst for this investigation was the publication of two studies that challenged the thermoregulatory view of epidural-related fever by showing a strong relationship between epidural-related fever and increases in interleukin-6, suggesting the possibility that the fever has an inflammatory basis (Am. J. Obstet. Gynecol. 2002;187:834-8; Am. J. Obstet. Gynecol. 2003;188: 269-74).

Dr. Mantha noted that the study was limited by the fact that it did not include women who had not received labor epidural analgesia; however, performing a randomized study including these women is difficult because more than 90% of parturients at Magee request labor epidural analgesia.

CHICAGO — Laboring women can rely on sports drinks for hydration and sustenance without increasing their risk for cesarean section or instrumental vaginal delivery and without affecting the metabolic profiles of their newborns, according to a study of 198 women.

Sports drink consumption alleviated maternal ketosis without affecting neonatal Apgar score, glycemia, or umbilical cord gas, Dr. Marie-Eve Perron reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The findings contradict previous research (BJOG 2002;109:178-81), which indicated a threefold increase in C-sections among women who drank isotonic fluids during labor.

“The dissimilar results may be explained by the difference in the population studied and by the use of a lower carbohydrate concentration sports drink [in this study],” Dr. Perron said.

The isotonic drink in the earlier study contained a 12.6% carbohydrate concentration, more than twice that in the present study. Most of the patients in the previous research had high-risk pregnancies, and some had also received opioids during the course of labor.

Dr. Perron and her associates at Laval University, Quebec City, reported on 198 consecutive women who requested epidural analgesia at cervical dilation of 5 cm or less and in whom labor had begun spontaneously.

All patients had a single fetus in cephalic presentation. Women with known obstetric or medical conditions such as diabetes or previous C-section were not included.

There were no significant differences in the incidence of C-sections or instrumental vaginal deliveries among the intervention patients, who were encouraged to drink 200 mL/hr of a clear isotonic liquid containing a 6% carbohydrate concentration, and the control patients, who were limited to 30 mL/hr of water (standard practice at the hospital). The two groups were similar demographically.

Patients' maternal ketone bodies and glycemia were measured immediately after randomization into the intervention or control group and at the end of the first stage of labor using the Precision Xtra system. Apgar scores, neonatal glycemias, and umbilical cord gases were measured as well.

C-section rates for the intervention and control groups were 12.2% and 15%, respectively. Instrumental vaginal delivery rates for the intervention and control groups were 14.3% and 13%, respectively.

Maternal ketone bodies (beta-oxybutyrate) were 0.23 and 0.22 in the intervention and control groups at baseline, but nearly four times greater in the control group (0.19) than in the intervention group (0.5) at the end of the first stage of labor.

Apgar scores were 8.9 and 8.7 in the intervention and control groups at 1 minute, and 9.9 and 9.8 at 5 minutes. Neonatal arterial pH, venous pH, and glucose in the two groups were almost identical.

“The possible risk of pulmonary aspiration led many hospitals to restrict oral intake during labor,” said Dr. Perron. “However, the metabolic demand of labor is high. As clear fluids are rapidly evacuated from the stomach, they could represent a suitable source of energy.”

CHICAGO — Laboring women can rely on sports drinks for hydration and sustenance without increasing their risk for cesarean section or instrumental vaginal delivery and without affecting the metabolic profiles of their newborns, according to a study of 198 women.

Sports drink consumption alleviated maternal ketosis without affecting neonatal Apgar score, glycemia, or umbilical cord gas, Dr. Marie-Eve Perron reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The findings contradict previous research (BJOG 2002;109:178-81), which indicated a threefold increase in C-sections among women who drank isotonic fluids during labor.

“The dissimilar results may be explained by the difference in the population studied and by the use of a lower carbohydrate concentration sports drink [in this study],” Dr. Perron said.

The isotonic drink in the earlier study contained a 12.6% carbohydrate concentration, more than twice that in the present study. Most of the patients in the previous research had high-risk pregnancies, and some had also received opioids during the course of labor.

Dr. Perron and her associates at Laval University, Quebec City, reported on 198 consecutive women who requested epidural analgesia at cervical dilation of 5 cm or less and in whom labor had begun spontaneously.

All patients had a single fetus in cephalic presentation. Women with known obstetric or medical conditions such as diabetes or previous C-section were not included.

There were no significant differences in the incidence of C-sections or instrumental vaginal deliveries among the intervention patients, who were encouraged to drink 200 mL/hr of a clear isotonic liquid containing a 6% carbohydrate concentration, and the control patients, who were limited to 30 mL/hr of water (standard practice at the hospital). The two groups were similar demographically.

Patients' maternal ketone bodies and glycemia were measured immediately after randomization into the intervention or control group and at the end of the first stage of labor using the Precision Xtra system. Apgar scores, neonatal glycemias, and umbilical cord gases were measured as well.

C-section rates for the intervention and control groups were 12.2% and 15%, respectively. Instrumental vaginal delivery rates for the intervention and control groups were 14.3% and 13%, respectively.

Maternal ketone bodies (beta-oxybutyrate) were 0.23 and 0.22 in the intervention and control groups at baseline, but nearly four times greater in the control group (0.19) than in the intervention group (0.5) at the end of the first stage of labor.

Apgar scores were 8.9 and 8.7 in the intervention and control groups at 1 minute, and 9.9 and 9.8 at 5 minutes. Neonatal arterial pH, venous pH, and glucose in the two groups were almost identical.

“The possible risk of pulmonary aspiration led many hospitals to restrict oral intake during labor,” said Dr. Perron. “However, the metabolic demand of labor is high. As clear fluids are rapidly evacuated from the stomach, they could represent a suitable source of energy.”

CHICAGO — Laboring women can rely on sports drinks for hydration and sustenance without increasing their risk for cesarean section or instrumental vaginal delivery and without affecting the metabolic profiles of their newborns, according to a study of 198 women.

Sports drink consumption alleviated maternal ketosis without affecting neonatal Apgar score, glycemia, or umbilical cord gas, Dr. Marie-Eve Perron reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The findings contradict previous research (BJOG 2002;109:178-81), which indicated a threefold increase in C-sections among women who drank isotonic fluids during labor.

“The dissimilar results may be explained by the difference in the population studied and by the use of a lower carbohydrate concentration sports drink [in this study],” Dr. Perron said.

The isotonic drink in the earlier study contained a 12.6% carbohydrate concentration, more than twice that in the present study. Most of the patients in the previous research had high-risk pregnancies, and some had also received opioids during the course of labor.

Dr. Perron and her associates at Laval University, Quebec City, reported on 198 consecutive women who requested epidural analgesia at cervical dilation of 5 cm or less and in whom labor had begun spontaneously.

All patients had a single fetus in cephalic presentation. Women with known obstetric or medical conditions such as diabetes or previous C-section were not included.

There were no significant differences in the incidence of C-sections or instrumental vaginal deliveries among the intervention patients, who were encouraged to drink 200 mL/hr of a clear isotonic liquid containing a 6% carbohydrate concentration, and the control patients, who were limited to 30 mL/hr of water (standard practice at the hospital). The two groups were similar demographically.

Patients' maternal ketone bodies and glycemia were measured immediately after randomization into the intervention or control group and at the end of the first stage of labor using the Precision Xtra system. Apgar scores, neonatal glycemias, and umbilical cord gases were measured as well.

C-section rates for the intervention and control groups were 12.2% and 15%, respectively. Instrumental vaginal delivery rates for the intervention and control groups were 14.3% and 13%, respectively.

Maternal ketone bodies (beta-oxybutyrate) were 0.23 and 0.22 in the intervention and control groups at baseline, but nearly four times greater in the control group (0.19) than in the intervention group (0.5) at the end of the first stage of labor.

Apgar scores were 8.9 and 8.7 in the intervention and control groups at 1 minute, and 9.9 and 9.8 at 5 minutes. Neonatal arterial pH, venous pH, and glucose in the two groups were almost identical.

“The possible risk of pulmonary aspiration led many hospitals to restrict oral intake during labor,” said Dr. Perron. “However, the metabolic demand of labor is high. As clear fluids are rapidly evacuated from the stomach, they could represent a suitable source of energy.”

Transfusions of red blood cells stored for 15 days or more increase the risk of serious complications and both short- and long-term mortality following cardiac surgery, according to a retrospective study of more than 6,000 patients.

“The relative risk of postoperative death is increased by 30% in patients given blood that has been stored for more than 2 weeks,” wrote Dr. Colleen Gorman Koch and her colleagues at the Cleveland Clinic Foundation.

Earlier studies comparing older and newer blood have yielded conflicting results. These studies examined small or heterogeneous samples, did not control for confounding factors, and used end points that did not reflect specific organ function, such as length of hospital stay.

The present study analyzed data on 3,130 cardiac surgery patients transfused with 10,782 units of blood stored for more than 14 days and 2,872 patients transfused with 8,802 units of blood stored for 14 or fewer days during cardiac surgery at Cleveland Clinic between 1998 and 2006. It excluded patients whose transfusions consisted of both newer and older blood and those with trauma and chronic diseases. Patients underwent coronary artery bypass graft surgery, cardiac valve surgery, or both. The older and newer blood groups shared similarities on most baseline and operative variables. The primary end point was a composite of in-hospital adverse events defined by the Society of Thoracic Surgeons. Follow-up survival status was obtained from the Social Security Death Index (N. Engl. J. Med. 2008;358:1229–39).

The study found a significant association between blood storage time and the serious adverse events composite end point, which occurred in 22.4% of the patients who received newer blood and 25.9% of those who received older blood. The link remained after adjusting for coexisting conditions and other risk factors. Patients transfused with older blood, compared with those who received newer blood, had significantly higher rates of in-hospital mortality (2.8% vs. 1.7%), prolonged ventilation (9.7% vs. 5.6%), renal failure (2.7% vs. 1.6%), septicemia or sepsis (4.0% vs. 2.8%), and multisystem organ failure (0.7% vs. 0.2%).

Risk of death was significantly lower among patients who received newer units of blood; 1-year death rates were 7.4% and 11.0% for the newer and older blood groups, respectively.

The mortality increase with older blood was most pronounced within 6 months of surgery. “The adverse effects of transfusing older blood persisted even after adjustment for perioperative factors known to be associated with an adverse outcome in this population,” the researchers wrote (data were not presented). Further study is needed before any broad-based changes in blood banking practices are made, they said. The study's results, while important, are not enough to change blood supply practices, said Dr. John W. Adamson of the University of California, San Diego, in an accompanying editorial. Because the study population had a median age of 70 years, “by definition, the patients had a substantial number of coexisting illnesses.”

Transfusions of red blood cells stored for 15 days or more increase the risk of serious complications and both short- and long-term mortality following cardiac surgery, according to a retrospective study of more than 6,000 patients.

“The relative risk of postoperative death is increased by 30% in patients given blood that has been stored for more than 2 weeks,” wrote Dr. Colleen Gorman Koch and her colleagues at the Cleveland Clinic Foundation.

Earlier studies comparing older and newer blood have yielded conflicting results. These studies examined small or heterogeneous samples, did not control for confounding factors, and used end points that did not reflect specific organ function, such as length of hospital stay.

The present study analyzed data on 3,130 cardiac surgery patients transfused with 10,782 units of blood stored for more than 14 days and 2,872 patients transfused with 8,802 units of blood stored for 14 or fewer days during cardiac surgery at Cleveland Clinic between 1998 and 2006. It excluded patients whose transfusions consisted of both newer and older blood and those with trauma and chronic diseases. Patients underwent coronary artery bypass graft surgery, cardiac valve surgery, or both. The older and newer blood groups shared similarities on most baseline and operative variables. The primary end point was a composite of in-hospital adverse events defined by the Society of Thoracic Surgeons. Follow-up survival status was obtained from the Social Security Death Index (N. Engl. J. Med. 2008;358:1229–39).

The study found a significant association between blood storage time and the serious adverse events composite end point, which occurred in 22.4% of the patients who received newer blood and 25.9% of those who received older blood. The link remained after adjusting for coexisting conditions and other risk factors. Patients transfused with older blood, compared with those who received newer blood, had significantly higher rates of in-hospital mortality (2.8% vs. 1.7%), prolonged ventilation (9.7% vs. 5.6%), renal failure (2.7% vs. 1.6%), septicemia or sepsis (4.0% vs. 2.8%), and multisystem organ failure (0.7% vs. 0.2%).

Risk of death was significantly lower among patients who received newer units of blood; 1-year death rates were 7.4% and 11.0% for the newer and older blood groups, respectively.

The mortality increase with older blood was most pronounced within 6 months of surgery. “The adverse effects of transfusing older blood persisted even after adjustment for perioperative factors known to be associated with an adverse outcome in this population,” the researchers wrote (data were not presented). Further study is needed before any broad-based changes in blood banking practices are made, they said. The study's results, while important, are not enough to change blood supply practices, said Dr. John W. Adamson of the University of California, San Diego, in an accompanying editorial. Because the study population had a median age of 70 years, “by definition, the patients had a substantial number of coexisting illnesses.”

Transfusions of red blood cells stored for 15 days or more increase the risk of serious complications and both short- and long-term mortality following cardiac surgery, according to a retrospective study of more than 6,000 patients.

“The relative risk of postoperative death is increased by 30% in patients given blood that has been stored for more than 2 weeks,” wrote Dr. Colleen Gorman Koch and her colleagues at the Cleveland Clinic Foundation.

Earlier studies comparing older and newer blood have yielded conflicting results. These studies examined small or heterogeneous samples, did not control for confounding factors, and used end points that did not reflect specific organ function, such as length of hospital stay.

The present study analyzed data on 3,130 cardiac surgery patients transfused with 10,782 units of blood stored for more than 14 days and 2,872 patients transfused with 8,802 units of blood stored for 14 or fewer days during cardiac surgery at Cleveland Clinic between 1998 and 2006. It excluded patients whose transfusions consisted of both newer and older blood and those with trauma and chronic diseases. Patients underwent coronary artery bypass graft surgery, cardiac valve surgery, or both. The older and newer blood groups shared similarities on most baseline and operative variables. The primary end point was a composite of in-hospital adverse events defined by the Society of Thoracic Surgeons. Follow-up survival status was obtained from the Social Security Death Index (N. Engl. J. Med. 2008;358:1229–39).

The study found a significant association between blood storage time and the serious adverse events composite end point, which occurred in 22.4% of the patients who received newer blood and 25.9% of those who received older blood. The link remained after adjusting for coexisting conditions and other risk factors. Patients transfused with older blood, compared with those who received newer blood, had significantly higher rates of in-hospital mortality (2.8% vs. 1.7%), prolonged ventilation (9.7% vs. 5.6%), renal failure (2.7% vs. 1.6%), septicemia or sepsis (4.0% vs. 2.8%), and multisystem organ failure (0.7% vs. 0.2%).

Risk of death was significantly lower among patients who received newer units of blood; 1-year death rates were 7.4% and 11.0% for the newer and older blood groups, respectively.

The mortality increase with older blood was most pronounced within 6 months of surgery. “The adverse effects of transfusing older blood persisted even after adjustment for perioperative factors known to be associated with an adverse outcome in this population,” the researchers wrote (data were not presented). Further study is needed before any broad-based changes in blood banking practices are made, they said. The study's results, while important, are not enough to change blood supply practices, said Dr. John W. Adamson of the University of California, San Diego, in an accompanying editorial. Because the study population had a median age of 70 years, “by definition, the patients had a substantial number of coexisting illnesses.”