Sherry Boschert

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?

When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D.—who is a psychiatrist and also a lawyer—physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.

A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently.

Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.

To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:

▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.

She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.

▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.

If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.

Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.

▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.

Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.

▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a common-sense way without exaggerating the probable success of the case and without painting an overly bleak outcome.

▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services.

If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.

Ask whether legal interns will bill at the same rate as senior lawyers in the firm, and be sure that you'll get access to all legal work generated on your behalf, she added.

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?

When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D.—who is a psychiatrist and also a lawyer—physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.

A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently.

Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.

To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:

▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.

She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.

▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.

If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.

Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.

▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.

Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.

▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a common-sense way without exaggerating the probable success of the case and without painting an overly bleak outcome.

▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services.

If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.

Ask whether legal interns will bill at the same rate as senior lawyers in the firm, and be sure that you'll get access to all legal work generated on your behalf, she added.

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?

When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D.—who is a psychiatrist and also a lawyer—physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.

A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently.

Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.

To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:

▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.

She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.

▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.

If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.

Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.

▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.

Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.

▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a common-sense way without exaggerating the probable success of the case and without painting an overly bleak outcome.

▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services.

If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.

Ask whether legal interns will bill at the same rate as senior lawyers in the firm, and be sure that you'll get access to all legal work generated on your behalf, she added.

RANCHO MIRAGE, CALIF. — Genital trauma during delivery was common but did not lead to postpartum urinary incontinence in a prospective study of 455 midwifery patients with low-risk pregnancies.

The findings of the study counter a common reason that is often cited for performing episiotomies: to prevent anterior genital trauma in hopes of avoiding future incontinence.

As episiotomy rates decreased from 55% of deliveries in 1991 to 29% in 2001, the rate of anterior lacerations increased, leading investigators in the current study to analyze whether the increase in lacerations was associated with urinary incontinence.

Only 20% of the 455 women had no lacerations after delivery. An additional 35% had anterior lacerations to the clitoral, labial, or periurethral tissues; 18% developed posterior (perineal) lacerations, and 25% had both anterior and posterior trauma, Rebecca Rogers, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 2% of women were excluded from analysis because their vaginal lacerations did not extend to external genitalia. Only two of these nine patients required sutures.

Most of the trauma included in the analyses was minor. Only 1% of patients developed a posterior third- or fourth-degree laceration, according to Dr. Rogers of the University of New Mexico, Albuquerque.

Urinary incontinence was reported by 27% of women 6 weeks after delivery and by 29% 3 months after delivery. These women answered “yes” to the question, “Since the birth of your baby, have you leaked urine when you did not mean to?”

Fewer women, however, felt that the incontinence significantly affected their social functioning. Postpartum, 16% of women at 6 weeks and 13% at 3 months scored greater than 0 on the Incontinence Impact Questionnaire-7 (IIQ-7), which defined significant impact.

The urinary incontinence was not associated with the presence of genital trauma or any of a number of other factors analyzed. On the contrary, women with anterior lacerations were less likely to have urinary incontinence at 3 months post partum, compared with all other women combined.

“This is a little surprising to us because, if anything, we thought we would find that anterior trauma was linked to complaints of incontinence,” Dr. Rogers said. “Isolated anterior trauma may serve as a marker for preservation of the continence mechanism in some way that I can't really explain at this point.”

In formal commentary after Dr. Rogers' presentation, Charles Nager, M.D., said, “The important part of this study is that it dispels a commonly held belief by many obstetricians that episiotomy, which does reduce the risk of anterior genital tract trauma, can be justified because it helps prevent incontinence.”

The results are consistent with a Cochrane Review of other studies on episiotomy at vaginal birth, which found that a “restricted episiotomy” protocol increased the relative risk of anterior trauma by 79%, compared with routine episiotomy—but this difference reportedly did not increase the risk for urinary incontinence or dyspareunia, said Dr. Nager of the University of California, San Diego.

“The authors [of the current study] should be commended for a well-done, prospective, clinically relevant and clinically important study,” he said.

Participants in the study agreed to mapping of genital trauma at birth and two postpartum assessments of perineal anatomy, urinary continence, and incontinence-related social functioning.

The study excluded women who underwent episiotomy or operative delivery, he said.

The participants were an average 25 years of age, and 40% were nulliparous. For delivery, 41% had epidural anesthesia and 23% received oxytocin.

The investigators will analyze data on sexual function and anal incontinence, Dr. Rogers said. In a preliminary review, genital trauma did not seem to be linked to either of these.

“Anterior genital tract trauma is not something that we need to be extremely concerned about preventing,” Dr. Rogers explained.

RANCHO MIRAGE, CALIF. — Genital trauma during delivery was common but did not lead to postpartum urinary incontinence in a prospective study of 455 midwifery patients with low-risk pregnancies.

The findings of the study counter a common reason that is often cited for performing episiotomies: to prevent anterior genital trauma in hopes of avoiding future incontinence.

As episiotomy rates decreased from 55% of deliveries in 1991 to 29% in 2001, the rate of anterior lacerations increased, leading investigators in the current study to analyze whether the increase in lacerations was associated with urinary incontinence.

Only 20% of the 455 women had no lacerations after delivery. An additional 35% had anterior lacerations to the clitoral, labial, or periurethral tissues; 18% developed posterior (perineal) lacerations, and 25% had both anterior and posterior trauma, Rebecca Rogers, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 2% of women were excluded from analysis because their vaginal lacerations did not extend to external genitalia. Only two of these nine patients required sutures.

Most of the trauma included in the analyses was minor. Only 1% of patients developed a posterior third- or fourth-degree laceration, according to Dr. Rogers of the University of New Mexico, Albuquerque.

Urinary incontinence was reported by 27% of women 6 weeks after delivery and by 29% 3 months after delivery. These women answered “yes” to the question, “Since the birth of your baby, have you leaked urine when you did not mean to?”

Fewer women, however, felt that the incontinence significantly affected their social functioning. Postpartum, 16% of women at 6 weeks and 13% at 3 months scored greater than 0 on the Incontinence Impact Questionnaire-7 (IIQ-7), which defined significant impact.

The urinary incontinence was not associated with the presence of genital trauma or any of a number of other factors analyzed. On the contrary, women with anterior lacerations were less likely to have urinary incontinence at 3 months post partum, compared with all other women combined.

“This is a little surprising to us because, if anything, we thought we would find that anterior trauma was linked to complaints of incontinence,” Dr. Rogers said. “Isolated anterior trauma may serve as a marker for preservation of the continence mechanism in some way that I can't really explain at this point.”

In formal commentary after Dr. Rogers' presentation, Charles Nager, M.D., said, “The important part of this study is that it dispels a commonly held belief by many obstetricians that episiotomy, which does reduce the risk of anterior genital tract trauma, can be justified because it helps prevent incontinence.”

The results are consistent with a Cochrane Review of other studies on episiotomy at vaginal birth, which found that a “restricted episiotomy” protocol increased the relative risk of anterior trauma by 79%, compared with routine episiotomy—but this difference reportedly did not increase the risk for urinary incontinence or dyspareunia, said Dr. Nager of the University of California, San Diego.

“The authors [of the current study] should be commended for a well-done, prospective, clinically relevant and clinically important study,” he said.

Participants in the study agreed to mapping of genital trauma at birth and two postpartum assessments of perineal anatomy, urinary continence, and incontinence-related social functioning.

The study excluded women who underwent episiotomy or operative delivery, he said.

The participants were an average 25 years of age, and 40% were nulliparous. For delivery, 41% had epidural anesthesia and 23% received oxytocin.

The investigators will analyze data on sexual function and anal incontinence, Dr. Rogers said. In a preliminary review, genital trauma did not seem to be linked to either of these.

“Anterior genital tract trauma is not something that we need to be extremely concerned about preventing,” Dr. Rogers explained.

RANCHO MIRAGE, CALIF. — Genital trauma during delivery was common but did not lead to postpartum urinary incontinence in a prospective study of 455 midwifery patients with low-risk pregnancies.

The findings of the study counter a common reason that is often cited for performing episiotomies: to prevent anterior genital trauma in hopes of avoiding future incontinence.

As episiotomy rates decreased from 55% of deliveries in 1991 to 29% in 2001, the rate of anterior lacerations increased, leading investigators in the current study to analyze whether the increase in lacerations was associated with urinary incontinence.

Only 20% of the 455 women had no lacerations after delivery. An additional 35% had anterior lacerations to the clitoral, labial, or periurethral tissues; 18% developed posterior (perineal) lacerations, and 25% had both anterior and posterior trauma, Rebecca Rogers, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 2% of women were excluded from analysis because their vaginal lacerations did not extend to external genitalia. Only two of these nine patients required sutures.

Most of the trauma included in the analyses was minor. Only 1% of patients developed a posterior third- or fourth-degree laceration, according to Dr. Rogers of the University of New Mexico, Albuquerque.

Urinary incontinence was reported by 27% of women 6 weeks after delivery and by 29% 3 months after delivery. These women answered “yes” to the question, “Since the birth of your baby, have you leaked urine when you did not mean to?”

Fewer women, however, felt that the incontinence significantly affected their social functioning. Postpartum, 16% of women at 6 weeks and 13% at 3 months scored greater than 0 on the Incontinence Impact Questionnaire-7 (IIQ-7), which defined significant impact.

The urinary incontinence was not associated with the presence of genital trauma or any of a number of other factors analyzed. On the contrary, women with anterior lacerations were less likely to have urinary incontinence at 3 months post partum, compared with all other women combined.

“This is a little surprising to us because, if anything, we thought we would find that anterior trauma was linked to complaints of incontinence,” Dr. Rogers said. “Isolated anterior trauma may serve as a marker for preservation of the continence mechanism in some way that I can't really explain at this point.”

In formal commentary after Dr. Rogers' presentation, Charles Nager, M.D., said, “The important part of this study is that it dispels a commonly held belief by many obstetricians that episiotomy, which does reduce the risk of anterior genital tract trauma, can be justified because it helps prevent incontinence.”

The results are consistent with a Cochrane Review of other studies on episiotomy at vaginal birth, which found that a “restricted episiotomy” protocol increased the relative risk of anterior trauma by 79%, compared with routine episiotomy—but this difference reportedly did not increase the risk for urinary incontinence or dyspareunia, said Dr. Nager of the University of California, San Diego.

“The authors [of the current study] should be commended for a well-done, prospective, clinically relevant and clinically important study,” he said.

Participants in the study agreed to mapping of genital trauma at birth and two postpartum assessments of perineal anatomy, urinary continence, and incontinence-related social functioning.

The study excluded women who underwent episiotomy or operative delivery, he said.

The participants were an average 25 years of age, and 40% were nulliparous. For delivery, 41% had epidural anesthesia and 23% received oxytocin.

The investigators will analyze data on sexual function and anal incontinence, Dr. Rogers said. In a preliminary review, genital trauma did not seem to be linked to either of these.

“Anterior genital tract trauma is not something that we need to be extremely concerned about preventing,” Dr. Rogers explained.

RANCHO MIRAGE, CALIF. — Posterior colporrhaphy with AlloDerm graft augmentation significantly improved bowel dysfunction while causing no major complications in a prospective study of 188 women treated for symptomatic rectocele.

Symptoms of constipation, incomplete evacuation, and fecal incontinence improved significantly over a mean 18-month follow-up period. Dyspareunia rates also improved, compared with baseline, but the difference was not statistically significant, Ahsen Chaudhry, M.D., and Robert W. Lobel, M.D., both of Albany, N.Y., reported in a poster at the annual meeting of the Society of Gynecologic Surgeons.

Among the study patients, 5% developed prolapse recurrence, and 4% reported rectal pain occurring more than once per month after the surgery. Rectal pain was not assessed preoperatively so any change in pain status remains unknown.

One patient rejected a 1-by-2-cm portion of the 4-by-7-cm dermal graft and was treated with partial graft excision and topical estrogen. Another patient developed a 2-cm abscess in the posterior vaginal wall and was treated with abscess drainage and antibiotics.

“Posterior colporrhaphy with AlloDerm graft augmentation shows good safety and efficacy. Recurrence of prolapse is minimal,” said Dr. Chaudhry in an oral presentation of the findings. “A randomized controlled trial would improve our knowledge of this operation.”

Gynecologists use various techniques to repair symptomatic rectoceles. Conventional colporrhaphy involving midline plication of rectovaginal fascia carries significant risks for midvaginal stenosis and dyspareunia, he said. Aggressive levatorplasty may lead to levator spasms and dyschezia.

Success rates for conventional posterior colporrhaphy of up to 75% at 1–2 years after surgery decline significantly beyond 3 years. More site-specific repair seems to cause fewer complications, with success rates of 72%–85% at 1 year after surgery, separate data suggest.

Both posterior colporrhaphy and site-specific repair can be hampered by the use of already weakened autologous endopelvic connective tissue, Dr. Chaudhry said. In particular, high rectoceles can be problematic because little or no autologous material is available for fixation.

These factors led the investigators to study the safety and efficacy of posterior colporrhaphy with AlloDerm graft augmentation. The investigators said they have no relationship with the manufacturer of AlloDerm.

The surgeries were performed over a 2-year period on patients with a mean age of 58 years and a mean body mass index of 30. Most patients (72%) were postmenopausal. The rectocele extended to or beyond the hymenal ring in 85% of patients.

The proportion of patients who said they were sexually active did not change significantly from before to after surgery (68% vs. 69%).

Previous surgeries included hysterectomy in 58% of patients, anterior colporrhaphy in 27%, posterior repair in 13%, sacrocolpopexy in 4%, and sacrospinous vaginal vault suspension in 2%.

Concomitant procedures performed at the time of posterior colporrhaphy with dermal graft augmentation included anterior colporrhaphy in 24% of patients, anterior colporrhaphy with AlloDerm graft in 6%, sacrospinous vaginal vault suspension in 59%, abdominal sacrocolpopexy in 22%, subtotal abdominal hysterectomy in 6%, total abdominal hysterectomy in 2%, anal sphincteroplasty in 2%, vaginal hysterectomy in 10%, and surgery for stress urinary incontinence in 59%.

There were no major complications perioperatively.

RANCHO MIRAGE, CALIF. — Posterior colporrhaphy with AlloDerm graft augmentation significantly improved bowel dysfunction while causing no major complications in a prospective study of 188 women treated for symptomatic rectocele.

Symptoms of constipation, incomplete evacuation, and fecal incontinence improved significantly over a mean 18-month follow-up period. Dyspareunia rates also improved, compared with baseline, but the difference was not statistically significant, Ahsen Chaudhry, M.D., and Robert W. Lobel, M.D., both of Albany, N.Y., reported in a poster at the annual meeting of the Society of Gynecologic Surgeons.

Among the study patients, 5% developed prolapse recurrence, and 4% reported rectal pain occurring more than once per month after the surgery. Rectal pain was not assessed preoperatively so any change in pain status remains unknown.

One patient rejected a 1-by-2-cm portion of the 4-by-7-cm dermal graft and was treated with partial graft excision and topical estrogen. Another patient developed a 2-cm abscess in the posterior vaginal wall and was treated with abscess drainage and antibiotics.

“Posterior colporrhaphy with AlloDerm graft augmentation shows good safety and efficacy. Recurrence of prolapse is minimal,” said Dr. Chaudhry in an oral presentation of the findings. “A randomized controlled trial would improve our knowledge of this operation.”

Gynecologists use various techniques to repair symptomatic rectoceles. Conventional colporrhaphy involving midline plication of rectovaginal fascia carries significant risks for midvaginal stenosis and dyspareunia, he said. Aggressive levatorplasty may lead to levator spasms and dyschezia.

Success rates for conventional posterior colporrhaphy of up to 75% at 1–2 years after surgery decline significantly beyond 3 years. More site-specific repair seems to cause fewer complications, with success rates of 72%–85% at 1 year after surgery, separate data suggest.

Both posterior colporrhaphy and site-specific repair can be hampered by the use of already weakened autologous endopelvic connective tissue, Dr. Chaudhry said. In particular, high rectoceles can be problematic because little or no autologous material is available for fixation.

These factors led the investigators to study the safety and efficacy of posterior colporrhaphy with AlloDerm graft augmentation. The investigators said they have no relationship with the manufacturer of AlloDerm.

The surgeries were performed over a 2-year period on patients with a mean age of 58 years and a mean body mass index of 30. Most patients (72%) were postmenopausal. The rectocele extended to or beyond the hymenal ring in 85% of patients.

The proportion of patients who said they were sexually active did not change significantly from before to after surgery (68% vs. 69%).

Previous surgeries included hysterectomy in 58% of patients, anterior colporrhaphy in 27%, posterior repair in 13%, sacrocolpopexy in 4%, and sacrospinous vaginal vault suspension in 2%.

Concomitant procedures performed at the time of posterior colporrhaphy with dermal graft augmentation included anterior colporrhaphy in 24% of patients, anterior colporrhaphy with AlloDerm graft in 6%, sacrospinous vaginal vault suspension in 59%, abdominal sacrocolpopexy in 22%, subtotal abdominal hysterectomy in 6%, total abdominal hysterectomy in 2%, anal sphincteroplasty in 2%, vaginal hysterectomy in 10%, and surgery for stress urinary incontinence in 59%.

There were no major complications perioperatively.

RANCHO MIRAGE, CALIF. — Posterior colporrhaphy with AlloDerm graft augmentation significantly improved bowel dysfunction while causing no major complications in a prospective study of 188 women treated for symptomatic rectocele.

Symptoms of constipation, incomplete evacuation, and fecal incontinence improved significantly over a mean 18-month follow-up period. Dyspareunia rates also improved, compared with baseline, but the difference was not statistically significant, Ahsen Chaudhry, M.D., and Robert W. Lobel, M.D., both of Albany, N.Y., reported in a poster at the annual meeting of the Society of Gynecologic Surgeons.

Among the study patients, 5% developed prolapse recurrence, and 4% reported rectal pain occurring more than once per month after the surgery. Rectal pain was not assessed preoperatively so any change in pain status remains unknown.

One patient rejected a 1-by-2-cm portion of the 4-by-7-cm dermal graft and was treated with partial graft excision and topical estrogen. Another patient developed a 2-cm abscess in the posterior vaginal wall and was treated with abscess drainage and antibiotics.

“Posterior colporrhaphy with AlloDerm graft augmentation shows good safety and efficacy. Recurrence of prolapse is minimal,” said Dr. Chaudhry in an oral presentation of the findings. “A randomized controlled trial would improve our knowledge of this operation.”

Gynecologists use various techniques to repair symptomatic rectoceles. Conventional colporrhaphy involving midline plication of rectovaginal fascia carries significant risks for midvaginal stenosis and dyspareunia, he said. Aggressive levatorplasty may lead to levator spasms and dyschezia.

Success rates for conventional posterior colporrhaphy of up to 75% at 1–2 years after surgery decline significantly beyond 3 years. More site-specific repair seems to cause fewer complications, with success rates of 72%–85% at 1 year after surgery, separate data suggest.

Both posterior colporrhaphy and site-specific repair can be hampered by the use of already weakened autologous endopelvic connective tissue, Dr. Chaudhry said. In particular, high rectoceles can be problematic because little or no autologous material is available for fixation.

These factors led the investigators to study the safety and efficacy of posterior colporrhaphy with AlloDerm graft augmentation. The investigators said they have no relationship with the manufacturer of AlloDerm.

The surgeries were performed over a 2-year period on patients with a mean age of 58 years and a mean body mass index of 30. Most patients (72%) were postmenopausal. The rectocele extended to or beyond the hymenal ring in 85% of patients.

The proportion of patients who said they were sexually active did not change significantly from before to after surgery (68% vs. 69%).

Previous surgeries included hysterectomy in 58% of patients, anterior colporrhaphy in 27%, posterior repair in 13%, sacrocolpopexy in 4%, and sacrospinous vaginal vault suspension in 2%.

Concomitant procedures performed at the time of posterior colporrhaphy with dermal graft augmentation included anterior colporrhaphy in 24% of patients, anterior colporrhaphy with AlloDerm graft in 6%, sacrospinous vaginal vault suspension in 59%, abdominal sacrocolpopexy in 22%, subtotal abdominal hysterectomy in 6%, total abdominal hysterectomy in 2%, anal sphincteroplasty in 2%, vaginal hysterectomy in 10%, and surgery for stress urinary incontinence in 59%.

There were no major complications perioperatively.

RANCHO MIRAGE, CALIF. — The risk of cystotomy while placing a tension-free transvaginal tape suburethral sling tripled when surgeons performed concomitant pelvic floor reconstructive surgery, according to a review of 106 sling procedures.

“I'm not sure why that was the case. It certainly has not been reported very prominently in other series” and may be related to the relative inexperience of the 14 community physicians who performed the procedures, compared with surgeons in earlier reports, Michael J. Bonidie, M.D., said during the annual meeting of the Society of Gynecologic Surgeons.

Cystotomy rates also tripled in patients whose surgeons had done fewer than 10 tension-free transvaginal tape (TVT) sling procedures, compared with physicians who had done more than 10.

Only 3 physicians performed more than 10 TVT sling procedures, and 11 physicians did fewer than 10 of the sling surgeries during the study's 3-year period, reported Dr. Bonidie and Neeka L. Sanders, M.D., both of the Western Pennsylvania Hospital, Pittsburgh.

Cystotomies occurred in 6 of 60 patients (10%) who underwent sling surgery alone and 13 of 46 patients (28%) who underwent sling and pelvic floor reconstruction surgery, said Dr. Bonidie, director of urogynecology at the hospital.

Cystotomy rates were markedly higher among the less-experienced physicians, whether placing a TVT sling alone or doing a sling plus pelvic floor reconstruction procedure.

The cystotomy rates in the current study are higher than those reported in earlier series of suburethral sling surgeries, most of which were done by a select group of specialists who were single operators in their case series, Dr. Bonidie noted during the meeting.

One series of 350 TVT sling surgeries, for example, reported a 5% cystotomy rate, significant bleeding in 1%, and postoperative voiding dysfunction in 5% of patients.

“We deemed that to be acceptable risks for this procedure,” he said.

Today, several different types of slings made by different companies are marketed to general gynecologists who may have little or no experience with suburethral sling placement.

This proliferation inspired the investigators to review results in a community hospital setting, where physicians tend to place slings less frequently than their counterparts in more specialized settings.

All slings in the current series were placed vaginally using similar techniques and one of two sling products.

Dr. Bonidie is a consultant for Bard Urological and Ethicon Endosurgery, the two companies that make the slings used in this series.

RANCHO MIRAGE, CALIF. — The risk of cystotomy while placing a tension-free transvaginal tape suburethral sling tripled when surgeons performed concomitant pelvic floor reconstructive surgery, according to a review of 106 sling procedures.

“I'm not sure why that was the case. It certainly has not been reported very prominently in other series” and may be related to the relative inexperience of the 14 community physicians who performed the procedures, compared with surgeons in earlier reports, Michael J. Bonidie, M.D., said during the annual meeting of the Society of Gynecologic Surgeons.

Cystotomy rates also tripled in patients whose surgeons had done fewer than 10 tension-free transvaginal tape (TVT) sling procedures, compared with physicians who had done more than 10.

Only 3 physicians performed more than 10 TVT sling procedures, and 11 physicians did fewer than 10 of the sling surgeries during the study's 3-year period, reported Dr. Bonidie and Neeka L. Sanders, M.D., both of the Western Pennsylvania Hospital, Pittsburgh.

Cystotomies occurred in 6 of 60 patients (10%) who underwent sling surgery alone and 13 of 46 patients (28%) who underwent sling and pelvic floor reconstruction surgery, said Dr. Bonidie, director of urogynecology at the hospital.

Cystotomy rates were markedly higher among the less-experienced physicians, whether placing a TVT sling alone or doing a sling plus pelvic floor reconstruction procedure.

The cystotomy rates in the current study are higher than those reported in earlier series of suburethral sling surgeries, most of which were done by a select group of specialists who were single operators in their case series, Dr. Bonidie noted during the meeting.

One series of 350 TVT sling surgeries, for example, reported a 5% cystotomy rate, significant bleeding in 1%, and postoperative voiding dysfunction in 5% of patients.

“We deemed that to be acceptable risks for this procedure,” he said.

Today, several different types of slings made by different companies are marketed to general gynecologists who may have little or no experience with suburethral sling placement.

This proliferation inspired the investigators to review results in a community hospital setting, where physicians tend to place slings less frequently than their counterparts in more specialized settings.

All slings in the current series were placed vaginally using similar techniques and one of two sling products.

Dr. Bonidie is a consultant for Bard Urological and Ethicon Endosurgery, the two companies that make the slings used in this series.

RANCHO MIRAGE, CALIF. — The risk of cystotomy while placing a tension-free transvaginal tape suburethral sling tripled when surgeons performed concomitant pelvic floor reconstructive surgery, according to a review of 106 sling procedures.

“I'm not sure why that was the case. It certainly has not been reported very prominently in other series” and may be related to the relative inexperience of the 14 community physicians who performed the procedures, compared with surgeons in earlier reports, Michael J. Bonidie, M.D., said during the annual meeting of the Society of Gynecologic Surgeons.

Cystotomy rates also tripled in patients whose surgeons had done fewer than 10 tension-free transvaginal tape (TVT) sling procedures, compared with physicians who had done more than 10.

Only 3 physicians performed more than 10 TVT sling procedures, and 11 physicians did fewer than 10 of the sling surgeries during the study's 3-year period, reported Dr. Bonidie and Neeka L. Sanders, M.D., both of the Western Pennsylvania Hospital, Pittsburgh.

Cystotomies occurred in 6 of 60 patients (10%) who underwent sling surgery alone and 13 of 46 patients (28%) who underwent sling and pelvic floor reconstruction surgery, said Dr. Bonidie, director of urogynecology at the hospital.

Cystotomy rates were markedly higher among the less-experienced physicians, whether placing a TVT sling alone or doing a sling plus pelvic floor reconstruction procedure.

The cystotomy rates in the current study are higher than those reported in earlier series of suburethral sling surgeries, most of which were done by a select group of specialists who were single operators in their case series, Dr. Bonidie noted during the meeting.

One series of 350 TVT sling surgeries, for example, reported a 5% cystotomy rate, significant bleeding in 1%, and postoperative voiding dysfunction in 5% of patients.

“We deemed that to be acceptable risks for this procedure,” he said.

Today, several different types of slings made by different companies are marketed to general gynecologists who may have little or no experience with suburethral sling placement.

This proliferation inspired the investigators to review results in a community hospital setting, where physicians tend to place slings less frequently than their counterparts in more specialized settings.

All slings in the current series were placed vaginally using similar techniques and one of two sling products.

Dr. Bonidie is a consultant for Bard Urological and Ethicon Endosurgery, the two companies that make the slings used in this series.

RANCHO MIRAGE, CALIF. — Graft augmentation did not offer additional protection against recurrence in patients undergoing vaginal surgery for symptomatic pelvic organ prolapse and was linked to an increase in postoperative complications in a review of 312 cases.

Two specialists in the treatment of pelvic floor disorders performed the surgeries over a 5-year period and used their discretion in select cases to add graft augmentation to support the anterior vaginal wall, posterior vaginal wall, or both.

Over a median 9-month follow-up, there were no differences in recurrence of prolapse or incontinence, or in the need for additional surgery between the 32% of patients who received grafts and those women who did not, Babak Vakili, M.D., said during the annual meeting of the Society of Gynecologic Surgeons.

Patients receiving graft augmentation had higher rates of postoperative complications, including vaginal or graft infection (18% vs. 5%) and granulation tissue (39% vs. 17%).

As a result, patients with grafts needed more postoperative visits—an average of four visits versus three visits, said Dr. Vakili of Cooper University Hospital, Voorhees, N.J.

The mean length of follow-up was 12 months in the graft group and 15 months in the other patients.

Recurrence rates were similar in both groups. (See accompanying graphic.) Eight percent of the graft group and 9% of the nongraft group needed additional surgery for incontinence.

Women in the graft group were older than in the nongraft group (65 years vs. 61 years), were more likely to be menopausal (93% vs. 83%), and were more parous (3.3 vs. 2.9 children). After controlling for these factors, investigators still found no difference in surgical outcomes.

A subanalysis comparing the cases by the biologic and synthetic materials in the grafts also found no difference in outcomes. Another subanalysis comparing anterior vaginal wall grafts and posterior vaginal wall grafts also found no difference in the likelihood of recurrent prolapse or incontinence.

“In the early postoperative period, there was no improvement in surgical outcomes when using grafts to augment vaginal repair of either the anterior vaginal wall, posterior vaginal wall, or both,” he said.

KEVIN FOLEY, RESEARCH/DESIGN

RANCHO MIRAGE, CALIF. — Graft augmentation did not offer additional protection against recurrence in patients undergoing vaginal surgery for symptomatic pelvic organ prolapse and was linked to an increase in postoperative complications in a review of 312 cases.

Two specialists in the treatment of pelvic floor disorders performed the surgeries over a 5-year period and used their discretion in select cases to add graft augmentation to support the anterior vaginal wall, posterior vaginal wall, or both.

Over a median 9-month follow-up, there were no differences in recurrence of prolapse or incontinence, or in the need for additional surgery between the 32% of patients who received grafts and those women who did not, Babak Vakili, M.D., said during the annual meeting of the Society of Gynecologic Surgeons.

Patients receiving graft augmentation had higher rates of postoperative complications, including vaginal or graft infection (18% vs. 5%) and granulation tissue (39% vs. 17%).

As a result, patients with grafts needed more postoperative visits—an average of four visits versus three visits, said Dr. Vakili of Cooper University Hospital, Voorhees, N.J.

The mean length of follow-up was 12 months in the graft group and 15 months in the other patients.

Recurrence rates were similar in both groups. (See accompanying graphic.) Eight percent of the graft group and 9% of the nongraft group needed additional surgery for incontinence.

Women in the graft group were older than in the nongraft group (65 years vs. 61 years), were more likely to be menopausal (93% vs. 83%), and were more parous (3.3 vs. 2.9 children). After controlling for these factors, investigators still found no difference in surgical outcomes.

A subanalysis comparing the cases by the biologic and synthetic materials in the grafts also found no difference in outcomes. Another subanalysis comparing anterior vaginal wall grafts and posterior vaginal wall grafts also found no difference in the likelihood of recurrent prolapse or incontinence.

“In the early postoperative period, there was no improvement in surgical outcomes when using grafts to augment vaginal repair of either the anterior vaginal wall, posterior vaginal wall, or both,” he said.

KEVIN FOLEY, RESEARCH/DESIGN

RANCHO MIRAGE, CALIF. — Graft augmentation did not offer additional protection against recurrence in patients undergoing vaginal surgery for symptomatic pelvic organ prolapse and was linked to an increase in postoperative complications in a review of 312 cases.

Two specialists in the treatment of pelvic floor disorders performed the surgeries over a 5-year period and used their discretion in select cases to add graft augmentation to support the anterior vaginal wall, posterior vaginal wall, or both.

Over a median 9-month follow-up, there were no differences in recurrence of prolapse or incontinence, or in the need for additional surgery between the 32% of patients who received grafts and those women who did not, Babak Vakili, M.D., said during the annual meeting of the Society of Gynecologic Surgeons.

Patients receiving graft augmentation had higher rates of postoperative complications, including vaginal or graft infection (18% vs. 5%) and granulation tissue (39% vs. 17%).

As a result, patients with grafts needed more postoperative visits—an average of four visits versus three visits, said Dr. Vakili of Cooper University Hospital, Voorhees, N.J.

The mean length of follow-up was 12 months in the graft group and 15 months in the other patients.

Recurrence rates were similar in both groups. (See accompanying graphic.) Eight percent of the graft group and 9% of the nongraft group needed additional surgery for incontinence.

Women in the graft group were older than in the nongraft group (65 years vs. 61 years), were more likely to be menopausal (93% vs. 83%), and were more parous (3.3 vs. 2.9 children). After controlling for these factors, investigators still found no difference in surgical outcomes.

A subanalysis comparing the cases by the biologic and synthetic materials in the grafts also found no difference in outcomes. Another subanalysis comparing anterior vaginal wall grafts and posterior vaginal wall grafts also found no difference in the likelihood of recurrent prolapse or incontinence.

“In the early postoperative period, there was no improvement in surgical outcomes when using grafts to augment vaginal repair of either the anterior vaginal wall, posterior vaginal wall, or both,” he said.

KEVIN FOLEY, RESEARCH/DESIGN

RANCHO MIRAGE, CALIF. — Three of 32 women regretted undergoing partial colpocleisis a mean of 28 months after surgery, two because of recurrent prolapse and one due to continued stress incontinence, Thomas L. Wheeler II, M.D., reported.

In follow-up interviews, none cited loss of sexual function as a reason for regret. Overall, satisfaction rates were high, he said at the annual meeting of the Society of Gynecologic Surgeons.

The surgery significantly reduced patient distress over symptoms and the impact of incontinence on their lives, compared with baseline levels, assessed by the short-form Incontinence Impact Questionnaire (IIQ) and the short-form Urogenital Distress Inventory (UDI).

There have been no published reports comparing preoperative and postoperative quality of life scores using validated instruments such as these to assess results from colpocleisis, noted Dr. Wheeler of the University of Alabama, Birmingham.

The investigators obtained records on 54 patients who had undergone partial colpocleises during a 5-year period, but 19 patients were demented, lost to follow-up, or deceased. Three declined to participate in the study. The remaining 32 patients answered a question about regret, and 28 of them also answered a question about satisfaction with results of the surgery. The mean age of respondents was 81 years.

In the three patients (9%) who regretted the surgery, the two recurrent prolapses occurred at 5 and 7 months after the operation. The third patient had undergone a modified Pereyra procedure at the time of colpocleisis and reported continuing incontinence.

Sixteen of the 28 patients said they were completely satisfied with their progress since the surgery, 8 were somewhat satisfied, and 4 (14%) were not satisfied, he said.

The IIQ asked seven questions about whether and how severely urine leakage affected various functions in patients' lives, emotional health, and feelings of frustration, with higher scores representing a greater impact of incontinence. Mean scores improved significantly from 41 before surgery to 14 at the last interview.

The UDI contained six questions about whether and how much patients were bothered by symptoms such as frequent urination, leakage, difficulty emptying the bladder, and pain or discomfort, with higher scores indicating worse outcomes. Mean scores improved significantly from 63 before surgery to 24 at the last interview, Dr. Wheeler said.

In previous reports, regret rates ranged from 0% to 10% in four case series, one of partial colpocleisis and three of total colpocleisis. A previous report of patient satisfaction in a series of total colpocleisis procedures reported that 5% of patients were not satisfied with results.

RANCHO MIRAGE, CALIF. — Three of 32 women regretted undergoing partial colpocleisis a mean of 28 months after surgery, two because of recurrent prolapse and one due to continued stress incontinence, Thomas L. Wheeler II, M.D., reported.

In follow-up interviews, none cited loss of sexual function as a reason for regret. Overall, satisfaction rates were high, he said at the annual meeting of the Society of Gynecologic Surgeons.

The surgery significantly reduced patient distress over symptoms and the impact of incontinence on their lives, compared with baseline levels, assessed by the short-form Incontinence Impact Questionnaire (IIQ) and the short-form Urogenital Distress Inventory (UDI).

There have been no published reports comparing preoperative and postoperative quality of life scores using validated instruments such as these to assess results from colpocleisis, noted Dr. Wheeler of the University of Alabama, Birmingham.

The investigators obtained records on 54 patients who had undergone partial colpocleises during a 5-year period, but 19 patients were demented, lost to follow-up, or deceased. Three declined to participate in the study. The remaining 32 patients answered a question about regret, and 28 of them also answered a question about satisfaction with results of the surgery. The mean age of respondents was 81 years.

In the three patients (9%) who regretted the surgery, the two recurrent prolapses occurred at 5 and 7 months after the operation. The third patient had undergone a modified Pereyra procedure at the time of colpocleisis and reported continuing incontinence.

Sixteen of the 28 patients said they were completely satisfied with their progress since the surgery, 8 were somewhat satisfied, and 4 (14%) were not satisfied, he said.

The IIQ asked seven questions about whether and how severely urine leakage affected various functions in patients' lives, emotional health, and feelings of frustration, with higher scores representing a greater impact of incontinence. Mean scores improved significantly from 41 before surgery to 14 at the last interview.

The UDI contained six questions about whether and how much patients were bothered by symptoms such as frequent urination, leakage, difficulty emptying the bladder, and pain or discomfort, with higher scores indicating worse outcomes. Mean scores improved significantly from 63 before surgery to 24 at the last interview, Dr. Wheeler said.

In previous reports, regret rates ranged from 0% to 10% in four case series, one of partial colpocleisis and three of total colpocleisis. A previous report of patient satisfaction in a series of total colpocleisis procedures reported that 5% of patients were not satisfied with results.

RANCHO MIRAGE, CALIF. — Three of 32 women regretted undergoing partial colpocleisis a mean of 28 months after surgery, two because of recurrent prolapse and one due to continued stress incontinence, Thomas L. Wheeler II, M.D., reported.

In follow-up interviews, none cited loss of sexual function as a reason for regret. Overall, satisfaction rates were high, he said at the annual meeting of the Society of Gynecologic Surgeons.

The surgery significantly reduced patient distress over symptoms and the impact of incontinence on their lives, compared with baseline levels, assessed by the short-form Incontinence Impact Questionnaire (IIQ) and the short-form Urogenital Distress Inventory (UDI).

There have been no published reports comparing preoperative and postoperative quality of life scores using validated instruments such as these to assess results from colpocleisis, noted Dr. Wheeler of the University of Alabama, Birmingham.

The investigators obtained records on 54 patients who had undergone partial colpocleises during a 5-year period, but 19 patients were demented, lost to follow-up, or deceased. Three declined to participate in the study. The remaining 32 patients answered a question about regret, and 28 of them also answered a question about satisfaction with results of the surgery. The mean age of respondents was 81 years.

In the three patients (9%) who regretted the surgery, the two recurrent prolapses occurred at 5 and 7 months after the operation. The third patient had undergone a modified Pereyra procedure at the time of colpocleisis and reported continuing incontinence.

Sixteen of the 28 patients said they were completely satisfied with their progress since the surgery, 8 were somewhat satisfied, and 4 (14%) were not satisfied, he said.

The IIQ asked seven questions about whether and how severely urine leakage affected various functions in patients' lives, emotional health, and feelings of frustration, with higher scores representing a greater impact of incontinence. Mean scores improved significantly from 41 before surgery to 14 at the last interview.

The UDI contained six questions about whether and how much patients were bothered by symptoms such as frequent urination, leakage, difficulty emptying the bladder, and pain or discomfort, with higher scores indicating worse outcomes. Mean scores improved significantly from 63 before surgery to 24 at the last interview, Dr. Wheeler said.

In previous reports, regret rates ranged from 0% to 10% in four case series, one of partial colpocleisis and three of total colpocleisis. A previous report of patient satisfaction in a series of total colpocleisis procedures reported that 5% of patients were not satisfied with results.

RANCHO MIRAGE, CALIF. — Aggressive surgery for epithelial ovarian cancer did not increase mortality or morbidity, compared with less aggressive surgery in patients over age 65 or with medical comorbidities, a review of 140 cases found.

Some surgeons are hesitant to pursue cytoreductive surgery in these kinds of patients as aggressively as they might in patients with fewer surgical risk factors because of previous data showing poorer survival rates in older women.

Federal data show that older patients with cancer are less likely to be treated surgically.

In the current study, only the amount of ovarian tumor removed was associated with survival, Sameer Sharma, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

Surgery reduced the tumor to less than 1 cm in diameter (considered “optimal debulking”) in 88% of patients. Patients with optimal debulking survived a median of 52 months, compared with 26 months for patients with more tumor left after surgery, said Dr. Sharma of the Roswell Park Cancer Institute, Buffalo, N.Y.

There appears to be no significant difference in survival based on age alone, which contradicts previous findings, Dr. Sharma reported.

There were no significant differences in survival or in the rate of complications during or after surgery among the 24% of patients who underwent standard debulking surgery, the 57% who had radical debulking surgery, or the 19% who underwent supraradical debulking surgery.

Patients with comorbid medical conditions tolerated the radical procedures without an increase in postoperative complications.

Older patients and those with comorbidities were just as likely to undergo extensive cytoreduction as less aggressive surgery.

Patients who underwent the more radical procedures, however, were more likely to need a blood transfusion, “which is probably due to underlying cardiovascular disease,” Dr. Sharma said.

Forty-five percent of patients were aged 65 years or older, and 49% of the total cohort had major medical comorbidity, most commonly cardiovascular disease.

A majority of patients had multiple surgical risk factors, such as advanced age plus medical comorbidities.

Despite this, “we were able to achieve highly respectable optimal cytoreductive rates, with 60% of patients having less than 0.5 cm of residual disease after surgery,” he added.

The study clearly shows that older women with ovarian cancer can tolerate aggressive surgery, which leads to better survival rates, Dr. Donald Gallup said in formal commentary that was given after Dr. Sharma's presentation.

“This study is important for those gynecologists who operate on the elderly with comorbidities, whether the patient has cancer or other female conditions that require major operative intervention,” said Dr. Gallup of Savannah, Ga.

The median age of patients in the study was 63 years. They remained hospitalized after surgery for a mean of 8 days, mainly for reasons related to bowel function, Dr. Sharma said.

Follow-up lasted a median of 30 months.

Overall, 24% of patients required transfusion within 30 days after surgery, and 18% had other postoperative complications, mostly problems related to infection or the ileus. Two patients required reoperation. There was one perioperative death in a patient with liver failure from multiple liver metastases.

Age and medical comorbidities should not preclude patients from receiving “maximal surgical effort. Optimal cytoreduction continues to be a critical factor in survival,” Dr. Sharma said.

In the United States, 48% of ovarian epithelial cancer is diagnosed in women older than 65 years. It is the leading cause of death from gynecologic cancers. In 2004, of the 26,000 U.S. women diagnosed, 16,000 will ultimately die of the disease, he said.

RANCHO MIRAGE, CALIF. — Aggressive surgery for epithelial ovarian cancer did not increase mortality or morbidity, compared with less aggressive surgery in patients over age 65 or with medical comorbidities, a review of 140 cases found.

Some surgeons are hesitant to pursue cytoreductive surgery in these kinds of patients as aggressively as they might in patients with fewer surgical risk factors because of previous data showing poorer survival rates in older women.

Federal data show that older patients with cancer are less likely to be treated surgically.

In the current study, only the amount of ovarian tumor removed was associated with survival, Sameer Sharma, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

Surgery reduced the tumor to less than 1 cm in diameter (considered “optimal debulking”) in 88% of patients. Patients with optimal debulking survived a median of 52 months, compared with 26 months for patients with more tumor left after surgery, said Dr. Sharma of the Roswell Park Cancer Institute, Buffalo, N.Y.

There appears to be no significant difference in survival based on age alone, which contradicts previous findings, Dr. Sharma reported.

There were no significant differences in survival or in the rate of complications during or after surgery among the 24% of patients who underwent standard debulking surgery, the 57% who had radical debulking surgery, or the 19% who underwent supraradical debulking surgery.

Patients with comorbid medical conditions tolerated the radical procedures without an increase in postoperative complications.

Older patients and those with comorbidities were just as likely to undergo extensive cytoreduction as less aggressive surgery.

Patients who underwent the more radical procedures, however, were more likely to need a blood transfusion, “which is probably due to underlying cardiovascular disease,” Dr. Sharma said.

Forty-five percent of patients were aged 65 years or older, and 49% of the total cohort had major medical comorbidity, most commonly cardiovascular disease.

A majority of patients had multiple surgical risk factors, such as advanced age plus medical comorbidities.

Despite this, “we were able to achieve highly respectable optimal cytoreductive rates, with 60% of patients having less than 0.5 cm of residual disease after surgery,” he added.

The study clearly shows that older women with ovarian cancer can tolerate aggressive surgery, which leads to better survival rates, Dr. Donald Gallup said in formal commentary that was given after Dr. Sharma's presentation.

“This study is important for those gynecologists who operate on the elderly with comorbidities, whether the patient has cancer or other female conditions that require major operative intervention,” said Dr. Gallup of Savannah, Ga.

The median age of patients in the study was 63 years. They remained hospitalized after surgery for a mean of 8 days, mainly for reasons related to bowel function, Dr. Sharma said.

Follow-up lasted a median of 30 months.

Overall, 24% of patients required transfusion within 30 days after surgery, and 18% had other postoperative complications, mostly problems related to infection or the ileus. Two patients required reoperation. There was one perioperative death in a patient with liver failure from multiple liver metastases.

Age and medical comorbidities should not preclude patients from receiving “maximal surgical effort. Optimal cytoreduction continues to be a critical factor in survival,” Dr. Sharma said.

In the United States, 48% of ovarian epithelial cancer is diagnosed in women older than 65 years. It is the leading cause of death from gynecologic cancers. In 2004, of the 26,000 U.S. women diagnosed, 16,000 will ultimately die of the disease, he said.

RANCHO MIRAGE, CALIF. — Aggressive surgery for epithelial ovarian cancer did not increase mortality or morbidity, compared with less aggressive surgery in patients over age 65 or with medical comorbidities, a review of 140 cases found.

Some surgeons are hesitant to pursue cytoreductive surgery in these kinds of patients as aggressively as they might in patients with fewer surgical risk factors because of previous data showing poorer survival rates in older women.

Federal data show that older patients with cancer are less likely to be treated surgically.

In the current study, only the amount of ovarian tumor removed was associated with survival, Sameer Sharma, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

Surgery reduced the tumor to less than 1 cm in diameter (considered “optimal debulking”) in 88% of patients. Patients with optimal debulking survived a median of 52 months, compared with 26 months for patients with more tumor left after surgery, said Dr. Sharma of the Roswell Park Cancer Institute, Buffalo, N.Y.

There appears to be no significant difference in survival based on age alone, which contradicts previous findings, Dr. Sharma reported.

There were no significant differences in survival or in the rate of complications during or after surgery among the 24% of patients who underwent standard debulking surgery, the 57% who had radical debulking surgery, or the 19% who underwent supraradical debulking surgery.

Patients with comorbid medical conditions tolerated the radical procedures without an increase in postoperative complications.

Older patients and those with comorbidities were just as likely to undergo extensive cytoreduction as less aggressive surgery.

Patients who underwent the more radical procedures, however, were more likely to need a blood transfusion, “which is probably due to underlying cardiovascular disease,” Dr. Sharma said.

Forty-five percent of patients were aged 65 years or older, and 49% of the total cohort had major medical comorbidity, most commonly cardiovascular disease.

A majority of patients had multiple surgical risk factors, such as advanced age plus medical comorbidities.

Despite this, “we were able to achieve highly respectable optimal cytoreductive rates, with 60% of patients having less than 0.5 cm of residual disease after surgery,” he added.

The study clearly shows that older women with ovarian cancer can tolerate aggressive surgery, which leads to better survival rates, Dr. Donald Gallup said in formal commentary that was given after Dr. Sharma's presentation.

“This study is important for those gynecologists who operate on the elderly with comorbidities, whether the patient has cancer or other female conditions that require major operative intervention,” said Dr. Gallup of Savannah, Ga.

The median age of patients in the study was 63 years. They remained hospitalized after surgery for a mean of 8 days, mainly for reasons related to bowel function, Dr. Sharma said.

Follow-up lasted a median of 30 months.

Overall, 24% of patients required transfusion within 30 days after surgery, and 18% had other postoperative complications, mostly problems related to infection or the ileus. Two patients required reoperation. There was one perioperative death in a patient with liver failure from multiple liver metastases.

Age and medical comorbidities should not preclude patients from receiving “maximal surgical effort. Optimal cytoreduction continues to be a critical factor in survival,” Dr. Sharma said.

In the United States, 48% of ovarian epithelial cancer is diagnosed in women older than 65 years. It is the leading cause of death from gynecologic cancers. In 2004, of the 26,000 U.S. women diagnosed, 16,000 will ultimately die of the disease, he said.

RANCHO MIRAGE, CALIF. — Women who had delivered vaginally were more than twice as likely to report stress urinary incontinence as were women who had delivered only by cesarean section in a study of 271 sets of identical twin sisters.

In a longstanding debate about the relationship of obstetric delivery mode and subsequent urinary incontinence, difficulty separating genetic from environmental factors has confounded study results. This study is the first on the subject with good control over the genetic factors, Roger P. Goldberg, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

Surveys completed by 542 women at the world's largest annual gathering of twins in 2003 and 2004 showed that 52% reported stress urinary incontinence.

Twelve percent of the women had more than five episodes of stress urinary incontinence per week.

Among all pairs of sisters, nulliparous women were the least likely to have stress incontinence, and having more than two births conferred nearly a fivefold increased risk of incontinence, compared with nulliparous women. With increasing numbers of vaginal births, the incontinence rate rose as high as 66%, said Dr. Goldberg of Northwestern University, Chicago, and his associates.

Higher body mass index (BMI) also was a risk factor for incontinence.

A second regression analysis of 196 sisters who were parous found that delivery mode was the major factor determining the risk of stress urinary incontinence, with vaginal birth doubling the chance of incontinence. “Parity and BMI were washed out by the effect of birth mode,” he said.

In this second analysis, 87% had at least one vaginal birth, and the rest delivered by cesarean only. The cesarean-only group had approximately half the rate of stress incontinence as did the vaginal birth group after the investigators controlled for age and BMI.

A final analysis that looked at 146 sisters who all had had at least one vaginal birth found that no factors specific to vaginal birth (such as forceps delivery) were significantly associated with incontinence.

The women had a mean age of 47 years. Among these relatively young, childbearing women, delivery mode “was the only modifiable risk factor for stress urinary incontinence that we were able to identify,” Dr. Goldberg said.

A separate study presented in poster format at the meeting found that insulin-requiring diabetes mellitus was independently associated with severe urinary incontinence in women aged 50–90 years, independent of other risk factors including patient age, BMI, and medical comorbidities.

Incontinence was not associated with diabetes that did not require insulin, reported Cynthia Lewis, M.D., of the University of New Mexico, Albuquerque, and her associates.

The study of 10,678 community-based women used self-reported data from the Health and Retirement Study, a large probability sample of U.S. households.

Severe incontinence was defined as losing urine on more than 15 days per month.

Overall, 22% of women reported some urinary incontinence, with 43% of that being severe incontinence.

The presence of insulin-requiring diabetes increased the risk for severe urinary incontinence by 63%, compared with nondiabetic women.

Among women with insulin-requiring diabetes mellitus, racial and ethnic minorities were less likely than were non-Hispanic white women to have urinary incontinence, Dr. Lewis said.

Mild incontinence (defined as leaking urine no more than five times per week) was associated with increasing BMI, hypertension, stroke, and arthritis, but not with diabetes, she added.

RANCHO MIRAGE, CALIF. — Women who had delivered vaginally were more than twice as likely to report stress urinary incontinence as were women who had delivered only by cesarean section in a study of 271 sets of identical twin sisters.

In a longstanding debate about the relationship of obstetric delivery mode and subsequent urinary incontinence, difficulty separating genetic from environmental factors has confounded study results. This study is the first on the subject with good control over the genetic factors, Roger P. Goldberg, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

Surveys completed by 542 women at the world's largest annual gathering of twins in 2003 and 2004 showed that 52% reported stress urinary incontinence.

Twelve percent of the women had more than five episodes of stress urinary incontinence per week.

Among all pairs of sisters, nulliparous women were the least likely to have stress incontinence, and having more than two births conferred nearly a fivefold increased risk of incontinence, compared with nulliparous women. With increasing numbers of vaginal births, the incontinence rate rose as high as 66%, said Dr. Goldberg of Northwestern University, Chicago, and his associates.

Higher body mass index (BMI) also was a risk factor for incontinence.

A second regression analysis of 196 sisters who were parous found that delivery mode was the major factor determining the risk of stress urinary incontinence, with vaginal birth doubling the chance of incontinence. “Parity and BMI were washed out by the effect of birth mode,” he said.

In this second analysis, 87% had at least one vaginal birth, and the rest delivered by cesarean only. The cesarean-only group had approximately half the rate of stress incontinence as did the vaginal birth group after the investigators controlled for age and BMI.

A final analysis that looked at 146 sisters who all had had at least one vaginal birth found that no factors specific to vaginal birth (such as forceps delivery) were significantly associated with incontinence.

The women had a mean age of 47 years. Among these relatively young, childbearing women, delivery mode “was the only modifiable risk factor for stress urinary incontinence that we were able to identify,” Dr. Goldberg said.

A separate study presented in poster format at the meeting found that insulin-requiring diabetes mellitus was independently associated with severe urinary incontinence in women aged 50–90 years, independent of other risk factors including patient age, BMI, and medical comorbidities.

Incontinence was not associated with diabetes that did not require insulin, reported Cynthia Lewis, M.D., of the University of New Mexico, Albuquerque, and her associates.

The study of 10,678 community-based women used self-reported data from the Health and Retirement Study, a large probability sample of U.S. households.

Severe incontinence was defined as losing urine on more than 15 days per month.

Overall, 22% of women reported some urinary incontinence, with 43% of that being severe incontinence.

The presence of insulin-requiring diabetes increased the risk for severe urinary incontinence by 63%, compared with nondiabetic women.

Among women with insulin-requiring diabetes mellitus, racial and ethnic minorities were less likely than were non-Hispanic white women to have urinary incontinence, Dr. Lewis said.

Mild incontinence (defined as leaking urine no more than five times per week) was associated with increasing BMI, hypertension, stroke, and arthritis, but not with diabetes, she added.

RANCHO MIRAGE, CALIF. — Women who had delivered vaginally were more than twice as likely to report stress urinary incontinence as were women who had delivered only by cesarean section in a study of 271 sets of identical twin sisters.

In a longstanding debate about the relationship of obstetric delivery mode and subsequent urinary incontinence, difficulty separating genetic from environmental factors has confounded study results. This study is the first on the subject with good control over the genetic factors, Roger P. Goldberg, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

Surveys completed by 542 women at the world's largest annual gathering of twins in 2003 and 2004 showed that 52% reported stress urinary incontinence.

Twelve percent of the women had more than five episodes of stress urinary incontinence per week.

Among all pairs of sisters, nulliparous women were the least likely to have stress incontinence, and having more than two births conferred nearly a fivefold increased risk of incontinence, compared with nulliparous women. With increasing numbers of vaginal births, the incontinence rate rose as high as 66%, said Dr. Goldberg of Northwestern University, Chicago, and his associates.

Higher body mass index (BMI) also was a risk factor for incontinence.

A second regression analysis of 196 sisters who were parous found that delivery mode was the major factor determining the risk of stress urinary incontinence, with vaginal birth doubling the chance of incontinence. “Parity and BMI were washed out by the effect of birth mode,” he said.

In this second analysis, 87% had at least one vaginal birth, and the rest delivered by cesarean only. The cesarean-only group had approximately half the rate of stress incontinence as did the vaginal birth group after the investigators controlled for age and BMI.

A final analysis that looked at 146 sisters who all had had at least one vaginal birth found that no factors specific to vaginal birth (such as forceps delivery) were significantly associated with incontinence.

The women had a mean age of 47 years. Among these relatively young, childbearing women, delivery mode “was the only modifiable risk factor for stress urinary incontinence that we were able to identify,” Dr. Goldberg said.

A separate study presented in poster format at the meeting found that insulin-requiring diabetes mellitus was independently associated with severe urinary incontinence in women aged 50–90 years, independent of other risk factors including patient age, BMI, and medical comorbidities.

Incontinence was not associated with diabetes that did not require insulin, reported Cynthia Lewis, M.D., of the University of New Mexico, Albuquerque, and her associates.

The study of 10,678 community-based women used self-reported data from the Health and Retirement Study, a large probability sample of U.S. households.

Severe incontinence was defined as losing urine on more than 15 days per month.

Overall, 22% of women reported some urinary incontinence, with 43% of that being severe incontinence.

The presence of insulin-requiring diabetes increased the risk for severe urinary incontinence by 63%, compared with nondiabetic women.

Among women with insulin-requiring diabetes mellitus, racial and ethnic minorities were less likely than were non-Hispanic white women to have urinary incontinence, Dr. Lewis said.

Mild incontinence (defined as leaking urine no more than five times per week) was associated with increasing BMI, hypertension, stroke, and arthritis, but not with diabetes, she added.

SAN DIEGO — When chronic pain and depression coexist, treat the patient under the assumption that the pain is causing the depression, not the reverse, Rollin M. Gallagher, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Studies have shown that pain precedes depression in a majority of patients who have both, he said. That said, depression or an anxiety disorder can intensify a patient's perception of pain.

Physicians need to ensure that patients with pain and depression get referred to pain specialists or psychiatrists early, said Dr. Gallagher, director of pain medicine at Philadelphia Veterans Affairs Medical Center and professor of psychiatry and anesthesiology at the University of Pennsylvania, Philadelphia.

Treatment that improves both physical and affective symptoms provides the best chance of remission of depression.

Keep an eye out for pain in patients treated for depression, he added. Someone with a history of recurrent depression is prone to relapse soon after the onset of pain. “You need to treat the pain right away,” Dr. Gallagher said.

Unexplained somatic symptoms, including pain, were the chief complaints among 69% of 1,146 patients who met the criteria for major depression, one international study found (N. Engl. J. Med. 1999;341:1329–35).

“Probably all of these patients have disorders of the sensory nervous system that you don't find on the typical physical exam but that you could see if you did imaging studies of the brain,” he said.

It's estimated that 30%–60% of depressed patients have pain, according to both clinical and population-based studies. Conversely, about two-thirds of patients with chronic pain conditions have a lifetime history of major depressive disorder.

Physical symptoms and depression are linked across cultures, which suggests that physical symptoms are as much a core part of depressive disorder as sleeplessness, depressed mood, and apathy. Pain associated with depression is more common in women than in men.

A study comparing 248 depressed patients in primary care with 794 nondepressed patients found that depressed patients were significantly more likely to have fatigue, sleep disturbance, more than three complaints, and a variety of pain complaints. Nonspecific musculoskeletal complaints and back pain especially are tip-offs that a patient may be depressed.

Psychiatrists and family physicians usually excel in looking for depression in patients with physical complaints, but other specialists often overlook the depression, Dr. Gallagher said.

He suggested routinely asking patients with physical complaints a couple of questions that are helpful to screen for depression: “Are you depressed most days, or have you been depressed most of the time in the last 2 weeks? Are you interested in doing the things you normally do?” While not specific for depression, these questions are quite sensitive in identifying patients who deserve further work-up for possible depression, studies have shown.

Dr. Gallagher described a 75-year-old woman whose grown children were considering placing her in a nursing home because she seemed confused and depressed, and would not leave her house. In an evaluation, Dr. Gallagher found no new disease, but she did have osteoarthritis in her knees, hip, and spine; spinal stenosis associated with corrective surgery for scoliosis; and brachial plexopathy following prior mastectomy and radiation for breast cancer. She was in severe pain, was quite depressed, and was wasting away.

He hospitalized her, treated the pain with a fentanyl patch and IV morphine, started an antidepressant, and 4 days later transferred her to a step-down clinic where she started physical therapy. She went home 10 days later with pain medications and an antidepressant, and has lived independently for the past 5 years.

SAN DIEGO — When chronic pain and depression coexist, treat the patient under the assumption that the pain is causing the depression, not the reverse, Rollin M. Gallagher, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Studies have shown that pain precedes depression in a majority of patients who have both, he said. That said, depression or an anxiety disorder can intensify a patient's perception of pain.

Physicians need to ensure that patients with pain and depression get referred to pain specialists or psychiatrists early, said Dr. Gallagher, director of pain medicine at Philadelphia Veterans Affairs Medical Center and professor of psychiatry and anesthesiology at the University of Pennsylvania, Philadelphia.

Treatment that improves both physical and affective symptoms provides the best chance of remission of depression.

Keep an eye out for pain in patients treated for depression, he added. Someone with a history of recurrent depression is prone to relapse soon after the onset of pain. “You need to treat the pain right away,” Dr. Gallagher said.

Unexplained somatic symptoms, including pain, were the chief complaints among 69% of 1,146 patients who met the criteria for major depression, one international study found (N. Engl. J. Med. 1999;341:1329–35).

“Probably all of these patients have disorders of the sensory nervous system that you don't find on the typical physical exam but that you could see if you did imaging studies of the brain,” he said.

It's estimated that 30%–60% of depressed patients have pain, according to both clinical and population-based studies. Conversely, about two-thirds of patients with chronic pain conditions have a lifetime history of major depressive disorder.

Physical symptoms and depression are linked across cultures, which suggests that physical symptoms are as much a core part of depressive disorder as sleeplessness, depressed mood, and apathy. Pain associated with depression is more common in women than in men.

A study comparing 248 depressed patients in primary care with 794 nondepressed patients found that depressed patients were significantly more likely to have fatigue, sleep disturbance, more than three complaints, and a variety of pain complaints. Nonspecific musculoskeletal complaints and back pain especially are tip-offs that a patient may be depressed.

Psychiatrists and family physicians usually excel in looking for depression in patients with physical complaints, but other specialists often overlook the depression, Dr. Gallagher said.

He suggested routinely asking patients with physical complaints a couple of questions that are helpful to screen for depression: “Are you depressed most days, or have you been depressed most of the time in the last 2 weeks? Are you interested in doing the things you normally do?” While not specific for depression, these questions are quite sensitive in identifying patients who deserve further work-up for possible depression, studies have shown.

Dr. Gallagher described a 75-year-old woman whose grown children were considering placing her in a nursing home because she seemed confused and depressed, and would not leave her house. In an evaluation, Dr. Gallagher found no new disease, but she did have osteoarthritis in her knees, hip, and spine; spinal stenosis associated with corrective surgery for scoliosis; and brachial plexopathy following prior mastectomy and radiation for breast cancer. She was in severe pain, was quite depressed, and was wasting away.

He hospitalized her, treated the pain with a fentanyl patch and IV morphine, started an antidepressant, and 4 days later transferred her to a step-down clinic where she started physical therapy. She went home 10 days later with pain medications and an antidepressant, and has lived independently for the past 5 years.

SAN DIEGO — When chronic pain and depression coexist, treat the patient under the assumption that the pain is causing the depression, not the reverse, Rollin M. Gallagher, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Studies have shown that pain precedes depression in a majority of patients who have both, he said. That said, depression or an anxiety disorder can intensify a patient's perception of pain.

Physicians need to ensure that patients with pain and depression get referred to pain specialists or psychiatrists early, said Dr. Gallagher, director of pain medicine at Philadelphia Veterans Affairs Medical Center and professor of psychiatry and anesthesiology at the University of Pennsylvania, Philadelphia.

Treatment that improves both physical and affective symptoms provides the best chance of remission of depression.

Keep an eye out for pain in patients treated for depression, he added. Someone with a history of recurrent depression is prone to relapse soon after the onset of pain. “You need to treat the pain right away,” Dr. Gallagher said.

Unexplained somatic symptoms, including pain, were the chief complaints among 69% of 1,146 patients who met the criteria for major depression, one international study found (N. Engl. J. Med. 1999;341:1329–35).

“Probably all of these patients have disorders of the sensory nervous system that you don't find on the typical physical exam but that you could see if you did imaging studies of the brain,” he said.

It's estimated that 30%–60% of depressed patients have pain, according to both clinical and population-based studies. Conversely, about two-thirds of patients with chronic pain conditions have a lifetime history of major depressive disorder.

Physical symptoms and depression are linked across cultures, which suggests that physical symptoms are as much a core part of depressive disorder as sleeplessness, depressed mood, and apathy. Pain associated with depression is more common in women than in men.

A study comparing 248 depressed patients in primary care with 794 nondepressed patients found that depressed patients were significantly more likely to have fatigue, sleep disturbance, more than three complaints, and a variety of pain complaints. Nonspecific musculoskeletal complaints and back pain especially are tip-offs that a patient may be depressed.

Psychiatrists and family physicians usually excel in looking for depression in patients with physical complaints, but other specialists often overlook the depression, Dr. Gallagher said.

He suggested routinely asking patients with physical complaints a couple of questions that are helpful to screen for depression: “Are you depressed most days, or have you been depressed most of the time in the last 2 weeks? Are you interested in doing the things you normally do?” While not specific for depression, these questions are quite sensitive in identifying patients who deserve further work-up for possible depression, studies have shown.

Dr. Gallagher described a 75-year-old woman whose grown children were considering placing her in a nursing home because she seemed confused and depressed, and would not leave her house. In an evaluation, Dr. Gallagher found no new disease, but she did have osteoarthritis in her knees, hip, and spine; spinal stenosis associated with corrective surgery for scoliosis; and brachial plexopathy following prior mastectomy and radiation for breast cancer. She was in severe pain, was quite depressed, and was wasting away.

He hospitalized her, treated the pain with a fentanyl patch and IV morphine, started an antidepressant, and 4 days later transferred her to a step-down clinic where she started physical therapy. She went home 10 days later with pain medications and an antidepressant, and has lived independently for the past 5 years.

SAN DIEGO – Medications for chronic neuropathic pain share similar efficacy, so choose therapy based on safety, tolerability, and ease of use, according to Scott M. Fishman, M.D.

“Each drug that we use has been studied in one or two different neuropathic pain disorders and found to be relatively efficacious, but there's no drug that's been tested in all the disorders,” and few head-to-head comparisons exist, he added at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

One exception in efficacy may apply to patients with shooting, lightening-bolt types of neuropathic pain as is seen with trigeminal neuralgia. For these patients, carbamazepine, baclofen (Lioresal), or tizanidine (Zanaflex) may be more effective than other medications, said Dr. Fishman, chief of the pain medicine division and professor of anesthesiology and pain medicine at the University of California, Davis. For other chronic neuropathic pain, traditional oral analgesic therapies contain either anticonvulsant or antiarrhythmic properties. An explosion in the number of anticonvulsants in the past decade has brought safer options to market.

Nationally, gabapentin (Neurontin) is the top first-line drug used in pain clinics to treat chronic neuropathic pain, not because it's most effective but because it's safer, he said. Dr. Fishman has been a speaker and researcher for Pfizer Inc., the company that makes Neurontin.

Neurontin is not metabolized by the liver, nor does it bind to protein–two traits that greatly reduce the risk of drug-drug interactions, compared with other conventional anticonvulsants including carbamazepine, valproic acid, lamotrigine (Lamictal), and topiramate (Topamax).

“If patients have neuropathic pain, they tend to have systemic diseases, they're often on a lot of other drugs, and drug interactions are a big concern,” he said.

Both the newer and older anticonvulsants for neuropathic pain can still cause major side effects, especially a “cognitive clouding” distinct from fatigue or sleepiness, he added. Other common side effects include fatigue, anorexia, kidney stones, rash, dizziness, drowsiness, visual side effects, and enzyme induction that can decrease the effectiveness of oral contraceptives. Less common side effects include hepatotoxicity, myeloma, and behavioral disinhibition syndromes.

Recent approval of pregabalin (Lyrica), which Dr. Fishman called “son of Neurontin” because it has the same mechanism of action, offers the advantages of easier dosing, linear pharmacokinetics, quicker onset of action, and efficacy from relatively modest doses in treating neuropathic pain, he said. Pfizer Inc. makes Lyrica; Dr. Fishman has been a speaker and researcher for the company.

Another medication, duloxetine (Cymbalta), won approval recently after a speedy review as both an antidepressant and an analgesic for diabetic polyneuropathy, “which really can translate to all the neuropathic pain states,” he said. The dual serotonin-noradrenaline reuptake inhibitor “is the first drug I've seen in my career get approved by the Food and Drug Administration for pain without a single published trial” on pain relief.

Tricyclic antidepressants also could provide dual relief for depression and neuropathic pain if you could get patients to tolerate high enough doses, but a long list of serious side effects makes that impossible. Many primary care physicians and primary care specialists may not be aware of the potential for seizures and cardiac problems with tricyclic antidepressants, he added.

“We see patients being put on tricyclics for diabetic neuropathy all the time without getting an ECG, and these are patients who almost certainly have small-vessel cardiac disease and a high probability of proarrhythmic potential,” he warned.

Among other antidepressants, venlafaxine (Effexor) may be a potent neuropathic analgesic, preliminary studies suggest. The mechanism of its analgesic properties is not understood.

SAN DIEGO – Medications for chronic neuropathic pain share similar efficacy, so choose therapy based on safety, tolerability, and ease of use, according to Scott M. Fishman, M.D.

“Each drug that we use has been studied in one or two different neuropathic pain disorders and found to be relatively efficacious, but there's no drug that's been tested in all the disorders,” and few head-to-head comparisons exist, he added at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

One exception in efficacy may apply to patients with shooting, lightening-bolt types of neuropathic pain as is seen with trigeminal neuralgia. For these patients, carbamazepine, baclofen (Lioresal), or tizanidine (Zanaflex) may be more effective than other medications, said Dr. Fishman, chief of the pain medicine division and professor of anesthesiology and pain medicine at the University of California, Davis. For other chronic neuropathic pain, traditional oral analgesic therapies contain either anticonvulsant or antiarrhythmic properties. An explosion in the number of anticonvulsants in the past decade has brought safer options to market.

Nationally, gabapentin (Neurontin) is the top first-line drug used in pain clinics to treat chronic neuropathic pain, not because it's most effective but because it's safer, he said. Dr. Fishman has been a speaker and researcher for Pfizer Inc., the company that makes Neurontin.

Neurontin is not metabolized by the liver, nor does it bind to protein–two traits that greatly reduce the risk of drug-drug interactions, compared with other conventional anticonvulsants including carbamazepine, valproic acid, lamotrigine (Lamictal), and topiramate (Topamax).

“If patients have neuropathic pain, they tend to have systemic diseases, they're often on a lot of other drugs, and drug interactions are a big concern,” he said.

Both the newer and older anticonvulsants for neuropathic pain can still cause major side effects, especially a “cognitive clouding” distinct from fatigue or sleepiness, he added. Other common side effects include fatigue, anorexia, kidney stones, rash, dizziness, drowsiness, visual side effects, and enzyme induction that can decrease the effectiveness of oral contraceptives. Less common side effects include hepatotoxicity, myeloma, and behavioral disinhibition syndromes.

Recent approval of pregabalin (Lyrica), which Dr. Fishman called “son of Neurontin” because it has the same mechanism of action, offers the advantages of easier dosing, linear pharmacokinetics, quicker onset of action, and efficacy from relatively modest doses in treating neuropathic pain, he said. Pfizer Inc. makes Lyrica; Dr. Fishman has been a speaker and researcher for the company.

Another medication, duloxetine (Cymbalta), won approval recently after a speedy review as both an antidepressant and an analgesic for diabetic polyneuropathy, “which really can translate to all the neuropathic pain states,” he said. The dual serotonin-noradrenaline reuptake inhibitor “is the first drug I've seen in my career get approved by the Food and Drug Administration for pain without a single published trial” on pain relief.

Tricyclic antidepressants also could provide dual relief for depression and neuropathic pain if you could get patients to tolerate high enough doses, but a long list of serious side effects makes that impossible. Many primary care physicians and primary care specialists may not be aware of the potential for seizures and cardiac problems with tricyclic antidepressants, he added.

“We see patients being put on tricyclics for diabetic neuropathy all the time without getting an ECG, and these are patients who almost certainly have small-vessel cardiac disease and a high probability of proarrhythmic potential,” he warned.

Among other antidepressants, venlafaxine (Effexor) may be a potent neuropathic analgesic, preliminary studies suggest. The mechanism of its analgesic properties is not understood.

SAN DIEGO – Medications for chronic neuropathic pain share similar efficacy, so choose therapy based on safety, tolerability, and ease of use, according to Scott M. Fishman, M.D.

“Each drug that we use has been studied in one or two different neuropathic pain disorders and found to be relatively efficacious, but there's no drug that's been tested in all the disorders,” and few head-to-head comparisons exist, he added at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

One exception in efficacy may apply to patients with shooting, lightening-bolt types of neuropathic pain as is seen with trigeminal neuralgia. For these patients, carbamazepine, baclofen (Lioresal), or tizanidine (Zanaflex) may be more effective than other medications, said Dr. Fishman, chief of the pain medicine division and professor of anesthesiology and pain medicine at the University of California, Davis. For other chronic neuropathic pain, traditional oral analgesic therapies contain either anticonvulsant or antiarrhythmic properties. An explosion in the number of anticonvulsants in the past decade has brought safer options to market.

Nationally, gabapentin (Neurontin) is the top first-line drug used in pain clinics to treat chronic neuropathic pain, not because it's most effective but because it's safer, he said. Dr. Fishman has been a speaker and researcher for Pfizer Inc., the company that makes Neurontin.

Neurontin is not metabolized by the liver, nor does it bind to protein–two traits that greatly reduce the risk of drug-drug interactions, compared with other conventional anticonvulsants including carbamazepine, valproic acid, lamotrigine (Lamictal), and topiramate (Topamax).

“If patients have neuropathic pain, they tend to have systemic diseases, they're often on a lot of other drugs, and drug interactions are a big concern,” he said.

Both the newer and older anticonvulsants for neuropathic pain can still cause major side effects, especially a “cognitive clouding” distinct from fatigue or sleepiness, he added. Other common side effects include fatigue, anorexia, kidney stones, rash, dizziness, drowsiness, visual side effects, and enzyme induction that can decrease the effectiveness of oral contraceptives. Less common side effects include hepatotoxicity, myeloma, and behavioral disinhibition syndromes.

Recent approval of pregabalin (Lyrica), which Dr. Fishman called “son of Neurontin” because it has the same mechanism of action, offers the advantages of easier dosing, linear pharmacokinetics, quicker onset of action, and efficacy from relatively modest doses in treating neuropathic pain, he said. Pfizer Inc. makes Lyrica; Dr. Fishman has been a speaker and researcher for the company.

Another medication, duloxetine (Cymbalta), won approval recently after a speedy review as both an antidepressant and an analgesic for diabetic polyneuropathy, “which really can translate to all the neuropathic pain states,” he said. The dual serotonin-noradrenaline reuptake inhibitor “is the first drug I've seen in my career get approved by the Food and Drug Administration for pain without a single published trial” on pain relief.

Tricyclic antidepressants also could provide dual relief for depression and neuropathic pain if you could get patients to tolerate high enough doses, but a long list of serious side effects makes that impossible. Many primary care physicians and primary care specialists may not be aware of the potential for seizures and cardiac problems with tricyclic antidepressants, he added.

“We see patients being put on tricyclics for diabetic neuropathy all the time without getting an ECG, and these are patients who almost certainly have small-vessel cardiac disease and a high probability of proarrhythmic potential,” he warned.

Among other antidepressants, venlafaxine (Effexor) may be a potent neuropathic analgesic, preliminary studies suggest. The mechanism of its analgesic properties is not understood.