Sherry Boschert

KAILUA KONA, HAWAII — Think of both ends of the fertility spectrum when advising women about preventing or treating cervical cancer, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

An increasing number of malpractice cases are being brought by teenagers who claim that no one adequately explained the risks of sexual activity and of avoiding Pap smears, said Ms. Baker, a defense lawyer in Seattle who also holds a bachelor's degree in nursing.

These adolescents lack an understanding of the threats that sexual activity and a lack of screening can pose to their bodies, their fertility, and even their lives if they contract a sexually transmitted disease. Physicians “are being too casual about this,” she said. “You need to document exactly what you said” in counseling the patient.

Explain things in terms that the teenager can understand, Ms. Baker said at the conference, which was sponsored by Boston University.

If a cervical lesion needs treatment, be sure to discuss the potential effects on fertility, especially when counseling young patients and older patients, she added. As more and more women delay childbearing, an increase in malpractice cases related to cervical cancer is being seen on the older end of the age spectrum when treatment fails to protect fertility, and the patient isn't warned of possible effects on fertility.

“Along with that, there needs to be a frank discussion about what is not available to them” if cervical cancer treatment affects fertility, she said.

KAILUA KONA, HAWAII — Think of both ends of the fertility spectrum when advising women about preventing or treating cervical cancer, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

An increasing number of malpractice cases are being brought by teenagers who claim that no one adequately explained the risks of sexual activity and of avoiding Pap smears, said Ms. Baker, a defense lawyer in Seattle who also holds a bachelor's degree in nursing.

These adolescents lack an understanding of the threats that sexual activity and a lack of screening can pose to their bodies, their fertility, and even their lives if they contract a sexually transmitted disease. Physicians “are being too casual about this,” she said. “You need to document exactly what you said” in counseling the patient.

Explain things in terms that the teenager can understand, Ms. Baker said at the conference, which was sponsored by Boston University.

If a cervical lesion needs treatment, be sure to discuss the potential effects on fertility, especially when counseling young patients and older patients, she added. As more and more women delay childbearing, an increase in malpractice cases related to cervical cancer is being seen on the older end of the age spectrum when treatment fails to protect fertility, and the patient isn't warned of possible effects on fertility.

“Along with that, there needs to be a frank discussion about what is not available to them” if cervical cancer treatment affects fertility, she said.

KAILUA KONA, HAWAII — Think of both ends of the fertility spectrum when advising women about preventing or treating cervical cancer, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

An increasing number of malpractice cases are being brought by teenagers who claim that no one adequately explained the risks of sexual activity and of avoiding Pap smears, said Ms. Baker, a defense lawyer in Seattle who also holds a bachelor's degree in nursing.

These adolescents lack an understanding of the threats that sexual activity and a lack of screening can pose to their bodies, their fertility, and even their lives if they contract a sexually transmitted disease. Physicians “are being too casual about this,” she said. “You need to document exactly what you said” in counseling the patient.

Explain things in terms that the teenager can understand, Ms. Baker said at the conference, which was sponsored by Boston University.

If a cervical lesion needs treatment, be sure to discuss the potential effects on fertility, especially when counseling young patients and older patients, she added. As more and more women delay childbearing, an increase in malpractice cases related to cervical cancer is being seen on the older end of the age spectrum when treatment fails to protect fertility, and the patient isn't warned of possible effects on fertility.

“Along with that, there needs to be a frank discussion about what is not available to them” if cervical cancer treatment affects fertility, she said.

KAILUA KONA, HAWAII — Five studies may change the way physicians think about prolonged premature rupture of membranes, perinatal stroke in the fetus, and other topics, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He delineated five areas in which obstetric practices could change because of these studies, which also included suctioning on the perineum, management of herpes in pregnancy, and vaginal birth after cesarean section.

PPROM

If a pregnant woman with prolonged premature rupture of membranes (PPROM) reaches 34 weeks' gestation, it's probably in the mother's and the baby's best interests to deliver the baby rather than continue expectant management, according to a single-institution observational study (Obstet. Gynecol. 2005;105:12–7).

The investigators studied 430 pregnancies in 1998–2000 with PPROM and 24–36 weeks' gestation to determine optimal delivery time.

Infants were delivered after reaching maturity (34 weeks or later) or after the development of chorioamnionitis, active labor, fetal compromise, or phosphatidylglycerol in vaginal pools.

Composite scores for neonatal morbidity suggested that there is limited benefit to continuing expectant management after 34 weeks in women with PPROM. Although this was not a randomized, controlled trial, physicians should seriously consider delivering these babies before 35 weeks' gestation to avoid the risk of abruption, the sudden onset of infection, or other problems, said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Perinatal Stroke

An analysis of data from the Kaiser Permanente system identified four major risk factors for perinatal arterial ischemic stroke (PAS), which is present in 50%–70% of fetuses with hemiplegic cerebral palsy, epilepsy, or cognitive impairment.

“Read this [report] and understand that it is possible for a baby to have a stroke in utero” even if clinicians did nothing wrong during the pregnancy or delivery, he said at the meeting sponsored by Boston University.

Two independent investigators reviewed 1,970 cases, compared them with three matched controls per case, and conducted multivariate analyses for risk factors. They found a rate of PAS of 20 per 100,000 live-born infants (JAMA 2005;293:723–9).

The four major risk factors for PAS were a history of infertility (with the risk perhaps related to the use of infertility drugs), preeclampsia, chorioamnionitis, and PPROM lasting longer than 18 hours. To defend against a lawsuit related to a bad outcome in a baby with PAS, look at the records to see if these risk factors were present, he suggested.

Trial of Labor

A 4-year observational study of 45,988 pregnant women with a prior cesarean section who underwent either a trial of labor or elective C-section answered an important question about the risks of Pitocin that had been left hanging by previous studies of vaginal births after C-section.

Inducing labor significantly increased the risk of uterine rupture and rate of perinatal complications, the investigators found (N. Engl. J. Med. 2004;351:2581–9). Keep that in mind when counseling patients, he suggested.

Suctioning

A randomized, controlled study of 2,514 infants with meconium called into question the routine intrapartum practice of oropharyngeal suctioning. “We're all trained to do that,” Dr. Belfort noted.

Routine intrapartum suctioning did not prevent meconium aspiration syndrome, and in rare cases it traumatized the nasopharynx or caused a cardiac arrythmia (Lancet 2004;364:597–602).

Recommendations for routine intrapartum suctioning should be revised, he said.

Herpes

A metaanalysis of five randomized, controlled trials involving 799 pregnant women with herpes simplex virus found that giving acyclovir therapy beginning at 36 weeks' gestation reduced herpes recurrences at delivery, viral load, symptomatic shedding, and the need for cesarean deliveries (Obstet. Gynecol. 2003;102:1396–403).

“This is hard evidence, in my mind at least, that this is the standard of care now for women with herpes,” he said.

'Read this [report] and understand that it is possible for a baby to have a stroke in utero.' DR. BELFORT

KAILUA KONA, HAWAII — Five studies may change the way physicians think about prolonged premature rupture of membranes, perinatal stroke in the fetus, and other topics, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He delineated five areas in which obstetric practices could change because of these studies, which also included suctioning on the perineum, management of herpes in pregnancy, and vaginal birth after cesarean section.

PPROM

If a pregnant woman with prolonged premature rupture of membranes (PPROM) reaches 34 weeks' gestation, it's probably in the mother's and the baby's best interests to deliver the baby rather than continue expectant management, according to a single-institution observational study (Obstet. Gynecol. 2005;105:12–7).

The investigators studied 430 pregnancies in 1998–2000 with PPROM and 24–36 weeks' gestation to determine optimal delivery time.

Infants were delivered after reaching maturity (34 weeks or later) or after the development of chorioamnionitis, active labor, fetal compromise, or phosphatidylglycerol in vaginal pools.

Composite scores for neonatal morbidity suggested that there is limited benefit to continuing expectant management after 34 weeks in women with PPROM. Although this was not a randomized, controlled trial, physicians should seriously consider delivering these babies before 35 weeks' gestation to avoid the risk of abruption, the sudden onset of infection, or other problems, said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Perinatal Stroke

An analysis of data from the Kaiser Permanente system identified four major risk factors for perinatal arterial ischemic stroke (PAS), which is present in 50%–70% of fetuses with hemiplegic cerebral palsy, epilepsy, or cognitive impairment.

“Read this [report] and understand that it is possible for a baby to have a stroke in utero” even if clinicians did nothing wrong during the pregnancy or delivery, he said at the meeting sponsored by Boston University.

Two independent investigators reviewed 1,970 cases, compared them with three matched controls per case, and conducted multivariate analyses for risk factors. They found a rate of PAS of 20 per 100,000 live-born infants (JAMA 2005;293:723–9).

The four major risk factors for PAS were a history of infertility (with the risk perhaps related to the use of infertility drugs), preeclampsia, chorioamnionitis, and PPROM lasting longer than 18 hours. To defend against a lawsuit related to a bad outcome in a baby with PAS, look at the records to see if these risk factors were present, he suggested.

Trial of Labor

A 4-year observational study of 45,988 pregnant women with a prior cesarean section who underwent either a trial of labor or elective C-section answered an important question about the risks of Pitocin that had been left hanging by previous studies of vaginal births after C-section.

Inducing labor significantly increased the risk of uterine rupture and rate of perinatal complications, the investigators found (N. Engl. J. Med. 2004;351:2581–9). Keep that in mind when counseling patients, he suggested.

Suctioning

A randomized, controlled study of 2,514 infants with meconium called into question the routine intrapartum practice of oropharyngeal suctioning. “We're all trained to do that,” Dr. Belfort noted.

Routine intrapartum suctioning did not prevent meconium aspiration syndrome, and in rare cases it traumatized the nasopharynx or caused a cardiac arrythmia (Lancet 2004;364:597–602).

Recommendations for routine intrapartum suctioning should be revised, he said.

Herpes

A metaanalysis of five randomized, controlled trials involving 799 pregnant women with herpes simplex virus found that giving acyclovir therapy beginning at 36 weeks' gestation reduced herpes recurrences at delivery, viral load, symptomatic shedding, and the need for cesarean deliveries (Obstet. Gynecol. 2003;102:1396–403).

“This is hard evidence, in my mind at least, that this is the standard of care now for women with herpes,” he said.

'Read this [report] and understand that it is possible for a baby to have a stroke in utero.' DR. BELFORT

KAILUA KONA, HAWAII — Five studies may change the way physicians think about prolonged premature rupture of membranes, perinatal stroke in the fetus, and other topics, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He delineated five areas in which obstetric practices could change because of these studies, which also included suctioning on the perineum, management of herpes in pregnancy, and vaginal birth after cesarean section.

PPROM

If a pregnant woman with prolonged premature rupture of membranes (PPROM) reaches 34 weeks' gestation, it's probably in the mother's and the baby's best interests to deliver the baby rather than continue expectant management, according to a single-institution observational study (Obstet. Gynecol. 2005;105:12–7).

The investigators studied 430 pregnancies in 1998–2000 with PPROM and 24–36 weeks' gestation to determine optimal delivery time.

Infants were delivered after reaching maturity (34 weeks or later) or after the development of chorioamnionitis, active labor, fetal compromise, or phosphatidylglycerol in vaginal pools.

Composite scores for neonatal morbidity suggested that there is limited benefit to continuing expectant management after 34 weeks in women with PPROM. Although this was not a randomized, controlled trial, physicians should seriously consider delivering these babies before 35 weeks' gestation to avoid the risk of abruption, the sudden onset of infection, or other problems, said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Perinatal Stroke

An analysis of data from the Kaiser Permanente system identified four major risk factors for perinatal arterial ischemic stroke (PAS), which is present in 50%–70% of fetuses with hemiplegic cerebral palsy, epilepsy, or cognitive impairment.

“Read this [report] and understand that it is possible for a baby to have a stroke in utero” even if clinicians did nothing wrong during the pregnancy or delivery, he said at the meeting sponsored by Boston University.

Two independent investigators reviewed 1,970 cases, compared them with three matched controls per case, and conducted multivariate analyses for risk factors. They found a rate of PAS of 20 per 100,000 live-born infants (JAMA 2005;293:723–9).

The four major risk factors for PAS were a history of infertility (with the risk perhaps related to the use of infertility drugs), preeclampsia, chorioamnionitis, and PPROM lasting longer than 18 hours. To defend against a lawsuit related to a bad outcome in a baby with PAS, look at the records to see if these risk factors were present, he suggested.

Trial of Labor

A 4-year observational study of 45,988 pregnant women with a prior cesarean section who underwent either a trial of labor or elective C-section answered an important question about the risks of Pitocin that had been left hanging by previous studies of vaginal births after C-section.

Inducing labor significantly increased the risk of uterine rupture and rate of perinatal complications, the investigators found (N. Engl. J. Med. 2004;351:2581–9). Keep that in mind when counseling patients, he suggested.

Suctioning

A randomized, controlled study of 2,514 infants with meconium called into question the routine intrapartum practice of oropharyngeal suctioning. “We're all trained to do that,” Dr. Belfort noted.

Routine intrapartum suctioning did not prevent meconium aspiration syndrome, and in rare cases it traumatized the nasopharynx or caused a cardiac arrythmia (Lancet 2004;364:597–602).

Recommendations for routine intrapartum suctioning should be revised, he said.

Herpes

A metaanalysis of five randomized, controlled trials involving 799 pregnant women with herpes simplex virus found that giving acyclovir therapy beginning at 36 weeks' gestation reduced herpes recurrences at delivery, viral load, symptomatic shedding, and the need for cesarean deliveries (Obstet. Gynecol. 2003;102:1396–403).

“This is hard evidence, in my mind at least, that this is the standard of care now for women with herpes,” he said.

'Read this [report] and understand that it is possible for a baby to have a stroke in utero.' DR. BELFORT

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned at the conference sponsored by Boston University

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may end up coming back with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay and [that] you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs, and either he or his staff calls the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

When ordering labs, not every patient needs a coagulogram, but you should get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura. “The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted. Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained.

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned at the conference sponsored by Boston University

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may end up coming back with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay and [that] you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs, and either he or his staff calls the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

When ordering labs, not every patient needs a coagulogram, but you should get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura. “The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted. Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained.

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned at the conference sponsored by Boston University

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may end up coming back with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay and [that] you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs, and either he or his staff calls the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

When ordering labs, not every patient needs a coagulogram, but you should get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura. “The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted. Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained.

SAN FRANCISCO — Two separate studies have produced strong evidence supporting both genetic and environmental risk factors for primary biliary cirrhosis. The findings were presented at the annual meeting of the American Association for the Study of Liver Diseases.

Little is known about the cause of this autoimmune cholestatic liver disease that affects an estimated 100,000 people in the United States. Primary biliary cirrhosis typically strikes women in the prime of their lives, attacking small ducts of the liver and ultimately requiring a liver transplant.

Symptoms include intractable itching, fatigue, and sometimes jaundice, although today many patients are diagnosed while asymptomatic based on abnormal liver function tests.

Detailed telephone surveys of 1,032 patients (93% women) and 1,041 closely matched controls (92% women) in all but two U.S. states found that the risk for primary biliary cirrhosis increased with a family history of the disease or of other autoimmune diseases. Other risk factors were smoking, a history of urinary tract infection (UTI), and high income, plus a slight increase in risk with the use of nail polish, Dr. Carlo Selmi reported.

The average age at diagnosis of primary biliary cirrhosis was 58 years in Dr. Selmi's study; the control subjects also averaged 58 years.

Six percent of patients with primary biliary cirrhosis had another family member with the disease—usually a mother or sister. One-third of patients had another autoimmune disease, reported Dr. Selmi of the University of California, Davis, and his associates.

A family history of primary biliary cirrhosis increased a person's risk for the disease 11-fold. The risk doubled with a family history of lupus and increased sixfold with a family history of Sjögren's disease.

Previous UTIs were associated with a 50% increase in risk for primary biliary cirrhosis. The risk increased by 60% with a history of smoking more than 10 cigarettes per day. Use of nail polish increased the risk only slightly, but the difference was significant, he said.

Patients with primary biliary cirrhosis had significantly higher family incomes, compared with controls, a risk factor that's hard to explain, said Dr. M. Eric Gershwin, a coinvestigator in the study and chief of rheumatology, allergy, and clinical immunology at the university.

One “hygiene hypothesis” posits that wealthier people may be “too clean,” disrupting the autoimmune system, he said at a press briefing.

Noting the higher rate of UTIs in patients with primary biliary cirrhosis, he hypothesized that certain bacteria resembling the pathogens of UTIs may predispose someone to primary biliary cirrhosis if the body attacks the lookalike bacteria by mistake.

A separate British study comparing 2,576 patients with primary biliary cirrhosis to 2,438 controls produced results that were “extraordinarily similar” to those of the U.S. study, Dr. Oliver James said in a separate presentation.

The cirrhosis group included 318 consecutive patients seen in one region and 2,258 members of the Primary Biliary Cirrhosis Foundation support group living in the United Kingdom.

A family history of primary biliary cirrhosis doubled the risk for disease in the regional patient group and quadrupled risk in the Foundation group, compared with controls. Previous obstetrical pruritus doubled the risk in both patient groups compared with controls, said Dr. James of the University of Newcastle Upon Tyne.

Other factors that increased risk for the disease in both patient groups, compared with controls, included smoking, use of hair dye, recurrent UTIs, thyroid disease, and rheumatoid arthritis. Additional factors increased risk in at least one of the patient groups; these factors were celiac disease, history of shingles, or prior tonsillectomy or appendectomy.

History of pregnancy slightly but significantly reduced risk in women and also in men whose partners became pregnant.

A family history of primary biliary cirrhosis increased a person's risk for the disease 11-fold. DR. SELMI

SAN FRANCISCO — Two separate studies have produced strong evidence supporting both genetic and environmental risk factors for primary biliary cirrhosis. The findings were presented at the annual meeting of the American Association for the Study of Liver Diseases.

Little is known about the cause of this autoimmune cholestatic liver disease that affects an estimated 100,000 people in the United States. Primary biliary cirrhosis typically strikes women in the prime of their lives, attacking small ducts of the liver and ultimately requiring a liver transplant.

Symptoms include intractable itching, fatigue, and sometimes jaundice, although today many patients are diagnosed while asymptomatic based on abnormal liver function tests.

Detailed telephone surveys of 1,032 patients (93% women) and 1,041 closely matched controls (92% women) in all but two U.S. states found that the risk for primary biliary cirrhosis increased with a family history of the disease or of other autoimmune diseases. Other risk factors were smoking, a history of urinary tract infection (UTI), and high income, plus a slight increase in risk with the use of nail polish, Dr. Carlo Selmi reported.

The average age at diagnosis of primary biliary cirrhosis was 58 years in Dr. Selmi's study; the control subjects also averaged 58 years.

Six percent of patients with primary biliary cirrhosis had another family member with the disease—usually a mother or sister. One-third of patients had another autoimmune disease, reported Dr. Selmi of the University of California, Davis, and his associates.

A family history of primary biliary cirrhosis increased a person's risk for the disease 11-fold. The risk doubled with a family history of lupus and increased sixfold with a family history of Sjögren's disease.

Previous UTIs were associated with a 50% increase in risk for primary biliary cirrhosis. The risk increased by 60% with a history of smoking more than 10 cigarettes per day. Use of nail polish increased the risk only slightly, but the difference was significant, he said.

Patients with primary biliary cirrhosis had significantly higher family incomes, compared with controls, a risk factor that's hard to explain, said Dr. M. Eric Gershwin, a coinvestigator in the study and chief of rheumatology, allergy, and clinical immunology at the university.

One “hygiene hypothesis” posits that wealthier people may be “too clean,” disrupting the autoimmune system, he said at a press briefing.

Noting the higher rate of UTIs in patients with primary biliary cirrhosis, he hypothesized that certain bacteria resembling the pathogens of UTIs may predispose someone to primary biliary cirrhosis if the body attacks the lookalike bacteria by mistake.

A separate British study comparing 2,576 patients with primary biliary cirrhosis to 2,438 controls produced results that were “extraordinarily similar” to those of the U.S. study, Dr. Oliver James said in a separate presentation.

The cirrhosis group included 318 consecutive patients seen in one region and 2,258 members of the Primary Biliary Cirrhosis Foundation support group living in the United Kingdom.

A family history of primary biliary cirrhosis doubled the risk for disease in the regional patient group and quadrupled risk in the Foundation group, compared with controls. Previous obstetrical pruritus doubled the risk in both patient groups compared with controls, said Dr. James of the University of Newcastle Upon Tyne.

Other factors that increased risk for the disease in both patient groups, compared with controls, included smoking, use of hair dye, recurrent UTIs, thyroid disease, and rheumatoid arthritis. Additional factors increased risk in at least one of the patient groups; these factors were celiac disease, history of shingles, or prior tonsillectomy or appendectomy.

History of pregnancy slightly but significantly reduced risk in women and also in men whose partners became pregnant.

A family history of primary biliary cirrhosis increased a person's risk for the disease 11-fold. DR. SELMI

SAN FRANCISCO — Two separate studies have produced strong evidence supporting both genetic and environmental risk factors for primary biliary cirrhosis. The findings were presented at the annual meeting of the American Association for the Study of Liver Diseases.

Little is known about the cause of this autoimmune cholestatic liver disease that affects an estimated 100,000 people in the United States. Primary biliary cirrhosis typically strikes women in the prime of their lives, attacking small ducts of the liver and ultimately requiring a liver transplant.

Symptoms include intractable itching, fatigue, and sometimes jaundice, although today many patients are diagnosed while asymptomatic based on abnormal liver function tests.

Detailed telephone surveys of 1,032 patients (93% women) and 1,041 closely matched controls (92% women) in all but two U.S. states found that the risk for primary biliary cirrhosis increased with a family history of the disease or of other autoimmune diseases. Other risk factors were smoking, a history of urinary tract infection (UTI), and high income, plus a slight increase in risk with the use of nail polish, Dr. Carlo Selmi reported.

The average age at diagnosis of primary biliary cirrhosis was 58 years in Dr. Selmi's study; the control subjects also averaged 58 years.

Six percent of patients with primary biliary cirrhosis had another family member with the disease—usually a mother or sister. One-third of patients had another autoimmune disease, reported Dr. Selmi of the University of California, Davis, and his associates.

A family history of primary biliary cirrhosis increased a person's risk for the disease 11-fold. The risk doubled with a family history of lupus and increased sixfold with a family history of Sjögren's disease.

Previous UTIs were associated with a 50% increase in risk for primary biliary cirrhosis. The risk increased by 60% with a history of smoking more than 10 cigarettes per day. Use of nail polish increased the risk only slightly, but the difference was significant, he said.

Patients with primary biliary cirrhosis had significantly higher family incomes, compared with controls, a risk factor that's hard to explain, said Dr. M. Eric Gershwin, a coinvestigator in the study and chief of rheumatology, allergy, and clinical immunology at the university.

One “hygiene hypothesis” posits that wealthier people may be “too clean,” disrupting the autoimmune system, he said at a press briefing.

Noting the higher rate of UTIs in patients with primary biliary cirrhosis, he hypothesized that certain bacteria resembling the pathogens of UTIs may predispose someone to primary biliary cirrhosis if the body attacks the lookalike bacteria by mistake.

A separate British study comparing 2,576 patients with primary biliary cirrhosis to 2,438 controls produced results that were “extraordinarily similar” to those of the U.S. study, Dr. Oliver James said in a separate presentation.

The cirrhosis group included 318 consecutive patients seen in one region and 2,258 members of the Primary Biliary Cirrhosis Foundation support group living in the United Kingdom.

A family history of primary biliary cirrhosis doubled the risk for disease in the regional patient group and quadrupled risk in the Foundation group, compared with controls. Previous obstetrical pruritus doubled the risk in both patient groups compared with controls, said Dr. James of the University of Newcastle Upon Tyne.

Other factors that increased risk for the disease in both patient groups, compared with controls, included smoking, use of hair dye, recurrent UTIs, thyroid disease, and rheumatoid arthritis. Additional factors increased risk in at least one of the patient groups; these factors were celiac disease, history of shingles, or prior tonsillectomy or appendectomy.

History of pregnancy slightly but significantly reduced risk in women and also in men whose partners became pregnant.

A family history of primary biliary cirrhosis increased a person's risk for the disease 11-fold. DR. SELMI

KAILUA KONA, HAWAII — By the time you detect changes in maternal blood pressure or heart rate suggesting postpartum hemorrhage, the woman already has lost a third of her blood volume, Dr. George R. Saade said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“Do not wait to start seeing signs and symptoms. As soon as you start estimating that the patient is losing a lot of blood, you have to start acting right then and there,” said Dr. Saade, professor of obstetrics and gynecology at the University of Texas Medical Branch, Galveston.

Orthostatic hypotension would tell you that the patient has lost 20%–25% of her blood, but if she is sitting or lying down on the delivery table, you're unlikely to detect that symptom. Hypotension reflects a loss of 30%–35% of blood volume. “Do not wait for hypotension” to treat for postpartum hemorrhage, he said at the meeting sponsored by Boston University. Clinicians typically underestimate postpartum blood loss by 30%–50%, studies suggest. On average, women lose about 500 cc in a vaginal delivery, 1,000 cc in a cesarean section, and 1,500 cc in a cesarean hysterectomy.

Dr. Garry Feinstadt, a general practitioner in Vancouver, B.C., said during a question-and-answer session that his work on quality assurance committees has convinced him that clinicians commonly record blood loss using inaccurately low numbers. “How can we teach people to accurately and honestly record blood loss?” he asked.

Dr. Saade suggested instituting a system of weighing uterine packs and learning how weights correlate with blood loss, then following a protocol of actions triggered by the weights.

Dr. Michael A. Belfort commented that his institution, St. Mark's Hospital in Salt Lake City, recently initiated a program to train nurses to estimate blood loss based on work done by Dr. Gary A. Dildy III, also of the hospital. A standard operating lap sponge soaked in blood, for example, will contain about 75 cc of blood. If it's dripping, it has absorbed about 100 cc of blood. The training sessions include photographs and evaluation of lap sponges and other materials soaked with blood.

“The critical area where you want to estimate blood loss is over 2,000 cc, and we almost always underestimate that,” he said. By that point, the patient has hypotension, has significant tachycardia, and is in shock.

Perhaps the easiest method of estimating is to picture a soda can, which would hold about 350 cc of blood. When you look at blood clots or blood in a canister, estimate how many cans of soda are represented, and you'll be close to blood volume lost. “The principle is to recognize volume,” Dr. Belfort said.

St. Mark's Hospital keeps scales in delivery rooms to weigh lap sponges and other materials to estimate blood loss. If a patient bleeds more than 1,000 cc, hospital policy mandates that a physician be there to evaluate blood loss. If more than 1,500 cc of blood is lost, two physicians must be on hand to manage the patient.

Consider organizing drills for your clinical staff on managing postpartum hemorrhage, Kimberly D. Baker, J.D., suggested in a commentary session on legal issues surrounding postpartum hemorrhage. Have the proper tools and instruments that you might need handy in delivery rooms.

Even women who develop early postpartum hemorrhage may be home before the bleeding starts, in part because they don't want to stay in the hospital any longer than they have to, noted Ms. Baker, a defense attorney in Seattle who also holds a BS in nursing. “If you are a provider who is involved with early discharge or home delivery, I can't emphasize strongly enough that you need to provide additional education to the patient to make sure that she really understands [what to do in case of bleeding]. … Educate her before delivery, not after,” she said.

'As soon as you start estimating that the patient is losing a lot of blood, you have to start acting.' DR. SAADE

KAILUA KONA, HAWAII — By the time you detect changes in maternal blood pressure or heart rate suggesting postpartum hemorrhage, the woman already has lost a third of her blood volume, Dr. George R. Saade said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“Do not wait to start seeing signs and symptoms. As soon as you start estimating that the patient is losing a lot of blood, you have to start acting right then and there,” said Dr. Saade, professor of obstetrics and gynecology at the University of Texas Medical Branch, Galveston.

Orthostatic hypotension would tell you that the patient has lost 20%–25% of her blood, but if she is sitting or lying down on the delivery table, you're unlikely to detect that symptom. Hypotension reflects a loss of 30%–35% of blood volume. “Do not wait for hypotension” to treat for postpartum hemorrhage, he said at the meeting sponsored by Boston University. Clinicians typically underestimate postpartum blood loss by 30%–50%, studies suggest. On average, women lose about 500 cc in a vaginal delivery, 1,000 cc in a cesarean section, and 1,500 cc in a cesarean hysterectomy.

Dr. Garry Feinstadt, a general practitioner in Vancouver, B.C., said during a question-and-answer session that his work on quality assurance committees has convinced him that clinicians commonly record blood loss using inaccurately low numbers. “How can we teach people to accurately and honestly record blood loss?” he asked.

Dr. Saade suggested instituting a system of weighing uterine packs and learning how weights correlate with blood loss, then following a protocol of actions triggered by the weights.

Dr. Michael A. Belfort commented that his institution, St. Mark's Hospital in Salt Lake City, recently initiated a program to train nurses to estimate blood loss based on work done by Dr. Gary A. Dildy III, also of the hospital. A standard operating lap sponge soaked in blood, for example, will contain about 75 cc of blood. If it's dripping, it has absorbed about 100 cc of blood. The training sessions include photographs and evaluation of lap sponges and other materials soaked with blood.

“The critical area where you want to estimate blood loss is over 2,000 cc, and we almost always underestimate that,” he said. By that point, the patient has hypotension, has significant tachycardia, and is in shock.

Perhaps the easiest method of estimating is to picture a soda can, which would hold about 350 cc of blood. When you look at blood clots or blood in a canister, estimate how many cans of soda are represented, and you'll be close to blood volume lost. “The principle is to recognize volume,” Dr. Belfort said.

St. Mark's Hospital keeps scales in delivery rooms to weigh lap sponges and other materials to estimate blood loss. If a patient bleeds more than 1,000 cc, hospital policy mandates that a physician be there to evaluate blood loss. If more than 1,500 cc of blood is lost, two physicians must be on hand to manage the patient.

Consider organizing drills for your clinical staff on managing postpartum hemorrhage, Kimberly D. Baker, J.D., suggested in a commentary session on legal issues surrounding postpartum hemorrhage. Have the proper tools and instruments that you might need handy in delivery rooms.

Even women who develop early postpartum hemorrhage may be home before the bleeding starts, in part because they don't want to stay in the hospital any longer than they have to, noted Ms. Baker, a defense attorney in Seattle who also holds a BS in nursing. “If you are a provider who is involved with early discharge or home delivery, I can't emphasize strongly enough that you need to provide additional education to the patient to make sure that she really understands [what to do in case of bleeding]. … Educate her before delivery, not after,” she said.

'As soon as you start estimating that the patient is losing a lot of blood, you have to start acting.' DR. SAADE

KAILUA KONA, HAWAII — By the time you detect changes in maternal blood pressure or heart rate suggesting postpartum hemorrhage, the woman already has lost a third of her blood volume, Dr. George R. Saade said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“Do not wait to start seeing signs and symptoms. As soon as you start estimating that the patient is losing a lot of blood, you have to start acting right then and there,” said Dr. Saade, professor of obstetrics and gynecology at the University of Texas Medical Branch, Galveston.

Orthostatic hypotension would tell you that the patient has lost 20%–25% of her blood, but if she is sitting or lying down on the delivery table, you're unlikely to detect that symptom. Hypotension reflects a loss of 30%–35% of blood volume. “Do not wait for hypotension” to treat for postpartum hemorrhage, he said at the meeting sponsored by Boston University. Clinicians typically underestimate postpartum blood loss by 30%–50%, studies suggest. On average, women lose about 500 cc in a vaginal delivery, 1,000 cc in a cesarean section, and 1,500 cc in a cesarean hysterectomy.

Dr. Garry Feinstadt, a general practitioner in Vancouver, B.C., said during a question-and-answer session that his work on quality assurance committees has convinced him that clinicians commonly record blood loss using inaccurately low numbers. “How can we teach people to accurately and honestly record blood loss?” he asked.

Dr. Saade suggested instituting a system of weighing uterine packs and learning how weights correlate with blood loss, then following a protocol of actions triggered by the weights.

Dr. Michael A. Belfort commented that his institution, St. Mark's Hospital in Salt Lake City, recently initiated a program to train nurses to estimate blood loss based on work done by Dr. Gary A. Dildy III, also of the hospital. A standard operating lap sponge soaked in blood, for example, will contain about 75 cc of blood. If it's dripping, it has absorbed about 100 cc of blood. The training sessions include photographs and evaluation of lap sponges and other materials soaked with blood.

“The critical area where you want to estimate blood loss is over 2,000 cc, and we almost always underestimate that,” he said. By that point, the patient has hypotension, has significant tachycardia, and is in shock.

Perhaps the easiest method of estimating is to picture a soda can, which would hold about 350 cc of blood. When you look at blood clots or blood in a canister, estimate how many cans of soda are represented, and you'll be close to blood volume lost. “The principle is to recognize volume,” Dr. Belfort said.

St. Mark's Hospital keeps scales in delivery rooms to weigh lap sponges and other materials to estimate blood loss. If a patient bleeds more than 1,000 cc, hospital policy mandates that a physician be there to evaluate blood loss. If more than 1,500 cc of blood is lost, two physicians must be on hand to manage the patient.

Consider organizing drills for your clinical staff on managing postpartum hemorrhage, Kimberly D. Baker, J.D., suggested in a commentary session on legal issues surrounding postpartum hemorrhage. Have the proper tools and instruments that you might need handy in delivery rooms.

Even women who develop early postpartum hemorrhage may be home before the bleeding starts, in part because they don't want to stay in the hospital any longer than they have to, noted Ms. Baker, a defense attorney in Seattle who also holds a BS in nursing. “If you are a provider who is involved with early discharge or home delivery, I can't emphasize strongly enough that you need to provide additional education to the patient to make sure that she really understands [what to do in case of bleeding]. … Educate her before delivery, not after,” she said.

'As soon as you start estimating that the patient is losing a lot of blood, you have to start acting.' DR. SAADE

SAN FRANCISCO — The burning issue of how best to make sure that patients get enough vitamin D comes down to this conclusion: Recommending intentional exposure to the sun is inappropriate, Dr. Henry W. Lim said.

For patients at risk of vitamin D deficiency, it is better to recommend a vitamin D-fortified diet and daily supplements of 800 IU of vitamin D (ideally vitamin D₃) plus calcium, he said at the annual meeting of the American Academy of Dermatology.

Dr. Lim, chairman of the dermatology residency program at Henry Ford Hospital, Detroit, organized a 2005 consensus conference for the academy called Sunlight, Tanning Booths, and Vitamin D. At the annual meeting he discussed more recent data on vitamin D and presented his preferred approach to vitamin D management.

Intentional sun exposure is a problem because the harmful side effects of UVB can't be separated from the beneficial vitamin D photosynthesis that sunlight provides. UV light acutely damages skin DNA and can cause erythema, sunburn, and photoimmunosuppression. In the long term, UV irradiation leads to photoaging and possible photocarcinogenesis. Half of all cancers in humans are skin cancers.

In addition, vitamin D synthesis appears to occur at different rates in people of different skin types. That, plus significant daily and seasonal variability in weather patterns and availability of sunlight make it difficult to craft public health policies based on intentional sun exposure, Dr. Lim said.

Studies have identified certain populations that may not be getting adequate vitamin D, including the elderly, people with darkly pigmented skin, and those living in wintry climates. Other studies, however, show that most people achieve adequate vitamin D serum levels in the course of normal daily life, even when using sunscreen, presumably through incidental sun exposure, dietary intake, and supplementation, he added.

Recent data suggest that levels in U.S. whites averaged 80 nmol/L, “which is considered nowadays by most studies to be an adequate level of serum vitamin D,” Dr. Lim noted. In Hispanic Americans, however, serum levels averaged 60 nmol/L, and in U.S. blacks, serum vitamin D averaged 50 nmol/L.

Very modest sun exposure produces maximal vitamin D photosynthesis in fair-skinned people. This makes prolonged sun exposure unnecessary and potentially dangerous for these people, he said.

Separate data on individuals older than 60 years—who presumably are less active and spend more time indoors—suggest that 67% of whites and 88% of blacks have serum vitamin D levels below 80 nmol/L.

The 2005 consensus conference concluded that it may be time to increase recommended dietary levels of vitamin D for both the frail elderly and dark-skinned people who get little sun exposure.

Natural dietary sources of vitamin D are few: saltwater fish, cod liver oil, and egg yolks. U.S. guidelines have led to vitamin D fortification of foods, most commonly milk, orange juice, cereal, butter, margarine, and chocolate mixes.

Current U.S. recommendations for daily vitamin D intake call for 200 IU for children and adults up to age 50 years, 400 IU for those aged 51–70 years, and 600–800 IU for those older than 70 years.

“In the past few years there is increasing evidence that these recommendations probably are too low,” Dr. Lim said. One recent study suggested that maintaining sufficient vitamin D levels requires 800–1,000 IU per day of vitamin D₃ or 50,000 IU once per month, a dose that's available by prescription only (Photochem. Photobiol. 2005;81:1246–51). Keep in mind that vitamin D intoxication doesn't occur until daily doses exceed 10,000 IU, Dr. Lim said. “Therefore, even at 800–1,000 IU, there is still a significant margin of safety.”

Dr. Lim recommended three sets of articles as helpful references in the ongoing debate about vitamin D:

▸ Results of the 2005 consensus conference: J. Am. Acad. Dermatol. 2005;52:868–76.

▸ A series of seven articles on UV radiation, beginning with one entitled, UV radiation, vitamin D, and human health: an unfolding controversy: Photochem. Photobiol. 2005;81:1243–5.

▸ An overview of the proceedings from the experimental biology 2004 symposium on vitamin D insufficiency: J. Nutr. 2005;135:301–37.

SAN FRANCISCO — The burning issue of how best to make sure that patients get enough vitamin D comes down to this conclusion: Recommending intentional exposure to the sun is inappropriate, Dr. Henry W. Lim said.

For patients at risk of vitamin D deficiency, it is better to recommend a vitamin D-fortified diet and daily supplements of 800 IU of vitamin D (ideally vitamin D₃) plus calcium, he said at the annual meeting of the American Academy of Dermatology.

Dr. Lim, chairman of the dermatology residency program at Henry Ford Hospital, Detroit, organized a 2005 consensus conference for the academy called Sunlight, Tanning Booths, and Vitamin D. At the annual meeting he discussed more recent data on vitamin D and presented his preferred approach to vitamin D management.

Intentional sun exposure is a problem because the harmful side effects of UVB can't be separated from the beneficial vitamin D photosynthesis that sunlight provides. UV light acutely damages skin DNA and can cause erythema, sunburn, and photoimmunosuppression. In the long term, UV irradiation leads to photoaging and possible photocarcinogenesis. Half of all cancers in humans are skin cancers.

In addition, vitamin D synthesis appears to occur at different rates in people of different skin types. That, plus significant daily and seasonal variability in weather patterns and availability of sunlight make it difficult to craft public health policies based on intentional sun exposure, Dr. Lim said.

Studies have identified certain populations that may not be getting adequate vitamin D, including the elderly, people with darkly pigmented skin, and those living in wintry climates. Other studies, however, show that most people achieve adequate vitamin D serum levels in the course of normal daily life, even when using sunscreen, presumably through incidental sun exposure, dietary intake, and supplementation, he added.

Recent data suggest that levels in U.S. whites averaged 80 nmol/L, “which is considered nowadays by most studies to be an adequate level of serum vitamin D,” Dr. Lim noted. In Hispanic Americans, however, serum levels averaged 60 nmol/L, and in U.S. blacks, serum vitamin D averaged 50 nmol/L.

Very modest sun exposure produces maximal vitamin D photosynthesis in fair-skinned people. This makes prolonged sun exposure unnecessary and potentially dangerous for these people, he said.

Separate data on individuals older than 60 years—who presumably are less active and spend more time indoors—suggest that 67% of whites and 88% of blacks have serum vitamin D levels below 80 nmol/L.

The 2005 consensus conference concluded that it may be time to increase recommended dietary levels of vitamin D for both the frail elderly and dark-skinned people who get little sun exposure.

Natural dietary sources of vitamin D are few: saltwater fish, cod liver oil, and egg yolks. U.S. guidelines have led to vitamin D fortification of foods, most commonly milk, orange juice, cereal, butter, margarine, and chocolate mixes.

Current U.S. recommendations for daily vitamin D intake call for 200 IU for children and adults up to age 50 years, 400 IU for those aged 51–70 years, and 600–800 IU for those older than 70 years.

“In the past few years there is increasing evidence that these recommendations probably are too low,” Dr. Lim said. One recent study suggested that maintaining sufficient vitamin D levels requires 800–1,000 IU per day of vitamin D₃ or 50,000 IU once per month, a dose that's available by prescription only (Photochem. Photobiol. 2005;81:1246–51). Keep in mind that vitamin D intoxication doesn't occur until daily doses exceed 10,000 IU, Dr. Lim said. “Therefore, even at 800–1,000 IU, there is still a significant margin of safety.”

Dr. Lim recommended three sets of articles as helpful references in the ongoing debate about vitamin D:

▸ Results of the 2005 consensus conference: J. Am. Acad. Dermatol. 2005;52:868–76.

▸ A series of seven articles on UV radiation, beginning with one entitled, UV radiation, vitamin D, and human health: an unfolding controversy: Photochem. Photobiol. 2005;81:1243–5.

▸ An overview of the proceedings from the experimental biology 2004 symposium on vitamin D insufficiency: J. Nutr. 2005;135:301–37.

SAN FRANCISCO — The burning issue of how best to make sure that patients get enough vitamin D comes down to this conclusion: Recommending intentional exposure to the sun is inappropriate, Dr. Henry W. Lim said.

For patients at risk of vitamin D deficiency, it is better to recommend a vitamin D-fortified diet and daily supplements of 800 IU of vitamin D (ideally vitamin D₃) plus calcium, he said at the annual meeting of the American Academy of Dermatology.

Dr. Lim, chairman of the dermatology residency program at Henry Ford Hospital, Detroit, organized a 2005 consensus conference for the academy called Sunlight, Tanning Booths, and Vitamin D. At the annual meeting he discussed more recent data on vitamin D and presented his preferred approach to vitamin D management.

Intentional sun exposure is a problem because the harmful side effects of UVB can't be separated from the beneficial vitamin D photosynthesis that sunlight provides. UV light acutely damages skin DNA and can cause erythema, sunburn, and photoimmunosuppression. In the long term, UV irradiation leads to photoaging and possible photocarcinogenesis. Half of all cancers in humans are skin cancers.

In addition, vitamin D synthesis appears to occur at different rates in people of different skin types. That, plus significant daily and seasonal variability in weather patterns and availability of sunlight make it difficult to craft public health policies based on intentional sun exposure, Dr. Lim said.

Studies have identified certain populations that may not be getting adequate vitamin D, including the elderly, people with darkly pigmented skin, and those living in wintry climates. Other studies, however, show that most people achieve adequate vitamin D serum levels in the course of normal daily life, even when using sunscreen, presumably through incidental sun exposure, dietary intake, and supplementation, he added.

Recent data suggest that levels in U.S. whites averaged 80 nmol/L, “which is considered nowadays by most studies to be an adequate level of serum vitamin D,” Dr. Lim noted. In Hispanic Americans, however, serum levels averaged 60 nmol/L, and in U.S. blacks, serum vitamin D averaged 50 nmol/L.

Very modest sun exposure produces maximal vitamin D photosynthesis in fair-skinned people. This makes prolonged sun exposure unnecessary and potentially dangerous for these people, he said.

Separate data on individuals older than 60 years—who presumably are less active and spend more time indoors—suggest that 67% of whites and 88% of blacks have serum vitamin D levels below 80 nmol/L.

The 2005 consensus conference concluded that it may be time to increase recommended dietary levels of vitamin D for both the frail elderly and dark-skinned people who get little sun exposure.

Natural dietary sources of vitamin D are few: saltwater fish, cod liver oil, and egg yolks. U.S. guidelines have led to vitamin D fortification of foods, most commonly milk, orange juice, cereal, butter, margarine, and chocolate mixes.

Current U.S. recommendations for daily vitamin D intake call for 200 IU for children and adults up to age 50 years, 400 IU for those aged 51–70 years, and 600–800 IU for those older than 70 years.

“In the past few years there is increasing evidence that these recommendations probably are too low,” Dr. Lim said. One recent study suggested that maintaining sufficient vitamin D levels requires 800–1,000 IU per day of vitamin D₃ or 50,000 IU once per month, a dose that's available by prescription only (Photochem. Photobiol. 2005;81:1246–51). Keep in mind that vitamin D intoxication doesn't occur until daily doses exceed 10,000 IU, Dr. Lim said. “Therefore, even at 800–1,000 IU, there is still a significant margin of safety.”

Dr. Lim recommended three sets of articles as helpful references in the ongoing debate about vitamin D:

▸ Results of the 2005 consensus conference: J. Am. Acad. Dermatol. 2005;52:868–76.

▸ A series of seven articles on UV radiation, beginning with one entitled, UV radiation, vitamin D, and human health: an unfolding controversy: Photochem. Photobiol. 2005;81:1243–5.

▸ An overview of the proceedings from the experimental biology 2004 symposium on vitamin D insufficiency: J. Nutr. 2005;135:301–37.

SALT LAKE CITY — Seventy-seven percent of 78 pediatric patients newly diagnosed with Crohn's disease were anemic, and 88% had upper gastrointestinal tract disease, Dr. Meena Thayu reported in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

“The striking prevalence of upper gastrointestinal tract disease suggests that anemia in these patients may be refractory to oral iron therapy,” wrote Dr. Thayu of the University of Pennsylvania, Philadelphia, and her associates.

The study recruited patients aged 5–18 years within 2 weeks of diagnosis at the Children's Hospital of Philadelphia's Center for Pediatric Inflammatory Bowel Diseases, and before they started therapy. All underwent colonoscopy and 75 of 78 had an esophagoduodenoscopy.

Anemia was associated with greater disease activity as assessed by the Pediatric Crohn's Disease Activity Index and higher erythrocyte sedimentation rates as well as with GI tract disease. There was no association between anemia and gender, duration of symptoms, body composition, growth parameters, or a history of abnormal growth at presentation.

The investigators also looked at changes in body composition, comparing this cohort to data from 669 healthy control children recruited from general pediatric clinics in the community. Crohn's disease is associated with decreased body mass index (BMI), but it also may have discrete effects on lean mass and fat mass that are not reflected in BMI, they noted.

The 34 girls with Crohn's disease had significantly less lean mass, appendicular lean mass (the sum of lean mass in the four extremities), and whole body fat mass compared with female controls as measured by whole-body densitometry scans. Two of these three deficits were more severe in girls with higher Tanner stage: lean mass, and appendicular lean mass.

Nonblack boys had significantly less lean mass and appendicular lean mass compared with controls. The control group had a significantly higher proportion of blacks (37%) compared with the Crohn's disease group (10%).

The deficits in body composition were not associated with disease characteristics such as the duration of symptoms, the presence of upper GI tract disease, and anemia.

A prospective study currently is evaluating the effect of Crohn's disease treatment on anemia and body composition in this cohort.

SALT LAKE CITY — Seventy-seven percent of 78 pediatric patients newly diagnosed with Crohn's disease were anemic, and 88% had upper gastrointestinal tract disease, Dr. Meena Thayu reported in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

“The striking prevalence of upper gastrointestinal tract disease suggests that anemia in these patients may be refractory to oral iron therapy,” wrote Dr. Thayu of the University of Pennsylvania, Philadelphia, and her associates.

The study recruited patients aged 5–18 years within 2 weeks of diagnosis at the Children's Hospital of Philadelphia's Center for Pediatric Inflammatory Bowel Diseases, and before they started therapy. All underwent colonoscopy and 75 of 78 had an esophagoduodenoscopy.

Anemia was associated with greater disease activity as assessed by the Pediatric Crohn's Disease Activity Index and higher erythrocyte sedimentation rates as well as with GI tract disease. There was no association between anemia and gender, duration of symptoms, body composition, growth parameters, or a history of abnormal growth at presentation.

The investigators also looked at changes in body composition, comparing this cohort to data from 669 healthy control children recruited from general pediatric clinics in the community. Crohn's disease is associated with decreased body mass index (BMI), but it also may have discrete effects on lean mass and fat mass that are not reflected in BMI, they noted.

The 34 girls with Crohn's disease had significantly less lean mass, appendicular lean mass (the sum of lean mass in the four extremities), and whole body fat mass compared with female controls as measured by whole-body densitometry scans. Two of these three deficits were more severe in girls with higher Tanner stage: lean mass, and appendicular lean mass.

Nonblack boys had significantly less lean mass and appendicular lean mass compared with controls. The control group had a significantly higher proportion of blacks (37%) compared with the Crohn's disease group (10%).

The deficits in body composition were not associated with disease characteristics such as the duration of symptoms, the presence of upper GI tract disease, and anemia.

A prospective study currently is evaluating the effect of Crohn's disease treatment on anemia and body composition in this cohort.

SALT LAKE CITY — Seventy-seven percent of 78 pediatric patients newly diagnosed with Crohn's disease were anemic, and 88% had upper gastrointestinal tract disease, Dr. Meena Thayu reported in a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

“The striking prevalence of upper gastrointestinal tract disease suggests that anemia in these patients may be refractory to oral iron therapy,” wrote Dr. Thayu of the University of Pennsylvania, Philadelphia, and her associates.

The study recruited patients aged 5–18 years within 2 weeks of diagnosis at the Children's Hospital of Philadelphia's Center for Pediatric Inflammatory Bowel Diseases, and before they started therapy. All underwent colonoscopy and 75 of 78 had an esophagoduodenoscopy.

Anemia was associated with greater disease activity as assessed by the Pediatric Crohn's Disease Activity Index and higher erythrocyte sedimentation rates as well as with GI tract disease. There was no association between anemia and gender, duration of symptoms, body composition, growth parameters, or a history of abnormal growth at presentation.

The investigators also looked at changes in body composition, comparing this cohort to data from 669 healthy control children recruited from general pediatric clinics in the community. Crohn's disease is associated with decreased body mass index (BMI), but it also may have discrete effects on lean mass and fat mass that are not reflected in BMI, they noted.

The 34 girls with Crohn's disease had significantly less lean mass, appendicular lean mass (the sum of lean mass in the four extremities), and whole body fat mass compared with female controls as measured by whole-body densitometry scans. Two of these three deficits were more severe in girls with higher Tanner stage: lean mass, and appendicular lean mass.

Nonblack boys had significantly less lean mass and appendicular lean mass compared with controls. The control group had a significantly higher proportion of blacks (37%) compared with the Crohn's disease group (10%).

The deficits in body composition were not associated with disease characteristics such as the duration of symptoms, the presence of upper GI tract disease, and anemia.

A prospective study currently is evaluating the effect of Crohn's disease treatment on anemia and body composition in this cohort.

SAN FRANCISCO — The burning issue of how best to make sure that patients get enough vitamin D comes down to this conclusion: Recommending intentional exposure to the sun is inappropriate, Dr. Henry W. Lim said.

For patients at risk of vitamin D deficiency, it is better to recommend a vitamin D-fortified diet and daily supplements of 800 IU of vitamin D (ideally vitamin D₃) plus calcium, he said at the annual meeting of the American Academy of Dermatology.

Dr. Lim, chair of the dermatology residency program at Henry Ford Hospital, Detroit, organized a 2005 consensus conference for the academy called Sunlight, Tanning Booths, and Vitamin D. At the annual meeting he discussed more recent data on vitamin D and presented his approach to vitamin D management.

Intentional sun exposure is a problem because the harmful side effects of UVB can't be separated from the beneficial vitamin D photosynthesis that sunlight provides. UV light acutely damages skin DNA and can cause erythema, sunburn, and photoimmunosuppression. In the long term, UV irradiation leads to photoaging and possible photocarcinogenesis. Half of all cancers in humans are skin cancers.

In addition, vitamin D synthesis appears to occur at different rates in people of different skin types. That, plus significant daily and seasonal variability in weather patterns and availability of sunlight make it difficult to craft public health policies based on intentional sun exposure, Dr. Lim said.

Studies have identified certain populations that may not be getting adequate vitamin D, including the elderly, people with darkly pigmented skin, and those living in wintry climates. Other studies, however, show that most people achieve adequate vitamin D serum levels in the course of normal daily life, even when using sunscreen, presumably through incidental sun exposure, dietary intake, and supplementation.

Recent data suggest that levels in U.S. whites averaged 80 nmol/L, “which is considered nowadays by most studies to be an adequate level of serum vitamin D,” Dr. Lim noted. In Hispanic Americans, however, serum levels averaged 60 nmol/L, and in U.S. blacks, serum vitamin D averaged 50 nmol/L.

Very modest sun exposure produces maximal vitamin D photosynthesis in fair-skinned people. This makes prolonged sun exposure unnecessary and potentially dangerous for these people, he said.

Separate data on individuals older than 60 years—who presumably are less active and spend more time indoors—suggest that 67% of whites and 88% of blacks have serum vitamin D levels below 80 nmol/L.

The 2005 consensus conference concluded that it may be time to increase recommended dietary levels of vitamin D for both the frail elderly and dark-skinned people who get little sun exposure.

Natural dietary sources of vitamin D are few: saltwater fish, cod liver oil, and egg yolks. U.S. guidelines have led to vitamin D fortification of foods, most commonly milk, orange juice, cereal, butter, margarine, and chocolate mixes.

Current U.S. recommendations for daily vitamin D intake call for 200 IU for children and adults up to age 50 years, 400 IU for those aged 51–70 years, and 600–800 IU for those older than 70 years. “In the past few years there is increasing evidence that these recommendations probably are too low,” Dr. Lim said.

One recent study suggested that maintaining sufficient vitamin D levels requires 800–1,000 IU per day of vitamin D₃ or 50,000 IU once per month, a dose that's available by prescription only (Photochem. Photobiol. 2005;81:1246–51).

Keep in mind that vitamin D intoxication doesn't occur until daily doses exceed 10,000 IU, Dr. Lim said. “Therefore, even at 800–1,000 IU, there is still a significant margin of safety.”

Dr. Lim advised reading three articles about the ongoing vitamin D debate:

▸ Results of the 2005 consensus conference: J. Am. Acad. Dermatol. 2005;52–868–76.

▸ A series of seven articles on UV radiation, beginning with one entitled, UV radiation, vitamin D, and human health: an unfolding controversy: Photochem. Photobiol. 2005;81:1243–5.

▸ An overview of the proceedings from the experimental biology 2004 symposium on vitamin D insufficiency: J. Nutr. 2005;135:301–37.

WHI Analyses Raise New Doubts

The failure of vitamin D and calcium supplementation to reduce the risks of fracture or colorectal cancer in two recently published placebo-controlled studies generated abundant media coverage and controversy.

Both studies had significant limitations, however, and ultimately shouldn't negate the epidemiologic evidence for the beneficial effects of vitamin D, Dr. Lim said.

Both of the recent studies analyzed data from 36,282 postmenopausal women in the Women's Health Initiative who were randomized to daily placebo or to supplementation with 1,000 mg calcium and 400 IU vitamin D₃ for 7 years.

One study found no significant differences between groups in the risk of fracture, but did find an increased risk for kidney stone formation in the supplementation group (N. Engl. J. Med. 2006;354:669–83). The results surprised medical experts. “This is contradictory to what we all expected and what we all believe is true,” Dr. Lim said. The second study found no difference between groups in the incidence of colorectal cancer or in tumor characteristics (N. Engl. J. Med. 2006;354:684–96).

Editorials in the same issue pointed out the studies' limitations. The 400 IU/day dose of vitamin D in both studies may have been suboptimal. There is a growing consensus to revise recommended doses upward.

In the study of fracture risk, subjects were not selected based on low bone mineral density, and 75% in both groups were on hormone replacement therapy. All subjects were allowed to take personal supplements. In the placebo group, 64% of women took calcium supplements, and 42% took 400 IU/day of vitamin D (N. Engl. J. Med. 2006;354:750–2).

In the other study, the mean age at entry was 62 years, “which is just reaching the high-risk age for development of colorectal cancer,” Dr. Lim said, and the 7-year follow-up was too early to detect significant differences between groups for cancer incidence (N. Engl. J. Med. 2006;354:752–4).

SAN FRANCISCO — The burning issue of how best to make sure that patients get enough vitamin D comes down to this conclusion: Recommending intentional exposure to the sun is inappropriate, Dr. Henry W. Lim said.

For patients at risk of vitamin D deficiency, it is better to recommend a vitamin D-fortified diet and daily supplements of 800 IU of vitamin D (ideally vitamin D₃) plus calcium, he said at the annual meeting of the American Academy of Dermatology.

Dr. Lim, chair of the dermatology residency program at Henry Ford Hospital, Detroit, organized a 2005 consensus conference for the academy called Sunlight, Tanning Booths, and Vitamin D. At the annual meeting he discussed more recent data on vitamin D and presented his approach to vitamin D management.

Intentional sun exposure is a problem because the harmful side effects of UVB can't be separated from the beneficial vitamin D photosynthesis that sunlight provides. UV light acutely damages skin DNA and can cause erythema, sunburn, and photoimmunosuppression. In the long term, UV irradiation leads to photoaging and possible photocarcinogenesis. Half of all cancers in humans are skin cancers.

In addition, vitamin D synthesis appears to occur at different rates in people of different skin types. That, plus significant daily and seasonal variability in weather patterns and availability of sunlight make it difficult to craft public health policies based on intentional sun exposure, Dr. Lim said.

Studies have identified certain populations that may not be getting adequate vitamin D, including the elderly, people with darkly pigmented skin, and those living in wintry climates. Other studies, however, show that most people achieve adequate vitamin D serum levels in the course of normal daily life, even when using sunscreen, presumably through incidental sun exposure, dietary intake, and supplementation.

Recent data suggest that levels in U.S. whites averaged 80 nmol/L, “which is considered nowadays by most studies to be an adequate level of serum vitamin D,” Dr. Lim noted. In Hispanic Americans, however, serum levels averaged 60 nmol/L, and in U.S. blacks, serum vitamin D averaged 50 nmol/L.

Very modest sun exposure produces maximal vitamin D photosynthesis in fair-skinned people. This makes prolonged sun exposure unnecessary and potentially dangerous for these people, he said.

Separate data on individuals older than 60 years—who presumably are less active and spend more time indoors—suggest that 67% of whites and 88% of blacks have serum vitamin D levels below 80 nmol/L.

The 2005 consensus conference concluded that it may be time to increase recommended dietary levels of vitamin D for both the frail elderly and dark-skinned people who get little sun exposure.

Natural dietary sources of vitamin D are few: saltwater fish, cod liver oil, and egg yolks. U.S. guidelines have led to vitamin D fortification of foods, most commonly milk, orange juice, cereal, butter, margarine, and chocolate mixes.

Current U.S. recommendations for daily vitamin D intake call for 200 IU for children and adults up to age 50 years, 400 IU for those aged 51–70 years, and 600–800 IU for those older than 70 years. “In the past few years there is increasing evidence that these recommendations probably are too low,” Dr. Lim said.

One recent study suggested that maintaining sufficient vitamin D levels requires 800–1,000 IU per day of vitamin D₃ or 50,000 IU once per month, a dose that's available by prescription only (Photochem. Photobiol. 2005;81:1246–51).

Keep in mind that vitamin D intoxication doesn't occur until daily doses exceed 10,000 IU, Dr. Lim said. “Therefore, even at 800–1,000 IU, there is still a significant margin of safety.”

Dr. Lim advised reading three articles about the ongoing vitamin D debate:

▸ Results of the 2005 consensus conference: J. Am. Acad. Dermatol. 2005;52–868–76.

▸ A series of seven articles on UV radiation, beginning with one entitled, UV radiation, vitamin D, and human health: an unfolding controversy: Photochem. Photobiol. 2005;81:1243–5.

▸ An overview of the proceedings from the experimental biology 2004 symposium on vitamin D insufficiency: J. Nutr. 2005;135:301–37.

WHI Analyses Raise New Doubts

The failure of vitamin D and calcium supplementation to reduce the risks of fracture or colorectal cancer in two recently published placebo-controlled studies generated abundant media coverage and controversy.

Both studies had significant limitations, however, and ultimately shouldn't negate the epidemiologic evidence for the beneficial effects of vitamin D, Dr. Lim said.

Both of the recent studies analyzed data from 36,282 postmenopausal women in the Women's Health Initiative who were randomized to daily placebo or to supplementation with 1,000 mg calcium and 400 IU vitamin D₃ for 7 years.

One study found no significant differences between groups in the risk of fracture, but did find an increased risk for kidney stone formation in the supplementation group (N. Engl. J. Med. 2006;354:669–83). The results surprised medical experts. “This is contradictory to what we all expected and what we all believe is true,” Dr. Lim said. The second study found no difference between groups in the incidence of colorectal cancer or in tumor characteristics (N. Engl. J. Med. 2006;354:684–96).

Editorials in the same issue pointed out the studies' limitations. The 400 IU/day dose of vitamin D in both studies may have been suboptimal. There is a growing consensus to revise recommended doses upward.

In the study of fracture risk, subjects were not selected based on low bone mineral density, and 75% in both groups were on hormone replacement therapy. All subjects were allowed to take personal supplements. In the placebo group, 64% of women took calcium supplements, and 42% took 400 IU/day of vitamin D (N. Engl. J. Med. 2006;354:750–2).

In the other study, the mean age at entry was 62 years, “which is just reaching the high-risk age for development of colorectal cancer,” Dr. Lim said, and the 7-year follow-up was too early to detect significant differences between groups for cancer incidence (N. Engl. J. Med. 2006;354:752–4).

SAN FRANCISCO — The burning issue of how best to make sure that patients get enough vitamin D comes down to this conclusion: Recommending intentional exposure to the sun is inappropriate, Dr. Henry W. Lim said.

For patients at risk of vitamin D deficiency, it is better to recommend a vitamin D-fortified diet and daily supplements of 800 IU of vitamin D (ideally vitamin D₃) plus calcium, he said at the annual meeting of the American Academy of Dermatology.

Dr. Lim, chair of the dermatology residency program at Henry Ford Hospital, Detroit, organized a 2005 consensus conference for the academy called Sunlight, Tanning Booths, and Vitamin D. At the annual meeting he discussed more recent data on vitamin D and presented his approach to vitamin D management.

Intentional sun exposure is a problem because the harmful side effects of UVB can't be separated from the beneficial vitamin D photosynthesis that sunlight provides. UV light acutely damages skin DNA and can cause erythema, sunburn, and photoimmunosuppression. In the long term, UV irradiation leads to photoaging and possible photocarcinogenesis. Half of all cancers in humans are skin cancers.

In addition, vitamin D synthesis appears to occur at different rates in people of different skin types. That, plus significant daily and seasonal variability in weather patterns and availability of sunlight make it difficult to craft public health policies based on intentional sun exposure, Dr. Lim said.

Studies have identified certain populations that may not be getting adequate vitamin D, including the elderly, people with darkly pigmented skin, and those living in wintry climates. Other studies, however, show that most people achieve adequate vitamin D serum levels in the course of normal daily life, even when using sunscreen, presumably through incidental sun exposure, dietary intake, and supplementation.

Recent data suggest that levels in U.S. whites averaged 80 nmol/L, “which is considered nowadays by most studies to be an adequate level of serum vitamin D,” Dr. Lim noted. In Hispanic Americans, however, serum levels averaged 60 nmol/L, and in U.S. blacks, serum vitamin D averaged 50 nmol/L.

Very modest sun exposure produces maximal vitamin D photosynthesis in fair-skinned people. This makes prolonged sun exposure unnecessary and potentially dangerous for these people, he said.

Separate data on individuals older than 60 years—who presumably are less active and spend more time indoors—suggest that 67% of whites and 88% of blacks have serum vitamin D levels below 80 nmol/L.

The 2005 consensus conference concluded that it may be time to increase recommended dietary levels of vitamin D for both the frail elderly and dark-skinned people who get little sun exposure.

Natural dietary sources of vitamin D are few: saltwater fish, cod liver oil, and egg yolks. U.S. guidelines have led to vitamin D fortification of foods, most commonly milk, orange juice, cereal, butter, margarine, and chocolate mixes.

Current U.S. recommendations for daily vitamin D intake call for 200 IU for children and adults up to age 50 years, 400 IU for those aged 51–70 years, and 600–800 IU for those older than 70 years. “In the past few years there is increasing evidence that these recommendations probably are too low,” Dr. Lim said.

One recent study suggested that maintaining sufficient vitamin D levels requires 800–1,000 IU per day of vitamin D₃ or 50,000 IU once per month, a dose that's available by prescription only (Photochem. Photobiol. 2005;81:1246–51).

Keep in mind that vitamin D intoxication doesn't occur until daily doses exceed 10,000 IU, Dr. Lim said. “Therefore, even at 800–1,000 IU, there is still a significant margin of safety.”

Dr. Lim advised reading three articles about the ongoing vitamin D debate:

▸ Results of the 2005 consensus conference: J. Am. Acad. Dermatol. 2005;52–868–76.

▸ A series of seven articles on UV radiation, beginning with one entitled, UV radiation, vitamin D, and human health: an unfolding controversy: Photochem. Photobiol. 2005;81:1243–5.

▸ An overview of the proceedings from the experimental biology 2004 symposium on vitamin D insufficiency: J. Nutr. 2005;135:301–37.

WHI Analyses Raise New Doubts

The failure of vitamin D and calcium supplementation to reduce the risks of fracture or colorectal cancer in two recently published placebo-controlled studies generated abundant media coverage and controversy.

Both studies had significant limitations, however, and ultimately shouldn't negate the epidemiologic evidence for the beneficial effects of vitamin D, Dr. Lim said.

Both of the recent studies analyzed data from 36,282 postmenopausal women in the Women's Health Initiative who were randomized to daily placebo or to supplementation with 1,000 mg calcium and 400 IU vitamin D₃ for 7 years.

One study found no significant differences between groups in the risk of fracture, but did find an increased risk for kidney stone formation in the supplementation group (N. Engl. J. Med. 2006;354:669–83). The results surprised medical experts. “This is contradictory to what we all expected and what we all believe is true,” Dr. Lim said. The second study found no difference between groups in the incidence of colorectal cancer or in tumor characteristics (N. Engl. J. Med. 2006;354:684–96).

Editorials in the same issue pointed out the studies' limitations. The 400 IU/day dose of vitamin D in both studies may have been suboptimal. There is a growing consensus to revise recommended doses upward.

In the study of fracture risk, subjects were not selected based on low bone mineral density, and 75% in both groups were on hormone replacement therapy. All subjects were allowed to take personal supplements. In the placebo group, 64% of women took calcium supplements, and 42% took 400 IU/day of vitamin D (N. Engl. J. Med. 2006;354:750–2).

In the other study, the mean age at entry was 62 years, “which is just reaching the high-risk age for development of colorectal cancer,” Dr. Lim said, and the 7-year follow-up was too early to detect significant differences between groups for cancer incidence (N. Engl. J. Med. 2006;354:752–4).

KAILUA KONA, HAWAII — Think of both ends of the fertility spectrum when advising women about preventing or treating cervical cancer, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

An increasing number of malpractice cases are being brought by teenagers who claim that no one adequately explained the risks of sexual activity and of avoiding Pap smears, said Ms. Baker, a defense lawyer in Seattle who also holds a bachelor's degree in nursing.

These adolescents lack an understanding of the threats that sexual activity and a lack of screening can pose to their bodies, their fertility, and even their lives if they contract a sexually transmitted disease. Physicians “are being too casual about this,” she said. “You need to document exactly what you said” in counseling the patient.

Explain things in terms that the teenager can understand, Ms. Baker said at the conference, which was sponsored by Boston University.

If a cervical lesion needs treatment, be sure to discuss the potential effects on fertility—especially when counseling young patients and older patients, she added. As more and more women delay childbearing, an increase in malpractice cases related to cervical cancer is being seen on the older end of the premenopausal age spectrum when treatment fails to protect fertility and the patient isn't warned of possible effects on fertility.

“Along with that, there needs to be a frank discussion about what is not available to them” if cervical cancer treatment affects fertility, she said. Without that discussion, women who cannot get pregnant may waste time, money, and energy on assisted reproductive technology that may not be appropriate for them.

If your “bedside manner” isn't the best, consider putting patients with cervical lesions in touch with a mental health care provider to provide support. Lack of rapport between patients and providers is a major contributor to lawsuits, Ms. Baker said.

Obstetricians need to keep in mind the whole health of the patient, not just the pregnancy, she added. In one case, a 22-year-old woman had Pap smears taken just before a pregnancy and in the first postpartum exam, but neither was followed up. She died of cervical cancer 18 months after giving birth to the child.

“While you're trying to be excited about the birth of her child and talking about contraception, weight loss, or whatever, be mindful” of conducting Pap smears and following up on results, she advised.

KAILUA KONA, HAWAII — Think of both ends of the fertility spectrum when advising women about preventing or treating cervical cancer, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

An increasing number of malpractice cases are being brought by teenagers who claim that no one adequately explained the risks of sexual activity and of avoiding Pap smears, said Ms. Baker, a defense lawyer in Seattle who also holds a bachelor's degree in nursing.

These adolescents lack an understanding of the threats that sexual activity and a lack of screening can pose to their bodies, their fertility, and even their lives if they contract a sexually transmitted disease. Physicians “are being too casual about this,” she said. “You need to document exactly what you said” in counseling the patient.

Explain things in terms that the teenager can understand, Ms. Baker said at the conference, which was sponsored by Boston University.

If a cervical lesion needs treatment, be sure to discuss the potential effects on fertility—especially when counseling young patients and older patients, she added. As more and more women delay childbearing, an increase in malpractice cases related to cervical cancer is being seen on the older end of the premenopausal age spectrum when treatment fails to protect fertility and the patient isn't warned of possible effects on fertility.

“Along with that, there needs to be a frank discussion about what is not available to them” if cervical cancer treatment affects fertility, she said. Without that discussion, women who cannot get pregnant may waste time, money, and energy on assisted reproductive technology that may not be appropriate for them.

If your “bedside manner” isn't the best, consider putting patients with cervical lesions in touch with a mental health care provider to provide support. Lack of rapport between patients and providers is a major contributor to lawsuits, Ms. Baker said.

Obstetricians need to keep in mind the whole health of the patient, not just the pregnancy, she added. In one case, a 22-year-old woman had Pap smears taken just before a pregnancy and in the first postpartum exam, but neither was followed up. She died of cervical cancer 18 months after giving birth to the child.

“While you're trying to be excited about the birth of her child and talking about contraception, weight loss, or whatever, be mindful” of conducting Pap smears and following up on results, she advised.

KAILUA KONA, HAWAII — Think of both ends of the fertility spectrum when advising women about preventing or treating cervical cancer, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

An increasing number of malpractice cases are being brought by teenagers who claim that no one adequately explained the risks of sexual activity and of avoiding Pap smears, said Ms. Baker, a defense lawyer in Seattle who also holds a bachelor's degree in nursing.

These adolescents lack an understanding of the threats that sexual activity and a lack of screening can pose to their bodies, their fertility, and even their lives if they contract a sexually transmitted disease. Physicians “are being too casual about this,” she said. “You need to document exactly what you said” in counseling the patient.

Explain things in terms that the teenager can understand, Ms. Baker said at the conference, which was sponsored by Boston University.

If a cervical lesion needs treatment, be sure to discuss the potential effects on fertility—especially when counseling young patients and older patients, she added. As more and more women delay childbearing, an increase in malpractice cases related to cervical cancer is being seen on the older end of the premenopausal age spectrum when treatment fails to protect fertility and the patient isn't warned of possible effects on fertility.

“Along with that, there needs to be a frank discussion about what is not available to them” if cervical cancer treatment affects fertility, she said. Without that discussion, women who cannot get pregnant may waste time, money, and energy on assisted reproductive technology that may not be appropriate for them.

If your “bedside manner” isn't the best, consider putting patients with cervical lesions in touch with a mental health care provider to provide support. Lack of rapport between patients and providers is a major contributor to lawsuits, Ms. Baker said.

Obstetricians need to keep in mind the whole health of the patient, not just the pregnancy, she added. In one case, a 22-year-old woman had Pap smears taken just before a pregnancy and in the first postpartum exam, but neither was followed up. She died of cervical cancer 18 months after giving birth to the child.

“While you're trying to be excited about the birth of her child and talking about contraception, weight loss, or whatever, be mindful” of conducting Pap smears and following up on results, she advised.

KAILUA KONA, HAWAII — Five studies may change the way physicians think about prolonged premature rupture of membranes, perinatal stroke in the fetus, and other topics, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He delineated the following areas in which obstetric practices could change because of these studies.

PPROM

If a pregnant woman with prolonged premature rupture of membranes (PPROM) reaches 34 weeks' gestation, it's probably in the mother's and the baby's best interests to deliver the baby rather than continue expectant management, according to a single-institution observational study (Obstet. Gynecol. 2005;105:12–7).

The investigators studied 430 pregnancies in 1998–2000 with PPROM and 24–36 weeks' gestation to determine optimal delivery time. Infants were delivered after reaching maturity (34 weeks or later) or after the development of chorioamnionitis, active labor, fetal compromise, or phosphatidylglycerol in vaginal pools.

Composite scores for neonatal morbidity suggested that there is limited benefit to continuing expectant management after 34 weeks in women with PPROM. Although this was not a randomized, controlled trial, physicians should seriously consider delivering these babies before 35 weeks' gestation to avoid the risk of abruption, the sudden onset of infection, or other problems, said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Perinatal Stroke

An analysis of data from the Kaiser Permanente system identified four major risk factors for perinatal arterial ischemic stroke (PAS), which is present in 50%–70% of fetuses with hemiplegic cerebral palsy, epilepsy, or cognitive impairment.

“Read this [report] and understand that it is possible for a baby to have a stroke in utero” even if clinicians did nothing wrong during pregnancy or delivery, he said at the meeting sponsored by Boston University.

Two independent investigators reviewed 1,970 cases, compared them with three matched controls per case, and conducted multivariate analyses for risk factors. They found a rate of PAS of 20 per 100,000 live-born infants (JAMA 2005;293:723–9).

The four major risk factors for PAS were a history of infertility (with the risk perhaps related to the use of infertility drugs), preeclampsia, chorioamnionitis, and PPROM lasting longer than 18 hours. To defend against a lawsuit related to a bad outcome in a baby with PAS, look at the records to see if these risk factors were present, he suggested.

Trial of Labor

A 4-year observational study of 45,988 pregnant women with a prior cesarean section who underwent either a trial of labor or elective C-section answered an important question about the risks of inducing labor with Pitocin (synthetic oxytocin) that had been left hanging by previous studies of vaginal births after cesarean section.

Inducing labor significantly increased the risk of uterine rupture and rate of perinatal complications, the investigators found (N. Engl. J. Med. 2004;351:2581–9). Keep that in mind when counseling patients, he suggested.

Suctioning

A randomized, controlled study of 2,514 infants with meconium called into question the routine intrapartum practice of oropharyngeal suctioning.

Routine intrapartum suctioning did not prevent meconium aspiration syndrome, and in rare cases it traumatized the nasopharynx or caused a cardiac arrythmia (Lancet 2004;364:597–602). Recommendations for routine intrapartum suctioning should be revised, Dr. Belfort said.

Herpes

A metaanalysis of five randomized, controlled trials involving 799 pregnant women with herpes simplex virus found that giving acyclovir therapy beginning at 36 weeks' gestation reduced herpes recurrences at delivery, viral load, symptomatic shedding, and the need for a C-section (Obstet. Gynecol. 2003;102:1396–403).

“This is hard evidence, in my mind at least, that this is the standard of care now for women with herpes,” he said.

KAILUA KONA, HAWAII — Five studies may change the way physicians think about prolonged premature rupture of membranes, perinatal stroke in the fetus, and other topics, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He delineated the following areas in which obstetric practices could change because of these studies.

PPROM

If a pregnant woman with prolonged premature rupture of membranes (PPROM) reaches 34 weeks' gestation, it's probably in the mother's and the baby's best interests to deliver the baby rather than continue expectant management, according to a single-institution observational study (Obstet. Gynecol. 2005;105:12–7).

The investigators studied 430 pregnancies in 1998–2000 with PPROM and 24–36 weeks' gestation to determine optimal delivery time. Infants were delivered after reaching maturity (34 weeks or later) or after the development of chorioamnionitis, active labor, fetal compromise, or phosphatidylglycerol in vaginal pools.

Composite scores for neonatal morbidity suggested that there is limited benefit to continuing expectant management after 34 weeks in women with PPROM. Although this was not a randomized, controlled trial, physicians should seriously consider delivering these babies before 35 weeks' gestation to avoid the risk of abruption, the sudden onset of infection, or other problems, said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Perinatal Stroke

An analysis of data from the Kaiser Permanente system identified four major risk factors for perinatal arterial ischemic stroke (PAS), which is present in 50%–70% of fetuses with hemiplegic cerebral palsy, epilepsy, or cognitive impairment.

“Read this [report] and understand that it is possible for a baby to have a stroke in utero” even if clinicians did nothing wrong during pregnancy or delivery, he said at the meeting sponsored by Boston University.

Two independent investigators reviewed 1,970 cases, compared them with three matched controls per case, and conducted multivariate analyses for risk factors. They found a rate of PAS of 20 per 100,000 live-born infants (JAMA 2005;293:723–9).

The four major risk factors for PAS were a history of infertility (with the risk perhaps related to the use of infertility drugs), preeclampsia, chorioamnionitis, and PPROM lasting longer than 18 hours. To defend against a lawsuit related to a bad outcome in a baby with PAS, look at the records to see if these risk factors were present, he suggested.

Trial of Labor

A 4-year observational study of 45,988 pregnant women with a prior cesarean section who underwent either a trial of labor or elective C-section answered an important question about the risks of inducing labor with Pitocin (synthetic oxytocin) that had been left hanging by previous studies of vaginal births after cesarean section.

Inducing labor significantly increased the risk of uterine rupture and rate of perinatal complications, the investigators found (N. Engl. J. Med. 2004;351:2581–9). Keep that in mind when counseling patients, he suggested.

Suctioning

A randomized, controlled study of 2,514 infants with meconium called into question the routine intrapartum practice of oropharyngeal suctioning.

Routine intrapartum suctioning did not prevent meconium aspiration syndrome, and in rare cases it traumatized the nasopharynx or caused a cardiac arrythmia (Lancet 2004;364:597–602). Recommendations for routine intrapartum suctioning should be revised, Dr. Belfort said.

Herpes

A metaanalysis of five randomized, controlled trials involving 799 pregnant women with herpes simplex virus found that giving acyclovir therapy beginning at 36 weeks' gestation reduced herpes recurrences at delivery, viral load, symptomatic shedding, and the need for a C-section (Obstet. Gynecol. 2003;102:1396–403).

“This is hard evidence, in my mind at least, that this is the standard of care now for women with herpes,” he said.

KAILUA KONA, HAWAII — Five studies may change the way physicians think about prolonged premature rupture of membranes, perinatal stroke in the fetus, and other topics, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He delineated the following areas in which obstetric practices could change because of these studies.

PPROM

If a pregnant woman with prolonged premature rupture of membranes (PPROM) reaches 34 weeks' gestation, it's probably in the mother's and the baby's best interests to deliver the baby rather than continue expectant management, according to a single-institution observational study (Obstet. Gynecol. 2005;105:12–7).

The investigators studied 430 pregnancies in 1998–2000 with PPROM and 24–36 weeks' gestation to determine optimal delivery time. Infants were delivered after reaching maturity (34 weeks or later) or after the development of chorioamnionitis, active labor, fetal compromise, or phosphatidylglycerol in vaginal pools.

Composite scores for neonatal morbidity suggested that there is limited benefit to continuing expectant management after 34 weeks in women with PPROM. Although this was not a randomized, controlled trial, physicians should seriously consider delivering these babies before 35 weeks' gestation to avoid the risk of abruption, the sudden onset of infection, or other problems, said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Perinatal Stroke

An analysis of data from the Kaiser Permanente system identified four major risk factors for perinatal arterial ischemic stroke (PAS), which is present in 50%–70% of fetuses with hemiplegic cerebral palsy, epilepsy, or cognitive impairment.

“Read this [report] and understand that it is possible for a baby to have a stroke in utero” even if clinicians did nothing wrong during pregnancy or delivery, he said at the meeting sponsored by Boston University.

Two independent investigators reviewed 1,970 cases, compared them with three matched controls per case, and conducted multivariate analyses for risk factors. They found a rate of PAS of 20 per 100,000 live-born infants (JAMA 2005;293:723–9).

The four major risk factors for PAS were a history of infertility (with the risk perhaps related to the use of infertility drugs), preeclampsia, chorioamnionitis, and PPROM lasting longer than 18 hours. To defend against a lawsuit related to a bad outcome in a baby with PAS, look at the records to see if these risk factors were present, he suggested.

Trial of Labor

A 4-year observational study of 45,988 pregnant women with a prior cesarean section who underwent either a trial of labor or elective C-section answered an important question about the risks of inducing labor with Pitocin (synthetic oxytocin) that had been left hanging by previous studies of vaginal births after cesarean section.

Inducing labor significantly increased the risk of uterine rupture and rate of perinatal complications, the investigators found (N. Engl. J. Med. 2004;351:2581–9). Keep that in mind when counseling patients, he suggested.

Suctioning

A randomized, controlled study of 2,514 infants with meconium called into question the routine intrapartum practice of oropharyngeal suctioning.

Routine intrapartum suctioning did not prevent meconium aspiration syndrome, and in rare cases it traumatized the nasopharynx or caused a cardiac arrythmia (Lancet 2004;364:597–602). Recommendations for routine intrapartum suctioning should be revised, Dr. Belfort said.

Herpes

A metaanalysis of five randomized, controlled trials involving 799 pregnant women with herpes simplex virus found that giving acyclovir therapy beginning at 36 weeks' gestation reduced herpes recurrences at delivery, viral load, symptomatic shedding, and the need for a C-section (Obstet. Gynecol. 2003;102:1396–403).

“This is hard evidence, in my mind at least, that this is the standard of care now for women with herpes,” he said.