Robin Seaton Jefferson

Nondiabetic patients with advanced renal insufficiency showed evidence of renal protection from benazepril therapy, along with conventional antihypertensive treatment, reported Dr. Fan Fan Hou of the Nanfang Hospital of Southern Medical University in Guangzhou, China, and associates.

The investigators reported that they observed substantial renal benefits in patients with advanced (stage 4 chronic) renal insufficiency in a randomized, double-blind controlled trial of benazepril (N. Engl. J. Med. 2006;354:131–40).

Based on the findings of the study, Dr. Hou and co-investigators suggested that treatment with ACE inhibitors be initiated at earlier stages of chronic kidney disease. ACE inhibitors have been shown to slow the progression of chronic kidney disease, but until now they have been limited to patients with serum creatinine levels of 3.0 mg/dL or less.

The 3-year study was conducted at the Nanfang (China) Hospital renal division. Patients were aged 18–70 years and had not received ACE inhibitors or angiotensin II-receptor antagonists for at least 6 weeks before screening. They had persistent proteinuria with serum creatinine levels of 1.5–5.0 mg/dL and creatinine clearance of 20–70 mL/min per 1.73 m

The study excluded patients if they had conditions such as renovascular disease, connective tissue disease, or obstructive uropathy, as well as patients being treated with corticosteroids, nonsteroidal anti-inflammatory drugs, or immunosuppressive drugs in the year preceding the trial.

The patients were divided into two groups: group 1 included patients with serum creatinine levels of 1.5–3.0 mg/dL, and group 2 consisted of patients with levels of 3.1–5.0 mg/dL.

During an 8-week run-in phase, patients were given benazepril 10 mg/day for 4 weeks with close monitoring. Then the dosage of the medication was increased to 10 mg twice a day for 4 weeks, and open-label antihypertensive agents were added as necessary.

After the run-in phase, benazepril was discontinued for 3 weeks. Antihypertensive agents were continued to control blood pressure.

After the 3 weeks, all patients in group 1 were given 10 mg of benazepril twice a day. Group 2 patients received either 10 mg of benazepril twice daily or placebo and antihypertensive agents.

“[The] primary efficacy measure was the time to the first event in the composite end point of a doubling of the serum creatinine level, end-stage renal disease or death,” they said.

Of the 422 patients who participated in the run-in phase, 104 in group 1 and 112 in group 2 were assigned to benazepril 20 mg/day; another 112 in group 2 were assigned to placebo.

After a mean follow-up of 3 years, 107 patients assigned to benazepril in group 2 and 108 assigned to placebo were included in the efficacy analysis.

A total of 44 patients in group 2 assigned to benazepril reached the primary end point, compared with 65 patients on placebo.

Although all patients who received benazepril took the same dose, renal outcome was worse in group 2 than in group 1.

Benazepril treatment of the participants in group 2 resulted in a 43% reduction in the risk of reaching the primary end point, compared with placebo, and reduced the risk of end-stage renal disease by 40%. Also in group 2, benazepril was associated with reduced severity of proteinuria, compared with placebo, and was associated with a 23% reduction in the rate of decline in renal function.

Dry cough and an acute increase in serum creatinine level were reported mainly in the first 2 months of benazepril therapy. The incidence of hyperkalemia in group 2 was similar for patients who received benazepril and those who received placebo.

In an editorial comment accompanying the report, Dr. Lee Hebert of Ohio State University, Columbus, wrote that “although their results indicate that it may be time to change our practice, a number of caveats should be considered before we do so” (N. Engl. J. Med. 2006;354:189–91).

He said that the researchers used only half the maximal recommended dose of benazepril for patients with chronic kidney disease, as well as a twice-daily regimen that provides little opportunity for nocturnal recovery from any hyperkalemia.

Dr. Hebert added that although the results of the study support the continuation of the ACE inhibitor benazepril for treatment of chronic kidney disease, whether other types of ACE inhibitors would achieve the same results is not clear.

Nondiabetic patients with advanced renal insufficiency showed evidence of renal protection from benazepril therapy, along with conventional antihypertensive treatment, reported Dr. Fan Fan Hou of the Nanfang Hospital of Southern Medical University in Guangzhou, China, and associates.

The investigators reported that they observed substantial renal benefits in patients with advanced (stage 4 chronic) renal insufficiency in a randomized, double-blind controlled trial of benazepril (N. Engl. J. Med. 2006;354:131–40).

Based on the findings of the study, Dr. Hou and co-investigators suggested that treatment with ACE inhibitors be initiated at earlier stages of chronic kidney disease. ACE inhibitors have been shown to slow the progression of chronic kidney disease, but until now they have been limited to patients with serum creatinine levels of 3.0 mg/dL or less.

The 3-year study was conducted at the Nanfang (China) Hospital renal division. Patients were aged 18–70 years and had not received ACE inhibitors or angiotensin II-receptor antagonists for at least 6 weeks before screening. They had persistent proteinuria with serum creatinine levels of 1.5–5.0 mg/dL and creatinine clearance of 20–70 mL/min per 1.73 m

The study excluded patients if they had conditions such as renovascular disease, connective tissue disease, or obstructive uropathy, as well as patients being treated with corticosteroids, nonsteroidal anti-inflammatory drugs, or immunosuppressive drugs in the year preceding the trial.

The patients were divided into two groups: group 1 included patients with serum creatinine levels of 1.5–3.0 mg/dL, and group 2 consisted of patients with levels of 3.1–5.0 mg/dL.

During an 8-week run-in phase, patients were given benazepril 10 mg/day for 4 weeks with close monitoring. Then the dosage of the medication was increased to 10 mg twice a day for 4 weeks, and open-label antihypertensive agents were added as necessary.

After the run-in phase, benazepril was discontinued for 3 weeks. Antihypertensive agents were continued to control blood pressure.

After the 3 weeks, all patients in group 1 were given 10 mg of benazepril twice a day. Group 2 patients received either 10 mg of benazepril twice daily or placebo and antihypertensive agents.

“[The] primary efficacy measure was the time to the first event in the composite end point of a doubling of the serum creatinine level, end-stage renal disease or death,” they said.

Of the 422 patients who participated in the run-in phase, 104 in group 1 and 112 in group 2 were assigned to benazepril 20 mg/day; another 112 in group 2 were assigned to placebo.

After a mean follow-up of 3 years, 107 patients assigned to benazepril in group 2 and 108 assigned to placebo were included in the efficacy analysis.

A total of 44 patients in group 2 assigned to benazepril reached the primary end point, compared with 65 patients on placebo.

Although all patients who received benazepril took the same dose, renal outcome was worse in group 2 than in group 1.

Benazepril treatment of the participants in group 2 resulted in a 43% reduction in the risk of reaching the primary end point, compared with placebo, and reduced the risk of end-stage renal disease by 40%. Also in group 2, benazepril was associated with reduced severity of proteinuria, compared with placebo, and was associated with a 23% reduction in the rate of decline in renal function.

Dry cough and an acute increase in serum creatinine level were reported mainly in the first 2 months of benazepril therapy. The incidence of hyperkalemia in group 2 was similar for patients who received benazepril and those who received placebo.

In an editorial comment accompanying the report, Dr. Lee Hebert of Ohio State University, Columbus, wrote that “although their results indicate that it may be time to change our practice, a number of caveats should be considered before we do so” (N. Engl. J. Med. 2006;354:189–91).

He said that the researchers used only half the maximal recommended dose of benazepril for patients with chronic kidney disease, as well as a twice-daily regimen that provides little opportunity for nocturnal recovery from any hyperkalemia.

Dr. Hebert added that although the results of the study support the continuation of the ACE inhibitor benazepril for treatment of chronic kidney disease, whether other types of ACE inhibitors would achieve the same results is not clear.

Nondiabetic patients with advanced renal insufficiency showed evidence of renal protection from benazepril therapy, along with conventional antihypertensive treatment, reported Dr. Fan Fan Hou of the Nanfang Hospital of Southern Medical University in Guangzhou, China, and associates.

The investigators reported that they observed substantial renal benefits in patients with advanced (stage 4 chronic) renal insufficiency in a randomized, double-blind controlled trial of benazepril (N. Engl. J. Med. 2006;354:131–40).

Based on the findings of the study, Dr. Hou and co-investigators suggested that treatment with ACE inhibitors be initiated at earlier stages of chronic kidney disease. ACE inhibitors have been shown to slow the progression of chronic kidney disease, but until now they have been limited to patients with serum creatinine levels of 3.0 mg/dL or less.

The 3-year study was conducted at the Nanfang (China) Hospital renal division. Patients were aged 18–70 years and had not received ACE inhibitors or angiotensin II-receptor antagonists for at least 6 weeks before screening. They had persistent proteinuria with serum creatinine levels of 1.5–5.0 mg/dL and creatinine clearance of 20–70 mL/min per 1.73 m

The study excluded patients if they had conditions such as renovascular disease, connective tissue disease, or obstructive uropathy, as well as patients being treated with corticosteroids, nonsteroidal anti-inflammatory drugs, or immunosuppressive drugs in the year preceding the trial.

The patients were divided into two groups: group 1 included patients with serum creatinine levels of 1.5–3.0 mg/dL, and group 2 consisted of patients with levels of 3.1–5.0 mg/dL.

During an 8-week run-in phase, patients were given benazepril 10 mg/day for 4 weeks with close monitoring. Then the dosage of the medication was increased to 10 mg twice a day for 4 weeks, and open-label antihypertensive agents were added as necessary.

After the run-in phase, benazepril was discontinued for 3 weeks. Antihypertensive agents were continued to control blood pressure.

After the 3 weeks, all patients in group 1 were given 10 mg of benazepril twice a day. Group 2 patients received either 10 mg of benazepril twice daily or placebo and antihypertensive agents.

“[The] primary efficacy measure was the time to the first event in the composite end point of a doubling of the serum creatinine level, end-stage renal disease or death,” they said.

Of the 422 patients who participated in the run-in phase, 104 in group 1 and 112 in group 2 were assigned to benazepril 20 mg/day; another 112 in group 2 were assigned to placebo.

After a mean follow-up of 3 years, 107 patients assigned to benazepril in group 2 and 108 assigned to placebo were included in the efficacy analysis.

A total of 44 patients in group 2 assigned to benazepril reached the primary end point, compared with 65 patients on placebo.

Although all patients who received benazepril took the same dose, renal outcome was worse in group 2 than in group 1.

Benazepril treatment of the participants in group 2 resulted in a 43% reduction in the risk of reaching the primary end point, compared with placebo, and reduced the risk of end-stage renal disease by 40%. Also in group 2, benazepril was associated with reduced severity of proteinuria, compared with placebo, and was associated with a 23% reduction in the rate of decline in renal function.

Dry cough and an acute increase in serum creatinine level were reported mainly in the first 2 months of benazepril therapy. The incidence of hyperkalemia in group 2 was similar for patients who received benazepril and those who received placebo.

In an editorial comment accompanying the report, Dr. Lee Hebert of Ohio State University, Columbus, wrote that “although their results indicate that it may be time to change our practice, a number of caveats should be considered before we do so” (N. Engl. J. Med. 2006;354:189–91).

He said that the researchers used only half the maximal recommended dose of benazepril for patients with chronic kidney disease, as well as a twice-daily regimen that provides little opportunity for nocturnal recovery from any hyperkalemia.

Dr. Hebert added that although the results of the study support the continuation of the ACE inhibitor benazepril for treatment of chronic kidney disease, whether other types of ACE inhibitors would achieve the same results is not clear.

One hundred fifty-three laboratory-confirmed influenza-associated deaths in children were reported during the 2003–2004 influenza season; this number may exceed childhood mortality associated with other vaccine-preventable diseases in the United States.

Dr. Niranjan Bhat and Jennifer G. Wright, D.V.M., and their associates at the National Center for Infectious Diseases, Atlanta, reported that high priority should be given to improvements in influenza-vaccine coverage and in the early diagnosis and treatment of influenza to reduce childhood mortality from influenza (N. Engl. J. Med. 2005;353:2559–67).

In the study, mortality was highest among children younger than 6 months and next highest among those 6–23 months of age.

Forty state health departments reported 153 influenza-associated deaths with a median age of 3 years between Oct. 11, 2003, and April 13, 2004.

Of 149 children for whom information was available, 33% had an underlying condition known to increase the risk of influenza-related complications, 20% had other chronic conditions, and 47% had previously been healthy.

One-third of the deaths occurred when chronic neurologic or neuromuscular conditions were present. These have not previously been considered a risk for complications, but compromised respiratory function or handling of respiratory secretions might be worth considering in terms of vaccination in some of the disorders identified in this study, the researchers said.

Of the 111 children whose influenza-vaccination status was available, 16% had received at least one dose of vaccine during the season.

The researchers reported that only 8 of the 18 children who had received at least one dose during the season had documentation of full vaccination during that season; 5 had been vaccinated in a previous season, and 3 were older than 9 years.

One hundred fifty-three laboratory-confirmed influenza-associated deaths in children were reported during the 2003–2004 influenza season; this number may exceed childhood mortality associated with other vaccine-preventable diseases in the United States.

Dr. Niranjan Bhat and Jennifer G. Wright, D.V.M., and their associates at the National Center for Infectious Diseases, Atlanta, reported that high priority should be given to improvements in influenza-vaccine coverage and in the early diagnosis and treatment of influenza to reduce childhood mortality from influenza (N. Engl. J. Med. 2005;353:2559–67).

In the study, mortality was highest among children younger than 6 months and next highest among those 6–23 months of age.

Forty state health departments reported 153 influenza-associated deaths with a median age of 3 years between Oct. 11, 2003, and April 13, 2004.

Of 149 children for whom information was available, 33% had an underlying condition known to increase the risk of influenza-related complications, 20% had other chronic conditions, and 47% had previously been healthy.

One-third of the deaths occurred when chronic neurologic or neuromuscular conditions were present. These have not previously been considered a risk for complications, but compromised respiratory function or handling of respiratory secretions might be worth considering in terms of vaccination in some of the disorders identified in this study, the researchers said.

Of the 111 children whose influenza-vaccination status was available, 16% had received at least one dose of vaccine during the season.

The researchers reported that only 8 of the 18 children who had received at least one dose during the season had documentation of full vaccination during that season; 5 had been vaccinated in a previous season, and 3 were older than 9 years.

One hundred fifty-three laboratory-confirmed influenza-associated deaths in children were reported during the 2003–2004 influenza season; this number may exceed childhood mortality associated with other vaccine-preventable diseases in the United States.

Dr. Niranjan Bhat and Jennifer G. Wright, D.V.M., and their associates at the National Center for Infectious Diseases, Atlanta, reported that high priority should be given to improvements in influenza-vaccine coverage and in the early diagnosis and treatment of influenza to reduce childhood mortality from influenza (N. Engl. J. Med. 2005;353:2559–67).

In the study, mortality was highest among children younger than 6 months and next highest among those 6–23 months of age.

Forty state health departments reported 153 influenza-associated deaths with a median age of 3 years between Oct. 11, 2003, and April 13, 2004.

Of 149 children for whom information was available, 33% had an underlying condition known to increase the risk of influenza-related complications, 20% had other chronic conditions, and 47% had previously been healthy.

One-third of the deaths occurred when chronic neurologic or neuromuscular conditions were present. These have not previously been considered a risk for complications, but compromised respiratory function or handling of respiratory secretions might be worth considering in terms of vaccination in some of the disorders identified in this study, the researchers said.

Of the 111 children whose influenza-vaccination status was available, 16% had received at least one dose of vaccine during the season.

The researchers reported that only 8 of the 18 children who had received at least one dose during the season had documentation of full vaccination during that season; 5 had been vaccinated in a previous season, and 3 were older than 9 years.

California reported one-third of the 2005 U.S. total of West Nile virus cases through December 1 and 25% of the cases of the viral neuroinvasive disease, the Centers for Disease Control and Prevention reported.

A total of 2,744 human cases of West Nile virus (WNV) disease were reported in 42 states in 2005, compared with 2,359 in 2004. There was a spread of the disease in both humans and animals into counties not previously affected, as well as recurrence where the disease had previously been reported. “The increase … suggests that endemic transmission of WNV in the United States will continue for the foreseeable future,” the CDC said (MMWR 2005;54:1253–6).

WNV infections in humans, birds, mosquitoes, and nonhuman mammals are reported to the CDC through ArboNET, an Internet-based arbovirus surveillance system managed by state health departments and the CDC.

Of the cases reported, 1,165 (43%) were WNV neuroinvasive disease (WNND), which includes meningitis, encephalitis, or acute flaccid paralysis; 1,434 (52%) were West Nile fever (WNF); and 145 (5%) were unspecified illnesses.

WNND had its highest incidence in the central United States, including South Dakota, Nebraska, and North Dakota, but there were also focal outbreaks in Illinois, Texas, and Louisiana.

“Nationally, reports of WNV disease began in late May, peaked during the third week in August, and lasted into November,” the CDC said.

The median age of WNND patients was 57 years (range 3 months to 98 years); 85% of the 1,165 patients were hospitalized and 7% died. The median age of those with WNND who died was 75 years (range 36–98 years).

The median age of patients with WNF was 48 years (range 1–92 years); 23% of the 1,434 patients were hospitalized and 0.3% died.

The median age of the four who died was 89 years (range 44–92 years).

California reported one-third of the 2005 U.S. total of West Nile virus cases through December 1 and 25% of the cases of the viral neuroinvasive disease, the Centers for Disease Control and Prevention reported.

A total of 2,744 human cases of West Nile virus (WNV) disease were reported in 42 states in 2005, compared with 2,359 in 2004. There was a spread of the disease in both humans and animals into counties not previously affected, as well as recurrence where the disease had previously been reported. “The increase … suggests that endemic transmission of WNV in the United States will continue for the foreseeable future,” the CDC said (MMWR 2005;54:1253–6).

WNV infections in humans, birds, mosquitoes, and nonhuman mammals are reported to the CDC through ArboNET, an Internet-based arbovirus surveillance system managed by state health departments and the CDC.

Of the cases reported, 1,165 (43%) were WNV neuroinvasive disease (WNND), which includes meningitis, encephalitis, or acute flaccid paralysis; 1,434 (52%) were West Nile fever (WNF); and 145 (5%) were unspecified illnesses.

WNND had its highest incidence in the central United States, including South Dakota, Nebraska, and North Dakota, but there were also focal outbreaks in Illinois, Texas, and Louisiana.

“Nationally, reports of WNV disease began in late May, peaked during the third week in August, and lasted into November,” the CDC said.

The median age of WNND patients was 57 years (range 3 months to 98 years); 85% of the 1,165 patients were hospitalized and 7% died. The median age of those with WNND who died was 75 years (range 36–98 years).

The median age of patients with WNF was 48 years (range 1–92 years); 23% of the 1,434 patients were hospitalized and 0.3% died.

The median age of the four who died was 89 years (range 44–92 years).

California reported one-third of the 2005 U.S. total of West Nile virus cases through December 1 and 25% of the cases of the viral neuroinvasive disease, the Centers for Disease Control and Prevention reported.

A total of 2,744 human cases of West Nile virus (WNV) disease were reported in 42 states in 2005, compared with 2,359 in 2004. There was a spread of the disease in both humans and animals into counties not previously affected, as well as recurrence where the disease had previously been reported. “The increase … suggests that endemic transmission of WNV in the United States will continue for the foreseeable future,” the CDC said (MMWR 2005;54:1253–6).

WNV infections in humans, birds, mosquitoes, and nonhuman mammals are reported to the CDC through ArboNET, an Internet-based arbovirus surveillance system managed by state health departments and the CDC.

Of the cases reported, 1,165 (43%) were WNV neuroinvasive disease (WNND), which includes meningitis, encephalitis, or acute flaccid paralysis; 1,434 (52%) were West Nile fever (WNF); and 145 (5%) were unspecified illnesses.

WNND had its highest incidence in the central United States, including South Dakota, Nebraska, and North Dakota, but there were also focal outbreaks in Illinois, Texas, and Louisiana.

“Nationally, reports of WNV disease began in late May, peaked during the third week in August, and lasted into November,” the CDC said.

The median age of WNND patients was 57 years (range 3 months to 98 years); 85% of the 1,165 patients were hospitalized and 7% died. The median age of those with WNND who died was 75 years (range 36–98 years).

The median age of patients with WNF was 48 years (range 1–92 years); 23% of the 1,434 patients were hospitalized and 0.3% died.

The median age of the four who died was 89 years (range 44–92 years).

California reported one-third of the 2005 U.S. total of West Nile virus cases through December 1 and 25% of the cases of the viral neuroinvasive disease, the Centers for Disease Control and Prevention reported.

A total of 2,744 human cases of West Nile virus (WNV) disease were reported in 42 states in 2005, compared with 2,359 in 2004. There was a spread of the disease in both humans and animals into counties not previously affected, as well as recurrence where the disease had previously been reported. “The increase … suggests that endemic transmission of WNV in the United States will continue for the foreseeable future,” the CDC said (MMWR 2005;54:1253–6).

WNV infections in humans, birds, mosquitoes, and nonhuman mammals are reported to the CDC through ArboNET, an Internet-based arbovirus surveillance system managed by state health departments and the CDC.

Of the cases reported, 1,165 (43%) were WNV neuroinvasive disease (WNND), which includes meningitis, encephalitis, or acute flaccid paralysis; 1,434 (52%) were West Nile fever (WNF); and 145 (5%) were unspecified illnesses.

WNND had its highest incidence in the central United States, including South Dakota, Nebraska, and North Dakota, but there were also focal outbreaks in Illinois, Texas, and Louisiana.

“Nationally, reports of WNV disease began in late May, peaked during the third week in August, and lasted into November,” the CDC said.

The median age of WNND patients was 57 years (range 3 months to 98 years); 85% of the 1,165 patients were hospitalized and 7% died. The median age of those with WNND who died was 75 years (range 36–98 years).

The median age of patients with WNF was 48 years (range 1–92 years); 23% of the 1,434 patients were hospitalized and 0.3% died. The median age of the four who died was 89 years (range 44–92 years).

“Approximately 80% of all WNV infections are asymptomatic, approximately 20% cause WNF, and less than 1% cause WNND. The large percentage of WNND among reported cases reflects underreporting of WNF and lack of reporting of asymptomatic infections,” the CDC said.

“A total of 11,263 mosquito pools from 410 counties in 43 states and the District of Columbia tested positive for WNV.” Of these, 64% were made up of Culex mosquitoes, and “control of Culex mosquitoes remains critical to reducing risk for human WNV disease,” the CDC said.

California reported one-third of the 2005 U.S. total of West Nile virus cases through December 1 and 25% of the cases of the viral neuroinvasive disease, the Centers for Disease Control and Prevention reported.

A total of 2,744 human cases of West Nile virus (WNV) disease were reported in 42 states in 2005, compared with 2,359 in 2004. There was a spread of the disease in both humans and animals into counties not previously affected, as well as recurrence where the disease had previously been reported. “The increase … suggests that endemic transmission of WNV in the United States will continue for the foreseeable future,” the CDC said (MMWR 2005;54:1253–6).

WNV infections in humans, birds, mosquitoes, and nonhuman mammals are reported to the CDC through ArboNET, an Internet-based arbovirus surveillance system managed by state health departments and the CDC.

Of the cases reported, 1,165 (43%) were WNV neuroinvasive disease (WNND), which includes meningitis, encephalitis, or acute flaccid paralysis; 1,434 (52%) were West Nile fever (WNF); and 145 (5%) were unspecified illnesses.

WNND had its highest incidence in the central United States, including South Dakota, Nebraska, and North Dakota, but there were also focal outbreaks in Illinois, Texas, and Louisiana.

“Nationally, reports of WNV disease began in late May, peaked during the third week in August, and lasted into November,” the CDC said.

The median age of WNND patients was 57 years (range 3 months to 98 years); 85% of the 1,165 patients were hospitalized and 7% died. The median age of those with WNND who died was 75 years (range 36–98 years).

The median age of patients with WNF was 48 years (range 1–92 years); 23% of the 1,434 patients were hospitalized and 0.3% died. The median age of the four who died was 89 years (range 44–92 years).

“Approximately 80% of all WNV infections are asymptomatic, approximately 20% cause WNF, and less than 1% cause WNND. The large percentage of WNND among reported cases reflects underreporting of WNF and lack of reporting of asymptomatic infections,” the CDC said.

“A total of 11,263 mosquito pools from 410 counties in 43 states and the District of Columbia tested positive for WNV.” Of these, 64% were made up of Culex mosquitoes, and “control of Culex mosquitoes remains critical to reducing risk for human WNV disease,” the CDC said.

California reported one-third of the 2005 U.S. total of West Nile virus cases through December 1 and 25% of the cases of the viral neuroinvasive disease, the Centers for Disease Control and Prevention reported.

A total of 2,744 human cases of West Nile virus (WNV) disease were reported in 42 states in 2005, compared with 2,359 in 2004. There was a spread of the disease in both humans and animals into counties not previously affected, as well as recurrence where the disease had previously been reported. “The increase … suggests that endemic transmission of WNV in the United States will continue for the foreseeable future,” the CDC said (MMWR 2005;54:1253–6).

WNV infections in humans, birds, mosquitoes, and nonhuman mammals are reported to the CDC through ArboNET, an Internet-based arbovirus surveillance system managed by state health departments and the CDC.

Of the cases reported, 1,165 (43%) were WNV neuroinvasive disease (WNND), which includes meningitis, encephalitis, or acute flaccid paralysis; 1,434 (52%) were West Nile fever (WNF); and 145 (5%) were unspecified illnesses.

WNND had its highest incidence in the central United States, including South Dakota, Nebraska, and North Dakota, but there were also focal outbreaks in Illinois, Texas, and Louisiana.

“Nationally, reports of WNV disease began in late May, peaked during the third week in August, and lasted into November,” the CDC said.

The median age of WNND patients was 57 years (range 3 months to 98 years); 85% of the 1,165 patients were hospitalized and 7% died. The median age of those with WNND who died was 75 years (range 36–98 years).

The median age of patients with WNF was 48 years (range 1–92 years); 23% of the 1,434 patients were hospitalized and 0.3% died. The median age of the four who died was 89 years (range 44–92 years).

“Approximately 80% of all WNV infections are asymptomatic, approximately 20% cause WNF, and less than 1% cause WNND. The large percentage of WNND among reported cases reflects underreporting of WNF and lack of reporting of asymptomatic infections,” the CDC said.

“A total of 11,263 mosquito pools from 410 counties in 43 states and the District of Columbia tested positive for WNV.” Of these, 64% were made up of Culex mosquitoes, and “control of Culex mosquitoes remains critical to reducing risk for human WNV disease,” the CDC said.

ST. LOUIS — Little is known of the functional status and quality of life of long-term survivors after curative resection for esophageal carcinoma.

“Clearly, a better understanding of the functional outcome of life of long-term survivors is needed in this new era of health care,” Claude Deschamps, M.D., told attendees of a thoracic surgery meeting sponsored by Washington University.

Because the incidence of adenocarcinoma of the esophagus and gastroesophageal junction is increasing, “Endoscopic surveillance for Barrett's disease will very likely lead to earlier cancer detection and resection, and possibly improved long-term survival,” said Dr. Deschamps, professor of surgery at the Mayo Clinic College of Medicine in Rochester, Minn.

Esophagectomy is currently the standard of care in esophageal carcinoma, Dr. Deschamps said.

“Appropriate tools to measure outcome, however, are limited and development of such instruments will become increasingly important in the future if surgeons are to better plan preoperative counseling, surgical approach, and postoperative care.”

The patient's perspective on quality of life is crucial, he said. “We are in an era during which health care outcome will increasingly be evaluated from the patient's point of view.”

Dr. Deschamps cited J.D. Kirby, founder of the Oesophageal Patients Association, who suggested nine elements of a good quality of life after esophagectomy. These include the ability to eat adequately and enjoy it, to consume alcohol moderately as desired, to eat and drink socially, to have weight stability, to sleep comfortably in a normal position, to be free of pain, to earn one's living, to participate in sports or hobbies, and to have an unimpaired libido.

“Health outcome is better measured by using general health measures and traditional biomedical tools synchronously,” Dr. Deschamps said “We prefer to combine a questionnaire aimed at upper- and lower-digestive functions with a quality-of-life survey.”

“We recently reviewed our experience with function and quality of life after esophagectomy for high-grade dysplasia in Barrett's esophagus,” he said. From June 1991 through July 1997, 54 consecutive patients underwent esophageal resection for Barrett's esophagus with high-grade dysplasia (HGD) at the Mayo Clinic in Rochester.

Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended Ivor Lewis esophagogastrectomy in 8 (15%), and other in 2.

Follow-up data was obtained from the patient clinical records and a two-part mail survey that was sent to all 46 patients thought to be alive in August 1999.

” All 46 two-part written surveys were returned for a response of 100%. The follow-up was complete in all 54 patients. The median follow-up was 5.3 years.

“At last follow-up, 43 patients (80%) were alive and without evidence of recurrent disease. This included 13 of the 19 patients diagnosed with cancer. Overall 5-year “survival was 86%, which did not significantly differ from an expected survival of 87%.”

Dr. Deschamps reported long-term (greater than 2-year) functional outcome available for 48 patients.

Seven patients (13%) were entirely asymptomatic. Ten patients experienced no change in their weight. Thirty-one patients lost a median of 9 kg and seven patients gained a median of 2 kg. Thirty patients had no dysphagia. Mild, moderate and severe incidences of dysphagia were seen in 15, 1, and 2 patients, respectively. Reflux was present in 36 patients. The majority had minimal symptoms with medical management. Dumping was present in eight patients.

Forty-four patients (82%) completed the MOS SF-36 Health Status Questionnaire. “Only seven (13%) of our patients were truly symptom free 2 or more years after esophagectomy. Thirty-eight percent of patients had swallowing difficulties but in only 6% was this moderate to severe. Reflux was present in 68% of our patients. This, however, was well controlled with medication in the majority of patients,” Dr. Deschamps said.

“While the functional outcomes were acceptable but less than ideal, esophagectomy had no measurable negative impact on these patients' quality of life,” he said.

ST. LOUIS — Little is known of the functional status and quality of life of long-term survivors after curative resection for esophageal carcinoma.

“Clearly, a better understanding of the functional outcome of life of long-term survivors is needed in this new era of health care,” Claude Deschamps, M.D., told attendees of a thoracic surgery meeting sponsored by Washington University.

Because the incidence of adenocarcinoma of the esophagus and gastroesophageal junction is increasing, “Endoscopic surveillance for Barrett's disease will very likely lead to earlier cancer detection and resection, and possibly improved long-term survival,” said Dr. Deschamps, professor of surgery at the Mayo Clinic College of Medicine in Rochester, Minn.

Esophagectomy is currently the standard of care in esophageal carcinoma, Dr. Deschamps said.

“Appropriate tools to measure outcome, however, are limited and development of such instruments will become increasingly important in the future if surgeons are to better plan preoperative counseling, surgical approach, and postoperative care.”

The patient's perspective on quality of life is crucial, he said. “We are in an era during which health care outcome will increasingly be evaluated from the patient's point of view.”

Dr. Deschamps cited J.D. Kirby, founder of the Oesophageal Patients Association, who suggested nine elements of a good quality of life after esophagectomy. These include the ability to eat adequately and enjoy it, to consume alcohol moderately as desired, to eat and drink socially, to have weight stability, to sleep comfortably in a normal position, to be free of pain, to earn one's living, to participate in sports or hobbies, and to have an unimpaired libido.

“Health outcome is better measured by using general health measures and traditional biomedical tools synchronously,” Dr. Deschamps said “We prefer to combine a questionnaire aimed at upper- and lower-digestive functions with a quality-of-life survey.”

“We recently reviewed our experience with function and quality of life after esophagectomy for high-grade dysplasia in Barrett's esophagus,” he said. From June 1991 through July 1997, 54 consecutive patients underwent esophageal resection for Barrett's esophagus with high-grade dysplasia (HGD) at the Mayo Clinic in Rochester.

Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended Ivor Lewis esophagogastrectomy in 8 (15%), and other in 2.

Follow-up data was obtained from the patient clinical records and a two-part mail survey that was sent to all 46 patients thought to be alive in August 1999.

” All 46 two-part written surveys were returned for a response of 100%. The follow-up was complete in all 54 patients. The median follow-up was 5.3 years.

“At last follow-up, 43 patients (80%) were alive and without evidence of recurrent disease. This included 13 of the 19 patients diagnosed with cancer. Overall 5-year “survival was 86%, which did not significantly differ from an expected survival of 87%.”

Dr. Deschamps reported long-term (greater than 2-year) functional outcome available for 48 patients.

Seven patients (13%) were entirely asymptomatic. Ten patients experienced no change in their weight. Thirty-one patients lost a median of 9 kg and seven patients gained a median of 2 kg. Thirty patients had no dysphagia. Mild, moderate and severe incidences of dysphagia were seen in 15, 1, and 2 patients, respectively. Reflux was present in 36 patients. The majority had minimal symptoms with medical management. Dumping was present in eight patients.

Forty-four patients (82%) completed the MOS SF-36 Health Status Questionnaire. “Only seven (13%) of our patients were truly symptom free 2 or more years after esophagectomy. Thirty-eight percent of patients had swallowing difficulties but in only 6% was this moderate to severe. Reflux was present in 68% of our patients. This, however, was well controlled with medication in the majority of patients,” Dr. Deschamps said.

“While the functional outcomes were acceptable but less than ideal, esophagectomy had no measurable negative impact on these patients' quality of life,” he said.

ST. LOUIS — Little is known of the functional status and quality of life of long-term survivors after curative resection for esophageal carcinoma.

“Clearly, a better understanding of the functional outcome of life of long-term survivors is needed in this new era of health care,” Claude Deschamps, M.D., told attendees of a thoracic surgery meeting sponsored by Washington University.

Because the incidence of adenocarcinoma of the esophagus and gastroesophageal junction is increasing, “Endoscopic surveillance for Barrett's disease will very likely lead to earlier cancer detection and resection, and possibly improved long-term survival,” said Dr. Deschamps, professor of surgery at the Mayo Clinic College of Medicine in Rochester, Minn.

Esophagectomy is currently the standard of care in esophageal carcinoma, Dr. Deschamps said.

“Appropriate tools to measure outcome, however, are limited and development of such instruments will become increasingly important in the future if surgeons are to better plan preoperative counseling, surgical approach, and postoperative care.”

The patient's perspective on quality of life is crucial, he said. “We are in an era during which health care outcome will increasingly be evaluated from the patient's point of view.”

Dr. Deschamps cited J.D. Kirby, founder of the Oesophageal Patients Association, who suggested nine elements of a good quality of life after esophagectomy. These include the ability to eat adequately and enjoy it, to consume alcohol moderately as desired, to eat and drink socially, to have weight stability, to sleep comfortably in a normal position, to be free of pain, to earn one's living, to participate in sports or hobbies, and to have an unimpaired libido.

“Health outcome is better measured by using general health measures and traditional biomedical tools synchronously,” Dr. Deschamps said “We prefer to combine a questionnaire aimed at upper- and lower-digestive functions with a quality-of-life survey.”

“We recently reviewed our experience with function and quality of life after esophagectomy for high-grade dysplasia in Barrett's esophagus,” he said. From June 1991 through July 1997, 54 consecutive patients underwent esophageal resection for Barrett's esophagus with high-grade dysplasia (HGD) at the Mayo Clinic in Rochester.

Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended Ivor Lewis esophagogastrectomy in 8 (15%), and other in 2.

Follow-up data was obtained from the patient clinical records and a two-part mail survey that was sent to all 46 patients thought to be alive in August 1999.

” All 46 two-part written surveys were returned for a response of 100%. The follow-up was complete in all 54 patients. The median follow-up was 5.3 years.

“At last follow-up, 43 patients (80%) were alive and without evidence of recurrent disease. This included 13 of the 19 patients diagnosed with cancer. Overall 5-year “survival was 86%, which did not significantly differ from an expected survival of 87%.”

Dr. Deschamps reported long-term (greater than 2-year) functional outcome available for 48 patients.

Seven patients (13%) were entirely asymptomatic. Ten patients experienced no change in their weight. Thirty-one patients lost a median of 9 kg and seven patients gained a median of 2 kg. Thirty patients had no dysphagia. Mild, moderate and severe incidences of dysphagia were seen in 15, 1, and 2 patients, respectively. Reflux was present in 36 patients. The majority had minimal symptoms with medical management. Dumping was present in eight patients.

Forty-four patients (82%) completed the MOS SF-36 Health Status Questionnaire. “Only seven (13%) of our patients were truly symptom free 2 or more years after esophagectomy. Thirty-eight percent of patients had swallowing difficulties but in only 6% was this moderate to severe. Reflux was present in 68% of our patients. This, however, was well controlled with medication in the majority of patients,” Dr. Deschamps said.

“While the functional outcomes were acceptable but less than ideal, esophagectomy had no measurable negative impact on these patients' quality of life,” he said.

ST. LOUIS — Recognition of the importance of the suspensory axis of the vagina is necessary for a successful pelvic support surgery, according to Carl W. Zimmerman, M.D.

If disruptions of this axis around the pericervical ring are corrected surgically, the mechanical function of suspension can be reestablished, said Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn. He outlined the restoration of the vaginal suspensory axis, what he called the “most important concept in pelvic reconstructive surgery,” at the 14th International Pelvic Reconstructive and Vaginal Surgery Conference.

The vaginal suspensory axis is a continuum of connective tissue that serves as the primary structure to hold the central pelvic organs above the levator plate and behind the urogenital hiatus. The named components of this axis are the perineum, rectovaginal septum, pericervical ring, uterosacral ligaments, and presacral periosteum. The elements involved with holding the bladder, uterus, rectum, and vagina above the pelvic diaphragm are located within the posterior vagina.

“When these structures are anatomically intact, prolapse does not occur. When they are disrupted, one or more of the central pelvic organs have a tendency to fall through the pelvic floor and to create prolapse,” Dr. Zimmerman said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons and Emory University.

“The mechanical function of suspension should be contrasted with support. Support of the pelvic floor is provided by the muscles of the pelvic diaphragm and their associated parietal fasciae,” he said.

Analysis of the mechanics of childbirth can provide information to deduce the most likely location of damage during labor. “The narrowest diameter in the pelvis is between the ischial spines. This plane is intersected by all named components of the endopelvic fascia. The passage of a baby's head through the diameter subjects this area to high and sustained pressures during childbirth,” he said.

In addition, the pericervical ring is substantially stressed by dilation of the cervix. The cardinal movements of internal rotation, flexion, and descent are required to allow the baby to negotiate this area of the pelvis. Maximum pelvic connective tissue strength is located within the most restricted portion of the pelvis.

“The usual result of labor is distal displacement of the pubocervical septum and rectovaginal septum. The uterosacral ligaments remain attached to the presacral periosteum. The most vulnerable location along the axis is at the uterosacral ligament/pericervical ring/rectovaginal septum junction within the interspinous diameter,” Dr. Zimmerman said. “Pelvic reconstructive surgeons are required to access the interspinous diameter and to reconnect these key structures in that area. Failure to reestablish the suspensory axis within the interspinous diameter violates the mechanical tenets of suspension.”

“In the typical case of prolapse, the rectovaginal septum is detached from its connections within the interspinous diameter and displaced downward. Enterocele, rectocele, and perineal descent result, because the entire posterior vaginal wall is allowed to descend. If the rectovaginal septum is exposed by dissection, elevated, and reattached to both uterosacral ligaments, the suspensory axis is reestablished, and posterior prolapse is repaired,” he added.

Site-specific techniques can allow this connection to be accomplished with minimal anatomic distortion, Dr. Zimmerman said. Both rectocele and enterocele protrude through the same anatomic defect. These hernias disappear when the rectovaginal septum is suspended apically with bilateral uterosacral colpopexy.

The apical edge of the pubocervical septum is also displaced distally, Dr. Zimmerman said. In addition, this septum is separated from the pelvic sidewall in the form of paravaginal defects. “When effectively repaired, the anterior connective tissues should be reconnected to the primary support axis in the posterior vaginal wall at the level of the ischial spines.”

Some techniques in the surgical literature describe correction of a defect between the distal rectovaginal septum and the apical perineal body. Damage to the perineum is either a laceration or an iatrogenic episiotomy. The mechanics of labor do not explain a fascial defect at this location. “Pulling the rectovaginal septum down to the perineal body will simply enlarge the defect that causes rectocele and enterocele. That type of repair usually is combined with an anatomically distorting midline plication and is not recommended,” he said.

ST. LOUIS — Recognition of the importance of the suspensory axis of the vagina is necessary for a successful pelvic support surgery, according to Carl W. Zimmerman, M.D.

If disruptions of this axis around the pericervical ring are corrected surgically, the mechanical function of suspension can be reestablished, said Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn. He outlined the restoration of the vaginal suspensory axis, what he called the “most important concept in pelvic reconstructive surgery,” at the 14th International Pelvic Reconstructive and Vaginal Surgery Conference.

The vaginal suspensory axis is a continuum of connective tissue that serves as the primary structure to hold the central pelvic organs above the levator plate and behind the urogenital hiatus. The named components of this axis are the perineum, rectovaginal septum, pericervical ring, uterosacral ligaments, and presacral periosteum. The elements involved with holding the bladder, uterus, rectum, and vagina above the pelvic diaphragm are located within the posterior vagina.

“When these structures are anatomically intact, prolapse does not occur. When they are disrupted, one or more of the central pelvic organs have a tendency to fall through the pelvic floor and to create prolapse,” Dr. Zimmerman said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons and Emory University.

“The mechanical function of suspension should be contrasted with support. Support of the pelvic floor is provided by the muscles of the pelvic diaphragm and their associated parietal fasciae,” he said.

Analysis of the mechanics of childbirth can provide information to deduce the most likely location of damage during labor. “The narrowest diameter in the pelvis is between the ischial spines. This plane is intersected by all named components of the endopelvic fascia. The passage of a baby's head through the diameter subjects this area to high and sustained pressures during childbirth,” he said.

In addition, the pericervical ring is substantially stressed by dilation of the cervix. The cardinal movements of internal rotation, flexion, and descent are required to allow the baby to negotiate this area of the pelvis. Maximum pelvic connective tissue strength is located within the most restricted portion of the pelvis.

“The usual result of labor is distal displacement of the pubocervical septum and rectovaginal septum. The uterosacral ligaments remain attached to the presacral periosteum. The most vulnerable location along the axis is at the uterosacral ligament/pericervical ring/rectovaginal septum junction within the interspinous diameter,” Dr. Zimmerman said. “Pelvic reconstructive surgeons are required to access the interspinous diameter and to reconnect these key structures in that area. Failure to reestablish the suspensory axis within the interspinous diameter violates the mechanical tenets of suspension.”

“In the typical case of prolapse, the rectovaginal septum is detached from its connections within the interspinous diameter and displaced downward. Enterocele, rectocele, and perineal descent result, because the entire posterior vaginal wall is allowed to descend. If the rectovaginal septum is exposed by dissection, elevated, and reattached to both uterosacral ligaments, the suspensory axis is reestablished, and posterior prolapse is repaired,” he added.

Site-specific techniques can allow this connection to be accomplished with minimal anatomic distortion, Dr. Zimmerman said. Both rectocele and enterocele protrude through the same anatomic defect. These hernias disappear when the rectovaginal septum is suspended apically with bilateral uterosacral colpopexy.

The apical edge of the pubocervical septum is also displaced distally, Dr. Zimmerman said. In addition, this septum is separated from the pelvic sidewall in the form of paravaginal defects. “When effectively repaired, the anterior connective tissues should be reconnected to the primary support axis in the posterior vaginal wall at the level of the ischial spines.”

Some techniques in the surgical literature describe correction of a defect between the distal rectovaginal septum and the apical perineal body. Damage to the perineum is either a laceration or an iatrogenic episiotomy. The mechanics of labor do not explain a fascial defect at this location. “Pulling the rectovaginal septum down to the perineal body will simply enlarge the defect that causes rectocele and enterocele. That type of repair usually is combined with an anatomically distorting midline plication and is not recommended,” he said.

ST. LOUIS — Recognition of the importance of the suspensory axis of the vagina is necessary for a successful pelvic support surgery, according to Carl W. Zimmerman, M.D.

If disruptions of this axis around the pericervical ring are corrected surgically, the mechanical function of suspension can be reestablished, said Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn. He outlined the restoration of the vaginal suspensory axis, what he called the “most important concept in pelvic reconstructive surgery,” at the 14th International Pelvic Reconstructive and Vaginal Surgery Conference.

The vaginal suspensory axis is a continuum of connective tissue that serves as the primary structure to hold the central pelvic organs above the levator plate and behind the urogenital hiatus. The named components of this axis are the perineum, rectovaginal septum, pericervical ring, uterosacral ligaments, and presacral periosteum. The elements involved with holding the bladder, uterus, rectum, and vagina above the pelvic diaphragm are located within the posterior vagina.

“When these structures are anatomically intact, prolapse does not occur. When they are disrupted, one or more of the central pelvic organs have a tendency to fall through the pelvic floor and to create prolapse,” Dr. Zimmerman said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons and Emory University.

“The mechanical function of suspension should be contrasted with support. Support of the pelvic floor is provided by the muscles of the pelvic diaphragm and their associated parietal fasciae,” he said.

Analysis of the mechanics of childbirth can provide information to deduce the most likely location of damage during labor. “The narrowest diameter in the pelvis is between the ischial spines. This plane is intersected by all named components of the endopelvic fascia. The passage of a baby's head through the diameter subjects this area to high and sustained pressures during childbirth,” he said.

In addition, the pericervical ring is substantially stressed by dilation of the cervix. The cardinal movements of internal rotation, flexion, and descent are required to allow the baby to negotiate this area of the pelvis. Maximum pelvic connective tissue strength is located within the most restricted portion of the pelvis.

“The usual result of labor is distal displacement of the pubocervical septum and rectovaginal septum. The uterosacral ligaments remain attached to the presacral periosteum. The most vulnerable location along the axis is at the uterosacral ligament/pericervical ring/rectovaginal septum junction within the interspinous diameter,” Dr. Zimmerman said. “Pelvic reconstructive surgeons are required to access the interspinous diameter and to reconnect these key structures in that area. Failure to reestablish the suspensory axis within the interspinous diameter violates the mechanical tenets of suspension.”

“In the typical case of prolapse, the rectovaginal septum is detached from its connections within the interspinous diameter and displaced downward. Enterocele, rectocele, and perineal descent result, because the entire posterior vaginal wall is allowed to descend. If the rectovaginal septum is exposed by dissection, elevated, and reattached to both uterosacral ligaments, the suspensory axis is reestablished, and posterior prolapse is repaired,” he added.

Site-specific techniques can allow this connection to be accomplished with minimal anatomic distortion, Dr. Zimmerman said. Both rectocele and enterocele protrude through the same anatomic defect. These hernias disappear when the rectovaginal septum is suspended apically with bilateral uterosacral colpopexy.

The apical edge of the pubocervical septum is also displaced distally, Dr. Zimmerman said. In addition, this septum is separated from the pelvic sidewall in the form of paravaginal defects. “When effectively repaired, the anterior connective tissues should be reconnected to the primary support axis in the posterior vaginal wall at the level of the ischial spines.”

Some techniques in the surgical literature describe correction of a defect between the distal rectovaginal septum and the apical perineal body. Damage to the perineum is either a laceration or an iatrogenic episiotomy. The mechanics of labor do not explain a fascial defect at this location. “Pulling the rectovaginal septum down to the perineal body will simply enlarge the defect that causes rectocele and enterocele. That type of repair usually is combined with an anatomically distorting midline plication and is not recommended,” he said.

ST. LOUIS — Physicians need to obtain comprehensive patient consent before surgery to help guide their approach to unexpected findings during the procedure, according to Ira Horowitz, M.D.

In a presentation at the 15th International Pelvic Reconstructive and Vaginal Surgery Conference, Dr. Horowitz looked at several hypothetical cases. “It is imperative that we discuss various scenarios with the patient prior to surgery,” said Dr. Horowitz, the Willaford Ransom Leach Professor and vice chairman and director of the division of gynecologic oncology in the department of gynecology and obstetrics at Emory University, Atlanta.

In one hypothetical case, a malpractice lawyer with a mucinous cystadenoma had signed a consent form to remove only the mass. The physician is permitted to remove the uterus and contralateral ovary if a carcinoma is present. “You have a suspicion of cancer. What do you do?” Dr. Horowitz asked.

“The answer might be to do nothing, because the patient has limited your ability to act independently with the consent signed,” he said.

Pelvic surgeons would be wise to have a gynecologic oncologist available if cancer is suspected. A seasoned pathologist also should be present to perform a frozen section. “There is an increased survival rate when a gynecologic oncologist assists in staging and debulking of the patient with ovarian carcinoma,” he said.

“A mucinous borderline tumor is frequently reread as invasive carcinoma,” Dr. Horowitz said. “The challenge to the gynecologists and the gynecologic oncologist is when to do staging without a definite diagnosis of cancer. This is why it is so important to discuss these options and possibilities with the patient prior to surgery. If you discuss this before the patient is put to sleep, you won't allow yourself to be put in this position,” he said.

ST. LOUIS — Physicians need to obtain comprehensive patient consent before surgery to help guide their approach to unexpected findings during the procedure, according to Ira Horowitz, M.D.

In a presentation at the 15th International Pelvic Reconstructive and Vaginal Surgery Conference, Dr. Horowitz looked at several hypothetical cases. “It is imperative that we discuss various scenarios with the patient prior to surgery,” said Dr. Horowitz, the Willaford Ransom Leach Professor and vice chairman and director of the division of gynecologic oncology in the department of gynecology and obstetrics at Emory University, Atlanta.

In one hypothetical case, a malpractice lawyer with a mucinous cystadenoma had signed a consent form to remove only the mass. The physician is permitted to remove the uterus and contralateral ovary if a carcinoma is present. “You have a suspicion of cancer. What do you do?” Dr. Horowitz asked.

“The answer might be to do nothing, because the patient has limited your ability to act independently with the consent signed,” he said.

Pelvic surgeons would be wise to have a gynecologic oncologist available if cancer is suspected. A seasoned pathologist also should be present to perform a frozen section. “There is an increased survival rate when a gynecologic oncologist assists in staging and debulking of the patient with ovarian carcinoma,” he said.

“A mucinous borderline tumor is frequently reread as invasive carcinoma,” Dr. Horowitz said. “The challenge to the gynecologists and the gynecologic oncologist is when to do staging without a definite diagnosis of cancer. This is why it is so important to discuss these options and possibilities with the patient prior to surgery. If you discuss this before the patient is put to sleep, you won't allow yourself to be put in this position,” he said.

ST. LOUIS — Physicians need to obtain comprehensive patient consent before surgery to help guide their approach to unexpected findings during the procedure, according to Ira Horowitz, M.D.

In a presentation at the 15th International Pelvic Reconstructive and Vaginal Surgery Conference, Dr. Horowitz looked at several hypothetical cases. “It is imperative that we discuss various scenarios with the patient prior to surgery,” said Dr. Horowitz, the Willaford Ransom Leach Professor and vice chairman and director of the division of gynecologic oncology in the department of gynecology and obstetrics at Emory University, Atlanta.

In one hypothetical case, a malpractice lawyer with a mucinous cystadenoma had signed a consent form to remove only the mass. The physician is permitted to remove the uterus and contralateral ovary if a carcinoma is present. “You have a suspicion of cancer. What do you do?” Dr. Horowitz asked.

“The answer might be to do nothing, because the patient has limited your ability to act independently with the consent signed,” he said.

Pelvic surgeons would be wise to have a gynecologic oncologist available if cancer is suspected. A seasoned pathologist also should be present to perform a frozen section. “There is an increased survival rate when a gynecologic oncologist assists in staging and debulking of the patient with ovarian carcinoma,” he said.

“A mucinous borderline tumor is frequently reread as invasive carcinoma,” Dr. Horowitz said. “The challenge to the gynecologists and the gynecologic oncologist is when to do staging without a definite diagnosis of cancer. This is why it is so important to discuss these options and possibilities with the patient prior to surgery. If you discuss this before the patient is put to sleep, you won't allow yourself to be put in this position,” he said.