Costlier robotic surgery soars for hysterectomies

CHICAGO (AP) — Robotic surgery is increasingly being used for women's hysterectomies, adding at least $2,000 to the cost without offering much benefit over less high-tech methods, a study found.

The technique was used in just 0.5 percent of operations studied in 2007, but that soared to almost 10 percent by early 2010. Columbia University researchers analyzed data on more than 260,000 women who had their wombs removed at 441 U.S. hospitals for reasons other than cancer. The database covered surgeries performed through the first few months of 2010.

Women who had the robotic operations were slightly less likely to spend more than two days in the hospital, but hospital stays were shorter than that for most women. Also, complications were equally rare among robotic surgery patients and those who had more conventional surgeries. Average costs for robotic hysterectomies totaled nearly $9,000, versus about $3,000 for the least expensive method, a different type of minimally invasive technique using more conventional surgery methods.

Traditionally hysterectomies were done by removing the womb through a large abdominal incision. Newer methods include removing the uterus through the vagina and minimally invasive "keyhole" abdominal operations using more conventional surgery methods, or surgeon-controlled robotic devices.

Robotic operations involve computer-controlled long, thin robot-like "arms" equipped with tiny surgery instruments. Surgeons operate the computer and can see inside the body on the computer screen, through a tiny camera attached to the robotic arms. The initial idea was for surgeons to do these operations miles away from the operating room, but robotic operations now are mostly done with the surgeon in the same room as the patient.

Theoretically, robotic surgeries make it easier to maneuver inside the patient, and are increasingly used for many types of operations, not just hysterectomies.

The main explanation for the big increase "is that robotic surgery has been marketed extensively to not only hospitals and physicians, but also directly to patients. There is minimal data in gynecology that it is advantageous," said Dr. Jason Wright, an assistant professor of women's health and the study's lead author.

The study was published Tuesday in the Journal of the American Medical Association.

"Our findings highlight the importance of developing rational strategies to implement new surgical technologies," the researchers wrote.

They note that 1 in 9 U.S. women will undergo a hysterectomy, usually after the age of 40. Reasons include fibroids and other non-cancerous growths, abnormal bleeding, and cancer.

Traditional abdominal operations remain common and more than 40 percent of women studied had them, costing on average about $6,600.

A JAMA editorial says the study doesn't answer whether the robotic method might be better for certain women, and says more research comparing methods is needed. Still, it says doctors and hospitals have a duty to inform patients about costs of different surgery options.

Dr. Myriam Curet of manufacturer Intuitive Surgical of Sunnyvale, Calif., said surgical robots can help surgeons overcome the limitations of other minimally invasive methods for very overweight patients, those with scarring from other surgeries and other complexities.

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JAMA: http://www.jama.ama-assn.org

Robotic surgery: http://tinyurl.com/byuljds

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AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner

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M&A deals lift Wall Street shares nearer a record high

NEW YORK (Reuters) - U.S. stocks rose on Tuesday as this year's ongoing surge in merger activity suggested investors were still finding value in the market even as indexes closed in on all-time highs.

Office Depot Inc surged 9.4 percent to $5.02 after a person familiar with the matter said the No. 2 U.S. office supply retailer was in advanced talks to merge with smaller rival OfficeMax Inc , which jumped more than 20 percent.

News of the potential move came just days after Berkshire Hathaway and a partner agreed to acquire H.J. Heinz Co for $23 billion, and following a revised $20 billion takeover of Mexican brewer Grupo Modelo by Anheuser-Busch InBev .

Deal activity has helped equities resist a pullback as investors use dips in stocks as buying opportunities. The S&P is up about 7 percent so far in 2013 and has climbed for the past seven weeks in its longest weekly winning streak since January 2011, though most of the weekly gains have been slim.

The Dow industrials closed 0.9 percent away from their record high while S&P 500 was 2.2 percent off its peak.

"Deals are good for the market," said Frank Lesh, a futures analyst and broker at FuturePath Trading LLC in Chicago. "The fact that they're being done is a positive."

More than $158 billion in deals has been announced so far in 2013, more than double the activity in the same period last year and accounting for 57 percent of global deal volumes, according to Thomson Reuters Deals Intelligence.

The Dow Jones industrial average <.dji> gained 53.91 points, or 0.39 percent, to 14,035.67. The Standard & Poor's 500 Index <.spx> gained 11.15 points, or 0.73 percent, to 1,530.94. The Nasdaq Composite Index <.ixic> gained 21.56 points, or 0.68 percent, to 3,213.59.

Other stocks in the office supplies sector also rose. Larger rival Staples Inc shot up 13.1 percent to $14.65 as the best performer on the S&P 500.

"Equity investors have to be encouraged by M&A since, if the number crunchers are offering large premiums, that shows how much value is still in the market," said Mike Gibbs, co-head of the equity advisory group at Raymond James in Memphis, Tennessee.

On the downside, health insurance stocks tumbled, led by a 6.4 percent drop in Humana Inc to $73.01. The company said the government's proposed 2014 payment rates for Medicare Advantage participants were lower than expected and would hurt its profit outlook.

UnitedHealth Group lost 1.2 percent to $56.66. The Morgan Stanley healthcare payor index <.hmo> dropped 1.2 percent.

Wall Street's strong start to the year was fueled by better-than-expected corporate earnings, as well as a compromise in Washington that temporarily averted automatic spending cuts and tax hikes that are predicted to damage the economy.

The compromise on across-the-board spending cuts postponed the matter until March 1, at which point the cuts take effect. Ahead of the debate over the cuts, known as sequestration, further gains for stocks may be difficult to come by.

Some investors say the debate could be the catalyst for a long anticipated sell-off after the market's recent strong run.

Carter Worth, a technical analyst at Oppenheimer, pointed to the "especially complacent action of the past six weeks," noting that, as of Friday, stocks have gone 33 sessions without a dip of more than 1.5 percent.

"We would be selling aggressively into the market's current strength," he said in a research note.

Economic data showed the NAHB/Wells Fargo Housing Market index unexpectedly edged down to 46 in February from 47 in the prior month as builders faced higher material costs.

According to the Thomson Reuters data through Monday morning, of the 391 companies in the S&P 500 that have reported results, 70.1 percent have exceeded analysts' expectations, compared with a 62 percent average since 1994 and 65 percent over the past four quarters.

Fourth-quarter earnings for S&P 500 companies have risen 5.6 percent, according to the data, above a 1.9 percent forecast at the start of the earnings season.

Express Scripts rose 2.5 percent to $56.98 after the pharmacy benefits manager posted fourth-quarter earnings.

About two stocks rose for everyone that fell on the New York Stock Exchange and Nasdaq. About 6.48 billion shares changed hands on the New York Stock Exchange, the Nasdaq and NYSE MKT, in line with the daily average so far this year.

(Additional reporting by Chuck Mikolajczak Ryan Vlastelica and Rodrigo Campos; Editing by Chizu Nomiyama, Kenneth Barry and Nick Zieminski)

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As Assad Holds Firm, Obama Could Revisit Arms Policy

WASHINGTON — When President Obama rebuffed four of his top national security officials who wanted to arm the rebels in Syria last fall, it put an end to a months-long debate over how aggressively Washington should respond to the strife there that has now left nearly 70,000 dead.

Reuters

A Free Syrian Army member smokes a cigarette inside a factory producing improvised mortar shells.

But the decision also left the White House with no clear strategy to resolve a crisis that has bedeviled it since a popular uprising erupted against President Bashar al-Assad almost two years ago. Despite an American program of nonlethal assistance to opponents of the Syrian government and $365 million in humanitarian aid, Mr. Obama appears to be running out of options to speed Mr. Assad’s exit.

With conditions continuing to deteriorate, officials said, the president could reopen the question of whether to provide weapons to select members of the resistance in an effort to break the impasse in Syria. The question is whether a wary Mr. Obama, surrounded by a new national security team, would come to a different conclusion.

“This is not a closed decision,” a senior administration official insisted. “As the situation evolves, as our confidence increases, we might revisit it.”

Mr. Obama’s refusal to provide arms when the proposal was broached before the November election, officials said, was driven by his reluctance to get drawn into a proxy war and his fear that the weapons would end up in unreliable hands, where they could be used against civilians or Israeli and American interests.

As the United States struggles to formulate a policy, however, Mr. Assad has given no sign that he is ready to yield power, and the Syrian resistance is adamant that it will not negotiate a transition in which he has a role. Mr. Obama, in his State of the Union address, did not repeat his oft-stated confidence that Mr. Assad’s days are numbered.

Even if Mr. Assad was overthrown, the convulsion could fragment Syria along sectarian and ethnic lines, each supported by competing outside powers, said Paul Salem, who runs the Beirut-based Middle East office for the Carnegie Endowment for International Peace. “Syria,” he said, “is in the process, not of transitioning, but disintegrating.”

The State Department has funneled $50 million of nonlethal assistance to the Syrian opposition, including satellite telephones, radios, broadcasting equipment, computers, survival equipment and the training in how to use them. This support, officials say, has helped Syrians opposed to the Assad regime communicate with one another and the outside world, despite efforts by Syrian forces to target rebel communications using Iranian-supplied equipment. A Syria-wide FM radio network is to connect broadcasting operations in several cities in the next several days. The State Department has also helped train local councils in areas that have freed from the Syrian government’s control.

But the State Department does not provide non-lethal assistance to armed rebel factions. This has greatly limited the influence the United States has with armed groups that are likely to control much of Syria if Mr. Assad is ousted..

“The odds are very high that, for better or worse, armed men will determine Syria’s course for the foreseeable future,” said Frederic C. Hof, a former senior State Department official and a senior fellow at the Atlantic Council. “For the U.S. not to have close, supportive relationships with armed elements, carefully vetted, is very risky.”

Because units of the anti-Assad Free Syria Army have captured prisoners and detained criminals in the areas they control, Mr. Hof said, it is essential that either the United States or an ally train rebel staff officers in judicial procedures and sensitive them to human rights concerns.

While the White House has focused on the risks of providing weapons, other nations have had no such reservations. Russia has continued to provide arms and financial support to the Assad government. Iran has supplied the regime with weapons and Quds Force advisers. Hezbollah has sent militants to Syria to help Mr. Assad’s forces. On the other side of the struggle, anti-government Qaeda-affiliated fighters have been receiving financial and other support from their backers in the Middle East.

The arming plan that was considered last year originated with David H. Petreaus, then the director of the Central Intelligence Agency, and was supported by former Secretary of State Hillary Rodham Clinton. The goal was to create allies in Syria with whom the United States could work during the conflict and if Mr. Assad was removed from power. Each had their reasons for supporting it.

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Mindy McCready: Under Police Scrutiny at Time of Suicide?

By Steve Helling and Mike Fleeman

02/18/2013 at 06:00 PM EST

Mindy McCready and David Wilson

Courtesy Mindy McCready

When Mindy McCready talked to police in recent weeks, her account of how her boyfriend came to be found with a fatal gunshot wound to the head concerned police, a law enforcement source tells PEOPLE.

"At first, she said she hadn't heard the gunshot because the TV was too loud. Then she said she had heard the gunshot," the source says. "So obviously there were a lot of questions, and the Sheriff was asking for clarification."

But before investigators could re-interview her, the long-troubled country singer also would die under eerily similar circumstances, her body discovered at the same Heber Springs, Ark., house just feet away from where David Wilson died.

McCready's death was blamed on what "appears to be a single self-inflicted gunshot wound," the Cleburne County Sheriff's Office said in a statement.

This differed from how the sheriff characterized Wilson's case. His cause and manner of death still have not been established by the coroner. It was McCready's publicist, and not a law enforcement official, who announced that Wilson had died of a self-inflicted gunshot wound.

After Wilson's death, McCready, 37, spoke to investigators three times, but they didn't feel as if they were through with her.

"At no point did [police] tell her she was a suspect, and she wasn't officially one," says the source. "But she knew that some of her answers didn't stand up to questioning. She was very cooperative, but she just wasn't making a lot of sense."

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Hip replacements more likely to fail in women

CHICAGO (AP) — A new study shows that hip replacements are more likely to fail in women than in men.

Researchers found that a small number of the hip implants failed overall, but women were 29 percent more likely than men to need a repeat surgery within the first three years.

Researchers looked at more than 35,000 surgeries at 46 hospitals in the Kaiser Permanente health system. The study is being published Monday in JAMA Internal Medicine. It was funded by the U.S. Food and Drug Administration.

Some experts say more research is needed to determine which models of hip implants perform best in women.

Women make up the majority of the more than 400,000 Americans who have full or partial hip replacements each year.

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Online:

Journal: http://www.jamainternalmed.com

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Yen resumes fall after G20, U.S. holiday thins trade

LONDON (Reuters) - The yen resumed falling on Monday after Japan signaled it would push ahead with expansionist monetary policies having escaped criticism from the world's 20 biggest economies at the weekend.

Industrial metals also dipped and European shares were soft on lingering worries about the economic outlook, especially for the euro zone. While the risk of an inconclusive outcome in Italy's forthcoming election added to investor concerns.

However, activity was curtailed by the closure of markets in the United States for the Presidents' Day holiday.

The yen, which has dropped 20 percent against the dollar since mid-November, fell further after financial leaders from the G20 promised not to devalue their currencies to boost exports and avoided singling out Japan for any direct criticism.

The dollar rose 0.5 percent to 93.95 yen, near a 33-month peak of 94.47 yen set a week ago. The euro added 0.3 percent to 125.40 yen, to be midway between Friday's two-week low of 122.90 and a 34-month high of 127.71 yen hit earlier this month.

Strategists said the yen was likely to stay weak, though its decline could lose momentum until it becomes clear who will be taking the helm at the Bank of Japan when the current governor steps down on March 19.

"The yen probably will weaken a little further in anticipation of more aggressive easing under a new leadership team at the Bank of Japan," said Julian Jessop, chief global economist at Capital Economics.

Japan's Prime Minister Shinzo Abe is poised to nominate the new governor in the next few days. Sources have told Reuters that former financial bureaucrat Toshiro Muto, considered likely to be less radical than other candidates, was leading the field.

Meanwhile the euro dipped slightly against the dollar when European Central Bank president Mario Draghi said the currency's recent gains made any rise in inflation less likely and added that he had yet to see any improvement in the euro zone economy.

Speaking before the European Parliament, Draghi said the euro's exchange rate was not a policy target but was important for growth and stability, adding that appreciation of the euro "is a risk".

The comments left the euro down 0.2 percent at $1.3334.

Elsewhere in the currency market, sterling hit a seven-month low against the dollar, after a key policymaker made comments about the need for further weakness and recent poor data which has kept alive worries of another British recession.

Sterling fell 0.25 percent to $1.5476 having earlier touched $1.5438, its lowest since July 13.

DATA LOOMS

A big week for data on the outlook for the world's economy weighed on other riskier asset markets following the recent dire fourth-quarter growth numbers for the euro zone and Japan, along with Friday's soft U.S. manufacturing figures.

In European markets, attention is focused on the euro area Purchasing Managers' Indexes for February and German sentiment indices due later in the week which could affect hopes for a recovery this year.

Analysts expect Thursday's euro area flash PMI indices, which offer pointers to economic activity around six months out, to show growth stabilizing across the recession-hit region, leaving intact hopes for a recovery in the second half of 2013.

Concerns over an inconclusive outcome in the Italian election on Sunday and Monday have added to the weaker sentiment as a fragmented parliament could hamper a future government's efforts to reform the struggling economy.

The worries about the outlook for Italy were encouraging investors back into safe-haven German government bonds on Monday, with 10-year Bund yields easing 3.5 basis points to be around 1.63 percent.

"Political uncertainty will keep Bunds well bid this week," ING rate strategist Alessandro Giansanti said, adding that only better than expected economic data could create selling pressure on German debt in the near term.

Italian 10-year yields were 4 basis points higher on the day at 4.41 percent.

EARNINGS HIT

European equity markets were taking their lead from corporate earnings reports which have been reflecting the sluggish economic conditions across the region.

Danish brewer Carlsberg , which generates just over 60 percent of its sales in western Europe, became the latest to report a weaker-than-expected quarterly profit, sending its shares to their lowest level in almost a month.

The 5.8-percent drop for shares in the world's fourth biggest brewery helped send the FTSEurofirst 300 index <.fteu3> of top European shares down 0.2 percent. Germany's DAX <.gdaxi>, France's CAC-40 <.fchi> and Britain's FTSE-100 <.ftse> ranged between 0.4 percent up and 0.15 percent lower.

Earlier, the G20 statement and subsequent comment from Prime Minster Abe indicating a renewed drive to stimulate the Japanese economy lifted the Nikkei stock index <.n225> by 2.1 percent, near to its highest level since September 2008.

MSCI's world equity index <.miwd00000pus> was flat as markets extended a two-week period of consolidation that has followed the big run-up in January, when demand was buoyed by the efforts of central banks to stimulate the world economy.

Data from EPFR Global, a U.S.-based firm that tracks the flows and allocations of funds globally, shows investors pulled $3.62 billion from U.S. stock funds in the latest week, the most in 10 weeks after taking a neutral stance the prior week.

But demand for emerging market equities remained strong, with investors putting $1.81 billion in new cash into stock funds, the fund-tracking firm said.

CHINA RETURN

In the commodity markets, traders played catch-up after a week-long holiday last week in China, the world's second biggest consumer of many raw materials, which had kept activity subdued, with worries about the economic outlook weighing on sentiment.

Copper, for which China is the world's largest consumer, dipped to a near three-week low at $8,125.25 a metric ton (1.1023 tons) on the London futures market. Benchmark tin and nickel also touched three-week lows.

Gold managed to edge away from six-month lows as jewelers in China returned to the physical market after the Lunar New Year holiday but a lack of demand from U.S. markets saw the precious metal slip back to be down 0.1 percent to $1,607.06 an ounce.

Crude oil markets were mostly steady after the weak U.S. industrial production data on Friday [ID:nL1N0BF44A] was seen dampening demand, while tensions in the Middle East lent some support.

"We continue to see a mixed picture out of the United States. Industry output was lower than expected but that shouldn't affect the general upward direction," Olivier Jakob, analyst at Geneva-based Petromatrix, said.

Brent crude was down 20 cents at $117.46 a barrel after posting its first weekly loss since the first half of January. U.S. crude slipped 24 cents to $95.62.

(Additional reporting by Marius Zaharia and Ron Bousso; Editing by Philippa Fletcher and Alastair Macdonald)

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Protests at Egypt Port Close Offices, but Not Suez Canal

CAIRO — Thousands of demonstrators shut down the administrative buildings of the Suez Canal terminal in the city of Port Said on Sunday, as part of a general strike protesting the death sentences handed down three weeks ago to 21 local soccer fans for their roles in a deadly riot last year.

The protests marked the closest that the chaos in Egypt over the last two years has come to threatening the operations of the Suez Canal, an artery of shipping critical to both international commerce and the battered Egyptian economy.

The administrative facilities were emptied as the protesters approached, residents said, but a military guard protected the port from disruption. President Mohamed Morsi, of the Muslim Brotherhood’s political arm, had deployed the military to protect the city when the protests there started three weeks ago.

The success of the strike, as life had begun to return to the streets, was a vivid reminder that the government in Cairo has not yet restored full control over Port Said, a major city at the Mediterranean head of the Suez Canal with a population of about 600,000. The government essentially backed down from its attempt to impose a curfew, and nothing has diminished the underlying anger behind the riots, first over the initial death sentences and then over the deaths of dozens of protesters in clashes with the police.

The possibility of a threat to the flow of traffic through the canal remains remote, but the Sunday protest raised the specter of such disruption at a critical time. Political turbulence has cut deeply into tourism and economic growth in the two years since the ouster of Hosni Mubarak. And now the political instability keeps delaying a proposed $4.8 billion loan from the International Monetary Fund, whose seal of approval is essential to obtaining the further billions in loans needed to close the country’s deficit.

The Egyptian pound is falling sharply against the dollar. Unemployment is high and prices are rising. The Suez Canal is one of Egypt’s main sources of hard currency, along with tourism, foreign aid, and remittances from Egyptians abroad.

The protest was also a rare example of major civil disobedience in Egypt since the revolution that overthrew Mr. Mubarak in early 2011. It was the first day of the work week here, and Egyptian state media and residents of Port Said said that demonstrators had gathered outside the provincial headquarters at 7 a.m., blocking access to the building.

The protesters urged employees of the provincial government, the court house, the telephone and natural gas utilities, customs offices and other government institutions to quit work and join their strike. Many did, the Web site of the state newspaper Al Ahram reported. Protesters blocked railways. Photographs that circulated on the Internet showed women sitting on desks they had dragged outside in a shutdown of a school, although residents said some schools and courts remained opened.

Al Ahram reported that the demonstrators were demanding legal action against police officers who had killed protesters during last month’s clashes. They also sought a review by a “neutral court” of the death sentences against the local soccer fans delivered in Cairo. The soccer brawl in the case took place at a match between bitter rivals, El Masry of Port Said and Al Ahly of Cairo, both of which have large followings of violent hard-core fans. Many residents of Port Said say they believe the sentencing judge succumbed to pressure from violent Cairo soccer fans who demanded retribution.

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Josh Kelley Dotes on Daughters Naleigh and Adalaide on Twitter

By Maggie Coughlan

02/17/2013 at 05:35 PM EST

Naleigh, Josh Kelley and Adalaide

Courtesy of Josh Kelley

Daddy's girls!

Proud papa Josh Kelley shared a photo of himself relaxing on the couch with daughters Naleigh, 4, and Adalaide, 9 months, on Twitter Saturday.

Posing with his arms around the girls, Kelley Tweeted, "I love my little chickadees. Everyone keeps saying it goes by so fast so I'm gonna soak it up!!"

This isn't the first time the husband to Katherine Heigl has doted on his daughters via Twitter.

On Feb. 6, he Tweeted he had gone golfing with Naleigh – who sported a panda hat to the green.

"Naleigh hitting golf balls with daddy rocking her panda bear ski hat. She's a nut if I've ever seen one!!!"

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UN warns risk of hepatitis E in S. Sudan grows

GENEVA (AP) — The United Nations says an outbreak of hepatitis E has killed 111 refugees in camps in South Sudan since July, and has become endemic in the region.

U.N. refugee agency spokesman Adrian Edwards says the influx of people to the camps from neighboring Sudan is believed to be one of the factors in the rapid spread of the contagious, life-threatening inflammatory viral disease of the liver.

Edwards said Friday that the camps have been hit by 6,017 cases of hepatitis E, which is spread through contaminated food and water.

He says the largest number of cases and suspected cases is in the Yusuf Batil camp in Upper Nile state, which houses 37,229 refugees fleeing fighting between rebels and the Sudanese government.

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G20 steps back from currency brink, heat off Japan

MOSCOW (Reuters) - The Group of 20 nations declared on Saturday there would be no currency war and deferred plans to set new debt-cutting targets, underlining broad concern about the fragile state of the world economy.

Japan's expansive policies, which have driven down the yen, escaped direct criticism in a statement thrashed out in Moscow by policymakers from the G20, which spans developed and emerging markets and accounts for 90 percent of the world economy.

Analysts said the yen, which has dropped 20 percent as a result of aggressive monetary and fiscal policies to reflate the Japanese economy, may now continue to fall.

"The market will take the G20 statement as an approval for what it has been doing -- selling of the yen," said Neil Mellor, currency strategist at Bank of New York Mellon in London. "No censure of Japan means they will be off to the money printing presses."

After late-night talks, finance ministers and central bankers agreed on wording closer than expected to a joint statement issued last Tuesday by the Group of Seven rich nations backing market-determined exchange rates.

A draft communiqué on Friday had steered clear of the G7's call for economic policy not to be targeted at exchange rates. But the final version included a G20 commitment to refrain from competitive devaluations and stated monetary policy would be directed only at price stability and growth.

"The mood quite clearly early on was that we needed desperately to avoid protectionist measures ... that mood permeated quite quickly," Canadian Finance Minister Jim Flaherty told reporters, adding that the wording of the G20 statement had been hardened up by the ministers.

As a result, it reflected a substantial, but not complete, endorsement of Tuesday's proclamation by the G7 nations - the United States, Japan, Britain, Canada, France, Germany and Italy.

As with the G7 intervention, Tokyo said it gave it a green light to pursue its policies unchecked.

"I have explained that (Prime Minister Shinzo) Abe's administration is doing its utmost to escape from deflation and we have gained a certain understanding," Finance Minister Taro Aso told reporters.

"We're confident that if Japan revives its own economy that would certainly affect the world economy as well. We gained understanding on this point."

Flaherty admitted it would be difficult to gauge if domestic policies were aimed at weakening currencies or not.

NO FISCAL TARGETS

The G20 also made a commitment to a credible medium-term fiscal strategy, but stopped short of setting specific goals as most delegations felt any economic recovery was too fragile.

The communiqué said risks to the world economy had receded but growth remained too weak and unemployment too high.

"A sustained effort is required to continue building a stronger economic and monetary union in the euro area and to resolve uncertainties related to the fiscal situation in the United States and Japan, as well as to boost domestic sources of growth in surplus economies," it said.

A debt-cutting pact struck in Toronto in 2010 will expire this year if leaders fail to agree to extend it at a G20 summit of leaders in St Petersburg in September.

The United States says it is on track to meet its Toronto pledge but argues that the pace of future fiscal consolidation must not snuff out demand. Germany and others are pressing for another round of binding debt targets.

"We had a broad consensus in the G20 that we will stick to the commitment to fulfill the Toronto goals," German Finance Minister Wolfgang Schaeuble said. "We do not have any interest in U.S.-bashing ... In St. Petersburg follow-up-goals will be decided."

The G20 put together a huge financial backstop to halt a market meltdown in 2009 but has failed to reach those heights since. At successive meetings, Germany has pressed the United States and others to do more to tackle their debts. Washington in turn has urged Berlin to do more to increase demand.

Backing in the communiqué for the use of domestic monetary policy to support economic recovery reflected the U.S. Federal Reserve's commitment to monetary stimulus through quantitative easing, or QE, to promote recovery and jobs.

QE entails large-scale bond buying -- $85 billion a month in the Fed's case -- that helps economic growth but has also unleashed destabilising capital flows into emerging markets.

A commitment to minimize such "negative spillovers" was an offsetting point in the text that China, fearful of asset bubbles and lost export competitiveness, highlighted.

"Major developed nations (should) pay attention to their monetary policy spillover," Vice Finance Minister Zhu Guangyao was quoted by state news agency Xinhua as saying in Moscow.

Russia, this year's chair of the G20, admitted the group had failed to reach agreement on medium-term budget deficit levels and expressed concern about ultra-loose policies that it and other emerging economies say could store up trouble for later.

On currencies, the G20 text reiterated its commitment last November, "to move more rapidly toward mores market-determined exchange rate systems and exchange rate flexibility to reflect underlying fundamentals, and avoid persistent exchange rate misalignments".

It said disorderly exchange rate movements and excess volatility in financial flows could harm economic and financial stability.

(Additional reporting by Gernot Heller, Lesley Wroughton, Maya Dyakina, Tetsushi Kajimoto, Jan Strupczewski, Lidia Kelly, Katya Golubkova, Jason Bush, Anirban Nag and Michael Martina. Writing by Douglas Busvine. Editing by Timothy Heritage/Mike Peacock)

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