Susan London

SEATTLE — Sleep-disordered breathing is an independent risk factor for gestational hypertension, and it also may confer an elevated risk of adverse fetal outcomes, according to Louise M. O'Brien, Ph.D., of the Sleep Disorders Center at the University of Michigan, Ann Arbor.

SDB, often diagnosed clinically as habitual snoring, is common in women of childbearing age, with a reported prevalence of 5%-10%, Dr. O'Brien said at the annual meeting of the Associated Professional Sleep Societies. “This is probably the tip of the iceberg, because [many] women actually go undiagnosed.”

The anatomic and physiological changes of pregnancy make pregnant women uniquely vulnerable to SDB, she noted. Indeed, studies show that the prevalence of habitual snoring rises with pregnancy, and ranges from 10% to nearly 40% of women during the third trimester. Data from a large ongoing study at the University of Michigan show that habitual snoring is markedly more common in unselected women during the third trimester of pregnancy than in nonpregnant women (35% vs. 7%). “What was particularly interesting is that this wasn't driven by women who were snoring before they got pregnant; in fact, the majority started habitually snoring only after they reached the second trimester,” she said. This finding suggests that one-time screening shortly after conception will miss a lot of women.

Obesity appears to further elevate the risk. Compared with their normal-weight peers, obese women are more likely to have SDB in early pregnancy and to experience a worsening as pregnancy progresses (Chest 2001;120:1448-54.). In addition, weight gain during pregnancy that exceeds the amount recommended by the Institute of Medicine independently predicts SDB (odds ratio, 1.9), based on the results of a study in 2009.

When it comes to maternal outcomes, evidence has linked SDB to both gestational hypertension and pre-eclampsia, according to Dr. O'Brien. Women who habitually snore during pregnancy are twice as likely to have gestational hypertension as their nonsnoring counterparts (Chest 2000;117:137-41). In addition, the upper airway has been found to be narrowed in pregnant women and even more so among pre-eclamptic pregnant women compared with their nonpregnant peers (Am. J. Respir. Crit. Care Med. 2003;167:137-40).

Obesity complicates this picture because it also increases the risk of hypertension, she observed. But even after obesity is taken into account, habitual snoring remains an independent predictor of gestational hypertension (OR, 2.0), the 2009 study found. Moreover, there is an interaction whereby women who habitually snore and are obese have a particularly elevated risk (OR, 4.1).

On a brighter note, treatment of maternal SDB with continuous positive airway pressure (CPAP) may improve outcomes, Dr. O'Brien observed. For example, pregnant hypertensive women who snore and are at high risk of preeclampsia have a drop in blood pressure and maintain or reduce their dose of antihypertensive medication if they are treated with CPAP; in contrast, their blood pressure rises further and their dose of medication triples if they receive only usual care (Sleep Med. 2007;9:15-21). CPAP also appears to help restore the reduced fetal movements seen in women with preeclampsia (Sleep Med Clin. 2008;3:81-95).

Taken together, the evidence suggests that awareness of SDB during pregnancy is important, Dr. O'Brien stressed, yet obstetricians are generally unaware that their patients have habitual snoring or even apnea. “One, the women don't realize it's important to tell their physicians about it,” she said. “And two, the obstetricians don't realize its important to ask about it.”

Some surrogate measures of SDB may help obstetricians assess SDB-associated risk in their pregnant patients. For example, women are more likely to have gestational hypertension if they have a Mallampati grade of III or IV, indicating a crowded airway (OR, 1.9), or a neck circumference of 40 cm or greater (OR, 2.5), a 2008 study found. Dr. O'Brien reported that she had no conflicts of interest.

SEATTLE — Sleep-disordered breathing is an independent risk factor for gestational hypertension, and it also may confer an elevated risk of adverse fetal outcomes, according to Louise M. O'Brien, Ph.D., of the Sleep Disorders Center at the University of Michigan, Ann Arbor.

SDB, often diagnosed clinically as habitual snoring, is common in women of childbearing age, with a reported prevalence of 5%-10%, Dr. O'Brien said at the annual meeting of the Associated Professional Sleep Societies. “This is probably the tip of the iceberg, because [many] women actually go undiagnosed.”

The anatomic and physiological changes of pregnancy make pregnant women uniquely vulnerable to SDB, she noted. Indeed, studies show that the prevalence of habitual snoring rises with pregnancy, and ranges from 10% to nearly 40% of women during the third trimester. Data from a large ongoing study at the University of Michigan show that habitual snoring is markedly more common in unselected women during the third trimester of pregnancy than in nonpregnant women (35% vs. 7%). “What was particularly interesting is that this wasn't driven by women who were snoring before they got pregnant; in fact, the majority started habitually snoring only after they reached the second trimester,” she said. This finding suggests that one-time screening shortly after conception will miss a lot of women.

Obesity appears to further elevate the risk. Compared with their normal-weight peers, obese women are more likely to have SDB in early pregnancy and to experience a worsening as pregnancy progresses (Chest 2001;120:1448-54.). In addition, weight gain during pregnancy that exceeds the amount recommended by the Institute of Medicine independently predicts SDB (odds ratio, 1.9), based on the results of a study in 2009.

When it comes to maternal outcomes, evidence has linked SDB to both gestational hypertension and pre-eclampsia, according to Dr. O'Brien. Women who habitually snore during pregnancy are twice as likely to have gestational hypertension as their nonsnoring counterparts (Chest 2000;117:137-41). In addition, the upper airway has been found to be narrowed in pregnant women and even more so among pre-eclamptic pregnant women compared with their nonpregnant peers (Am. J. Respir. Crit. Care Med. 2003;167:137-40).

Obesity complicates this picture because it also increases the risk of hypertension, she observed. But even after obesity is taken into account, habitual snoring remains an independent predictor of gestational hypertension (OR, 2.0), the 2009 study found. Moreover, there is an interaction whereby women who habitually snore and are obese have a particularly elevated risk (OR, 4.1).

On a brighter note, treatment of maternal SDB with continuous positive airway pressure (CPAP) may improve outcomes, Dr. O'Brien observed. For example, pregnant hypertensive women who snore and are at high risk of preeclampsia have a drop in blood pressure and maintain or reduce their dose of antihypertensive medication if they are treated with CPAP; in contrast, their blood pressure rises further and their dose of medication triples if they receive only usual care (Sleep Med. 2007;9:15-21). CPAP also appears to help restore the reduced fetal movements seen in women with preeclampsia (Sleep Med Clin. 2008;3:81-95).

Taken together, the evidence suggests that awareness of SDB during pregnancy is important, Dr. O'Brien stressed, yet obstetricians are generally unaware that their patients have habitual snoring or even apnea. “One, the women don't realize it's important to tell their physicians about it,” she said. “And two, the obstetricians don't realize its important to ask about it.”

Some surrogate measures of SDB may help obstetricians assess SDB-associated risk in their pregnant patients. For example, women are more likely to have gestational hypertension if they have a Mallampati grade of III or IV, indicating a crowded airway (OR, 1.9), or a neck circumference of 40 cm or greater (OR, 2.5), a 2008 study found. Dr. O'Brien reported that she had no conflicts of interest.

SEATTLE — Sleep-disordered breathing is an independent risk factor for gestational hypertension, and it also may confer an elevated risk of adverse fetal outcomes, according to Louise M. O'Brien, Ph.D., of the Sleep Disorders Center at the University of Michigan, Ann Arbor.

SDB, often diagnosed clinically as habitual snoring, is common in women of childbearing age, with a reported prevalence of 5%-10%, Dr. O'Brien said at the annual meeting of the Associated Professional Sleep Societies. “This is probably the tip of the iceberg, because [many] women actually go undiagnosed.”

The anatomic and physiological changes of pregnancy make pregnant women uniquely vulnerable to SDB, she noted. Indeed, studies show that the prevalence of habitual snoring rises with pregnancy, and ranges from 10% to nearly 40% of women during the third trimester. Data from a large ongoing study at the University of Michigan show that habitual snoring is markedly more common in unselected women during the third trimester of pregnancy than in nonpregnant women (35% vs. 7%). “What was particularly interesting is that this wasn't driven by women who were snoring before they got pregnant; in fact, the majority started habitually snoring only after they reached the second trimester,” she said. This finding suggests that one-time screening shortly after conception will miss a lot of women.

Obesity appears to further elevate the risk. Compared with their normal-weight peers, obese women are more likely to have SDB in early pregnancy and to experience a worsening as pregnancy progresses (Chest 2001;120:1448-54.). In addition, weight gain during pregnancy that exceeds the amount recommended by the Institute of Medicine independently predicts SDB (odds ratio, 1.9), based on the results of a study in 2009.

When it comes to maternal outcomes, evidence has linked SDB to both gestational hypertension and pre-eclampsia, according to Dr. O'Brien. Women who habitually snore during pregnancy are twice as likely to have gestational hypertension as their nonsnoring counterparts (Chest 2000;117:137-41). In addition, the upper airway has been found to be narrowed in pregnant women and even more so among pre-eclamptic pregnant women compared with their nonpregnant peers (Am. J. Respir. Crit. Care Med. 2003;167:137-40).

Obesity complicates this picture because it also increases the risk of hypertension, she observed. But even after obesity is taken into account, habitual snoring remains an independent predictor of gestational hypertension (OR, 2.0), the 2009 study found. Moreover, there is an interaction whereby women who habitually snore and are obese have a particularly elevated risk (OR, 4.1).

On a brighter note, treatment of maternal SDB with continuous positive airway pressure (CPAP) may improve outcomes, Dr. O'Brien observed. For example, pregnant hypertensive women who snore and are at high risk of preeclampsia have a drop in blood pressure and maintain or reduce their dose of antihypertensive medication if they are treated with CPAP; in contrast, their blood pressure rises further and their dose of medication triples if they receive only usual care (Sleep Med. 2007;9:15-21). CPAP also appears to help restore the reduced fetal movements seen in women with preeclampsia (Sleep Med Clin. 2008;3:81-95).

Taken together, the evidence suggests that awareness of SDB during pregnancy is important, Dr. O'Brien stressed, yet obstetricians are generally unaware that their patients have habitual snoring or even apnea. “One, the women don't realize it's important to tell their physicians about it,” she said. “And two, the obstetricians don't realize its important to ask about it.”

Some surrogate measures of SDB may help obstetricians assess SDB-associated risk in their pregnant patients. For example, women are more likely to have gestational hypertension if they have a Mallampati grade of III or IV, indicating a crowded airway (OR, 1.9), or a neck circumference of 40 cm or greater (OR, 2.5), a 2008 study found. Dr. O'Brien reported that she had no conflicts of interest.

SEATTLE — Evidence from recent and ongoing trials is helping to clarify the best strategies for managing cutaneous melanoma.

A hurdle to better melanoma management has been the high variability of the disease, exemplified in part by its wide-ranging presentations, said Dr. William Dzwierzynski, professor of plastic and reconstructive surgery at the Medical College of Wisconsin in Milwaukee. In fact, accumulating evidence suggests that melanoma may encompass several different diseases with differing biology.

When initially evaluating a suspicious skin lesion, the type of biopsy is critical. "Excisional biopsy is probably the most key thing. You really try not to do an incisional or a shave biopsy," he said, unless the latter is deep and removes the whole lesion. Reassuringly, though, the type of biopsy does not affect survival (Am. J. Surg. 2005;190:913–7)."But we'll never know the depth of the lesion" with an incisional or shave biopsy, he pointed out, "so we'll never have the right prognosis."

Accurate diagnosis of melanoma requires permanent sections. "Melanoma is not accurately diagnosed on frozen sections. Don't do frozen sections on melanoma—you get a lot of false-negatives and a lot of false-positives," Dr. Dzwierzynski said at the annual meeting of the American Society of Plastic Surgeons.

Positron emission tomography (PET) imaging is unreliable for staging in patients with melanoma, yielding a false-negative rate of 79% when used preoperatively to identify occult nodal metastases (Cancer 2005;104:570–9). "There is not any conclusive data that PET scan is any more accurate than a chest x-ray or lab tests," he added. On the flip side, patients should not be assumed to have metastases solely based on a positive PET scan.

"I send everybody who has a melanoma that is 1 mm or greater to an oncologist," he added. "I tell them that the oncologist probably won't have anything to offer you, and that's a good thing. But they are the ones who are going to know if there are any investigational studies or treatment trials."

Whenever possible, patients with advanced disease should be referred for clinical trials. "Investigational therapies—I think this is where the promise is," Dr. Dzwierzynski commented.

When it comes to resecting the tumor, contemporary margins are 1–3 cm for most invasive melanomas. Prospective studies have found no difference in survival between margins of 1–2 cm and larger margins of 3–5 cm, but methodologic limitations leave the issue unresolved, he said.

Mohs surgery for invasive melanoma remains controversial. "There is a lot of distortion when you do Mohs," he noted. "It's really easy to get false-negatives and false-positives." To date, controlled survival data and randomized trials are lacking.

Sentinel node biopsy (SNB) is recommended for patients whose tumors have a Breslow thickness of greater than 1 mm and for those whose tumors are thinner but have adverse features, such as ulceration or a Clark level of IV or V. Currently, it is done to obtain prognostic information and identify the roughly 20% of patients who may benefit from a complete lymph node dissection, Dr. Dzwierzynski noted.

The results of the first Multicenter Selective Lymphadenectomy Trial (MSLT-1) raised the possibility that SNB also may be curing disease in some patients and improving survival (N. Engl. J. Med. 2006;355;1307–17). An ongoing follow-up trial, MSLT-2, is looking more closely at the issue and the possibility that patients with only microscopic disease in the sentinel node may be spared further surgery.

Importantly, there is a learning curve to the SNB procedure. In MSLT-1, the false-negative rate was 10% in a physician's first 25 cases, but fell to 5% thereafter (Ann. Surg. 2005;242:302–13). "So right now, the recommendation is that it does take probably 30 cases for that learning curve," he said.

For pathologic evaluation of sentinel nodes, the combination of step sectioning (at less than 1-mm intervals) and hematoxylin and eosin staining with HMB-45 and S-100 immunohistochemistry has sensitivity approaching 98%, according to Dr. Dzwierzynski. A triple stain used at his institution—the MCW melanoma cocktail (Melan-A, MART-1, and tyrosinase)—has high accuracy (BMC Cancer 2003;3:15), albeit at a fairly high cost. In contrast, polymerase chain reaction has proven to be of limited use because it can be falsely positive in patients with subcapsular nevi.

The National Comprehensive Cancer Network recommends complete lymph node dissection for patients with a positive SNB, but a recent analysis of national data found that only half of such patients underwent the procedure (Ann. Surg. Oncol. 2008;15:1566–76).

"Complete lymph node dissection is a curative procedure," he commented. As such, it is extensive, more so than the lymph node sampling done for, say, breast cancer. "In most of my axillary dissections, I will remove 35–40 lymph nodes," Dr. Dzwierzynski said. "For a superficial inguinal dissection, you should have at least 10 nodes, and for a deep dissection, you have at least 5 nodes."

Complication rates of complete lymph node dissection are generally high, and they tend to be higher after inguinal procedures (48%–84%) than after axillary ones (47%–53%), he noted.

Several trials have shown that adjuvant high-dose interferon therapy modestly improves outcomes among patients with melanoma at high risk for recurrence, but with the tradeoff of substantial toxicity. The benefits are lost when the dose is reduced and therapy is shortened. "But there may be a subgroup in which interferon is useful," he added, so an individualized approach, with discussion of risks and benefits, is needed. It should not be given automatically "because it's the only thing that's available," he said.

The optimal approach to follow-up of patients with treated melanoma has not been established, but follow-up is typically lifelong and multidisciplinary, according to Dr. Dzwierzynski. Importantly, all patients must have lymph node palpation for detection of recurrences, and full-body skin checks for detection of second primaries.

Dr. Dzwierzynski reported that he had no conflicts of interest in association with his presentation.

'Don't do frozen sections on melanoma—you get a lot of false-negatives and a lot of false-positives.'

Source Dr. Dzwierzynski

SEATTLE — Evidence from recent and ongoing trials is helping to clarify the best strategies for managing cutaneous melanoma.

A hurdle to better melanoma management has been the high variability of the disease, exemplified in part by its wide-ranging presentations, said Dr. William Dzwierzynski, professor of plastic and reconstructive surgery at the Medical College of Wisconsin in Milwaukee. In fact, accumulating evidence suggests that melanoma may encompass several different diseases with differing biology.

When initially evaluating a suspicious skin lesion, the type of biopsy is critical. "Excisional biopsy is probably the most key thing. You really try not to do an incisional or a shave biopsy," he said, unless the latter is deep and removes the whole lesion. Reassuringly, though, the type of biopsy does not affect survival (Am. J. Surg. 2005;190:913–7)."But we'll never know the depth of the lesion" with an incisional or shave biopsy, he pointed out, "so we'll never have the right prognosis."

Accurate diagnosis of melanoma requires permanent sections. "Melanoma is not accurately diagnosed on frozen sections. Don't do frozen sections on melanoma—you get a lot of false-negatives and a lot of false-positives," Dr. Dzwierzynski said at the annual meeting of the American Society of Plastic Surgeons.

Positron emission tomography (PET) imaging is unreliable for staging in patients with melanoma, yielding a false-negative rate of 79% when used preoperatively to identify occult nodal metastases (Cancer 2005;104:570–9). "There is not any conclusive data that PET scan is any more accurate than a chest x-ray or lab tests," he added. On the flip side, patients should not be assumed to have metastases solely based on a positive PET scan.

"I send everybody who has a melanoma that is 1 mm or greater to an oncologist," he added. "I tell them that the oncologist probably won't have anything to offer you, and that's a good thing. But they are the ones who are going to know if there are any investigational studies or treatment trials."

Whenever possible, patients with advanced disease should be referred for clinical trials. "Investigational therapies—I think this is where the promise is," Dr. Dzwierzynski commented.

When it comes to resecting the tumor, contemporary margins are 1–3 cm for most invasive melanomas. Prospective studies have found no difference in survival between margins of 1–2 cm and larger margins of 3–5 cm, but methodologic limitations leave the issue unresolved, he said.

Mohs surgery for invasive melanoma remains controversial. "There is a lot of distortion when you do Mohs," he noted. "It's really easy to get false-negatives and false-positives." To date, controlled survival data and randomized trials are lacking.

Sentinel node biopsy (SNB) is recommended for patients whose tumors have a Breslow thickness of greater than 1 mm and for those whose tumors are thinner but have adverse features, such as ulceration or a Clark level of IV or V. Currently, it is done to obtain prognostic information and identify the roughly 20% of patients who may benefit from a complete lymph node dissection, Dr. Dzwierzynski noted.

The results of the first Multicenter Selective Lymphadenectomy Trial (MSLT-1) raised the possibility that SNB also may be curing disease in some patients and improving survival (N. Engl. J. Med. 2006;355;1307–17). An ongoing follow-up trial, MSLT-2, is looking more closely at the issue and the possibility that patients with only microscopic disease in the sentinel node may be spared further surgery.

Importantly, there is a learning curve to the SNB procedure. In MSLT-1, the false-negative rate was 10% in a physician's first 25 cases, but fell to 5% thereafter (Ann. Surg. 2005;242:302–13). "So right now, the recommendation is that it does take probably 30 cases for that learning curve," he said.

For pathologic evaluation of sentinel nodes, the combination of step sectioning (at less than 1-mm intervals) and hematoxylin and eosin staining with HMB-45 and S-100 immunohistochemistry has sensitivity approaching 98%, according to Dr. Dzwierzynski. A triple stain used at his institution—the MCW melanoma cocktail (Melan-A, MART-1, and tyrosinase)—has high accuracy (BMC Cancer 2003;3:15), albeit at a fairly high cost. In contrast, polymerase chain reaction has proven to be of limited use because it can be falsely positive in patients with subcapsular nevi.

The National Comprehensive Cancer Network recommends complete lymph node dissection for patients with a positive SNB, but a recent analysis of national data found that only half of such patients underwent the procedure (Ann. Surg. Oncol. 2008;15:1566–76).

"Complete lymph node dissection is a curative procedure," he commented. As such, it is extensive, more so than the lymph node sampling done for, say, breast cancer. "In most of my axillary dissections, I will remove 35–40 lymph nodes," Dr. Dzwierzynski said. "For a superficial inguinal dissection, you should have at least 10 nodes, and for a deep dissection, you have at least 5 nodes."

Complication rates of complete lymph node dissection are generally high, and they tend to be higher after inguinal procedures (48%–84%) than after axillary ones (47%–53%), he noted.

Several trials have shown that adjuvant high-dose interferon therapy modestly improves outcomes among patients with melanoma at high risk for recurrence, but with the tradeoff of substantial toxicity. The benefits are lost when the dose is reduced and therapy is shortened. "But there may be a subgroup in which interferon is useful," he added, so an individualized approach, with discussion of risks and benefits, is needed. It should not be given automatically "because it's the only thing that's available," he said.

The optimal approach to follow-up of patients with treated melanoma has not been established, but follow-up is typically lifelong and multidisciplinary, according to Dr. Dzwierzynski. Importantly, all patients must have lymph node palpation for detection of recurrences, and full-body skin checks for detection of second primaries.

Dr. Dzwierzynski reported that he had no conflicts of interest in association with his presentation.

'Don't do frozen sections on melanoma—you get a lot of false-negatives and a lot of false-positives.'

Source Dr. Dzwierzynski

SEATTLE — Evidence from recent and ongoing trials is helping to clarify the best strategies for managing cutaneous melanoma.

A hurdle to better melanoma management has been the high variability of the disease, exemplified in part by its wide-ranging presentations, said Dr. William Dzwierzynski, professor of plastic and reconstructive surgery at the Medical College of Wisconsin in Milwaukee. In fact, accumulating evidence suggests that melanoma may encompass several different diseases with differing biology.

When initially evaluating a suspicious skin lesion, the type of biopsy is critical. "Excisional biopsy is probably the most key thing. You really try not to do an incisional or a shave biopsy," he said, unless the latter is deep and removes the whole lesion. Reassuringly, though, the type of biopsy does not affect survival (Am. J. Surg. 2005;190:913–7)."But we'll never know the depth of the lesion" with an incisional or shave biopsy, he pointed out, "so we'll never have the right prognosis."

Accurate diagnosis of melanoma requires permanent sections. "Melanoma is not accurately diagnosed on frozen sections. Don't do frozen sections on melanoma—you get a lot of false-negatives and a lot of false-positives," Dr. Dzwierzynski said at the annual meeting of the American Society of Plastic Surgeons.

Positron emission tomography (PET) imaging is unreliable for staging in patients with melanoma, yielding a false-negative rate of 79% when used preoperatively to identify occult nodal metastases (Cancer 2005;104:570–9). "There is not any conclusive data that PET scan is any more accurate than a chest x-ray or lab tests," he added. On the flip side, patients should not be assumed to have metastases solely based on a positive PET scan.

"I send everybody who has a melanoma that is 1 mm or greater to an oncologist," he added. "I tell them that the oncologist probably won't have anything to offer you, and that's a good thing. But they are the ones who are going to know if there are any investigational studies or treatment trials."

Whenever possible, patients with advanced disease should be referred for clinical trials. "Investigational therapies—I think this is where the promise is," Dr. Dzwierzynski commented.

When it comes to resecting the tumor, contemporary margins are 1–3 cm for most invasive melanomas. Prospective studies have found no difference in survival between margins of 1–2 cm and larger margins of 3–5 cm, but methodologic limitations leave the issue unresolved, he said.

Mohs surgery for invasive melanoma remains controversial. "There is a lot of distortion when you do Mohs," he noted. "It's really easy to get false-negatives and false-positives." To date, controlled survival data and randomized trials are lacking.

Sentinel node biopsy (SNB) is recommended for patients whose tumors have a Breslow thickness of greater than 1 mm and for those whose tumors are thinner but have adverse features, such as ulceration or a Clark level of IV or V. Currently, it is done to obtain prognostic information and identify the roughly 20% of patients who may benefit from a complete lymph node dissection, Dr. Dzwierzynski noted.

The results of the first Multicenter Selective Lymphadenectomy Trial (MSLT-1) raised the possibility that SNB also may be curing disease in some patients and improving survival (N. Engl. J. Med. 2006;355;1307–17). An ongoing follow-up trial, MSLT-2, is looking more closely at the issue and the possibility that patients with only microscopic disease in the sentinel node may be spared further surgery.

Importantly, there is a learning curve to the SNB procedure. In MSLT-1, the false-negative rate was 10% in a physician's first 25 cases, but fell to 5% thereafter (Ann. Surg. 2005;242:302–13). "So right now, the recommendation is that it does take probably 30 cases for that learning curve," he said.

For pathologic evaluation of sentinel nodes, the combination of step sectioning (at less than 1-mm intervals) and hematoxylin and eosin staining with HMB-45 and S-100 immunohistochemistry has sensitivity approaching 98%, according to Dr. Dzwierzynski. A triple stain used at his institution—the MCW melanoma cocktail (Melan-A, MART-1, and tyrosinase)—has high accuracy (BMC Cancer 2003;3:15), albeit at a fairly high cost. In contrast, polymerase chain reaction has proven to be of limited use because it can be falsely positive in patients with subcapsular nevi.

The National Comprehensive Cancer Network recommends complete lymph node dissection for patients with a positive SNB, but a recent analysis of national data found that only half of such patients underwent the procedure (Ann. Surg. Oncol. 2008;15:1566–76).

"Complete lymph node dissection is a curative procedure," he commented. As such, it is extensive, more so than the lymph node sampling done for, say, breast cancer. "In most of my axillary dissections, I will remove 35–40 lymph nodes," Dr. Dzwierzynski said. "For a superficial inguinal dissection, you should have at least 10 nodes, and for a deep dissection, you have at least 5 nodes."

Complication rates of complete lymph node dissection are generally high, and they tend to be higher after inguinal procedures (48%–84%) than after axillary ones (47%–53%), he noted.

Several trials have shown that adjuvant high-dose interferon therapy modestly improves outcomes among patients with melanoma at high risk for recurrence, but with the tradeoff of substantial toxicity. The benefits are lost when the dose is reduced and therapy is shortened. "But there may be a subgroup in which interferon is useful," he added, so an individualized approach, with discussion of risks and benefits, is needed. It should not be given automatically "because it's the only thing that's available," he said.

The optimal approach to follow-up of patients with treated melanoma has not been established, but follow-up is typically lifelong and multidisciplinary, according to Dr. Dzwierzynski. Importantly, all patients must have lymph node palpation for detection of recurrences, and full-body skin checks for detection of second primaries.

Dr. Dzwierzynski reported that he had no conflicts of interest in association with his presentation.

'Don't do frozen sections on melanoma—you get a lot of false-negatives and a lot of false-positives.'

Source Dr. Dzwierzynski

SEATTLE — Children who are allergic to gelatin or egg protein still can receive key childhood vaccines containing these agents, but vaccination should be done by an allergy specialist under well-controlled conditions, according to Dr. John Kelso.

Gelatin is one of the ingredients in the measles, mumps, and rubella vaccine (MMR-II), Dr. Kelso said at a meeting sponsored by the American Academy of Pediatrics. “In the vast majority of people who have an allergic reaction to MMR, it's because of allergy to the gelatin.”

Various other vaccines also contain gelatin, said Dr. Kelso, who is a pediatric allergy and immunology specialist at the Scripps Clinic in San Diego. (See table below.)

“Prior to giving someone a gelatin-containing vaccine, you should ask them if they are allergic to Jell-O or gelatin,” he advised. “There is some yield with that question, but it's not a perfect test because there are children who can eat Jell-O and not have a problem, but when it is injected in their arm, they have anaphylaxis.”

Children who have a history of reactions to gelatin should be referred to an allergist for definitive testing, Dr. Kelso said. If the child is confirmed to have an allergy, the allergist can administer the vaccine using strategies such as graded dosing.

Two types of vaccines—influenza vaccines and the yellow fever vaccine—contain egg protein. Hence, children should be asked about egg allergy before these vaccines are administered.

“In one study, they gave influenza vaccine to egg-allergic children and nothing happened,” he noted. However, the amount of egg protein in any given year's influenza vaccine varies considerably, so it is unclear what would happen if the current year's vaccine contained greater amounts of the protein.

“The AAP's Red Book unfortunately concluded that egg-allergic children should just not be given the influenza vaccine and that antivirals should be considered instead. But if you have a child whom you would really like to receive an influenza vaccine—even if they are egg allergic—please send them to your local allergist,” he said. “We can skin test them with the vaccine itself and with egg for that matter because that's an allergy that is commonly outgrown. Then, if we need to, we can administer the vaccine in graded doses.”

The MMR and rabies vaccines are grown in cell cultures of chick embryo fibroblasts and not in eggs, observed Dr. Kelso, who said he had no conflicts of interest related to this presentation. Hence, these vaccines contain virtually no egg protein. “So even children who have a truly life-threatening egg allergy can get these vaccines with no testing and no graded dosing,” he said.

He encouraged pediatricians to report any reaction even potentially related to a vaccine through the online Vaccine Adverse Event Reporting System (VAERS) at https://secure.vaers.org/VaersDataEntryIntro.htm

“Please submit these reports—it's very important because this is how these very rare reactions to vaccines come to light,” he explained.

For definitive, current information on vaccines, including their components, Dr. Kelso recommended the Pink Book, formally titled “Epidemiology and Prevention of Vaccine-Preventable Diseases,” which is published by the Centers for Disease Control and Prevention. “The entire book is available online. It's a tremendous resource and it is continually updated,” he noted. Go to www.cdc.gov/vaccines/Pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf

Elsevier Global Medical News

SEATTLE — Children who are allergic to gelatin or egg protein still can receive key childhood vaccines containing these agents, but vaccination should be done by an allergy specialist under well-controlled conditions, according to Dr. John Kelso.

Gelatin is one of the ingredients in the measles, mumps, and rubella vaccine (MMR-II), Dr. Kelso said at a meeting sponsored by the American Academy of Pediatrics. “In the vast majority of people who have an allergic reaction to MMR, it's because of allergy to the gelatin.”

Various other vaccines also contain gelatin, said Dr. Kelso, who is a pediatric allergy and immunology specialist at the Scripps Clinic in San Diego. (See table below.)

“Prior to giving someone a gelatin-containing vaccine, you should ask them if they are allergic to Jell-O or gelatin,” he advised. “There is some yield with that question, but it's not a perfect test because there are children who can eat Jell-O and not have a problem, but when it is injected in their arm, they have anaphylaxis.”

Children who have a history of reactions to gelatin should be referred to an allergist for definitive testing, Dr. Kelso said. If the child is confirmed to have an allergy, the allergist can administer the vaccine using strategies such as graded dosing.

Two types of vaccines—influenza vaccines and the yellow fever vaccine—contain egg protein. Hence, children should be asked about egg allergy before these vaccines are administered.

“In one study, they gave influenza vaccine to egg-allergic children and nothing happened,” he noted. However, the amount of egg protein in any given year's influenza vaccine varies considerably, so it is unclear what would happen if the current year's vaccine contained greater amounts of the protein.

“The AAP's Red Book unfortunately concluded that egg-allergic children should just not be given the influenza vaccine and that antivirals should be considered instead. But if you have a child whom you would really like to receive an influenza vaccine—even if they are egg allergic—please send them to your local allergist,” he said. “We can skin test them with the vaccine itself and with egg for that matter because that's an allergy that is commonly outgrown. Then, if we need to, we can administer the vaccine in graded doses.”

The MMR and rabies vaccines are grown in cell cultures of chick embryo fibroblasts and not in eggs, observed Dr. Kelso, who said he had no conflicts of interest related to this presentation. Hence, these vaccines contain virtually no egg protein. “So even children who have a truly life-threatening egg allergy can get these vaccines with no testing and no graded dosing,” he said.

He encouraged pediatricians to report any reaction even potentially related to a vaccine through the online Vaccine Adverse Event Reporting System (VAERS) at https://secure.vaers.org/VaersDataEntryIntro.htm

“Please submit these reports—it's very important because this is how these very rare reactions to vaccines come to light,” he explained.

For definitive, current information on vaccines, including their components, Dr. Kelso recommended the Pink Book, formally titled “Epidemiology and Prevention of Vaccine-Preventable Diseases,” which is published by the Centers for Disease Control and Prevention. “The entire book is available online. It's a tremendous resource and it is continually updated,” he noted. Go to www.cdc.gov/vaccines/Pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf

Elsevier Global Medical News

SEATTLE — Children who are allergic to gelatin or egg protein still can receive key childhood vaccines containing these agents, but vaccination should be done by an allergy specialist under well-controlled conditions, according to Dr. John Kelso.

Gelatin is one of the ingredients in the measles, mumps, and rubella vaccine (MMR-II), Dr. Kelso said at a meeting sponsored by the American Academy of Pediatrics. “In the vast majority of people who have an allergic reaction to MMR, it's because of allergy to the gelatin.”

Various other vaccines also contain gelatin, said Dr. Kelso, who is a pediatric allergy and immunology specialist at the Scripps Clinic in San Diego. (See table below.)

“Prior to giving someone a gelatin-containing vaccine, you should ask them if they are allergic to Jell-O or gelatin,” he advised. “There is some yield with that question, but it's not a perfect test because there are children who can eat Jell-O and not have a problem, but when it is injected in their arm, they have anaphylaxis.”

Children who have a history of reactions to gelatin should be referred to an allergist for definitive testing, Dr. Kelso said. If the child is confirmed to have an allergy, the allergist can administer the vaccine using strategies such as graded dosing.

Two types of vaccines—influenza vaccines and the yellow fever vaccine—contain egg protein. Hence, children should be asked about egg allergy before these vaccines are administered.

“In one study, they gave influenza vaccine to egg-allergic children and nothing happened,” he noted. However, the amount of egg protein in any given year's influenza vaccine varies considerably, so it is unclear what would happen if the current year's vaccine contained greater amounts of the protein.

“The AAP's Red Book unfortunately concluded that egg-allergic children should just not be given the influenza vaccine and that antivirals should be considered instead. But if you have a child whom you would really like to receive an influenza vaccine—even if they are egg allergic—please send them to your local allergist,” he said. “We can skin test them with the vaccine itself and with egg for that matter because that's an allergy that is commonly outgrown. Then, if we need to, we can administer the vaccine in graded doses.”

The MMR and rabies vaccines are grown in cell cultures of chick embryo fibroblasts and not in eggs, observed Dr. Kelso, who said he had no conflicts of interest related to this presentation. Hence, these vaccines contain virtually no egg protein. “So even children who have a truly life-threatening egg allergy can get these vaccines with no testing and no graded dosing,” he said.

He encouraged pediatricians to report any reaction even potentially related to a vaccine through the online Vaccine Adverse Event Reporting System (VAERS) at https://secure.vaers.org/VaersDataEntryIntro.htm

“Please submit these reports—it's very important because this is how these very rare reactions to vaccines come to light,” he explained.

For definitive, current information on vaccines, including their components, Dr. Kelso recommended the Pink Book, formally titled “Epidemiology and Prevention of Vaccine-Preventable Diseases,” which is published by the Centers for Disease Control and Prevention. “The entire book is available online. It's a tremendous resource and it is continually updated,” he noted. Go to www.cdc.gov/vaccines/Pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf

Elsevier Global Medical News

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said. Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996; Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak said. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended.

Clinicians should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

'Early recognition, management, and treatment of sleep disturbances [may] prevent adverse perinatal outcomes.'

Source DR. BALSERAK

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said. Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996; Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak said. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended.

Clinicians should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

'Early recognition, management, and treatment of sleep disturbances [may] prevent adverse perinatal outcomes.'

Source DR. BALSERAK

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said. Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996; Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak said. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended.

Clinicians should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

'Early recognition, management, and treatment of sleep disturbances [may] prevent adverse perinatal outcomes.'

Source DR. BALSERAK

SEATTLE — Questionnaires commonly used to assess sleep symptoms were ineffective for identifying obstructive sleep apnea among obese patients with diabetes, according to a study reported at the annual meeting of the Associated Professional Sleep Societies.

The study—Sleep AHEAD (Action for Health in Diabetes)—was a substudy of Look AHEAD, a multicenter clinical trial testing interventions among overweight and obese adults with type 2 diabetes, explained Dr. Samuel T. Kuna, a sleep medicine specialist at the University of Pennsylvania Medical Center in Philadelphia, and the study's lead author.

Adult patients were eligible for the parent study if they were 45–76 years old and had physician-diagnosed diabetes, a body mass index of at least 25 kg/m

To be eligible for the sleep substudy, patients could not be receiving any therapy for OSA and could not have had surgery for the disorder.

The Sleep AHEAD participants underwent home unattended polysomnography. On the basis of their apnea-hypopnea index, they were classified as having no OSA (index less than 5) or as having OSA that was mild (5–14), moderate (15–29), or severe (30 or greater).

In addition, the participants completed two questionnaires used to assess sleep symptomatology: the Epworth Sleepiness Scale (ESS) and the Functional Outcomes of Sleep Questionnaire (FOSQ).

Analyses were based on 305 participants who had a mean age of 61 years, Dr. Kuna reported. A total of 60% were women, and 73% were white. On average, they had a body mass index of 36.5 kg/m

Polysomnography results showed that the mean apnea-hypopnea index was 20.5, the mean oxygen saturation nadir was 81%, and 16% of participants spent more than 10% of sleep time below an oxygen saturation of 90%. A mere 13% percent of this population did not have OSA, while 33% had mild OSA, 31% had moderate OSA, and 23% had severe OSA.

The mean total ESS score ranged from 7.5 to 8.1 points across the four OSA groups. After adjustment for sex and study center, there was no significant difference across groups.

The fairly low ESS scores were somewhat surprising, Dr. Kuna commented, but could indicate that perhaps these people are not able to recognize their daytime sleepiness. The mean total FOSQ score ranged from 17.5 to 18.0 points across OSA groups. Again, after adjustment, there was no significant difference across groups.

Of all the characteristics studied, only waist circumference predicted the presence of OSA. Dr. Kuna noted that with each 1-cm increase, the patients' odds of having the disorder rose by about 10%.

“The ESS and FOSQ do not predict the presence or severity of OSA in obese patients with type 2 diabetes,” he said.

“Given the high prevalence and severity of OSA in obese patients with type 2 diabetes, the decision to perform sleep testing in these patients should not be based solely on symptom-related questionnaires,” Dr. Kuna recommended.

As a side note, he observed that, in a follow-up of the Sleep AHEAD population, fewer than 5% of the participants diagnosed with OSA were using continuous positive-airway pressure therapy 1 year later, even though they and their primary care physicians had been sent letters detailing the polysomnography results.

This highlights people's misunderstanding of the seriousness of sleep apnea.

Dr. Kuna reported that he had no conflicts of interest.

'The decision to perform sleep testing … should not be based solely on symptom-related questionnaires.'

Source DR. KUNA

SEATTLE — Questionnaires commonly used to assess sleep symptoms were ineffective for identifying obstructive sleep apnea among obese patients with diabetes, according to a study reported at the annual meeting of the Associated Professional Sleep Societies.

The study—Sleep AHEAD (Action for Health in Diabetes)—was a substudy of Look AHEAD, a multicenter clinical trial testing interventions among overweight and obese adults with type 2 diabetes, explained Dr. Samuel T. Kuna, a sleep medicine specialist at the University of Pennsylvania Medical Center in Philadelphia, and the study's lead author.

Adult patients were eligible for the parent study if they were 45–76 years old and had physician-diagnosed diabetes, a body mass index of at least 25 kg/m

To be eligible for the sleep substudy, patients could not be receiving any therapy for OSA and could not have had surgery for the disorder.

The Sleep AHEAD participants underwent home unattended polysomnography. On the basis of their apnea-hypopnea index, they were classified as having no OSA (index less than 5) or as having OSA that was mild (5–14), moderate (15–29), or severe (30 or greater).

In addition, the participants completed two questionnaires used to assess sleep symptomatology: the Epworth Sleepiness Scale (ESS) and the Functional Outcomes of Sleep Questionnaire (FOSQ).

Analyses were based on 305 participants who had a mean age of 61 years, Dr. Kuna reported. A total of 60% were women, and 73% were white. On average, they had a body mass index of 36.5 kg/m

Polysomnography results showed that the mean apnea-hypopnea index was 20.5, the mean oxygen saturation nadir was 81%, and 16% of participants spent more than 10% of sleep time below an oxygen saturation of 90%. A mere 13% percent of this population did not have OSA, while 33% had mild OSA, 31% had moderate OSA, and 23% had severe OSA.

The mean total ESS score ranged from 7.5 to 8.1 points across the four OSA groups. After adjustment for sex and study center, there was no significant difference across groups.

The fairly low ESS scores were somewhat surprising, Dr. Kuna commented, but could indicate that perhaps these people are not able to recognize their daytime sleepiness. The mean total FOSQ score ranged from 17.5 to 18.0 points across OSA groups. Again, after adjustment, there was no significant difference across groups.

Of all the characteristics studied, only waist circumference predicted the presence of OSA. Dr. Kuna noted that with each 1-cm increase, the patients' odds of having the disorder rose by about 10%.

“The ESS and FOSQ do not predict the presence or severity of OSA in obese patients with type 2 diabetes,” he said.

“Given the high prevalence and severity of OSA in obese patients with type 2 diabetes, the decision to perform sleep testing in these patients should not be based solely on symptom-related questionnaires,” Dr. Kuna recommended.

As a side note, he observed that, in a follow-up of the Sleep AHEAD population, fewer than 5% of the participants diagnosed with OSA were using continuous positive-airway pressure therapy 1 year later, even though they and their primary care physicians had been sent letters detailing the polysomnography results.

This highlights people's misunderstanding of the seriousness of sleep apnea.

Dr. Kuna reported that he had no conflicts of interest.

'The decision to perform sleep testing … should not be based solely on symptom-related questionnaires.'

Source DR. KUNA

SEATTLE — Questionnaires commonly used to assess sleep symptoms were ineffective for identifying obstructive sleep apnea among obese patients with diabetes, according to a study reported at the annual meeting of the Associated Professional Sleep Societies.

The study—Sleep AHEAD (Action for Health in Diabetes)—was a substudy of Look AHEAD, a multicenter clinical trial testing interventions among overweight and obese adults with type 2 diabetes, explained Dr. Samuel T. Kuna, a sleep medicine specialist at the University of Pennsylvania Medical Center in Philadelphia, and the study's lead author.

Adult patients were eligible for the parent study if they were 45–76 years old and had physician-diagnosed diabetes, a body mass index of at least 25 kg/m

To be eligible for the sleep substudy, patients could not be receiving any therapy for OSA and could not have had surgery for the disorder.

The Sleep AHEAD participants underwent home unattended polysomnography. On the basis of their apnea-hypopnea index, they were classified as having no OSA (index less than 5) or as having OSA that was mild (5–14), moderate (15–29), or severe (30 or greater).

In addition, the participants completed two questionnaires used to assess sleep symptomatology: the Epworth Sleepiness Scale (ESS) and the Functional Outcomes of Sleep Questionnaire (FOSQ).

Analyses were based on 305 participants who had a mean age of 61 years, Dr. Kuna reported. A total of 60% were women, and 73% were white. On average, they had a body mass index of 36.5 kg/m

Polysomnography results showed that the mean apnea-hypopnea index was 20.5, the mean oxygen saturation nadir was 81%, and 16% of participants spent more than 10% of sleep time below an oxygen saturation of 90%. A mere 13% percent of this population did not have OSA, while 33% had mild OSA, 31% had moderate OSA, and 23% had severe OSA.

The mean total ESS score ranged from 7.5 to 8.1 points across the four OSA groups. After adjustment for sex and study center, there was no significant difference across groups.

The fairly low ESS scores were somewhat surprising, Dr. Kuna commented, but could indicate that perhaps these people are not able to recognize their daytime sleepiness. The mean total FOSQ score ranged from 17.5 to 18.0 points across OSA groups. Again, after adjustment, there was no significant difference across groups.

Of all the characteristics studied, only waist circumference predicted the presence of OSA. Dr. Kuna noted that with each 1-cm increase, the patients' odds of having the disorder rose by about 10%.

“The ESS and FOSQ do not predict the presence or severity of OSA in obese patients with type 2 diabetes,” he said.

“Given the high prevalence and severity of OSA in obese patients with type 2 diabetes, the decision to perform sleep testing in these patients should not be based solely on symptom-related questionnaires,” Dr. Kuna recommended.

As a side note, he observed that, in a follow-up of the Sleep AHEAD population, fewer than 5% of the participants diagnosed with OSA were using continuous positive-airway pressure therapy 1 year later, even though they and their primary care physicians had been sent letters detailing the polysomnography results.

This highlights people's misunderstanding of the seriousness of sleep apnea.

Dr. Kuna reported that he had no conflicts of interest.

'The decision to perform sleep testing … should not be based solely on symptom-related questionnaires.'

Source DR. KUNA

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings. The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias. The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended. Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

Dr. Balserak reported that she had no conflicts of interest.

'The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester.'

Source Dr. Balserak

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings. The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias. The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended. Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

Dr. Balserak reported that she had no conflicts of interest.

'The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester.'

Source Dr. Balserak

SEATTLE — Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes, such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings. The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias. The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive behavioral therapy strategies,” she recommended. Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

Dr. Balserak reported that she had no conflicts of interest.

'The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester.'

Source Dr. Balserak

SEATTLE — Sleep disturbances are exceedingly common among pregnant women, but it remains unclear to what extent they represent a normal part of pregnancy and how they may affect birth and maternal health outcomes, according to findings from two studies of nulliparous and multiparous women.

“Between 66% and 94% of pregnant women report pronounced changes to their sleep in the 9 months preceding delivery,” Leigh Signal, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

Clinicians generally view these changes as normal, she noted. “It's often a topic that doesn't receive a great deal of attention in consultations with women, and they are rarely provided with strategies and guidance to help them improve their sleep across this time frame.”

Four factors seem to be responsible for sleep disturbances in pregnancy, according to Dr. Signal of Massey University in Wellington, New Zealand:

Endocrine changes.

Respiratory changes.

Mechanical changes related to the increasing size of the fetus and uterus.

Psychological factors such as worry about the pregnancy and birth.

In the first trimester of pregnancy, sleep disturbances are primarily a consequence of altered hormones, she noted. Rising progesterone levels are thought to increase daytime sleepiness, and the hormonal changes also trigger nausea, vomiting, and nocturia, all of which disturb sleep. In the second trimester, the main disruptions are movement of the fetus and possibly the onset of snoring resulting from increased nasal congestion, she said, although sleep and daytime sleepiness improve from the preceding trimester.

Sleep disturbances are most common during the third trimester and stem from numerous causes, including nocturia, discomfort, shortness of breath, and heartburn. “Sleep efficiency declines, and wake [time] after sleep onset increases to approximately double that reported in prepregnancy,” she noted.

To further characterize sleep patterns in pregnancy and compare them by parity, Dr. Signal and her colleagues conducted a study among healthy pregnant New Zealand women—8 nulliparous women (mean age, 31 years) and 11 multiparous (mean age, 36 years) women. Sleep was assessed objectively with actigraphy and sleep diaries in midpregnancy (about 24 weeks' gestation), in the week before delivery (38-40 weeks' gestation), in the week after delivery, and at 6-7 weeks post partum.

In the study population overall, both time in bed and total sleep time varied significantly across the time points studied, she reported, with lowest values seen in the first week post partum (Aust. N. Z. J. Obstet. Gynaecol. 2007;47:16-22).

By parity, time in bed was greater among nulliparous women than among their multiparous counterparts at both midpregnancy and 6-7 weeks post partum, whereas the reverse was seen in the first week post partum.

But total sleep time did not differ according to parity at any time point. Dr. Signal noted that this lack of difference appeared to be due to comparatively poorer sleep efficiency and greater wake time after sleep onset in the nulliparous group. “Our results suggest that during pregnancy, although multiparous women do not spend as much time in bed as nulliparous women, when they do attempt to sleep, their sleep is more efficient,” she said.

In a second study, a pilot to one that will look at the influence of sleep on birth outcomes and maternal mood disorders, Dr. Signal's team assessed sleep subjectively with questionnaires and phone interviews among 20 nulliparous women (mean age, 33 years) and 14 multiparous women (mean age, 36 years) in New Zealand. Sleep was assessed in the prepregnancy period (retrospectively), in late pregnancy (35-37 weeks' gestation), at 3-4 weeks post partum, and at 12 weeks post partum.

In the study population overall, total sleep time in late pregnancy and at 12 weeks post partum was less than that before pregnancy. But there was no difference in this measure between prepregnancy and 3-4 weeks post partum.

“That was largely due to an increase in sleep time reported by nulliparous women,” she noted, which may help reconcile these findings with those from the earlier study showing reduced sleep in the first week post partum. “It may be that in our sample, nulliparous women utilized the opportunity to recover from the severe sleep loss in the first week post partum at 3-4 weeks post partum.”

Both groups reported more good nights of sleep weekly before pregnancy than late in pregnancy and than at 12 weeks post partum, although the nulliparous group had more such nights to begin with. There was no difference in sleep quality between groups as assessed by scores on the General Sleep Disturbance Scale.

Late in pregnancy, the factors most commonly cited as disturbing sleep often or always (on three or more nights a week) were bathroom visits (cited by 94% of women), discomfort (75%), and pain (59%). Of note, Dr. Signal said, nearly all women, 91%, reported more than one factor disturbing their sleep often or always, and fully 74% reported four or more.

“One point I want to make about sleep across pregnancy is the enormous individual variability in the data,” she commented. As far as the change in total sleep time from before pregnancy to late pregnancy, 21% of women had little change (18 minutes or less), 15% had an increase of 1 hour or more, and 64% had a decrease of 1 hour or more. “Some women manage to maintain their sleep across pregnancy,” she observed. “Understanding the difference between these women and those who have more extreme changes may help identify strategies that can be utilized to improve sleep.”

Dr. Signal reported that she had no relevant conflicts of interest.

Data suggest that between 66% and 94% of pregnant women report pronounced changes in their sleep.

Source ©Nathan Gleave/iStockphoto.com

SEATTLE — Sleep disturbances are exceedingly common among pregnant women, but it remains unclear to what extent they represent a normal part of pregnancy and how they may affect birth and maternal health outcomes, according to findings from two studies of nulliparous and multiparous women.

“Between 66% and 94% of pregnant women report pronounced changes to their sleep in the 9 months preceding delivery,” Leigh Signal, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

Clinicians generally view these changes as normal, she noted. “It's often a topic that doesn't receive a great deal of attention in consultations with women, and they are rarely provided with strategies and guidance to help them improve their sleep across this time frame.”

Four factors seem to be responsible for sleep disturbances in pregnancy, according to Dr. Signal of Massey University in Wellington, New Zealand:

Endocrine changes.

Respiratory changes.

Mechanical changes related to the increasing size of the fetus and uterus.

Psychological factors such as worry about the pregnancy and birth.

In the first trimester of pregnancy, sleep disturbances are primarily a consequence of altered hormones, she noted. Rising progesterone levels are thought to increase daytime sleepiness, and the hormonal changes also trigger nausea, vomiting, and nocturia, all of which disturb sleep. In the second trimester, the main disruptions are movement of the fetus and possibly the onset of snoring resulting from increased nasal congestion, she said, although sleep and daytime sleepiness improve from the preceding trimester.

Sleep disturbances are most common during the third trimester and stem from numerous causes, including nocturia, discomfort, shortness of breath, and heartburn. “Sleep efficiency declines, and wake [time] after sleep onset increases to approximately double that reported in prepregnancy,” she noted.

To further characterize sleep patterns in pregnancy and compare them by parity, Dr. Signal and her colleagues conducted a study among healthy pregnant New Zealand women—8 nulliparous women (mean age, 31 years) and 11 multiparous (mean age, 36 years) women. Sleep was assessed objectively with actigraphy and sleep diaries in midpregnancy (about 24 weeks' gestation), in the week before delivery (38-40 weeks' gestation), in the week after delivery, and at 6-7 weeks post partum.

In the study population overall, both time in bed and total sleep time varied significantly across the time points studied, she reported, with lowest values seen in the first week post partum (Aust. N. Z. J. Obstet. Gynaecol. 2007;47:16-22).

By parity, time in bed was greater among nulliparous women than among their multiparous counterparts at both midpregnancy and 6-7 weeks post partum, whereas the reverse was seen in the first week post partum.

But total sleep time did not differ according to parity at any time point. Dr. Signal noted that this lack of difference appeared to be due to comparatively poorer sleep efficiency and greater wake time after sleep onset in the nulliparous group. “Our results suggest that during pregnancy, although multiparous women do not spend as much time in bed as nulliparous women, when they do attempt to sleep, their sleep is more efficient,” she said.

In a second study, a pilot to one that will look at the influence of sleep on birth outcomes and maternal mood disorders, Dr. Signal's team assessed sleep subjectively with questionnaires and phone interviews among 20 nulliparous women (mean age, 33 years) and 14 multiparous women (mean age, 36 years) in New Zealand. Sleep was assessed in the prepregnancy period (retrospectively), in late pregnancy (35-37 weeks' gestation), at 3-4 weeks post partum, and at 12 weeks post partum.

In the study population overall, total sleep time in late pregnancy and at 12 weeks post partum was less than that before pregnancy. But there was no difference in this measure between prepregnancy and 3-4 weeks post partum.

“That was largely due to an increase in sleep time reported by nulliparous women,” she noted, which may help reconcile these findings with those from the earlier study showing reduced sleep in the first week post partum. “It may be that in our sample, nulliparous women utilized the opportunity to recover from the severe sleep loss in the first week post partum at 3-4 weeks post partum.”

Both groups reported more good nights of sleep weekly before pregnancy than late in pregnancy and than at 12 weeks post partum, although the nulliparous group had more such nights to begin with. There was no difference in sleep quality between groups as assessed by scores on the General Sleep Disturbance Scale.

Late in pregnancy, the factors most commonly cited as disturbing sleep often or always (on three or more nights a week) were bathroom visits (cited by 94% of women), discomfort (75%), and pain (59%). Of note, Dr. Signal said, nearly all women, 91%, reported more than one factor disturbing their sleep often or always, and fully 74% reported four or more.

“One point I want to make about sleep across pregnancy is the enormous individual variability in the data,” she commented. As far as the change in total sleep time from before pregnancy to late pregnancy, 21% of women had little change (18 minutes or less), 15% had an increase of 1 hour or more, and 64% had a decrease of 1 hour or more. “Some women manage to maintain their sleep across pregnancy,” she observed. “Understanding the difference between these women and those who have more extreme changes may help identify strategies that can be utilized to improve sleep.”

Dr. Signal reported that she had no relevant conflicts of interest.

Data suggest that between 66% and 94% of pregnant women report pronounced changes in their sleep.

Source ©Nathan Gleave/iStockphoto.com

SEATTLE — Sleep disturbances are exceedingly common among pregnant women, but it remains unclear to what extent they represent a normal part of pregnancy and how they may affect birth and maternal health outcomes, according to findings from two studies of nulliparous and multiparous women.

“Between 66% and 94% of pregnant women report pronounced changes to their sleep in the 9 months preceding delivery,” Leigh Signal, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.

Clinicians generally view these changes as normal, she noted. “It's often a topic that doesn't receive a great deal of attention in consultations with women, and they are rarely provided with strategies and guidance to help them improve their sleep across this time frame.”

Four factors seem to be responsible for sleep disturbances in pregnancy, according to Dr. Signal of Massey University in Wellington, New Zealand:

Endocrine changes.

Respiratory changes.

Mechanical changes related to the increasing size of the fetus and uterus.

Psychological factors such as worry about the pregnancy and birth.

In the first trimester of pregnancy, sleep disturbances are primarily a consequence of altered hormones, she noted. Rising progesterone levels are thought to increase daytime sleepiness, and the hormonal changes also trigger nausea, vomiting, and nocturia, all of which disturb sleep. In the second trimester, the main disruptions are movement of the fetus and possibly the onset of snoring resulting from increased nasal congestion, she said, although sleep and daytime sleepiness improve from the preceding trimester.

Sleep disturbances are most common during the third trimester and stem from numerous causes, including nocturia, discomfort, shortness of breath, and heartburn. “Sleep efficiency declines, and wake [time] after sleep onset increases to approximately double that reported in prepregnancy,” she noted.

To further characterize sleep patterns in pregnancy and compare them by parity, Dr. Signal and her colleagues conducted a study among healthy pregnant New Zealand women—8 nulliparous women (mean age, 31 years) and 11 multiparous (mean age, 36 years) women. Sleep was assessed objectively with actigraphy and sleep diaries in midpregnancy (about 24 weeks' gestation), in the week before delivery (38-40 weeks' gestation), in the week after delivery, and at 6-7 weeks post partum.

In the study population overall, both time in bed and total sleep time varied significantly across the time points studied, she reported, with lowest values seen in the first week post partum (Aust. N. Z. J. Obstet. Gynaecol. 2007;47:16-22).

By parity, time in bed was greater among nulliparous women than among their multiparous counterparts at both midpregnancy and 6-7 weeks post partum, whereas the reverse was seen in the first week post partum.

But total sleep time did not differ according to parity at any time point. Dr. Signal noted that this lack of difference appeared to be due to comparatively poorer sleep efficiency and greater wake time after sleep onset in the nulliparous group. “Our results suggest that during pregnancy, although multiparous women do not spend as much time in bed as nulliparous women, when they do attempt to sleep, their sleep is more efficient,” she said.

In a second study, a pilot to one that will look at the influence of sleep on birth outcomes and maternal mood disorders, Dr. Signal's team assessed sleep subjectively with questionnaires and phone interviews among 20 nulliparous women (mean age, 33 years) and 14 multiparous women (mean age, 36 years) in New Zealand. Sleep was assessed in the prepregnancy period (retrospectively), in late pregnancy (35-37 weeks' gestation), at 3-4 weeks post partum, and at 12 weeks post partum.

In the study population overall, total sleep time in late pregnancy and at 12 weeks post partum was less than that before pregnancy. But there was no difference in this measure between prepregnancy and 3-4 weeks post partum.

“That was largely due to an increase in sleep time reported by nulliparous women,” she noted, which may help reconcile these findings with those from the earlier study showing reduced sleep in the first week post partum. “It may be that in our sample, nulliparous women utilized the opportunity to recover from the severe sleep loss in the first week post partum at 3-4 weeks post partum.”

Both groups reported more good nights of sleep weekly before pregnancy than late in pregnancy and than at 12 weeks post partum, although the nulliparous group had more such nights to begin with. There was no difference in sleep quality between groups as assessed by scores on the General Sleep Disturbance Scale.

Late in pregnancy, the factors most commonly cited as disturbing sleep often or always (on three or more nights a week) were bathroom visits (cited by 94% of women), discomfort (75%), and pain (59%). Of note, Dr. Signal said, nearly all women, 91%, reported more than one factor disturbing their sleep often or always, and fully 74% reported four or more.

“One point I want to make about sleep across pregnancy is the enormous individual variability in the data,” she commented. As far as the change in total sleep time from before pregnancy to late pregnancy, 21% of women had little change (18 minutes or less), 15% had an increase of 1 hour or more, and 64% had a decrease of 1 hour or more. “Some women manage to maintain their sleep across pregnancy,” she observed. “Understanding the difference between these women and those who have more extreme changes may help identify strategies that can be utilized to improve sleep.”

Dr. Signal reported that she had no relevant conflicts of interest.

Data suggest that between 66% and 94% of pregnant women report pronounced changes in their sleep.

Source ©Nathan Gleave/iStockphoto.com

SEATTLE — The clinical features of lupus in children may be subtle and easily overlooked, Dr. David Sherry said.

Vasculitis, the pathologic hallmark of lupus, can produce a challenging clinical picture with a wide differential diagnosis, noted Dr. Sherry, who is a pediatric rheumatologist at the Children's Hospital of Philadelphia.

When a child presents who is sick and is not getting better, who continues to have a fever, to lose weight, to have an elevated sedimentation rate, and the “virus” still isn't going away, it's time to consider the diagnosis of a vasculitic condition, he commented at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off that a child has vasculitis. “Why should a kid be peeing blood and coughing up blood?” he said. “That's two different organs.”

Seeing an unusual patient for the symptom, such as a teenager with a heart attack, also should raise a suspicion of vasculitis.

Finally, there is the vasculitic rash, which can have a variety of appearances.

In describing the malar rash of lupus, textbooks often show photos of a vivid, contiguous red rash in the classic butterfly distribution on the cheeks and nose, according to Dr. Sherry. But what is actually seen clinically may instead mimic rosacea, wind chapping, sunburn, or even acne. In addition, in black children, the rash may be subtle and especially hard to identify.

Key features that can help identify a malar rash of lupus include its distribution (typically with crossing over the bridge of the nose and spreading onto the cheeks) and a well-defined border between the affected skin and normal skin. Children with malar rashes usually, but not always, have other symptoms or clinical findings, too.

Additional clues to the presence of lupus can often be found on parts of the body that are easily overlooked on examination, according to Dr. Sherry. For example, children may have a vasculitic rash on their hands or feet, or a painless ulcer on their hard palate. “You need to look up to see the hard palate,” he pointed out. “If you look at the back of the throat, you will miss this.”

The discoid rash of lupus is less common and causes crusts or scabs that scar. “If you lift up these crusts or scabs, you see what's called carpet tacking—little pinpoints of bleeding underneath.” he said. “Discoid lupus especially likes the helix of the ear.”

Children also may have so-called lupus hairs, which are fragile and break easily. “You pull on their hair, you get three, four, or five hairs, even if they just brushed it,” he explained. The breakage is accompanied by the presence of short hairs resulting from regrowth.

When lupus is first suspected in children, Dr. Sherry recommended that physicians obtain a complete blood cell count, an erythrocyte sedimentation rate (ESR), a C-reactive protein (CRP) level, a urinalysis, a comprehensive metabolic panel, and an antinuclear antibody (ANA) titer. Lupus has the unique property of producing a high ESR and a normal CRP level—unless the child also has an infection.

An ANA panel can be deferred unless suspicion of the disease is high, he said. Related tests should be guided by symptoms, such as rheumatoid factor assessment in a child with pronounced joint symptoms, creatine kinase assessment in a child with muscle weakness, and coagulation studies in a child with deep vein thrombosis.

Dr. Sherry noted that to be classified as having lupus, children must meet at least 4 of the 11 clinical and laboratory criteria of the American College of Rheumatology, of which a positive ANA titer is merely one.

In fact, he cautioned, 12%–20% of normal children have a positive ANA titer.

If the ANA result is positive but at a titer of only 1:80 or 1:160, the child is unlikely to have lupus; if it is higher, the ANA panel should be done. “If the panel is negative, you can cool your jets and cool the mom's jets,” he said. “The child doesn't have lupus.”

Management in children with lupus, in addition to antirheumatic therapy, includes counseling about sun protection because of photosensitivity, antihypertensive therapy when blood pressure is elevated, and attention to calcium and vitamin D status, both because steroid therapy adversely affects bone health and because lower levels of vitamin D have been linked to increased disease activity. “We give these kids calcium and, if they are low in vitamin D, we certainly can give them that too,” he said.

“More than 90% of our kids do very well and have long-term survival.” In fact, “now that we are saving these kids, we have to worry about the side effects of treatment.” Hence, where possible, treatment strategies have been modified to reduce long-term toxicity.

Importantly, he concluded, as children with lupus increasingly survive into adulthood, their providers will need to be aware of risks related to the disease and its treatment that may emerge over time, including hyperlipidemia, heart attack, and complicated pregnancy.

Dr. Sherry reported that he had no conflicts of interest in association with his presentation.

Spotty malar rash may mimic rosacea instead of having the butterfly shape.

Vasculitic rash on the hands may be overlooked in a child with lupus.

The classic malar rash crosses the nose of the young affected patient.

Painless oral ulcer of the hard palate may be the only outward sign of lupus.

Source Photos courtesy Dr. David D. Sherry

SEATTLE — The clinical features of lupus in children may be subtle and easily overlooked, Dr. David Sherry said.

Vasculitis, the pathologic hallmark of lupus, can produce a challenging clinical picture with a wide differential diagnosis, noted Dr. Sherry, who is a pediatric rheumatologist at the Children's Hospital of Philadelphia.

When a child presents who is sick and is not getting better, who continues to have a fever, to lose weight, to have an elevated sedimentation rate, and the “virus” still isn't going away, it's time to consider the diagnosis of a vasculitic condition, he commented at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off that a child has vasculitis. “Why should a kid be peeing blood and coughing up blood?” he said. “That's two different organs.”

Seeing an unusual patient for the symptom, such as a teenager with a heart attack, also should raise a suspicion of vasculitis.

Finally, there is the vasculitic rash, which can have a variety of appearances.

In describing the malar rash of lupus, textbooks often show photos of a vivid, contiguous red rash in the classic butterfly distribution on the cheeks and nose, according to Dr. Sherry. But what is actually seen clinically may instead mimic rosacea, wind chapping, sunburn, or even acne. In addition, in black children, the rash may be subtle and especially hard to identify.

Key features that can help identify a malar rash of lupus include its distribution (typically with crossing over the bridge of the nose and spreading onto the cheeks) and a well-defined border between the affected skin and normal skin. Children with malar rashes usually, but not always, have other symptoms or clinical findings, too.

Additional clues to the presence of lupus can often be found on parts of the body that are easily overlooked on examination, according to Dr. Sherry. For example, children may have a vasculitic rash on their hands or feet, or a painless ulcer on their hard palate. “You need to look up to see the hard palate,” he pointed out. “If you look at the back of the throat, you will miss this.”

The discoid rash of lupus is less common and causes crusts or scabs that scar. “If you lift up these crusts or scabs, you see what's called carpet tacking—little pinpoints of bleeding underneath.” he said. “Discoid lupus especially likes the helix of the ear.”

Children also may have so-called lupus hairs, which are fragile and break easily. “You pull on their hair, you get three, four, or five hairs, even if they just brushed it,” he explained. The breakage is accompanied by the presence of short hairs resulting from regrowth.

When lupus is first suspected in children, Dr. Sherry recommended that physicians obtain a complete blood cell count, an erythrocyte sedimentation rate (ESR), a C-reactive protein (CRP) level, a urinalysis, a comprehensive metabolic panel, and an antinuclear antibody (ANA) titer. Lupus has the unique property of producing a high ESR and a normal CRP level—unless the child also has an infection.

An ANA panel can be deferred unless suspicion of the disease is high, he said. Related tests should be guided by symptoms, such as rheumatoid factor assessment in a child with pronounced joint symptoms, creatine kinase assessment in a child with muscle weakness, and coagulation studies in a child with deep vein thrombosis.

Dr. Sherry noted that to be classified as having lupus, children must meet at least 4 of the 11 clinical and laboratory criteria of the American College of Rheumatology, of which a positive ANA titer is merely one.

In fact, he cautioned, 12%–20% of normal children have a positive ANA titer.

If the ANA result is positive but at a titer of only 1:80 or 1:160, the child is unlikely to have lupus; if it is higher, the ANA panel should be done. “If the panel is negative, you can cool your jets and cool the mom's jets,” he said. “The child doesn't have lupus.”

Management in children with lupus, in addition to antirheumatic therapy, includes counseling about sun protection because of photosensitivity, antihypertensive therapy when blood pressure is elevated, and attention to calcium and vitamin D status, both because steroid therapy adversely affects bone health and because lower levels of vitamin D have been linked to increased disease activity. “We give these kids calcium and, if they are low in vitamin D, we certainly can give them that too,” he said.

“More than 90% of our kids do very well and have long-term survival.” In fact, “now that we are saving these kids, we have to worry about the side effects of treatment.” Hence, where possible, treatment strategies have been modified to reduce long-term toxicity.

Importantly, he concluded, as children with lupus increasingly survive into adulthood, their providers will need to be aware of risks related to the disease and its treatment that may emerge over time, including hyperlipidemia, heart attack, and complicated pregnancy.

Dr. Sherry reported that he had no conflicts of interest in association with his presentation.

Spotty malar rash may mimic rosacea instead of having the butterfly shape.

Vasculitic rash on the hands may be overlooked in a child with lupus.

The classic malar rash crosses the nose of the young affected patient.

Painless oral ulcer of the hard palate may be the only outward sign of lupus.

Source Photos courtesy Dr. David D. Sherry

SEATTLE — The clinical features of lupus in children may be subtle and easily overlooked, Dr. David Sherry said.

Vasculitis, the pathologic hallmark of lupus, can produce a challenging clinical picture with a wide differential diagnosis, noted Dr. Sherry, who is a pediatric rheumatologist at the Children's Hospital of Philadelphia.

When a child presents who is sick and is not getting better, who continues to have a fever, to lose weight, to have an elevated sedimentation rate, and the “virus” still isn't going away, it's time to consider the diagnosis of a vasculitic condition, he commented at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off that a child has vasculitis. “Why should a kid be peeing blood and coughing up blood?” he said. “That's two different organs.”

Seeing an unusual patient for the symptom, such as a teenager with a heart attack, also should raise a suspicion of vasculitis.

Finally, there is the vasculitic rash, which can have a variety of appearances.

In describing the malar rash of lupus, textbooks often show photos of a vivid, contiguous red rash in the classic butterfly distribution on the cheeks and nose, according to Dr. Sherry. But what is actually seen clinically may instead mimic rosacea, wind chapping, sunburn, or even acne. In addition, in black children, the rash may be subtle and especially hard to identify.

Key features that can help identify a malar rash of lupus include its distribution (typically with crossing over the bridge of the nose and spreading onto the cheeks) and a well-defined border between the affected skin and normal skin. Children with malar rashes usually, but not always, have other symptoms or clinical findings, too.

Additional clues to the presence of lupus can often be found on parts of the body that are easily overlooked on examination, according to Dr. Sherry. For example, children may have a vasculitic rash on their hands or feet, or a painless ulcer on their hard palate. “You need to look up to see the hard palate,” he pointed out. “If you look at the back of the throat, you will miss this.”

The discoid rash of lupus is less common and causes crusts or scabs that scar. “If you lift up these crusts or scabs, you see what's called carpet tacking—little pinpoints of bleeding underneath.” he said. “Discoid lupus especially likes the helix of the ear.”

Children also may have so-called lupus hairs, which are fragile and break easily. “You pull on their hair, you get three, four, or five hairs, even if they just brushed it,” he explained. The breakage is accompanied by the presence of short hairs resulting from regrowth.

When lupus is first suspected in children, Dr. Sherry recommended that physicians obtain a complete blood cell count, an erythrocyte sedimentation rate (ESR), a C-reactive protein (CRP) level, a urinalysis, a comprehensive metabolic panel, and an antinuclear antibody (ANA) titer. Lupus has the unique property of producing a high ESR and a normal CRP level—unless the child also has an infection.

An ANA panel can be deferred unless suspicion of the disease is high, he said. Related tests should be guided by symptoms, such as rheumatoid factor assessment in a child with pronounced joint symptoms, creatine kinase assessment in a child with muscle weakness, and coagulation studies in a child with deep vein thrombosis.

Dr. Sherry noted that to be classified as having lupus, children must meet at least 4 of the 11 clinical and laboratory criteria of the American College of Rheumatology, of which a positive ANA titer is merely one.

In fact, he cautioned, 12%–20% of normal children have a positive ANA titer.

If the ANA result is positive but at a titer of only 1:80 or 1:160, the child is unlikely to have lupus; if it is higher, the ANA panel should be done. “If the panel is negative, you can cool your jets and cool the mom's jets,” he said. “The child doesn't have lupus.”

Management in children with lupus, in addition to antirheumatic therapy, includes counseling about sun protection because of photosensitivity, antihypertensive therapy when blood pressure is elevated, and attention to calcium and vitamin D status, both because steroid therapy adversely affects bone health and because lower levels of vitamin D have been linked to increased disease activity. “We give these kids calcium and, if they are low in vitamin D, we certainly can give them that too,” he said.

“More than 90% of our kids do very well and have long-term survival.” In fact, “now that we are saving these kids, we have to worry about the side effects of treatment.” Hence, where possible, treatment strategies have been modified to reduce long-term toxicity.

Importantly, he concluded, as children with lupus increasingly survive into adulthood, their providers will need to be aware of risks related to the disease and its treatment that may emerge over time, including hyperlipidemia, heart attack, and complicated pregnancy.

Dr. Sherry reported that he had no conflicts of interest in association with his presentation.

Spotty malar rash may mimic rosacea instead of having the butterfly shape.

Vasculitic rash on the hands may be overlooked in a child with lupus.

The classic malar rash crosses the nose of the young affected patient.

Painless oral ulcer of the hard palate may be the only outward sign of lupus.

Source Photos courtesy Dr. David D. Sherry

SEATTLE – Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

In a study that was conducted among women in the third trimester of pregnancy that used the Center for Epidemiologic Studies-Depression (CES-D) scale, relative to their nondepressed counterparts (those with a CES-D score less than or equal to 15), depressed women (CES-D score of 16 or greater) had a greater frequency of sleep disturbances overall, as well as a longer latency to sleep onset, greater difficulty in maintaining sleep, poorer sleep quality, and less sleep time (J. Perinat. Neonatal Nurs. 2007;21:123-9).

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive-behavioral therapy strategies,” she recommended.

Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

Altered sleep during pregnancy stems from various hormonal, physiologic, and psychological factors.

Source Dr. Balserak

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms.

Source Nathan Gleave/iStockphoto.com

SEATTLE – Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

In a study that was conducted among women in the third trimester of pregnancy that used the Center for Epidemiologic Studies-Depression (CES-D) scale, relative to their nondepressed counterparts (those with a CES-D score less than or equal to 15), depressed women (CES-D score of 16 or greater) had a greater frequency of sleep disturbances overall, as well as a longer latency to sleep onset, greater difficulty in maintaining sleep, poorer sleep quality, and less sleep time (J. Perinat. Neonatal Nurs. 2007;21:123-9).

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive-behavioral therapy strategies,” she recommended.

Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

Altered sleep during pregnancy stems from various hormonal, physiologic, and psychological factors.

Source Dr. Balserak

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms.

Source Nathan Gleave/iStockphoto.com

SEATTLE – Sleep disturbances during pregnancy increase the risk of adverse perinatal outcomes such as gestational diabetes and cesarean delivery, according to an overview of research presented at the annual meeting of the Associated Professional Sleep Societies.

“Sleep disturbances are common during pregnancy,” said Bilgay Izci Balserak, Ph.D., of the University of Glasgow (Scotland) Sleep Centre. “The majority of pregnant women experience some level of sleep disturbance, especially in the third trimester of pregnancy.”

A 2007 poll conducted by the National Sleep Foundation, Washington, found that 84% of pregnant women reported experiencing sleep problems at least a few nights per week, she noted. This compared with 67% of all women surveyed.

Altered sleep during pregnancy stems from a variety of hormonal, physiologic, and psychological factors, according to Dr. Balserak. These factors can affect sleep directly, as in the case of progesterone causing sedation, or indirectly, as in the case of heartburn or nocturia causing awakenings.

The sleep disturbances seen during pregnancy include both nocturnal perturbations (poor sleep quality, insomnia, and frequent awakenings) and daytime symptoms (fatigue and daytime sleepiness), she noted.

Pregnancy-related changes can also trigger frank sleep disorders or exacerbate preexisting ones, such as restless legs syndrome, sleep-disordered breathing, and parasomnias.

The acute sleep loss or fragmented sleep that results from sleep disturbances “can cause adverse perinatal outcomes,” she said.

Retrospective and prospective studies, for example, have shown that pregnant women with sleep-disordered breathing have a two- to fivefold increased risk of developing gestational diabetes after body mass index is taken into account (Am. J. Respir. Crit. Care Med. 2007;175:A996, and Sleep 2009;32:A320-1).

Other research has linked sleep disturbances to birth outcomes. For instance, compared with women with a total sleep time of at least 7 hours in late pregnancy, women with a total sleep time of less than 6 hours or 6-6.9 hours have sharply elevated odds of cesarean delivery (odds ratios, 4.5 and 3.7, respectively) (Am. J. Obstet. Gynecol. 2004;191:2041-6). Women sleeping less than 6 hours also have longer labor, on average, than those sleeping at least 7 hours (29 vs. 18 hours).

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms, both at that time and in the early postpartum period, she noted.

In a study that was conducted among women in the third trimester of pregnancy that used the Center for Epidemiologic Studies-Depression (CES-D) scale, relative to their nondepressed counterparts (those with a CES-D score less than or equal to 15), depressed women (CES-D score of 16 or greater) had a greater frequency of sleep disturbances overall, as well as a longer latency to sleep onset, greater difficulty in maintaining sleep, poorer sleep quality, and less sleep time (J. Perinat. Neonatal Nurs. 2007;21:123-9).

“Early recognition, management, and treatment of sleep disturbances are important to prevent adverse perinatal outcomes,” Dr. Balserak asserted. However, she added, there are currently no practice parameters when it comes to screening for and managing sleep disturbances during pregnancy.

“Regarding management, nonpharmacologic interventions should be considered as the first choice, including lifestyle modifications and cognitive-behavioral therapy strategies,” she recommended.

Providers should encourage women to adopt healthy lifestyle behaviors, such as daily exercise, that may improve sleep, Dr. Balserak said. And they should counsel women about measures to address specific symptoms disrupting sleep, such as modifying eating habits to reduce heartburn.

“If pharmacological treatment is necessary, it should be used with caution due to potential side effects on the fetus,” she concluded.

Dr. Balserak reported that she had no conflicts of interest in association with her presentation.

Altered sleep during pregnancy stems from various hormonal, physiologic, and psychological factors.

Source Dr. Balserak

Several studies have found correlations between unfavorable sleep parameters in late pregnancy and elevated levels of depressive symptoms.

Source Nathan Gleave/iStockphoto.com

SEATTLE – Epileptic children are less likely to take antiepileptic drugs as prescribed if they also have psychiatric illnesses, according to a review of an administrative claims database.

“It's well established that nonadherence to prescribed antiepileptic drugs has serious potential consequences, including exacerbation of seizures, morbidity, and, now we are learning, even potentially mortality,” said Dr. Alan B. Ettinger, a neurologist at the Comprehensive Epilepsy Center at North Shore Long Island Jewish Medical Center, New Hyde Park, N.Y. “Establishing a possible relationship between these issues–psychiatric comorbidity and adherence–really has practical utility because if this is the case, then clinicians need to use some special interventions to try to promote better adherence.”

Using a PharMetrics administrative claims database, Dr. Ettinger and his colleagues reviewed claims for January 2000 through December 2006 for more than 50 million individuals covered by U.S. managed care plans.

The researchers found 5,343 children aged 4-18 years who had a diagnosis of epilepsy, received at least one prescription for an antiepileptic drug (AED), and were enrolled in their health plan for at least 1 year before and 1 year after starting the medication. There were slightly more boys than girls (55%), and about half of the children were 11 years old or younger.

Fully 65% of the children were nonadherent to their AED therapy. The children's mean medication possession ratio, a measure of adherence, was 0.54. Children with a ratio of less than 0.8 were considered nonadherent. The ratio was calculated by dividing the total number of days for which AEDs were supplied during the 1-year follow-up period by 365 days, Dr. Ettinger said at the annual meeting of the American Epilepsy Society.

Nearly half of the children had a psychiatric illness, as diagnosed by any physician, said Dr. Ettinger.

The most common were attention-deficit/hyperactivity disorder (17%) and attention deficit disorder (10%). But sizable proportions of children had more serious psychiatric illnesses, such as bipolar disorder (8%), developmental disorders (5%), schizophrenia (1%), or other psychoses (7%).

In multivariate analyses that took into account age, sex, geographic region, overall comorbidity burden, type of AED (newer vs. older), starting regimen (monotherapy vs. combination therapy), and initial AED dosing (one or fewer pills daily vs. more), children were significantly more likely to be nonadherent if they had a diagnosis of attention-deficit/hyperactivity disorder or bipolar disorder before starting AED therapy (odds ratios, 1.17 and 1.22, respectively) and if they received a diagnosis of bipolar disorder after starting AED therapy (odds ratio, 1.37).

Schizophrenia alone was not associated with elevated odds of nonadherence. But relative to their counterparts who did not have any of the more serious psychiatric illnesses, children who had at least one of them (regardless of type) were significantly more likely to be nonadherent (odds ratio, 1.15).

“Recognizing psychiatric comorbidity in pediatric patients with epilepsy is very important, and we hope that this study lends another compelling reason why clinicians need to be screening for psychiatric comorbidity,” concluded Dr. Ettinger, who reported that he is a project consultant for GlaxoSmithKline.

SEATTLE – Epileptic children are less likely to take antiepileptic drugs as prescribed if they also have psychiatric illnesses, according to a review of an administrative claims database.

“It's well established that nonadherence to prescribed antiepileptic drugs has serious potential consequences, including exacerbation of seizures, morbidity, and, now we are learning, even potentially mortality,” said Dr. Alan B. Ettinger, a neurologist at the Comprehensive Epilepsy Center at North Shore Long Island Jewish Medical Center, New Hyde Park, N.Y. “Establishing a possible relationship between these issues–psychiatric comorbidity and adherence–really has practical utility because if this is the case, then clinicians need to use some special interventions to try to promote better adherence.”

Using a PharMetrics administrative claims database, Dr. Ettinger and his colleagues reviewed claims for January 2000 through December 2006 for more than 50 million individuals covered by U.S. managed care plans.

The researchers found 5,343 children aged 4-18 years who had a diagnosis of epilepsy, received at least one prescription for an antiepileptic drug (AED), and were enrolled in their health plan for at least 1 year before and 1 year after starting the medication. There were slightly more boys than girls (55%), and about half of the children were 11 years old or younger.

Fully 65% of the children were nonadherent to their AED therapy. The children's mean medication possession ratio, a measure of adherence, was 0.54. Children with a ratio of less than 0.8 were considered nonadherent. The ratio was calculated by dividing the total number of days for which AEDs were supplied during the 1-year follow-up period by 365 days, Dr. Ettinger said at the annual meeting of the American Epilepsy Society.

Nearly half of the children had a psychiatric illness, as diagnosed by any physician, said Dr. Ettinger.

The most common were attention-deficit/hyperactivity disorder (17%) and attention deficit disorder (10%). But sizable proportions of children had more serious psychiatric illnesses, such as bipolar disorder (8%), developmental disorders (5%), schizophrenia (1%), or other psychoses (7%).

In multivariate analyses that took into account age, sex, geographic region, overall comorbidity burden, type of AED (newer vs. older), starting regimen (monotherapy vs. combination therapy), and initial AED dosing (one or fewer pills daily vs. more), children were significantly more likely to be nonadherent if they had a diagnosis of attention-deficit/hyperactivity disorder or bipolar disorder before starting AED therapy (odds ratios, 1.17 and 1.22, respectively) and if they received a diagnosis of bipolar disorder after starting AED therapy (odds ratio, 1.37).

Schizophrenia alone was not associated with elevated odds of nonadherence. But relative to their counterparts who did not have any of the more serious psychiatric illnesses, children who had at least one of them (regardless of type) were significantly more likely to be nonadherent (odds ratio, 1.15).

“Recognizing psychiatric comorbidity in pediatric patients with epilepsy is very important, and we hope that this study lends another compelling reason why clinicians need to be screening for psychiatric comorbidity,” concluded Dr. Ettinger, who reported that he is a project consultant for GlaxoSmithKline.

SEATTLE – Epileptic children are less likely to take antiepileptic drugs as prescribed if they also have psychiatric illnesses, according to a review of an administrative claims database.

“It's well established that nonadherence to prescribed antiepileptic drugs has serious potential consequences, including exacerbation of seizures, morbidity, and, now we are learning, even potentially mortality,” said Dr. Alan B. Ettinger, a neurologist at the Comprehensive Epilepsy Center at North Shore Long Island Jewish Medical Center, New Hyde Park, N.Y. “Establishing a possible relationship between these issues–psychiatric comorbidity and adherence–really has practical utility because if this is the case, then clinicians need to use some special interventions to try to promote better adherence.”

Using a PharMetrics administrative claims database, Dr. Ettinger and his colleagues reviewed claims for January 2000 through December 2006 for more than 50 million individuals covered by U.S. managed care plans.

The researchers found 5,343 children aged 4-18 years who had a diagnosis of epilepsy, received at least one prescription for an antiepileptic drug (AED), and were enrolled in their health plan for at least 1 year before and 1 year after starting the medication. There were slightly more boys than girls (55%), and about half of the children were 11 years old or younger.

Fully 65% of the children were nonadherent to their AED therapy. The children's mean medication possession ratio, a measure of adherence, was 0.54. Children with a ratio of less than 0.8 were considered nonadherent. The ratio was calculated by dividing the total number of days for which AEDs were supplied during the 1-year follow-up period by 365 days, Dr. Ettinger said at the annual meeting of the American Epilepsy Society.

Nearly half of the children had a psychiatric illness, as diagnosed by any physician, said Dr. Ettinger.

The most common were attention-deficit/hyperactivity disorder (17%) and attention deficit disorder (10%). But sizable proportions of children had more serious psychiatric illnesses, such as bipolar disorder (8%), developmental disorders (5%), schizophrenia (1%), or other psychoses (7%).

In multivariate analyses that took into account age, sex, geographic region, overall comorbidity burden, type of AED (newer vs. older), starting regimen (monotherapy vs. combination therapy), and initial AED dosing (one or fewer pills daily vs. more), children were significantly more likely to be nonadherent if they had a diagnosis of attention-deficit/hyperactivity disorder or bipolar disorder before starting AED therapy (odds ratios, 1.17 and 1.22, respectively) and if they received a diagnosis of bipolar disorder after starting AED therapy (odds ratio, 1.37).

Schizophrenia alone was not associated with elevated odds of nonadherence. But relative to their counterparts who did not have any of the more serious psychiatric illnesses, children who had at least one of them (regardless of type) were significantly more likely to be nonadherent (odds ratio, 1.15).

“Recognizing psychiatric comorbidity in pediatric patients with epilepsy is very important, and we hope that this study lends another compelling reason why clinicians need to be screening for psychiatric comorbidity,” concluded Dr. Ettinger, who reported that he is a project consultant for GlaxoSmithKline.