Susan London

SEATTLE — Surgery for obstructive sleep apnea may reduce patients' C-reactive protein levels even if the procedure doesn't cure their apnea, new study data show.

“Although it's controversial, there is certainly evidence that C-reactive protein [CRP] elevation is related to obstructive sleep apnea, with or without obesity,” Dr. Michael Friedman said at the annual meeting of the Associated Professional Sleep Societies. “Evidence of the relationship to sleep apnea without obesity is the fact that many studies show that good continuous positive airway pressure [CPAP] compliance decreases CRP levels.”

The investigators set out to determine first whether surgical treatment of obstructive sleep apnea (OSA) reduces CRP levels, explained Dr. Friedman, who is an otolaryngologist at the Rush University Medical Center in Chicago. “More important, because many of our patients treated with surgery are not cured, we sought to determine whether patients who are not cured also benefit by having a decrease in CRP level.”

The investigators retrospectively reviewed the charts of all adult patients who underwent surgery for OSA at the medical center between 2004 and 2008, had a moderately elevated preoperative CRP level (greater than 0.1 mg/dL but less than 1.0 mg/dL), and had pre- and postoperative polysomnography data. All of the patients had tried and failed CPAP, Dr. Friedman noted.

The change in apnea-hypopnea index (AHI) before and after surgery was used to classify patients' OSA as cured (AHI reduced by greater than 50% and AHI score less than 20), substantially improved (AHI reduced by greater than 50% but AHI score greater than 20), improved (AHI reduced by 20%-50%), unchanged (AHI reduced by less than 20%), and worsened (AHI increased).

Results were based on 75 patients. Mean age was 47 years, and 79% of the patients were men. The surgical procedure was an uvulopalatopharyngoplasty in 51% of patients, and minimally invasive single-stage multilevel surgery in 49% of patients, according to Dr. Friedman.

All patients had three palatal pillar implants placed in the midline and, if their uvula measured greater than 1.5 cm, a partial uvulectomy. In addition, all patients had radiofrequency treatment of the tongue base.

A comparison of pre- and postoperative data in the population overall showed that surgery was associated with a significant decrease in the AHI (from 48 to 30) and a significant increase in the minimum oxygen saturation during sleep (from 81% to 85%). Body mass index was unchanged.

According to the polysomnography criteria, OSA was cured in 24% of patients, substantially improved in 15%, improved in 24%, unchanged in 26%, and worsened in 11%. The AHI was significantly reduced from the preoperative level in all of the groups except for the patients who had a worsening of their OSA, Dr. Friedman reported.

The CRP level fell significantly from the preoperative level in patients whose OSA met the criteria for cure (from 0.341 mg/dL to 0.122 mg/dL). CRP levels also declined in those patients whose OSA was substantially improved (from 0.520 mg/dL to 0.314 mg/dL) or improved (from 0.335 mg/dL to 0.151 mg/dL).

“In this study, surgery reduced CRP levels even in those patients where cure was not achieved,” he concluded.

“The fact that elevated CRP relates to an increased risk of cardiovascular disease is clear,” he commented. Therefore, by reducing levels of that inflammatory marker, surgery for OSA may ultimately lower patients' cardiovascular risk.

Dr. Friedman said he had no conflicts of interest in association with the study.

SEATTLE — Surgery for obstructive sleep apnea may reduce patients' C-reactive protein levels even if the procedure doesn't cure their apnea, new study data show.

“Although it's controversial, there is certainly evidence that C-reactive protein [CRP] elevation is related to obstructive sleep apnea, with or without obesity,” Dr. Michael Friedman said at the annual meeting of the Associated Professional Sleep Societies. “Evidence of the relationship to sleep apnea without obesity is the fact that many studies show that good continuous positive airway pressure [CPAP] compliance decreases CRP levels.”

The investigators set out to determine first whether surgical treatment of obstructive sleep apnea (OSA) reduces CRP levels, explained Dr. Friedman, who is an otolaryngologist at the Rush University Medical Center in Chicago. “More important, because many of our patients treated with surgery are not cured, we sought to determine whether patients who are not cured also benefit by having a decrease in CRP level.”

The investigators retrospectively reviewed the charts of all adult patients who underwent surgery for OSA at the medical center between 2004 and 2008, had a moderately elevated preoperative CRP level (greater than 0.1 mg/dL but less than 1.0 mg/dL), and had pre- and postoperative polysomnography data. All of the patients had tried and failed CPAP, Dr. Friedman noted.

The change in apnea-hypopnea index (AHI) before and after surgery was used to classify patients' OSA as cured (AHI reduced by greater than 50% and AHI score less than 20), substantially improved (AHI reduced by greater than 50% but AHI score greater than 20), improved (AHI reduced by 20%-50%), unchanged (AHI reduced by less than 20%), and worsened (AHI increased).

Results were based on 75 patients. Mean age was 47 years, and 79% of the patients were men. The surgical procedure was an uvulopalatopharyngoplasty in 51% of patients, and minimally invasive single-stage multilevel surgery in 49% of patients, according to Dr. Friedman.

All patients had three palatal pillar implants placed in the midline and, if their uvula measured greater than 1.5 cm, a partial uvulectomy. In addition, all patients had radiofrequency treatment of the tongue base.

A comparison of pre- and postoperative data in the population overall showed that surgery was associated with a significant decrease in the AHI (from 48 to 30) and a significant increase in the minimum oxygen saturation during sleep (from 81% to 85%). Body mass index was unchanged.

According to the polysomnography criteria, OSA was cured in 24% of patients, substantially improved in 15%, improved in 24%, unchanged in 26%, and worsened in 11%. The AHI was significantly reduced from the preoperative level in all of the groups except for the patients who had a worsening of their OSA, Dr. Friedman reported.

The CRP level fell significantly from the preoperative level in patients whose OSA met the criteria for cure (from 0.341 mg/dL to 0.122 mg/dL). CRP levels also declined in those patients whose OSA was substantially improved (from 0.520 mg/dL to 0.314 mg/dL) or improved (from 0.335 mg/dL to 0.151 mg/dL).

“In this study, surgery reduced CRP levels even in those patients where cure was not achieved,” he concluded.

“The fact that elevated CRP relates to an increased risk of cardiovascular disease is clear,” he commented. Therefore, by reducing levels of that inflammatory marker, surgery for OSA may ultimately lower patients' cardiovascular risk.

Dr. Friedman said he had no conflicts of interest in association with the study.

SEATTLE — Surgery for obstructive sleep apnea may reduce patients' C-reactive protein levels even if the procedure doesn't cure their apnea, new study data show.

“Although it's controversial, there is certainly evidence that C-reactive protein [CRP] elevation is related to obstructive sleep apnea, with or without obesity,” Dr. Michael Friedman said at the annual meeting of the Associated Professional Sleep Societies. “Evidence of the relationship to sleep apnea without obesity is the fact that many studies show that good continuous positive airway pressure [CPAP] compliance decreases CRP levels.”

The investigators set out to determine first whether surgical treatment of obstructive sleep apnea (OSA) reduces CRP levels, explained Dr. Friedman, who is an otolaryngologist at the Rush University Medical Center in Chicago. “More important, because many of our patients treated with surgery are not cured, we sought to determine whether patients who are not cured also benefit by having a decrease in CRP level.”

The investigators retrospectively reviewed the charts of all adult patients who underwent surgery for OSA at the medical center between 2004 and 2008, had a moderately elevated preoperative CRP level (greater than 0.1 mg/dL but less than 1.0 mg/dL), and had pre- and postoperative polysomnography data. All of the patients had tried and failed CPAP, Dr. Friedman noted.

The change in apnea-hypopnea index (AHI) before and after surgery was used to classify patients' OSA as cured (AHI reduced by greater than 50% and AHI score less than 20), substantially improved (AHI reduced by greater than 50% but AHI score greater than 20), improved (AHI reduced by 20%-50%), unchanged (AHI reduced by less than 20%), and worsened (AHI increased).

Results were based on 75 patients. Mean age was 47 years, and 79% of the patients were men. The surgical procedure was an uvulopalatopharyngoplasty in 51% of patients, and minimally invasive single-stage multilevel surgery in 49% of patients, according to Dr. Friedman.

All patients had three palatal pillar implants placed in the midline and, if their uvula measured greater than 1.5 cm, a partial uvulectomy. In addition, all patients had radiofrequency treatment of the tongue base.

A comparison of pre- and postoperative data in the population overall showed that surgery was associated with a significant decrease in the AHI (from 48 to 30) and a significant increase in the minimum oxygen saturation during sleep (from 81% to 85%). Body mass index was unchanged.

According to the polysomnography criteria, OSA was cured in 24% of patients, substantially improved in 15%, improved in 24%, unchanged in 26%, and worsened in 11%. The AHI was significantly reduced from the preoperative level in all of the groups except for the patients who had a worsening of their OSA, Dr. Friedman reported.

The CRP level fell significantly from the preoperative level in patients whose OSA met the criteria for cure (from 0.341 mg/dL to 0.122 mg/dL). CRP levels also declined in those patients whose OSA was substantially improved (from 0.520 mg/dL to 0.314 mg/dL) or improved (from 0.335 mg/dL to 0.151 mg/dL).

“In this study, surgery reduced CRP levels even in those patients where cure was not achieved,” he concluded.

“The fact that elevated CRP relates to an increased risk of cardiovascular disease is clear,” he commented. Therefore, by reducing levels of that inflammatory marker, surgery for OSA may ultimately lower patients' cardiovascular risk.

Dr. Friedman said he had no conflicts of interest in association with the study.

SEATTLE — The greater endothelial dysfunction is among patients with obstructive sleep apnea, the more cardiovascular conditions they are likely to develop over time, according to a survey of 86 patients.

“The fact that endothelial dysfunction is predictive of cardiovascular events is well established in the cardiovascular literature,” Dr. Giora Pillar, a sleep medicine specialist with the Technion–Israel Institute of Technology, Haifa, said at the annual meeting of the Associated Professional Sleep Societies. However, this association has not been well studied among patients with obstructive sleep apnea (OSA).

He and his colleagues conducted follow-up telephone interviews with 86 patients with OSA who had undergone assessment of endothelial function with the postobstruction reactive hyperemia test when their OSA was diagnosed. Most (77%) were men and, at diagnosis, the patients had a mean age of 53 years and a mean body mass index of 29.2 kg/m

During the interviews, which took place an average of 4.3 years after the endothelial function assessment, patients were asked about OSA treatment, lifestyle changes, and diagnoses made and medications prescribed by their primary care physicians.

The investigators assessed the new onset of seven cardiovascular-related conditions: hypertension, diabetes, dyslipidemia, angina pectoris, myocardial infarction, stroke, and cardiac arrhythmia. Each condition was assigned one point, and the points were totaled.

“It could be argued whether diabetes and dyslipidemia are cardiovascular complications,” Dr. Pillar acknowledged. But they were included because “recent publications show that if you take lean patients [with OSA], they are at risk to develop obesity and dyslipidemia because of insulin resistance, changes in their lipid profiles, and other factors.”

Results indicated that 13% of the patients who smoked at baseline had stopped smoking at follow-up, and 22% of patients had started exercising, he reported. However, the patients' BMI was unchanged.

“Surprisingly, only 17 patients, which is 20% of our cohort, were treated with continuous positive airway pressure (CPAP),” Dr. Pillar said. “These patients were older and had more severe OSA.”

In terms of new cardiovascular conditions, 28% of patients had developed dyslipidemia during follow-up, 15% had developed hypertension, 12% had developed angina pectoris, 7% had developed diabetes, 2% had experienced a stroke, and 1% had developed arrhythmia. None experienced a myocardial infarction.

When the number of new conditions per patient was totaled, 73% of the patients had not developed any new conditions, 15% had developed one, 9% had developed two, and 3% had developed three.

There was a significant correlation between poorer endothelial function at baseline and a greater number of new cardiovascular conditions at follow-up, according to Dr. Pillar.

In multiple regression analyses, endothelial dysfunction was the strongest significant determinant of new cardiovascular morbidity. It was followed by body mass index and time since OSA diagnosis. Respiratory disturbance index was a marginally significant predictor.

A variety of other factors (age, total sleep time, and extent of oxygen desaturation) were not significant determinants of cardiovascular morbidity.

Study limitations included the insufficient power to compare the CPAP group with the untreated group, and the lack of data on potential confounders such as pulmonary hypertension, Dr. Pillar said.

“Endothelial dysfunction, body mass index, time of follow-up, and respiratory disturbance index are predictive of cardiovascular complications in patients with OSA,” he concluded, adding that future research in this cohort may help to better clarify the mechanisms of these observed associations.

Dr. Pillar reported that he is a consultant and member of the speakers bureau for Itamar Medical Ltd., which manufactures the device used to assess endothelial function.

SEATTLE — The greater endothelial dysfunction is among patients with obstructive sleep apnea, the more cardiovascular conditions they are likely to develop over time, according to a survey of 86 patients.

“The fact that endothelial dysfunction is predictive of cardiovascular events is well established in the cardiovascular literature,” Dr. Giora Pillar, a sleep medicine specialist with the Technion–Israel Institute of Technology, Haifa, said at the annual meeting of the Associated Professional Sleep Societies. However, this association has not been well studied among patients with obstructive sleep apnea (OSA).

He and his colleagues conducted follow-up telephone interviews with 86 patients with OSA who had undergone assessment of endothelial function with the postobstruction reactive hyperemia test when their OSA was diagnosed. Most (77%) were men and, at diagnosis, the patients had a mean age of 53 years and a mean body mass index of 29.2 kg/m

During the interviews, which took place an average of 4.3 years after the endothelial function assessment, patients were asked about OSA treatment, lifestyle changes, and diagnoses made and medications prescribed by their primary care physicians.

The investigators assessed the new onset of seven cardiovascular-related conditions: hypertension, diabetes, dyslipidemia, angina pectoris, myocardial infarction, stroke, and cardiac arrhythmia. Each condition was assigned one point, and the points were totaled.

“It could be argued whether diabetes and dyslipidemia are cardiovascular complications,” Dr. Pillar acknowledged. But they were included because “recent publications show that if you take lean patients [with OSA], they are at risk to develop obesity and dyslipidemia because of insulin resistance, changes in their lipid profiles, and other factors.”

Results indicated that 13% of the patients who smoked at baseline had stopped smoking at follow-up, and 22% of patients had started exercising, he reported. However, the patients' BMI was unchanged.

“Surprisingly, only 17 patients, which is 20% of our cohort, were treated with continuous positive airway pressure (CPAP),” Dr. Pillar said. “These patients were older and had more severe OSA.”

In terms of new cardiovascular conditions, 28% of patients had developed dyslipidemia during follow-up, 15% had developed hypertension, 12% had developed angina pectoris, 7% had developed diabetes, 2% had experienced a stroke, and 1% had developed arrhythmia. None experienced a myocardial infarction.

When the number of new conditions per patient was totaled, 73% of the patients had not developed any new conditions, 15% had developed one, 9% had developed two, and 3% had developed three.

There was a significant correlation between poorer endothelial function at baseline and a greater number of new cardiovascular conditions at follow-up, according to Dr. Pillar.

In multiple regression analyses, endothelial dysfunction was the strongest significant determinant of new cardiovascular morbidity. It was followed by body mass index and time since OSA diagnosis. Respiratory disturbance index was a marginally significant predictor.

A variety of other factors (age, total sleep time, and extent of oxygen desaturation) were not significant determinants of cardiovascular morbidity.

Study limitations included the insufficient power to compare the CPAP group with the untreated group, and the lack of data on potential confounders such as pulmonary hypertension, Dr. Pillar said.

“Endothelial dysfunction, body mass index, time of follow-up, and respiratory disturbance index are predictive of cardiovascular complications in patients with OSA,” he concluded, adding that future research in this cohort may help to better clarify the mechanisms of these observed associations.

Dr. Pillar reported that he is a consultant and member of the speakers bureau for Itamar Medical Ltd., which manufactures the device used to assess endothelial function.

SEATTLE — The greater endothelial dysfunction is among patients with obstructive sleep apnea, the more cardiovascular conditions they are likely to develop over time, according to a survey of 86 patients.

“The fact that endothelial dysfunction is predictive of cardiovascular events is well established in the cardiovascular literature,” Dr. Giora Pillar, a sleep medicine specialist with the Technion–Israel Institute of Technology, Haifa, said at the annual meeting of the Associated Professional Sleep Societies. However, this association has not been well studied among patients with obstructive sleep apnea (OSA).

He and his colleagues conducted follow-up telephone interviews with 86 patients with OSA who had undergone assessment of endothelial function with the postobstruction reactive hyperemia test when their OSA was diagnosed. Most (77%) were men and, at diagnosis, the patients had a mean age of 53 years and a mean body mass index of 29.2 kg/m

During the interviews, which took place an average of 4.3 years after the endothelial function assessment, patients were asked about OSA treatment, lifestyle changes, and diagnoses made and medications prescribed by their primary care physicians.

The investigators assessed the new onset of seven cardiovascular-related conditions: hypertension, diabetes, dyslipidemia, angina pectoris, myocardial infarction, stroke, and cardiac arrhythmia. Each condition was assigned one point, and the points were totaled.

“It could be argued whether diabetes and dyslipidemia are cardiovascular complications,” Dr. Pillar acknowledged. But they were included because “recent publications show that if you take lean patients [with OSA], they are at risk to develop obesity and dyslipidemia because of insulin resistance, changes in their lipid profiles, and other factors.”

Results indicated that 13% of the patients who smoked at baseline had stopped smoking at follow-up, and 22% of patients had started exercising, he reported. However, the patients' BMI was unchanged.

“Surprisingly, only 17 patients, which is 20% of our cohort, were treated with continuous positive airway pressure (CPAP),” Dr. Pillar said. “These patients were older and had more severe OSA.”

In terms of new cardiovascular conditions, 28% of patients had developed dyslipidemia during follow-up, 15% had developed hypertension, 12% had developed angina pectoris, 7% had developed diabetes, 2% had experienced a stroke, and 1% had developed arrhythmia. None experienced a myocardial infarction.

When the number of new conditions per patient was totaled, 73% of the patients had not developed any new conditions, 15% had developed one, 9% had developed two, and 3% had developed three.

There was a significant correlation between poorer endothelial function at baseline and a greater number of new cardiovascular conditions at follow-up, according to Dr. Pillar.

In multiple regression analyses, endothelial dysfunction was the strongest significant determinant of new cardiovascular morbidity. It was followed by body mass index and time since OSA diagnosis. Respiratory disturbance index was a marginally significant predictor.

A variety of other factors (age, total sleep time, and extent of oxygen desaturation) were not significant determinants of cardiovascular morbidity.

Study limitations included the insufficient power to compare the CPAP group with the untreated group, and the lack of data on potential confounders such as pulmonary hypertension, Dr. Pillar said.

“Endothelial dysfunction, body mass index, time of follow-up, and respiratory disturbance index are predictive of cardiovascular complications in patients with OSA,” he concluded, adding that future research in this cohort may help to better clarify the mechanisms of these observed associations.

Dr. Pillar reported that he is a consultant and member of the speakers bureau for Itamar Medical Ltd., which manufactures the device used to assess endothelial function.

Seattle — Treating obstructive sleep apnea in patients with type 2 diabetes could improve glycemic control as much as using common antidiabetic drugs, according to the results of an observational study.

Blood glucose levels may be harder to control in cases of untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Study results showed that mean glycosylated hemoglobin A_1c rose significantly from 6.5% in patients without OSA to 8.7% in those with severe OSA, she said.

The higher HbA_1c values also were significantly related to the number of episodes of oxygen desaturation of 3% or more during REM sleep.

In published reports, the prevalence of polysomnography-proven OSA in type 2 diabetes has ranged from 58% to 86%. “Despite this strikingly high prevalence of disease in patients with type 2 diabetes, the impact of OSA on glucose control in this patient population” has remained unknown, said Dr. Aronsohn, an endocrinology fellow at the University of Chicago.

She and her colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication. A total of 29 patients were women, and 29 were black.

Participants completed a diabetes and quality of life survey, performed wrist actigraphy monitoring for 5 days at home, underwent overnight laboratory polysomnography, and had a glycosylated HbA1_c) measurement.

Patients were classified as having no OSA (apnea-hypopnea index less than 5), mild OSA (5-14), moderate OSA (15-29), or severe OSA (index of 30 or greater).

Overall, 76% of the patients had OSA (mild in 35%, moderate in 26%, and severe in 15%). Compared with their non-OSA counterparts, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 kg/m

In a multivariate analysis that adjusted for potential confounders (age, sex, race, BMI, insulin use, duration of diabetes, and total sleep time), mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%. 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

“It's important to note that the magnitude of the effect sizes we see here are comparable to—if not exceeding—those seen with widely used pharmacologic agents,” Dr. Aronsohn said.

Dr. Aronsohn noted that a 100% increase in the number of obstructive events during REM sleep, from the median of 35 to 70 events per night, would result in a predicted increase in median HbA_1c from 7.2% to 7.7%. “This again is a clinically significant change in hemoglobin A_1c value,” she pointed out.

“Our findings suggest that untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy,” she said. “Conversely, treatment of OSA may improve glucose control comparable to that of widely used pharmacologic agents.”

Previous studies in patients with type 2 diabetes implicated sleep perturbations in poorer glycemic control, but failed to address OSA as a cause of the sleep problems, she said.

Studies assessing the impact of continuous positive airway pressure treatment on glycemic control in type 2 diabetes have been inconclusive and confounded by compliance issues, she noted. “So, our next step is looking at how treatment affects control.”

Dr. Aronsohn reported that she had no conflicts of interest associated with the study.

'Untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy.'

Source DR. ARONSOHN

Seattle — Treating obstructive sleep apnea in patients with type 2 diabetes could improve glycemic control as much as using common antidiabetic drugs, according to the results of an observational study.

Blood glucose levels may be harder to control in cases of untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Study results showed that mean glycosylated hemoglobin A_1c rose significantly from 6.5% in patients without OSA to 8.7% in those with severe OSA, she said.

The higher HbA_1c values also were significantly related to the number of episodes of oxygen desaturation of 3% or more during REM sleep.

In published reports, the prevalence of polysomnography-proven OSA in type 2 diabetes has ranged from 58% to 86%. “Despite this strikingly high prevalence of disease in patients with type 2 diabetes, the impact of OSA on glucose control in this patient population” has remained unknown, said Dr. Aronsohn, an endocrinology fellow at the University of Chicago.

She and her colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication. A total of 29 patients were women, and 29 were black.

Participants completed a diabetes and quality of life survey, performed wrist actigraphy monitoring for 5 days at home, underwent overnight laboratory polysomnography, and had a glycosylated HbA1_c) measurement.

Patients were classified as having no OSA (apnea-hypopnea index less than 5), mild OSA (5-14), moderate OSA (15-29), or severe OSA (index of 30 or greater).

Overall, 76% of the patients had OSA (mild in 35%, moderate in 26%, and severe in 15%). Compared with their non-OSA counterparts, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 kg/m

In a multivariate analysis that adjusted for potential confounders (age, sex, race, BMI, insulin use, duration of diabetes, and total sleep time), mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%. 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

“It's important to note that the magnitude of the effect sizes we see here are comparable to—if not exceeding—those seen with widely used pharmacologic agents,” Dr. Aronsohn said.

Dr. Aronsohn noted that a 100% increase in the number of obstructive events during REM sleep, from the median of 35 to 70 events per night, would result in a predicted increase in median HbA_1c from 7.2% to 7.7%. “This again is a clinically significant change in hemoglobin A_1c value,” she pointed out.

“Our findings suggest that untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy,” she said. “Conversely, treatment of OSA may improve glucose control comparable to that of widely used pharmacologic agents.”

Previous studies in patients with type 2 diabetes implicated sleep perturbations in poorer glycemic control, but failed to address OSA as a cause of the sleep problems, she said.

Studies assessing the impact of continuous positive airway pressure treatment on glycemic control in type 2 diabetes have been inconclusive and confounded by compliance issues, she noted. “So, our next step is looking at how treatment affects control.”

Dr. Aronsohn reported that she had no conflicts of interest associated with the study.

'Untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy.'

Source DR. ARONSOHN

Seattle — Treating obstructive sleep apnea in patients with type 2 diabetes could improve glycemic control as much as using common antidiabetic drugs, according to the results of an observational study.

Blood glucose levels may be harder to control in cases of untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Study results showed that mean glycosylated hemoglobin A_1c rose significantly from 6.5% in patients without OSA to 8.7% in those with severe OSA, she said.

The higher HbA_1c values also were significantly related to the number of episodes of oxygen desaturation of 3% or more during REM sleep.

In published reports, the prevalence of polysomnography-proven OSA in type 2 diabetes has ranged from 58% to 86%. “Despite this strikingly high prevalence of disease in patients with type 2 diabetes, the impact of OSA on glucose control in this patient population” has remained unknown, said Dr. Aronsohn, an endocrinology fellow at the University of Chicago.

She and her colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication. A total of 29 patients were women, and 29 were black.

Participants completed a diabetes and quality of life survey, performed wrist actigraphy monitoring for 5 days at home, underwent overnight laboratory polysomnography, and had a glycosylated HbA1_c) measurement.

Patients were classified as having no OSA (apnea-hypopnea index less than 5), mild OSA (5-14), moderate OSA (15-29), or severe OSA (index of 30 or greater).

Overall, 76% of the patients had OSA (mild in 35%, moderate in 26%, and severe in 15%). Compared with their non-OSA counterparts, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 kg/m

In a multivariate analysis that adjusted for potential confounders (age, sex, race, BMI, insulin use, duration of diabetes, and total sleep time), mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%. 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

“It's important to note that the magnitude of the effect sizes we see here are comparable to—if not exceeding—those seen with widely used pharmacologic agents,” Dr. Aronsohn said.

Dr. Aronsohn noted that a 100% increase in the number of obstructive events during REM sleep, from the median of 35 to 70 events per night, would result in a predicted increase in median HbA_1c from 7.2% to 7.7%. “This again is a clinically significant change in hemoglobin A_1c value,” she pointed out.

“Our findings suggest that untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy,” she said. “Conversely, treatment of OSA may improve glucose control comparable to that of widely used pharmacologic agents.”

Previous studies in patients with type 2 diabetes implicated sleep perturbations in poorer glycemic control, but failed to address OSA as a cause of the sleep problems, she said.

Studies assessing the impact of continuous positive airway pressure treatment on glycemic control in type 2 diabetes have been inconclusive and confounded by compliance issues, she noted. “So, our next step is looking at how treatment affects control.”

Dr. Aronsohn reported that she had no conflicts of interest associated with the study.

'Untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy.'

Source DR. ARONSOHN

SEATTLE – Pramipexole reduces depressive symptoms in patients with Parkinson's disease, largely independent of its effect on motor symptoms, according to the results of a randomized trial.

An estimated 45% of patients with Parkinson's disease (PD) have a depressive disorder, said lead investigator Dr. Paolo Barone, a neurologist at the University of Naples “Federico II” in Italy. Recent evidence suggests that depression is not simply reactive in this population, but occurs independently of motor symptoms and may be related to dysfunction in limbic dopaminergic circuits.

“Generally speaking, there are very few placebo-controlled studies of depression in Parkinson's disease,” he noted. “We have several open-label studies showing that dopaminergic agents, pramipexole [Mirapex] in particular, are able to reduce [or] improve depressive symptoms in Parkinson's disease.” Pramipexole is approved by the Food and Drug Administration for the treatment of the signs and symptoms of idiopathic Parkinson's disease and moderate to severe primary restless legs syndrome.

Patients in the trial were 30 years or older and had idiopathic PD with stable motor function; a score of 5 or greater on the Geriatric Depression Scale score; a score of 2 or greater on part I, question 3 (depression) of the Unified Parkinson's Disease Rating Scale (UPDRS); and a score of 24 or greater on the Mini-Mental State Examination, Dr. Barone reported at the annual meeting of the American Academy of Neurology

They were allowed to continue on other medications for PD, depression, and comorbidities at constant doses.

In the 12-week study, 152 patients were randomly assigned to placebo and 144 were assigned to pramipexole, with optional titration up to a dose of 1.0 mg three times a day. Rates of trial completion were 88% and 86%, respectively.

The patients were 67 years old on average, and 53% were female. The mean duration of PD was 4 years, and 77% of patients had a modified Hoehn and Yahr stage of 2 or 3. Ninety percent were receiving concomitant therapy for their PD.

The baseline total score on the Beck Depression Inventory (BDI) was 19.2 in the placebo group and 18.7 in the pramipexole group, corresponding to moderate depression, he said. By week 12, the respective scores were 15.0 and 13.1. The adjusted mean difference in the change in scores between groups–the trial's primary end point–was 1.9, significantly favoring the active treatment.

Compared with placebo, pramipexole was also associated with significantly greater improvements in Geriatric Depression Scale score (adjusted mean difference, 0.8), UPDRS II score (adjusted mean difference, 1.2), and UPDRS III score (adjusted mean difference, 2.2).

Control of depression and control of PD motor symptoms were only poorly correlated, Dr. Barone reported, with a correlation coefficient between the BDI score and UPDRS III score of 0.088 for placebo-treated patients and 0.215 for pramipexole-treated patients.

In addition, a path analysis showed that 80% of the treatment effect on depressive symptoms was accounted for directly by BDI score, whereas only 20% was accounted for by the indirect effect of UPDRS III score.

Adverse event profiles showed that patients in the pramipexole group had higher rates of certain types of events, compared with the control group, such as dizziness (11% vs. 6%, respectively), somnolence (10% vs. 8%), and dyskinesia (7% vs. 3%), he observed.

Dr. Barone reported that he has received research support and personal compensation for consulting activities from Boehringer Ingelheim Pharmaceuticals Inc., the manufacturer of Mirapex.

SEATTLE – Pramipexole reduces depressive symptoms in patients with Parkinson's disease, largely independent of its effect on motor symptoms, according to the results of a randomized trial.

An estimated 45% of patients with Parkinson's disease (PD) have a depressive disorder, said lead investigator Dr. Paolo Barone, a neurologist at the University of Naples “Federico II” in Italy. Recent evidence suggests that depression is not simply reactive in this population, but occurs independently of motor symptoms and may be related to dysfunction in limbic dopaminergic circuits.

“Generally speaking, there are very few placebo-controlled studies of depression in Parkinson's disease,” he noted. “We have several open-label studies showing that dopaminergic agents, pramipexole [Mirapex] in particular, are able to reduce [or] improve depressive symptoms in Parkinson's disease.” Pramipexole is approved by the Food and Drug Administration for the treatment of the signs and symptoms of idiopathic Parkinson's disease and moderate to severe primary restless legs syndrome.

Patients in the trial were 30 years or older and had idiopathic PD with stable motor function; a score of 5 or greater on the Geriatric Depression Scale score; a score of 2 or greater on part I, question 3 (depression) of the Unified Parkinson's Disease Rating Scale (UPDRS); and a score of 24 or greater on the Mini-Mental State Examination, Dr. Barone reported at the annual meeting of the American Academy of Neurology

They were allowed to continue on other medications for PD, depression, and comorbidities at constant doses.

In the 12-week study, 152 patients were randomly assigned to placebo and 144 were assigned to pramipexole, with optional titration up to a dose of 1.0 mg three times a day. Rates of trial completion were 88% and 86%, respectively.

The patients were 67 years old on average, and 53% were female. The mean duration of PD was 4 years, and 77% of patients had a modified Hoehn and Yahr stage of 2 or 3. Ninety percent were receiving concomitant therapy for their PD.

The baseline total score on the Beck Depression Inventory (BDI) was 19.2 in the placebo group and 18.7 in the pramipexole group, corresponding to moderate depression, he said. By week 12, the respective scores were 15.0 and 13.1. The adjusted mean difference in the change in scores between groups–the trial's primary end point–was 1.9, significantly favoring the active treatment.

Compared with placebo, pramipexole was also associated with significantly greater improvements in Geriatric Depression Scale score (adjusted mean difference, 0.8), UPDRS II score (adjusted mean difference, 1.2), and UPDRS III score (adjusted mean difference, 2.2).

Control of depression and control of PD motor symptoms were only poorly correlated, Dr. Barone reported, with a correlation coefficient between the BDI score and UPDRS III score of 0.088 for placebo-treated patients and 0.215 for pramipexole-treated patients.

In addition, a path analysis showed that 80% of the treatment effect on depressive symptoms was accounted for directly by BDI score, whereas only 20% was accounted for by the indirect effect of UPDRS III score.

Adverse event profiles showed that patients in the pramipexole group had higher rates of certain types of events, compared with the control group, such as dizziness (11% vs. 6%, respectively), somnolence (10% vs. 8%), and dyskinesia (7% vs. 3%), he observed.

Dr. Barone reported that he has received research support and personal compensation for consulting activities from Boehringer Ingelheim Pharmaceuticals Inc., the manufacturer of Mirapex.

SEATTLE – Pramipexole reduces depressive symptoms in patients with Parkinson's disease, largely independent of its effect on motor symptoms, according to the results of a randomized trial.

An estimated 45% of patients with Parkinson's disease (PD) have a depressive disorder, said lead investigator Dr. Paolo Barone, a neurologist at the University of Naples “Federico II” in Italy. Recent evidence suggests that depression is not simply reactive in this population, but occurs independently of motor symptoms and may be related to dysfunction in limbic dopaminergic circuits.

“Generally speaking, there are very few placebo-controlled studies of depression in Parkinson's disease,” he noted. “We have several open-label studies showing that dopaminergic agents, pramipexole [Mirapex] in particular, are able to reduce [or] improve depressive symptoms in Parkinson's disease.” Pramipexole is approved by the Food and Drug Administration for the treatment of the signs and symptoms of idiopathic Parkinson's disease and moderate to severe primary restless legs syndrome.

Patients in the trial were 30 years or older and had idiopathic PD with stable motor function; a score of 5 or greater on the Geriatric Depression Scale score; a score of 2 or greater on part I, question 3 (depression) of the Unified Parkinson's Disease Rating Scale (UPDRS); and a score of 24 or greater on the Mini-Mental State Examination, Dr. Barone reported at the annual meeting of the American Academy of Neurology

They were allowed to continue on other medications for PD, depression, and comorbidities at constant doses.

In the 12-week study, 152 patients were randomly assigned to placebo and 144 were assigned to pramipexole, with optional titration up to a dose of 1.0 mg three times a day. Rates of trial completion were 88% and 86%, respectively.

The patients were 67 years old on average, and 53% were female. The mean duration of PD was 4 years, and 77% of patients had a modified Hoehn and Yahr stage of 2 or 3. Ninety percent were receiving concomitant therapy for their PD.

The baseline total score on the Beck Depression Inventory (BDI) was 19.2 in the placebo group and 18.7 in the pramipexole group, corresponding to moderate depression, he said. By week 12, the respective scores were 15.0 and 13.1. The adjusted mean difference in the change in scores between groups–the trial's primary end point–was 1.9, significantly favoring the active treatment.

Compared with placebo, pramipexole was also associated with significantly greater improvements in Geriatric Depression Scale score (adjusted mean difference, 0.8), UPDRS II score (adjusted mean difference, 1.2), and UPDRS III score (adjusted mean difference, 2.2).

Control of depression and control of PD motor symptoms were only poorly correlated, Dr. Barone reported, with a correlation coefficient between the BDI score and UPDRS III score of 0.088 for placebo-treated patients and 0.215 for pramipexole-treated patients.

In addition, a path analysis showed that 80% of the treatment effect on depressive symptoms was accounted for directly by BDI score, whereas only 20% was accounted for by the indirect effect of UPDRS III score.

Adverse event profiles showed that patients in the pramipexole group had higher rates of certain types of events, compared with the control group, such as dizziness (11% vs. 6%, respectively), somnolence (10% vs. 8%), and dyskinesia (7% vs. 3%), he observed.

Dr. Barone reported that he has received research support and personal compensation for consulting activities from Boehringer Ingelheim Pharmaceuticals Inc., the manufacturer of Mirapex.

SEATTLE — Treating obstructive sleep apnea in patients with type 2 diabetes could improve glycemic control as much as using common antidiabetic drugs, according to the results of an observational study.

The study of 54 patients with type 2 diabetes indicated that blood glucose levels may be harder to control in those with untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Results showed that mean glycosylated hemoglobin (HbA_1c) rose significantly from a value of 6.5% in patients without OSA to 8.7% in those with severe OSA, she said. The higher HbA_1c values also were significantly related to the number of episodes of oxygen desaturation of 3% or more during REM sleep.

In published reports, the prevalence of polysomnography-proven OSA in type 2 diabetes has ranged from 58% to 86%. “Despite this strikingly high prevalence of disease in patients with type 2 diabetes, the impact of OSA on glucose control in this patient population” has remained unknown, said Dr. Aronsohn, an endocrinology fellow at the University of Chicago.

She and her colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication for diabetes and comorbidities. A total of 29 patients (54%) were women, and 29 (54%) were black.

Participants completed a diabetes and quality of life survey, performed wrist actigraphy monitoring for 5 days at home, underwent overnight laboratory polysomnography, and had an HbA_1c measurement.

On the basis of their apnea-hypopnea index, 76% of the patients had OSA, which was classified as mild in 35% (score of 5-14), moderate in 26% (15-29), and severe in 15% (30 or greater). Compared with their counterparts without OSA, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 vs. 29 kg/m

In a multivariate analysis that adjusted for potential confounders (age, sex, race, BMI, insulin use, duration of diabetes, and total sleep time), mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%, 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

“It's important to note that the magnitude of the effect sizes we see here are comparable to—if not exceeding—those seen with widely used pharmacologic agents,” Dr. Aronsohn commented.

Two other measures of OSA severity were significantly and positively associated with log-transformed HbA_1c values: the number of obstructive events in REM sleep and the number of oxygen desaturations of 3% or greater during REM sleep.

Giving a clinical example, she noted that a 100% increase in the number of obstructive events during REM sleep, from the median of 35 to 70 events per night, would result in a predicted increase in median HbA_1c from 7.2% to 7.7%, which is clinically significant, she said.

“Our findings suggest that untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy,” Dr. Aronsohn said. “Conversely, treatment of OSA may improve glucose control comparable to that of widely used pharmacologic agents.”

Dr. Aronsohn reported that she had no conflicts of interest associated with the study.

Treating OSA may improve glucose control as much as widely used pharmacologic agents.

Source DR. ARONSOHN

SEATTLE — Treating obstructive sleep apnea in patients with type 2 diabetes could improve glycemic control as much as using common antidiabetic drugs, according to the results of an observational study.

The study of 54 patients with type 2 diabetes indicated that blood glucose levels may be harder to control in those with untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Results showed that mean glycosylated hemoglobin (HbA_1c) rose significantly from a value of 6.5% in patients without OSA to 8.7% in those with severe OSA, she said. The higher HbA_1c values also were significantly related to the number of episodes of oxygen desaturation of 3% or more during REM sleep.

In published reports, the prevalence of polysomnography-proven OSA in type 2 diabetes has ranged from 58% to 86%. “Despite this strikingly high prevalence of disease in patients with type 2 diabetes, the impact of OSA on glucose control in this patient population” has remained unknown, said Dr. Aronsohn, an endocrinology fellow at the University of Chicago.

She and her colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication for diabetes and comorbidities. A total of 29 patients (54%) were women, and 29 (54%) were black.

Participants completed a diabetes and quality of life survey, performed wrist actigraphy monitoring for 5 days at home, underwent overnight laboratory polysomnography, and had an HbA_1c measurement.

On the basis of their apnea-hypopnea index, 76% of the patients had OSA, which was classified as mild in 35% (score of 5-14), moderate in 26% (15-29), and severe in 15% (30 or greater). Compared with their counterparts without OSA, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 vs. 29 kg/m

In a multivariate analysis that adjusted for potential confounders (age, sex, race, BMI, insulin use, duration of diabetes, and total sleep time), mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%, 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

“It's important to note that the magnitude of the effect sizes we see here are comparable to—if not exceeding—those seen with widely used pharmacologic agents,” Dr. Aronsohn commented.

Two other measures of OSA severity were significantly and positively associated with log-transformed HbA_1c values: the number of obstructive events in REM sleep and the number of oxygen desaturations of 3% or greater during REM sleep.

Giving a clinical example, she noted that a 100% increase in the number of obstructive events during REM sleep, from the median of 35 to 70 events per night, would result in a predicted increase in median HbA_1c from 7.2% to 7.7%, which is clinically significant, she said.

“Our findings suggest that untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy,” Dr. Aronsohn said. “Conversely, treatment of OSA may improve glucose control comparable to that of widely used pharmacologic agents.”

Dr. Aronsohn reported that she had no conflicts of interest associated with the study.

Treating OSA may improve glucose control as much as widely used pharmacologic agents.

Source DR. ARONSOHN

SEATTLE — Treating obstructive sleep apnea in patients with type 2 diabetes could improve glycemic control as much as using common antidiabetic drugs, according to the results of an observational study.

The study of 54 patients with type 2 diabetes indicated that blood glucose levels may be harder to control in those with untreated OSA, Dr. Renee Simon Aronsohn reported at the annual meeting of the Associated Professional Sleep Societies.

Results showed that mean glycosylated hemoglobin (HbA_1c) rose significantly from a value of 6.5% in patients without OSA to 8.7% in those with severe OSA, she said. The higher HbA_1c values also were significantly related to the number of episodes of oxygen desaturation of 3% or more during REM sleep.

In published reports, the prevalence of polysomnography-proven OSA in type 2 diabetes has ranged from 58% to 86%. “Despite this strikingly high prevalence of disease in patients with type 2 diabetes, the impact of OSA on glucose control in this patient population” has remained unknown, said Dr. Aronsohn, an endocrinology fellow at the University of Chicago.

She and her colleagues enrolled 54 patients seen in outpatient clinics during 2000-2008 who had physician-diagnosed type 2 diabetes and were on stable doses of medication for diabetes and comorbidities. A total of 29 patients (54%) were women, and 29 (54%) were black.

Participants completed a diabetes and quality of life survey, performed wrist actigraphy monitoring for 5 days at home, underwent overnight laboratory polysomnography, and had an HbA_1c measurement.

On the basis of their apnea-hypopnea index, 76% of the patients had OSA, which was classified as mild in 35% (score of 5-14), moderate in 26% (15-29), and severe in 15% (30 or greater). Compared with their counterparts without OSA, patients with OSA, on average, were older (60 years vs. 53 years), had a higher body mass index (35 vs. 29 kg/m

In a multivariate analysis that adjusted for potential confounders (age, sex, race, BMI, insulin use, duration of diabetes, and total sleep time), mean HbA_1c increased significantly across OSA categories, with values of 6.5%, 7.5%, 7.8%, and 8.7% among patients with no, mild, moderate, and severe OSA, respectively.

“It's important to note that the magnitude of the effect sizes we see here are comparable to—if not exceeding—those seen with widely used pharmacologic agents,” Dr. Aronsohn commented.

Two other measures of OSA severity were significantly and positively associated with log-transformed HbA_1c values: the number of obstructive events in REM sleep and the number of oxygen desaturations of 3% or greater during REM sleep.

Giving a clinical example, she noted that a 100% increase in the number of obstructive events during REM sleep, from the median of 35 to 70 events per night, would result in a predicted increase in median HbA_1c from 7.2% to 7.7%, which is clinically significant, she said.

“Our findings suggest that untreated OSA may worsen glucose control and increase the need for more intensive pharmacotherapy,” Dr. Aronsohn said. “Conversely, treatment of OSA may improve glucose control comparable to that of widely used pharmacologic agents.”

Dr. Aronsohn reported that she had no conflicts of interest associated with the study.

Treating OSA may improve glucose control as much as widely used pharmacologic agents.

Source DR. ARONSOHN

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

“Few studies have shown a relationship between OSA and type 2 diabetes,” said Dr. Sonia Togeiro, the study's lead author. Moreover, the role of obesity in this association is not yet clear, she noted.

Dr. Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil. All study participants underwent full-night polysomnography and were classified according to their apnea-hypopnea index as having no OSA(index less than 5), mild OSA (5-15), or moderate or severe OSA (greater than 15).

Participants were defined as having type 2 diabetes if they had a fasting plasma glucose level of 126 mg/dL or higher, took antidiabetic medication, or reported a previous diagnosis of the disease.

Study results indicated that 62% of participants did not have OSA, 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with their counterparts who did not have OSA, participants with mild OSA and those with moderate or severe OSA were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 vs. 28 and 30 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis adjusted for age, sex, and BMI, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (OR 1.97).

Conversely, OSA was much more prevalent in participants with diabetes, she said. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes.

“The severity of OSA was a highly significant predictor of type 2 diabetes in this population-based survey of São Paulo residents, independent of obesity, age, and gender,” Dr. Togeiro said.

Discussing the findings and possible explanations, Dr. Togeiro noted that laboratory research suggests that the severity of hypoxemia (as opposed to the frequency of arousals) appears to be the component of the apnea-hypopnea index linking OSA to type 2 diabetes.

“Our data suggest that clinicians should be attentive for OSA among diabetic patients and vice versa,” she concluded.

She reported that she had no conflicts of interest related to the study.

More severe obstructive sleep apnea was associated with a more unfavorable metabolic profile.

Source DR. TOGEIROimnews@elsevier.com

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

“Few studies have shown a relationship between OSA and type 2 diabetes,” said Dr. Sonia Togeiro, the study's lead author. Moreover, the role of obesity in this association is not yet clear, she noted.

Dr. Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil. All study participants underwent full-night polysomnography and were classified according to their apnea-hypopnea index as having no OSA(index less than 5), mild OSA (5-15), or moderate or severe OSA (greater than 15).

Participants were defined as having type 2 diabetes if they had a fasting plasma glucose level of 126 mg/dL or higher, took antidiabetic medication, or reported a previous diagnosis of the disease.

Study results indicated that 62% of participants did not have OSA, 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with their counterparts who did not have OSA, participants with mild OSA and those with moderate or severe OSA were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 vs. 28 and 30 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis adjusted for age, sex, and BMI, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (OR 1.97).

Conversely, OSA was much more prevalent in participants with diabetes, she said. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes.

“The severity of OSA was a highly significant predictor of type 2 diabetes in this population-based survey of São Paulo residents, independent of obesity, age, and gender,” Dr. Togeiro said.

Discussing the findings and possible explanations, Dr. Togeiro noted that laboratory research suggests that the severity of hypoxemia (as opposed to the frequency of arousals) appears to be the component of the apnea-hypopnea index linking OSA to type 2 diabetes.

“Our data suggest that clinicians should be attentive for OSA among diabetic patients and vice versa,” she concluded.

She reported that she had no conflicts of interest related to the study.

More severe obstructive sleep apnea was associated with a more unfavorable metabolic profile.

Source DR. TOGEIROimnews@elsevier.com

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

“Few studies have shown a relationship between OSA and type 2 diabetes,” said Dr. Sonia Togeiro, the study's lead author. Moreover, the role of obesity in this association is not yet clear, she noted.

Dr. Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil. All study participants underwent full-night polysomnography and were classified according to their apnea-hypopnea index as having no OSA(index less than 5), mild OSA (5-15), or moderate or severe OSA (greater than 15).

Participants were defined as having type 2 diabetes if they had a fasting plasma glucose level of 126 mg/dL or higher, took antidiabetic medication, or reported a previous diagnosis of the disease.

Study results indicated that 62% of participants did not have OSA, 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with their counterparts who did not have OSA, participants with mild OSA and those with moderate or severe OSA were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 vs. 28 and 30 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis adjusted for age, sex, and BMI, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (OR 1.97).

Conversely, OSA was much more prevalent in participants with diabetes, she said. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes.

“The severity of OSA was a highly significant predictor of type 2 diabetes in this population-based survey of São Paulo residents, independent of obesity, age, and gender,” Dr. Togeiro said.

Discussing the findings and possible explanations, Dr. Togeiro noted that laboratory research suggests that the severity of hypoxemia (as opposed to the frequency of arousals) appears to be the component of the apnea-hypopnea index linking OSA to type 2 diabetes.

“Our data suggest that clinicians should be attentive for OSA among diabetic patients and vice versa,” she concluded.

She reported that she had no conflicts of interest related to the study.

More severe obstructive sleep apnea was associated with a more unfavorable metabolic profile.

Source DR. TOGEIROimnews@elsevier.com

SEATTLE — The treatment of acne in adolescents should be tailored to the type and severity of lesions and the adolescent's age, according to Dr. Annette Wagner.

Fully 80% of teenagers develop acne, noted Dr. Wagner, a pediatric dermatologist at Northwestern University in Chicago. "But the age of onset is really young now that puberty is starting earlier," she commented. "I see comedones on many 8-year-olds in my clinic."

Myths abound when it comes to the cause of acne, she said at a meeting sponsored by the American Academy of Pediatrics. Chocolate, fatty foods, poor eating habits, and lack of cleanliness have all been wrongly accused. The real culprit is an inherited genetic predisposition to form comedones, or pores plugged by keratin behind which oil and bacteria can accumulate.

"This is familial," she stressed. "That's the No. 1 big thing, and I tell that to every adolescent in the room in front of the parent, because parents can make their kids feel responsible for their acne," nagging them about diet, not washing their face, and such.

Myths are equally common when it comes to treating acne. Removing oil is ineffective because oil itself is not to blame, she said. And although most teenagers believe otherwise, sunlight does not improve acne; in fact, because it stimulates T cells in the skin, sun exposure causes the condition to flare.

As long as cosmetics are labeled noncomedogenic or nonacneogenic—and most today are—they neither cause nor worsen acne, according to Dr. Wagner. Facials promote desquamation of the skin, but this process is not impaired in adolescence, and facials can do more harm than good. "Don't let cosmetologists manipulate the faces of your adolescents," she recommended. "That's not an appropriate treatment for acne."

Perhaps the most important myth of all is that acne is harmless, she commented. "Not only does it cause scarring, it does so much to make adolescents feel bad about themselves," she observed. "If you can offer treatment that will help, you are doing the right thing."

Moreover, "acne should be treated at any age—don't wait for these children to be adolescents or high school students," Dr. Wagner commented, offering some rules of thumb as to when treatment is appropriate. "I always treat it when any patient requests it, even if it's minor acne," she said, and all adolescents with lesions should be offered treatment. Systemic treatment is also warranted if acne is visible from across the examination room or if it has caused any scarring.

As far as skin care basics, Dr. Wagner recommended that young people with acne be advised to wash their skin gently. "Tell them, use your hands—not washcloths, not buff puffs, not exfoliants. Those make acne worse." They should also use a mild soap, preferably a liquid one, and apply sunscreen daily.

Excessive washing, application of petroleum jelly, and manipulation should be avoided. "I tell kids, if you squeeze a zit, you are going to be looking at it for about a month; if you don't squeeze it, it will dry up in about 10 days," she said.

Topical steroids used to treat seborrheic dermatitis also will worsen acne, she noted, so other agents should be selected for managing scale around the nose and scalp, or in the skin creases. Friction and sweating under clothing, as occur especially in young athletes, and exposure to aerosolized fat, as occurs in teenagers who work over deep fryers, also are exacerbating factors.

"But probably the thing that worsens acne more than anything else is working too hard to get rid of it," Dr. Wagner commented. "So less is better in this particular case."

Adolescents with relatively mild acne should be started on benzoyl peroxide, Dr. Wagner advised. "I like to put it in a wash form," she noted. "I tell them, wash your face with it in the morning and at night. That prevents them from using cleansers that aren't right."

In addition, they also should be prescribed a topical retinoid and, if they have inflammatory lesions, a topical antibiotic. Because retinoids can cause peeling, they should initially be used every other day and applied in a very small amount—a quarter of the size of a pea—only to the area affected by comedones, with a gradual increase in frequency and amount.

Importantly, Dr. Wagner noted, adolescents should be counseled about a realistic time frame for seeing improvement. "It takes 3 months to get a comedone out of your skin with appropriate treatment, and it sometimes takes a month and half to even be able to use the retinoid every night," she said. "So this is not going to happen for this weekend's dance, and you have got to tell them that because that is their expectation."

New combination topical products offer some advantages, she observed. For example, benzoyl peroxide or a retinoid promotes desquamation, so combining these with a topical antibiotic helps an antibiotic better penetrate the skin. And zinc helps overcome antibiotic resistance. Furthermore, adolescents—especially boys, who dislike putting anything on their skin—may have better compliance when given a combination product.

Noting that skin care may be a low priority in this age group generally, she recommended telling adolescents to just apply their medication at night even if they are too tired to wash their face. "It's not a problem of dirt or not removing oil," she said. "It's a problem of not doing the treatment."

Resorting to oral antibiotic therapy should be based on several factors, but age is not one of them, she said. Instead, this therapy should be initiated whenever a child has inflammatory lesions and topical therapy has failed, or when the acne can be seen from across the room, is cystic, or involves the trunk. In addition, "I go much more quickly to oral treatment in boys with inflammatory acne because they will take pills much more willingly than they will put products on their skin."

"You should treat with oral antibiotics for a minimum of 6 months," she said. "And it's typical to treat for several years because it's not a short period of time that acne is a problem."

Birth control pills should be considered for acne treatment in older girls.

Finally, if adolescents wish to treat acne scars, they must be free of any new lesions for at least a year, said Dr. Wagner.

She reported having no conflicts of interest relevant to her presentation.

'Probably the thing that worsens acne more than anything else is working too hard to get rid of it.'

Source DR. WAGNER

Adolescents—especially boys, who dislike putting anything on their skin—may do best with a combination product.

Source ©Stephen Strathdee/iStockphoto.com

SEATTLE — The treatment of acne in adolescents should be tailored to the type and severity of lesions and the adolescent's age, according to Dr. Annette Wagner.

Fully 80% of teenagers develop acne, noted Dr. Wagner, a pediatric dermatologist at Northwestern University in Chicago. "But the age of onset is really young now that puberty is starting earlier," she commented. "I see comedones on many 8-year-olds in my clinic."

Myths abound when it comes to the cause of acne, she said at a meeting sponsored by the American Academy of Pediatrics. Chocolate, fatty foods, poor eating habits, and lack of cleanliness have all been wrongly accused. The real culprit is an inherited genetic predisposition to form comedones, or pores plugged by keratin behind which oil and bacteria can accumulate.

"This is familial," she stressed. "That's the No. 1 big thing, and I tell that to every adolescent in the room in front of the parent, because parents can make their kids feel responsible for their acne," nagging them about diet, not washing their face, and such.

Myths are equally common when it comes to treating acne. Removing oil is ineffective because oil itself is not to blame, she said. And although most teenagers believe otherwise, sunlight does not improve acne; in fact, because it stimulates T cells in the skin, sun exposure causes the condition to flare.

As long as cosmetics are labeled noncomedogenic or nonacneogenic—and most today are—they neither cause nor worsen acne, according to Dr. Wagner. Facials promote desquamation of the skin, but this process is not impaired in adolescence, and facials can do more harm than good. "Don't let cosmetologists manipulate the faces of your adolescents," she recommended. "That's not an appropriate treatment for acne."

Perhaps the most important myth of all is that acne is harmless, she commented. "Not only does it cause scarring, it does so much to make adolescents feel bad about themselves," she observed. "If you can offer treatment that will help, you are doing the right thing."

Moreover, "acne should be treated at any age—don't wait for these children to be adolescents or high school students," Dr. Wagner commented, offering some rules of thumb as to when treatment is appropriate. "I always treat it when any patient requests it, even if it's minor acne," she said, and all adolescents with lesions should be offered treatment. Systemic treatment is also warranted if acne is visible from across the examination room or if it has caused any scarring.

As far as skin care basics, Dr. Wagner recommended that young people with acne be advised to wash their skin gently. "Tell them, use your hands—not washcloths, not buff puffs, not exfoliants. Those make acne worse." They should also use a mild soap, preferably a liquid one, and apply sunscreen daily.

Excessive washing, application of petroleum jelly, and manipulation should be avoided. "I tell kids, if you squeeze a zit, you are going to be looking at it for about a month; if you don't squeeze it, it will dry up in about 10 days," she said.

Topical steroids used to treat seborrheic dermatitis also will worsen acne, she noted, so other agents should be selected for managing scale around the nose and scalp, or in the skin creases. Friction and sweating under clothing, as occur especially in young athletes, and exposure to aerosolized fat, as occurs in teenagers who work over deep fryers, also are exacerbating factors.

"But probably the thing that worsens acne more than anything else is working too hard to get rid of it," Dr. Wagner commented. "So less is better in this particular case."

Adolescents with relatively mild acne should be started on benzoyl peroxide, Dr. Wagner advised. "I like to put it in a wash form," she noted. "I tell them, wash your face with it in the morning and at night. That prevents them from using cleansers that aren't right."

In addition, they also should be prescribed a topical retinoid and, if they have inflammatory lesions, a topical antibiotic. Because retinoids can cause peeling, they should initially be used every other day and applied in a very small amount—a quarter of the size of a pea—only to the area affected by comedones, with a gradual increase in frequency and amount.

Importantly, Dr. Wagner noted, adolescents should be counseled about a realistic time frame for seeing improvement. "It takes 3 months to get a comedone out of your skin with appropriate treatment, and it sometimes takes a month and half to even be able to use the retinoid every night," she said. "So this is not going to happen for this weekend's dance, and you have got to tell them that because that is their expectation."

New combination topical products offer some advantages, she observed. For example, benzoyl peroxide or a retinoid promotes desquamation, so combining these with a topical antibiotic helps an antibiotic better penetrate the skin. And zinc helps overcome antibiotic resistance. Furthermore, adolescents—especially boys, who dislike putting anything on their skin—may have better compliance when given a combination product.

Noting that skin care may be a low priority in this age group generally, she recommended telling adolescents to just apply their medication at night even if they are too tired to wash their face. "It's not a problem of dirt or not removing oil," she said. "It's a problem of not doing the treatment."

Resorting to oral antibiotic therapy should be based on several factors, but age is not one of them, she said. Instead, this therapy should be initiated whenever a child has inflammatory lesions and topical therapy has failed, or when the acne can be seen from across the room, is cystic, or involves the trunk. In addition, "I go much more quickly to oral treatment in boys with inflammatory acne because they will take pills much more willingly than they will put products on their skin."

"You should treat with oral antibiotics for a minimum of 6 months," she said. "And it's typical to treat for several years because it's not a short period of time that acne is a problem."

Birth control pills should be considered for acne treatment in older girls.

Finally, if adolescents wish to treat acne scars, they must be free of any new lesions for at least a year, said Dr. Wagner.

She reported having no conflicts of interest relevant to her presentation.

'Probably the thing that worsens acne more than anything else is working too hard to get rid of it.'

Source DR. WAGNER

Adolescents—especially boys, who dislike putting anything on their skin—may do best with a combination product.

Source ©Stephen Strathdee/iStockphoto.com

SEATTLE — The treatment of acne in adolescents should be tailored to the type and severity of lesions and the adolescent's age, according to Dr. Annette Wagner.

Fully 80% of teenagers develop acne, noted Dr. Wagner, a pediatric dermatologist at Northwestern University in Chicago. "But the age of onset is really young now that puberty is starting earlier," she commented. "I see comedones on many 8-year-olds in my clinic."

Myths abound when it comes to the cause of acne, she said at a meeting sponsored by the American Academy of Pediatrics. Chocolate, fatty foods, poor eating habits, and lack of cleanliness have all been wrongly accused. The real culprit is an inherited genetic predisposition to form comedones, or pores plugged by keratin behind which oil and bacteria can accumulate.

"This is familial," she stressed. "That's the No. 1 big thing, and I tell that to every adolescent in the room in front of the parent, because parents can make their kids feel responsible for their acne," nagging them about diet, not washing their face, and such.

Myths are equally common when it comes to treating acne. Removing oil is ineffective because oil itself is not to blame, she said. And although most teenagers believe otherwise, sunlight does not improve acne; in fact, because it stimulates T cells in the skin, sun exposure causes the condition to flare.

As long as cosmetics are labeled noncomedogenic or nonacneogenic—and most today are—they neither cause nor worsen acne, according to Dr. Wagner. Facials promote desquamation of the skin, but this process is not impaired in adolescence, and facials can do more harm than good. "Don't let cosmetologists manipulate the faces of your adolescents," she recommended. "That's not an appropriate treatment for acne."

Perhaps the most important myth of all is that acne is harmless, she commented. "Not only does it cause scarring, it does so much to make adolescents feel bad about themselves," she observed. "If you can offer treatment that will help, you are doing the right thing."

Moreover, "acne should be treated at any age—don't wait for these children to be adolescents or high school students," Dr. Wagner commented, offering some rules of thumb as to when treatment is appropriate. "I always treat it when any patient requests it, even if it's minor acne," she said, and all adolescents with lesions should be offered treatment. Systemic treatment is also warranted if acne is visible from across the examination room or if it has caused any scarring.

As far as skin care basics, Dr. Wagner recommended that young people with acne be advised to wash their skin gently. "Tell them, use your hands—not washcloths, not buff puffs, not exfoliants. Those make acne worse." They should also use a mild soap, preferably a liquid one, and apply sunscreen daily.

Excessive washing, application of petroleum jelly, and manipulation should be avoided. "I tell kids, if you squeeze a zit, you are going to be looking at it for about a month; if you don't squeeze it, it will dry up in about 10 days," she said.

Topical steroids used to treat seborrheic dermatitis also will worsen acne, she noted, so other agents should be selected for managing scale around the nose and scalp, or in the skin creases. Friction and sweating under clothing, as occur especially in young athletes, and exposure to aerosolized fat, as occurs in teenagers who work over deep fryers, also are exacerbating factors.

"But probably the thing that worsens acne more than anything else is working too hard to get rid of it," Dr. Wagner commented. "So less is better in this particular case."

Adolescents with relatively mild acne should be started on benzoyl peroxide, Dr. Wagner advised. "I like to put it in a wash form," she noted. "I tell them, wash your face with it in the morning and at night. That prevents them from using cleansers that aren't right."

In addition, they also should be prescribed a topical retinoid and, if they have inflammatory lesions, a topical antibiotic. Because retinoids can cause peeling, they should initially be used every other day and applied in a very small amount—a quarter of the size of a pea—only to the area affected by comedones, with a gradual increase in frequency and amount.

Importantly, Dr. Wagner noted, adolescents should be counseled about a realistic time frame for seeing improvement. "It takes 3 months to get a comedone out of your skin with appropriate treatment, and it sometimes takes a month and half to even be able to use the retinoid every night," she said. "So this is not going to happen for this weekend's dance, and you have got to tell them that because that is their expectation."

New combination topical products offer some advantages, she observed. For example, benzoyl peroxide or a retinoid promotes desquamation, so combining these with a topical antibiotic helps an antibiotic better penetrate the skin. And zinc helps overcome antibiotic resistance. Furthermore, adolescents—especially boys, who dislike putting anything on their skin—may have better compliance when given a combination product.

Noting that skin care may be a low priority in this age group generally, she recommended telling adolescents to just apply their medication at night even if they are too tired to wash their face. "It's not a problem of dirt or not removing oil," she said. "It's a problem of not doing the treatment."

Resorting to oral antibiotic therapy should be based on several factors, but age is not one of them, she said. Instead, this therapy should be initiated whenever a child has inflammatory lesions and topical therapy has failed, or when the acne can be seen from across the room, is cystic, or involves the trunk. In addition, "I go much more quickly to oral treatment in boys with inflammatory acne because they will take pills much more willingly than they will put products on their skin."

"You should treat with oral antibiotics for a minimum of 6 months," she said. "And it's typical to treat for several years because it's not a short period of time that acne is a problem."

Birth control pills should be considered for acne treatment in older girls.

Finally, if adolescents wish to treat acne scars, they must be free of any new lesions for at least a year, said Dr. Wagner.

She reported having no conflicts of interest relevant to her presentation.

'Probably the thing that worsens acne more than anything else is working too hard to get rid of it.'

Source DR. WAGNER

Adolescents—especially boys, who dislike putting anything on their skin—may do best with a combination product.

Source ©Stephen Strathdee/iStockphoto.com

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

“Few studies have shown a relationship between OSA and type 2 diabetes,” said Dr. Sonia Togeiro, the study's lead author. Moreover, the role of obesity in this association is not yet clear, she noted.

Dr. Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil.

All study participants underwent full-night polysomnography and were classified according to their apnea-hypopnea index as having no OSA (index less than 5), mild OSA (index 5-15), or moderate or severe OSA (index greater than 15).

Participants were defined as having type 2 diabetes if they had a fasting plasma glucose level of 126 mg/dL or higher, took antidiabetic medication, or reported a previous diagnosis of the disease.

Study results indicated that 62% of participants did not have OSA, whereas 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with their counterparts who did not have OSA, participants with mild OSA and participants with moderate or severe OSA alike were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis adjusted for age, sex, and body mass index, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (odds ratio 1.97).

Conversely, OSA was much more prevalent in participants with diabetes, she said. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes.

“The severity of OSA was a highly significant predictor of type 2 diabetes in this population-based survey of São Paulo residents, independent of obesity, age, and gender,” Dr. Togeiro said. Furthermore, nearly three-fourths of participants with type 2 diabetes had comorbid OSA.

Discussing the findings and possible explanations for them, Dr. Togeiro noted that laboratory research suggests that the severity of hypoxemia (as opposed to the frequency of arousals) appears to be the component of the apnea-hypopnea index linking OSA to type 2 diabetes.

“Our data suggest that clinicians should be attentive for OSA among diabetic patients and vice versa,” she concluded.

Dr. Togeiro reported that she had no conflicts of interest in association with the study.

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

“Few studies have shown a relationship between OSA and type 2 diabetes,” said Dr. Sonia Togeiro, the study's lead author. Moreover, the role of obesity in this association is not yet clear, she noted.

Dr. Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil.

All study participants underwent full-night polysomnography and were classified according to their apnea-hypopnea index as having no OSA (index less than 5), mild OSA (index 5-15), or moderate or severe OSA (index greater than 15).

Participants were defined as having type 2 diabetes if they had a fasting plasma glucose level of 126 mg/dL or higher, took antidiabetic medication, or reported a previous diagnosis of the disease.

Study results indicated that 62% of participants did not have OSA, whereas 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with their counterparts who did not have OSA, participants with mild OSA and participants with moderate or severe OSA alike were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis adjusted for age, sex, and body mass index, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (odds ratio 1.97).

Conversely, OSA was much more prevalent in participants with diabetes, she said. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes.

“The severity of OSA was a highly significant predictor of type 2 diabetes in this population-based survey of São Paulo residents, independent of obesity, age, and gender,” Dr. Togeiro said. Furthermore, nearly three-fourths of participants with type 2 diabetes had comorbid OSA.

Discussing the findings and possible explanations for them, Dr. Togeiro noted that laboratory research suggests that the severity of hypoxemia (as opposed to the frequency of arousals) appears to be the component of the apnea-hypopnea index linking OSA to type 2 diabetes.

“Our data suggest that clinicians should be attentive for OSA among diabetic patients and vice versa,” she concluded.

Dr. Togeiro reported that she had no conflicts of interest in association with the study.

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

“Few studies have shown a relationship between OSA and type 2 diabetes,” said Dr. Sonia Togeiro, the study's lead author. Moreover, the role of obesity in this association is not yet clear, she noted.

Dr. Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil.

All study participants underwent full-night polysomnography and were classified according to their apnea-hypopnea index as having no OSA (index less than 5), mild OSA (index 5-15), or moderate or severe OSA (index greater than 15).

Participants were defined as having type 2 diabetes if they had a fasting plasma glucose level of 126 mg/dL or higher, took antidiabetic medication, or reported a previous diagnosis of the disease.

Study results indicated that 62% of participants did not have OSA, whereas 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with their counterparts who did not have OSA, participants with mild OSA and participants with moderate or severe OSA alike were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis adjusted for age, sex, and body mass index, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (odds ratio 1.97).

Conversely, OSA was much more prevalent in participants with diabetes, she said. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes.

“The severity of OSA was a highly significant predictor of type 2 diabetes in this population-based survey of São Paulo residents, independent of obesity, age, and gender,” Dr. Togeiro said. Furthermore, nearly three-fourths of participants with type 2 diabetes had comorbid OSA.

Discussing the findings and possible explanations for them, Dr. Togeiro noted that laboratory research suggests that the severity of hypoxemia (as opposed to the frequency of arousals) appears to be the component of the apnea-hypopnea index linking OSA to type 2 diabetes.

“Our data suggest that clinicians should be attentive for OSA among diabetic patients and vice versa,” she concluded.

Dr. Togeiro reported that she had no conflicts of interest in association with the study.

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.

“It's such a black hole, a lot of clinicians just don't want to think about it.” But clinicians should think about it under certain circumstances, he said.

One is when a child has constitutional symptoms that persist. “When you have a kid who is sick and they are not getting better—they still have a fever, they are still losing weight, they have an elevated sedimentation rate, and the 'virus' still isn't going away—you need to think maybe they've got a vasculitic condition,” he said at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off of 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. “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, so pay attention to the helix.”

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 venous 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. “Please do not send all those normal kids with positive ANAs to your rheumatologists saying that they have lupus,” he said. “You can tell them 'You have a positive ANA.' And if you are really worried about it, we are happy to see those kids and reassure them, but ANA does not a diagnosis [of lupus] make.”

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.”

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

This patient's malar rash is largely confined to the nose and isn't typical.

Children with lupus may have a vasculitic rash on their hands.

A painless oral ulcer of the hard palate can be easily overlooked.

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.

“It's such a black hole, a lot of clinicians just don't want to think about it.” But clinicians should think about it under certain circumstances, he said.

One is when a child has constitutional symptoms that persist. “When you have a kid who is sick and they are not getting better—they still have a fever, they are still losing weight, they have an elevated sedimentation rate, and the 'virus' still isn't going away—you need to think maybe they've got a vasculitic condition,” he said at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off of 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. “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, so pay attention to the helix.”

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 venous 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. “Please do not send all those normal kids with positive ANAs to your rheumatologists saying that they have lupus,” he said. “You can tell them 'You have a positive ANA.' And if you are really worried about it, we are happy to see those kids and reassure them, but ANA does not a diagnosis [of lupus] make.”

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.”

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

This patient's malar rash is largely confined to the nose and isn't typical.

Children with lupus may have a vasculitic rash on their hands.

A painless oral ulcer of the hard palate can be easily overlooked.

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.

“It's such a black hole, a lot of clinicians just don't want to think about it.” But clinicians should think about it under certain circumstances, he said.

One is when a child has constitutional symptoms that persist. “When you have a kid who is sick and they are not getting better—they still have a fever, they are still losing weight, they have an elevated sedimentation rate, and the 'virus' still isn't going away—you need to think maybe they've got a vasculitic condition,” he said at a meeting sponsored by the American Academy of Pediatrics.

Multiorgan disease can also be a tip-off of 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. “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, so pay attention to the helix.”

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 venous 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. “Please do not send all those normal kids with positive ANAs to your rheumatologists saying that they have lupus,” he said. “You can tell them 'You have a positive ANA.' And if you are really worried about it, we are happy to see those kids and reassure them, but ANA does not a diagnosis [of lupus] make.”

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.”

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

This patient's malar rash is largely confined to the nose and isn't typical.

Children with lupus may have a vasculitic rash on their hands.

A painless oral ulcer of the hard palate can be easily overlooked.

Source Photos courtesy Dr. David D. Sherry

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

Dr. Sonia Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil. All study participants underwent full-night polysomnography.

A total of 62% of participants did not have OSA, 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with patients who did not have OSA, those with mild OSA and participants with moderate or severe OSA alike were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (odds ratio 1.97).

OSA also was more prevalent in participants with diabetes. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes, said Dr. Togeiro, who reported having no conflicts of interest.

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

Dr. Sonia Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil. All study participants underwent full-night polysomnography.

A total of 62% of participants did not have OSA, 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with patients who did not have OSA, those with mild OSA and participants with moderate or severe OSA alike were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (odds ratio 1.97).

OSA also was more prevalent in participants with diabetes. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes, said Dr. Togeiro, who reported having no conflicts of interest.

SEATTLE — The risk of type 2 diabetes increased with the severity of obstructive sleep apnea, even after obesity was taken into account, researchers reported at the annual meeting of the Associated Professional Sleep Societies.

Dr. Sonia Togeiro and her colleagues conducted a population-based study of OSA and diabetes among 1,042 men and women aged 20-80 years living in São Paulo, Brazil. All study participants underwent full-night polysomnography.

A total of 62% of participants did not have OSA, 21% had mild OSA, and 17% had moderate or severe OSA, reported Dr. Togeiro, an endocrinologist at Federal University of São Paulo. A total of 7% overall had diabetes. In addition, 38% were overweight, and 21% were obese.

Compared with patients who did not have OSA, those with mild OSA and participants with moderate or severe OSA alike were older (mean age 37 years vs. 48 years and 53 years, respectively), had a higher body mass index (25 kg/m

The presence and severity of OSA were also associated with a more unfavorable metabolic profile, Dr. Togeiro noted. Both OSA groups had higher levels of total cholesterol, triglycerides, fasting glucose, and fasting insulin, and a higher homeostasis model assessment index, compared with the unaffected group.

In a multivariate analysis, participants with mild OSA had a nonsignificant increase in the risk of diabetes relative to their counterparts who did not have OSA (odds ratio 1.07), and participants with moderate or severe OSA had a significant near doubling of risk (odds ratio 1.97).

OSA also was more prevalent in participants with diabetes. A total of 73% of individuals with diabetes had the condition, compared with 36% of those without diabetes, said Dr. Togeiro, who reported having no conflicts of interest.