Doug Brunk

HUNTINGTON BEACH, CALIF. – The way pioneering researcher Dr. Mark S. Gold sees it, food addiction is akin to dependence on alcohol, nicotine, and other drugs, and the earlier clinicians intervene and treat, the better.

“The evidence that sugar and other constituents of food can be an addiction is quite good, especially if you think about binging, craving, withdrawal, cross-sensitization, increased consumption, and drive for the ‘drug’ in a classic manner,” Dr. Gold said at the annual meeting of the American College of Psychiatrists. “If you focus on dopamine, sugar and food would be a drug. There’s anticipatory dopamine release if you’re presented with dessert, even after a huge meal, for example.”

Just as gambling, sex, and work can be addicting and result in a pathologic attachment, one’s drive for certain foods can lead to loss of control and/or continued use despite serious consequences such as the development of type 2 diabetes or knee and joint disease tied to weight gain. In the case of sugar, for example, “not only does it stimulate its own taking [in the form of] self-administration, loss of self-control, and binging, it can produce withdrawal as if the person is taking opiates,” said Dr. Gold, coauthor of “Food and Addiction: A Comprehensive Handbook” (New York: Oxford University Press, 2012) and the former chair of the department of psychiatry at the University of Florida, Jacksonville. “There’s an indirect opiate effect if naloxone (Narcan) produces withdrawal after sugar self-administration.”

And while obesity is currently the nation’s No. 2 health problem behind tobacco and secondhand smoke, it will be No. 1 soon, predicted Dr. Gold, a psychiatrist who has spent more than 40 years developing models for understanding the effects of tobacco, opiates, cocaine, other drugs, and food on the brain and behavior (Physiol. Behav. 2011;104:157-61).He pointed to a recent comparison of data from the Medical Expenditure Panel Survey between 2000 and 2010, which suggests that obesity “is going to bankrupt the health system because, as compared to tobacco, where death and disability tend to occur in the last 7 years of a person’s life, obesity is an unwanted gift to the health system that keeps on giving, with type 2 diabetes and other complications,” he said. “Now, bariatric surgery is the fastest-growing operation in the United States, and it’s been successful in treating teenagers. Two-thirds of Americans now qualify for obesity treatment.”

He went on to note that Americans are “conditioned by fast food,” and cited potential addictive factors as a nutritionally imbalanced prenatal diet, child rearing, genetics, and lack of exercise. “We [Americans] eat abnormally fast,” Dr. Gold added. “Our group has shown in functional imaging that it takes about 12 minutes for a thin person’s brain to get the food signal. It takes 25 minutes for an obese person to get the signal. So if the obese person goes into a fast food restaurant” and starts eating, that person gets back in line because he’s still hungry.

When first meeting a patient with a suspected food addiction, he advises clinicians to measure the person’s body mass index and to administer the Yale Food Addiction Scale, “which is easy to use,” he said. “Think about intervening and treating people when they have a BMI of 25 or greater, rather than just when they have a pre–bariatric surgery evaluation. One size doesn’t fit all when it comes to treatment.

“It’s important to have a careful look [at what’s causing their obesity]. It could be due to a thyroid condition or to a medication they’re taking.”

In addition to early intervention, “you want cognitive-behavioral treatment, new psychopharmacologic treatment where relevant, and group treatment rather than individualized treatment alone. The food addiction model is leading to a new way of thinking and new pharmacological treatment based on addiction research.”

Dr. Gold reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

HUNTINGTON BEACH, CALIF. – The way pioneering researcher Dr. Mark S. Gold sees it, food addiction is akin to dependence on alcohol, nicotine, and other drugs, and the earlier clinicians intervene and treat, the better.

“The evidence that sugar and other constituents of food can be an addiction is quite good, especially if you think about binging, craving, withdrawal, cross-sensitization, increased consumption, and drive for the ‘drug’ in a classic manner,” Dr. Gold said at the annual meeting of the American College of Psychiatrists. “If you focus on dopamine, sugar and food would be a drug. There’s anticipatory dopamine release if you’re presented with dessert, even after a huge meal, for example.”

Just as gambling, sex, and work can be addicting and result in a pathologic attachment, one’s drive for certain foods can lead to loss of control and/or continued use despite serious consequences such as the development of type 2 diabetes or knee and joint disease tied to weight gain. In the case of sugar, for example, “not only does it stimulate its own taking [in the form of] self-administration, loss of self-control, and binging, it can produce withdrawal as if the person is taking opiates,” said Dr. Gold, coauthor of “Food and Addiction: A Comprehensive Handbook” (New York: Oxford University Press, 2012) and the former chair of the department of psychiatry at the University of Florida, Jacksonville. “There’s an indirect opiate effect if naloxone (Narcan) produces withdrawal after sugar self-administration.”

And while obesity is currently the nation’s No. 2 health problem behind tobacco and secondhand smoke, it will be No. 1 soon, predicted Dr. Gold, a psychiatrist who has spent more than 40 years developing models for understanding the effects of tobacco, opiates, cocaine, other drugs, and food on the brain and behavior (Physiol. Behav. 2011;104:157-61).He pointed to a recent comparison of data from the Medical Expenditure Panel Survey between 2000 and 2010, which suggests that obesity “is going to bankrupt the health system because, as compared to tobacco, where death and disability tend to occur in the last 7 years of a person’s life, obesity is an unwanted gift to the health system that keeps on giving, with type 2 diabetes and other complications,” he said. “Now, bariatric surgery is the fastest-growing operation in the United States, and it’s been successful in treating teenagers. Two-thirds of Americans now qualify for obesity treatment.”

He went on to note that Americans are “conditioned by fast food,” and cited potential addictive factors as a nutritionally imbalanced prenatal diet, child rearing, genetics, and lack of exercise. “We [Americans] eat abnormally fast,” Dr. Gold added. “Our group has shown in functional imaging that it takes about 12 minutes for a thin person’s brain to get the food signal. It takes 25 minutes for an obese person to get the signal. So if the obese person goes into a fast food restaurant” and starts eating, that person gets back in line because he’s still hungry.

When first meeting a patient with a suspected food addiction, he advises clinicians to measure the person’s body mass index and to administer the Yale Food Addiction Scale, “which is easy to use,” he said. “Think about intervening and treating people when they have a BMI of 25 or greater, rather than just when they have a pre–bariatric surgery evaluation. One size doesn’t fit all when it comes to treatment.

“It’s important to have a careful look [at what’s causing their obesity]. It could be due to a thyroid condition or to a medication they’re taking.”

In addition to early intervention, “you want cognitive-behavioral treatment, new psychopharmacologic treatment where relevant, and group treatment rather than individualized treatment alone. The food addiction model is leading to a new way of thinking and new pharmacological treatment based on addiction research.”

Dr. Gold reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

HUNTINGTON BEACH, CALIF. – The way pioneering researcher Dr. Mark S. Gold sees it, food addiction is akin to dependence on alcohol, nicotine, and other drugs, and the earlier clinicians intervene and treat, the better.

“The evidence that sugar and other constituents of food can be an addiction is quite good, especially if you think about binging, craving, withdrawal, cross-sensitization, increased consumption, and drive for the ‘drug’ in a classic manner,” Dr. Gold said at the annual meeting of the American College of Psychiatrists. “If you focus on dopamine, sugar and food would be a drug. There’s anticipatory dopamine release if you’re presented with dessert, even after a huge meal, for example.”

Just as gambling, sex, and work can be addicting and result in a pathologic attachment, one’s drive for certain foods can lead to loss of control and/or continued use despite serious consequences such as the development of type 2 diabetes or knee and joint disease tied to weight gain. In the case of sugar, for example, “not only does it stimulate its own taking [in the form of] self-administration, loss of self-control, and binging, it can produce withdrawal as if the person is taking opiates,” said Dr. Gold, coauthor of “Food and Addiction: A Comprehensive Handbook” (New York: Oxford University Press, 2012) and the former chair of the department of psychiatry at the University of Florida, Jacksonville. “There’s an indirect opiate effect if naloxone (Narcan) produces withdrawal after sugar self-administration.”

And while obesity is currently the nation’s No. 2 health problem behind tobacco and secondhand smoke, it will be No. 1 soon, predicted Dr. Gold, a psychiatrist who has spent more than 40 years developing models for understanding the effects of tobacco, opiates, cocaine, other drugs, and food on the brain and behavior (Physiol. Behav. 2011;104:157-61).He pointed to a recent comparison of data from the Medical Expenditure Panel Survey between 2000 and 2010, which suggests that obesity “is going to bankrupt the health system because, as compared to tobacco, where death and disability tend to occur in the last 7 years of a person’s life, obesity is an unwanted gift to the health system that keeps on giving, with type 2 diabetes and other complications,” he said. “Now, bariatric surgery is the fastest-growing operation in the United States, and it’s been successful in treating teenagers. Two-thirds of Americans now qualify for obesity treatment.”

He went on to note that Americans are “conditioned by fast food,” and cited potential addictive factors as a nutritionally imbalanced prenatal diet, child rearing, genetics, and lack of exercise. “We [Americans] eat abnormally fast,” Dr. Gold added. “Our group has shown in functional imaging that it takes about 12 minutes for a thin person’s brain to get the food signal. It takes 25 minutes for an obese person to get the signal. So if the obese person goes into a fast food restaurant” and starts eating, that person gets back in line because he’s still hungry.

When first meeting a patient with a suspected food addiction, he advises clinicians to measure the person’s body mass index and to administer the Yale Food Addiction Scale, “which is easy to use,” he said. “Think about intervening and treating people when they have a BMI of 25 or greater, rather than just when they have a pre–bariatric surgery evaluation. One size doesn’t fit all when it comes to treatment.

“It’s important to have a careful look [at what’s causing their obesity]. It could be due to a thyroid condition or to a medication they’re taking.”

In addition to early intervention, “you want cognitive-behavioral treatment, new psychopharmacologic treatment where relevant, and group treatment rather than individualized treatment alone. The food addiction model is leading to a new way of thinking and new pharmacological treatment based on addiction research.”

Dr. Gold reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

HUNTINGTON BEACH, CALIF. – Five years ago, Dr. Bradley S. Peterson was about to give up on the idea that advanced neuroimaging could one day be used as a diagnostic tool for clinical practice in child psychiatry.

“I thought it was completely hopeless; I really did,” Dr. Peterson told attendees at the annual meeting of the American College of Psychiatrists. “I’m extremely optimistic now.”

Thanks to advances in technology and more rigorously designed studies, imaging will aid clinical diagnoses in the foreseeable future, predicted Dr. Peterson, director of the Institute for the Developing Mind at Children’s Hospital Los Angeles.

“I sincerely believe it’s around the corner,” he said. “I think the biggest challenge may be addressing regulatory issues, as some of these computer algorithms, depending on how they are used, may constitute a medical device. Getting things through the [Food and Drug Administration] can be prohibitively expensive, time consuming, and arduous.”

Using examples from studies conducted by his lab and that of colleagues in the field, he discussed four cutting-edge new uses of imaging studies in childhood disorders psychiatry.

Identifying biological vulnerabilities

In an ongoing study conducted with Myrna M. Weissman, Ph.D., division chief of epidemiology in the department of psychiatry at Columbia University, New York, researchers are prospectively following a three-generation cohort for more than 25 years in an effort to understand families at high and low risk for major depressive disorder. A large sample of patients with chronic, severe, highly impairing depression was recruited in and around New Haven, Conn., along with a group of community controls who, according to self-report, spouses, and other family members, had never suffered from depression. Longitudinal studies of that cohort to date have demonstrated that grandchildren in families with multiple generations of major depressive disorder are at high risk for depression and anxiety disorders.

In a study that Dr. Peterson conducted with Dr. Weissman and colleagues, the brains of 131 study participants were imaged “to identify in the brain what is transmitted between these generations that place these biological offspring of depressed people at risk for depression,” he explained. He presented published brain measurement findings from 66 subjects in the high-risk group and 65 in the low-risk group (PNAS 2009;105:6273-8). The primary measurement of interest was the cortical mantle, which he described as “the gray matter at the surface of the brain, which contains most of the nerve cell bodies and synapses of the brain that carry information from one part of the brain to another. This is generally about 6 mm thick on average, but it varies slightly across the brain.”

Dr. Peterson and his associates found that subjects at high risk for depression had a 28% average reduction in cortical thickness, compared with their counterparts in the low-risk group, primarily in the right hemisphere of the brain. He characterized this as “a massive finding in two respects. It’s massive in its spatial extent, from the back of the brain to the front. It’s also massive at each point of the brain. The average reduction of 28% in offspring of the high-risk people is a massive biological effect. It’s astounding that we can find this in offspring. Even people who are offspring of depressed individuals two generations removed carry this abnormality, and it’s there even if they’ve never been sick in their lifetime. This high-risk approach is one way of identifying true biological vulnerability to illness.”

Identifying brain-based causal mechanisms

This effort involves yoking MRI or other imaging technology to randomized, controlled trials. “Instead of having a change in symptoms be an outcome measure, here it’s a change in MRI or brain-based measure,” said Dr. Peterson, who is also director of child and adolescent psychiatry at the University of Southern California, Los Angeles.

In a recent study, he and other researchers, including Dr. David J. Hellerstein and Dr. Jonathan Posner at Columbia University, conducted functional MRIs to determine whether antidepressant medication normalizes default mode network connectivity in adults with dysthymia. They imaged 25 healthy controls at one point in time and imaged 41 dysthymic adults twice: once before and once after a 10-week trial of duloxetine (JAMA Psychiatry 2013;70:373-82). They were interested in the effects of duloxetine on the default mode network of the brain, a “circuit” of brain regions that include the ventral anterior cingulate, the posterior cingulate, and the inferior parietal lobule.

“It’s called the default mode [circuit] because when you daydream or mind wander or introspect, this set of circuits is highly active,” Dr. Peterson said. “If you have to perform a task rather than let your mind wander, that system has to shut off. This region has been implicated many times in depression, because it’s been shown to be hyperactive in currently depressed people. It’s been especially related to ruminations. So the more people ruminate, the more this default system is active.”

At baseline, the researchers found that the coherence of neural activity within the brain’s default mode network was greater in persons with dysthymia than in healthy controls. Following the 10-week trial, they found that treatment with duloxetine, but not placebo, normalized default mode network connectivity (P < .03). “If they received placebo, the activity [in this brain region] didn’t change at all; it’s exactly the same as it was before the medication trial,” Dr. Peterson said. “If they received active medication, activity normalized; it reduced the cross-talk across nodes of the default mode network so that now, their [default mode network] activity is no longer discernible or different from the healthy controls. This shows that duloxetine is causing the reduction in the cross-talk between these circuits, and by doing so, it’s normalizing activity in the default mode system.”

A similar effect was observed in a study that assessed the impact of stimulant medications in children with attention-deficit/hyperactivity disorder (ADHD). Specifically, researchers including Dr. Peterson used cross-sectional MRI to examine the morphologic features of the basal ganglia nuclei in 48 children with ADHD who were off medication and 56 healthy controls (Am. J. Psychiatry 2010;167:977-86).

“Reduced volume in portions of the basal ganglia structures is important for impulse control and attention,” Dr. Peterson said. “We found that those same structures are enlarged when kids are on their medication so as not to be different from healthy controls. We think that stimulant medications in ADHD are normalizing these disturbances in the structure of the basal ganglia.”

Identifying neurometabolic dysfunction

Prior studies measured lactate in peripheral blood, muscle, or postmortem samples of people with autism spectrum disorders (ASD), “but these do not necessarily indicate the presence of metabolic dysfunction in the brain,” Dr. Peterson said. In a recent study he and other researchers used magnetic resonance spectroscopic imaging to measure lactate in the brains of people at risk for ASD. The analysis included 75 high-functioning ASD participants and 96 typically developing children and adults (JAMA Psychiatry 2014;71:665:71). Definite lactate peaks were present at a significantly higher rate in the ASD participants, compared with controls (13% vs. 1%, P = .001). In addition, the presence of lactate was significantly greater in adults, compared with children (20% vs. 6%; P = .004), ”perhaps suggesting that this could be a degenerative process that exacerbates through time,” Dr. Peterson said.

The presence of lactate did not correlate with clinical symptoms based on ASD subtype, autism diagnostic observation schedule domain score, or full-scale IQ. Dr. Peterson said the presence of lactate is “definitive proof that mitochondria are dysfunctional in the brains of a substantial number of autistic people. This disturbance is found now in autism, but it will likely be true in people with other neuropsychiatric disorders as well.”

A key advantage of MR spectroscopic imaging, he continued, “is that we can determine where in the brain lactate’s being produced. These kinds of studies will help guide studies in mitochondrial genetics and dysfunction in ASD and other conditions. It also has important clinical implications, because there are novel treatment approaches now for mitochondrial dysfunction, such as dietary interventions that can reduce the metabolic dysfunction.”

Using automated, brain-based diagnostic classifications

Dr. Peterson and other researchers used an automated method to diagnose individuals as having one of various neuropsychiatric illnesses using only anatomical MRI scans. “The method employs a semisupervised learning algorithm that discovers natural groupings of brains based on the spatial patterns of variation in the morphology of the cerebral cortex and other brain regions,” they explained in their article (PLoS One 2012;7:e50698). “We used split-half and leave-one-out cross-validation analyses in large MRI datasets to assess the reproducibility and diagnostic accuracy of those groupings.”

Conceptually, “we look at the volume increases and decreases throughout the surface of the cortex,” Dr. Peterson said at the meeting. “We do the same thing at the basal ganglia, thalamus, cerebellum, amygdala, and hippocampus. What we’re trying to do is to use structural variation in the brain to identify spatial patterns in brain structure that help to identify people who have brain features in common, just as the pattern of dermatomal ridges on your finger can identify specific individuals with great accuracy.

“We use machine learning algorithms to identify a pattern of abnormality in brain structure that’s more similar among people with Tourette’s syndrome, for example, than in people who have ADHD.”

Using this automated approach to making clinical diagnoses yielded impressive results. For example, the sensitivity and specificity to differentiate ADHD subjects from healthy controls was 93.6% and 89.5%, respectively. It also was strong for diagnosis of Tourette’s syndrome, (94.6% sensitive and 79% specific) and for schizophrenia (93.1% sensitive and 94.5% specific).

Dr. Peterson disclosed that he has received research funding from the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute of Environmental Health Sciences, the National Science Foundation, the Brain & Behavior Research Foundation (formerly NARSAD), and the Simons Foundation. He also has received investigator-initiated funding from Eli Lilly and Pfizer.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

HUNTINGTON BEACH, CALIF. – Five years ago, Dr. Bradley S. Peterson was about to give up on the idea that advanced neuroimaging could one day be used as a diagnostic tool for clinical practice in child psychiatry.

“I thought it was completely hopeless; I really did,” Dr. Peterson told attendees at the annual meeting of the American College of Psychiatrists. “I’m extremely optimistic now.”

Thanks to advances in technology and more rigorously designed studies, imaging will aid clinical diagnoses in the foreseeable future, predicted Dr. Peterson, director of the Institute for the Developing Mind at Children’s Hospital Los Angeles.

“I sincerely believe it’s around the corner,” he said. “I think the biggest challenge may be addressing regulatory issues, as some of these computer algorithms, depending on how they are used, may constitute a medical device. Getting things through the [Food and Drug Administration] can be prohibitively expensive, time consuming, and arduous.”

Using examples from studies conducted by his lab and that of colleagues in the field, he discussed four cutting-edge new uses of imaging studies in childhood disorders psychiatry.

Identifying biological vulnerabilities

In an ongoing study conducted with Myrna M. Weissman, Ph.D., division chief of epidemiology in the department of psychiatry at Columbia University, New York, researchers are prospectively following a three-generation cohort for more than 25 years in an effort to understand families at high and low risk for major depressive disorder. A large sample of patients with chronic, severe, highly impairing depression was recruited in and around New Haven, Conn., along with a group of community controls who, according to self-report, spouses, and other family members, had never suffered from depression. Longitudinal studies of that cohort to date have demonstrated that grandchildren in families with multiple generations of major depressive disorder are at high risk for depression and anxiety disorders.

In a study that Dr. Peterson conducted with Dr. Weissman and colleagues, the brains of 131 study participants were imaged “to identify in the brain what is transmitted between these generations that place these biological offspring of depressed people at risk for depression,” he explained. He presented published brain measurement findings from 66 subjects in the high-risk group and 65 in the low-risk group (PNAS 2009;105:6273-8). The primary measurement of interest was the cortical mantle, which he described as “the gray matter at the surface of the brain, which contains most of the nerve cell bodies and synapses of the brain that carry information from one part of the brain to another. This is generally about 6 mm thick on average, but it varies slightly across the brain.”

Dr. Peterson and his associates found that subjects at high risk for depression had a 28% average reduction in cortical thickness, compared with their counterparts in the low-risk group, primarily in the right hemisphere of the brain. He characterized this as “a massive finding in two respects. It’s massive in its spatial extent, from the back of the brain to the front. It’s also massive at each point of the brain. The average reduction of 28% in offspring of the high-risk people is a massive biological effect. It’s astounding that we can find this in offspring. Even people who are offspring of depressed individuals two generations removed carry this abnormality, and it’s there even if they’ve never been sick in their lifetime. This high-risk approach is one way of identifying true biological vulnerability to illness.”

Identifying brain-based causal mechanisms

This effort involves yoking MRI or other imaging technology to randomized, controlled trials. “Instead of having a change in symptoms be an outcome measure, here it’s a change in MRI or brain-based measure,” said Dr. Peterson, who is also director of child and adolescent psychiatry at the University of Southern California, Los Angeles.

In a recent study, he and other researchers, including Dr. David J. Hellerstein and Dr. Jonathan Posner at Columbia University, conducted functional MRIs to determine whether antidepressant medication normalizes default mode network connectivity in adults with dysthymia. They imaged 25 healthy controls at one point in time and imaged 41 dysthymic adults twice: once before and once after a 10-week trial of duloxetine (JAMA Psychiatry 2013;70:373-82). They were interested in the effects of duloxetine on the default mode network of the brain, a “circuit” of brain regions that include the ventral anterior cingulate, the posterior cingulate, and the inferior parietal lobule.

“It’s called the default mode [circuit] because when you daydream or mind wander or introspect, this set of circuits is highly active,” Dr. Peterson said. “If you have to perform a task rather than let your mind wander, that system has to shut off. This region has been implicated many times in depression, because it’s been shown to be hyperactive in currently depressed people. It’s been especially related to ruminations. So the more people ruminate, the more this default system is active.”

At baseline, the researchers found that the coherence of neural activity within the brain’s default mode network was greater in persons with dysthymia than in healthy controls. Following the 10-week trial, they found that treatment with duloxetine, but not placebo, normalized default mode network connectivity (P < .03). “If they received placebo, the activity [in this brain region] didn’t change at all; it’s exactly the same as it was before the medication trial,” Dr. Peterson said. “If they received active medication, activity normalized; it reduced the cross-talk across nodes of the default mode network so that now, their [default mode network] activity is no longer discernible or different from the healthy controls. This shows that duloxetine is causing the reduction in the cross-talk between these circuits, and by doing so, it’s normalizing activity in the default mode system.”

A similar effect was observed in a study that assessed the impact of stimulant medications in children with attention-deficit/hyperactivity disorder (ADHD). Specifically, researchers including Dr. Peterson used cross-sectional MRI to examine the morphologic features of the basal ganglia nuclei in 48 children with ADHD who were off medication and 56 healthy controls (Am. J. Psychiatry 2010;167:977-86).

“Reduced volume in portions of the basal ganglia structures is important for impulse control and attention,” Dr. Peterson said. “We found that those same structures are enlarged when kids are on their medication so as not to be different from healthy controls. We think that stimulant medications in ADHD are normalizing these disturbances in the structure of the basal ganglia.”

Identifying neurometabolic dysfunction

Prior studies measured lactate in peripheral blood, muscle, or postmortem samples of people with autism spectrum disorders (ASD), “but these do not necessarily indicate the presence of metabolic dysfunction in the brain,” Dr. Peterson said. In a recent study he and other researchers used magnetic resonance spectroscopic imaging to measure lactate in the brains of people at risk for ASD. The analysis included 75 high-functioning ASD participants and 96 typically developing children and adults (JAMA Psychiatry 2014;71:665:71). Definite lactate peaks were present at a significantly higher rate in the ASD participants, compared with controls (13% vs. 1%, P = .001). In addition, the presence of lactate was significantly greater in adults, compared with children (20% vs. 6%; P = .004), ”perhaps suggesting that this could be a degenerative process that exacerbates through time,” Dr. Peterson said.

The presence of lactate did not correlate with clinical symptoms based on ASD subtype, autism diagnostic observation schedule domain score, or full-scale IQ. Dr. Peterson said the presence of lactate is “definitive proof that mitochondria are dysfunctional in the brains of a substantial number of autistic people. This disturbance is found now in autism, but it will likely be true in people with other neuropsychiatric disorders as well.”

A key advantage of MR spectroscopic imaging, he continued, “is that we can determine where in the brain lactate’s being produced. These kinds of studies will help guide studies in mitochondrial genetics and dysfunction in ASD and other conditions. It also has important clinical implications, because there are novel treatment approaches now for mitochondrial dysfunction, such as dietary interventions that can reduce the metabolic dysfunction.”

Using automated, brain-based diagnostic classifications

Dr. Peterson and other researchers used an automated method to diagnose individuals as having one of various neuropsychiatric illnesses using only anatomical MRI scans. “The method employs a semisupervised learning algorithm that discovers natural groupings of brains based on the spatial patterns of variation in the morphology of the cerebral cortex and other brain regions,” they explained in their article (PLoS One 2012;7:e50698). “We used split-half and leave-one-out cross-validation analyses in large MRI datasets to assess the reproducibility and diagnostic accuracy of those groupings.”

Conceptually, “we look at the volume increases and decreases throughout the surface of the cortex,” Dr. Peterson said at the meeting. “We do the same thing at the basal ganglia, thalamus, cerebellum, amygdala, and hippocampus. What we’re trying to do is to use structural variation in the brain to identify spatial patterns in brain structure that help to identify people who have brain features in common, just as the pattern of dermatomal ridges on your finger can identify specific individuals with great accuracy.

“We use machine learning algorithms to identify a pattern of abnormality in brain structure that’s more similar among people with Tourette’s syndrome, for example, than in people who have ADHD.”

Using this automated approach to making clinical diagnoses yielded impressive results. For example, the sensitivity and specificity to differentiate ADHD subjects from healthy controls was 93.6% and 89.5%, respectively. It also was strong for diagnosis of Tourette’s syndrome, (94.6% sensitive and 79% specific) and for schizophrenia (93.1% sensitive and 94.5% specific).

Dr. Peterson disclosed that he has received research funding from the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute of Environmental Health Sciences, the National Science Foundation, the Brain & Behavior Research Foundation (formerly NARSAD), and the Simons Foundation. He also has received investigator-initiated funding from Eli Lilly and Pfizer.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

HUNTINGTON BEACH, CALIF. – Five years ago, Dr. Bradley S. Peterson was about to give up on the idea that advanced neuroimaging could one day be used as a diagnostic tool for clinical practice in child psychiatry.

“I thought it was completely hopeless; I really did,” Dr. Peterson told attendees at the annual meeting of the American College of Psychiatrists. “I’m extremely optimistic now.”

Thanks to advances in technology and more rigorously designed studies, imaging will aid clinical diagnoses in the foreseeable future, predicted Dr. Peterson, director of the Institute for the Developing Mind at Children’s Hospital Los Angeles.

“I sincerely believe it’s around the corner,” he said. “I think the biggest challenge may be addressing regulatory issues, as some of these computer algorithms, depending on how they are used, may constitute a medical device. Getting things through the [Food and Drug Administration] can be prohibitively expensive, time consuming, and arduous.”

Using examples from studies conducted by his lab and that of colleagues in the field, he discussed four cutting-edge new uses of imaging studies in childhood disorders psychiatry.

Identifying biological vulnerabilities

In an ongoing study conducted with Myrna M. Weissman, Ph.D., division chief of epidemiology in the department of psychiatry at Columbia University, New York, researchers are prospectively following a three-generation cohort for more than 25 years in an effort to understand families at high and low risk for major depressive disorder. A large sample of patients with chronic, severe, highly impairing depression was recruited in and around New Haven, Conn., along with a group of community controls who, according to self-report, spouses, and other family members, had never suffered from depression. Longitudinal studies of that cohort to date have demonstrated that grandchildren in families with multiple generations of major depressive disorder are at high risk for depression and anxiety disorders.

In a study that Dr. Peterson conducted with Dr. Weissman and colleagues, the brains of 131 study participants were imaged “to identify in the brain what is transmitted between these generations that place these biological offspring of depressed people at risk for depression,” he explained. He presented published brain measurement findings from 66 subjects in the high-risk group and 65 in the low-risk group (PNAS 2009;105:6273-8). The primary measurement of interest was the cortical mantle, which he described as “the gray matter at the surface of the brain, which contains most of the nerve cell bodies and synapses of the brain that carry information from one part of the brain to another. This is generally about 6 mm thick on average, but it varies slightly across the brain.”

Dr. Peterson and his associates found that subjects at high risk for depression had a 28% average reduction in cortical thickness, compared with their counterparts in the low-risk group, primarily in the right hemisphere of the brain. He characterized this as “a massive finding in two respects. It’s massive in its spatial extent, from the back of the brain to the front. It’s also massive at each point of the brain. The average reduction of 28% in offspring of the high-risk people is a massive biological effect. It’s astounding that we can find this in offspring. Even people who are offspring of depressed individuals two generations removed carry this abnormality, and it’s there even if they’ve never been sick in their lifetime. This high-risk approach is one way of identifying true biological vulnerability to illness.”

Identifying brain-based causal mechanisms

This effort involves yoking MRI or other imaging technology to randomized, controlled trials. “Instead of having a change in symptoms be an outcome measure, here it’s a change in MRI or brain-based measure,” said Dr. Peterson, who is also director of child and adolescent psychiatry at the University of Southern California, Los Angeles.

In a recent study, he and other researchers, including Dr. David J. Hellerstein and Dr. Jonathan Posner at Columbia University, conducted functional MRIs to determine whether antidepressant medication normalizes default mode network connectivity in adults with dysthymia. They imaged 25 healthy controls at one point in time and imaged 41 dysthymic adults twice: once before and once after a 10-week trial of duloxetine (JAMA Psychiatry 2013;70:373-82). They were interested in the effects of duloxetine on the default mode network of the brain, a “circuit” of brain regions that include the ventral anterior cingulate, the posterior cingulate, and the inferior parietal lobule.

“It’s called the default mode [circuit] because when you daydream or mind wander or introspect, this set of circuits is highly active,” Dr. Peterson said. “If you have to perform a task rather than let your mind wander, that system has to shut off. This region has been implicated many times in depression, because it’s been shown to be hyperactive in currently depressed people. It’s been especially related to ruminations. So the more people ruminate, the more this default system is active.”

At baseline, the researchers found that the coherence of neural activity within the brain’s default mode network was greater in persons with dysthymia than in healthy controls. Following the 10-week trial, they found that treatment with duloxetine, but not placebo, normalized default mode network connectivity (P < .03). “If they received placebo, the activity [in this brain region] didn’t change at all; it’s exactly the same as it was before the medication trial,” Dr. Peterson said. “If they received active medication, activity normalized; it reduced the cross-talk across nodes of the default mode network so that now, their [default mode network] activity is no longer discernible or different from the healthy controls. This shows that duloxetine is causing the reduction in the cross-talk between these circuits, and by doing so, it’s normalizing activity in the default mode system.”

A similar effect was observed in a study that assessed the impact of stimulant medications in children with attention-deficit/hyperactivity disorder (ADHD). Specifically, researchers including Dr. Peterson used cross-sectional MRI to examine the morphologic features of the basal ganglia nuclei in 48 children with ADHD who were off medication and 56 healthy controls (Am. J. Psychiatry 2010;167:977-86).

“Reduced volume in portions of the basal ganglia structures is important for impulse control and attention,” Dr. Peterson said. “We found that those same structures are enlarged when kids are on their medication so as not to be different from healthy controls. We think that stimulant medications in ADHD are normalizing these disturbances in the structure of the basal ganglia.”

Identifying neurometabolic dysfunction

Prior studies measured lactate in peripheral blood, muscle, or postmortem samples of people with autism spectrum disorders (ASD), “but these do not necessarily indicate the presence of metabolic dysfunction in the brain,” Dr. Peterson said. In a recent study he and other researchers used magnetic resonance spectroscopic imaging to measure lactate in the brains of people at risk for ASD. The analysis included 75 high-functioning ASD participants and 96 typically developing children and adults (JAMA Psychiatry 2014;71:665:71). Definite lactate peaks were present at a significantly higher rate in the ASD participants, compared with controls (13% vs. 1%, P = .001). In addition, the presence of lactate was significantly greater in adults, compared with children (20% vs. 6%; P = .004), ”perhaps suggesting that this could be a degenerative process that exacerbates through time,” Dr. Peterson said.

The presence of lactate did not correlate with clinical symptoms based on ASD subtype, autism diagnostic observation schedule domain score, or full-scale IQ. Dr. Peterson said the presence of lactate is “definitive proof that mitochondria are dysfunctional in the brains of a substantial number of autistic people. This disturbance is found now in autism, but it will likely be true in people with other neuropsychiatric disorders as well.”

A key advantage of MR spectroscopic imaging, he continued, “is that we can determine where in the brain lactate’s being produced. These kinds of studies will help guide studies in mitochondrial genetics and dysfunction in ASD and other conditions. It also has important clinical implications, because there are novel treatment approaches now for mitochondrial dysfunction, such as dietary interventions that can reduce the metabolic dysfunction.”

Using automated, brain-based diagnostic classifications

Dr. Peterson and other researchers used an automated method to diagnose individuals as having one of various neuropsychiatric illnesses using only anatomical MRI scans. “The method employs a semisupervised learning algorithm that discovers natural groupings of brains based on the spatial patterns of variation in the morphology of the cerebral cortex and other brain regions,” they explained in their article (PLoS One 2012;7:e50698). “We used split-half and leave-one-out cross-validation analyses in large MRI datasets to assess the reproducibility and diagnostic accuracy of those groupings.”

Conceptually, “we look at the volume increases and decreases throughout the surface of the cortex,” Dr. Peterson said at the meeting. “We do the same thing at the basal ganglia, thalamus, cerebellum, amygdala, and hippocampus. What we’re trying to do is to use structural variation in the brain to identify spatial patterns in brain structure that help to identify people who have brain features in common, just as the pattern of dermatomal ridges on your finger can identify specific individuals with great accuracy.

“We use machine learning algorithms to identify a pattern of abnormality in brain structure that’s more similar among people with Tourette’s syndrome, for example, than in people who have ADHD.”

Using this automated approach to making clinical diagnoses yielded impressive results. For example, the sensitivity and specificity to differentiate ADHD subjects from healthy controls was 93.6% and 89.5%, respectively. It also was strong for diagnosis of Tourette’s syndrome, (94.6% sensitive and 79% specific) and for schizophrenia (93.1% sensitive and 94.5% specific).

Dr. Peterson disclosed that he has received research funding from the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute of Environmental Health Sciences, the National Science Foundation, the Brain & Behavior Research Foundation (formerly NARSAD), and the Simons Foundation. He also has received investigator-initiated funding from Eli Lilly and Pfizer.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – An investigational system that provides precise measurement and real-time maternal feedback of descent during the second stage of labor shortened the second stage in pregnant women who received epidural anesthesia, a randomized, controlled study demonstrated.

The system also reduced composite adverse maternal outcomes and reduced neonatal ICU admissions, Dr. Merlin B. Fausett reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

“The length of second-stage labor is highly correlated with the incidence of maternal morbidities and the incidence of neonatal ICU admissions,” said Dr. Fausett, a maternal-fetal medicine specialist in Missoula, Montana. “The majority of laboring women in the U.S. have epidurals during labor for labor pain management. In some studies, the length of second-stage labor is increased in women receiving regional anesthesia, compared with women without. This increased length of labor may be due to the lack of maternal sensation, resulting in decreased physiologic feedback that inhibits learning and decreases the efficacy of maternal expulsive efforts.”

Recognizing the difficulties with a long second stage of labor, clinicians have developed several nonoperative methods of attempting to reduce its length, including coached pushing, allowing periods of passive descent, and waiting for the laboring women to develop an urge to push. Some physicians also provide maternal visual feedback with a mirror.

“These methods have proven to be of limited benefit at best,” Dr. Fausett said. “With coached pushing, for example, frequent or continuous vaginal examinations may cause genital trauma, perinatal edema, and increased rates of infection. This method also requires a significant amount of the provider’s time. Finally, the use of mirrors is not well accepted by many patients and is only effective if the baby is already low enough in the pelvis to be visible to the mother with the mirror.”

Dr. Fausett and his colleagues hypothesized that using an experimental metrology device and software to give real-time quantitative maternal feedback of fetal descent during labor could result in more effective expulsion efforts, reduce the length of second stage, and improve perinatal outcomes.

They designed a prospective randomized, nonblinded trial to assess the clinical impact of providing laboring women real-time audiovisual feedback regarding fetal descent during second stage. The primary outcomes were a comparison of the length of time from initiation of pushing until delivery of the baby and a comparison of a composite of clinical outcomes.

“The pushing time comparison was to be made between study and control group subjects who had a spontaneous vaginal delivery, thus excluding those whose second stage was short with an operational or cesarean delivery,” Dr. Fausett said. “This comparison was also to control for fetal station at the initiation of pushing, as well as neonatal birth weight.”

The composite outcome was defined as a comparison of the number of women in the study versus control group who had any one of the following outcomes: cesarean delivery, operative vaginal delivery, third- or fourth-degree lacerations, an intra-amniotic infection, or NICU admission.

Developed by OB Technologies, the metrology device consisted of a support arm attached to the maternal sacral area using tape. This support arm extended through the gluteal cleft and terminated distal to the perineum. An optical sensor was then attached to the distal center of the support arm. A standard needle scalp electrode was modified by placing a semirigid wire at the base of the attachment where the spiral electrode attached to the needle head.

“This wire extended from the scalp across the optical sensor, and thus movement of the fetal head relative to the maternal pelvis was detected,” Dr. Fausett explained. “The instrument allowed detection of movements as small as 50 micrometers. Fetal station relative to the position in the pelvis was recorded. For feedback subjects, the movement was conveyed to them graphically and audibly using piano tones that occurred as often as every 150 milliseconds. The feedback was related to both the velocity and the distance of descent.”

Dr. Fausett reported results from 69 laboring nulliparous women with singleton pregnancies who were at least 36 weeks’ gestational age with epidural anesthesia.

Women in the study group received feedback on descent during the second stage by way of a laptop that displayed graphics and sounded musical notes corresponding to the movement of the fetus relative to the maternal bony pelvis.

Control subjects were not provided the visual and auditory feedback but the descent information was recorded with the same equipment. Normal labor and delivery procedures, including pelvic examination and nurse-provided feedback to the patient, were allowed in both groups. On postpartum day one, study subjects were asked to complete an anonymous survey about the use of the feedback device.

The study was halted after the planned interim analysis because the researchers identified a difference in the composite outcome between study and controls that was substantially above the threshold prescribed by the study design (more than 30%), Dr. Fausett said.

He presented findings from 46 women in the feedback group and 23 women in the control group. There were no differences between the groups in birth weights, mean station at the initiation of pushing, or in the maternal body mass indexes. However, the incidence of the composite adverse outcome was 9% in the feedback group, compared with 33% in the control group (P = .011). This corresponded to a 73% reduction in the composite outcome in the feedback group.

With regard to pushing time, the median pushing time was 77 minutes versus 58 minutes for control and study groups, respectively (P = .016).

The researchers did not identify any statistical differences in the incidence of cesarean delivery or intra-amniotic infections between the study and control groups. However, in the feedback group there were significant reductions in the incidences of operative vaginal deliveries (6.6% vs. 25%; P = .035), third- and fourth-degree lacerations (0% vs. 17%; P = .005), and neonatal ICU admission (0% vs. 13%; P = .015).

Among the 35 subjects that responded to a survey about the device on postpartum day one, “the majority strongly agreed that the device was comfortable, it helped them to push better, and they felt it gave them an increased sense of control during pushing,” he said.

Dr. Fausett acknowledged certain limitations of the study, including the potential for bias since it was not a blinded trial.

“We also did not address the optimal method or methods of feedback in this study,” he said. “Additional studies should evaluate and validate our findings as well as focus on fine-tuning the methods of graphic, auditory, and haptic feedback. If such feedback continues to prove effective, there are significant potential benefits on perinatal outcomes with important medical and economic consequences.”

Dr. Fausett disclosed that he is a shareholder in OB Technologies.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – An investigational system that provides precise measurement and real-time maternal feedback of descent during the second stage of labor shortened the second stage in pregnant women who received epidural anesthesia, a randomized, controlled study demonstrated.

The system also reduced composite adverse maternal outcomes and reduced neonatal ICU admissions, Dr. Merlin B. Fausett reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

“The length of second-stage labor is highly correlated with the incidence of maternal morbidities and the incidence of neonatal ICU admissions,” said Dr. Fausett, a maternal-fetal medicine specialist in Missoula, Montana. “The majority of laboring women in the U.S. have epidurals during labor for labor pain management. In some studies, the length of second-stage labor is increased in women receiving regional anesthesia, compared with women without. This increased length of labor may be due to the lack of maternal sensation, resulting in decreased physiologic feedback that inhibits learning and decreases the efficacy of maternal expulsive efforts.”

Recognizing the difficulties with a long second stage of labor, clinicians have developed several nonoperative methods of attempting to reduce its length, including coached pushing, allowing periods of passive descent, and waiting for the laboring women to develop an urge to push. Some physicians also provide maternal visual feedback with a mirror.

“These methods have proven to be of limited benefit at best,” Dr. Fausett said. “With coached pushing, for example, frequent or continuous vaginal examinations may cause genital trauma, perinatal edema, and increased rates of infection. This method also requires a significant amount of the provider’s time. Finally, the use of mirrors is not well accepted by many patients and is only effective if the baby is already low enough in the pelvis to be visible to the mother with the mirror.”

Dr. Fausett and his colleagues hypothesized that using an experimental metrology device and software to give real-time quantitative maternal feedback of fetal descent during labor could result in more effective expulsion efforts, reduce the length of second stage, and improve perinatal outcomes.

They designed a prospective randomized, nonblinded trial to assess the clinical impact of providing laboring women real-time audiovisual feedback regarding fetal descent during second stage. The primary outcomes were a comparison of the length of time from initiation of pushing until delivery of the baby and a comparison of a composite of clinical outcomes.

“The pushing time comparison was to be made between study and control group subjects who had a spontaneous vaginal delivery, thus excluding those whose second stage was short with an operational or cesarean delivery,” Dr. Fausett said. “This comparison was also to control for fetal station at the initiation of pushing, as well as neonatal birth weight.”

The composite outcome was defined as a comparison of the number of women in the study versus control group who had any one of the following outcomes: cesarean delivery, operative vaginal delivery, third- or fourth-degree lacerations, an intra-amniotic infection, or NICU admission.

Developed by OB Technologies, the metrology device consisted of a support arm attached to the maternal sacral area using tape. This support arm extended through the gluteal cleft and terminated distal to the perineum. An optical sensor was then attached to the distal center of the support arm. A standard needle scalp electrode was modified by placing a semirigid wire at the base of the attachment where the spiral electrode attached to the needle head.

“This wire extended from the scalp across the optical sensor, and thus movement of the fetal head relative to the maternal pelvis was detected,” Dr. Fausett explained. “The instrument allowed detection of movements as small as 50 micrometers. Fetal station relative to the position in the pelvis was recorded. For feedback subjects, the movement was conveyed to them graphically and audibly using piano tones that occurred as often as every 150 milliseconds. The feedback was related to both the velocity and the distance of descent.”

Dr. Fausett reported results from 69 laboring nulliparous women with singleton pregnancies who were at least 36 weeks’ gestational age with epidural anesthesia.

Women in the study group received feedback on descent during the second stage by way of a laptop that displayed graphics and sounded musical notes corresponding to the movement of the fetus relative to the maternal bony pelvis.

Control subjects were not provided the visual and auditory feedback but the descent information was recorded with the same equipment. Normal labor and delivery procedures, including pelvic examination and nurse-provided feedback to the patient, were allowed in both groups. On postpartum day one, study subjects were asked to complete an anonymous survey about the use of the feedback device.

The study was halted after the planned interim analysis because the researchers identified a difference in the composite outcome between study and controls that was substantially above the threshold prescribed by the study design (more than 30%), Dr. Fausett said.

He presented findings from 46 women in the feedback group and 23 women in the control group. There were no differences between the groups in birth weights, mean station at the initiation of pushing, or in the maternal body mass indexes. However, the incidence of the composite adverse outcome was 9% in the feedback group, compared with 33% in the control group (P = .011). This corresponded to a 73% reduction in the composite outcome in the feedback group.

With regard to pushing time, the median pushing time was 77 minutes versus 58 minutes for control and study groups, respectively (P = .016).

The researchers did not identify any statistical differences in the incidence of cesarean delivery or intra-amniotic infections between the study and control groups. However, in the feedback group there were significant reductions in the incidences of operative vaginal deliveries (6.6% vs. 25%; P = .035), third- and fourth-degree lacerations (0% vs. 17%; P = .005), and neonatal ICU admission (0% vs. 13%; P = .015).

Among the 35 subjects that responded to a survey about the device on postpartum day one, “the majority strongly agreed that the device was comfortable, it helped them to push better, and they felt it gave them an increased sense of control during pushing,” he said.

Dr. Fausett acknowledged certain limitations of the study, including the potential for bias since it was not a blinded trial.

“We also did not address the optimal method or methods of feedback in this study,” he said. “Additional studies should evaluate and validate our findings as well as focus on fine-tuning the methods of graphic, auditory, and haptic feedback. If such feedback continues to prove effective, there are significant potential benefits on perinatal outcomes with important medical and economic consequences.”

Dr. Fausett disclosed that he is a shareholder in OB Technologies.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – An investigational system that provides precise measurement and real-time maternal feedback of descent during the second stage of labor shortened the second stage in pregnant women who received epidural anesthesia, a randomized, controlled study demonstrated.

The system also reduced composite adverse maternal outcomes and reduced neonatal ICU admissions, Dr. Merlin B. Fausett reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

“The length of second-stage labor is highly correlated with the incidence of maternal morbidities and the incidence of neonatal ICU admissions,” said Dr. Fausett, a maternal-fetal medicine specialist in Missoula, Montana. “The majority of laboring women in the U.S. have epidurals during labor for labor pain management. In some studies, the length of second-stage labor is increased in women receiving regional anesthesia, compared with women without. This increased length of labor may be due to the lack of maternal sensation, resulting in decreased physiologic feedback that inhibits learning and decreases the efficacy of maternal expulsive efforts.”

Recognizing the difficulties with a long second stage of labor, clinicians have developed several nonoperative methods of attempting to reduce its length, including coached pushing, allowing periods of passive descent, and waiting for the laboring women to develop an urge to push. Some physicians also provide maternal visual feedback with a mirror.

“These methods have proven to be of limited benefit at best,” Dr. Fausett said. “With coached pushing, for example, frequent or continuous vaginal examinations may cause genital trauma, perinatal edema, and increased rates of infection. This method also requires a significant amount of the provider’s time. Finally, the use of mirrors is not well accepted by many patients and is only effective if the baby is already low enough in the pelvis to be visible to the mother with the mirror.”

Dr. Fausett and his colleagues hypothesized that using an experimental metrology device and software to give real-time quantitative maternal feedback of fetal descent during labor could result in more effective expulsion efforts, reduce the length of second stage, and improve perinatal outcomes.

They designed a prospective randomized, nonblinded trial to assess the clinical impact of providing laboring women real-time audiovisual feedback regarding fetal descent during second stage. The primary outcomes were a comparison of the length of time from initiation of pushing until delivery of the baby and a comparison of a composite of clinical outcomes.

“The pushing time comparison was to be made between study and control group subjects who had a spontaneous vaginal delivery, thus excluding those whose second stage was short with an operational or cesarean delivery,” Dr. Fausett said. “This comparison was also to control for fetal station at the initiation of pushing, as well as neonatal birth weight.”

The composite outcome was defined as a comparison of the number of women in the study versus control group who had any one of the following outcomes: cesarean delivery, operative vaginal delivery, third- or fourth-degree lacerations, an intra-amniotic infection, or NICU admission.

Developed by OB Technologies, the metrology device consisted of a support arm attached to the maternal sacral area using tape. This support arm extended through the gluteal cleft and terminated distal to the perineum. An optical sensor was then attached to the distal center of the support arm. A standard needle scalp electrode was modified by placing a semirigid wire at the base of the attachment where the spiral electrode attached to the needle head.

“This wire extended from the scalp across the optical sensor, and thus movement of the fetal head relative to the maternal pelvis was detected,” Dr. Fausett explained. “The instrument allowed detection of movements as small as 50 micrometers. Fetal station relative to the position in the pelvis was recorded. For feedback subjects, the movement was conveyed to them graphically and audibly using piano tones that occurred as often as every 150 milliseconds. The feedback was related to both the velocity and the distance of descent.”

Dr. Fausett reported results from 69 laboring nulliparous women with singleton pregnancies who were at least 36 weeks’ gestational age with epidural anesthesia.

Women in the study group received feedback on descent during the second stage by way of a laptop that displayed graphics and sounded musical notes corresponding to the movement of the fetus relative to the maternal bony pelvis.

Control subjects were not provided the visual and auditory feedback but the descent information was recorded with the same equipment. Normal labor and delivery procedures, including pelvic examination and nurse-provided feedback to the patient, were allowed in both groups. On postpartum day one, study subjects were asked to complete an anonymous survey about the use of the feedback device.

The study was halted after the planned interim analysis because the researchers identified a difference in the composite outcome between study and controls that was substantially above the threshold prescribed by the study design (more than 30%), Dr. Fausett said.

He presented findings from 46 women in the feedback group and 23 women in the control group. There were no differences between the groups in birth weights, mean station at the initiation of pushing, or in the maternal body mass indexes. However, the incidence of the composite adverse outcome was 9% in the feedback group, compared with 33% in the control group (P = .011). This corresponded to a 73% reduction in the composite outcome in the feedback group.

With regard to pushing time, the median pushing time was 77 minutes versus 58 minutes for control and study groups, respectively (P = .016).

The researchers did not identify any statistical differences in the incidence of cesarean delivery or intra-amniotic infections between the study and control groups. However, in the feedback group there were significant reductions in the incidences of operative vaginal deliveries (6.6% vs. 25%; P = .035), third- and fourth-degree lacerations (0% vs. 17%; P = .005), and neonatal ICU admission (0% vs. 13%; P = .015).

Among the 35 subjects that responded to a survey about the device on postpartum day one, “the majority strongly agreed that the device was comfortable, it helped them to push better, and they felt it gave them an increased sense of control during pushing,” he said.

Dr. Fausett acknowledged certain limitations of the study, including the potential for bias since it was not a blinded trial.

“We also did not address the optimal method or methods of feedback in this study,” he said. “Additional studies should evaluate and validate our findings as well as focus on fine-tuning the methods of graphic, auditory, and haptic feedback. If such feedback continues to prove effective, there are significant potential benefits on perinatal outcomes with important medical and economic consequences.”

Dr. Fausett disclosed that he is a shareholder in OB Technologies.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

EXPERT ANALYSIS AT THE PREGNANCY MEETING

SAN DIEGO – In inflammatory bowel disease, it’s active disease – not therapy – that poses the greatest risk to pregnancy.

“You want quiescent disease at the time of conception,” Dr. Chad A. Grotegut said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

Women in remission from IBD at the time of conception face a 20%-25% increased risk of flare during the course of their pregnancy, said Dr. Grotegut of the division of maternal-fetal medicine in the department of obstetrics and gynecology at Duke University, Durham, N.C. But IBD patients with active disease at the time of conception face a 50%-70% increased risk of flare.

Two confounding factors that influence a woman’s risk for flare during pregnancy are smoking cessation and the cessation of medications to control symptoms.

“Interestingly, there is no correlation of symptoms from one pregnancy to another,” said Dr. Grotegut, who added that IBD patients who become pregnant appear to be at increased risk for poor pregnancy outcomes, compared with women who don’t have the disorder.

“Many of the studies on that topic are problematic, though,” he said. “They’re typically small, there may be conflicting results, but the most consistent findings are increased rates of preterm birth, low birth weight, and cesarean delivery.”

Active disease seems to increase the risk of adverse outcomes, especially in those who have active disease at the time of conception.

“It’s unclear what drives the association with adverse outcomes,” Dr. Grotegut said. “It may be the disease itself, disease activity, the generalized inflammatory state, medications, and other factors. The most consistent outcome associated with IBD disease activity in pregnancy is preterm birth.”

He said that women with IBD who wish to become pregnant often ask him about the safety of medications they’re taking. The main classes used for IBD are corticosteroids, aminosalicylates, antibiotics, immunomodulators, and biologics.

Corticosteroids are safe and used only for flares, while aminosalicylates are often used as frontline agents for inducing remission, primarily in ulcerative colitis.

Common aminosalicylates used in IBD include sulfasalazine, balsalazide, mesalamine, and olsalazine. Sulfasalazine is a pro-drug of 5-ASA linked to sulfapyridine, which allows passage to the colon. It potentially interferes with folic acid metabolism, “so expert opinion is that women who are on sulfasalazine have increased folic supplementation 2 mg daily preconception,” he said.

Antibiotics are primarily used for flares and complications, not for maintenance. Common agents include metronidazole and ciprofloxacin, though ciprofloxacin is not typically used in pregnancy due to potential concerns for fetal arthropathies.

Immunomodulators are primarily used to maintain remission. From this category of agents Dr. Grotegut and his associates at Duke most commonly use azathioprine and 6-mercaptopurine.

“They are closely related medications [that] interfere with DNA synthesis and both are classified as FDA pregnancy category D,” he said. “There was initial concern for anomalies in transplant populations but current data suggest no increased risk. Discontinuation results in a high rate of relapse.”

Cyclosporine is used for severe flares in severe steroid-refractory ulcerative colitis. The experience with this agent is largely among transplant recipients but it does not seem to be associated with congenital anomalies, Dr. Grotegut said.

The use of methotrexate is contraindicated during pregnancy and it is advised to wait 3-6 months for conception following discontinuation. Thalidomide is also contraindicated.

As for the safety of biologic agents, the most data exist for infliximab, which crosses the placenta and is detected in cord blood, Dr. Grotegut said. Infliximab is used for both induction and maintenance of IBD remission. It is not associated with congenital anomalies, “but it theoretically may increase the risk of infection, and it may decrease responsiveness to vaccination,” he said. “Because of this, expert opinion is to avoid live vaccinations in newborns exposed to perinatal infliximab.”

There is also increasing recognition that IBD is an independent predictor of venous thromboembolism (VTE), Dr. Grotegut said.

In the nonpregnant population, all IBD patients have a threefold increased risk of VTE, compared with the general population. The relative risk rises to 15- to 20-fold during flares, he said.

VTE prophylaxis and IBD are not currently addressed in guidelines from the American College of Chest Physicians, but the Canadian Association of Gastroenterology recommends anticoagulation prophylaxis during moderate to severe outpatient flare with history of VTE, hospitalization for flare, and during hospitalization for other indications, including those in remission and those undergoing major pelvic surgery.

The Canadian Association of Gastroenterology goes on to recommend anticoagulant prophylaxis for “women with IBD who have undergone cesarean delivery while hospitalized,” Dr. Grotegut said.

“The ACCP recommends postcesarean anticoagulant prophylaxis for women with one major or at least two minor factors for VTE, but it does not specifically consider IBD a risk factor for VTE,” he said.

At the same time, he continued, the United Kingdom’s Royal College of Obstetricians and Gynaecologists includes IBD as an intermediate risk factor for consideration of anticoagulation prophylaxis.

Dr. Grotegut reported having no relevant financial disclosures.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

EXPERT ANALYSIS AT THE PREGNANCY MEETING

SAN DIEGO – In inflammatory bowel disease, it’s active disease – not therapy – that poses the greatest risk to pregnancy.

“You want quiescent disease at the time of conception,” Dr. Chad A. Grotegut said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

Women in remission from IBD at the time of conception face a 20%-25% increased risk of flare during the course of their pregnancy, said Dr. Grotegut of the division of maternal-fetal medicine in the department of obstetrics and gynecology at Duke University, Durham, N.C. But IBD patients with active disease at the time of conception face a 50%-70% increased risk of flare.

Two confounding factors that influence a woman’s risk for flare during pregnancy are smoking cessation and the cessation of medications to control symptoms.

“Interestingly, there is no correlation of symptoms from one pregnancy to another,” said Dr. Grotegut, who added that IBD patients who become pregnant appear to be at increased risk for poor pregnancy outcomes, compared with women who don’t have the disorder.

“Many of the studies on that topic are problematic, though,” he said. “They’re typically small, there may be conflicting results, but the most consistent findings are increased rates of preterm birth, low birth weight, and cesarean delivery.”

Active disease seems to increase the risk of adverse outcomes, especially in those who have active disease at the time of conception.

“It’s unclear what drives the association with adverse outcomes,” Dr. Grotegut said. “It may be the disease itself, disease activity, the generalized inflammatory state, medications, and other factors. The most consistent outcome associated with IBD disease activity in pregnancy is preterm birth.”

He said that women with IBD who wish to become pregnant often ask him about the safety of medications they’re taking. The main classes used for IBD are corticosteroids, aminosalicylates, antibiotics, immunomodulators, and biologics.

Corticosteroids are safe and used only for flares, while aminosalicylates are often used as frontline agents for inducing remission, primarily in ulcerative colitis.

Common aminosalicylates used in IBD include sulfasalazine, balsalazide, mesalamine, and olsalazine. Sulfasalazine is a pro-drug of 5-ASA linked to sulfapyridine, which allows passage to the colon. It potentially interferes with folic acid metabolism, “so expert opinion is that women who are on sulfasalazine have increased folic supplementation 2 mg daily preconception,” he said.

Antibiotics are primarily used for flares and complications, not for maintenance. Common agents include metronidazole and ciprofloxacin, though ciprofloxacin is not typically used in pregnancy due to potential concerns for fetal arthropathies.

Immunomodulators are primarily used to maintain remission. From this category of agents Dr. Grotegut and his associates at Duke most commonly use azathioprine and 6-mercaptopurine.

“They are closely related medications [that] interfere with DNA synthesis and both are classified as FDA pregnancy category D,” he said. “There was initial concern for anomalies in transplant populations but current data suggest no increased risk. Discontinuation results in a high rate of relapse.”

Cyclosporine is used for severe flares in severe steroid-refractory ulcerative colitis. The experience with this agent is largely among transplant recipients but it does not seem to be associated with congenital anomalies, Dr. Grotegut said.

The use of methotrexate is contraindicated during pregnancy and it is advised to wait 3-6 months for conception following discontinuation. Thalidomide is also contraindicated.

As for the safety of biologic agents, the most data exist for infliximab, which crosses the placenta and is detected in cord blood, Dr. Grotegut said. Infliximab is used for both induction and maintenance of IBD remission. It is not associated with congenital anomalies, “but it theoretically may increase the risk of infection, and it may decrease responsiveness to vaccination,” he said. “Because of this, expert opinion is to avoid live vaccinations in newborns exposed to perinatal infliximab.”

There is also increasing recognition that IBD is an independent predictor of venous thromboembolism (VTE), Dr. Grotegut said.

In the nonpregnant population, all IBD patients have a threefold increased risk of VTE, compared with the general population. The relative risk rises to 15- to 20-fold during flares, he said.

VTE prophylaxis and IBD are not currently addressed in guidelines from the American College of Chest Physicians, but the Canadian Association of Gastroenterology recommends anticoagulation prophylaxis during moderate to severe outpatient flare with history of VTE, hospitalization for flare, and during hospitalization for other indications, including those in remission and those undergoing major pelvic surgery.

The Canadian Association of Gastroenterology goes on to recommend anticoagulant prophylaxis for “women with IBD who have undergone cesarean delivery while hospitalized,” Dr. Grotegut said.

“The ACCP recommends postcesarean anticoagulant prophylaxis for women with one major or at least two minor factors for VTE, but it does not specifically consider IBD a risk factor for VTE,” he said.

At the same time, he continued, the United Kingdom’s Royal College of Obstetricians and Gynaecologists includes IBD as an intermediate risk factor for consideration of anticoagulation prophylaxis.

Dr. Grotegut reported having no relevant financial disclosures.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

EXPERT ANALYSIS AT THE PREGNANCY MEETING

SAN DIEGO – In inflammatory bowel disease, it’s active disease – not therapy – that poses the greatest risk to pregnancy.

“You want quiescent disease at the time of conception,” Dr. Chad A. Grotegut said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

Women in remission from IBD at the time of conception face a 20%-25% increased risk of flare during the course of their pregnancy, said Dr. Grotegut of the division of maternal-fetal medicine in the department of obstetrics and gynecology at Duke University, Durham, N.C. But IBD patients with active disease at the time of conception face a 50%-70% increased risk of flare.

Two confounding factors that influence a woman’s risk for flare during pregnancy are smoking cessation and the cessation of medications to control symptoms.

“Interestingly, there is no correlation of symptoms from one pregnancy to another,” said Dr. Grotegut, who added that IBD patients who become pregnant appear to be at increased risk for poor pregnancy outcomes, compared with women who don’t have the disorder.

“Many of the studies on that topic are problematic, though,” he said. “They’re typically small, there may be conflicting results, but the most consistent findings are increased rates of preterm birth, low birth weight, and cesarean delivery.”

Active disease seems to increase the risk of adverse outcomes, especially in those who have active disease at the time of conception.

“It’s unclear what drives the association with adverse outcomes,” Dr. Grotegut said. “It may be the disease itself, disease activity, the generalized inflammatory state, medications, and other factors. The most consistent outcome associated with IBD disease activity in pregnancy is preterm birth.”

He said that women with IBD who wish to become pregnant often ask him about the safety of medications they’re taking. The main classes used for IBD are corticosteroids, aminosalicylates, antibiotics, immunomodulators, and biologics.

Corticosteroids are safe and used only for flares, while aminosalicylates are often used as frontline agents for inducing remission, primarily in ulcerative colitis.

Common aminosalicylates used in IBD include sulfasalazine, balsalazide, mesalamine, and olsalazine. Sulfasalazine is a pro-drug of 5-ASA linked to sulfapyridine, which allows passage to the colon. It potentially interferes with folic acid metabolism, “so expert opinion is that women who are on sulfasalazine have increased folic supplementation 2 mg daily preconception,” he said.

Antibiotics are primarily used for flares and complications, not for maintenance. Common agents include metronidazole and ciprofloxacin, though ciprofloxacin is not typically used in pregnancy due to potential concerns for fetal arthropathies.

Immunomodulators are primarily used to maintain remission. From this category of agents Dr. Grotegut and his associates at Duke most commonly use azathioprine and 6-mercaptopurine.

“They are closely related medications [that] interfere with DNA synthesis and both are classified as FDA pregnancy category D,” he said. “There was initial concern for anomalies in transplant populations but current data suggest no increased risk. Discontinuation results in a high rate of relapse.”

Cyclosporine is used for severe flares in severe steroid-refractory ulcerative colitis. The experience with this agent is largely among transplant recipients but it does not seem to be associated with congenital anomalies, Dr. Grotegut said.

The use of methotrexate is contraindicated during pregnancy and it is advised to wait 3-6 months for conception following discontinuation. Thalidomide is also contraindicated.

As for the safety of biologic agents, the most data exist for infliximab, which crosses the placenta and is detected in cord blood, Dr. Grotegut said. Infliximab is used for both induction and maintenance of IBD remission. It is not associated with congenital anomalies, “but it theoretically may increase the risk of infection, and it may decrease responsiveness to vaccination,” he said. “Because of this, expert opinion is to avoid live vaccinations in newborns exposed to perinatal infliximab.”

There is also increasing recognition that IBD is an independent predictor of venous thromboembolism (VTE), Dr. Grotegut said.

In the nonpregnant population, all IBD patients have a threefold increased risk of VTE, compared with the general population. The relative risk rises to 15- to 20-fold during flares, he said.

VTE prophylaxis and IBD are not currently addressed in guidelines from the American College of Chest Physicians, but the Canadian Association of Gastroenterology recommends anticoagulation prophylaxis during moderate to severe outpatient flare with history of VTE, hospitalization for flare, and during hospitalization for other indications, including those in remission and those undergoing major pelvic surgery.

The Canadian Association of Gastroenterology goes on to recommend anticoagulant prophylaxis for “women with IBD who have undergone cesarean delivery while hospitalized,” Dr. Grotegut said.

“The ACCP recommends postcesarean anticoagulant prophylaxis for women with one major or at least two minor factors for VTE, but it does not specifically consider IBD a risk factor for VTE,” he said.

At the same time, he continued, the United Kingdom’s Royal College of Obstetricians and Gynaecologists includes IBD as an intermediate risk factor for consideration of anticoagulation prophylaxis.

Dr. Grotegut reported having no relevant financial disclosures.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – If a pregnant woman presents with a headache accompanied by nausea, think migraine unless proven otherwise.

“One in five women will have migraines, so the first thing you want to do is get a good history,” Dr. Kathleen B. Digre said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

Dr. Digre, chief of the division of headache and neuro-ophthalmology at the University of Utah, subscribes to the “five histories” of headache, starting with family history. “You want to know if this person is genetically susceptible to migraine, so you want to ask, ‘Does anybody in your family get migraine?’ If they say ‘no, but my mom had sinus headaches,’ that’s telling because most sinus headaches end up being migraine.”

The second phase involves asking about life history of headache, such as having car sickness or abdominal pains as a child.

The third phase involves asking about the history of headache attacks, such as location, frequency, length, and accompanying features, including photophobia, phonophobia, nausea, vomiting, and autonomic symptoms. “I spend some time trying to determine if they have headache with aura, which is a neurologic event, usually visual like zig-zagging lines. But it can affect speech and [result in] numbness in the hand,” Dr. Digre said. “Usually this happens before the headache starts. Then I ask about key features of migraine [such as] are you light sensitive? Sound sensitive? Do you have any nausea? As soon as a person has nausea with a headache and they don’t have a secondary headache, it’s migraine.”

The fourth phase of history-taking involves questions about medical and psychiatric history, “because there are some medical conditions that increase the incidence of headache, such as thyroid disease, anemia, anxiety, and depression,” she said.

The fifth phase involves an investigation of medication history: prescriptions, over-the-counter herbal supplements, and the use of alcohol, amphetamines, or other drugs.

Key components of the physical exam involve taking blood pressure to make sure patients are not preeclamptic, and inspecting the back of their eyes with an ophthalmoscope to rule out papilledema. The brief neurologic exam should also be normal.

Red flags in the history-taking of headache include comments such as “I’ve never had a headache before; I just had a sudden onset of the worst headache of my life.”

“You’ve got to work that one up,” Dr. Digre advised. “That could be an aneurysm or something else serious like reversible cerebral vasoconstriction syndrome.”

Other worrisome signs include unexplained worsening of the headache; changes in the typical headache; headaches that wake people up in the middle of the night; headaches that get worse with coughing, sneezing, or Valsalva maneuver; and headaches that occur in women with underlying cancer, HIV, or some kind of systemic condition or fever. “If I’m worried about a stroke or a TIA I can order an MR with diffusion, which is very sensitive to acute ischemic events,” Dr. Digre said. “A CT scan with contrast is helpful but involves ionizing radiation; I’d rather go with the MR.”

Pregnancy itself impacts women with a preexisting history of migraine. “Often it will worsen the first trimester and migraines will get better the second and third trimester, but there are people who experience worsening of symptoms throughout pregnancy,” she said. “Sometimes migraines start with the pregnancy.”

Dr. Digre noted that women with migraines tend to have a higher incidence of preterm birth and preeclampsia, increased blood pressure, and increased odds of stroke. “Having migraine, especially migraine with aura, should alert you to follow that person closely,” she said.

Dr. Digre emphasized the importance of behavioral approaches to headache and migraine prevention, such as getting ample sleep, eating regularly, and avoiding fasts. “Those are trigger factors for getting migraine,” she said. “You also need to stay hydrated and you need to exercise. People can also do biofeedback and relaxation training.”

As for medications to consider in pregnant patients with migraines, triptans are effective, but Dr. Digre cautions against the use of narcotics, which “set up more headaches and make them harder to treat.”

Antinauseants can be effective, as can tricyclic antidepressants, “especially if people aren’t sleeping well,” she said. “Small doses work. If auras continue I use baby aspirin as a preventive. It usually works well.”

Dr. Digre reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – If a pregnant woman presents with a headache accompanied by nausea, think migraine unless proven otherwise.

“One in five women will have migraines, so the first thing you want to do is get a good history,” Dr. Kathleen B. Digre said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

Dr. Digre, chief of the division of headache and neuro-ophthalmology at the University of Utah, subscribes to the “five histories” of headache, starting with family history. “You want to know if this person is genetically susceptible to migraine, so you want to ask, ‘Does anybody in your family get migraine?’ If they say ‘no, but my mom had sinus headaches,’ that’s telling because most sinus headaches end up being migraine.”

The second phase involves asking about life history of headache, such as having car sickness or abdominal pains as a child.

The third phase involves asking about the history of headache attacks, such as location, frequency, length, and accompanying features, including photophobia, phonophobia, nausea, vomiting, and autonomic symptoms. “I spend some time trying to determine if they have headache with aura, which is a neurologic event, usually visual like zig-zagging lines. But it can affect speech and [result in] numbness in the hand,” Dr. Digre said. “Usually this happens before the headache starts. Then I ask about key features of migraine [such as] are you light sensitive? Sound sensitive? Do you have any nausea? As soon as a person has nausea with a headache and they don’t have a secondary headache, it’s migraine.”

The fourth phase of history-taking involves questions about medical and psychiatric history, “because there are some medical conditions that increase the incidence of headache, such as thyroid disease, anemia, anxiety, and depression,” she said.

The fifth phase involves an investigation of medication history: prescriptions, over-the-counter herbal supplements, and the use of alcohol, amphetamines, or other drugs.

Key components of the physical exam involve taking blood pressure to make sure patients are not preeclamptic, and inspecting the back of their eyes with an ophthalmoscope to rule out papilledema. The brief neurologic exam should also be normal.

Red flags in the history-taking of headache include comments such as “I’ve never had a headache before; I just had a sudden onset of the worst headache of my life.”

“You’ve got to work that one up,” Dr. Digre advised. “That could be an aneurysm or something else serious like reversible cerebral vasoconstriction syndrome.”

Other worrisome signs include unexplained worsening of the headache; changes in the typical headache; headaches that wake people up in the middle of the night; headaches that get worse with coughing, sneezing, or Valsalva maneuver; and headaches that occur in women with underlying cancer, HIV, or some kind of systemic condition or fever. “If I’m worried about a stroke or a TIA I can order an MR with diffusion, which is very sensitive to acute ischemic events,” Dr. Digre said. “A CT scan with contrast is helpful but involves ionizing radiation; I’d rather go with the MR.”

Pregnancy itself impacts women with a preexisting history of migraine. “Often it will worsen the first trimester and migraines will get better the second and third trimester, but there are people who experience worsening of symptoms throughout pregnancy,” she said. “Sometimes migraines start with the pregnancy.”

Dr. Digre noted that women with migraines tend to have a higher incidence of preterm birth and preeclampsia, increased blood pressure, and increased odds of stroke. “Having migraine, especially migraine with aura, should alert you to follow that person closely,” she said.

Dr. Digre emphasized the importance of behavioral approaches to headache and migraine prevention, such as getting ample sleep, eating regularly, and avoiding fasts. “Those are trigger factors for getting migraine,” she said. “You also need to stay hydrated and you need to exercise. People can also do biofeedback and relaxation training.”

As for medications to consider in pregnant patients with migraines, triptans are effective, but Dr. Digre cautions against the use of narcotics, which “set up more headaches and make them harder to treat.”

Antinauseants can be effective, as can tricyclic antidepressants, “especially if people aren’t sleeping well,” she said. “Small doses work. If auras continue I use baby aspirin as a preventive. It usually works well.”

Dr. Digre reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – If a pregnant woman presents with a headache accompanied by nausea, think migraine unless proven otherwise.

“One in five women will have migraines, so the first thing you want to do is get a good history,” Dr. Kathleen B. Digre said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

Dr. Digre, chief of the division of headache and neuro-ophthalmology at the University of Utah, subscribes to the “five histories” of headache, starting with family history. “You want to know if this person is genetically susceptible to migraine, so you want to ask, ‘Does anybody in your family get migraine?’ If they say ‘no, but my mom had sinus headaches,’ that’s telling because most sinus headaches end up being migraine.”

The second phase involves asking about life history of headache, such as having car sickness or abdominal pains as a child.

The third phase involves asking about the history of headache attacks, such as location, frequency, length, and accompanying features, including photophobia, phonophobia, nausea, vomiting, and autonomic symptoms. “I spend some time trying to determine if they have headache with aura, which is a neurologic event, usually visual like zig-zagging lines. But it can affect speech and [result in] numbness in the hand,” Dr. Digre said. “Usually this happens before the headache starts. Then I ask about key features of migraine [such as] are you light sensitive? Sound sensitive? Do you have any nausea? As soon as a person has nausea with a headache and they don’t have a secondary headache, it’s migraine.”

The fourth phase of history-taking involves questions about medical and psychiatric history, “because there are some medical conditions that increase the incidence of headache, such as thyroid disease, anemia, anxiety, and depression,” she said.

The fifth phase involves an investigation of medication history: prescriptions, over-the-counter herbal supplements, and the use of alcohol, amphetamines, or other drugs.

Key components of the physical exam involve taking blood pressure to make sure patients are not preeclamptic, and inspecting the back of their eyes with an ophthalmoscope to rule out papilledema. The brief neurologic exam should also be normal.

Red flags in the history-taking of headache include comments such as “I’ve never had a headache before; I just had a sudden onset of the worst headache of my life.”

“You’ve got to work that one up,” Dr. Digre advised. “That could be an aneurysm or something else serious like reversible cerebral vasoconstriction syndrome.”

Other worrisome signs include unexplained worsening of the headache; changes in the typical headache; headaches that wake people up in the middle of the night; headaches that get worse with coughing, sneezing, or Valsalva maneuver; and headaches that occur in women with underlying cancer, HIV, or some kind of systemic condition or fever. “If I’m worried about a stroke or a TIA I can order an MR with diffusion, which is very sensitive to acute ischemic events,” Dr. Digre said. “A CT scan with contrast is helpful but involves ionizing radiation; I’d rather go with the MR.”

Pregnancy itself impacts women with a preexisting history of migraine. “Often it will worsen the first trimester and migraines will get better the second and third trimester, but there are people who experience worsening of symptoms throughout pregnancy,” she said. “Sometimes migraines start with the pregnancy.”

Dr. Digre noted that women with migraines tend to have a higher incidence of preterm birth and preeclampsia, increased blood pressure, and increased odds of stroke. “Having migraine, especially migraine with aura, should alert you to follow that person closely,” she said.

Dr. Digre emphasized the importance of behavioral approaches to headache and migraine prevention, such as getting ample sleep, eating regularly, and avoiding fasts. “Those are trigger factors for getting migraine,” she said. “You also need to stay hydrated and you need to exercise. People can also do biofeedback and relaxation training.”

As for medications to consider in pregnant patients with migraines, triptans are effective, but Dr. Digre cautions against the use of narcotics, which “set up more headaches and make them harder to treat.”

Antinauseants can be effective, as can tricyclic antidepressants, “especially if people aren’t sleeping well,” she said. “Small doses work. If auras continue I use baby aspirin as a preventive. It usually works well.”

Dr. Digre reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – The prevalence of sleep-disordered breathing during pregnancy is low, but a large prospective study links it to both hypertensive disorders of pregnancy and gestational diabetes.

In an analysis of 3,702 nulliparous women, researchers found that the prevalence of sleep-disordered breathing (SDB) was 3.3% during early pregnancy (weeks 6-15) and 8.1% in midpregnancy (weeks 22-31).

SDB in midpregnancy was significantly associated with hypertensive disorders of pregnancy, while having SDB in both early and midpregnncy was significantly associated with gestational diabetes mellitus (GDM).

While the majority of sleep-disordered breathing cases in the study were mild, “clinical experience tells us that these women are not routinely being diagnosed and treated for SDB,” Dr. Francesca L. Facco said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. “Our data demonstrate that even modest elevations of apnea-hypopnea index scores in pregnancy are associated with cardiometabolic morbidity. These findings are important because SDB, unlike many other risk factors, is potentially modifiable.”

In a study that Dr. Facco presented on behalf of the National Institute of Child Health and Human Development NuMoM2b Network, researchers at eight clinical sites in the United States set out to determine if SDB during pregnancy is a risk factor for adverse pregnancy outcomes.

Obstructive sleep apnea is the most common type of sleep disorder, said Dr. Facco of the department of obstetrics and gynecology at Magee-Women’s Hospital at the University of Pittsburgh Medical Center. In adults, an apnea-hypopnea index (AHI) of greater than or equal to 5 is the minimum criterion for establishing a sleep-disordered breathing diagnosis, while severity is classified by the number of events per hour.

“The prevalence, incidence, and severity of SDB and its impact on pregnancy remain undetermined,” Dr. Facco said. “This is despite the fact that pregnant women may be particularly disposed to SDB, given the physiologic changes associated with the gravid state, such as rapid weight gain and edema.”

Researchers recruited 3,702 women from a prospective cohort of 10,000 nulliparous women. The subjects underwent overnight in-home assessments of SDB during early pregnancy and midpregnancy. All studies were scored by a central sleep reading center.

“Currently there are no pregnancy-specific guidelines for SDB treatment and no data on which to base fetal and maternal parameters for treatment,” Dr. Facco noted. “Given the clinical equipoise that surrounds the issue, all participants and care providers were blinded to the sleep study results unless a study was identified as an urgent alert study.”

The primary outcome measures were hypertensive disorders of pregnancy and gestational diabetes. Hypertensive disorders included mild, severe, or superimposed preeclampsia, eclampsia, and gestational hypertension diagnosed in the antepartum period. The Embletta Portable Diagnostic System was used to perform the home sleep test.

Data were analyzed using multivariable logistic regression adjusted for age, body mass index, and the presence of chronic hypertension in early pregnancy analyses, as well as weight gain between visits for the midpregnancy analyses. All of the women included in the study had singleton pregnancies.

The researchers obtained complete data from 3,261 women in early pregnancy and from 2,511 women in midpregnancy. Among the 3,132 women with hypertension data, there was a 12.4% incidence of hypertensive disorders at baseline, with a 5.5% incidence of preeclampsia. Among 3,076 women with gestational diabetes mellitus data (cases of pregestational diabetes were excluded), the rate of GDM was 3.9%.

The mean age of study participants was 27 years; 60% were non-Hispanic white, 18% were Hispanic, 14% were non-Hispanic black, and the remainder were from other ethnic groups. At baseline, about half (49%) were normal weight, 25% were overweight, 23% were obese or morbidly obese, and the remainder were underweight.

SDB in midpregnancy was significantly associated with hypertensive disorders of pregnancy (an adjusted odds ratio of 1.62; P = .0156). A similar trend was seen in early pregnancy, but the association did not reach statistical significance in adjusted analyses (aOR, 1.44; P = .1434), according to Dr. Facco.

SDB in both early and midpregnancy was significantly associated with GDM (aOR, 3.62; P < .0001 and aOR, 2.79; P = .0002, respectively).

The study was funded by the NICHD. Dr. Facco reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – The prevalence of sleep-disordered breathing during pregnancy is low, but a large prospective study links it to both hypertensive disorders of pregnancy and gestational diabetes.

In an analysis of 3,702 nulliparous women, researchers found that the prevalence of sleep-disordered breathing (SDB) was 3.3% during early pregnancy (weeks 6-15) and 8.1% in midpregnancy (weeks 22-31).

SDB in midpregnancy was significantly associated with hypertensive disorders of pregnancy, while having SDB in both early and midpregnncy was significantly associated with gestational diabetes mellitus (GDM).

While the majority of sleep-disordered breathing cases in the study were mild, “clinical experience tells us that these women are not routinely being diagnosed and treated for SDB,” Dr. Francesca L. Facco said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. “Our data demonstrate that even modest elevations of apnea-hypopnea index scores in pregnancy are associated with cardiometabolic morbidity. These findings are important because SDB, unlike many other risk factors, is potentially modifiable.”

In a study that Dr. Facco presented on behalf of the National Institute of Child Health and Human Development NuMoM2b Network, researchers at eight clinical sites in the United States set out to determine if SDB during pregnancy is a risk factor for adverse pregnancy outcomes.

Obstructive sleep apnea is the most common type of sleep disorder, said Dr. Facco of the department of obstetrics and gynecology at Magee-Women’s Hospital at the University of Pittsburgh Medical Center. In adults, an apnea-hypopnea index (AHI) of greater than or equal to 5 is the minimum criterion for establishing a sleep-disordered breathing diagnosis, while severity is classified by the number of events per hour.

“The prevalence, incidence, and severity of SDB and its impact on pregnancy remain undetermined,” Dr. Facco said. “This is despite the fact that pregnant women may be particularly disposed to SDB, given the physiologic changes associated with the gravid state, such as rapid weight gain and edema.”

Researchers recruited 3,702 women from a prospective cohort of 10,000 nulliparous women. The subjects underwent overnight in-home assessments of SDB during early pregnancy and midpregnancy. All studies were scored by a central sleep reading center.

“Currently there are no pregnancy-specific guidelines for SDB treatment and no data on which to base fetal and maternal parameters for treatment,” Dr. Facco noted. “Given the clinical equipoise that surrounds the issue, all participants and care providers were blinded to the sleep study results unless a study was identified as an urgent alert study.”

The primary outcome measures were hypertensive disorders of pregnancy and gestational diabetes. Hypertensive disorders included mild, severe, or superimposed preeclampsia, eclampsia, and gestational hypertension diagnosed in the antepartum period. The Embletta Portable Diagnostic System was used to perform the home sleep test.

Data were analyzed using multivariable logistic regression adjusted for age, body mass index, and the presence of chronic hypertension in early pregnancy analyses, as well as weight gain between visits for the midpregnancy analyses. All of the women included in the study had singleton pregnancies.

The researchers obtained complete data from 3,261 women in early pregnancy and from 2,511 women in midpregnancy. Among the 3,132 women with hypertension data, there was a 12.4% incidence of hypertensive disorders at baseline, with a 5.5% incidence of preeclampsia. Among 3,076 women with gestational diabetes mellitus data (cases of pregestational diabetes were excluded), the rate of GDM was 3.9%.

The mean age of study participants was 27 years; 60% were non-Hispanic white, 18% were Hispanic, 14% were non-Hispanic black, and the remainder were from other ethnic groups. At baseline, about half (49%) were normal weight, 25% were overweight, 23% were obese or morbidly obese, and the remainder were underweight.

SDB in midpregnancy was significantly associated with hypertensive disorders of pregnancy (an adjusted odds ratio of 1.62; P = .0156). A similar trend was seen in early pregnancy, but the association did not reach statistical significance in adjusted analyses (aOR, 1.44; P = .1434), according to Dr. Facco.

SDB in both early and midpregnancy was significantly associated with GDM (aOR, 3.62; P < .0001 and aOR, 2.79; P = .0002, respectively).

The study was funded by the NICHD. Dr. Facco reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk

SAN DIEGO – The prevalence of sleep-disordered breathing during pregnancy is low, but a large prospective study links it to both hypertensive disorders of pregnancy and gestational diabetes.

In an analysis of 3,702 nulliparous women, researchers found that the prevalence of sleep-disordered breathing (SDB) was 3.3% during early pregnancy (weeks 6-15) and 8.1% in midpregnancy (weeks 22-31).

SDB in midpregnancy was significantly associated with hypertensive disorders of pregnancy, while having SDB in both early and midpregnncy was significantly associated with gestational diabetes mellitus (GDM).

While the majority of sleep-disordered breathing cases in the study were mild, “clinical experience tells us that these women are not routinely being diagnosed and treated for SDB,” Dr. Francesca L. Facco said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. “Our data demonstrate that even modest elevations of apnea-hypopnea index scores in pregnancy are associated with cardiometabolic morbidity. These findings are important because SDB, unlike many other risk factors, is potentially modifiable.”

In a study that Dr. Facco presented on behalf of the National Institute of Child Health and Human Development NuMoM2b Network, researchers at eight clinical sites in the United States set out to determine if SDB during pregnancy is a risk factor for adverse pregnancy outcomes.

Obstructive sleep apnea is the most common type of sleep disorder, said Dr. Facco of the department of obstetrics and gynecology at Magee-Women’s Hospital at the University of Pittsburgh Medical Center. In adults, an apnea-hypopnea index (AHI) of greater than or equal to 5 is the minimum criterion for establishing a sleep-disordered breathing diagnosis, while severity is classified by the number of events per hour.

“The prevalence, incidence, and severity of SDB and its impact on pregnancy remain undetermined,” Dr. Facco said. “This is despite the fact that pregnant women may be particularly disposed to SDB, given the physiologic changes associated with the gravid state, such as rapid weight gain and edema.”

Researchers recruited 3,702 women from a prospective cohort of 10,000 nulliparous women. The subjects underwent overnight in-home assessments of SDB during early pregnancy and midpregnancy. All studies were scored by a central sleep reading center.

“Currently there are no pregnancy-specific guidelines for SDB treatment and no data on which to base fetal and maternal parameters for treatment,” Dr. Facco noted. “Given the clinical equipoise that surrounds the issue, all participants and care providers were blinded to the sleep study results unless a study was identified as an urgent alert study.”

The primary outcome measures were hypertensive disorders of pregnancy and gestational diabetes. Hypertensive disorders included mild, severe, or superimposed preeclampsia, eclampsia, and gestational hypertension diagnosed in the antepartum period. The Embletta Portable Diagnostic System was used to perform the home sleep test.

Data were analyzed using multivariable logistic regression adjusted for age, body mass index, and the presence of chronic hypertension in early pregnancy analyses, as well as weight gain between visits for the midpregnancy analyses. All of the women included in the study had singleton pregnancies.

The researchers obtained complete data from 3,261 women in early pregnancy and from 2,511 women in midpregnancy. Among the 3,132 women with hypertension data, there was a 12.4% incidence of hypertensive disorders at baseline, with a 5.5% incidence of preeclampsia. Among 3,076 women with gestational diabetes mellitus data (cases of pregestational diabetes were excluded), the rate of GDM was 3.9%.

The mean age of study participants was 27 years; 60% were non-Hispanic white, 18% were Hispanic, 14% were non-Hispanic black, and the remainder were from other ethnic groups. At baseline, about half (49%) were normal weight, 25% were overweight, 23% were obese or morbidly obese, and the remainder were underweight.

SDB in midpregnancy was significantly associated with hypertensive disorders of pregnancy (an adjusted odds ratio of 1.62; P = .0156). A similar trend was seen in early pregnancy, but the association did not reach statistical significance in adjusted analyses (aOR, 1.44; P = .1434), according to Dr. Facco.

SDB in both early and midpregnancy was significantly associated with GDM (aOR, 3.62; P < .0001 and aOR, 2.79; P = .0002, respectively).

The study was funded by the NICHD. Dr. Facco reported having no relevant financial conflicts.

dbrunk@frontlinemedcom.com

On Twitter @dougbrunk