Doug Brunk

SAN DIEGO — The presence of obstructive sleep apnea independently increases the risk of death after acute ischemic stroke, results from a single-center study showed.

The finding underscores the importance of screening for obstructive sleep apnea (OSA) as a risk factor for the development of stroke, since effective treatment for the condition is available, researchers led by Dr. Meghna P. Mansukhani reported during a poster session at the International Stroke Conference.

The finding also confirms results of a 10-year Swedish study that demonstrated an increase in mortality in stroke patients diagnosed with OSA after the stroke by polysomnography (Arch. Intern. Med. 2008;168:297–301).

For the study, Dr. Mansukhani and her colleagues in the departments of family medicine, emergency medicine, and cardiovascular diseases at the Mayo Clinic, Rochester, Minn., studied 174 consecutive patients who presented with acute ischemic stroke during June 2007–March 2008. The patients were asked to complete the Berlin Sleep Questionnaire, a simple instrument that has been shown to have good sensitivity and specificity as a screening test for OSA in the primary care setting.

The mean age of the patients was 72 years, and 55% were female.

The three most common stroke subtypes were cardioembolic (33%), large vessel disease (27%), and undetermined etiology (27%).

A total of 105 patients (61%) had a high risk of sleep apnea on the basis of their responses to the Berlin Sleep Questionnaire. Of these, seven had a previous diagnosis of OSA, and there was no difference by gender or age in the prevalence of high or low risk for OSA.

Of the 174 patients studied, 11 died (6%). Those who had a previous diagnosis of OSA were 5 times more likely to die within the first month following the stroke, compared with those who did not have a diagnosis of OSA.

“We were trying to establish whether there was an increase in mortality in patients at risk of or with previous diagnosis of OSA in our cohort, and indeed, the study did confirm this,” Dr. Mansukhani said in an interview after the conference, which was sponsored by the American Heart Association.

Limitations of the study, she added, included the fact that “there could be potential confounders such as diabetes mellitus that were not accounted for and that may have biased the results.”

Dr. Mansukhani said she had no conflicts to disclose.

'There was an increase in mortality in patients at risk of or with previous diagnosis of OSA in our cohort.' DR. MANSUKHANI

SAN DIEGO — The presence of obstructive sleep apnea independently increases the risk of death after acute ischemic stroke, results from a single-center study showed.

The finding underscores the importance of screening for obstructive sleep apnea (OSA) as a risk factor for the development of stroke, since effective treatment for the condition is available, researchers led by Dr. Meghna P. Mansukhani reported during a poster session at the International Stroke Conference.

The finding also confirms results of a 10-year Swedish study that demonstrated an increase in mortality in stroke patients diagnosed with OSA after the stroke by polysomnography (Arch. Intern. Med. 2008;168:297–301).

For the study, Dr. Mansukhani and her colleagues in the departments of family medicine, emergency medicine, and cardiovascular diseases at the Mayo Clinic, Rochester, Minn., studied 174 consecutive patients who presented with acute ischemic stroke during June 2007–March 2008. The patients were asked to complete the Berlin Sleep Questionnaire, a simple instrument that has been shown to have good sensitivity and specificity as a screening test for OSA in the primary care setting.

The mean age of the patients was 72 years, and 55% were female.

The three most common stroke subtypes were cardioembolic (33%), large vessel disease (27%), and undetermined etiology (27%).

A total of 105 patients (61%) had a high risk of sleep apnea on the basis of their responses to the Berlin Sleep Questionnaire. Of these, seven had a previous diagnosis of OSA, and there was no difference by gender or age in the prevalence of high or low risk for OSA.

Of the 174 patients studied, 11 died (6%). Those who had a previous diagnosis of OSA were 5 times more likely to die within the first month following the stroke, compared with those who did not have a diagnosis of OSA.

“We were trying to establish whether there was an increase in mortality in patients at risk of or with previous diagnosis of OSA in our cohort, and indeed, the study did confirm this,” Dr. Mansukhani said in an interview after the conference, which was sponsored by the American Heart Association.

Limitations of the study, she added, included the fact that “there could be potential confounders such as diabetes mellitus that were not accounted for and that may have biased the results.”

Dr. Mansukhani said she had no conflicts to disclose.

'There was an increase in mortality in patients at risk of or with previous diagnosis of OSA in our cohort.' DR. MANSUKHANI

SAN DIEGO — The presence of obstructive sleep apnea independently increases the risk of death after acute ischemic stroke, results from a single-center study showed.

The finding underscores the importance of screening for obstructive sleep apnea (OSA) as a risk factor for the development of stroke, since effective treatment for the condition is available, researchers led by Dr. Meghna P. Mansukhani reported during a poster session at the International Stroke Conference.

The finding also confirms results of a 10-year Swedish study that demonstrated an increase in mortality in stroke patients diagnosed with OSA after the stroke by polysomnography (Arch. Intern. Med. 2008;168:297–301).

For the study, Dr. Mansukhani and her colleagues in the departments of family medicine, emergency medicine, and cardiovascular diseases at the Mayo Clinic, Rochester, Minn., studied 174 consecutive patients who presented with acute ischemic stroke during June 2007–March 2008. The patients were asked to complete the Berlin Sleep Questionnaire, a simple instrument that has been shown to have good sensitivity and specificity as a screening test for OSA in the primary care setting.

The mean age of the patients was 72 years, and 55% were female.

The three most common stroke subtypes were cardioembolic (33%), large vessel disease (27%), and undetermined etiology (27%).

A total of 105 patients (61%) had a high risk of sleep apnea on the basis of their responses to the Berlin Sleep Questionnaire. Of these, seven had a previous diagnosis of OSA, and there was no difference by gender or age in the prevalence of high or low risk for OSA.

Of the 174 patients studied, 11 died (6%). Those who had a previous diagnosis of OSA were 5 times more likely to die within the first month following the stroke, compared with those who did not have a diagnosis of OSA.

“We were trying to establish whether there was an increase in mortality in patients at risk of or with previous diagnosis of OSA in our cohort, and indeed, the study did confirm this,” Dr. Mansukhani said in an interview after the conference, which was sponsored by the American Heart Association.

Limitations of the study, she added, included the fact that “there could be potential confounders such as diabetes mellitus that were not accounted for and that may have biased the results.”

Dr. Mansukhani said she had no conflicts to disclose.

'There was an increase in mortality in patients at risk of or with previous diagnosis of OSA in our cohort.' DR. MANSUKHANI

SAN DIEGO — Coffee consumption by adults is associated with a reduced prevalence of stroke, and the more cups that are guzzled per day, the greater the protective effect, results from a large study show.

In an interview at the International Stroke Conference, lead study investigator Dr. David S. Liebeskind cautioned that further studies are required to pursue the underlying beneficial effects of coffee on stroke before specific recommendations about consumption can be made.

“Is this a green light to go out and start drinking coffee? I don't think so,” said Dr. Liebeskind, associate neurology director at the University of California, Los Angeles, Stroke Center. “There's a danger in the fact that some people may be very sensitive to caffeine, and the caffeine content varying amongst coffee products is very different.

“Coffee consumption can increase your blood pressure in the short term. Any increase in blood pressure is seen as a risk factor for stroke, but it's the long-term or sustained high blood pressure on a daily basis that really drives that risk.”

Presented during a poster session at the conference, the study used data from the Third National Health and Nutrition Examination Survey (NHANES III) to examine the relationship between coffee consumption and stroke in 19,994 respondents. They used multivariate logistic regression to relate the amount of coffee use reported by respondents while controlling for other vascular risk factors. They also analyzed the amount of caffeine use with respect to self-reported transient ischemic attack (TIA) or stroke symptoms.

The median age of the survey respondents was 44 years, 53% were female, and the median self-reported coffee consumption was 1 cup per day, with a range of 0–20 cups.

The researchers reported that 644 respondents (3.2%) had been told by their physician that they had suffered a stroke.

Noncoffee drinkers had higher rates of stroke, compared with those who reported regular coffee consumption, and there was a dose-related response to the protective effect. For example, the prevalence of stroke was 5% among those who reported consuming 1–2 cups per day, compared with 3.5% among those consuming 3–4 cups per day and 2.9% among those consuming more than 6 cups per day.

Coffee consumption was higher among men, compared with women; higher among those aged 50 and older, compared with their younger counterparts; and highest among whites, followed by blacks, Hispanics, and respondents from other ethnic groups.

“Interestingly, cardiac disease, diabetes, and hypertension were all less frequent with increasing number of cups of coffee per day,” the researchers noted in their poster. “Other habits such as smoking were more frequent in heavy coffee drinkers. TIA or stroke symptoms were far less common in subjects reporting greater than six cups of coffee intake per day.”

Dr. Liebeskind, who is known primarily for his research work in stroke imaging, said the mechanism of action behind coffee's possible impact on the reduced prevalence of stroke remains unclear. “Perhaps there's a synergistic effect between the caffeine and another component,” he said. “I don't see coffee as a drug for stroke, yet it remains impressive that heavy coffee drinkers have lower stroke prevalence. Whenever we estimate risk or tailor preventive strategies to avert future strokes, we need to identify influential variables.”

The conference was sponsored by the American Heart Association. Dr. Liebeskind had no conflicts to disclose.

'I don't see coffee as a drug for stroke, [but] … heavy coffee drinkers have lower stroke prevalence.' DR. LIEBESKIND

SAN DIEGO — Coffee consumption by adults is associated with a reduced prevalence of stroke, and the more cups that are guzzled per day, the greater the protective effect, results from a large study show.

In an interview at the International Stroke Conference, lead study investigator Dr. David S. Liebeskind cautioned that further studies are required to pursue the underlying beneficial effects of coffee on stroke before specific recommendations about consumption can be made.

“Is this a green light to go out and start drinking coffee? I don't think so,” said Dr. Liebeskind, associate neurology director at the University of California, Los Angeles, Stroke Center. “There's a danger in the fact that some people may be very sensitive to caffeine, and the caffeine content varying amongst coffee products is very different.

“Coffee consumption can increase your blood pressure in the short term. Any increase in blood pressure is seen as a risk factor for stroke, but it's the long-term or sustained high blood pressure on a daily basis that really drives that risk.”

Presented during a poster session at the conference, the study used data from the Third National Health and Nutrition Examination Survey (NHANES III) to examine the relationship between coffee consumption and stroke in 19,994 respondents. They used multivariate logistic regression to relate the amount of coffee use reported by respondents while controlling for other vascular risk factors. They also analyzed the amount of caffeine use with respect to self-reported transient ischemic attack (TIA) or stroke symptoms.

The median age of the survey respondents was 44 years, 53% were female, and the median self-reported coffee consumption was 1 cup per day, with a range of 0–20 cups.

The researchers reported that 644 respondents (3.2%) had been told by their physician that they had suffered a stroke.

Noncoffee drinkers had higher rates of stroke, compared with those who reported regular coffee consumption, and there was a dose-related response to the protective effect. For example, the prevalence of stroke was 5% among those who reported consuming 1–2 cups per day, compared with 3.5% among those consuming 3–4 cups per day and 2.9% among those consuming more than 6 cups per day.

Coffee consumption was higher among men, compared with women; higher among those aged 50 and older, compared with their younger counterparts; and highest among whites, followed by blacks, Hispanics, and respondents from other ethnic groups.

“Interestingly, cardiac disease, diabetes, and hypertension were all less frequent with increasing number of cups of coffee per day,” the researchers noted in their poster. “Other habits such as smoking were more frequent in heavy coffee drinkers. TIA or stroke symptoms were far less common in subjects reporting greater than six cups of coffee intake per day.”

Dr. Liebeskind, who is known primarily for his research work in stroke imaging, said the mechanism of action behind coffee's possible impact on the reduced prevalence of stroke remains unclear. “Perhaps there's a synergistic effect between the caffeine and another component,” he said. “I don't see coffee as a drug for stroke, yet it remains impressive that heavy coffee drinkers have lower stroke prevalence. Whenever we estimate risk or tailor preventive strategies to avert future strokes, we need to identify influential variables.”

The conference was sponsored by the American Heart Association. Dr. Liebeskind had no conflicts to disclose.

'I don't see coffee as a drug for stroke, [but] … heavy coffee drinkers have lower stroke prevalence.' DR. LIEBESKIND

SAN DIEGO — Coffee consumption by adults is associated with a reduced prevalence of stroke, and the more cups that are guzzled per day, the greater the protective effect, results from a large study show.

In an interview at the International Stroke Conference, lead study investigator Dr. David S. Liebeskind cautioned that further studies are required to pursue the underlying beneficial effects of coffee on stroke before specific recommendations about consumption can be made.

“Is this a green light to go out and start drinking coffee? I don't think so,” said Dr. Liebeskind, associate neurology director at the University of California, Los Angeles, Stroke Center. “There's a danger in the fact that some people may be very sensitive to caffeine, and the caffeine content varying amongst coffee products is very different.

“Coffee consumption can increase your blood pressure in the short term. Any increase in blood pressure is seen as a risk factor for stroke, but it's the long-term or sustained high blood pressure on a daily basis that really drives that risk.”

Presented during a poster session at the conference, the study used data from the Third National Health and Nutrition Examination Survey (NHANES III) to examine the relationship between coffee consumption and stroke in 19,994 respondents. They used multivariate logistic regression to relate the amount of coffee use reported by respondents while controlling for other vascular risk factors. They also analyzed the amount of caffeine use with respect to self-reported transient ischemic attack (TIA) or stroke symptoms.

The median age of the survey respondents was 44 years, 53% were female, and the median self-reported coffee consumption was 1 cup per day, with a range of 0–20 cups.

The researchers reported that 644 respondents (3.2%) had been told by their physician that they had suffered a stroke.

Noncoffee drinkers had higher rates of stroke, compared with those who reported regular coffee consumption, and there was a dose-related response to the protective effect. For example, the prevalence of stroke was 5% among those who reported consuming 1–2 cups per day, compared with 3.5% among those consuming 3–4 cups per day and 2.9% among those consuming more than 6 cups per day.

Coffee consumption was higher among men, compared with women; higher among those aged 50 and older, compared with their younger counterparts; and highest among whites, followed by blacks, Hispanics, and respondents from other ethnic groups.

“Interestingly, cardiac disease, diabetes, and hypertension were all less frequent with increasing number of cups of coffee per day,” the researchers noted in their poster. “Other habits such as smoking were more frequent in heavy coffee drinkers. TIA or stroke symptoms were far less common in subjects reporting greater than six cups of coffee intake per day.”

Dr. Liebeskind, who is known primarily for his research work in stroke imaging, said the mechanism of action behind coffee's possible impact on the reduced prevalence of stroke remains unclear. “Perhaps there's a synergistic effect between the caffeine and another component,” he said. “I don't see coffee as a drug for stroke, yet it remains impressive that heavy coffee drinkers have lower stroke prevalence. Whenever we estimate risk or tailor preventive strategies to avert future strokes, we need to identify influential variables.”

The conference was sponsored by the American Heart Association. Dr. Liebeskind had no conflicts to disclose.

'I don't see coffee as a drug for stroke, [but] … heavy coffee drinkers have lower stroke prevalence.' DR. LIEBESKIND

As a new physician in 1991, Dr. Jay Winner was troubled by the number of patients who complained of telltale stress symptoms such as severe headaches, elevated blood pressure, and stomach cramps.

"I could have done what I'd seen many other physicians do: Say, 'Here's Fioricet for your headache,' or 'Here's some Ativan; I'll see you back in 3 months,' and just ignore that they talked about stress, but I would not be doing my patients any good," recalled Dr. Winner, who practices family medicine in Santa Barbara, Calif. "The standard of care was woefully inadequate to address patients' real needs."

He found that a 15-minute office visit left little time to teach his patients stress-management skills, so in his spare time, he began to teach stress-management classes at Sansum Clinic in Santa Barbara.

"I thought it was important to teach people skills that could last a lifetime, that could help them deal with a whole variety of problems, and help with a variety of their physical ailments," Dr. Winner said.

Topics included how to reduce anger and frustration, how to get a better night's sleep, practical ways to achieve relaxation, and how to squeeze the most enjoyment out of every day.

He assembled his class notes and other material into the 2008 book, "Take the Stress Out of Your Life: A Medical Doctor's Proven Program to Minimize Stress and Maximize Health" (Cambridge, Mass.: Da Capo Press, 2008), which includes two CDs of stress-reduction exercises.

Stress is no stranger to physicians, with ready triggers such as tight patient schedules, reimbursement hassles with insurance companies, and administrative paperwork that never seems to end. Physicians are "seeing scores of different people in a day, all of whom have their different personalities and idiosyncrasies," Dr. Winner added. "Dealing with those different personalities can be stressful. Then there are sometimes stressful things at home."

He discussed three stress-management skills for his physician peers:

▸ Diaphragmatic breathing. Breathe through your nose and focus your attention on your abdomen, expanding it with the in breath, and breathing out through your nose or mouth. "As you do that you'll likely have a thought, such as 'if only this or that were different,' " said Dr. Winner, founder and director of Sansum Clinic's stress-management program. "Just notice it as a thought and let it float by, like a cloud floating overhead, and tune your full attention to the breath."

This ability to put aside your thoughts and observe them in a nonjudgmental way puts a different face on the stress trigger, he said; you start to view the trigger as no big deal.

For example, when you are scheduled to see a patient who has been difficult to deal with in the past, instead of dreading the appointment, "take 20 seconds before going into the exam room and focus on your breath; let go of the thoughts of how you want them to be different, and then be really present with that person," he explained. "Let go of all thoughts of the other patients and be fully with that person."

A 6-minute mini-meditation exercise that includes diaphragmatic breathing can be heard on Dr. Winner's Web site at www.stressremedy.com/relax

▸ Reframing. This involves placing a situation into a new context. For example, if you're running late in the office and a patient is rude to you for the extra waiting time, "Your temptation is to get angry," Dr. Winner said. "Instead, you can think, 'Hey, what's going on with that person?' When people are rude, they are usually suffering in some way. If people are always rude, they often have chronic depression, pain, or anxiety disorders. Maybe this is the case with your patient."

In his book, Dr. Winner noted that this principle can be applied to seeming mundane aspects of life as well, such as finding yourself in a long line at the grocery checkout counter. Consider that "free time," he writes, a rarity for many physicians.

He would reframe the wait at the grocery store "as an opportunity to focus on my breathing, reflect on my plans, maybe list those aspects of my life for which I am grateful. I might even chat with another person in line or indulge in the opportunity to flip through a magazine I wouldn't normally buy."

▸ Mindfulness. "Most of us have had the thought 'I'm overwhelmed' at one time or another," Dr. Winner writes in another passage from the book. "Mindfulness teaches us to let that thought go and do what's next."

He went on to describe his first year of when at times "I might get called to see three people at once: Mr. A with shortness of breath, Mrs. B with chest pain, and Mr. C with leg pain. Rather than getting increasingly stressed, I let go of the thought 'I'm overwhelmed' and focused my attention on taking care of one person at a time. I might ask Dr. Y to see Mr. A; then I would see Mrs. B, and then Mr. C. Alternatively, I might quickly check one patient to see that he was stable, then go examine the next patient, and then return to the first. The point is to do what is next and focus on one thing at a time."

He likened mindfulness to a basketball player being "in the zone," or being in the moment. "Instead of thinking, 'I don't want to do all of this dictation at the end of the day; what a pain,' let go of that thought," he advised. "Dictate one word at a time with the energy of an actor on stage. Get into what you're doing at the moment. That's mindfulness."

Diaphragmatic breathing, reframing, and mindfulness "are skills that can be learned, just like the skill of riding a bike," Dr. Winner offered.

"Once you get the hang of it, it's something that you can have the rest of your life. The first step is to notice your thoughts and not necessarily believe all of them. That way you can let them go, reframe them, or dispute them if they're irrational," he added.

He underscored the importance of embracing life's present moments instead of fretting about yesterday or tomorrow. "Unfortunately, a lot of people try to rush through life as opposed to enjoying each of the moments," Dr. Winner said.

"When you start thinking about things that aren't going right, take a moment to list the things that you're grateful for, including your family, your friends, and having a job where you have the opportunity to help people and think about science," he added.

Dr. Jay Winner, pictured with his book, began teaching a stress-management class after seeing patients under stress. Courtesy Dr. Jay Winner

As a new physician in 1991, Dr. Jay Winner was troubled by the number of patients who complained of telltale stress symptoms such as severe headaches, elevated blood pressure, and stomach cramps.

"I could have done what I'd seen many other physicians do: Say, 'Here's Fioricet for your headache,' or 'Here's some Ativan; I'll see you back in 3 months,' and just ignore that they talked about stress, but I would not be doing my patients any good," recalled Dr. Winner, who practices family medicine in Santa Barbara, Calif. "The standard of care was woefully inadequate to address patients' real needs."

He found that a 15-minute office visit left little time to teach his patients stress-management skills, so in his spare time, he began to teach stress-management classes at Sansum Clinic in Santa Barbara.

"I thought it was important to teach people skills that could last a lifetime, that could help them deal with a whole variety of problems, and help with a variety of their physical ailments," Dr. Winner said.

Topics included how to reduce anger and frustration, how to get a better night's sleep, practical ways to achieve relaxation, and how to squeeze the most enjoyment out of every day.

He assembled his class notes and other material into the 2008 book, "Take the Stress Out of Your Life: A Medical Doctor's Proven Program to Minimize Stress and Maximize Health" (Cambridge, Mass.: Da Capo Press, 2008), which includes two CDs of stress-reduction exercises.

Stress is no stranger to physicians, with ready triggers such as tight patient schedules, reimbursement hassles with insurance companies, and administrative paperwork that never seems to end. Physicians are "seeing scores of different people in a day, all of whom have their different personalities and idiosyncrasies," Dr. Winner added. "Dealing with those different personalities can be stressful. Then there are sometimes stressful things at home."

He discussed three stress-management skills for his physician peers:

▸ Diaphragmatic breathing. Breathe through your nose and focus your attention on your abdomen, expanding it with the in breath, and breathing out through your nose or mouth. "As you do that you'll likely have a thought, such as 'if only this or that were different,' " said Dr. Winner, founder and director of Sansum Clinic's stress-management program. "Just notice it as a thought and let it float by, like a cloud floating overhead, and tune your full attention to the breath."

This ability to put aside your thoughts and observe them in a nonjudgmental way puts a different face on the stress trigger, he said; you start to view the trigger as no big deal.

For example, when you are scheduled to see a patient who has been difficult to deal with in the past, instead of dreading the appointment, "take 20 seconds before going into the exam room and focus on your breath; let go of the thoughts of how you want them to be different, and then be really present with that person," he explained. "Let go of all thoughts of the other patients and be fully with that person."

A 6-minute mini-meditation exercise that includes diaphragmatic breathing can be heard on Dr. Winner's Web site at www.stressremedy.com/relax

▸ Reframing. This involves placing a situation into a new context. For example, if you're running late in the office and a patient is rude to you for the extra waiting time, "Your temptation is to get angry," Dr. Winner said. "Instead, you can think, 'Hey, what's going on with that person?' When people are rude, they are usually suffering in some way. If people are always rude, they often have chronic depression, pain, or anxiety disorders. Maybe this is the case with your patient."

In his book, Dr. Winner noted that this principle can be applied to seeming mundane aspects of life as well, such as finding yourself in a long line at the grocery checkout counter. Consider that "free time," he writes, a rarity for many physicians.

He would reframe the wait at the grocery store "as an opportunity to focus on my breathing, reflect on my plans, maybe list those aspects of my life for which I am grateful. I might even chat with another person in line or indulge in the opportunity to flip through a magazine I wouldn't normally buy."

▸ Mindfulness. "Most of us have had the thought 'I'm overwhelmed' at one time or another," Dr. Winner writes in another passage from the book. "Mindfulness teaches us to let that thought go and do what's next."

He went on to describe his first year of when at times "I might get called to see three people at once: Mr. A with shortness of breath, Mrs. B with chest pain, and Mr. C with leg pain. Rather than getting increasingly stressed, I let go of the thought 'I'm overwhelmed' and focused my attention on taking care of one person at a time. I might ask Dr. Y to see Mr. A; then I would see Mrs. B, and then Mr. C. Alternatively, I might quickly check one patient to see that he was stable, then go examine the next patient, and then return to the first. The point is to do what is next and focus on one thing at a time."

He likened mindfulness to a basketball player being "in the zone," or being in the moment. "Instead of thinking, 'I don't want to do all of this dictation at the end of the day; what a pain,' let go of that thought," he advised. "Dictate one word at a time with the energy of an actor on stage. Get into what you're doing at the moment. That's mindfulness."

Diaphragmatic breathing, reframing, and mindfulness "are skills that can be learned, just like the skill of riding a bike," Dr. Winner offered.

"Once you get the hang of it, it's something that you can have the rest of your life. The first step is to notice your thoughts and not necessarily believe all of them. That way you can let them go, reframe them, or dispute them if they're irrational," he added.

He underscored the importance of embracing life's present moments instead of fretting about yesterday or tomorrow. "Unfortunately, a lot of people try to rush through life as opposed to enjoying each of the moments," Dr. Winner said.

"When you start thinking about things that aren't going right, take a moment to list the things that you're grateful for, including your family, your friends, and having a job where you have the opportunity to help people and think about science," he added.

Dr. Jay Winner, pictured with his book, began teaching a stress-management class after seeing patients under stress. Courtesy Dr. Jay Winner

As a new physician in 1991, Dr. Jay Winner was troubled by the number of patients who complained of telltale stress symptoms such as severe headaches, elevated blood pressure, and stomach cramps.

"I could have done what I'd seen many other physicians do: Say, 'Here's Fioricet for your headache,' or 'Here's some Ativan; I'll see you back in 3 months,' and just ignore that they talked about stress, but I would not be doing my patients any good," recalled Dr. Winner, who practices family medicine in Santa Barbara, Calif. "The standard of care was woefully inadequate to address patients' real needs."

He found that a 15-minute office visit left little time to teach his patients stress-management skills, so in his spare time, he began to teach stress-management classes at Sansum Clinic in Santa Barbara.

"I thought it was important to teach people skills that could last a lifetime, that could help them deal with a whole variety of problems, and help with a variety of their physical ailments," Dr. Winner said.

Topics included how to reduce anger and frustration, how to get a better night's sleep, practical ways to achieve relaxation, and how to squeeze the most enjoyment out of every day.

He assembled his class notes and other material into the 2008 book, "Take the Stress Out of Your Life: A Medical Doctor's Proven Program to Minimize Stress and Maximize Health" (Cambridge, Mass.: Da Capo Press, 2008), which includes two CDs of stress-reduction exercises.

Stress is no stranger to physicians, with ready triggers such as tight patient schedules, reimbursement hassles with insurance companies, and administrative paperwork that never seems to end. Physicians are "seeing scores of different people in a day, all of whom have their different personalities and idiosyncrasies," Dr. Winner added. "Dealing with those different personalities can be stressful. Then there are sometimes stressful things at home."

He discussed three stress-management skills for his physician peers:

▸ Diaphragmatic breathing. Breathe through your nose and focus your attention on your abdomen, expanding it with the in breath, and breathing out through your nose or mouth. "As you do that you'll likely have a thought, such as 'if only this or that were different,' " said Dr. Winner, founder and director of Sansum Clinic's stress-management program. "Just notice it as a thought and let it float by, like a cloud floating overhead, and tune your full attention to the breath."

This ability to put aside your thoughts and observe them in a nonjudgmental way puts a different face on the stress trigger, he said; you start to view the trigger as no big deal.

For example, when you are scheduled to see a patient who has been difficult to deal with in the past, instead of dreading the appointment, "take 20 seconds before going into the exam room and focus on your breath; let go of the thoughts of how you want them to be different, and then be really present with that person," he explained. "Let go of all thoughts of the other patients and be fully with that person."

A 6-minute mini-meditation exercise that includes diaphragmatic breathing can be heard on Dr. Winner's Web site at www.stressremedy.com/relax

▸ Reframing. This involves placing a situation into a new context. For example, if you're running late in the office and a patient is rude to you for the extra waiting time, "Your temptation is to get angry," Dr. Winner said. "Instead, you can think, 'Hey, what's going on with that person?' When people are rude, they are usually suffering in some way. If people are always rude, they often have chronic depression, pain, or anxiety disorders. Maybe this is the case with your patient."

In his book, Dr. Winner noted that this principle can be applied to seeming mundane aspects of life as well, such as finding yourself in a long line at the grocery checkout counter. Consider that "free time," he writes, a rarity for many physicians.

He would reframe the wait at the grocery store "as an opportunity to focus on my breathing, reflect on my plans, maybe list those aspects of my life for which I am grateful. I might even chat with another person in line or indulge in the opportunity to flip through a magazine I wouldn't normally buy."

▸ Mindfulness. "Most of us have had the thought 'I'm overwhelmed' at one time or another," Dr. Winner writes in another passage from the book. "Mindfulness teaches us to let that thought go and do what's next."

He went on to describe his first year of when at times "I might get called to see three people at once: Mr. A with shortness of breath, Mrs. B with chest pain, and Mr. C with leg pain. Rather than getting increasingly stressed, I let go of the thought 'I'm overwhelmed' and focused my attention on taking care of one person at a time. I might ask Dr. Y to see Mr. A; then I would see Mrs. B, and then Mr. C. Alternatively, I might quickly check one patient to see that he was stable, then go examine the next patient, and then return to the first. The point is to do what is next and focus on one thing at a time."

He likened mindfulness to a basketball player being "in the zone," or being in the moment. "Instead of thinking, 'I don't want to do all of this dictation at the end of the day; what a pain,' let go of that thought," he advised. "Dictate one word at a time with the energy of an actor on stage. Get into what you're doing at the moment. That's mindfulness."

Diaphragmatic breathing, reframing, and mindfulness "are skills that can be learned, just like the skill of riding a bike," Dr. Winner offered.

"Once you get the hang of it, it's something that you can have the rest of your life. The first step is to notice your thoughts and not necessarily believe all of them. That way you can let them go, reframe them, or dispute them if they're irrational," he added.

He underscored the importance of embracing life's present moments instead of fretting about yesterday or tomorrow. "Unfortunately, a lot of people try to rush through life as opposed to enjoying each of the moments," Dr. Winner said.

"When you start thinking about things that aren't going right, take a moment to list the things that you're grateful for, including your family, your friends, and having a job where you have the opportunity to help people and think about science," he added.

Dr. Jay Winner, pictured with his book, began teaching a stress-management class after seeing patients under stress. Courtesy Dr. Jay Winner

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert

"The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop," Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "So even though the bug might be susceptible on paper, over time it might develop resistance."

Other strikes against clindamycin include its poor palatability—"most kids will throw it up," she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20–40 mg/kg per day IV divided every 6–8 hours, and 10–30 mg/kg per day orally divided every 6–8 hours.

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and "it doesn't taste too bad," said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego. However, it's not effective for group A streptococci, "so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble."

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating MRSA, but "in many cases it probably works as well as anything else," Dr. Pong said.

The recommended dosage is 8–12 mg/kg per day trimethoprim/40–60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating MRSA, "and it works well for acne, too," she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2–4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but it cannot be used alone as rapid resistance will ensue. The recommended dosage is 10–20 mg/kg per day IV or orally every 12–24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation. Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children "only in situations where there is no other antibiotic available."

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell.

"If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression," Dr. Pong warned. "But it works pretty well. We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole."

Dr. Pong reported that she had no financial conflicts to disclose.

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert

"The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop," Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "So even though the bug might be susceptible on paper, over time it might develop resistance."

Other strikes against clindamycin include its poor palatability—"most kids will throw it up," she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20–40 mg/kg per day IV divided every 6–8 hours, and 10–30 mg/kg per day orally divided every 6–8 hours.

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and "it doesn't taste too bad," said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego. However, it's not effective for group A streptococci, "so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble."

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating MRSA, but "in many cases it probably works as well as anything else," Dr. Pong said.

The recommended dosage is 8–12 mg/kg per day trimethoprim/40–60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating MRSA, "and it works well for acne, too," she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2–4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but it cannot be used alone as rapid resistance will ensue. The recommended dosage is 10–20 mg/kg per day IV or orally every 12–24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation. Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children "only in situations where there is no other antibiotic available."

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell.

"If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression," Dr. Pong warned. "But it works pretty well. We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole."

Dr. Pong reported that she had no financial conflicts to disclose.

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert

"The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop," Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "So even though the bug might be susceptible on paper, over time it might develop resistance."

Other strikes against clindamycin include its poor palatability—"most kids will throw it up," she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20–40 mg/kg per day IV divided every 6–8 hours, and 10–30 mg/kg per day orally divided every 6–8 hours.

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and "it doesn't taste too bad," said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego. However, it's not effective for group A streptococci, "so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble."

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating MRSA, but "in many cases it probably works as well as anything else," Dr. Pong said.

The recommended dosage is 8–12 mg/kg per day trimethoprim/40–60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating MRSA, "and it works well for acne, too," she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2–4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but it cannot be used alone as rapid resistance will ensue. The recommended dosage is 10–20 mg/kg per day IV or orally every 12–24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation. Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children "only in situations where there is no other antibiotic available."

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell.

"If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression," Dr. Pong warned. "But it works pretty well. We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole."

Dr. Pong reported that she had no financial conflicts to disclose.

SAN DIEGO — The presence of obstructive sleep apnea independently increases the risk of death after acute ischemic stroke, results from a single-center study showed.

The finding underscores the importance of screening for obstructive sleep apnea (OSA) as a risk factor for the development of stroke, since effective treatment for the condition is available, researchers led by Dr. Meghna P. Mansukhani reported during a poster session at the International Stroke Conference.

The finding also confirms results of a 10-year-long Swedish study that demonstrated an increase in mortality in stroke patients diagnosed with OSA after the stroke by polysomnography (Arch. Intern. Med. 2008;168:297-301).

Dr. Mansukhani and colleagues at the Mayo Clinic, Rochester, Minn., studied 174 consecutive patients who presented with acute ischemic stroke during June 2007-March 2008. The patients completed the Berlin Sleep Questionnaire, a screening test for OSA in the primary care setting. The mean age of the patients was 72 years, and 55% were female.

A total of 105 patients (61%) had a high risk of sleep apnea. Of these, seven had a previous diagnosis of OSA.

Of the 174 patients studied, 11 died (6%). Those who had a previous diagnosis of OSA were 5 times more likely to die within the first month following the stroke, compared with those who did not have a diagnosis of OSA, according to the presentation at a conference sponsored by the American Heart Association.

Dr. Mansukhani said she had no conflicts to disclose.

SAN DIEGO — The presence of obstructive sleep apnea independently increases the risk of death after acute ischemic stroke, results from a single-center study showed.

The finding underscores the importance of screening for obstructive sleep apnea (OSA) as a risk factor for the development of stroke, since effective treatment for the condition is available, researchers led by Dr. Meghna P. Mansukhani reported during a poster session at the International Stroke Conference.

The finding also confirms results of a 10-year-long Swedish study that demonstrated an increase in mortality in stroke patients diagnosed with OSA after the stroke by polysomnography (Arch. Intern. Med. 2008;168:297-301).

Dr. Mansukhani and colleagues at the Mayo Clinic, Rochester, Minn., studied 174 consecutive patients who presented with acute ischemic stroke during June 2007-March 2008. The patients completed the Berlin Sleep Questionnaire, a screening test for OSA in the primary care setting. The mean age of the patients was 72 years, and 55% were female.

A total of 105 patients (61%) had a high risk of sleep apnea. Of these, seven had a previous diagnosis of OSA.

Of the 174 patients studied, 11 died (6%). Those who had a previous diagnosis of OSA were 5 times more likely to die within the first month following the stroke, compared with those who did not have a diagnosis of OSA, according to the presentation at a conference sponsored by the American Heart Association.

Dr. Mansukhani said she had no conflicts to disclose.

SAN DIEGO — The presence of obstructive sleep apnea independently increases the risk of death after acute ischemic stroke, results from a single-center study showed.

The finding underscores the importance of screening for obstructive sleep apnea (OSA) as a risk factor for the development of stroke, since effective treatment for the condition is available, researchers led by Dr. Meghna P. Mansukhani reported during a poster session at the International Stroke Conference.

The finding also confirms results of a 10-year-long Swedish study that demonstrated an increase in mortality in stroke patients diagnosed with OSA after the stroke by polysomnography (Arch. Intern. Med. 2008;168:297-301).

Dr. Mansukhani and colleagues at the Mayo Clinic, Rochester, Minn., studied 174 consecutive patients who presented with acute ischemic stroke during June 2007-March 2008. The patients completed the Berlin Sleep Questionnaire, a screening test for OSA in the primary care setting. The mean age of the patients was 72 years, and 55% were female.

A total of 105 patients (61%) had a high risk of sleep apnea. Of these, seven had a previous diagnosis of OSA.

Of the 174 patients studied, 11 died (6%). Those who had a previous diagnosis of OSA were 5 times more likely to die within the first month following the stroke, compared with those who did not have a diagnosis of OSA, according to the presentation at a conference sponsored by the American Heart Association.

Dr. Mansukhani said she had no conflicts to disclose.

SAN DIEGO — Before you recommend a treatment for erectile dysfunction, make sure to rule out underlying factors that may contribute to the condition.

“Treat the whole person. Try to take care of other medical problems they might have,” Dr. Edward (Lev) Linkner advised at a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine.

Medical conditions that should be ruled out include arteriosclerosis, diabetes, Syndrome X (cardiometabolic syndrome), hypothyroidism, and hypogonadism. Emotional etiologies such as depression and relationship difficulties should also be investigated, as should stress and lifestyle habits, especially smoking and alcohol consumption.

“Even bicycling can put abnormal pressure on pelvic nerves and result in erectile dysfunction,” said Dr. Linkner, a founder of the American Board of Holistic Medicine and current member of their board of directors. He is in private practice in Ann Arbor, Mich.

If erectile dysfunction is secondary to a treatable disease or condition, treatment of that disease or condition may be all that's necessary. If not, consider one of the following herbs:

▸ Yohimbine. This herb is derived from bark shavings of a West African tree, Pausinystalia yohimbe. “Some studies show positive results, some don't,” Dr. Linkner said. “The major side effects are hypertension, anxiety, nausea, trembling, and insomnia.” Yohimbine is contraindicated for use by those with liver and kidney disease. It is available in tablet form as the prescription drug Yocon (yohimbine hydrochloride), an alpha2-adrenergic blocker that increases blood flow to the penis. “It may be especially helpful for erectile dysfunction induced by the use of selective serotonin reuptake inhibitors,” Dr. Linkner said. He recommends a dose of one-half to one whole 5.4-mg tablet t.i.d.

▸ Ginkgo biloba. A German study showed that this herb increased blood flow to the penis within 8 weeks of starting treatment, and half of the participants regained normal potency (J. Sex Educ. Ther. 1991;17:53–61). The recommended dose is 60–120 mg b.i.d.

▸ Damiana (Turnera diffusa). Although poorly studied, this herb has been used as an aphrodisiac for centuries, especially in Mexico. Its leaves also are used to make a tea. The recommended dose is 300–450 mg once daily.

▸ Ginseng. Panax ginseng appears to works best for erectile dysfunction, but Siberian ginseng also can be used. Ginsenoside, a triterpenoid saponin, increases nitric oxide and “works like a natural Viagra,” Dr. Linkner said. The recommended dose is 200–1,000 mg.

▸ Muria puama. In European studies, this extract of a shrub (Ptychopetalum olacoides) from the Amazon has been shown to increase erections and libido. It is listed in the British Herbal Pharmacopoeia as a treatment for erectile dysfunction and dysentery.

▸ Maca (Lepidum meyenii). This radishlike plant native to the Peruvian Andes is thought to increase sexual function and stamina. The recommended dose is 1.5–3 g daily.

Adaptogens—herbs that are restorative or enhance physical performance—also may have a role in the treatment of erectile dysfunction, said Dr. Linkner, also of the University of Michigan, Ann Arbor. They “increase energy and resistance to all types of stress, thereby preventing fatigue, enhancing memory, concentration, and improving work performance.” Some adaptogens are cordyceps, ashwagandha, and rhodiola.

Other herbs with historical use in treating erectile dysfunction include oats, which increase stamina and decrease irritability; rosemary, which may help the adrenal gland produce more sex hormones; and catuba, a Brazilian herb that may increase libido.

Arginine, a biologic precursor to nitric oxide, also is used as a treatment for erectile dysfunction. However, it may reduce blood pressure, so precautions should be taken with patients on antihypertensive medications. The recommended dose of arginine is 500–1,500 mg b.i.d., or 1,000 mg 30 minutes before sex.

Dr. Linkner had no conflicts of interest to disclose.

SAN DIEGO — Before you recommend a treatment for erectile dysfunction, make sure to rule out underlying factors that may contribute to the condition.

“Treat the whole person. Try to take care of other medical problems they might have,” Dr. Edward (Lev) Linkner advised at a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine.

Medical conditions that should be ruled out include arteriosclerosis, diabetes, Syndrome X (cardiometabolic syndrome), hypothyroidism, and hypogonadism. Emotional etiologies such as depression and relationship difficulties should also be investigated, as should stress and lifestyle habits, especially smoking and alcohol consumption.

“Even bicycling can put abnormal pressure on pelvic nerves and result in erectile dysfunction,” said Dr. Linkner, a founder of the American Board of Holistic Medicine and current member of their board of directors. He is in private practice in Ann Arbor, Mich.

If erectile dysfunction is secondary to a treatable disease or condition, treatment of that disease or condition may be all that's necessary. If not, consider one of the following herbs:

▸ Yohimbine. This herb is derived from bark shavings of a West African tree, Pausinystalia yohimbe. “Some studies show positive results, some don't,” Dr. Linkner said. “The major side effects are hypertension, anxiety, nausea, trembling, and insomnia.” Yohimbine is contraindicated for use by those with liver and kidney disease. It is available in tablet form as the prescription drug Yocon (yohimbine hydrochloride), an alpha2-adrenergic blocker that increases blood flow to the penis. “It may be especially helpful for erectile dysfunction induced by the use of selective serotonin reuptake inhibitors,” Dr. Linkner said. He recommends a dose of one-half to one whole 5.4-mg tablet t.i.d.

▸ Ginkgo biloba. A German study showed that this herb increased blood flow to the penis within 8 weeks of starting treatment, and half of the participants regained normal potency (J. Sex Educ. Ther. 1991;17:53–61). The recommended dose is 60–120 mg b.i.d.

▸ Damiana (Turnera diffusa). Although poorly studied, this herb has been used as an aphrodisiac for centuries, especially in Mexico. Its leaves also are used to make a tea. The recommended dose is 300–450 mg once daily.

▸ Ginseng. Panax ginseng appears to works best for erectile dysfunction, but Siberian ginseng also can be used. Ginsenoside, a triterpenoid saponin, increases nitric oxide and “works like a natural Viagra,” Dr. Linkner said. The recommended dose is 200–1,000 mg.

▸ Muria puama. In European studies, this extract of a shrub (Ptychopetalum olacoides) from the Amazon has been shown to increase erections and libido. It is listed in the British Herbal Pharmacopoeia as a treatment for erectile dysfunction and dysentery.

▸ Maca (Lepidum meyenii). This radishlike plant native to the Peruvian Andes is thought to increase sexual function and stamina. The recommended dose is 1.5–3 g daily.

Adaptogens—herbs that are restorative or enhance physical performance—also may have a role in the treatment of erectile dysfunction, said Dr. Linkner, also of the University of Michigan, Ann Arbor. They “increase energy and resistance to all types of stress, thereby preventing fatigue, enhancing memory, concentration, and improving work performance.” Some adaptogens are cordyceps, ashwagandha, and rhodiola.

Other herbs with historical use in treating erectile dysfunction include oats, which increase stamina and decrease irritability; rosemary, which may help the adrenal gland produce more sex hormones; and catuba, a Brazilian herb that may increase libido.

Arginine, a biologic precursor to nitric oxide, also is used as a treatment for erectile dysfunction. However, it may reduce blood pressure, so precautions should be taken with patients on antihypertensive medications. The recommended dose of arginine is 500–1,500 mg b.i.d., or 1,000 mg 30 minutes before sex.

Dr. Linkner had no conflicts of interest to disclose.

SAN DIEGO — Before you recommend a treatment for erectile dysfunction, make sure to rule out underlying factors that may contribute to the condition.

“Treat the whole person. Try to take care of other medical problems they might have,” Dr. Edward (Lev) Linkner advised at a meeting sponsored by the Scripps Center for Integrative Medicine and the American Board of Integrative Holistic Medicine.

Medical conditions that should be ruled out include arteriosclerosis, diabetes, Syndrome X (cardiometabolic syndrome), hypothyroidism, and hypogonadism. Emotional etiologies such as depression and relationship difficulties should also be investigated, as should stress and lifestyle habits, especially smoking and alcohol consumption.

“Even bicycling can put abnormal pressure on pelvic nerves and result in erectile dysfunction,” said Dr. Linkner, a founder of the American Board of Holistic Medicine and current member of their board of directors. He is in private practice in Ann Arbor, Mich.

If erectile dysfunction is secondary to a treatable disease or condition, treatment of that disease or condition may be all that's necessary. If not, consider one of the following herbs:

▸ Yohimbine. This herb is derived from bark shavings of a West African tree, Pausinystalia yohimbe. “Some studies show positive results, some don't,” Dr. Linkner said. “The major side effects are hypertension, anxiety, nausea, trembling, and insomnia.” Yohimbine is contraindicated for use by those with liver and kidney disease. It is available in tablet form as the prescription drug Yocon (yohimbine hydrochloride), an alpha2-adrenergic blocker that increases blood flow to the penis. “It may be especially helpful for erectile dysfunction induced by the use of selective serotonin reuptake inhibitors,” Dr. Linkner said. He recommends a dose of one-half to one whole 5.4-mg tablet t.i.d.

▸ Ginkgo biloba. A German study showed that this herb increased blood flow to the penis within 8 weeks of starting treatment, and half of the participants regained normal potency (J. Sex Educ. Ther. 1991;17:53–61). The recommended dose is 60–120 mg b.i.d.

▸ Damiana (Turnera diffusa). Although poorly studied, this herb has been used as an aphrodisiac for centuries, especially in Mexico. Its leaves also are used to make a tea. The recommended dose is 300–450 mg once daily.

▸ Ginseng. Panax ginseng appears to works best for erectile dysfunction, but Siberian ginseng also can be used. Ginsenoside, a triterpenoid saponin, increases nitric oxide and “works like a natural Viagra,” Dr. Linkner said. The recommended dose is 200–1,000 mg.

▸ Muria puama. In European studies, this extract of a shrub (Ptychopetalum olacoides) from the Amazon has been shown to increase erections and libido. It is listed in the British Herbal Pharmacopoeia as a treatment for erectile dysfunction and dysentery.

▸ Maca (Lepidum meyenii). This radishlike plant native to the Peruvian Andes is thought to increase sexual function and stamina. The recommended dose is 1.5–3 g daily.

Adaptogens—herbs that are restorative or enhance physical performance—also may have a role in the treatment of erectile dysfunction, said Dr. Linkner, also of the University of Michigan, Ann Arbor. They “increase energy and resistance to all types of stress, thereby preventing fatigue, enhancing memory, concentration, and improving work performance.” Some adaptogens are cordyceps, ashwagandha, and rhodiola.

Other herbs with historical use in treating erectile dysfunction include oats, which increase stamina and decrease irritability; rosemary, which may help the adrenal gland produce more sex hormones; and catuba, a Brazilian herb that may increase libido.

Arginine, a biologic precursor to nitric oxide, also is used as a treatment for erectile dysfunction. However, it may reduce blood pressure, so precautions should be taken with patients on antihypertensive medications. The recommended dose of arginine is 500–1,500 mg b.i.d., or 1,000 mg 30 minutes before sex.

Dr. Linkner had no conflicts of interest to disclose.

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis has demonstrated.

Common pregnancy stressors such as divorce or separation or a physical fight also were found to increase the risk.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risks are so high that we should either be identifying ways to prevent depression in this group or carrying out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the obstetrics and gynecology department at the University of California, San Diego.

She and her associate, Dr. Michael W. Varner of the maternal-fetal medicine division at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007. At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, as well as a psychiatric, medical, obstetric, and family history. Participants completed the Pregnancy Risk Assessment Monitoring System (PRAMS).

Self-reported prepregnancy BMI was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

When the researchers controlled for demographic, psychological, medical, and obstetric risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class II women and 3.94 for class III women.

In the PRAMS stressors component, Dr. LaCoursiere and Dr. Varner found that common pregnancy stressors increase the risk of postpartum depression. For example, the adjusted odds ratio for postpartum depression among women who reported partner-associated stressors such as divorce or arguing more than usual was 2.61, versus 1.66 for those who reported traumatic stressors such as being homeless or being in a physical fight. The adjusted odds ratio for those who reported both types of stressors was 8.48.

Forty-four percent of the women reported that clinicians asked about their mood during pregnancy; 54% said they were asked during the postpartum period.

Study limitations included the self-reported height and weight data and the fact that while women being actively treated for depression were excluded, the questionnaire was not given antepartum or immediately post partum. So the cohort “may represent women who were depressed antenatally and continued to have antenatal depression into the postpartum period,” said Dr. LaCoursiere, who reported no conflicts of interest.

We should find ways to prevent depression or conduct early surveillance and treatment in this high-risk group. DR. LACOURSIERE

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis has demonstrated.

Common pregnancy stressors such as divorce or separation or a physical fight also were found to increase the risk.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risks are so high that we should either be identifying ways to prevent depression in this group or carrying out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the obstetrics and gynecology department at the University of California, San Diego.

She and her associate, Dr. Michael W. Varner of the maternal-fetal medicine division at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007. At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, as well as a psychiatric, medical, obstetric, and family history. Participants completed the Pregnancy Risk Assessment Monitoring System (PRAMS).

Self-reported prepregnancy BMI was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

When the researchers controlled for demographic, psychological, medical, and obstetric risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class II women and 3.94 for class III women.

In the PRAMS stressors component, Dr. LaCoursiere and Dr. Varner found that common pregnancy stressors increase the risk of postpartum depression. For example, the adjusted odds ratio for postpartum depression among women who reported partner-associated stressors such as divorce or arguing more than usual was 2.61, versus 1.66 for those who reported traumatic stressors such as being homeless or being in a physical fight. The adjusted odds ratio for those who reported both types of stressors was 8.48.

Forty-four percent of the women reported that clinicians asked about their mood during pregnancy; 54% said they were asked during the postpartum period.

Study limitations included the self-reported height and weight data and the fact that while women being actively treated for depression were excluded, the questionnaire was not given antepartum or immediately post partum. So the cohort “may represent women who were depressed antenatally and continued to have antenatal depression into the postpartum period,” said Dr. LaCoursiere, who reported no conflicts of interest.

We should find ways to prevent depression or conduct early surveillance and treatment in this high-risk group. DR. LACOURSIERE

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis has demonstrated.

Common pregnancy stressors such as divorce or separation or a physical fight also were found to increase the risk.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risks are so high that we should either be identifying ways to prevent depression in this group or carrying out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the obstetrics and gynecology department at the University of California, San Diego.

She and her associate, Dr. Michael W. Varner of the maternal-fetal medicine division at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007. At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, as well as a psychiatric, medical, obstetric, and family history. Participants completed the Pregnancy Risk Assessment Monitoring System (PRAMS).

Self-reported prepregnancy BMI was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

When the researchers controlled for demographic, psychological, medical, and obstetric risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class II women and 3.94 for class III women.

In the PRAMS stressors component, Dr. LaCoursiere and Dr. Varner found that common pregnancy stressors increase the risk of postpartum depression. For example, the adjusted odds ratio for postpartum depression among women who reported partner-associated stressors such as divorce or arguing more than usual was 2.61, versus 1.66 for those who reported traumatic stressors such as being homeless or being in a physical fight. The adjusted odds ratio for those who reported both types of stressors was 8.48.

Forty-four percent of the women reported that clinicians asked about their mood during pregnancy; 54% said they were asked during the postpartum period.

Study limitations included the self-reported height and weight data and the fact that while women being actively treated for depression were excluded, the questionnaire was not given antepartum or immediately post partum. So the cohort “may represent women who were depressed antenatally and continued to have antenatal depression into the postpartum period,” said Dr. LaCoursiere, who reported no conflicts of interest.

We should find ways to prevent depression or conduct early surveillance and treatment in this high-risk group. DR. LACOURSIERE

SAN DIEGO — Treatment of mild gestational diabetes did not reduce the frequency of several commonly reported morbidities associated with diabetic pregnancy, results from a large multicenter randomized trial demonstrated.

However, treatment did lower birth weight and resulted in a 50% reduction in macrosomia, as well as lower neonatal fat mass, rates of shoulder dystocia, cesarean delivery, preeclampsia, and gestational hypertension.

“Identification and treatment of mild gestational diabetes is clearly associated with significant clinical benefits,” Dr. Mark B. Landon said at the annual meeting of the Society for Maternal-Fetal Medicine.

The incidence of gestational diabetes, defined as glucose intolerance with onset or first recognition during pregnancy, is rising in the United States, said Dr. Landon, professor of obstetrics and gynecology at Ohio State University, Columbus. More than 45 years ago, researchers “first proposed criteria for the diagnosis, which were based on the subsequent development of adult-onset diabetes and not on any association between carbohydrate intolerance and adverse pregnancy outcomes,” he said. “Thus, the clinical significance of gestational diabetes and, in particular, mild gestational diabetes as it relates to perinatal morbidity, is unclear and has been challenged for decades.”

Based largely on results of retrospective single-center studies to date, there has been “widespread acceptance of screening and treatment of gestational diabetes by professional organizations with little evidence of demonstrable benefit,” he said.

However, in 2003 and 2008, the U.S. Preventive Services Task Force concluded that there is insufficient evidence to determine if treatment of mild gestational diabetes provides a health benefit.

The controversy prompted the maternal-fetal medicine units network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to conduct a randomized trial to determine if treatment of mild gestational diabetes reduced perinatal morbidity.

For the study, 958 women with a singleton gestation who met criteria for mild gestational diabetes (a fasting value of less than 95 mg/dL on a blinded 3-hour oral glucose tolerance test) were allocated to one of two groups. The 485 women in the treatment group received formal nutrition counseling, instruction on self-monitoring of blood glucose, and insulin administration, if necessary. The 473 controls received standard routine obstetric care, and clinicians and study participants were unaware of their glucose tolerance test results.

The primary end point was a composite outcome that consisted of perinatal mortality; neonatal hypoglycemia defined as a value less than 35 mg/dL during the first 2 hours of life without feeding; a serum bilirubin greater than 8 mg/dL between 16 and 36 hours of life, hyperinsulinemia as reflected by a cord blood C-peptide greater than the 95th percentile, or birth trauma.

The average age of the study participants was 29 years. There were no differences in the frequency of composite primary neonatal outcome (32% in the treatment group vs. 37% in the control group).

Among secondary outcomes, Dr. Landon and his associates observed a significant difference between the treatment and control groups in mean birth weight (3,302 g vs. 3,408 g, respectively), fetal fat mass (427 g vs. 464 g), and frequency of infants weighing greater than 4,000 g at birth (6% vs. 14%).

No differences were seen inNICU admission, preterm delivery, respiratory distress syndrome, or need for intravenous glucose treatment.

In maternal outcomes, induction of labor rates were similar between the two groups (about 27%), but the treatment group had significantly lower overall rates of cesarean delivery (27% vs. 34%) and rates of cesarean corrected for abnormal presentation and prior cesarean (13% vs. 20%).

The shoulder dystocia rate also was reduced with treatment (2% vs. 4%) as was the rate of preeclampsia and gestational hypertension as a composite (9% vs. 14%).

Dr. Landon disclosed no conflicts of interest related to the study.

The clinical significance of mild gestational diabetes 'is unclear and has been challenged for decades.' DR. LANDON

SAN DIEGO — Treatment of mild gestational diabetes did not reduce the frequency of several commonly reported morbidities associated with diabetic pregnancy, results from a large multicenter randomized trial demonstrated.

However, treatment did lower birth weight and resulted in a 50% reduction in macrosomia, as well as lower neonatal fat mass, rates of shoulder dystocia, cesarean delivery, preeclampsia, and gestational hypertension.

“Identification and treatment of mild gestational diabetes is clearly associated with significant clinical benefits,” Dr. Mark B. Landon said at the annual meeting of the Society for Maternal-Fetal Medicine.

The incidence of gestational diabetes, defined as glucose intolerance with onset or first recognition during pregnancy, is rising in the United States, said Dr. Landon, professor of obstetrics and gynecology at Ohio State University, Columbus. More than 45 years ago, researchers “first proposed criteria for the diagnosis, which were based on the subsequent development of adult-onset diabetes and not on any association between carbohydrate intolerance and adverse pregnancy outcomes,” he said. “Thus, the clinical significance of gestational diabetes and, in particular, mild gestational diabetes as it relates to perinatal morbidity, is unclear and has been challenged for decades.”

Based largely on results of retrospective single-center studies to date, there has been “widespread acceptance of screening and treatment of gestational diabetes by professional organizations with little evidence of demonstrable benefit,” he said.

However, in 2003 and 2008, the U.S. Preventive Services Task Force concluded that there is insufficient evidence to determine if treatment of mild gestational diabetes provides a health benefit.

The controversy prompted the maternal-fetal medicine units network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to conduct a randomized trial to determine if treatment of mild gestational diabetes reduced perinatal morbidity.

For the study, 958 women with a singleton gestation who met criteria for mild gestational diabetes (a fasting value of less than 95 mg/dL on a blinded 3-hour oral glucose tolerance test) were allocated to one of two groups. The 485 women in the treatment group received formal nutrition counseling, instruction on self-monitoring of blood glucose, and insulin administration, if necessary. The 473 controls received standard routine obstetric care, and clinicians and study participants were unaware of their glucose tolerance test results.

The primary end point was a composite outcome that consisted of perinatal mortality; neonatal hypoglycemia defined as a value less than 35 mg/dL during the first 2 hours of life without feeding; a serum bilirubin greater than 8 mg/dL between 16 and 36 hours of life, hyperinsulinemia as reflected by a cord blood C-peptide greater than the 95th percentile, or birth trauma.

The average age of the study participants was 29 years. There were no differences in the frequency of composite primary neonatal outcome (32% in the treatment group vs. 37% in the control group).

Among secondary outcomes, Dr. Landon and his associates observed a significant difference between the treatment and control groups in mean birth weight (3,302 g vs. 3,408 g, respectively), fetal fat mass (427 g vs. 464 g), and frequency of infants weighing greater than 4,000 g at birth (6% vs. 14%).

No differences were seen inNICU admission, preterm delivery, respiratory distress syndrome, or need for intravenous glucose treatment.

In maternal outcomes, induction of labor rates were similar between the two groups (about 27%), but the treatment group had significantly lower overall rates of cesarean delivery (27% vs. 34%) and rates of cesarean corrected for abnormal presentation and prior cesarean (13% vs. 20%).

The shoulder dystocia rate also was reduced with treatment (2% vs. 4%) as was the rate of preeclampsia and gestational hypertension as a composite (9% vs. 14%).

Dr. Landon disclosed no conflicts of interest related to the study.

The clinical significance of mild gestational diabetes 'is unclear and has been challenged for decades.' DR. LANDON

SAN DIEGO — Treatment of mild gestational diabetes did not reduce the frequency of several commonly reported morbidities associated with diabetic pregnancy, results from a large multicenter randomized trial demonstrated.

However, treatment did lower birth weight and resulted in a 50% reduction in macrosomia, as well as lower neonatal fat mass, rates of shoulder dystocia, cesarean delivery, preeclampsia, and gestational hypertension.

“Identification and treatment of mild gestational diabetes is clearly associated with significant clinical benefits,” Dr. Mark B. Landon said at the annual meeting of the Society for Maternal-Fetal Medicine.

The incidence of gestational diabetes, defined as glucose intolerance with onset or first recognition during pregnancy, is rising in the United States, said Dr. Landon, professor of obstetrics and gynecology at Ohio State University, Columbus. More than 45 years ago, researchers “first proposed criteria for the diagnosis, which were based on the subsequent development of adult-onset diabetes and not on any association between carbohydrate intolerance and adverse pregnancy outcomes,” he said. “Thus, the clinical significance of gestational diabetes and, in particular, mild gestational diabetes as it relates to perinatal morbidity, is unclear and has been challenged for decades.”

Based largely on results of retrospective single-center studies to date, there has been “widespread acceptance of screening and treatment of gestational diabetes by professional organizations with little evidence of demonstrable benefit,” he said.

However, in 2003 and 2008, the U.S. Preventive Services Task Force concluded that there is insufficient evidence to determine if treatment of mild gestational diabetes provides a health benefit.

The controversy prompted the maternal-fetal medicine units network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to conduct a randomized trial to determine if treatment of mild gestational diabetes reduced perinatal morbidity.

For the study, 958 women with a singleton gestation who met criteria for mild gestational diabetes (a fasting value of less than 95 mg/dL on a blinded 3-hour oral glucose tolerance test) were allocated to one of two groups. The 485 women in the treatment group received formal nutrition counseling, instruction on self-monitoring of blood glucose, and insulin administration, if necessary. The 473 controls received standard routine obstetric care, and clinicians and study participants were unaware of their glucose tolerance test results.

The primary end point was a composite outcome that consisted of perinatal mortality; neonatal hypoglycemia defined as a value less than 35 mg/dL during the first 2 hours of life without feeding; a serum bilirubin greater than 8 mg/dL between 16 and 36 hours of life, hyperinsulinemia as reflected by a cord blood C-peptide greater than the 95th percentile, or birth trauma.

The average age of the study participants was 29 years. There were no differences in the frequency of composite primary neonatal outcome (32% in the treatment group vs. 37% in the control group).

Among secondary outcomes, Dr. Landon and his associates observed a significant difference between the treatment and control groups in mean birth weight (3,302 g vs. 3,408 g, respectively), fetal fat mass (427 g vs. 464 g), and frequency of infants weighing greater than 4,000 g at birth (6% vs. 14%).

No differences were seen inNICU admission, preterm delivery, respiratory distress syndrome, or need for intravenous glucose treatment.

In maternal outcomes, induction of labor rates were similar between the two groups (about 27%), but the treatment group had significantly lower overall rates of cesarean delivery (27% vs. 34%) and rates of cesarean corrected for abnormal presentation and prior cesarean (13% vs. 20%).

The shoulder dystocia rate also was reduced with treatment (2% vs. 4%) as was the rate of preeclampsia and gestational hypertension as a composite (9% vs. 14%).

Dr. Landon disclosed no conflicts of interest related to the study.

The clinical significance of mild gestational diabetes 'is unclear and has been challenged for decades.' DR. LANDON

SAN DIEGO — Women with prior early spontaneous preterm birth and a midtrimester sonographic cervical length of less than 25 mm may benefit from cerclage, but the benefit is most pronounced when the cervical length is less than 15 mm, results from a large, multicenter, randomized study showed.

“Although clinicians have recommended cerclage for shortened cervical lengths, previous randomized trials have not supported this practice,” Dr. John Owen said at the annual meeting of the Society for Maternal-Fetal Medicine.

A recent meta-analysis of four randomized trials of cerclage for shortened cervical length uncovered a relationship between pregnancy history and cerclage effectiveness. Cerclage was helpful only in singletons—it was harmful in multiples—but it was especially helpful in women who'd had a prior preterm birth (Obstet. Gynecol. 2005;106:181–9).

“Our hypothesis was that in women with a prior early spontaneous preterm birth [gestational age less than 34 weeks] and cervical length less than 25 mm, cerclage would reduce the rate of preterm birth before 35 weeks' gestation,” said Dr. Owen of the department of obstetrics and gynecology at the University of Alabama at Birmingham.

To test the hypothesis, he and his colleagues at 15 centers in the United States, known as the Vaginal Ultrasound Trial Consortium, studied 1,014 women with a prior spontaneous birth at less than 34 weeks and a current singleton pregnancy who underwent serial ultrasound evaluation in the period beginning at 16 weeks and ending before 23 weeks (that is, no later than 22 weeks and 6 days). Of these, 301 women with a cervical length of less than 25 mm were randomized to either cerclage or no cerclage.

Vaginal ultrasound exams lasted a minimum of 5 minutes to allow the clinician to observe any spontaneous shortening, and included fundal pressure as a provocative measure to induce cervical shortening. The scans were scheduled every 2 weeks as long as the cervical length remained at least 30 mm. They were performed weekly if the cervical length shortened to 25–29 mm. The last scan was scheduled to occur just before the 23 weeks' gestational point.

Dr. Owen reported that the cerclage and no-cerclage groups were similar in terms of race/ethnicity, mean cervical length (18.7 vs. 19.5 mm, respectively), mean gestational age at randomization (19.4 vs. 19.5 weeks), and mean gestational age of earliest prior preterm birth (24.4 vs. 24.9 weeks).

Preterm birth before 35 weeks occurred in 42% of the no-cerclage group, compared with 32% of the cerclage group, a difference that revealed a statistical trend (P = .09).

However, further analysis revealed that women in the cerclage group maintained their pregnancies significantly better if their cervical length was less than 15 mm (odds ratio, 0.23), but there was no significantly positive effect if their cervical length was 15–24 mm (OR, 0.84).

Dr. Owen had no conflicts to disclose.

SAN DIEGO — Women with prior early spontaneous preterm birth and a midtrimester sonographic cervical length of less than 25 mm may benefit from cerclage, but the benefit is most pronounced when the cervical length is less than 15 mm, results from a large, multicenter, randomized study showed.

“Although clinicians have recommended cerclage for shortened cervical lengths, previous randomized trials have not supported this practice,” Dr. John Owen said at the annual meeting of the Society for Maternal-Fetal Medicine.

A recent meta-analysis of four randomized trials of cerclage for shortened cervical length uncovered a relationship between pregnancy history and cerclage effectiveness. Cerclage was helpful only in singletons—it was harmful in multiples—but it was especially helpful in women who'd had a prior preterm birth (Obstet. Gynecol. 2005;106:181–9).

“Our hypothesis was that in women with a prior early spontaneous preterm birth [gestational age less than 34 weeks] and cervical length less than 25 mm, cerclage would reduce the rate of preterm birth before 35 weeks' gestation,” said Dr. Owen of the department of obstetrics and gynecology at the University of Alabama at Birmingham.

To test the hypothesis, he and his colleagues at 15 centers in the United States, known as the Vaginal Ultrasound Trial Consortium, studied 1,014 women with a prior spontaneous birth at less than 34 weeks and a current singleton pregnancy who underwent serial ultrasound evaluation in the period beginning at 16 weeks and ending before 23 weeks (that is, no later than 22 weeks and 6 days). Of these, 301 women with a cervical length of less than 25 mm were randomized to either cerclage or no cerclage.

Vaginal ultrasound exams lasted a minimum of 5 minutes to allow the clinician to observe any spontaneous shortening, and included fundal pressure as a provocative measure to induce cervical shortening. The scans were scheduled every 2 weeks as long as the cervical length remained at least 30 mm. They were performed weekly if the cervical length shortened to 25–29 mm. The last scan was scheduled to occur just before the 23 weeks' gestational point.

Dr. Owen reported that the cerclage and no-cerclage groups were similar in terms of race/ethnicity, mean cervical length (18.7 vs. 19.5 mm, respectively), mean gestational age at randomization (19.4 vs. 19.5 weeks), and mean gestational age of earliest prior preterm birth (24.4 vs. 24.9 weeks).

Preterm birth before 35 weeks occurred in 42% of the no-cerclage group, compared with 32% of the cerclage group, a difference that revealed a statistical trend (P = .09).

However, further analysis revealed that women in the cerclage group maintained their pregnancies significantly better if their cervical length was less than 15 mm (odds ratio, 0.23), but there was no significantly positive effect if their cervical length was 15–24 mm (OR, 0.84).

Dr. Owen had no conflicts to disclose.

SAN DIEGO — Women with prior early spontaneous preterm birth and a midtrimester sonographic cervical length of less than 25 mm may benefit from cerclage, but the benefit is most pronounced when the cervical length is less than 15 mm, results from a large, multicenter, randomized study showed.

“Although clinicians have recommended cerclage for shortened cervical lengths, previous randomized trials have not supported this practice,” Dr. John Owen said at the annual meeting of the Society for Maternal-Fetal Medicine.

A recent meta-analysis of four randomized trials of cerclage for shortened cervical length uncovered a relationship between pregnancy history and cerclage effectiveness. Cerclage was helpful only in singletons—it was harmful in multiples—but it was especially helpful in women who'd had a prior preterm birth (Obstet. Gynecol. 2005;106:181–9).

“Our hypothesis was that in women with a prior early spontaneous preterm birth [gestational age less than 34 weeks] and cervical length less than 25 mm, cerclage would reduce the rate of preterm birth before 35 weeks' gestation,” said Dr. Owen of the department of obstetrics and gynecology at the University of Alabama at Birmingham.

To test the hypothesis, he and his colleagues at 15 centers in the United States, known as the Vaginal Ultrasound Trial Consortium, studied 1,014 women with a prior spontaneous birth at less than 34 weeks and a current singleton pregnancy who underwent serial ultrasound evaluation in the period beginning at 16 weeks and ending before 23 weeks (that is, no later than 22 weeks and 6 days). Of these, 301 women with a cervical length of less than 25 mm were randomized to either cerclage or no cerclage.

Vaginal ultrasound exams lasted a minimum of 5 minutes to allow the clinician to observe any spontaneous shortening, and included fundal pressure as a provocative measure to induce cervical shortening. The scans were scheduled every 2 weeks as long as the cervical length remained at least 30 mm. They were performed weekly if the cervical length shortened to 25–29 mm. The last scan was scheduled to occur just before the 23 weeks' gestational point.

Dr. Owen reported that the cerclage and no-cerclage groups were similar in terms of race/ethnicity, mean cervical length (18.7 vs. 19.5 mm, respectively), mean gestational age at randomization (19.4 vs. 19.5 weeks), and mean gestational age of earliest prior preterm birth (24.4 vs. 24.9 weeks).

Preterm birth before 35 weeks occurred in 42% of the no-cerclage group, compared with 32% of the cerclage group, a difference that revealed a statistical trend (P = .09).

However, further analysis revealed that women in the cerclage group maintained their pregnancies significantly better if their cervical length was less than 15 mm (odds ratio, 0.23), but there was no significantly positive effect if their cervical length was 15–24 mm (OR, 0.84).

Dr. Owen had no conflicts to disclose.

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis demonstrates.

Common pregnancy stressors such as divorce or separation or being involved in a physical fight also were found to increase the risk.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risk is so high that we should either be identifying ways to prevent depression in this group or carry out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Previous research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and subsequent postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the department of obstetrics and gynecology at the University of California at San Diego.

She and her associate, Dr. Michael W. Varner of the division of maternal-fetal medicine at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007.

At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, in addition to a psychiatric, medical, obstetric, and family history. Participants were also asked to complete the Pregnancy Risk Assessment Monitoring System (PRAMS).

Self-reported prepregnancy body mass index was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

At 6–8 weeks after delivery, the women were asked to complete the Edinburgh Postnatal Depression Scale. Postpartum depression was defined as a score of 12 or more.

Dr. LaCoursiere reported that the rate of postpartum depression was directly related to the extremes of body mass index. For example, the rates of postpartum depression among those in the underweight, normal weight, and preobese groups were 18%, 14%, and 19%, respectively, while the rates among those in the obese class I, class II, and class III groups were 19%, 32%, and 40%, respectively.

After the researchers controlled for demographic, psychological, medical, and obstetrical risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class II women and 3.94 for obese class III women.

In the PRAMS stressors component of the study, Dr. LaCoursiere and Dr. Varner found that common pregnancy stressors increase the risk of postpartum depression. For example, the adjusted odds ratio for postpartum depression among women who reported partner-associated stressors such as divorce or arguing more than usual was 2.61, while the adjusted odds ratio for those who reported traumatic stressors such as being homeless or being involved in a physical fight was 1.66.

The adjusted odds ratio for those who reported both types of stressors was 8.48.

Fewer than half of the study participants (44%) reported that their clinician asked about their mood during pregnancy, while 54% reported that they were asked about their mood during the postpartum period.

Dr. LaCoursiere acknowledged certain limitations of the study, including the self-reported height and weight data and the fact that while women who were being actively treated for depression were excluded, the questionnaire was not administered antepartum or immediately post partum. Therefore, she said, “this cohort may represent women who were depressed antenatally and continued to have antenatal depression into the postpartum period.”

Dr. LaCoursiere reported that she had no conflicts to disclose.

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis demonstrates.

Common pregnancy stressors such as divorce or separation or being involved in a physical fight also were found to increase the risk.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risk is so high that we should either be identifying ways to prevent depression in this group or carry out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Previous research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and subsequent postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the department of obstetrics and gynecology at the University of California at San Diego.

She and her associate, Dr. Michael W. Varner of the division of maternal-fetal medicine at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007.

At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, in addition to a psychiatric, medical, obstetric, and family history. Participants were also asked to complete the Pregnancy Risk Assessment Monitoring System (PRAMS).

Self-reported prepregnancy body mass index was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

At 6–8 weeks after delivery, the women were asked to complete the Edinburgh Postnatal Depression Scale. Postpartum depression was defined as a score of 12 or more.

Dr. LaCoursiere reported that the rate of postpartum depression was directly related to the extremes of body mass index. For example, the rates of postpartum depression among those in the underweight, normal weight, and preobese groups were 18%, 14%, and 19%, respectively, while the rates among those in the obese class I, class II, and class III groups were 19%, 32%, and 40%, respectively.

After the researchers controlled for demographic, psychological, medical, and obstetrical risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class II women and 3.94 for obese class III women.

In the PRAMS stressors component of the study, Dr. LaCoursiere and Dr. Varner found that common pregnancy stressors increase the risk of postpartum depression. For example, the adjusted odds ratio for postpartum depression among women who reported partner-associated stressors such as divorce or arguing more than usual was 2.61, while the adjusted odds ratio for those who reported traumatic stressors such as being homeless or being involved in a physical fight was 1.66.

The adjusted odds ratio for those who reported both types of stressors was 8.48.

Fewer than half of the study participants (44%) reported that their clinician asked about their mood during pregnancy, while 54% reported that they were asked about their mood during the postpartum period.

Dr. LaCoursiere acknowledged certain limitations of the study, including the self-reported height and weight data and the fact that while women who were being actively treated for depression were excluded, the questionnaire was not administered antepartum or immediately post partum. Therefore, she said, “this cohort may represent women who were depressed antenatally and continued to have antenatal depression into the postpartum period.”

Dr. LaCoursiere reported that she had no conflicts to disclose.

SAN DIEGO — Prepregnancy obesity is an independent risk factor for postpartum depression, a large analysis demonstrates.

Common pregnancy stressors such as divorce or separation or being involved in a physical fight also were found to increase the risk.

“While I advocate that we should screen all women for depression, I think there are subsets of women whose risk is so high that we should either be identifying ways to prevent depression in this group or carry out early targeted surveillance and treatment,” Dr. D. Yvette LaCoursiere said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

“So if a woman comes to pregnancy with a BMI of greater than 35 kg/m

Previous research has shown that women with a history of depression are at increased risk of developing postpartum depression, but the possible association between prepregnancy obesity and subsequent postpartum depression has not been sufficiently studied, said Dr. LaCoursiere of the department of obstetrics and gynecology at the University of California at San Diego.

She and her associate, Dr. Michael W. Varner of the division of maternal-fetal medicine at the University of Utah, Salt Lake City, followed 1,053 women who were delivered of a term, singleton, live-born infant at one of four hospitals in Utah between 2005 and 2007.

At intake, the researchers obtained demographic and anthropomorphic information and pregnancy stressors, in addition to a psychiatric, medical, obstetric, and family history. Participants were also asked to complete the Pregnancy Risk Assessment Monitoring System (PRAMS).

Self-reported prepregnancy body mass index was stratified by the World Health Organization classification system for underweight (less than 18.5 kg/m

At 6–8 weeks after delivery, the women were asked to complete the Edinburgh Postnatal Depression Scale. Postpartum depression was defined as a score of 12 or more.

Dr. LaCoursiere reported that the rate of postpartum depression was directly related to the extremes of body mass index. For example, the rates of postpartum depression among those in the underweight, normal weight, and preobese groups were 18%, 14%, and 19%, respectively, while the rates among those in the obese class I, class II, and class III groups were 19%, 32%, and 40%, respectively.

After the researchers controlled for demographic, psychological, medical, and obstetrical risk factors, the overall adjusted odds ratio of postpartum depression was 2.87 for obese class II women and 3.94 for obese class III women.

In the PRAMS stressors component of the study, Dr. LaCoursiere and Dr. Varner found that common pregnancy stressors increase the risk of postpartum depression. For example, the adjusted odds ratio for postpartum depression among women who reported partner-associated stressors such as divorce or arguing more than usual was 2.61, while the adjusted odds ratio for those who reported traumatic stressors such as being homeless or being involved in a physical fight was 1.66.

The adjusted odds ratio for those who reported both types of stressors was 8.48.

Fewer than half of the study participants (44%) reported that their clinician asked about their mood during pregnancy, while 54% reported that they were asked about their mood during the postpartum period.

Dr. LaCoursiere acknowledged certain limitations of the study, including the self-reported height and weight data and the fact that while women who were being actively treated for depression were excluded, the questionnaire was not administered antepartum or immediately post partum. Therefore, she said, “this cohort may represent women who were depressed antenatally and continued to have antenatal depression into the postpartum period.”

Dr. LaCoursiere reported that she had no conflicts to disclose.