Kate Johnson

HOUSTON — Controlling the intense pruritus of vulvar lichen sclerosus is important, not only for patients' quality of life, but also to reduce their risk of developing cancer, according to several experts at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

It is estimated that between 3% and 5% of untreated patients with vulvar lichen sclerosus will develop vulvar carcinoma in the following 10–20 years, said Dr. Raymond H. Kaufman, professor emeritus in obstetrics, gynecology, and pathology at Baylor College of Medicine, Houston. That compares to an annual incidence of vulvar carcinoma of 1 in 150,000 (0.0006%) in the general population. “There is an increased risk [in patients with lichen sclerosus], and even though it is small, these patients should be warned,” he said. “Generally, it's the noncompliant patients, or the scratchers, who are most at risk.” In fact, between 50% and 80% of patients with vulvar cancer have a history of lichen sclerosus, he said.

“This condition is itchy, itchy, itchy,” agreed Dr. Libby Edwards, a dermatologist who has a private practice in Charlotte, N.C. Poor control can also result in excoriations and secondary infections in many patients, she said in an interview.

A review by Dr. Kaufman found that in 88% of his patients, the clinical appearance of the vulvar skin was white and crinkled, with thickening of the skin in 38%, fissures in 30%, and phimosis in 23%. “The labia minora may fuse with the labia majora, and the tissue is easily traumatized,” said Dr. Kaufman. “Areas of ecchymosis are very common and can cause anxieties about melanoma.”

Both experts noted that testosterone cream, once thought to be an effective treatment for lichen sclerosus, is now considered no better than placebo. Dr. Kaufman recommends clobetasol ointment 0.05%, twice daily for 2 months, at bedtime for the next 2 months, and then every other day for 2 months—with a maintenance regimen of once or twice weekly or according to symptoms.

Dr. Edwards said she also recommends starting treatment with clobetasol ointment twice daily but reevaluates monthly. “Without monthly follow-up, patients often stop using the medication because their symptoms go away, and I want to monitor them for improvement and possible side effects with this very potent steroid.” When the skin texture becomes normal, she reduces the dosage to once daily three times per week. When patients are on this regimen, she said, follow-up visits are necessary only at 6-month intervals to assess for recurrence, side effects, or signs of cancer.

For those patients who do not respond to clobetasol, Dr. Kaufman recommends Elidel 1% or Protopic 0.1% cream twice a day, but he advises caution because these creams can cause significant vulvar irritation. In such cases, it may be necessary to titrate the dosage down to once a day or even every other day until the patient becomes more comfortable, he said.

Typical lichen sclerosus shows a white plaque with parchment-like texture.

Advanced disease can cause loss of the labia minora and scar the clitoral hood. Photos courtesy Dr. Libby Edwards

HOUSTON — Controlling the intense pruritus of vulvar lichen sclerosus is important, not only for patients' quality of life, but also to reduce their risk of developing cancer, according to several experts at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

It is estimated that between 3% and 5% of untreated patients with vulvar lichen sclerosus will develop vulvar carcinoma in the following 10–20 years, said Dr. Raymond H. Kaufman, professor emeritus in obstetrics, gynecology, and pathology at Baylor College of Medicine, Houston. That compares to an annual incidence of vulvar carcinoma of 1 in 150,000 (0.0006%) in the general population. “There is an increased risk [in patients with lichen sclerosus], and even though it is small, these patients should be warned,” he said. “Generally, it's the noncompliant patients, or the scratchers, who are most at risk.” In fact, between 50% and 80% of patients with vulvar cancer have a history of lichen sclerosus, he said.

“This condition is itchy, itchy, itchy,” agreed Dr. Libby Edwards, a dermatologist who has a private practice in Charlotte, N.C. Poor control can also result in excoriations and secondary infections in many patients, she said in an interview.

A review by Dr. Kaufman found that in 88% of his patients, the clinical appearance of the vulvar skin was white and crinkled, with thickening of the skin in 38%, fissures in 30%, and phimosis in 23%. “The labia minora may fuse with the labia majora, and the tissue is easily traumatized,” said Dr. Kaufman. “Areas of ecchymosis are very common and can cause anxieties about melanoma.”

Both experts noted that testosterone cream, once thought to be an effective treatment for lichen sclerosus, is now considered no better than placebo. Dr. Kaufman recommends clobetasol ointment 0.05%, twice daily for 2 months, at bedtime for the next 2 months, and then every other day for 2 months—with a maintenance regimen of once or twice weekly or according to symptoms.

Dr. Edwards said she also recommends starting treatment with clobetasol ointment twice daily but reevaluates monthly. “Without monthly follow-up, patients often stop using the medication because their symptoms go away, and I want to monitor them for improvement and possible side effects with this very potent steroid.” When the skin texture becomes normal, she reduces the dosage to once daily three times per week. When patients are on this regimen, she said, follow-up visits are necessary only at 6-month intervals to assess for recurrence, side effects, or signs of cancer.

For those patients who do not respond to clobetasol, Dr. Kaufman recommends Elidel 1% or Protopic 0.1% cream twice a day, but he advises caution because these creams can cause significant vulvar irritation. In such cases, it may be necessary to titrate the dosage down to once a day or even every other day until the patient becomes more comfortable, he said.

Typical lichen sclerosus shows a white plaque with parchment-like texture.

Advanced disease can cause loss of the labia minora and scar the clitoral hood. Photos courtesy Dr. Libby Edwards

HOUSTON — Controlling the intense pruritus of vulvar lichen sclerosus is important, not only for patients' quality of life, but also to reduce their risk of developing cancer, according to several experts at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

It is estimated that between 3% and 5% of untreated patients with vulvar lichen sclerosus will develop vulvar carcinoma in the following 10–20 years, said Dr. Raymond H. Kaufman, professor emeritus in obstetrics, gynecology, and pathology at Baylor College of Medicine, Houston. That compares to an annual incidence of vulvar carcinoma of 1 in 150,000 (0.0006%) in the general population. “There is an increased risk [in patients with lichen sclerosus], and even though it is small, these patients should be warned,” he said. “Generally, it's the noncompliant patients, or the scratchers, who are most at risk.” In fact, between 50% and 80% of patients with vulvar cancer have a history of lichen sclerosus, he said.

“This condition is itchy, itchy, itchy,” agreed Dr. Libby Edwards, a dermatologist who has a private practice in Charlotte, N.C. Poor control can also result in excoriations and secondary infections in many patients, she said in an interview.

A review by Dr. Kaufman found that in 88% of his patients, the clinical appearance of the vulvar skin was white and crinkled, with thickening of the skin in 38%, fissures in 30%, and phimosis in 23%. “The labia minora may fuse with the labia majora, and the tissue is easily traumatized,” said Dr. Kaufman. “Areas of ecchymosis are very common and can cause anxieties about melanoma.”

Both experts noted that testosterone cream, once thought to be an effective treatment for lichen sclerosus, is now considered no better than placebo. Dr. Kaufman recommends clobetasol ointment 0.05%, twice daily for 2 months, at bedtime for the next 2 months, and then every other day for 2 months—with a maintenance regimen of once or twice weekly or according to symptoms.

Dr. Edwards said she also recommends starting treatment with clobetasol ointment twice daily but reevaluates monthly. “Without monthly follow-up, patients often stop using the medication because their symptoms go away, and I want to monitor them for improvement and possible side effects with this very potent steroid.” When the skin texture becomes normal, she reduces the dosage to once daily three times per week. When patients are on this regimen, she said, follow-up visits are necessary only at 6-month intervals to assess for recurrence, side effects, or signs of cancer.

For those patients who do not respond to clobetasol, Dr. Kaufman recommends Elidel 1% or Protopic 0.1% cream twice a day, but he advises caution because these creams can cause significant vulvar irritation. In such cases, it may be necessary to titrate the dosage down to once a day or even every other day until the patient becomes more comfortable, he said.

Typical lichen sclerosus shows a white plaque with parchment-like texture.

Advanced disease can cause loss of the labia minora and scar the clitoral hood. Photos courtesy Dr. Libby Edwards

HOUSTON — Intralesional steroid injections or systemic therapy with tumor necrosis factor-α inhibitors are two nonsurgical treatments that are well worth considering for hidradenitis suppurativa, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Intralesional steroid injections are perfect if the woman has only two or three lesions and they only become active every couple of weeks,” he said in an interview. “It's easier and less painful than incising, but reactivation is almost certain to occur. It's almost like first aid—not a definitive approach.”

Dr. Lynch recommended using triamcinolone acetonide at a dose of 10 mg/cc for this treatment.

“With a 27- or 30-gauge needle, you can place one- or two-tenths of a cc into a fingertip- or thumb-sized nodule and that will really quiet it down for a couple of weeks at least, maybe a month or two,” said Dr. Lynch, professor and chair of the dermatology department at the University of California, Davis.

Dr. Lynch said systemic therapy with tumor necrosis factor-α (TNF-α) inhibitors is the second nonsurgical treatment about which he recently has become excited. “TNF-α inhibitors seem to be particularly effective for granulomatous type infections and, of course, that's exactly what's happening in hidradenitis suppurativa,” he said.

Although use of these drugs for hidradenitis is considered off label, the therapy's safety record now is good for treating Crohn's disease, rheumatoid arthritis, psoriasis, and psoriatic arthritis, he said. However, he warned insurance coverage is difficult to get, and the cost is prohibitive at $10,000–$15,000 a year.

HOUSTON — Intralesional steroid injections or systemic therapy with tumor necrosis factor-α inhibitors are two nonsurgical treatments that are well worth considering for hidradenitis suppurativa, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Intralesional steroid injections are perfect if the woman has only two or three lesions and they only become active every couple of weeks,” he said in an interview. “It's easier and less painful than incising, but reactivation is almost certain to occur. It's almost like first aid—not a definitive approach.”

Dr. Lynch recommended using triamcinolone acetonide at a dose of 10 mg/cc for this treatment.

“With a 27- or 30-gauge needle, you can place one- or two-tenths of a cc into a fingertip- or thumb-sized nodule and that will really quiet it down for a couple of weeks at least, maybe a month or two,” said Dr. Lynch, professor and chair of the dermatology department at the University of California, Davis.

Dr. Lynch said systemic therapy with tumor necrosis factor-α (TNF-α) inhibitors is the second nonsurgical treatment about which he recently has become excited. “TNF-α inhibitors seem to be particularly effective for granulomatous type infections and, of course, that's exactly what's happening in hidradenitis suppurativa,” he said.

Although use of these drugs for hidradenitis is considered off label, the therapy's safety record now is good for treating Crohn's disease, rheumatoid arthritis, psoriasis, and psoriatic arthritis, he said. However, he warned insurance coverage is difficult to get, and the cost is prohibitive at $10,000–$15,000 a year.

HOUSTON — Intralesional steroid injections or systemic therapy with tumor necrosis factor-α inhibitors are two nonsurgical treatments that are well worth considering for hidradenitis suppurativa, Dr. Peter J. Lynch said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“Intralesional steroid injections are perfect if the woman has only two or three lesions and they only become active every couple of weeks,” he said in an interview. “It's easier and less painful than incising, but reactivation is almost certain to occur. It's almost like first aid—not a definitive approach.”

Dr. Lynch recommended using triamcinolone acetonide at a dose of 10 mg/cc for this treatment.

“With a 27- or 30-gauge needle, you can place one- or two-tenths of a cc into a fingertip- or thumb-sized nodule and that will really quiet it down for a couple of weeks at least, maybe a month or two,” said Dr. Lynch, professor and chair of the dermatology department at the University of California, Davis.

Dr. Lynch said systemic therapy with tumor necrosis factor-α (TNF-α) inhibitors is the second nonsurgical treatment about which he recently has become excited. “TNF-α inhibitors seem to be particularly effective for granulomatous type infections and, of course, that's exactly what's happening in hidradenitis suppurativa,” he said.

Although use of these drugs for hidradenitis is considered off label, the therapy's safety record now is good for treating Crohn's disease, rheumatoid arthritis, psoriasis, and psoriatic arthritis, he said. However, he warned insurance coverage is difficult to get, and the cost is prohibitive at $10,000–$15,000 a year.

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris.

Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 years or under. DR. BERENSON

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris.

Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 years or under. DR. BERENSON

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris.

Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 years or under. DR. BERENSON

Women who become pregnant after bariatric surgery should experience fewer complications and adverse outcomes than if they had remained obese if managed appropriately, according to experts.

“There's more risk for obese patients who become pregnant than for pregnant patients who've had bariatric surgery and lost weight,” said Dr. Jacques S. Abramowicz, codirector of the fetal and neonatal medicine program, professor of obstetrics and gynecology, and director of ob.gyn. ultrasound at Rush University Medical Center in Chicago.

“Once women have had the bariatric surgery, as long as they make an effort to wait the recommended year before getting pregnant, we are more than happy to take care of them,” agreed Dr. Laura Riley, director of labor and delivery at Massachusetts General Hospital and a high-risk obstetrician.

Dr. Riley chaired the committee that wrote the American College of Obstetricians and Gynecologists Committee Opinion (#315) on Obesity in Pregnancy in 2005. It recommends that women wait 12–18 months after bariatric surgery before conceiving to allow time for weight loss and postsurgical adjustment, she said in an interview (see box).

“I do a fair number of prepregnancy consultations, and I've seen many women who at 6 months after bariatric surgery are not ready to become pregnant because they haven't yet gotten the full effect of the surgery, so their obesity-related risks are essentially the same as before the surgery,” Dr. Riley said.

Also, it takes time to figure out which foods and how much of them they can eat. “It's important to allow time for surgical healing,” she said.

Nutritional issues are acute in the early postsurgical phase, but this risk is never eliminated entirely, Dr. Abramowicz said in an interview: “Both malabsorptive and restrictive bariatric surgery can cause deficiencies in folic acid, iron, vitamin B₁₂, and calcium—so supplementation and nutritional counseling are important.” The greatest risk lies with unintended pregnancies, he said. “If it's a planned pregnancy, [the women] can take supplements from the start, but what happens often, if they are not warned, is that—because they lose so much weight—their fertility returns unexpectedly, and they become pregnant but do not realize it because they are used to irregular cycles.”

At least one study suggests “patient and physician anxiety over poor outcome of pregnancy during the first year can be allayed” (Am. J. Surg. 2006;192:762–6). A retrospective review of 21 pregnancies conceived within 1 year of bariatric surgery and 13 conceived after 1 year found “no significant episodes of malnutrition, adverse fetal outcomes, or intrauterine growth retardation” in either group. However, compared with the group that conceived later, patients in the early group did have a significantly higher miscarriage rate (24% vs. 0%), which was also higher than the 15%–20% incidence seen in the general population, noted Dr. Tuoc N. Dao and colleagues from the department of surgery at Baylor University Medical Center in Dallas.

Studies on post-bariatric surgery pregnancies are sparse in the obstetric literature, but in one comparison of all pregnancies with (298) and without (158,912) a history of bariatric surgery between 1998 and 2002 at Soroka University Medical Center, Beer-Sheva, Israel, Dr. Eyal Sheiner and colleagues found no association between the surgery and adverse perinatal outcomes (Am. J. Obstet. Gynecol. 2004;190:1335–40).

Dr. Abramowicz participated in a subsequent study with Dr. Sheiner, which included pregnancies with gestational diabetes from the first study, comparing 28 pregnancies with a history of bariatric surgery with 7,986 pregnancies without such a history. “Perinatal outcome was comparable between the groups, and no significant differences were noted with regard to complications such as perinatal mortality, congenital malformations, and low Apgar scores at 1 and 5 minutes,” they wrote (Am. J. Obstet. Gynecol. 2006;194:431–5).

A government report released in January shows a ninefold increase from 1998 to 2004 in the number of bariatric surgeries performed in the United States (from 13,386 to 121,055). “We're doing a better job of making women aware of the extreme pregnancy complications if they are obese—and they are turning to bariatric surgery more than they did in the past,” said Dr. Riley.

Four Points to Reinforce

The ACOG Committee Opinion #315 on Obesity in Pregnancy recommends that women who have undergone bariatric surgery require the following counseling before and during pregnancy:

▸ Patients with adjustable gastric banding should be advised that they are at risk of becoming pregnant unexpectedly after weight loss following surgery.

▸ All patients are advised to delay pregnancy for 12–18 months after surgery to avoid pregnancy during the rapid weight-loss phase.

▸ Women with a gastric band should be monitored by their general surgeons during pregnancy because adjustment of the band may be necessary.

▸ Patients should be evaluated for nutritional deficiencies and vitamin supplementation when necessary.

Women who become pregnant after bariatric surgery should experience fewer complications and adverse outcomes than if they had remained obese if managed appropriately, according to experts.

“There's more risk for obese patients who become pregnant than for pregnant patients who've had bariatric surgery and lost weight,” said Dr. Jacques S. Abramowicz, codirector of the fetal and neonatal medicine program, professor of obstetrics and gynecology, and director of ob.gyn. ultrasound at Rush University Medical Center in Chicago.

“Once women have had the bariatric surgery, as long as they make an effort to wait the recommended year before getting pregnant, we are more than happy to take care of them,” agreed Dr. Laura Riley, director of labor and delivery at Massachusetts General Hospital and a high-risk obstetrician.

Dr. Riley chaired the committee that wrote the American College of Obstetricians and Gynecologists Committee Opinion (#315) on Obesity in Pregnancy in 2005. It recommends that women wait 12–18 months after bariatric surgery before conceiving to allow time for weight loss and postsurgical adjustment, she said in an interview (see box).

“I do a fair number of prepregnancy consultations, and I've seen many women who at 6 months after bariatric surgery are not ready to become pregnant because they haven't yet gotten the full effect of the surgery, so their obesity-related risks are essentially the same as before the surgery,” Dr. Riley said.

Also, it takes time to figure out which foods and how much of them they can eat. “It's important to allow time for surgical healing,” she said.

Nutritional issues are acute in the early postsurgical phase, but this risk is never eliminated entirely, Dr. Abramowicz said in an interview: “Both malabsorptive and restrictive bariatric surgery can cause deficiencies in folic acid, iron, vitamin B₁₂, and calcium—so supplementation and nutritional counseling are important.” The greatest risk lies with unintended pregnancies, he said. “If it's a planned pregnancy, [the women] can take supplements from the start, but what happens often, if they are not warned, is that—because they lose so much weight—their fertility returns unexpectedly, and they become pregnant but do not realize it because they are used to irregular cycles.”

At least one study suggests “patient and physician anxiety over poor outcome of pregnancy during the first year can be allayed” (Am. J. Surg. 2006;192:762–6). A retrospective review of 21 pregnancies conceived within 1 year of bariatric surgery and 13 conceived after 1 year found “no significant episodes of malnutrition, adverse fetal outcomes, or intrauterine growth retardation” in either group. However, compared with the group that conceived later, patients in the early group did have a significantly higher miscarriage rate (24% vs. 0%), which was also higher than the 15%–20% incidence seen in the general population, noted Dr. Tuoc N. Dao and colleagues from the department of surgery at Baylor University Medical Center in Dallas.

Studies on post-bariatric surgery pregnancies are sparse in the obstetric literature, but in one comparison of all pregnancies with (298) and without (158,912) a history of bariatric surgery between 1998 and 2002 at Soroka University Medical Center, Beer-Sheva, Israel, Dr. Eyal Sheiner and colleagues found no association between the surgery and adverse perinatal outcomes (Am. J. Obstet. Gynecol. 2004;190:1335–40).

Dr. Abramowicz participated in a subsequent study with Dr. Sheiner, which included pregnancies with gestational diabetes from the first study, comparing 28 pregnancies with a history of bariatric surgery with 7,986 pregnancies without such a history. “Perinatal outcome was comparable between the groups, and no significant differences were noted with regard to complications such as perinatal mortality, congenital malformations, and low Apgar scores at 1 and 5 minutes,” they wrote (Am. J. Obstet. Gynecol. 2006;194:431–5).

A government report released in January shows a ninefold increase from 1998 to 2004 in the number of bariatric surgeries performed in the United States (from 13,386 to 121,055). “We're doing a better job of making women aware of the extreme pregnancy complications if they are obese—and they are turning to bariatric surgery more than they did in the past,” said Dr. Riley.

Four Points to Reinforce

The ACOG Committee Opinion #315 on Obesity in Pregnancy recommends that women who have undergone bariatric surgery require the following counseling before and during pregnancy:

▸ Patients with adjustable gastric banding should be advised that they are at risk of becoming pregnant unexpectedly after weight loss following surgery.

▸ All patients are advised to delay pregnancy for 12–18 months after surgery to avoid pregnancy during the rapid weight-loss phase.

▸ Women with a gastric band should be monitored by their general surgeons during pregnancy because adjustment of the band may be necessary.

▸ Patients should be evaluated for nutritional deficiencies and vitamin supplementation when necessary.

Women who become pregnant after bariatric surgery should experience fewer complications and adverse outcomes than if they had remained obese if managed appropriately, according to experts.

“There's more risk for obese patients who become pregnant than for pregnant patients who've had bariatric surgery and lost weight,” said Dr. Jacques S. Abramowicz, codirector of the fetal and neonatal medicine program, professor of obstetrics and gynecology, and director of ob.gyn. ultrasound at Rush University Medical Center in Chicago.

“Once women have had the bariatric surgery, as long as they make an effort to wait the recommended year before getting pregnant, we are more than happy to take care of them,” agreed Dr. Laura Riley, director of labor and delivery at Massachusetts General Hospital and a high-risk obstetrician.

Dr. Riley chaired the committee that wrote the American College of Obstetricians and Gynecologists Committee Opinion (#315) on Obesity in Pregnancy in 2005. It recommends that women wait 12–18 months after bariatric surgery before conceiving to allow time for weight loss and postsurgical adjustment, she said in an interview (see box).

“I do a fair number of prepregnancy consultations, and I've seen many women who at 6 months after bariatric surgery are not ready to become pregnant because they haven't yet gotten the full effect of the surgery, so their obesity-related risks are essentially the same as before the surgery,” Dr. Riley said.

Also, it takes time to figure out which foods and how much of them they can eat. “It's important to allow time for surgical healing,” she said.

Nutritional issues are acute in the early postsurgical phase, but this risk is never eliminated entirely, Dr. Abramowicz said in an interview: “Both malabsorptive and restrictive bariatric surgery can cause deficiencies in folic acid, iron, vitamin B₁₂, and calcium—so supplementation and nutritional counseling are important.” The greatest risk lies with unintended pregnancies, he said. “If it's a planned pregnancy, [the women] can take supplements from the start, but what happens often, if they are not warned, is that—because they lose so much weight—their fertility returns unexpectedly, and they become pregnant but do not realize it because they are used to irregular cycles.”

At least one study suggests “patient and physician anxiety over poor outcome of pregnancy during the first year can be allayed” (Am. J. Surg. 2006;192:762–6). A retrospective review of 21 pregnancies conceived within 1 year of bariatric surgery and 13 conceived after 1 year found “no significant episodes of malnutrition, adverse fetal outcomes, or intrauterine growth retardation” in either group. However, compared with the group that conceived later, patients in the early group did have a significantly higher miscarriage rate (24% vs. 0%), which was also higher than the 15%–20% incidence seen in the general population, noted Dr. Tuoc N. Dao and colleagues from the department of surgery at Baylor University Medical Center in Dallas.

Studies on post-bariatric surgery pregnancies are sparse in the obstetric literature, but in one comparison of all pregnancies with (298) and without (158,912) a history of bariatric surgery between 1998 and 2002 at Soroka University Medical Center, Beer-Sheva, Israel, Dr. Eyal Sheiner and colleagues found no association between the surgery and adverse perinatal outcomes (Am. J. Obstet. Gynecol. 2004;190:1335–40).

Dr. Abramowicz participated in a subsequent study with Dr. Sheiner, which included pregnancies with gestational diabetes from the first study, comparing 28 pregnancies with a history of bariatric surgery with 7,986 pregnancies without such a history. “Perinatal outcome was comparable between the groups, and no significant differences were noted with regard to complications such as perinatal mortality, congenital malformations, and low Apgar scores at 1 and 5 minutes,” they wrote (Am. J. Obstet. Gynecol. 2006;194:431–5).

A government report released in January shows a ninefold increase from 1998 to 2004 in the number of bariatric surgeries performed in the United States (from 13,386 to 121,055). “We're doing a better job of making women aware of the extreme pregnancy complications if they are obese—and they are turning to bariatric surgery more than they did in the past,” said Dr. Riley.

Four Points to Reinforce

The ACOG Committee Opinion #315 on Obesity in Pregnancy recommends that women who have undergone bariatric surgery require the following counseling before and during pregnancy:

▸ Patients with adjustable gastric banding should be advised that they are at risk of becoming pregnant unexpectedly after weight loss following surgery.

▸ All patients are advised to delay pregnancy for 12–18 months after surgery to avoid pregnancy during the rapid weight-loss phase.

▸ Women with a gastric band should be monitored by their general surgeons during pregnancy because adjustment of the band may be necessary.

▸ Patients should be evaluated for nutritional deficiencies and vitamin supplementation when necessary.

Children who lose sleep may have an increased risk of weight gain, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and fuels the argument for later school day start times, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study, 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also said “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The link between sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators said strategies toward earlier bedtimes and later wake times depending on age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”

Children who lose sleep may have an increased risk of weight gain, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and fuels the argument for later school day start times, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study, 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also said “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The link between sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators said strategies toward earlier bedtimes and later wake times depending on age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”

Children who lose sleep may have an increased risk of weight gain, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and fuels the argument for later school day start times, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study, 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also said “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The link between sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators said strategies toward earlier bedtimes and later wake times depending on age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”

HOUSTON — Women with Crohn's disease can sometimes present with knifelike vulvar ulcers that are very specific to the disorder and may be its only manifestation, according to several experts who spoke at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“There are three things in the vulvar or perianal area that might make you think of unrecognized Crohn's: knifelike ulcerations, vulvar edema that has no other cause, or fistula around the anus,” said Dr. Libby Edwards, a dermatologist in private practice in Charlotte, N.C. “It has been said that vulvar Crohn's is rare, but it is not. It's uncommon but it's not rare. I see it several times a year, and most gynecologists will see it without necessarily recognizing what it is,” she said in an interview.

Although vulvar signs may be the first presentation of Crohn's for some patients, this tends to be the exception, said Dr. Hope K. Haefner, professor of obstetrics and gynecology at the University of Michigan and director of the university's Center for Vulvar Diseases in Ann Arbor.

“There is the rare patient who doesn't have any gastrointestinal symptoms and might develop them later, but usually the majority already have a diagnosis of gastrointestinal Crohn's and are seeking gynecologic care for their vulvar symptoms,” she said in an interview. In her opinion, perianal fistulae may be the most common of the three gynecologic manifestations of Crohn's. “I see them every couple of months, in children and in the elderly—there's a big age range,” she said.

Vulvar and perianal Crohn's is a marker for severe disease that needs to be aggressively treated systemically, said Dr. Edwards, also of the department of dermatology at the University of North Carolina at Chapel Hill. “First of all, if [these patients] don't have an aggressive gastroenterologist, they really need one,” she said, adding that aggressive systemic treatment for Crohn's might relieve some vulvar symptoms. But, she said, patients also need local vulvar care. “These patients get secondary infections, and when they do, they need oral antibiotics—maybe even on a long-term basis if they have open, draining sores.” In addition, both oral antibiotics and immunosuppressive therapy for Crohn's can make patients susceptible to yeast infections, which may require weekly antifungal therapy, she said.

“Knife-cut” ulcerations in skin folds are pathognomonic for vulvar Crohn's. Courtesy Dr. Libby Edwards

Fistulous tracts on the vulva are also a characteristic marker for Crohn's. Courtesy Dr. Hope K. Haefner

Perianal Crohn's consists of large anal skin tags, perianal edema, and fistulae. Courtesy Dr. Hope K. Haefner

HOUSTON — Women with Crohn's disease can sometimes present with knifelike vulvar ulcers that are very specific to the disorder and may be its only manifestation, according to several experts who spoke at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“There are three things in the vulvar or perianal area that might make you think of unrecognized Crohn's: knifelike ulcerations, vulvar edema that has no other cause, or fistula around the anus,” said Dr. Libby Edwards, a dermatologist in private practice in Charlotte, N.C. “It has been said that vulvar Crohn's is rare, but it is not. It's uncommon but it's not rare. I see it several times a year, and most gynecologists will see it without necessarily recognizing what it is,” she said in an interview.

Although vulvar signs may be the first presentation of Crohn's for some patients, this tends to be the exception, said Dr. Hope K. Haefner, professor of obstetrics and gynecology at the University of Michigan and director of the university's Center for Vulvar Diseases in Ann Arbor.

“There is the rare patient who doesn't have any gastrointestinal symptoms and might develop them later, but usually the majority already have a diagnosis of gastrointestinal Crohn's and are seeking gynecologic care for their vulvar symptoms,” she said in an interview. In her opinion, perianal fistulae may be the most common of the three gynecologic manifestations of Crohn's. “I see them every couple of months, in children and in the elderly—there's a big age range,” she said.

Vulvar and perianal Crohn's is a marker for severe disease that needs to be aggressively treated systemically, said Dr. Edwards, also of the department of dermatology at the University of North Carolina at Chapel Hill. “First of all, if [these patients] don't have an aggressive gastroenterologist, they really need one,” she said, adding that aggressive systemic treatment for Crohn's might relieve some vulvar symptoms. But, she said, patients also need local vulvar care. “These patients get secondary infections, and when they do, they need oral antibiotics—maybe even on a long-term basis if they have open, draining sores.” In addition, both oral antibiotics and immunosuppressive therapy for Crohn's can make patients susceptible to yeast infections, which may require weekly antifungal therapy, she said.

“Knife-cut” ulcerations in skin folds are pathognomonic for vulvar Crohn's. Courtesy Dr. Libby Edwards

Fistulous tracts on the vulva are also a characteristic marker for Crohn's. Courtesy Dr. Hope K. Haefner

Perianal Crohn's consists of large anal skin tags, perianal edema, and fistulae. Courtesy Dr. Hope K. Haefner

HOUSTON — Women with Crohn's disease can sometimes present with knifelike vulvar ulcers that are very specific to the disorder and may be its only manifestation, according to several experts who spoke at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“There are three things in the vulvar or perianal area that might make you think of unrecognized Crohn's: knifelike ulcerations, vulvar edema that has no other cause, or fistula around the anus,” said Dr. Libby Edwards, a dermatologist in private practice in Charlotte, N.C. “It has been said that vulvar Crohn's is rare, but it is not. It's uncommon but it's not rare. I see it several times a year, and most gynecologists will see it without necessarily recognizing what it is,” she said in an interview.

Although vulvar signs may be the first presentation of Crohn's for some patients, this tends to be the exception, said Dr. Hope K. Haefner, professor of obstetrics and gynecology at the University of Michigan and director of the university's Center for Vulvar Diseases in Ann Arbor.

“There is the rare patient who doesn't have any gastrointestinal symptoms and might develop them later, but usually the majority already have a diagnosis of gastrointestinal Crohn's and are seeking gynecologic care for their vulvar symptoms,” she said in an interview. In her opinion, perianal fistulae may be the most common of the three gynecologic manifestations of Crohn's. “I see them every couple of months, in children and in the elderly—there's a big age range,” she said.

Vulvar and perianal Crohn's is a marker for severe disease that needs to be aggressively treated systemically, said Dr. Edwards, also of the department of dermatology at the University of North Carolina at Chapel Hill. “First of all, if [these patients] don't have an aggressive gastroenterologist, they really need one,” she said, adding that aggressive systemic treatment for Crohn's might relieve some vulvar symptoms. But, she said, patients also need local vulvar care. “These patients get secondary infections, and when they do, they need oral antibiotics—maybe even on a long-term basis if they have open, draining sores.” In addition, both oral antibiotics and immunosuppressive therapy for Crohn's can make patients susceptible to yeast infections, which may require weekly antifungal therapy, she said.

“Knife-cut” ulcerations in skin folds are pathognomonic for vulvar Crohn's. Courtesy Dr. Libby Edwards

Fistulous tracts on the vulva are also a characteristic marker for Crohn's. Courtesy Dr. Hope K. Haefner

Perianal Crohn's consists of large anal skin tags, perianal edema, and fistulae. Courtesy Dr. Hope K. Haefner

Cigarette smoke and breast-feeding respectively increase and decrease the risk of rheumatoid factor positivity in children who have no genetic susceptibility to rheumatoid arthritis, according to recent study results.

However, among children who do have genetic susceptibility to the disease, these environmental factors are not associated with rheumatoid factor positivity, reported Kendra A. Young of the University of Colorado at Denver and Health Sciences Center and her colleagues (Ann. Rheum. Dis. 2007;66:179–83).

The observation could possibly be related to “a multi-hit aetiology,” suggested the authors, “where those without the genetic susceptibility marker need environmental exposures to convert to autoantibody positivity, whereas those who already have a genetic susceptibility marker do not need these exposures to become positive.”

The study included 651 children who made up a subgroup of the Diabetes Autoimmunity Study in the Young (DAISY), a prospective study of the natural history of environmental risk factors of type 1 diabetes in genetically predisposed children. Participants in DAISY were selected if they had either a genetic susceptibility to diabetes identified by the presence of HLA-DR4 and -DR3 alleles or a parent or sibling with type 1 diabetes, regardless of their HLA genotype. HLA-DR4 alleles are also associated with an increased risk of rheumatoid arthritis and polyarticular juvenile rheumatoid arthritis (JRA), noted the authors.

The subgroup of children was selected for the current study because they had also had their blood tested for rheumatoid factor—an intermediate phenotype of RA and polyarticular JRA.

All study patients had data collected on sociodemographic factors and perinatal variables including birth order, mother's education, race/ethnicity, mother's age at child's birth, and mother's smoking status during pregnancy. Data on infant diet as well as regular height, weight, and body mass index measurements were recorded. Prospective data were also collected on the child's exposure to tobacco smoke.

A total of 23 of the 651 children tested positive for rheumatoid factor. An analysis of all variables “strongly suggested that risk factors for autoantibody positivity differed by HLA-DR status,” wrote the authors. They therefore performed separate analyses in children who were and were not HLA-DR4 positive.

The study found that, in children who were HLA-DR4 positive, no risk factors were associated with the presence of rheumatoid factor. But in children with no HLA-DR4 alleles, breast-feeding for more than 3 months was protective (odds ratio 0.18), and caregiver (but not parental) smoking increased the risk (OR 5.38). Additionally, compared with children who were rheumatoid factor negative, children with rheumatoid factor were more likely to be of an ethnic/racial background other than non-Hispanic white (OR 6.94).

“Examination of the risk factors for rheumatoid factor positivity in healthy children may yield important clues as to the early pathogenesis of polyarticular JRA or, potentially, seropositive rheumatoid arthritis in general,” they wrote. “An additional follow-up of this and other cohorts of children is necessary to elucidate whether these influences result in clinical diseases,” they concluded.

Cigarette smoke and breast-feeding respectively increase and decrease the risk of rheumatoid factor positivity in children who have no genetic susceptibility to rheumatoid arthritis, according to recent study results.

However, among children who do have genetic susceptibility to the disease, these environmental factors are not associated with rheumatoid factor positivity, reported Kendra A. Young of the University of Colorado at Denver and Health Sciences Center and her colleagues (Ann. Rheum. Dis. 2007;66:179–83).

The observation could possibly be related to “a multi-hit aetiology,” suggested the authors, “where those without the genetic susceptibility marker need environmental exposures to convert to autoantibody positivity, whereas those who already have a genetic susceptibility marker do not need these exposures to become positive.”

The study included 651 children who made up a subgroup of the Diabetes Autoimmunity Study in the Young (DAISY), a prospective study of the natural history of environmental risk factors of type 1 diabetes in genetically predisposed children. Participants in DAISY were selected if they had either a genetic susceptibility to diabetes identified by the presence of HLA-DR4 and -DR3 alleles or a parent or sibling with type 1 diabetes, regardless of their HLA genotype. HLA-DR4 alleles are also associated with an increased risk of rheumatoid arthritis and polyarticular juvenile rheumatoid arthritis (JRA), noted the authors.

The subgroup of children was selected for the current study because they had also had their blood tested for rheumatoid factor—an intermediate phenotype of RA and polyarticular JRA.

All study patients had data collected on sociodemographic factors and perinatal variables including birth order, mother's education, race/ethnicity, mother's age at child's birth, and mother's smoking status during pregnancy. Data on infant diet as well as regular height, weight, and body mass index measurements were recorded. Prospective data were also collected on the child's exposure to tobacco smoke.

A total of 23 of the 651 children tested positive for rheumatoid factor. An analysis of all variables “strongly suggested that risk factors for autoantibody positivity differed by HLA-DR status,” wrote the authors. They therefore performed separate analyses in children who were and were not HLA-DR4 positive.

The study found that, in children who were HLA-DR4 positive, no risk factors were associated with the presence of rheumatoid factor. But in children with no HLA-DR4 alleles, breast-feeding for more than 3 months was protective (odds ratio 0.18), and caregiver (but not parental) smoking increased the risk (OR 5.38). Additionally, compared with children who were rheumatoid factor negative, children with rheumatoid factor were more likely to be of an ethnic/racial background other than non-Hispanic white (OR 6.94).

“Examination of the risk factors for rheumatoid factor positivity in healthy children may yield important clues as to the early pathogenesis of polyarticular JRA or, potentially, seropositive rheumatoid arthritis in general,” they wrote. “An additional follow-up of this and other cohorts of children is necessary to elucidate whether these influences result in clinical diseases,” they concluded.

Cigarette smoke and breast-feeding respectively increase and decrease the risk of rheumatoid factor positivity in children who have no genetic susceptibility to rheumatoid arthritis, according to recent study results.

However, among children who do have genetic susceptibility to the disease, these environmental factors are not associated with rheumatoid factor positivity, reported Kendra A. Young of the University of Colorado at Denver and Health Sciences Center and her colleagues (Ann. Rheum. Dis. 2007;66:179–83).

The observation could possibly be related to “a multi-hit aetiology,” suggested the authors, “where those without the genetic susceptibility marker need environmental exposures to convert to autoantibody positivity, whereas those who already have a genetic susceptibility marker do not need these exposures to become positive.”

The study included 651 children who made up a subgroup of the Diabetes Autoimmunity Study in the Young (DAISY), a prospective study of the natural history of environmental risk factors of type 1 diabetes in genetically predisposed children. Participants in DAISY were selected if they had either a genetic susceptibility to diabetes identified by the presence of HLA-DR4 and -DR3 alleles or a parent or sibling with type 1 diabetes, regardless of their HLA genotype. HLA-DR4 alleles are also associated with an increased risk of rheumatoid arthritis and polyarticular juvenile rheumatoid arthritis (JRA), noted the authors.

The subgroup of children was selected for the current study because they had also had their blood tested for rheumatoid factor—an intermediate phenotype of RA and polyarticular JRA.

All study patients had data collected on sociodemographic factors and perinatal variables including birth order, mother's education, race/ethnicity, mother's age at child's birth, and mother's smoking status during pregnancy. Data on infant diet as well as regular height, weight, and body mass index measurements were recorded. Prospective data were also collected on the child's exposure to tobacco smoke.

A total of 23 of the 651 children tested positive for rheumatoid factor. An analysis of all variables “strongly suggested that risk factors for autoantibody positivity differed by HLA-DR status,” wrote the authors. They therefore performed separate analyses in children who were and were not HLA-DR4 positive.

The study found that, in children who were HLA-DR4 positive, no risk factors were associated with the presence of rheumatoid factor. But in children with no HLA-DR4 alleles, breast-feeding for more than 3 months was protective (odds ratio 0.18), and caregiver (but not parental) smoking increased the risk (OR 5.38). Additionally, compared with children who were rheumatoid factor negative, children with rheumatoid factor were more likely to be of an ethnic/racial background other than non-Hispanic white (OR 6.94).

“Examination of the risk factors for rheumatoid factor positivity in healthy children may yield important clues as to the early pathogenesis of polyarticular JRA or, potentially, seropositive rheumatoid arthritis in general,” they wrote. “An additional follow-up of this and other cohorts of children is necessary to elucidate whether these influences result in clinical diseases,” they concluded.

PRAGUE — Low dietary vitamin D intake is linked to an increased rate of knee osteoarthritis, Dr. Nigel K. Arden reported at the 2006 World Congress on Osteoarthritis.

The association was seen in tibiofemoral but not patellofemoral disease, and in women but not in men, Dr. Arden said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

“This effect was driven by dietary intake, not supplementation,” he added, noting that the mean dietary vitamin D intake in the 957 British patients, measured by food frequency questionnaires, was 3.2 mcg per day. A total of 39% of the cohort took vitamin D supplements, boosting their daily intake to 4.3 mcg per day, which is still “woefully below what's recommended,” said Dr. Arden of the University of Southampton (England).

The study randomized patients from the larger Hertfordshire Cohort Study, a multiple outcome study which included patients born in Hertfordshire, England, from 1931 to 1939 and still living there. It noted a 10.5% rate of symptomatic, radiographic tibiofemoral OA in the cohort at baseline; this was negatively associated with dietary vitamin D intake.

While vitamin D insufficiency is known to increase with age, it is expected to increase more significantly with the growing emphasis on sun avoidance and the use of sunscreen, Dr. Arden said.

PRAGUE — Low dietary vitamin D intake is linked to an increased rate of knee osteoarthritis, Dr. Nigel K. Arden reported at the 2006 World Congress on Osteoarthritis.

The association was seen in tibiofemoral but not patellofemoral disease, and in women but not in men, Dr. Arden said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

“This effect was driven by dietary intake, not supplementation,” he added, noting that the mean dietary vitamin D intake in the 957 British patients, measured by food frequency questionnaires, was 3.2 mcg per day. A total of 39% of the cohort took vitamin D supplements, boosting their daily intake to 4.3 mcg per day, which is still “woefully below what's recommended,” said Dr. Arden of the University of Southampton (England).

The study randomized patients from the larger Hertfordshire Cohort Study, a multiple outcome study which included patients born in Hertfordshire, England, from 1931 to 1939 and still living there. It noted a 10.5% rate of symptomatic, radiographic tibiofemoral OA in the cohort at baseline; this was negatively associated with dietary vitamin D intake.

While vitamin D insufficiency is known to increase with age, it is expected to increase more significantly with the growing emphasis on sun avoidance and the use of sunscreen, Dr. Arden said.

PRAGUE — Low dietary vitamin D intake is linked to an increased rate of knee osteoarthritis, Dr. Nigel K. Arden reported at the 2006 World Congress on Osteoarthritis.

The association was seen in tibiofemoral but not patellofemoral disease, and in women but not in men, Dr. Arden said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

“This effect was driven by dietary intake, not supplementation,” he added, noting that the mean dietary vitamin D intake in the 957 British patients, measured by food frequency questionnaires, was 3.2 mcg per day. A total of 39% of the cohort took vitamin D supplements, boosting their daily intake to 4.3 mcg per day, which is still “woefully below what's recommended,” said Dr. Arden of the University of Southampton (England).

The study randomized patients from the larger Hertfordshire Cohort Study, a multiple outcome study which included patients born in Hertfordshire, England, from 1931 to 1939 and still living there. It noted a 10.5% rate of symptomatic, radiographic tibiofemoral OA in the cohort at baseline; this was negatively associated with dietary vitamin D intake.

While vitamin D insufficiency is known to increase with age, it is expected to increase more significantly with the growing emphasis on sun avoidance and the use of sunscreen, Dr. Arden said.

PRAGUE — Blood lead levels significantly below those that are defined as toxic by the Centers for Disease Control and Prevention are associated with increased rates of moderate to severe knee osteoarthritis, reported Dr. Joanne M. Jordan, associate director of the Thurston Arthritis Research Center at the University of North Carolina, Chapel Hill.

“Essentially this is subclinical lead toxicity,” she said in an interview at the 2006 World Congress on Osteoarthritis. “This may be a new, potentially modifiable risk factor for osteoarthritis.”

In a cohort of 790 subjects, mean age 60 years, taken from the Johnston County Osteoarthritis Project Metals Exposure study, Dr. Jordan found that blood lead levels were not associated with the presence of osteoarthritis (OA), but they were associated with severity of the condition.

The subjects had a mean lead level of 2.0 mcg/dL, with most being well below the level of 10.0 mcg/dL that the CDC considers toxic, she said. After adjustment for age, gender, race, education, body mass index, current alcohol use, and current smoking status, the study found that subjects with blood lead levels in the highest quintile had a significant 30% greater chance of having moderate to severe knee OA, compared with subjects in the lowest quintile, she reported at the congress, which was sponsored by the Osteoarthritis Research Society International. Additionally, those in the highest quintile also had a 60% greater chance of having bilateral knee OA—although this difference did not reach statistical significance.

In general, blood lead levels were higher in older subjects, and in African Americans compared with whites. Additionally, there were higher lead levels in men compared with women, in subjects with less education compared with those who had more education, and in current alcohol users and smokers compared with abstainers.

Roughly 95% of the body's lead burden is stored in bone, and this store contributes 65% to blood lead levels, said Dr. Jordan. With a half-life of decades, bone and blood lead interfere with the uptake of dietary calcium and vitamin D.

'This may be a new, potentially modifiable risk factor for osteoarthritis.' DR. JORDAN

PRAGUE — Blood lead levels significantly below those that are defined as toxic by the Centers for Disease Control and Prevention are associated with increased rates of moderate to severe knee osteoarthritis, reported Dr. Joanne M. Jordan, associate director of the Thurston Arthritis Research Center at the University of North Carolina, Chapel Hill.

“Essentially this is subclinical lead toxicity,” she said in an interview at the 2006 World Congress on Osteoarthritis. “This may be a new, potentially modifiable risk factor for osteoarthritis.”

In a cohort of 790 subjects, mean age 60 years, taken from the Johnston County Osteoarthritis Project Metals Exposure study, Dr. Jordan found that blood lead levels were not associated with the presence of osteoarthritis (OA), but they were associated with severity of the condition.

The subjects had a mean lead level of 2.0 mcg/dL, with most being well below the level of 10.0 mcg/dL that the CDC considers toxic, she said. After adjustment for age, gender, race, education, body mass index, current alcohol use, and current smoking status, the study found that subjects with blood lead levels in the highest quintile had a significant 30% greater chance of having moderate to severe knee OA, compared with subjects in the lowest quintile, she reported at the congress, which was sponsored by the Osteoarthritis Research Society International. Additionally, those in the highest quintile also had a 60% greater chance of having bilateral knee OA—although this difference did not reach statistical significance.

In general, blood lead levels were higher in older subjects, and in African Americans compared with whites. Additionally, there were higher lead levels in men compared with women, in subjects with less education compared with those who had more education, and in current alcohol users and smokers compared with abstainers.

Roughly 95% of the body's lead burden is stored in bone, and this store contributes 65% to blood lead levels, said Dr. Jordan. With a half-life of decades, bone and blood lead interfere with the uptake of dietary calcium and vitamin D.

'This may be a new, potentially modifiable risk factor for osteoarthritis.' DR. JORDAN

PRAGUE — Blood lead levels significantly below those that are defined as toxic by the Centers for Disease Control and Prevention are associated with increased rates of moderate to severe knee osteoarthritis, reported Dr. Joanne M. Jordan, associate director of the Thurston Arthritis Research Center at the University of North Carolina, Chapel Hill.

“Essentially this is subclinical lead toxicity,” she said in an interview at the 2006 World Congress on Osteoarthritis. “This may be a new, potentially modifiable risk factor for osteoarthritis.”

In a cohort of 790 subjects, mean age 60 years, taken from the Johnston County Osteoarthritis Project Metals Exposure study, Dr. Jordan found that blood lead levels were not associated with the presence of osteoarthritis (OA), but they were associated with severity of the condition.

The subjects had a mean lead level of 2.0 mcg/dL, with most being well below the level of 10.0 mcg/dL that the CDC considers toxic, she said. After adjustment for age, gender, race, education, body mass index, current alcohol use, and current smoking status, the study found that subjects with blood lead levels in the highest quintile had a significant 30% greater chance of having moderate to severe knee OA, compared with subjects in the lowest quintile, she reported at the congress, which was sponsored by the Osteoarthritis Research Society International. Additionally, those in the highest quintile also had a 60% greater chance of having bilateral knee OA—although this difference did not reach statistical significance.

In general, blood lead levels were higher in older subjects, and in African Americans compared with whites. Additionally, there were higher lead levels in men compared with women, in subjects with less education compared with those who had more education, and in current alcohol users and smokers compared with abstainers.

Roughly 95% of the body's lead burden is stored in bone, and this store contributes 65% to blood lead levels, said Dr. Jordan. With a half-life of decades, bone and blood lead interfere with the uptake of dietary calcium and vitamin D.

'This may be a new, potentially modifiable risk factor for osteoarthritis.' DR. JORDAN

Children who lose sleep may have an increased risk of gaining weight, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and further fuels the argument for later starts to the school day, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study of 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, the children were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also noted that “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring in preadolescence, as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The mediating pathway between inadequate sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators suggested that a combination of strategies geared toward earlier bedtimes and later wake times depending on a child's age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”

Children who lose sleep may have an increased risk of gaining weight, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and further fuels the argument for later starts to the school day, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study of 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, the children were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also noted that “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring in preadolescence, as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The mediating pathway between inadequate sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators suggested that a combination of strategies geared toward earlier bedtimes and later wake times depending on a child's age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”

Children who lose sleep may have an increased risk of gaining weight, according to findings of a new study.

This points to the importance of sleep in the fight against obesity and further fuels the argument for later starts to the school day, reported Emily K. Snell and colleagues in Child Development.

“Encouraging parents to put their younger children to bed earlier at night and allowing both younger and older children to sleep longer in the morning, as well as urging school districts to avoid very early school start times for later elementary and middle school aged children, might represent an important and relatively low cost strategy to reduce childhood weight problems,” wrote Ms. Snell of the Department of Human Development and Social Policy and the Institute for Policy Research at Northwestern University, Chicago (Child Development 2007;78:309–23).

In a study of 2,281 children from a nationally representative survey called the Child Development Supplement of the Panel Survey of Income Dynamics, the children were aged 3–12 years at baseline and 8–17 years at follow-up. Time diaries were used on a randomly selected weekday and weekend to record sleep behavior, and then a subsample of 1,441 children were examined to see whether sleep behavior at baseline influenced weight at follow-up.

The study found “a large decline in weekday sleep across middle childhood and adolescence, driven largely by later weekday bedtimes,” a finding that the researchers described as “troubling.” While they recommend a minimum of 10–11 hours of sleep per night for younger children, a goal which the study subjects usually achieved on weekends, children as young as 7 years old were already falling short on weeknight sleep. “The fact that a substantial portion of American children achieve such small amounts of sleep should be of concern in light of findings from prior studies suggesting associations between poor sleep hygiene and decreased cognitive and social functioning,” they wrote.

The investigators also noted that “the shift towards later weekday bedtimes might begin earlier than some researchers have suspected,” occurring in preadolescence, as early as age 8 or 9 years. “There is clear evidence for the appropriateness of later bedtimes for adolescents, as these changes … may be biologically driven. … For younger children, however, the change to later bedtimes may be driven more by social factors rather than changes in biology,” they suggested.

The study also found that lost sleep shows up on the scales 5 years later—with later bedtimes for younger children (aged 3–7.9 years) having the most impact on subsequent body mass index (BMI), while later wake times were more important for older children (aged 8–12.9 years) and subsequent BMI. “Even 1 additional hour of sleep may have a significant and meaningful effect on BMI and overweight status,” they wrote, noting that at baseline, 1 extra hour of sleep above average lowered a child's risk of being overweight 5 years later—from 36% to 30%, even after controlling for baseline BMI, family socioeconomics, and race. The study found no evidence that gender or physical activity influenced the effect of sleep on BMI.

The mediating pathway between inadequate sleep and weight gain may be the disruption of hormones that regulate appetite and metabolism, suggested the authors, “with insufficient sleep hours causing reduced levels of leptin and increased levels of ghrelin, a hormonal profile associated with increased hunger and appetite for carbohydrate-rich foods.”

The investigators suggested that a combination of strategies geared toward earlier bedtimes and later wake times depending on a child's age “might well improve multiple aspects of children's health, emotional well-being, and academic performance.”