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High burden of Iodine deficiency found in Israel’s first national survey

27/03/2017

62% of school-age children and 85% of pregnant women have low iodine intakes

“High risk of impaired neurological development of the fetus in Israel”

Ministry of Health supported research effort; now, eradicating iodine deficiency will require government funding and legislation, and a government-regulated program of salt or food iodization

The first national iodine survey conducted in Israel has revealed a high burden of iodine deficiency among Israelis, posing a high risk of maternal and fetal hypothyroidism and impaired neurological development of the fetus in Israel.

The International Child Development Steering Group has identified iodine deficiency (ID) as a key global risk factor for impaired child development, and the World Health Organization’s recommends routine monitoring of population-based data on urinary iodine every five years as a means of sustainable elimination of ID. Yet Israel is among the few countries that have never performed a national iodine survey, and does not provide iodine prophylaxis, even though some of its population has suffered from ID in the past. Israel similarly lacks current data on the incidence and prevalence of thyroid disease.

Now, researchers from the Hebrew University of Jerusalem, and their colleagues at Maccabi Healthcare Services and Barzilai University Medical Center in Ashkelon in Israel, and ETH Zurich in Switzerland, with support of the Iodine Global Network, have obtained the first nationally representative data about iodine status in the Israeli population. To do this, they collected pre-discard spot-urine samples, from 1,023 school-age children and 1,074 pregnant women, representing all regions and major sectors in Israel (Arab, Jewish secular and orthodox), during 2016 at the Maccabi Healthcare Services (MHS) central laboratory.

They found a high burden of iodine deficiency in the general population: 62% of school-age children and 85% of pregnant women fall below the WHO’s adequacy range.

The median urinary iodine concentration (UIC) among Israel’s pregnant women, only 61 micrograms iodine/liter and for school-age children, the median of 83 micrograms/liter suggest that the iodine status in Israel is amongst the lowest in the world. Iodine adequacy is defined by the WHO as a population median of 150-249 micrograms/liter for pregnant women and 100-199 micrograms/liter for school-age children. Virtually no differences were seen between different ethnicities and regions of the country suggesting that low iodine status is widespread and universal throughout the country.

Adequate iodine intake is essential for thyroid function and human health throughout life. Even mild iodine deficiency might prevent children from attaining their full intellectual potential, and mild to moderate ID has been linked with decreased cognitive performance. Iodine deficiency in utero and in early childhood impairs brain development, and severe iodine deficiency causes cretinism (physical malformation, dwarfism and mental retardation) and goiter (the enlargement of the thyroid gland).

According to the researchers, the high burden of iodine insufficiency in Israel is a serious public health and clinical concern. By comparison to data from other countries with a similar extent of deficiency, these data suggest that there is a high risk of maternal and fetal hypothyroidism and impaired neurological development of the fetus in Israel. By extrapolation, given the rate of insufficiency in Israeli pregnant women, nearly all pregnant women and their children may be at risk, implying that the majority of the population could be unlikely to realize its full intellectual potential.

“The immediate implication of our findings is that we need to improve the public’s intake of iodine,” said Prof. Aron Troen, Principal Investigator at the Nutrition and Brain Health Laboratory, School of Nutrition Science, Hebrew University’s Robert H. Smith Faculty of Agriculture, Food and Environment. “It seems that as in most other countries, Israel’s food supply and our collective dietary habits do not ensure iodine sufficiency. Thus eliminating iodine deficiency and achieving optimal iodine status in Israel’s population will require a sustainable, government-regulated program of salt or food iodization. The costs are small and the benefits substantial and have been proven in over 160 countries around the world where this is done.”

Until now, isolated but persistent calls to address this issue have not translated to action, perhaps due to lack of awareness, or the unfounded but widespread belief that Israel's proximity to the sea likely prevents ID, leading to a corresponding lack of political will.

However, in the absence of a universal salt iodization program, and in light of the heavy national reliance on iodine-depleted desalinated seawater as drinking and irrigating water, the study’s results point to a major national public health problem.

The research findings were presented at The 46th Annual Meeting of the Israel Endocrine Society, which took place on March 20-21 in Ramat Gan, Israel (http://www.ies.org.il/fromtheassociation/abstracts2017).

According to the researchers, a universal salt iodization and monitoring program should be urgently initiated. Dr. Jonathan Arbelle, lead co-investigator from Maccabi Healthcare Services, who presented the findings at the meeting, called upon the Israel Endocrine Society to develop guidelines for clinical practitioners who care for pregnant and lactating women. “Caregivers should recommend adequate iodine intake during pregnancy and lactation, and a randomized clinical trial of risk and benefit for correction of mild-moderate iodine deficiency during pregnancy must be considered,” said Dr. Arbelle.

“A healthful diet is a foundation of a prosperous nation. The public has a right, and government has both a moral obligation and clear-cut social and economic incentive to ensure that the nation’s food supply supports the public’s health, well-being and productivity,” said Prof. Troen.

Yaniv Ovadia, the doctoral student and registered dietitian who performed the study, said, “Individuals can improve their iodine status through increased consumption of iodine-rich foods such as milk, dairy and salt water fish. They can also replace regular table salt with iodized salt." However, only a small fraction of the salt sold in Israel is iodized, and it is sold at a much higher price than regular salt, although it does not need to be. The World Health Organization and Iodine Global Network encourage mandatory, universal salt iodization, including the all discretionary household salt.  However, some countries have effectively been able to increase their iodine intakes through the use of iodized salt in processed foods, including bread and condiments, and this may be considered in Israel.  “Government action is needed to ensure that everyone has access to iodized salt, added Prof. Troen.  

These findings also highlight the critical need for routine public health surveillance, not only of iodine, but also of other nutritional and environmental exposures that determine the Israeli population’s collective health. 

“I’m pleased that the Ministry of Health has been supportive of this particular research effort, but to act on the findings and make a sustainable change will require government funding and legislation," said Prof. Troen.

The research team included doctoral student Yaniv Ovadia, Varda Nadler, Hadassa Brik, Tamar Wolf, Michael Zimmermann, Sandra Weibel, Dov Gefel, Jonathan Arbelle, and Aron Troen.

Participating institutions included the Nutrition and Brain Health Laboratory, Institute of Biochemistry, Food Sciences, and Nutrition, Robert H Smith Faculty of Agriculture, Food and Environment, Hebrew University of Jerusalem, Israel; Department of Internal Medicine "C", Barzilai Medical University Center, Israel; Central Laboratory, Maccabi Healthcare Services, Israel; and the Human Nutrition Laboratory, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH) Zurich, Switzerland.

The Hebrew University Nutrition and Brain Health Laboratory is a partner in EUthyroid (http://euthyroid.eu), an EU-funded research project to evaluate current national efforts aimed at preventing iodine deficiency disorders, which aims to provide the basis to develop appropriate measures for harmonizing and improving iodine intake in cooperation with national authorities.

FUNDING: The research was supported by grants from the Medical Research and Development Fund for Health Services – Jerusalem, and the Israel Ministry of Health Chief Scientists Office, with partial funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 634453, “EUthyroid”, and funding to the ETH Zurich iodine laboratory from the Iodine Global Network.

PHOTO: (Left to right) – Researchers Dov Gefel, Yaniv Ovadia, Aron Troen, and Jonathan Arbelle (Credit: Hebrew University) http://media.huji.ac.il/new/photos/hu170323_LR_Gefel_Ovadia_Troen_Arbelle.jpg

 

 

High burden of Iodine deficiency found in Israel’s first national survey
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Prevalence of smoking increases substantially during compulsory military service, Israeli research shows

23/01/2017

Study of 30,000 soldiers from 1987 to 2011 found that during compulsory military service, smoking increased by almost 40%. Researchers: comprehensive military tobacco-control plans are needed.

In new research published in the peer-reviewed journal Nicotine & Tobacco Research, researchers found that cigarette smoking increased by almost 40% during compulsory military service in the Israel Defense Forces (IDF). In a systematic sample of nearly 30,000 soldiers from 1987 to 2011, the prevalence of smoking grew from 26.2% at recruitment to 36.5% at discharge, a 39.4% increase.

The researchers, from Tel Aviv University, the University of Haifa, and the Hebrew University of Jerusalem, in cooperation with the IDF Medical Corps, say the increased smoking prevalence among military personnel, and the increase during military service, should act as a wake-up call to governments and health systems in countries lacking strong military tobacco control policies.

The research was conducted by Dr. Laura Rosen of the School of Public Health at Tel Aviv University; Dr. Hagai Levine from the Hebrew University-Hadassah Braun School of Public and Community Medicine; Dr. Salman Zarka from the University of Haifa; and Vladi Rozhavski, Tamar Sela, Dr. Yael Bar-Ze’ev, and Dr. Vered Molina-Hazan from the IDF Medical Corps. It was funded by the Israel National Institute for Health Policy Research. 

Former smoking and combat profiles are risk factors for smoking initiation

Among nonsmokers at recruitment, 18% initiated smoking during service. Former smokers were at greatest risk:  56% began smoking during service. Men and women with combat profiles were also at an increased risk, after adjusting for personal, family, and military factors. Prevalence of smoking was greater among males at discharge (40.3%) than among females (32.4%), but the increase during service was similar. On the other hand, 12% of smokers at recruitment quit smoking during service. There were no clear trends over the decades regarding smoking prevalence at recruitment and discharge. There was a slight increase in smoking cessation during service among males.

A tobacco control plan in the army is desperately needed

Nearly a fifth of nonsmoking new recruits initiated smoking during service, and over half of former smokers relapsed to smoking. Because 50%– 65% of smokers die prematurely from smoking-related causes, the ongoing and future damage is enormous. The large increase in smoking during service, combined with high subsequent mortality of smokers, suggests that military tobacco control policy affects long-term survival of military personnel, and is an important contributor to population-wide mortality in countries such as Israel where a large percentage of individuals serve.

Dr. Laura Rosen, Chair of the Department of Health Promotion in the School of Public Health at Tel Aviv University’s Sackler Faculty of Medicine, said: "The use of tobacco harms IDF soldiers and security in general. The government and the Ministry of Health need to cooperate with the IDF, in order to reduce the number of soldiers who start smoking, to encourage soldiers to quit smoking, and to protect non-smokers from exposure to cigarette smoke. We should take an example from the United States, which conducted extensive changes to the smoking policy in its military, to protect its soldiers and to improve the readiness and performance of its combat units. "

Dr. Hagai Levine, Head of the Environmental Health Track at the Hebrew University-Hadassah Braun School of Public Health and Community Medicine, said: "The increase we found in the rate of smoking during compulsory military service is of great concern in light of the serious consequences for public health. We must concentrate our efforts in the war against smoking in order to protect the health of young men and women, and to coordinate civilian and military efforts in order to fight smoking throughout the life course. I hope that the IDF will adopt similar measures to those implemented successfully in other armies."

The investigators recommend the creation of a central tobacco control body with comprehensive tobacco control policy, similar to programs in the U.S. military. The following steps are recommended: enforcement of smoking bans in public areas; prevention of supply of free or reduced-cost cigarettes to soldiers; prevention and treatment of tobacco dependence tailored for the military environment; monitoring of personal and army-wide smoking status.

The investigators also recommend that commanders disseminate health messages and no-smoking messages through personal example, particularly in combat units and during combat operations. A special program should target former smokers, given the high chance of returning to smoking. Special attention should be paid to those who score higher in their recruitment profiles, who often end up serving in combat units where the smoking rate is higher. 

The dramatic increase in smoking during military service presents a window of opportunity for changes in health behaviors, and suggests a need for a multi-year war on tobacco among soldiers, in order to protect their health and military fitness. The study also showed that smoking is already problem prior to recruitment, which adds urgency to the call for national efforts to prevent smoking initiation, which could be coordinated with the Ministries of Education and Defense.

CITATION: Smoking Behavior Change During Compulsory Military Service in Israel, 1987–2011. Salman Zarka*, Hagai Levine*, Vladislav Rozhavski, Tamar Sela, Yael Bar-Ze’ev, Vered Molina-Hazan, Laura J. Rosen. Nicotine & Tobacco Research, 2016, 1–8 doi:10.1093/ntr/ntw285. *Equal contribution.

- Dov Smith

Prevalence of smoking increases substantially during compulsory military service, Israeli research shows
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Higher BMI in Adolescence May Affect Cognitive Function in Midlife

11/12/2016

Study of Israeli adolescents also looks at impact of socioeconomic position on subsequent cognitive impairment

Overweight and obesity in adolescents have increased substantially in recent decades, and today affect a third of the adolescent population in some developed countries. While the dangers posed by high adult BMI on cognitive function in later life have been documented, the association of adolescent BMI with cognitive function in midlife has not yet been reported. (BMI, or Body Mass Index, is a calculation of a person’s weight in kilograms divided by the square of their height in meters.)

To shed light on this issue, scientists at the Hebrew University-Hadassah Braun School of Public Health and Community Medicine set out to determine the association between cumulative life course burden of high-ranked body mass index (BMI), and cognitive function in midlife. The research, which will appear in the Journal of Alzheimer’s Disease 55(3), was led by Prof. Jeremy Kark from the Braun School, in the Hebrew University of Jerusalem’s Faculty of Medicine, working with colleagues in Israel and the United States.

The researchers used weight and height data from 507 individuals tracked from over 33 years starting at age 17. The participants completed a computerized cognitive assessment at ages 48–52, and their socioeconomic position was assessed by multiple methods. Using mixed models the researchers calculated the life-course burden of BMI from age 17 to midlife, and used multiple regression to assess associations of BMI and height with global cognition and its five component domains.

In this population-based study of a Jerusalem cohort, followed longitudinally from adolescence for over 33 years, we found that higher BMI in late adolescence and the long-term cumulative burden of BMI predicted poorer cognitive function later in life. Importantly, this study shows that an impact of obesity on cognitive function in midlife may already begin in adolescence, independently of changes in BMI over the adult life course,” said the paper’s senior author, Prof.  Jeremy Kark of the Hebrew University-Hadassah Braun School of Public Health and Community Medicine.

“Our results also show that taller stature was associated with better global cognitive function, independent of childhood and adult socioeconomic position, and that height increase in late adolescence, reflecting late growth, conferred a protective effect, but among women only,” added Irit Cohen-Manheim, doctoral candidate at the Braun School and lead author.

The researchers point out that while socioeconomic position may have a particularly important role in the trajectory of a person’s lifetime cognitive function, it has rarely been adequately taken into account: “To the best of our knowledge, the association between BMI and cognition as a function of childhood and adult socioeconomic position has not been previously reported. Childhood household socioeconomic position appears to strongly modify the association between adolescent BMI and poorer cognition in midlife, the inverse association being restricted to low childhood socioeconomic position,” said Prof. Kark.

"Our results are consistent with the hypothesis that childhood living conditions, as reflected also by height, influence cognitive function later in life; however, our study is unique in showing that an adverse association of higher BMI with cognitive function appears to begin in adolescence and that it appears to be restricted to adults with lower childhood socioeconomic position,” said Prof.  Kark.

Evidence for the association between impaired cognitive function in midlife and subsequent dementia supports the clinical relevance of our results. Findings of the relation of BMI in adolescence with poorer midlife cognitive status, particularly in light of the ongoing epidemic of childhood obesity, require confirmation," said Irit Cohen-Manheim.

Scientists involved in this research are affiliated with the Hebrew University-Hadassah Braun School of Public Health and Community Medicine, Jerusalem, Israel; Department of Clinical Research, NeuroTrax Corporation, Modiin, Israel; Centre for Medical Decision Making, Ono Academic College, Kiryat Ono, Israel; Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA; Biostatistics Unit, Gertner Institute for Epidemiology and Health Policy Research, Tel-Hashomer, Israel.

FUNDING: The research was supported by grants from the Chief Scientist of the Israel Ministry of Health, the Israel Science Foundation, and the US-Israel Binational Science Foundation to Prof. Jeremy Kark.

REFERENCE: Irit Cohen-Manheim, Glen M. Doniger, Ronit Sinnreich, Ely S. Simon, Havi Murad, Ronit Pinchas-Mizrachi and Jeremy D. Kark. Body Mass Index, Height, and Socioeconomic Position in Adolescence, Their Trajectories into Adulthood, and Cognitive Function in Midlife. The Journal of Alzheimer's Disease 55(3), article pre-published on December 6, 2016, DOI: 10.3233/JAD-160843.

The Hebrew University of Jerusalem is Israel’s leading academic and research institution, producing one-third of all civilian research in Israel. For more information, visit http://new.huji.ac.il/en.

Higher BMI in Adolescence May Affect Cognitive Function in Midlife
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Study of Israelis and Palestinians Calls for Rethinking How HDL Protects Against Coronary Heart Disease

03/08/2016

Small and medium sized HDL particles were more closely associated than HDL-C with protection against coronary atherosclerosis in a Jerusalem study

The idea that plasma high-density lipoprotein cholesterol (HDL-C) is protective against coronary heart disease has been part of medical conventional wisdom for five decades. HDL-C has traditionally been considered the most important component of so-called "good cholesterol" HDL. However, drug trials that increased HDL-C have failed to support a causal role for the amount of cholesterol carried in HDL in reducing the risk of coronary heart disease.

With advances in the separation of lipoproteins by size and functionality, research has intensified to identify HDL measures that may be better predictors of coronary heart disease than the traditional HDL-C.  Recent evidence suggests that small, dense, protein-rich particles in HDL may be more atheroprotective than large, buoyant cholesterol-rich particles.

To explore this further, 274 Arabs and 230 Jews residing in Jerusalem were recruited for a new study by researchers at the Braun School of Public Health in the Hebrew University of Jerusalem’s Faculty of Medicine. This work, led by Prof. Jeremy Kark of the Hebrew University-Hadassah Braun School of Public Health and Community Medicine, was undertaken by Dr. Chobufo Ditah, a physician from Cameroon, as his thesis for the Braun School’s International Masters of Public Health (IMPH) program. 

(Dr. Ditah, who received the Faculty of Medicine's award of excellence for his MSc thesis and graduated Magna Cum Laude from the IMPH  program, credits the Pears Foundation of Britain for enabling him to study at the Hebrew University. The IMPH program is made possible by donors who provide full scholarships to students from low-income countries, with the Pears Foundation endowing the largest number of scholarships and underpinning the associated alumni network. Dr. Ditah currently serves as a Medical Referent with the humanitarian NGO Doctors Without Borders (MSF), overseeing the implementation, evaluation and reorientation of medical interventions in host countries.)

The researchers used Nuclear Magnetic Resonance (NMR) spectroscopy to identify the numbers and sizes of plasma HDL particles, and helical CT-scanning to identify calcification in their coronary arteries, reflecting the overall burden of coronary atherosclerosis. With these data in hand, they looked for associations between the concentrations and sizes of different HDL particles, and coronary artery calcification.

Their findings, published in the prestigious journal Atherosclerosis, showed a statistically significant inverse association of both the number of HDL particles (HDL-P) and the concentration of small and medium-sized HDL particles (MS-HDL-P) with coronary artery calcification, after adjusting for age, statin use, smoking, and other factors. There was no association between large HDL-P and coronary artery calcification in either population group. The association with HDL-C was weaker and inconsistent between men and women.

"Our findings indicate that HDL-P and MS-HDL-P are better independent markers of coronary artery disease, as reflected by coronary artery calcification, than HDL-C, at least in this bi-ethnic population of Israelis and Palestinians," said Dr. Chobufo Ditah.

"With a better understanding of HDL's complexity and a better ability to measure its components, it is now possible to move past HDL-C to more refined measures that better reflect HDL's role in coronary heart disease risk. Based on the accumulating evidence, incorporation of MS-HDL-P or HDL-P into the routine prediction of coronary heart disease risk should be considered," said Prof. Jeremy Kark.

"These findings support previous reports, based on studies in other population groups, suggesting that small dense HDL particles are protectively associated with risk of coronary heart disease. The consistency of this finding in a new population of urban Arabs and Jews, using different disease outcomes and different separation methods, add more strength to those findings," added Dr. Ditah.

Participants in this research are affiliated with the following institutions: Hebrew University-Hadassah Braun School of Public Health and Community Medicine; Hebrew University Faculty of Medicine; Hadassah Medical Center, Ein Kerem, Jerusalem; Mankon Sub-Divisional Hospital, Cameroon; LipoScience, Laboratory Corporation of America Holdings, USA.

The Hebrew University-Hadassah Braun School of Public Health and Community Medicine (link), in the Hebrew University’s Faculty of Medicine, is the first school of public health in Israel. Its world-renowned International Master’s in Public Health (IMPH) program (link) graduated its 40th class in 2015, featuring a diverse student body ranging from Cameroon to Kosovo, the United States to Jerusalem. The International MPH degree has been awarded to more than 800 graduates from 92 low-income countries in Africa, Asia, Latin America, Eastern Europe, as well as developed countries of North America and Western Europe. The comprehensive multi-disciplinary 12-month training experience prepares graduates to take up key positions as leaders and teachers of public health in their home countries, and to initiate and participate in the promotion and development of public health practices and develop capacity-building programs for training public health personnel.

The Hebrew University of Jerusalem is Israel’s leading academic and research institution, producing one-third of all civilian research in Israel. For more information, visit http://new.huji.ac.il/en.

FUNDING: This study was supported by research grants from the USAID Middle Eastern Regional Cooperation (MERC) Program (grant no TA-MOU-01-M21-002) and from D-CURE-Diabetes Care in Israel to Jeremy Kark.

CITATION: Small and medium sized HDL particles are protectively associated with coronary calcification in a cross-sectional population-based sample. Atherosclerosis, Volume 251, August 2016, Pages 124–131.  Chobufo Ditah, James Otvos, Hisham Nassar, Dorith Shaham, Ronit Sinnreich, Jeremy D. Kark. doi:10.1016/j.atherosclerosis.2016.06.010 http://www.sciencedirect.com/science/article/pii/S0021915016302556

Study of Israelis and Palestinians Calls for Rethinking How HDL Protects Against Coronary Heart Disease
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'Gestational Sleep Apnea': Time To Wake Up to a New Diagnosis

26/07/2016

Sleep researchers call for a new diagnostic code to enable research and treatment of Obstructive Sleep Apnea in the 1/4 of pregnant women who may suffer from it

Diagnosis would parallel others like ‘gestational hypertension’ and ‘gestational diabetes mellitus’

Recent studies reveal that approximately one quarter of pregnant women may suffer from Obstructive Sleep Apnea (OSA), the recurrent cessation or limitation of normal breathing during sleep. In addition to being the cause of daytime fatigue, the consequences of untreated OSA include but are not limited to high blood pressure, high blood sugar, and heart disease.

In non-pregnant adults, protocols have been proposed for OSA screening, diagnosis and therapy, the mainstay being continuous positive airway pressure (CPAP).  However, in pregnant women OSA is usually untreated, since it is still underdiagnosed, and not fully appreciated as a risk factor for negative outcomes for mother and baby.

Now, in an editorial in the International Journal of Obstetric Anesthesia, sleep researchers from Israel and the United States recommend a new diagnosis, ‘‘Gestational Sleep Apnea” (GSA). This would allow health professionals to properly describe, diagnose and treat OSA in pregnant women, and would parallel other established transient diagnoses of pregnancy, like gestational hypertension and gestational diabetes mellitus.

“Currently there is a lack of uniform criteria to diagnose, treat and classify OSA in the pregnant population, which in turn complicates efforts to determine the risk factors for, and complications of, gestational sleep apnea," said Prof. Yehuda Ginosar, director of the Mother and Child Anesthesia Unit at the Hebrew University-Hadassah Medical Center and professor at the Hebrew University’s Faculty of Medicine. Ginosar is currently Professor of Anesthesiology and Chief of the Division of Obstetric Anesthesiology at Washington University School of Medicine.

In terms of diagnosis, doctors and patients may attribute daytime tiredness to “just being pregnant” rather than to sleep apnea. In terms of treatment, some physicians and patients might consider the disease too temporary to warrant referral to a Sleep-Certified Physician, which usually requires an overnight sleep study for diagnosis (although the recent increased use of home sleep studies should encourage more opportunities for diagnosis).

The researchers argue that establishing and coding for a specific diagnosis of gestational sleep apnea will require further investigation to determine criteria and therapies. But, like in the case of other gestational diseases, it will allow for more targeted surveillance of maternal and fetal outcomes, and facilitate epidemiologic research to monitor the course of the condition from its genesis to its possible path to chronicity.

"The time has come for our profession to wake up to the diagnosis of Gestational Sleep Apnea. This will allow us to research obstructive sleep apnea in pregnant women more effectively, and to develop and implement more effective treatments,” said co-author Dr. Suzanne Karan, a visiting researcher at the Hebrew University-Hadassah Medical Center who is an Associate Professor of Anesthesiology and Director of the Anesthesiology Respiratory Physiology Laboratory at the University of Rochester School of Medicine.

The Hebrew University of Jerusalem is Israel’s leading academic and research institution, producing one-third of all civilian research in Israel. For more information, visit http://new.huji.ac.il/en.

REFERENCE: Gestational sleep apnea: have we been caught napping? Karan, Suzanne and Ginosar, Yehuda. International Journal of Obstetric Anesthesia, Volume 26, 1 - 3. DOI: doi:10.1016/j.ijoa.2016.03.001 (link: http://www.sciencedirect.com/science/article/pii/S0959289X16000388)

'Gestational Sleep Apnea': Time To Wake Up to a New Diagnosis
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