#Obstructive # Sleep #Apnea

An article in JAMA on November 15, 2022 reviewed recent national recommendations for screening adults for obstructive sleep apnea (OSA) who do not have symptoms. The bottom line is that there is insufficient evidence to recommend screening asymptomatic adults for OSA.

Nevertheless, OSA is a common disorder that should be treated when patients are having symptoms. The most common symptoms are excessive daytime sleepiness, periodically stopping to breathe while asleep, and snoring.

OSA is a sleep disorder in which the patient has partial obstruction of the airway during sleep. This results in inability to breathe, either partially or completely. This results in low oxygen levels, elevated blood pressure, and rapid heart rate.

There are a number of treatments for OSA. The most common one is using a machine (cPAP) that provides extra pressure when the user takes a breath so that the airway remains open. The machine is relatively quiet. It has been shown to reduce “excessive daytime sleepiness and may improve general health-related and sleep-related quality of life.”

High blood pressure can also be reduced in patients using positive airway pressure machines. This is a benefit to patients on medications for hypertension because sleep apnea can elevate blood pressure.

In addition to the cPAP machines there are other treatments available if a patient does not tolerate it or prefers not to use one. There is an oral appliance that advances the jaw forward, which reduces the airway obstruction. Also, there is an implant that is surgically attached to the nerve that causes the tongue to protrude. That reduces the airway narrowing. Finally, there is surgical removal of certain tissues that enlarges the airway. A sleep medicine specialist can educate patients about treatment options.

If you or a loved one struggles with loud snoring, stops breathing for periods of time during sleep, and/or has excessive daytime sleepiness, see your physician to determine if a sleep study should be done to determine if that person has OSA. There is also a form of sleep apnea that is not due to obstruction of the airway but is due to the brain episodically not giving a signal to breathe while asleep. This is called central apnea. It can exist alone or with OSA.

Sleep apnea is a common disorder that can cause a number of health problems and interfere with one’s quality of life. Screening of asymptomatic adults is not recommended but adults with symptoms should be evaluated.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#RSV (Respiratory Syncytial Virus) Infection Rate Increasing

This blog is mainly based on an article published online by Jennifer Abbasi in Jamanetwork on Nov. 11, 2022. It is a publication of the American Medical Association.

The U.S. is facing a significant outbreak of RSV (respiratory syncytial virus) infections that began earlier than usual this year. This is bad enough, but the flu has also begun early this year.

In fact, there is now an outbreak of several viral illnesses that are overloading pediatric hospitals. These virus include RSV, influenza, parainfluenza viruses (viruses that mimic the flu), COVID, rhinoviruses (main cause of the common cold), and enterovirus D68 (can rarely cause acute flaccid myelitis).

Acute flaccid myelitis is a rare disease of the spinal cord caused by a virus. It results in weakening of the muscles and reduced reflexes. It usually goes away in a matter of days but can very rarely cause permanent paralysis. Again, the vast majority of people recover.

RSV is in the news because we are experiencing a more severe outbreak than usual. This may partly be due to the fact that precautions to prevent COVID (such wearing a mask in public) also prevented RSV infections. There were virtually no cases in 2020, but the virus re-emerged in the summer of 2021.

Usually, children get RSV infection before the age of two. Most do well, but others develop an infection of the small lung passages (bronchiolitis) or even pneumonia. They can get re-infected as they get older, but they have some immunity so it is just like a regular cold.

Because kids under age 2 did not get infected in the last couple of years, they now lack immunity, and a number of them have gotten sick enough to require hospitalization. Some have needed to be on a respirator. This situation is overwhelming pediatric hospital emergency rooms (average wait time in many is 8 hours) and ICU beds.

High-risk infants can receive preventive treatment with 5 doses of an antibody given a month apart. High -risk includes babies born prematurely.

Adults are also experiencing an increase in RSV infections. It is usually mild with cold-like symptoms. However, in a minority of cases it can cause pneumonia and worsen respiratory illnesses such as asthma. These infections are more risky among the elderly due to age-related weakening of their immune system.

Treatment is symptomatic because there is no curative treatment for RSV infection at this time.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Abortion by Medication

After the Supreme Court overturned Roe v Wade the laws regarding abortion were left to the states. Due to increased restrictions in some states, interest in abortions induced by medication has increased. This post only addresses medical information and takes no side regarding any other consideration about abortion.

Medication abortion has been available in the US for about 20 years. It is almost always safe and effective. It has the advantage of being done in the privacy of the woman’s home and feels more natural than having a procedure done. This is largely because the physiology is very similar to what happens during a spontaneous miscarriage.

Medication abortion is an option during the first trimester (specifically, before 11 weeks of pregnancy). There are contraindications. Because the abortion does cause some bleeding from the vagina, women with significant anemia, are on a blood thinner, or who have a bleeding disorder are generally not a candidate for a medication-induced abortion.

Other relative contraindications include allergy to one or both medications, disorders of the adrenal gland, taking steroid medications, or having an ectopic pregnancy (anywhere outside of the womb such as in an ovarian tube).

Typically, medication-induced abortion requires taking two medication at separate times; the second medication is taken up to 24-48 hours after the first one.

The first pill is mifepristone (trade names are Korlym and Mifeprex). It causes the embryo to detach from the wall of the uterus. The second pill is misoprostol (trade name is Cytotec). It causes the cervix to soften, enlarges the opening, and causes uterine contractions. This is what happens naturally during a miscarriage.

This treatment is 98% effective when done before 7 weeks and 95% when done up to 11 weeks. It is important to know how long the woman has been pregnant. This can be determined with good reliability in women with regular periods, and she is confident of the date of onset of her last period. Otherwise, a uterine ultrasound is usually performed before considering a medication-induced pregnancy.

An additional reason to perform an ultrasound is if the woman is at increased risk of a pregnancy outside of the womb (ectopic). The risk is increased if she has an IUD, had a tubal ligation, had an infection involving one or both uterine tubes, or the woman is experiencing lower abdominal pain and/or vaginal bleeding.

The experience of having a medication-induced abortion varies from woman to woman. However, most women have few side effects, mainly nausea (less often vomiting) and vaginal spotting due to the mifepristone. Following the second pill (misoprostol) she will typically experience more spotting and cramps similar to menstrual cramps; passing blood clots may also occur and sometimes a small amount of light tissue may be seen. Cramps usually subside in two days; light bleeding may persist for a few weeks.

While complications are unusual, they can occur. Beyond the vaginal bleeding, there can be retained products of conception, gastrointestinal symptoms, infection, and, sometimes, the medications don’t work (uncommon).

Medication-induced abortion does not increase risks for future pregnancies, does not cause blood clots in veins, and does not increase the risk of any form of cancer.

Some women omit the second medication, either because they think they don’t need it or they forget to take it. About half the time the pregnancy ends anyway. There may be only a partial detachment, and excessive bleeding may occur. Excessive bleeding is recognized if the woman soaks two maxi pads in one hour at least two times. She should see a physician promptly.

After a medication-induced abortion, fertility rapidly returns. If the woman wants to avoid getting pregnant, birth control should be made available. This could be birth control pills, an IUD, injectable birth control, or a tubal ligation (if no future pregnancies are desired).

Women should see a physician if they are considering medication-induced abortion. The doctor can determine if the approach is safe for that woman, can provide information about the correct way to take the medication (e.g., misoprostol can be taken vaginally, under the tongue, or between the tongue and the teeth), provide education, examine the woman if needed, and answer questions.

If a woman is experiencing any untoward symptoms during or after taking the medications, such as heavy bleeding, she should contact her doctor.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Mental Health News

1. A drug used in animals (xylazine) for sedation and analgesia has started to show up in #illicit opiates such as fentanyl and heroin. #Xylazine can be fatal in humans. It is not yet known if its effects can be reversed with naloxone. It is not detected in routine urine drug tests.

If anyone needed another reason to fear using illicit opiates, this is a scary one.

2. #Mindfulness was shown to be as effective as the oral psychiatric medication, escitalopram (Lexapro) for the treatment of #anxiety.

Properly done, mindfulness is an excellent psychological method to assist with many health-related conditions such as stress, chronic pain, anxiety, and others. It is well worth learning.

3. #Delirium is a serious complication of many serious acute illnesses, especially in intensive care units. A study in Japan showed that giving a relatively new medication used for insomnia can help prevent delirium.

The medication is suvorexant (Belsomra), which suppresses wakefulness. It has a unique mechanism of action quite different from other insomnia medications.

#Critical #Race Theory and #Marxism

Did you know that Critical Theory was developed by Marxist German intellectuals? Critical Theory was initially applied to race by law school professors in the U.S.

If you are curious about this topic, read my short book, Critical Race Theory and K-12 Education. Aspects of CRT are being taught in K-12 schools. This is controversial. Find out why.

Sold on Amazon ($5.50 for paperback; $4.99 for eBook).

Total #Knee Replacement

The risk of needing total knee replacement surgery increases significantly with only a small amount of weight gain. Gaining an extra 11 pounds increases the risk by 34% in women and 25% in men.

For adults already at risk, e.g., having arthritis of one or both knees, attention to weight management is a helpful preventive measure.

Peter M. Hartmann, MD

Family Medicine & Psychiatry