Sep 9, 2016

Rest easy

The story

Snoring is a great tool to drown out your 5 AM alarm clock, but your sleep apnea patients might not find it so helpful. Two new trials help us better understand therapy options.

The basics

Don't take it personally when your patients fall asleep on you in clinic. Document excessive daytime sleepiness and begin a work up for sleep apnea. Use a sleep study as your preferred method of diagnosis, and recommend lifestyle measures and weight loss for mild disease. Moderate to severe disease will need further treatment.

Apply pressure

Continuous positive airway pressure (CPAP, the mask therapy that looks way too sexy on the internet) is the first therapy prescribed for most patients with obstructive sleep apnea (OSA). The SAVE trial looked at cardiovascular outcomes in 2,600 patients with OSA and found no difference between CPAP and usual care, disappointing many who hoped to find a benefit. CPAP proponents suggest that the patients failed to use CPAP frequently enough or for long enough duration in the intention-to-treat analysis. The CPAP group did report improved quality of life and less daytime sleepiness. 

Touch a nerve

Neurostimulation is a new, invasive therapy for central sleep apnea. An implantable device stimulates the phrenic nerve to contract the diaphragm and normalize breathing pattens. An RCT of 151 sleep apnea patients with heart failure found that neurostimulation improved sleep apnea severity scores, as measured by the apnea-hypopnea index, in 51% of the therapy group vs. 11% in the control group. Rates of device-related malfunction and infection were low, but research has not yet addressed long-term safety or cardiovascular benefit.

Say it on rounds

When you cross your fingers at your annual PPD 

We all get nervous. In their recommendations on tuberculosis (TB) screening, the USPSTF suggests screening high-risk individuals, including foreigners from countries with high TB prevalence and those from prisons or shelters, with PPD or interferon-gamma release assays. The agency says screening tests are accurate, harms are small, and treatment of latent TB confers a moderate health benefit by preventing progression to active disease.

When you and your attending are not quite on the same page

Argue as appropriate, but try to muster proof. A big topic at last week's European Society of Cardiology meeting was whether cardiologists were on board with the aggressive blood pressure targets suggested by November's SPRINT trial results. Fueling anti-SPRINT sentiment is a large cohort study that found blood pressures below 120/70 mmHG to be associated with increased mortality and worse cardiovascular outcomes in hypertensive patients with known coronary artery disease. Some think that myocardial perfusion suffers when diastolic blood pressure is too low.

When yet another 27-hour shift puts your body in a funk

Sleep and time off should once again solve the problem. Keeping in theme with repetition, investigators found that repeat rifaximin (Xifaxan) treatment was efficacious in patients with diarrhea-predominant irritable bowel syndrome (IBS) with relapsed symptoms following initial treatment response. The treatment group reported improved abdominal pain and less bowel movement urgency compared to placebo.

Brush up


Did someone say friction rub? Consider pericardial injury in young and middle-aged patients presenting with chest pain. Two of these 4 criteria are used for diagnosis: pleuritic chest pain, friction rub, pericardial effusion, or diffuse ST segment elevations on EKG. Viruses are a common infectious cause, but also think about neoplastic, autoimmune, and traumatic etiologies. Treatment starts with nonsteroidal anti-inflammatories (NSAIDs).

What's the evidence

For using colchicine to prevent recurrent pericarditis? When dosed with NSAIDs, colchicine reduced recurrence rates by more than half in a 2013 RCT for first-episode patients. Combo therapy also improved early remission rates and decreased subsequent hospitalizations. Tell your patients to stick with it, since recommended treatment duration is 3 months.

Pushing paper

A new Annals study found that for every hour ambulatory care physicians spent seeing patients, they did two additional hours of paperwork

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