Sunday, April 9, 2017

"Why is it That the One Who Snores Always Falls Asleep First?

The federal Centers for Disease Control and Prevention calls sleeplessness a public health concern. Good sleep helps brain plasticity, studies in mice have shown; poor sleep will make you fat and sad, and then will kill you.  Where we're concerned, it'll help make you the athlete you want to be.

One of the negatives of being a triathlete, or having the personality that gravitates toward triathlon, is that each of us wants to get six things done in the time allotted for four.  Something has to give; frequently that's time in the sack.  The old, "I know it's bedtime, I'm almost done with ______________"  When you have a couple minutes, this is a good read.  Sleep is the New Status Symbol

While on a Sunday bike ride recently, the topic of snoring came up. I ride with an older group, several of whom will have wine or beer with dinner most nights or maybe something 
later in the evening and that snoring was becoming more of problem.  Two agreed that it was considerably worse on weekend nights after a race.

I'd remembered a couple of things from med school that could contribute, one being alcohol that can overly relax the upper airway tissue.  The other was having a fat neck, not much of a concern in the bike group. But I was sure there were other contributing factors of which we should be aware. The piece from Harvard below covers the subject pretty thoroughly, isn't overly "med speak"  and could be a big help if one is interested.  My thanks to the folks at Harvard.

Snoring solutions

Simple changes can help to turn down the volume.
If your wife or sleep partner often seems bleary-eyed and resentful in the morning, you may be one of the millions of adults who snore habitually—a condition that affects twice as many men as women. Snoring occurs when your upper airways narrow too much, causing turbulent airflow. This, in turn, makes the surrounding tissues vibrate, producing noise.
Snoring is a sign that there is a really narrowed space,” says Dr. Sanjay Patel, a sleep disorder specialist at Harvard-affiliated Beth Israel Deaconess Medical Center. “That happens either in your nasal passages or in the back of your throat.” Some men are snorers because they have excess throat and nasal tissue. Others have floppy tissue that’s more likely to vibrate. The tongue can also get in the way of smooth breathing.
Once the source of the snoring is identified, you can take appropriate steps to dampen the nightly din. These include not drinking alcohol at night, changing sleep position, avoiding snore-inducing medications, and addressing causes of nasal congestion.

How to alleviate snoring

Here are some factors that contribute to snoring and what you can do to alleviate them.
Alcohol. Alcohol, a muscle relaxant, can slacken the tissues of your throat while you sleep. “We see this all the time,” Dr. Patel says. “Spouses say the snoring is tolerable except for the nights when their partner has had a couple of beers.”
Body weight. Extra fat tissue in the neck and throat can narrow the airways. Losing some weight could help to open the airways if the person is overweight or obese, although many people who are lean also snore.
Medications. Medications that relax muscles can make snoring worse. For example, tranquilizers such as lorazepam (Ativan) and diazepam (Valium) can have this effect. In contrast, antihistamines may actually alleviate snoring by reducing nasal congestion.
Nasal congestion. Mucus constricts the nasal airways. Before bed, rinse stuffy sinuses with saline. If you have allergies, reduce dust mites and pet dander in your bedroom or use an allergy medication. If swollen nasal tissues are the problem, a humidifier or medication may reduce swelling.
Sleep position. When you lie on your back, slack tissues in the upper airways may droop and constrict breathing. Sleeping on your side may alleviate this. You can also try raising your torso with an extra pillow or by propping up the head of the bed a few inches.
Smoking. Men who snore are often advised not to smoke, but the evidence this will help is weak. Needless to say, there are already plenty of other good reasons to quit smoking.

Anti-snoring products

Many products claim to help with snoring, but few of them are backed by solid research. One potentially effective option is wearing an anti-snoring mouth appliance, which pulls the jaw (along with the tongue) slightly forward to open the upper airway. An appliance made by a dentist can cost around $1,000. Do-it-yourself kits cost much less, but may not be as well tailored to your mouth.
Nasal-dilating strips are inexpensive and harmless, and some small studies suggest they may help reduce snoring. You apply these adhesive strips across your nose at bedtime to help to open up the nasal passages. Breathe Right is one well-known brand, but there are many others available at relatively low cost.
If you are unsure what to do about snoring, a physician can advise you and also make sure your snoring is not related to an underlying sleep disturbance, common in men, called obstructive sleep apnea. “The louder the snoring, the more likely it is to be related to sleep apnea,” Dr. Patel says. “Not all men who snore have sleep apnea, but if the snoring is frequent, loud, or bothersome, they should at least be evaluated.”

Sunday, April 2, 2017

MRI's Are Good, But Are They Good For You?

So, after putting your bike on the rack on the car after today's ride, you accidentally step back off the curb and roll your ankle. This is pain, big time pain, as you reflexively flop around on the pavement in agony. As the intensity slowly dissipates, and your bike buddies encourage you to get up if you can and get out of the traffic, you find that you can hardly walk on it and wonder now what? If this is serious, everything's going to change from your scheduled track work out tomorrow to the trip to Disney World next week (you hope not that one, the kids have been looking forward to this for weeks.)

When you get home, you visit you favorite tri forum, post the injury looking for direction from the knowledgeable, but often anonymous (and not so knowledgeable) audience.  The call for an MRI or two, the foot and the ankle, to "see what's going on in there" is heard more than once.

Some time later, rroof (a noted Sports Podiatrist from Cincinnati - and not anonymous) posts, "uh, well maybe you need an examination and a diagnosis first, perhaps an x-ray if indicated." Of course he's right.

This scenario plays out every day on tri forums, in athlete to coach communications, and simple every day life. Those of us in medicine get pushed every day to "take a look" with an MRI when a more appropriate course, and perhaps a less aggressive course, is correct. (MRI - nuclear magnetic resonance - produces images of the molecules that make up a substance, especially the soft tissues of the human body. Magnetic resonance imaging is used in medicine to diagnose disorders of body structures that do not show up well on x-rays.*) Noted researcher Jennifer Hodges has found that, "If they're not the ones paying for the examination, they'll be much more likely to request that it be performed."

Jack Wennberg of Dartmouth’s Center for the Evaluative Clinical Sciences is often quoted as having said: "…up to one-third of the over $2 trillion that we now spend annually on health care is squandered on unnecessary hospitalizations; unneeded and often redundant tests; unproven treatments; over-priced, cutting edge drugs; devices no better than the less expensive products they replaced; and end-of-life care that brings neither comfort, care, nor cure."

It's also interesting to note that this is not just a patient driven phenomenon. In a recent study in the Orthopedic literature, it was found that with physician owned MRI scanners, there was a higher likelihood that a study would be ordered than if the doctor had no financial interest in the unit. Makes you think doesn't it. And these are my peers.

The take home lesson here is that, with MRI examinations that are sometimes billed at over $3000 each (thus the consideration of an ankle MRI, and foot MRI as suggested above, could be billed in excess of $6,000,) some measure of restraint is needed. "Fiscal restraint on the part of both parties," says Hodges. If there's a diagnostic unknown between the doctor and the patient, ask the question, "Would my treatment be changed/enhanced with an MRI? Would we use the information from the scan, positive or negative, to make a decision in my care?" If the answer's no, or perhaps not right now, maybe another treatment entity is appropriate at this time.  Plus, the time you'd be using in the scanner may be used by someone who's really sick or injured and needs it badly.