David Hupin

We need clear health messages about exercise

Simplifying health messages can be puzzling. French media1 recently criticised WHO’s 2016 physical activity recommendations,2 based on the data published by Kyu and colleagues in The BMJ .3 Two years ago, they ran a very different headline: “Sitting kills more people than tobacco,” based on a commentary published in 2009.4 The …

A 7-year follow-up study of obstructive sleep apnoea in healthy elderly: The PROOF cohort study: Long-term study of OSA in healthy elderly

Clinical and epidemiological cohort studies have shown that obstructive sleep apnoea (OSA) is a common but largely undiagnosed disorder in senior subjects, where progressive deterioration of the pathology would be expected as a consequence of the ageing processes. Our study examines the longitudinal progression of OSA over a 7‐year period in a community‐based sample of healthy subjects.

Restless Genital Syndrome: Differential Diagnosis and Treatment With Pramipexole

ABSTRACT Restless genital syndrome refers to excessive and persistent sensations of genital and clitoral arousal with the absence of conscious feeling of sexual desire. These sensations have been linked to symptoms of restless legs syndrome (RLS) or an overactive bladder. Restless genital syndrome may be related to small fiber sensory neuropathy of the dorsal nerve of the clitoris, so it more frequently occurs in women. The association with RLS suggests a possible dopaminergic mechanism. We report a case of a 74-year-old woman who presented restless genital symptoms every night in association with RLS symptoms. During polysomnography she reported 3 awakenings from rapid eye movement sleep with associated genital symptoms followed by a period of insomnia with RLS symptoms and sexual activity. The frequency and the intensity of the symptoms were responsive to treatment by pramipexole after 1 week of treatment and the efficacy was maintained at follow-up.

CPAP for excessive sleepiness in elderly patients

Expansion of the ageing population has led to questions about the rationalisation of health-care support and the cost-eff ectiveness ratio of all treatment approaches for elderly patients. Sleep-related breathing disorders are highly prevalent after age 65 years, and their treatment is a major reason for the increase in health-care spending. Obstructive sleep apnoea (OSA) syndrome is a well established risk factor for cardiovascular diseases in adults, but the deleterious eff ect of OSA syndrome in elderly people remains controversial, and some authors have discussed the concept of so-called preconditioning with chronic intermittent hypoxia, meaning elderly apnoeic patients could have less chance of myocardial infarction. The unknown benefi ts routinely off ered by the treatment of OSA syndrome in elderly patients should be taken into account by public authorities when planning resource allocation. However, the main symptom associated with sleep apnoea, diurnal sleepiness, seems to be costly and dangerous in this population and seems to be a valid target for the effi cacy of treatment of OSA syndrome in older people. In the PREDICT study published in The Lancet Respiratory Medicine, Alison McMillan and colleagues show in a multicentre, randomised, two-parallel-group study of continuous positive airway pressure (CPAP) that this treatment signifi cantly reduced daytime sleepiness in patients aged 65 years or older at 3-month and 1-year follow-up visits. The quality of work done by the authors should be emphasised. The magnitude of improvement is quite similar to that noted in younger adults, and this amplitude is well correlated with the average night duration use of CPAP. The short median duration of CPAP usage in the PREDICT study (1 h 52 min per night at 3 months and 2 h 22 min per night at 12 months) suggests a greater effi ciency of CPAP for patients with longer nightly CPAP use. A minimum duration of 5 h of daily use for patients should be insisted upon if CPAP is to have a substantial eff ect on neurocognitive function. The authors did not attempt to explain the important question of the benefi cial role of CPAP on cardiovascular morbidity and mortality in patients aged 65 years or older. This treatment approach leads to a marginal reduction in health costs. During 1-year follow-up, CPAP does not seem to improve mood, cognitive function, or incidence of accidents. We should emphasise here that the study was not originally designed to address these issues, and thus, fi rm conclusions could not be derived from these secondary endpoint analyses. In our opinion, the decrease in plasma LDL cholesterol is diffi cult to explain by the nocturnal CPAP alone. Somewhat surprisingly, the lower blood pressure noted in the group who received best supporting care can only encourage us to heavily emphasise advice on lifestyle (reducing physical inactivity, reducing salt intake, and improving medication adherence) when patients are seen in our sleep medicine clinics. The reported decrease of 3–4 mm Hg in blood pressure could be very profi table in terms of health costs at the 10-year follow-up point. Several criticisms can be made of this study. First is the use of the Epworth sleepiness scale to characterise the extent of daytime sleepiness; this questionnaire is sometimes not suitable for elderly patients because most are not able to answer all of the Epworth scale score items, thus this scale might underestimate sleepiness severity in older patients. However, signifi cant and consistent improvements in the Oxford Sleep Resistance test reported in the CPAP group confi rm an objective improvement in daytime sleepiness from use of CPAP. Additionally, a detailed comparative analysis of the macroarchitecture and microarchitecture of sleep in the two groups of patients is absent. In fact, sleep apnoea syndrome in elderly people is often entangled with other sleep diseases, and it would have been interesting to compare the improvement of the eff ectiveness and Published Online August 27, 2014 http://dx.doi.org/10.1016/ S2213-2600(14)70164-X

Fifteen Minutes Daily Brisk Walk May Be a New Best Target in Very Old Adults: Age Is Not an Excuse to Not Exercise

lunchtime electives teach medical students medical Spanish vocabulary, so we sought to create a complementary, immersive cultural experience where medical students could apply those skills to real-life conversations with Hispanic patients outside of the hospital. El Intercambio Cultural is a community service project for medical students to enhance the quality of life of Hispanic nursing home residents who need both company and assistance. Through dialogue and activities with nursing home residents, students learn about their histories, families, beliefs, joys, and hardships, thereby enhancing their cultural awareness. Furthermore, it provides a unique opportunity for students to practice speaking Spanish in a low-risk setting, years before their first day of clinical rotations. In its first semester, we paired 11 Spanish-speaking nursing home residents with 18 medical students. Students attended bimonthly visits with their assigned compañero, which typically lasted an hour. Nearing the end of the term, we organized a fiesta for all medical students and nursing home residents where we ate taco salads and played lotería before concluding the night with a piñata. El Intercambio’s first term was remarkably successful, with high student retention rates. In post-participation questionnaires, students expressed satisfaction with their interactions with older adults, gaining exposure to their long-term care, and the opportunity to learn Spanish in the absence of the pressure associated with practicing the language in a formal medical setting. Furthermore, the nursing home residents reportedly cherished themedical students’ companionship and found joy in helping them practice speaking Spanish. While not formally assessed, the expression of gratitude for the program from the residents’ family members and nursing home staff has been striking. However, our program has not been without its growing pains. Most nursing home residents in the program have some degree of cognitive and physical decline. It was an adjustment for many studentsdourselves includeddto sit and talk one-on-one with adults whowere sometimes confused and repetitive and often incontinent or bedbound. For some this yielded a less effective means to practice their Spanish, which ultimately resulted in their departure from the program. Given unexpected circumstances that sometimes arise, on multiple occasions students were unable to visit their assigned compañero. While in some cases inconvenient, it gave students an opportunity to visit with other residents and hear different Spanish dialects since the nursing home residents are from many different countries and regions, including Mexico, Argentina, and all around Texas. Despite these challenges, the students that participated in El Intercambio’s first termd including those who left prematurelydanswered 1 question in the postparticipation questionnaire the same: they were glad they participated. In light of the progressive diversification of the United States’ population, training medical students in cultural competence and other social determinants of health has become increasingly more important for adequate patient care. Beyond markedly improving clinical outcomes, there are numerous intangible benefits that stem from communicating with patients in their native language and from understanding their cultural context. Dialogue is the bridge to understanding. El Intercambio gives students an opportunity to learn about their compañero’s culture and practice speaking Spanish, while simultaneously enhancing the quality of life of Hispanic nursing home residents. Through this project we hope to make medical students better healers and more powerful advocates for the Hispanic community.

Obstructive Sleep Apnea in Cardiac Rehabilitation Patients

STUDY OBJECTIVES Although regular physical activity improves obstructive sleep apnea (OSA) in the general population, this finding has not been assessed in postmyocardial infarction (MI) patients in a rehabilitation setting (coronary artery disease, CAD). We aimed to determine whether cardiac rehabilitation may benefit post-MI patients in terms of OSA disease and associated autonomic nervous system (ANS) activity. METHODS Consecutive post-MI patients participating in the ambulatory cardiac rehabilitation program of St-Etienne University Hospital were included in this study. The apnea-hypopnea index calculated from electrocardiogram (ECG)-derived respiration (AHIEDR) was obtained through nocturnal Holter ECG recordings. According to AHIEDR, patients were classified as normal, mild, moderate, or severe OSA (< 5, 5-14, 15-29, ≥ 30, respectively). Physiological performance (peak VO2) was established via cardiopulmonary exercise testing. ANS activity was evaluated through spontaneous baroreflex sensibility as well as heart rate variability analysis. RESULTS Of the 105 patients with CAD and OSA included (95 men, 55.2 ± 12.4 years), 100 had at least 1 cardiovascular risk factor (98%) and 52 patients (50%) had an ANS dysfunction. Surprisingly, 68 of these patients with OSA (65%) were free of classical diurnal symptoms usually associated with sleep apnea. In response to cardiac rehabilitation, AHIEDR decreased significantly (-9.3 ± 9.5, P < .0001) only in patients with severe OSA, and the decrease was even greater when peak VO2 and baroreflex sensibility improved beyond 20% compared to basal values (-11.6 ± 9.1, P < .001). CONCLUSIONS Severe OSA in patients with CAD is significantly improved after 2 months of cardiopulmonary rehabilitation. Reviving ANS activity through physical activity might be a target for complementary therapy of OSA in patients with CAD.