Robert E. Rakel

Clinical and Societal Consequences of Obstructive Sleep Apnea and Excessive Daytime Sleepiness

Abstract Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although frequently undiagnosed, OSA is highly prevalent and presents most often with excessive daytime sleepiness (EDS). While obesity is the major predisposing factor, patients with OSA and EDS are at increased risk of other conditions, including cardiovascular disease, type 2 diabetes, cognitive impairment, and depression. Significant consequences include morbidity and mortality from the associated conditions in addition to personal and societal consequences of cognitive impairment, such as driving and workplace accidents. Primary care physicians are ideally placed to screen for OSA and EDS in patients who present with commonly comorbid conditions such as obesity, cardiovascular disease, metabolic syndrome, and depression. Conversely, treatment of OSA and associated EDS might help alleviate significant comorbidities and their clinical and societal consequences.

Improving patient acceptance and adherence in diabetes management: a focus on insulin therapy

Maintaining tight glycemic control is an important issue for patients with type 2 diabetes. Empowering patients to be actively involved in the management of their diabetes can improve glycemic control through education, communication, and the use of patient-friendly insulin regimens. The primary care physician plays an important role in helping patients manage their disease by encouraging initiation of treatment with insulin analogs, which are more convenient, more predictable, and better tolerated than traditional human insulin therapies. Modern insulin delivery devices, such as insulin pens, may also help improve patient acceptance of insulin therapy.

Success Strategies For Departments Of Family Medicine

Strong departments of family medicine in academic medical centers help assure the future scope and quality of family practice patient care, the ongoing evolution of family medicine as a scholarly discipline, and a continued flow of qualified medical school graduates into family practice residency programs and eventually into practice. This report presents key strategies of six successful departments of family medicine and describes the methods and skills considered important by the leaders of these departments. Common themes that emerge are (1) recruit and mentor the best faculty, (2) build a reputation for clinical excellence of faculty and residents, (3) become part of schoolwide curriculum activities, (4) establish a scholarly presence, and (5) develop networks of support.

The greater safety of trazodone over tricyclic antidepressant agents: 5-year experience in the United States.

Trazodone demonstrates comparable efficacy with the tricyclic antidepressant agents (TCAs) but produces fewer of the untoward side effects associated with these drugs. All of the TCAs are potentially lethal when taken in overdose; they cause serious cardiovascular side effects; produce anticholinergic effects, which often are severe enough to result in discontinuation of medication; and impair cognition, especially in elderly patients. In contrast, trazodone is relatively safe when taken in overdose; no deaths have been reported to the manufacturer when trazodone was the only agent taken. Trazodone produces fewer and milder cardiovascular disturbances and anticholinergic effects than TCAs. If anticholinergic side effects do occur then they are rarely bothersome enough to result in discontinuation of therapy. In addition, cognitive skills, even in elderly patients, are less impaired in patients receiving trazodone therapy than in patients receiving TCA drugs. Although trazodone therapy has been associated with lethargy, dizziness, drowsiness, and confusion in some patients, symptoms have been mild and can be further minimized by administering the drug either after meals or once daily at bedtime.

Assessing the efficacy of antianxiety agents

Proper evaluation of anxiolytic therapy, involving the possible use of rating scales as well as the physicians skill in observation and communication, is essential in identifying the most appropriate treatment for a given patient and facilitating the management of therapy. These issues are discussed herein, using the clinical trials of buspirone, a new, nonsedating antianxiety agent, as a model for the process of drug selection.