PTSD, Sleep Apnea and GERD: A Hypothesis

Wanted to share some thoughts I had today about the difficult problem of treating sleep apnea in people who are hypervigilant and therefore sleep too lightly to use CPAP. A group which includes me (as you will know if you have read any of my books on the subject)

Recent studies have shown that Post Traumatic Stress ( PTSD) is strongly associated with sleep apnea. For instance, servicemen and women returning from combat will often have a constellation of problems including PTSD/sleep apnea/migraine headaches. In order to treat any one of these three problems, all must be addressed. Many of these soldiers are young, have normal body weight and have no family history of sleep apnea (or migraines or mental illness). Compare this to the average sleep apnea sufferer in the civilian world who tends to be older, heavier and to have a strong family history of sleep apnea. These PTSD/sleep apnea patients tend to sleep more lightly, and they often cannot tolerate CPAP (which wakes them up).

Recently, dronabinol, the marijuana derivative that is used for intractable nausea and vomiting due to chemotherapy has been shown to decrease the severity of sleep apnea by one half in people with sleep apnea who are intolerant of CPAP. How does a medication whose primary effect is on the stomach and GI tract improve sleep apnea?

Let’s go back a moment to early infancy. There is something called the laryngeal chemoreflex that is very active in the new born up until about 6 months of age. When gastric acid creeps up the throat and gets near the airway---bam!—the airway squeezes shut, the baby stops breathing for a few seconds, the heart rate goes down, the baby swallows—and then the apneic spell is over. These spells happen an average of one to two times an hour in the sleeping infant. Usually no harm is done. The baby does not even wake up.
This type of reflex is important in the infant who spends most of his time lying on his back including immediately after meals. Aspiration pneumonia is dangerous. Eventually, the child outgrows the laryngeal chemoreflex---

But what if the chemical changes associated with PTSD bring the laryngeal chemoreflex back? A patient suffering from post-traumatic stress lies down to sleep. A little bit of stomach acid regurgitates into the esophagus—not enough to actually threaten the airway with aspiration. But if the same mechanism that makes that woman a bundle of nerves who jumps at every slammed door and car backfire during the day is working overtime at night too, then maybe the mere hint of stomach acid near the airway is enough to shut down breathing activity altogether. And, in an adult, such apneic spells are more likely to disturb the sleep, taking one from deep to light sleep or even causing the sleeper to wake to a feeling of panic or smothering.

The next part will get a little technical, so feel free to skip if biochemistry and neuroanatomy are not your hobbies. There is a portion of the vagus nerve called the nodose ganglion which, when 5HT receptors are stimulated causes reflex apnea. Researchers injected that ganglion with cannabinoids---and respiration improved, the apnea stopped. PTSD has been linked to disruption of normal neuroendocrine hormones including 5HT and serotonin.

If this hypothesis is correct, then perhaps we should be applying the lessons learned by pediatric sleep experts to the sleep apnea of young adults with PTSD. Gastroesophageal reflux disease is understood to be a factor in infantile sleep apnea. Perhaps it is a factor in certain forms of adult sleep apnea. This in turn raises the possibility that control of GERD might do more to help PTSD patients get a good night sleep than CPAP. It is also possible that we will see real progress in sleep apnea therapy, either through medications or treatments that affect the vagus nerve or even biofeedback to down grade the laryngeal chemoreflex.

Below are two particularly well written abstracts followed by a list of other references.

Obstructive sleep apnea (OSA) affects one in five adult males and is associated with significant comorbidity, cognitive impairment, excessive daytime sleepiness, and reduced quality of life. For over 25 years, the primary treatment has been continuous positive airway pressure, which introduces a column of air that serves as a pneumatic splint for the upper airway, preventing the airway collapse that is the physiologic definition of this syndrome. However, issues with patient tolerance and unacceptable levels of treatment adherence motivated the exploration of other potential treatments. With greater understanding of the physiologic mechanisms associated with OSA, novel interventions have emerged in the last 5 years. The purpose of this article is to describe new treatments for OSA and associated complex sleep apnea. New approaches to complex sleep apnea have included adaptive servoventilation. There is increased literature on the contribution of behavioral interventions to improve adherence with continuous positive airway pressure that have proven quite effective. New non-surgical treatments include oral pressure devices, improved mandibular advancement devices, nasal expiratory positive airway pressure, and newer approaches to positional therapy. Recent innovations in surgical interventions have included laser-assisted uvulopalatoplasty, radiofrequency ablation, palatal implants, and electrical stimulation of the upper airway muscles. No drugs have been approved to treat OSA, but potential drug therapies have centered on increasing ventilatory drive, altering the arousal threshold, modifying loop gain (a dimensionless value quantifying the stability of the ventilatory control system), or preventing airway collapse by affecting the surface tension. An emerging approach is the application of cannabinoids to increase upper airway tone.

The classic fight-or-flight response to perceived threat is a reflexive nervous phenomenon that has obvious survival advantages in evolutionary terms. However, the systems that organize the constellation of reflexive survival behaviors following exposure to perceived threat can under some circumstances become dysregulated in the process. Chronic dysregulation of these systems can lead to functional impairment in certain individuals who become “psychologically traumatized” and suffer from post-traumatic stress disorder (PTSD), A body of data accumulated over several decades has demonstrated neurobiological abnormalities in PTSD patients. Some of these findings offer insight into the pathophysiology of PTSD as well as the biological vulnerability of certain populations to develop PTSD, Several pathological features found in PTSD patients overlap with features found in patients with traumatic brain injury paralleling the shared signs and symptoms of these clinical syndromes.

Just Because It Annoyed You, That Does Not Make It Criminal

We have seen one candidate reviled because she annoyed a staffer by demanding a fork for her salad. We have seen another reviled because he annoyed a politician by touching her shoulders and hair. What's next? A candidate knee-capped because he cut off someone in traffic (we all know how annoying that is)?

Thanks to twitter, every one of us can now be the center of the universe. All the (mostly imagined) slings and arrows that we have endured can be transformed into sweet, sweet revenge. But at what cost?

Catholics are Touchie-Feelie. Joe Biden is Catholic

If you have never been to a Catholic mass, you probably do not know that part of the proceedings involve blatant, deliberate bodily contact with strangers.

http://catholicphilly.com/2019/01/catholic-spirituality/beyond-a-handshake-the-profound-nature-of-the-sign-of-peace/

John Mitchell, Alberto Gonzales..and now Bill Barr

I happen to believe that the entire Mueller report has already been leaked to House Democrats. For one thing, unless it was typed on an old IBM Selectric and mailed via carrier pigeons a la John Wick, it has probably been hacked at least a half dozen times. At least one of the hackers would have shared it with someone who would have given it to a prominent Democrat or Democratic Party supporter or an enemy of Donald Trump (and there are many). Plus, there are plenty of media outlets that would be wiling to pay a hacker large sums of money for the real thing. What a scoop!.

So, why is no one claiming to have the report yet? For one thing, that would give Donald trump and his Republican stooges a chance to demand an investigation. "Who leaked?" would be Fox News' response to "Trump Obstructed Justice." Better to sit tight until the official release date. And then, those who are already pouring over it can quickly announce the evidence of obstruction and issue subpoenas to those who will be called upon to testify before Congress.

But there is another possibility, one that Barr ought to be considering as he prepares to redact the investigation report to please his boss, Donald Trump. The Democratic House could be setting Barr up. Allow him to redact everything that might indicate that Trump obstructed justice (we already know he did, from the firing of Comey to his illegal witness tampering) and then compare the document he presents to Congress with the real one. If the Barr document carefully trims every evidence of Trump's obstruction of justice that makes the current Attorney General an accessory to obstruction of justice. And there is no easier target for a Congressional investigation and impeachment effort than an Attorney General who breaks the law, because the Attorney General is the law and can not plead ignorance or act like an idiot who did not know better or even plead the Fifth.

Prediction--first head to roll will be Barr's himself unless he is very, very careful.

Big Pharm's Greed and the Ever Rising Cost of Drugs

Pharmacy Bro was not an aberration. He was just an overachiever. Here are some modern examples of price gouging by Big Pharm

1) take colchicine, an old generic, get a new FDA indication for a short course for gout and then the only colchicine on the market is the overpriced Colcrys

2) take guafenesin, the generic mucolytic in Robutussin and declare that one company, Mucinex owns a patent to it in pill form

3) Take Doxycyclne an old generic antibiotic that used to be $4, get a monopoly on th precursor ingredient and suddenly you can charge $50 or more dollars for a course

4) Take cefixime (used to be Suprax) the only generic oral third generation cephalosprin and got to court any time any other generic manufacturer tries to make it, meaning that a course can cost $200.

5) Bribe the Bush FDA to ban ergot (migraine) and quinine (restless leg) so that Glaxo-Smith-Kline can make more money selling Imitrex and Reqip.

6)Wait until Lyrica, the expensive version of gabapentin loses its patent to begin a public relations campaign aimed at driving gabapentin (cheap generic) from the market where it is widely used as a non-opiate chronic pain treatment.

7) Wait until your own product Seldane, at that time the only non-sedating antihistamine is about to go generic and petition the FDA to take it from the market due to rare side effects just as your company is about to release its new, patent non-sedating antihistamine.

8) Mylan raaised the price of Epi-Pen 500%--because they could.

9) and now Mylan is suddenly not producing Buspar (buspirone) a popular anti-anxiety med that is not a benzo creating national shortage and panic among anxiety patients. Wanna bet that when it comes back to the market, it will have a higher price?

Here is the Washington Post on how Big Pharm conspires to fix prices of generics.

https://www.washingtonpost.com/business/economy/investigation-of-generic-cartel-expands-to-300-drugs/2018/12/09/fb900e80-f708-11e8-863c-9e2f864d47e7_story.html?utm_term=.3b6d925acafb

In Answer to Paul Krugman's Question: How Do We Save Rural America? Answer: Medicaid Expansion

NYT has not published any of my comments since I suggested that David Brooks was only supporting reparations because it is an issue the GOP hopes will fan the flames of white victim-hood. So, here is what I sent in response to Paul Krugman's latest piece about how to fix rural America:

Here is one simple thing that could make a world of difference. Encourage all states to accept the Medicaid expansion. Anyone who has visited rural Colorado or New Mexico recently knows that clinics, pharmacies and even hospitals spring up in rural areas when the population is insured. And then, these rural areas flourish. Compare this to rural Texas/Georgia and the southern states in between where you have to travel to a big city for health care--and where small towns are mostly boarded up.

Why does health care matter? One, it creates jobs. Well paying jobs. Health care spending is second only to education spending as a way to encourage economic growth.

Two, it keeps the local population healthy so the kids can go to school and get higher educations. It keeps the kids' parents healthy so they can work to put their kids through school.

And three, employers that offer health insurance are more likely to locate in an area that has health care providers. And those who work from home--say by computer, often highly skilled and highly paid professionals---will be more likely to buy the house of their dreams in the country if they know that the closest ER is not three hours away.

Help Me Out Here? WTF is the "Purity Patrol" in regards to the Democratic Primaries?

I googled "Purity Patrol" and got an environmental group that tests water. But in a political context this makes no sense. How does "purity patrol" relate to the Democratic Primaries? Is there some broader meaning to this phrase that I do not understand? In the context in which I heard it used, it struck me as being sort of a politically loaded comment, like "political correctness" as it used to be used to protect hate speech and "welfare queen" as used by Reagan to make poverty something to despise rather than something to pity.

Or maybe it is like Paws Patrol? My grandson loves Paws Patrol.

BTW, I will be here often checking for Divide and Conquer/Kneecapping/ and Anyone is a Phony (favorite GOP Democratic Primary lie of the 21st century). And if something troubles me, I will say so. This is a political forum that encourages political debate. We should all come away from this forum at the end of the day a little bit more politically savvy (I know I do. I now know the phrase "purity patrol') Anyone who objects to me checking for Divide and Conquer/Kneecapping/Anyone is a Phony, please let me know why. If your objection is that for the first time in decades, I have chosen not to remain undecided, well, sometimes Granny has to shake things up a bit. If your objection is that I am a smart ass, then you are correct. The snark is strong within you, McCamy. If your objection is that my comments do not reflect the opinions of the guy at the bottom of my page, I am not pretending to reflect his opinions. I have been around for a long time and my opinions are my own and no young whippersnapper from El Paso will make me change my opinions.

Party on, dudes. And by that, I mean Democratic Party on! And if you have not read Hunter S. Thompson's "Fear and loathing on the Campaign Trail 1972" Angela Davis's "Women, Race and Class" and Eric Hobsbawn's "Bandits" (the last pertains specifically to Trump and his popularity with his rural base and gives clues as to how best to divide him from his base) then add them to your summer reading list.

This is shaping up to be a great primary. I wish Dr. Gonzo and Molly Ivins were here. They would love this one.

Beto Wrote This and Bernie Wrote That Could Well be a GOP/Kremlin Divide and Conquer Trap

Thanks to TexasTowelie for reminding me of a bit of political trivia, a stupid story that really "disturbed" people like Glenn Beck about how Sanders once wrote something about a woman's rape fantasy. In 1972. The very first time in all of recorded history that anyone has ever written about a woman's rape fantasy. OMG! Sanders invented the myth of women have rape fantasies! What a monster! I'm literally pulling my hair out and foaming at the mouth!

......



So, if someone tells us that Beto wrote a bit of fiction about a teenager's momentary murderous impulse, not acted upon, it becomes easy to claim that Beto single handedly is responsible for all the teenagers who have ever committed murder. And then, Beto supporters will be up in arms and declare "Not True! But Sanders is responsible for everyone who ever imagined that women sometimes fantasize about being raped!" And then the supporters of the two candidates can get into poo flinging battle that would make a band of chimps watch in awe. And then the so called "feminists" can jump in with "Women seldom commit violent crimes and rape. You can not trust a candidate with a penis." And then the shit really hits the fan.

Remember Pat Buchanan's strategy in 1972 when he created CREEP for Tricky Dick Nixon:

https://www.washingtonpost.com/wp-srv/national/longterm/watergate/stories/buchananmemo.htm?noredirect=on

No kneecapping please.

Not only can this weaken the eventual nominee in the general, it can also weaken a later nominee in a later general——as we recently witnessed. So, for instance, please do not post that a candidate “went off” which feeds a MSM Big Lie that women in power are emotionally unstable. Instead use language like “delivered a stinging indictment.” The Russians and their trolls will be doing a lot of kneecapping.

Remember, kneecapping is another form of Divide and Conquer, the GOP’s favorite dirty political trick.

Solidarity!

PS this donkey needs it’s knees to run!

David Brooks Thinks Reparations Ought to Be an Important Dem Primary Topic