This is It!

If we had confidence after a thorough investigation of the facts that the president clearly did not commit obstruction of justice, we would so state.

Not Sure "White haired elderly man gives hugs" is Having Its Intended Political Effect.

It may just be me, but I think it is making Biden seem friendly, avuncular. You know. Like a regular Joe.



Here is another white haired elderly man who gives hugs:

Health Care Journalism: Who Does It Serve?

There is a code of ethics for Health care Journalists, just as there is for health care providers.

https://healthjournalism.org/principles

However, health care news is a mine field that can cost patients their lives. Two recent examples:

1) Stories about how elderly with no history of heart disease and no risk factors of heart disease should not be started on aspirin for heart disease prevention since their risk of getting an ulcer from the aspirin is higher than their risk of developing the health disease that they obviously are not going to get. These have been presented in such a way that patients have gotten the impression that aspirin is bad for the elderly. I have encountered elderly heart patients with coronary artery disease and stents who have stopped their aspirin because of these stories. This is not good. They are at high risk for platelet clumping followed by acute myocardial infarction followed by congestive heart failure and death without that aspirin 81 mg a day. Note that there are no stories about how Plavix/Eliquis/Brilinta can cause ulcers. I see upper gastrointestinal bleeds in patients on these much more than I see it on people taking aspirin 81 mg.

2) Stories about how a few lots of Losartan were contaminated have turned into rumors that all Losartan causes cancer. I have seen patients who have stopped their Losartan as a result. Note that Losartan not only controls the blood pressure. It also relieves strain on the heart in people with congestive heart failure and prevents kidney damage in people with diabetes. Losartan is the cheapest of its class, the ARBs.

Sensationalism sells copy. But I wonder how many health care journalists print what their corporate masters in Big Pharm and Wall Street tell them to write. And before you accuse me of wearing a tinfoil hate, remember that during the W. Bush administration, the FDA banned ergot for migraines and quinine for leg cramps in the same day, increasing the potential market for Glaxo-Smith-Klines Requip and Imitrex . And the makers of Seldane (at that time the only non-sedating antihistamine) successfully petitioned the FDA to ban Seldane one month before it was due to go generic, meaning there would be no cheap generic competition for their new, patent non-sedating antihistamine, Allegra.

https://www.latimes.com/archives/la-xpm-1997-dec-30-mn-3495-story.html

Meaning that Big Pharm makes big money of they can take away patient's options to use cheap, generic medications.



Maybe we need a Media Matters for health care journalism.

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/