Link Roundup: Less is more edition

I Hate Rashes is practicing restraint during this week of excess.  Cleanse your palate with these links from around the web.

I’m beginning to think that the future of medicine is to use less of it.  Here’s a great post from one of my favorite bloggers: Gaia and Snake Oil

And here’s something from the New Yorker on Prescription Opiates.  We could definitely use less of these. Who is Responsible for the Pain Pill Epidemic

Similarly, two links on insomnia that DON’T mention medicines. Just don’t read these after your turkey sandwich.  Sleep Therapy as Depression Treatment and Sleep Help Guide. The second link was mentioned in the last blog post; it’s a great patient self-help website.

Once you finish eating, check out this short commentary from the UK. Green snot does not equal a Z-pack. 

After a long weekend with your nieces and nephews, you might appreciate this.  The less is more, Babies edition. Contraception Practice Essentials. A quick, comprehensive guide for diagnosis and treatment. (requires Medscape Subscription)
Check this HILARIOUS patient education website for contraception in the real world.

Finally, after the third helping of sweet potato pie, some more perspective on lipid guidelines.  The Statinization of America.  Dr. Centor’s (and here)and Dr. Shaneyfelt’s take on the risk calculator in the new ACC/AHA guidelines.

Happy Thanksgivukkah Everyone!



Night shift at the Sawmill

Here’s one of those things that I should have learned about in medical school, but really didn’t.  If my patient’s snoring isn’t caused by sleep apnea, then I’m tapped out as to what to do about it.  But Twitter and AMR inspired me to do a little research this week.

Some snoring is nearly universal, and up to 45% of us are habitual snorers.  So be careful before you criticize your spouse or parent too much, next time you have a cold, or get pregnant, or gain that extra 5 pounds, your criticism may come back to you.  Funny how that works.

The overall cause of snoring is increased upper airway resistance, and the reason for that can be pretty broad. Certainly OSA can also be a cause of the snoring, but may also be a result. The more resistance there is, the more likely that arousals and apnea are also present.  Nasal congestion, tonsillar hypertrophy, obesity, and craniofacial abnormalities like acromegaly can all increase resistance by just having less room for air to move through.  Sort of like a stenotic valve causes a murmur.

So why care?  Certainly we all know the health risks of untreated sleep apnea, that I won’t cover here, but what if there isn’t apnea?  There have been some mixed results, but there are few observational studies that link snoring (without apnea) to hypertension and atherosclerosis.  But in reality, it is often the bed partner who urges the patient to get some help.  Marital harmony and relieving embarrassment are real issues for patients and probably the place where treatment can have the most benefit.

Treatment for snoring can take a variety of approaches.  Weight loss alone can go a long way. A very small observational study showed statistically significant decreases in snoring with as little as 3kg of weight loss, and near absence of snoring in patients who lost 8kg.  Other lifestyle changes that are always good: quit smoking and drinking.  Snorers are more likely to use both substances.

Changing sleep position may work.  Many snorers sleep on their backs, which causes open mouths, and smaller airways.  About ½ of patients can be trained to sleep on their sides instead.  The entrepreneurs of the world have come up with a ton of products, but a simple home remedy is to attach a tennis ball to the back of a T-shirt.  You can pin a sock to the shirt, and then put the ball inside, or you can duct tape the ball on the back of the shirt.

Increasing nasal patency may do the trick.  During a cold, nasal decongestants can be helpful (although only for 3 days or you risk rhinitis medicamentosa). Nasal steroid may help some, and are worth a trial.  Some nasal dilators have been proven effective, particularly the external ones like Breathe Right strips. 

Finally, mechanical appliances (mouth guards, chin straps) or surgery may be the answer for some, if the above approaches don’t help.

A good bit of this information came from a great patient education website that I found. It is a great place to direct patients to find out info about all sorts of things that really don’t need a “medicine” to fix.  Sleep, diet, stress relief, even a variety of psychiatric topics such as ADD, bipolar disorder, and PTSD.

Statins in the water

You might have heard about new cholesterol screening and treatment guidelines released this week.  I had 3 patients ask me about it during a single clinic session, and would have been clueless if it hadn’t been for a very smart Facebook friend.  Social media at work..

Here’s the skinny on the new guidelines.


  • it is risk for heart disease that is important, not so much an LDL target.  Four major groups are deemed high enough risk to warrant treatment
  • Use statins.  High potency ones like atorvastatin or rosuvastatin for higher risk patients, lower potency (pravastatin) for lower risk patients.
  • If you are going to use it, put people on a good dose and leave them there.  Really no need to check lipids every year.
  • The four groups to consider treating
    1. Known atherosclerotic cardiovascular disease: less than 75, use high potency statin; >75 use moderate potentcy statin
    2. LDL >190: high intensity statin
    3. Diabetic: moderate potency statin, use higher potency if they otherwise are high risk
    4. 10 year risk of atherosclerotic CV disease >7.5%: use moderate or high potency statin


The risk calculator to find out if your patient fits into that last group is here.  It is a little cumbersome to use, but is NOT the same as the Framingham or Reynolds Risk calculators that you may be used to. This might be a good thing, as the “pooled cohort” risk calculator was validated in White and African American men and women, which is somewhere that Framingham falls short.

So that’s the overview.  There are lots of questions about these guidelines that I haven’t delved into here.  It really represents a major shift in our thinking about cholesterol, which may be a good thing. It remains to be seen if our performance targets will change based on these recommendations. It follow that if our patients are on appropriate doses of high potency statins and the LDL is >100 or >70, or whatever your target may be, they may still be getting the benefit from statins.  Adding more drugs just to lower the number may not do anything for their overall risk of heart disease or stroke.

Smarter people than I have had some good things to say about the guidelines. I suggest you take a look at NY time op eds and Dr. Centor’s take- both below.  macstatin31