What is Obstructive Sleep Apnea? Who is at Risk?

Obstructive Sleep Apnea (OSA) is a very common condition in which the upper airway gets obstructed by relaxed soft structures during sleep. This obstruction leads to inadequate air exchange in the lungs, increased diaphragm and chest wall muscle contractions as efforts to relieve the obstruction occur. In addition, OSA is characterized by poor sleep quality due to multiple brief periods of waking up during the night as the body moves and loud gasps happen. Finally, due the the poor sleep quality, daytime sleepiness is a feature of this condition, with all the problems this entrails.

There are certain groups of people who are at risk of having OSA. Obese or overweight individuals, patients with enlarged tonsils or large tongues, people with a thick or large neck or individuals who have upper airways with small diameters. The formal diagnosis of OSA is made with an overnight sleep study, however it can be strongly suspected if a person has daytime sleepiness, snores loudly and if there are visible episodes of “not breathing” (apnea) during sleep.

OSA can lead to elevated blood pressure, problems with attention and concentration, daytime sleepiness, irritability, and headaches. Treatment includes the avoidance of alcohol, sleeping on a side, use of a continuous positive air pressure (CPAP) device, surgery to remove extra tissue, and the use of an implantable upper airway stimulator. A primary physician will be able to refer someone who may have this condition to a local sleep specialist.

Marco A. Ramos MD

Atrial Fibrillation. Will you Ever Have it?

Atrial Fibrillation is one of the most common arrhythmias of the heart. It is often referred as “irregular heart beat” or “quivering of the heart”¹. It is important because it is related to strokes, heart failure and cognitive decline. Its treatment, in addition to trying to control the arrhythmia, usually involves anticoagulation in order to decrease the risk of stroke.

Even if people are healthy and have few or no cardiovascular risk factors, there is a age-related risk of developing atrial fibrillation. This risk has been measured and it increases progressively with age. In one study, people between 55-59 years old have a 0.7% risk, 60-64 years old 1.7%, 65-69 years old 4.0%, 70-74 years old 6.0%, 75-79 years old, 9.0%, 80-84 years old 13.5% and older than 85 years old 17.8%². The risk seems to be slightly higher in men than in women.

The risk of developing atrial fibrillation increases with the presence of conditions such as hypertension, diabetes mellitus, hyperthyroidism, heart failure, obesity, obstructive sleep apnea, excessive sports practice, chronic inflammatory states, and alcohol abuse³. In addition there are genetic markers that might explain why certain people develop atrial fibrillation at a younger age and why white people are more affected than people from African of Hispanic descent. There are mutations in certain genes that increase the risk and there are genetic variants called single nucleotide polymorphisms (SNP) that are associated with early onset atrial fibrillation.

Like with every condition, there are modifiable risk factors and non-modifiable risk factors (like the genetic ones). If anyone has any of the non-modifiable risk factors, it is better to be on the safer side and make sure that more risk is not added to the already present ones. Also, be in close communication with your personal physician for proper prevention and treatment if needed.

References

1. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp#.V3RKAFeL1M8. Obtained June 20, 2016

2. Jan Heeringa, Deirdre A.M. van der Kuip, Albert Hofman, Jan A. Kors, Gerard van Herpen, Bruno H.Ch. Stricker, Theo Stijnen, Gregory Y.H. Lip3, and Jacqueline C.M. Witteman. European Heart Journal. 2006;27: 949-953

Marco A. Ramos MD

3 Reasons to be Careful with Genetic Testing

Nowadays, it is possible to obtain access to one’s genome data easily and relatively cheap. There are several companies offering this information and together with interesting information regarding ancestry they provide medically relevant data.

The first reason to be careful with is the meaning of the data by itself. The majority of diseases are multifactorial in origin, meaning that not one, but many genes could be involved in their genesis. In addition, the environment is also important, meaning that if even if the “defective genes” are present, a healthy diet and physical fitness can ameliorate the effects. An adequate interpretation of the data has to be performed by a physician and if further questions arise this should be followed by a second medical opinion of a physician with training in genetic counseling.

A second reason to be cautious is the abundance of information in the internet about certain conditions and the recommendations provided by well intentioned, non-medically trained people. We always have to keep in mind that we are unique and that the combinations in our genetic material probably do not repeat in another person. Therefore, the recommendations have to personalized. Again, as in the previous paragraph, your physician has to be in charge of starting a necessary treatment or reassuring the patient if necessary.

Finally, what would happen if an insurance company obtains someone’s personal information? Would they use to raise premiums if they know that you are at risk for a certain condition? Would a person become uninsurable? Privacy of course has to be a key factor here. Even if you disclose information to your personal doctor and he or he makes it part of the medical record, the insurance company might have access to it.

Genetic testing, now widely available and cheap can provide medically relevant information. However, there are risks associated with obtaining it. The primary physician should be in charge of guiding the interpretation and possible therapies associated with it and also has to be instrumental helping you keep the privacy of the information. Also, we cannot underestimate the importance of a second medical opinion.

Marco A. Ramos MD

Three Reasons for Electing Private Pay Over Insurance for Outpatient Health Care

Being insured in order to to see your primary doctor or specialty physician has become the norm. Many traditional physician practices will only accept you as a patient if you are enrolled in an insurance plan, either government funded or non-government funded. This has created a change in the relationship between a physician and the patients. In this post, I will show three reasons why patients should seek private pay arrangements with the physicians of their choice. 

1. To keep the decision-making between the doctor and the patient. The moment a doctor is allowed by an insurance company to see  patients who pay premiums to it, that doctor is accepting that there is a third entity that will monitor, question and in many changes change the decisions made by the doctor and the patient in the office encounter. 

2. To assure privacy. Once a patient participates in an insurance plan, the patient is surrendering its private health information to a third party. There will be other individuals, employed or contracted by the insurance company, that will review the medical record for different purposes including quality of care, financial analysis and approval or denial of specific treatments.

3. To not be subject to restrictions and limits in insurance plans. Insurance companies can change their plans. Benefits that were part of the plan might not be present in the amended plan. Most of benefits are partially paid and the remainder has to be paid “out-of pocket” by the patient.

The concept of insurance is to spread the risk amongst a pool of people. The greater the pool, the better spread the risk is and the premiums may be lower. This is necessary when we take into account that hospitalizations, surgeries and prolonged treatments like, for example, dialysis or chemotherapy can be extremely costly. However, for outpatient care, when we deal with preventive medicine or with specialist consultations, it would be probably better to seek models that keep the relationship between a doctor and patient strictly between them.

Marco A. Ramos MD

The Importance of Knowing your Disease Process and its Treatment Options

Health issues can be complicated. Not only the diagnoses can be complex and difficult to understand, but the treatment options can also be overwhelming. This is why an encounter with a physician is extremely important. It can have the effect of making the patient understand fully the condition he or she is going through or, it can have the opposite effect if the encounter is too short or the communication skills are just not there.

The first thing that needs to be understood fully by the patient is the disease process that leads to the situation the patient is on. If the case is cancer, renal failure, or heart failure, there is a unique set of circumstances that led to that situation. What needs to be always remembered is that every person is unique. Everyone of us carries a distinct genetic background and have lived different lives with different nutrition and exercise habits. Unless a person is victim of an accident, the causes for any condition are usually multiple. This is  what doctors mean when they use the term “multifactorial”.

In this information era, many people resort to the internet as their source of information. This is the consequence of the internet being readily available, as opposed to a physician, who is usually difficult to find and when found, the encounter might be short and not yielding the expected answers. The internet can be a good source of information, however, there is so much out there that the wrong conclusions can be drawn easily. The other consequence is to make the patient more confused.

The same happens for the treatment options. A long term therapy such as chemotherapy or dialysis should be a process that the doctor and the patient go in (or not go) together, with the doctor providing guidance, not orders. When the patient lacks the right set of information, the decisions made at a given point in time, can lead to expectations that might seem unrealistic in the eyes of the doctor. 

For a patient, knowing the disease process and its treatment options are crucial elements for good healthcare outcomes and a good physician-patient relationship. When the point in which either or these elements are not achieved, a second medical opinion can be what is needed to achieve the elements and ensure good healer outcomes and solidify the relationship between the patient and his or her doctor.

Marco A. Ramos MD