Evidence-based guidance for two sleep disorders in adults

- Kenny Lin, MD, MPH

At an American Family Physician editors' meeting several years ago, a colleague, who marveled at amount of academic and clinical activities that I cram into a typical workweek, asked half-seriously, "Do you sleep?" Yes, I answered, not only do I need at least seven hours of uninterrupted sleep each night, I don't feel the least bit guilty about making it a priority. As Dr. Jennifer Middleton wrote in a previous AFP Community Blog post, the negative health consequences of chronic sleep deprivation are legion. Unfortunately, a recent survey found that nearly half of U.S. military personnel report poor sleep quality. From 2003 to 2011, the incidence of insomnia and obstructive sleep apnea (OSA) in active duty U.S. Army soldiers increased by 652% and 600%, respectively.

Concerns about these two common sleep disorders led the U.S. Departments of Veterans Affairs (VA) and Defense (DoD) to develop a joint clinical practice guideline for their diagnosis and management; a synopsis was published this week in Annals of Internal Medicine. Key recommendations for treating chronic insomnia (insomnia occurring for three or more nights per week for three or more months) generally agree with those from a 2016 American College of Physicians guideline and Agency for Healthcare Research and Quality review: offer cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, and reserve short-term pharmacologic therapy (low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists) for patients who are unable to access or complete CBT-I.

The VA/DoD panel suggests not using antipsychotic drugs, benzodiazepines, or trazodone for chronic insomnia due to harms outweighing benefits or lack of benefit. It also advises against two common ingredients in over-the-counter sleep aids, diphenhydramine and melatonin. The panel suggests that clinicians not use sleep hygiene education as a standalone treatment due to its limited effectiveness and potential to discourage patients from pursuing the more effective CBT-I.

For OSA, the VA/DoD guideline suggests using the STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure) to stratify risk in patients who report sleep symptoms and performing home sleep apnea testing rather than in-laboratory polysomnography in patients with a high pretest probability of OSA. Although continuous positive airway pressure (PAP) therapy is recommended for persons with severe OSA, mandibular advancement devices may be used as an alternative in mild or moderate cases. The VA/DoD panel did not evaluate positional therapy (techniques to promote side sleeping) for OSA. However, a recent Cochrane review found that patients are more likely to tolerate and adhere to positional therapy than PAP, compensating somewhat for the former's lower effectiveness.

Obtaining a detailed sexual health history: why and how

- Jennifer Middleton, MD, MPH

Conversations about sexual health are critical to ensuring that all persons eligible for PrEP (pre-exposure prophylaxis for HIV) receive it. The AFP review article on "Sexual Health History: Techniques and Tips," epublished ahead of print this past week, provides pragmatic guidance to obtain the often sensitive history elements required to meet these aims.

The authors encourage physicians to take a proactive approach to obtaining a sexual history. They review steps to creating an environment conducive to sexual history conversations, introduce the "5 Ps" model (partners, practices, past STI history, pregnancy plans, pleasure) for obtaining a detailed sexual history, and remind readers of trauma-informed care resources to minimize retraumatizing victims of prior abuse.

In addition to these universally useful tips, the February 1 AFP review article on "Screening and Counseling Young Adults" emphasizes the importance of providing adolescents with the opportunity to be evaluated confidentially by a physician, as teens are then more likely to disclose sensitive information. The SSHADESS tool advocates for a strengths-based interviewing approach instead of focusing solely on risks. "Clinicians should thank patients for disclosing personal information, share their concerns respectfully and empathetically..., and reflect patients' previously disclosed examples of resilience."

Both adolescents and adults can lower their risk of HIV infection with PrEP. As this editorial, also just epublished ahead of print, succinctly states:

Taking a thorough and complete sexual history can assist with screening and treatment of sexually transmitted infections, which are currently at record high levels and can facilitate HIV acquisition.

Roughly 1 million persons in the United States are candidates for PrEP, but only about 77,000 received prescriptions in 2016 (latest year for which data is available). Black and Hispanic men who have sex with men were less likely to receive PrEP prescriptions than white men in one study; this same study showed that rates for PrEP initiation are similar across all backgrounds if patients were offered PrEP by their physician. Obtaining an adequate sexual health history on all of our patients, regardless of their race or ethnic background, may help to correct this disparity.

You can find more information about identifying persons who may benefit from PrEP in the CDC's 2017 Clinical Practice Guideline, which is summarized on the CDC PrEP website. Relevant AFP resources include this overview of the United States Preventive Services Task Force (USPSTF) "A" recommendation to prescribe PrEP, this POEM on "Preexposure Prophylaxis with Tenofovir/Emtricitabine Prevents HIV Infection in Men Who Have Unprotected Anal Intercourse," and the AFP By Topic on HIV/AIDS.

Preparing to respond to the novel Wuhan coronavirus

- Kenny Lin, MD, MPH

* NOTE: A more recent post on COVID-19 is available here. *

In a 2015 editorial on global health in American Family Physician, Drs. Ranit Mishori and Jessica Evert noted that "the world is not only smaller than ever, but it is also more intricately connected," with transportation networks facilitating the spread of exotic infectious diseases across oceans and borders. These words seem prescient today as China, the World Health Organization, and the international community work feverishly to contain the outbreak of the 2019 novel coronavirus (2019-nCoV), which was initially reported in patients with pneumonia in Wuhan, Hubei Province, China but has spread via travel and person-to-person transmission to 24 other countries, including 11 confirmed cases in the United States as of February 3. As scientists race to answer basic questions about this new respiratory infection, travel to China has been heavily restricted, U.S. citizens have been evacuated from the region, and travelers recently returned from Hubei Province are being quarantined by state governments.

To keep clinicians up-to-date on the evolving epidemic, the Centers for Disease Control and Prevention (CDC) has posted a comprehensive collection of resources for health care professionals who encounter patients with suspected 2019-nCoV, including an assessment flowchart and interim management guidance for patients with confirmed infection. Forward-thinking family physicians can also consult a previous Family Practice Management (now FPM) article for tips on on preparing your office for an infectious disease epidemic. Key points highlighted in this article include:

- Begin planning now.
- Master the detection, prevention and management of seasonal influenza and community-acquired pneumonia.
- Practice scrupulous infection control - "wash in and wash out."
- Communicate at all levels, and coordinate with public health agencies.
- Focus on staff management and business continuity.

Although the origin of the 2019-nCoV is not known, the linkage of the majority of early infections to a wholesale seafood market suggests the existence of an animal reservoir. A previous novel coronavirus outbreak that began in China, severe acute respiratory syndrome (SARS), was eventually traced to infected bats. However, the estimated 2% fatality rate of 2019-nCoV is substantially lower than the 10% fatality rate of SARS. In addition, it's important to remind worried patients that the CDC projects that the less lethal but far more prevalent (and preventable) seasonal influenza virus will cause 180,000-310,000 hospitalizations and 10,000-25,000 deaths during the current flu season.