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The adequacy of a health information system may be judged by the type of questions people ask. For example, if people do not know the answer to simple health questions or if they carry around unanswered questions, this may be evidence that the health information system is defective. In this study we sought to identify and analyze the unanswered health questions of adults and through this came to understand more about their health information needs and how to address them.
The health literature is thick with references that identify the public’s level of knowledge on specific health issues. For example, a Medline search on the medical subject heading “knowledge attitudes and practice” reveals over 8,000 entries related to health since 1981. For the most part, this literature is clinical and focuses on questions such as the patient’s level of knowledge of particular risks, conditions, and treatments. Other studies assess a community’s need for particular types of information, for example, about the causes of hypertension or asthma. Few studies, however, focus on the broader questions: What health questions do the public have? Where do they go for information? Do these questions and practices vary by demographics? Only one study in the recent health literature has sought to identify the type of questions people have - in this case, to ascertain the type of information needed for a local healthy living center (Winn & Bradford, 1991). Studies that seek to determine where people get health information are more common and have been used to assess the adequacy of these sources for meeting the health education needs of particular sub-populations (Arnold & Hom, 1996; Gollop, 1997; Richmond, McCracken, & Broad, 1996).
The current study identifies the health questions of adults and the sources of health information they use in a mid-sized town in south-central Indiana. This information was used to assess the adequacy of the health information system and to make recommendations to improve it.
METHODS
We set up a table in a discount department store on the fringe of a mid-sized town in Indiana (population 60,000) and offered to research answers to the health questions of adults. A store on the outskirts of the town was chosen to give us access to more of the rural population, which makes up a large portion of the population of southern Indiana.
While those who participated in the study were not chosen randomly, they may be more like the population of users of health information services. To use most health information services, a person must initiate an action to get an answer to their questions. Participants in this study had to approach a table and ask for help with a question. Participants in random surveys may not have taken an action on their own.
Participation was restricted to adults and each adult was allowed to ask one or two questions on any health topic. Health education students in training recorded the questions, researched the answers, wrote a response, and mailed the responses back to participants. In addition to the health questions, socio-demographic information was collected as well as responses to an open-ended question about where the participants go for health information.
RESULTS
Demographics
We collected 255 questions from 158 people (100 female and 58 male) within the space of 26 hours spread over a week. The sample size was limited by the students’ ability to write responses to each question - a process that occupied fifteen students a fair portion of the semester. The age range of participants was from 18 to 85 with a mean age of 38. Roughly half (54.9%) were under forty, about a third (34.6%) were between 40 and 59 and the rest were over 60. Most respondents were White (78.5%), with African-Americans making up 13.9% of the sample, Asians 5.7% and Hispanics 1.9%. Over half the sample (58.7%) had a household income below 25,000; only 14.7% had an income greater than $50,000. The sample approximated the demographics of the county which is 94% White with a median household income of $24,781. The adult population of the county is 53% female with 64.6% of adults being under 40 and. 21.1% between 40 and 60.
Question Type
Sixty-one percent of the sample asked more than one question. The questions were tremendously diverse, sorting into forty-two different categories - determined by major subject. For example, all questions on health care system were grouped together, and all questions related to diet were grouped together. Categorization was not always easy. In cases where the question could be fit into two categories, the question was placed into what was considered to be the narrower category. For example, a question about diet change to reduce the risk of heart disease was placed in the diet, not the heart disease category, as the diet questions were more similar in nature and less varied in scope than the heart disease questions. Many categories contained only a single question, for example, individuals wanted to know what is: cri du chat disease, celiac disease, the success rate for Islets of Langorhans transplantation, the latest research on Lopressor and Dilantin, and the latest research on Hereditary Hemorrhagic Telangiectasia. Table 1 lists the top ten most frequently asked question categories and the number of questions in each one. The categories with less than eight questions were collapsed into an “other” category.

To get around it, you can do one of two things: just let it happen or be on the offensive with compensating measures.

The obvious thing to do is to be on the offensive. But how do you do that?

Let’s talk about dehydration. Do you drink coffee or caffeine drinks such as colas or so-called energy drinks? If so, then you must compensate by drinking more water. Caffeine is dehydrating. For every can of caffeinated soda or cup of coffee - at least an equal amount of water is in order. If you don’t compensate, the dehydration shows up as gray, flaky dry skin.

Do you drink alcohol? It’s dehydrating. That’s one reason why your face looks like the wrath of God the morning after just a few drinks the night before. For every glass of wine or bottle of beer, you should consume an equal amount of water - or more. The hard stuff is even more damaging. Yes, you will be running to the potty, but you will be compensating for the dehydration and you will feel better in the morning because you have eliminated a lot of the alcohol toxicity.

Alcohol also depletes B vitamins. Some folks who like a glass of wine follow it with a B Complex capsule and a glass of water.

Overall, caffeine and alcohol are the least egregious offenders. Most folks don’t drink an excessive amount of coffee or alcohol on a daily basis.

There is something more damaging than daily caffeine and occasional alcohol. It’s what most people use a lot of on a daily basis over a long period of time: prescription medications.

Medication induced nutrient loss is responsible for more health problems that anyone realizes. The pharmaceutical companies do not mention nutrient loss in advertising, although warnings may appear in literature no one reads. And chances are that traditionally trained physicians and pharmacists aren’t educated enough about nutrition to be aware.

For example, has your physician or pharmacist ever warned you that estrogen replacement depletes magnesium? Magnesium depletion causes muscle weakness, depression, dizziness, hypertension, and heart problems. That doesn’t mean you should stop taking estrogen (if in fact you choose to replace estrogen) but you do need to make certain you are getting enough magnesium. A physician who practices integrative medicine will know enough to prescribe compensating nutrients.

Blood pressure medications such as Tenormin and Lopressor deplete CoQ10 which is absolutely vital to stabilize cellular membranes and give cells energy to function. Statin drugs that lower cholesterol deplete CoQ10 as well.

Diuretics (”water pills”) may cause magnesium, potassium, and zinc depletion. Men with prostate problems already tend to have zinc deficiency and if it is not supplemented the prostate can enlarge.

Medications such as Tagamet and Pepcid cause depletion of vitamin B12 and folic acid. A deficiency of these two vitamins causes homocysteine levels to rise. High homocysteine causes irritation of blood vessel walls. When cholesterol flows throw them, it clings to the irritated walls and then you have clogged arteries. We can’t live without cholesterol. It is vital for cell membrane integrity and hormone production among other things. But we can’t live with cholesterol when it is clogging arteries as a result of high homocysteine.

You don’t have to wait for your doctor to prescribe B12 and folic acid. You can buy B12, preferably in the form of methylcobalamin under-the-tongue tablets available over the counter. Folic acid tablets are also available without a prescription.

If you want to learn more about how prescription medications deplete nutrients, read the Drug-Induced Nutrient Depletion Handbook by Ross Pelton, James B. Lavalle and Ernest B. Hawkins.

Don’t suffer premature aging and loss of youthful attributes due to dietary indiscretion, neglect, or just not knowing. You can do a lot to help yourself. When you learn to compensate, or find a doctor who can help you avoid what you don’t need, or help with what you do need, you will stay healthier and more youthful a lot longer.

The Anti-aging Law of Compensation is too important to ignore. Educate, compensate, and take care of yourself! If you don’t, who will?

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“Turns out this pharmacist had given me 25 milligrams of the drug, not the 50 milligram doses my doctor prescribed,” recalls Fleming. “The pharmacist was very apologetic, but I was upset. What happened wasn’t lifethreatening at that point, but it certainly impacted how I felt.” If Fleming had continued taking the drug at the wrong dosage, however, he may have been at risk for a stroke.
Consumers like Fleming are wondering why pharmacists can’t seem to follow doctors’ orders when it comes to dispensing medication. In some instances, patients are shortchanged on the number of pills or in the dosage prescribed. In more serious cases, patients can receive the wrong medication, with fatal results. An estimated 100,000 people die from prescription drug use every year, according to a study reported in the Journal of the American Medical Association.
These errors stem from the great changes sweeping the pharmacy industry. Hospitals and large-chain drugstores have cut staffing to hold down costs and increase profits. At the same time, pharmacists’ workloads have increased due to the additional paperwork required by insurance companies.
This is a major reason for the errors and slow service consumers face at the pharmacy Counter, says Michael Hogue, a pharmacist ‘In Albertville, Alabama, and member of the American Pharmaceutical Association. “Your pharmacist literally becomes an insurance agent. While dispensing medication, he or she is likely to be on the phone trying to process your insurance claim.”
In the case of Fleming’s short supply of blood pressure medication, Hogue says it’s likely the insurance carrier had a limit on the quantity that could be dispensed at one time. “Most consumers don’t realize that their insurance company won’t allow for more than a 15- or 30-day supply of medication. Whenever you get fewer pills than prescribed, ask the pharmacist if your insurance carrier has limits on that prescription,” advises Hogue.
And what about the wrong dosage Fleming received? Hogue blames poor management at many of the large-chain drugstores. “Many of the chain pharmacies are not managed by a pharmacist who understands the need for time to process an order. They may be managed by someone who puts pharmacists under lots of pressure to fill orders quickly, and that leads to errors.”
Larry D. Sasich, a pharmacist and analyst with the Washington, D.C.-based Public Citizen Health Research Group, a watchdog organization for consumer health issues, calls it the prescription milt. “There may be one pharmacist behind the counter and two technicians. That pharmacist may have to fill 200 prescriptions a day on a 12-hour shift with no breaks or no lunch,” he says.
“Our managed care system doesn’t work very well to protect consumers against drug-induced injuries,” says Sasich. “Consumers must be vigilant about what they’re getting from their pharmacist.”
Start monitoring your medications before you leave your doctor’s office. “Ask your doctor both the brand name and generic name of the drug prescribed, the dosage required and why it’s being given,” counsels Sasich. “When you get the prescription from the pharmacist, read the label to make sure you’ve been given the drug your doctor prescribed and that the dosage is correct.” Also make sure that the pharmacist gives you the FDA-approved package insert or computer printout that outlines information about the drug you’ve been prescribed, dosage directions, adverse reactions and side effects, drug-to-drug interactions and other precautions.
You can also protect yourself by asking your pharmacist about some key points before you head home with your prescription in tow. Here are some suggested questions from the National Council on Patient Information and Education, in Washington, D.C.:
1. What is the name of the medicine and what is it supposed to do?
2. How and when do I take the medication and for how long?
3. What foods, drinks, other medicines or activities should I avoid while taking this medication?
4. Are there any side effects, and what do I do if they occur?
5. Will this prescription work safely with the other prescription and nonprescription medicines I’m taking?

TREATING HEADACHES

Contrary to popular belief, headaches cannot be cured but they can be managed or controlled. Today, more and more medications have emerged that aim to stop the throbbing pain associated with it or stop the symptoms that have resulted from it.

Taking in medications is the most popular way of combating the pains brought about by headaches. People from the medical field have categorized these into two: the Prophylactic treatment that is done every day to reduce the severity and frequency of attacks and Abortive treatment that is done once the headache attack begins.

A physician usually suggests prophylactic treatment only if the person is experiencing numerous headache attacks monthly. Once you have undergone this treatment, the doctor will strictly monitor the possible side effects like lethargy, drastic weight gain, hallucinations, memory impairment, and water retention.

While taking in this medication, make sure that you don’t combine it with any weight loss products. For starters, make sure that you are taking in low doses first before taking in large dose under prescription to test if it’s working correctly. Your physician should also constantly monitor any drug or vitamin intake and see if these interfere with the medication.

Pregnant women are not allowed to take this kind of medication and make sure that the medication is discontinued once the headache becomes manageable.

Prophylactic treatment involves the use of Beta Blockers like tenormin, lopressor, and inderal, Calcium Channel Blockers like cardizem, dilacor, and procardia, Antidepressants like elavil and Zoloft, Serotonin Antagonists like Sansert, Anticonvulsants like tegretol, depakote, and dilantin, and Ergot derivatives like cafergot.

Abortive treatment, on the other hand, is considered the first line of defense against headaches by taking in over-the-counter painkillers like aspirin, acetaminophen like tylenol, panadol or ibuprofen. Usually, physicians prescribe a medication that is a combination of analgesic with other substances in order to increase its effects.

In order to relieve anxiety, abortive treatments also involve the usage of anti-inflammatory drugs known as nonsteroidal anti-inflammatory drugs or NSAIDs that include naprosyn, anaprox, ponstel, meclomen, tolectin, and toradol which are helpful in treating headaches.

Although NSAIDs are used both symptomatically and prophylactically, experts warn future users that these may lead to side effects like gastrointestinal pains and disorder like diarrhea or constipation along with nausea or dizziness.

REMEDYING HEADACHES

Headaches are usually caused by physical and emotional stress. If you are dying to find a solution to your persistent headache, try taking in over the counter remedies like aspirin, acetaminophen, and ibuprofen. But if you are not a big fan of prescribed or over the counter medications, try these home remedies for a change.

- Try using compresses or cold packs. For tension headaches the most common form of headache try applying a warm or cold compress to your forehead and the base of your neck to numb the pain.

- Try using heat. If cold compresses wouldn’t work out for you, try using a warm washcloth or a hot water bottle can ease pain.

- Develop a routine of deep breathing exercises. If you suffer from headaches very often, try sitting in a darkened room, take in deep breaths using your nose, and let it pass through your mouth.

- Experience the wonders of acupressure. By squeezing the web of skin between and the thumb through acupressure, it can reduce the pains and can help you relax.

- Try relaxation techniques such as meditation, yoga, and biofeedback. By trying these relaxation techniques, the person who suffers from headache can feel the pain flowing out of the head. It can also help reduce stress.

- Relieve the affected area by applying ointment with heat. Ben-Gay or Icy Hot rubbed on forehead or on the base of the neck, can give a soothing warm feeling to your head.

- The power of music. Try listening to a relaxing music while lying down or resting.

- Exercise regularly. Physical activities like regular exercise can relieve stress because it can loosen up the knots and balls of pain in your head.

- Get enough sleep. Having six to eight hours of sleep can help you soothe your tired nerves. But, beware of sleeping more than 10 hours because it can cause major headache as well.

- If possible, use a neck pillow in bed. If you are prone to experiencing morning headaches, try using a neck pillow to your neck while you sleep.

- Totally eliminate caffeine, salt, MSG, and chocolate in your diet. Load up on lots of fruits, veggies, and water to keep your body well hydrated.

- If you can, avoid bright light because it leads to a major headache once your squint.

- Don’t skip meals. Skipping meals can lead to low blood sugar. When your sugar level goes down, your blood vessels in the brain tightens that leads to headache.

- Don’t eat foods that have nitrates, sulfites, and msg because these are primary headache causers. Also avoid aged cheeses and nuts so you won’t experience headaches.

- Don’t smoke and avoid smoke-filled rooms.

Common Regimen or Brand-Name
Brand Name/Strength[*] Quantity (30 day supply) Cost[**]

Ativan 1mg BID $70.25
BuSpar 15mg BID $141.80
Cardizem CD 240mg QD $68.37
Cardura 4mg QD $34.38
Cleocin T 1% - 60ml QD $70.45
Darvocet-N 100 100; 650mg QID $105.42
Dyazide 25; 37.5mg QD $16.61
Hytrin 5mg QD $61.17
Imdur 60mg QD $55.13
K-Dur 20mg BID $34.22
Klonopin 0.5mg BID $46.50
Lasix 40mg QD $9.23
Lopressor 50mg BID $48.27
Nitrostat 0.4mg 100 Count Vial $20.91
Pepcid 20mg BID $121.67
Procardia XL 30mg QD $45.49
Prozac 20mg QD $93.38
Ritalin 10mg TID $55.78
Tenormin 50mg QD $35.51
Valium 5mg BID $62.98
Vasotec 10mg BID $74.97
Vicodin ES 7.5; 750mg QID $78.06
Xanax 0.5mg BID $73.41
Zantac 150mg BID $113.90
Ziac 5; 6.25mg QD $40.68

Generic
Brand Name/Strength[*] Cost[***]

Ativan 1mg $27.11
BuSpar 15mg $48.46
Cardizem CD 240mg $38.45
Cardura 4mg $13.94
Cleocin T 1% - 60ml $26.73
Darvocet-N 100 100; 650mg $19.08
Dyazide 25; 37.5mg $7.42
Hytrin 5mg $30.09
Imdur 60mg $6.64
K-Dur 20mg $21.25
Klonopin 0.5mg $22.39
Lasix 40mg $0.71
Lopressor 50mg $4.35
Nitrostat 0.4mg $9.21
Pepcid 20mg $24.91
Procardia XL 30mg $28.87
Prozac 20mg $10.50
Ritalin 10mg $29.47
Tenormin 50mg $1.28
Valium 5mg $1.82
Vasotec 10mg $15.84
Vicodin ES 7.5; 750mg $17.02
Xanax 0.5mg $2.55
Zantac 150mg $12.60
Ziac 5; 6.25mg $17.03

Generic
Brand Name/Strength[*] Generic Name Savings

Ativan 1mg Lorazepam $43.14
BuSpar 15mg Buspirone HCL $93.34
Cardizem CD 240mg Diltiazem HCL $29.92
Cardura 4mg Doxazosin Mesylate $20.44
Cleocin T 1% - 60ml Clindamycin Phosphate $43.72
Darvocet-N 100 100; 650mg Propoxyphene/Acetaminophen $86.34
Dyazide 25; 37.5mg Triamterene/HCTZ $9.19
Hytrin 5mg Terazosin HCL $31.08
Imdur 60mg Isosorbide Mononitrate $48.48
K-Dur 20mq Potassium Chloride $12.96
Klonopin 0.5mg Clonazepam $24.11
Lasix 40mg Furosemide $8.53
Lopressor 50mg Metoprolol Tartrate $43.92
Nitrostat 0.4mg Nitroglycerin $11.70
Pepcid 20mg Famotidine $96.76
Procardia XL 30mg Nifedipine Extended Release $16.62
Prozac 20mg Fluoxetine HCL $82.88
Ritalin 10mg Methylphenidate HCL $26.31
Tenormin 50mg Atenolol $34.23
Valium 5mg Diazepam $61.15
Vasotec 10mg Enalapril Maleate $59.13
Vicodin ES 7.5; 750mg Hydrocodone/Acetaminophen $61.04
Xanax 0.5mg Alprazolam $70.86
Zantac 150mg Ranitidine HCL $101.30
Ziac 5; 6.25mg Bisoprolol Fumarate/HCTZ $23.65

QD: Once a Day BID: Twice a Day TID: Three a Day QID: Four a Day

[*] Most common strength dispensed for BCBBM members
[**] Brand-name cost based on Average Wholesale Price (AWP) obtained using
First DataBank (4/15/02) [***] Generic cost based on BCBBM
Maximum Allowable Cost (MAC) schedule or discounted AWP (4/01/02)

Source: Blue Cross Blue Shield of Michigan.

COPYRIGHT 2002 Atlantic Information Services, Inc.
COPYRIGHT 2003 Gale Group

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For six of the seven the U.S. generics were priced below the Canadian brand name versions. Five of the seven U.S. generic drugs were also less expensive than the Canadian generics.
Of the remaining two U.S. generic drugs, enalapril was unavailable as a generic in Canada and its brand name version in that country was over five times the price of the U.S. generic equivalent.
Metformin, the other U.S. generic, sold for less in Canada both as a generic and as a brand name. But, point out economists who conducted the research, metformin did not debut as a U.S. generic until January 2002, so its price as a generic has probably not dropped to the level it will eventually reach.
The study compared the average price of the generic and brand name version of the seven drugs sold in the U.S. and Canada by calculating the price per milligram of active ingredients in U.S. dollars. (Prices in Canada were converted to prices in U.S. dollars using a 2002 exchange rate.)
The prices were the costs to retailers, and the study used the assumption that retail markups were the same in both countries. Pricing information was collected by market research company IMS Health.
“Advocates of legalizing imports of drugs from Canada and other countries have typically cited studies showing that brand name drugs are much cheaper abroad than in the United States,” states the FDA.
“These studies ignore how competition in the U.S. market lowers generic drug prices so they are lower than drug prices abroad.”
COPYRIGHT 2004 Racher Press, Inc.
COPYRIGHT 2008 Gale, Cengage Learning

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The Study: The unblinded, randomized trial included children who had been hospitalized for recurrent syncope and who had a positive tilt-table test. Patients with nonvasovagal causes of syncope were excluded. The control group was instructed on nonpharmacologic treatment measures (e.g., increasing water and salt intake, avoiding blood-pooling activities such as leg-crossing). The treatment group was given the same instructions plus 1.25 mg of midodrine twice a day. Both groups had repeat tilt-table testing after one week. Children in the treatment group who had a positive repeat tilt-table test received an increased dosage of midodrine (2.5 mg twice a day) and were retested one week later. All patients were followed for at least six months to evaluate patients’ clinical status and to assess for potential adverse effects of midodrine, such as elevated blood pressure or heart rate.
Results: The study included 26 children six to 16 years of age. The mean number of syncopal episodes was 3.5 per year with a range of three to 40 episodes. Three participants in the control group and one in the treatment group were excluded because of failure to have a repeat tilt-table test.
At one week, repeat positive tilt-table tests were observed in eight out of 10 (80 percent) participants in the control group and in nine out of 12 (75 percent) participants in the treatment group. The latter nine patients received 2.5 mg of midodrine twice a day and were retested one week later; at that time, six out of the nine had a negative tilt-table test. The overall improvement rate was 75 percent (nine out of 12) in the treatment group and 20 percent (two out of 10) in the control group, which was statistically significant. After six months, the treatment group showed no significant changes in mean heart rate or blood pressure, and no episodes of supine hypertension occurred. The only adverse event reported was mild gastrointestinal discomfort in one patient.
Conclusion: The authors conclude that midodrine is a well tolerated and effective treatment for vasovagal syncope in children.
KENNETH T. MOON, MD
Source: Qingyou Z, et al. The efficacy of midodrine hydrochloride in the treatment of children with vasovagal syncope. J Pediatr December 2006;149:777-80.
EDITOR’S NOTE: Qingyou and colleagues conducted the first study of midodrine use in children with vasovagal syncope. It is an attractive treatment option for this population because, as an alpha-adrenergic agonist, it increases venous return and blood pressure by constricting the peripheral vasculature while avoiding the cardiac inotropic and arrhythmic effects that can occur with beta-adrenergic agents. Midodrine also does not cross the blood-brain barrier and, therefore, will not affect the central nervous system. Of course, its use does have some caveats. Ischemic or myopathic hearts are more sensitive to alpha-adrenergic stimulation, and the agent should be used cautiously in patients with these conditions. Midodrine also should not be used for at least three to four hours before lying down because of its potential to cause supine hypertension. (1)
This study was not placebo-controlled or blinded, and larger controlled studies should be performed. Recent studies have not shown that traditional medications (e.g., metoprolol [Lopressor], propranolol [Inderal]) improve vasovagal syncope symptoms compared with placebo. (2, 3) Until further research is complete, midodrine could be a useful and effective treatment for vasovagal syncope in children.–K. T. M.
REFERENCES
(1.) Stewart JM. Midodrine for the treatment of vasovagal syncope (simple faint). J Pediatr 2006;149:740-2.
(2.) Theodorakis GN, Leftheriotis D, Livanis EG, Flevari P, Karabela G, Aggelopoulou N, et al. Fluoxetine vs. propranolol in the treatment of vasovagal syncope: a prospective, randomized, placebo-controlled study. Europace 2006;8:193-8.
(3.) Sheldon R, Connolly S, Rose S, Klingenheben T, Krahn A, Morillo C, et al. Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation 2006;113:1164-70.
COPYRIGHT 2007 American Academy of Family Physicians
COPYRIGHT 2008 Gale, Cengage Learning

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AN IDEAL SOLUTION
Regular exercise is always prescribed as one of the three major cornerstones of good sleep hygiene. (The other two are a regular sleep schedule and avoiding stimulants, hard-to-digest foods and alcohol before bedtime.) Exercise is ideal as a preventive measure and a treatment because it is a health-promoting, inexpensive, safe, and simple means of eliminating troubled sleep. So does it work?
In a detailed review of the existing literature on sleep and exercise, the Department of Exercise Science at the University of South Carolina offers a fresh overview of what is currently known about the relationship between exercise and improved sleep patterns.
The literature on the effectiveness of exercise in promoting sleep has limitations. Presently, there is a lack of large-scale studies that rely on objective measures over self-reporting, which is less reliable and may fall prey to widely-held beliefs that exercise promotes sleep. Second, a causal mechanism can be difficult to pin down; it may be that better sleep leads to a greater willingness to exercise. There are, however, genuine threads of evidence that exercise improves sleep. In most cases, these have been repeated with great consistency across several published studies.
THE THEORY GOES
There are several hypothetical mechanisms by which researchers postulate that exercise promotes sleep. Because it is widely believed that sleep serves an energy conservation function, regulates body temperature downward, and allows for body tissue restitution, exercise is the best candidate stimulus to promote it since nothing else elicits greater energy depletion, body temperature elevation or tissue breakdown in humans.
One of the most plausible scenarios in which exercise would promote sleep is through anxiety reduction. It’s well documented in the literature that exercise can lower anxiety and also, as the review author writes, that “disturbed sleep is a hallmark of anxiety.” Additionally, chronic insomnia has been associated with increased physiological arousal. As it acts to counterbalance this excess arousal, exercise is a likely candidate on both of these fronts to promote undisturbed sleep. Similarly, the well-established antidepressant effects of chronic exercise may result in better, longer sleep.
WHAT WE DO KNOW
A new view of a long-held assumption. The literature reflects that the most positive effects occur following exercise four to eight hours before bedtime, as opposed to more than eight or less than four. Yet the accuracy of the oft-touted view that late-night exercise disrupts sleep is far from apparent. It turns out that, almost universally, exercise completed within four hours of sleep increases total sleep time while still decreasing wake time after sleep onset. Since the evening is for many people the only feasible time to run or weight train, this is an important finding, and holds true across nearly all existing studies.
Good news for marathoners. Another interesting finding is that exercise duration significantly moderates sleep duration, with the greatest effects seen at exercise times over an hour. It appears that endurance runners may enjoy the most benefit in terms of longer, less interrupted sleep than other exercising populations or only occasional exercisers.
Intensity isn’t an asset. It’s worth noting that exercise need not be intense to reduce wake time after sleep onset–light exercisers, in fact, reduce their time awake after turning in by about 16 minutes; high-intensity exercisers increase their time awake by approximately four minutes. A 2003 study of 173 overweight post-menopausal women found that even low-intensity stretching improved sleep quality and lengthened duration. And in 2004, researchers reported that three hour-long sessions of tai chi per week improved sleep quality in a group of elderly men and women.
Help for the elderly. In fact, older adults make up an important segment of the population for whom to explore insomnia cures. In a 2003 survey, the National Sleep Foundation found that 50% of adults over 50 reported having one or more symptoms of insomnia at least a few nights a week. This may in part be due to declining levels of the sleep-promoting hormone melatonin, poor bladder control, heartburn, diuretics such as Lasix or Bumex or use of the beta blockers Inderal and Lopressor.

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Hypertensive drug classes: brand names only

FDA First-time generics approvals–2004.(RX Special Report)

Stephen B.Sourmerai, ScD., and colleagues at the Harvard Medical School, looked at all New Jersey Medicare patients who survived a heart attack between 1987 and 1992. Their drug claims for the 30 days post–heart attack were also assessed. Only 21% of the eligible people recieved a prescription for beta–blocker drug therapy. What were they getting instead? Calcium cha el blocker drugs, which are heavily promoted to doctors by the drug companies. (This drug class has a long history of misuse and potentially fatal side effects. See HealthFacts, August 1996, September 1995, April 1993, December 1992.)
The elderlypeople were three times more likely to have been given a prescription for calcium cha el blockers, which have many brand names, including Cardizem, Procardia, and Adalat. The use of this drug class was associated with a doubled risk of death, according to the researchers, not because they have a demonstrable adverse effect, but because they were used as substitutes for beta–blockers.
When the researchers looked at the people treated appropriately with beta–blocker drugs, they found a 43% lower death rate, compared to those who had been given calcium cha el blockers.
In an editorial that accompanied this study, Drs.William Campbell Felch and Donald M.Scanlon noted that this new study is not the first to identify the underuse of beta–blockers. They cited a review from the National Registry of Myocardial Infarction from 1990 to 1993, which reported that only 36–42% of over 240,000 patients received the appropriate drug. The prescribing practices of specialists aren’t much better. They cited an earlier study showing that even cardiologists prescribed beta–blockers in only half the circumstances for which they were warranted. Drs.Felch and Scanlon speculated about why the prescribing practices of so many physicians do not reflect the evidence from carefully designed clinical trials. They didn’t come up with any good answers.
COPYRIGHT 1997 Center for Medical Consumers, Inc.
COPYRIGHT 2004 Gale Group

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Hypertensive drug classes: brand names only

FDA First-time generics approvals–2004.(RX Special Report)

Investigators randomized 45,852 patients who presented to participating Chinese hospitals because of symptoms of acute MI accompanied by left bundle branch block or S-T elevation or depression. Exclusion criteria included patients scheduled for primary coronary intervention and those with contraindications to beta blockers. Participants were assigned randomly to receive intravenous followed by oral administration of metoprolol or identical placebo. The first intravenous injection of 5 mg of metoprolol or placebo was given immediately. If the heart rate was more than 50 beats per minute and the systolic blood pressure was greater than 90 mm Hg after two to three minutes, a second ampule was given. A third ampule could be given if indicated.
Fifteen minutes after the intravenous medication was administered, patients received 50 mg of metoprolol given orally or placebo every six hours for one day. From day 2, patients received 200 mg of controlled-release metoprolol daily for up to four weeks. All other management was at the discretion of physicians. The two primary outcomes were death from any cause and the composite of death, reinfarction, and cardiac arrest during hospitalization or up to day 28. Secondary end points included reinfarction, ventricular fibrillation, cardiac arrest, and cardiogenic shock.
The treatment and control groups were comparable in all major variables. The mean age of participants was 61 years, and 26 percent were 70 years or older. Overall, 28 percent of participants were women. Eight percent of participants had a previous MI, and 43 percent had hypertension. The mean time from onset of symptoms to randomization was 10 hours, with 34 percent of patients randomized within six hours. On study entry, 24 percent had heart failure, 34 percent had systolic blood pressure lower than 120 mm Hg, and 7 percent had tachycardia (110 beats per minute). One half of the patients received fibrinolysis before the study treatment.
Three injections were received by 90 percent of patients allocated to metoprolol and 96 percent of those allocated to placebo. The primary outcomes were not significantly different between the treatment and placebo groups. The 1,774 deaths (7.7 percent) in the metoprolol group were comparable with the 1,797 deaths (7.8 percent) in the control group and corresponded to an odds ratio (OR) of 0.99. Similarly, the composite end point of death, reinfarction, or cardiac arrest occurred in 2,166 (9.4 percent) of the intervention group and 2,261 (9.9 percent) of the control group (OR, 0.96). Further analysis of the cause of death showed that the metoprolol group had a highly significant 22 percent reduction in deaths attributed to arrhythmia but a highly significant 29 percent increase in deaths from cardiogenic shock. The metoprolol group also showed a highly significant 18 percent reduction in any reinfarction and a highly significant 17 percent reduction in ventricular fibrillation during treatment. Conversely, metoprolol was associated with a highly significant 12 percent increase in heart failure and an increase in reported cardiovascular conditions (mainly bradycardia, sinus arrest, or atrial arrhythmia) and respiratory conditions (mainly asthma or bronchospasm).
The authors conclude that the early use of beta blockers in acute MI is associated with a reduced risk of reinfarction and ventricular fibrillation but an increased risk of cardiogenic shock. The risk of cardiogenic shock was greatest during the first day. They advise consideration of beta blocker therapy only when patients are hemodynamically stable following acute MI.
ANNE D. WALLING, M.D.
COMMIT Collaborative Group. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet November 5, 2005;366:1622-32.
COPYRIGHT 2006 American Academy of Family Physicians
COPYRIGHT 2008 Gale, Cengage Learning