Over the past 5 years, new sleeping medications have been developed which have influenced the ways we treat insomnia or the complaint of insomnia.  Many of the older sleeping pills interfere with certain stages of sleep.  These medications suppress the REM sleep stage(dreaming sleep) and the slow-wave deep non-dreaming sleep stage.  Suppressing these stages of sleep interferes with normal brain function and the FDA had previously restricted physicians from prescribing sleeping medications for more than a 2 month period.  The newer sleep medications including Ambien and Lunesta do not appear to interfere with these sleep stages and therefore should not interfere with normal brain function.  The FDA has subsequently changed the prescribing restrictions for these medications.

There are other concerns with taking sleeping pills including dependence.  Patients should be aware of this and should be cautioned against using these medications routinely.  Patients with a diagnosis of insomnia should always attempt to fall asleep before taking the sleeping pill.  Patients should be cautious not to mix sleeping pills with alcohol or other depressants.  Patients should take attempt to take the lowest dose for the shortest possible period of time.

Over the counter sleeping pills use antihistamine types medications that cross the blood-brain barrier and induce sleep by inhibiting the histamine neurotransmitter.  This slows brain functions and causes sleepiness.  Although these medications can be taken without a prescription, they interfere with memory and can cause forgetfulness.

So what is the answer?  Practice good sleep hygiene.  This includes avoiding all napping in order to concentrate sleep at night.  Get regular exercise and eat dinner at a reasonable time.  You should reduce noise in the room while sleeping and avoid caffeine, alcohol, and cold medications.  Avoid clock watching while trying to sleep (take the clock out of the bedroom).  If not asleep within 15 minutes after going to bed, get up and return to bed when you feel sleepy
If you still want to lie down, do so in another room.  These easy techniques cure 80% of all cases of insomnia.

Cristopher Geiler, MD

Nature Medicine 15, 481 (2009)

• Abdominal pain while pregnant may be caused by:
· Ectopic pregnancy which is a life threatening emergency in which a fertilized embryo implants in the fallopian tubes instead of the uterus.  This can be very dangerous and as the fetus grows it may rupture the fallopian tube.
· Braxton-Hicks contractions are irregular and uncoordinated uterine contractions that may occur particularly during late pregnancy.
· Premature labor
· Uterine rupture should be considered when abdominal pain occurs during late second and third trimesters.
· Vascular congestion and swelling of the pelvic tissue
· Ligament tension or stretching of the ligaments that support the uterus.  As the uterus expands with the developing fetus, the pelvic ligaments  may stretch cause lower abdominal discomfort early in pregnancy.
· Threatened abortion in which uterine contractions may lead to the loss of the pregnancy and this should always be considered if abdominal pains occur during the first trimester of pregnancy.
· Round ligament tension can causes sharp pain on one or both sided of the pelvis and is often worse with movement

Other causes of abdominal pain include:
appendicitis
cholecystitis (gall stone disease)
intestinal obstruction
stomach ulcers
inflammatory bowel disease

• Abdominal pains while pregnant should be evaluated by your doctor.

• Pregnancy abdominal pains may be unique to the physiology of being pregnancy or may be attributed to other non-pregnancy causes of abdominal pain.

• Pregnancy abdominal pains may be caused by:
· Ectopic pregnancy which is a life threatening emergency in which a fertilized embryo implants in the fallopian tubes instead of the uterus.  This can be very dangerous and as the fetus grows it may rupture the fallopian tube.
· Threatened abortion in which uterine contractions may lead to the loss of the pregnancy and this should always be considered if abdominal pains occur during the first trimester of pregnancy.
· Premature labor
· Uterine rupture should be considered when abdominal pain occurs during late second and third trimesters.
· Vascular congestion and swelling of the pelvic tissue
· Ligament tension or stretching of the ligaments that support the uterus.  As the uterus expands with the developing fetus, the pelvic ligaments  may stretch cause lower abdominal discomfort early in pregnancy.
· Round ligament tension can causes sharp pain on one or both sided of the pelvis and is often worse with movement
· Braxton-Hicks contractions are irregular and uncoordinated uterine contractions that may occur particularly during late pregnancy.

Other causes of abdominal pain include:
appendicitis
cholecystitis (gall stone disease)
intestinal obstruction
stomach ulcers
inflammatory bowel disease

• Pregnancy abdominal pains should be evaluated by your doctor.

Researchers reported on a study of 20 college-aged men who were enrolled in a trial to determine whether repeated resistance exercise resulted in increased circulating BDNF after exercise.  The study authors report that blood levels of the BDNF protein increased 32% from resting levels at 1 minute after exercise compared to the baseline levels.  This study showed a robust and transient increase in circulating BDNF concentrations with weight lifting exercises.

The incidence of neurodegenerative diseases such as Alzheimer’s disease is lower in people who participate in regular exercise programs.  This may be in part due to the beneficial affects of this neuro-protecting protein (neurotrophins).

Increasing the amount of these near protective (neurotrophins) proteins can have a positive effect on cognition, mood, emotions, and several other domains of brain function. Additional studies may focus on ways to maximize the release of these beneficial proteins.

Cristopher Geiler, M.D.

• Insomnia is a prominent early symptom.
Patients with Fatal familial insomnia develop progressive autonomic dysfunction, followed by difficulty speaking, coma, and death.

• Fatal familial insomnia is believed to be caused by a mutation in the prion gene similar to Mad Cow Disease

• Insomnia is habitual sleeplessness.

• Background:
There are two distinct types of sleep.
1. REM sleep is the dreaming sleep known as Rapid Eye Movement(REM)) sleep
2. Non-REM sleep is the deep restful stage of sleep which is divided into 4 distinct stages.

• Overview:
Insomnia is very common and affects up to 40% of the population.
Insomnia is more common in the elderly and in women.
Insomnia is defined by a complaint of the quality or amount of sleep for at least three times per week for at least one month.
Chronic insomnia is sleeplessness lasting longer than 3 weeks
Although the human body requires sleep for normal function, the exact amount of sleep is not known.
Although the human body requires sleep for normal function, the exact amount of sleep is not known.
Eight hours of sleep per night is average.

• Symptoms:
Sleeplessness
Multiple awakenings while trying to sleep
Nonrestorative sleep, not feeling refreshed after sleep
Anxiety

• Causes:
Insomnia is common and more than 80% of all cases of insomnia are the result of:
· medications (decongestants, amphetamines, anti depressants)
· caffeine (coffee, tea, soda, chocolate)
· tobacco
· alcohol
· pain
· anxiety
· depression

• Complications:
Sleep-related motor vehicle accidents
Hypertension
Depression
Anxiety disorder

• Treatment:
1. Practice good sleep hygiene:
Avoid all napping
Get regular exercise
Reduce noise in the room while sleeping
Eat dinner at a reasonable time
Avoid caffeine, alcohol, cold medications
Avoid excessive fluid intake before bed
Avoid non-sleep activities while in bed such as eating, reading, or watching television
Avoid clock watching while trying to sleep (take the clock out of the bedroom)
If not asleep within 15 minutes after going to bed, get up and return to bed when you feel sleepy
If you still want to lie down, do so in another room

2. Sedatives.  Sleep with medication is better than no sleep

• Insomnia that persists or recurs should be evaluated by your doctor.

References
Principles and Practice of Sleep Medicine, 4th ed. Philadelphia, Saunders, 2005
Hypothalamic regulation of sleep and circadian rhythms. Nature 437:1257, 2005 [PMID: 16251950]
Insights from studying human sleep disorders. Nature 437:1279, 2005 [PMID: 16251953]

Researchers analyzed data from more than 11,000 people who participated in the Scottish Health Survey, in which individuals were asked about lifestyle behaviors such as smoking, physical activity, and oral health routines. Questions asked include how often they visited the dentist and how often they brushed their teeth.  This information was analyzed and compared with the participant’s medical history and family history of heart disease and blood pressure. Additionally, blood samples were taken from a subgroup of participants and tested for the inflammatory protein CRP and fibrinogen levels. The data gathered from the interviews were linked to hospital admissions and deaths.

The results showed that generally good oral hygiene practices, with 62% of participants saying they visited the dentist every six months and 71% reporting that they brushed their teeth twice a day.

Researchers analyzed the data and adjustment for established risk factors for heart disease which include age, sex, diabetes, smoking, physical activity, visits to dentist, body-mass index, family history of cardiovascular disease, hypertension, and socioeconomic group.

Researchers found that participants who reported less frequent toothbrushing had an increased risk of heart disease compared with people who brushed their teeth twice a day.  Researchers also found that participants who had poor oral hygiene also had increased levels of the CRP and fibrinogen blood tests.

The study authors comment that while it has been established that inflammation in the body (including mouth and gums) plays an important role in the buildup of atherosclerosis, this is the first study to investigate whether the number of times individuals brush their teeth has any bearing on the risk of developing heart disease.

The study authors also comment that “to the best of our knowledge, this is the first study to show an association between a single-item self-reported measure of toothbrushing and incident cardiovascular disease in a large representative sample of adults without overt cardiovascular disease.”   Additionally they add, “Our study suggests a possible role of poor oral hygiene in the risk of cardiovascular disease via systemic inflammation. Raised inflammatory responses as well as lipid metabolism disturbance caused by periodontal infection might be possible pathways underlying the observed association between periodontal disease and the increased risk for cardiovascular disease.”

The results of this study need to be further evaluated with additional studies to confirm whether the observed association between dental hygiene and cardiovascular disease is in fact causal or merely a risk marker.
Cristopher Geiler, MD
BMJ 2010; DOI:10.1136/bmj.c2451. Available at: http://www.bmj.com.

The protein Banana lectin, also called BanLec, can bind to certain molecules on the surface of the HIV virus inhibiting infection.

Researchers from the University of Michigan studied the function of BanLec and determined that it binds to a specific surface protein called gp120.  BanLec inhibited the ability of the HIV virus to enter cells.  A virus must be able to enter a cell in order to cause an infection.  BanLec appears to inhibit this process and therefore may inhibit an infection of HIV.

BanLec appears to be a promising potential future treatment to prevent HIV infection.

Cristopher Geiler, MD

Reference

J. Biol. Chem. 2010 285: 8646-8655

· Overview
Marfan Syndrome is common and affects 1 in 5000 people.
The protein fibrillin is important in the formation of blood vessels, parts of the eyes and the skeleton.  The Marfan Syndrome results in the abnormal formation bones, weak blood vessels and eye abnormalities.

· Types
There are 2 basic types of Marfan Syndrome.
· Marfan Syndrome Type 1 affects the formation of the skeleton, blood vessels and eyes.
· Marfan Syndrome Type 2 affects the formation of the skeleton and blood vessels and does not affect the eyes

· Symptoms
Symptoms of Marfan Syndrome vary significantly.

· Common signs of Marfan Syndrome include:
Scoliosis
Mitral valve prolapse (affecting about 85% of people with Marfan Syndrome)
Chest wall deformities such as a depression of the sternum(prectus excavatum) or protrusion of the sternum(precuts carinatum)
Aortic valve regurgitation
Aortic root dilation and risk of aortic dissection (aneurysm)
Excessively long extremities
People with Marfan Syndrome tend to be tall compared to the other members of their family.
Fingers and hands tend to be long and slender and may have a spider-like appearance (arachnodactyly)
Eyes problems such a retinal detachment, lens dislocation, and severe nearsightedness

· Complications
People with Marfan syndrome may die from aortic dissection(aneurysm)  or congestive heart failure.

· Treatment
There is no cure for Marfan syndrome.  Treatment for encompasses controlling the complications of Marfan syndrome such as treating patients with blood pressure medications such as beta blockers to protect against aortic aneurysms.

References
Marfan syndrome and related disorders. In: Emery and Rimoin’s Principles and Practice of Medical Genetics, 5th ed. Rimoin DL et al (editors). Churchill Livingstone, 2007.

Researchers report that this gene not only predisposes people to weight gain, it also causes premature aging of the brain.
In order to learn more about the implications of this very common gene,  study authors analyzed brain imaging scans of more than 200, otherwise healthy individuals, age 55 to 90 years.  Researchers found that there was consistently less tissue in the brains of people who carry the variant of the FTO gene compared to non-carriers of the gene.

Researchers commented that reduced brain volume (atrophy) is associated with the development of Alzheimer’s disease.  This happens because the brain atrophy leads to a reduced amount of brain reserve a person has to compensate for cerebral damage from vascular disease (strokes) and from the deposition of the specific proteins in the brain that cause Alzheimer’s disease.

The study authors noted that the atrophy of the brain tissue in the affected people was not attributed to differences in cholesterol levels, nor from hypertension.

This is a very common gene variant and it is affecting a large portion of our population.  This is an observational study and it does not offer answers.  Hopefully future researchers will find ways to silence the the effects of this gene.

Cristopher Geiler, MD
Proc Natl Acad Scie USA 2010