Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville
Dr. Kuritzky is a retained consultant for Boehringer Ingelheim, Daiichi Sankyo, Forest Pharmaceuticals,
Janssen, Lilly, Novo Nordisk, Pfizer, and Sanofi.
CV Hope for the Exercise-Disinclined
Source: Kearney TM, et al. Accumulated brisk walking reduces arterial stiffness in overweight adults: Evidence from a randomized control trial. J Am Soc Hypertens 2014;8:117-126.
The favorable relationship between exercise and cardiovascular health has been announced, and reannounced, and reannounced for decades. Nonetheless, only a minority of Americans participate in regular vigorous exercise, and the numbers of adult Americans who are categorized as overweight or obese continues to climb. Does one have to be an athlete to claim the rewards of physical activity? Maybe not.
Kearney et al performed a study among overweight adult men and women who acknowledged being essentially sedentary. Subjects randomized to exercise were compared to subjects performing stretching activities, with the outcome of interest being the effects on vascular health as measured by arterial stiffness (reflected in pulse wave velocity) and production of nitric oxide.
It is the novelty of the applied exercise program that might strike clinicians as having potential for widespread use: The exercise subjects were asked to engage in three 10-minute sessions of brisk walking on 5 days of each week. Brisk walking was described as sufficient to produce slight shortness of breath but not impede the ability to hold a conversation. Outcomes were measured at the end of the 6-month intervention, and 4 months after the intervention ended.
At study end, as well as 4 months post-intervention, there was a statistically significant difference in pulse-wave velocity and nitric oxide production in the exercise group compared to the stretching group. Even for those with too-busy schedules, lack of athletic prowess, and distaste for overly strenuous activity, a menu of brief episodes of brisk walking for only 5 days per week might be an attractive option.
The Elbow Sign for OSA
Source: Fenton ME, et al. The utility of the elbow sign in the diagnosis of OSA. Chest 2014;145:518-524.
Obstructive sleep apnea (osa) is garnering ever-growing respect from clinicians who recognize it is responsible for diverse toxicities beyond simple sleep disruption: hypertension, cardiac arrhythmia, auto accidents, and excessive daytime sleepiness among them. Clinicians tend to uncover OSA when persons of "typical" phenotype (overweight mid-life men and women) present with associated symptoms. Sometimes, the consequence of OSA triggers an evaluation, even in the absence of overt OSA symptoms, such as the recent observation that among persons with resistant hypertension and no history or overt stigmata of OSA, sleep studies were positive for OSA in more than 80%!
Not everyone can afford a sleep study, so clinicians would like to identify simple methods to refine the pretest probability of OSA. The elbow sign may be just such an intervention.
Fenton et al provide data on asking patients referred for a sleep study two questions: 1) Does your bed partner ever poke or elbow you because you are snoring? or 2) Does your bed partner ever poke or elbow you because you have stopped breathing?
Persons who answered affirmatively to either question were 4-6 times more likely to emerge with sleep studies that were positive for OSA. Correction for other OSA-related items (body mass index, Epworth Sleepiness Scale, etc.) did not alter this relationship.
These two simple questions may help identify patients most likely to benefit from a sleep study investigation.
Another New and Underrecognized Psoriasis Comorbidity
Source: van der Voort EA, et al. Psoriasis is independently associated with nonalcoholic fatty liver disease in patients 55 years old or older: Results from a population-based study. J Am Acad
Dermatol 2014;70:517-524.
Upon encountering the word psoriasis, clinicians typically first think "skin," and might next reflect on "joints," and perhaps even "nails," but rarely does the internal intellectual discussion go any further. It is only in the last decade that an immunologically related disorder — rheumatoid arthritis — has been recognized to be associated with marked increase for cardiovascular (CV) disease. More recently, an association between psoriasis and CV disease has also been confirmed, and although the mechanism by which either of these inflammatory disorders induces vasculopathy is unclear, their common immunologic underpinnings suggest shared pathology.
According to a report by van der Voort et al, we should consider adding nonalcoholic fatty liver disease (NAFLD) to the list of comorbidities related to psoriasis. Reflecting on earlier case-control studies that indicated an increased prevalence of NAFLD among psoriasis patients, the authors studied a large population of persons enrolled in the Rotterdam Study (n = 2292) who underwent hepatic ultrasound. The prevalence of NAFLD was more than 30% greater in psoriasis subjects than controls (46.2% vs 33%).
The mechanism by which NAFLD is induced by psoriasis is unclear, although specific culprit genes are suspected. Because most of these patients did not have severe psoriasis, clinicians should be vigilant for the potential development of NAFLD, even in psoriatic patients with mild-moderate disease.
