Saturday, June 03, 2006

A nap and a cup of coffee-What a concept.

I have posted before on the excessive sleepiness awareness "educational" programs that are appearing on the free doctor dinner programs and in various publications, there was a interesting juxtaposition of reading material arriving in my mail box.

The Annals of Internal Medicine ( June 6, 2006 issue) featured two articles on the effect of naps and coffee on "real life" situations and an editorial (" Naps and Drugs to Combat Fatigue and Sleepiness") by a well known and prolific sleep researcher, Dr. Christian Guilleminault. ( Annals Internal Medicine-volume 144,number 11 p. 856)

The other was a special issue of Internal Medicine World Report on the topic of excessive Sleepiness (ES). (ES has joined the ranks of conditions designated by an abbreviation and may soon rival ED in the level of promotional material produced.) The Report offered free CME and the authors credited with its material were an academic family doctor teamed with PhD sleep researcher from University of Michigan. The readers are told that the supplement was provided by "CME Outfitters,LLC" and was supported by an educational grant from Cephalon, Inc.,the manufacturer of modafinil (trade name Provigil).

The readers of the supplement are told that in order to accurately diagnose ES a detailed sleep history is necessary. A 14 item list of questions is suggested and the readers are told that it is critical to ask patients about the quality and quantity of sleep. It seems that ES is not only wide spread but it is said to be under recognized so we should seek it out in our patients.The list of "alertness-promoting agents" is reviewed and not surprisingly modafinil seems to be the best choice.

One of the Annals' article dealt with nighttime driving and demonstrated that either a nap or a caffeine containing beverage reduced the number of impaired driving events.A study involving interns showed that naps lead to less sensation of fatigue. Both sets of results conform with common sense and everyday experience (and with references noted in the articles and the editorial) and neither seems particularly monumental and I cannot help but wonder if this was a slow news day at the Annals editorial offices.

I found one of Dr. Guilleminault's editorial comments thought provoking. Apparently some of the interns did not really nap during their nap time.Some worked on the charts and others continued to take call for their own patients. He says :

"Clearly a 'medical culture element' (responsibility for one's own patients) was conflicting with the napping concept.
" He continues, " Perhaps it is time for medical housestaff to give the same weight to their responsibility to be alert as they do to their responsibility to be available to their patients.".

I will need more time to mull that over. I thought being responsible for your patients was a good thing.

The editorial is supportive of the use of napping and coffee to battle fatigue and sleepiness and is less enthusiastic about modafinil "The shortcomings of modafinil raise questions about the use of pharmacologic agents..."

Those comments are not surprising as a NEJM article and editorial last year seemed to indicate that modafinil was about as good as a big dose of coffee.

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