Is sleep apnea keeping you awake?

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If you snore, it can be hard on those within earshot, especially bed partners. But if you snore and have sleep apnea, it's hard on you, too. Without realizing it, people with sleep apnea briefly stop breathing or breathe very shallowly many times during the night.

The consequences include bad sleep and all that can come from that: grogginess when you're awake, an inability to concentrate, depression, accidents. Numerous studies have linked sleep apnea to various cardiovascular problems, including high blood pressure, stroke, and heart arrhythmias. Uneven breathing lowers oxygen levels in the blood, which can trigger aspects of the flight-or-fight response that boosts blood pressure. The herky-jerky breathing of sleep apnea may overtax the heart.

Central or obstructive

In one type of sleep apnea, breathing stops because the part of the brain that controls respiration "forgets" to send signals to the diaphragm and chest muscles. This form of the condition is called central sleep apnea. Central sleep apnea doesn't cause snoring, but it can interfere with sleep. It's an unusual condition, although it does become more common with age.

Far more often, sleep apnea is caused by the fleshy tissues in the back of the mouth — the tongue, tonsils, soft palate — getting in the way of air flow in and out of the throat. Obstructive sleep apnea, as it is called, is sometimes a consequence of being overweight: extra fat tissue in the neck area can narrow the airway. But some people have obstructive sleep apnea because they have naturally lax tissues or a narrow airway to begin with.

Not everyone who snores has obstructive sleep apnea, but snoring is a good clue. Proper diagnosis of sleep apnea often requires an overnight stay in a sleep clinic and being hooked up to machines that measure brain, breathing, and heart activity.

Extra air for the airways

If excess weight and extra fat tissue in the neck are the cause of obstructive sleep apnea, then losing weight can ease sleep apnea, even make it go away. For some people, just a change in sleeping position (usually from the back to the side) can make a difference. And dental devices — they resemble athletic mouth guards — can open up the back of the throat by moving the lower jaw and tongue forward. There are also some surgical procedures that will get rid of excess tissue, but they're usually offered as a distant second or third choice.

The main treatment for problematic cases of obstructive sleep apnea is continuous positive airway pressure, a term almost always shortened to its acronym, CPAP (pronounced see-pap). It usually involves wearing a small plastic mask over the nose. A hose connects the mask to a small air pump. Extra air from the pump opens the airway by applying pressure to the floppy tissue, and, essentially, pushing it out of the way.

Sticking with it

CPAP has been a common treatment for obstructive sleep apnea since the early 1990s. If people stick with it, CPAP does an impressive job of improving the quality of their sleep. But adherence to CPAP therapy is a serious problem. A large proportion of people who start CPAP quit within a year, and most of those gave up during the first four weeks. It's understandable that people would want to abandon a treatment that involves wearing a mask and being tethered to a machine while in bed.

Usually sleeping pills and obstructive sleep apnea don't mix, because sleeping pills tend to relax airway tissue, so they're even more likely to block the airway. But the results of a study reported in 2009 suggest that giving people a sleeping pill — in this case eszopiclone (Lunesta) — for the first two weeks of CPAP therapy might help them get used to it and improve compliance later on. A single, industry-sponsored study shouldn't change clinical practice, but this approach deserves more research.

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Does laser treatment work for toenail fungus?

Q. I've tried a lot of things for a fungal infection in one of my toenails, but it just won't go away. What do you know about a new treatment that uses laser?

A. Two lasers using different types of laser energy have attracted attention as treatments for fungal infection of the toenails, a condition called onychomycosis (pronounced oh-nee-koh-my-KOH-sis), which can also affect the fingernails: Noveon and the PathoLase PinPointe FootLaser. The theory is that a precisely directed laser can eliminate the fungus without harming the surrounding nail tissue. The underlying technologies are already in use for other conditions, including cataract surgery, dental work, and hair removal. Although there is some laboratory evidence that lasers can squelch fungal organisms, clinical studies in humans thus far are limited.

The desire to find a cure for onychomycosis is understandable. Fungal infection can cause a toenail to thicken and look crumbly, discolored, and distorted. The nail can become difficult to cut and a source of embarrassment. Worse, it may be painful and make walking difficult. In people with diabetes or a suppressed immune system, toenail fungus may progress to more serious infections.

The fungus is notoriously difficult to eradicate. Fungi are very hardy microorganisms. They can invade the nail through a tiny crack in the skin or even a small separation between the nail plate and nail bed. There are many over-the-counter nail creams and ointments, but none of them is very effective. Topical ciclopirox (Penlac) works somewhat better than a placebo, but it's not a cure. So far, prescription oral antifungal medications have the best track record, though they're not an easy fix. They must be taken for at least six to 12 weeks, and they can have side effects such as a rash, diarrhea, and liver damage, so users must be monitored by a clinician. If treatment succeeds, a new fungus-free nail will grow out to replace the old one, a process that may take several months. Even after successful treatment, the fungal infection may return in as short a time as a year.

The interest in laser treatment is growing partly because it does not have the side effects of oral medication. Despite the lack of FDA approval, some podiatrists are already using the PathoLase PinPointe laser. It's painless and takes only 10 minutes per toe. But the cost (roughly $1,000) is not covered by any health insurance, and, more important, there is little information about its long-term safety and effectiveness. For the time being, I suggest that you save your money and explore currently approved therapies under the care of an experienced clinician.

How to prevent toenail fungus

Fungi thrive in moist environments, so it's important to keep your toenails short and as clean and dry as possible. Here are some tips:

  • Dry your feet and toes thoroughly after showering or bathing. If you have a hair dryer, use it on a low setting to dry your toes.
  • Always wear shoes in locker rooms, in public showers, and around public pools.
  • Whenever possible, wear synthetic socks that wick moisture from your feet; if your feet sweat a lot, change your socks during the day.
  • Wear shoes that fit well and are made of breathable materials.
  • Avoid tight-fitting socks and stockings, which can trap moisture between your toes.
  • Don't pick the skin around your toenails.
  • Use antifungal spray or powder in your shoes or on your feet.
  • Keep your pedicure instruments clean and disinfected, and if you use a pedicure salon, make sure your pedicurist does the same.
  • Don't try to cover up the infected toenail with nail polish. It will trap moisture and worsen the infection.

— Celeste Robb-Nicholson, M.D.
Editor in Chief, Harvard Women's Health Watch

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