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6 June 2006 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians. These highlights are not intended to substitute for articles as sources of information. For an embargoed copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656.

Long-Acting Inhaled Beta-Agonists Increase Risk for Asthma Complications, Including Death

A meta-analysis of 19 published studies involving 33,826 asthma patients found that those receiving inhaled long-acting beta-agonists were 2.5 times more likely to be hospitalized and about two times more likely to have life-threatening asthma attacks than those receiving placebo. Fifty-three of 3,083 patients receiving B-agonists were hospitalized for an asthma attack compared to 12 of 2,008 patients who received a placebo. The absolute increase in hospitalizations was one event per 71 patients treated per year. Fifty of 15,443 patients receiving B-agonists had life-threatening asthma attacks compared to 25 of the 14,538 who received placebos. While death from asthma was rare (thirteen deaths in the B-agonist group and three in the placebo group), those taking long-acting B-agonists died about 3.5 times as often as those receiving placebo. The authors say that, “use of long-acting B-agonists could be associated with a clinically significant number of unnecessary hospitalizations, intensive care unit admissions, and deaths each year.” An editorialist notes that this analysis was not able to fully account for the effects of disease severity, co-treatments, adherence to treatment, or racial profile on the risk of poor outcomes. The editorialist suggests that physicians follow current guidelines which advise not using long-acting B-agonists as first line treatment for patients with “mild to moderate persistent asthma symptoms.”

The article and editorial appear early online on June 6, 2006, and are available to the public at They will be published in the July 4, 2006, print edition of the journal.

Naps and Caffeine Can Combat Fatigue in the Hospital and on the Road

—Chronic Sleep Deprivation in a 24-Hour Society Can Have Bad Effects

Two studies in the June 6, 2006, issue of Annals of Internal Medicine show that naps and caffeine can combat fatigue and sleepiness. A hospital divided a group of medical interns into a group that could take an uninterrupted nap during long shifts and a group that did not have this opportunity (Article, p. 792). Sleep time was measured by a special wristwatch device. At the end of the work shift and the next day, the nap group was much less tired, even after only a short nap. One alternative to shortening work shifts for doctors would be to build naps into the work schedule.

A small study of the effects of drinking coffee and napping on night driving found that driving performance was better after drinking half a cup of coffee or taking a 30-minute nap than when drinking decaffeinated coffee or not taking a nap (Article, p. 785). While previous studies have used driving simulators, in this study 12 participants drove 125 miles on a highway in four sessions, accompanied by a professional driving instructor in a car equipped with dual controls.

An editorial writer summarizes that as the United States moves toward a 24-hour society, sleep deprivation is a growing problem in the workplace (Editorial, p. 856). The writer says that employers of night shift workers and individuals who work or drive at night have an obligation to encourage safety: even “a nap followed by a cup of coffee may save a life.”

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