Study Objectives: Obstructive sleep apnea (OSA) has been associated with hypertension, which is one of the intermediary mechanisms leading to increased cardiovascular morbidity. This study aimed at evaluating the effects of a combination of continuous positive airway pressure (CPAP) and telemedicine support on blood pressure (BP) reduction in high cardiovascular risk OSA patients. Design: A multi-center randomized controlled trial that compared standard CPAP care and CPAP care and a telemedicine intervention. Setting: Sleep clinics in France. Patients or Participants: 107 adult (18-65 years old) OSA patients (AHI > 15 events/h) with a high cardiovascular risk (cardiovascular SCORE > 5% or secondary prevention). Interventions: Patients were randomized to either standard care CPAP (n = 53) or CPAP and telemedicine (n = 54). Patients assigned to telemedicine were equipped with a smartphone for uploading BP measurements, CPAP adherence, sleepiness, and quality of life data; in return, they received pictograms containing health-related messages. Measurements: The main outcome was home self-measured BP and secondary outcomes were cardiovascular risk evolution, objective physical activity, CPAP adherence, sleepiness and quality of life. Results: Self-measured BP did not improve in either group (telemedicine or standard care). Patients in primary prevention showed greater BP reduction with CPAP treatment than those in secondary prevention. Conclusions: CPAP treatment supported by telemedicine alone did not improve blood pressure and cardiovascular risk in high cardiovascular risk OSA patients. This study emphasizes the need for diet and physical activity training programs in addition to CPAP when aiming at decreasing cardiometabolic risk factors in these patients. Clinical Trials Registration: ClinicalTrials.gov identifier: NCT01226641.

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INTRODUCTION:Obstructive sleep apnea (OSA) is associated with cardiovascular morbidity, including hypertension. Beyond the severity of nocturnal hypoxia, other factors such as metabolic abnormalities but also sedentary behaviors and insufficient physical activity may contribute to elevated blood pressure (BP). To clarify the respective role of these factors as determinants of BP in OSA patients, we examined the relationship between BP and anthropometrics, severity of sleep apnea, and objectively measured physical activity and sedentary behaviors. METHODS: Ninetyfive adults presenting with OSA (apnea-hypopnea index > 10 events/h) and high cardiovascular risk (63.3 ؎ 8.8 y; body mass index: 29.9 ؎ 4.9 kg/m 2 ; apnea-hypopnea index: 41.3 ؎ 17.5/h; cardiovascular risk score: 13.5 ؎ 3.7%) were included. Physical activity and sedentary behaviors were objectively assessed by actigraphy, and self-measured home BP monitoring was measured. Logistic regression models adjusted for sex, age, and body mass index were built to identify the predictors of self-measured morning and evening BP. RESULTS: Physical activity was significantly related to obesity but not to the severity of sleep apnea or sleepiness. Sedentary behaviors were associated with self-measured morning and evening systolic BP (r ‫؍‬ 0.32, P ‫؍‬ .002; r ‫؍‬ 0.29, P ‫؍‬ .004). Steps per day were inversely associated with evening BP (r ‫؍‬ ؊0.27, P ‫؍‬ .01). Univariate analysis identified steps/d and time spent in vigorous physical activity as determinants for evening self-measured BP. In multivariate analysis, only steps/d were identified as a significant determinant of evening BP. CONCLUSIONS: Physical activity is the major determinant for evening BP in adults with OSA presenting high cardiovascular risk. Our results emphasize the need for lifestyle counseling programs in combination with CPAP to encourage regular physical activity in OSA subjects to obtain better BP control. (ClinicalTrials.gov registration NCT01226641.)

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Polymedication among the elderly is associated with an increased iatrogenic morbidity. Few studies have estimated this poly medication in general practice, and explored the possibility of a reduction in the number of prescribed drugs within the framework of a regular patient's follow up by his usual General Practitioner.Furthermore, little data has been published on the increase in cost of care linked to Poly medication among the elderly,The objectives of this program were to measure the impact of a General Practitioner led intervention on their prescription decisions among their poly medicated elderly patients.The program was defined by a group of General Practitioners working in their own private practice in a rural area in eastern France (Department of the Ardennes).This group of 12 practitioners has been meeting on a voluntary basis, with no financial incentive every 6 weeks for the last 4 years in order to share and improve their own professional practices and medical decision making processes. The group is animated by two general practitioners from public and private insurance companies (MSA and Groupama). The group of GPs identified poly medication as a priority issue that could improve their daily medical practice.The program consisted in the identification of their polymedicalised elderly patients with the objective of re evaluating their prescription drugs. This re evaluation was made by GPs for their own patients, after debate within the group, and following HAS's PMSA programs, which had been presented to the group by un expert of this institution.Within this framework, an intervention study was implemented. Each participating practitioner (n=8) included the first 15 poly medicated patients he encountered in his daily practice starting at a defined date. The inclusion criterions were the following: patients aged 70 or more, and having eight or more of prescription drugs. At the time of inclusion, the practitioner completed a set of information about each patient, including the patient's demographic characteristic (age and sex), information about their current chronic diseases and their cardiovascular risk factors.The creatinin clearance was also collected for each patient, calculated according to the Cockcroft et Gault formula.Patients were followed until the end of the study in June 2009, at which date the general practitioners filled in the second part of the survey and collected the same set of information regarding his prescriptions as the inclusion data. Reasons for changes of prescriptions were recorded as well.Overall, 120 patients were included in the study. Two patients died during the follow-up, and thus were not included in the analysis. The analysis comprised 118 patients, followed for an average of 262 days. Upon entry in the study, the average number of prescribed molecules was 9.4 (SE, 1,99). At the end of the study, the average number of prescribed molecules was 7.7 (SE, 2.2), resulting in an average reduction of 1.7 drugs (IC95%, 1.4–2).This reduction was significantly higher for patie...