Monday, January 23, 2006

Grand Rounds

Grand Rounds are now up at Kevin, MD.

Thursday, January 19, 2006

Watching television in bed

Watching television in bed can contribute to insomnia. This study found another adverse effect of having a television in the bedroom:
A study by an Italian sexologist has found that couples who have a TV set in their bedroom have sex half as often as those who don't.
"If there's no television in the bedroom, the frequency (of sexual intercourse) doubles," said Serenella Salomoni whose team of psychologists questioned 523 Italian couples to see what effect television had on their sex lives.

Sunday, January 15, 2006

Obstructive Sleep Apnea

Childhood Sleep Disorders

Word of the Day

somnolent (SOM-nuh-luhnt) adjective1. Sleepy; drowsy; inclined to sleep.2. Tending to cause sleepiness or drowsiness.[From Latin somnolentus, from somnus, "sleep." A related word is insomnia (in-, "not" + somnus).] Use: "Meanwhile, many a somnolent local authority has been stirred into action by Davidson's blunt approach."--John Lucas. "Memorials are made of these on the eve of Remembrance Sunday." Daily Telegraph: November 7, 1998.

Alcohol and Sleep

Wednesday, January 11, 2006

Update on Requirements for the New Sleep Board Examinations

The new ABMS examination [sleep medicine board examinations], starting in 2007, will be co-sponsored by the American Board of Internal Medicine, the American Board of Psychiatry and Neurology, and the American Board of Pediatrics with the addition of the American Board of Otolaryngology pending ABMS approval. There are three pathways that qualify physicians to sit for the new examination: (1) certification by one of the primary sponsoring boards and the current American Board of Sleep Medicine (ABSM); (2) certification by one of the primary sponsoring boards and completion of training in a 1-year sleep medicine fellowship program, not overlapping with any other residency or fellowship; and (3) clinical practice experience: this clinical practice experience pathway consists of a 5-year "grandfathering" period open to physicians who are board certified in one of the sponsoring specialty boards and who can attest that he or she has the equivalent of 1 year of clinical practice experience in sleep medicine during the prior 5 years.
Starting in 2007, to sit for the new sleep board exams and become board certfied in sleep medicine, a physician must first become board certified in psychiatry, internal medicine, neurology, pediatrics, or ENT. The current requirement of the American Board of Sleep Medicine is only that a physician be board certified in any speciality prior to taking their exam. No official word yet on whether or not the Family Practice Board is planning on becoming a sponsoring board for the new sleep exams.

Tuesday, January 10, 2006

Bedwetting and Obstructive Sleep Apnea

Nocturnal enuresis (bedwetting) affects approximately 5 million school-aged children. A child must be at least five-years old before this diagnosis can be made. A child with nocturnal enuresis should be examined by a physician to rule out an organic etiology, such as a urinary tract infection. Often no specific organic cause is found. However, pediatricians frequently neglect to ask their enuretic patients about symptoms of obstructive sleep apnea, a common cause of nocturnal enuresis.

Nocturnal enuresis is present in approximately 1/3 of children with obstructive sleep apnea. Besides enuresis, other symptoms of pediatric sleep apnea include snoring, sleepiness, hyperactivity, poor school performance, and behavior problems. In a recent study of children with both nocturnal enuresis and obstructive sleep apnea, Basha and colleagues found that treatment of obstructive sleep apnea by adenotonsillectomy often cured enuresis. In their study, postoperatively 61.4% of children were free of enuresis, 22.8% had a decrease in enuresis, and 15.8% had no change in enuresis.

How does obstructive sleep apnea (OSA) cause enuresis? Proposed factors include: 1) decreased arousal response, 2) impaired urodynamics, and 3) altered secretion of hormones that regulate fluid balance.

Decreased Arousal Response – OSA may promote enuresis by decreasing the arousal response from sleep.
Impaired Urodynamics – Increased intra-abdominal pressure during obstructive respiratory events increases bladder pressure.
Altered Secretion of Hormones – OSA can affect the secretion of atrial natriuretic peptide and antidiuretic hormone.

Nocturnal enuresis is a common childhood condition. Nocturnal enuresis is frequently due to OSA, and in these cases it usually resolves or improves with treatment of OSA.


1. Sheldon SH. “Sleep-Related Enuresis”. In Principals and Practice of Pediatric Sleep Medicine.

2. Basha S, et al. Effectiveness of Adenotonsillectomy in the Resolution of Nocturnal Enuresis Secondary to Obstructive Sleep Apnea. Laryngoscope, 115:1101-03, 2005.

3. Brooks LJ and Topol HI. Enuresis in Children with Sleep Apnea. J Pediatr 2003, 142:515-8.

Sunday, January 08, 2006

Friday, January 06, 2006

night eating syndrome (NES)

People with NES overeat in the evening and even awaken from sleep to eat one to two times a night on average, according to Kelly Allison, Ph.D. They consume one-quarter or more of their daily food intake after their evening meal, said Allison, a research assistant professor of psychology in psychiatry at the University of Pennsylvania School of Medicine and director of a NES-focused cognitive-behavioral therapy (CBT) study.
People with NES typically lack appetite in the morning. Some curb their daytime food intake, knowing they will graze after dark.
Not all people with NES are obese. Some maintain normal weight via daytime food restriction or intensive exercise. These individuals typically are younger by about a decade than obese people with NES, suggesting NES may serve as a pathway to obesity.
Many people with NES keep a small refrigerator next to the bed, favoring peanut butter, popsicles, candy bars, nuts, and sometimes fruit as handy middle-of-the-night snacks. They rely on food as an aid to returning to sleep, probably a conditioned response, Allison reported.
People with NES remember what they eat in the night, unlike people with sleep-related eating disorder (SRED), a rare parasomnia [similar to sleepwalking]. Those with SRED often have only partial recall of having consumed frequently unpalatable items, such as buttered cigarettes, raw bacon, or cat food.
"We think NES represents a dysregulation of circadian patterns of food intake, but without disruption of the circadian sleep pattern," he explained. "NES is primarily an eating disorder, and only secondarily a sleep disorder." While appetite normally shuts down in sleep, NES appears to be a rare clinical example of an uncoupling of eating and the sleep/wake cycle. Its cause has not been determined.
"While people with NES who stay on sertraline continue to do well," Allison notes, "learning CBT strategies may give them a better long term prognosis."

Tuesday, January 03, 2006

Study Finds Behavioral Therapy Benefits Older Adults with Insomnia

While insomnia in older adults is often treated with pharmacological therapies, a new study finds that behavioral therapies are effective and have the benefit that they continue to work over a long period of time. The review, conducted by lead author Michael Irwin, MD of UCLA and fellow researchers examined 23 randomized, controlled clinical research trials of more than 500 participants in total. The results showed that behavioral therapies including cognitive behavioral therapy (CBT), relaxation therapy and modifications in sleep behavior offered significant benefits to insomnia sufferers. The most common complaint among older adults with insomnia, frequent nighttime awakenings, was markedly improved by behavioral therapy.
The study comes on the heels of a 2005 National Institutes of Health state-of-the-science report which indicates that CBT is an effective treatment for chronic insomnia and may yield long-term benefits for patients. Yet both the NIH report and Irwin’s study call for more scientific investigation when it comes to insomnia treatments. In fact, Irwin’s review found that only eight studies on individuals over age 55 yielded statistically significant results. Irwin and fellow researchers call for more studies of older adults using objective measures to determine how insomnia can be treated best long-term.
The study is published in the January 2006 issue of Health Psychology and is the first in a series of evidence-based health reviews to be published by the journal.

From the National Sleep Foundation

The Relationship between Sleep and Metabolism

Karine Spiegel, PhD, and colleagues published an article in the December 7, 2004 issue of the Annuals of Internal Medicine that suggests that sleep restriction can lead to weight gain. They found that sleep restriction (4 hrs /night) leads to decreased levels of the hormone Leptin and increased levels of Ghrelin, another hormone. The alteration of the levels of these appetite and energy regulating hormones was associated with increased hunger and appetite in the study. This study adds to the evidence linking insufficient sleep to obesity. Other studies have linked sleep restriction to impaired glucose tolerance and diabetes mellitus.

It is important for physicians to counsel their overweight and obese patients to allow for at least 8 hours of sleep per night. Since obstructive sleep apnea is both a cause and consequence of obesity, practitioners should screen their obese patients for this common disorder. Useful symptoms to ask about include snoring and excessive daytime sleepiness.