Nasal Orexin for Sleepiness

Wired.com reports on an experimental orexin nasal spray that combats sleepiness. Orexin deficiency is the main cause of narcolepsy with cataplexy. This sounds like a promising treatment for narcolepsy and idiopathic hypersomnia. I do not think this would be an appropriate treatment for voluntary sleep deprivation (except perhaps in the military):
Darpa-funded scientists might have found a drug that will eliminate sleepiness.
A nasal spray containing a naturally occurring brain hormone called orexin A reversed the effects of sleep deprivation in monkeys, allowing them to perform like well-rested monkeys on cognitive tests. The discovery's first application will probably be in treatment of the severe sleep disorder narcolepsy.
"It reduces sleepiness without causing edginess."
Orexin A is a promising candidate to become a "sleep replacement" drug. For decades, stimulants have been used to combat sleepiness, but they can be addictive and often have side effects, including raising blood pressure or causing mood swings.
The monkeys were deprived of sleep for 30 to 36 hours and then given either orexin A or a saline placebo before taking standard cognitive tests. The monkeys given orexin A in a nasal spray scored about the same as alert monkeys, while the saline-control group was severely impaired.
The study, published in the Dec. 26 edition of The Journal of Neuroscience, found orexin A not only restored monkeys' cognitive abilities but made their brains look "awake" in PET scans.
Siegel said that orexin A is unique in that it only had an impact on sleepy monkeys, not alert ones, and that it is "specific in reversing the effects of sleepiness" without other impacts on the brain.
Such a product could be widely desired by the more than 70 percent of Americans who the National Sleep Foundation estimates get less than the generally recommended eight hours of sleep per night
The research follows the discovery by Siegel that the absence of orexin A appears to cause narcolepsy. That finding pointed to a major role for the peptide's absence in causing sleepiness. It stood to reason that if the deficit of orexin A makes people sleepy, adding it back into the brain would reduce the effects, said Siegel.
"What we've been doing so far is increasing arousal without dealing with the underlying problem," he said. "If the underlying deficit is a loss of orexin, and it clearly is, then the best treatment would be orexin."
Dr. Michael Twery, director of the National Center on Sleep Disorders Research, said that while research into drugs for sleepiness is "very interesting," he cautioned that the long-term consequences of not sleeping were not well-known.
Both Twery and Siegel noted that it is unclear whether or not treating the brain chemistry behind sleepiness would alleviate the other problems associated with sleep deprivation.
"New research indicates that not getting enough sleep is associated with increased risk of cardiovascular disease and metabolic disorders," said Twery.
Still, Siegel said that Americans already recognize that sleepiness is a problem and have long treated it with a variety of stimulants.
"We have to realize that we are already living in a society where we are already self-medicating with caffeine," he said.
He also said that modafinil, which is marketed as Provigil by Cephalon and Alertec in Canada, has become widely used by healthy individuals for managing sleepiness.
"We have these other precedents, and it's not clear that you can't use orexin A temporarily to reduce sleep," said Siegel. "On the other hand, you'd have to be a fool to advocate taking this and reducing sleep as much as possible."
Sleep advocates probably won't have to worry about orexin A reaching drugstore shelves for many years. Any commercial treatment using the substance would need approval from the Food and Drug Administration, which can take more than a decade.

Home Testing Comments

Interested in commenting on home testing for OSA? Here is the link:

http://www.cms.hhs.gov/mcd/viewpubliccomments.asp?nca_id=204&rangebegin=12_14_2007&rangeend=01_13_2008

Or you can just read the comments others have made to CMS.

AASM Holiday Sleep Tips

AASM Issues Holiday Sleep Tips (via Sleep Review)
Rest of Sleep Review quote deleted, due to their request
Chediak offers these suggestions for better sleep during the holiday season:
• Take time to relax, and ensure time to wind down before bed.• Keep a regular sleep schedule. Maintain a regular bedtime and wake-up time. Other regular rituals, such as a warm bath, a light snack or a few minutes of reading, also may help.• Plan ahead for holiday activities. Set aside time earlier in the day to wrap gifts, decorate the house, plan your holiday menu, and do similar tasks. To stay on track, write these “appointments” in a daily planner.• Drowsy drivers should pull off to a rest area and take a short nap, preferably 15 to 20 minutes in length.• Do not eat heavy meals right before bedtime. This might cause heartburn or discomfort, which can disturb sleep.• Love eggnog? Avoid too much alcoholic eggnog or coffee at evening holiday parties. Alcohol and caffeine can inhibit normal sleep patterns.

IDTF's can no longer perform sleep studies in hotels

Sleep Review reports that:
Hotels/Motels Not Appropriate for Sleep Studies, CMS Says
New regulatory standards for independent diagnostic testing facilities released by CMS last month are scheduled to take effect January 1, 2008.
Among the standards is one that rules out the use of hotels and motels for performing sleep studies.
For more info, see here.
I believe that this ruling only applies to IDTF's. As an AASM accreditation site visitor, I have inspected a university-owned sleep lab that was based in a hotel. It was a nice operation. I don't agree with this CMS decision, though it will affect only a few sleep labs.

More on home testing for sleep apnea

Sleep Review Magazine reports on home testing for osa:
Last week, home testing took a step closer to becoming a covered benefit under CMS....
deleted upon request of Sleep Review Magazine.
reimbursement criteriaRead the entire announcement by clicking here.

Portable Monitoring Webinar

From the American Academy of Sleep Medicine website:

Get an in-depth overview of the new guidelines for portable monitoring and answers to frequently asked questions by registering for Portable Monitoring Discussion Forum.
AASM Portable Monitoring Task Force chair Nancy Collop, MD, will lead this 60-minute Webinar on December 18, 2007, at 12 p.m. CST. Please note that registrants must submit questions in advance to rrosenberg@aasmnet.org. The deadline to submit questions has been extended to 5 p.m. CST, December 14, 2007.
Log on to www.aasmnet.org/SleepEdSeries.aspx to register for Portable Monitoring Discussion Forum.
The new guideline will be published in the December issue of the Journal of Clinical Sleep Medicine; visit www.aasmnet.org/PortableMonitoring.aspx for comprehensive information.

Preliminary Approval for Home Testing for OSA

Home testing for OSA preliminarly approved: http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?from2=viewdraftdecisionmemo.asp&id=204&

Not only were type 2 (unattended polysomnogram) and type 3 devices (four channel) approved, but unexpectedly type 4 (1 or 2 channel) devices were also approved.

I am glad that I sold off my shares of Sleep Holdings Inc last week. I wish I would have bought Respironics instead of Resmed on Friday- Respironics makes the superior pulse oximeter (type 4 device)- the 920 M series.

Organized Medicine Endorses Home Testing

I've previously blogged in depth about the American Academy of Sleep Medicine endorsing home testing for the diagnosis of obstructive sleep apnea. Now the American Board of Internal Medicine has also (implicitly) endorsed it:

The ability to interpret results of polysomnography multiple sleep latency testing, maintenance of wakefulness testing, actigraphy, and portable monitoring related to sleep disorders.The ability to interpret results of polysomnography multiple sleep latency testing, maintenance of wakefulness testing, actigraphy, and portable monitoring related to sleep disorders.
From the ABIM website, training and procedural requirements for sleep medicine certification

The preliminary decision from the Center for Medicare Services regarding home testing for osa is expected today.

Sleep Lab Busted by Medicare

Sleep Review magazine reports that HMS Diagnostics Inc was recently busted by CMS (Medicare) for having uncertified technicians run sleep studies on Medicare patients:
Sleep Lab Medicare Claims Under Investigation
According to the release, the US Attorney's Office seems to be suggesting that any CPT 98510 or CPT 98511 study not actually performed by a credentialed technician cannot be billed. The fact that the credentialed technician is on site and supervising apparently is not a factor, HMS Diagnostics stated in the release.
Rest of quote from Sleep Review article deleted, due to their request
“If what CMS is saying is true, then the amount of money that would be owed to Medicare by the industry is phenomenal,” says Goodman. “The liability potential on an industry such as ours with Medicare could be a very big number.”
This is a disturbing development. The requirement for tech certification is virtually unknown in the sleep community. On the AASM message boards, we were recently discussing a new CMS regulation that All studies are to be done by a certified polysomnographer by January 1, 2008 in Arkansas, Louisiana, Eastern Missouri, New Mexico, and Oklahoma and by October 1, 2008 in Rhode Island; and the consensus was that uncertified technicians were ok for the time being in most other states. Most sleep labs have a combination of certified and uncertified techs, and I agree with the article that if CMS is going to enforce this newly discovered regulation, the amount of money owed would be phenomenal.

More on Portable Home Testing and Auto-CPAP

In response to a reader who emailed regarding my predictions of cpap vs. auto-cpap useage:

I don't think that APAP will entirely replace CPAP, but its marketshare will increase somewhat. This will be good for Respironics/RESmed, and bad for the durable medical equipment companies (DME's are reimbursed the same for cpap/auto-cpap machines and therefore there is a higher profit margin on the regular cpap machines for the DME companies). APAP will be prescribed in certain rural areas of the country by some primary care docs. After diagnosing a patient with portable home testing, they will tend to prescribe an auto-cpap machine rather than refer their patients to a sleep lab for a cpap titration. This will have little economic effect on the primary care doc, they will do this to maintain control of the process and maintain their independence from sleep labs. Some primary care docs, especially family practitioners in rural areas, take pride in being able to handle most problems themselves rather than referring to specialists.

Don't Blame the Turkey

Feel sleepy after a big Thanksgiving meal? Contrary to popular thinking, it's not the turkey's fault.
While there is an amino acid in turkey that induces sleepiness, experts say it's much more likely the reason you're tired after having Thanksgiving dinner is a combination of simple factors: you ate and drank too much and didn't sleep enough.
So don't blame the turkey.
"The poor turkeys have enough problems on Thanksgiving," said Dr. Carol Ash of Somerset Medical Center's Sleep for Life Center in Hillsborough, New Jersey.
The reason turkey gets blamed for making people sleepy is because it contains tryptophan, an amino acid that produces the brain chemical serotonin, which promotes calm and sleepiness. But as part of a big dinner, the tryptophan has a hard time reaching the brain.
Even if it did, "you'd have to ingest quite a number of turkeys" for it to have an effect, she said.
If the tiredness has anything to do with dinner, Ash said, it would be because of carbohydrates, which studies show are more likely to make people sleepy. And even that would only be a small factor, she said.
There's the travel, working longer days to get things done and lack of sleep, along with the carbs and alcohol, she said.
Overeating also contributes to feeling tired at Thanksgiving, said Joan Salge Blake, a registered dietitian and nutrition professor at Boston University.
"You're just eating a whole heck of a lot of foods and are stuffed," said Salge Blake.
On top of that, she added, you're "often just sitting around afterward, watching football."
From Cnn.com
Bottom line: if you are sleepy after thanksgiving dinner, it is probably due to a combination of over-eating, alcohol, sleep deprivation, and excessive carbohydrates. It's not due to the tryptophan in turkeys.

Duloxetine may improve sleep in patients with diabetic neuropathy

Clinical Psychiatry News reports on a poster presentation suggesting that duloxetine improves sleep in in patients with diabetic neuropathy:
WASHINGTON – Not only does duloxetine appear to reduce the severity of pain, especially during the night, but it may also help patients with diabetic peripheral neuropathy get a better night's sleep, according to a poster presentation at the annual meeting of the American Pain Society.
After 12 weeks of treatment, patients on 60 mg of duloxetine once or twice daily had improvements in average daily pain severity, night pain severity, and pain-related sleep interference, wrote Dr. David A. Fishbain, professor of psychiatry and behavioral sciences at the University of Miami, and his colleagues at Eli Lilly, maker of duloxetine (Cymbalta).
Although causality cannot be demonstrated between duloxetine and better sleep, the findings suggest that improvements in pain will be associated with less interference in sleep, the authors wrote.
The researchers pooled data from three double-blind, placebo-controlled trials of duloxetine in patients with diabetic peripheral neuropathic pain (DPNP). In the first study, 457 patients were randomized to receive 20 mg of duloxetine once daily, 60 mg of duloxetine once or twice daily, or placebo. In studies two and three, 334 and 348 patients, respectively, were randomized to receive 60 mg of duloxetine once daily, 60 mg of duloxetine twice daily, or placebo. Although the primary efficacy measure for the studies was the reduction in the weekly mean of the 24-hour average pain score, secondary end points included average daily night pain severity (measured on an 11-point Likert scale) and the Brief Pain Inventory sleep interference item.
Patients were included in the trials if they were 18 years or older with pain because of bilateral peripheral neuropathy caused by type 1 or type 2 diabetes mellitus. Pain had to have begun in the feet with relatively symmetric onset. Diagnosis was confirmed by a score of at least three on the Michigan Neuropathy Screening Instrument. Daily pain had to be present for at least 6 months. Patients also had to have at least a 4 on the 24-hour average pain severity (11-point Likert) scale and stable glycemic control. Notably, patients with a current or recent (within the last year) diagnosis of major depressive disorder as defined by the DSM-IV were excluded from the studies.
The researchers identified a subset of nonsomnolent patients by excluding those who reported treatment-emergent somnolence or who were on concomitant sedating medications. Treatment-emergent somnolence included reports of daytime sleepiness, drowsiness, being drowsy upon awakening, excessive daytime sleepiness, a feeling of residual sleepiness, groggy, groggy and sluggish, groggy on awakening, hard to awaken, less alert on rising, sleepiness, sleepy, and somnolence.
In all three studies, 339 patients received placebo. Of these, 307 met the criteria for the nonsomnolent subset. A total of 685 patients received 60 mg or 120 mg per day of duloxetine in all three studies. Of these, 607 met the criteria for the nonsomnolent subset. Patients in the nonsomnolent/nonsedating subgroup who were on duloxetine showed improvements in daily average pain and night pain severity, compared with those on placebo. The improvements started as early as 1 week and were maintained for 12 weeks. At 12 weeks, subset patients on 60 mg of duloxetine once and twice daily had improvements in daily average pain severity of 47% and 50%, compared with 29% for those on placebo.
Also at 12 weeks, subset patients on 60 mg of duloxetine once and twice daily had improvements in night pain severity of 47% and 51%, respectively, compared with 34% for those on placebo.
Most of the SSRI's and dual reuptake antidepressants can cause insomnia when used to treat major depressive disorder. This study suggests that by improving pain, duloxetine (which increases synaptic levels of serotonin and norepinephrine by inhibiting their reuptake) improves sleep in non-depressed patients with diabetic neuropathy. One limitation to this study is that patients who developed somnolence were excluded from analysis.

Respiratory Therapists Try to Take Over Polysomnography

Sleep Review Magazine reports on the attempt of California respiratory therapists to take control of polysomnography:
Respiratory Care Board of California Increases Efforts to Regulate Sleep Industry
In August, the Respiratory Care Board of California (RCB) voted unanimously to pass a motion allowing for the issuance of citations and fines for the unlicensed practice of respiratory care associated with polysomnography. Not only are investigations stemming from this motion under way, but also the RCB has now drafted new licensure legislation.
According to the Respiratory Care Board of California's Fall 2007 newsletter (launches PDF), "Citations may be issued to both unlicensed personnel and employers of unlicensed personnel illegally practicing respiratory care, with fine amounts up to $15,000. The issuance of these citations and fines is separate from, and in addition to, citations issued to employers by the Department of Health Care Services for failure to use properly licensed personnel."
This move heated up debate among many sleep professionals who feel requiring licensure of RPSGTs is doing little more than widening a divide between the sleep and the respiratory care professions.
Signed into law in 1983, the Respiratory Care Practice Act tasks the RCB with overseeing the licensure and regulation of respiratory professionals.
"In 2002 we added a code, Section 3767, which authorized us to cite and fine for the unlicensed practice of respiratory therapy," said Stephanie Nunez, executive officer for the Respiratory Care Board of California (Sacramento). Section 3767 became effective January 1, 2003. "We've been working on this since 2001 and have reached out to the community through surveys and roundtable meetings. Unfortunately, because these individuals are not licensed or regulated, we were very limited in how we were able to contact them." Nunez added that in 2004, there weren't many techs who were credentialed, a fact that has changed in recent years.
While, to date, there have not been any citations or fines issued to either sleep techs or their employers, there has been an ongoing effort from the RCB to inform the community about the new requirement.
"We sent a [online] survey out to more than 400 people, as well as a notice, in 2004," Nunez added. A hard copy of the survey was also distributed to about 150 people. "We received only 29 responses." This type of minimal involvement is a point of frustration for Nunez.
Polysomnographic Technologist Act
In addition to gathering information from the industry on, among other things, how licensing should be instituted, the RCB has put forth its suggested solution, the Polysomnographic Technologist Act. The proposed legislation—which is available on the organization's site (launches PDF)—is sitting idle, waiting for backing by a public official who could push it into law.
According to an AASMAdvocacy e-mail to AAST members, the proposal would require a sleep technologist to fulfill one of the following criteria to obtain licensure: - Possession of a current license to practice respiratory care in California.- Completion of an accredited respiratory care program as prescribed by the board and has an associated degree.- Completion of an accredited electroneurodiagnostics program as prescribed by the board and has an associated degree.- Completion of a polysomnography educational program prescribed by the board and has an associated degree.- Completion of 18 months or 3,000 hours of full-time paid work experience as an applicant sleep technologist, including 1,000 hours in polysomnography-related respiratory care services as prescribed by the board and satisfactorily performed as verified by a physician or surgeon.
The e-mail also stated, "AAST and AASM are formulating a number of strategies to counter this measure, one of which includes introducing our own bill, but no decision has been made at this time. Though we have not made a decision, we will still be working with our attorneys on our own bill so we are prepared for the upcoming legislative session."
The tone of the e-mail conveys concern—a feeling that Nunez has also recognized among techs. "The feedback we are getting is that [those in the sleep field] are adamantly against any type of regulation, but the fact is that respiratory care has to be performed by a licensed person," Nunez said. "So, we are seeking a resolution to this, and we've tried to stress that we want the techs to get involved, we want them to help us fix this problem."
Those techs are also feeling frustration. In many cases, they view the RCB as "playing favorites" and as trying to eliminate or ignore sleep professionals with additional legislation. Such accusations are unfounded, according to Nunez.
"We recognize that respiratory therapists need additional training in this area and that RPSGTs are probably the best qualified," she said. "Our recommendation is to establish a license category within our board, and it isn't excluding anyone: it recognizes the BRPT exam, it recognizes experience, and it recognizes all the people who are in the practice right now. It is not a turf war. It is a consumer protection effort."
Driving the goal of licensing is the ability to screen and monitor those in the profession. Among other requirements, licensure would mandate that techs pass a criminal background check. Not all hospitals—and very few independent facilities—perform such checks, according to Nunez, and even those who do are not privy to the privileged information the government can access.
"Licensure also addresses employees who are incompetent or who did something unethical. In those cases, the employer, most times, will terminate the tech and that person goes on to work somewhere else, with no record of it," said Nunez. "Granted, someone can do an employment check, but not everyone does—and employers are also leery of giving out that type of information, for fear of being sued."
Accusations of sexual assault by a respiratory therapist this summer focused the spotlight on the importance of regulating the profession, said Nunez.
"I think what's happening right now is the good [techs] are taking offense, because they feel they're being accused and criticized for not being good enough—and that is absolutely not true," she said. "It is the other people that we are worried about. It is about creating a level playing ground and ensuring that everyone has competency testing, such as the BRPT [Board of Registered Polysomnographic Technologists] exam or the NBRC [National Board for Respiratory Care] exam, if that comes about. We are not putting one above the other—we would recognize both."
Essentially, what the Respiratory Care Board of California (RCB) is doing is stating that the performance of sleep studies (polysomnography, cpap/bipap titrations) is respiratory care, and that any sleep center technician who is not a licensed respiratory therapist will be fined, along with their employer (the sleep center).
Rumor has it that in Mississippi respiratory therapists are planning a similar power play, and will try to get state legislation passed in 2008 to require a respiratory therapist to be present whenever cpap/bipap is titrated.
I personally strongly disagree with the RCB in its assertion that polysomnography is respiratory care. Polysomnogaphy was originally developed by psychiatrists, not pulmonologists. The RPSGT credential is the standardard in polysomnography, not the RRT credential.

The Sleep-Industrial Complex

A sleep boom, or as Forbes put it last year, “a sleep racket,” is under way. Business 2.0 estimates American “sleeponomics” to be worth $20 billion a year, which includes everything from the more than 1,000 accredited sleep clinics (some of them at spas) conducting overnight tests for disorders like apnea, to countless over-the-counter and herbal sleep aids, to how-to books and sleep-encouraging gadgets and talismans. Zia Sleep Sanctuary, a first of its kind luxury sleep store that I visited in Eden Prairie, Minn., carries “light-therapy” visors, the Zen Alarm Clock, the Mombasa Majesty mosquito net and a $600 pair of noise-canceling earplugs as well as 16 varieties of mattresses and 30 different pillows.
From the New York Times Sunday Magazine

More on Auto-CPAP

Currently there are a few major financial barriers to the use of Auto-CPAP:

Medicare and most insurance companies reimburse the DME companies for Auto-CPAP at the same rate as a regular CPAP machine. Auto-CPAP machines are more expensive (for the DME company) than regular CPAP machines. Unless a DME company is able to negiotiate a discount with the manufacturer, DME companies typically lose money on Auto-CPAP machines.

As far as using Auto-CPAP for an "at home titration study" (number 3 on my previous post)- that titration period (typically 3 nights) currently is unreimbursed and I am not aware of any plans for reimbursement for this.
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When portable testing is approved, I think that some primary care physicians will try to evaluate and treat osa without the involvement of sleep specialists by ordering portable testing and then treating the patient with an auto-CPAP machine (number 2 on my previous post). The auto-CPAP manufacturers have been known to negotiate discounts with large DME companies so this may be financially possible in certain areas. I think that we will see more auto-CPAP use by primary care doctors over the next several years, along with a temporary increase in profits by the Auto-CPAP manufacturers. However, results will be poorer than the current standard of having a patient undergo an in-lab titration before prescribing cpap. A lot of auto-cpap machines will end up sitting in closets and the auto-cpap trend will end by 2012.

Auto-CPAP in the new portable testing world

To paraphrase a reader question, what role will auto-CPAP play in the future?

Auto-CPAP is basically CPAP that is self-adjusting based on the patient's pressure needs (various manufacturers have different alogorithms to monitor airlow). There are 3 main ways to use auto-CPAP:

1. Some patients who undergoe an in-lab regular CPAP titration are found to have large pressure difference needs between different body positions or sleep stages. In these cases, the patient can be prescribed auto-CPAP within a preset pressure range. For example, if someone needs a pressure of 6 during stage 2 sleep and 10 during REM, he might be prescribed an auto-CPAP machine that was set to automatically adjust between 6 and 10.

2. A patient could just skip the in-lab titration and be sent home with an auto-cpap machine for permanent use. The pressure range might initially be set at 4-20 and then gradually narrowed based on the data generated by the auto-cpap machine.

3. Instead of an in-lab titration, a patient could be loaned an auto-cpap machine for a few days to use at home. Based on the data generated by the machine, the patient could be prescribed a regular fixed pressure cpap machine.

Most sleep specialists, including myself, do option 1 at times. Some sleep specialists will do options 2 and 3 occasionally, but this requires close patient follow up and in my opinion is not appropriate for widespread use, nor for use by non-specialists. If options 2 and 3 become more widespread it would reduce the number of titration studies done by sleep labs and have a negative financial impact on the sleep testing industry.
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Edit (11/21)

A reader asked about reimbursement for options 2 and 3:

I am not directly involved in the DME business, so I don't know exactly what the profit margin is on cpap and auto-cpap machines. For option #2, the physician would collect standard office visit fees and the DME company would sell the patient an auto-cpap machine. Currently, most insurance companies reimburse auto cpap machines (for permanent home use) at the same amount as a standard cpap machine. I have been told by DME companies that they lose money every time they do this.
For option #3, usually the patient (at least in my area) is not charged for borrowing the auto-cpap machine (from the DME company) for a few days for an at-home auto-cpap titration. The DME makes its money by then selling the patient a regular cpap machine. The physician charges standard office visit codes.

Is There a Sleep Study Backlog?

A reader asks: Is there actually a backlog of undiagnosed patients? If so, how significant is this backlog (2 weeks? 2 months?)? Do you believe the move to home testing will result in a quick resolution of this backlog?
In most urban areas, there is only a 1 to 2 week wait for sleep studies for patients with Medicare or commercial insurance. Not all sleep labs take Medicaid, so those patients may have to go to University sleep labs, which can sometimes have backlogs of 3 to 4 months. Waiting times in The Veterans Administration can be problematic; I have heard of patients waiting 6 to 12 months for sleep studies and I believe that portable testing may make sense in the VA system.

Not all rural areas have sleep labs, but more and more 2 bed sleep labs are popping in small community hospitals.

Overall I do not think that their is a significant backlog, except in the VA system and some university hospitals. There remains a large number of people with undiagnosed obstructive sleep apnea, but it's not due to a lack of sleep labs.

Quick Sleep Stock Pick

Respironic's products are superior to Resmed's, especially when it comes to the new servoventilation technology. Respironics is coming out with a new "PAP" machine which combines all the different PAP modalities (BiPAP, BiPAP ST, CPAP, SV) into one easily useable machine for sleep lab use- less work for the sleep lab technicians in switching from one treatment to the other. I remain bullish on Respironics and anticipate their stock reaching 55 within 6 months.

Sleep Review Magazine reports on Portable Monitoring

AASM Gives Green Light to Portable Monitoring Systems
Formed by the AASM to examine limitations and unanswered questions related to the practice parameters published in 2003's "Practice Parameters for the Use of Portable Monitoring Devices in the Investigation of Suspected Obstructive Sleep Apnea in Adults" (launches PDF), the (AASM) Task Force spent the last year developing a set of sound recommendations based on a review of the available literature and expert consensus.
The result of their effort will be published in the December 15 issue of the Journal of Clinical Sleep Medicine.
Please note that the link above is to the old (2003) practice parameters, the new practice parameters are currently available only to AASM members

Reader Comments on Home Testing, "certified polysomnographer"

This is an interesting take on the issue. For me, "certified polysomnographer" does not by default include RRTs. THE ONLY ONE BY DEFAULT IT DOES INCLUDE IS RPSGTs.As a Sleep tech since the early eighties, the costs associated with PSG have grown from the staffing side of the equation. At first, I worked in a world class Neurology based sleep laboratory. I was paid a salary commensurate with other Neuro-based technicians. Only with my move to a pulmonary based sleep facility, did I enjoy a major "bump" in my salary, as the facility did not have a pay scale for this "sleep tech" classification. Taking this new job allowed me to be the only technical sleep person in the facility and as such, I fit a unique role, but got wedged into a generic technician job category. I quickly exceeded that description and moved up, and hired other techs to work under me. Some of them had Respiratory backgrounds, and thus, we equalized the sleep tech and respiratory therapists pay scale, since we had to pay some "techs" who were also RTs. This now raised our costs significantly. We are paid equal to the RTs in Respiratory, but that was just a market demand, the equation of duties is nowhere near equal. The RTs, working in "Respiratory" perform Respiratory treatments, and we perform Sleep testing and Sleep treatments, irrespective of one's background. The only RTs who can perform sleep medicine testing and therapies are the ones the AASM, ACCP, and ATS have considered appropriate; those that are properly educated and proficient in sleep medicine. Otherwise, they are performing outside of their scope of practice. So, in the end, my history does not offer a similar perspective on the issue of cost, as the equipment has lowered in cost, but the staffing has artificially increased. And, as these two major components of sleep testing continue to hurtle towards their eventual end points, the need to control quality sleep medicine in whatever aspect, arena or capacity a patient is tested in, should ALWAYS fall to properly trained and experienced individuals. As for a 3/1 pt/tech ratio, 3 techs (whatever their backgrounds) taking care of 9 patients with all of the hand holding and interaction that patients undergoing PSG for titrations, pediatrics, or seizures, etc, necessitate, it does at least include a modicum of expectation of response from the technical staff. The 3 patients being taken care of, offer no consolation for the 6 (66%) of the other patients possibly calling out for them.Proper ambulatory testing can be accomplished, if all portable testing go through sleep doctors; on the front end (proper sleep consultation) and the back end; (sleep doc interpretation.) This would force the "certified polysomnographers" to be the ones performing these portable testing duties, and how that will interplay with the expectations of different allied health field entrants into the pool of "certified polysomnographers," we will have to wait and see. Some of these entrants might get bored, thinking that portable sleep testing and therapies is below their training, and some might find it a very interesting and important aspect to the milieu of sleep testing, that if anything, this shows is not stagnate.
Thank you for your comments on this post. I agree that "certified polysomnographer" should = RPSGT. However, respiratory therapists are making power plays in some states. For example, in some states respiratory therapists are trying to enact statutes making it mandatory that a respiratory therapist be present during all CPAP/BiPAP titrations.
As for technician/patient ratio, I think that a 3:1 ration would be appropriate only under limited circumstances (adult patients, psg's - not titrations). I agree that the current standard of 2:1 leads to better quality studies. However, I feel that portable home testing is vastly inferior to both ratios.

Drowsy Driving

The National Sleep Foundation's first annual Drowsy Driving Prevention Week (DDPW) is November 5th through 11th.

Each year, crashes due to drowsy driving result in at least 1,550 deaths and 71,000 injuries.

One of the most common causes of sleepiness while driving is voluntary insufficient sleep. Although a majority of us have the physiological ability to obtain the 7.5 to 8.5 hours (up to 9.5 hours in teenagers) of sleep necessary each night to feel fully rested - work, school, and family pressures often make it difficult to find enough time to sleep. Alcohol, when combined with sleep deprivation, can be particularly deadly.

Other causes of sleepiness include disrupted sleep (from obstructive sleep apnea or other sleep disorders), medication effect, circadian rhythm disorders (more about these below) and medical conditions that directly cause sleepiness (e.g., narcolepsy). After insufficient sleep, obstructive sleep apnea is the most common cause of daytime sleepiness. Many medications, including anti-seizure medications and many psychiatric medications, can also cause drowsiness.

Circadian rhythm disorders are conditions in which the body's 24 hour clock is out of alignment with the environment, producing insomnia and/or sleepiness during unusual hours. Examples include delayed sleep phase syndrome and shift work sleep disorder. In delayed sleep phase syndrome, which is common among adolescents and young adults, the main sleep period is delayed. A typical sleep period with this disorder would be from 3 am to 11 am. Insomnia occurs if the person tries to sleep outside this time bracket. If the person needs to get up early for work or school, sleepiness will occur. Insomnia and sleepiness are also common in shift workers, especially if the shifts are rapidly rotating.

It is important to allow sufficient time in your schedule for sleep. If you feel sleepy despite obtaining 8 hours at sleep at night, consultation with a physician is recommended. Also, talk to your doctor if insomnia prevents you from obtaining the necessary amount of sleep to feel fully rested.

Do not drive if you are feeling drowsy. If you become drowsy while driving, pull over and take a break (and a nap, if possible). Caffeine can have a mild effect in improving alertness.

More on Home Testing for OSA

Anyone interested in learning more about the pro's and con's of home testing for obstructive sleep apnea is encouraged to review Public Comments for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093R2) on the Medicare site.

I did not submit a comment at the time. As a sleep professional, I foolishly assumed that the American Academy of Sleep Medicine would adequately represent my interests in the matter.

Job Security in Sleep Medicine

A reader asks about the implications of portable home testing for OSA: Certainly some sleep labs will remain active. There are pediatrics and very sick patients that will need all night testing. I work as an RPSGT at a lab that is highly regarded and has a good reputation. What can I expect for the future? How will doctors discriminate between those patients that can use portable units at home and those that need in lab testing?

As a RPSGT, you have good job security, at least for the next 10 years. New AASM and Medicare standards (Medicare standards vary region by region) are making RPSGT's increasingly in demand.
For example in the following five states, all studies on Medicare patients must be performed by a "certified polysomnographer" by January 1 2008: Arkansas, New Mexico - Oklahoma - Missouri (Eastern) Louisiana. No one knows exactly what "certified polysomnographer" means but it almost definitely includes RPSGT's and probably also RRT's.

Due to Medicare/AASM standards, sleep studies are becoming increasingly expensive tests to perform. The AASM requirement of at least 1 tech per 2 patients, certification requirements for techs, restrictive policies on performing split-night studies, etc make sleep studies expensive. So what's their solution for high cost sleep studies? Portable home studies in which their will be no technician to replace electrodes that come loose and take care of other problems that invariably come up. Medicare and the AASM created the problem of expensive testing with all their requirements, and now their solution is a low cost, inferior test. If saving money is the goal, why not just relax the standards (maybe 1 tech for 3 patients) and lower the reimbursement a little bit. This would be a better solution, in my opinion, than widespread portable home testing.

Home testing for OSA is a complex subject, and I will be posting more about this in the coming weeks. Thanks for reading.

Stabbed in the Back

I previously posted regarding the controversy about portable home testing for obstructive sleep apnea. This Sept 20 post gives some background information about the issue. Briefly, CMS (Medicare) is considering allowing portable home testing for the diagnosis of OSA, prompted by a request by the ENT physicians. A little more info is provided in my 9/21/07 post. Initially, The American Academy of Sleep Medicine (AASM) opposed home testing for OSA.

Now, The bureacrats at the AASM have joined the ENT docs in stabbing the field of sleep medicine in the back. If you look at this link, you'll notice under recent announcements "AASM Approves Portable Monitoring in Adult Patients". Basically, an AASM task force report is coming out in December recommending portable testing for OSA.

It’s all over. With the AASM caving in and publishing a task force report recommending portable testing, it’s a done deal. CMS (Medicare) will approve home testing for OSA. Within 3 years, the financial foundation of sleep medicine will crumble. Much of the evaluation and tx of OSA (the bread and butter of sleep medicine) will now be done by Primary care docs, who will diagnose with portable testing and treat with auto-CPAP machines. This will lead to worse outcomes for patients and many sleep labs going out of business.

Buy Respironics (at under 49). Begin to liquidate your Sleep Holdings positions (or if you are a speculator like me, buy and sell the volatility). Disclaimer- my stock picking ability isn't perfect, I recently tried to get a bargain with Washington Mutual and ended up catching a falling knife.

I will post more about this issue later. I need to get ready for a trip to inspect a sleep lab for the AASM, as well as complete some committee work (for the AASM Behavioral Sleep Medicine Committee).
---------------------------------------
Edit (11/8) Thank you to Kevin, MD for linking to this post. Also, I regret using the phrase "bureaucrats at the AASM". I should have used the phrase "academics at the AASM". The leadership of the AASM, like that of most of organized medicine, is out of touch with the needs of physicians out in the community.

Michael Rack, MD

Sleep Board Tip #4

Cardiac deaths and MI's tend to occur between 6 am and noon in the average person. In people with OSA, they occur between midnight and 6 am.

Sleep Board Tip #3

Congenital Central Hypoventilation Syndrome (CCHS) is linked to mutations in the homeobox gene Phox2B.
In some families CCHS exhibits autosomal dominant transmission.

Sleep Board Tip #2

End Tidal CO2 is often used to aid in the diagnosis of OSA in children.

Various parameters are listed in the literature. The one that will probably appear on the boards is:
ETCO2> 50 mm Hg for >10% TST is abnormal

Sleep Board Tip # 1

The new sleep boards are coming up in mid-November. Here is something that will probably appear on the exam:

Shy-Drager Syndrome ( a subset of Multiple System Atrophy) is a Parkinsonian syndrome with prominent autonomic failure.
Respiratory dysrhythmias during sleep are common in Multiple System Atrophy (and are even more common in Shy-Drager syndrome), especially NOCTURNAL STRIDOR, which can be fatal. This is a result of vocal cord dysfunction- Posterior Cricoarytenoid Muscles- the abductors of the vocal cords. Treatment includes obligatory cpap or tracheostomy. Respiratory dysrhythmias due to Shy-Drager syndrome can also result in nocturnal awakenings, sleep disruption, and hypersomnia.

(This info was covered during the AASM 2007 Chicago Board Review course)

Fish can get Insomnia too

Yahoo News reports that Zebrafish lacking a hypocretin receptor sleep 30% less than fish without this mutation:
LOS ANGELES (Reuters) - Fish might not have eyelids, but they do sleep, and some suffer from insomnia, scientists reported on Monday.

California scientists studying sleep disorders in humans found that some zebrafish, a common aquarium pet, have a mutant gene that disrupts their sleep patterns in a way similar to insomnia in humans.

Zebrafish with the mutant gene slept 30 percent less than fish without the mutation. When they finally drifted off they remained asleep half as long as the normal fish, the researchers at the Stanford University School of Medicine said.

The mutant fish lacked a working receptor for hypocretin, a neuropeptide that is secreted in normal fish by neurons in the region of the brain that controls hunger, sex and other basic behaviors.

The researchers, led by Emmanuel Mignot, said they would look for fish that have a mutation that causes them to oversleep or never sleep in the hope of discovering if sleep-regulating molecules and brain networks developed through evolution.

The study was published in Tuesday's edition of the Public Library of Science-Biology.

Hypocretin is the neurochemical linked to the narcolepsy-cataplexy syndrome; human narcoleptics (with cataplexy) have a hypocretin deficiency. Disturbed, fragmented nocturnal sleep is a common, underrecognized symptom of narcolepsy.

Narcolepsy without cataplexy is a poorly understood condition and we sleep doctors have no idea what causes most cases of this condition.

The Uvula

A tribute to the uvula (via Kevin MD).

Today (10/22), Dr. Rob blogs about the pharynx, which is very important to sleep specialists.

Opioids and sleep apnea

Opioids such as methadone are well known to cause central sleep apnea. Sleep Review Magazine reports a high rate of obstructive and central sleep apnea in patients who use opioids for chronic pain:
Sleep-disordered breathing is very common in patients who use opioids for chronic pain conditions, according to a report issued online September 6th by the journal Pain Medicine.
Of the 147 patients on chronic opioid therapy who agreed to undergo testing, 140 had data available for analysis, the report indicates.
"The biggest finding was an extraordinarily high prevalence of sleep-disordered breathing in opioid-treated chronic pain patients," Dr. Webster noted. "Obstructive and central sleep apnea syndromes occurred in the studied population at a far greater rate (75%) than is observed in the general population."
The most common type of sleep apnea, seen in 39% of all patients, was the obstructive type, followed by central sleep apnea in 24%, central and obstructive sleep apnea in 8%, and indeterminate type in 4%.
The apnea-hypopnea index was directly related to the daily dosage of methadone, but not to that of other opioids (p = 0.002). The central apnea index was directly linked to the daily dosage of both methadone (p = 0.008) and benzodiazepines (p = 0.004).
It is interesting that in this study methadone appeared to have a greater effect on sleep apnea than other opioids.
I run a suboxone clinic to treat persons addicted to opioids. I'll have to increase my monitoring of their sleep.

Read about Insomnia at MySleepCentral.com

I am now a blogger for MySleepCentral.com. Read my latest post about Insomnia, here.

Update on home testing for osa

The American Academy of Sleep Medicine reports:
The Medicare Evidence Development and Coverage Advisory Committee (MedCAC) met September 12, 2007, to evaluate national coverage determination (NCD) 240.4 continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA).

Alex Chediak, MD, president, and Mary Susan Esther, MD, president-elect, represented the American Academy of Sleep Medicine (AASM). As communicated to AASM members via the Weekly Update, Dr. Chediak presented official testimony, completely based on available published evidence and data, on behalf of the AASM.

Download his testimony by visiting www.aasmnet.org/resources/pdf/testimony.pdf.
According to its Web site, the Centers for Medicare & Medicaid Services (CMS) has until December 14, 2007, to issue a preliminary decision memo, which will be followed by a 60-day public comment period. CMS expects to publish the final NCD by March 14, 2008.
The AASM will continue to communicate more information on NCD 240.4 to members as it becomes available.

I am currently at a CME conference sponsored by the AASM. I hope to post more when I get back to Mississippi on Sunday.

Home Testing for Obstructive Sleep Apnea

As reported in Sleep Review, last week Medicare (actually the Medicare Evidence Development and Coverage Advisory Committee) met to decide the future of sleep medicine:
On September 12, industry leaders with varying positions about adopting home testing for the diagnosis of OSA gathered to present their opinions to a Medicare Evidence Development & Coverage Advisory Committee (MedCAC) panel. Based on the content of the meeting, the panel will make a recommendation to CMS about the future of home testing.
Earlier this year, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) submitted a formal request to CMS to revisit its national coverage determination (NCD) to not reimburse patients for positive airway pressure therapy if their sleep apnea was diagnosed with any form of testing other than in-laboratory polysomnography (PSG).
The AAO-HNS letter triggered the home testing debate...
rest of sleep review quote deleted at their request.

The MedCAC panel recommendation is expected to be out December 14, 2007, when the proposed decision memo is due.

Currently a polysomnogram (sleep study) performed in a sleep lab is required by CMS (medicare) to cover the purchase of a CPAP machine, the most common treatment for obstructive sleep apnea. Usually another sleep study, a CPAP titration (in which the CPAP settings are adjusted), is performed before CPAP is prescribed.
If CMS approves home testing for the diagnosis of sleep apnea, it will be disastorous for sleep labs that are currently in operation. Most private insurance companies follow CMS guidelines, and there will be a drastic drop in the number of sleep studies performed. Many sleep labs will close. It takes a lot of money to keep a sleep lab going, the typical yearly overhead (technician costs, equipment, rent) for a sleep lab is approximately $100,000 per bed, and much of this expensed is fixed.
Home testing, in my opinion, will be bad for patients. Sleep apnea will be less accurately diagnosed. CPAP will be titrated inadequately, and patients will get poorer results with CPAP.

I don't think that CMS is going to make the change, though. The final decision is expected March 14, 2008

Somnus test video

I am not Responsible for your CPAP Machine

CPAP (Continuous Positive Airway Pressure) is the most common treatment for obstructive sleep apnea. Most sleep physicians do not directly provide their patients with CPAP machines, but instead give a prescription for each patient to take to a durable medical equipment (DME)company. I typically give patients a list of several companies to choose from, while telling them that they are legally free to pick any DME company they desire.
===============
Once a patient selects a DME company, he is essentially stuck with that company for 5 years. Due to reimbursement issues, it is difficult to switch companies (though there are a few exceptions- insurance reimbursement for CPAP is a complicated matter). Choosing the right DME company is critical- the DME company is responsible for adjusting the settings (as ordered by a physician prescription), supplying/fitting CPAP masks, periodically replacing filters and other supplies, and servicing the CPAP machines.
So pick a good DME company- go with your doctor's suggestion.
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Do not lose your CPAP machine. There is nothing I can do about it. Medicare and most other insurance companies won't cover a new CPAP machine for 5 years, unless your machine becomes unrepairable. If you lose your machine, you are out of luck.
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If you plan on moving soon, pick a national DME company, such as Lincare or Apria. If your DME company does not have an office in the state you are moving to, it may be difficult to get your CPAP machine serviced.
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I am not responsible for your CPAP machine. If it malfunctions, I will try to help out and will call your DME company, if necessary. However, I am often limited in what I can do. If you are one of my patients, please go to one of the companies that I recommend. I only recommend companies that provide good service.

Snoring

Obama's wife reports that he snores:
Referring to their daughters, Mrs. Obama says: “We have this ritual in the morning. They come in my bed, and Dad isn’t there — because he’s too snore-y and stinky, they don’t want to ever get into bed with him. But we cuddle up and we talk about everything from what is a period to the big topic of when we get a dog: what kind?”
According to the National Sleep Foundation, Snoring is noisy breathing during sleep. It is a common problem among all ages and both genders, and it affects approximately 90 million American adults — 37 million on a regular basis. Snoring may occur nightly or intermittently. Persons most at risk are males and those who are overweight, but snoring is a problem of both genders, although it is possible that women do not present with this complaint as frequently as men. Snoring usually becomes more serious as people age. It can cause disruptions to your own sleep and your bed-partner's sleep. It can lead to fragmented and un-refreshing sleep which translates into poor daytime function (tiredness and sleepiness).
About 25 % of people with snoring have obstructive sleep apnea. Some indications that your snoring may be a problem include:

Excessive daytime sleepiness
Morning headaches
Recent weight gain
Awakening in the morning not feeling rested
Awaking at night feeling confused
Change in your level of attention, concentration, or memory
Observed pauses in breathing during sleep

CBT for Insomnia

Clinical Psychiatry News recently published a nice summary on the use of cognitive behavioral treatments for insomnia. The article focuses on secondary/comorbid insomnia, but the techniques discussed can also be utilized in primary insomnia:

Cognitive-behavioral treatments can help people overcome chronic insomnia, even when a medical or psychiatric disorder appears to be the primary cause of sleeplessness, Edward J. Stepanski, Ph.D., said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.
Traditionally, behavioral treatments have been reserved for primary insomnia and not recommended for people whose lack of sleep is secondary to other conditions, said Dr. Stepanski, vice president for scientific affairs of the Accelerated Community Oncology Research Network (ACORN) in Memphis, Tenn.
The underlying assumptions—both of which he challenged—are that insomnia will remit if the primary condition is resolved and that cognitive-behavioral treatment (CBT) approaches will not be effective against an etiology such as pain or depression. People continue to sleep poorly after successful treatment of posttraumatic stress disorder, he said, and randomized controlled trials have shown that people with a primary condition such as arthritis or chronic obstructive pulmonary disease can sleep better after CBT.

Sometimes secondary insomnia does remit with treatment of the underlying condition, and optimal treatment of the underlying condition is important.

“Use [CBT] in any chronic insomnia,” Dr. Stepanski said, suggesting comorbid insomnia would be a better name than secondary insomnia when diagnosed in patients with other conditions. “CBT has its place,” he said. “There are always behavioral and cognitive features to a chronic patient with insomnia.”
For most patients, he recommended that behavioral treatments come before cognitive therapy. Many worry that they will have a mental breakdown or lose their jobs if they don't get more sleep. Once they are sleeping better, he suggested they may be more open to cognitive restructuring—in particular, to considering how their lives would be different without insomnia. Not everyone will embrace the possibility.
“If every failure in their entire life is due to insomnia, they are not going to give that up,” warned Dr. Stepanski. “Some personality disorder patients don't really want help.”
For insomniacs who do want better sleep, he recommended trying a variety of behavioral treatments, as there is no way to predict which would be the most beneficial to a particular patient. These include:
▸ Sleep hygiene education. For example, telling patients that they can't drink coffee before bedtime or nap 3 hours in the afternoon and then expect to sleep through the night.

Sleep hygiene alone is not very helpful, but can be useful when combined with other CBT techniques.

▸ Stimulus control therapy. The patient should only go to bed when sleepy and not use the bedroom for activities, such as television viewing or aerobic exercises, that are incompatible with sleep. If the patient can't sleep, he should get up and leave the bedroom. “If you force yourself to lie in bed wide awake, you are doing damage to yourself. [There's] nothing else to do but ruminate and catastrophize,” he said.
▸ Sleep restriction therapy. The goal is to use partial sleep deprivation to increase homeostatic sleep drive. Use a sleep log to reduce time in bed to the amount of time the patient actually sleeps. Five hours of good sleep is better than 8 hours of intermittent sleep, said Dr. Stepanski: “Excess time in bed is death to normal sleep.”

I have found that sleep restriction is a powerful behavioral method for treating insomnia. The basic concepts are rather simple, but it does take time to explain to the patient and get them to comply- many are hesitant to use this technique.

▸ Relaxation training. Examples include progressive muscle relaxation, guided imagery, biofeedback, and self-hypnosis.
As none of these techniques work quickly, Dr. Stepanski said practitioners should devote time early on to educating, reassuring, and encouraging patients—and preparing them for relapse. Patients “must understand the rationale for the treatment approach,” he said. “Sleep is a biological rhythm. It doesn't change right away.”
Medication works faster than CBT, but is not as effective, said Dr. Stepanski. Combining the two approaches can relieve panic about sleep deprivation while giving CBT more time to work. Studies have shown, however, that CBT alone is more effective than CBT combined with medication.

Sleep deprivation and weight gain

Voluntary sleep deprivation has been shown to lead altered metabolic hormones and increased appetite. I have posted on this previously. Today, a newspaper article by Harry Jackson Jr. discusses this topic:

Sleep and insulin choreograph the dance between leptin, which tells the brain there's no need for food, and ghrelin, which tells the brain it's chow time.
Poor sleep, researchers learned, causes the dancers to start tripping over one another.
Here's what happened: The test subjects slept only four hours a night rather than eight. In only two nights, the hormones malfunctioned.
Leptin production decreased by 18 percent; ghrelin production increased by 28 percent.
On top of that, the test subjects - healthy, young, male college students - started eating like they were at a frat party. They reported craving more high-calorie, high-density, high-carbohydrate foods - including a 24 percent increase in appetite for candy, cookies, chips, nuts and starchy foods such as bread and pasta.
A week into the experiment, blood tests showed an inability to use insulin so intense that it mimicked diabetes. Also, lack of sleep increased the production of cortisol, a hormone associated with increased belly fat.
The researchers concluded that sleep starvation boosted appetite; increased appetite caused overeating; overeating caused weight gain. Weight gain causes obesity.

This short-term study suggests that voluntary sleep deprivation can contribute to obesity. Epidemiological studies have found a relationship between decreased sleep time (which can be caused by either insomnia or voluntary sleep deprivation) and weight gain.

It has been hypothesized (but not proven) that the sleep disruption produced by obstructive sleep apnea causes weight gain:
Once you're obese, you're more prone to sleep apnea, the collapse of the upper windpipe which interrupts breathing during sleep. That's the vicious circle: sleep apnea can help cause obesity, and obesity can cause sleep apnea.

Book Review of Sleep Disorders and Neurologic Diseases, 2e

NEW REVIEW -- CULEBRAS/Sleep Disorders and Neurologic Diseases, 2nd Edition
informa Healthcare/Taylor & Francis, 2007, $229.95

[AUTHOR]
Culebras, Antonio, MD

[BIBLIOGRAPHIC DATA]
ISBN: 978-0-8493-4324-7, Series Title: Sleep Disorders, v. 2, 432 pages, hard
cover.

[DOODY'S NOTES]


[REVIEWER'S EXPERT OPINION]
Regina Lopez, MD(Rush University Medical Center)

**Description**
This book examines the neurology of sleep and sleep disorders in neurologic
diseases. New sections in this edition cover topics such as the
hypocretin-hypothalamic system, sleep disorders associated with mental
retardation, and autonomic dysfunctions in sleep disorders. The previous
edition was published in 2000.

**Purpose**
According to the editor, the book's purpose is to serve as a reference for those
who practice sleep medicine and encounter neurological pathology. It also
provides specialized information for the non-neurologist. These are worthy
objectives given the increased interest and research in the field of sleep
medicine.

**Audience**
The author's targeted audience includes those specialists who practice sleep
medicine and manage those with neuropathology. In addition, the book is written
for both neurologists and non-neurologists dealing with patients with sleep
disorders. The book is least relevant for the non-neurologist, because it is
written with the assumption that the reader has a decent knowledge base in
sleep medicine and neurologic diseases. The contributors are international
experts in sleep and its disorders.

**Features**
Most chapters cover the epidemiology, clinical features, pathophysiology,
diagnosis, and management of a specific disorder or group of disorders.
Historical perspectives and clinical cases are used in some chapters. Although
multiple polysomnographic recordings are incorporated as examples, the quality
is not great in some. Overall, the figures tend to be too small.

**Assessment**
This is a worthy contribution to the field that thoroughly and understandably
covers the interface between sleep disorders and neurologic diseases. The
extensive literature referenced is both up-to-date and relevant. As a
non-neurologist, I recommend this book to those who already have a basic
understanding of the subject and want to learn more about it.

-----------------------------------------------------------

Weighted Numerical Score: 85 - 3 Stars

I highly recommend this book, especially for those interested in the interface between sleep medicine and neurologic disease.

AASM Site Visitor Opportunity

The American Academy of Sleep Medicine is now accepting applications for an AASM Accreditation Site Visitor to perform accreditation duties as an independent contractor of the AASM. The Accreditation Site Visitor performs all professional aspects of the sleep center accreditation process, including review of applications, performance of site visits, writing of reports, and review of responses to provisos. The AASM Site Visitor will be expected to travel and conduct a minimum of 25 site visits per year. An applicant should be a board-certified sleep specialist and, currently or in the past, served as the Medical Director/Director of an AASM-accredited sleep center. Contact the Accreditation Department at (708) 273-9325 or accreditation@aasmnet.org with a letter of interest and CV.

I have been a site visitor for the last 4 months. It's a good opportunity to examine different polysomnographic systems and see how things are done in other parts of the country.
Elgible sleep specialists are encouraged to apply.

Sleep Problems are Common in Primary Care Patients

A study recently published in the Journal of the American Board of Family Medicine found that over one-third of adults who visit a primary care practice have sleep problems.
As summarized by the American College of Physicians:

34% woke up at least three times a night
14% had symptoms of sleep apnea
28% had symptoms of restless legs syndrome at least weekly
55% felt sleepy at least once a week during daily activities
37% dozed off at least once a week during daily activities
33% snored loudly at least once a week

Not all of the complaints could be attributed to specific sleep disorders such as obstructive sleep apnea or restless leg syndrome. Pain was a common cause of sleep disturbance. However, it is often difficult to tell if pain alone is causing the sleep disturbance:

Chronic back pain, arthritis, and joint pain and stiffness were associated with all of the sleep complaints studied. This finding is consistent with clinical research indicating the connection between pain and sleep disturbance21; however, in these analyses, it is impossible to determine which preceded or caused the other.22 Our analyses also identified increased risk of OSAS in patients with musculoskeletal pain. The cause of this relationship is unclear, but it can be postulated that disability and medications (especially opioids) may contribute to sleep apnea. RLS symptoms were also significant in patients with pain, a finding that mirrors others in the literature.23 Thus, a plan that addresses the sleep complaints as well as the pain can optimize the treatment of pain and improve quality of life.

Sleep disturbance is common in primary care patients. In many cases, the primary care physican can evaluate and treat the problem. In difficult cases, or when sleep apnea is suspected, referral to a sleep specialist is indicated.

Narcoleptic dogs

Here is a nice video of cataplexy in dogs (via National Sleep Foundation/Dr. Mignot):

http://www.youtube.com/watch?v=tOAvWbspeSQ&tr=y&auid=2815016

Narcolepsy is a sleep disorder that affects about 1 in 2,000 people in the U.S., but did you know that it also occurs in animals? Courtesy of the Center for Narcolepsy at Stanford School of Medicine, NSF has published footage on YouTube of narcoleptic episodes in dogs with a narration by Dr. Emmanuel Mignot. Watch it now!

SleepEducation.com

Check out the American Academy of Sleep Medicine's website for patients, SleepEducation.com.

Mississippi Sleep Society Meeting

You're invited

The Mississippi Sleep Society will be meeting for lunch at the Steam Room Grille
Interstate 55N Jackson, MS

Monday July 2, 2007
11:30- 1:00

This is a formative meeting for this new organization. All those involved in Sleep Medicine and especially sleep technicians are encouraged to attend.

Lunch is provided.

No Games Here

This blog has been tagged with a meme. For my response, please see:

http://rebeldoctor.blogspot.com/2007/06/8-random-facts-meme.html

Sleep Myths

From MSN:
Do we really need eight hours of sleep per night?
Not necessarily, but that’s the average for healthy adults. According to the National Institutes of Health, when healthy adults are given unlimited opportunity to sleep they are on the pillow eight to eight-and-a-half hours a night. Most sleep experts recommend between seven and nine hours to be at one’s optimum performance mentally and physically.
Do naps help?
If we really believed that life’s most valuable lessons were learned in kindergarten, we’d all be eating more cookies and taking more naps. Our grown-up culture generally frowns on the notion of daytime sleeping, but 15 or 20 minutes of shut-eye can help make up for a sleepless night and provide a freshness and clarity that seldom comes in the last few hours at work. Resting too long or too late in the day, however, can defeat the benefits by leaving the catnapper groggy in the afternoon and sleepless again at night.

Circadian Rhythms

USAToday has a nice article today about circadian rhythms, with the final part of the article focusing on the possible role of circadian rhythm disturbance in bipolar disorder:

In people, circadian rhythm disorders can trigger serious problems, notably depression. Seasonally affective disorder is a winter depression tied to a lack of the sunlight cues that trigger the SCN into proper rhythm.
Also, there are indications that bipolar disorder also involves circadian problems, McClung says. This disorder causes unusual shifts in mood and energy, with episodes varying between extremes and afflicting some 5.7 million people nationwide, according to the National Institute of Mental Health. "People might sleep all the time or not sleep at all," says McClung. Body temperatures and hormone levels similarly race, all pointing to a body clock with its springs missing.
At the Cold Harbor conference, McClung presented a mouse engineered to lack a specific clock gene which "looks as close to a bipolar person in a manic state as we can determine in a mouse," she says. The manic mice are hyperactive, sleep little, disregard signs of predators and voraciously consume cocaine.
For medical research, the most intriguing thing about the manic mice is that lithium, which human bipolar patients take to treat their illness, cuts their symptoms. "We don't know why lithium works, and we hope the mouse gives us an opportunity to explore its mechanism," McClung says.
Opening up the mechanism by which clock genes work, or don't work, is the task before scientists today, McClung adds. "Everyone on this planet has a 24-hour internal clock, and it is deeply ingrained in our biology," she says. "If we lived on a different planet, we'd have a different rhythm — that's how fundamental they are."

Another Sleep Blog

At the Annual Sleep Meeting in Minneapolis last week, I met the executive director of the American Sleep Apnea Association. Here is his blog.

Sleep Apnea and Pregnancy

Sleep Review reports on the adverse effects of sleep apnea during pregnancy:


A study presented last month at the American Thoracic Society 2007 International Conference in San Francisco found that even when controlling for obesity, sleep apnea in the mother increased the risk that diabetes and/or hypertension would develop during the pregnancy.



When the women’s weight was taken into account, sleep apnea was associated with a doubling of the incidence of gestational diabetes and a fourfold increase in the risk of pregnancy-induced hypertension, which includes eclampsia and preeclampsia.

rest of sleep review quote deleted at their request

Treating sleep apnea has reduced the risk of diabetes and hypertension in non-pregnant women, so now research is needed to confirm if this is also true for pregnant women.


There are few studies examining sleep apnea during pregnancy. This study was a large database review; it is very difficult to do a clinical trial involving pregnant women. It would be interesting to perform a controlled trial to see if CPAP improves pregnancy outcomes in women with sleep apnea, but such a trial would never be approved by an IRB board.

Adjusting to Sleep Deprivation

A reader asks:
As a fan of your blog, I had a quick question that I was hoping I could get your advice on. I’m a 20 year old male, living in Australia where it’s currently a Wednesday night. On Saturday night I will be attending the final session of a fitness and self protection course I signed up to at college. According to friends of mine who had done the course before, the final session is akin to basic training for army recruits! (Here’s where you come in)

I’ve been told by friends that practically from Saturday night to Sunday lunch time they deprive you of sleep and run you through non stop intense fitness exercises like running, push-ups, sit-ups etc.

What I was thinking of doing was perhaps changing my sleeping pattern so my body will effectively not be missing out on sleep. Let’s say I stayed up tomorrow night (Thursday night), slept all of Friday, stayed up all Friday night, and slept all Saturday - come Saturday night my body will expect to be awake and it won’t be as gruelling – right? Would this be effective? Is this enough time for my body to adjust or would I just be making things worse?
It's too short of a time for you to adjust your biological clock- the body is only capable of adjusting 1 hr each day. You are essentially facing 2 problems- 1) sleep deprivation and 2) circadian rhythm dysfunction (you will be expected to be active during a time when your body expects you to be asleep).
I recommend that you keep your normal sleep schedule and then try to take a 2-3 hour nap right before your final course begins. If allowed during your course, caffeine and Provigil would be helpful. Bright light exposure during your course, if possible, would also be helpful.
Hope this helps
Michael Rack, MD

Another Sleep Blog

Check out Dr. Poceta's blog, Sleep Expert.

Treatment of Alcohol-related sleep disorders

The following is from an article I wrote for Medlink Neurology on "Sleep disorders associated with alcohol use and abuse." It is copyrighted by Medlink Neurology:

For the sleep disorders occurring during alcohol intake, cessation of alcohol use is often the only necessary treatment. Treatment of the sleep apnea exacerbated by alcohol requires avoidance of alcohol intake at least for 4 hours to 6 hours before going to bed. If the apnea does not resolve with alcohol cessation, then standard treatments for obstructive sleep apnea, such as nasal continuous positive airway pressure, are required. The hypersomnia that can occur with alcohol use is usually eliminated after 1 day or 2 days without alcohol, but insomnia may actually worsen for the first 2 weeks to 7 weeks off alcohol. It is important not to restart the alcohol even at a low dose to ameliorate this problem; similarly, use of hypnotics is contraindicated because of the cross-tolerance with alcohol and the potential for both abuse and dependence. Sedating antihistamines or low doses of sedating antidepressants can be used for temporary relief when insomnia episodes are particularly severe. Patients should be reassured that in most cases the insomnia gradually gets better.
Behavioral treatments for insomnia with good sleep hygiene, relaxation training, desensitization, or sleep restriction should be used during the withdrawal period. If evidence develops for depression then a sedating antidepressant (eg, amitriptyline or mirtazapine) may be helpful for both sleep and depression.
As mentioned above, sleep abnormalities in alcoholics can persist for several years after alcohol cessation; this sleep disturbance may contribute to relapse of alcoholism. Various medications and psychotherapy techniques have been used to treat this sleep disturbance. Gabapentin, at doses of 300 mg to 1800 mg at bedtime, is useful in treating insomnia in abstinent alcohol-dependent outpatients and appears to be more effective than trazodone (Karam-Hage and Brower 2003). Although quetiapine is of potential benefit for this condition (Monnelly et al 2004; Sattar et al 2004), the risk of tardive dyskinesia and metabolic abnormalities associated with the use of atypical antipsychotics suggests that they should be used cautiously, if at all, for insomnia. Cognitive-behavioral treatments, including stimulus control, sleep restriction, and cognitive restructuring, have been shown to improve subjective sleep quality in recovering alcoholics (Currie et al 2004).
The melatonin receptor agonist Ramelteon (Rozerem-Takeda) is an option for treating insomnia in recovering alcoholics, though controlled trials are lacking. Ramelteon is not a controlled substance, and has essentially no abuse liability (Anonymous 2005; Griffiths and Johnson 2005). It is approved for the treatment of insomnia characterized by difficulty with sleep onset (Laustsen and Andersen 2006). The standard dose is 8 mg, taken within 30 minutes of going to bed. It is metabolized by cytochrome p450 enzyme 1A2 but does not appear to inhibit or induce this enzyme (Laustsen and Andersen 2006). It should not be used in combination with fluvoxamine, a strong 1A2 inhibitor (Takeda Pharmaceuticals 2005).
Acamprosate (Campral- Forest Pharmaceuticals) is a glutamate modulator that is FDA-approved for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation (Forest Pharmaceuticals 2005). A recent parallel double-blind placebo-controlled study found that acamprosate improved sleep quality during early abstinence (Staner et al 2006).
disclaimer: this is not the final edited version that will appear in Medlink Neurology. I encourage you to check out the website for Medlink Neurology for the full version of this article as well as numerous other articles about sleep (a few written by me).

I don't know much about beds

Occasionally a patient will complain about their mattress or ask me what type of matress I recommend.
I don't have a clue. Mattresses were not covered in medical school, residency, or fellowship.
A good, comfortable mattress is probably important for sleep-but my patients are better off asking a matress salesman than me. If you live in Mississippi, you might want to try Miskellys

idiopathic hypersomnia

A reader (Claire) asks: "However he has been unable to diagnose or treat my particular sleep problem and I can find no info anywhere that describes my particular symptoms.I find so much research has been done in some areas but not enough in others in regards to sleep.My problem; I sleep if allowed 10hours a day but am constantly tired. 2 afternoon naps not unusual, but I don’t fall asleep randomly..."
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If a sleep study (polysomnogram) is negative, you may have idiopathic hypersomnia. Consider asking your primary care doctor for a referral to a sleep specialist.

REM-related obstructive sleep apnea

A reader (Franto) asks "Sorry to butt in with this question for you! I had a recent sleep study that showed I am getting v little REM sleep because I start getting hypopneic as soon as I enter into REM and have an arousal. Overall there was little obstruction and no apnea (lowest O2 sat was 91%). The problem was entirely REM specific, and I had good deep sleep. My total REM percentage was only 6.5%. There apparently were several aborted REM episodes. The reason I had the study done was that I have been having unrefreshing sleep and working memory issues for a few years now! My sleep physician wants me to do CPAP study to see if it helps improve my REM. My Q to you is if you see cases like mine at all, since I havent read about such a selective REM condition on the web or Pubmed. I know about UARS but that too involves both REM and NREM. Would CPAP help in such a situation?"
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Some people have OSA primarily during REM sleep. I found the following in Sleep Medicine Pearls, by Richard B. Berry, MD (2nd edition, page 118):
In patients with excessive daytime sleepiness and significant, REM-specific sleep apnea, treatment is indicated. Other possible causes of daytime sleepiness should be excluded.
The reason for the higher AHI during REM sleep are commplex. REM sleep is not homogenous, and episodes of decreased upper airway muscle activity or ventilatory drive may be the cause of hypopneas or apneas during REM sleep.
In my experience, in many people, OSA is worse during REM sleep. It is unusual for sleep apnea to occur exclusively during REM, but it is possible. I think your sleep physician's advice is reasonable and CPAP is worth a try.