The life of a sleep doctor

I have answered 20 questions about the life of a sleep physician for the Student Doctor Network.
Here is a sample question and answer:
What is the best way to prepare for this specialty?
Sleep medicine is a one year fellowship after a psychiatry, neurology, ENT, family practice, pediatrics, or internal medicine residency. The best way to prepare is to do one or two sleep medicine elective months during residency. Sleep medicine is becoming a more competitive fellowship, and it is hard for someone who has only completed an internal medicine residency to get- general internists are competing with pulmonary specialists for slots. If a resident is trying to go straight from internal medicine residency to sleep fellowship (rather than doing a pulmonary fellowship first), some sleep research during residency would be helpful.
Read more here.

Treatment of Posttraumatic Sleep Disturbances

Sleep disturbance is common after head injury. Here is part of an article I wrote on posttraumatic sleep disturbance:

Patients with narcolepsy secondary to a head injury or posttraumatic hypersomnia often require stimulant medication such as methylphenidate or amphetamines in doses similar to those for idiopathic narcolepsy-cataplexy syndrome. Modafinil may be the medication of first intention; it has fewer side-effects overall than the other stimulants. The dosage is usually 300 to 400 mg, administered in 2 divided doses in the morning and at lunch time. Modafinil, however, activates hypothalamic regions and does not act directly through dopaminergic or noradrenergic pathways; and patients with severe head trauma who complain of intellectual slowness may benefit more from amphetamine-like medications. These medications will have a general “activating” effect that is not solely devoted to sleepiness. Of course, any coexistent sleep pathology or neurologic disease requires independent management. The potential beneficial effects of naps have not been studied; they should probably be restricted to less than 30 minutes to avoid significant sleep inertia effects. They should be taken when the patient feels sleepiest but not within 4 or 5 hours of habitual nocturnal sleep time.
Cases of sleep apnea resulting from a head injury are treated in the usual manner with continuous or bilevel positive airway pressure therapy. Sometimes the spontaneous/timed mode of bilevel positive airway pressure therapy is necessary for central sleep apnea and mixed obstructive/central sleep apnea. Adaptive-servo ventilation has recently become available to treat central and mixed sleep apnea, but experience in non-heart failure patients is limited. Treatment of sleep apnea should be conducted by a sleep disorders specialist. Posttraumatic organic insomnia has generally proven difficult to treat. Patients respond rather poorly to the benzodiazepine hypnotics employed to help initiate and maintain sleep. Cognitive behavioral therapy, including stimulus control, sleep restriction, cognitive restructuring, sleep hygiene education, and fatigue management, can improve nocturnal sleep quality as well as reduce daytime fatigue (Ouellet and Morin 2007

You can read more at Medlink Neurology

Cell Phones and Sleep

A new study suggests that mobile phones interfere with sleep:
By Geoffrey Lean, Environment Editor
Published: 20 January 2008
Radiation from mobile phones delays and reduces sleep, and causes headaches and confusion, according to a new study.
The research, sponsored by the mobile phone companies themselves, shows that using the handsets before bed causes people to take longer to reach the deeper stages of sleep and to spend less time in them, interfering with the body's ability to repair damage suffered during the day.
The scientists studied 35 men and 36 women aged between 18 and 45. Some were exposed to radiation that exactly mimicked what is received when using mobile phones; others were placed in precisely the same conditions, but given only "sham" exposure, receiving no radiation at all.
The people who had received the radiation took longer to enter the first of the deeper stages of sleep, and spent less time in the deepest one. The scientists concluded: "The study indicates that during laboratory exposure to 884 MHz wireless signals components of sleep believed to be important for recovery from daily wear and tear are adversely affected."
The embarrassed Mobile Manufacturers Forum played down the results, insisting – at apparent variance with this published conclusion – that its "results were inconclusive" and that "the researchers did not claim that exposure caused sleep disturbance".
But Professor Bengt Arnetz, who led the study, says: "We did find an effect from mobile phones from exposure scenarios that were realistic. This suggests that they have measurable effects on the brain."

My Official Comment on Home Testing

Although several posts ago I stated that I was not going to comment on home testing for osa at the official CMS comment site, I changed my mind. Here is what I posted a few minutes ago:

Comment: I am against home testing for osa, but if home testing is to be implemented, allow me to make the following suggestions:
1. DME companies should not be allowed to provide home testing, due to the conflict of interest in providing a qualifying test for a product the DME company provides.
2. Any licensed physician should be able to provide home testing for osa. I am not aware of any precedent limiting a diagnostic test to a particular specialty, and I do not believe that limiting a safe test such as portable monitoring for osa to sleep specialists is justified.
3. Related to point #2, home testing should NOT be limited to sleep labs. One of the main rationales of home testing for osa is to expand diagnosis of osa to areas/populations currently not being served by sleep labs, and limiting home testing to sleep labs would defeat this purpose.

I am against home testing for osa. With the rapidly expanding number of sleep labs, I think that most of the US is now within convenient location of a sleep lab, and I don''t see the need for a test that is inferior to in-lab polysomnography. However, now that the American Academy of Sleep Medicine has signed off on home testing, I don''t see any point in arguing further against it, and hope that you will consider my suggestions for implementing home testing.

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Resmed Consultant Behind Home Testing Movement

Sleep Well and Live has an interesting post today about the movement for home osa testing and its originator:
At the 2004 Annual Meeting of the American Academy of Otolaryngology - Head and Neck Surgery Foundation in New York, Terence Davidson, an Otolaryngologist (ENT) and Dean of Continuing Education at the University of California, San Diego, was invited to give a “mini seminar” entitled “Thinking of Opening a Sleep Lab?” Dr. Davidson could also be called the “father” of the current attempt to get Medicare to approve unattended home testing for sleep apnea. It was his Jan. 29, 2004 letter to the Centers for Medicare and Medicaid Services (CMS) that argued that the current policy is inhibiting the diagnosis of obstructive sleep apnea (OSA) because the nation’s 692 sleep labs are simply too full.

During Dr. Davidson’s presentation in New York, he had some interesting opinions and comments and also seemed to have some conflicts of interest and an astounding degree of arrogance towards the Sleep Medicine and Pulmonary Medicine professions.
Although he has claimed to have no conflicts of interest, Dr. Davidson is on the Medical Advisory Board of Directors of ResMed, Inc. as a paid consultant. ResMed and their auto titration CPAP units stand to benefit substantially from gaining Medicare’s approval of in-home, unattended testing.
As to Dr. Davidson’s assertion that the current policy for our Medicare population is inhibiting the diagnosis of OSA because the nation’s sleep labs are simply too full, recent data from the American Academy of Sleep Medicine states that the availability of sleep laboratories across the United States based on a 2001 study of 2001 data estimates that 427 PSG were performed per year per 100,000 population. (5) Since 2001, the number of sleep laboratories accredited by the AASM has more than doubled to 1,169, with 129 applications having been received in just the first three months of 2007, alone.
In a 2004 AASM survey, there was an average wait of about three weeks for a sleep study or sleep consultation. An independent survey in 2004 by Shariq estimated there were more than 2,500 accredited and non-accredited sleep laboratories in the US with an average wait time for a PSG between two and three weeks.
I encourage you to read the full post.

osa home testing hits the mainstream media

This is the first news article I've seen about home testing for osa outside of an industry publication:
Last month, the American Academy of Sleep Medicine, which represents sleep centers, changed its position to say home tests can help certain high-risk patients - but should be administered by sleep specialists.Medicare's proposal wouldn't limit which doctors offer home tests. The American Academy of Otolaryngology, head-and-neck surgeons, requested the change.
There are some inaccuracies in the article, like this statement:
In fact, Medicare concluded a sleep-lab test isn't perfect, either - and thus proposed that all patients get a 12-week trial of CPAP treatment. Only if their doctors certify they're being helped would treatment continue.

Why I am not commenting (officially) on Home Testing

On the AASM discussion forum (open to members only), some have been advocating that sleep physicians comment on the CMS (Medicare) website either 1) in oppostion to home testing for osa or 2) to request that home testing be limited to certain devices or to AASM accredited sleep labs. I posted this on the AASM discussion forum a few minutes ago:

I am not going to comment on the CMS website comment section because:
1. Home testing is inevitable. How can a sleep physician argue against home testing when industry publications, such as Sleep Review Magazine, have "AASM Approves Home Sleep Testing to Detect Sleep Apnea" as one of their headlines.
2. Some have argued that sleep physicians should try to limit home testing to type 3 devices, as opposed to type 4. This would make very little economic difference to sleep centers. Frankly, if home testing is going to be a reality, I would like the freedom to pick the device that I, as a sleep professional, felt was most appropriate for the situation. For example, home oximetry could be useful for triaging patients to psg vs split-night study. Here is a study from the JCSM that supports the use of the ApneaLink, a single channel recording device: http://www.aasmnet.org/jcsm/Articles/030409.pdf
3. Some have argued that home testing should be limited to AASM-accredited labs. As an accreditation site visitor for nearly a year, it is my understanding that AASM accreditation was always meant to be voluntary, and that the AASM's position was that it did not promote accreditation status as being necessary for insurance reimbursement. The AASM is not a government agency! I don't think that the AASM should have the power to determine which sleep labs are elgible for government (Medicare) reimbursement. Michael Rack, MD

sleep and diabetes

The evidence continues to grow linking poor sleep to diabetes:
WASHINGTON (Dec. 31) - When Shakespeare called sleep the "chief nourisher of life's feast," he may have been well ahead of his time, medically at least. Researchers at the University of Chicago Medical Center report that disrupting sleep damages the body's ability to regulate blood sugar levels, potentially raising the risk of developing type 2 diabetes.More than 18 million Americans have diabetes and the most common form is type 2, in which the body either becomes resistant to insulin or doesn't produce enough of it to regulate sugar in the bloodstream.In a small experiment, researchers led by Dr. Esra Tasali, an assistant professor of medicine, found that disrupting the deepest sleep periods of volunteers rapidly resulted in reduction in their ability to regulate blood-sugar levels.The findings are reported in Monday's online edition of Proceedings of the National Academy of Sciences.The researchers studied the sleep patterns of nine volunteers, five men and four women, all of normal weight, in good health and aged 20 to 31.Normal sleep is divided into several stages, with the so-called slow-wave sleep considered the deepest.Whenever the volunteers went into slow-wave sleep the researchers made noise — enough to disturb the sleep though not to fully awaken them.After just three days the ability of the volunteers to regulate blood sugar was reduced by 25 percent, the researchers reported.Earlier studies have indicated that lack of sleep can reduce the ability to regulate sugar, and this report adds evidence that poor sleep quality is also a diabetes risk."This decrease in slow-wave sleep resembles the changes in sleep patterns caused by 40 years of aging," Tasali said in a statement. Young adults spend 80 to 100 minutes per night in slow-wave sleep, while people over age 60 generally have less than 20 minutes. "In this experiment," she said, "we gave people in their 20s the sleep of those in their 60s.""Since reduced amounts of deep sleep are typical of aging and of common obesity-related sleep disorders, such as obstructive sleep apnea, these results suggest that strategies to improve sleep quality, as well as quantity, may help to prevent or delay the onset of type 2 diabetes in populations at risk," said co-author Dr. Eve Van Cauter, a professor of medicine.

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.