Tuesday, September 25, 2007
Read about Insomnia at MySleepCentral.com
I am now a blogger for MySleepCentral.com. Read my latest post about Insomnia, here.
Friday, September 21, 2007
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.
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.
Thursday, September 20, 2007
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
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
Saturday, September 15, 2007
Wednesday, September 12, 2007
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.
-----------------------------------
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.
--------------------------------
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.
--------------
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.
===============
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.
-----------------------------------
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.
--------------------------------
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.
--------------
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.
Thursday, September 06, 2007
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
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
Sunday, September 02, 2007
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.
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.
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.
Wednesday, August 22, 2007
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.
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.
Friday, July 20, 2007
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.
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.
Tuesday, July 17, 2007
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.
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.
Tuesday, July 03, 2007
Narcoleptic dogs
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!
Sunday, July 01, 2007
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.
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.
Sunday, June 24, 2007
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
http://rebeldoctor.blogspot.com/2007/06/8-random-facts-meme.html
Wednesday, June 20, 2007
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.
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.
Tuesday, June 19, 2007
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."
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.
Thursday, June 07, 2007
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.
Wednesday, June 06, 2007
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
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
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