Sleep and Health

Parsimony in Somnology?

2010-09-18T09:29:00.000-07:00

Even more interestingly, OSA diagnosis, characterized by ODI - as detected using the oximeter and, by AHI - as detected using the flow transducer - was no different.

Most morbidity - cardiovascular and metabolic- in sleep apnea is believed to be related primarily to the burden of intermittent hypoxia. Use of single channel recorders to detect reductions in flow with or without concomitant oximetry has gained credence as a method of screening or possible even diagnosing sleep apnea in appropriately selected high-risk patients or patients with high pre-test probability for OSA.
The question arises - does nasal airflow measurements add significantly more to a simpler and more cost-effective continuous nocturnal oximetry recording with a finger oximeter.

A study from Australia seems to have an answer. About 100 patients had laboratory PSG, and 2 sets of 3 consecutive nights on each device; nasal airflow and oximetry at home in random order.

Measurements of nasal airflow had high accuracy when compared to lab based PSG for not only severe OSA (AUC 0.92) but also any OSA (AUC 0.87)!

Cost to diagnose by the three modalities would be $1500:$500:$50.
Cost to diagnose per 1,00,000 general population assuming a 10% testing rate in order to diagnose 6% of the disease -$15 milion; $5 million; $0.5 million

The results are intriguing and add to the (slowly) growing body of literature that support a parsimonious approach to a diagnosis of sleep apnea is feasible.

Cat-ch a Nap

2010-08-30T08:18:00.000-07:00

http://www.businessweek.com/magazine/content/10_36/b4193084949626.htm?chan=magazine+channel_etc.

Behavior August 26, 2010, 5:00PM EST text size: T T

Napping Gets a Nod at the Workplace

A growing number of companies are encouraging employees to snooze at work—and boost their productivity

From Thomas Edison and Winston Churchill to Bill Clinton and George Costanza, the nap has had many famous champions. And with good reason. Ever since sleep scientist David Dinges helped found the modern science of napping in the early '80s at the University of Pennsylvania School of Medicine, short periods of sleep have been shown to improve alertness, memory, motor skills, decision-making, and mood. All while cutting down on stress, carelessness, and even heart disease.
With Americans averaging fewer than seven hours of sleep per night—and around 20 percent suffering from sleepiness during the day, according to a recent Stanford University study—many companies have turned to the humble nap in an attempt to stave off billions in lost productivity each year. Following the rise of workplace perks like lactation rooms, gyms, and child-care facilities, Nike (NKE) workers now have access to nap-friendly "quiet rooms" that can also be used for meditation. Google (GOOG), a forerunner in employee perks, has a number of futuristic napping pods scattered throughout its Mountain View (Calif.) campus.

Jawa, a small mobile technology company in Scottsdale, Ariz., has two resting rooms—one with a similar pod, the other with an old-fashioned couch—that are popular among programmers working long hours. Many airlines, including Continental (CAL) and British Airways, allow pilots to sleep during long international flights while colleagues take over the controls. (The practice is prohibited for domestic flights by the Federal Aviation Administration.) Other companies, such as Ben & Jerry's, have no official policy but provide unofficial space for the practice and don't bat an eye when someone spends an extra half hour snoozing in the massage room. "If you have employees working 16-hour days, you want to give them an opportunity to take a power nap," says Melissa Gierginger, a spokeswoman for Jawa.
Other companies have opted to outsource their daytime sleeping solutions. Yelo, a napping spa in midtown Manhattan, has provided its services to Hearst, Newsweek, and Time Warner (TWX). It offers naps in a "cocoon-like" treatment room in which clients can adjust aromatherapy, sound, and lighting. A 20-minute nap goes for $15. (A half-hour "Nap Plus"—including a 10-minute foot rub—costs $40.)
"Over the last few years, there's been a lot of focus on exercise and nutrition, but adequate sleep is arguably the most important element of productivity," says Christopher Lindholst, co-founder of MetroNaps, which markets a napping chair called the EnergyPod to such companies as Google, Procter & Gamble (PG), and Cisco Systems (CSCO). The EnergyPod, which looks like Pacman with a really long tongue, boasts ergonomic support and a built-in music system with a headphone jack to eliminate background noise. "The EnergyPod is designed to provide some privacy, but it's typically installed in a common area so you create an environment of awareness and acceptance," says Lindholst. MetroNaps rents its EnergyPod for $795 per month.
"Tiny naps are much more refreshing than people tend to realize," said Jim Horne, director of the Sleep Research Centre at Loughborough University in England. "A short nap in the afternoon will get rid of sleepiness without interfering with nighttime sleep." That said, it's best not to depend on napping as a permanent replacement for lost sleep. "On occasion it will get you over the hump, but whether it gets you back to peak is an open question," says Dr. Roger Rosa, a senior scientist at the National Institute for Occupational Safety and Health. "If you've lost an hour of your previous night's sleep, a nap may be just the ticket. If you've been up all night, it may give you a hangover effect" known as "sleep inertia."
According to Dr. Sara Mednick, a professor of psychiatry at the University of California at San Diego, not all naps are created equal. Mednick believes that naps weighted toward different stages of the sleep cycle confer different benefits. "If you do physical labor, you need more Stage 2 sleep," says Mednick. "If you are doing memorization or verbal work, you need more slow-wave sleep. And if you do creative or visual work, you need more REM sleep."
Dr. Mednick has devised an "Optimized Napping Formula" so ambitious nappers can maximize the desired phase of sleep. Napping newbies can purchase a device called Zeo ($199), which promises to track your sleep cycles for you via your brainwaves with a special headband. Those looking for a simpler contraption might prefer the Dream Helmet ($29.95), which serves as mask, pillow, and earplugs all at once.
Some researchers are skeptical about efforts to cultivate a given phase of sleep. "On a practical level, all a person can choose is how long they sleep," says Dr. Rosa. "You can't change the pace of the sleep cycle without sleep deprivation, which would be counterproductive." A strict dozing regimen, such as the kind employed by sailboat racers, military pilots, and astronauts, can replace nocturnal sleep altogether for a limited time. Leonardo da Vinci experimented with erratic sleep schedules, but it wasn't until the early 1980s that Italian researcher Claudio Stampi invented "polyphasic ultrashort sleep," which breaks up the day into several equal sections, each of which ends with a brief nap. As long as these mini "days" are kept intact, one can then whittle the naps down to as little as two hours of sleep per 24 hours—at least according to research published in Stampi's 1992 book, Why We Nap.
Such daring sleep habits are not for everybody. "Going ultrashort is like running a marathon or climbing Mount Everest," writes Dr. Mednick in her book, Take a Nap! Change Your Life. "You need careful training and a generous period of recovery." However, the simple "productivity nap" does hold an undeniable appeal for time-crunched workers. Most sleep experts welcome the consequent uptick in nap-friendliness at work, though some are leery of its unintended consequences. "It can get out of hand: If you start encouraging the workforce to sleep in the afternoon, you're encouraging them to have late nights," says Horne. "Our society is getting more used to napping in the workplace, but it is still seen as something that could get you fired."

DO'S AND DON'TS OF DOZING

Napping at work has become acceptable at some companies. Yet pulling off a "productivity nap" at the office isn't easy. Here are suggestions from sleep scientist Dr. Sara Mednick, author of Take a Nap! Change Your Life.
1. Make time and space
Twenty to 30 minutes is all you need to reap the rewards of midday slumber. The best time is the early afternoon when your body is tired—so consider reserving the second half of your lunch break for shut-eye. If your employer doesn't have a nap room, a yoga mat beats a bathroom stall, though the most comfortable option may be a parked car.
2. Set the proper conditions
In the dark our brains produce more of the sleep-inducing hormone melatonin, so close the blinds, turn off the lights, and consider using a sleeping mask. Keep the temperature on the warmer side. If you must nap sitting up, use a travel pillow to avoid the dreaded "nap nod." And don't forget to turn off your cell phone.
3. Careful with the chemicals
Avoid caffeine for a few hours before a nap. The same goes for nicotine, diet pills, and antidepressants. Although alcohol makes it easier to nod off during the day, it interferes with sleep and should also be avoided. Refined sugars and carbs may keep you up, but meat, dairy, and some nuts have tryptophan, which our bodies break down into melatonin.

Can we tell if we are sleepy?

2010-08-23T07:05:00.000-07:00

A sleepy state is similar to being under the influence of alcohol - our attention span is limited and our ability to respond and react and make critical decisions is impaired. While one knows one is drunk (hopefully), knowing whether one is sleepy is perhaps not so easy. A shift worker driving home after a night at work is putting himself at great risk if he drives without knowing how sleepy, or how likely to doze-off he or she is. The NHTSA conservatively estimates that 100,000 police-reported crashes are the direct result of driver fatigue each year.

A research study from Switzerland, shows just how hard this really is. A MWT is a test where a subject is asked to maintain wakefulness for a continuous period of 40minutes, while undergoing continuous recording of EEG and other parameters. They were told to give a signal as soon as they felt sleepy. The experiment was repeated by offering a monetary award if the subject was able to make a correct call.

As much as 61% of subjects were NOT able to identify sleep onset.

Interestingly women were more reliably aware of sleepiness than men. Even more interestingly, once the monetary reward $$ was introduced men improved their performance to match the women, although on the whole, the majority were still not able to predict their dozing off spells with any accuracy.

This shows that the general assumption that one cannot fall asleep without feeling sleepy first may not hold true. This has important safety as well as medico-legal implications. The state of New Jersey, for example, has enforced Maggies law - "driving a vehicle or vessel while knowingly fatigued shall constitute 'recklessness.'" Drivers are "fatigued" if they have gone for "more than 24 consecutive hours without sleep". Violation of the law, which applies to operators of boats as well as car drivers, is a second-degree crime and penalties can range as high as 10 years in prison and a $100,000 fine.

Tools to better identify drowsiness will go a long way in assisting public health measures aimed at curbing Deaths from Drowsy Driving.

Gulf War Illness : Sleep Apnea in Disguise?

2010-08-16T07:08:00.000-07:00

Persian Gulf War veterans from the 1990–1991 conflict have a higher prevalence of chronic multisymptom health problems than either nondeployed personnel or those deployed elsewhere. Termed the "Gulf War Illness " (also "Desert Storm Disease") the syndrome is characterized primarily by fatigue, short term memory loss, impaired cognition, depression, and musculoskeletal symptoms. Nearly a third of all personnel deployed to the Persian Gulf are estimated to be afflicted.

Inspiratory flow limitation reflects augmented upper airway resistance to breathing. In a small study involving 17 veterans with GWI researchers have shown inspiratory flow limitation to be almost universal in patients with GWI - 96% of them had evidence of flow limitation. The results are striking as the control group, with the same age and BMI, only had a 35% prevalence of these findings.

Does sleep apnea predispose individuals to this illness? Or is OSA play a key role in the pathogenesis of certain aspects of the syndrome? Can CPAP therapy provide therapeutic benefit in some/multiple domains related to GWI? We will all stay tuned to an ongoing clinical trial by the NIH (NCT00252629)

What is the moral of this story?

2010-08-10T09:47:00.000-07:00

We typically do not associate the capacity for righteous judgments and ethical decisions with our sleep. An new study from Norway has thrown up interesting data.

71 Naval and Army cadets were presented 5 dilemmas where-in they were asked to exercise their judgement in two scenarios - one with normal sleep for five nights, and one, after five sleep-deprived nights.

They found that "the officers’ ability to conduct mature and principally oriented moral reasoning was severely impaired during partial sleep deprivation compared to the rested state." Also, even more interestingly, those officers who displayed high levels of mature moral reasoning in the rested condition, lost much of this capacity during sleep deprivation whereas officers at low levels of mature moral reasoning in rested condition were unaffected by sleep deprivation.

One wonders if these findings might perhaps apply to the overall Commander-in-Chief - aka - The President - someone who is more sleep-deprived than any other military serviceman.

These findings are both novel and very thought-provoking. As a society we are getting increasingly sleep deprived. Is it cutting into our sense of ethical integrity as well?

e-sleep - an i-cure for shut-i?

2010-08-09T07:09:00.000-07:00

Insomnia is not only widespread but likely the most underrecognized and misstreated of medical conditions. The therapeutic potential of the world wide web is being untapped by researchers in the US and Canada.

In an interesting study 145 adults were randomly assigned to an Internet intervention (n = 22) or wait-list control group (n = 23). The Insomnia Severity Index and daily sleep diary data were used to determine changes in insomnia severity and the main sleep variables, including wake after sleep onset and sleep efficiency. Scores on the Insomnia Severity Index significantly improved from 15.73 to 6.59, and were unchanged in the control group. The Internet group maintained their gains at the 6-month follow-up. Internet participants also achieved significant decreases in wake after sleep onset (55%) and increases in sleep efficiency (16%)

The program itself -

The SHUTi program is based on CBT for insomnia. It can be conceptualized as 6 cores - The first core, overview, introduces the intervention and provides a rationale for treatment. There are 2 behavioral cores that incorporate sleep restriction and stimulus control, providing a set of rules to follow to regulate the sleep-wake schedule and strengthen the association between the bed or bedroom, bedtime, and sleep. The educational core (also called sleep hygiene) focuses on general education about sleep and improving sleep hygiene practices. The cognitive core (also called cognitive restructuring) attempts to address and change the unhelpful beliefs (eg, the absolute necessity for 8 hours of sleep) and thoughts (eg, worry about the consequences of insomnia) about sleep and insomnia that may exacerbate sleep difficulties. Finally, the last core, consolidation or relapse prevention, integrates the behavioral, educational, and cognitive elements, promotes adherence, generalizes the information, helps identify risk situations, and incorporates strategies to reduce relapse.

Another group from Manitoba, Canada, studied a large randomized controlled trial in 184 participants with insomnia. Online treatment produced statistically significant improvements in the primary end points of sleep quality (Wake After Sleep Onset was reduced from 70 minutes to 53 minutes), and insomnia severity (ISI scores decreased from 18 to 12). Online treatment also produced significant changes in process variables of pre-sleep cognitive arousal and dysfunctional beliefs about sleep.

The results are very encouraging and point to what is sure to be a trend in making creative use of web-based resources to positively impact short- and long-term health in a myriad of disease states. Sleep experts may do well to focus efforts on creating and evaluating processes whereby such treatments could be administered in a standardized and efficient and most importantly cost-effective manner.

Surgery for OSA - Not Palat-able

2010-08-05T07:59:00.000-07:00

The role of ENT surgery in Sleep Apnea therapy continues to evolve.

UPPP or "U-triple P" or uvulopharyngopalatoplasty has been the mainstay for surgical treatment of sleep apnea now for over three decades. Recently the Mayo Clinic described their "success" with this modality of treatment for OSA.
The group looked at their adult patients with OSA who underwent UPPP over the last two decades (between January 1, 1988, and August 31, 2006). Sixty-three patients (surprisingly small numbers over 2 decades?) were identified, 51 of them men. Surgical cure was defined as a postoperative apnea-hypopnea index (AHI) of 5 or less. Based on this criteria only 24% achieved a surgical cure. Twenty-one patients (33%) had a postoperative AHI of 10 or less. Patients with a cure were had lower and had less severe OSA. In those with residual OSA who received continuous positive airway pressure, the required pressure setting decreased by a mere 1.4 cm H(2)O.

These results again reinforce that UPPP as a treatment choice for OSA has extremely limited chance of success and in my opinion, should never be offered to patients with OSA without first exhausting the treatment options of CPAP and use of oral appliance. A 24% success rate is certainly unacceptable for making the patient undergo a major surgical procedure. What is worse is the recurrence rate even in the small number of cures tends to be high. Also there is a negligible effect in reducing PAP requirements which in itself is quite an interesting finding.

A team from Turkey has reported on the use of temperature-controlled radiofrequency tissue volume reduction (TCRFTVR) for patients with mild to moderate sleep apnea. Interestingly while the researchers conclude this to be a "a good alternative in primary treatment of mild to moderate obstructive sleep apnea", a look at the actual results show that mean post-procedure AHI was still high at 16 (!) and treatment success - even when defined by the suspect; 50% reduction in AHI measure - was only a little over 50%.

This adds to the growing body of evidence that show that any upper airway ENT surgical techniques have at best modest results in OSA and should never be considered first line therapy except in some very circumscribed clinical scenarios.

ENT does play a very important role in OSA therapy - but primarily in the treatment of nasal pathology which can significantly enhance CPAP compliance.

Do Not Disturb - Sound Policy.

2010-08-04T06:41:00.000-07:00

Being in a hospital for any reason is almost incompatible with getting a good night's rest. Of course being sick, being in pain, being on multiple medications are some of the important reasons for this. But more important may be interruptions from nursing staff. In an interesting study from Harvard, the reserachers introduced what they term a Somerville protocol - establishment of an 8-hour "Quiet Time" that began with automated lights-off and lullaby; staff-monitored noise; and avoidance of waking of patients for routine vital signs and medications. The result - patient reports of being disturbed by nursing visits reduced from 42% to 26%. More importantly, need for sedative use amongst these patients was reduced by 50%!. In the elderly - those over 60yrs, the reduction in sedative use was as high as 62%!....

A different study simulated an ICU environment with lights and noise, and looked at a simple intervention- earplugs and eye masks. The results were dramatic - more time spent in REM, shorter latency to REM, marked reductions in arousals and elevated melatonin levels.
So the next time you are in the hospital, ask your nurse for some ear-plugs and eye-masks, and, talk to your doctor about having a DND sign outside your door - it may your ticket to a speedier recovery!

MAD Predictions.

2010-08-03T06:33:00.000-07:00

Niehls Bohr famously remarked - "Prediction is very difficult, especially about the future". Predicting which patients with sleep apnea will do well with oral appliance therapy (OAT) is always a challenge. Two recent studies have yielded different results.

A recent study from Japan has shown that optimal positive airway pressure predicts oral appliance response to sleep apnoea. Oral appliances were inserted in nCPAP users after washing-out the nCPAP effect. Follow-up polysomnography was undertaken with the adjusted oral appliance in place. Overall the oral appliance showed good results -AHI was seen to be reduced with the oral appliance from 36 to 12/hr in 35 patients. They found that those patients needing CPAP of greater than 10.5 cmH2O were unlikely to respond to oral appliance therapy. This study thereby provides a very useful benchmark when discussing alternatives to CPAP with patients with sleep apnea.

It was hoped that waveform characteristics on the inspiratory portion of a flow volume loop could predict success with oral appliance. A team from Australia just published data showing that use of data obtained from a FVC "was not sufficient to reliably predict the response to treatment of OSA with MAS". A combined cut-off of an inspiratory flow rate at 50% of vital capacity (MIF(50)) less than 6.0 L/s and a ratio of the expiratory flow rate at 50% of vital capacity to MIF(50) of greater than 0.7 correctly classified 48.6% of the patients. Positive predictive value was high - 81% - but negative predictive value was unacceptably poor - 33%.

A recent abstract presented data at the AADS meeting showing that the ratio of tongue to bony enclosure CSA may offer utility in predicting success.

Can a Diet Cure Sleep Apnea?

2010-08-02T05:42:00.000-07:00

There is guarded to little optimism amongst many sleep physicians that non-surgical weight loss leads to meaningful differences in outcome in sleep apnea. Recent data from 2 studies would suggest that the effect could indeed be disease altering.

Researchers at Temple University 26 participants with Type 2 Diabetes mellitus and obesity - mean weight 102kg - were randomly assigned to a intensive lifestyle (IL) modifying regimen. IL participants lost more weight at 1 year than did controls - a mean of 10.8 kg! This was then associated with a decrease in AHI of close to 10 events per hour. More than 3 times as many participants in the ILI group had TOTAL remission of their OSA. Predictably, participants with a weight loss of 10 kg or more had the greatest reductions in AHI.

Another team from Sweden looked at the effect of a very low calorie liquid diet for nine weeks, in a randomized controlled trial. The intervention group, mean initial weight 112kg - lost 20kg in 9 weeks(!) - this resulted in improvements in their AHI - from 35 to 12. Nearly a fifth of the intervention group had their sleep apnea cured - i.e. AHI < 5 in nine short weeks.

Data would suggest that integrating weight loss treatment programs into sleep apnea treatment facilities might provide a markedly improved outcome potential for patients with OSA.

ADHD - is there a "safety blanket"?

2010-08-01T06:44:00.000-07:00

Designed based on the theory of sensory integration (Jean Ayres) the Ball Blanket

consists of balls integrated inside a blanket, and works due to the weight from the loose balls pressing at certain points of the body. The multi-focal sensory input increases "bodily consciousness" - the sense of the body and its limits, provides confidence and this is postulated to result in a tranquilising influence on the kid. A study from Denmark was just published which shows promising objective data. 21 children were ADHD and 21 controls were enrolled in a case control study - parents filled sleep diaries for 28 days and actigraphy was used for 14 days. The Ball blanket was shown to improve the time it takes to fall asleep - number of nights that the ADHD child spent more than 30 min falling asleep went from 19% to 0%. Teacher ratings of attention and activity also improved modestly.

This brings up the interesting question of the tradition of parents co-sleeping with the children - something that is, or at least used to be, quite prevalent in Eastern cultures, where ADHD has never been a blip on the pediatric healthscape. If a ball blanket can infuse a tranquil effect on a sleeping child, it seems perfectly reasonable that the warmth and familiarity of a sleeping parent should be able to multiply this effect manifold. Besides being easy on the wallet...

Sleep apnea and Medicare

2010-07-31T06:10:00.000-07:00

1. What sleep apnea products does Medicare cover?

A. Most sleep apnea therapeutic devices related to positive airway pressure are covered by Medicare. This includes a capped rental of CPAP/BiPAP equipment and other authorized supplies. There is some variance in the fee levels from state to state - all within a Medicare-determined range of fees for each product.

2. What amount will Medicare cover?

A. Medicare will cover 80% of their published fee schedule.

3. What about the 20% Medicare does not cover?

A. If you have secondary insurance, that may help offset it - in most cases your secondary insurance company is automatically sent a bill for the 20% Medicare does not cover. Some companies may work out payment plans to meet your needs - this is usually done on a case by case basis and so it always helps to shop around.

4. What is the Medicare deductible for 2009/2010?

A. The Medicare deductible for 2009/2010 is $155, which is the responsibility of the patient, (unless they have a secondary insurance coverage that picks up the deductible.) This deductible is non-negotiable and must be paid.

5. How are CPAP/BiPAP/APAP machines covered?

A. CPAPs, APAPs, and BiPAPs cannot be purchased directly per Medicare guidelines. Instead, CPAP Machines, Auto CPAP Machines (APAP), and BiLevel Machines (BiPAP) are purchased through Medicare via a 13-month rental process, whereby Medicare is billed on a monthly basis and the machine is then converted to a purchase and owned by the patient at the end of this timeframe. Medicare sets the monthly bill and covers 80% of the rental cost (the remaining cost (co-pay) is the responsibility of the patient or secondary insurance provider).

6. What qualifies a patient for a CPAP with Medicare?

A. Medicare has certain qualifications that must be met before they will cover a CPAP machine.

The patient must have documented clinical notes from the physician office visit which states the patient presented with sleep symptoms: snoring, witnessed stop breathing, excessive daytime sleepiness resulting in the physician to order a sleep study
The patient must have a sleep study performed at a (in some States accredited) sleep facility.
The AHI (Apnea Hypopnea Index) must be greater than 15 episodes per hour on that study with a minimum of 2 hours of recorded sleep. A signed prescription from a physician including your parameter settings is also necessary.
Finally, for continued coverage for CPAP, Medicare requires documented follow-up visits that show patient compliance is 70% or greater and patient improvement of sleep symptoms.

7. Are CPAP supplies covered by Medicare?

A. Medicare covers most CPAP supplies including masks, headgear, tubing, filters, humidifiers, and replacement pillows and cushions. Medicare has guidelines for beneficiary receipt of CPAP/Sleep Apnea related equipment, giving patients the opportunity to replenish their equipment regularly through us. See below for a list of eligible supplies, their HCPCS codes, and the Medicare allowed replacement frequency.

8. How often can I get the accessories replaced?

A. Medicare approves of the following replacement schedule.

CPAP Mask 90 days (1)

CPAP Headgear 180 days (1)

CPAP Tubing 30 days (1)

Disposable Filter 30 days (2)

CPAP Chinstrap 180 days (1)

Full Face Mask 90 days (1)

Full Face Cushion 30 days (1)

Nasal Cushion 30 days (2)

Replacement Pillow 30 days (2)

Non-disposable Filters 180 days (2)

Oral Interface 90 days (1)

Tonsils = lower IQ?

2010-07-30T06:38:00.000-07:00

It is well recognized that kids with enlarged tonsils and adenoids are at high risk for sleep apnea, and this can significantly affect their neurocognitive development. There are studies that have shown associations with Attention Deficit Hyperactivity Disorder (ADHD) as well. A study published today from Egypt looked at IQ levels of kids with adenotonsillar hypertrophy before and after surgery, and also did sleep studies on the kids prior to surgery. A control group was used to draw valid comparisons.

The results were striking. IQ levels were reduced in children before surgery, the degree of reduction was related not to the severity of the enlargement but to the severity of the associated sleep apnea, and interestingly, these IQ levels improved after surgery, to levels similar to those of the control group. It is time adenotonsillar enlargement in kids was taken more seriously, especially in those who do not meet "traditional" criteria for surgery. We know that size of the tonsils does not predict presence of sleep apnea - getting a formal sleep study may be the best way to triage candidates for surgery appropriately.

Sleep apnea - underdiagnosed in heart failure.

2010-07-29T06:40:00.000-07:00

People with congestive heart failure have a very high prevalence of sleep apnea - more than half have significant disease. Moreover treatment of these patients with CPAP therapy improves their heart function and quality of life and also improves their survival if they are compliant with therapy. Despite this, very few of them are tested. A recent study among Medicare beneficiaries shows that only 2% of ALL patients with heart failure get tested for sleep apnea. A pity because the group that actually got tested had markedly better survival. More education and better screening strategy is the urgent need.

Yogurt - good for asthma?

2010-07-28T06:35:00.000-07:00

Researchers from Taiwan just published data demonstrating striking benefits of lactobacillus ingestion in kids with asthma. 49 kids - ages 6 to 12 - were given lactobacillus for 8 weeks (in a placebocontrolled RCT).

Not only was pulmonary function and peak flow rates significantly better in the kids who received the probiotic, the group found significant reductions in the TNF-alpha, IFN-gamma, IL-12, and IL-13 production as well.

Much ado about...?

2010-07-26T15:37:00.000-07:00

There is a lot of speculation about the health hazards if any about the binannual winding the clocks forward and back an hour that we in the US are forced to indulge in. Some studies have shown a spike in everything from car crashes, to heart attacks, to suicide rates to mining and other high risk occupational accidents - at both ends of these time changes. One study from Finland was just published today and shows "transitions into and out of daylight saving time did not increase the number of traffic road accidents." The researchers looked at the number of road traffic accidents one week before and one week after transitions into and out of daylight saving time during years from 1981 to 2006 - a 25 year time period! Of course data from a nation where the sun never sets in summer may not be readily applicable to ciradian rhtyhms that beat to a Yankee tune. The jury is still out on this one.

Sleep affects attention - really early....?

2010-07-23T20:56:00.000-07:00

Sleep disturbances are well-known to lead to attention deficits in older children and of course adults. An Australian group has just published data that suggest that this influence may start very early in child development. Sleep problems between the ages of 2 and 4 were strongly associated with attention deficits at age 5 and persisting into as late as adolescence - the link was seen equally for boys and girls. With the current epidemic of diagnosing ADHD in older kids, parents may need to take their kids' sleep more seriously at a much younger age.

Kids with sleep apnea - more than tonsils..

2010-07-23T05:56:00.000-07:00

Sleep apnea in kids has always been linked primarily with tonsillar and adenoid enlargement. Researchers have just published data showing a high prevalence of multiple nasal pathologies in these kids - inferior turbinate hypertrophy, maxillary and ethmoid sinus involvement, including opacification as well as middle ear effusions. This resembles the profile seen in adults for the most part. With the growing epidemic of obesity in kids, a growing number of kids with sleep apnea may not have tonsillar enlargement.

Novel pill-duo for sleep apnea?

2010-07-22T07:10:00.000-07:00

Attempts to treat sleep apnea with a pill continue - and here is one more attempt with one - actually two pills. Researchers from Chicago used 4 weeks of a an interesting combination of combination of fluoxitene, a serotonin reuptake inhibitor, and ondansetron (a 5HT3 antagonist) in 35 adults with sleep apnea. Participants received either drug alone, only placebo and the combination of both. A 40% reduction in AHI was seen at the end of the study period. Interesting data -- may point to some potential novel targets for the future.

Another zzzz pill...

2010-07-21T14:52:00.000-07:00

Somaxon pharma reported good data on what is hopes is going to be a blockbuster in the evergrowing insomnia market -Silenor (Doxepin). Primarily used an antidepressant with sedating properties, 12 week trial of doxepin showed acceptable levels of objective and subjective improvements in sleep maintenance.

More than two-thirds of patients with depression interestingly have significant insomnia and vice versa.

Treatment of choice for insomnia remains cognitive behavioral therapy with pharmacotherapy use primarily restricted to short-term management.

Contraindications to doxepin include glaucoma, sleep apnea, and patients on MAO inhibitors.

Testosterone treatment? Test for OSA first

2010-07-20T16:07:00.000-07:00

Task force for the Endocrine society just released its guidelines for testosterone replacement therapy. One of the key contraindications is severe sleep apnea. Every patient being considered for testosterone replacement therapy needs to be evaluated and screened for a sleep study. This is also important because sleep apnea itself can lead to low testosterone levels, which may improve with CPAP. Patients with severe sleep apnea need to be on CPAP before testosterone therapy can begin.

Circadin - holds promise

2010-07-17T21:11:00.000-07:00

A long-acting melatonin agonist has been approved in Europe for the shortterm management of insomnia. This is the first and only long-acting melatonin molecule. It should find ready acceptance in a variety of settings including jet lag, shift work related sleep disorder as well as delayed sleep phase, which is typically seen in teens. How delayed will be its availability in the US is of course anyone's guess. A company release identifies it as "the first insomnia treatment approved for up to 13 weeks."

The new "Retro"

2010-07-17T06:34:00.003-07:00

XMRV - this may well be the virus of the next decade. Studies are starting to suggest a strong link to Chronic Fatigue Syndrome. Last year SCIENCE carried an article showing a astounding 67% of patients with Chronic Fatigue tested positive (compared to 4% of healthy controls)
Researchers were supposed to release some new findings in the PNAS but are awaiting further analyses. For once a breakthrough appears imminent.

Late to rise makes your teen wise?

2010-07-16T06:55:00.000-07:00

An eye-opening study says delaying high school starting times by just 30 minutes can reap big rewards for tired teens.

A small study at St. George's School in Middletown, Rhode Island, says students there were more alert in class, expressed better moods, arrived to class on time, and even reported eating a healthier breakfast due to the later start.
"The results were stunning. There's no other word to use," says Patricia Moss, academic dean at the boarding school where the study was done. Overall, 201 high school students completed sleep habit surveys before and after the nine-week experiment last year. The portion of students reporting at least eight hours of sleep on school nights jumped from about 16 percent to almost 55 percent; reports of daytime sleepiness dropped substantially, from 49 percent to 20 percent;
The results were so impressive that the school made the change permanent.

Dropside cribs to get dropped...

2010-07-15T14:57:00.000-07:00

U.S. Consumer Product Safety Commission is now mandating new standards for cribs - most crucial of them being a total ban on drop-side cribs. Pottery Barn has issued a recall on over 80,000 drop side cribs.

The primary danger with these cribs is that multiple factors can allow a gap to form between the crib mattress and part of the drop side. Babies can become trapped and suffocate in that gap.

A Cherry Good Night?

2010-07-15T14:21:00.000-07:00

According to a new study, researchers from Rochester,NY, have tested cherry juice - daily intake at bedtime for 2 weeks - and found that it "has modest beneficial effects on sleep in older adults with insomnia with effect equal to or exceeding those observed with valerian and melatonin, the two most studied natural products for insomnia."

This is one buddy you can sleep with

2009-10-19T09:04:00.000-07:00

This is a great system that may help patients with sleep apnea who need CPAP. The Hose Buddy tubing holder is very effective at getting rid of the tugs or tangles of CPAP tubing! Its base can snugly fit under any mattress and helps patients be able to move from side to side without getting entangled with their tubings or similar disturbances that might awaken them from sleep.

Walk your way to better sleep

2009-10-17T05:34:00.000-07:00

Regular exercise is one of the most important lifestyle modifications that has tremendous influences on promoting health. One of the positive health benefits of regular exercise is in promoting sleep.
Now a study from Taiwan shows this to be true even in cancer patients, where patients have a high prevalence of sleep problems. They compared the effect of 8 weeks of a introducing a daily "regular walk" regimen and found that it improved sleep significantly. Not only that other benefits like reduced pain as well as improved quality of life was seen with this simple intervention

Sleep and Sex

2009-10-16T05:48:00.000-07:00

Sleep apnea has been strongly linked to sexual dysfunction. A recent study from Germany shows that the prevalence of sexual dysfunction in men with OSA is as high as 70%. Thye also were able to show that even after accounting for many other variables such as age, prostate surgery, cardiovascular disease, etc that sleep apnea was clearly a major risk factor for erectile dysfunction in this group.

There are many mechanisms that contribute to sexual dysfunction in men with sleep apnea - the primary reason may be the effect of nocturnal hypoxia causing endothelial dysfunction, which then impairs blood flow and interferes with tumescence. Another important reason is the low testosterone levels that are commonly seen in OSA, again possibly due to the effect of low oxygen at night. Sleep apnea also leads to depression and fatigue - which may also be contributing to sexual dysfunction. Other studies have shown that CPAP therapy is effective in reversing the sexual dysfunction. This may well be a more definitive alternative to Viagra Cialis and the rest..

How reliable is the CPAP download?

2009-10-15T06:31:00.000-07:00

Physicians rely on the CPAP download to determine adherence and more importantly efficacy of CPAP. A recent study from Chicago compared manually scored sleep study records and a direct downloads to see if the two mayched accurately. The results found that the REMstar Pro detects sleep-disordered breathing events similar to that of a manually scored PSG only for apneas but not for hypopneas.

What this means is that a download reading may be underestimating the true presence of as yet uncontrolled or under-treated sleep apnea. A situation with a patient with persistent or residual sleepiness on CPAP with a download showing complete resolution of sleep apnea may thus necessitate a sleep study in order to verify that the sleep apnea is indeed being fully and reliably controlled.

Pregnant? Pay close attention to your sleep

2009-10-14T18:04:00.000-07:00

It is no secret that one of the commonest and often times most disabling complaints during pregnancy is that of disturbed sleep and daytime fatigue. A group of researchers from have studied the correlation between sleep disturbances experienced during the second trimester and late pregnancy depressive symptoms. In the study involving healthy pregnant women (N=257) sleep quality in mid-pregnancy correlated moderately with depressive symptoms at late pregnancy. Obstetricians are advised to screen for sleep quality during early pregnancy.

Problem with CPAP condensation or rain-out?

2009-10-13T07:16:00.000-07:00

Many patients with sleep apnea discontinue use of CPAP because of water condensation - this either causes a gurgling noise in the tubing at night or is uncomfortable because it tracks into the mouth or nose. The typical solution is to use a sleeve for the tubing. Now comes a custom-desgined tubing! This product may be a great solution for CPAP condensation or rain-out.

The SleepZone heated CPAP tube has a spiral integrated, insulated heating element in the tubing itself, which is powered by a low voltage transformer. The entire tube is then covered with a special lightweight rib-knit "stretch" material that enhances the heating and insulating effects.

Sleep apnea and cortisol

2009-10-13T06:38:00.000-07:00

Sleep apnea is known to adversely and significantly influence the - HPA (HypotahalamoPituitaryAdrenal) axis - body's pathway involved in the cortisol synthesis.

Now researchers from Bristol have measured levels of cortisol and its regulator ACTH in patients with sleep apnea and have shown that production of both hormones are elevated - both total and pulsatile production.

This may be important in explaining the link between sleep apnea and weight gain and obesity, as well as sleep apnea and mood changes such as depression, as the HPA axis plays a central role in both these clinical conditions. It also has important implications for glucose control as well as immune function.

Hispanics with sleep apnea - more at risk for diabetes?

2009-10-13T06:14:00.000-07:00

Obstructive sleep apnea has been known to worsen insulin resistance and predispose patients to diabetes mellitus. Morover it has been demonstrated that CPAP therapy can reverse insulin resistance in these patients. Leptin resistance may be playing a central role in this link as well.
A new study conducted from researchers at the Baylor College of Medicine shows that amongst patients with sleep apnea, Hispanic patients seem to be most at risk. IN a large group of unselected patients with sleep apnea, 42% of the entire cohort was seen to have diabetes mellitus. One particular feature that seems to be strongly related to presence of diabetes is REM-related apneas.
Physicians should screen Hispanic patients with sleep apnea very closely for presence of prediabetic state and provide them appropriate lifestyle counseling.

If your physician is sleepy, are you safe?

2009-10-12T19:36:00.000-07:00

An interesting article on ethical considerations when it comes to sleepiness in medical residents by Czeisler from Harvard..

"The Institute of Medicine recently concluded that-on average-medical residents make more serious medical errors and have more motor vehicle crashes when they are deprived of sleep. In the interest of public safety, society has required limitations on work hours in many other safety sensitive occupations, including transportation and nuclear power generation. Those who argue in favor of traditional extended duration resident work hours often suggest that there are inter- individual differences in response to acute sleep loss or chronic sleep deprivation, implying that physicians may be more resistant than the average person to the detrimental effects of sleep deprivation on performance... recent investigations have identified genetic polymorphisms that may convey a relative resistance to the effects of prolonged wakefulness on a subset of the healthy population,..there are also genetic polymorphisms, sleep disorders and other inter-individual differences that appear to convey an increased vulnerability to the performance-impairing effects of 24 hours of wakefulness....hospitals face a number of ethical dilemmas. How should the work hours of physicians be limited to protect patient safety optimally? .. work schedules that repeatedly induce sleep loss are uniquely essential to the training of physicians. ....how should such training be ethically accomplished in the quartile of physicians and surgeons who are most vulnerable to the effects of sleep loss on performance without unacceptably compromising patient safety? Moreover, once it is possible to identify reliably those most vulnerable to the adverse effects of sleep loss on performance, will academic medical centers have an obligation to evaluate the proficiency of both residents and staff physicians under conditions of acute and chronic sleep deprivation? Should work-hour policy limits be modified to ensure that they are not hazardous for the patients of the most vulnerable quartile of physicians, or should the limits be personalized to enable the most resistant quartile to work longer hours? Given that the prevalence of sleep disorders has increased in our society overall, and increases markedly with age, how should fitness for extended duration work hours be monitored over a physician's career? In the spirit of the dictum to do no harm, advances in understanding the medical and genetic basis of inter-individual differences in the performance vulnerability to sleep loss should be incorporated into the development of work-hour policy limits for both physicians and surgeons."

A very thought provoking piece - and one that is going to assume centerstage as two things becomes increasingly clearer - strong evidence linking errors in the medical workplace to physician fatigue and the failure of work hour limitations to improve the situation.

Solzira - a new prodrug in RLS.

2009-10-11T11:20:00.000-07:00

While first line therapy for restless legs syndrome continue to be dopa-agoinsts ropirinole and pramipexole, a very useful secondline agent that has been routinely prescribed for this condition is gabapentin or Neurontin. Now a new study shows that a new prodrug for gapabentin (GEn or Solzira) is very effective, but only when the dosages were 1200mg. Dosages of 600mg were no different than placebo. While the new prodrug is yet to become widely available, the study may point to te fact that when gabapentin is being used for RLS, dosages may need to be at least 1200mg or higher. A key side effect is daytime somnolence, which in this study was seen in as many as a third of patients.

Restless legs syndrome - is it a marker for diabetes mellitus?

2009-10-11T11:08:00.000-07:00

Restless legs syndrome is characterized by a sensation of discomfort in the legs that charactisitically occur at night prior to bedtime, and seem to be partially relieved by moving the legs. While a association with iron deficiency is well recognized, a new study from Italy suggests that there may be strong link with diabetes mellitus. The group studied 132 subjects with RLS and did a test for early diabetes mellitus - the glucose tolerance test. They found that 20% of the group had frank diabetes mellitus and another 40% had abnormal values for the GTT indicating a pre-diabetic state. Patients with RLS should be carefully evaluated for diabetes mellitus. Interestingly, a related disorder restless genital syndrome has been described in a subgroup of patients with RLS recently by a group from the Netherlands.

Bright Light therapy: useful in Nocturnal Eating Syndrome

2009-10-11T06:30:00.000-07:00

Bright Light Therapy - click on this link to watch a video.

is a commonly prescribed modality of therapy for chronic insomnia. It modulates the body's internal clock - the circadian clock - and reinforces the integrity of the body's day-night rhythms. Sleep specialists commonly use it for treating patients with longstanding insomnia, and for people with altered body-clock settings - which are called delayed sleep phase and advanced sleep phase syndromes. Delayed sleep phase is commonly seen in teenagers and young adults. Now researches from the University of Pennsylvania have found that birght light therapy may be useful in women with Nocturnal Eating Syndrome. NES is an increasingly recognized sleep disorder characterized by excessive food intake in the evenings and multiple night-time awakenings for consumption of food. By providing bright therapy to a group of 15 women with NES, the team was able to effect "significant changes in the timing and amplitude of various behavioral and physiological circadian markers involved in appetite and neuroendocrine regulation."

New nasal pillows from Fisher-Paykel - Opus 360

2009-10-10T11:23:00.000-07:00

This is quite a popular mask. The anatomically shaped Nasal Pillows provide easy fitting with an excellent seal, with contours that ensure greater comfort. What seems to be well-liked is the facially Contoured Mask Frame, with three-dimensional support structures, that conforms naturally to the shape of the faceand a slim-line design that allows side-sleeping without mask displacement. The patient has a choice of anchoring the tube at the top, side, or leaving it free to track, allowing true 360° of freedom. Lastly, the pillows are not only soft on the nose but are designed to be "off the upper lip" for maximum comfort.

Gingko biloba : good for dementia, but no effect in ADHD

2009-10-10T07:36:00.000-07:00

Gingko biloba has been shown to have important effects on memory, especially in people with dementia. A recent study from the Ukraine showed that supplementation with a gingko extract for 22 weeks improved multiple aspects of function in a large group (more than 750 adults) of patients with demential. However a new study evaluating its use in children with ADHD has proven to be disappointing - it is unlikely to have a significant role in that condition, and patients using these supplements for attention deficits should be asked to discontinue their use.

Sleep Distrurbances in Menopause

2009-10-10T06:52:00.000-07:00

Menopause is a time with significant hormonal changes in a woman and has been associated with sleep problems. A group from Turkey has published data showing that 54% of menopausal women had significant sleep disturbances - women were more than twice as likely to develop sleep problems after menopause than before. Domains related to vasomotor symptoms (hot flashes), psychosocial (mood changes), physical (fatigue) and sexual function were more impaired in those women with sleep disturbances.

Menopause is also the time many women develop sleep apnea. Sleep is a vital component of women's health, and special attention may need to be paid to this aspect especially during the menopausal period.

Foods rich in tryptophan : may help you sleep like a baby.

2009-10-10T06:13:00.000-07:00

Tryptophan is a metabolite that has a sleep-promoting effect most likely due to its influence on brain chemicals - serotonin and melatonin. Researchers from Spain studied infants receiving formula milk enriched in tryptophan and found that, compared to infants on normal formula, these babies had better sleep. Another group from Netherlands studied 14 adults who were given alphalactalbumin which was rich in tryptophan at nbight and found that not only was their sleep modestly improved but there was a significant difference in daytime alertness.

Foods that are rich in tryptophan include:
Baked potato with skin

Bananas
Beans
Beef
Cheddar cheese
Cottage cheese
Eggs
Fish
Hazelnuts
Lentils
Milk
Nuts
Peanuts
Sesame seeds
Shellfish
Soy milk
Soybean nuts
Sunflower seeds
Swiss cheese
Tofu
Tuna
Turkey
Yogurt

Stroke - sleep apnea treatment reduces the risk of death

2009-10-09T10:23:00.000-07:00

It has long been recognized that as many as 70% of all stroke victims have sleep apnea. Now new research from Spain shows that identifying and treating sleep apnea in stroke patients can lead to a reduction in mortality. The group studied 166 patients with stroke, with polysomnography and found that 135 of them had sleep apnea. Those patients who did not tolerate and did not use their CPAP had a greater than two-fold risk of death than those who used CPAP. There was no difference in the mortality between those who did not have sleep apnea and those who were compliant with their CPAP.

Screening and treating sleep apnea in ALL patients with stroke is thus a matter of life and death.

One (more) reason to avoid alcohol when you are pregnant

2009-10-08T20:22:00.000-07:00

Alcohol has been shown to have deleterious health effects for both mom and growing baby. Now researchers from Finland have published data that show that poor sleep habits in babies are directly related to alcohol consumption when their moms were pregnant. The team studies nearly 300 infants and found that the highest risk factor for poor sleep and short sleep in the infant was a history of consumption of alcohol during the pregnancy - irrespective of gender, socioeconomic class, allergies, and perinatal complications. If you find your baby not sleeping right you may ave to ask yourself if it was something you did.

Apelin Diabetes and Sleep Apnea

2009-10-08T10:48:00.000-07:00

Apelin, a hormone produced by fat and other tissues, might serve as a promising target for managing insulin resistance and type 2 diabetes, according to a new study. Usually, insulin makes it possible to store blood sugar in the form of glucose in the liver or adipose tissue (fat). Many times, the mechanism gets disrupted either because insulin is no longer produced (type 1 diabetes), or because the receptors located on the surface of liver cells are desensitized (type II diabetes). Thus, the cell becomes incapable of assimilating glucose.Such a dysfunction causes a rise in blood sugar levels leading to the onset of numerous complications. Researchers have found that our cells are equipped with a second pathway for the assimilation of glucose, which involves “apelin”. The protein is not only a “key” that is different from insulin, but it also passes through a different receptor or “doorway”. A recent study from Bristol,UK now suggests that sleep apnea may significantly modulate apelin expression. 15 obese males with newly diagnosed OSA underwent very detailed measurements of serum apelin levels as well as tests of glucose metabolism before and after CPAP. They found that OSA was associated with elevated plasma apelin levels, altered apelin secretory dynamics in response to oral glucose and lack of circadian variability. What was more striking was that these effects were reversed with just three months of CPAP therapy. This again underscores why patients with diabetes mellitus need to be aggressively screened for OSA - treatment often helps their glucose control in ways we are only now beginning to better understand.

New mask from Resmed - Mirage Softgel

2009-10-08T09:20:00.000-07:00

Resmed is introducing a new mask next month - the Mirage Softgel - "the soft and durable gel mask" It gives the user a choice of two styles of mask cushion on "one durable frame which is compatible with both Mirage SoftGel and Mirage Activa LT cushions."
It will be interesting to see how patients feel about it and whether it fares better at compliance and acceptance than the Activa LT - the latter is one of the more popular maks.

Chronic fatigue syndrome : brains wired differently?

2009-10-08T05:45:00.000-07:00

Chronic fatigue is a poorly understood and debilitating illness which unfortunately does not have very reliably effective treatment options. A team of researches led by M.Decker have studied the brain activity in these patients and found some unique characteristics - a reduced delta power in slow wave sleep, and reduced theta and alpha power in stage 2.

The findings are intriguing as some of these findings may also be seen in fibromyalgia and these may indicate a common factor predisposing these individuals to daytime fatigue. It will be interesting to see if pharmacotherapy directed at mitigating these EEG effects is able to improve the daytime fatigue in these individuals.

Fatigue common in dialysis patients

2009-10-08T05:36:00.000-07:00

Patients with renal failure and who are on dialysis have significant degree of fatigue according to a new multi-center study. They studied 917 dialysis patients and found the following factors made it more likely to have a low vitality score - white race, obesity, and antidepressant use. Patients with the highest vitality scores were associated with longer survival.

This study implies that a. we need to be more aggressive about screening patients with renal failure for fatigue, and b. aggressively try to identify and treat the reasons for fatigue in these individuals - typically sleep disruptions, sleep apnea and restless legs syndrome.

The cost of insomnia : a labor perspective

2009-10-07T11:59:00.000-07:00

Insomnia is not only widely prevalent but can impact the bottomline of any major corporation. In a recent study by Human Capital Management Services, it is estimated that the annual mean incremental costs were $2,053 greater (in total) for employees with insomnia (specific increments: medical $751, drug $735, sick leave $208, short-term disability $179, long-term disability $10, and workers' compensation $170).
Employees with insomnia missed a mean of 3.10 more workdays annually than those without insomnia.
Based on these data, the study estimated the annual cost of insomnia in the US civilian labor force to be approximately $15.0-17.7 billion US dollars. This adds to the growing body of evidence that employers who are proactive about the sleep-health of their employees can find it having a positive impact not only on their workforce but on their own bottomlines as well.

Sleep apnea and alcohol - not a good mix.

2009-10-07T06:20:00.000-07:00

Alcohol has long been recognized as a detrimental factor in patients with sleep apnea and a team of Australian researchers have presented new evidence that shows the implications on driving. Using simulated driving tests, they studied patients with unrestricted sleep, sleep restricted to 4 hours, and ingestion of an amount of 40% vodka calculated to achieve a blood alcohol level of 0.05 g/dL. Patients with OSA demonstrated increased steering deviation and crashed more frequently and especially so with both sleep restriction and alcohol consumption than after normal sleep. In patients with OSA, prolonged eye closure (>2 seconds) and microsleeps (> 2 seconds) were significant crash predictors.

It is imperative that patients with sleep apnea avoid sleep restriction and alcohol, as both these can impair their driving skills and put them at risk for crashes.

C-flex - no better than C-PAP at C-ompliance

2009-10-06T13:41:00.000-07:00

Yet more one more study reinforces the fact that C-flex - while holding much promise in theory as a method to provide expiratory pressure relief - does precious little to improve CPAP compliance.

This time, a study out of France - 218 patients with OSA were randomly assigned to receive 3 months of treatment with CPAP or C-Flex. After 3 months, patients in the CPAP arm were moved to the C-Flex arm for 3 additional months (open study). There were no differences at 3 months between C-Flex and CPAP use in terms of compliance, and comfort.

Previous studies have also yielded similar results - at this point, in my opinion, there is little data to support the routine use of C-flex while prescribing CPAP.

IPF - do all patients need a sleep study?

2009-10-06T12:35:00.000-07:00

Researchers at Vanderbilt have reported on their study involving patients with idiopathic pulmonary fibrosis - IPF. They had 50 patients with IPF undergo formal polysomnography, and found that 88% of them had OSA as defined as a AHI of >5. Nearly 705 of the patients with OSA had moderate to severe OSA - defined as an AHI of > 15. Routine screening tools including the Epworth were not efective at predicting the presence of OSA.

These results are interesting, as we typically do not consider patients with IPF to be at risk for OSA, and tend to screen for nocturnal hypoxemia by means of nocturnal oximetry. The results of this study would make a strong case for routine polysomnography in ALL patients with a diagnosis of IPF.

Fibromyalgia : it may be the way you sleep?

2009-10-06T11:12:00.000-07:00

In a large study of over 180 patients with fibromyalgia syndrome (FMS), a research team from San Antonio evaluated the role of sodium oxybate (brand name xyrem), a medication currently FDA approved primarily for the treatment of narcolepsy.

Patients with FMS have a lot of alpha-intrusions - which show intrusion of "awake" type of sleep electrical activity into periods of deep sleep. Sodium oxybate may have a role in improving the quality of deep sleep.

The results of this study showed significant improvements in the patient's pain rating (on a visual analog scale), as well as on the Fibromyalgia Impact Questionnaire (FIQ) score.

The precise mechanisms of the effect is yet to be determined, but this does promise to be a significant line of treatment in what has proven to be a very difficult disorder to manage for physicians and rheumatologists. A significant number of FMS may also have concomitant sleep disorders such as sleep apnea and treating these primary sleep disorders often times enables the patient to improve tremedously their FMS symptoms - esp chronic pain.

Traumatic brain injury : sleep is important

2009-10-06T08:50:00.000-07:00

In a study from Glasgow UK, researchers studied the influence of sleep on recovery from traumatic brain injury and found that "the poor sleep group had significantly poorer sustained attention ability than the good sleep group."

It is important for physicians treating trauma victims to pay close attention their sleep duration and sleep quality and be proactive about identifying and treating sleep disorders in this group. It is interesting that undiagnosed sleep apnea is the second leading cause of motor vehicle accidents and trauma victims in this particular group may be even more vulnerable.