NESS 25th Anniversary Meeting

Romero-Corral A, Caples SM, Lopez-Jimenez F, Somers VK.

Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Mayo Foundation, Rochester, MN 55905, USA

Abstract

Obstructive sleep apnea (OSA) adversely affects multiple organs and systems, with particular relevance to cardiovascular disease. Several conditions associated with OSA, such as high BP, insulin resistance, systemic inflammation, visceral fat deposition, and dyslipidemia, are also present in other conditions closely related to OSA, such as obesity and reduced sleep duration. Weight loss has been accompanied by improvement in characteristics related not only to obesity but to OSA as well, suggesting that weight loss might be a cornerstone of the treatment of both conditions. This review seeks to explore recent developments in understanding the interactions between body weight and OSA. Weight loss helps reduce OSA severity and attenuates the cardiometabolic abnormalities common to both diseases. Nevertheless, weight loss has been hard to achieve and maintain using conservative strategies. Since bariatric surgery has emerged as an alternative treatment of severe or complicated obesity, impressive results have often been seen with respect to sleep apnea severity and cardiometabolic disturbances. However, OSA is a complex condition, and treatment cannot be limited to any single symptom or feature of the disease. Rather, a multidisciplinary and integrated strategy is required to achieve effective and long-lasting therapeutic success.

Chest. 2010 Mar;137(3):711-9.

Full Text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879275

Officials at the Orange County, Calif-based Judy & Richard Voltmer Sleep Center make sleep health a priority throughout the many specialties at Hoag Memorial Hospital.

Even in the population-dense region of Southern California, sleep labs used to be rare. When compared to 2011, sleep apnea awareness in the 1980s significantly trailed other conditions.

Officials at Hoag Memorial Hospital Presbyterian in Orange County, Calif, recognized early on that there was a need for a specialized center to evaluate and treat sleep disorders. The Judy & Richard Voltmer Sleep Center, backed by the resources at Hoag, filled this void back in 1987 in Newport Beach, Calif. More recently, the center moved to gleaming new quarters in an effort to modernize and accommodate more patients.

With considerable resources, expertise, and referrals flowing from Hoag, the state-of-the-art 8-bed facility never lacks for patients. Paul Selecky, MD, FACP, FCCP, FAASM, long-time medical director of the Voltmer Sleep Center, has tirelessly spread the message of sleep health among his colleagues. The result is that clinicians from diverse specialties appreciate the value of healthy sleep, and they don’t hesitate to ask for help when they need it.

Under the umbrella of Hoag Neurosciences Institute, the Voltmer Sleep Center is seamlessly integrated within the continuum of care. Sleep is not an afterthought. Neurologists, ENTs, pulmonologists, endocrinologists, and primary care physicians all readily send patients to the center.

Colleagues on Board

The evidence for the sleep/health connection seems to build each year, with ever-more co-morbidities related to poor sleep. The more apt question these days is what is not affected by sleep.

When the American Society of Anesthesiology (ASA) came out with its 2006 guidelines on peri-operative management of patients with known or suspected sleep apnea, clinicians at Voltmer Sleep Center were ready. “Our anesthesiologists asked if we could help them develop a program to screen patients who were coming in for elective surgery,” says Selecky. “That protocol has now grown, and nearly every admission coming into Hoag is evaluated for the risk factors of sleep apnea.”

Hoag has taken a proactive approach, and patients who come in for other ailments benefit from the extra attention. “About 70% of stroke patients have sleep apnea,” says Selecky. “It’s a chicken-egg type of thing, but at least they get sent here to lower that risk. Others who come in for total knee, hip, chest pain—we ask them about sleep and the patient is educated about serious breathing problems.”

Not surprisingly, about 90% of all referrals to Voltmer Sleep Center come from Hoag, but outside referrals are growing. If a patient is referred by a Hoag neurologist for sleep problems related to that neurologic problem, a neurologist working on staff at Voltmer Sleep Center is the one to see that patient.

If COPD was the primary problem, a pulmonologist would visit with the patient. “This is not just an independent sleep center,” explains Trish Stiger, BBA, RPSGT, CRT, manager of the Voltmer Sleep Center. “It is part of Hoag, and they refer from the Diabetes Center, the Cardiovascular Institute, and more. Even obstetricians are reminded that a snoring pregnant woman should not be ignored as if she merely has nasal congestion, as this can lead to complications of pregnancy.”

In line with the large body of evidence linking sleep apnea and congestive heart failure, Voltmer Sleep Center clinicians provide information and education to all Hoag cardiologists. “A lot of them have gotten the message,” says Selecky. “They ask every congestive heart patient, ‘Do you snore?’ If the patient snores, and has other features of sleep apnea,  he comes to us.” Cardiologists will also send patients whom they are treating for resistant hypertension, as is recommended by the American College of Cardiology and American Heart Association because of the link with untreated obstructive sleep apnea.

Much the same can be said for diabetes management. Endocrinologists who prescribe several different medications for diabetes have referred their patients to the Center, again because of the link between diabetes management and sleep apnea  . “The first thing that should be done is to rule out sleep apnea,” says Selecky.

Education and Follow-up

Every physician takes patients to the lab bedrooms to explain the diagnostic tests and procedures, and these in-person consultations provide vital information. Despite all the media attention on sleep, Selecky admits that some convincing is often part of the job. “Sometimes there is too much negative information out there,” laments Selecky. “People come in and say, ‘I don’t want that breathing machine. I know somebody that hated it.’ It gets a bad rap, so we must provide a lot of education.”

When it comes time to dispensing the actual CPAP machine, Selecky and Stiger work closely with trusted durable medical equipment (DME) providers who are known for their good service. “If they don’t provide good service, we don’t refer to them—it’s that simple,” says Selecky. “That means excellent follow-up, because if patients don’t have a positive experience in the first few weeks of CPAP use, they are more likely  to abandon it. Nationally, the average for CPAP users is that 50% drop it by the end of the first year. We have several of the DME RTs spend time in the Center so patients can try a dozen different masks. It’s like buying a pair of shoes. If it doesn’t fit well, you are not going to use it.”

In addition to the familiar sleep apnea/CPAP combination, officials at Voltmer are keen to address all sleep disorders and treatments. “Insomnia is not a huge percentage of our patient population at this point, but it’s significant enough and our physicians treat it,” says Stiger. “Patients may need extensive cognitive behavioral therapy, sometimes with the aid of  psychologists.

In addition to CPAP for apnea, we embrace dental sleep medicine as a valid option.  “Oral corrective devices have been used throughout our history with the help of local dentists who started treating some of our milder patients, or those who could not tolerate CPAP,” adds Selecky.

The Future

Unlike the 1980s, Selecky says it seems as though these days there is a sleep lab on every corner. Favorable demographic trends suggest that won’t change, despite the furor caused last year when Medicare approved home sleep studies—much to the chagrin of lab owners. “People said that might be the end of all sleep centers,” says Selecky. “But as time has gone on, that has not occurred at all. Part of it is that reimbursement for home sleep studies is low. However, it has made every lab consider whether it should be involved in home sleep studies. The answer is yes for certain populations.”

In 2011, Selecky believes the keys to success looks a lot like the keys of the past. Education, clinical excellence, follow-up, and compliance must be the driving forces. As understanding of sleep medicine grows and physicians know more about it, they will inevitably order more sleep studies.

Those who have worked to be a full service center will remain in the black as they gain the trust of physicians and patients alike. “There is a difference between establishing yourself as a sleep center vs a sleep lab,” adds Stiger. “A center deals with everything. You educate, go out and teach the community, and work with all the other specialties to care for patients—which should always be the number one goal.”

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Tradition of Excellence
Hoag Memorial Hospital Presbyterian is accredited by the Joint Commission on Accreditations of Healthcare Organizations (JCAHO), and home to Centers of Excellence in cancer, heart, orthopedics and women’s health services. Orange County residents named Hoag the “Hospital of Choice” in a National Research Corporation poll, as well as the county’s top hospital in a a local newspaper survey.

The Voltmer Sleep Center is an accredited member of the American Academy of Sleep Medicine, and features a Web site (http://www.hoag.org/services/neurosciences-institute/voltmer-sleep-center) where potential patients can view online sleep assessments, photos of the sleep center, and information about the physicians. “Many people simply don’t realize that an adequate night’s sleep is needed to maintain good health and stay fully alert throughout the day,” says Selecky. “We are excited about the opportunity to use the Internet to educate the public and to let them know there is help nearby.”

An air traffic controller who was unavailable to help two jets land at a busy Washington DC airport has been suspended, an official has said.

The planes landed safely, despite being unable to make contact with the control tower early on Wednesday.

The lone nighttime controller at Reagan National Airport had fallen asleep, the Associated Press reported.

In response, regulators have ordered that two controllers be on duty on the midnight shift.

The jets carried a total of 165 people.

The FAA has launched a national inquiry into tower staffing, officials said.

Aviation officials told media the overnight shift at the airport was typically manned by a single controller.

The jet pilots were unable to raise the airport control tower on the radio as they approached to land. The efforts of other controllers elsewhere to reach the tower by telephone failed as well.

US Transportation Secretary Ray LaHood said that in response he had directed the FAA to put two controllers on the midnight shift at Reagan National Airport.

Source: AP

The U.S. Food and Drug Administration (FDA) has requested additional efficacy information on the Apnea Risk Evaluation System (ARES TM). Company officials informed customers with a letter that detailed the FDA’s request to obtain more data on the respiratory effort signal found within the ARES Model 610.

In a letter issued by the manufacturer of the ARES  users of the device were notified that the FDA has advised the Ares does not provide data consistent with the measurement of respiratory effort.

In the interim, company engineers will remove the respiratory effort signal from ARES labeling and disable its capability within the Model 610. Company officals, apologized for the inconvenience while assuring customers they were working diligently with the FDA to satisfy their requests.

Source: SleepScholar

A San Diego company ImThera is currently testing a new Neuro Stimulation device the company is researching the product in Belgium. If successful there will be a new implantable device as a solution for OSA patients.

“Targeted Hypoglossal Neurostimulation (THN) Sleep Therapy utilizes a small electrical device to achieve increased upper airway flow. This device includes a small electrode that is implanted under the skin near the lower jaw and attached to the Hypoglossal Nerve (12th cranial nerve) connected to a pulse generator implanted near the surface of the upper chest. THN Sleep Therapy controls the movement of the tongue muscles such that the tongue is not allowed to fall back and block the airway during sleep. A doctor implants and programs the device to produce short bursts of electrical pulses that are delivered to the nerve.”

ImThera a privatley funded startup has developed an implant that sits next to the touge to provide enough stimulation to maintain tone in parts of the tougue during sleep to keep it out of the airway. The battery and control pack is implanted in the neck and upper chest with the stimulator placed against specific nerves in the tongue.

This device is not available for sale in the USA however indications for use include:

- tongue based OSA

- AHI greater than 15

- must be a surgical candidate

- Patient must have refused or be contraindicated for CPAP

Surgery takes between 30-45 minutes

More info can be found below

Read more: http://news.cnet.com/8301-27083_3-10456870-247.html#ixzz1HC895sv7

Youetube: http://www.youtube.com/watch?v=RSTKSt5hxgU

website: http://www.imtheramedical.com

Gehrman PR, Harb GC.

Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA. gehrman@exchange.upenn.edu

Abstract

Nightmares are a common feature of posttraumatic stress disorder (PTSD) and are frequently resistant to treatment. Two emerging treatments for nightmares are pharmacotherapy with prazosin and psychotherapy using imagery rehearsal (IR). A case illustration demonstrates the application of these treatments with a client suffering from chronic, severe PTSD. The case illustrates the use of these strategies for managing PTSD-related nightmares, as well as the novel approach of scheduled awakenings following relapse.

J Clin Psychol. 2010 Nov;66(11):1185-94

Andrén A, Sjöquist M, Tegelberg A.

Department of Stomatognathic Physiology, Central Hospital, SE-721 89 Västerås, Sweden. ann.andren@bredband.net

Abstract

Obstructive sleep apnoea (OSA) is a highly prevalent sleep disorder; it affects 4% of males and 2% of females. Hypertension has been shown to occur in 28-57% of OSA patients. There is a steady increase in evidence linking OSA to long-term cardiovascular morbidity including hypertension. The purpose of this study was to investigate whether mandibular advancement oral appliance (OA) treatment of OSA affects the patient’s blood pressure (BP) in a 3-month and a 3-year perspective. Twenty-nine consecutive patients, with verified OSA defined as apnoea index (AI) >5 per hour and/or apnoea/hypopnoea index (AHI) > or =10 per hour, received an OA as treatment. BP was measured on three occasions; before treatment, after 3 months of treatment, and after 3 years of treatment. BP was measured with an electronic blood pressure monitor. The treatment effect of OA was measured after 3 months by repeated somnographic registration while the patient was wearing the OA. A treatment response was defined as AHI < 10; this was achieved in 25 of 29 patients (86%) at the 3-month evaluation. Significant reductions in blood pressure were attained between baseline and the 3-month evaluation (P < 0.001) and these changes remained at the 3-year follow-up in both systolic BP of -15.4 +/- 18.7 mm Hg and diastolic BP of -10.3 +/- 10.0 mm Hg. OA therapy reduced blood pressure in both a 3-month and a 3-year perspective in patients with OSA.

J Oral Rehabil. 2009 Oct;36(10):719-25. Epub 2009 Aug 12

Abstract

Scientifically rigorous clinical trials are needed to test continuous positive airway pressure’s (CPAP) effect on important clinical endpoints known to be associated with obstructive sleep apnea, such as myocardial infarction, cardiac arrhythmias, stroke, mortality, seizures, and cognitive function. In this “Special Article,” we review the regulatory and ethical issues that surround the design and conduct of CPAP trials, including selection of the appropriate control condition, exclusion criteria, and follow-up duration. CITATION: Brown DL; Anderson CS; Chervin RD; Kushida CA; Lewin DS; Malow BA; Redline S; Goldman EB. Ethical issues in the conduct of clinical trials in obstructive sleep apnea. J Clin Sleep Med 2011;7(1):103-108.