PNAS Study: Naps for Pre-Schoolers During School, Helps Children Learn

A midday nap can help pre-school children remember what they learned in the morning.

According to recent research published with the Proceedings of the National Academy of Sciences (PNAS)

“Pre-schoolers who went without a midday sleep fared worse on memory tests than those who napped. They also failed to improve their scores even after a good night’s sleep, the researchers found”.

The report titled “Sleep spindles in midday naps enhance learning in preschool children” suggests that carers and nurseries that phase out after-lunch sleeps may be harming children’s ability to learn, by disrupting the way their brains store memories.

Read Abstract Here

For the study, psychologists went into pre-school classrooms and taught 40 children aged three to nearly five years old a simple computer game. It required them to memorise the positions on a grid of images including a cat, an umbrella, and a policeman. The children were trained from 10am until they could remember the positions of around 75% of the pictures.

The scientists visited each child twice over the course of the study. On one visit, the child slept for an hour or so between 1pm and 3pm, and stayed awake on the other. To see how sleep affected their memory, the scientists tested each child again later the same afternoon. Those who napped saw no change in their morning score of 75%, but the ones who stayed awake fared much worse, averaging scores of 65%.

The scientists went on to look at the brain activity of 14 children while they slept in the unversity’s sleep lab. They found that children with the best memory recall experienced more “sleep spindles” – brief bursts of activity thought to happen when the brain shunts memories from short-term storage in the hippocampus to the neocortex.

Source: PNAS

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High-Flow Nasal Cannulae similar to that of CPAP for Preemies

As published in the New England Journal of Medicine, “High-Flow Nasal Cannulae in Very Preterm Infants after Extubation”,  subtle differences matter when it comes to premature babies. Although the result for the primary outcome was close to the margin of noninferiority, the efficacy of high-flow nasal cannulae was similar to that of CPAP as respiratory support for very preterm infants after extubation.

Read Abstract Here

Treatment failure occurred at a rate of 34.2% with the high-flow nasal cannulae and 25.8% with CPAP, Manley and colleagues found. That comparison met non-inferiority criteria, though narrowly so, as reported in the Oct. 10 issue of the New England Journal of Medicine.

Alan Lantzy, MD, vice-chair of pediatrics at West Penn Hospital in Pittsburgh, stated that, “More neonatal units and more neonatologists will be convinced that their switch from CPAP to high-flow nasal cannulae after extubation is evidence-based.”

At least two-thirds of U.S. academic center neonatal ICUs have reportedly already switched to high-flow nasal cannulae that deliver more than 1 L/min of heated, humidified air through small prongs, and the strategy is increasingly popular in other countries too, Manley’s group noted.

“Because high-flow nasal cannulae have a simpler interface with the infant and smaller prongs than nasal CPAP, the cannulae are perceived as easier to use, more comfortable for the infant, and advantageous for mother-infant bonding,” added Manley and his team.

Source: NEJM

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SleepImage – The first and only objective measure of sleep quality

Now there is a simple and easy way to measure “sleep quality” at home that identifies how well we sleep. This new measure of sleep was developed by Dr. Robert Thomas and colleagues at the Beth Israel Deaconess Medical Center, an affiliate of the Harvard Medical School, is called cardio pulmonary coupling, and it is now available exclusively with the SleepImage system.

request more information1 SleepImage   The first and only objective measure of sleep quality

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Man on a Mobile Mission


Childrens Hospital of Orange County Breathmobile Program 

It’s not quite a house call, but a visit from the 38-foot “Breath Mobile” represents an old school devotion to bringing care directly to patients. The idea has roots in Los Angeles, but Stanley P. Galant, MD, made it a reality in nearby Orange
County, California.

As medical director of the Children’s Hospital of Orange County (dubbed CHOC Children’s) Breathmobile, the 75-year-old Galant has used his considerable experience to bring expert medical care to children who have little or no attachment to physicians or even clinics. “Our target is the underserved child with asthma,” says Galant, a board certified allergist/asthma specialist. “These kids may have Medicaid insurance, called Cal Optima, or they are simply uninsured. Whatever the case, we do not turn anybody away if there is a need.”

In pitching the idea to CHOC Children’s more than a decade ago, Galant sought to address the familiar problem of access to preventive care—a scenario that routinely leads to costly emergency room visits and hospitalizations. Hospital officials readily embraced the concept and schools, community clinics, and community centers soon benefited from the mobile model.

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These days, two “Winnebago-like” vehicles each have a staff of three composed of a driver/administrative person, a nurse, and a health care provider. The vans visit 24 sites every 4 to 6 weeks to all points north and south.

Each patient receives a detailed history and physical, skin test, and breath test (spirometry). “We save a lot of money for payors because the kids don’t end up in the hospital,” says Galant, who also serves as a clinical professor of Pediatrics at
the University of California, Irvine. “Most importantly, the quality of life improves for patients and parents alike.”

Interacting with a minority group of mostly Mexican Americans means that most Breathmobile workers speak both Spanish and English. According to Galant, this “culturally compatible” bilingual approach ensures that nothing is missed in the vital communication process.

Consistent communication through continuity of care is attained by going to the same site every 4 to 6 weeks to follow-up with patients. “It takes three visits to reach asthma control,” explains Galant. “Patients see the same health care provider,
nurse, and driver, so there is bonding and trust.”

Galant estimates his Breathmobile has helped close to 10,000 patients over the last 11 years. All interactions are tracked, and results thus far have been worth the cost. “Everything we do is recorded into a computer program called Asma Trax, and we
have been able to produce metrics or outcomes that are impressive,” he says. “Among these patients, we have helped cut down ER visits and hospitalizations by approximately 60%. We have decreased school absenteeism by over 70%.”

Galant has been keen to systematically collect the data and present the results at local and national conferences. In terms of education, he set up an allergy/immunology/asthma elective. Pediatric residents,pharmacy residents,and nursing have spent
time in the “floating classroom”—a symbiotic relationship that provides in-the-trenches experience and expert care for patients.

Fight for Funding

Despite the mobile unit’s undeniable success, funding has been the biggest challenge. A small percentage comes from Medicaid, but the rest is cobbled together through a variety of 1- to 2-year grants. Galant spends many hours with staff pouring
over grant paperwork—tedious work to be sure—but necessary for the program’s continued success.

Actual home visits are occasionally done by the Breathmobile, a special concession for children who are an especially high risk of hospitalization. “Education is the critical piece here,” says Galant. “We’ll go wherever the need is. That is the beauty of mobility. The good side is mobility and accessibility. The bad side is it is extremely expensive. There are no economies of size. We are it when we go out there, and we must have a full complement of staff. It is a sizable financial burden.”

Galant has more of a managerial role these days, but he still goes out on the “van” under certain circumstances. “I am training some allergy fellows, and I am going with them to go over the cases,” he says. “I have gone out three times in April 2013, and I fill in when my docs are ill or on vacation.

“In spirit, I am working on the Breath Mobile 24/7,” continues Galant, who retired from clinical practice 6 years ago. “I work a lot from home, so I’m in constant contact with my staff. I help write grant proposals, papers, and work on curricula for CHOC/UC Irvine Pediatric residents. I come to the office about two days a week, and I’m on the phone quite a bit. I also play the violin and I’ve been married for 53 years. I would work more, but my wife would like to see me occasionally.”
Fight for Funding Past, Present, and Future: Q&A with a Trailblazer

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What Breath Mobile cases stand out in your memory?

SG: MD, medical director of the Children’s Hospital of Orange County Breath Mobile, a 38-foot “Winnebago-style” medical van that visits schools, CHOC community clinics and community centers to administer preventative asthma care: I was on the van
about a month or two ago, and this 17-year-old kid came in with his mother. He is a star football player at one of the high schools. His problem was he couldn’t exercise adequately, even though he’s playing football. He had a lot of trouble on and off the field. He and his mother came aboard the Breath Mobile. His mother looked at me and asked, “Are you Dr. Galant? Do you remember me?” It turns out I took care of her son when he was two years old. She explained that he was well for a number of years and she had always remembered me. She gave me a big hug and took my picture with her son. He also gave me a big hug.

I convinced him that if he wanted to be the star athlete he was capable of being, he should take his medication regularly. I had seen him 15 years ago, and fate had it that I was on the van the day he came aboard. I’ve been doing this since 1970 when I was board certified, and those kinds of things are known to happen. This was a very emotional moment for me.

How far can this mobile concept go?

SG: I think it can and will be part of programs to reach disenfranchised populations. I think the van is an entree into the community. If you do it right, you can successfully provide access to specialty care, and you need specialty care particularly for chronic diseases.

How viable is the 38-foot Breath Mobile from a financial standpoint?

SG: The van can give a good return on investment, because it’s the only way of consistently reaching the disenfranchised population—which is enormous. It can prevent many people from going to emergency rooms for costly visits. It’s money now for money later. It is the future.

Why is the Breath Mobile so important in tough economic times?

SG: Well, even if the economy turns around, there’s always going to be a large cadre of disenfranchised people. If you go to where they live, which the van can do, you’re going to have much better results. And if they see the same personnel each time, that engenders a lot of trust. You don’t get that now in medicine. You don’t know who the doctor is going to be for that day. It could be anybody. They don’t know you, and you don’t know them. That’s a problem.

What is your opinion of modern health care?

SG: Well, we talk about disparities in health care, and I think medicine is as much social as it is medical. At Children’s Hospital of Orange County we do things very well, so I’m just talking philosophically about what I see with different plans and the way medicine has been going for the last 30 to 40 years.

What is your opinion of modern health care?

SG: Well, we talk about disparities in health care, and I think medicine is as much social as it is medical. At Children’s Hospital of Orange County we do things very well, so I’m just talking philosophically about what I see with different plans and the way medicine has been going for the last 30 to 40 years.

What is the state of the doctor-patient relationship these days?

SG: There has been a real disconnect between the patient and the doctor with all kinds of intermediaries. There is little trust and bonding. That’s as much a part of medicine as is giving the medication. It’s particularly important for chronic disease like diabetes, asthma, and arthritis where you need a bond between patient and doctor.

What are the limitations of this kind of care?

SG: You’re asking a biased person, because I love the program. I think it’s a great idea, but it does have limitations. We only see 8 to 10 patients a day, because part of the 8 hours is drive time, and some of the distances are pretty long, and then the school shuts down at about 2:00 or 3:00, so you can’t stay later. We’ve initiated some Saturday morning clinics and some later afternoon clinics, but it is limited. You can’t see 30 patients. When I was in private practice as a specialist, I
might have seen that many in a day.

Can the mobile concept apply to medical problems besides asthma and/or respiratory concerns?

SG: Fifty to sixty percent of the kids we see on the van are either overweight or obese. It’s a major problem. This is primarily a Mexican-American population, which is known to have a high prevalence of obesity. We have a perfect model for looking at obesity because we do all the things you need to do for obesity management. We go where they live. We go to the same site every 4 to 6 weeks. We do home visits, and we spend a lot of time on education. I think I may be able to expand the van from just asthma to asthma/obesity. I am optimistic.

How big is the mobile concept nationwide?

SG: There are over 2,000mobile medical vans in the United States. Harvard did a study with their van where they did a lot of preventative care that dealt with blood pressure, blood sugar, and cholesterol. They figure there is a big return on investment, and their data shows it was very effective. If you don’t catch diabetes or high blood pressure, morbidities are enormous.

This is a nationwide movement, not just with the Breath Mobile, but for other outreach programs that go into the community to reach a population that ordinarily does not get medical care. Ultimately, it is a very attractive model.

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  1. The relationship of the bronchodilator response phenotype to poor asthma control in children with normal spirometry. Galant SP, Morphew T, Newcomb RL, Hioe K, Guijon O, Lian O. J. Pediatr. 2011 Jun;158(6):953-949.e1
  2. Lung function measurement in the assessment of childhood asthma: recent important developments. Galant SP, Nickerson B.
    Curr Opin Allergy Clin Immunol. 2010 Apr; 10(2): 149-54 doi: 10.1097/ACI.0b013e328335cd48
  3. The Breathmobile: a novel comprehensive school-based mobile asthma care clinic for urban underprivileged children. Liao O, Morphew T, Amaro S, Galant SP. J Sch Health 2006 Aug; 76(6):313-9

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SleepImage Keeps it Simple


With cardiopulmonary coupling (CPC) technology, the makers of SleepImage are reaching a diverse audience of clinicians and patients who want and need a better way to measure sleep quality.

When clinicians of various stripes are able to set aside turf wars and reimbursement concerns, it turns out that many want a simple, low-cost, and objective way to measure sleep quality. David Baker, president and CEO of SleepImage, knows this because he has talked to countless members of the medical community while traveling in the United States and beyond.Enthusiasm among so-called “integrative docs” has been particularly high, with NDs, DCs, and other complementary practitioners embracing the notion that good sleep is critical to overall health. “They really understand what SleepImage can do for their patients,” says Baker, an engineer by trade who many know as the former CEO of Embla® Sleep Diagnostics. “These docs know that patients will pay for a test to look at overall sleep quality if it means validating the extent of their problem, which may or may not require a PSG or Home Sleep Test, which most of the time is really just a Home Apnea Test since they primarily focus on apnea.” Many of these cash-savvy patients pay out of pocket because they want to find out what is “really wrong” with them. Thanks to a holistic perspective, integrative and even traditional docs are bringing sleep into the conversation because they increasingly view sleep as a vital sign of human health and now have a way to measure it simply and easily.

CPC Technology Drives Data

At the core of the diminutive SleepImage device is proprietary cardiopulmonary coupling (CPC) technology that measures sleep quality through breathing and heart rate patterns known to indicate stable, healthy sleep versus unstable, unhealthy sleep.
During healthy sleep, the heartbeat and respiration have a very characteristic pattern and “couple” together giving a very clear “Image” of healthy sleep.

Unhealthy and unstable sleep is very evident on this Image, as the heart rate and respiratory rate are coupled with one another. SleepImage measures the coupling and displays this information in a graph that gives clinicians a simple picture or image of patients’ sleep quality. The graph is essentially a data-driven scale called the Sleep Quality Index™ (SQI).

The first real clinical evaluation of SleepImage was done in 2005 by Robert Thomas, MD, MMSc, and fellow researchers at Beth Israel Deaconess Medical Center, a teaching school of Harvard University. Since then, numerous other studies have demonstrated the clinical validity of CPC.

The sheer volume of validation studies is made possible by the existing technologies that work well with CPC. “Because we are using ECG, a measure that is commonly used among many sleep labs, we can actually look at anonymous data from thousands of patients from partnering sleep labs,” explains Baker. “Running our algorithm through the existing data that sleep labs
collected allows us to do far more research.”

In addition to the vast adult population that can readily use SleepImage, a pediatric doctor in Oklahoma is looking at using SleepImage on pediatric patients—including those with disabilities such as Down’s Syndrome. Its design is unobtrusive, making it an ideal choice for this patient population. “The science behind SleepImage is solid,” says Baker, “and it has a broad spectrum of application.”

Sleep Clinic or Apnea Lab?

David Baker believes that the much-hyped estimates of undiagnosed sleep apnea patients are real. Patients are out there, and they are suffering from more than just sleep apnea. And while SleepImage identifies apnea, it is more concerned
with the overall picture that encompasses additional sleep-related disorders—as well as the business side of running a sleep lab.

Astute marketing of screening services to referral sources can potentially generate numerous additional patients. Identifying more patients who require full PSG is one possible consequence of additional screening. Validating the necessity of e-titrating (post therapy) is yet another possibility. Ultimately, sleep lab administrators who seek to expand the pool of
patients can partner with a wide range of sleep specialists for a multi-disciplinary approach.

As a crucial element of overall wellness, Baker and Kristen Hitner, Marketing Director at SleepImage, also believe that sleep quality can continue to work its way into corporate programs designed to foster healthier employees. “Occupational health is growing trend,” says Hitner. “Fortune 500 companies are more and more interested in employee wellness programs, and we are going to target the companies that wish to test sleep as part of those programs.”

“Truck drivers get a lot of attention, but the reality is that with truck drivers it is usually only apnea that is being looked at,” adds Baker. “But proper sleep is not just about upper airway resistance. Everybody is going to sleep poorly for lots of different reasons. SleepImage is one of the only devices that actually measures whether or not a person is sleeping well—whether it was because of pain, apnea, or insomnia.”

“SleepImage will help identify sleep disruption, and most importantly help people manage it,” continues Baker. “A far better measure for any occupational health efforts, whether it’s a truck driver, ship’s captain, or airline pilot.”

“SleepImage is one of the only devices that actuallymeasures whether or not a person is sleeping well whether it was because of pain, apnea, or insomnia.”


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