"Year in Review" Meghna P. Mansukhani (03.17.2021)
March 22, 2021ID6310
To CiteDCA Citation Guide
- 00:05And Magna you may see people
- 00:07just coming in during the talk.
- 00:09You don't have to admit everybody
- 00:11Debbie and I'll take care of
- 00:12letting everyone into this session.
- 00:14Sounds good, but sometimes
- 00:15you you do see those pop up.
- 00:17So I'm sorry if it's a little
- 00:19distracting. No, no, that's a.
- 00:29Alright, hi everyone,
- 00:30we're going to get started.
- 00:32I am Lauren Tobias.
- 00:33We're back after a hiatus for a few
- 00:35weeks here and I'd like to welcome you
- 00:38to our sleep seminar this afternoon
- 00:40if you brief announcements before
- 00:42I introduce today's speaker first,
- 00:44please take a moment to ensure
- 00:46that you're muted in order to
- 00:48receive CME credit for attendance,
- 00:50you can see this chat room for instructions.
- 00:53You can text the unique ID for this
- 00:56conference anytime until 3:15.
- 00:57If you're not already registered with,
- 00:59you'll see me.
- 01:00You will need to do that first,
- 01:02and if you have any questions
- 01:04during the presentation,
- 01:05I encourage you to make use of the
- 01:07chat room 3 throughout the hour.
- 01:09We will have recorded versions of these
- 01:12lectures available online within two
- 01:13weeks at the link provided in the chat.
- 01:15And finally,
- 01:16please feel free to share announcements
- 01:18for our electric series with anyone
- 01:20who you think may be interested,
- 01:22or contact Debbie Lovejoy to
- 01:23be added to the email list.
- 01:25So this afternoon I am delighted
- 01:27to introduce Doctor Megna.
- 01:28Monster Connie did provide us with
- 01:30a year in review of Sleep Medicine.
- 01:33Doctor Monster Connie is a professor
- 01:35of family medicine at the Mayo
- 01:37College of Medicine and Science and
- 01:40a consultant with joint appointments
- 01:42under both Family Medicine and
- 01:44pulmonary critical care Medicine at
- 01:46the Mayo Clinic in Rochester, MN.
- 01:48She Co directs the Center for Sleep
- 01:51Medicine at Mayo and serves as
- 01:53program director for their Sleep
- 01:55Medicine Fellowship program.
- 01:57She is a tremendously accomplished clinician
- 01:59educator who has received multiple awards.
- 02:02For excellence in teaching has
- 02:04taught and mentored medical trainees
- 02:06at all levels of education,
- 02:08as well as practicing physicians,
- 02:10sleep and otherwise nationally
- 02:11and internationally.
- 02:12She's been very active within the
- 02:15American Academy of Sleep Medicine,
- 02:17where she is currently chair
- 02:19of the Education Committee,
- 02:21and she's played a fundamental role in
- 02:23curriculum and course development there,
- 02:25including questions for their review course,
- 02:28and she founded the ASM Mentor program
- 02:31that matches trainees and mentors.
- 02:33Throughout the world.
- 02:34Her research has included topics ranging
- 02:37from the role of sleep disturbance in
- 02:39patients with depression and alcohol
- 02:41use disorder to the relationship
- 02:43between sleep apnea and chronic opioid
- 02:46use to the link between sleep apnea
- 02:48and car hypertrophic cardiomyopathy.
- 02:50Dochtermann sekani is one of those
- 02:53consummate Sleep Medicine practitioners
- 02:55who has a broad overview of the entire field,
- 02:58so I think she's a perfect
- 03:00person to give today's talk.
- 03:02She's going to give us an overview of.
- 03:05Important updates in Sleep
- 03:06Medicine over the past year,
- 03:07so please join me in giving
- 03:09her a warm welcome.
- 03:10And with that I'll turn it over to you.
- 03:15Thank you so much,
- 03:16Doctor Tobias for inviting me and
- 03:19for that very kind introduction.
- 03:21I'm so happy to be here and
- 03:23present the year in review 2020.
- 03:26I really like your interviews.
- 03:28I hope you do too.
- 03:30A lot of information and a lot
- 03:32of work but also not a fun.
- 03:35So let's dive in.
- 03:38No disclosures that are relevant.
- 03:42And this is the CME code. For today.
- 03:48For those of you on the phone,
- 03:52it's 21612 again.
- 03:56That's 21612.
- 03:58Alright,
- 03:58so the objectives today are to
- 04:01discuss relevant articles in Sleep
- 04:03Medicine published last year,
- 04:04so we're going to identify the
- 04:07main objective for each study and
- 04:09the population that was studied
- 04:11and then quickly critique the
- 04:13major strengths and limitations
- 04:15of each of the studies at Mayo.
- 04:18We're not allowed to use
- 04:20Journal article figures anymore,
- 04:22which was fine because the bullet
- 04:24point summarizes a figure quite quickly,
- 04:27so I have.
- 04:28All the ICS, these sleep disorders,
- 04:31one study on each of them.
- 04:33Plus I threw in a couple special
- 04:36topics that were important last year
- 04:39COVID-19 and disparities in sleep health.
- 04:42And then I have one basic science Paper,
- 04:451 technology paper,
- 04:47an one pediatric sleep disorders
- 04:49paper because the others are
- 04:52conducted in adult populations.
- 04:54Alright,
- 04:55so the first topic is COVID-19 and
- 04:58sleep and this was a study that
- 05:01was published in Sleep Medicine.
- 05:04Owls and larks do not exist.
- 05:07So the question that this
- 05:09study aimed answer was,
- 05:10is there a difference between
- 05:12daily sleep habits in the
- 05:14normal operational environment
- 05:15versus a stay at home condition?
- 05:18And to answer this,
- 05:19they conducted a prospective study
- 05:21that looked at questionnaires,
- 05:22logs and phone and zoom interviews in
- 05:25healthy volunteers aged 15 to 60 years,
- 05:28who would receive stay at home orders
- 05:30for over a month and they shouldn't
- 05:33have had any sleep disorders or mood
- 05:36symptoms to enter into the study.
- 05:39And shouldn't have been in any online
- 05:42daily timetable related activities an it
- 05:44was performed across various countries.
- 05:47So.
- 05:49This study had close to 4000 subjects
- 05:51who were at home for over 2 months,
- 05:54and it appeared that most of the
- 05:57changes happened in the first 10 days,
- 05:59meaning the difference between the
- 06:01weekdays and weekend night time sleep.
- 06:04That disappeared and pay.
- 06:06People started napping.
- 06:08Interestingly,
- 06:08most folks 2/3 shifted towards
- 06:11even eveningness,
- 06:12where the word half being
- 06:15classic ALS some shoulder.
- 06:17Typical sleep pattern.
- 06:19Only 22% somewhere lurks somewhere
- 06:21completely desynchronized and some
- 06:24alternated their sleep habits.
- 06:26The ones who were desynchronized
- 06:29tended to be older an Mail.
- 06:33So the conclusion from this study was
- 06:35that in self selected sleep conditions,
- 06:38such as with prolonged stay at
- 06:40home orders secondary to covid,
- 06:42sleep habits significantly differed
- 06:43from those of socially and economically
- 06:46fixed daily routine conditions.
- 06:47To me,
- 06:48this study was very interesting.
- 06:50There were a lot of covert studies
- 06:53that came out last year.
- 06:54There's a whole issue devoted to
- 06:57it in JC Assam from February.
- 06:59Of course this is that is this year,
- 07:02but it was interesting.
- 07:04And also an interesting finding
- 07:05was that the Desynchronized Group
- 07:07did not have any sleep complaints,
- 07:10which would be different from what we
- 07:12would see in our circadian sleep disorder.
- 07:15Patients who present to clinic.
- 07:18So what are the limitations of this study?
- 07:21Well, it's a one time snapshot itself report.
- 07:25There could be variation by country,
- 07:27by sunlight, exposure,
- 07:28effects of religion with praying in the
- 07:31middle of the night in some of the countries,
- 07:35the effect of alcohol and
- 07:37substances was not accounted for,
- 07:39and it's not generalizable to you know
- 07:41healthy outside of the healthy volunteer
- 07:44population that was studied here.
- 07:46Without psychiatric and sleep disorders.
- 07:49So we move on to the second study,
- 07:53which is on disparities in sleep help.
- 07:56And this is a Jackson heart
- 07:58study that was published in the
- 08:01American Journal of Hypertension.
- 08:03So the objective here was to
- 08:06study the Association between
- 08:07obstructive sleep apnea in nighttime,
- 08:10blood pressure in African Americans.
- 08:12As you know, both of these conditions,
- 08:15sleep apnea and hypertension are very common.
- 08:19In this population.
- 08:20So for this study they enrolled
- 08:23206 participants who had 24 blood
- 08:26pressure monitoring 24 hour.
- 08:28In 2000 to 2004,
- 08:30and then subsequently participated
- 08:32in the Jackson Heart,
- 08:34Jackson Heart Studies,
- 08:36the Sleep Study portion
- 08:38of it in 2012 to 2016,
- 08:41and they did age sets with a 4%
- 08:45REI and calculated time below
- 08:4890% nocturnal hypertension,
- 08:49defined as 120 slash 70 or greater and
- 08:53performed linear regression models
- 08:56to test the Association between.
- 08:58OSA and nocturnal systolic
- 09:01and diastolic blood pressure.
- 09:04So 51% of.
- 09:06These subjects had nocturnal hypertension
- 09:08and 26% had moderate to severe OSA,
- 09:12and it's at an after adjustment.
- 09:15Each standard deviation,
- 09:16which was a 13 per hour increase in the REI,
- 09:21was associated with a 2 millimeter higher
- 09:24nighttime diastolic blood pressure.
- 09:26Anna prevalence ratio of 1.1
- 09:29for nocturnal hypertension.
- 09:31What about time below 90% each standard
- 09:34deviation increase in hypoxemia,
- 09:36which was a 10% increase.
- 09:38Or should I decrease from baseline was
- 09:41associated with a 2 millimeter higher
- 09:44systolic blood pressure at night?
- 09:47And seemed to be more so an obese
- 09:50individuals but not statistically
- 09:53significant.
- 09:53So what were the conclusions of this study?
- 09:56First of all,
- 09:58high prevalence of nocturnal hypertension.
- 10:00On dipping blood pressure,
- 10:02I'm sure most of you know what that is.
- 10:05An moderate to severe OSA.
- 10:07In this population the severity
- 10:09of sleep apnea and hypoxemia was
- 10:11associated with high nighttime blood
- 10:13pressure in a dose response manner,
- 10:15and so the results supported the
- 10:17use of ambulatory blood pressure
- 10:19monitoring routinely in this population.
- 10:21So this is the first study actually
- 10:24looking at this Association in
- 10:26this population,
- 10:27and they stated that having more women
- 10:29was a limitation, but again, this.
- 10:32Is in contradistinction to the previous
- 10:34literature on hypertension sleep apnea,
- 10:36so I thought that was good standardized
- 10:38protocol that they used and
- 10:40accounted for multiple confounders.
- 10:42Now what are the limitations?
- 10:44It might not be generalizable
- 10:46to other populations,
- 10:47such as those with lower
- 10:49socioeconomic status.
- 10:49They had single measures and a
- 10:51small number of the Jackson help up
- 10:54place and actually completed both.
- 10:56Both of these, the blood
- 10:58pressure and sleep measures,
- 11:00and they were ten years apart.
- 11:05All right, shifting gears and moving to
- 11:08basic science this I found interesting.
- 11:11This study was published in the
- 11:14Journal of Physiology last Year and
- 11:17the question was is opioid induced
- 11:20respiratory depression and lethality in
- 11:22sleep apnea related to bouts of chronic
- 11:25intermittent hypercapnic hypoxia?
- 11:27So what they did is they measured
- 11:30respiratory depression across rats that had.
- 11:33Well, normoxic normal oxygen saturation
- 11:35was his those exposed to hypoxia
- 11:38for 8 hours a day for a week and
- 11:40they recorded phrenic nerve activity
- 11:43and quantified burst inhibition.
- 11:45Phrenic nerve activity to graded
- 11:47doses of fentanyl that was given Ivy.
- 11:50So if you want to read the what actually
- 11:54happened to the phrenic nerve activity,
- 11:56you can read the paper.
- 11:58But summarized here are the results.
- 12:01The rats that were exposed to chronic.
- 12:04Bouts of hypoxia for a week showed an
- 12:07exaggerated respiratory depression response
- 12:09to fentanyl both while anesthetized as
- 12:12well as while breathing spontaneously,
- 12:15so this study showed a heightened
- 12:18CNS inhibitory efficacy of fentanyl,
- 12:21but also there was tonic and Agenus
- 12:24opioid suppression of neural inspiration,
- 12:26so this was the first study showing
- 12:29a possible mechanism for respiratory
- 12:32depression, an increase mortality.
- 12:34That is seen in patients with
- 12:36sleep apnea on opioids.
- 12:37Of course, the study needs to be replicated.
- 12:42OK, so moving on to sleep technology.
- 12:47This was a study again,
- 12:49pretty relevant to our practice nowadays.
- 12:52Is looking at performance of watch packed
- 12:55and this was published in JC ** so.
- 12:59They attempted to answer the question
- 13:01how does watch Part 200 compare against
- 13:05Polysomnogram Polysomnographers?
- 13:06He in a clinic based cohort so they had 500
- 13:10patients with suspected OSA at the Atlanta,
- 13:14VA,
- 13:15mostly male,
- 13:15mostly black and very few studies were
- 13:18excluded as technically inadequate.
- 13:21This was performed from 2018 to 2020.
- 13:24Now most patients were sleepy as
- 13:27judged by the essm they were.
- 13:30Was Heiko mobility Burden and they use
- 13:33the 3% or arousal which is the recommended
- 13:36scoring rule for high pop nears?
- 13:39Interestingly,
- 13:40they did not exclude patients with
- 13:43atrial fibrillation or heart failure,
- 13:45so the median PSG HI was 18 and
- 13:50watch pad 3% HI was 25 and so it
- 13:55overestimated it compared to PSG,
- 13:57the diagnostic concordance was
- 14:00higher in the category of those
- 14:04judged to be severe by PSG.
- 14:07Now,
- 14:07what about the ones that turn
- 14:10out to be mild on the watchpad?
- 14:13What it PSG show?
- 14:15Well,
- 14:16PSG showed no OSA in 30% an actually
- 14:19moderate to severe OSA in 20%.
- 14:23So the watchpad 3% using the 3%
- 14:26rule over estimated prevalence and
- 14:29severity by about four per hour.
- 14:32Then they also use the 4% rule on
- 14:36the watchpad again comparing with the
- 14:39recommended hypopnea rule on PSG.
- 14:41So not really comparing apples to apples.
- 14:45But anyway,
- 14:46as expected that under estimated
- 14:48it by 6 per hour.
- 14:50So what were the conclusions of this study?
- 14:54There was an overall tendency of watch
- 14:57Pat to overestimate severely and a
- 15:00significant percent had clinically relevant.
- 15:03Misclassifications there was
- 15:05more discrepancy with the RTI,
- 15:08possibly relating to the algorithm
- 15:10that the watch Pat uses for arousals,
- 15:14and this study showed much lower correlation
- 15:17than we've seen in previous studies.
- 15:21So the authors suggested that we
- 15:23use a 4% threshold on the watchpad.
- 15:26Given that it has a much higher specificity.
- 15:30But then if it's negative,
- 15:32definitely consider performing a PSG.
- 15:35The advantages of the study of
- 15:37the strengths of the study were
- 15:39that the data will complete.
- 15:41It was blinded.
- 15:42The patients with triage very well.
- 15:44Of course, it was not a randomized study.
- 15:47The watch parts were not
- 15:48manually over scored.
- 15:50This is a single center study
- 15:52with limited generalizability.
- 15:55Alright, so this what next topic next
- 15:58article is on the topic of Insomnia
- 16:01was a little hard to sift through,
- 16:05but very interesting and important
- 16:07article that came out in JAMA Psychiatry.
- 16:11Published by Maureen at all.
- 16:14So the questions were what should the
- 16:17first line treatment of insomnia be?
- 16:20An how to proceed when that fails?
- 16:23Also, is there a moderating effect of
- 16:27psychiatric comorbidity on the outcomes?
- 16:29So for this they performed a
- 16:32sequential multiple assignment RCT of
- 16:35200 patients with chronic insomnia.
- 16:38Most were women, middle aged.
- 16:40They were randomized to behavioral
- 16:43treatment or dissolve them.
- 16:45After being stratified by age,
- 16:48*** and psychiatric Co mobility.
- 16:51Then those that did not remit to
- 16:54the first line with the first line
- 16:57treatment went into the medical.
- 17:00ARM, which was zolpidem or Trazodone,
- 17:03or they went into the psychological
- 17:05treatment arm,
- 17:06which was behavioral treatment
- 17:09or cognitive treatment therapy.
- 17:11And this was performed at two
- 17:13sites in Canada and in Colorado.
- 17:16An enrollment took place between
- 17:182012 to 2017,
- 17:19so 1/3 of the cohort had
- 17:22comorbid anxiety or depression.
- 17:242/3 of the cohort had other
- 17:26medical comorbidities.
- 17:27The primary outcomes they were
- 17:29looking at were the first treatment
- 17:32responder in remission rates,
- 17:34as judged by the Insomnia Severity
- 17:36Index and the secondary endpoint were
- 17:39the other Sleep diary data points.
- 17:42There were multiple follow up
- 17:44points and they finally looked at.
- 17:46The 12 month follow-up visit
- 17:49was the last one,
- 17:52so initially responder rate was
- 17:5446% versus 50% equivalent with
- 17:57behavioral treatment and zolpidem,
- 17:59you can see the confidence
- 18:02intervals crossing one there.
- 18:04How about remission rates 38% versus
- 18:0830% with behavioral and zolpidem?
- 18:12Then we move on to second stage.
- 18:15There was an increase in the
- 18:17percentage of remitters when you
- 18:19went from behavior to zolpidem in
- 18:21zolpidem to Trazodone meaning to
- 18:23the medications and the remission.
- 18:25Rates were lower in those who
- 18:27had psychiatric comorbidities,
- 18:28but Interestingly,
- 18:29they did better if they stayed
- 18:31with the same modality.
- 18:33Meaning in the behavioral arm
- 18:35or in the medical domain.
- 18:36Medicine to medicine so.
- 18:39DST total Sleep Time was better
- 18:41with medications,
- 18:42but most of the other endpoints
- 18:45improved with behavioral treatment and
- 18:48this if these effects were maintained
- 18:50at the 12 month follow-up point.
- 18:53So what were the conclusions of this study?
- 18:57Behavioral treatment and zolpidem
- 18:58initially produced equivalent
- 19:00response and remission rates.
- 19:02Pretty good if you add up the
- 19:05responders and remission was 50 to 75%,
- 19:08addition of a second treatment
- 19:10produced added value for those
- 19:13who failed first line treatment.
- 19:16The best sequences in Ward behavioral
- 19:18treatment first followed by
- 19:20cognitive or zolpidem treatment.
- 19:22So what were the strengths of this study?
- 19:25So these questions have
- 19:28not been answered before.
- 19:30The problem is that in in
- 19:33clinical practice we do CBT.
- 19:35We don't necessarily do BT or CD separately.
- 19:38There was no control group.
- 19:40If you look at the various combinations
- 19:42of sequences that were the different
- 19:45sequences that were followed,
- 19:46number of patients in each of
- 19:49those categories were small.
- 19:50Women actually received 5
- 19:52milligrams of zolpidem, no higher.
- 19:54The men received 10 milligrams,
- 19:55so that may have affected the results,
- 19:58and so the conclusion was.
- 20:00Future studies should aim to match patients
- 20:04with their preferred form of treatment
- 20:07in consider the insomnia phenotype.
- 20:09Alright, so moving next to sleep apnea.
- 20:14So this study made it to Java
- 20:17effect is called the Sam's RCT.
- 20:20In short, and the question they attempted
- 20:23to answer is is combined palate and tongue
- 20:27surgery effective for patients with OSA
- 20:31who have failed first line treatment.
- 20:33So this was a multicenter parallel
- 20:36group open label RCT of surgery versus
- 20:39medical management of 102 patients
- 20:42who had moderate to severe OSA.
- 20:45Anne, who had failed either C Pap
- 20:48or an oral appliance so middle aged
- 20:51individuals may 18% only being women
- 20:54conducted at 6 sites in Australia.
- 20:57Enrollment took place between 2014
- 20:59to 2017 and patients were followed
- 21:02up to six months,
- 21:04so 51 in the modified UPP
- 21:07plus tongue reduction arm.
- 21:10And 51 in the medical management arm.
- 21:14The primary outcomes they looked
- 21:16at were hi an SS and they looked
- 21:19at number of secondary outcomes.
- 21:2189% of patients completed the trial.
- 21:23So what happened to hi?
- 21:25Hi,
- 21:26went from 48 to 21 in the surgical group.
- 21:29Not much change in the Medical
- 21:32Group between the two groups.
- 21:34The difference was 18 power.
- 21:36ESS went from 12 to five in
- 21:39the surgical group and remain
- 21:41unchanged at 11 in the Medical
- 21:43Group between group Difference 7.
- 21:45So there were improvements in all
- 21:48most of the secondary outcomes in two
- 21:51patients had serious adverse events.
- 21:53So their conclusion was that
- 21:57combined typing surgery may be used
- 22:01to treat patients who have failed
- 22:03conventional treatment for sleep apnea.
- 22:05It was rigorously done study.
- 22:07They standardized technique across this.
- 22:09All the surgical sites in the surgeons
- 22:11were trained to do the same procedure.
- 22:14They recruited those who fail.
- 22:16Standard treatment was simple
- 22:17preop assessment and they looked
- 22:19at patient centered outcomes.
- 22:23So um lot. More on this study in
- 22:26terms of strengths and limitations
- 22:28resulted in an editorial for Jamaan,
- 22:30so it dug into it quite a bit.
- 22:33Middle aged obese patients compared to what
- 22:36you would normally refer for surgery and
- 22:39they actually expanded their BMI criteria
- 22:41'cause they didn't have enough patients.
- 22:43Initially they use the 3% the saturation
- 22:46criteria, which might be different
- 22:48from what you're using in your lab.
- 22:50So you're looking at higher H hi's here.
- 22:54Greater improvement in Essm, but there
- 22:56was no blinding or placebo control group.
- 22:59And if you do the math in the paper,
- 23:0357% were actually left with an H,
- 23:06I-15 or higher, and there was no effect
- 23:09on hard outcomes like hypertension.
- 23:12So the selection criteria for which patients
- 23:15might benefit the most need to be refined.
- 23:18We need studies with women and
- 23:21minorities on longer term efficacy.
- 23:23Um?
- 23:26The effects of weight and age
- 23:28may play a role in the long term,
- 23:31and also comparative trials against
- 23:33maxillomandibular advancement.
- 23:34An upper airway stimulation or inspire.
- 23:39Alright, I don't know if we
- 23:41can do this on zoom or not,
- 23:44but I had a couple of questions
- 23:47that I threw in there.
- 23:49We might just skip that and
- 23:51I give you the answer.
- 23:5310% increase in nighttime oxyhemoglobin
- 23:55saturation associated with a 2
- 23:57millimeter increase in blood pressure
- 23:59with systolic blood pressure for oxygen
- 24:02saturation in the Jackson Heart study.
- 24:07Alright. Next we have the
- 24:12second half of the talk and.
- 24:16We moved to central disorders of
- 24:19Hypersomnolence, so this was a
- 24:22study published in JC ** last year.
- 24:26And the question was do RAM
- 24:30suppressing antidepressants
- 24:31indeed affect MSL T results?
- 24:33So for this study,
- 24:35we enrolled adult patients who are
- 24:38undergoing MSL tease for the indication
- 24:42of daytime sleepiness at Mayo
- 24:45Clinic Rochester from 2014 to 2018,
- 24:48and the clinical data the test
- 24:51results were all manually abstracted.
- 24:55Primary outcomes were mean sleep
- 24:57latency and number of saw ramps in those
- 25:00who discontinued these medications
- 25:02versus those who remained on him,
- 25:04and regression analysis were
- 25:06done accounting for confounders.
- 25:09502 patients were included.
- 25:11Mean age 38, mostly women and more
- 25:14than a third were on RAM antidepressants.
- 25:18REM suppressing antidepressants.
- 25:20An it was discontinued in a majority
- 25:24of these patients.
- 25:26So those who discontinued their
- 25:29ramp suppressing any depressants,
- 25:31were more likely odds ratio of 12.
- 25:36To have two or more storms versus those
- 25:38who did not discontinue the medications,
- 25:41they were also more likely
- 25:43to have a shorter MSL.
- 25:45Versus those who did not.
- 25:48Higher odds of two Sorum,
- 25:50so more versus those who were
- 25:52never on these medications,
- 25:54and the differences persisted
- 25:56after accounting for confounders.
- 25:58So the conclusion?
- 25:59Of the study was that patients who
- 26:03taper of REM suppressing antidepressants
- 26:06are more likely to demonstrate to
- 26:10a more sore imsan shorter MSL.
- 26:12So pending prospective investigations,
- 26:15the authors concluded that clinicians
- 26:17should preferably withdraw REM
- 26:20suppressing antidepressants where feasible.
- 26:22Otherwise,
- 26:23an interpretation should include the
- 26:27statement regarding the potential
- 26:30effect of these drugs on the results.
- 26:33So this was the first study to
- 26:36actually answer these questions and
- 26:38support the ASM recommendations for
- 26:40performance of the conduct of the SLT.
- 26:43A large number of patients
- 26:45near complete data,
- 26:46but it's a retrospective study.
- 26:49There are a few ***** drug
- 26:51screen results missing,
- 26:52and if patients didn't follow the
- 26:54instructions of tapering the medications,
- 26:57there could be potential withdrawal effects.
- 26:59The actual severity of depression
- 27:01was not accounted for.
- 27:03It seems unlikely that if
- 27:05they were severely depressed,
- 27:07they would've been taken off the medication.
- 27:12Alright, so. Then we move on to the next.
- 27:18Study which is on circadian
- 27:20rhythm sleep wake disorders.
- 27:21If anybody wants a break, I know it's pretty.
- 27:24There's a lot of data that we talked about.
- 27:28Just raise your hand in the chat
- 27:30or indicate in some other way and
- 27:33we can take a short break.
- 27:40Can I just remember the quick
- 27:42question? Actually magnets Lauren.
- 27:45Hi, this is wonderful.
- 27:46Thank you it is it is dented,
- 27:49a lot of information but it's great.
- 27:51I was just curious with regard to
- 27:53the JAMA study that you brought up
- 27:55that you had written an editorial
- 27:57for about the combined palatal then
- 27:59tongue reduction surgery in patients
- 28:01who fail kind of first line treatment.
- 28:04Do you know of centers that
- 28:06are doing that here?
- 28:07Because that study, as you mention,
- 28:09was done in Australia.
- 28:11'cause I was pretty impressed to
- 28:13say what I saw that come out.
- 28:15Last year that you know of
- 28:18all the surgical studies that
- 28:19we've had for sleep apnea,
- 28:21that was, I thought,
- 28:23one of the better done ones
- 28:24with impressive outcomes.
- 28:27You summarized it well, Lauren,
- 28:29that is the biggest trend of
- 28:30this study that it was so well
- 28:32done and so rigorously done.
- 28:34I think a big problem here
- 28:36is insurance coverage.
- 28:37You know Orientee surgeons are doing
- 28:39tongue reduction and things like
- 28:40that for indications of snoring,
- 28:42but that's not usually covered here,
- 28:44so I don't know of any centers that
- 28:46are actually doing that combined
- 28:48surgery as of now for the indication
- 28:50of sleep apnea and a large part of
- 28:52it might be insurance reimbursement.
- 28:55Gotcha, thank you.
- 28:57Any other questions before we
- 28:59move on to the next study?
- 29:01It might be good to take a little
- 29:04break and just talk through
- 29:06some things like that.
- 29:08Like Lauren just did.
- 29:14Alright. Nobody alright,
- 29:17we'll go to the next study.
- 29:19So the next study is looking at the
- 29:21effect of patient safety on resident
- 29:24physicians schedule without 24 hour shifts.
- 29:26And this was published in the New
- 29:29England Journal of Medicine last
- 29:31year by the roster Study Group.
- 29:34And what they attempted to
- 29:35answer is what is the,
- 29:37what are the effects of eliminating extended
- 29:41shifts for residents on patient safety?
- 29:43This was a multicenter cluster,
- 29:45randomized crossover trial
- 29:47that compared two feeds,
- 29:48ICU schedules.
- 29:49The control schedule was the 24
- 29:52hour or greater schedule and the
- 29:55intervention schedule was the less than
- 29:5816 Hour cycling day and night shifts.
- 30:00The primary outcome they looked at was
- 30:03serious medical errors and this was
- 30:06determined through intensive surveillance,
- 30:09including direct observation
- 30:10and chart review.
- 30:12So the characteristics of the patients
- 30:15themselves were similar between the
- 30:17two schedules and the number of ICU
- 30:19patients was higher during the intervention,
- 30:22which is the less than 16 hour
- 30:25rotating shift schedule versus
- 30:26the control schedule an actually
- 30:28there were more serious errors with
- 30:31the intervention schedule,
- 30:33which is a less than 16 hour rotating shift
- 30:36schedule and serious errors unit wide.
- 30:39So not just related to residents was
- 30:42higher during the intervention schedule.
- 30:45But there was wide variability among
- 30:47sites and the secondary analysis that
- 30:50adjusted for number of patients per resident.
- 30:54The results were no longer significant.
- 30:59So, contrary to the hypothesis,
- 31:01residents that were randomly assigned
- 31:03to schedules that eliminated extended
- 31:06shifts made more errors.
- 31:08Of course,
- 31:09the effects varied by site.
- 31:11These residents actually
- 31:13obtained more sleep there.
- 31:15Neuro behavioral performance
- 31:16performance improved,
- 31:17but the number of patients that
- 31:19they cared for was higher,
- 31:21so the conclusions of the authors
- 31:24was that workout reduction should
- 31:26not occur without investment.
- 31:28An high workload or poor handoffs could
- 31:31also be detrimental to patient care,
- 31:34so there are a number of studies
- 31:36looking at work hour limitations
- 31:38and patient outcomes,
- 31:40so this adds to the literature but looked at.
- 31:44Things slightly differently and
- 31:47provided some new information.
- 31:49There was definitely variation
- 31:51in data collection by side,
- 31:54so there may have been variation
- 31:56and workload or handoffs or
- 31:59supervision at each of the sites
- 32:01that may have affected the results.
- 32:04An of course there's limited
- 32:07generalizability to non ICU settings.
- 32:12Alright, so study #8 is on
- 32:14parasomnias and this one was published
- 32:17in sleep by Winkleman at all.
- 32:20Topiramate reduces nocturnal eating
- 32:23in sleep related eating disorder or
- 32:26srat as we will call it is devira made
- 32:30an effective treatment for S red is
- 32:33the question that they were trying to
- 32:36answer for this a placebo controlled
- 32:39randomized control trial was done.
- 32:42Of 34 patients who strictly Matt ICS,
- 32:45D Two or three criteria for S ride with
- 32:49symptoms on going more than six months
- 32:52in at least three episodes per week.
- 32:55Flexible dozing of topiramate up to a
- 32:58maximum of 300 milligrams for 13 weeks.
- 33:01The primary outcomes were the
- 33:04percentage of nights with eating and
- 33:07occlusion global improvement scales.
- 33:10Um? I think global impression,
- 33:13improvement, scale mean age was 40 years,
- 33:1774% were female.
- 33:18An mean duration of Srat was 14
- 33:23years in these subjects.
- 33:25So symptoms reduced with topiramate from
- 33:2975% to 33% of Knights versus placebo,
- 33:33and definitely more CGI responders
- 33:36on topiramate 71% versus 27% with
- 33:40placebo all statistically significant.
- 33:43If they were less awake an had
- 33:45less memory of eating at night
- 33:48that actually predicted response,
- 33:50better,
- 33:50the topiramate group lost more weight,
- 33:53about 8 1/2 pounds versus £1.00 with
- 33:56placebo and the most common side effects
- 34:00were paresthesias and cognitive dysfunction.
- 34:03So the conclusions of this study were that
- 34:06this was the first randomized control trial,
- 34:09showing efficacy of the pyramid for ESRD.
- 34:12The effects were seen as early as the
- 34:15first week until they became asymptomatic,
- 34:18most of them at four to six weeks at
- 34:21a dose of hundred 225 milligrams.
- 34:24Now,
- 34:25many patients who seek medical
- 34:27treatment for S red is because
- 34:29of weight gain and topiramate.
- 34:31Did help with that.
- 34:33So the mechanism we're not sure what it is.
- 34:37It could be related to appetite
- 34:39suppression or something else.
- 34:41There was no reported improvement in
- 34:43other sleep measures or hemoglobin,
- 34:46A1C and side effects were prominent,
- 34:48so the results of this study were
- 34:51similar to previous open label studies
- 34:54of the pyramid or for treatment of estrogen.
- 34:58The stands were there patients
- 35:01were rigorously screened,
- 35:02small sample with a high dropout
- 35:05rate in both groups.
- 35:09Alright, so moving to the study #9
- 35:12sleep related movement disorders.
- 35:14This was a study published again
- 35:17by Winkleman at all in sleep last
- 35:20year that looked at baseline,
- 35:22an one year longitudinal data from
- 35:25the national or less opioid registry.
- 35:29And the question was,
- 35:30what is the long term efficacy and
- 35:33safety of opioids for treatment of
- 35:36refractory restless leg syndrome?
- 35:39So for this they looked at 500
- 35:42participants in the registry.
- 35:44Comprised mostly of white, elderly,
- 35:47educated and retired folks,
- 35:50they looked at baseline,
- 35:52an one year longitudinal dozing
- 35:55and symptom outcomes.
- 35:57Those who are currently taking a
- 36:00prescribed opioids for diagnosed are
- 36:03less that were included in the registry.
- 36:06They obtained information
- 36:08on the dosing side effects,
- 36:10past or current treatments,
- 36:12severity of arlis, psychiatric history,
- 36:14opioid abuse risk factors,
- 36:16so comprehensive look at each of
- 36:19these participants at baseline,
- 36:21and then they did follow up surveys
- 36:25on line at six months and one year.
- 36:29So what is the study show?
- 36:3350% were on opioids is monotherapy.
- 36:3750% were actually on methadone
- 36:39and 25% on oxycodone formulations
- 36:42with a median dose of 30 me,
- 36:45so most of them were on the
- 36:48medication for a year or longer.
- 36:513/4 of participants,
- 36:52an 1 third were on it for
- 36:55five years or longer.
- 36:57Most of them indicated mild to
- 37:00moderate symptoms on opioids.
- 37:03At one year follow up.
- 37:06About a third close to 1/3
- 37:09increase their doors,
- 37:10but by a small amount median of 10
- 37:14me and 16% decrease their doors.
- 37:17A significant increase in dose.
- 37:20Which they called an enemy increase
- 37:23of 25 or higher was associated
- 37:26with use of opioid for non RLS
- 37:29related pain or if they had used
- 37:32it for less than one year.
- 37:36If they were switching to methadone,
- 37:39or if they were discontinuing
- 37:43other RLS medications.
- 37:45So what were the conclusions of
- 37:48this study in refractory RLS opioids
- 37:51are generally used at low dose and
- 37:55with good efficacy over a year.
- 37:581/3 increase their dose.
- 38:00The larger dose increases were
- 38:03accounted by predictable features.
- 38:05So this is the largest sample
- 38:07of patients with RLS followed on
- 38:09opioids that were followed long-term,
- 38:11and it's the first study to assess
- 38:14the features that are associated
- 38:16with prescription of these
- 38:18medications and those increase.
- 38:19Of course there's limited generalizability.
- 38:22These are volunteer patients in the registry.
- 38:25It may be related to prescribing bias.
- 38:29These are the patients that get
- 38:32prescribed opioids more frequently,
- 38:34and the participants are
- 38:36usually from academic centers.
- 38:42Alright, that brings us to our last.
- 38:46Study on pediatric sleep disorders.
- 38:50And this study came out in JAMA
- 38:53Pediatrics last year by Videoman out
- 38:56looking at the Association of delaying
- 38:59School start time with sleep duration,
- 39:02timing and quality among adolescents.
- 39:04The question was,
- 39:05is delayed school start time associated
- 39:08with objective sleep measures in a dollar
- 39:11sense and this was an observation.
- 39:14ULL study with district initiated
- 39:16change in school times five public
- 39:19schools in Minneapolis, Saint Paul.
- 39:22Minnesota.
- 39:22Close to 500 students that were
- 39:26followed from 2016 through 2018,
- 39:29so grades nine through 11 and the
- 39:33data was analyzed finally in 2019.
- 39:37Now all of the schools started at 7:30,
- 39:40Seven 45 at Baseline at follow up.
- 39:43Two of the schools delayed their start
- 39:46time by 50 to 60 minutes and three
- 39:50other schools stayed at 7:30 throughout.
- 39:53So all of the students got wrist actigraph,
- 39:57so to measure sleep duration,
- 39:59timing quality.
- 40:00An linear mixed effects models
- 40:02were used to estimate difference
- 40:04in changes in sleep time.
- 40:07Mean age of 15 years with
- 40:09subjects with 50% being girls.
- 40:13Now in the delate cohort.
- 40:17The night time sleep at follow up.
- 40:20One increased by 41 minutes an at
- 40:23follow up two by 43 minutes and this
- 40:27was not associated with falling going
- 40:30to sleep later on school nights.
- 40:33An on weekends at follow up
- 40:36one they were sleeping,
- 40:38a mean of 24 minutes less an at
- 40:40follow up 234 minutes less versus
- 40:43the comparison called it the
- 40:45differences in differences analysis.
- 40:48So that difference in most of the other
- 40:52measures between the two groups or the
- 40:56two conditions I could say was minimal.
- 40:59So the conclusion of this study was
- 41:02that delaying high school start times
- 41:05could extend school night sleep duration
- 41:08an lessen the need for catch up,
- 41:11sleep on weekends.
- 41:13It could be a durable strategy
- 41:15for addressing population wide
- 41:18adolescent sleep deficits.
- 41:20We had before and after measures in
- 41:22the same students with objective
- 41:25sleep measures from actigraphy.
- 41:27It was not randomized and potentially
- 41:30there could be a confounder that
- 41:32accounted for both the change in the
- 41:36starts timings as well as the sleep change.
- 41:39Uh,
- 41:40in Minneapolis.
- 41:41Saint Paul is public schools with had
- 41:45limited racial and ethnic diversity.
- 41:48There was no data on other outcomes.
- 41:51The big question always is about grades.
- 41:54'cause there's conflicting data there
- 41:56an an actual daytime sleepiness.
- 42:01Start a question in there,
- 42:03but it's hard to do again on zoom.
- 42:07The answer is that over one year,
- 42:09patients who are taking chronic
- 42:12opioids for RLS increase the
- 42:14dose in about 1/3 of the cases.
- 42:19Alright, so that's what I have learned.
- 42:22Told me to leave 15 minutes for
- 42:26questions I have about 16 minutes.
- 42:30So I'm going to stop sharing my screen.
- 42:34And take any questions.
- 42:38Thank you for listening to me.
- 42:40And if you have any questions.
- 42:43That I don't answer today.
- 42:44You can always email me.
- 42:54Lauren, should I look in the chat?
- 43:111st, I have a nice message from Craig
- 43:14Canepari who is well known to me.
- 43:16Welcome message. Hi Magna,
- 43:17another Wednesday afternoon together.
- 43:19Craig and I work on the Education committee.
- 43:22Thank you, Craig. Next we have.
- 43:26This might be Debbie,
- 43:28who's sending some information on
- 43:30the code that you need to text.
- 43:33Although this looks different from the
- 43:36one I said was 21612 and here's 21334.
- 43:40Not sure which one is correct.
- 43:43OK 21612 OK
- 43:44sorry I got disconnected
- 43:46for a second so I'm back on
- 43:50my phone I think.
- 43:55Daily 1612 correct code.
- 43:56It wasn't working at the beginning,
- 43:59but it is working now.
- 44:01So what's that?
- 44:03Yeah, can you hear me?
- 44:04OK, now we can hear you.
- 44:08OK yeah, so the two 1612 is the correct code.
- 44:14Then next question from Craig,
- 44:15could we get a list of these papers?
- 44:18Sure I can send them to you.
- 44:20Craig and I tend the slides too.
- 44:24I will definitely make
- 44:25sure to send those to you.
- 44:27Thank you, you can just send them
- 44:29to me and I can pass them on
- 44:30to anyone who's interested.
- 44:32And another question,
- 44:33maybe from the VA I haven't had good
- 44:36success with topiramate for S red for the
- 44:38limited number of patients that I have,
- 44:41what are the treatment strategies?
- 44:42Have you tried at your center?
- 44:44I have had a little bit of luck
- 44:47with topiramate but I would say
- 44:49that most of the patients I've had
- 44:51luck with have been on clonazepam,
- 44:53and again I don't know if it's
- 44:55because they are not able to
- 44:57walk to the kitchen or if it's
- 44:59actually treating the estimate,
- 45:01but I've had a little bit
- 45:03of success with that.
- 45:07Any other questions?
- 45:15I have a question. This is mere
- 45:18creating, so the question that I
- 45:20have this was a paper that that
- 45:23I thought was very important that
- 45:25came out in December last year and
- 45:28I think was in New England Journal.
- 45:31Looking at Oximetry and the fact that
- 45:33Oximetry was frequently inaccurate
- 45:35and African Americans yes and it
- 45:37sort of makes you wonder about
- 45:40how much do people know about the
- 45:42oximeters that they're using,
- 45:44and whether they are.
- 45:45Accurate in their own populations.
- 45:48Yes, exactly that one missed
- 45:50my review because I obviously
- 45:52made my slides before that,
- 45:54but we just had a discussion about
- 45:57that here recently and that's a great
- 46:00paper for everybody to be aware of.
- 46:02That doctor Mayer just mentioned an again,
- 46:05you have to do what is relevant
- 46:08in your population. Yeah.
- 46:15Any other comments? Any other
- 46:17papers that I might have missed?
- 46:22There are so many on sleep apnea
- 46:24and insomnia that were important,
- 46:26but I was trying to get all
- 46:28of the sleep disorders and is
- 46:30hard to pick sometimes, but.
- 46:35Thank you, that was really
- 46:36a wonderful overview.
- 46:37Thank you so much. That was great.
- 46:41If there's any other questions folks,
- 46:44feel free to speak up.
- 46:45I will just mention or talk.
- 46:48Next week is going to be from
- 46:50Doctor Santosh Peg Bag Ala.
- 46:52Who is one of the Sleep Medicine
- 46:54Fellows at Norwalk Hospital
- 46:56and his talk is entitled Sleep
- 46:58Medicine in the 21st century.
- 47:00Using technology to empower
- 47:02patients and physicians.
- 47:06And it looks like he may
- 47:08be set for questions, so
- 47:09thank you again, Doctor,
- 47:11Johnson County. Thanks so
- 47:12much for being here.
- 47:13Thank you everyone.
- 47:14Thanks for every help.
- 47:16Take care bye bye see you next week.
- 47:18See bye bye bye.