"Year in Review" Meghna P. Mansukhani (03.17.2021)

March 22, 2021

ID6310

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.