Anita Valanju Shelgikar

Hypertension, snoring, and obstructive sleep apnoea during pregnancy: A cohort study

To assess the frequency of obstructive sleep apnoea among women with and without hypertensive disorders of pregnancy.

Validation of Watch-PAT-200 against polysomnography during pregnancy.

STUDY OBJECTIVES To determine the relationships between key variables obtained from ambulatory polysomnography (PSG) and the wrist-worn Watch-PAT 200 device in pregnant women. METHODS In this prospective cohort study, women in their third trimester of pregnancy underwent full overnight home PSG using the 22-channel MediPalm system and the Watch-PAT 200 device. PSGs were scored by a blinded, experienced technologist using AASM 2007 criteria; the Watch-PAT was scored automatically by the manufacturers proprietary software. RESULTS A total of 31 pregnant women were studied. Mean age was 30.2 ± 7.1 years; mean gestational age was 33.4 ± 3.0 weeks; mean BMI was 31.9 ± 8.1 kg/m(2); 39% of women were nulliparous. Key variables generated by PSG and Watch-PAT correlated well over a wide range, including the apnea-hypopnea index (AHI, r = 0.76, p < 0.001); respiratory disturbance index (RDI, r = 0.68, p < 0.001), mean oxygen saturation (r = 0.94, p < 0.001), and minimum oxygen saturation (r = 0.88, p < 0.001). The area under the curve for AHI ≥ 5 and RDI ≥ 10 were 0.96 and 0.94, respectively. Association between stage 3 sleep on PSG and deep sleep on Watch-PAT was poor. Watch-PAT tended to overscore RDI, particularly as severity increased. CONCLUSIONS Among pregnant women, Watch-PAT demonstrates excellent sensitivity and specificity for identification of obstructive sleep apnea, defined as AHI ≥ 5 on full PSG. Watch-PAT may overestimate RDI somewhat, especially at high RDI values.

Respiratory cycle-related EEG changes: response to CPAP.

STUDY OBJECTIVES Respiratory cycle-related EEG changes (RCREC) quantify statistically significant synchrony between respiratory cycles and EEG spectral power, vary to some extent with work of breathing, and may help to predict sleepiness in patients with obstructive sleep apnea. This study was designed to assess the acute response of RCREC to relief of upper airway obstruction by positive airway pressure (PAP). DESIGN Comparison of RCREC between baseline diagnostic polysomnograms and PAP titration studies. SETTING Accredited academic sleep disorders center. PATIENTS Fifty adults referred for suspected sleep disordered breathing. INTERVENTIONS For each recording, the RCREC in specific physiologic EEG frequency ranges were computed as previously described for the last 3 h of sleep not occupied by apneic events. RESULTS The sample included 27 women; mean age was 47 ± 11 (SD) years; and median respiratory disturbance index at baseline was 24 (inter-quartile range 15-43). Decrements in RCREC, from baseline to PAP titration, reached 43%, 24%, 14%, 22%, and 31% for delta (P = 0.0004), theta (P = 0.01), alpha (P = 0.10), sigma (P = 0.08), and beta (P = 0.01) EEG frequency ranges, respectively. Within each specific sleep stage, these reductions from baseline to PAP studies in synchrony between EEG power and respiratory cycles still reached significance (P < 0.05) for one or more EEG frequency ranges and for all frequency ranges during REM sleep. CONCLUSIONS RCREC tends to diminish acutely with alleviation of upper airway obstruction by PAP. These data in combination with previous observations support the hypothesis that RCREC reflect numerous, subtle, brief, but consequential inspiratory microarousals.

Sleep Tracking, Wearable Technology, and Opportunities for Research and Clinical Care

Consumer-driven sleep-tracking technologies are becoming increasingly popular with patients with sleep disorders and the general population. As the list of sleep-tracking technologies continues to grow, clinicians and researchers are faced with new challenges and opportunities to incorporate these technologies into current practice. We review diagnostic tools used in sleep medicine clinical practice, discuss categories of consumer sleep-tracking technologies currently available, and explore the advantages and disadvantages of each. Potential uses of consumer sleep-tracking technologies to enhance sleep medicine patient care and research are also discussed.

Approach to and evaluation of sleep disorders.

Purpose of Review: This article provides a framework for the clinical assessment of patients with sleep-related complaints and outlines a systematic approach to a sleep-specific history and physical examination, subjective assessment tools, and diagnostic testing modalities.Recent Findings: Physical examination findings may suggest the presence of a sleep disorder, and obstructive sleep apnea in particular, but the clinical history remains the most important element of the assessment for most sleep problems. While nocturnal polysomnography in a sleep laboratory remains the gold standard for diagnosis of sleep-disordered breathing, out-of-center testing may be considered when the clinician has a high pretest suspicion for obstructive sleep apnea and the patient has no significant cardiopulmonary, neuromuscular, or other sleep disorders.Summary: Sleep-related symptoms are common in adult and pediatric patients. A comprehensive sleep history, physical examination with detailed evaluation of the head and neck, and judicious use of sleep-specific questionnaires guide the decision to pursue diagnostic testing. Understanding of the benefits and limitations of various diagnostic modalities is important as the spectrum of testing options increases.

Sex Differences in Academic Rank and Publication Rate at Top-Ranked US Neurology Programs

Importance Women are underrepresented in academic neurology, and the reasons for the underrepresentation are unclear. Objective To explore potential sex differences in top-ranked academic neurology programs by comparing the number of men and women at each academic faculty rank and how many articles each group has published. Design, Setting, and Participants Twenty-nine top-ranked neurology programs were identified by combining the top 20 programs listed on either the 2016 or 2017 Doximity Residency Navigator tool with the top 20 programs listed in the US News and World Report ranking of Best Graduate Schools. An internet search of the departmental websites was performed between December 1, 2015, and April 30, 2016. For each faculty member on a program site, the following biographical information was obtained: first name, last name, academic institution, sex, academic faculty rank, educational leadership (clerkship, fellowship, or residency director/assistant director), and year of medical school graduation. Main Outcomes and Measures To compare the distribution of men vs women and the number of publications for men vs women at each academic faculty rank. Secondary analyses included Scopus h-index, book authorship, educational leadership (clerkship, residency, or fellowship director/assistant director), and clinical activity as inferred through Medicare claims data in men vs women after controlling for years since medical school graduation. Results Of 1712 academic neurologists in our sample, 528 (30.8%) were women and 1184 (69.2%) were men (P < .001). Men outnumbered women at all academic faculty ranks, and the difference increased with advancing rank (instructor/lecturer, 59.4% vs 40.5%; assistant professor, 56.7% vs 43.3%; associate professor, 69.8% vs 30.2%; and professor, 86.2% vs 13.8%). After controlling for clustering and years since medical school graduation, men were twice as likely as women to be full professors (odds ratio [OR], 2.06; 95% CI, 1.40-3.01), whereas men and women had the same odds of being associate professors (OR, 1.04; 95% CI, 0.82-1.32). Men had more publications than women at all academic ranks, but the disparity in publication number decreased with advancing rank (men vs women after adjusting for years since medical school graduation: assistant professor [exponentiated coefficient, 1.85; 95% CI, 1.57-2.12]; associate professor [1.53; 95% CI, 1.22-1.91]; and full professor [1.36; 95% CI, 1.09-1.69]). Men had a higher log Scopus h-index than women after adjustment (linear coefficient, 0.44; 95% CI, 0.34-0.55). There was no significant association between sex and clinical activity (linear coefficient, 0.02; 95% CI, −0.10 to 0.13), educational leadership (OR, 1.09; 95% CI, 0.85-1.40), or book authorship (OR, 2.75; 95% CI, 0.82-9.29) after adjusting for years since medical school graduation. Conclusions and Relevance Men outnumber women at all faculty ranks in top-ranked academic neurology programs, and the discrepancy increases with advancing rank. Men have more publications than women at all ranks, but the gap narrows with advancing rank. Other measures of academic productivity do not appear to differ between men and women.

Disorders of Excessive Daytime Sleepiness Including Narcolepsy and Idiopathic Hypersomnia

Central disorders of hypersomnolence are rare conditions with a poorly understood pathophysiology, making the identification and management challenging for sleep clinicians. Clinical history is essential for ruling out secondary causes of hypersomnolence and distinguishing among diagnoses. Current diagnostic criteria rely heavily on the polysomnogram and multiple sleep latency test. The current focus of treatment of hypersomnolence is on drugs that promote alertness. Additionally, in the case of narcolepsy type 1, medication management addresses control of cataplexy, the hallmark symptom of this disorder. Elucidation of pathophysiology of these disorders in the future will be essential to better categorization and management.

ATS Core Curriculum 2016: Part I. Adult Sleep Medicine

Jay S. Balachandran, Columbia St. Marys Hospital Carey C. Thomson, Mount Auburn Hospital Dezmond B. Sumter, University of Michigan Anita V. Shelgikar, University of Michigan Philippe Lachapelle, McGill University Health Centre Sushmita Pamidi, McGill University Health Centre Michael Fall, Medical University of South Carolina Chitra Lal, Medical University of South Carolina Ridhwan Y. Baba, Case Western Reserve University Neomi Shah, Icahn School of Medicine at Mount Sinai

Friedman tongue position and cone beam computed tomography in patients with obstructive sleep apnea

Evaluate the correlation between Friedman Tongue Position (FTP) and airway cephalometrics in patients with obstructive sleep apnea (OSA).

Apnea in New-Onset Heart Failure.

A 46-year-old man presented with increased dyspnea and fatigue over several months, which worsened acutely before his presentation to an emergency department. He was an avid body builder and gave a history of alcohol and anabolic steroid abuse. The man was admitted to the intensive care unit for management of severe systolic heart failure, with an ejection fraction of 10–15% and cardiogenic shock with hypoxic respiratory failure requiring intubation. Further evaluation led to a diagnosis of chronic nonischemic cardiomyopathy due to alcohol abuse and anabolic steroid use. The acute decompensation was attributed to viral myocarditis, given the history of recent upper respiratory infection. Heart failure was treated by diuresis and afterload reduction. He was euvolemic at the time of extubation. Shortly afterward, a caregiver observed episodes of apnea during sleep, with oxygen desaturations into the 80s. Additional history from the patient’s family revealed a long-standing history of snoring and significant use of abdominal muscles during sleep, but no witnessed apneas before the current hospitalization. The patient reported that, before admission, he often took daily “catnaps” lasting approximately 30 minutes. He denied drowsiness while driving. An Epworth Sleepiness Scale score was not calculated. The patient was seen and evaluated by a sleep medicine physician 11 days after initial presentation (4 d after extubation). When the patient was awake, arterial oxygen saturation was in the low 90s while he breathed ambient air. The patient appeared euvolemic and intermittently dozed with significant snoring. Body mass index was 30 kg/m. Neck circumference was 17.5 inches. Oral airway was crowded (modified Mallampati class IV) with slight retrognathia and a large tongue. Ejection fraction improved from less than 10–20% on repeat echocardiogram. An inpatient split-night polysomnogram was performed (Table 1; and Figures 1 and 2) followed the next night by a retitration study (Figure 3).