Sabin R. Bista

The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses.

The International Classification of Sleep Disorders, Second Edition (ICSD-2) distinguishes 5 subtypes of central sleep apnea syndromes (CSAS) in adults. Review of the literature suggests that there are two basic mechanisms that trigger central respiratory events: (1) post-hyperventilation central apnea, which may be triggered by a variety of clinical conditions, and (2) central apnea secondary to hypoventilation, which has been described with opioid use. The preponderance of evidence on the treatment of CSAS supports the use of continuous positive airway pressure (CPAP). Much of the evidence comes from investigations on CSAS related to congestive heart failure (CHF), but other subtypes of CSAS appear to respond to CPAP as well. Limited evidence is available to support alternative therapies in CSAS subtypes. The recommendations for treatment of CSAS are summarized as follows: CPAP therapy targeted to normalize the apnea-hypopnea index (AHI) is indicated for the initial treatment of CSAS related to CHF. (STANDARD)Nocturnal oxygen therapy is indicated for the treatment of CSAS related to CHF. (STANDARD)Adaptive Servo-Ventilation (ASV) targeted to normalize the apnea-hypopnea index (AHI) is indicated for the treatment of CSAS related to CHF. (STANDARD)BPAP therapy in a spontaneous timed (ST) mode targeted to normalize the apnea-hypopnea index (AHI) may be considered for the treatment of CSAS related to CHF only if there is no response to adequate trials of CPAP, ASV, and oxygen therapies. (OPTION)The following therapies have limited supporting evidence but may be considered for the treatment of CSAS related to CHF after optimization of standard medical therapy, if PAP therapy is not tolerated, and if accompanied by close clinical follow-up: acetazolamide and theophylline. (OPTION)Positive airway pressure therapy may be considered for the treatment of primary CSAS. (OPTION)Acetazolamide has limited supporting evidence but may be considered for the treatment of primary CSAS. (OPTION)The use of zolpidem and triazolam may be considered for the treatment of primary CSAS only if the patient does not have underlying risk factors for respiratory depression. (OPTION)The following possible treatment options for CSAS related to end-stage renal disease may be considered: CPAP, supplemental oxygen, bicarbonate buffer use during dialysis, and nocturnal dialysis. (OPTION) .

The treatment of restless legs syndrome and periodic limb movement disorder in adults - An update for 2012: Practice parameters with an evidence-based systematic review and meta-analyses

A systematic literature review and meta-analyses (where appropriate) were performed to update the previous AASM practice parameters on the treatments, both dopaminergic and other, of RLS and PLMD. A considerable amount of literature has been published since these previous reviews were performed, necessitating an update of the corresponding practice parameters. Therapies with a STANDARD level of recommendation include pramipexole and ropinirole. Therapies with a GUIDELINE level of recommendation include levodopa with dopa decarboxylase inhibitor, opioids, gabapentin enacarbil, and cabergoline (which has additional caveats for use). Therapies with an OPTION level of recommendation include carbamazepine, gabapentin, pregabalin, clonidine, and for patients with low ferritin levels, iron supplementation. The committee recommends a STANDARD AGAINST the use of pergolide because of the risks of heart valve damage. Therapies for RLS secondary to ESRD, neuropathy, and superficial venous insufficiency are discussed. Lastly, therapies for PLMD are reviewed. However, it should be mentioned that because PLMD therapy typically mimics RLS therapy, the primary focus of this review is therapy for idiopathic RLS.

Update to the AASM Clinical Practice Guideline: “The Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder in Adults—An Update for 2012: Practice Parameters with an Evidence-Based Systematic Review and Meta-Analyses”

In January 2012, the AASM Board of Directors approved the Standards of Practice paper titled “The Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder in Adults - An Update for 2012: Practice Parameters with an Evidence-Based Systematic Review and Meta-Analyses.” The 2012 update included a new drug not reviewed in the previous 2004 AASM guidelines for the treatment of Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD) – rotigotine. Rotigotine was originally approved by the US Food and Drug Administration (FDA) for the treatment of signs and symptoms associated with early stage idiopathic Parkinson’s disease. Additionally, rotigotine had been shown in clinical trials to be effective for the treatment of moderate-to-severe RLS. In 2008, rotigotine was withdrawn from the US market due to concerns about inconsistent absorption from the patch; therefore, rotigotine was not an FDA-approved treatment option for RLS or PLMD when the 2012 update was accepted for publication. Thus, despite high level evidence supporting the efficacy of this drug for the treatment of moderate-to-severe RLS, the Standards of Practice Committee (SPC) made no recommendation regarding the use of rotigotine in the setting of RLS. The issue of drug absorption was subsequently resolved by the manufacturer, and the new formulation of rotigotine received FDA approval in April 2012. Rotigotine is currently FDA approved both for the treatment of signs and symptoms associ

Practice Parameters for the Non-Respiratory Indications for Polysomnography and Multiple Sleep Latency Testing for Children

BACKGROUND Although a level 1 nocturnal polysomnogram (PSG) is often used to evaluate children with non-respiratory sleep disorders, there are no published evidence-based practice parameters focused on the pediatric age group. In this report, we present practice parameters for the indications of polysomnography and the multiple sleep latency test (MSLT) in the assessment of non-respiratory sleep disorders in children. These practice parameters were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine (AASM). METHODS A task force of content experts was appointed by the AASM to review the literature and grade the evidence according to the American Academy of Neurology grading system. RECOMMENDATIONS FOR PSG AND MSLT USE PSG is indicated for children suspected of having periodic limb movement disorder (PLMD) for diagnosing PLMD. (STANDARD)The MSLT, preceded by nocturnal PSG, is indicated in children as part of the evaluation for suspected narcolepsy. (STANDARD)Children with frequent NREM parasomnias, epilepsy, or nocturnal enuresis should be clinically screened for the presence of comorbid sleep disorders and polysomnography should be performed if there is a suspicion for sleep-disordered breathing or periodic limb movement disorder. (GUIDELINE)The MSLT, preceded by nocturnal PSG, is indicated in children suspected of having hypersomnia from causes other than narcolepsy to assess excessive sleepiness and to aid in differentiation from narcolepsy. (OPTION)The polysomnogram using an expanded EEG montage is indicated in children to confirm the diagnosis of an atypical or potentially injurious parasomnia or differentiate a parasomnia from sleep-related epilepsy (OPTION)Polysomnography is indicated in children suspected of having restless legs syndrome (RLS) who require supportive data for diagnosing RLS. (OPTION) RECOMMENDATIONS AGAINST PSG USE: Polysomnography is not routinely indicated for evaluation of children with sleep-related bruxism. (STANDARD) CONCLUSIONS: The nocturnal polysomnogram and MSLT are useful clinical tools for evaluating pediatric non-respiratory sleep disorders when integrated with the clinical evaluation.

The Association of Sleep Loss and Balance Stability in Farmers

ABSTRACT Sleep deprivation has been linked to injuries, illnesses, and reduced performance measures. Yet, it is unclear how sleep loss contributes to the high rates of injuries and falls in agriculture. In this study, the authors evaluated sleep loss and quantified its association with balance in five farmers, who wore an ActiWatch to record their sleeping patterns in six repeated weekly observation periods. Acute sleep loss was computed as the net sleep (sleeping hours the night before balance testing − average sleep hours during the week). All farmers performed four balance tests on either one foot or both feet and with eyes open or closed. Balance was measured using a pressure mat to monitor the change in center of pressure (CoP) of the feet in anteroposterior (AP) and mediolateral (ML) directions. Spearman’s rank correlation coefficient indicated balance outcomes were strongly and negatively correlated with the net sleep (P < .05). As the net sleep decreased, farmers became less stable, particularly indicated by an increase in the area, total displacement, and deviations of CoP in both AP and ML directions while standing on both feet with eyes open. Fisher’s exact test showed an association between the CoP in AP direction and the net sleep (P = .020, odds ratio [OR] = 7.37). Thus, the odds of having reduced balance stability were 7.4 times higher when farmers slept less than their average hours during the night prior to the balance test. These results suggest that acute sleep loss impacts balance stability that may lead to falls. Understanding the association of sleep loss and balance stability is important in prevention of agricultural injuries.

Medical disorders impacted by obstructive sleep apnea.

Normal-sleeping individuals experience a lower metabolic rate and relative cardiovascular quiescent state with lower heart rate and blood pressure that naturally occurs during sleep compared with the waking state. In patients with obstructive sleep apnea (OSA), this quiescent state becomes disrupted. Research has shown a higher risk for several medical disorders, most ominous being a myocardial infarction or stroke. This article serves as an overview to the cardiovascular, cerebrovascular, metabolic, and gastroesophageal effects of OSA.

Quantifying the association of sleeping hours and balance biomarkers in farmers

The Kingdom of Thailand, an agricultural country and one of the world’s major food producers, relies heavily on the use of pesticides to protect crops and increase yields. During the past decade, the import of pesticides into Thailand has increased four-fold and the use of pesticides is expected to increase in the future. In recent years, more environmentally friendly pesticides have been produced; however, they still remain toxic to the applicators and harvesters. Organophosphate, pyrethroid, and carbamate insecticides are the most commonly used pesticides in Thailand. The highest rates of pesticide poisonings have been reported in northern Thailand, over 8.07 cases per 100,000 capita in 2008. Past studies have identified a wide range of pesticide concentrations and urinary organophosphate metabolites have been detected in farmworkers along with a broad range in exposure magnitude to a variety of pesticides such as methamidophos, methyl parathion, chlorpyrifos, cyfluthrin, permethrin, cypermethrin, carbaryl, methomyl, etc. Acute signs and symptoms such as dizziness, blurred vision, nausea/vomiting, tearing, difficulty breathing, abdominal cramps, numbness or pins and needles in hands or feet, and chest pain were usually reported by farmworkers within 24 hours of exposure to organophosphates. Organophosphate pesticides are still being detected in the environment in several agricultural areas in Thailand even though these pesticides have been banned. Chronic health risks due to exposure to these pesticides are still a major public health concern. Thailand is, and will remain a major agricultural country for food production, however the proper use of pesticides still needs to be addressed to maintain a sustainable Thai agricultural system and to protect human health.

Revisiting Evidence-Based Guidelines: Not Such a Nightmare.

Dr. Cranston and colleagues should be commended for the thorough job they did expanding upon the foundation of the article, “Best Practice Guide for the Treatment of Nightmare Disorder in Adults.”1 The authors have 3 criticisms of the article: (1) the methodology was used inconsistently at updated time points; (2) the article was missing references that were within the search criteria and therefore not reported; and (3) the search database used was insufficient. In the following sections, these concerns are addressed.