Scott G. Williams

Electroencephalographic hypersynchrony in a child with night terrors

Hypersynchronous activity (whether hypnagogic or when associated with an arousal) is a common feature in childhood sleep [1]. Monorhythmic and paroxysmal hypnagogic hypersynchrony is most often seen from 3 months to 12 years of age at sleep onset, typically in stage 1. It is characterized by bursts of bisynchronous 75–350 μV 3– 4.5 Hz waves often maximal in the fronto-central channels [2]. Paroxysms of hypersynchronous theta (4–7 Hz) and delta (0.5–2 Hz) waves have also been described as an arousal pattern out of non-rapid eye movement (NREM) sleep in children [3]. If these paroxysms are not accompanied by an increase in EMG tone or a return of the posterior dominant rhythm of wakefulness, it may be difficult to differentiate from an epileptiform discharge. In one case series, rhythmic theta and delta activity was not a distinguishing feature between nocturnal frontal lobe epilepsy (NFLE) and parasomnias [4]. As such, it can be difficult to rule out epilepsy without a comprehensive clinical and electroencephalographic evaluation. We report a case of a child without epilepsy who demonstrated hypersynchronous EEG activity which preceded complex motor movements out of stage 3 sleep.

Strategies to Enhance Adherence to PAP Therapy for OSA

Recent technological advances in diagnostics and therapeutics have allowed for widespread recognition and treatment of obstructive sleep apnea (OSA). However, practice standards are highly variable and adherence remains poor in many patients. Untreated OSA has numerous well-documented health consequences, including cardiovascular disease and metabolic sequelae. It is therefore crucial to optimize treatment of OSA by enhancing adherence to proven therapies. Utilizing technological advancements, identifying barriers to continuous positive airway pressure use, ensuring proper education regarding the need for and proper use of continuous positive airway pressure, and implementing robust follow-up programs can result in an improved therapeutic response as well as a higher rate of adherence. We review the current literature and provide personal anecdotes, emphasizing the importance of patient education as well as common troubleshooting strategies, particularly during the initial phase of therapy.

Challenges in the Management of Sleep Apnea and PTSD: Is the Low Arousal Threshold an Unrealized Target?

Journal of Clinical Sleep Medicine, Vol. 13, No. 6, 2017 We greatly appreciate Dr. Gupta’s comments regarding the complexities of managing comorbid obstructive sleep apnea (OSA) in patients with posttraumatic stress disorder (PTSD) and the bidirectional relationship between these two conditions.1 Dr. Gupta’s experiences parallel those described by the journal’s recent article by Orr et al.2 and our prior studies on this topic.3,4 Dr. Gupta raises an important question regarding the potential benefits of adjunctive pharmacotherapy for comorbid OSA and PTSD.1,5 Although this practice has not been systematically assessed, there appears to be value in utilizing sedative hypnotic medication to assist in the management of OSA for some patients, particularly those with PTSD. Similar to Dr. Gupta, we have also found this beneficial in our clinical practice. Insomnia and sleep fragmentation are common in those with PTSD. This further compromises sleep quality and negatively affects positive airway pressure use, which diminishes the therapeutic response and further impairs outcomes. We have previously assessed cohorts of patients with PTSD and OSA and demonstrated poor positive airway pressure adherence and a truncated benefit of therapy.3,4 As noted in the article by Orr and colleagues,2 this is a challenging population. Although treatment with continuous positive airway pressure improves symptoms of PTSD based on an objective measure (PTSD Checklist-Specific), these improvements are modest. Given the high stakes in this population, it is important to consider all options available. Dr. Gupta suggests mood stabilizers to improve sleep and potentially decrease the apnea-hypopnea index. This strategy could be applicable to OSA patients with the low arousal threshold phenotype. These patients often have mild to moderate OSA, predominantly obstructive hypopneas, and minimal oxygen desaturations,6 which is consistent with the profile of patients with PTSD we see in our practice. Although some studies have demonstrated that sedatives can raise the arousal threshold and potentially decrease the apnea-hypopnea index, there is no evidence that doing so improves clinical outcomes among those with PTSD. As Dr. Gupta alludes to, most of the data are anecdotal and difficult to quantify. LETTERS TO THE EDITOR

A dozen years of American Academy of Sleep Medicine (AASM) International Mini-Fellowship: program evaluation and future directions.

UNLABELLED Sleep medicine remains an underrepresented medical specialty worldwide, with significant geographic disparities with regard to training, number of available sleep specialists, sleep laboratory or clinic infrastructures, and evidence-based clinical practices. The American Academy of Sleep Medicine (AASM) is committed to facilitating the education of sleep medicine professionals to ensure high-quality, evidence-based clinical care and improve access to sleep centers around the world, particularly in developing countries. In 2002, the AASM launched an annual 4-week training program called Mini-Fellowship for International Scholars, designed to support the establishment of sleep medicine in developing countries. The participating fellows were generally chosen from areas that lacked a clinical infrastructure in this specialty and provided with training in AASM Accredited sleep centers. This manuscript presents an overview of the program, summarizes the outcomes, successes, and lessons learned during the first 12 years, and describes a set of programmatic changes for the near-future, as assembled and proposed by the AASM Education Committee and recently approved by the AASM Board of Directors. CITATION Ioachimescu OC; Wickwire EM; Harrington J; Kristo D; Arnedt JT; Ramar K; Won C; Billings ME; DelRosso L; Williams S; Paruthi S; Morgenthaler TI. A dozen years of American Academy of Sleep Medicine (AASM) international mini-fellowship: program evaluation and future directions.

CPAP: enhancing its use

Despite many advances in the treatment of obstructive sleep apnea with CPAP therapy, adherence remains poor in many patients. To optimize the treatment of OSA, it is crucial to enhance the efficacy and effectiveness of CPAP. Identifying barriers to CPAP use, applying technological advancements, and implementing strategies to maximize both the therapeutic response and rate of adherence are fundamentally important in the care of patients with OSA. We review the current literature and provide personal anecdotes, emphasizing the importance of patient education as well as common troubleshooting strategies, particularly during the initial phase of therapy.