Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement

The period of the year from spring to fall, when clocks in most parts of the United States are set one hour ahead of standard time, is called daylight saving time, and its beginning and ending dates and times are set by federal law. The human biological clock is regulated by the timing of light and darkness, which then dictates sleep and wake rhythms. In daily life, the timing of exposure to light is generally linked to the social clock. When the solar clock is misaligned with the social clock, desynchronization occurs between the internal circadian rhythm and the social clock. The yearly change between standard time and daylight saving time introduces this misalignment, which has been associated with risks to physical and mental health and safety, as well as risks to public health. In 2020, the American Academy of Sleep Medicine (AASM) published a position statement advocating for the elimination of seasonal time changes, suggesting that evidence best supports the adoption of year-round standard time. This updated statement cites new evidence and support for permanent standard time. It is the position of the AASM that the United States should eliminate seasonal time changes in favor of permanent standard time, which aligns best with human circadian biology. Evidence supports the distinct benefits of standard time for health and safety, while also underscoring the potential harms that result from seasonal time changes to and from daylight saving time.

CITATION

Rishi MA, Cheng JY, Strang AR, et al. Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2024;20(1):121-125.

A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults

STUDY OBJECTIVES

The treatment of obstructive sleep apnea is often impeded by intolerance of positive airway pressure therapy, which is frequently attributed to the inability to breathe through the nose. Providers caring for patients with sleep apnea need a working knowledge of nasal passage disease and available treatments to better manage this common comorbidity.

METHODS

This review examines the literature connecting rhinosinusitis to adverse sleep and sleep apnea outcomes. It explores the different types of nasal and sinus diseases a sleep apnea provider might encounter, focusing on the medications used to treat them and indications for referral to otolaryngology.

RESULTS

Chronic rhinosinusitis can be either allergic or nonallergic. Both types can interfere with sleep and sleep apnea therapy. The successful management of chronic rhinosinusitis can improve positive airway pressure tolerance and adherence. A wide range of over-the-counter and prescription pharmacotherapy is available, with data supporting intranasal over oral treatment. Surgical treatment for chronic rhinosinusitis in obstructive sleep apnea addresses nasal obstruction, often with inferior turbinate reduction and septoplasty.

CONCLUSIONS

Sleep specialists should have a working knowledge of the available options to treat chronic rhinosinusitis. These options are often safe, effective, and readily accessible. Otolaryngologists and allergists/immunologists provide additional treatment options for more complicated patients. Providing treatment for chronic rhinosinusitis should be included as part of comprehensive sleep apnea care.

CITATION

Ali MM, Ellison M, Iweala OI, Spector AR. A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults. J Clin Sleep Med. 2023;19(8):1545-1552.

Non-REM Sleep Parasomnias

OBJECTIVE

Non-rapid eye movement (non-REM) parasomnias are common across the lifespan. This article describes the manifestations, diagnosis, and management of non-REM parasomnias in adults and discusses the social implications of these conditions.

LATEST DEVELOPMENTS

Non-REM parasomnias represent a hybrid state of wakefulness and sleep, often triggered by events that increase the frequency of arousals or make it more difficult to fully arouse from sleep. Sleep deprivation, certain medications, and untreated obstructive sleep apnea are known to provoke parasomnias, particularly in those who are genetically predisposed. Non-REM parasomnias include disorders of arousal (ie, sleepwalking, sleep terrors, and confusional arousals), sleep-related eating disorder, and exploding head syndrome. Clinical overlap exists between sleep-related eating disorder and disorders of arousal, suggesting that sleep-related eating disorder may be a fourth disorder of arousal or a manifestation of sleepwalking. Exploding head syndrome is a unique parasomnia of uncertain etiology.

ESSENTIAL POINTS

Non-REM parasomnias can range from minor nuisances to severe, life-altering events. While some patients with non-REM parasomnia experience significant consequences during sleep, wakefulness, or both, non-REM parasomnias do not pose a major risk to most patients. For all patients with non-REM parasomnias, safety should be explicitly discussed and addressed. Nonpharmacologic treatment should be prioritized, as increasing total sleep time, avoiding triggering substances, and treating comorbid sleep disorders is often sufficient for the management of non-REM parasomnias. If symptoms persist despite these interventions, treatment with clonazepam or other medications can be considered.

The potential link between obstructive sleep apnea and postoperative neurocognitive disorders: current knowledge and possible mechanisms

PURPOSE

This narrative review examines the current evidence on whether obstructive sleep apnea (OSA) is associated with postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). The mechanisms that could predispose OSA patients to these disorders are also explored.

SOURCE

Relevant literature was identified by searching for pertinent terms in Medline®, Pubmed, ScopusTM, and Google scholar databases. Case reports, abstracts, review articles, original research articles, and meta-analyses were reviewed. The bibliographies of retrieved sources were also searched to identify relevant papers.

PRINCIPAL FINDINGS

Seven studies have investigated the association between OSA and POD, with mixed results. No studies have examined the potential link between OSA and POCD. If these relationships exist, they could be mediated by several mechanisms, including increased neuroinflammation, blood-brain barrier breakdown, cerebrovascular disease, Alzheimer's disease neuropathology, disrupted cerebral autoregulation, sleep disruption, sympathovagal imbalance, and/or disrupted brain bioenergetics.

CONCLUSION

There is very limited evidence that OSA plays a role in postoperative neurocognitive disorders because few studies have been conducted in the perioperative setting. Additional perioperative prospective observational cohort studies and randomized controlled trials of sleep apnea treatment are needed. These investigations should also assess potential underlying mechanisms that could predispose patients with OSA to postoperative neurocognitive disorders. This review highlights the need for more research to improve postoperative neurocognitive outcomes for patients with OSA.

Neurological interest and career exploration among black medical students: Perceptions and solutions for the pipeline

PURPOSE

The goal of this study was to identify factors that influence the selection of Neurology as a career choice for Black medical students.

METHODS

Survey data was collected from attendees at a national educational conference and at a large academic medical school. Two proportion z-tests were used to assess responses among students of different racial/ethnic backgrounds.

RESULTS

199 students participated in the survey. Compared to their Asian and White counterparts, Black students were significantly less likely to choose or consider a career in Neurology. In addition, we found that these students relied more heavily on their pre-clinical experiences to make this determination, citing preference for another specialty, lack of exposure, a preference for a different patient population, and a lack of racial/ethnic diversity as key reasons to not choose a career in Neurology.

CONCLUSIONS

Neurological disorders are important contributors to morbidity and mortality. It is imperative that the field attract medical students toward careers in Neurology, particularly those students from traditionally and persistently underrepresented backgrounds. Our findings suggest that Black medical students consider Neurology as a specialty choice less frequently than their counterparts do, and this decision may be made prior to training. We conclude that a multifaceted approach is best to improve the racial/ethnic diversity within the neurological workforce, which should include targeted interventions prior to and after matriculation to medical school.

Developing the Neurology Diversity Officer: A Roadmap for Academic Neurology Departments

Academic neurology departments must confront the challenges of developing a diverse workforce, reducing inequity and discrimination within academia, and providing neurologic care for an increasingly diverse society. A neurology diversity officer should have a specific role and associated title within a neurology department as well as a mandate to focus their efforts on issues of equity, diversity, and inclusion that affect staff, trainees, and faculty. This role is expansive and works across departmental missions, but it has many challenges related to structural intolerance and cultural gaps. In this review, we describe the many challenges that diversity officers face and how they might confront them. We delineate the role and duties of the neurology diversity officer and provide a guide to departmental leaders on how to assess qualifications and evaluate progress. Finally, we describe the elements necessary for success. A neurology diversity officer should have the financial, administrative, and emotional support of leadership in order for them to carry out their mission and to truly have a positive influence.

Qualifying Patients for Noninvasive Positive Pressure Ventilation Devices on Hospital Discharge

When and how do I qualify inpatients with acute on chronic hypercapnic respiratory failure for home noninvasive positive-pressure ventilation at the time of discharge? A 44-year-old woman with morbid obesity (BMI, 48) was brought to the hospital by her boyfriend for 1 day of confusion and reduced alertness. She had a history of chronic dyspnea on exertion and 10-pack-years of smoking. She also had history of well-treated diabetes and hypertension. In the ER, she was found to be somnolent but arousable and following commands appropriately. Her oxygen saturation was 86% on room air, and arterial blood gases indicated a pH of 7.16 with a Paco₂ of 87 mm Hg, a Pao₂ of 60 mm Hg, and a bicarbonate of 42 mEq/L. Chest radiograph showed mild pulmonary vascular congestion. She was started on continuous bilevel positive airway pressure and medical therapy, with clinical improvement.

Obstructive sleep apnea in late-onset Pompe disease treated by enzyme replacement therapy

Obstructive sleep apnea is a common complication of Pompe disease. Treatment for obstructive sleep apnea in patients with Pompe disease is similar to treatment in the general population, typically involving positive airway pressure therapy. We present a case in which a patient with late-onset Pompe disease was able to discontinue positive airway pressure therapy after treatment with enzyme replacement therapy for his Pompe disease. It is likely that an improvement in muscle tone from the enzyme replacement therapy was sufficient to eliminate his obstructive sleep apnea. Pharmacological therapies for obstructive sleep apnea are lacking but could apply to certain populations, such as Pompe disease.

Phrenic Nerve Stimulation for the Treatment of Central Sleep Apnea: A Pooled Cohort Analysis

STUDY OBJECTIVES

Early evidence with transvenous phrenic nerve stimulation (PNS) demonstrates improved disease severity and quality of life (QOL) in patients with central sleep apnea (CSA). The goal of this analysis is to evaluate the complete prospective experience with PNS in order to better characterize its efficacy and safety, including in patients with concomitant heart failure (HF).

METHODS

Using pooled individual data from the pilot (n = 57) and pivotal (n = 151) studies of the remedē System in patients with predominant moderate to severe CSA, we evaluated 12-month safety and 6- and 12-month effectiveness based on polysomnography data, QOL, and cardiac function.

RESULTS

Among 208 combined patients (June 2010 to May 2015), a remedē device implant was successful in 197 patients (95%), 50/57 pilot study patients (88%) and 147/151 pivotal trial patients (97%). The pooled cohort included patients with CSA of various etiologies, and 141 (68%) had concomitant HF. PNS reduced apnea-hypopnea index (AHI) at 6 months by a median of -22.6 episodes/h (25th and 75th percentile; -38.6 and -8.4, respectively) (median 58% reduction from baseline, P < .001). Improvement in sleep variables was maintained through 12 months of follow-up. In patients with HF and ejection fraction ≤ 45%, PNS was associated with improvement in systolic function from 27.0% (23.3, 36.0) to 31.1% (24.0, 41.5) at 12 months (P = .003). In the entire cohort, improvement in QOL was concordant with amelioration of sleep measures.

CONCLUSIONS

Transvenous PNS significantly improves CSA severity, sleep quality, ventricular function, and QOL regardless of HF status. Improvements, which are independent of patient compliance, are sustained at 1 year and are associated with acceptable safety.

The Clinical Significance of Apneas Versus Hypopneas: Is There Really a Difference?

Introduction

Obstructive sleep apnea is diagnosed by identifying obstructive apneas and hypopneas, but no study has shown that it is necessary to distinguish these events from each other. Our goal was to analyze results from polysomnograms to determine if adverse health outcomes were more likely in patients with higher apnea indices relative to their hypopnea indices. Our hypothesis was that scoring apneas separately from hypopneas has no predictive value.

Methods

A retrospective case series was performed for consecutive diagnostic and split-night polysomnograms with apnea-hypopnea indices greater than five per hour. Clinical data reviewed included the presence of cardiovascular diseases, hypertension, depression, and migraine. Both univariate and multivariate analyses were performed to look for correlations between polysomnographic indices and the comorbidities.

Results

Three hundred fifty-one records were included. Univariate analysis showed no significant difference between the apnea index (AI) and hypopnea index (HI) based on the presence of any of the comorbidities. Multivariate logistic regression also indicated no significant association between indices and comorbidities, aside from one statistically significant correlation between a higher HI and depression.

Conclusions

Clinical comorbidities are no more likely in patients with higher apnea indices than hypopnea indices. While apneas are considered a more severe form of obstruction, this distinction does not have any known clinically predictive value. This finding raises the question as to whether scoring hypopneas and apneas as different events on polysomnograms is necessary or helpful. Scoring apneas and hypopneas as “obstructions” could save resources and increase inter-scorer reliability.

The Influence of the Menstrual Phases on Polysomnography

PURPOSE

 The primary objective of this study is to determine how the phases of the menstrual cycle influence the results of polysomnography (PSG).

METHODS

 Twenty-eight adult subjects who reported regular menstrual periods, last menstrual period (LMP) within 26 days of their PSG, no exogenous hormone use, no history of polycystic ovarian syndrome, and who were scheduled for diagnostic PSG at Boston Medical satisfied inclusion criteria for the study. These subjects were divided into a Follicular Cohort (days 0-13 of the cycle) or Luteal Cohort (days 14-26 of the cycle), and a one-way analysis using a t-test was performed to test the hypothesis that the follicular phase confers protection against obstructive sleep apnea (OSA). A likelihood-ratio chi-square test was also applied to assess for a statistically significant association between menstrual stage and the presence of moderate-to-severe sleep apnea (apnea-hypopnea index (AHI) > 15/h). Thus, the statistical analysis was performed using AHI as both a continuous and a categorical outcome.

RESULTS

 The mean AHI for patients in the Follicular Cohort (6.1/h) was significantly lower than the Luteal Cohort (14.3/h, p = 0.033). In the Follicular Cohort, 12% of patients had moderate to severe OSA. In the Luteal Cohort, 46% of patients had moderate to severe OSA (p = 0.045).

CONCLUSIONS

 Subjects undergoing PSG during the follicular phase have significantly lower AHIs than those in the luteal phase. Thus, the timing of PSG acquisition for regularly menstruating women should be considered when interpreting results.

Levothyroxine improves subjective sleepiness in a euthyroid patient with narcolepsy without cataplexy

OBJECTIVE

We discuss the use of levothyroxine for excessive daytime sleepiness (EDS) and prolonged nocturnal sleep time in a euthyroid patient with narcolepsy.

METHODS

After failure of first-line narcolepsy treatments, a 48-year-old female began levothyroxine (25 mcg/day). After 12 weeks of treatment, the patient was evaluated for improvement in total sleep time and subjective daytime sleepiness assessed by Epworth Sleepiness Scale (ESS).

RESULTS

At baseline, ESS score was 16 and total sleep time averaged 16 h/day. After 12 weeks, ESS was 13 and reported total sleep time was 13 h/day.

CONCLUSIONS

Levothyroxine improved EDS and total sleep time in a euthyroid patient with narcolepsy without cataplexy after 12 weeks without side effects.

CPAP treats muscle cramps in patients with obstructive sleep apnea

We describe a case series of 4 patients with varying degrees of obstructive sleep apnea who incidentally had a history of nocturnal leg cramps. None of the patients had periodic limb movements during the study and denied symptoms consistent with restless legs syndrome. In 3 of the 4 patients, nocturnal leg cramps resolved with CPAP treatment for OSA, while the fourth patient noted near-resolution of cramping after starting CPAP. In patients presenting with muscle cramps, obstructive sleep apnea should be considered.

Anatomy of disturbed sleep in pallido-ponto-nigral degeneration

OBJECTIVE

Pallido-ponto-nigral degeneration (PPND), caused by an N279K mutation of the MAPT gene, is 1 of a family of disorders collectively referred to as frontotemporal dementia and parkinsonism linked to chromosome 17. This study aims to characterize the nature of the sleep disturbance in PPND and compare these findings to those in other progressive neurological illnesses. Pathological findings are also provided.

METHODS

Ten subjects were recruited from the PPND kindred; 5 affected and 5 unaffected. The subjects underwent clinical assessment, polysomnography, and wrist actigraphy. Available sleep-relevant areas (pedunculopontine/laterodorsal tegmentum, nucleus basalis of Meynert, thalamus, and locus ceruleus) of affected subjects were analyzed postmortem.

RESULTS

The affected group's total sleep time was an average of 130.8 minutes compared to 403.6 minutes in the control group (p < 0.01). Initial sleep latency was significantly longer in affected subjects (range, 58-260 minutes vs 3-34 minutes). Affected subjects also had an increase in stage I sleep (8.5% vs 1%), and less stage III/IV sleep (8.5% vs 17%). At the time of autopsy, all cases had severe neuronal tau pathology in wake-promoting nuclei, as well as decreases in thalamic cholinergic innervations. There was no difference in orexinergic fiber density in nucleus basalis of Meynert or locus ceruleus compared to controls.

INTERPRETATION

The PPND kindred showed severe sleep disturbance. Sleep abnormalities are common in neurodegenerative illnesses, but this is the first study of sleep disorders in PPND. Unlike most neurodegenerative conditions, PPND is characterized by decreased total sleep time, increased sleep latency, and decreased sleep efficiency, without daytime hypersomnolence.

Cricopharyngeal myotomy in a patient with situs inversus totalis

Otolaryngologists must remain vigilant in understanding the complex anatomy of the head and neck and must always be cognizant of deviations from normal anatomy. This text discusses an interesting case that should remind surgeons of the variable course that the recurrent laryngeal nerve takes on either side of the neck and the special consideration that must be taken in performing surgery near the nerve.

Behavioral and emotional disturbances in the offspring of depressed parents with anger attacks

BACKGROUND

To examine the emotional and behavioral characteristics of the offspring of depressed parents with and without anger attacks.

METHODS

Forty-three parents who met criteria for major depressive disorder (MDD) completed the Achenbach Child Behavior Checklist - Parent Report Version (CBCL) for each of their birth children (n = 58, age range 6-17 years). Unpaired t tests were used to evaluate the CBCL scale score differences between children of parents with and children of parents without anger attacks. Baseline demographics and clinical differences between the two groups of parents were also evaluated.

RESULTS

Parents with anger attacks had a significantly younger age of onset of MDD. Offspring of depressed parents with anger attacks were found to have significantly lower social and school competency scale scores and higher scores for delinquency, attention problems, and aggressive behavior. In addition, this group was found to have a significantly higher total T score (a global measure of psychopathology).

CONCLUSIONS

There are some important differences between offspring of depressed parents with and without anger attacks. This finding may be important in identifying and formulating intervention strategies for childhood problems in the offspring of depressed parents.

Functioning and interpersonal relationships as predictors of response in treatment-resistant depression

The purpose of this study was to examine whether occupational functioning or the quality of interpersonal relationships is predictive of clinical response to a 6-week open trial of nortriptyline (NT) in patients with treatment-resistant depression (TRD). Ninety-two subjects with TRD were treated openly with NT for 6 weeks. The longitudinal interval follow-up evaluation (LIFE) scale was administered at baseline. A logistic regression was performed using occupational functioning and interpersonal relationships (over the past month and over the past 5 years) as predictors of treatment response. Unpaired t tests were performed to examine mean composite LIFE score values between responders and nonresponders. The composite scores that were statistically significant were used as single predictors of treatment status in separate logistic regression equations. Better occupational function over the past 5 years predicted better response to treatment with NT in patients with TRD. Beyond a history of nonresponse to antidepressants, long-term occupational function may be a predictor of outcome in the treatment of TRD.

Tracheal cartilaginous sleeve in Crouzon syndrome

Tracheal cartilaginous sleeve (TCS) is a congenital malformation characterized by fusion of the tracheal arches that may be isolated to a few tracheal arches, include the entire trachea, or extend beyond the carina into the bronchi. TCS has been reported only in children with craniosynostosis. Seven cases of TCS and Crouzon syndrome (CS) are mentioned in the literature. In addition to our case study, a review of the literature on TCS in CS, a classification of TCS and treatment options will be provided. Tracheotomy and frequent airway endoscopy coupled with a keen understanding of the shifting sites of obstruction will permit longterm survival in patients with TCS and CS.

Kidney stone matrix. Differences in acidic protein composition

Organic matrices from kidney stones of several mineral compositions (calcium oxalate, uric acid, and apatite-struvite) were isolated and found to contain an abundance of acidic amino acids. The calcium oxalate stones contained 50% aspartic and glutamic acid residues while the uric acid stones contained over 65%. The apatite-struvite stones had only 30% of these two amino acid residues and also contained 20% glycine residues. Since the specific amino acid composition differed for stones of different mineral content, it was felt that the organic matrix might play the role of a nucleating agent.