Thirteen things I learned at the Sleep Disorders meeting

Every so often, I feel honor-bound to share my knowledge with you, my beloved readers. I’ve told you how to clean your ears and pick your noses; I’ve given you helpful pointers on how to reduce your risk (or your husband’s risk) of prostate cancer. I’ve taught you how to douche your noses, and I’ve helped you deal with the heartbreak of orchialgia (AKA testalgia, AKA stone ache). Today, we’ll talk about the other third of your life: sleep.

Over Presidents’ Day Weekend, I attended the University of Pennsylvania’s 13th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring meeting in Orlando, Florida. THIRTEENTH Annual — I’m not making that up. And they say the Thursday Thirteen is dead! Anyway, here are thirteen things I learned at the meeting.

1. Watch out for semis. From the New England Journal of Medicine, this frightening factoid: on average, American and Canadian long haul truck drivers get fewer than 5 hours of sleep per night. In other studies, researchers found that 24 hours of sleep deprivation impaired driving skills as much as an 0.10 blood alcohol level.

In most places, if you cause an injury or death in a sleep-related accident, you are not guilty of a crime. The exceptions are New Jersey and England, where people have been found criminally liable for such events.

2. GHB, a date rape drug, has a legitimate clinical application. No, really! According to the wiki, it has a number of applications, one of them being the treatment of narcolepsy. (By the way, I’m not talking about Rohypnol, that other date rape drug.) If you’re not familiar with this disorder, meet Rusty, the narcoleptic daschund.

Hypnos, Greek God of Sleep

3. Coolest excuse for nocturnal bad behavior: REM Sleep Behavior Disorder (RBD). Under ordinary circumstances, we have no voluntary muscle control during rapid eye movement (dream) sleep. But in REM Sleep Behavior Disorder, the patient acts out what he is dreaming. Eighty to ninety percent of those affected are men. According to this abstract,

Typical behaviours are screaming, grasping, punching, kicking and occasionally jumping out of bed, which are potentially harmful for the patient and their bed partner.

Aggressive dream content seems to be a common feature of this disorder; sexual content is lacking. Thus, RBD differs from Sexual Behavior during Sleep, which sounds like a good deal more fun.

4. Sleepwalking can land you in a world of trouble. Our lecturer cited a number of cases in which an adult sleepwalker found himself naked in bed with a child in the same household. In most cases, an expert witness managed to save the culprit, but in this case, the man did time.

Wear clothes to bed, people.

And sleepwalking is potentially dangerous. Imagine what this guy* might have done with his lawnmower.

Ian, 34, later got back into bed and didn’t believe Rebekah when she told him what he’d been up to.

Rebekah added: “It wasn’t until I told him to look at the soles of his feet that he finally believed me – they were filthy.”

5. We need eight hours of sleep each night. The best evidence of impaired function with a less-than-adequate sleep regimen comes from studies of medical house staff. With recent laws mandating a reduction in work hours for this population, sleep researchers have been in hog heaven.

Residents are still sleep-deprived, but they’re not as bad as they used to be. When researchers compared extremely sleep-deprived medical residents with modestly sleep-deprived residents, they found the Extra Sleepies took more time to intubate patients, more time to perform surgery, more likelihood of needle stick injuries, impaired ability to read EKGs, increased risk of medication errors, poorer professionalism, and greater likelihood of motor vehicle accidents.

Unfortunately, duty hour restriction has a price: residents under the new regime felt that their training had been adversely affected. Only 31% of residents thought so, however, compared with 69% of their faculty.

Well, when I was your age we worked TWO hundred hours a week and never complained . . .

6. A new treatment for mild to moderate obstructive sleep apnea and snoring: didgeridoo. This was published last year in the British Medical Journal, and the results looked fairly convincing. I’m curious about this, and I’m a snorer, so I bought a didj on eBay last week. I’ll let you know what happens.

The thought (unproven, as yet) is that didj-playing improves resting tone of the pharyngeal musculature. Thus, while sleeping, the didj-player’s less-flabby throat doesn’t collapse as readily as a non-didj player’s throat.

7. The sleep apnea/blood pressure link is growing murkier by the moment. We know that obstructive sleep apnea (OSA) patients tend to have high blood pressure. Less clear is whether the relationship is causal or not. Last year, Robinson et al. published an article in the European Respiratory Journal showing that continuous positive airway pressure (CPAP) did not reduce blood pressure in this population. This was a small study, though, which means the power to detect small changes was poor. We also worry about CPAP compliance, since poor compliance would tend to minimize any treatment effect.

A second study in Spain (Campos-Rodriquez et al., published in Chest) said the same basic thing . . . so the question is unresolved.

8. Pickwickian Syndrome is a misnomer. In Dickens’ The Posthumous Papers of the Pickwick Club, Pickwick himself is tall and slender. Pickwickian Syndrome, AKA Obesity-Hypoventilation Syndrome, is more accurately poster-boyed by a character in the book known only as Joe:

The object that presented itself to the eyes of the astonished clerk, was a boy – a wonderfully fat boy – habited as a serving lad, standing upright on the mat, with his eyes closed as if in sleep. He had never seen such a fat boy, in or out of a travelling caravan; and this, coupled with the calmness and repose of his appearance, so very different from what was reasonably to have been expected in the inflicter of such knock, smote him with wonder. “What’s the matter” inquired the clerk. The extraordinary boy replied not a word; but he nodded once, and seemed, to the clerk’s imagination, to snore feebly. “Where do you come from?” inquired the clerk. The boy made no sign. He breathed heavily, but in all other respects was motionless.

Pickwickian Syndrome is a particular form of OSA characterized by extreme obesity, hypoventilation, and in some instances, right heart failure.

9. Does effective treatment of sleep apnea decrease cardiovascular risk? For years, we’ve put the Fear of God into people with obstructive sleep apnea, threatening them with a higher incidence of heart attack, stroke, and accidental death. While this data is solid, is the corollary true? Does treatment of OSA decrease a patient’s risk of heart attack or stroke?

The hypothesis that treatment reduces risk has been unusually difficult to prove, but the few studies we have suggest that treatment does indeed decrease risk. It surprised me how I always assumed this to be the case — and yet, this is far from being in the realm of established fact.

10. The Body Mass Index ain’t all it’s cracked up to be. Folks who treat sleep apnea inevitably treat obesity, too. We see OSA in slender patients — infrequently — but most of our patients are overweight. How overweight? Well, for years, the BMI has been our single metric for measuring obesity. But according to the usual calculation, I’M obese. How effed up is that?

In fact, it seems (based on MRI data one of our faculty presented) that neck fat is more important than body fat, at least as far as OSA is concerned. This makes sense on a physical level, but unfortunately, BMI will remain a cheap and easy way of assessing body habitus.

But I’m not obese. I’m not.

11. If obesity has a strong association with OSA, does losing weight cure OSA? Once again, this “obviously true” hypothesis has no easy solution. Obesity does indeed correlate strongly with OSA, with higher BMI corresponding to worse OSA. But we don’t have a single randomized, controlled trial assessing the affects of weight loss on OSA. Not one! What we have are several uncontrolled studies suggesting a connection, but uncontrolled studies aren’t worth bupkes when it comes to evidence-based medicine.

Despite the lack of evidence, we still believe the hypothesis is true. And that’s why we spent thirty minutes discussing . . .

12. New treatment options for obesity! Well, not that new. But if you’re curious, here’s a link to NIH’s practice guidelines for the treatment of obesity (a link to the pdf, actually). Anyway, here’s what I learned about weight loss:

1. Write down what you ate, how much you ate, and when you ate it. Merely focusing attention on your eating habits can produce substantial results.

2. Low carb diets probably work by reducing overall calorie intake. That’s how any diet works. Low carb diets are good at lowering triglycerides, though, and adherence rates are better for low carb diets than for other diets.

3. The only drugs approved for long term weight management are Meridian and Xenical. (Xenical, the Nazi Diet Drug — eat too much fat, and you might as well kiss your clothes goodbye. Then again, you had better skip the kissing part and throw your underwear into the furnace.)

4. Patients’ expectations for any weight loss program are amazingly out of whack with what is realistically achievable. On the upside, it doesn’t take much weight loss to improve cardiovascular risk factors.

and here’s what you’ve all been waiting for . . .

5. Rimonabant is THE new drug on the horizon for weight loss. Presently, it’s an investigational agent only. It works by inhibiting the cannabinoid-1 receptor. In other words, it blocks the Munchy Receptor, thus decreasing appetite. Early data look promising. (By the way: even if you combine weight loss drugs, you hit the wall at the 10% weight loss mark. At present, no pharmaceutical will enable you to lose more than 10% of your body weight.)

13. I’ve been treating my insomnia incorrectly all these years. My cocktail of benadryl and melatonin earned poor marks from our resident insomnia guy. The Establishment is still hawking Ambien, the drug that made me want to kill myself, and the newer Ambien, Lunesta. Melatonin has a bad rap because there’s no standardization in its manufacture. More interesting is Rozerem (ramelteon), which targets the melatonin receptor — essentially the same idea as melatonin, but vastly more expensive.

Well, folks, there was lots more than that at the meeting, but I’ve been working at this 13 off and on since yesterday evening and I’M TIRED! Maybe even tired enough to get to sleep in a timely fashion tonight . . . we’ll see.

Leave a comment and you’ll get your love. Get it in links!

Kate’s ignoring the Thirteen moratorium, too.

Revel in Erin’s treatise on female ejaculation . . . and she’s having a raffle!

May interviews urban fantasy author Vicki Pettersson

Dean updates us on the status of Kris’s bikini

Steven has Teh Snark on Abigail Whatsername’s Oscar dress!

Go give Michelle your morning sickness tips

SxKitten’s toddler lexicon

D.

*I love Ananova. You find the strangest things there . . . like this story about a musical condom.