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Why sleep?. The origins and development of Sleep Medicine A.W.A.K.E. NOVEMBER 4, 2009. light. 2007 Grand Rounds RIH. How many of you would aggressively treat HTN in a patient with a TIA or stroke? How many of you would treat a hypercoaguable state in a patient with a TIA or stroke?
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Why sleep? The origins and development of Sleep Medicine A.W.A.K.E. NOVEMBER 4, 2009
2007Grand Rounds RIH • How many of you would aggressively treat HTN in a patient with a TIA or stroke? • How many of you would treat a hypercoaguable state in a patient with a TIA or stroke? • How many of you would treat an O2 sat of 80% in an acute stroke patient? • How many of you would test for OSA in a patient with stroke or TIA?
Circadian rhythm disorder • Obstructive Sleep Apnea (OSA) • REM sleep behavior disorder • Narcolepsy
Circadian rhythm disorder • Obstructive Sleep Apnea (OSA) • REM sleep behavior disorder • Narcolepsy
Hypermetabolic state • Skin lesions and erosions • Hypothermia • Death (sepsis)
Discovery of the electroencephalogram • 1875 Caton • 1929 Berger
The original ‘sleep stages’ • 1937 Loomis
Discovery of REM sleep 1951 Kleitman & Aserinsky
Circadian rhythm disorders • Definition: Unable to sleep and wake at the times required for normal work, school, and social needs. Unless they have another sleep disorder, their sleep is of normal quality. Timing of sleep is the problem. • Extrinsic type • Jet lag • Shift work sleep disorder • Intrinsic type • Delayed sleep phase syndrome (DSPS) • Advanced sleep phase syndrome (ASPS) • Non-24-hour sleep-wake syndrome (Non-24) • Irregular sleep-wake pattern
Circadian rhythm disorders • Affect us health care shiftworkers • Affect our patients • Neuroanatomy elucidates the problem
A clamor of incessant knocking besieged Mr. Pickwick’s lodgings. Once opened, the doorway revealed a “wonderfully fat boy” who stood “upright. His eyes closed as if in sleep,” his expression one of “calmness and repose. Asked his business, he said nothing, but “nodded once, and seemed . . .to snore feebly,” immobile through three repetitions of the question. Then, as the door was about to close on him, he “suddenly opened his eyes, winked several times, sneezed once, and raised his hand as if to repeat the knocking.”
OSA Misconceptions • 1956, Burwell’s “obesity hypoventilation (Pickwickian) syndrome” pulmonologists’ misconception • Not corrected until 1966 by Gastaut
“What happens?” • Upper airway collapses during sleep reduction, or cessation, of airflow less oxygen saturation increases in inspiratory efforts sleep fragmentation
1993, Wisconsin Sleep Cohort Study • AHI > 5 • 9% women • 24% men
Epidemiology of OSA Cadilhac 2005
Why ask about OSA? • Worsens hypertension • Causes endothelial cell dysfunction • Increases inflammatory response • Alters cerebral hemodynamics • Increases hypercoagulability • Increases insulin resistance and obesity • Increases atrial fibrillation • Increased cholesterol (dyslipidemia) • Proven stroke prevention
Dr. Johnson’s Summary Slide:OSA and Stroke • 1. OSA is an independent stroke risk factor and worsens other stroke risk factors • 2. OSA is common in stroke patients and increases stroke mortality and morbidity, which can be decreased with CPAP • 3. Treating OSA with CPAP in asymptomatic patients decreases cardiovascular morbidity and mortality • 4. Decision to test for OSA can’t be based on positive sleep history alone, so screening with polysomnography is necessary
VIDEO • http://med.stanford.edu/news_releases/2009/may/narcolepsy.html
narkenumbness, stupor + lepsisattack, seizure Narcolepsy ‘Tetrad’ (1957) • Cataplexy • sleep paralysis • hypnagogic hallucinations • automatic behavior
VIDEO • http://med.stanford.edu/news_releases/2009/may/narcolepsy.html