Studying Innovative Surgery For Effectively Treating Obstructive Sleep Apnea

Sleep disorder and ear, nose and throat specialists at Thomas Jefferson University are examining an innovative procedure to treat obstructive sleep apnea syndrome.
In the procedure, known as Genial Bone Advancement Trephine (GBAT), a small portion of the lower jaw which attaches to the tongue is moved forward, to pull the tongue away from the back of the airway, increasing the airway space. It is considered an option for patients when medications or a continuous positive airway pressure (C-PAP) device, which increases the supply of oxygen and reduces the work of breathing, have proven to be ineffective.
"Even immediately after the procedure patients have an easier time breathing,  noted Maurits Boon, M.D., Clinical Instructor in Otolaryngology-Head and Neck Surgery, Jefferson Medical College of Thomas Jefferson University. "We have also observed that in a select group of patients hypertension drops off.
This procedure is often employed as an adjunct to more conventional surgery and can be very effective at treating OSA (obstructive sleep apnea).
Sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. Obstructive sleep apnea occurs when there is collapse of upper airway structures that prevent normal airflow. This essentially, results in cessation of breathing with resultant decreases in oxygen in the blood stream. The consequence is that this pattern of breathing causes interruptions in the normal sleep cycle and makes it difficult to get a restful night of sleep
Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood, noted Karl Doghramji, M.D., director of Jefferson University Hospitals Sleep Disorders Center, which recently opened a new all-inclusive facility in Center City.
"Sleep apnea occurs in all age groups and both genders, said Dr. Doghramji, Professor of Psychiatry and Human Behavior, Jefferson "It is more common in men, although it may be under-diagnosed in women. It is estimated that as many as 12 million Americans have sleep apnea.
Early recognition and treatment of sleep apnea is important, as it may be associated with:
* irregular heartbeat
* high blood pressure
* heart attack
* stroke
In the GBAT procedure, a small window is made in the lower jaw and advanced forward, said Dr. Boon. Because the tongue is attached to this portion of the jaw, it effectively moves the tongue forward to open the airway.
In this procedure, the surgeon is able to go through the inside of the mouth, avoiding the need to make any external incisions and avoiding any cosmetic changes. The procedure is usually done in conjunction with an uvulopalatopharyngoplasty-- surgery used to remove excess tissue at the back of the throat (tonsils, uvula, and part of the soft palate).
The piece of bone along with the attachment for the tongue is pulled forward and down, then fastened to the outside of the lower jaw. A small titanium plate is used to affix the bone.
The patient may experience soreness but will not have any change in dental occlusion (the way the teeth fit together), said Dr. Boon. The recovery period is usually about two weeks.

Insomnia patients with mental conditions often denied sleep treatment

Patients with insomnia who are diagnosed with accompanying mental health ailments often are not prescribed medication that will help them sleep – which could then make related anxiety or depression worse, new research suggests.
Scientists examining treatment patterns for insomniacs say that their findings suggest that many doctors appear to be reluctant to prescribe sleep aids, even those that pose no risk of dependence, if patients also have depression, anxiety or mood disorders. An exception is psychiatrists, who were found to be twice as likely as primary care physicians to prescribe medication for insomnia.
“Insomnia can cause you to have anxiety and depression, and depression and anxiety can cause you to have insomnia. It’s a chicken-and-egg type of story. But research has shown that if one of the conditions is left untreated it can exacerbate the other condition,” said senior study author Rajesh Balkrishnan, the Merrell Dow professor of pharmacy at Ohio State University.
“What this calls for is specific guidelines related to the treatment of insomnia that takes into consideration these different types of patients, because insomnia has become such a big public health problem.”
An estimated 20 percent of Americans have occasional sleep problems, with about one in 10 suffering from chronic insomnia.
Balkrishnan acknowledges concerns that physicians might have about prescribing certain medications that can cause dependence, especially to patients with mental health disorders. Older sleep aids, a class of drugs called benzodiazepines, are muscle relaxants with addictive properties and high potential for abuse. However, since the early 1990s, a new class of drugs for insomnia called non-benzodiazepines has been on the market. They are effective sleep aids that don’t carry the risk of addiction, Balkrishnan said, and for that reason, patients should have ready access to these medications.
“This research highlights the need to take into account that many patients who see their doctors with complaints of insomnia also have a psychiatric condition. But the presence of those mental conditions should not preclude them from being appropriately treated for their insomnia,” he said.
The study is published in the January issue of the Journal of Medical Economics.
Balkrishnan and colleagues collected data from the National Ambulatory Medical Care Survey, which tracks Americans’ annual outpatient medical visits. The researchers identified 5,487 physician visits by patients with insomnia between 1995 and 2004, which was calculated to represent about 161 million U.S. patients over that 10-year period.
According to the analysis, an estimated 6.5 million Americans who saw a doctor for insomnia also were diagnosed with a mental health disorder. Of the visits examined, 38 percent of patients with insomnia were diagnosed with at least one other condition, and at least four of every 10 of those accompanying conditions related to mental health. The most common additional condition was anxiety (15.6 percent), followed by episodic mood disorders (14.9 percent), high blood pressure (10.1 percent), depression (7 percent) and diabetes (3.5 percent).
The study showed that insomnia patients with mental health disorders were 36 percent less likely to receive medication for their sleeping problems than were patients without the mental health diagnosis. Those with anxiety were the least likely to receive a sleep aid, with a 45 percent decreased likelihood of receiving medication for insomnia compared to patients without anxiety.
Balkrishnan said that with generic forms of nonaddictive insomnia medication available by prescription, even patients taking antidepressants and anti-anxiety drugs can safely – and affordably – add a sleep aid to their regimen. The most common forms of antidepressants prescribed in the United States are a class of drugs called selective serotonin reuptake inhibitors (SSRIs).

Sleepwalking Easily Spotted After Sleep Deprivation

Keeping those with somnambulism awake for a whole day makes sleepwalking episodes occur more frequently as soon as they get asleep.
A team of researchers from University of Montreal conducted a study of somnambulistic behavior between August 2003 and March 2007. Study examined 30 people suspected in sleepwalking, who were diagnosed to have a condition not a result of trauma or medication. Some 10 patients with mild sleep apnea and leg movement were added to the group.
All participants were monitored in a laboratory during a night for baseline sleepwalking behavior. On the next day they were not allowed to sleep for 25 hours. The nigh after sleep deprivation was also monitored in a laboratory. This night showed significantly more somnambulism episodes: 90% of participants had at least one sleepwalking episode, compared to 50% of participants during the baseline night.
Sleepwalking episodes were rated in a 3 level scale: level 1 includes simple confusing behavior, such as playing with bed sheets, level 2 includes any attempt to get out of the bed, such as sitting up in the bed, level 3 includes all episodes with patients leaving bed.
During the night after sleep deprivation the number of sleepwalking episodes were 69, compared to 24 baseline episodes. The 10 participants with other sleep disorders reported even greater increase than those with no additional sleep problems. They increased the frequency of episodes from 8 to 23. Men also reported more sleepwalking episodes than women.
The study comes to ease monitoring for somnambulism behavior in laboratories. Current sleepwalking episodes are not frequent enough to be monitored and patients have not clear diagnosis. In addition the research confirms the need in regular sleep for patients to cut frequency of sleepwalking episodes and to ensure deep sleep for patients.

Intensity of snoring sounds linked to sleepiness

This study is the first to use polysomnography and sound measurements to demonstrate the relationship between snoring sounds and sleepiness.
A study in the Dec. 15 issue of the Journal of Clinical Sleep Medicine shows that objectively measured snoring intensity is correlated with subjective sleepiness independent of the apnea-hypopnea index (AHI) in patients with moderate to severe obstructive sleep apnea (OSA).
Results indicate that the sound intensity of objectively measured snoring in patients with OSA is independently correlated with subjective sleepiness as measured by the Epworth Sleepiness Scale (ESS), and subjective sleepiness is better explained by snoring intensity than by AHI. Independent variables such as snoring intensity, desaturation severity, daily sleep time, subjective snoring frequency and nasal obstruction symptoms accounted for 22 percent of the variance in ESS scores. Snoring intensity and AHI together, however, could explain only 15 percent of the variance in ESS scores.
Principal investigator Hiroshi Nakano, MD, PhD, of the department of pulmonology at the Fukuoka National Hospital in Fukuoka, Japan, says that the results of the study indicate that daytime sleepiness is affected not only by the severity of OSA, but also by the loudness of snoring.
"The results were not so surprising, because previous studies in general population have shown an independent relationship between the degree of snoring, by a questionnaire, and sleepiness," said Nakano.
Records of 507 patients who were referred to Fukuoka National Hospital for suspected OSA and who underwent diagnostic polysomnography (PSG) between September 2002 and January 2005 were retrospectively reviewed. Subjective sleepiness was assessed using the ESS, and snoring intensity was assessed using the highest one percentile ambient sound-pressure level attained while asleep during PSG.
Patients were placed into groups of non-to-mild OSA (AHI less than 15) and moderate-to-severe OSA (AHI greater than 15) in order to clarify the effect of OSA severity on the relationship between snoring intensity and sleepiness in subsequent analyses.
Findings suggest that snoring intensity is significantly correlated with age, body mass index (BMI) and AHI. Insufficient sleep in daily life was taken into consideration as a possible cofounder, as it may enhance snoring intensity and sleepiness. Although sleepiness is one of the most important symptoms of OSA, the authors report that the correlation between the degree of sleepiness and the severity of OSA has been found to be relatively weak in many studies.
Because objectively measured snoring is related to sleepiness independent of OSA, the authors conclude that quantitative measurements of snoring are desirable in ordinary sleep studies.