Center for Sleep Medicine

Rochester, MN, United States

Center for Sleep Medicine

Rochester, MN, United States
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Silber M.H.,Center for Sleep Medicine | Becker P.M.,Sleep Medicine Associates of Texas | Earley C.,Johns Hopkins University | Garcia-Borreguero D.,Sleep Research Institute | Ondo W.G.,University of Houston
Mayo Clinic Proceedings | Year: 2013

Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is a common disorder, occurring at least twice a week and causing at least moderate distress in 1.5% to 2.7% of the population. It is important for primary care physicians to be familiar with this disorder and its management. Much has changed in its management since our previous algorithm was published in 2004, including the availability of several new drugs. This revised algorithm was written by members of the Medical Advisory Board of the Willis-Ekbom Disease Syndrome Foundation based on scientific evidence and expert opinion. It considers the management of RLS/ WED under intermittent RLS/WED, chronic persistent RLS/WED, and refractory RLS/WED. Nonpharmacological approaches, including mental alerting activities, avoiding substances or medications that may exacerbate RLS, and the role of iron supplementation, are outlined. Chronic persistent RLS/WED should be treated with either a nonergot dopamine agonist or a calciumchannel α-2-δ ligand. We discuss the available drugs, the factors determining which to use, and their adverse effects. We define refractory RLS/WED and describe management approaches, including combination therapy and the use of high-potency opioids. © 2013 Mayo Foundation for Medical Education and Research.


Parish J.M.,Center for Sleep Medicine
Chest | Year: 2013

The study of genetics is providing new and exciting insights into the pathogenesis, diagnosis, and treatment of disease. Both normal sleep and several types of sleep disturbances have been found to have significant genetic influences, as have traits of normal sleep, such as those evident in EEG patterns and the circadian sleep-wake cycle. The circadian sleep-wake cycle is based on a complex feedback loop of genetic transcription over a 24-h cycle. Restless legs syndrome (RLS) and periodic limb movements in sleep (PLMS) have familial aggregation, and several genes have a strong association with them. Recent genome-wide association studies have identified single nucleotide polymorphisms linked to RLS/PLMS, although none has a definite functional correlation. Narcolepsy/cataplexy are associated with HLA DQB1*0602 and a T-cell receptor a locus, although functional correlations have not been evident. Obstructive sleep apnea is a complex disorder involving multiple traits, such as anatomy of the oropharynx, ventilatory control, and traits associated with obesity. Although there is clear evidence of familial aggregation in the obstructive sleep apnea syndrome, no specific gene or locus has been identified for it. Angiotensin-converting enzyme has been proposed as a risk variant, but evidence is weak. Fatal familial insomnia and advanced sleep phase syndrome are sleep disorders with a definite genetic basis. © 2013 American College of Chest Physicians.


Boeve B.F.,Center for Sleep Medicine
The Lancet Neurology | Year: 2013

Parkinson's disease is a progressive neurodegenerative disorder associated with Lewy body disease pathology in central and peripheral nervous system structures. Although the cause of Parkinson's disease is not fully understood, clinicopathological analyses have led to the development of a staging system for Lewy body disease-associated pathological changes. This system posits a predictable topography of progression of Lewy body disease in the CNS, beginning in olfactory structures and the medulla, then progressing rostrally from the medulla to the pons, then to midbrain and substantia nigra, limbic structures, and neocortical structures. If this topography and temporal evolution of Lewy body disease does occur, other manifestations of the disease as a result of degeneration of olfactory and pontomedullary structures could theoretically begin many years before the development of prominent nigral degeneration and the associated parkinsonian features of Parkinson's disease. One such manifestation of prodromal Parkinson's disease is rapid eye movement (REM) sleep behaviour disorder, which is a parasomnia manifested by vivid dreams associated with dream enactment behaviour during REM sleep. Findings from animal and human studies have suggested that lesions or dysfunction in REM sleep and motor control circuitry in the pontomedullary structures cause REM sleep behaviour disorder phenomenology, and degeneration of these structures might explain the presence of REM sleep behaviour disorder years or decades before the onset of parkinsonism in people who develop Parkinson's disease. © 2013 Elsevier Ltd.


Caples S.M.,Center for Sleep Medicine | Rowley J.A.,Harper University Hospital | Pallanch J.F.,Mayo Medical School | Elamin M.B.,Knowledge and Encounter Research Unit | Harwick J.D.,University of Florida
Sleep | Year: 2010

A substantial portion of patients with obstructive sleep apnea (OSA) seek alternatives to positive airway pressure (PAP), the usual first-line treatment for the disorder. One option is upper airway surgery. As an adjunct to the American Academy of Sleep Medicine (AASM) Standards of Practice paper, we conducted a systematic review and meta-analysis of literature reporting outcomes following various upper airway surgeries for the treatment of OSA in adults, including maxillomandibular advancement (MMA), pharyngeal surgeries such as uvulopharyngopalatoplasty (UPPP), laser assisted uvulopalatoplasty (LAUP), and radiofrequency ablation (RFA), as well as multi-level and multi-phased procedures. We found that the published literature is comprised primarily of case series, with few controlled trials and varying approaches to pre-operative evaluation and post-operative follow-up. We include surgical morbidity and adverse events where reported but these were not systematically analyzed. Utilizing the ratio of means method, we used the change in the apnea-hypopnea index (AHI) as the primary measure of efficacy. Substantial and consistent reductions in the AHI were observed following MMA; adverse events were uncommonly reported. Outcomes following pharyngeal surgeries were less consistent; adverse events were reported more commonly. Papers describing positive outcomes associated with newer pharyngeal techniques and multi-level procedures performed in small samples of patients appear promising. Further research is needed to better clarify patient selection, as well as efficacy and safety of upper airway surgery in those with OSA.


Kotagal S.,Mayo Medical School | Kotagal S.,Center for Sleep Medicine | Broomall E.,Mayo Medical School
Pediatric Neurology | Year: 2012

Children with autism spectrum disorder demonstrate an increased prevalence of difficulties with sleep initiation and maintenance. The consequences may include alterations in daytime behavior, memory, and learning in patients, and significant stress in caretakers. The dysregulation of melatonin synthesis, sensitization to environmental stimuli, behavioral insomnia syndromes, delayed sleep phase syndrome, rapid eye movement sleep behavior disorder, and comorbid anxiety, depression, and epilepsy comprise common etiologic factors. The clinical assessment of sleep problems in this population and a management algorithm are presented. © 2012 Elsevier Inc. All rights reserved.


Cajochen C.,University of Basel | Altanay-Ekici S.,University of Basel | Munch M.,Ecole Polytechnique Federale de Lausanne | Frey S.,University of Basel | And 2 more authors.
Current Biology | Year: 2013

Endogenous rhythms of circalunar periodicity (∼29.5 days) and their underlying molecular and genetic basis have been demonstrated in a number of marine species [1, 2]. In contrast, there is a great deal of folklore but no consistent association of moon cycles with human physiology and behavior [3]. Here we show that subjective and objective measures of sleep vary according to lunar phase and thus may reflect circalunar rhythmicity in humans. To exclude confounders such as increased light at night or the potential bias in perception regarding a lunar influence on sleep, we retrospectively analyzed sleep structure, electroencephalographic activity during non-rapid-eye-movement (NREM) sleep, and secretion of the hormones melatonin and cortisol found under stringently controlled laboratory conditions in a cross-sectional setting. At no point during and after the study were volunteers or investigators aware of the a posteriori analysis relative to lunar phase. We found that around full moon, electroencephalogram (EEG) delta activity during NREM sleep, an indicator of deep sleep, decreased by 30%, time to fall asleep increased by 5 min, and EEG-assessed total sleep duration was reduced by 20 min. These changes were associated with a decrease in subjective sleep quality and diminished endogenous melatonin levels. This is the first reliable evidence that a lunar rhythm can modulate sleep structure in humans when measured under the highly controlled conditions of a circadian laboratory study protocol without time cues. © 2013 Elsevier Ltd.


St. Louis E.K.,Center for Sleep Medicine
Neurology: Clinical Practice | Year: 2014

Sleep disorders are frequent comorbidities in neurologic patients. This review focuses on clinical aspects and prognosis of 3 neurologic sleep disorders: narcolepsy, restless legs syndrome/Willis-Ekbom disease (RLS/WED), and REM sleep behavior disorder (RBD). Narcolepsy causes pervasive, enduring excessive daytime sleepiness, adversely affecting patients' daily functioning. RLS/WED is characterized by an uncomfortable urge to move the legs before sleep, often evolving toward augmentation and resulting in daylong bothersome symptoms. RBD causes potentially injurious dream enactment behaviors that often signify future evolution of overt synucleinopathy neurodegen-eration in as many as 81% of patients. Timely recognition, referral for polysomnography, and longitudinal follow-up of narcolepsy, RLS/WED, and RBD patients are imperatives for neurologists in providing quality comprehensive patient care. © 2014 American Academy of Neurology.


Mansukhani M.P.,Center for Sleep Medicine | Kotagal S.,Center for Sleep Medicine | Kotagal S.,Mayo Medical School
Sleep Medicine | Year: 2012

Objective: To evaluate the efficacy and side effect profile of sodium oxybate in the treatment for narcolepsy-cataplexy in the pediatric age group. Methods: A retrospective study was conducted on 15 children and adolescents with narcolepsy-cataplexy who had been treated with sodium oxybate. The mean age at diagnosis of narcolepsy was 11. years (range 3-17. years). Subjects were followed for 3-90. months (mean 33) after starting sodium oxybate. During this period of time they were also maintained on other medications for sleepiness (n= 14) and cataplexy (n= 6). The charts were reviewed for documentation of improvement in sleepiness or cataplexy, side effects, and functioning in daily life. Results: Subsequent to the addition of sodium oxybate, sleepiness improved in 13/15 patients. In patients who had Epworth Sleepiness Scale (ESS) assessments, the score fell from a baseline median of 18 to 12 (n= 10, p= 0.01). The number of cataplexy episodes estimated by parents decreased from a median of 38/week pre-treatment to <1/week post treatment (n= 14, p< 0.001). Cataplexy severity, measured on an arbitrary scale, fell from a median of 3 (severe) to 1 (mild) in all 15 subjects (p< 0.001).Two of the 15 patients (13%) discontinued sodium oxybate, one for insurance reasons and the other due to constipation and dissociative feelings. A third patient stopped the medication temporarily due to body aches and dizziness, but then resumed treatment without recurrence of symptoms. Side effects in four others included tremor, blurring of vision, nocturnal awakenings, and increased nightmares. Overall, side effects occurred in 6/15 (40%) individuals. Improvement in social/academic spheres was noted in 11/15 (73%) subjects after starting sodium oxybate. The median BMI before and after treatment remained unchanged at 23 (n= 14, p= 0.99). Median values of height and weight before and after treatment also did not change significantly. The mean dose of sodium oxybate was 5 ± 2. g. Dose escalation owing to development of tolerance was not encountered. Conclusions: Sodium oxybate is effective in alleviating sleepiness and cataplexy in childhood onset narcolepsy-cataplexy. The therapeutic response was sustained over time, and without development of tolerance. Forty percent of the subjects experienced adverse effects. © 2012 Elsevier B.V.


Nannapaneni S.,Mayo Medical School | Ramar K.,Center for Sleep Medicine
Sleep Medicine | Year: 2014

Periodic limb movements during sleep (PLMS) is a sleep-related movement disorder characterized by repetitive limb movements during sleep, seen predominantly in the legs but also occasionally involving the arms. These movements may be associated with arousals that can lead to increases in sympathetic tone, resulting in tachycardia and elevated systolic blood pressure. Chronic sustained tachycardia and elevated systolic blood pressure are known to be associated with the development of arrhythmias, hypertension, left ventricular hypertrophy, and congestive heart failure. However, the data are not entirely clear on whether untreated PLMS is associated with these cardiovascular risks. This review examines the current evidence on whether PLMS has any effect on the cardiovascular system. © 2014 Elsevier B.V.


Ramar K.,Center for Sleep Medicine | Ramar P.,Health Science Research | Morgenthaler T.I.,Center for Sleep Medicine
Journal of Clinical Sleep Medicine | Year: 2012

Study Objectives: Adaptive servoventilation (ASV) is often used to treat central sleep apnea (CSA) and complex sleep apnea syndrome (CompSAS). Both CompSAS and CSA may occur in the setting of CHF and with the use of chronic opioids. We hypothesized that ASV would be less successful in treatment of CSA and CompSAS secondary to opioid use than in CHF patients. Methods: Consecutive patients were studied between January and December 2009 who underwent ASV titration for CSA or CompSAS due to CHF (defi ned as EF < 45%, or > 50% with evidence for diastolic dysfunction on echocardiogram) and chronic opioid users (defi ned by the use of opioids > 6 months). Results: Study included one hundred and eight patients with 77 males (71.3%) and 31 females (28.7%). Subjects had severe sleep apnea at baseline (AHI 45.6 ± 27.4) and inadequate control of sleep disordered breathing on CPAP (AHI 50.0 ± 32.2, CAI 36.6 ± 32). No signifi cant differences were found between the groups in overall ASV success, defi ned as AHI < 10/h (p = 0.236). ASV was successful in 28 (59.6%) of those in the opioid group, compared to 43 (70.5%) of those in the CHF group. When ASV success was defi ned as AHI < 5/h at optimum EEP, there was again no signifi cant difference between the groups (p-value = 0.812). Logistic regression showed unit increases in BMI, unit increases in HCO3, and presence of CSR were each associated with decreased likelihood of ASV success. Conclusion: We did not fi nd a statistically signifi cant difference in the effectiveness of ASV between CHF patients and chronic opioid users, with the overall success rate approaching 70%, as defi ned by an AHI < 10/h.

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