Suvorexant alters dynamics of the sleep-electroencephalography-power spectrum and depressive-symptom trajectories during inpatient opioid withdrawal.

STUDY OBJECTIVES: Opioid withdrawal is an aversive experience that often exacerbates depressive symptoms and poor sleep. The aims of the present study were to examine the effects of suvorexant on oscillatory sleep-electroencephalography (EEG) band power during medically managed opioid withdrawal, and to examine their association with withdrawal severity and depressive symptoms. METHODS: Participants with opioid use disorder (N = 38: age-range:21-63, 87% male, 45% white) underwent an 11-day buprenorphine taper, in which they were randomly assigned to suvorexant (20 mg [n = 14] or 40 mg [n = 12]), or placebo [n = 12], while ambulatory sleep-EEG data was collected. Linear mixed-effect models were used to explore: (1) main and interactive effects of drug group, and time on sleep-EEG band power, and (2) associations between sleep-EEG band power change, depressive symptoms, and withdrawal severity. RESULTS: Oscillatory spectral power tended to be greater in the suvorexant groups. Over the course of the study, decreases in delta power were observed in all study groups (ß = -189.082, d = -0.522, p = <0.005), increases in beta power (20 mg: ß = 2.579, d = 0.413, p = 0.009 | 40 mg ß = 5.265, d = 0.847, p < 0.001) alpha power (20 mg: ß = 158.304, d = 0.397, p = 0.009 | 40 mg: ß = 250.212, d = 0.601, p = 0.001) and sigma power (20 mg: ß = 48.97, d = 0.410, p < 0.001 | 40 mg: ß = 71.54, d = 0.568, p < 0.001) were observed in the two suvorexant groups. During the four-night taper, decreases in delta power were associated with decreases in depressive symptoms (20 mg: ß = 190.90, d = 0.308, p = 0.99 | 40 mg: ß = 433.33, d = 0.889 p = <0.001), and withdrawal severity (20 mg: ß = 215.55, d = 0.034, p = 0.006 | 40 mg: ß = 192.64, d = -0.854, p = <0.001), in both suvorexant groups and increases in sigma power were associated with decreases in withdrawal severity (20 mg: ß = -357.84, d = -0.659, p = 0.004 | 40 mg: ß = -906.35, d = -1.053, p = <0.001). Post-taper decreases in delta (20 mg: ß = 740.58, d = 0.964 p = <0.001 | 40 mg: ß = 662.23, d = 0.882, p = <0.001) and sigma power (20 mg only: ß = 335.54, d = 0.560, p = 0.023) were associated with reduced depressive symptoms in the placebo group. CONCLUSIONS: Results highlight a complex and nuanced relationship between sleep-EEG power and symptoms of depression and withdrawal. Changes in delta power may represent a mechanism influencing depressive symptoms and withdrawal.

Letter to the Editor on "Leveraging Biomedical Engineering Engineers to Improve Obstructive Sleep Apnea (OSA) Care for Our Stroke Patients".

Obstructive sleep apnea (OSA), a condition of recurring, episodic complete or upper airway collapse, is a common disorder, affecting an estimated 17.4% of women and 33.9% of men in the United States [1]. The first line treatment for OSA is Continuous Positive Airway Pressure (CPAP) therapy, a medical device that delivers adequate airflow and oxygenation during sleep by way of a tube that connects an air compressor to a face mask that can fit over the nose, under the nose, or over the nose and mouth.

The promotion of sleep wellness: Resilience as a protective factor.

Objectives: To evaluate the association between resilience, sleep quality, and health. Methods: This cross-sectional study included 190 patients (Mean age = 51, SD = 15.57) recruited from the Johns Hopkins Center for Sleep and Wellness. Patients completed a modified version of the brief resilience scale (BRS) to assess characteristics of resilience and questions to assess aspects of mental health, physical health, sleep quality, and daytime functioning. Results: Participants' average score on the BRS was 4.67 (SD = 1.32, range = 1.17-7), reflecting a high level of resilience. There was a significant gender difference in resilience levels for men (Mean = 5.04, SD = 1.14) and women (Mean = 4.30, SD = 1.38), such that men reported significantly higher levels of resilience compared to women (t (188) = 4.02, p < 0.001) [lower levels of resilience were significantly associated with higher levels of (current) fatigue and tiredness after adjusting for demographic, physical, and mental covariates. In those reporting between one and three mental health symptoms, high levels of resilience minimized the negative influence that these symptoms had on sleep quality. This minimizing effect was no longer evident in those experiencing >3 mental health symptoms, who also reported significantly higher symptoms of fatigue despite their high resilience scores. Conclusions: This study emphasizes how resilience may affect the relationship between mental health and sleep quality in sleep patients. Resilience may further our understanding of the inter-relationships between sleep and the manifestation of physical health symptoms, a relationship that will likely heighten in relevance during personal and global crisis. An awareness of this interaction could be used as a proactive prevention and treatment strategy. In other words, incorporating methods to evaluate resilience in patients with mental illnesses regularly can be useful for predicting the potential manifestation and severity of sleep disturbance. Therefore, strategies that focus on promoting resilience could improve health and wellness.

An Integrated Interdisciplinary Sleep Care Model-The Ultimate Dream Team.

This Viewpoint discusses the need for diverse physicians to manage sleep health.

Comparative effectiveness study of flipped classroom versus online-only instruction of clinical reasoning for medical students.

CONTEXT: Bedside clinical teaching is the backbone of clerkship education. Data-driven methods for supplementing bedside encounters with standardized content from vetted resources are needed. OBJECTIVE: To compare a flipped-classroom versus an interactive online-only instruction for improving knowledge, skills, self-directed learning (SDL) behaviors, and satisfaction in a medical school clerkship. METHODS: An IRB-approved prospective study employing a peer-reviewed clinical reasoning curriculum in neurology was conducted; 2nd-4th year medical students rotating through a required clerkship were enrolled. Students were randomized to flipped-classroom (i.e., flipped) or interactive asynchronous online instruction (i.e., online-only), which supplemented existing bedside teaching. Baseline and end-of-course knowledge, skill development, SDL behaviors, satisfaction, and long-term retention were assessed by peer-reviewed clinical reasoning exam, NBME scores, faculty/resident clinical evaluations, non-compulsory assignment completion, end-of-clerkship surveys, and objective structured clinical exam (OSCE). RESULTS: 104 students (49 flipped, 55 online-only) were enrolled. Age, gender, and training level did not differ by group (all p > 0.43); baseline knowledge was higher in the flipped group (p = 0.003). Knowledge-based exam scores did not differ by group even after adjusting for differences in baseline knowledge (2.3-points higher in flipped group, 95%CI -0.4-4.8, p = 0.07). Clinical skills were significantly higher in the flipped group, including examination skills (4.2 ± 0.5 vs. 3.9 ± 0.7, p = 0.03) and future housestaff potential (4.8 ± 0.3 vs 4.5 ± 0.6, p = 0.03). Students in the online-only group were more likely to engage in SDL (42 vs. 12%, p = 0.001) and reported more hours studying (6.1 vs. 3.8 hours, p = 0.03). Satisfaction (p = 0.51) and OSCE scores (p = 0.28) were not different by group. CONCLUSIONS: In this comparative study of two evidence-based curricular delivery approaches, we observed no difference in knowledge acquired. Greater clinical skills were observed with flipped instruction, while more SDL was observed with online-only instruction. Supplementing bedside teaching with blended instruction that balances live skill development with vetted online resources is optimal for clerkship education.

It's a Win-Win: The Effect of Medical Students on Clinic Productivity.

Objective: We sought to explore whether obstetrics and gynecology (Ob-Gyn) ambulatory clinic preceptors can maintain their clinical productivity with a learner (medical student) present. Methods: We studied the productivity of five exemplary Ob-Gyn faculty over the 2016-2017 academic year. We used paired two-tailed t tests to compare physician productivity with and without a student. Faculty were interviewed and qualitative analyses were performed on faculty interview data to identify themes used to create sample best-practice workflows for student involvement in the clinic. Results: Three faculty had significant increases in relative value units (RVUs) per clinic half-day when a medical student was present (11%-31% increase, P<.05). Four faculty had average increases in net charges billed per clinic half-day ranging from $172.39 to $343.14. One faculty preceptor had a decrease in RVUs and charges billed when a student was present, which was not statistically significant. Themes derived from faculty interviews regarding their incorporation of medical students in the clinic included setting expectations, allowing students to assist with clinic workflow, note-writing, and efficient use of time and clinic space. In an iterative feedback process, we developed ideal workflow models for student involvement during clinic visits with and without a procedure. Conclusion: This mixed-methods pilot study suggests that medical students do not impede clinician productivity when utilized effectively in the outpatient setting. Further contemporary research is needed to assess the impact of learners on ambulatory clinician productivity in light of Medicare policy changes and modifications in medical education due to the COVID-19 pandemic.

Suvorexant ameliorated sleep disturbance, opioid withdrawal, and craving during a buprenorphine taper.

Increased orexin/hypocretin signaling is implicated in opioid withdrawal, sleep disturbances, and drug-seeking behaviors. This study examined whether a dual-orexin receptor antagonist would improve sleep and withdrawal outcomes when compared with placebo during a buprenorphine/naloxone taper. Thirty-eight participants with opioid use disorder were recruited to a clinical research unit and maintained on 8/2 to 16/4 mg of buprenorphine/naloxone treatment for 3 days before being randomized to 20 mg of suvorexant (n = 14), 40 mg of suvorexant (n = 12), or placebo (n = 12); 26 individuals completed the study. After randomization, participants underwent a 4-day buprenorphine/naloxone taper and 4-day post-taper observation period. Total sleep time (TST) was collected nightly with a wireless electroencephalography device and wrist-worn actigraphy; opioid withdrawal symptoms were assessed via the Subjective Opiate Withdrawal Scale (SOWS); and abuse potential was assessed on a 0- to 100-point visual analog scale of "High" every morning. A priori outcomes included two-group (collapsing suvorexant doses versus placebo) and three-group comparisons of area-under-the-curve (AUC) scores for TST, SOWS, and High. In two-group comparisons, participants receiving suvorexant displayed increased TST during the buprenorphine/naloxone taper and decreased SOWS during the post-taper period. In three-group comparisons, participants receiving 20 mg of suvorexant versus placebo displayed increased AUC for TST during the buprenorphine/naloxone taper, but there was no difference in SOWS among groups. There was no evidence of abuse potential in two- or three-group analyses. The results suggest that suvorexant might be a promising treatment for sleep and opioid withdrawal in individuals undergoing a buprenorphine/naloxone taper.

Worsening sleep quality across the lifespan and persistent sleep disturbances in persons with opioid use disorder.

STUDY OBJECTIVES: Individuals with opioid use disorder (OUD) may experience worsening sleep quality over time, and a subset of individuals may have sleep disturbances that precede opioid use and do not resolve following abstinence. The purpose of the present study was to (1) collect retrospective reports of sleep across the lifespan and (2) identify characteristics associated with persistent sleep disturbance and changes in sleep quality in persons with OUD. METHODS: Adults with OUD (n = 154) completed a cross-sectional study assessing current and past sleep disturbance, opioid use history, and chronic pain. Repeated-measures analysis of variance was used to examine changes in retrospectively reported sleep quality, and whether changes varied by screening positive for insomnia and/or chronic pain. Multivariate linear regression analyses were used to identify additional correlates of persistent sleep disturbance. RESULTS: Participants reported that their sleep quality declined over their lifespan. Changes in reported sleep over time varied based on whether the individual screened positive for co-occurring insomnia and/or chronic pain. In regression analyses, female sex (ß = 0.16, P = .042), a greater number of treatment episodes (ß = 0.20, P = .024), and positive screens for chronic pain (ß = 0.19, P = .018) and insomnia (ß=0.22, P = .013) were associated with self-reported persistent sleep disturbance. Only a portion of participants who screened positive for sleep disorders had received a formal diagnosis. CONCLUSIONS: OUD treatment providers should routinely screen for co-occurring sleep disturbance and chronic pain. Interventions that treat co-occurring OUD, sleep disturbance, and chronic pain are needed. CITATION: Ellis JD, Mayo JL, Gamaldo CE, Finan PH, Huhn AS. Worsening sleep quality across the lifespan and persistent sleep disturbances in persons with opioid use disorder. J Clin Sleep Med. 2022;18(2):587-595.

Clinical correlates of drug-related dreams in opioid use disorder.

BACKGROUND AND OBJECTIVES: Drug-related dreams are commonly reported by individuals in treatment for substance use disorders, which may be distressing. Existing evidence suggests that dream recollection may be influenced by clinically relevant phenomena, such as opioid use and withdrawal, general sleep disturbance, affective symptoms, and chronic pain. However, very few studies have explored drug-related dreams among individuals who screened positive for opioid use disorder (OUD). METHODS: Adults recruited from Amazon Mechanical Turk (MTurk) who screened positive for OUD (N = 154) completed a questionnaire about drug-related dreams, as well as measures assessing sleep, opioid use history, stress, anxiety, and chronic pain. χ2 analyses, one-way analysis of variance, and bivariate correlations, correcting for the false discovery rate, were used as appropriate to explore correlates of (1) recollecting a drug-related dream, and (2) experiencing post-dream craving and distress. RESULTS: Individuals who recollected a past-week drug-related dream were more likely to report other recent sleep disturbances, including poorer sleep quality, greater insomnia symptoms, and a higher risk for sleep apnea. Post-dream craving and distress were both associated with greater insomnia symptoms, poor sleep hygiene behaviors, and greater anxiety symptoms. Individuals who had ever experienced a drug-related dream (recently, or in their lifetime) were more likely to report a history of severe withdrawal, overdose, and intravenous opioid use. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Drug-related dreams were common among individuals in the present sample and were related to other clinically relevant phenomena. Interventions that treat co-occurring OUD, pain, sleep symptoms, and affective symptoms may improve overall well-being in this population.

Training in Neurology: Implementation and Evaluation of an Objective Structured Clinical-Examination Tool for Neurology Postgraduate Trainees in Lusaka, Zambia.

BACKGROUND: We established Zambia's first neurology residency program at the University of Zambia School of Medicine and the University Teaching Hospital in Lusaka. OBJECTIVE: To evaluate the feasibility and effectiveness of a modified objective structured clinical examination (OSCE) to assess clinical skills. METHODS: The neurology training program's 3 participants completed the OSCE exercise in February 2019. We used smartphones to videotape trainees performing a physical examination and oral presentation in the neurology clinic. Trainees and faculty reviewed the videos independently using a standardized rubric and then met for in-person feedback. RESULTS: Three trainees completed pre- and post-OSCE surveys rating their confidence in elements of the history and examination. Trainees' average self-confidence scores improved from the pre- to post-OSCE survey in every category (pre-OSCE: mean score 6.84, range 4.8-7.8, SD 0.92; post-OSCE: mean score 7.9, range 5.67-9.33, SD 0.86). Qualitative feedback showed trainees found the OSCE helpful, routinely applied feedback, and would appreciate repeating OSCEs. CONCLUSIONS: OSCEs improve trainees' self-confidence and can be modified and successfully implemented in a resource-limited neurology postgraduate training program. Important OSCE modifications involved using smartphones for videotaping and a real patient encounter rather than a standardized patient. Embedding the experience within a busy clinic day was practical, applicable, and efficient. Future work should expand use of OSCEs both within the Zambian neurology residency program and non-neurology training programs. Including additional video reviewers could add to the validity of clinical skills assessment. Videos could also be used for remote mentorship and teaching purposes.

Assessing Sleep Concerns in Individuals With Acquired Brain Injury: The Feasibility of a Smartpad Sleep Tool.

OBJECTIVE: The investigators examined the presence of disrupted sleep in acquired brain injury (ABI) and the utility of a mobile health program, MySleepScript, as an effective clinical tool to detect sleep disturbances. METHODS: A cross-sectional pilot study of MySleepScript, a customizable electronic battery of validated sleep questionnaires, was conducted. Participants were recruited at the Acquired Brain Injury Clinic at Johns Hopkins Bayview Medical Center. RESULTS: Sixty-eight adults with ABI (mean age, 46.3 years [SD=14.8]) participated in the study, with a mean completion time of 16.6 minutes (SD=5.4). Time to completion did not differ on individual completion or staff assistance. The mean score on the Pittsburgh Sleep Quality Index was 9.2 (SD=4.7); 83.9% of individuals had poor sleep quality (defined as a score >5). Insomnia Severity Index scores indicated moderate to severe insomnia in 45% of participants; 36.5% of participants screened positive for symptoms concerning sleep apnea, while 39.3% of individuals screened positive for restless legs syndrome. CONCLUSIONS: Poor sleep quality was highly prevalent in this ABI cohort. MySleepScript may be an effective method of assessing for sleep disturbance in ABI. Further efforts to identify sleep disorders in this patient population should be pursued to optimize ABI management.

Identifying Sleep Biomarkers to Evaluate Cognition in HIV.

Sleep disturbance and cognitive impairment represent two of the most common and debilitating conditions facing seropositive (HIV+) individuals who are otherwise well controlled with antiretroviral therapy. Sleep-assessment-based biomarkers represent an important step towards improving our understanding of the unique mechanistic features that may link sleep disruption and cognition in HIV+ individuals, ultimately leading to advancements in treatment and management options. In this study, a risk score was computed via a generalized linear model (GLM), which optimally combines polysomnography (PSG) features extracted from EEG, EMG, and EOG signals, to distinguish 18 HIV+ Black male individuals with and without cognitive impairment. The optimal set of features was identified via the least absolute shrinkage and selection operator (LASSO) approach, and the risk separation between the two groups, i.e., cognitively normal and cognitive impaired, was significant (and has a P-value < .001). The optimal set of predictive features were all EEG derived and sleep stage-specific. These preliminary findings suggest that sleep-based EEG features may be used as both diagnostic and prognostic biomarkers for cognition in HIV+ subjects.

Education Research: The medical student perspective on challenging conversations.

OBJECTIVE: Medical students experience difficult conversations with patients during clinical clerkships. This study aimed to characterize barriers to and opportunities for learning in the setting of challenging conversations. METHODS: Neurology clerkship medical students were enrolled prospectively in a concurrent nested mixed methods study. Qualitative data were collected using a postclerkship survey and semi-structured focus groups. Students were asked to reflect on challenging conversations they experienced with patients and to identify the top reasons why conversations were challenging. Responses were analyzed using directed content analysis. RESULTS: A total of 159 medical students were enrolled (MS2: n = 35 [22%]; MS3: n = 97 [61%]; MS4: n = 27 [17%]). Three themes of difficulty were identified in survey and focus group data: (1) tough clinical realities: how the clinical environment makes conversations challenging; (2) communication skill needs: the difficulty of finding the words to say; and (3) navigating emotions: of patients, clinicians, and students themselves. Tough clinical realities were cited by over two-thirds of students in all years (MS2: n = 30 [86%]; MS3: n = 74 [76%]; MS4: n = 23 [85%]). Communication skills needs were cited most frequently by third-year students (MS2: n = 15 [43%]; MS3: n = 55 [57%]; MS4: n = 10 [37%]). Students early in training were more likely to cite difficulty navigating emotions (MS2: n = 28 [80%]; MS3: n = 71 [73%]; MS4: n = 19 [70%]). CONCLUSIONS: Medical students frequently observe and participate in challenging conversations with patients. Here, students identified what makes these conversations most difficult. Communication curricula should leverage clinical communication encounters, prepare students for inherent clinical realities, and help students navigate emotions in the health care setting.

Attracting neurology's next generation: A qualitative study of specialty choice and perceptions.

OBJECTIVES: To better understand the reasons medical students select or avoid a career in neurology by using a qualitative methodology to explore these factors, with the long-term objective of attracting more graduates to the field. METHODS: In 2017, 27 medical students and 15 residents participated in 5 focus groups, and 33 fourth-year medical students participated in semistructured individual interviews. Participants were asked predefined open-ended questions about specialty choice, experiences in their basic neuroscience course and neurology clerkship, and perceptions about the field. Interviews were audio recorded and transcribed. We used a flexible coding methodology to generate themes across groups and interviews. RESULTS: Four main analytical themes emerged: (1) early and broad clinical exposure allows students to "try on" neurology and experience the variety of career options; (2) preclerkship experiences and a strong neuroscience curriculum lay the foundation for interest in the field; (3) personal interactions with neurology providers may attract or deter students from considering the specialty; and (4) persistent stereotypes about neurologists, neurology patients, and treatment options harm student perceptions of neurology. CONCLUSION: Efforts to draw more students to neurology may benefit from focusing on clinical correlations during preclerkship neuroscience courses and offering earlier and more diverse clinical experiences, including hands-on responsibilities whenever possible. Finally, optimizing student interactions with faculty and residents and reinforcing the many positive aspects of neurology are likely to favorably affect student perceptions.

Therapeutic Uses of Cannabis on Sleep Disorders and Related Conditions.

Marijuana generally refers to the dried mixture of leaves and flowers of the cannabis plant, and the term cannabis is a commonly used to refer to products derived from the Cannabis sativa L. plant. There has been an increasing interest in the potential medicinal use of cannabis to treat a variety of diseases and conditions. This review will provide the latest evidence regarding the medical risks and potential therapeutic benefits of cannabis in managing patients with sleep disorders or those with other medical conditions who commonly suffer with sleep disturbance as an associated comorbidity. Published data regarding the effects of cannabis compounds on sleep in the general population, as well as in patients with insomnia, chronic pain, posttraumatic stress disorder, and other neurological conditions, will be presented. Current trends for marijuana use and its effects on the economy and the implications that those trends and effects have on future research into medical cannabis are also presented.

Cross-Cultural Chronotypes: Educating Medical Students in America, Malaysia and the UAE.

This article was migrated. The article was marked as recommended. Background: Ample data demonstrates that sleep deprivation leads to impaired functioning including cognitive performance, memory and fine motor skills. Medical students represent a professional sector in which optimizing cognitive performance and functioning is critical from a personal, public health and safety perspective. Aims: To characterize chronotypes of an international cohort of medical students and determine if chronotype is affected by demographics or latitude. Samples: 328 students from medical schools in the United States (US), Malaysia and United Arab Emirates (UAE) were assessed for differences in chronotype and sleep habits. Methods: A cross-sectional, questionnaire-based study from medical schools in the US, Malaysia and UAE between 2013 and 2015. Results: There was a significant difference in mean waking times for Malaysian students who reported awakening earlier than US or UAE students. Malaysian students were most likely to feel their best earlier in the day and consider themselves a "morning type." UAE students were more likely to do "hard physical work" later in the day, followed by US and Malaysian. On average, US students were less likely to shift their bedtime later if they had no commitments the next day. Overall, mean chronotype score was "neither" type for all three groups however the Malaysian group showed a significant preference for morning hours in some individual questions. Conclusion: Medical student sleep patterns vary internationally but chronotype may not. Improving sleep education globally, with awareness of the effects of chronotype, could ultimately result in improved sleep awareness, potentially influencing physician wellbeing, patient care and safety.

Facets of personality related to sleep habits in Black adults.

OBJECTIVE: The objective of this study is to explore the relationship between personality traits and sleep in community-dwelling older Blacks, and to examine whether conscientiousness moderates relationships between neuroticism and sleep (quality and duration) within this cohort. METHOD: Black adults (age range: 55-86 years) residing in the Tampa Bay Area, Florida, completed the Big Five Inventory to examine broad personality traits (e.g., neuroticism) and specific facets (e.g., anxiety or depression) and the Pittsburgh Sleep Quality Index to evaluate sleep habits and quality. RESULTS: Ninety-three participants (Mean age: 66.6, standard deviation: 7.4) were included in the final sample. High neuroticism, low extraversion, low conscientiousness, and low openness were each significantly associated with worse overall sleep habits. Individuals high on the facets for neuroticism (e.g., anxiety, depression) and/or low for extraversion (e.g., assertiveness), conscientiousness (e.g., self-discipline and order), and openness (e.g., aesthetics and ideas) were more likely to report poorer sleep. However, only neuroticism and extraversion each remained significantly associated with worse sleep in our regression models adjusting for demographic and health covariates. Adults with both higher neuroticism and lower conscientiousness indicated a greater likelihood for experiencing daytime dysfunction within this population. CONCLUSIONS: Recognizing specific personality traits associated with disrupted sleep, particularly in those who self-identify as Black, may enhance the ability of sleep clinicians to diagnose and deliver more personalized treatments and interventions (e.g., cognitive behavioral therapy). The present study's findings further support existing literature, suggesting that clinicians should incorporate personality assessments to identify individuals most susceptible to severe sleep disturbances.