The Veterans Administration and Department of Defense clinical practice guidelines for the diagnosis and management of sleep disorders: what does this mean for the practice of sleep medicine?

In 2017 the Veterans Administration (VA) and Department of Defense (DOD) launched development of clinical practice guidelines (CPGs) for the diagnosis and treatment of sleep disorders, with the goal of informing and improving patient care. The guideline development process followed GRADE methodology, considering studies and systematic reviews published over the 10-year period prior to guideline development. A total of 41 recommendations were made,18 related to the diagnosis and treatment of obstructive sleep apnea (OSA) and 23 regarding chronic insomnia disorder. In contrast to other published guidelines, the VA DoD CPGs provide a comprehensive approach to diagnosis and management of the two most common sleep disorders, including a discussion of the sequencing of diagnostic approaches and treatment options. Regarding OSA, strong recommendations were made for follow-up evaluation after non-diagnostic home sleep apnea tests, positive airway pressure therapy as first-line treatment, and the incorporation of supportive, educational and behavioral interventions for patients at high risk for PAP therapy non-adherence due to comorbid conditions. Strong recommendations were also made for the use of cognitive-behavioral therapy for insomnia and against the use of kava (an herbal supplement) in the treatment of chronic insomnia disorder. These guidelines, while intended to directly inform care within VA and DOD, are broadly relevant to the practice of sleep medicine. The majority of scientific evidence was based on studies of non-military, non-veteran populations. The CPG is a major milestone for the VA and DOD in recognizing the importance of evidence-based treatments for sleep disorders in military personnel and veterans.

Value and Payment in Sleep Medicine.

ABSTRACT: Value, like beauty, exists in the eye of the beholder. This article places the value of clinical sleep medicine services in historical context and presents a vision for the value-based sleep of the future. First, the history of value and payment in sleep medicine is reviewed from the early days of the field, to innovative disruption, to the widespread adoption of home sleep apnea testing. Next, the importance of economic perspective is discussed, with emphasis on cost containment and cost-shifting between payers, employers, providers, and patients. Specific recommendations are made for sleep medicine providers and the field at large to maximize the perceived value of sleep. Finally, alternate payment models and value-based care are presented, with an eye toward the future for clinical service providers as well as integrated health delivery networks.

Medical Cannabis and the Treatment of Obstructive Sleep Apnea: An American Academy of Sleep Medicine Position Statement.

ABSTRACT: The diagnosis and effective treatment of obstructive sleep apnea (OSA) in adults is an urgent health priority. Positive airway pressure (PAP) therapy remains the most effective treatment for OSA, although other treatment options continue to be explored. Limited evidence citing small pilot or proof of concept studies suggest that the synthetic medical cannabis extract dronabinol may improve respiratory stability and provide benefit to treat OSA. However, side effects such as somnolence related to treatment were reported in most patients, and the long-term effects on other sleep quality measures, tolerability, and safety are still unknown. Dronabinol is not approved by the United States Food and Drug Administration (FDA) for treatment of OSA, and medical cannabis and synthetic extracts other than dronabinol have not been studied in patients with OSA. The composition of cannabinoids within medical cannabis varies significantly and is not regulated. Synthetic medical cannabis may have differential effects, with variable efficacy and side effects in the treatment of OSA. Therefore, it is the position of the American Academy of Sleep Medicine (AASM) that medical cannabis and/or its synthetic extracts should not be used for the treatment of OSA due to unreliable delivery methods and insufficient evidence of effectiveness, tolerability, and safety. OSA should be excluded from the list of chronic medical conditions for state medical cannabis programs, and patients with OSA should discuss their treatment options with a licensed medical provider at an accredited sleep facility. Further research is needed to understand the functionality of medical cannabis extracts before recommending them as a treatment for OSA.

Treatment guidelines for Circadian Rhythm Sleep-Wake Disorders of the Polish Sleep Research Society and the Section of Biological Psychiatry of the Polish Psychiatric Association. Part I. Physiology, assessment and therapeutic methods. / Standardy leczenia zaburzen rytmu okolodobowego snu i czuwania opracowane przez Polskie Towarzystwo Badan nad Snem i Sekcje Psychiatrii Biologicznej Polskiego Towarzystwa Psychiatrycznego. Czesc I. Fizjologia, metody oceny i oddzialywania terapeutyczne.

Majority of the physiological processes in the human organism are rhythmic. The most common are the diurnal changes that repeat roughly every 24 hours, called circadian rhythms. Circadian rhythms disorders have negative influence on human functioning. The aim of this article is to present the current understanding of the circadian rhythms physiological role, with particular emphasis on the circadian rhythm sleep-wake disorders (CRSWD), principles of their diagnosis and chronobiological therapy. The guidelines are based on the review of recommendations from the scientific societies involved in sleep medicine and the clinical experiences of the authors. Researchers participating in the preparation of guidelines were invited by the Polish Sleep Research Society and the Section of Biological Psychiatry of the Polish Psychiatric Association, based on their significant contributions in circadian rhythm research and/or clinical experience in the treatment of such disorders. Finally, the guidelines were adjusted to the questions and comments given by the members of both Societies. CRSWD have a significant negative impact on human health and functioning. Standard methods used to assess CRSWD are sleep diaries and sleep logs, while the actigraphy, when available, should be also used. The most effective methods of CRSWD treatment are melatonin administration and light therapy. Behavioral interventions are also recommended. Afourteen-day period of sleep-wake rhythm assessment in CRSWD enables accurate diagnosis, adequate selection of chronobiological interventions, and planning adequate diurnal timing of their application. This type of assessment is quite easy, low-cost, and provides valuable indications how to adjust the therapeutic approach to the circadian phase of the particular patient.

Treatment guidelines for Circadian Rhythm Sleep - Wake Disorders of the Polish Sleep Research Society and the Section of Biological Psychiatry of the Polish Psychiatric Association. Part II. Diagnosis and treatment. / Standardy leczenia zaburzen rytmu okolodobowego snu i czuwania Polskiego Towarzystwa Badan nad Snem i Sekcji Psychiatrii Biologicznej Polskiego Towarzystwa Psychiatrycznego. Czesc II. Diagnoza i leczenie.

AIM: Circadian rhythm sleep-wake disorders (CRSWD) are a group of disorders, in which the timing of sleep and wakefulness significantly differs from a patient's expectations or socially acceptable times. The aimof the article is to present the current principles for the diagnosis and treatment of CRSWD in adults and children. METHOD: Guidelines proposed as CRSWD treatment standard are based on the recommendations from the scientific societies involved in the sleep research and medicine. Researchers participating in the guidelines preparation were invited by the Polish Sleep Research Society and the Section of Biological Psychiatry of the Polish Psychiatric Association based on their significant contribution to the circadian rhythm research and/or clinical experience in the treatment of these disorders. Finally, the guidelines were adjusted to the questions and comments given by the members of both Societies. RESULTS: Patients with endogenous CRSWD are often misdiagnosed and treated for insomnia or hypersomnia. Therefore, each patient reporting sleep-wake disorders should be interviewed about the quality of sleep and its timing during free days (e.g. weekends, holidays). Avalid CRSWD diagnosis can be also established by using sleep diaries/logs and actigraphy. The treatment of choice for CRSWD is chronotherapy, which involves melatonin application, light therapy, and behavioral interventions. Sleep disorders associated with shift work and time zone changes are a growing health problem. Interventions for these disorders should primarily focus on prevention. CONCLUSIONS: The main problem in the treatment of CRSWD is an invalid diagnosis. Hypnotics and/or psychostimulants are often used instead of chronotherapeutic interventions, what can alleviate symptoms but is not an effective treatment.

Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline.

A systematic literature review and meta-analyses (where appropriate) were performed and the GRADE approach was used to update the previous American Academy of Sleep Medicine Practice Parameters on the treatment of intrinsic circadian rhythm sleep-wake disorders. Available data allowed for positive endorsement (at a second-tier degree of confidence) of strategically timed melatonin (for the treatment of DSWPD, blind adults with N24SWD, and children/ adolescents with ISWRD and comorbid neurological disorders), and light therapy with or without accompanying behavioral interventions (adults with ASWPD, children/adolescents with DSWPD, and elderly with dementia). Recommendations against the use of melatonin and discrete sleep-promoting medications are provided for demented elderly patients, at a second- and first-tier degree of confidence, respectively. No recommendations were provided for remaining treatments/ populations, due to either insufficient or absent data. Areas where further research is needed are discussed.

American Thoracic Society member survey on climate change and health.

The American Thoracic Society (ATS), in collaboration with George Mason University, surveyed a random sample of ATS members to assess their perceptions of, clinical experiences with, and preferred policy responses to climate change. An e-mail containing an invitation from the ATS President and a link to an online survey was sent to 5,500 randomly selected U.S. members; up to four reminder e-mails were sent to nonrespondents. Responses were received from members in 49 states and the District of Columbia (n = 915); the response rate was 17%. Geographic distribution of respondents mirrored that of the sample. Survey estimates' confidence intervals were ±3.5% or smaller. Results indicate that a large majority of ATS members have concluded that climate change is happening (89%), that it is driven by human activity (68%), and that it is relevant to patient care ("a great deal"/"a moderate amount") (65%). A majority of respondents indicated they were already observing health impacts of climate change among their patients, most commonly as increases in chronic disease severity from air pollution (77%), allergic symptoms from exposure to plants or mold (58%), and severe weather injuries (57%). A larger majority anticipated seeing these climate-related health impacts in the next 2 decades. Respondents indicated that physicians and physician organizations should play an active role in educating patients, the public, and policy makers on the human health effects of climate change. Overall, ATS members are observing that human health is already adversely affected by climate change and support responses to address this situation.

Sleep medicine care under one roof: a proposed model for integrating dentistry and medicine.

Integrating oral appliance therapy into the delivery of care for sleeprelated breathing disorders has been a challenge for dental and medical professionals alike. We review the difficulties that have been faced and propose a multidisciplinary care delivery model that integrates dental sleep medicine and sleep medicine under the same roof with educational and research components. The model promises to offer distinct advantages to improved patient care, continuity of treatment, and the central coordination of clinical and insurance-related benefits.

The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy of Sleep Medicine Clinical Practice Guideline.

A systematic literature review and meta-analyses (where appropriate) were performed to update the previous AASM practice parameters on the treatments, both dopaminergic and other, of RLS and PLMD. A considerable amount of literature has been published since these previous reviews were performed, necessitating an update of the corresponding practice parameters. Therapies with a STANDARD level of recommendation include pramipexole and ropinirole. Therapies with a GUIDELINE level of recommendation include levodopa with dopa decarboxylase inhibitor, opioids, gabapentin enacarbil, and cabergoline (which has additional caveats for use). Therapies with an OPTION level of recommendation include carbamazepine, gabapentin, pregabalin, clonidine, and for patients with low ferritin levels, iron supplementation. The committee recommends a STANDARD AGAINST the use of pergolide because of the risks of heart valve damage. Therapies for RLS secondary to ESRD, neuropathy, and superficial venous insufficiency are discussed. Lastly, therapies for PLMD are reviewed. However, it should be mentioned that because PLMD therapy typically mimics RLS therapy, the primary focus of this review is therapy for idiopathic RLS.

[Sleep medicine services in Germany]. / Schlafmedizinische Versorgung in Deutschland.

The increase in sleep medicine services has paralleled the increased in nocturnal ventilation therapy in patients with sleep apnea. Even if the sleep medicine expertise did increase in the past, this is not sufficient to cover the increasing demand for sleep medicine services. To serve patients with nonrestorative sleep, a clinical algorithm showing the pathway from the clinical interview to sleep laboratory investigations is available. However, there is a gap in the services offered by family physicians, other medical specialists, and sleep medicine practitioners. For sleep apnea, the diagnostic process and therapy are established; however, for other sleep disorders such as insomnia, parasomnia, movement disorders, hypersomnia, and circadian rhythm disorders, this is not the case. A basic investigation for sleep disorders is attended cardiorespiratory polysomnography, which is not always essential. There is a network of qualified sleep centers for stationary and ambulatory care, but their work is becoming more difficult under increasing health care economic pressure. Sleep medicine needs a solid structural and financial basis to provide good coverage of high quality health care service. New sleep medicine service centers for ambulatory care with a better network structure linked with other medical specialties and with offers for preventive medicine can serve all patients with sleep disorders over long periods of time.

Training issues pertaining to sleep medicine and child neurology.

Co-morbid sleep disorders are quite common in Child Neurology. Formal training in the field of sleep medicine and routine attention to sleep-wake function in clinical practice enhances the ability of the child neurologist to deliver comprehensive care.