Thread by @gretchemaben

My next #ATS2022 tweetucation session for the day is the Sleep Clinical Core Curriculum!

First up we have Dr. Kiran Maski with “When Laughing Makes You Weak: Narcolepsy Diagnosis and Management.” #ATS2022

Overview of narcolepsy. It is a condition of REM sleep dysregulation characterized by a sleep and wake state balance. #ATS2022

Narcolepsy diagnostic criteria #ATS2022

A multiple sleep latency test looks for how quickly they fall asleep and whether they enter REM sleep. #ATS2022

New guidelines allow for one of the sleep onset REM periods to be present during the overnight sleep study. #ATS2022

Cataplexy is triggered by strong emotions, most commonly laughter. It can be partial or complete cataplexy. #ATS2022

Some children can have a constant state of atonic features even without an emotional trigger. #ATS2022

Type 1 narcolepsy is caused by a selective loss of the orexin neurons in the lateral hypothalamus. #ATS2022

You can measure CSF orexin levels as a diagnostic criteria. Narcolepsy without cataplexy does not typically have pathologically low orexin levels. #ATS2022

We don’t know for sure but it is likely that this neuronal loss is of an autoimmune etiology. #ATS2022

Orexin helps to maintain wake or sleep states so lower levels may make it easier for wakefulness or sleep to intrude into periods of the other. #ATS2022

Cataplexy physiology #ATS2022

The diagnosis of narcolepsy is often delayed. #ATS2022

The pediatric hypersomnolence survey can be used for screening.
#ATS2022

Recommendations for recommended adequate sleep and actigraphy before MSLT. #ATS2022

Insufficient sleep can lead to false positive testing for narcolepsy. #ATS2022

False positive sleep MSLT results can occur with shift work. #ATS2022

False positive MSLT results can occur with OSA, and false negatives can occur with antidepressant use. #ATS2022

Approved treatments for excessive sleepiness include traditional stimulants and these other medications. #ATS2022

These medications can be used for the treatment of cataplexy. #ATS2022

These practice parameters came out in 2021. #ATS2022

Summary points! #ATS2022

Next is “Medical and Psychological Consequences of Insomnia” with Dr. Hugo Paz y Mar! #ATS2022

Learning objectives #ATS2022

Insomnia definitions - Short-term vs chronic #ATS2022

Clinical manifestations of insomnia
#ATS2022

Why is insomnia a problem? #ATS2022

Mean total healthcare costs over 12 months prior to and post insomnia diagnosis #ATS2022

There was an almost 4 fold increase in the risk of HTN in patients with insomnia in this study. #ATS2022

Other studies also show an association between insomnia and hypertension. #ATS2022

Why does this happen? Patients with insomnia have increased cardiovascular autonomic activity that leads to increased blood pressure. But we don’t know which is the chicken and the egg. #ATS2022

There are different ways to assess cardiovascular autonomic activity, including heart rate variability. #ATS2022

There is increasing evidence that insomnia is associated with worse cardiovascular disease. #ATS2022

Insomnia is also a risk factor for the development of type 2 diabetes. #ATS2022

This study evaluated sleep restriction’s effect on insulin sensitivity and stress hormones. #ATS2022

They found increased levels of stress hormones. #ATS2022

They also found decreased insulin sensitivity (thus increased insulin resistance) with sleep restriction. #ATS2022

This study also found sleep restriction was associated with insulin resistance. #ATS2022

This study found that more patients with pre-DM who developed insomnia developed diabetes than those without insomnia. #ATS2022

Pathophysiological mechanisms for consequences of insomnia. #ATS2022

This study evaluated the effects of CBT-I on insomnia and depression. #ATS2022

They found that CBT-I improved insomnia and depression severity.
#ATS2022

This meta-analysis looked at the effect of insomnia treatments on depression. #ATS2022

Why is this important? #ATS2022

Insomnia has been associated with different mental health disorders.
#ATS2022

Possible mechanisms of insomnia and depression. Note that it is a bidirectional relationship. #ATS2022

Overview model of insomnia, pathophysiology, and consequences. #ATS2022

Summary! #ATS2022

And last up we have Dr. Sabra Abbott with “Jet Lag, Shift Work, and How to Get Along with Your Circadian Rhythm”! #ATS2022

Learning objectives #ATS2022

Most people have a circadian rhythm that is a little longer than 24 hours, so their sleep cycle would naturally start a little later each day. #ATS2022

Exposure to light early in a sleep cycle will move your sleep cycle later the following day. #ATS2022

Exposure to light early in the day will move your sleep cycle earlier that day. #ATS2022

Phase response curve to light. The blue box is when this patient would fall asleep and wake up. Light during the blue box would worsen the delay, but light right after the box would improve it. #ATS2022

Melatonin taken before the natural time causes phase advancement, and melatonin taken after you would naturally stop taking it would cause a phase delay. #ATS2022

When trying to fix jet lag with bright lights you need to make sure the light exposure falls at the right time for the sleep schedule they are coming FROM. If you give light at a time that falls kn the middle of the old sleep period it will worsen their phase delay. #ATS2022

Why do we not recommend taking Ambien on flights? It brings out the crazy! #ATS2022

What about diet? Make sure to eat two cows and pasta on the right days (joking)! But changing timing of your meals to your new time zone can help. #ATS2022

General strategies for Eastward travel #ATS2022

General strategies for Westward travel #ATS2022

For patients with shift work disorder, figure out what symptom bothers them most - is it trouble falling asleep or trouble staying awake? #ATS2022

Strategies for patients who have difficulty falling asleep #ATS2022

Strategies for patients who have difficulty staying awake #ATS2022

For people who do shift work but want to be awake during the day on their days off, you can do a compromised sleep shift, where they sleep more like 3-11am on their days off so they aren’t trying to flip 12 hours back and forth. #ATS2022

Summary points!