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
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
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
This meta-analysis looked at the effect of insomnia treatments on depression. #ATS2022
Why is this important? #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!
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