The Official Patient's Sourcebook on Sleep Apnea 0597831580, 9780597831584

Citation preview

THE OFFICIAL PATIENT’S SOURCEBOOK

on

J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

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ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright

2002 by ICON Group International, Inc.

Copyright 2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher’s note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your physician. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified physician. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The Official Patient’s Sourcebook on Sleep Apnea: A Revised and Updated Directory for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83158-0 1. Sleep Apnea-Popular works. I. Title.

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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

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Dedication To the healthcare professionals dedicating their time and efforts to the study of sleep apnea.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to sleep apnea. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

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About ICON Health Publications In addition to sleep apnea, Official Patient’s Sourcebooks are available for the following related topics: The Official Patient's Sourcebook on Insomnia The Official Patient's Sourcebook on Narcolepsy The Official Patient's Sourcebook on Restless Legs Syndrome To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents vii

Table of Contents INTRODUCTION ................................................................................................................................. 1 Overview .................................................................................................................................... 1 Organization ............................................................................................................................. 3 Scope ............................................................................................................................................ 3 Moving Forward ...................................................................................................................... 4

PART I: THE ESSENTIALS ..................................................................... 7 CHAPTER 1. THE ESSENTIALS ON SLEEP APNEA: GUIDELINES .......................................................................................................................... 9

Overview .................................................................................................................................... 9 What Is Sleep Apnea?........................................................................................................... 12 Who Gets Sleep Apnea? ....................................................................................................... 12 What Causes Sleep Apnea? ................................................................................................ 13 What Are the Effects of Sleep Apnea? ............................................................................. 13 When Should Sleep Apnea Be Suspected? ..................................................................... 14 How Is Sleep Apnea Diagnosed? ...................................................................................... 14 How Is Sleep Apnea Treated? ............................................................................................ 15 For More Information ........................................................................................................... 17 More Guideline Sources....................................................................................................... 17 Vocabulary Builder ............................................................................................................... 23

CHAPTER 2. SEEKING GUIDANCE ................................................................. 25 Overview .................................................................................................................................. 25 Associations and Sleep Apnea............................................................................................ 25 Finding More Associations................................................................................................. 34 Finding Doctors ..................................................................................................................... 36 Selecting Your Doctor .......................................................................................................... 38 Working with Your Doctor ................................................................................................. 38 Broader Health-Related Resources.................................................................................... 40 Vocabulary Builder ............................................................................................................... 40

CHAPTER 3. CLINICAL TRIALS AND SLEEP APNEA...................... 43 Overview .................................................................................................................................. 43 Recent Trials on Sleep Apnea............................................................................................. 46 Benefits and Risks .................................................................................................................. 55 Keeping Current on Clinical Trials.................................................................................. 58 General References................................................................................................................. 59 Vocabulary Builder ............................................................................................................... 60

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL ....................................................................... 63 CHAPTER 4. STUDIES ON SLEEP APNEA .................................................. 65

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Overview .................................................................................................................................. 65 The Combined Health Information Database ................................................................ 65 Federally-Funded Research on Sleep Apnea .................................................................. 75 E-Journals: PubMed Central .............................................................................................. 85 The National Library of Medicine: PubMed.................................................................. 85 Vocabulary Builder ............................................................................................................... 86

CHAPTER 5. PATENTS ON SLEEP APNEA ................................................ 91 Overview .................................................................................................................................. 91 Patents on Sleep Apnea........................................................................................................ 92 Patent Applications on Sleep Apnea .............................................................................. 107 Keeping Current................................................................................................................... 114 Vocabulary Builder ............................................................................................................. 114

CHAPTER 6. BOOKS ON SLEEP APNEA.................................................... 117

Overview ................................................................................................................................ 117 Book Summaries: Federal Agencies ................................................................................ 117 Book Summaries: Online Booksellers............................................................................. 119 The National Library of Medicine Book Index ............................................................ 122 Chapters on Sleep Apnea ................................................................................................... 126 General Home References .................................................................................................. 132 Vocabulary Builder ............................................................................................................. 132

CHAPTER 7. MULTIMEDIA ON SLEEP APNEA .................................. 139 Overview ................................................................................................................................ 139 Bibliography: Multimedia on Sleep Apnea .................................................................. 139 Vocabulary Builder ............................................................................................................. 142

CHAPTER 8. PERIODICALS AND NEWS ON SLEEP APNEA ... 143

Overview ................................................................................................................................ 143 News Services & Press Releases ...................................................................................... 143 Newsletters on Sleep Apnea ............................................................................................. 155 Academic Periodicals covering Sleep Apnea................................................................ 156

CHAPTER 9. PHYSICIAN GUIDELINES AND DATABASES ....... 159 Overview ................................................................................................................................ 159 NIH Guidelines .................................................................................................................... 159 NIH Databases ..................................................................................................................... 161 Other Commercial Databases ........................................................................................... 166 The Genome Project and Sleep Apnea ........................................................................... 167 Specialized References ........................................................................................................ 171

CHAPTER 10. DISSERTATIONS ON SLEEP APNEA ......................... 173 Overview ................................................................................................................................ 173 Dissertations on Sleep Apnea........................................................................................... 173 Keeping Current................................................................................................................... 174

PART III. APPENDICES .......................................................................... 175

Contents

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APPENDIX A. RESEARCHING YOUR MEDICATIONS .................. 177 Overview ................................................................................................................................ 177 Your Medications: The Basics.......................................................................................... 178 Learning More about Your Medications ...................................................................... 179 Commercial Databases ....................................................................................................... 180 Contraindications and Interactions (Hidden Dangers) ........................................... 182 A Final Warning.................................................................................................................. 183 General References............................................................................................................... 183

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ........ 185 Overview ................................................................................................................................ 185 What Is CAM? ..................................................................................................................... 185 What Are the Domains of Alternative Medicine? ..................................................... 186 Can Alternatives Affect My Treatment?...................................................................... 189 Finding CAM References on Sleep Apnea ................................................................... 190 Additional Web Resources ................................................................................................ 198 General References............................................................................................................... 203 Vocabulary Builder ............................................................................................................. 205

APPENDIX C. RESEARCHING NUTRITION ........................................... 207 Overview ................................................................................................................................ 207 Food and Nutrition: General Principles ....................................................................... 208 Finding Studies on Sleep Apnea ..................................................................................... 212 Federal Resources on Nutrition ....................................................................................... 216 Additional Web Resources ................................................................................................ 216 Vocabulary Builder ............................................................................................................. 218

APPENDIX D. FINDING MEDICAL LIBRARIES ................................... 221 Overview ................................................................................................................................ 221 Preparation ............................................................................................................................ 221 Finding a Local Medical Library..................................................................................... 222 Medical Libraries Open to the Public ............................................................................ 222

APPENDIX E. NIH CONSENSUS STATEMENT ON THE TREATMENT OF SLEEP DISORDERS OF OLDER PEOPLE ........... 229 Overview ................................................................................................................................ 229 Abstract .................................................................................................................................. 230 What Is the Treatment of Sleep Disorders of Older People? ................................... 230 Sleep and Wakefulness of Older People ......................................................................... 232 Diagnostic Evaluation ........................................................................................................ 234 Treatment of Sleep Disorders ........................................................................................... 236 Common Medical Practices .............................................................................................. 237 Good Sleep Hygiene and Treatment ............................................................................... 239 Future Research.................................................................................................................... 240 Conclusions and Recommendations ............................................................................... 242

APPENDIX F. MORE ON PROBLEM SLEEPINESS .............................. 245

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Contents

Overview ................................................................................................................................ 245 What Causes Problem Sleepiness? ................................................................................. 245 Sleep Disorders ..................................................................................................................... 246 Medical Conditions/Drugs ............................................................................................... 247 Problem Sleepiness and Adolescents .............................................................................. 247 What Can Help? .................................................................................................................. 249

ONLINE GLOSSARIES............................................................................. 253 Online Dictionary Directories ......................................................................................... 258

SLEEP APNEA GLOSSARY ............................................................... 259 General Dictionaries and Glossaries .............................................................................. 289

INDEX ................................................................................................................................... 291

Introduction

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INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don’t know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many physicians and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1

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Sleep Apnea

Since the late 1990s, physicians have seen a general increase in patient Internet usage rates. Patients frequently enter their doctor’s offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that doctors often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Sleep Apnea has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to sleep apnea, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on sleep apnea. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on sleep apnea should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on appropriate

Introduction

3

options is always up to the patient in consultation with their physician and healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching sleep apnea (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to sleep apnea. It also gives you sources of information that can help you find a doctor in your local area specializing in treating sleep apnea. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with sleep apnea. Part II moves on to advanced research dedicated to sleep apnea. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on sleep apnea. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “freeto-use” options. Part III provides appendices of useful background reading for all patients with sleep apnea or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with sleep apnea. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with sleep apnea.

Scope While this sourcebook covers sleep apnea, your doctor, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that sleep apnea is often considered a synonym or a condition closely related to the following: Central Sleep Apnea Nocturnal Upper Airway Occlusion Obstructive Sleep Apnea

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Sleep Apnea

Ondine's Curse Pediatric Obstructive Sleep Apnea Pickwickian Syndrome Sleep Apnea Syndrome In addition to synonyms and related conditions, physicians may refer to sleep apnea using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world’s illnesses. Your physician may use this coding system as an administrative or tracking tool. The following classification is commonly used for sleep apnea:4 780.51 insomnia with sleep apnea 780.53 hypersomnia with sleep apnea 780.57 other and unspecified sleep apnea For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to sleep apnea. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.

Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson’s approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by physicians or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as

This list is based on the official version of the World Health Organization’s 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

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Introduction

5

recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients diagnosed with sleep apnea will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with sleep apnea is even indexed in search engines, a non-systematic approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. While we focus on the more scientific aspects of sleep apnea, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

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PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on sleep apnea. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your doctor or healthcare provider may have already explained the essentials of sleep apnea to you or even given you a pamphlet or brochure describing sleep apnea. Now you are searching for more in-depth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your doctor has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Guidelines

CHAPTER 1. GUIDELINES

THE

ESSENTIALS

ON

SLEEP

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APNEA:

Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on sleep apnea. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on sleep apnea can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them. The National Institutes of Health (NIH)5 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on sleep apnea. Originally founded in 1887, the NIH is one of the world’s foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years 5

Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

10 Sleep Apnea

include the world’s most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine. There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with sleep apnea and associated conditions: Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html National Heart, Lung, and Blood Institute (NHLBI); guidelines at http://www.nhlbi.nih.gov/guidelines/index.htm Among these, the National Heart, Lung, and Blood Institute (NHLBI) is particularly noteworthy. The NHLBI provides leadership for a national program in diseases of the heart, blood vessels, lung, and blood; blood resources; and sleep disorders.6 Since October 1997, the NHLBI has also had administrative responsibility for the NIH Woman’s Health Initiative. The Institute plans, conducts, fosters, and supports an integrated and coordinated program of basic research, clinical investigations and trials, observational studies, and demonstration and education projects. Research is related to the causes, prevention, diagnosis, and treatment of heart, blood vessel, lung, and blood diseases; and sleep disorders. The NHLBI plans and directs research in development and evaluation of interventions and devices related to prevention, treatment, and rehabilitation of patients suffering from such diseases and disorders. It also supports research on clinical use of blood and all aspects of the management of blood resources. Research is conducted in the Institute’s own laboratories and by scientific institutions and individuals supported by research grants and contracts. For health professionals and the public, the NHLBI conducts educational activities, including development and dissemination of materials in the above areas, with an emphasis on prevention.

This paragraph has been adapted from the NHLBI: http://www.nhlbi.nih.gov/about/org/mission.htm. “Adapted” signifies that a passage is reproduced exactly or slightly edited for this book. 6

Guidelines 11

Within the NHLBI, the National Center on Sleep Disorders Research (NCSDR) was established in 1993 to combat a serious public health concern.7 About 70 million Americans suffer from sleep problems; among them, nearly 60 percent have a chronic disorder. Each year, sleep disorders, sleep deprivation, and sleepiness add an estimated $15.9 billion to the national healthcare bill. Additional costs to society for related health problems, lost worker productivity, and accidents have not been calculated. Sleep disorders and disturbances of sleep comprise a broad range of problems, including sleep apnea, narcolepsy, insomnia, parasomnia, jet-lag syndrome, and disturbed biological and circadian rhythms. The Center seeks to fulfill its goal of improving the health of Americans by serving four key functions: research, training, technology transfer, and coordination. Research: Sleep disorders span many medical fields, requiring multidisciplinary approaches not only to treatment, but also to basic research. The Center works with neuroscientists, cellular and molecular biologists, geneticists, physiologists, neuropsychiatrists, immunologists, pulmonary specialists, cardiologists, epidemiologists, behavioral scientists, and other experts. Ongoing research is supported by the NIH and other Federal agencies. Training: Training researchers in sleep disorders is rigorous and timeconsuming. The Center seeks to support and promote formal training programs on the doctoral and postdoctoral levels. It also plans to expand existing career development paths and create new training programs for scientists in sleep disorders research. Technology Transfer: The Center seeks to ensure that research results lead to health benefits. It works towards this goal by educating health care professionals about sleep disorders and research findings, encouraging medical schools to add sleep disorders to their curricula, working with leading experts to develop clinical guidelines, and sponsoring continuing medical education programs. Coordination: The Center coordinates the Federal Government’s efforts on sleep disorders and works closely with other public, private, and nonprofit groups. The Center works to share information among these groups and encourage their cooperation, especially in crosscutting areas. It also seeks to improve communication among scientists, policymakers, and health care professionals.

This paragraph has been adapted from the NCSDR: http://www.nhlbisupport.com/sleep/about/about.htm. 7

12 Sleep Apnea

The following patient guideline was recently published by the NHLBI and the NCSDR on sleep apnea.

What Is Sleep Apnea?8 Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood. First described in 1965, sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. It owes its name to a Greek word, apnea, meaning “want of breath.” There are two types of sleep apnea: central and obstructive. Central sleep apnea, which is less common, occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respirations. Obstructive sleep apnea is far more common and occurs when air cannot flow into or out of the person’s nose or mouth although efforts to breathe continue. In a given night, the number of involuntary breathing pauses or “apneic events” may be as high as 20 to 30 or more per hour. These breathing pauses are almost always accompanied by snoring between apnea episodes, although not everyone who snores has this condition. Sleep apnea can also be characterized by choking sensations. The frequent interruptions of deep, restorative sleep often lead to early morning headaches and excessive daytime sleepiness. Early recognition and treatment of sleep apnea is important because it may be associated with irregular heartbeat, high blood pressure, heart attack, and stroke.

Who Gets Sleep Apnea? Sleep apnea occurs in all age groups and both sexes but is more common in men (it may be underdiagnosed in women) and possibly young African Americans. It has been estimated that as many as 18 million Americans have sleep apnea. Four percent of middle-aged men and 2 percent of middle-aged women have sleep apnea along with excessive daytime sleepiness. People most likely to have or develop sleep apnea include those who snore loudly and also are overweight, or have high blood pressure, or have some physical

Adapted from the National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/public/sleep/sleepapn.htm.

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Guidelines 13

abnormality in the nose, throat, or other parts of the upper airway. Sleep apnea seems to run in some families, suggesting a possible genetic basis.

What Causes Sleep Apnea? Certain mechanical and structural problems in the airway cause the interruptions in breathing during sleep. In some people, apnea occurs when the throat muscles and tongue relax during sleep and partially block the opening of the airway. When the muscles of the soft palate at the base of the tongue and the uvula (the small fleshy tissue hanging from the center of the back of the throat) relax and sag, the airway becomes blocked, making breathing labored and noisy and even stopping it altogether. Sleep apnea also can occur in obese people when an excess amount of tissue in the airway causes it to be narrowed. With a narrowed airway, the person continues his or her efforts to breathe, but air cannot easily flow into or out of the nose or mouth. Unknown to the person, this results in heavy snoring, periods of no breathing, and frequent arousals (causing abrupt changes from deep sleep to light sleep). Ingestion of alcohol and sleeping pills increases the frequency and duration of breathing pauses in people with sleep apnea.

How Is Normal Breathing Restored During Sleep? During the apneic event, the person is unable to breathe in oxygen and to exhale carbon dioxide, resulting in low levels of oxygen and increased levels of carbon dioxide in the blood. The reduction in oxygen and increase in carbon dioxide alert the brain to resume breathing and cause an arousal. With each arousal, a signal is sent from the brain to the upper airway muscles to open the airway; breathing is resumed, often with a loud snort or gasp. Frequent arousals, although necessary for breathing to restart, prevent the patient from getting enough restorative, deep sleep.

What Are the Effects of Sleep Apnea? Because of the serious disturbances in their normal sleep patterns, people with sleep apnea often feel very sleepy during the day and their concentration and daytime performance suffer. The consequences of sleep apnea range from annoying to life-threatening. They include depression, irritability, sexual dysfunction, learning and memory difficulties, and falling asleep while at work, on the phone, or driving. It has been estimated that up to 50 percent of sleep apnea patients have high blood pressure. Although it is

14 Sleep Apnea

not known with certainty if there is a cause and effect relationship, it appears that sleep apnea contributes to high blood pressure. Risk for heart attack and stroke may also increase in those with sleep apnea. In addition, sleep apnea is sometimes implicated in sudden infant death syndrome.

When Should Sleep Apnea Be Suspected? For many sleep apnea patients, their spouses are the first ones to suspect that something is wrong, usually from their heavy snoring and apparent struggle to breathe. Coworkers or friends of the sleep apnea victim may notice that the individual falls asleep during the day at inappropriate times (such as while driving a car, working, or talking). The patient often does not know he or she has a problem and may not believe it when told. It is important that the person see a doctor for evaluation of the sleep problem.

How Is Sleep Apnea Diagnosed? In addition to the primary care physician, pulmonologists, neurologists, or other physicians with specialty training in sleep disorders may be involved in making a definitive diagnosis and initiating treatment. Diagnosis of sleep apnea is not simple because there can be many different reasons for disturbed sleep. Several tests are available for evaluating a person for sleep apnea. Polysomnography is a test that records a variety of body functions during sleep, such as the electrical activity of the brain, eye movement, muscle activity, heart rate, respiratory effort, airflow, and blood oxygen levels. These tests are used both to diagnose sleep apnea and to determine its severity. The Multiple Sleep Latency Test (MSLT) measures the speed of falling asleep. In this test, patients are given several opportunities to fall asleep during the course of a day when they would normally be awake. For each opportunity, time to fall asleep is measured. People without sleep problems usually take an average of 10 to 20 minutes to fall asleep. Individuals who fall asleep in less than 5 minutes are likely to require some treatment for sleep disorders. The MSLT may be useful to measure the degree of excessive daytime sleepiness and to rule out other types of sleep disorders. Diagnostic tests usually are performed in a sleep center, but new technology may allow some sleep studies to be conducted in the patient’s home.

Guidelines 15

How Is Sleep Apnea Treated? The specific therapy for sleep apnea is tailored to the individual patient based on medical history, physical examination, and the results of polysomnography. Medications are generally not effective in the treatment of sleep apnea. Oxygen administration may safely benefit certain patients but does not eliminate sleep apnea or prevent daytime sleepiness. Thus, the role of oxygen in the treatment of sleep apnea is controversial, and it is difficult to predict which patients will respond well. It is important that the effectiveness of the selected treatment be verified; this is usually accomplished by polysomnography. Behavioral Therapy Behavioral changes are an important part of the treatment program, and in mild cases behavioral therapy may be all that is needed. The individual should avoid the use of alcohol, tobacco, and sleeping pills, which make the airway more likely to collapse during sleep and prolong the apneic periods. Overweight persons can benefit from losing weight. Even a 10 percent weight loss can reduce the number of apneic events for most patients. In some patients with mild sleep apnea, breathing pauses occur only when they sleep on their backs. In such cases, using pillows and other devices that help them sleep in a side position is often helpful. Physical or Mechanical Therapy Nasal continuous positive airway pressure (CPAP) is the most common effective treatment for sleep apnea. In this procedure, the patient wears a mask over the nose during sleep, and pressure from an air blower forces air through the nasal passages. The air pressure is adjusted so that it is just enough to prevent the throat from collapsing during sleep. The pressure is constant and continuous. Nasal CPAP prevents airway closure while in use, but apnea episodes return when CPAP is stopped or used improperly. Variations of the CPAP device attempt to minimize side effects that sometimes occur, such as nasal irritation and drying, facial skin irritation, abdominal bloating, mask leaks, sore eyes, and headaches. Some versions of CPAP vary the pressure to coincide with the person’s breathing pattern, and others start with low pressure, slowly increasing it to allow the person to fall asleep before the full prescribed pressure is applied.

16 Sleep Apnea

Dental appliances that reposition the lower jaw and the tongue have been helpful to some patients with mild sleep apnea or who snore but do not have apnea. Possible side effects include damage to teeth, soft tissues, and the jaw joint. A dentist or orthodontist is often the one to fit the patient with such a device. Surgery Some patients with sleep apnea may need surgery. Although several surgical procedures are used to increase the size of the airway, none of them is completely successful or without risks. More than one procedure may need to be tried before the patient realizes any benefits. Some of the more common procedures include removal of adenoids and tonsils (especially in children), nasal polyps or other growths, or other tissue in the airway and correction of structural deformities. Younger patients seem to benefit from these surgical procedures more than older patients. Uvulopalatopharyngoplasty (UPPP) is a procedure used to remove excess tissue at the back of the throat (tonsils, uvula, and part of the soft palate). The success of this technique may range from 30 to 50 percent. The long-term side effects and benefits are not known, and it is difficult to predict which patients will do well with this procedure. Laser-assisted uvulopalatoplasty (LAUP) is done to eliminate snoring but has not been shown to be effective in treating sleep apnea. This procedure involves using a laser device to eliminate tissue in the back of the throat. Like UPPP, LAUP may decrease or eliminate snoring but not sleep apnea itself. Elimination of snoring, the primary symptom of sleep apnea, without influencing the condition may carry the risk of delaying the diagnosis and possible treatment of sleep apnea in patients who elect LAUP. To identify possible underlying sleep apnea, sleep studies are usually required before LAUP is performed. Tracheostomy is used in persons with severe, life- threatening sleep apnea. In this procedure, a small hole is made in the windpipe and a tube is inserted into the opening. This tube stays closed during waking hours, and the person breathes and speaks normally. It is opened for sleep so that air flows directly into the lungs, bypassing any upper airway obstruction. Although this procedure is highly effective, it is an extreme measure that is poorly tolerated by patients and rarely used.

Guidelines 17

Other procedures. Patients in whom sleep apnea is due to deformities of the lower jaw may benefit from surgical reconstruction. Finally, surgical procedures to treat obesity are sometimes recommended for sleep apnea patients who are morbidly obese.

For More Information Information about sleep disorders research can be obtained from the NCSDR. In addition, the NHLBI Information Center can provide you with sleep education materials as well as other publications relating to heart, lung, and blood diseases. National Center on Sleep Disorders Research Two Rockledge Centre Suite 7024 6701 Rockledge Drive MSC 7920 Bethesda, MD 20892-7920 (301) 435-0199 (301) 480-3451 (fax) The mission of the NCSDR is to support research, training, and education about sleep disorders. The center is located within the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. The NHLBI supports a variety of research and training programs focusing on cardiopulmonary disorders in sleep, designed to fill critical gaps in the understanding of the causes, diagnosis, treatment, and prevention of sleep-disordered breathing. NHLBI Information Center P.O. Box 30105 Bethesda, MD 20824-0105 (301) 592-8573 (301) 592-8563 (fax)

More Guideline Sources The guideline above on sleep apnea is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to sleep apnea. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with sleep

18 Sleep Apnea

apnea. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.

Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search. The Combined Health Information Database (CHID) CHID Online is a reference tool that maintains a database directory of thousands of journal articles and patient education guidelines on sleep apnea and related conditions. One of the advantages of CHID over other sources is that it offers summaries that describe the guidelines available, including contact information and pricing. CHID’s general Web site is To search this database, go to http://chid.nih.gov/. http://chid.nih.gov/detail/detail.html. In particular, you can use the advanced search options to look up pamphlets, reports, brochures, and information kits. The following was recently posted in this archive: Do You Know the Health Risks of Being Overweight? Source: Bethesda, MD: Weight-Control Information Network. 1998. 10 p.

Guidelines 19

Contact: Available from Weight-Control Information Network. 1 WIN Way, Bethesda, MD 20892-3665. (800) 946-8098 or (301) 984-7378. Fax (301) 984-7196. E-mail: [email protected]. PRICE: Single copy free. Summary: This brochure discusses the health risks of being overweight. It uses a question and answer format to help people determine whether they are overweight, whether their waist measurement indicates a risk for health problems, and what health problems overweight people may experience. Health risks associated with being overweight include heart disease and stroke, type 2 diabetes, various cancers, sleep apnea, osteoarthritis, gout, and gallbladder disease. The brochure suggests that even a small weight loss can improve one's health. It recommends that people make long-term changes in eating habits and physical activity to lose weight and keep it off over time. In addition, the brochure provides a list of additional reading materials and identifies organizations that have information and educational materials available to the public on health problems associated with being overweight. 1 figure. Sleep Apnea and Snoring Source: Rochester, MN: American Sleep Disorders Association. 1992. 13 p.

Contact: Available from American Sleep Disorders Association. 1610 14th Street, NW, Suite 300. Rochester, MN 55901. (507) 287- 6006; FAX (507) 287-6008. PRICE: Free. Summary: This brochure discusses snoring and sleep apnea, their causes and how they can affect individuals' daily lives. Guidelines for seeking help and available treatments as well as developing proper sle ep habits are presented. Additional resources about snoring and sleep apnea are listed. Nature of Sleep and Its Disorders Source: Washington, DC: National Sleep Foundation. 12 p. Contact: Available from National Sleep Foundation. 1367 Connecticut Avenue NW, Suite 200, Washington, DC 20036. (202) 785-2300; FAX (202) 785-2880. PRICE: Free. Summary: This brochure presents general information about the physiology of sleep and describes the onset and characteristics of the following types of sleep disorders: insomnia, sleep apnea, narcolepsy, restless legs syndrome, and parasomnias. The use of sleeping pills and when to seek medical attention for a sleep disorder are briefly discussed. The role of the National Sleep Foundation also is described.

20 Sleep Apnea

Improving your health: Tips for African American men and women Source: Weight-control Information Network (WIN). Contact: WIN, 1 WIN WAY, Bethesda, MD 20892-3665. 1-800-984-. Summary: Overweight and obesity have become a growing problem for African Americans in the United States. Being overweight can lead to high blood pressure, heart disease, stroke, diabetes, certain types of cancer, gout, gallbladder disease, sleep apnea and osteoarthritis. This brochure presents steps African American adults can take to change eating and exercise habits for healthier living. The brochure also includes a substitution list that provides lowfat, healthier alternatives to traditional African American foods. The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “sleep apnea” or synonyms. The following was recently posted: Practice parameters for the use of portable recording in the assessment of obstructive sleep apnea. Source: American Academy of Sleep Medicine.; 1994 (reviewed 2000); 6 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 0896&sSearch_string=sleep+apnea Healthfinder™ Healthfinder™ is an additional source sponsored by the U.S. Department of Health and Human Services which offers links to hundreds of other sites that contain healthcare information. This Web site is located at http://www.healthfinder.gov. Again, keyword searches can be used to find guidelines. The following was recently found in this database:

Guidelines 21

Facts About Sleep Apnea Summary: This brochure discusses sleep apnea and how it is treated. Source: National Center on Sleep Disorders Research, National Heart, Lung, and Blood Institute http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=411 Lessening the Effects of Sleep Apnea Summary: This consumer health information fact sheet focuses on the treatment possibilities available for people experiencing sleep apnea. Source: American Association for Respiratory Care http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=3860 Oral Appliance Therapy Summary: This fact sheet provides a general overview of oral appliances and how they can be used to help promote adequate air intake and provide normal sleep in people who snore and have sleep apnea. Source: Academy of Dental Sleep Medicine http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=5231 Sleep Changes in Older Adults Summary: Answers to questions about the sleep patterns of the elderly -including sleep changes; restless legs syndrome; sleep apnea; and solutions to sleeping better. Source: American Academy of Family Physicians http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=6161

22 Sleep Apnea

Snoring & Apnea Summary: This consumer health informtion document discusses snoring, obstructive sleep apnea and the advantages of oral appliance therapy to treat sleep apnea. Source: Academy of Dental Sleep Medicine http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=4404 Tossing and Turning No More: How to Get a Good Night's Sleep Summary: This consumer health information article discusses sleep disorders -- insomnia, sleep apnea (snoring) -- and the effectiveness of various treatment methods including, melatonin. Source: Office of Consumer Affairs, U.S. Food and Drug Administration http://www.healthfinder.gov/scripts/recordpass.asp?RecordType=0&R ecordID=3587 The NIH Search Utility After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to sleep apnea. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.

Guidelines 23

Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats drkoop.com : http://www.drkoop.com/conditions/ency/index.html Family Village: http://www.familyvillage.wisc.edu/specific.htm Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/ Med Help International: http://www.medhelp.org/HealthTopics/A.html Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/ Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/ WebMD Health: http://my.webmd.com/health_topics

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter: Apnea: A transient absence of spontaneous respiration. [NIH] Cardiopulmonary: Pertaining to the heart and lungs. [EU] Chronic: Of long duration; frequently recurring. [NIH] Gout: Hereditary metabolic disorder characterized by recurrent acute arthritis, hyperuricemia and deposition of sodium urate in and around the joints, sometimes with formation of uric acid calculi. [NIH] Heartbeat: One complete contraction of the heart. [NIH] Ingestion: The act of taking food, medicines, etc., into the body, by mouth. [EU]

Insomnia: Inability to sleep; abnormal wakefulness. [EU] Osteoarthritis: Noninflammatory degenerative joint disease occurring chiefly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain and stiffness. [NIH]

24 Sleep Apnea

Overweight: An excess of body weight but not necessarily body fat; a body mass index of 25 to 29.9 kg/m2. [NIH] Prenatal: Occurring before birth. [NIH] Pulmonary: Relating to the lungs. [NIH] Respiration: Process of exchanging oxygen from the air for carbon dioxide from the body; includes the mechanical process of breathing, gas exchange, and oxygen and carbon dioxide transport to and from the cells. [NIH] Snoring: Rough, noisy breathing during sleep, due to vibration of the uvula and soft palate. [NIH] Stroke: Sudden loss of function of part of the brain because of loss of blood flow. Stroke may be caused by a clot (thrombosis) or rupture (hemorrhage) of a blood vessel to the brain. [NIH] Surgical: Of, pertaining to, or correctable by surgery. [EU] Tracheostomy: Surgical formation of an opening into the trachea through the neck, or the opening so created. [NIH]

Seeking Guidance 25

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with sleep apnea. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.9 In addition to support groups, your physician can be a valuable source of guidance and support. Therefore, finding a physician that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with sleep apnea. The chapter ends with a discussion on how to find a doctor that is right for you.

Associations and Sleep Apnea As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.10 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, your expectations, and how well you cope with your condition can all Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 10 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 9

26 Sleep Apnea

influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. In addition to associations or groups that your doctor might recommend, we suggest that you consider the following list (if there is a fee for an association, you may want to check with your insurance provider to find out if the cost will be covered): American Narcolepsy Association Address: PO Box 26230 San Francisco, CA 94126-6230 Telephone: (800) 222-6085 Fax: (415) 788-4795 Background: The American Narcolepsy Association (ANA) was established in 1975 to help solve the many problems associated with narcolepsy and related disorders. The ANA distributes information about narcolepsy and related sleep disorders to the public, to patients, and to health professionals, and maintains listings of diagnostic facilities and of physicians familiar with the disease annd treatment of sleep disorders. Research related to the early diagnosis, understanding, improved treatment, and cure of sleep disorders is supported through volunteer work, direct funding fund-assistance, and providing evidence of the need for such research. The Association conducts small scale research projects and helps to secure volunteers for research conducted by others. Self-help groups are conducted to help persons suffering from sleep disorders. Publication(s): The Association publishes leaflets providing information on narcolepsy and sleep apnea, a treatment guide for physicians, a list of sleep disorders centers, and an educational film on narcolepsy. Serial publications: Eye Opener (newsletter)--information on ANA activities and services. Relevant area(s) of interest: educational materials; films; funding sources; narcolepsy; patient education; referral services; research; self help; sleep; sleep disorders; spanish language materials; technical assistance American Sleep Apnea Association Address: American Sleep Apnea Association 1424 K Street NW, Suite 302, Washington, DC 20005 Telephone: (202) 293-3650

Seeking Guidance 27

Fax: (202) 293- 3656 Email: [email protected] Web Site: http://www.sleepapnea.org Background: The American Sleep Apnea Association (ASAA) is a not-forprofit, health service organization dedicated to reducing injuries, disabilities, and potentially life-threatening complications that may be caused by sleep apnea, a condition characterized by breathing difficulties while sleeping. Sleep apnea may occur during childhood and/or adulthood, may be genetic, and/or may occur due to or in association with a number of different underlying disorders. Established in 1990, the Association works to improve the well-being of affected individuals and family members; promotes early diagnosis and appropriate treatment of sleep apnea through innovative efforts to educate the general public and health care professionals; and supports basic research into the causes and treatments of the disorder. The Association also fosters the nationwide ASAA A.W.A.K.E. Network, a network of self-help groups that provide additional information and support to individuals affected by sleep apnea. The American Sleep Apnea Association provides educational materials including a videotape, brochures, a regular newsletter, and guidelines to help individuals start local support groups. American Sleep Disorders Association Address: American Sleep Disorders Association 1610 14th Street NW, Suite 300, Rochester, MN 55901 Telephone: (507) 287-6006 Fax: (507) 287-6008 Email: [email protected] Background: Established in 1975, the American Sleep Disorders Association (ASDA) is a voluntary, not-for-profit, medical and scientific society dedicated to quality medical care for individuals with sleep disorders and service to its individual and center members through education, research, and the development of practice standards related to the field of sleep medicine. The Association is committed to fostering professional education through meetings, courses, publications, and educational materials; defining, developing, distributing, and updating standards, guidelines, and policies that result in optimal access to and delivery of care for all patients with sleep disorders; and fostering basic and clinical sleep research. The Association is also dedicated to promoting training programs for practitioners of sleep medicine; representing the field to all government and private agencies involved in

28 Sleep Apnea

research, training, policy, practice, and healthcare delivery issues that affect the field; and educating the public about sleep disorders and related conditions. The Association offers a variety of educational and support materials including an educational slide series; manuals for physicians, healthcare professionals, medical students, sleep specialists, and other professionals, CD-ROM and computer-based information resources for professionals; an interdisciplinary medical journal entitled 'Sleep'; and patient education pamphlets. Relevant area(s) of interest: Narcolepsy, Sleep Disorders American Thoracic Society Address: American Thoracic Society 1740 Broadway, New York, NY 10019 Telephone: (212) 315-8700 http://www.thoracic.org

E-mail:

None

Website:

Web Site: http://www.thoracic.org Background: The American Thoracic Society (ATS) is an international professional and scientific society that focuses on respiratory and critical care medicine. Established in 1905, the Society currently has approximately 12,500 members in the United States and around the world. The ATS membership is dedicated to preventing and fighting respiratory disease through research, education, patient care, and advocacy. The Society's long range goal is to decrease morbidity and mortality from respiratory disorders and life threatening acute illnesses. In keeping with these goals, the American Thoracic Society also serves as the medical section of the American Lung Association and interacts with both national and international organizations that have similar goals. One of the Society's primary activities is its annual International Scientific Conference, an international forum for physicians and scientists who work in pulmonary and critical care medicine. Sessions are held on such topics as pneumonia, asthma, critical care, tuberculosis, pediatric pulmonology, sleep apnea, environmental and occupational lung disease, nursing studies, cell biology, lung structure and function, and AIDS. The ATS also is committed to advocating for key state and federal health issues. Through its ATS Advocacy Network, the Society works to educate Congress and federal agencies about tobacco control, health care policy, environmental policy, medical reimbursement issues, research funding, and other public policy issues. The ATS has also earned full accreditation by the Accreditation Council on Continuing Medical Education for direct sponsorship of educational activities as well as joint sponsorships with ATS chapters and local Lung Associations. In addition, the ATS publishes

Seeking Guidance 29

two journals including the 'American Journal of Respiratory and Critical Care Medicine' (AJRCCM) and the 'American Journal of Respiratory Cell and Molecular Biology' (AJRCMB). The AJRCCM focuses on human biology and disease as well as animal and in vitro studies that contribute to the understanding of pathophysiology and treatment of pulmonary disease. The AJRCMB publishes papers that report significant and original observations in the area of pulmonary biology. Center for Research in Sleep Disorders Address: Center for Research in Sleep Disorders 1275 East Kemper Rd., Cincinnati, OH 45246 Telephone: (513) 671-3101 Fax: (513) 671- 4159 TTY: (311) 111-6111 Email: [email protected] Background: The Center for Research in Sleep Disorders is a not-forprofit organization dedicated to assisting individuals with night tremors, sleep apnea, and other sleep disorders. Established in 1970, the Center seeks to educate affected individuals, physicians, and the public about sleep disorders and their effects and supports ongoing studies into the causes, prevention, and treatment of sleep disorders. In addition, the Center for Research in Sleep Disorders produces educational materials including brochures and fact sheets. Relevant area(s) of interest: Sleep Disorders Joubert Syndrome Foundation Address: 12348 Summer Meadow Road Rock, MI 49880 Telephone: (410) 997-8084 (Cheryl Duquette); (906) 359-4707 (Mary Van Damme) Email: [email protected] Web Site: http://www.joubertfoundation.com Background: Joubert Syndrome Parents in Touch Network, Corp. is a self-help group for parents of children with Joubert syndrome, a genetic disorder. Joubert syndrome is a rare disorder that affects the area of the brain that controls balance and coordination. The disorder is characterized by absence or underdevelopment of a part of the brain called the cerebellar vermis, and a malformed brain stem. The most common features include ataxia (lack of muscle control), an abnormal breathing pattern called hypernea, sleep apnea, abnormal eye and tongue movements, and hypotonia. Other malformations such as extra fingers

30 Sleep Apnea

and toes, cleft lip or palate, tongue abnormalities, and seizures may also occur. There may be mild or moderate retardation. The Network offers a networking list, newsletter, and a biannual conference. Relevant area(s) of interest: Balance disorders; Coordination disrders; Joubert syndrome; Parent groups; Self help programs Narcolepsy Network Address: 277 Fairfield Road, Suite 310B Fairfield, NJ 07004 Telephone: (513) 891-3522 Fax: (513) 891-3836 Email: [email protected] Web Site: http://narcolepsynetwork.org Background: The Narcolepsy Network (NN) is a national voluntary organization that was formed to serve the needs of people with narcolepsy. Narcolepsy is a condition characterized by sudden and uncontrollable attacks of deep sleep. NN is also for families, friends and professionals involved with patients. The network is devoted to improving the lives of narcolepsy patients and to finding a cure. They maintain local support groups, promote communication, advocacy, research and education. Information available through the network includes discussions on symptoms, causes, diagnosis, associated sleep apnea, treatments and social implications. Publication(s): Narcolepsy: A Guide to Understanding (phamphlet) Relevant area(s) of interest: Apnea; Drug addiction; Genetic disorders; Marijuana addiction; Narcolepsy; Sleep disorders Narcolepsy Network, Inc Address: Narcolepsy Network, Inc. 277 Fairfield Road, Suite 310B, Fairfield, NJ 07004 Telephone: (973) 276-0115 Fax: (973) 227-822 Email: [email protected] Web Site: http://www.websciences.org/narnet Background: The Narcolepsy Network is a national voluntary organization that was formed to serve the needs of people with narcolepsy. It is composed of people with narcolepsy, their families, friends, health care professionals, and other interested individuals. The Network is dedicated to improving the quality of life for people with

Seeking Guidance 31

narcolepsy and finding a cure for this disorder. To this end, the organization maintains a network of local support groups and chapters. The organization promotes programs of communication, advocacy, research, support, and education. A booklet entitled 'Narcolepsy: A Guide to Understanding' provides information on narcolepsy. Topics covered within the booklet include the symptoms, causes, diagnosis of the disorder, associated sleep apnea, treatments, and social implications. The organization also distributes a reading list, bibliography, and an educational materials order form. Relevant area(s) of interest: Narcolepsy National Center on Sleep Disorders Research National Heart Lung and Blood Institute National Institutes of Health Address: 6701 Rockledge Drive, MSC 7920 Bethesda, MD 20892-7920 Two Rockledge Centre, Suite 10038 Telephone: (301) 435-0199 Fax: (301) 480-3451 Email: [email protected] Web Site: http://www.nhlbi.nih.gov/about/ncsdr/index.htm Background: The National Center on Sleep Disorders Research (NCSDR), located within the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), was established in 1993 to combat a serious public health concern. About 70 million Americans suffer from sleep problems; among them, nearly 60 percent have a chronic disorder. Each year, sleep disorders, sleep deprivation, and sleepiness add billiions of dollars to the national health care bill. Additional costs to society for related health problems, lost worker productivity, and accidents have not been calculated. Sleep disorders and disturbances of sleep comprise a broad range of problems, including sleep apnea, narcolepsy, insomnia, parasomnia, jet-lag syndrome, and disturbed biological and circadian rhythms. The Center seeks to fulfill its goal of improving the health of Americans by serving four key functions: research, training, technology transfer, and coordination. Some publications and videos are available to the public. Relevant area(s) of interest: Circadian rhythm; Insomnia; Sleep apnea; Sleep disorders National Sleep Foundation Address: National Sleep Foundation 729 15th Street, N.W., 4th Floor, Washington, D.C. 20005

32 Sleep Apnea

Telephone: (202) 347-3471 Fax: (202) 347-3472 Email: [email protected] Web Site: http://www.sleepfoundation.org Background: The National Sleep Foundation (NSF) is a not-for-profit organization dedicated to improving the quality of life for those who are affected by sleep disorders (e.g., Sleep Apnea, Narcolepsy, Restless Legs Syndrome, and Periodic Limb Movement Disorder) and preventing accidents related to sleep deprivation or sleep disorders. Established in 1991, the National Sleep Foundation increases public awareness of sleep disorders through all forms of media; encourages the development of patient services, community resources, and support groups for affected individuals; and creates partnerships with business and government to extend its educational reach. The National Sleep Foundation also provides referrals to regional sleep disorder centers; conducts symposia for physicians across the United States; and provides research grants and fellowships. The Foundation offers a variety of educational and supportive information through its database, brochures and pamphlets designed for physicians and the general public, a regular newsletter for physicians entitled 'Sleep Medicine Alert,' and 'NSF Connection,' a newsletter for the public. Relevant area(s) of interest: Narcolepsy, Sleep Disorders School of Medicine Sleep Disorders Clinic and Research Center Stanford University Address: 701 Welch Rd., Suite 2226 Palo Alto, CA 94304 Telephone: (415) 723-3181 Web Site: http://www.med.stanford.edu/school/psychiatry/coe/ Background: Partially sponsored by the National Institutes of Health and private foundations, the Sleep Disorders Clinic and Research Center of Stanford University School of Medicine is accredited by the Association of Sleep Disorders Centers. The Center chief focus is on sleep disorders, including narcolepsy, sleep apnea, and other related sleep/awake problems; and canine narcolepsy. The Clinic provides diagnostic, evaluation, consulting, and some treatment services for a fee, and makes referrals to other appropriate sources for diagnosis or treatment. Patients are seen on referral of a physician. Polysomnograph services are available to patients as part of the diagnostic procedure. General information on sleep problems and complaints is also available.

Seeking Guidance 33

Publication(s): The Center is the editorial office for the quarterly journal Sleep. Technical reports; books; journal articles; state-of-the-art reviews; standards; critical reviews; abstracts; indexes; research summaries; bibliographies; reprints. Relevant area(s) of interest: bioassay for the study of sleep and circadian rhythms (using; Circadian rhythms; Dogs (mammals); Facilities include the only canine narcolepsy colony in the; Holdings; Insomnia; Narcolepsy; rhythms in the United States;and SCORE (TM), the largest online; rodent models).; Sleep apnea; Sleep disorders; world; a temporal isolation facility for the study of circadian Sleep Disorders Center University of California at Los Angeles Address: 24-221 CHS Box 957069 Los Angeles, CA 90095-7069 Telephone: (310) 206-8005 Web Site: http://www.programs.healthcare.ucla.edu Background: Chief concerns of the Sleep Disonders Center include sleep, sleep disorders, narcolepsy, sleep apnea, insomnia, myoclonus, circadian rhythm disturbance, and nocturnal seizures. The Center answers inquiries, provides advisory and current-awareness services, provides information on research in progress, conducts seminars, evaluates data, and makes referrals to other sources of information. Fees are charged for consultations and testing. Relevant area(s) of interest: Circadian rhythms; Insomnia; Myoclonus; Narcolepsy; Sleep; Sleep apnea; Sleep disorders Sleep/Wake Disorders Canada Address: Sleep/Wake Disorders Canada 3080 Yonge Street, Suite 5055, Toronto, Ontario, M4N 3N1, Canada Telephone: (416) 483-965 Toll-free: (800) 387-9253 Fax: (416) 483-7081 Email: [email protected] Web Site: http://www.geocities.com/~sleepwake/ Background: Sleep/Wake Disorders Canada (SWDC) is a national notfor-profit self-help organization of volunteers dedicated to providing information, practical support, and resources to Canadians with sleep/wake disorders. Such disorders include difficulties falling or staying asleep (insomnia); sleep apnea, a disorder in which breathing periodically ceases during sleep; narcolepsy, which is characterized by excessive daytime sleepiness, recurrent episodes of sleep during the day,

34 Sleep Apnea

and, in some cases, sudden loss of muscle tone (hypotonia) without loss of consciousness (cataplexy); and restless legs syndrome, a disorder characterized by unusual, unpleasant sensations deep in the legs, an overwhelming desire to move the legs to relieve such sensations, motor restlessness, and occurrence of such symptoms most frequently during the evening or early part of the night and while at rest. Established in 1981 and currently consisting of approximately 1,000 members, Sleep/Wake Disorders Canada has self-help chapters and contact representatives across Canada to provide local access for affected individuals and family members who seek information and peer support. The organization is committed to providing accurate and timely information on sleep/wake disorders to affected individuals and health care professionals; promoting awareness among affected families, medical professionals, and the general public concerning the implications of sleep/wake disorders in the home environment, the workplace, and the community; and promoting and supporting research on the underlying causes of such disorders to improve prevention, diagnosis, and disease management efforts. Sleep/Wake Disorders Canada has a register of sleep laboratories and sleep specialists from across Canada, holds regular group meetings, conducts an annual conference to bring together volunteers and medical professionals in order to review the current state of sleep/wake research and to plan initiatives for the organization, and conducts National Sleep Awareness week activities to raise public awareness. Sleep/Wake Disorders Canada also offers a wide range of educational materials including informational brochures on insomnia, sleep apnea, narcolepsy, restless legs syndrome, and other sleep disorders; several books on sleep/wake disorders; 'Sleep Solutions,' a 10-volume informational booklet series for general practitioners; and a regular newsletter entitled 'Good Night/Good Day' that provides updates on research and chapter activities and enables affected individuals from across Canada to exchange information and mutual support. Relevant area(s) of interest: Narcolepsy, Sleep Disorders

Finding More Associations There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information than what is listed above, by consulting all of them, you will have nearly exhausted all sources for patient associations.

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The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about sleep apnea. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797. DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “sleep apnea” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations.

The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “sleep apnea”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred language and the format option “Organization Resource Sheet.” By making these selections and typing in “sleep apnea” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with sleep apnea. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option

36 Sleep Apnea

called “Organizational Database (ODB)” and type “sleep apnea” (or a synonym) in the search box.

Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMD , for example, offers such a service at their Web site: http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your doctor or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective. The following Internet sites may be of particular interest: SleepNet www.sleepnet.com/support.htm American Sleep Apnea Association www.sleepapnea.org Living with Sleep Apnea www.lung.ca/sleepapnea/support

Finding Doctors One of the most important aspects of your treatment will be the relationship between you and your doctor or specialist. All patients with sleep apnea must go through the process of selecting a physician. While this process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:11 If you are in a managed care plan, check the plan’s list of doctors first. Ask doctors or other health professionals who work with doctors, such as hospital nurses, for referrals. Call a hospital’s doctor referral service, but keep in mind that these services usually refer you to doctors on staff at that particular hospital.

11

This section is adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

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The services do not have information on the quality of care that these doctors provide. Some local medical societies offer lists of member doctors. Again, these lists do not have information on the quality of care that these doctors provide. Additional steps you can take to locate doctors include the following: Check with the associations listed earlier in this chapter. Information on doctors in some states is available on the Internet at http://www.docboard.org. This Web site is run by “Administrators in Medicine,” a group of state medical board directors. The American Board of Medical Specialties can tell you if your doctor is board certified. “Certified” means that the doctor has completed a training program in a specialty and has passed an exam, or “board,” to assess his or her knowledge, skills, and experience to provide quality patient care in that specialty. Primary care doctors may also be certified as specialists. The AMBS Web site is located at 12 http://www.abms.org/newsearch.asp. You can also contact the ABMS by phone at 1-866-ASK-ABMS. You can call the American Medical Association (AMA) at 800-665-2882 for information on training, specialties, and board certification for many licensed doctors in the United States. This information also can be found in “Physician Select” at the AMA’s Web site: http://www.amaassn.org/aps/amahg.htm. If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of doctors with expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

While board certification is a good measure of a doctor’s knowledge, it is possible to receive quality care from doctors who are not board certified. 12

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Selecting Your Doctor13 When you have compiled a list of prospective doctors, call each of their offices. First, ask if the doctor accepts your health insurance plan and if he or she is taking new patients. If the doctor is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen physician. During the first visit you will have the opportunity to evaluate your doctor and to find out if you feel comfortable with him or her. Ask yourself, did the doctor: Give me a chance to ask questions about sleep apnea? Really listen to my questions? Answer in terms I understood? Show respect for me? Ask me questions? Make me feel comfortable? Address the health problem(s) I came with? Ask me my preferences about different kinds of treatments for sleep apnea? Spend enough time with me? Trust your instincts when deciding if the doctor is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your doctor to get to know each other.

Working with Your Doctor14 Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care and have better results. Here are some tips to help you and your doctor become partners: You know important things about your symptoms and your health history. Tell your doctor what you think he or she needs to know. It is important to tell your doctor personal information, even if it makes you feel embarrassed or uncomfortable. 13 This

section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm. 14 This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

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Bring a “health history” list with you (and keep it up to date). Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications. Tell your doctor about any natural or alternative medicines you are taking. Bring other medical information, such as x-ray films, test results, and medical records. Ask questions. If you don’t, your doctor will assume that you understood everything that was said. Write down your questions before your visit. List the most important ones first to make sure that they are addressed. Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers. Ask your doctor to draw pictures if you think that this would help you understand. Take notes. Some doctors do not mind if you bring a tape recorder to help you remember things, but always ask first. Let your doctor know if you need more time. If there is not time that day, perhaps you can speak to a nurse or physician assistant on staff or schedule a telephone appointment. Take information home. Ask for written instructions. Your doctor may also have brochures and audio and videotapes that can help you. After leaving the doctor’s office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your doctor, call for your test results. If your doctor recommended that you have certain tests, schedule an appointment to get them done. If your doctor said you should see an additional specialist, make an appointment. By following these steps, you will enhance the relationship you will have with your physician.

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Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:15 Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html Choosing a Doctor or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

Vocabulary Builder The following vocabulary builder provides definitions of words used in this chapter that have not been defined in previous chapters: Ataxia: Failure of muscular coordination; irregularity of muscular action. [EU]

Consciousness: Sense of awareness of self and of the environment. [NIH] Epidemiological: Relating to, or involving epidemiology. [EU] Hypotonia: A condition of diminished tone of the skeletal muscles; diminished resistance of muscles to passive stretching. [EU] Malformation: A morphologic defect resulting from an intrinsically abnormal developmental process. [EU] Paralysis: Loss or impairment of motor function in a part due to lesion of the neural or muscular mechanism; also by analogy, impairment of sensory function (sensory paralysis). In addition to the types named below, paralysis is further distinguished as traumatic, syphilitic, toxic, etc., according to its cause; or as obturator, ulnar, etc., according to the nerve part, or muscle specially affected. [EU] Pathophysiology: Altered functions in an individual or an organ due to disease. [NIH] Pneumonia: Inflammation of the lungs. [NIH] Seizures: Clinical or subclinical disturbances of cortical function due to a You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html. 15

Seeking Guidance 41

sudden, abnormal, excessive, and disorganized discharge of brain cells. Clinical manifestations include abnormal motor, sensory and psychic phenomena. Recurrent seizures are usually referred to as epilepsy or "seizure disorder." [NIH] Thoracic: Pertaining to or affecting the chest. [EU] Tremor: An involuntary trembling or quivering. [EU] Tuberculosis: Any of the infectious diseases of man and other animals caused by species of mycobacterium. [NIH]

Clinical Trials 43

CHAPTER 3. CLINICAL TRIALS AND SLEEP APNEA Overview Very few medical conditions have a single treatment. The basic treatment guidelines that your physician has discussed with you, or those that you have found using the techniques discussed in Chapter 1, may provide you with all that you will require. For some patients, current treatments can be enhanced with new or innovative techniques currently under investigation. In this chapter, we will describe how clinical trials work and show you how to keep informed of trials concerning sleep apnea.

What Is a Clinical Trial?16 Clinical trials involve the participation of people in medical research. Most medical research begins with studies in test tubes and on animals. Treatments that show promise in these early studies may then be tried with people. The only sure way to find out whether a new treatment is safe, effective, and better than other treatments for sleep apnea is to try it on patients in a clinical trial.

The discussion in this chapter has been adapted from the NIH and the NEI: www.nei.nih.gov/netrials/ctivr.htm. 16

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What Kinds of Clinical Trials Are There? Clinical trials are carried out in three phases: Phase I. Researchers first conduct Phase I trials with small numbers of patients and healthy volunteers. If the new treatment is a medication, researchers also try to determine how much of it can be given safely. Phase II. Researchers conduct Phase II trials in small numbers of patients to find out the effect of a new treatment on sleep apnea. Phase III. Finally, researchers conduct Phase III trials to find out how new treatments for sleep apnea compare with standard treatments already being used. Phase III trials also help to determine if new treatments have any side effects. These trials--which may involve hundreds, perhaps thousands, of people--can also compare new treatments with no treatment. How Is a Clinical Trial Conducted? Various organizations support clinical trials at medical centers, hospitals, universities, and doctors’ offices across the United States. The “principal investigator” is the researcher in charge of the study at each facility participating in the clinical trial. Most clinical trial researchers are medical doctors, academic researchers, and specialists. The “clinic coordinator” knows all about how the study works and makes all the arrangements for your visits. All doctors and researchers who take part in the study on sleep apnea carefully follow a detailed treatment plan called a protocol. This plan fully explains how the doctors will treat you in the study. The “protocol” ensures that all patients are treated in the same way, no matter where they receive care. Clinical trials are controlled. This means that researchers compare the effects of the new treatment with those of the standard treatment. In some cases, when no standard treatment exists, the new treatment is compared with no treatment. Patients who receive the new treatment are in the treatment group. Patients who receive a standard treatment or no treatment are in the “control” group. In some clinical trials, patients in the treatment group get a new medication while those in the control group get a placebo. A placebo is a harmless substance, a “dummy” pill, that has no effect on sleep apnea. In other clinical trials, where a new surgery or device (not a medicine) is being tested, patients in the control group may receive a “sham treatment.” This

Clinical Trials 45

treatment, like a placebo, has no effect on sleep apnea and does not harm patients. Researchers assign patients “randomly” to the treatment or control group. This is like flipping a coin to decide which patients are in each group. If you choose to participate in a clinical trial, you will not know which group you will be appointed to. The chance of any patient getting the new treatment is about 50 percent. You cannot request to receive the new treatment instead of the placebo or sham treatment. Often, you will not know until the study is over whether you have been in the treatment group or the control group. This is called a “masked” study. In some trials, neither doctors nor patients know who is getting which treatment. This is called a “double masked” study. These types of trials help to ensure that the perceptions of the patients or doctors will not affect the study results. Natural History Studies Unlike clinical trials in which patient volunteers may receive new treatments, natural history studies provide important information to researchers on how sleep apnea develops over time. A natural history study follows patient volunteers to see how factors such as age, sex, race, or family history might make some people more or less at risk for sleep apnea. A natural history study may also tell researchers if diet, lifestyle, or occupation affects how a disease or disorder develops and progresses. Results from these studies provide information that helps answer questions such as: How fast will a disease or disorder usually progress? How bad will the condition become? Will treatment be needed? What Is Expected of Patients in a Clinical Trial? Not everyone can take part in a clinical trial for a specific disease or disorder. Each study enrolls patients with certain features or eligibility criteria. These criteria may include the type and stage of disease or disorder, as well as, the age and previous treatment history of the patient. You or your doctor can contact the sponsoring organization to find out more about specific clinical trials and their eligibility criteria. If you are interested in joining a clinical trial, your doctor must contact one of the trial’s investigators and provide details about your diagnosis and medical history. If you participate in a clinical trial, you may be required to have a number of medical tests. You may also need to take medications and/or undergo

46 Sleep Apnea

surgery. Depending upon the treatment and the examination procedure, you may be required to receive inpatient hospital care. Or, you may have to return to the medical facility for follow-up examinations. These exams help find out how well the treatment is working. Follow-up studies can take months or years. However, the success of the clinical trial often depends on learning what happens to patients over a long period of time. Only patients who continue to return for follow-up examinations can provide this important long-term information.

Recent Trials on Sleep Apnea The National Institutes of Health and other organizations sponsor trials on various diseases and disorders. Because funding for research goes to the medical areas that show promising research opportunities, it is not possible for the NIH or others to sponsor clinical trials for every disease and disorder at all times. The following lists recent trials dedicated to sleep apnea.17 If the trial listed by the NIH is still recruiting, you may be eligible. If it is no longer recruiting or has been completed, then you can contact the sponsors to learn more about the study and, if published, the results. Further information on the trial is available at the Web site indicated. Please note that some trials may no longer be recruiting patients or are otherwise closed. Before contacting sponsors of a clinical trial, consult with your physician who can help you determine if you might benefit from participation. Incorporating Flow Limitation into the Diagnosis and Quantification of Sleep Disordered Breathing Condition(s): Sleep-Disordered Breathing Study Status: This study is currently recruiting patients. Sponsor(s): National Center for Research Resources (NCRR) Purpose - Excerpt: The diagnosis and treatment of sleep disordered breathing have come to the forefront of clinical medicine following recognition of the high prevalence and associated morbidity of sleep apnea. The effects on quality of life as well as societal costs have been well documented. The NYU Sleep Research Laboratory has spent the last several years working on the problem of improving the diagnosis of mild sleep disordered breathing which manifests as the upper airway resistance syndrome. Our approach has been to develop a non-invasive technique to detect increased upper airway resistance directly from analysis of the airflow signal. A characteristic intermittent change of the inspiratory flow contour, which is indicative of the occurrence of flow 17

These are listed at www.ClinicalTrials.gov.

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limitation, correlates well with increased airway resistance. Currently all respiratory events are identified manually and totaled. This is time consuming and subject to variability. The objective of the present project is to improve upon the manual approach by implementing an artificially intelligent system for the identification and quantification of sleep disordered breathing based solely on non-invasive cardiopulmonary signals collected during a routine sleep study. The utility of other reported indices of sleep disorded breathing obtained during a sleep study will be evaluated. Successful development of an automated system that can identify and classify upper airway resistance events will simplify, standardize and improve the diagnosis of sleep disordered breathing, and greatly facilitate research and clinical work in this area. Using a physiological based determination of disease should allow better assessment of treatment responses in mild disease. Study Type: Interventional Contact(s): Dr. Indu Ayappa, c/o Tina Flores 1-212-263-8423; New York; NYU Sleep Disorders Center, New York, New York, 10016, United States; Recruiting Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00004569 Safety and Efficacy of Xenical in Children and Adolescents with Obesity-Related Diseases Condition(s): Diabetes Mellitus; Hypertension; Metabolic Disease; Obesity; Sleep Apnea Syndrome Study Status: This study is currently recruiting patients. Sponsor(s): National Institute of Child Health and Human Development (NICHD) Purpose - Excerpt: Obesity is a condition affecting one-third off the U.S. population and is a major risk actor for the development of Type 2 diabetes, hyperlipidemia (increased levels of fat in the blood), hypertension (high blood pressure), and other disorders of the heart and lungs. Individuals with the onset of obesity during childhood or adolescence are at an increased risk of obesity-related, diseases, both during adolescence and later in adult life. African American girls and women are at an increased risk for obesity, and have substantial rates of obesity-related diseases and causes of death. Further, many African American adult women fail to respond to many of the therapeutic approaches used to treat obesity. At present there are no medical therapies proven effective for the correction of severe obesity in children or adolescents. One medication that may have a favorable risk-benefit ratio in pediatric populations is Orlistat (Xenical, Hoffmann LaRoche).

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Orlistat works by preventing the action of enzymes in the digestive process, interfering with the absorption of approximately 1/3 of the fat eaten in the diet. Xenical appears to be effective for reducing weight and obesity-associated diseases in obese adults. Researchers propose to determine the safety, tolerability, and efficacy of Xenical in 12-17 year old severely obese African American and Caucasian children and adolescents who have one or more obesity-related disease (hypertension, hyperlipidemia, sleep apnea, hepatic steatosis, insulin resistance, impaired glucose tolerance, or Type 2 diabetes). Phase(s): Phase II Study Type: Interventional Contact(s): Maryland; National Institute of Child Health and Human Development (NICHD), 9000 Rockville Pike Bethesda, Maryland, 20892, United States; Recruiting; Patient Recruitment and Public Liaison Office 1-800-411-1222 [email protected]; TTY 1-866-411-1010 Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00001723 SCOR in Neurobiology of Sleep--Intermediate Traits for Sleep Apnea Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is currently recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To determine intermediate traits for sleep apnea in a case-control study. Study Type: Epidemiology Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005511 Epidemiology of Sleep Disordered Breathing in Children Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To collect fundamental data regarding the distribution of measures of sleep disordered breathing (SDB) in a pediatric population, prevalence of clinically significant SDB in children, risk factors, and associated co-morbidity. Study Type: Epidemiology Contact(s): see Web site below

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Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005516 Epidemiology of Sleep-Disordered Breathing in Adults Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To characterize the natural history and biologic spectrum of sleep disordered breathing (SDB) and test hypotheses regarding SDB causes and consequences. Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005557 Familial Aggregation and Natural History of Sleep Apnea Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To quantify the influence of genetic and environmental factors on the development of sleep apnea. Study Type: Epidemiology Contact(s): Redline, Susan Cleveland, Ohio, United States . Study chairs or principal investigators: Redline, Susan, Study Chair; Case Western Reserve University Cleveland, Ohio, United States Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005299 Neurobehavioral Consequences of Sleep Apnea in Children Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To identify physiological and clinical measures of obstructive sleep-disordered breathing that are associated with increased morbidity in children. Study Type: Epidemiology Contact(s): Gottlieb, Daniel J. Boston, Massachusetts, United States . Study chairs or principal investigators: Gottlieb, Daniel J., Study Chair; Boston University Boston, Massachusetts, United States Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00006323

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Neurocognitive Function in Snoring Children Condition(s): Lung Diseases; Sleep apnea syndromes; Neurologic Manifestations Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose Excerpt: To assess associations between behavioral/neuropsychological measures and various measures of sleep disordered breathing (SDB) and to determine the prevalence of SDB in children with Attention Deficit Hyperactivity Disorder (ADHD). Study Type: Epidemiology Contact(s): Gozal, David A. Louisville, Kentucky, United States . Study chairs or principal investigators: Gozal, David A., Study Chair; University of Louisville Louisville, Kentucky, United States Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00006321 Prevalence and Correlates of Childhood Sleep Apnea Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To determine if there are anatomic and physical characteristics that distinguish pre-adolescent children with sleep disordered breathing and if the sleep disordered breathing is associated with adverse effects on school and neurocognitive performance. Study Type: Epidemiology Contact(s): Quan, Stuart F. Tucson, Arizona, United States . Study chairs or principal investigators: Quan, Stuart F., Study Chair; University of Arizona Tucson, Arizona, United States Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005560 Sleep Apnea in a Non-Clinical Population Condition(s): Lung Diseases; Sleep apnea syndromes; Cardiovascular Diseases; Heart Diseases; Hypertension

Obesity;

Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To investigate the causes, consequences and quantitation of sleep disordered breathing (SDB). Contact(s): see Web site below

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Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005551 Sleep Apnea in Elderly Male Twins Condition(s): Lung Diseases; Sleep apnea syndromes; Obesity Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To conduct a genetic analysis of anatomic risk factors for sleep apnea in a well-characterized United States population-based registry of elderly male twins who have been successfully followed for the past 30 years. Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005525 Sleep Apnea in Look AHEAD Participants - Ancillary to Look AHEAD Condition(s): Sleep apnea syndromes; Diabetes Mellitus, non-insulin dependent; Obesity Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To assess the effects of weight loss on sleep disordered breathing in obese, Type 2 diabetics with obstructive sleep apnea. Study Type: Epidemiology Contact(s): Foster, Gary D. Philadelphia, Pennsylvania, United States . Study chairs or principal investigators: Foster, Gary D., Study Chair; University of Pennsylvania Philadelphia, Pennsylvania, United States Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00031239 Sleep Heart Health Study (SHHS) Condition(s): Lung Diseases; Sleep apnea syndromes; Cardiovascular Diseases; Heart Diseases; Coronary Disease; Cerebrovascular accident; Hypertension; Myocardial Infarction Study Status: This study is no longer recruiting patients. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To test whether sleep-disordered breathing is associated with an increased risk of coronary heart disease, stroke, allcause mortality, and hypertension. The multicenter, longitudinal study draws on existing, well-characterized, and established epidemiologic cohorts.

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Study Type: Epidemiology Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005275 Age-related Prevalence of Sleep Respiratory Disturbances Condition(s): Lung Diseases; Heart Diseases; Hypertension; Sleep apnea syndromes Study Status: This study is completed. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To determine the prevalence and longitudinal course of sleep apnea among men and women and to examine the associations of apnea, oxygen desaturation, snoring, high blood pressure, and other biomedical correlates. Study Type: Epidemiology Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005297 Epidemiology of Sleep Apnea Syndrome Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is completed. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To define the prevalence of Sleep Apnea Syndrome (SAS) in a community-based sample of Hispanic adults. Study Type: Epidemiology Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005286 Epidemiology of Sleep Disordered Cardiopulmonary Disorders of Sleep

Breathing

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SCOR

in

Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is completed. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To address the public health importance of sleep disordered breathing and ultimately reduce morbidity through information gained from longitudinal, population-based, epidemiologic studies.

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Study Type: Epidemiology Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005321 Impact of Sleep Disordered Breathing in Older Adults Condition(s): Cardiovascular Diseases; Hypertension; Depression; Sleep apnea syndromes; Lung Diseases Study Status: This study is completed. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To test the hypothesis that clinically inapparent sleepdisordered breathing was associated with blood pressure elevation, impairment of health-related quality of life, and depression. Study Type: Epidemiology Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005378 Prevalence of Sleep Apnea in Women Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is completed. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To identify the prevalence of sleep apnea (SA) in women and its relationship to age; to predict those women at risk for sleep apnea; and to define the natural history of those with sleep apnea. Study Type: Epidemiology Contact(s): Bixler, Edward O. Hershey, Pennsylvania, United States . Study chairs or principal investigators: Bixler, Edward O., Study Chair; Pennsylvania State University Hershey Medical Center Hershey, Pennsylvania, United States Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005381 Prevalence of Sleep Disordered Breathing in Children Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is not yet open for patient recruitment. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To investigate the prevalence and clinical significance of sleep disordered breathing (SDB) in children.

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Study Type: Epidemiology Contact(s): Bixler, Edward O. Hershey, Pennsylvania, United States . Study chairs or principal investigators: Bixler, Edward O., Study Chair; Pennsylvania State University Hershey Medical Center Hershey, Pennsylvania, United States Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00022789 Regulation of Pharyngeal Muscle Cardiopulmonary Disorders of Sleep

Contraction

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SCOR

in

Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is completed. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To determine the degree to which neuro-psychological performance and general health status and function may be impaired in subjects with mild and moderate degrees of sleep-related respiratory disturbances (SRRD), as compared to subjects with minimal apneic activity. Also, to assess the degree to which improvement may occur following specific treatment. Study Type: Longitudinal Human Study Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005320 Sleep Apnea: Age Effects On Prevalence and Natural History Condition(s): Lung Diseases; Sleep apnea syndromes Study Status: This study is completed. Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To identify the prevalence of sleep apnea in men and its relationship to age, assess the natural history of the disorder, and predict those men at risk. Study Type: Epidemiology Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005296 Validation and Exploration of Sleep and Mood Predictors Condition(s): Sleep apnea syndromes; Depression; Lung Diseases; Sleep Study Status: This study is completed.

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Sponsor(s): National Heart, Lung, and Blood Institute (NHLBI) Purpose - Excerpt: To determine whether objectively recorded sleep durations were mortality risk factors, whether sleep duration could be distinguished from depression as a risk factor in Women's Health Initiative (WHI) data, and whether sleep-associated risks were attributable to specific pathophysiologic processes such as sleep apnea, circadian rhythm phase advances, or deficiencies of melatonin, or deficiencies of reproductive steroids. The study was ancillary to the WHI. Study Type: Epidemiology Contact(s): see Web site below Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00005401

Benefits and Risks18 What Are the Benefits of Participating in a Clinical Trial? If you are interested in a clinical trial, it is important to realize that your participation can bring many benefits to you and society at large: A new treatment could be more effective than the current treatment for sleep apnea. Although only half of the participants in a clinical trial receive the experimental treatment, if the new treatment is proved to be more effective and safer than the current treatment, then those patients who did not receive the new treatment during the clinical trial may be among the first to benefit from it when the study is over. If the treatment is effective, then it may improve health or prevent diseases or disorders. Clinical trial patients receive the highest quality of medical care. Experts watch them closely during the study and may continue to follow them after the study is over. People who take part in trials contribute to scientific discoveries that may help other people with sleep apnea. In cases where certain diseases or disorders run in families, your participation may lead to better care or prevention for your family members.

This section has been adapted from ClinicalTrials.gov, a service of the National Institutes of Health: http://www.clinicaltrials.gov/ct/gui/c/a1r/info/whatis?JServSessionIdzone_ct=9jmun6f291. 18

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The Informed Consent Once you agree to take part in a clinical trial, you will be asked to sign an “informed consent.” This document explains a clinical trial’s risks and benefits, the researcher’s expectations of you, and your rights as a patient. What Are the Risks? Clinical trials may involve risks as well as benefits. Whether or not a new treatment will work cannot be known ahead of time. There is always a chance that a new treatment may not work better than a standard treatment. There is also the possibility that it may be harmful. The treatment you receive may cause side effects that are serious enough to require medical attention. How Is Patient Safety Protected? Clinical trials can raise fears of the unknown. Understanding the safeguards that protect patients can ease some of these fears. Before a clinical trial begins, researchers must get approval from their hospital’s Institutional Review Board (IRB), an advisory group that makes sure a clinical trial is designed to protect patient safety. During a clinical trial, doctors will closely watch you to see if the treatment is working and if you are experiencing any side effects. All the results are carefully recorded and reviewed. In many cases, experts from the Data and Safety Monitoring Committee carefully monitor each clinical trial and can recommend that a study be stopped at any time. You will only be asked to take part in a clinical trial as a volunteer giving informed consent. What Are a Patient’s Rights in a Clinical Trial? If you are eligible for a clinical trial, you will be given information to help you decide whether or not you want to participate. As a patient, you have the right to: Information on all known risks and benefits of the treatments in the study. Know how the researchers plan to carry out the study, for how long, and where. Know what is expected of you.

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Know any costs involved for you or your insurance provider. Know before any of your medical or personal information is shared with other researchers involved in the clinical trial. Talk openly with doctors and ask any questions. After you join a clinical trial, you have the right to: Leave the study at any time. Participation is strictly voluntary. However, you should not enroll if you do not plan to complete the study. Receive any new information about the new treatment. Continue to ask questions and get answers. Maintain your privacy. Your name will not appear in any reports based on the study. Know whether you participated in the treatment group or the control group (once the study has been completed). What about Costs? In some clinical trials, the research facility pays for treatment costs and other associated expenses. You or your insurance provider may have to pay for costs that are considered standard care. These things may include inpatient hospital care, laboratory and other tests, and medical procedures. You also may need to pay for travel between your home and the clinic. You should find out about costs before committing to participation in the trial. If you have health insurance, find out exactly what it will cover. If you don’t have health insurance, or if your insurance company will not cover your costs, talk to the clinic staff about other options for covering the cost of your care. What Should You Ask before Deciding to Join a Clinical Trial? Questions you should ask when thinking about joining a clinical trial include the following: What is the purpose of the clinical trial? What are the standard treatments for sleep apnea? Why do researchers think the new treatment may be better? What is likely to happen to me with or without the new treatment?

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What tests and treatments will I need? Will I need surgery? Medication? Hospitalization? How long will the treatment last? How often will I have to come back for follow-up exams? What are the treatment’s possible benefits to my condition? What are the short- and long-term risks? What are the possible side effects? Will the treatment be uncomfortable? Will it make me feel sick? If so, for how long? How will my health be monitored? Where will I need to go for the clinical trial? How will I get there? How much will it cost to be in the study? What costs are covered by the study? How much will my health insurance cover? Will I be able to see my own doctor? Who will be in charge of my care? Will taking part in the study affect my daily life? Do I have time to participate? How do I feel about taking part in a clinical trial? Are there family members or friends who may benefit from my contributions to new medical knowledge?

Keeping Current on Clinical Trials Various government agencies maintain databases on trials. The U.S. National Institutes of Health, through the National Library of Medicine, has developed ClinicalTrials.gov to provide patients, family members, and physicians with current information about clinical research across the broadest number of diseases and conditions. The site was launched in February 2000 and currently contains approximately 5,700 clinical studies in over 59,000 locations worldwide, with most studies being conducted in the United States. ClinicalTrials.gov receives about 2 million hits per month and hosts approximately 5,400 visitors daily. To access this database, simply go to their Web site (www.clinicaltrials.gov) and search by “sleep apnea” (or synonyms). While ClinicalTrials.gov is the most comprehensive listing of NIH-supported clinical trials available, not all trials are in the database. The database is updated regularly, so clinical trials are continually being added. The

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following is a list of specialty databases affiliated with the National Institutes of Health that offer additional information on trials: For clinical studies at the Warren Grant Magnuson Clinical Center located in Bethesda, Maryland, visit their Web site: http://clinicalstudies.info.nih.gov/ For clinical studies conducted at the Bayview Campus in Baltimore, Maryland, visit their Web site: http://www.jhbmc.jhu.edu/studies/index.html For heart, lung and blood trials, visit the Web page of the National Heart, Lung and Blood Institute: http://www.nhlbi.nih.gov/studies/index.htm

General References The following references describe clinical trials and experimental medical research. They have been selected to ensure that they are likely to be available from your local or online bookseller or university medical library. These references are usually written for healthcare professionals, so you may consider consulting with a librarian or bookseller who might recommend a particular reference. The following includes some of the most readily available references (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): A Guide to Patient Recruitment : Today’s Best Practices & Proven Strategies by Diana L. Anderson; Paperback - 350 pages (2001), CenterWatch, Inc.; ISBN: 1930624115; http://www.amazon.com/exec/obidos/ASIN/1930624115/icongroupinterna A Step-By-Step Guide to Clinical Trials by Marilyn Mulay, R.N., M.S., OCN; Spiral-bound - 143 pages Spiral edition (2001), Jones & Bartlett Pub; ISBN: 0763715697; http://www.amazon.com/exec/obidos/ASIN/0763715697/icongroupinterna The CenterWatch Directory of Drugs in Clinical Trials by CenterWatch; Paperback - 656 pages (2000), CenterWatch, Inc.; ISBN: 0967302935; http://www.amazon.com/exec/obidos/ASIN/0967302935/icongroupinterna The Complete Guide to Informed Consent in Clinical Trials by Terry Hartnett (Editor); Paperback - 164 pages (2000), PharmSource Information Services, Inc.; ISBN: 0970153309; http://www.amazon.com/exec/obidos/ASIN/0970153309/icongroupinterna Dictionary for Clinical Trials by Simon Day; Paperback - 228 pages (1999), John Wiley & Sons; ISBN: 0471985961; http://www.amazon.com/exec/obidos/ASIN/0471985961/icongroupinterna

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Extending Medicare Reimbursement in Clinical Trials by Institute of Medicine Staff (Editor), et al; Paperback 1st edition (2000), National Academy Press; ISBN: 0309068886; http://www.amazon.com/exec/obidos/ASIN/0309068886/icongroupinterna Handbook of Clinical Trials by Marcus Flather (Editor); Paperback (2001), Remedica Pub Ltd; ISBN: 1901346293; http://www.amazon.com/exec/obidos/ASIN/1901346293/icongroupinterna

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Coronary: Encircling in the manner of a crown; a term applied to vessels; nerves, ligaments, etc. The term usually denotes the arteries that supply the heart muscle and, by extension, a pathologic involvement of them. [EU] Efficacy: The extent to which a specific intervention, procedure, regimen, or service produces a beneficial result under ideal conditions. Ideally, the determination of efficacy is based on the results of a randomized control trial. [NIH] Enzyme: Substance, made by living cells, that causes specific chemical changes. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Hyperlipidemia: An excess of lipids in the blood. [NIH] Hypertension: High blood pressure (i.e., abnormally high blood pressure tension involving systolic and/or diastolic levels). The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure defines hypertension as a systolic blood pressure of 140 mm Hg or greater, a diastolic blood pressure of 90 mm Hg or

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greater, or taking hypertensive medication. The cause may be adrenal, benign, essential, Goldblatt's, idiopathic, malignant pate, portal, postpartum, primary, pulmonary, renal or renovascular. [NIH] Indicative: That indicates; that points out more or less exactly; that reveals fairly clearly. [EU] Infarction: 1. the formation of an infarct. 2. an infarct. [EU] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Intermittent: Occurring at separated intervals; having periods of cessation of activity. [EU] Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Neurologic: Pertaining to neurology or to the nervous system. [EU] Orlistat: A lipase inhibitor used for weight loss. Lipase is an enzyme found in the bowel that assists in lipid absorption by the body. Orlistat blocks this enzyme, reducing the amount of fat the body absorbs by about 30 percent. It is known colloquially as a "fat blocker." Because more oily fat is left in the bowel to be excreted, Orlistat can cause an oily anal leakage and fecal incontinence. Orlistat may not be suitable for people with bowel conditions such as irritable bowel syndrome or Crohn's disease. [NIH] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Standardize: To compare with or conform to a standard; to establish standards. [EU] Steatosis: Fatty degeneration. [EU] Steroid: A group name for lipids that contain a hydrogenated cyclopentanoperhydrophenanthrene ring system. Some of the substances included in this group are progesterone, adrenocortical hormones, the gonadal hormones, cardiac aglycones, bile acids, sterols (such as cholesterol), toad poisons, saponins, and some of the carcinogenic hydrocarbons. [EU]

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PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on sleep apnea. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on sleep apnea. In Part II, as in Part I, our objective is not to interpret the latest advances on sleep apnea or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with sleep apnea is suggested.

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CHAPTER 4. STUDIES ON SLEEP APNEA Overview Every year, academic studies are published on sleep apnea or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or physicians. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on sleep apnea. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on sleep apnea and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and sleep apnea, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the

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format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type in “sleep apnea” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is a sample of what you can expect from this type of search: Sleep Apnea in Alzheimer's Patients and the Healthy Elderly Source: Scholarly Inquiry for Nursing Practice: An International Journal. 1(3): 221-235. 1987. Summary: The incidence of sleep apnea was explored in 80 elderly subjects. Through the use of several criteria, sleep apnea was found more frequently in Alzheimer's patients (n equals 24) than in healthy controls (n equals 56). Alzheimer's patients were also found to have a significantly higher proportion of apnea related to non-rapid eye movement than to rapid eye movement sleep. Apnea-positive Alzheimer's patients also had significantly more awake time during the course of the night. A significant positive correlation between apnea index and severity of dementia, as measured by the Blessed Dementia Rating Scale, was found for apnea-positive Alzheimer's patients (r equals 0.57, p less than .01) as well as for the entire sample of Alzheimer's patients (r equals 0.41, p less than .05). Neuropathological implications are discussed, as well as the implications for nursing practice. 37 references. (AA). Musculoskeletal Complaints and Fibromyalgia in Patients Attending a Respiratory Sleep Disorders Clinic Source: Journal of Rheumatology. 23(9):1612-1616; 1996. Summary: This journal article for health professionals describes a study that examined the prevalence of musculoskeletal complaints, including tender point score and diagnosis of fibromyalgia (FM), in 108 consecutive patients attending a respiratory sleep disorders clinic. The study also examined the association of physical activity and levels of reported pain. Assessment of musculoskeletal pain symptoms included patient history of pain, painful sites marked on a mannequin, visual analog scale (VAS) pain score, and tender point count. Daily physical activity was recorded, and all patients underwent nocturnal polysomnography, blind to clinical status. Results indicate that FM was identified in 3 patients. Pain reporting was more strongly associated with reduced physical activity than with a specific sleep disorder. Patients with reduced physical activity were more likely to have pain symptoms than physically active

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patients, six or more tender points, three or more sites marked on a mannequin, axial pain, and VAS pain score. The article concludes that FM by defined criteria was uncommon in patients with a primary complaint of disturbed sleep, and in particular, patients with sleep apnea. Reduced physical activity was strongly associated with reported pain symptoms. 35 references and 4 tables. (AA-M). Improvement of Sleep Apnea in Patients with Chronic Renal Failure Who Undergo Nocturnal Hemodialysis Source: New England Journal of Medicine. 344(2): 102-107. January 11, 2001. Summary: Sleep apnea (defined as the absence of airflow for longer than 10 seconds; it usually interrupts sleep) is common in patients with chronic renal failure (CRF) and is not improved by either conventional hemodialysis of peritoneal dialysis. With nocturnal hemodialysis, patients undergo hemodialysis seven nights per week at home, while sleeping. This article reports on a study undertaken to investigate the role of nocturnal hemodialysis in correcting sleep apnea in patients with CRF. Fourteen patients who were undergoing conventional hemodialysis for four hours on each of three days per week underwent overnight polysomnography (a measurement of sleep). The patients were then switched to nocturnal hemodialysis for eight hours during each of six or seven nights a week. They underwent polysomnography again 6 to 15 months later on one night when they were undergoing nocturnal hemodialysis and on another night when they were not. The mean serum creatinine concentration (a measurement of kidney or replacement kidney function) was significantly lower during the period when the patients were undergoing nocturnal hemodialysis than during the period when they were undergoing conventional hemodialysis. The conversion from conventional hemodialysis to nocturnal hemodialysis was associated with a reduction in the frequency of apnea and hypopnea from 25 (plus or minus 25) to 8 (plus or minus 8) episodes per hour of sleep. This reduction occurred predominantly in seven patients with sleep apnea, in whom the frequency of episodes fell from 46 (plus or minus 19) to 9 (plus or minus 9) episodes per hour, accompanied by increases in the minimal oxygen saturation, transcutaneous partial pressure of carbon dioxide, and serum bicarbonate concentration. During the period when these seven patients were undergoing nocturnal hemodialysis, the apnea hypopnea index measured on nights when they were not undergoing nocturnal hemodialysis was greater than that on nights when they were undergoing nocturnal hemodialysis, but it still remained lower than it had been during the period when they were

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undergoing conventional hemodialysis. The authors conclude that nocturnal hemodialysis corrects sleep apnea associated with chronic renal failure. 2 figures. 4 tables. 22 references. Sleep Apnea in End-Stage Renal Disease Source: Seminars in Dialysis. 4(1): 52-58. January-March 1991. Summary: Information regarding the prevalence and diagnosis of sleep disorders in patients with renal disease is limited, but interest in such abnormalities has increased over the last several years. This article reviews the literature on sleep apnea in end-stage renal disease (ESRD). Topics include diagnosis, the prevalence of sleep apnea in ESRD, etiological considerations, and treatment interventions. The author stresses that effective diagnosis and treatment of sleep apnea are required by physicians if we are to continue to make headway in improving the quality of life for ESRD patients. 1 figure. 2 tables. 58 references. Interface of Epilepsy and Sleep Disorders Source: Seizure. 8(2):97-102, April 1999. Summary: Australian researchers examined individuals referred to an outpatient neurological clinic for evaluation of possible seizures between 1991 and 1997 in whom sleep disorder was suspected, either due to snoring during an electroencephalogram (EEG), or based on history. They used all-night diagnostic polysomnography (PSG) and appropriate intervention as indicated. Participants were individuals age 10 to 83 who underwent PSG following an EEG and demonstration of early-onset snoring during either sleep-deprived EEG or a standard waking study. Other patients referred for assessment of epilepsy, but in whom the history was suggestive of sleep apnea or in whom other diagnostic procedures indicated the potential for sleep apnea, were referred for similar PSG investigation. Researchers reviewed patient and seizure demography, sleep disorder, and response to therapy, and they explored the interface. Data analysis indicated that approximately half of the 50 individuals who underwent PSG were diagnosed with epilepsy, and almost three-quarters had sleep disorders sufficiently intrusive to require therapy (either continuous positive air pressure or medication). The researchers concluded that with co-existence of epilepsy and sleep disorders, proper management of sleep disorders provides significant benefit for seizure control. Snoring during EEG recordings could alert individuals to the possibility of a sleep disorder even with epilepsy diagnosed. Where both epilepsy and sleep disorder co-exist, appropriate management of the sleep disorder improves control of the epilepsy. 2 tables, 35 references.

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Glossoptosis (Posterior Displacement of the Tongue) During Sleep: A Frequent Cause of Sleep Apnea in Pediatric Patients Referred for Dynamic Sleep Fluoroscopy Source: AJR (American Journal of Roentgenology). 175(6): 1557-1559. December 2000. Contact: Available from American Roentgen Ray Society. 44211 Slatestone Court, Leesburg, VA 20147-5109. (800) 438-2777 or (703) 7293353. Fax (703) 729-4839. Email: [email protected]. Summary: This article reports on a study undertaken to evaluate the frequency of glossoptosis (posterior displacement of the tongue) as a cause of sleep apnea in pediatric patients referred for fluoroscopic sleep studies. The authors reviewed seventy consecutive dynamic fluoroscopic sleep studies performed to evaluate sleep apnea. All patients had been sedated and examined with lateral fluoroscopy during sleep. Anatomic changes in the airway were correlated with episodes of oxygen desaturation (lower levels of oxygen in the blood). Cases of glossoptosis, in which the tongue moved posteriorly during sleep and abutted the posterior pharynx (airway), resulting in airway obstruction and oxygen desaturation, were identified. Of the 70 sleep studies reviewed, glossoptosis was the cause of airway obstruction in 17 patients (24 percent). Mean age in these 17 patients was 3 years (range, 5 days to 13 years). Seven of the 17 children were younger than 1 year old. Only three patients had no underlying medical problems. Four patients had macroglossia (Down syndrome, n = 3; duplicated tongue, n = 1) as a cause and three patients had micro or retrognathia (small or receding jaw). Six patients had neuromuscular abnormalities. The authors conclude that glossoptosis was a cause of airway obstruction in 25 percent of pediatric patients referred for fluoroscopic sleep studies. Attention to this anatomic region is important when evaluating children with sleep apnea. 2 figures. 19 references. Obstructive Sleep Apnea Is Common in Medically Refractory Epilepsy Patients Source: Neurology. 55(7):1002-1007 (2000). Summary: Researchers investigated the prevalence of obstructive sleep apnea (OSA) among 39 patients with medically refractory epilepsy who were undergoing presurgical evaluation. None had previously been diagnosed with OSA. The patients underwent a polysomnographic (PSG) examination during overnight sleep. The patients were asked to complete the Sleep Apnea Scale of the Sleep Disorder Questionnaire (SA/SDQ) and the Epworth Sleepiness Scale (ESS). Researchers analyzed PSG data

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for signs of apnea or hypopnea, and calculated a respiratory disturbance index (RDI). OSA was judged to be present in PSG records in which the RDI was 5 or greater. They analyzed associations between age, number and types of antiepileptic drugs (AED's) prescribed, localization of seizures (temporal versus extratemporal), SA/SDQ and ESS scores and body mass index (BMI) and the presence of OSA by univariate and multivariate logistic regression analysis techniques. Thirteen patients (33 percent) had OSA. Of these, five were judged to have moderate to severe OSA, as indicated by RDI's of greater than 20. In the remaining patients, OSA was judged to be mild, the RDI's being below 10. Patients with OSA were more likely to be older, male, have a higher SA/SDQ score, have a higher BMI, and to have seizures during sleep than those without OSA. A final logistic regression model showed that SDQ score was a strong predictor of OSA. Seizure frequency per month, number and types of AED's prescribed, seizure localizaton, and the ESS were not significantly associated with OSA. Researchers conclude that OSA is common among patients with medically refractory seizures. 2 tables, 19 references. Oral Appliances for the Treatment of Snoring and Obstructive Sleep Apnea Source: Journal of Practical Hygiene. 10(5): 27-30. September-October 2001. Contact: Available from Montage Media Corporation. 1000 Wyckoff Avenue, Mahwah, NJ 07430-3164. (201) 891-3200. Summary: Obstructive sleep apnea (OSA) is a condition that develops from the obstruction (blockage) of the upper airway during sleep and necessitates awakening to resume breathing. Recently developed oral appliances, fabricated to maintain upper airway patency (opening) during sleep, are shown to be effective to treat patients with OSA. Among the appliances devised are tongue retaining and mandibular (lower jaw) advancing devices. This article outlines the role of the dental hygienist in the diagnosis and treatment of OSA, including patient education on the use of oral appliances, as well as intervention strategies to prevent dental diseases from occurring during oral appliance therapy. 3 figures. 2 tables. 11 references. Obstructive Sleep Apnea Surgery: Genioglossus Advancement Revisited Source: Journal of Oral and Maxillofacial Surgery. 59(10): 1181-1184. October 2001.

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Contact: Available from W.B. Saunders Company. Periodicals Department, P.O. Box 629239, Orlando, FL 32862-8239. (800) 654-2452. Summary: This article reports on a study that evaluated the accuracy of a genioglossus advancement (GA) technique (rectangular window) to incorporate the genial tubercle or genioglossus muscle complex (GGC) in patients with obstructive sleep apnea. The prospective study consisted of 38 consecutive patients who underwent GA. All 38 pairs of genial tubercles were captured. Thirty-one patients had both bellies of the genioglossus muscle incorporated. Two patients had a complete belly and a partial (greater than 50 percent) belly of the muscle captured. Five patients had only a portion of both muscle bellies included. The incomplete incorporation of the muscles in the bone flap was caused by the limited lateral extension of the osteotomy beyond the genial tubercles. The causes of the limited lateral osteotomy extension included crowding of the lower incisors as well as the presence of elongated or medially angulated canine roots. The results of this study show that the rectangular osteotomy technique accurately captures the genial tubercles and enables an adequate amount of the genioglossus muscle to be incorporated and advanced. 6 figures. 15 references. Treating Obstructive Sleep Apnea and Snoring: Assessment of an Anterior Mandibular Positioning Device Source: JADA. Journal of the American Dental Association. 131(6): 765771. June 2000. Contact: Available from American Dental Association. ADA Publishing Co, Inc., 211 East Chicago Avenue, Chicago, IL 60611. Summary: Dental devices have been used to help manage snoring and obstructive sleep apnea, or OSA. This article reports on patients' compliance with and complications of long term use of an anterior mandibular positioning, or AMP, device. The device used was a custom made, two piece, full coverage, adjustable acrylic appliance, used nightly. The appliance advanced the mandible by 75 percent of the patient's maximum protrusive distance. The study sample included 65 consecutive patients with mild to moderate obstructive sleep apnea and snoring. Long term use (three years or more) of the AMP device in these patients was 51 percent (27 of 53 patients). Of the 53 responding patients, 40 percent reported jaw or facial muscle pain, 40 percent had occlusal changes, 38 percent reported tooth pain, 30 percent reported jaw joint pain, and 30 percent experienced xerostomia. Of the 27 long term AMP users, 22 rated themselves as being very satisfied and four as somewhat satisfied; one person was neither satisfied nor dissatisfied with the appliance. The authors conclude that with use of the AMP device, 40

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percent of patients will develop some minor complications of jaw, mouth, or tooth pain, and approximately 26 percent of long term users might experience a painless but irreversible change in their occlusion. Annual follow up office visits with the dentist appear necessary for early detection of these changes. 4 figures. 23 references. Dental Side Effects of an Oral Device To Treat Snoring and Obstructive Sleep Apnea Source: Sleep. 22(2): 237-240. March 15, 1999. Contact: Available from American Sleep Disorders Association. 6301 Bandel Road, Suite 101, Rochester, MN 55901. (507) 529-0804. Summary: Snoring and obstructive sleep apnea (OSA) are common and related conditions with major social and health implication. These conditions can be treated successfully with dental devices that reposition the mandible (lower jaw). Despite wide use, side effects of these devices have not yet been systematically evaluated. This article reports on a study undertaken to evaluate the side effects of a mandibular advancement splint (MAS). The research consisted of a questionnaire survey and dental examination of a consecutive case series of patients treated with the MAS. Attempts were made to contact all 191 patients treated over a 5 year period in a dental outpatient clinic; all patients had snored loudly and habitually with or without OSA prior to treatment. Of 191 patients treated, 132 agreed to complete the questionnaire and 106 underwent examination. Of the 132 interviewed, patient and partner report indicated that the device was well tolerated and controlled snoring satisfactorily in 100 patients after 31 (plus or minus 18) months of use. Dental side effects were reported in 107 patients, although these were mostly minor, and only 10 patients ceased using the device because of them. Side effects included excessive salivation (40 patients), xerostomia (30 patients), temporomandibular joint pain (35 patients), dental discomfort (35 patients), myofacial discomfort (33 patients), and bite changes (16 patients). Of 106 patients examined, 30 had increased maximal opening and 76 had no change compared with pretreatment records. Temporomandibular joint noises were found in 9 patients, and occlusal changes in 15. None of these effects could be related to degree of opening or protrusion produced by the MAS. The authors conclude that dental side effects occur in a significant proportion of patients using the MAS. In most cases, these are minor and their importance must be balanced against the efficacy of the MAS in treating snoring and OSA. 1 appendix. 2 figures. 9 references. (AA-M).

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Dentistry's Role in the Management of Obstructive Sleep Apnea Source: Journal of the Greater Houston Dental Society. 71(4): 29-30. November 1999. Contact: Available from Greater Houston Dental Society. One Greenway Plaza, Suite 110, Houston, TX 77046. (713) 961-4337. Fax (713) 961-3617. Email: [email protected]. Website: www.ghds.com. Summary: Snoring may be one symptom of a potentially life threatening sleep related disorder known as obstructive sleep apnea (OSA). This article describes how the dental community is actively playing a role in understanding, managing, and treating OSA. OSA occurs when the pharyngeal airways, which include the tongue, palate, and pharynx, collapse during sleep. The authors outline the signs and symptoms, complications of the condition, diagnosis, treatment, use of oral appliances, and the effects of oral appliance therapy. Dentists may participate in the management of OSA patients by understanding OSA, recognizing the signs and symptoms, developing a relationship with the patient's physician or sleep specialist, and having resources and referrals available for patients. Diagnosis is based on the clinical signs and symptoms, physical examination, as well as head, neck, and oral examinations. Age and obesity are two significant predictors of OSA. The two most commonly used types of oral appliances used during sleep are the tongue retaining device and the mandibular (lower jaw) repositioning splint. 6 references. Sleep Apnea in End Stage Renal Disease Source: ANNA Journal. American Nephrology Nurses Association Journal. 24(6): 645-654. December 1997. Contact: Available from American Nephrology Nurses Association. Box 56, East Holly Avenue, Pitman, NJ 08071. (609) 256-2320. Summary: This article familiarizes nephrology nurses with the sleep apnea syndrome, a disorder that is characterized by repetitive episodes of the cessation of breathing (apneas) or diminished airflow (hypopneas) that occur during sleep, and is usually, although not always, associated with a reduction in the oxygen saturation of the blood. The author reviews risk factors, clinical features, diagnostic strategies, and treatments. The author also discusses recent research linking sleep apnea with end-stage renal disease (ESRD). In diagnosing sleep apnea syndrome, the total number of apneas and hypopneas that occur during a sleep period are usually added together and then divided by the number of hours spent sleeping to obtain a respiratory disturbance index (RDI). While disrupted sleep and daytime sleepiness are significant problems,

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cardiopulmonary abnormalities are also important complications associated with sleep apnea. Risk factors for sleep apnea include obesity, craniofacial abnormalities, male gender, certain medical illnesses, lifestyle factors (use of alcohol and central nervous system depressants, smoking, exposure to allergens), and cardiovascular diseases. The author reviews nine studies of ESRD and sleep apnea, all of which demonstrated that sleep apnea has a prominent presence in ESRD, that both hemodialysis and peritoneal dialysis patients are vulnerable to it, and that dialysis itself seems to have little effect on its clinical expression. These studies showed that the incidence of sleep apnea is most likely much higher in this group than in the general population, but they did not succeed in determining the exact prevalence of sleep apnea in chronic renal failure because of subject selection bias and small sample sizes. The author concludes that patients with ESRD who have symptoms related to sleepwake problems should be evaluated. Treatment of a sleeping disorder thus revealed is likely to have a drastic impact on the quality of life experienced by these patients. 4 figures. 2 tables. 26 references. (AA-M). Diagnosing and Comanaging Patients with Obstructive Sleep Apnea Syndrome Source: JADA. Journal of the American Dental Association. 131(8): 11781184. August 2000. Contact: Available from American Dental Association. ADA Publishing Co, Inc., 211 East Chicago Avenue, Chicago, IL 60611. Summary: This article discusses the diagnosis and management of patients with obstructive sleep apnea syndrome (OSAS), a common, but underdiagnosed, disorder that can be fatal. The disorder is characterized by repetitive episodes of complete or partial upper airway obstruction leading to absent or diminished airflow into the lungs. These episodes usually last 10 to 30 seconds and result in loud snoring, a decrease in oxygen saturation, and chronic daytime sleepiness and fatigue. The obstruction is caused by the soft palate, base of the tongue or both collapsing against the pharyngeal walls because of decreased muscle tone during sleep. Potentially fatal systemic illnesses frequently associated with this disorder include hypertension, pulmonary (lung) hypertension, heart failure, nocturnal cardiac dysrhythmias, myocardial infarction (heart attack), and ischemic stroke. The classic signs and symptoms of OSAS may be recognizable by dental practitioners. Common findings in the medical history include daytime sleepiness, snoring, hypertension, and type 2 diabetes mellitus. Common clinical findings include male gender, obesity, increased neck circumference, excessive fat deposition in the palate, tongue (macroglossia) and pharynx, a long soft palate, a small

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recessive mandible and maxilla, and calcified carotid artery atheromas on parnoramic and lateral cephalometric radiographs. After confirmation of the diagnosis by a physician, dentists can participate in management of the disorder by fabricating mandibular advancement appliances and performing surgical procedures that prevent recurrent airway obstruction. 6 figures. 43 references.

Federally-Funded Research on Sleep Apnea The U.S. Government supports a variety of research studies relating to sleep apnea and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.19 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to sleep apnea and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore sleep apnea and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for sleep apnea: Project Title: Acute Effects of Light on Sleep Principal Investigator & Institution: Benca, Ruth M.; Professor; Psychiatry; University of Wisconsin Madison 500 Lincoln Dr Madison, Wi 53706 Timing: Fiscal Year 2000; Project Start 1-JAN-1995; Project End 0-JUN2004 Summary: Light is an important regulator of behavioral state in mammals. In addition to effects on the circadian clock, changes in 19 Healthcare projects are funded by the national institutes of health (nih), substance abuse and mental health services (samhsa), health resources and services administration (hrsa), food and drug administration (fda), centers for disease control and prevention (cdcp), agency for healthcare research and quality (ahrq), and office of assistant secretary of health (oash).

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lighting conditions can induce immediate changes in sleep-wakefulness. For example, light increases wakefulness in humans and induces sleep in nocturnal rodents. We have used the albino rat as a model to study acute effects of light-dark shifts on sleep patterns. Albino rats show exaggerated responses to abrupt lighting changes, particularly in their rapid eye-movement (REM) sleep patterns; following lights-off, they exhibit large increases in REM sleep (REM sleep triggering), whereas lights-on suppresses REM sleep. In addition, light acutely increases nonREM (NREM) sleep and dark increases waking in both albino and pigmented rats. During the past 4 years of funding, we have characterized acute sleep-wakefulness responses to changes in light conditions and demonstrated that lesions of the superior colliculus (SC) and pretectum (PT) attenuate these responses in albino rats. We propose an integrated series of studies to further elucidate the mechanisms by which the SC-PT region regulates sleep-wakefulness in response to lighting changes: (1) Localize areas within the SC and PT which mediate REM sleep, NREM sleep and/or waking responses to light-dark shifts; (2) Describe connections between the SC-PT and brain regions known to be involved in mediating sleep and waking; (3) Use immediate early gene expression to identify brain regions which respond to acute lighting changes and correlate with behavioral responses; and (4) Determine the effects of SCN lesions on sleep-waking responses to light-dark shifts. Results from these studies should increase our understanding of how light affects the nervous system, including effects of light therapy on sleep and mood. Furthermore, we hope to elucidate the role of the SC-PT in REM sleep regulation, which may have relevance to disorders characterized by abnormalities in REM sleep, and depression Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket Project Title: Bright Light Treatment of Sleep Disturbance in Elderly Principal Investigator & Institution: Campbell, Scott S.; Professor of Psychology; Psychiatry; Weill Medical College of Cornell Univ of Cornell University New York, Ny 10021 Timing: Fiscal Year 2000; Project Start 1-FEB-1989; Project End 1-DEC2002 Summary: (Adapted from applicant's abstract): It is widely recognized that changes in the sleep/wake system accompany the aging process. As a consequence, a large proportion of older people complain of significant sleep disturbance-Age-related sleep changes are commonly expressed as shallow and fragmented sleep, and multiple, often prolonged awakenings, particularly in the second half of the night. Few older subjects report difficulties getting to sleep. Therefore, sleep disturbance in

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people over 65 is generally considered to be a disorder of maintaining, rather than initiating, sleep. Recent evidence indicates that timed exposure to bright light can be effective in managing these age-related sleep changes by acting directly on the circadian timing system. Yet, effectiveness, of light treatment may be compromised by compliance problems associated with the time required for, and the constraints involved in, the treatment regimen. Response to treatment is likely to be affected also by one's recent history of light exposure. Until issues of compliance are fully understood and effectively dealt with, light treatment for age-related sleep disturbance cannot be employed to its full potential. This competing continuation will examine three important issues related to compliance: First, it is proposed to quantify the effects of prior light history on the phase-shifting capacity of bright light. Second, a novel procedure for light delivery will be tested, the development of which may hold promise for significantly enhancing user compliance. Finally, an in-home treatment will be implemented which administers light in a manner that may be more acceptable to patients. In the labbased studies, circadian variables of young (65 yrs) will be monitored at baseline, and throughout an interval during which subjects' prior light history is controlled, immediately preceding exposure to 1) a conventionally-administered bright light phase-shifting stimulus, or 2) a bright light phase-shifting stimulus administered using a non-ocular site for phototransduction. In the treatment study, two groups of healthy, older subjects (>65 yrs) who complain of sleep maintenance insomnia, and whose complaints are verified polygraphically, will undergo either 1) a one-month regimen of timed room-light exposure combined with timed light avoidance, or 2) a well-validated control condition, while living at home and continuing normal daily activities. All three studies address issues crucial to the successful development and implementation of bright light treatment. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket Project Title: Cholinergic Mechanisms of REM Sleep Generation Principal Investigator & Institution: Baghdoyan, Helen A.; Professor; Anesthesiology; University of Michigan at Ann Arbor Ann Arbor, Mi 48109 Timing: Fiscal Year 2000; Project Start 1-SEP-1989; Project End 0-APR2004 Summary: (Adapted From The Applicant's Abstract): The broad, longterm objectives of this application are to specify, at the level of muscarinic cholinergic receptors (mAChRs) and mAChR-coupled signal transduction pathways, the mechanisms generating and modulating

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REM sleep. The specific aims are unified by their focus on cholinergic neurotransmission, mAChRs, and mAChR- activated guanine nucleotide binding proteins (G proteins) in pontine and forebrain nuclei known to regulate REM sleep. The proposed studies will advance scientific knowledge by localizing a specific signal transduction pathway to REMsleep-related brain stem regions, by demonstrating GABAergic modulation of acetycholine (Ach) release in the medial pontine reticular formation (mPRF), and by elucidating the relationship between pontine muscarinic autoreceptors and electroencephalographic (EEG) spindle generation. Aims 1 and 2 will use techniques of in vitro autoradiography and [35s]GTPGS binding to localize and quantify cholinergicallyactivated G proteins in specific brain nuclei. Aim 1 will test the hypothesis that a pertussis toxin sensitive (Gi- like) G protein is activated by stimulating mACHRs in REM sleep- related nuclei of the pontine brain stem. Aim 2 will test the hypothesis that cholinergic agonists activate G proteins in forebrain regions known to modulate cortical EEG arousal and sleep/wake states. Aims 3 and 4 will use techniques of in vivo microdialysis, HPLC and polygraphic recordings of sleep/wake states. Aim 3 will test the hypothesis that GABAergic neurotransmission at the GABAa receptor alters REM sleep, in part, by modulating Ach release in the mPRF. Aim 4 will test the hypothesis that muscarinic autoreceptors in the mPRF modulate the cortical EEG, in part, by altering thalamic Ach release. Basic studies of sleep neurobiology continue to provide insight into brain mechanisms regulating human sleep and mental health. Most psychiatric disorders are characterized by disrupted sleep, and altered cholinergic neurotransmission is thought to contribute to the etiology of certain types of depression. The potential health relatedness of the proposed project derives from the good correspondence between pre-clinical and clinical research demonstrating that pontine cholinergic neurotransmission contributes to the regulation of sleep and affective states. This application proposes novel experiments aiming to elucidate the role of mAChRs, ACH release, and cholinergically activated G proteins in the regulation of REM sleep. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket Project Title: Circadian Patterns of Sleep Tendency in the Elderly Principal Investigator & Institution: Buysse, Daniel J.; Associate Professor; Psychiatry; University of Pittsburgh at Pittsburgh 4200 5Th Ave Pittsburgh, Pa 15260 Timing: Fiscal Year 2000; Project Start 1-JUL-1998; Project End 0-JUN2002

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Summary: (Adapted from applicant's abstract): This is a revised RO1 application originally reviewed by the MDA Review Committee in June, 1997. Elderly individuals have a high rate of both subjective and objective sleep disturbances, and these sleep problems have significant health consequences. Developing effective non-pharmacological treatments for sleep disturbances in the elderly is an important goal. However, behavioral sleep interventions for the elderly should be based on the underlying sleep physiology of the elderly. Current behavioral interventions are based on physiological models of sleep regulation developed in younger adults, which assume a strong circadian pattern of sleep tendency. The elderly may have a different pattern, marked by reduced amplitude of the circadian rhythm in sleep tendency. Thus, behavioral treatments which emphasize a single, consolidated nocturnal sleep period may not be consonant with underlying sleep physiology of the elderly. A controlled laboratory study is crucial in order to define the circadian sleep physiology of the healthy elderly. The major aim of this project is to compare circadian patterns of sleep tendency and subjective sleepiness in healthy elderly and young adults. Secondary aims are: To examine age-related differences in circadian patterns of mood, activation, and psychomotor performance; and to examine the relationships between circadian core body temperature (CBT) rhythms and circadian patterns of sleep tendency, mood, activation, and performance. Subjects will include 20 healthy adults 20-30 years old (10 women and 10 men) and 20 healthy adults 70-85 years old (10 women and 10 men). Subjects will be studied on a schedule of 30 minutes sleep alternating with 60 minutes of wakefulness, which will continue around the clock (i.e., at multiple circadian phases) for 40 cycles (2 1/2 days). This study will test the following specific hypotheses: 1) Compared to young adults, elderly subjects will have a "flattened" circadian pattern of objective and subjective sleep tendency. Specifically, the circadian pattern of sleep tendency in elderly subjects will demonstrate a lower mean level (i.e., less overall sleepiness), reduced amplitude, and an earlier phase. 2) Compared to young adults, elderly subjects will have reduced amplitude in circadian patterns of mood, activation, and psychomotor performance (manual dexterity, four-choice reaction time, and a stop signal task). 3) The timing (phase) of the core body temperature rhythm will correlate with the timing (phase) of circadian rhythms in sleep tendency, mood, activation, and performance in both young and elderly adults. This study will yield important new information regarding sleep physiology and circadian rhythms in the elderly. These data will help us to better understand the widely prevalent sleep problems of elderly individuals and to develop more effective physiologic assessments and behavioral sleep interventions for them.

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Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket Project Title: Control of Sleep and Arousal Principal Investigator & Institution: Alam, Md N.; ; Sepulveda Research Corporation 16111 Plummer St Los Angeles, Ca 91343 Timing: Fiscal Year 2000; Project Start 5-MAY-2000; Project End 0-APR2004 Summary: (adapted from applicant's abstract): Extensive evidence supports the idea that the magnocellular basal forebrain (MBF) plays a critical role in EEG activation and behavioral arousal. Evidence suggests that the onset of non-rapid eye movement (NREM) sleep, in part, involves the inhibition of the arousal mechanism located within the MBF. Adenosine and GABA have been implicated in sleep-regulation and hypothesized to inhibit the MBF arousal system. While putative wake(WRNs) and sleep-regulating neurons (SRNs) within MBF have been electrophysiologically studied in detail, very little is known about the in vivo neurochemical regulation of these cell types across the sleep-wake cycle in freely moving animals. The proposed experiments will evaluate the contributions of adenosinergic and GABAergic mechanisms in the discharge modulation of WRNs and SRNs in the MBF across sleepwaking states, during sleep-deprivation, and recovery sleep. We hypothesize that adenosine suppresses WRNs in the MBF via A1 adenosine receptors and activates SRNs via A2 adenosine receptors. We hypothesize that GABA-mediated inhibition contributes to the suppression of WRNs in the MBF during NREM sleep. We hypothesize that the extracellular levels of adenosine in the MBF will be higher during waking as compared with sleep. In contrast, extracellular levels of GABA during sleep will be higher than during waking. We hypothesize that extracellular levels of adenosine will increase during short-term sleep deprivation, whereas GABA levels will be higher during recovery sleep. We hypothesize that WRNs in the MBF will exhibit decreased spontaneous discharge during recovery sleep as compared to its baseline. Adenosine and GABA antagonists will partially attenuate changes in neuronal discharge and excitability that occur during sleep deprivation and recovery sleep. The effects of adenosinergic and GABAergic agents on MBF neurons will be studied by combining chronic microwire methods for extracellular unit recording with the delivery of pharmacological agents adjacent to the neurons with a microdialysis probe in freely behaving rats. The extracellular levels of adenosine and GABA in the MBF will be measured across the sleep-wake cycle during sleep-deprivation and recovery sleep. These pharmacological manipulations and analytical procedures will help understanding of the

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adenosinergic and GABAergic mechanisms that shape the discharge patterns of the MBF neurons across the sleep-waking cycle. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket Project Title: Depression, Sleep Disorders and Coronary Heart Disease Principal Investigator & Institution: Carney, Robert M.; Professor of Medical Psychology; Psychiatry; Washington University Lindell and Skinker Blvd St. Louis, Mo 63130 Timing: Fiscal Year 2000; Project Start 0-SEP-2000; Project End 1-JUL-2003 Summary: Description (adapted from the investigator's abstract): Clinical depression is a risk factor for mortality and morbidity after acute myocardial infarction (MI), yet little is known about the underlying mechanisms that account for this. The purpose of this study is to examine a potential mechanism, cardiovascular response to disordered sleep. Three months after an MI, 75 patients who meet the DSM-IV criteria for major depression will be selected and matched for gender, age, BMI to patients without depression. Polysomnography will be performed to determine the frequency and severity of cardiac responses to sleep disordered breathing and sleep architecture measures. The following hypotheses will be tested: 1) patients with depression have greater cardiac response to episodes of sleep apnea than non-depressed patients; 2) patients with depression without sleep disordered breathing have shorter REM latency, increased REM density, reduced slow wave sleep and worse sleep efficiency; 3) increased cardiac response to sleep disordered breathing, a shorter REM latency, increased REM density, decreased slow wave sleep are associated with electro cardio-graphic abnormalities predictive of cardiac events in post MI patients. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket Project Title: Measuring QOL During Treatment for Sleep Apnea Principal Investigator & Institution: Breugelmans, Jeannette G.; Epidemiology; Johns Hopkins University 3400 N Charles St Baltimore, Md 21218 Timing: Fiscal Year 2000; Project Start 5-JUN-2000; Project End 4-DEC2001 Summary: The objective of this study is to examine the relative importance of acquiring health status information on a sleep apnea patient's functioning and quality of life by partners as proxy raters. Sleep apnea is a common sleep disorder and it is estimated to affect 2-4% of middle-aged adults. This disorder is characterized by frequent episodes of upper airway collapse, which is associated with nocturnal

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oxyhemoglobin desaturation, and daytime sleepiness. Without treatment, patients with sleep apnea often report a general impairment in their daily functioning and demonstrate several neurocognitive deficits including decrements in attention, vigilance, and memory. Several studies have shown an impaired quality of life in patients with sleep apnea by use of generic and disease-specific quality of life measures. Clinical experience suggests that patients with sleep apnea often underreport their symptoms. The cognitive dysfunction that accompanies sleep apnea may, in part, be responsible for this under-reporting. Moreover, patients gradually become accustomed to the impaired state and, therefore, cannot discern the overall impact of underlying disease on their functional status. In this situation, the decision to seek medical attention is often initiated by a proxy, usually the spouse. Proxy interviews reveal not only the lack of agreement between subjective and observed quality of life, but also the impact that the disease has on the proxy's quality of life. As ongoing and future studies examine the impact of sleep apnea on quality of life, we need to determine whether self-report is an accurate means for assessing quality of life in sleep apnea. Studies in other medical disorders that have associated cognitive dysfunction have shown that proxy-reported quality of life might provide a better substitute of the overall impact of the disease. Such analyses have not been previously done for patients with sleep apnea. Therefore, the primary objective of this proposal is to examine the level of agreement between self- and proxy- reported quality of life in patients-with sleep apnea. We hypothesize that there will be a lack of agreement between self- and proxy-reported quality of life in patients sleep apnea and that proxies will report a measurable decrement in their own quality of life that will improve after the patient has been initiated on treatment. A consecutive sampling scheme will be employed and a total of 150 pairs will be enrolled in the study. Patients and their proxies will complete a battery of quality of life instruments at baseline and 1-month after initiation of treatment with continuous positive airway pressure (CPAP). In addition, at baseline and 1-month follow up, information on disease severity, sleepiness, psychomotor vigilance functioning and CPAP adherence will be obtained for each patient. Proxies will assess their own quality of life with a generic measure at baseline and at 1-month follow up. Statistical analyses will include bivariate and multivariate analyses including Pearson Correlation, Kappa, and Intraclasss Correlation Coefficient calculations, linear and logistic regression. This study will provide the first systematic evaluation of proxy quality of life reporting in sleep apnea, and the completion of this study will increase our knowledge concerning the potential impact of proxy- generated data on study outcomes in sleep apnea research.

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Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket Project Title: Neurobiology of Sleep Apnea in Aging Principal Investigator & Institution: Carley, David W.; Research Associate Professor; Medicine; University of Illinois at Chicago at Chicago Chicago, Il 60612 Timing: Fiscal Year 2000; Project Start 1-JUL-1999; Project End 0-JUN2004 Summary: (Applicant's abstract): Sleep apnea syndrome affects at least 3 percent - 5 percent of the adult population in this country and available data suggest that significant morbidity and mortality result from this disorder. It is now well established that the prevalence of sleep-related apnea is dramatically elevated in the elderly with recent estimates ranging from 28 percent - 67 percent for elderly males and from 20 percent - 54 percent for elderly females. However, the mechanisms underlying the age related increase in apnea genesis remain poorly understood. This uncertainly stems in part from a paucity of appropriate animal models to study spontaneous apneas in all stages of sleep. Rapid eye movement (REM) sleep is associated with apneas, reductions in respiratory and upper airway motor outputs, and increased variability of respiration, heart rate and blood pressure. We present novel preliminary evidence suggesting that increased apnea expression with aging results from dysregulation of brainstem respiratory control systems by brainstem phasic events (BPE) in the elderly. Ponto-geniculo-occipital (PGO) waves are a close marker of BPE and are closely associated with cardio- respiratory changes, including apnea. The overall goals of this proposal are to (i) investigate the neural mechanisms by which BPE influence apnea genesis, and (ii) establish the importance of these mechanisms to the age-related increase in apnea. To achieve these goals, we will combine descriptive and interventional human studies with invasive central nervous system measurements and manipulations in rats using a model of sleep-related respiratory instability which we have characterized. We will focus our attention on the pedunculopontine tegmental nucleus (PPT), the putative site of the burst generator responsible brainstem phasic events detectable as PGO waves. We will manipulate BPE expression in two directions: 1) we will augment expression by acoustic stimulation and sleep deprivation in man and rat and by microinjection of cholinergic agonists into PPT in the rat; and 2) we will reduce expression by electrolytic lesions of the PPT in the rat. These manipulations in old and young patients, controls, and rats will provide a comprehensive approach to define the mechanisms and

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importance of brainstem phasic event-induced respiratory instability in aging. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket Project Title: Sleep Apnea in Elderly Male Twins Principal Investigator & Institution: Carmelli, Dorit; Sr. Biostatistician/Epidemiologist; Sri International 333 Ravenswood Ave Menlo Park, Ca 94025 Timing: Fiscal Year 2000; Project Start 1-AUG-1998; Project End 1-JUL2002 Summary: The contribution of genetic factors to sleep disorders has been demonstrated in twin and family studies, and further understanding of the genetic underpinning of sleep disorders is considered an important area of research. Many of the suggested risk factors for sleep apnea (e.g., craniofacial morphology, obesity) have genetic determinants. However, a formal genetic analysis of these anatomical risk factors with sleeprecorded physiological measurements has not so far been conducted. The objective of the proposed study is to conduct such an analysis in a wellcharacterized U.S. population-based registry of elderly male twins who have been successfully followed for the past 30 years. Specifically, we propose: (1) to recruit a subsample of 150 pairs from the NAS-NRC World War II Twin Registry in which at least one of the twin brothers reported sleep apnea symptoms and a subsample of 30 control pairs in which both twins reported no symptoms; (2) monitor the subgroup of 180 twin pairs with overnight sleep recording; (3) collect on these subjects anthropometric measurements of weight, height, neck circumference, and craniofacial morphology; and (4) collect blood samples for determination of zygosity and DNA extraction for future molecular studies. The twin design is most powerful for estimating the genetic and/or environmental overlap between physiological measurements such as sleep-recorded disordered breathing, obesity, and craniofacial morphology. We have chosen to focus on an elderly male twin sample for which a wealth of data relevant to this study has been previously collected. Twin pair concordance or discordance for monitored sleep-disordered breathing will allow the full characterization of genetic/familial and individual environmental factors associated with the expression and severity of this condition. The investigators of this study represent a multidisciplinary team who have the knowledge and experience to conduct a comprehensive genetic study of sleep-disordered breathing in the only existing and well-studied U.S. twin registry of elderly men. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket

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E-Journals: PubMed Central20 PubMed Central (PMC) is a digital archive of life sciences journal literature developed and managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).21 Access to this growing archive of e-journals is free and unrestricted.22 To search, go to http://www.pubmedcentral.nih.gov/index.html#search, and type “sleep apnea” (or synonyms) into the search box. This search gives you access to full-text articles. The following is a sample of items found for sleep apnea in the PubMed Central database: Obstructive sleep apnea and vascular disease by Paola Lanfranchi and Virend A. Somers; 2001 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=64798

The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign references. It is also free to the public.23 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals. To generate your own bibliography of studies dealing with sleep apnea, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type Adapted from the National Library of Medicine: http://www.pubmedcentral.nih.gov/about/intro.html. 21 With pubmed central, ncbi is taking the lead in preservation and maintenance of open access to electronic literature, just as nlm has done for decades with printed biomedical literature. Pubmed central aims to become a world-class library of the digital age. 22 the value of pubmed central, in addition to its role as an archive, lies the availability of data from diverse sources stored in a common format in a single repository. Many journals already have online publishing operations, and there is a growing tendency to publish material online only, to the exclusion of print. 23 PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication. 20

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“sleep apnea” (or synonyms) into the search box, and click “Go.” The following is the type of output you can expect from PubMed for “sleep apnea” (hyperlinks lead to article summaries): The effects of transcutaneous electrical stimulation during wakefulness and sleep in patients with obstructive sleep apnea. Author(s): Edmonds LC, Daniels BK, Stanson AW, Sheedy PF 3rd, Shepard JW Jr. Source: Am Rev Respir Dis. 1992 October; 146(4): 1030-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1416392&dopt=Abstract Ventilatory dynamics of transient arousal in patients with obstructive sleep apnea. Author(s): Khoo MC, Shin JJ, Asyali MH, Kim TS, Berry RB. Source: Respiration Physiology. 1998 June; 112(3): 291-303. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9749952&dopt=Abstract

Vocabulary Builder Adenosine: A nucleoside that is composed of adenine and d-ribose. Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. [NIH] Agonist: In anatomy, a prime mover. In pharmacology, a drug that has affinity for and stimulates physiologic activity at cell receptors normally stimulated by naturally occurring substances. [EU] Allergen: A antigenic substance capable of producing immediate-type hypersensitivity (allergy). [EU] Anatomical: Pertaining to anatomy, or to the structure of the organism. [EU] Anesthesiology: A specialty concerned with the study of anesthetics and anesthesia. [NIH] Antiepileptic: An agent that combats epilepsy. [EU] Artery: Vessel-carrying blood from the heart to various parts of the body. [NIH]

Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] BMI: Body mass index; the body weight in kilograms divided by the height in meters squared (wt/ht2) used as a practical marker to assess obesity; often

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referred to as the Quetelet Index. An indicator of optimal weight for health and different from lean mass or percent body fat calculations because it only considers height and weight. [NIH] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Cholinergic: Resembling acetylcholine in pharmacological stimulated by or releasing acetylcholine or a related compound. [EU]

action;

Dementia: An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness. [NIH] Diphenhydramine: A histamine H1 antagonist used as an antiemetic, antitussive, for dermatoses and pruritus, for hypersensitivity reactions, as a hypnotic, an antiparkinson, and as an ingredient in common cold preparations. It has some undesired antimuscarinic and sedative effects. [NIH] Fluoroscopy: screen. [NIH]

Production of an image when x-rays strike a fluorescent

Homeostasis: A tendency to stability in the normal body states (internal environment) of the organism. It is achieved by a system of control mechanisms activated by negative feedback; e.g. a high level of carbon dioxide in extracellular fluid triggers increased pulmonary ventilation, which in turn causes a decrease in carbon dioxide concentration. [EU] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Localization: 1. the determination of the site or place of any process or lesion. 2. restriction to a circumscribed or limited area. 3. prelocalization. [EU] Locomotor: Of or pertaining to locomotion; pertaining to or affecting the locomotive apparatus of the body. [EU] Mandible: The largest and strongest bone of the face constituting the lower jaw. It supports the lower teeth. [NIH] Microdialysis: A technique for measuring extracellular concentrations of substances in tissues, usually in vivo, by means of a small probe equipped with a semipermeable membrane. Substances may also be introduced into the extracellular space through the membrane. [NIH] Mutagenesis: Process of generating genetic mutations. It may occur spontaneously or be induced by mutagens. [NIH]

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Nephrology: A subspecialty of internal medicine concerned with the anatomy, physiology, and pathology of the kidney. [NIH] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neuroanatomy: Study of the anatomy of the nervous system as a specialty or discipline. [NIH] Neurology: A medical specialty concerned with the study of the structures, functions, and diseases of the nervous system. [NIH] Neuromuscular: Pertaining to muscles and nerves. [EU] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Neurons: The basic cellular units of nervous tissue. Each neuron consists of a body, an axon, and dendrites. Their purpose is to receive, conduct, and transmit impulses in the nervous system. [NIH] Neurophysiology: The scientific discipline concerned with the physiology of the nervous system. [NIH] Neurosciences: The scientific disciplines concerned with the embryology, anatomy, physiology, biochemistry, pharmacology, etc., of the nervous sytem. [NIH] Osteotomy: The surgical cutting of a bone. [EU] Oximetry: The determination of oxygen-hemoglobin saturation of blood either by withdrawing a sample and passing it through a classical photoelectric oximeter or by electrodes attached to some translucent part of the body like finger, earlobe, or skin fold. It includes non-invasive oxygen monitoring by pulse oximetry. [NIH] Oxygenation: To provide with oxygen. [NIH] Phenotype: The entire physical, biochemical, and physiological makeup of an individual as determined by his or her genes and by the environment in the broad sense. [NIH] Phototransduction: The transducing of light energy to afferent nerve impulses, such as takes place in the retinal rods and cones. After light photons are absorbed by the photopigments, the signal is transmitted to the outer segment membrane by the cyclic GMP second messenger system, where it closes the sodium channels. This channel gating ultimately generates an action potential in the inner retina. [NIH] Posterior: Situated in back of, or in the back part of, or affecting the back or dorsal surface of the body. In lower animals, it refers to the caudal end of the body. [EU] Proxy: A person authorized to decide or act for another person, for example,

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a person having durable power of attorney. [NIH] Puberty: The period during which the secondary sex characteristics begin to develop and the capability of sexual reproduction is attained. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Rheumatology: A subspecialty of internal medicine concerned with the study of inflammatory or degenerative processes and metabolic derangement of connective tissue structures which pertain to a variety of musculoskeletal disorders, such as arthritis. [NIH] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Systemic: Relating to a process that affects the body generally; in this instance, the way in which blood is supplied through the aorta to all body organs except the lungs. [NIH] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Transcutaneous: Transdermal. [EU] Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU] Valerian: Valeriana officinale, an ancient, sedative herb of the large family Valerianaceae. The roots were formerly used to treat hysterias and other neurotic states and are presently used to treat sleep disorders. [NIH] Wakefulness: A state in which there is an enhanced potential for sensitivity and an efficient responsiveness to external stimuli. [NIH] Xerostomia: Dryness of the mouth from salivary gland dysfunction, as in Sjögren's syndrome. [EU]

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CHAPTER 5. PATENTS ON SLEEP APNEA Overview You can learn about innovations relating to sleep apnea by reading recent patents and patent applications. Patents can be physical innovations (e.g. chemicals, pharmaceuticals, medical equipment) or processes (e.g. treatments or diagnostic procedures). The United States Patent and Trademark Office defines a patent as a grant of a property right to the inventor, issued by the Patent and Trademark Office.24 Patents, therefore, are intellectual property. For the United States, the term of a new patent is 20 years from the date when the patent application was filed. If the inventor wishes to receive economic benefits, it is likely that the invention will become commercially available to patients with sleep apnea within 20 years of the initial filing. It is important to understand, therefore, that an inventor’s patent does not indicate that a product or service is or will be commercially available to patients with sleep apnea. The patent implies only that the inventor has “the right to exclude others from making, using, offering for sale, or selling” the invention in the United States. While this relates to U.S. patents, similar rules govern foreign patents. In this chapter, we show you how to locate information on patents and their inventors. If you find a patent that is particularly interesting to you, contact the inventor or the assignee for further information.

24Adapted

from The U. S. Patent and Trademark Office: http://www.uspto.gov/web/offices/pac/doc/general/whatis.htm.

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Patents on Sleep Apnea By performing a patent search focusing on sleep apnea, you can obtain information such as the title of the invention, the names of the inventor(s), the assignee(s) or the company that owns or controls the patent, a short abstract that summarizes the patent, and a few excerpts from the description of the patent. The abstract of a patent tends to be more technical in nature, while the description is often written for the public. Full patent descriptions contain much more information than is presented here (e.g. claims, references, figures, diagrams, etc.). We will tell you how to obtain this information later in the chapter. The following is an example of the type of information that you can expect to obtain from a patent search on sleep apnea: Integrated sleep apnea screening system Inventor(s): Hadas; Noam (Tel Aviv, IL) Assignee(s): S.L.P. Ltd. (Tel Aviv, IR) Patent Number: 6,368,287 Date filed: June 14, 2000 Abstract: This invention is a method, and device, suitable for use without professional medical supervision, for screening for sleep apnea. All elements of the device are housed in a small, flexible, plastic housing which is placed on the user's philtrum. A thermistor acquires data describing the respiratory pattern. A processor analyzes the respiratory pattern in real time and outputs a study result, describing the occurrence of any episodes of apnea, to a non-volatile colored marker on the plastic housing. A flashing LED display informs the user when placement of the device is appropriate. A lithium battery, which powers all elements of the device, is activated by a pull-tab removed by the user. Excerpt(s): The present invention relates to medical monitoring devices and, in particular, it relates to a monitor for the detection of sleep apnea. ... It is known that sleep related breathing disorders are a common medical problem. Two common sleep pathology syndromes are Obstructive Sleep Apnea (OSA) and Central Sleep Apnea (CSA). ... Obstructive Sleep Apnea (OSA) occurs when the upper airway (the nose, mouth or throat) become obstructed in some way during sleep, and is usually accompanied by a decrease in the oxygen saturation of the blood (SpO.sub.2). Snoring indicates an intermittent obstruction, which at times may become complete, stopping air flow. Apnea (the cessation of breathing) may occur hundreds of times during one night of sleep, leading to severe sleep disruption and excessive daytime somnolence. As

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such, the patient may easily fall asleep during working hours, such as when the patient is driving a car or a truck. Many commercial trucking firms thus require that their drivers undergo sleep studies to determine if they suffer from OSA. Furthermore, OSA may cause heart problems such as cardiac arrhythmias and Cor Pulmonale. Web site: http://www.delphion.com/details?pn=US06368287__ Method and apparatus for optimizing the continuous positive airway pressure for treating obstructive sleep apnea Inventor(s): Rapoport; David M. (New York, NY), Norman; Robert G. (New Windsor, NY), Gruenke; Roger A. (Overland Park, KS) Assignee(s): New York University (New York, NY), Puritan Bennett Corporation (St. Louis, MI) Patent Number: 6,299,581 Date filed: May 10, 1996 Abstract: In the treatment of obstructive sleep apnea, a method and apparatus are disclosed for optimizing the controlled positive pressure to minimize the flow of air from a flow generator while still ensuring that flow limitation in the patient's airway does not occur. In particular, the invention relates to a breathing device and method of use to adjust a controlled positive pressure to the airway of a patient by detecting flow limitation from analysis of an inspiratory flow waveform. Once the presence of flow limitation has been analyzed, the system determines an action to take for adjustment of the controlled positive pressure. The pressure setting is raised, lowered or maintained depending on whether flow limitation has been detected and on the previous actions taken by the system. The preferred breathing apparatus consists of a flow generator, a flow sensor, an analog to digital converter, a microprocessor, and a pressure controller, a patient supply hose, a nasal fitting, and, optionally, a pressure transducer. Using the method of the present invention, the microprocessor adjusts the air pressure in the patient supply hose when flow limitation is detected in the airway of the patient. Excerpt(s): This invention relates to a method and apparatus for adjusting the positive airway pressure of a patient to an optimum value in the treatment of obstructive sleep apnea, and more particularly to a breathing device which maintains constant positive airway pressure and method of use which analyzes an inspiratory flow waveform to titrate such a pressure value. ... Obstructive sleep apnea syndrome (OSAS) is a well recognized disorder which may affect as much as 1-5% of the adult population. OSAS is one of the most common causes of excessive

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daytime somnolence. OSAS is most frequent in obese males, and it is the single most frequent reason for referral to sleep disorder clinics. ... Since 1981, continuous positive airway pressure (CPAP) applied by a tight fitting nasal mask worn during sleep has evolved as the most effective treatment for this disorder, and is now the standard of care. The availability of this non-invasive form of therapy has resulted in extensive publicity for apnea and the appearance of large numbers of patients who previously may have avoided the medical establishment because of the fear of tracheostomy. Increasing the comfort of the system, which is partially determined by minimizing the necessary nasal pressure, has been a major goal of research aimed at improving patient compliance with therapy. Various systems for the treatment of obstructive sleep apnea are disclosed, for example, in "Reversal of Obstructive Sleep Apnea by Continuous Positive Airway Pressure Applied Through The Nares", Sullivan et al, Lancet, 1981, 1:862-865; and "Reversal Of The `Pickwickian Syndrome` By Long-Term Use of Nocturnal Nasal-Airway Pressure"; Rapaport et al., New England Journal of Medicine, Oct. 7, 1982. Similarly, the article "Induction of upper airway occlusion in sleeping individuals with subatmospheric nasal pressure", Schwartz et al, Journal of Applied Physiology, 1988, 64, pp. 535-542, discusses various polysomnographic techniques. Each of these articles are hereby incorporated herein by reference. Web site: http://www.delphion.com/details?pn=US06299581__ Sleep apnea headgear Inventor(s): Blaszczykiewicz; Thomas J. (Hamburg, NY), Holfoth; David E. (Lewiston, NY) Assignee(s): Accu-Med Technologies, Inc. (Buffalo, NY) Patent Number: 6,269,814 Date filed: June 14, 2000 Abstract: A sleep apnea headgear for positioning breathing apparatus on the head of a user includes a T-shaped rear portion and a T-shaped front portion each having latitudinal and longitudinal legs and a chinstrap made from a stretchable, breathable, laminated neoprene substitute having an inner surface of LYCRA.RTM. fabric and an outer surface of UBL loop material. The rear portion includes a hook-and-loop fastener at opposite lateral segments of its latitudinal leg for securing opposite ends of the chinstrap to the outer surface of the latitudinal leg, and a hook pad on the inner surface at each lateral end of the latitudinal leg. The front portion includes a slot opening at each lateral end of its latitudinal leg

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sized for receiving a corresponding lateral end of the latitudinal leg of the rear portion, whereby the hook pads may be attached directly to the outer loop surface of the latitudinal leg of the front portion. The front portion preferably includes its own hook pad on its inner surface at a distal end of the longitudinal leg for connecting to the outer surface loop material of the longitudinal leg of the rear portion. The assembled headgear is free of hook and/or loop pads openly facing the head or skin, and is also free of chemical adhesives. Excerpt(s): The present invention relates generally to the field of medical devices, and more particularly to an improved headgear for holding breathing apparatus in position adjacent a face of a person during sleep for treating sleep apnea. ... Applicants are aware of a prior art headgear for sleep apnea treatment apparatus comprising a T-shaped rear portion, a T-shaped front portion releasably attached to the T-shaped rear portion to form a shell or cap for the head, and a chin strap releasably attached to the assembled shell. Two adjustable loops are fixed along an outer surface of a longitudinal leg of the T-shaped front portion for holding an oxygen feeder tube. The various components of the prior art headgear are made from a stretchable layered fabric having an inner layer of lycra, and an outer layer of nylon each adhered to a middle layer of neoprene, with hook-and-loop fastening elements being sewn at various locations for attachment purposes. ... Therefore, it is an object of the present invention to provide an improved headgear for supporting breathing apparatus on the head of a sleep apnea sufferer that is comfortable to wear, durable, easy to adjust, and free of chemical adhesive. Web site: http://www.delphion.com/details?pn=US06269814__ Implantable microstimulation system for treatment of sleep apnea Inventor(s): Richmond; Frances J. R. (South Pasadena, CA), Loeb; Gerald E. (South Pasadena, CA) Assignee(s): Advanced Bionics Corporation (Sylmar, CA) Patent Number: 6,240,316 Date filed: August 6, 1999 Abstract: One or more implantable microminiature electronic devices, termed "microstimulators", are used to treat sleep apnea. The microstimulators are implanted at strategic locations within the patient and are then controlled in a manner so as to stimulate muscle and nerve tissue in a constructive manner which helps open blocked airways. In one embodiment, the microstimulators sense blockage of a patient's airway and provide electrical stimuli in a closed loop fashion to open the airway.

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In another embodiment, at least one microstimulator treats sleep apnea in an open loop fashion by providing electrical stimulation pulses in a rhythm or cycle having a period corresponding approximately to the natural respiratory rhythm of the patient. Such open loop stimulation entrains the patient's respiratory rate to follow the pattern set by the microstimulator so that stimulation is applied to open the airway during a period of inspiration by the patient. The microstimulator devices receive power and programming (control) signals by inductive or RF coupling from an external transmitter, either during actual use by the sleeping patient or during recharging periods in the awake patient. Excerpt(s): The present invention relates to a system and method for treating sleep apnea, and more particularly to a system and method for treatment of obstructive sleep apnea using implantable microstimulators. ... Unfortunately, the muscles that control the airway and the nerves that supply them are, for the most part, located deep in the neck and oropharynx, adjacent to many vital and delicate structures. The present invention describes an approach in which very small electronic devices can be implanted with minimal surgical intervention in order to control these muscles to prevent or interrupt sleep apnea without disturbing the sleeping patient. ... Obstructive sleep apnea (OSA) is characterized by frequent periods of airway occlusion during sleep, with concomitant obstruction of inspiratory airflow, drop in blood oxygen and interruption of sleep when the patient awakes to use voluntary muscle contraction to open the airway and take a few deep breaths. The mechanical locations and structural causes of obstruction are multiple. The most frequent mechanisms include settling of the tongue, uvula, soft palate or other tissues against the airway during the negative pressure associated with inspiration. This may be related to adipose tissue accumulation, lack of muscle tone or inadequate central respiratory drive to the tongue and/or other accessory respiratory muscles around the oropharyngeal airway. Web site: http://www.delphion.com/details?pn=US06240316__ Method of treating snoring and obstructive sleep apnea Inventor(s): Halstrom; Leonard Wayne (Lion's Bay, CA) Assignee(s): Silent Knights Ventures Inc. (Vancouver, CA) Patent Number: 6,161,542 Date filed: July 29, 1999 Abstract: A dentally retained intra-oral appliance worn at night for treatment of snoring and obstructive sleep apnea. The appliance maintains the patient's mandible in an anterior, protruded position to

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prevent obstruction of the pharyngeal airway. The appliance allows a limited degree of lateral movement of the mandible relative to the upper jaw in the protruded position to prevent aggravation of the patient's tempromandibular joint and associated muscles and ligaments. The appliance preferably consists of an upper bite block conforming to the patient's maxillary dentition, a lower bite block conforming to the patient's mandibular dentition, and a connecting assembly secured to the upper and lower bite blocks for adjustably coupling the upper and lower bite blocks together. The invention also relates to a method of treating snoring and obstructive sleep apnea using the dental appliance. Excerpt(s): This application relates to a dentally retained intra-oral appliance worn at night for treatment of snoring and obstructive sleep apnea. The appliance maintains the patient's mandible in an anterior, protruded position to prevent obstruction of the pharyngeal airway. The appliance allows a limited degree of lateral movement of the mandible relative to the upper jaw in the protruded position to prevent aggravation of the tempromandibular joint and associated muscles and ligaments. ... Snoring and obstructive sleep apnea are typically caused by complete or partial obstruction of an individual's pharyngeal airway during sleep. Usually airway obstruction results from the apposition of the rear portion of the tongue or soft palate with the posterior pharyngeal wall. Obstructive sleep apnea is a potentially lethal disorder in which breathing stops during sleep for 10 seconds or more, sometimes up to 300 times per night. Snoring occurs when the pharyngeal airway is partially obstructed, resulting in vibration of the oral tissues during respiration. These sleep disorders tend to become more severe as patients grow older, likely due to a progressive loss of muscle tone in the patient's throat and oral tissues. ... Habitual snoring and sleep apnea have been associated with other potentially serious medical conditions, such as hypertension, ischemic heart disease and strokes. Accordingly, early diagnosis and treatment is recommended. One surgical approach, known as uvulopalatopharyngoplasty, involves removal of a portion of the soft palate to prevent closure of the pharyngeal airway during sleep. However, this operation is not always effective and may result in undesirable complications, such as nasal regurgitation. Web site: http://www.delphion.com/details?pn=US06161542__

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Apparatus for management of sleep apnea Inventor(s): Bourgeois; Ivan (Verviers, BE), Sutton; Richard (London, GB) Assignee(s): Medtronic, Inc. (Minneapolis, MN) Patent Number: 6,126,611 Date filed: January 29, 1999 Abstract: A device for treating sleep apnea comprising means for detecting an apnea event and means responsive to detection of an apnea event for stimulating the heart at a higher rate than the heart's natural rate. Excerpt(s): This invention relates to an apparatus for management of sleep apnea. ... Sleep apnea has been known for some time as a medical syndrome in two generally recognized forms. The first is central sleep apnea, which is associated with the failure of the body to automatically generate the neuro-muscular stimulation necessary to initiate and control a respiratory cycle at the proper time. Work associated with employing electrical stimulation to treat this condition is discussed in Glenn, "Diaphragm Pacing: Present Status", Pace, V. I, pp 357-370 (JulySeptember 1978). ... The second sleep apnea syndrome is known as obstructive sleep apnea. Ordinarily, the contraction of the dilator muscles of the upper airways (nose and pharynx) allows their patency at the time of inspiration. In obstructive sleep apnea, the obstruction of the airways results in a disequilibrium between the forces which tend to their collapse (negative inspiratory transpharyngeal pressure gradient) and those which contribute to their opening (muscle contraction). The mechanisms which underlie the triggering of obstructive apnea include a reduction in the size of the superior airways, an increase in their compliance, and a reduction in the activity of the dilator muscles. The dilator muscles are intimately linked to the respiratory muscles and these muscles respond in a similar manner to a stimulation or a depression of the respiratory centre. The ventilatory fluctuations observed during sleep (alternately hyper and hypo ventilation of periodic respiration) thus favour an instability of the superior airways and the occurrence of oropharyngeal obstruction. The respiratory activation of the genioglossus has been particularly noted to be ineffective during sleep. The cardiovascular consequences of apnea include disorders of cardiac rhythm (bradycardia, auriculoventricular block, ventricular extrasystoles, tachyarrhythmias) and hemodynamic (pulmonary and systemic hypertension). This results in a stimulatory effect on the autonomic nervous system. The electroencephalographic awakening is responsible for the fragmentation of sleep. The syndrome is therefore associated with an increased

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morbidity (the consequence cardiovascular complications).

of

diurnal

hypersomnolence

and

Web site: http://www.delphion.com/details?pn=US06126611__ Humidifier sleep apnea treatment apparatus Inventor(s): Daniell; Michael Grenfell (Auckland, NZ), Gradon; Lewis George (Auckland, NZ) Assignee(s): Fisher & Paykel Limited (Auckland, NZ) Patent Number: 6,050,260 Date filed: December 1, 1997 Abstract: Apparatus and method of treating OSA (Obstructve Sleep Apnea) are disclosed wherein a Positive Airway Pressure device is utilized to provide a gases supply which is then passed through a humidifier. As the amount of water vapor generated by the humidifier is very low at start up (typically the humidifier comprises a water container on a heating plate) the pressure of gases supplied by the apparatus are controlled so that the humidity of the gases supplied to a patient are always at the maximum of the capability of the humidifier to humidify that air flow. Excerpt(s): This invention relates to healthcare apparatus and in paroular, though not solely to humidified Positive Airway Pressure (PAP) apparatus used in the treatment of Obstructive Sleep Apnea (OSA) and a method of controlling such apparatus. ... Accordingly, the present invention provides a humidified breathing assistance system in which the patient is provided with beneficially humidified gases during the period when the humidifier is warming up and also when the humidifier is running (and at its set temperature). In addition, the humidity of the gases supplied to the patient are maintained throughout both of these periods within the limits of the humidifiers ability to humidify those gases to the benefit of the patient making it possible to deliver gases orally to treat disorders such as Obstructive Sleep Apnea. This is extremely beneficial to the patient as even a flow of unhumidified gases or insufficiently humidified gases to the patient for a short duration of time (for example 10 minutes) cm cause detrimental swelling of the nasal passages and even greater discomfort if delivered orally. Web site: http://www.delphion.com/details?pn=US06050260__

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Support pillow for pregnant women, obese people, people who suffer from various forms of back pain and people who suffer from sleep apnea, snoring and sciatica Inventor(s): Friedman; Loretta (9269 Shore Rd., Apt. B1, Brooklyn, NY 11209) Assignee(s): none reported Patent Number: 6,044,505 Date filed: August 27, 1998 Abstract: A pillow (10) for pregnant, over weight, back-pain suffering, sleep apnea suffering, and sciatica suffering persons lying in a prone position, is provided. The pillow has an aperture (90) extending through it, and is sized for receipt of a portion of the abdomen of the user. The aperture is defined by at least first (20), second (30) and third (40) support structures, and is of a substantially uniform thickness (T). The first support structure extends substantially traversely across the lower-chest and upper-abdominal regions of the user, the second support structure extends along a first side-abdominal region of the user to end proximate to the person's pelvic region, and the third support structure extends along a second side-abdominal region of the user to also end proximate to the pelvic region of the user. Excerpt(s): The symptoms of bad health and poor physical condition are the end result of the body's inability to function properly. Currently, if you are a pregnant woman, an obese person, an athlete, an individual who suffers from back pain, sleep apnea, snoring or sciatica, your ability to lay on your stomach is greatly diminished. The posture that is assumed during pregnancy, or in the obese, creates hyper-extension in the low back region, causing jamming of the thoracolumbar facets, posterior narrowing of the disc space and myospasms in the erector spinae muscles. Sciatica, and lower back pain, are usually caused by misalignment of bones, nerve interference and vertebral subluxation. ... Accordingly, it would be desirable to provide a pillow that supports pregnant women, obese, back-pain suffering, sleep apnea suffering and sciatica suffering people, while they are lying in a prone position, which pillow simplifies past constructions of such pillows in such a way as to make them more accessible for regular use in any and all locations. ... In accordance with the invention, a support pillow for a pregnant, over weight, back-pain suffering, sleep apnea suffering, and sciatica suffering person lying in a prone position, is provided. The pillow has an aperture extending through it, and sized for receipt of a portion of the abdomen of the person. The aperture is defined by at least first, second and third support structures, and is of a substantially uniform thickness. The first

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support structure extending substantially traversely across the lowerchest and upper-abdominal regions of the person, the second support structure extending along a first side-abdominal region of the person to end proximate to the person's pelvic region, and the third support structure extending along a second side-abdominal region of the person to also end proximate to the pelvic region of the person. Web site: http://www.delphion.com/details?pn=US06044505__ Dental appliance for treatment of snoring and obstructive sleep apnea Inventor(s): Halstrom; Leonard Wayne (Lions Bay, CA) Assignee(s): Silent Knights Ventures Inc. (CA) Patent Number: 6,041,784 Date filed: November 8, 1995 Abstract: A dentally retained intra-oral appliance worn at night for treatment of snoring and obstructive sleep apnea. The appliance maintains the patient's mandible in an anterior, protruded position to prevent obstruction of the pharyngeal airway. The appliance allows a limited degree of lateral movement of the mandible relative to the upper jaw in the protruded position to prevent aggravation of the patient's tempromandibular joint and associated muscles and ligaments. The appliance preferably consists of an upper bite block conforming to the patient's maxillary dentition, a lower bite block conforming to the patient's mandibular dentition, and a connecting assembly secured to an anterior region of the upper and lower bite blocks for adjustably coupling the upper and lower bite blocks together. Excerpt(s): This application relates to a dentally retained intra-oral appliance worn at night for treatment of snoring and obstructive sleep apnea. The appliance maintains the patient's mandible in an anterior, protruded position to prevent obstruction of the pharyngeal airway. The appliance allows a limited degree of lateral movement of the mandible relative to the upper jaw in the protruded position to prevent aggravation of the tempromandibular joint and associated muscles and ligaments. ... Snoring and obstructive sleep apnea are typically caused by complete or partial obstruction of an individual's pharyngeal airway during sleep. Usually airway obstruction results from the apposition of the rear portion of the tongue or soft palate with the posterior pharyngeal wall. Obstructive sleep apnea is a potentially lethal disorder in which breathing stops during sleep for 10 seconds or more, sometimes up to 300 times per night. Snoring occurs when the pharyngeal airway is partially obstructed, resulting in vibration of the oral tissues during respiration.

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These sleep disorders tend to become more severe as patients grow older, likely due to a progressive loss of muscle tone in the patient's throat and oral tissues. ... Habitual snoring and sleep apnea have been associated with other potentially serious medical conditions, such as hypertension, ischemic heart disease and strokes. Accordingly, early diagnosis and treatment is recommended. One surgical approach, known as uvulopalatopharyngoplasty, involves removal of a portion of the soft palate to prevent closure of the pharyngeal airway during sleep. However, this operation is not always effective and may result in undesirable complications, such as nasal regurgitation. Web site: http://www.delphion.com/details?pn=US06041784__ Methods and devices for the treatment of airway obstruction, sleep apnea and snoring Inventor(s): Sohn; Ze'ev (Modiin, IL), DeRowe; Ari (Moshav Salit, IL) Assignee(s): Influence Medical Technologies, Ltd. (Herzelia B., IL) Patent Number: 5,988,171 Date filed: June 26, 1997 Abstract: Methods and devices for the treatment of airway obstruction, sleep apnea and snoring, by tongue suspension for treatment of airway obstruction in a human subject, including the steps of inserting a bone anchor into the mandible of the subject, and fastening at least one suture to the bone anchor to suspend the tongue to the mandible. Preferably, the bone anchors used are surgical screws. The sutures are fastened to at least one surgical screw, and are preferably inserted in positions adjacent to the mandible's midline. Alternatively, suspension of the hyoid bone is accomplished. Excerpt(s): The present invention relates to surgical methods and devices, and more specifically, to methods and devices for the treatment of upper airway obstruction, obstructive sleep apnea and/or snoring. ... Obstructive sleep apnea (OSA) is a potentially life-threatening disorder, which affects up to 2-4% of the adult population. OSA, it has been determined, is associated with snoring, which affects 20% of adults. Both of these conditions can be triggered when the base of the tongue collapses during sleep, so that it partly obstructs the airway. ... European patent application EP 0 743 076 A1, the teachings of which are incorporated herein by reference, describes an apparatus for treatment of sleep apnea by electrical stimulation of a patient's hypoglossal nerve. An electrode is positioned in electrical contact with a portion of the nerve, and a stimulating electrical current is applied to the electrode. The electrical

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current thus stimulates muscles of the upper airway, so as to cause contralateral extension of the patient's tongue and/or to increase the volume of the oropharynx. The apparatus requires, however, that the electrode be maintained in wired connection with an electronic nerve stimulator unit located outside the body. It also requires accurate and consistent contact with the nerve so as to avoid unwanted tongue movements. Web site: http://www.delphion.com/details?pn=US05988171__ Method of inhibiting sleep apnea Inventor(s): Winokur; Andrew (Merion, PA), Pack; Allan I. (Glen Mills, PA) Assignee(s): Gruenenthal GmbH (Aachen, DE) Patent Number: 5,968,932 Date filed: August 20, 1998 Abstract: A method of inhibiting sleep apnea is disclosed comprising administering an effective amount of 6-methyl-5-oxo-3thiomorpholinylcarbonyl-L-histidine-L-prolinamide or a pharmaceutically acceptable acid addition salt thereof. Excerpt(s): Obstructive sleep apnea is a serious disorder in which normal breathing during sleep is interrupted for periods of 10 seconds to a minute or even longer as a result of obstruction of the upper airway. Sleep apnea syndrome also involves decreases in blood oxygen levels. To resume breathing and restore blood oxygen, the subject must wake up. Thus, normal sleep is interrupted. Sleep apnea may be classified as mild, five to 25 events per hour; moderate, 25 to 40 events per hour; or severe more than 40 events per hour. Persons with sleep apnea are prevented from attaining essential rest and suffer from chronic sleep fragmentation/deprivation occurring as a consequence of frequent nightly arousals brought about by critical decreases in blood oxygen levels secondary to disruptions in respiration. It has been estimated that from 1 to 3 percent of the adult population of North America suffers from sleep apnea. Sleep apnea has been associated with increased risk of heart attacks or strokes. Sleep apnea sufferers also frequently experience excessive daytime sleepiness which can result in them suddenly falling asleep while engaged in activities requiring alertness, such as driving a car. ... Although consideration has been given to the possibility of treating sleep apnea with drugs such as medroxyprogesterone, protriptyline, acetazolamide, nicotine or even strychnine, there is currently no satisfactory pharmacotherapy for sleep apnea. Instead, sleep apnea is

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commonly treated either by throat surgery designed to maintain airway patency during sleep or with mechanical devices such as dental retainers. Surgery to remove tissues thought to contribute to obstruction of the airway is effective in only about 50 to 60% of patients. Cases of obstructive sleep apnea are generally managed with apparatus known as a continuous positive airway pressure (CPAP) machine. The CPAP comprises a mask that fits over the nose of the patient. The mask has an hose attached to it and a small box with a fan that blows air through the hose and into the nasal passages. The CPAP machine provides positive air pressure in the patient airway in order to prevent collapse of the airway which initiates a sleep apnea episode. While the CPAP is generally effective if used consistently, it is also expensive, cumbersome and highly inconvenient, thereby giving rise to significant patient compliance problems. ... Thus, there has remained a substantial need for improved methods of treating obstructive sleep apnea, and particularly for an effective pharmacotherapy for treating this disorder. Web site: http://www.delphion.com/details?pn=US05968932__ Sleep apnea treatment apparatus with minimum leakage assurance circuit Inventor(s): Estes; Mark C. (Irwin, PA), Cattano; Janice M. (Gibsonia, PA) Assignee(s): Respironics, Inc. (Pittsburgh, PA) Patent Number: 5,901,704 Date filed: May 13, 1996 Abstract: Improved methodology and apparatus for the clinical study and treatment of sleep apnea which incorporates one or more of the following features: (1) application of mono-level, alternating high and low level, or variable positive airway pressure generally within the airway of the patient with the mono-level, high and low level, or variable airway pressure generally being coordinated with and/or responsive to the spontaneous respiration of the patient, (2) usage of adjustably programmable pressure ramp circuitry capable of producing multiple pressure ramp cycles of predetermined duration and pattern whereby the ramp cycles may be customized to accommodate the specific needs of an individual sleep apnea patient so as to ease the patient's transition from wakefulness to sleep, (3) remote control or patient-sensed operation of the apparatus, (4) employment of safety circuitry, reset circuitry and minimum system leak assurance circuitry, controls and methods, and (5) utilization of clinical control circuitry whereby sleep disorder data may

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be compiled and appropriate therapy implemented during a one-night sleep study. Excerpt(s): The present invention relates generally to methodology and apparatus for treatment of sleep apnea and, more particularly, to monolevel, bi-level and variable positive airway pressure apparatus, as well as feedback type versions thereof, including circuitry for enabling a patient to selectively actuate one or more pressure ramp cycles wherein, during each ramp cycle, available airway pressure increases with time from a predetermined minimum pressure value to a prescription pressure, thereby facilitating the patient's transition from a waking to a sleeping state. ... The sleep apnea syndrome afflicts an estimated 1% to 5% of the general population and is due to episodic upper airway obstruction during sleep. Those afflicted with sleep apnea experience sleep fragmentation and intermittent, complete or nearly complete cessation of ventilation during sleep with potentially severe degrees of oxyhemoglobin desaturation. These features may be translated clinically into extreme daytime sleepiness, cardiac arrhythmias, pullman-artery hypertension, congestive heart failure and/or cognitive dysfunction. Other sequelae of sleep apnea include right ventricular dysfunction with cor pulmonale, carbon dioxide retention during wakefulness as well as during sleep, and continuous reduced arterial oxygen tension. Hypersomnolent sleep apnea patients may be at risk for excessive mortality from these factors as well as by an elevated risk for accidents while driving and/or operating potentially dangerous equipment. ... Although details of the pathogenesis of upper airway obstruction in sleep apnea patients have not been fully defined, it is generally accepted that the mechanism includes either anatomic or functional abnormalities of the upper airway which result in increased air flow resistances. Such abnormalities may include narrowing of the upper airway due to suction forces evolved during inspiration, the effect of gravity pulling the tongue back to appose the pharyngeal wall, and/or insufficient muscle tone in the upper airway dilator muscles. It has also been hypothesized that a mechanism responsible for the known association between obesity and sleep apnea is excessive soft tissue in the anterior and lateral neck which applies sufficient pressure on internal structures to narrow the airway. Web site: http://www.delphion.com/details?pn=US05901704__

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Appliance for preventing snoring and obstructive sleep apnea Inventor(s): Anderson; Clarence D. (6526 E. Holly Dr., Mesa, AZ 85215) Assignee(s): none reported Patent Number: 5,893,365 Date filed: July 28, 1997 Abstract: An appliance for preventing snoring and sleep apnea includes a headgear and a mouthpiece. The headgear includes an adjustable headband encircling the upper portion of a user's head at the forehead; an adjustable chin strap passing over the crown of the head and under the chin of the user to maintain the user's mouth closed about the mouthpiece; a back strap passing from the forehead over the crown of the head and down the back of the user; a means secured to the rear end of the back strap for exerting a restraining force on the back strap and the upper portion of the headgear to keep the user's head from slouching forward; and an object secured to the rear end of the back strap for making it uncomfortable for the user to lie on his/her back. The mouthpiece includes a thin, flexible front sheet extending across the front of the user's mouth in front of the user's teeth to prevent breathing through the mouth and a thin, flexible back tab extending from an inner upper portion of the flexible sheet to behind the user's lower front teeth for pulling the user's lower jaw forward. Excerpt(s): The present invention relates to an appliance for preventing snoring and obstructive sleep apnea, and in particular, to an appliance which utilizes a headgear and mouthpiece that function as a unit to provide the necessary relief from snoring and obstructive sleep apnea. ... The following conditions have been found to increase the problem of snoring and obstructive sleep apnea. Obesity further constricts the airway, increases the work of breathing and further compounds the problem. Temporary swelling caused by hay fever, inflamed sinuses, etc, also narrow the air passages and cause snoring in a person normally free from that affliction. However, the use of antihistamines promotes drying of the mucous membranes and further promotes vibration in the relaxed structures. Smoking, two byproducts of which are carbon monoxide and formaldehyde, tends to stimulate snoring by drying or irritating the air passages, inducing hypoxemia, and even causing the swallowing muscles to spasm. When an afflicted person uses central nervous system depressants, such as alcoholic beverages or tranquilizers before retiring, it has been found that the tendency to snore is exacerbated. ... As socially unattractive as snoring may be, sleep apnea, which frequently accompanies snoring, is much more dangerous. In some cases, the relaxed tissues of the airway may so effectively seal off the passage of air

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to the lungs as to completely prevent inspiration. Persons suffering from this problem may actually stop breathing 30 to 300 times per night for periods of ten seconds to two minutes (three minutes may be fatal). Consequently, such persons spend as much half of their sleep time with abnormally low blood oxygen levels. Such persons resume normal breathing, albeit briefly, when they wake into a lighter sleep stage, causing the relaxed muscles to tense sufficiently to relieve the obstruction. As will be appreciated, persons with obstructive sleep apnea spend an insufficient portion of their nighttime hours in the deep sleep stages that are essential for good rest, awakening unrefreshed and feeling sleepy much of the day. In addition to the above, cardiac arrhythmias may occur during apneic episodes that can possibly lead to death in sleep. Web site: http://www.delphion.com/details?pn=US05893365__

Patent Applications on Sleep Apnea As of December 2000, U.S. patent applications are open to public viewing.25 Applications are patent requests which have yet to be granted (the process to achieve a patent can take several years). The following patent applications have been filed since December 2000 relating to sleep apnea: Ventilation interface for sleep apnea therapy Inventor(s): Wood, Thomas J. ; (Waycross, GA) Correspondence: Richard C. Litman; Litman Law Offices LTD.; P.O. Box 15035; Arlington; VA; 22215; US Patent Application Number: 20020059935 Date filed: January 15, 2002 Abstract: The ventilation interface for sleep apnea therapy interfaces a ventilation device to the patient's airways. The ventilation interface includes a pair of nasal inserts made from flexible, resilient silicone which are oval shaped in cross-section and slightly tapered from a base proximal the ventilation supply to the distal tip end. A bead flange is disposed about the exterior of each insert at the distal end of the insert. A bleed port for release of exhaled air is defined through a conical vent projecting normally to the path of the incoming air flow, and continues through a nipple extending to the exterior of the air conduit. In one embodiment, a pair of nasal inserts are integral with a nasal cannula 25

This has been a common practice outside the United States prior to December 2000.

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body, with bleed ports axially aligned with each insert. In another embodiment, each insert is independently connected to a separate, thinwalled, flexible supply line. Excerpt(s): The present invention relates to ventilation devices, and particularly to a ventilation device having a nasal inserts which are inserted into the nostrils and seal against the nostrils without the aid of harnesses, head straps, adhesive tape or other external devices, and having exhalation ports designed to eliminate whistling noises, the ventilation interface having particular utility in various modes of therapy for obstructive sleep apnea. ... Sleep apnea is a potentially lethal affliction in which breathing stops recurrently during sleep. Sleep apnea may be of the obstructive type (sometimes known as the pickwickian syndrome) in which the upper airway is blocked in spite of airflow drive; the central type with decreased respiratory drive; or a mixed type. Breathing may cease for periods long enough to cause or to exacerbate cardiac conditions, and may be accompanied by swallowing of the tongue. Sleep apnea frequently results in fitful periods of both day and night sleeping with drowsiness and exhaustion, leaving the patient physically and mentally debilitated. ... U.S. Pat. Nos. 5,269,296, issued to Landis on Dec. 14, 1993, and U.S. Pat. Nos. 5,477,852 and 5,687,715, issued to Landis et al. on Dec. 26, 1995, and Nov. 18, 1997, respectively, describe CPAP devices for the treatment of sleep apnea with relatively stiff or rigid nasal cannulae or prongs surrounded by inflatable cuffs to retain the cannulae in the nares, but which also may be supplemented by an inflatable head harness to position the cannulae and hold them in place, the two cannulae being joined by a conduit having vent holes to vent exhaled air. U.S. Pat. No. 5,533,506, issued Jul. 9, 1996 to the present inventor, discloses a nasal tube assembly in which the tubes are tapered, frustroconical assemblies with a soft membrane over the distal tip and a washer at the base of the nasal tube to prevent the tubes from falling through a support bar connected to a harness, the nasal tubes forming a positive seal with the inside of the nostrils to prevent the escape of gases. Web site: http://appft1.uspto.gov/netahtml/PTO/search-bool.html

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Method and apparatus for creating afferents to prevent obstructive sleep apnea Inventor(s): Pitts, Walter C. ; (La Quinta, CA) Correspondence: Christie, Parker & Hale, LLP; 350 West Colorado Boulevard; Suite 500; Pasadena; CA; 91105; US Patent Application Number: 20020049479 Date filed: September 17, 2001 Abstract: A method and device for creating an afferent stimulus for preventing obstructive sleep apnea are disclosed. The device includes at least one implantable electrode and a stimulator, of which at least one electrode is implanted in the genioglossus muscle of a patient having obstructive sleep apnea. The electrode is capable of conducting selected electrical stimulation generated by the stimulator, and the system is capable of delivering the selected electrical stimulation during a selected time of day. The electrical stimulation is selected to maintain sufficient muscle tone of the genioglossus muscle to prevent it from obstructing the airway during sleep, preferably at a stimulus intensity low enough to avoid awakening the patient during sleep. Excerpt(s): Obstructive sleep apnea (OSA) is a disorder resulting from an affected individual's upper airway being obstructed or partially obstructed during sleep causing arousals from sleep. In obstructive apnea, the airflow stops, but the effort by the diaphragm continues. The individual stops breathing for many seconds during sleep and may awake repeatedly with a loud snore or gasp for breath. ... There is also a family history of apnea, which may be due to inherited physical craniofacial characteristics, such as retrognathia, which can cause breathing abnormalities, such as snoring, hypopneas, and apneas. Obesity has been associated with sleep apnea because fatty cells infiltrate the throat tissue, which may cause a narrowing of the airways and increase the risk for sleep apnea. While OSA occurs more frequently in overweight men, both genders are affected and even men and women with body mass indexes (BMI) in the range between 25 and 30 suffer from OSA. Contributing factors may include use of alcohol or sedatives before sleep, anatomically narrowed airways, and massively enlarged tonsils and adenoids. Hypertension or pulmonary hypertension with enlarged right ventricle may be present. Persistent low levels of oxygen (hypoxia) cause daytime symptoms such as hypersomnolence, headaches, intellectual deterioration, and cardiac arrhythmias. If the condition is severe enough patients are at risk for stroke and heart attack. ... Historically, treatment of obstructive sleep apnea syndrome initially consisted of avoidance of sedatives or alcohol consumption, and weight

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loss. The objective of treatment is to keep the airway open to prevent apneic episodes during sleep. Weight management (or intentional weight loss) and the avoidance of alcohol and sedatives at bedtime may achieve the desired results in some individuals. If these measures are unsuccessful in stopping sleep apnea, continuous positive airway pressure (CPAP), involving the use of a specially designed mask worn over the nose at night, with air pressure applied through tubing into the airway to keep the airway from collapsing, may be prescribed. Alternatively, mechanical devices such as intra-oral airway dental prostheses, may be used. They are inserted into the mouth at night to keep the jaw forward. Oxygen therapy in select cases may achieve the desired results. Finally, surgery (e.g., uvulopalatopharyngoplasty (UPPP), laser assisted uvuloplasty (LAUP), and somnoplasty) to remove soft palate tissue, or tracheostomy to create an opening in the trachea to bypass the obstructed airway during sleep has been performed on some patients with refractory OSA. Web site: http://appft1.uspto.gov/netahtml/PTO/search-bool.html Oral orthesis to reduce snoring and sleep apnea symptoms Inventor(s): Tielemans, W.M.J. ; (Maaseik, BE) Correspondence: Bierman Muserlian and Lucas; 600 Third Avenue; New York; NY; 10016 Patent Application Number: 20010027793 Date filed: January 11, 2001 Abstract: An oral orthesis for reduction of snoring and sleep apnea symptoms. Excerpt(s): The invention relates to an oral orthesis for reducing snoring and sleep apnea symptoms comprising a maxilla pallatum plate (1) and, attached thereon, fixing means (2) to fix the plate in the oral cavity and a tongue positioning device (3). Snoring results from the blocking of the airway by the tongue causing the vibrations when air is passed through. In serious occasions, the blocking can cause a temporary lack of oxygen supply to the brain and unconsciousness which may be life threatening. ... The disadvantage of the known oral orthesis is that it does not sufficiently prevent the blocking of the airway in all circumstances. The object of the present invention therefor is to provide an improved oral orthesis that better prevents snoring and sleep apnea. Web site: http://appft1.uspto.gov/netahtml/PTO/search-bool.html

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Microprocessor system for the simplified diagnosis of sleep apnea Inventor(s): Lynn, Lawrence A. ; (Columbus, OH), Lynn, Eric N. ; (Columbus, OH) Correspondence: Pillsbury Winthrop LLP; Intellectual Property Group; East Tower, Ninth Floor; 1100 New York Avenue, N.W.; Washington; DC; 20005-3918; US Patent Application Number: 20010018557 Date filed: February 6, 2001 Abstract: A method of evaluating a patient with sleep apnea includes monitoring a patient to produce at least one timed waveform of at least one physiologic parameter, identifying along the waveform a first waveform variation indicative of an apnea, identifying along the waveform a second waveform variation indicative of another apnea, determining the interval intermediate at least one portion of the first waveform variation and at least one portion of the second waveform, and assessing the severity of sleep apnea based on at least the determining. A device for determining the severity of sleep apnea comprises a monitor capable of generating a signal indicative of at least one physiologic parameter and a processor capable of processing the signal, the processor operating to generate a timed waveform of the parameter and to identify a plurality of sequential waveform variations indicative of a corresponding plurality of sequential apneas, the sequential waveform variations having temporal and spatial relationships between the waveform variations and along the waveform, the processor further operating to determine at least one of the temporal and the spatial relationships and displaying the determining so that the determining can be used to assess the severity of sleep apnea. Excerpt(s): Obstructive Sleep Apnea is now recognized as one of the most common disorders in the US. The lower oxygen levels associated with Obstructive Sleep Apnea is now known to be a major cause of cardiovascular morbidity including heart attack and stroke. A crisis exists in the US in that traditional expensive polysomnography cannot be used to identify these patients on a sufficient scale. The situation is analogous to having a disease as common and subtle as insulin dependent diabetes without an inexpensive and widely implementable and simple mechanism to diagnose the disorder (such as exists for diabetes). Millions of patients remain undiagnosed. The development of a diagnostic system which can allow simplified diagnosis of obstructive sleep apnea by the primary care physician is a national healthcare priority of substantial scale. The prevention of hundreds of thousands of annual excess deaths, stroke and heart attacks associated with obstructive sleep apnea through

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simplified recognition of this disorder is the most important purpose of the present invention. These excess deaths are occurring annually in a great part due to the lack of availability of this technology resulting in a vast pool of undiagnosed cases of Sleep Apnea. Despite the fact that obstructive sleep apnea is easily treated, both the patient and the family are often completely unaware of the presence of this dangerous disease, thinking the patient just a "heavy snorer". ... Obstructive sleep apnea often develops insidiously as a patient enters middle age and begins to snore. The major cause is an increase in fat deposition (often age related) in the neck which results in narrowing of the airway. (In fact the probability that a 40 year old has sleep apnea is directly related to his or her neck circumference). When the muscle tone of the upper airway diminishes during sleep and negative pressure associated with inspiration through this somewhat narrow airway results in collapse of the upper airway in a manner analogous to the collapse of a cellophane straw. This results in airway obstruction and, effectively chokes off all air movement. The choking patient (still asleep) begins to struggle and inhales more forcibly, thereby, further lowering upper airway pressure and causing further collapse of the upper airway. During this time, substantially no air movement into the chest occurs and the patient experiences a progressively fall in oxygen (similar to the fall occurring early in drowning). The fall in oxygen produce central nervous system stimulation contributing to hypertension and potential heart and blood vessel injury and finally results in arousal. Upon arousal, increase in airway muscle tone opens the airways and the patient rapidly inhales and ventilates quickly to correct the low oxygen levels. Generally, the arousal is brief and the patient is not aware of the arousal (or of the choking since this occurs during sleep). Once oxygen levels have been restored, the patient begins again to sleep more deeply, upper airway tone again diminishes, the upper airway collapses and the cycle is repeated stressing the heart with low oxygen in a repetitive fashion. Often this repeating cycle over many years eventually results in damage to the heart muscle and/or the coronary arteries. As the patient ages, the consequences of undiagnosed obstructive sleep apnea is often either a progressive decline in heart muscle function (and eventual heart failure) or heart infarction. ... Although this disease commonly affects obese patients, it may occur in patients with any body habitus. Because this disease is so common and because it presents with the subtle and common symptoms of excessive daytime sleepiness, morning headache, and decreasing ability to concentrate during the day, it is critical that an inexpensive technique for accurately diagnosing and treating this disease be developed. Traditionally, this disease has been diagnosed utilizing a complex and expensive multi-channel polysomnogram. This is generally

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performed in a sleep lab and involves the continuous and simultaneous measurement and recording of an encephalogram, electromyogram, extraoculogram, chest wall plethysmogram, electrocardiogram, measurements of nasal and oral air flow, and pulse oximetry. These, and often other, channels are measured simultaneously throughout the night and these complex recordings are then analyzed to determine the presence or absence of sleep apnea. Web site: http://appft1.uspto.gov/netahtml/PTO/search-bool.html Method of treating obstructive sleep apnea using implantable electrodes Inventor(s): Richmond, Francis J.R. ; (South Pasadena, CA), Loeb, Gerald E. ; (South Pasadena, CA) Correspondence: Advanced Bionics Corporation; 12740 San Fernando Road; Sylmar; CA; 91342; US Patent Application Number: 20010010010 Date filed: March 20, 2001 Abstract: Electrodes are implanted at strategic locations within a patient and are then controlled in a manner so as to stimulate muscle and nerve tissue in a constructive manner which helps open blocked airways. In a preferred method, at least one microstimulator treats sleep apnea in an open loop fashion by providing electrical stimulation pulses in a rhythm or cycle having a period corresponding approximately to the natural respiratory rhythm of the patient. Such open loop stimulation entrains the patient's respiratory rate to follow the pattern set by the microstimulator so that stimulation is applied to open the airway during a period of inspiration by the patient. Excerpt(s): The present invention relates to a system and method for treating sleep apnea, and more particularly to a system and method for treatment of obstructive sleep apnea using implantable microstimulators. ... Unfortunately, the muscles that control the airway and the nerves that supply them are, for the most part, located deep in the neck and oropharynx, adjacent to many vital and delicate structures. The present invention describes an approach in which very small electronic devices can be implanted with minimal surgical intervention in order to control these muscles to prevent or interrupt sleep apnea without disturbing the sleeping patient. ... Obstructive sleep apnea (OSA) is characterized by frequent periods of airway occlusion during sleep, with concomitant obstruction of inspiratory airflow, drop in blood oxygen and interruption of sleep when the patient awakes to use voluntary muscle contraction to

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open the airway and take a few deep breaths. The mechanical locations and structural causes of obstruction are multiple. The most frequent mechanisms include settling of the tongue, uvula, soft palate or other tissues against the airway during the negative pressure associated with inspiration. This may be related to adipose tissue accumulation, lack of muscle tone or inadequate central respiratory drive to the tongue and/or other accessory respiratory muscles around the oropharyngeal airway. Web site: http://appft1.uspto.gov/netahtml/PTO/search-bool.html

Keeping Current In order to stay informed about patents and patent applications dealing with sleep apnea, you can access the U.S. Patent Office archive via the Internet at no cost to you. This archive is available at the following Web address: http://www.uspto.gov/main/patents.htm. Under “Services,” click on “Search Patents.” You will see two broad options: (1) Patent Grants, and (2) Patent Applications. To see a list of granted patents, perform the following steps: Under “Patent Grants,” click “Quick Search.” Then, type “sleep apnea” (or synonyms) into the “Term 1” box. After clicking on the search button, scroll down to see the various patents which have been granted to date on sleep apnea. You can also use this procedure to view pending patent applications concerning sleep apnea. Simply go back to the following Web address: http://www.uspto.gov/main/patents.htm. Under “Services,” click on “Search Patents.” Select “Quick Search” under “Patent Applications.” Then proceed with the steps listed above.

Vocabulary Builder Antihistamine: A drug that counteracts the action of histamine. The antihistamines are of two types. The conventional ones, as those used in allergies, block the H1 histamine receptors, whereas the others block the H2 receptors. Called also antihistaminic. [EU] Arrhythmia: An irregular heartbeat. [NIH] Arteries: The vessels carrying blood away from the heart. [NIH] Bionics: The study of systems, particularly electronic systems, which function after the manner of, in a manner characteristic of, or resembling living systems. Also, the science of applying biological techniques and principles to the design of electronic systems. [NIH] Bradycardia: Slowness of the heart beat, as evidenced by slowing of the

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pulse rate to less than 60. [EU] Cannula: A tube for insertion into a duct or cavity; during insertion its lumen is usually occupied by a trocar. [EU] Dentition: The teeth in the dental arch; ordinarily used to designate the natural teeth in position in their alveoli. [EU] Diaphragm: The musculofibrous partition that separates the thoracic cavity from the abdominal cavity. Contraction of the diaphragm increases the volume of the thoracic cavity aiding inspiration. [NIH] Distal: Remote; farther from any point of reference; opposed to proximal. In dentistry, used to designate a position on the dental arch farther from the median line of the jaw. [EU] Electrocardiogram: [NIH]

Measurement of electrical activity during heartbeats.

Extrasystole: A premature contraction of the heart that is independent of the normal rhythm and arises in response to an impulse in some part of the heart other than the sinoatrial node; called also premature beat. [EU] Histidine: An essential amino acid important in a number of metabolic processes. It is required for the production of histamine. [NIH] Ligament: A band of fibrous tissue that connects bones or cartilages, serving to support and strengthen joints. [EU] Lithium: Lithium. An element in the alkali metals family. It has the atomic symbol Li, atomic number 3, and atomic weight 6.94. Salts of lithium are used in treating manic-depressive disorders. [NIH] Maxillary: Pertaining to the maxilla : the irregularly shaped bone that with its fellow forms the upper jaw. [EU] Membrane: Thin, flexible film of proteins and lipids that encloses the contents of a cell; it controls the substances that go into and come out of the cell. Also, a thin layer of tissue that covers the surface or lines the cavity of an organ. [NIH] Neoprene: An oil-resistant synthetic rubber made by the polymerization of chloroprene. [NIH] Nicotine: Nicotine is highly toxic alkaloid. It is the prototypical agonist at nicotinic cholinergic receptors where it dramatically stimulates neurons and ultimately blocks synaptic transmission. Nicotine is also important medically because of its presence in tobacco smoke. [NIH] Pathogenesis: The cellular events and reactions that occur in the development of disease. [NIH] Pharmacotherapy: A regimen of using appetite suppressant medications to manage obesity by decreasing appetite or increasing the feeling of satiety.

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These medications decrease appetite by increasing serotonin catecholamine—two brain chemicals that affect mood and appetite. [NIH]

or

Protriptyline: Tricyclic antidepressant similar in action and side effects to imipramine. It may produce excitation. [NIH] Regurgitation: A backward flowing, as the casting up of undigested food, or the backward flowing of blood into the heart, or between the chambers of the heart when a valve is incompetent. [EU] Sciatica: A syndrome characterized by pain radiating from the back into the buttock and into the lower extremity along its posterior or lateral aspect, and most commonly caused by prolapse of the intervertebral disk; the term is also used to refer to pain anywhere along the course of the sciatic nerve. [EU] Strychnine: An alkaloid found in the seeds of nux vomica. It is a competitive antagonist at glycine receptors and thus a convulsant. It has been used as an analeptic, in the treatment of nonketotic hyperglycinemia and sleep apnea, and as a rat poison. [NIH] Suction: The removal of secretions, gas or fluid from hollow or tubular organs or cavities by means of a tube and a device that acts on negative pressure. [NIH] Tachyarrhythmia: Tachycardia associated with an irregularity in the normal heart rhythm. [EU] Trachea: The cartilaginous and membranous tube descending from the larynx and branching into the right and left main bronchi. [NIH] Ventilation: The process of exchange of air between the lungs and the atmosphere leading to exchange of gases in the blood. [NIH]

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CHAPTER 6. BOOKS ON SLEEP APNEA Overview This chapter provides bibliographic book references relating to sleep apnea. You have many options to locate books on sleep apnea. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on sleep apnea include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.

Book Summaries: Federal Agencies The Combined Health Information Database collects various book abstracts from a variety of healthcare institutions and federal agencies. To access these summaries, go to: http://chid.nih.gov/detail/detail.html. You will need to use the “Detailed Search” option. To find book summaries, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer. For the format option, select “Monograph/Book.” Now type “sleep apnea” (or synonyms) into the “For these words:” box. You will only receive results on books. You should check back periodically with this database which is updated every 3 months. The following is a typical result when searching for books on sleep apnea: Ear, Nose, and Throat Disorders Sourcebook Source: Detroit, MI: Omnigraphics, Inc. 1998. 576 p.

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Contact: Available from Omnigraphics, Inc. Penobscot Building, Detroit, MI 48226. (800) 234-1340. Fax (800) 875-1340. PRICE: $78.00. ISBN: 0780802063. Summary: This reference book provides information about some of the most common disorders of the ears, nose, and throat. The text describes diseases and their accompanying symptoms, as well as treatment options and current research initiatives. The book's 67 chapters are arranged in six parts: introduction, disorders of the inner and outer ear, vestibular disorders, disorders of the nose and sinuses, disorders of the throat, and cancers related to the ears, nose, and throat. Specific disorders and topics include otitis externa, otitis media, allergy, perforated eardrum, cholesteatoma, otosclerosis, tinnitus, hyperacusis, ear surgery, dizziness, BPPV (benign paraoxysmal positional vertigo), labyrinthitis, Meniere's disease, perilymph fistula, sinusitis, rhinitis, antihistamines, nosebleeds, smell and taste problems, sore throats, hoarseness, swallowing disorders, salivary glands, snoring, sleep apnea, spasmodic dysphonia, laryngeal diseases and disorders, smoking cessation, head and neck cancer, cancer of the oral cavity and upper throat, esophageal cancer, and oropharyngeal cancer. Simple line drawings illustrate some of the anatomical concepts discussed. The book also includes a glossary of terms and an annotated directory of organizational resources with addresses, telephone numbers, e-mail addresses, and web site locations. Mayo Clinic on High Blood Pressure Source: New York, NY: Kensington Publishing. 1999. 180 p. Contact: Available from Mayo Clinic. 200 First Street, S.W., Rochester, MN 55905. (800) 291-1128 or (507) 284-2511. Fax (507) 284-0161. Website: www.mayo.edu. PRICE: $14.95 plus shipping and handling. ISBN: 1893005011. Summary: This book focuses on what people who have high blood pressure can do to better manage their blood pressure and keep it at a safe level. The book begins with a chapter that explains the basics of blood pressure, how high blood pressure develops, and why it can be harmful. This is followed by a chapter that identifies unmodifiable and modifiable risk factors for high blood pressure. Unmodifiable risk factors include race, age, family history, and gender. Modifiable risk factors include obesity, inactivity, tobacco use, sodium sensitivity, low potassium, excessive alcohol consumption, stress, chronic illness, high cholesterol, diabetes, sleep apnea, and heart failure. Other topics addressed in this chapter include secondary high blood pressure and ways of preventing high blood pressure. The third chapter focuses on the diagnosis and treatment of high blood pressure. Topics include

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measuring blood pressure, receiving a diagnosis, getting a medical evaluation, and deciding on treatment with either medication or lifestyle changes. Subsequent chapters discuss determining a healthy weight, losing weight, becoming more physically active, and eating well using the Dietary Approaches to Stop Hypertension (DASH) plan. The following chapters detail the effects of sodium, tobacco, alcohol, caffeine, and stress on blood pressure. Another chapter focuses on the mode of action and side effects of various medications used in controlling high blood pressure, including diuretics, beta blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium antagonists, alpha blockers, central acting agents, and direct vasodilators. Remaining chapters examine factors unique to women, management of high blood pressure among specific populations and groups, treatment of difficultto-control high blood pressure, management of a hypertensive emergency, and home monitoring of blood pressure. The book also includes a week of menus based on the recommendations of the DASH eating plan. 17 figures. 2 tables.

Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in Print ). The following have been recently listed with online booksellers as relating to sleep apnea (sorted alphabetically by title; follow the hyperlink to view more details at Amazon.com): Abnormalities of Respiration During Sleep : Diagnosis, Pathophysiology, and Treatment by Eugene Fletcher (Editor) (1986); ISBN: 0808918125; http://www.amazon.com/exec/obidos/ASIN/0808918125/icongroupin terna Breathing Disorders of Sleep (Contemporary Issues in Pulmonary Disease) by Norman H., Md Edelman, Teodoro V., MD Santiago (Editor) (1986); ISBN: 0443083983; http://www.amazon.com/exec/obidos/ASIN/0443083983/icongroupin terna Cardiorespiratory Disorders During Sleep (1990); ISBN: 0879932082; http://www.amazon.com/exec/obidos/ASIN/0879932082/icongroupin terna

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Cardiorespiratory Disorders During Sleep by Richard J. Martin (Editor) (1990); ISBN: 0879933801; http://www.amazon.com/exec/obidos/ASIN/0879933801/icongroupin terna Control of Breathing During Sleep and Anesthesia by Witold A. Karczewski (Editor) (1988); ISBN: 0306429934; http://www.amazon.com/exec/obidos/ASIN/0306429934/icongroupin terna No More Snoring : A Proven Program to Conquer Snoring and Sleep Apnea by Victor Hoffstein, Shirley Linde (1998); ISBN: 0471243752; http://www.amazon.com/exec/obidos/ASIN/0471243752/icongroupin terna Obstructive Sleep Apnea Syndrome : Clinical Research and Treatment by Christian Guilleminault, Markku Partinen (Editor) (1990); ISBN: 0881675857; http://www.amazon.com/exec/obidos/ASIN/0881675857/icongroupin terna Obstructive Sleep Apnea Syndrome : Diagnosis and Treatment (Continuing Education Program (American Academy of Otolaryngology--Head and Neck Surgery fo by B. Tucker Woodson, et al (1996); ISBN: 1567720501; http://www.amazon.com/exec/obidos/ASIN/1567720501/icongroupin terna Sleep and Breathing by Nicholas A. Saunders, Colin E. Sullivan; ISBN: 082478877X; http://www.amazon.com/exec/obidos/ASIN/082478877X/icongroupi nterna Sleep and Breathing in Children: A Developmental Approach by Gerald M. Loughlin (Editor), et al; ISBN: 0824703006; http://www.amazon.com/exec/obidos/ASIN/0824703006/icongroupin terna Sleep and cardiorespiratory control : proceedings of the Symposium on Sleep and Cardiorespiratory Control held in Kremlin-Bicãetre (France) September 12-13, 1991 = Sommeil et contrãole cardio-respiratoire ; ISBN: 0861963075; http://www.amazon.com/exec/obidos/ASIN/0861963075/icongroupin terna Sleep and health risk ; ISBN: 3540530835; http://www.amazon.com/exec/obidos/ASIN/3540530835/icongroupin terna

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Sleep and Health Risk by J.H. Peter, et al (1991); ISBN: 0387530835; http://www.amazon.com/exec/obidos/ASIN/0387530835/icongroupin terna Sleep and Respiration (Progress in Clinical and Biological Research Volume 345) by G. Issa Faig, et al; ISBN: 0471568082; http://www.amazon.com/exec/obidos/ASIN/0471568082/icongroupin terna Sleep Apnea and Rhonchopathy : 3rd World Congress on Sleep Apnea and Phonchopathy, Tokyo, September 21-23, 1991 by Kiyoshi Togawa (1993); ISBN: 380555611X; http://www.amazon.com/exec/obidos/ASIN/380555611X/icongroupi nterna Sleep Apnea: Implications in Cardiovascular and Cerebrovascular Disease by T. Douglas Bradley (Editor), John S. Floras (Editor); ISBN: 0824702999; http://www.amazon.com/exec/obidos/ASIN/0824702999/icongroupin terna Sleep Related Breathing Disorders by Zwick Hartmut (Editor) (1992); ISBN: 038782376X; http://www.amazon.com/exec/obidos/ASIN/038782376X/icongroupi nterna Sleep related disorders and internal diseases ; ISBN: 3540176225; http://www.amazon.com/exec/obidos/ASIN/3540176225/icongroupin terna Sleep Related Disorders and Internal Diseases by J.H. Peter, et al (1988); ISBN: 0387176225; http://www.amazon.com/exec/obidos/ASIN/0387176225/icongroupin terna Snoring and Obstructive Sleep Apnea by David N. F. Fairbanks, Shiro Fujita (Editor); ISBN: 0781701961; http://www.amazon.com/exec/obidos/ASIN/0781701961/icongroupin terna Snoring and Obstructive Sleep Apnea (1994); ISBN: 0881672971; http://www.amazon.com/exec/obidos/ASIN/0881672971/icongroupin terna Snoring and Sleep Apnea (1994); ISBN: 0963594540; http://www.amazon.com/exec/obidos/ASIN/0963594540/icongroupin terna

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Snoring and Sleep Apnea : Personal and Family Guide to Diagnosis and Treatment by Ralph A. Pascualy, Sally Warren Soest (1994); ISBN: 0781701368; http://www.amazon.com/exec/obidos/ASIN/0781701368/icongroupin terna Snoring and Sleep Apnea: Sleep Well, Feel Better by Ralph, Md Pascualy, et al; ISBN: 1888799293; http://www.amazon.com/exec/obidos/ASIN/1888799293/icongroupin terna Snoring from A to ZZzz : Proven Cures for the Night's Worst Nuisance by Dered S. Lipman, Derek S. Stop Your husban Lipman (1997); ISBN: 0965070808; http://www.amazon.com/exec/obidos/ASIN/0965070808/icongroupin terna Stop the Snoring! by Ralph Schoenstein, Yosef Krespi (Editor); ISBN: 0446604607; http://www.amazon.com/exec/obidos/ASIN/0446604607/icongroupin terna The sleepwatchers by William C. Dement; ISBN: 0964933802; http://www.amazon.com/exec/obidos/ASIN/0964933802/icongroupin terna

The National Library of Medicine Book Index The National Library of Medicine at the National Institutes of Health has a massive database of books published on healthcare and biomedicine. Go to the following Internet site, http://locatorplus.gov/, and then select “Search LOCATORplus.” Once you are in the search area, simply type “sleep apnea” (or synonyms) into the search box, and select “books only.” From there,

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results can be sorted by publication date, author, or relevance. The following was recently catalogued by the National Library of Medicine:26 Abnormalities of respiration during sleep: diagnosis, pathophysiology, and treatment. Author: edited by Eugene C. Fletcher; Year: 1986; Orlando: Grune & Stratton, c1986; ISBN: 0808918125 http://www.amazon.com/exec/obidos/ASIN/0808918125/icongroupin terna Apnea monitors. ECRI, c2001

Author: ECRI; Year: 2001; Plymouth Meeting, PA:

Breathing disorders during sleep. Author: [prepared by Division of Lung Diseases and Office of Prevention, Education, and Control, National Institutes of Health, National Heart, Lung, and Blood Institute]; Year: 1994; [Bethesda, Md.]: National Institutes of Health, National Heart, Lung, and Blood Institute, [1994] Breathing disorders of sleep. Author: edited by Norman H. Edelman, Teodoro V. Santiago; Year: 1986; New York: Churchill Livingstone, 1986; ISBN: 0443083983 http://www.amazon.com/exec/obidos/ASIN/0443083983/icongroupin terna Continuous positive airway pressure for the treatment of obstructive sleep apnea in adults. Author: [authors, H. Handelsman, and E. Carter]; Year: 1987; Rockville, Md.: National Center for Health Services Research and Health Care Technology Assessment, U.S. Dept. of Health and Human Services, Public Health Service, [1987] Control of breathing during sleep and anesthesia. Author: edited by W.A. Karczewski ... [et al.]; Year: 1988; New York: Plenum Press, c1988; ISBN: 0306429934 http://www.amazon.com/exec/obidos/ASIN/0306429934/icongroupin terna

In addition to LOCATORPlus, in collaboration with authors and publishers, the National Center for Biotechnology Information (NCBI) is adapting biomedical books for the Web. The books may be accessed in two ways: (1) by searching directly using any search term or phrase (in the same way as the bibliographic database PubMed), or (2) by following the links to PubMed abstracts. Each PubMed abstract has a “Books” button that displays a facsimile of the abstract in which some phrases are hypertext links. These phrases are also found in the books available at NCBI. Click on hyperlinked results in the list of books in which the phrase is found. Currently, the majority of the links are between the books and PubMed. In the future, more links will be created between the books and other types of information, such as gene and protein sequences and macromolecular structures. See http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books. 26

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Handbook of sleep-related breathing disorders. Author: J.R. Stradling; Year: 1993; Oxford; New York: Oxford University Press, 1993; ISBN: 0192618342 (H'Bk: alk. paper) http://www.amazon.com/exec/obidos/ASIN/0192618342/icongroupin terna No more snoring: a proven program for conquering snoring and sleep apnea. Author: Victor Hoffstein, Shirley Linde; Year: 1999; New York: John Wiley & Sons, Inc., c1999; ISBN: 0471243752 (pbk.: alk. paper) http://www.amazon.com/exec/obidos/ASIN/0471243752/icongroupin terna Obstructive sleep apnea syndrome: clinical research and treatment. Author: editors, Christian Guilleminault, Markku Partinen; Year: 1990; New York: Raven Press, c1990; ISBN: 0881675857 http://www.amazon.com/exec/obidos/ASIN/0881675857/icongroupin terna Obstructive sleep apnea syndrome: diagnosis and treatment. Author: B. Tucker Woodson, Philip Stanley Ledereich, Patrick Strollo; Year: 1996; Alexandria, VA: American Academy of Otolaryngology--Head and Neck Surgery Foundation, Inc., 1996; ISBN: 1567720501 http://www.amazon.com/exec/obidos/ASIN/1567720501/icongroupin terna Role of a dentist in sleep apnea. Author: James F. Garry; Year: 1992; Dallas, TX: MyoData, [1992?] Sleep and cardiorespiratory control = Sommeil et contrôl cardiorespiratoire: proceedings of the Symposium on Sleep and Cardiorespiratory Control held in Kremlin-Bicêtre (France), September 12-13, 1991. Author: supported by the Institut national de la santé; Year: 1991; Paris: Editions INSERM; Montrouge, France: John Libbey Eurotext, 1991; ISBN: 285598484X Sleep and health risk. Author: J.H. Peter ... [et al.] (eds.); Year: 1991; Berlin; New York: Springer-Verlag, c1991; ISBN: 3540530835 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/3540530835/icongroupin terna Sleep and respiration: proceedings of the First International Symposium on Sleep and Respiration, held in Banff, Alberta, April 1-4, 1989. Author: edited by Faiq G. Issa, Paul M. Suratt, John E. Remmers; Year: 1990; New York: Wiley-Liss, c1990; ISBN: 0471568082 http://www.amazon.com/exec/obidos/ASIN/0471568082/icongroupin terna Sleep and respiration in aging adults: proceedings of the Second International Symposium on Sleep and Respiration, held at South

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Shore Harbour Resort and Conference Center, League City, Texas, March 9-13, 1991. Author: edited by Samuel T. Kuna,Paul M. Suratt, J; Year: 1991; New York: Elsevier, c1991; ISBN: 0444016538 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0444016538/icongroupin terna Sleep apnea: implications in cardiovascular and cerebrovascular disease. Author: edited by T. Douglas Bradley, John S. Floras; Year: 2000; New York: Dekker, c2000; ISBN: 0824702999 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0824702999/icongroupin terna Sleep apnea and related disorders. Author: A. Jay Block; Year: 1985; Chicago: Year Book Medical Publishers, c1985 Sleep apnea and rhonchopathy. Author: 3rd World Congress on Sleep Apnea and Rhonchopathy, Tokyo, September 21-23, 1991; editor, Kiyoshi Togawa ... [et al.]; Year: 1993; Basel; New York: Karger, 1993; ISBN: 380555611X (alk. paper) http://www.amazon.com/exec/obidos/ASIN/380555611X/icongroupi nterna Sleep apnea. Author: Anthony R. Dal Nogare; Year: 1993; [Dallas?: University of Texas Southwestern Medical School? 1992] Sleep disorders of older people: January 1985 through March 1990: 725 citations. Author: prepared by Lori J. Klein, Loretta D. Ulincy, Andrew A. Monjan; Year: 1990; Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Library of Medicine, Reference Section; Washington, D.C.: Sold by the Supt. of Docs., U.S. G.P.O., [1990] Sleep medicine. Author: Michael S. Aldrich; Year: 1999; New York: Oxford University Press, 1999; ISBN: 0195129571 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0195129571/icongroupin terna Sleep related breathing disorders. Author: Hartmut Zwick (ed.); Year: 1992; Wien; New York: Springer-Verlag, c1992; ISBN: 321182376X (Wien: alk. paper) Sleep related disorders and internal diseases. Author: J.H. Peter, Th. Podszus, P. von Wichert (eds.); Year: 1987; Berlin; New York: SpringerVerlag, c1987; ISBN: 0387176225 (U.S.) http://www.amazon.com/exec/obidos/ASIN/0387176225/icongroupin terna Sleep-wake disorders. Author: edited by K. Meier-Ewert and M. Okawa; Year: 1997; New York: Plenum Press, c1997; ISBN: 0306457717

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http://www.amazon.com/exec/obidos/ASIN/0306457717/icongroupin terna Snoring and obstructive sleep apnea [edited by] David N.F. Fairbanks ... [et al.]; contributors, Marc F. Colman ... [et al.]. Author: International Symposium on Control of Breathing during Sleep and Anesthesia (1987: Warsaw, Poland); Year: 1987; New York: Raven Press, c1987; ISBN: 0881672971 http://www.amazon.com/exec/obidos/ASIN/0881672971/icongroupin terna Snoring and obstructive sleep apnea. Author: editors, David N.F. Fairbanks, Shiro Fujita; Year: 1994; New York: Raven Press, c1994; ISBN: 0781701961 http://www.amazon.com/exec/obidos/ASIN/0781701961/icongroupin terna Snoring and sleep apnea: personal and family guide to diagnosis and treatment. Author: Ralph A. Pascualy, Sally Warren Soest; foreword by William C. Dement; Year: 1994; New York: Raven Press, c1994; ISBN: 0781701368 (trade pbk.) http://www.amazon.com/exec/obidos/ASIN/0781701368/icongroupin terna Systematic review of the literature regarding the diagnosis of sleep apnea. Author: prepared by MetaWorks Inc; Year: 1999; Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, [1999] Treatment of obstructive sleep apnea: a report. Author: by the Australian Health Technology Advisory Committee; Year: 1993; [Canberra]: National Health and Medical Research Council, [c1993] Treatment of obstructive sleep apnea by nasal continuous positive airway pressure--executive summary. ; Year: 1990; Montréal: CETS, 1990; ISBN: 2550208307

Chapters on Sleep Apnea Frequently, sleep apnea will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are specifically dealing with sleep apnea, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and sleep apnea using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You

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may refine your search by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “sleep apnea” (or synonyms) into the “For these words:” box, you will only receive results on chapters in books. The following is a typical result when searching for book chapters on sleep apnea: How Vocal Abilities Can Be Limited by Non-Infectious Diseases and Disorders of the Respiratory and Digestive Systems Source: in Thurman, L. and Welch, G., eds. Bodymind and Voice: Foundations of Voice Education, Volumes 1-3. 2nd ed. Collegeville, MN: VoiceCare Network. 2000. p. 546-555. Contact: Available from National Center for Voice and Speech (NCVS). Book Sales, 334 Speech and Hearing Center, University of Iowa, Iowa City, IA 52242. Website: www.ncvs.org. PRICE: $75.00 plus shipping and handling. ISBN: 0874141230. Summary: This chapter on noninfectious diseases and disorders of the respiratory and digestive systems is from a multi-volume text that brings a biopsychosocial approach to the study of the voice. The authors use the phrase 'bodyminds' to describe the interrelationship of perception, memory, learning, behavior, and health, as they combine to affect all environmental interactions, adaptations, and learning. The books are written for teachers, voice professionals, people who use their voices on an avocational basis, and interested members of the general public. This chapter describes the effects of smoking and other pollutants, sinusitis and rhinitis, laryngitis, bronchitis and other pulmonary (lung) diseases, the effects of outdoor and indoor air pollution, normal and disordered nasal (nose) conditions, asthma, obstructive sleep apnea, emphysema, and gastroesophageal reflux disease (GERD, the return of stomach acid to the esophagus and larynx). GERD can result in hoarseness, lowering of the average speaking pitch range, increased effort when singing, and a 'tired voice.' Asthma can affect voice primarily by decreasing the ability of the respiratory system to inhale and then pressurize the lung air to create sufficient breathflow between the vocal folds. Asthma symptoms can be triggered by inhalation of allergens or pollutant particles of irritant chemicals, infection, cold air, vigorous exercise, acute neuropsychobiological distress, or even vigorous singing. 68 references. Oral Cavity, Pharynx and Esophagus Source: in Strome, M.; Kelly, J.H.; Fried, M.P., eds. Manual of Otolaryngology: Diagnosis and Therapy. 2nd ed. Boston, MA: Little, Brown and Company. 1992. p. 137-171.

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Contact: Available from Little, Brown and Company. 34 Beacon Street, Boston, MA 02108. (800) 759-0190. PRICE: $27.50 plus shipping and handling. ISBN: 0316819689. Summary: This chapter, from a reference manual detailing the essentials of otolaryngology and head and neck surgery, discusses the oral cavity, pharynx, and esophagus. Topics covered include oropharyngeal anatomy; physical examination of the pharynx; infectious pharyngitis, including acute bacterial pharyngotonsillitis, diptheria, infectious mononucleosis, Vincent's angina, candidiasis, syphilis, gonococcal pharyngitis, tuberculosis, viral pharyngitis, lingual tonsillitis, nasopharyngitis, and AIDS; noninfectious etiology, including pemphigus, retropharyngeal abscess, parapharyngeal abscess, and submandibular space abscess (Ludwig's angina); allergic edema; tissue hypertrophy, including adenotonsillar hypertrophy, and obstructive sleep apnea; congenital obstruction, including Pierre-Robin syndrome, Thornwald's bursa or nasopharyngeal cyst, and choanal atresia; cysts and neoplasms; dysphasia; and esophageal disorders. The manual summarizes the signs and symptoms, diagnosis, and treatment for each disease or disorder. 26 references. How Vocal Abilities Can Be Limited by Anatomical Abnormalities and Bodily Injuries Source: in Thurman, L. and Welch, G., eds. Bodymind and Voice: Foundations of Voice Education, Volumes 1-3. 2nd ed. Collegeville, MN: VoiceCare Network. 2000. p. 582-585. Contact: Available from National Center for Voice and Speech (NCVS). Book Sales, 334 Speech and Hearing Center, University of Iowa, Iowa City, IA 52242. Website: www.ncvs.org. PRICE: $75.00 plus shipping and handling. ISBN: 0874141230. Summary: This chapter on anatomical abnormalities and bodily injuries is from a multi-volume text that brings a biopsychosocial approach to the study of the voice. The authors use the phrase 'bodyminds' to describe the interrelationship of perception, memory, learning, behavior, and health, as they combine to affect all environmental interactions, adaptations, and learning. The books are written for teachers, voice professionals, people who use their voices on an avocational basis, and interested members of the general public. This chapter notes that malformations of auditory (hearing) and neural vocal anatomy can have genetic sources, and can lead to abnormalities of speaking or singing functions. Insufficient sensorimotor stimulation during late gestation and childhood can result in underdeveloped neural networks, suboptimum neural capabilities, or functional abnormalities that can affect vocal self

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expression. Bodily injuries of many types and in many different parts of the body also can impact upon voice and speech. Manifestations of injury may be subtle and short lived, or overt and permanent. The chapter covers morphologic voice disorders, including laryngeal webs, congenital anomalies of the vocal tract, obstructive sleep apnea syndrome (OSAS), swollen soft palate, short soft palate, cleft palate, and enlarged turbinates; and injury to vocal skeleton or soft tissues, including trauma to the anterior neck or cervical spine, laryngeal fracture, mandibular (lower jaw) fracture, trauma to the torso, iatrogenic (physician caused) trauma, recurrent laryngeal nerve injury, vocal fold mucosal scarring, intubation injury, and acquired laryngeal webs. 22 references. Pediatric Phonatory Disorders Source: in Andrews, M.L. Manual of Voice Treatment: Pediatrics Through Geriatrics. 2nd ed. San Diego, CA: Singular Publishing Group, Inc. 1999. p. 151-217. Contact: Available from Singular Publishing Group, Inc. 401 West 'A' Street, Suite 325, San Diego, CA 92101-7904. (800) 521-8545 or (619) 2386777. Fax (800) 774-8398 or (619) 238-6789. E-mail: [email protected]. Website: www.singpub.com. PRICE: $55.00 plus shipping and handling. ISBN: 1565939880. Summary: This chapter on pediatric phonatory disorders is from a resource book for clinicians and clinicians in training who are treating patients with voice disorders. The chapter offers five sections: preschool children, school age children, pediatric voice problems associated with other conditions (hearing impairment, cerebral palsy, craniofacial dysmorphology, nasal obstruction, obstructive sleep apnea syndrome, trauma, lesions), the voice at puberty, and the treatment of resonance disorders. The chapter discusses the physiologic systems relevant to voice production from a developmental perspective. To emphasize the importance of complete case history information, the relevance of the possible effects on voice of infant airway obstruction and medical and surgical treatments to alleviate it are reviewed. Other topics include the reasons for tracheotomy and possible complications and sequelae of this surgery; the common symptoms of vocal disruption in school age children; hyperfunctional and hypofunctional patterns associated with respiration, phonation, resonance, and psychodynamics; and the importance of explaining the effects of specific voice disorders in children to their parents, teachers, and allied health professionals. 9 figures. 3 tables.

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Voice Surgery Source: in Sataloff, R.T., ed. Professional Voice: The Science and Art of Clinical Care. 2nd ed. San Diego, CA: Singular Publishing Group, Inc. 1997. p. 603-645. Contact: Available from Singular Publishing Group, Inc. 401 West 'A' Street, Suite 325, San Diego, CA 92101-7904. (800) 521-8545 or (619) 2386777. Fax (800) 774-8398 or (619) 238-6789. E-mail: [email protected]. Website: www.singpub.com. PRICE: $325.00 plus shipping and handling. ISBN: 1565937287. Summary: This chapter, from a book on the clinical care of the professional voice, reviews the current thinking regarding voice surgery. Most surgical procedures for voice disorders can be performed endoscopically, obviating the need for external incisions and minimizing the amount of tissue disruption. The author stresses that, when endoscopic visualization is not adequate because of patient anatomy, disease extent, or other factors, the surgeon should not compromise the results of treatment or risk patient injury by attempting to complete an endoscopic procedure. Topics include patient selection and consent, documentation (preoperative assessment), timing of voice surgery, indirect laryngoscopy, direct laryngoscopy, anesthesia (local and general), instrumentation, laryngeal microsurgery, contact endoscopy, vocal fold cysts, vocal fold polyps, varicosities and ectatic vessels and vocal fold hemorrhage, Reinke's edema, granulomas and vocal process ulcers, papillomas, ventricular fold cysts, epiglottic cysts, laryngoceles, miscellaneous masses, sulcus vocalis, laryngeal webs, bowed vocal folds, presbyphonia, vocal fold paralysis and framework dysfunction, Teflon injection, Gelfoam injection, collagen injection, autologous fat injection, removal of Teflon, thyroplasty, nomenclature, arytenoid adduction or rotation, nerve anastomosis, nerve muscle pedicle surgery, arytenoid reduction for arytenoid dislocation, arytenoidectomy, voice rest, and related surgery, including that for velopharyngeal insufficiency and obstructive sleep apnea syndrome in professional voice users. 31 figures. 1 table. 99 references. Lungs and Pleura Source: in Daugirdas, J.T. and Ing, T.S., eds. Handbook of Dialysis. 2nd ed. Boston, MA: Little, Brown and Company. 1994. p. 598-603. Contact: Available from Lippincott-Raven Publishers. 12107 Insurance Way, Hagerstown, MD 21740. (800) 777-2295. Fax (301) 824-7390. E-mail: [email protected]. Website: http://www.lrpub.com. PRICE: $37.95. ISBN: 0316173835.

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Summary: This chapter on complications affecting the lungs and pleura is from a handbook that outlines all aspects of dialysis therapy, emphasizing the management of dialysis patients. Topics include pulmonary edema, pleural effusion, infection, dyspnea during dialysis, respiratory failure due to hyperkalemia, hypophosphatemia, or glucose load, dosages of pulmonary drugs in dialysis patients, and sleep apnea syndrome in dialysis patients. The author presents information in outline form, for easy reference. 17 references. Respiratory Disorders Source: in Scully, C. and Cawson, R.A. Medical Problems in Dentistry. 4th ed. Woburn, MA: Butterworth-Heinemann. 1998. p. 154-172. Contact: Available from Butterworth-Heinemann. 225 Wildwood Avenue, Woburn, MA 01801-2041. (800) 366-2665 or (781) 904-2500. Fax (800) 446-6520 or (781) 933-6333. E-mail: [email protected]. Website: www.bh.com. PRICE: $110.00. ISBN: 0723610568. Summary: Respiratory disorders are common and may significantly affect dental treatment, especially general anesthesia. Respiratory diseases are often also a contraindication to opioids, benzodiazepines and other respiratory depressants. This chapter on respiratory disorders is from a text that covers the general medical and surgical conditions relevant to the oral health care sciences. Topics include upper respiratory tract viral infections, sinusitis, lower respiratory tract infections, pulmonary tuberculosis, Legionnaire's disease (legionellosis), lung abscess, bronchiectasis, cystic fibrosis, chronic obstructive airways diseases, asthma, bronchogenic carcinoma (lung cancer), occupational lung disease, sarcoidosis, postoperative respiratory complications (including aspiration of gastric contents), obstructive sleep apnea syndrome, and respiratory distress syndromes (RDS). For each disease, the authors discuss general aspects, diagnosis and management issues, dental aspects, and patient care strategies. The chapter includes a summary of the points covered. 1 figure. 5 tables. 51 references.

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General Home References In addition to references for sleep apnea, you may want a general home medical guide that spans all aspects of home healthcare. The following list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): 100 Questions About Sleep and Sleep Disorders by Sudhansu Chokroverty, M.D.; Paperback - 110 pages, 1st edition (February 15, 2001), Blackwell Science Inc; ISBN: 0865425833; http://www.amazon.com/exec/obidos/ASIN/0865425833/icongroupinterna The Bible Cure for Sleep Disorders by Don Colbert; Paperback - 96 pages (March 2001), Siloam Press; ISBN: 0884197484; http://www.amazon.com/exec/obidos/ASIN/0884197484/icongroupinterna Sleep and Its Disorders : What You Should Know by Robert G. Hooper, M.D., Melissa Mulera (Illustrator); Paperback - 176 pages (January 2001), Just Peachy Press; ISBN: 0970002645; http://www.amazon.com/exec/obidos/ASIN/0970002645/icongroupinterna Sleep Disorders Sourcebook: Basic Consumer Health Information About Sleep and Its Disorders, Including Insomnia, Sleepwalking, Sleep Apmea, Restless) by Jenifer Swanson (Editor); Library Binding - 600 pages (January 1999), Omnigraphics, Inc.; ISBN: 0780802349; http://www.amazon.com/exec/obidos/ASIN/0780802349/icongroupinterna Sleeping Well: The Sourcebook for Sleep and Sleep Disorders (The Facts for Life) by Michael J. Thorpy, M.D., Jan Yager; Paperback - 342 pages (October 2001), Checkmark Books; ISBN: 0816040907; http://www.amazon.com/exec/obidos/ASIN/0816040907/icongroupinterna

Vocabulary Builder Anastomosis: An opening created by surgical, traumatic or pathological means between two normally separate spaces or organs. [EU] Benzodiazepines: A two-ring heterocyclic compound consisting of a benzene ring fused to a diazepine ring. Permitted is any degree of hydrogenation, any substituents and any H-isomer. [NIH] Bronchiectasis: Chronic dilatation of the bronchi marked by fetid breath and paroxysmal coughing, with the expectoration of mucopurulent matter. It may effect the tube uniformly (cylindric b.), or occur in irregular pockets (sacculated b.) or the dilated tubes may have terminal bulbous enlargements (fusiform b.).

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Candidiasis: Infection with a fungus of the genus Candida. It is usually a superficial infection of the moist cutaneous areas of the body, and is generally caused by C. albicans; it most commonly involves the skin (dermatocandidiasis), oral mucous membranes (thrush, def. 1), respiratory tract (bronchocandidiasis), and vagina (vaginitis). Rarely there is a systemic infection or endocarditis. Called also moniliasis, candidosis, oidiomycosis, and formerly blastodendriosis. [EU] Carbamazepine: An anticonvulsant used to control grand mal and psychomotor or focal seizures. Its mode of action is not fully understood, but some of its actions resemble those of phenytoin; although there is little chemical resemblance between the two compounds, their three-dimensional structure is similar. [NIH] Carcinoma: A malignant new growth made up of epithelial cells tending to infiltrate the surrounding tissues and give rise to metastases. [EU] Cholesteatoma: A non-neoplastic keratinizing mass with stratified squamous epithelium, frequently occurring in the meninges, central nervous system, bones of the skull, and most commonly in the middle ear and mastoid region. [NIH] Cholesterol: A soft, waxy substance manufactured by the body and used in the production of hormones, bile acid, and vitamin D and present in all parts of the body, including the nervous system, muscle, skin, liver, intestines, and heart. Blood cholesterol circulates in the bloodstream. Dietary cholesterol is found in foods of animal origin. [NIH] Collagen: The protein substance of the white fibres (collagenous fibres) of skin, tendon, bone, cartilage, and all other connective tissue; composed of molecules of tropocollagen (q.v.), it is converted into gelatin by boiling. collagenous pertaining to collagen; forming or producing collagen. [EU] Cortex: The outer layer of an organ or other body structure, as distinguished from the internal substance. [EU] Cyst: Any closed cavity or sac; normal or abnormal, lined by epithelium, and especially one that contains a liquid or semisolid material. [EU] Dislocation: The displacement of any part, more especially of a bone. Called also luxation. [EU] Dizziness: An imprecise term which may refer to a sense of spatial disorientation, motion of the environment, or lightheadedness. [NIH] Dyspnea: Shortness of breath; difficult or labored breathing. [NIH] Edema: Abnormal fluid accumulation in body tissues. [NIH] Effusion: The escape of fluid into a part or tissue, as an exudation or a transudation. [EU]

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Emphysema: Chronic lung disease in which there is permanent destruction of alveoli. [NIH] Endoscopy: Visual inspection of any cavity of the body by means of an endoscope. [EU] Febrile: Pertaining to or characterized by fever. [EU] Fibrosis: Process by which inflamed tissue becomes scarred. [NIH] Fistula: An abnormal passage or communication, usually between two internal organs, or leading from an internal organ to the surface of the body; frequently designated according to the organs or parts with which it communicates, as anovaginal, brochocutaneous, hepatopleural, pulmonoperitoneal, rectovaginal, urethrovaginal, and the like. Such passages are frequently created experimentally for the purpose of obtaining body secretions for physiologic study. [EU] Gestation: The period of development of the young in viviparous animals, from the time of fertilization of the ovum until birth. [EU] Granulomas: Small lumps in tissues caused by inflammation. [NIH] Hemorrhage: Bleeding or escape of blood from a vessel. [NIH] Hoarseness: An unnaturally deep or rough quality of voice. [NIH] Hyperacusis: An abnormally disproportionate increase in the sensation of loudness in response to auditory stimuli of normal volume. Cochlear diseases; vestibulocochlear nerve diseases; facial nerve diseases; stapes surgery; and other disorders may be associated with this condition. [NIH] Hypertrophy: Nutrition) the enlargement or overgrowth of an organ or part due to an increase in size of its constituent cells. [EU] Iatrogenic: Resulting from the activity of physicians. Originally applied to disorders induced in the patient by autosuggestion based on the physician's examination, manner, or discussion, the term is now applied to any adverse condition in a patient occurring as the result of treatment by a physician or surgeon, especially to infections acquired by the patient during the course of treatment. [EU] Intubation: Insertion of a tube into an organ in the body. [NIH] Labyrinthitis: Inflammation of the inner ear. [NIH] Laryngitis: Inflammation of the larynx, a condition attended with dryness and soreness of the throat, hoarseness, cough and dysphagia. [EU] Laryngoscopy: Examination, therapy or surgery of the interior of the larynx performed with a specially designed endoscope. [NIH] Larynx: An irregularly shaped, musculocartilaginous tubular structure, lined with mucous membrane, located at the top of the trachea and below the root of the tongue and the hyoid bone. It is the essential sphincter

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guarding the entrance into the trachea and functioning secondarily as the organ of voice. [NIH] Legionellosis: Infections with bacteria of the genus legionella. [NIH] Mononucleosis: The presence of an abnormally large number of mononuclear leucocytes (monocytes) in the blood. The term is often used alone to refer to infectious mononucleosis. [EU] Nasopharyngitis: Inflammation of the nasopharynx. [NIH] Neoplasms: New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. [NIH] Neoplastic: Pertaining to or like a neoplasm (= any new and abnormal growth); pertaining to neoplasia (= the formation of a neoplasm). [EU] Otitis: Inflammation of the ear, which may be marked by pain, fever, abnormalities of hearing, hearing loss, tinnitus, and vertigo. [EU] Otolaryngology: A surgical specialty concerned with the study and treatment of disorders of the ear, nose, and throat. [NIH] Otosclerosis: A pathological condition of the bony labyrinth of the ear, in which there is formation of spongy bone (otospongiosis), especially in front of and posterior to the footplate of the stapes; it may cause bony ankylosis of the stapes, resulting in conductive hearing loss. Cochlear otosclerosis may also develop, resulting in sensorineural hearing loss. [EU] Particle: A tiny mass of material. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Pemphigus: A group of chronic, relapsing, sometimes fatal skin diseases characterized clinically by the development of successive crops of vesicles and bullae, histologically by acantholysis, and immunologically by serum autoantibodies directed against antigens in the intracellular zones of the epidermis. The specific disease is usually indicated by a modifying term; but the term pemphigus is often used alone to designate pemphigus vulgaris. [EU] Pharmacokinetics: The action of drugs in the body over a period of time, including the processes of absorption, distribution, localization in tissues, biotransformation, and excretion. [EU] Phenytoin: An anticonvulsant that is used in a wide variety of seizures. It is also an anti-arrhythmic and a muscle relaxant. The mechanism of therapeutic action is not clear, although several cellular actions have been described including effects on ion channels, active transport, and general membrane stabilization. The mechanism of its muscle relaxant effect appears to involve a reduction in the sensitivity of muscle spindles to stretch. Phenytoin has

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been proposed for several other therapeutic uses, but its use has been limited by its many adverse effects and interactions with other drugs. [NIH] Phonation: The process of producing vocal sounds by means of vocal cords vibrating in an expiratory blast of air. [NIH] Pleura: The thin serous membrane enveloping the lungs and lining the thoracic cavity. [NIH] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Reflux: A backward or return flow. [EU] Rhinitis: Inflammation of the mucous membrane of the nose. [EU] Sarcoidosis: An idiopathic systemic inflammatory granulomatous disorder comprised of epithelioid and multinucleated giant cells with little necrosis. It usually invades the lungs with fibrosis and may also involve lymph nodes, skin, liver, spleen, eyes, phalangeal bones, and parotid glands. [NIH] Sinusitis: Inflammation of a sinus. The condition may be purulent or nonpurulent, acute or chronic. Depending on the site of involvement it is known as ethmoid, frontal, maxillary, or sphenoid sinusitis. [EU] Spasmodic: Of the nature of a spasm. [EU] Syncope: Fainting; temporary loss of consciousness. [NIH] Tinnitus: A noise in the ears, as ringing, buzzing, roaring, clicking, etc. Such sounds may at times be heard by others than the patient. [EU] Toxic: Pertaining to, due to, or of the nature of a poison or toxin; manifesting the symptoms of severe infection. [EU] Tracheotomy: Surgical incision of the trachea. [NIH] Turbinates: The scroll-like bony plates with curved margins on the lateral wall of the nasal cavity. [NIH] Ulcer: A local defect, or excavation, of the surface of an organ or tissue; which is produced by the sloughing of inflammatory necrotic tissue. [EU] Vasodilator: An agent that widens blood vessels. [NIH] Vertigo: An illusion of movement; a sensation as if the external world were revolving around the patient (objective vertigo) or as if he himself were revolving in space (subjective vertigo). The term is sometimes erroneously used to mean any form of dizziness. [EU] Vestibular: Pertaining to or toward a vestibule. In dental anatomy, used to refer to the tooth surface directed toward the vestibule of the mouth. [EU]

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Viral: Pertaining to, caused by, or of the nature of virus. [EU] Warfarin: An anticoagulant that acts by inhibiting the synthesis of vitamin K-dependent coagulation factors. Warfarin is indicated for the prophylaxis and/or treatment of venous thrombosis and its extension, pulmonary embolism, and atrial fibrillation with embolization. It is also used as an adjunct in the prophylaxis of systemic embolism after myocardial infarction. Warfarin is also used as a rodenticide. [NIH]

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CHAPTER 7. MULTIMEDIA ON SLEEP APNEA Overview Information on sleep apnea can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on sleep apnea. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.

Bibliography: Multimedia on Sleep Apnea The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in sleep apnea (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on sleep apnea. For more information, follow the hyperlink indicated: Advances in diagnosis and treatment of sleep apnea and snoring. Source: sponsored by University of Pennsylvania School of Medicine; CME Information Services, Inc., CMEVideo; Year: 1998; Format: Videorecording; Mt. Laurel, NJ: CMEVideo, 1998

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Advances in diagnosis and treatment of sleep apnea and snoring. Source: CMEVideo, Inc., CME Information Services, Inc.; sponsored by University of Pennsylvania Medical School, February 16-18, 1996; Year: 1996; Format: Videorecording; Mt. Laurel, NJ: CMEVideo, 1996 Anesthesia for the uncommon surgical challenge. Source: produced by Rainbow Productions, Inc.; Ohio Medical Anesthetics; Year: 1983; Format: Motion picture; United States: Airco, c1983 Apnea in the newborn. Source: produced by Medical Educational Resources Program, Indiana University, School of Medicine; Year: 1978; Format: Videorecording; Indianapolis, Ind.: The Program, 1978 Apnea of the newborn. Source: Michigan Perinatal Education Project; [produced by] University of Michigan Medical Center, Independent Study Unit; Year: 1978; Format: Slide; Ann Arbor: The University: [for loan and sale by its Medical Center Media Library], c1978 Broken bond. Source: a presentation of Films for the Humanities & Sciences; produced by Medstar, TLC; Year: 1999; Format: Videorecording; Princeton, N.J.: Films for the Humanities and Sciences, c1999 Effects of shift work and common sleep disorders on motor vehicle safety, workers health and performance. Source: Marshfield Clinic, Saint Joseph's Hospital; a presentation of the Marshfield Video Network; Year: 1998; Format: Videorecording; Marshfield, WI: The Network, c1998 Evaluation and treatment of sleep disorders by the general physician. Source: Sleep Research and Treatment Center Pennsylvania State University, The Milton S. Hershey Medical Center; Year: 1976; Format: Motion picture; Hershey: The University, 1976 Fundamentals of adult sleep apnea. Source: AJN, American Journal of Nursing Company; [presented by] Belson/Hanwright Video [and] Miramar Communications, Inc; Year: 1995; Format: Videorecording; [United States]: Belson/Hanwright Video, c1995 Gastric bypass for morbid obesity and conversion of dilated vertical banded gastroplasty to gastric bypass. Source: American College of Surgeons; produced by Ciné-Med; Year: 1995; Format: Videorecording; Woodbury, Conn.: Ciné-Med, c1995 Graft versus host disease. Source: Evan R. Farmer; Year: 1996; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, c1996 Infantile apnea & home monitoring. Source: with George A. Little; Year: 1987; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, 1987

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Insomniacs. Source: Dept. of Psychiatry and Behavioral Sciences, Stanford University, School of Medicine; Year: 1978; Format: Videorecording; Palo Alto, Calif.: The University, c1978 Lung function tests and what they mean. Source: John B. West; Year: 1978; Format: Slide; San Diego, Calif.: West; [New York: for loan or sale by Audio Visual Medical Marketing, p1978 Mystery of the dreaming brain. Source: produced by Twenty Twenty Television for Channel 4 Television and Discovery Channel; Year: 1998; Format: Videorecording; New York: Ambrose Video Publishing, 1998 Night mare. Source: produced by Twenty Twenty Television for Channel 4 Television and Discovery Channel; Year: 1998; Format: Videorecording; New York: Ambrose Video Publishing, 1998 Oral and maxillofacial surgery. Source: sponsored by University of Pennsylvania Medical Center/School of Dental Medicine; CME Information Services, Inc., CMEVideo; Year: 1998; Format: Videorecording; Mt. Laurel, NJ: CMEVideo, c1998 Permanent tracheostomy. Source: Dept. of Instructional Media, Stanford University, School of Medicine; Year: 1977; Format: Videorecording; Stanford, Calif.: The Department, [1977] Psoriasis in the patient with HIV disease. Source: Madeleine Duvic; Year: 1996; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, c1996 Sleep: the dark side of life. Source: Oklahoma University, Health Sciences Center, Media Productions; Year: 1978; Format: Videorecording; Oklahoma City: The Center: [for sale by its Media Productions], c1978 Sleep apnea : recognition and management. Source: Barry S. DiCicco; Year: 1996; Format: Videorecording; Secaucus, N.J.: Network for Continuing Medical Education, c1996 Sleep apnea: an overview. Source: Ohio State University, College of Medicine; Year: 1977; Format: Videorecording; [Columbus]: The University: [for loan and sale by its Health Services Audiovisual and Television Center], c1977 Sleep apnea hypersomnolence syndrome. Source: William Orr; produced by Media and Educational Materials, University of Oklahoma, Health Sciences Center; Year: 1977; Format: Videorecording; Oklahoma City: The Center: [for sale by its Media Productions], c1977 Sleep apnea syndrome. Source: Dept. of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Year: 1977; Format: Videorecording; [Palo Alto, Calif.]: The University, c1977

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Sleep apnea. Source: a presentation of Films for the Humanities & Sciences, a presentation of OETA and Medstar Communications, Inc; Year: 1995; Format: Videorecording; Princeton, N.J.: Films for the Humanities & Sciences, c1995 Sleep disorders. Source: Films for the Humanities & Sciences; produced for Discovery Health Channel by Big Rock Productions; Year: 2002; Format: Videorecording; Princeton, N.J.: Films for the Humanities & Sciences, c2002 Sleeping well. Source: a presentation of Films for the Humanities & Sciences; Year: 1997; Format: Videorecording; Princeton, N.J.: Films for the Humanities & Sciences, c1997 Sudden infant death syndrome : apnea, sleep studies and monitoring, when and why. Source: presented by the Department of Pediatrics, Emory University, School of Medicine; Year: 1983; Format: Videorecording; Atlanta, Ga.: Emory Medical Television Network, 1983 Understanding sleep. Source: a presentation of Films for the Humanities & Sciences; produced by the Cronkite Ward Company for TLC; Year: 2001; Format: Videorecording; Princeton, N.J.: Films for the Humanities & Sciences, c2001 Wake up, America : a sleep alert. Source: a presentation of Films for the Humanities & Sciences; a presentation of WKRC-TV and Medstar Communications, Inc; Year: 1995; Format: Videorecording; Princeton, N.J.: Films for the Humanities and Sciences, c1995

Vocabulary Builder Gastroplasty: A surgical procedure that limits the amount of food the stomach can hold by closing off part of the stomach. Food intake is restricted by creating a small pouch at the top of the stomach where the food enters from the esophagus. The pouch initially holds about 1 ounce of food and expands to 2-3 ounces with time. The pouch's lower outlet usually has a diameter of about 1/4 inch. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness. [NIH] Perinatal: Pertaining to or occurring in the period shortly before and after birth; variously defined as beginning with completion of the twentieth to twenty-eighth week of gestation and ending 7 to 28 days after birth. [EU]

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CHAPTER 8. PERIODICALS AND NEWS ON SLEEP APNEA Overview Keeping up on the news relating to sleep apnea can be challenging. Subscribing to targeted periodicals can be an effective way to stay abreast of recent developments on sleep apnea. Periodicals include newsletters, magazines, and academic journals. In this chapter, we suggest a number of news sources and present various periodicals that cover sleep apnea beyond and including those which are published by patient associations mentioned earlier. We will first focus on news services, and then on periodicals. News services, press releases, and newsletters generally use more accessible language, so if you do chose to subscribe to one of the more technical periodicals, make sure that it uses language you can easily follow.

News Services & Press Releases Well before articles show up in newsletters or the popular press, they may appear in the form of a press release or a public relations announcement. One of the simplest ways of tracking press releases on sleep apnea is to search the news wires. News wires are used by professional journalists, and have existed since the invention of the telegraph. Today, there are several major “wires” that are used by companies, universities, and other organizations to announce new medical breakthroughs. In the following sample of sources, we will briefly describe how to access each service. These services only post recent news intended for public viewing.

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PR Newswire Perhaps the broadest of the wires is PR Newswire Association, Inc. To access this archive, simply go to http://www.prnewswire.com. Below the search box, select the option “The last 30 days.” In the search box, type “sleep apnea” or synonyms. The search results are shown by order of relevance. When reading these press releases, do not forget that the sponsor of the release may be a company or organization that is trying to sell a particular product or therapy. Their views, therefore, may be biased. The following is typical of press releases that can be found on PR Newswire: New Study Reveals People Unaware of Massage Benefits for Seniors Summary: Boca Raton, Fla., May 21 /PRNewswire/ -- With 76 million baby boomers expected to have less tolerance for pain than previous generations, the words "Oh, my aching ... " will be more popular than ever when it applies to back, knee, feet, etc. pain. In an effort to ease physical discomforts, Med Gen Inc. (OTC Bulletin Board: MGNI) is introducing FDA cleared ComfortCare(TM), elastic compression supports with magnets, serving as a non-invasive treatment to the painful discomforts that are associated with the wear and tear of everyday strain and repetitive action athletic activities. ComfortCare (http://www.first-aidcomfortcare.com) neoprene and latex-free supports provide orthopedic firmness and compression to the injured area by contouring to the body without bunching or binding. The current FDA clearance has approved the supports as an effective treatment to help relieve physical discomforts due to muscle stress, strain and sprains, and their Absortek(R) Perspiration Control material, which provides for absorption and venting of perspiration to minimize potential for skin irritation, and a long term barrier against bacterial growth. The ComfortCare line includes six support products - back, knee, ankle, wrist, elbow and feet. "With consumers spending approximately $1.6 billion annually on firstaid products for alleviating physical discomfort, drug-free health care has become a way of life many Americans take seriously," says Paul Mitchell, president of Med Gen. "We believe this product will be the answer to many consumers' minor pains and injuries. Everyone from professional athletes to seniors to weekend warriors experience everyday minor physical discomforts-and, it is our goal to deliver safe, effective, approved products to help ease their pains." The ComfortCare line includes:

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* Back Compression Support with Magnets ($31.95) - alleviates lower back discomfort related to strain of bending, lifting, twists, turns, golfing, weightlifting, etc.

* Knee Compression Support with Magnets ($31.95) - helps relieve strain and sprain injuries associated with repetitive-motions activities, such as soccer, climbing, jogging, etc.

* Wrist Compression Support with Magnets ($16.95) - provides comfort and compression for overexertion due to repetitive actions related to typing, in-line skating, bowling, etc.

* Elbow Compression Support with Magnets ($20.95) - protects and supports muscles and helps relieve strain of repetitive injuries associated with tennis, volleyball, racquetball, etc. * Ankle Compression Support with Magnets ($19.95) - keeps the ankle moving, fully-supported and protected from discomfort or potential injuries due to walking, running, athletic activity, etc. * Magnetic Insole ($17.50) - provides comfort and hygiene, with perspiration control to keep feet dry, along with anti-bacterial, antifungal, and anti-odor surface agents. ComfortCare supports with magnets can be found by visiting http://www.first-aidcomfortcare.com or by calling 1-800-521-9311. ComfortCare will be available at retail outlets in late fall of 2002. Med Gen markets other drug-free health care products, notably SNORenz(R), (http://www.snorenz.com) which are sold in the sleep-aid section of leading drug, supermarket and mass market retailers, including Walgreens, Eckerd and others. About Med Gen Inc. Founded in 1996, Med Gen Inc. (OTCC Bulletin Board: MGNI) manufactures, markets and licenses drug-free health care products,

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specifically to the health self-care market. The company's product line includes its flagship brand SNORenz(R), a liquid-based throat spray, which reduces the sounds ordinarily associated with snoring and ComfortCare(TM), compression support devices with magnets, which has received two FDA approvals for its six products -- back, knee, ankle, wrist, elbow and feet. ComfortCare products reduce physical discomfort associated with aches and painful injuries due to muscle stress, strain and sprains. ComfortCare products are presently available through its website, and retail distribution is planned for late fall 2002. SNORenz(R) products are marketed and sold by more than 25,000 retail stores nationwide and approximately 5,000 stores outside the United States, and via the Internet. This Press Release contains or incorporates by reference "forward-looking statements" including certain information with respect to plans and strategies of Med Gen Inc. (MedGen(TM)). For this purpose, any statement contained herein or incorporated herein, by reference that are not statements of historical fact may be deemed forward looking statements. Without limiting the foregoing, the "believes," "suggests," "anticipates," "plans," "expects," and similar expressions are intended to identify forward-looking statements. There a number of events or actual results of MedGen(TM) operations that could differ materially from those indicated by such forward looking statements. Reuters The Reuters’ Medical News database can be very useful in exploring news archives relating to sleep apnea. While some of the listed articles are free to view, others can be purchased for a nominal fee. To access this archive, go to http://www.reutershealth.com/frame2/arch.html and search by “sleep apnea” (or synonyms). The following was recently listed in this archive for sleep apnea: Study links sleep apnea with risk of blood clots Source: Reuters Health eLine Date: May 21, 2002 http://www.reuters.gov/archive/2002/05/21/eline/links/20020521elin 007.html

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Israeli study doubts laser surgery for sleep apnea Source: Reuters Health eLine Date: April 15, 2002 http://www.reuters.gov/archive/2002/04/15/eline/links/20020415elin 020.html Favorable results of laser surgery for sleep apnea deteriorate with time Source: Reuters Medical News Date: April 15, 2002 http://www.reuters.gov/archive/2002/04/15/professional/links/20020 415clin009.html Pediatricians advised to screen children for snoring, sleep apnea Source: Reuters Medical News Date: April 04, 2002 http://www.reuters.gov/archive/2002/04/04/professional/links/20020 404prof001.html Sleep apnea common in men with idiopathic intracranial hypertension Source: Reuters Medical News Date: April 02, 2002 http://www.reuters.gov/archive/2002/04/02/professional/links/20020 402clin003.html Doctor should screen kids for snoring, sleep apnea Source: Reuters Health eLine Date: April 01, 2002 http://www.reuters.gov/archive/2002/04/01/eline/links/20020401elin 008.html Dental appliance beats surgery for sleep apnea Source: Reuters Health eLine Date: March 27, 2002 http://www.reuters.gov/archive/2002/03/27/eline/links/20020327elin 007.html Dental appliances improves sleep apnea index without adverse effects Source: Reuters Medical News Date: March 26, 2002 http://www.reuters.gov/archive/2002/03/26/professional/links/20020 326clin020.html

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Support program increases compliance rates with CPAP for sleep apnea Source: Reuters Medical News Date: March 15, 2002 http://www.reuters.gov/archive/2002/03/15/professional/links/20020 315clin003.html Speeding up heartbeat may improve sleep apnea Source: Reuters Health eLine Date: February 06, 2002 http://www.reuters.gov/archive/2002/02/06/eline/links/20020206elin 014.html Narrow upper airway may contribute to sleep apnea Source: Reuters Medical News Date: February 06, 2002 http://www.reuters.gov/archive/2002/02/06/professional/links/20020 206clin017.html Narrow throat may cause sleep apnea Source: Reuters Health eLine Date: February 06, 2002 http://www.reuters.gov/archive/2002/02/06/eline/links/20020206elin 022.html Atrial overdrive pacing reduces sleep apnea episodes in bradycardia patients Source: Reuters Medical News Date: February 06, 2002 http://www.reuters.gov/archive/2002/02/06/professional/links/20020 206clin008.html Obstructive sleep apnea linked to peripheral vasoconstriction Source: Reuters Medical News Date: January 28, 2002 http://www.reuters.gov/archive/2002/01/28/professional/links/20020 128clin005.html Preeclampsia augments obstructive sleep apnea Source: Reuters Medical News Date: December 17, 2001 http://www.reuters.gov/archive/2001/12/17/professional/links/20011 217clin001.html

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Size of upper airway explains lower prevalence of sleep apnea in women Source: Reuters Medical News Date: November 27, 2001 http://www.reuters.gov/archive/2001/11/27/professional/links/20011 127clin002.html Minor orthodontic changes seen with mandibular advancement for sleep apnea Source: Reuters Industry Breifing Date: October 15, 2001 http://www.reuters.gov/archive/2001/10/15/business/links/20011015 clin009.html CPAP improves cardiac function in sleep apnea patients Source: Reuters Medical News Date: October 09, 2001 http://www.reuters.gov/archive/2001/10/09/professional/links/20011 009clin005.html Cephalon's Provigil looks promising as adjunct in sleep apnea patients Source: Reuters Industry Breifing Date: October 09, 2001 http://www.reuters.gov/archive/2001/10/09/business/links/20011009 clin006.html Sleep apnea ups risk of postsurgical complication Source: Reuters Health eLine Date: September 25, 2001 http://www.reuters.gov/archive/2001/09/25/eline/links/20010925elin 009.html Short trial of CPAP for sleep apnea predicts long-term use Source: Reuters Medical News Date: September 05, 2001 http://www.reuters.gov/archive/2001/09/05/professional/links/20010 905clin007.html Sleep apnea-hypopnea linked to elevated VEGF Source: Reuters Medical News Date: August 24, 2001 http://www.reuters.gov/archive/2001/08/24/professional/links/20010 824clin003.html

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Short-term followup advised after provision of mandibular advancement device for sleep apnea Source: Reuters Medical News Date: August 10, 2001 http://www.reuters.gov/archive/2001/08/10/professional/links/20010 810clin009.html Nasal corticosteroid may ameliorate pediatric obstructive sleep apnea Source: Reuters Industry Breifing Date: July 04, 2001 http://www.reuters.gov/archive/2001/07/04/business/links/20010704 clin012.html Sleep apnea twice as common in bronchitis patients as in healthy subjects Source: Reuters Medical News Date: July 03, 2001 http://www.reuters.gov/archive/2001/07/03/professional/links/20010 703epid004.html Mandibular advancement splint may improve treatment of sleep apnea Source: Reuters Medical News Date: June 21, 2001 http://www.reuters.gov/archive/2001/06/21/professional/links/20010 621clin005.html Treating sleep apnea reduces car crash risk Source: Reuters Health eLine Date: June 19, 2001 http://www.reuters.gov/archive/2001/06/19/eline/links/20010619elin 009.html ApoE e4 associated with sleep apnea Source: Reuters Medical News Date: June 13, 2001 http://www.reuters.gov/archive/2001/06/13/professional/links/20010 613epid001.html Sleep apnea linked to Alzheimer's gene Source: Reuters Health eLine Date: June 12, 2001 http://www.reuters.gov/archive/2001/06/12/eline/links/20010612elin 009.html

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Oral CPAP an option for sleep apnea patients Source: Reuters Industry Breifing Date: June 12, 2001 http://www.reuters.gov/archive/2001/06/12/business/links/20010612 clin009.html Positive airway pressure not effective in sleep apnea without daytime sleepiness Source: Reuters Medical News Date: June 06, 2001 http://www.reuters.gov/archive/2001/06/06/professional/links/20010 606clin004.html Sleep apnea--a culprit in heart disease Source: Reuters Health eLine Date: March 28, 2001 http://www.reuters.gov/archive/2001/03/28/eline/links/20010328elin 034.html HRT decreases risk of sleep apnea in postmenopausal women Source: Reuters Industry Breifing Date: March 23, 2001 http://www.reuters.gov/archive/2001/03/23/business/links/20010323 epid001.html Sleep bruxism associated with obstructive sleep apnea Source: Reuters Medical News Date: January 23, 2001 http://www.reuters.gov/archive/2001/01/23/professional/links/20010 123epid005.html Risk of vision loss due to papilledema increased in sleep apnea patients Source: Reuters Medical News Date: January 11, 2001 http://www.reuters.gov/archive/2001/01/11/professional/links/20010 111clin001.html Nocturnal hemodialysis effective for sleep apnea in chronic renal failure patients Source: Reuters Medical News Date: January 10, 2001 http://www.reuters.gov/archive/2001/01/10/professional/links/20010 110clin004.html

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Night dialysis aids kidney patients with sleep apnea Source: Reuters Health eLine Date: January 10, 2001 http://www.reuters.gov/archive/2001/01/10/eline/links/20010110elin 004.html CPAP restores abnormally low nitric oxide levels in sleep apnea patients Source: Reuters Medical News Date: December 29, 2000 http://www.reuters.gov/archive/2000/12/29/professional/links/20001 229clin020.html Sleep apnea-hypopnea improves with moderate weight loss Source: Reuters Medical News Date: December 20, 2000 http://www.reuters.gov/archive/2000/12/20/professional/links/20001 220epid001.html BMI associated with asthma in patients with obstructive sleep apnea Source: Reuters Medical News Date: October 27, 2000 http://www.reuters.gov/archive/2000/10/27/professional/links/20001 027epid008.html Side-sleeping can help sleep apnea patients Source: Reuters Health eLine Date: October 24, 2000 http://www.reuters.gov/archive/2000/10/24/eline/links/20001024elin 013.html Obstructive sleep apnea common in patients with refractory epilepsy Source: Reuters Medical News Date: October 19, 2000 http://www.reuters.gov/archive/2000/10/19/professional/links/20001 019clin015.html Epilepsy may sometimes cause sleep apnea Source: Reuters Health eLine Date: October 13, 2000 http://www.reuters.gov/archive/2000/10/13/eline/links/20001013elin 031.html

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Vital Signs gets US market clearance for sleep apnea device Source: Reuters Industry Breifing Date: September 08, 2000 http://www.reuters.gov/archive/2000/09/08/business/links/20000908 rglt003.html Single observation night not sufficient for diagnosis of sleep apnea Source: Reuters Medical News Date: August 15, 2000 http://www.reuters.gov/archive/2000/08/15/professional/links/20000 815clin019.html Low energy may be due to sleep apnea Source: Reuters Health eLine Date: August 10, 2000 http://www.reuters.gov/archive/2000/08/10/eline/links/20000810elin 001.html "Mini tracheostomy" shows promise for treatment of obstructive sleep apnea Source: Reuters Medical News Date: June 21, 2000 http://www.reuters.gov/archive/2000/06/21/professional/links/20000 621clin003.html Sleep apnea more prevalent, severe in postmenopausal women Source: Reuters Medical News Date: May 11, 2000 http://www.reuters.gov/archive/2000/05/11/professional/links/20000 511clin016.html Laser assisted uvulopalatoplasty not recommended for obstructive sleep apnea Source: Reuters Medical News Date: May 08, 2000 http://www.reuters.gov/archive/2000/05/08/professional/links/20000 508clin006.html Polysomnography necessary to diagnose sleep apnea in children correctly Source: Reuters Medical News Date: May 05, 2000 http://www.reuters.gov/archive/2000/05/05/professional/links/20000 505clin007.html

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The NIH Within MEDLINEplus, the NIH has made an agreement with the New York Times Syndicate, the AP News Service, and Reuters to deliver news that can be browsed by the public. Search news releases at http://www.nlm.nih.gov/medlineplus/alphanews_a.html. MEDLINEplus allows you to browse across an alphabetical index. Or you can search by date at http://www.nlm.nih.gov/medlineplus/newsbydate.html. Often, news items are indexed by MEDLINEplus within their search engine.

Business Wire Business Wire is similar to PR Newswire. To access this archive, simply go to http://www.businesswire.com. You can scan the news by industry category or company name. Internet Wire Internet Wire is more focused on technology than the other wires. To access this site, go to http://www.internetwire.com and use the “Search Archive” option. Type in “sleep apnea” (or synonyms). As this service is oriented to technology, you may wish to search for press releases covering diagnostic procedures or tests that you may have read about. Search Engines Free-to-view news can also be found in the news section of your favorite search engines (see the health news page at Yahoo: http://dir.yahoo.com/Health/News_and_Media/, or use this Web site’s general news search page http://news.yahoo.com/. Type in “sleep apnea” (or synonyms). If you know the name of a company that is relevant to sleep apnea, you can go to any stock trading Web site (such as www.etrade.com) and search for the company name there. News items across various news sources are reported on indicated hyperlinks.

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BBC Covering news from a more European perspective, the British Broadcasting Corporation (BBC) allows the public free access to their news archive located at http://www.bbc.co.uk/. Search by “sleep apnea” (or synonyms).

Newsletters on Sleep Apnea Given their focus on current and relevant developments, newsletters are often more useful to patients than academic articles. You can find newsletters using the Combined Health Information Database (CHID). You will need to use the “Detailed Search” option. To access CHID, go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. Your investigation must limit the search to “Newsletter” and “sleep apnea.” Go to the bottom of the search page where “You may refine your search by.” Select the dates and language that you prefer. For the format option, select “Newsletter.” By making these selections and typing in “sleep apnea” or synonyms into the “For these words:” box, you will only receive results on newsletters. The following list was generated using the options described above: Wake-Up Call: The Wellness Letter for Snoring and Apnea Source: Washington, DC: American Sleep Apnea Association. 1994-. Contact: Available from American Sleep Apnea Association, 2025 Pennsylvania Avenue, NW, Suite 905, Washington, DC 20006. (202) 2933650, (202) 293-3656 (Fax), [email protected] (Email), http://[email protected] (Website). Free with membership fee of $25.00 to persons living in the U.S.; membership fee is $50.00 for persons living outside the U.S. Summary: This newsletter is intended to keep snorers and sufferers of sleep apnea up to date on the treatment and management of these conditions. A typical issue includes articles on treatment and management, medical complications associated with the disorders (e.g., cardiovascular disease), risk factors for apnea, funding for research, patient advocacy, health policy, and public health campaigns; a questionand-answer column written by a sleep disorders specialist; and information on the activities of the AWAKE (Alert, Well and Keeping Energetic) Network, a nationwide network of mutual help and health awareness groups for individuals who suffer from sleep-disordered breathing.

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Academic Periodicals covering Sleep Apnea Academic periodicals can be a highly technical yet valuable source of information on sleep apnea. We have compiled the following list of periodicals known to publish articles relating to sleep apnea and which are currently indexed within the National Library of Medicine’s PubMed database (follow hyperlinks to view more information, summaries, etc., for each). In addition to these sources, to keep current on articles written on sleep apnea published by any of the periodicals listed below, you can simply follow the hyperlink indicated or go to the following Web site: www.ncbi.nlm.nih.gov/pubmed. Type the periodical’s name into the search box to find the latest studies published. If you want complete details about the historical contents of a periodical, you can also visit http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi. Here, type in the name of the journal or its abbreviation, and you will receive an index of published articles. At http://locatorplus.gov/ you can retrieve more indexing information on medical periodicals (e.g. the name of the publisher). Select the button “Search LOCATORplus.” Then type in the name of the journal and select the advanced search option “Journal Title Search.” The following is a sample of periodicals which publish articles on sleep apnea: Annals of the New York Academy of Sciences. (Ann N Y Acad Sci) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=An nals+of+the+New+York+Academy+of+Sciences&dispmax=20&dispstart =0 Current Opinion in Pulmonary Medicine. (Curr Opin Pulm Med) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Cu rrent+Opinion+in+Pulmonary+Medicine&dispmax=20&dispstart=0 International Journal of Oral and Maxillofacial Surgery. (Int J Oral Maxillofac Surg) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Int ernational+Journal+of+Oral+and+Maxillofacial+Surgery&dispmax=20& dispstart=0 Psychiatry and Clinical Neurosciences. (Psychiatry Clin Neurosci) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Ps ychiatry+and+Clinical+Neurosciences&dispmax=20&dispstart=0

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Respiration Physiology. (Respir Physiol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Re spiration+Physiology&dispmax=20&dispstart=0

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CHAPTER 9. PHYSICIAN GUIDELINES AND DATABASES Overview Doctors and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internet-based guidelines created or written for this professional audience.

NIH Guidelines For the more common diseases, The National Institutes of Health publish guidelines that are frequently consulted by physicians. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/ National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html National Heart, Lung, and Blood Institute (NHLBI); guidelines available at http://www.nhlbi.nih.gov/guidelines/index.htm

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The NHLBI, in particular, suggests the following publications to physicians: Sleep Disorders Restless Legs Syndrome: Detection and Management in Primary Care: http://www.nhlbi.nih.gov/health/prof/sleep/rls_gde.htm Sleep Apnea: Is Your Patient at Risk?: http://www.nhlbi.nih.gov/health/prof/sleep/slpaprsk.htm Insomnia: Assessment and Management in Primary Care: http://www.nhlbi.nih.gov/health/prof/sleep/insom_pc.htm Problem Sleepiness in Your Patient: http://www.nhlbi.nih.gov/health/prof/sleep/pslp_pat.htm Working Group Report on Problem Sleepiness: http://www.nhlbi.nih.gov/health/prof/sleep/pslp_wg.htm National Center on Sleep Disorders Pamphlet: http://www.nhlbi.nih.gov/health/prof/sleep/sleep.txt Sleep in Youth Awake At the Wheel Materials: http://www.nhlbi.nih.gov/health/public/sleep/aaw/awake.htm Educating Youth About Sleep and Drowsy Driving: http://www.nhlbi.nih.gov/health/prof/sleep/dwydrv_y.htm Drowsy Driving and Automobile Crashes: http://www.nhlbi.nih.gov/health/prof/sleep/drsy_drv.htm Additional Resources National Center on Sleep Disorders Research Web Site: http://www.nhlbi.nih.gov/about/ncsdr/index.htm Trans-NIH Sleep Research Coordinating Committee Annual Report: http://www.nhlbi.nih.gov/health/prof/sleep/sleep00.htm Sleep Disorders Research Advisory Board (SDRAB): http://www.nhlbi.nih.gov/meetings/sdrab/index.htm National Sleep Disorders Research Plan: http://www.nhlbi.nih.gov/health/prof/sleep/reschpln.htm List of Publications: http://www.nhlbi.nih.gov/health/pubs/index.htm

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Information Center: http://www.nhlbi.nih.gov/health/infoctr/index.htm Sleep Information for Patients/Public: http://www.nhlbi.nih.gov/health/public/sleep/index.htm

NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.27 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:28 Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/ Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs,

27 Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 28 See http://www.nlm.nih.gov/databases/databases.html.

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fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/ Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html While all of the above references may be of interest to physicians who study and treat sleep apnea, the following are particularly noteworthy.

The Combined Health Information Database A comprehensive source of information on clinical guidelines written for professionals is the Combined Health Information Database. You will need to limit your search to “Brochure/Pamphlet,” “Fact Sheet,” or “Information Package” and sleep apnea using the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For the publication date, select “All Years,” select your preferred language, and the format option “Fact Sheet.” By

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making these selections and typing “sleep apnea” (or synonyms) into the “For these words:” box above, you will only receive results on fact sheets dealing with sleep apnea. The following is a sample result: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report Source: Bethesda, MD, National Institutes of Health, National Heart, Lung, and Blood Institute, 258 p., September 1998. Contact: National Institutes of Health, National Heart, Lung, and Blood Institute, NHLBI Information Center, P.O. Box 30105, Bethesda, MD 20824. NIH Publication No. 98-4083. Summary: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report is the result of a 1995 panel consisting of experts from the National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases. This panel convened because of the recognition that the prevalence of overweight and obesity in the United States is increasing, and that practitioners need to be alerted to the accompanying health risks. Evidence examined by the panel included (1) research on the relationship of overweight and obesity to hypertension, high cholesterol, type two diabetes, stroke, congestive heart failure, coronary heart disease, cancer, osteoarthritis, and sleep apnea; (2) risks associated with the distribution and amount of body fat; and (3) various treatment strategies, including diet, physical activity, behavior therapy, pharmacotherapy, and surgery. This report is organized into seven sections: (1) Introduction, (2) a background on overweight and obesity, (3) examination of randomized controlled trial evidence, (4) treatment guidelines, (5) summary of recommendations, (6) future research, and (7) appendixes. The recommendations are divided into seven categories: (1) Advantages of weight loss, (2) measurement and degree of overweight and obesity, (3) goals for weight loss, (4) how to achieve weight loss, (5) goals for weight maintenance, (6) how to maintain weight loss, and (7) special treatment groups. The guidelines are intended to help the health care practitioner understand the importance of weight management, and provide practitioners with the tools to assess and treat patients more effectively. Narcolepsy: A Guide to Understanding Source: New York, NY: Narcolepsy Network, Inc. 28 p. Contact: Available from Narcolepsy Network, Inc. P.O. Box 1365, FDR Station, New York NY 10150. (914) 834-2855. PRICE: $4.75.

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Summary: This booklet report by the Narcolepsy Network describes narcolepsy, its incidence and impact on those affected by the disorder. Symptoms, causes, diagnosis, and its relation to sleep apnea are described. Information is also presented about possible treatments for the disorder and the social implications of having narcolepsy. 28 References. The NLM Gateway29 The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM’s information resources or databases.30 One target audience for the Gateway is the Internet user who is new to NLM’s online resources and does not know what information is available or how best to search for it. This audience may include physicians and other healthcare providers, researchers, librarians, students, and, increasingly, patients, their families, and the public.31 To use the NLM Gateway, simply go to the search site at http://gateway.nlm.nih.gov/gw/Cmd. Type “sleep apnea” (or synonyms) into the search box and click “Search.” The results will be presented in a tabular form, indicating the number of references in each database category.

Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH). 31 Other users may find the Gateway useful for an overall search of NLM’s information resources. Some searchers may locate what they need immediately, while others will utilize the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 29

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Results Summary Category Items Found Journal Articles 9805 Books / Periodicals / Audio Visual 160 Consumer Health 40 Meeting Abstracts 11 Other Collections 9 Total 10025

HSTAT32 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.33 HSTAT’s audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ’s Put Prevention Into Practice.34 Simply search by “sleep apnea” (or synonyms) at the following Web site: http://text.nlm.nih.gov. Coffee Break: Tutorials for Biologists35 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that may one day assist physicians in developing treatments. To this end, we Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. The HSTAT URL is http://hstat.nlm.nih.gov/. 34 Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force’s Guide to Clinical Preventive Services; the independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 35 Adapted from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. 32

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recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.36 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.37 This site has new articles every few weeks, so it can be considered an online magazine of sorts, and intended for general background information. You can access the Coffee Break Web site at http://www.ncbi.nlm.nih.gov/Coffeebreak/.

Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/. Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center’s MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html. Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/. MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical literature, and to explore relevant Web sites; see http://www.med.virginia.edu/~wmd4n/medweaver.html. Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language generally used by caregivers into terms from formal, controlled vocabularies; see http://www.lexical.com/Metaphrase.html. 36 The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 37 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process.

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The Genome Project and Sleep Apnea With all the discussion in the press about the Human Genome Project, it is only natural that physicians, researchers, and patients want to know about how human genes relate to sleep apnea. In the following section, we will discuss databases and references used by physicians and scientists who work in this area.

Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).38 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI’s Entrez database of MEDLINE articles and sequence information. Go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html to search the database. Type “sleep apnea” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases are overly technical and seldom used by the general public, but offer an abundance of information. The following is an example of the results you can obtain from the OMIM for sleep apnea: Glaucoma and Sleep Apnea Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?137763

38 Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.

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Genes and Disease (NCBI - Map) The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. This Web site categorizes each disorder by the system of the body associated with it. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: Metabolism: Food and energy. Examples: Adreno-leukodystrophy, Atherosclerosis, Best disease, Gaucher disease, Glucose galactose malabsorption, Gyrate atrophy, Juvenile onset diabetes, Obesity, Paroxysmal nocturnal hemoglobinuria, Phenylketonuria, Refsum disease, Tangier disease, Tay-Sachs disease. Web site: http://www.ncbi.nlm.nih.gov/disease/Metabolism.html Muscle and Bone: Movement and growth. Examples: Duchenne muscular dystrophy, Ellis-van Creveld syndrome, Marfan syndrome, myotonic dystrophy, spinal muscular atrophy. Web site: http://www.ncbi.nlm.nih.gov/disease/Muscle.html Nervous System: Mind and body. Examples: Alzheimer disease, Amyotrophic lateral sclerosis, Angelman syndrome, Charcot-Marie-Tooth disease, epilepsy, essential tremor, Fragile X syndrome, Friedreich’s ataxia, Huntington disease, NiemannPick disease, Parkinson disease, Prader-Willi syndrome, Rett syndrome, Spinocerebellar atrophy, Williams syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Brain.html Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html Transporters: Pumps and channels. Examples: Cystic Fibrosis, deafness, diastrophic dysplasia, Hemophilia A, long-QT syndrome, Menkes syndrome, Pendred syndrome, polycystic kidney disease, sickle cell anemia, Wilson’s disease, Zellweger syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Transporters.html

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Entrez Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo 3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo NCBI’s Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/ To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez/, and then select the database that you would like to search. The databases available are listed in

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the drop box next to “Search.” In the box next to “for,” enter “sleep apnea” (or synonyms) and click “Go.”

Jablonski’s Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database39 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html you can also search across syndromes using an alphabetical index. You can also search at http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database40 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB’s mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type “sleep apnea” (or synonyms) into the search box, and review the results. If 39 Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 40 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission.

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more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to non-professionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.

Specialized References The following books are specialized references written for professionals interested in sleep apnea (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): Clinical Companion to Sleep Disorders Medicine Second Edition by Sudhansu Chokroverty; Paperback - 232 pages, 2nd edition (April 2000), Butterworth-Heinemann Medical; ISBN: 0750696877; http://www.amazon.com/exec/obidos/ASIN/0750696877/icongroupinterna Concise Guide to Evaluation and Management of Sleep Disorders (Concise Guides) by Martin Reite, et al; Paperback 3rd edition (April 2002), American Psychiatric Press; ISBN: 1585620459; http://www.amazon.com/exec/obidos/ASIN/1585620459/icongroupinterna The Encyclopedia of Sleep and Sleep Disorders, Second Edition by Michael J. Thorpy, M.D, Jan Yager; Library Binding - 352 pages, 2nd Updated edition (May 2001), Facts on File, Inc.; ISBN: 0816040893; http://www.amazon.com/exec/obidos/ASIN/0816040893/icongroupinterna Sleep Disorders (Encyclopedia of Psychological Disorders) by Linda N. Bayer, et al; Library Binding (October 2000), Chelsea House Pub (Library); ISBN: 0791053148; http://www.amazon.com/exec/obidos/ASIN/0791053148/icongroupinterna Sleep Disorders: Diagnosis and Treatment by J. Steven Poceta (Editor), Merrill Morris Mitler (Editor); Hardcover - 232 pages, 1st edition (June 15, 1998), Humana Press; ISBN: 0896035271; http://www.amazon.com/exec/obidos/ASIN/0896035271/icongroupinterna Sleep Disorders and Neurological Disease by Antonio Culebras (Editor); Hardcover - 422 pages, 1st edition (October 15, 1999), Marcel Dekker; ISBN: 0824776054; http://www.amazon.com/exec/obidos/ASIN/0824776054/icongroupinterna Sleep Disorders Handbook by Peretz Lavie, M.D., et al; Paperback (March 2002), Boston Medical Pub Inc; ISBN: 1841840556; http://www.amazon.com/exec/obidos/ASIN/1841840556/icongroupinterna

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Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects by Sudhansu Chokroverty (Editor), Robert B. Daroff (Introduction); Hardcover - 781 pages, 2nd edition (January 15, 1999), Butterworth-Heinemann Medical; ISBN: 075069954X; http://www.amazon.com/exec/obidos/ASIN/075069954X/icongroupinterna

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CHAPTER 10. DISSERTATIONS ON SLEEP APNEA Overview University researchers are active in studying almost all known diseases. The result of research is often published in the form of Doctoral or Master’s dissertations. You should understand, therefore, that applied diagnostic procedures and/or therapies can take many years to develop after the thesis that proposed the new technique or approach was written. In this chapter, we will give you a bibliography on recent dissertations relating to sleep apnea. You can read about these in more detail using the Internet or your local medical library. We will also provide you with information on how to use the Internet to stay current on dissertations.

Dissertations on Sleep Apnea ProQuest Digital Dissertations is the largest archive of academic dissertations available. From this archive, we have compiled the following list covering dissertations devoted to sleep apnea. You will see that the information provided includes the dissertation’s title, its author, and the author’s institution. To read more about the following, simply use the Internet address indicated. The following covers recent dissertations dealing with sleep apnea: Affective Disturbance in Severe Obstructive Sleep Apnea Syndrome: Neuropsychological and Morphometric Concomitants by Brooks, Michael Paul; Phd from Brigham Young University, 2001, 111 pages http://wwwlib.umi.com/dissertations/fullcit/3012215

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Cognitive Executive Functions in Children with Mild Obstructive Sleep Apnea by Hedger, Kristen Marie; Phd from University of Michigan, 2001, 174 pages http://wwwlib.umi.com/dissertations/fullcit/3000961 Comparative Study between Automated and Continuous Positive Airway Pressure for Treatment of Obstructive Sleep Apnea by Shehadeh, Firass; Ms from The University of Texas at Arlington, 2000, 98 pages http://wwwlib.umi.com/dissertations/fullcit/1400202 Obstructive Sleep Apnea Syndrome: the Role of Perceptions of Illness and Treatment in Compliance Issues by Wong, Michi Hatashita; Phd from Fordham University, 2000, 193 pages http://wwwlib.umi.com/dissertations/fullcit/9981412 Prevalence of Proteinuria in the Obstructive Sleep Apnea Syndrome by Iliescu, Eduard Andrei; Msc from Queen's University at Kingston (canada), 2000, 69 pages http://wwwlib.umi.com/dissertations/fullcit/MQ54460 Psychosocial Adjustment in Obstructive Sleep Apnea Patients Treated with Continuous Positive Airway Pressure by Means, Melanie K.; Phd from The University of Memphis, 2001, 68 pages http://wwwlib.umi.com/dissertations/fullcit/3017968 The Associations of Cardiovascular Risk Factors and Sleep Apnea with White Matter Disease in the Brain Stem by Ding, Jingzhong; Phd from The Johns Hopkins University, 2002, 130 pages http://wwwlib.umi.com/dissertations/fullcit/3028258

Keeping Current As previously mentioned, an effective way to stay current on dissertations dedicated to sleep apnea is to use the database called ProQuest Digital Dissertations via the Internet, located at the following Web address: http://wwwlib.umi.com/dissertations. The site allows you to freely access the last two years of citations and abstracts. Ask your medical librarian if the library has full and unlimited access to this database. From the library, you should be able to do more complete searches than with the limited 2-year access available to the general public.

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PART III. APPENDICES

ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with sleep apnea and related conditions.

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APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with sleep apnea. While a number of hard copy or CD-Rom resources are available to patients and physicians for research purposes, a more flexible method is to use Internet-based databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for sleep apnea. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of sleep apnea. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.

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Your Medications: The Basics41 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of sleep apnea. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with sleep apnea take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid problems later. Here are some points to cover each time a new medicine is prescribed: Ask about all parts of your treatment, including diet changes, exercise, and medicines. Ask about the risks and benefits of each medicine or other treatment you might receive. Ask how often you or your doctor will check for side effects from a given medication. Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your doctor believes will work the best. Telling your doctor will help him or her select the best treatment for you. Do not be afraid to “bother” your doctor with your concerns and questions about medications for sleep apnea. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your doctor. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your doctor the following: The name of the medicine and what it is supposed to do. How and when to take the medicine, how much to take, and for how long. What food, drinks, other medicines, or activities you should avoid while taking the medicine. What side effects the medicine may have, and what to do if they occur. If you can get a refill, and how often. 41

This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.

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About any terms or directions you do not understand. What to do if you miss a dose. If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions). Do not forget to tell your doctor about all the medicines you are currently taking (not just those for sleep apnea). This includes prescription medicines and the medicines that you buy over the counter. Then your doctor can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your doctor, you may wish to prepare a list of medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: Name of medicine Reason taken Dosage Time(s) of day Also include any over-the-counter medicines, such as: Laxatives Diet pills Vitamins Cold medicine Aspirin or other pain, headache, or fever medicine Cough medicine Allergy relief medicine Antacids Sleeping pills Others (include names)

Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the medications your doctor has recommended for sleep apnea. One such source

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is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting USP DI Advice for the Patient can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially derived from lists of federally approved medications in the Food and Drug Administration’s (FDA) Drug Approvals database.42 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: To view http://www.nlm.nih.gov/medlineplus/druginformation.html. examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia (USP). It is important to read the disclaimer by the USP (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided.

Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to physicians and their institutions. You may be able to access these sources from your local medical library or your doctor’s office.

Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. The following medications are listed in the Reuters’ database as associated with sleep apnea (including those with contraindications):43 Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm. 43 Adapted from A to Z Drug Facts by Facts and Comparisons. 42

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Brompheniramine Maleate http://www.reutershealth.com/atoz/html/Brompheniramine_Maleate. htm Chlorpheniramine Maleate http://www.reutershealth.com/atoz/html/Chlorpheniramine_Maleate. htm Clemastine Fumarate http://www.reutershealth.com/atoz/html/Clemastine_Fumarate.htm Cyproheptadine HCl http://www.reutershealth.com/atoz/html/Cyproheptadine_HCl.htm Diphenhydramine HCl http://www.reutershealth.com/atoz/html/Diphenhydramine_HCl.htm Medroxyprogesterone Acetate http://www.reutershealth.com/atoz/html/Medroxyprogesterone_Acet ate.htm Promethazine HCl http://www.reutershealth.com/atoz/html/Promethazine_HCl.htm Protriptyline HCl http://www.reutershealth.com/atoz/html/Protriptyline_HCl.htm Quazepam http://www.reutershealth.com/atoz/html/Quazepam.htm Triprolidine HCl http://www.reutershealth.com/atoz/html/Triprolidine_HCl.htm

Mosby’s GenRx Mosby’s GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information in Mosby’s GenRx database can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html. Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand name, generic name or by indication. It features multiple drug interactions

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reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm.

Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information in the Pharmacopeia as well as commercial information. You may also want to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.

Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with sleep apnea--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat sleep apnea or potentially create deleterious side effects in patients with sleep apnea. You should ask your physician about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense. Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it’s especially important to read the label every time you use a

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medication. When your doctor prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take. The package insert provides more information about potential drug interactions.

A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with sleep apnea. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with sleep apnea. The FDA warns patients to watch out for44: Secret formulas (real scientists share what they know) Amazing breakthroughs or miracle cures (real breakthroughs don’t happen very often; when they do, real scientists do not call them amazing or miracles) Quick, painless, or guaranteed cures If it sounds too good to be true, it probably isn’t true. If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.

General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): Complete Guide to Prescription and Nonprescription Drugs 2001 (Complete Guide to Prescription and Nonprescription Drugs, 2001) by H. 44

This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.

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Winter Griffith, Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/039952634X/icongroupinterna The Essential Guide to Prescription Drugs, 2001 by James J. Rybacki, James W. Long; Paperback - 1274 pages (2001), Harper Resource; ISBN: 0060958162; http://www.amazon.com/exec/obidos/ASIN/0060958162/icongroupinterna Handbook of Commonly Prescribed Drugs by G. John Digregorio, Edward J. Barbieri; Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/0942447417/icongroupinterna Johns Hopkins Complete Home Encyclopedia of Drugs 2nd ed. by Simeon Margolis (Ed.), Johns Hopkins; Hardcover - 835 pages (2000), Rebus; ISBN: 0929661583; http://www.amazon.com/exec/obidos/ASIN/0929661583/icongroupinterna Medical Pocket Reference: Drugs 2002 by Springhouse Paperback 1st edition (2001), Lippincott Williams & Wilkins Publishers; ISBN: 1582550964; http://www.amazon.com/exec/obidos/ASIN/1582550964/icongroupinterna PDR by Medical Economics Staff, Medical Economics Staff Hardcover 3506 pages 55th edition (2000), Medical Economics Company; ISBN: 1563633752; http://www.amazon.com/exec/obidos/ASIN/1563633752/icongroupinterna Pharmacy Simplified: A Glossary of Terms by James Grogan; Paperback 432 pages, 1st edition (2001), Delmar Publishers; ISBN: 0766828581; http://www.amazon.com/exec/obidos/ASIN/0766828581/icongroupinterna Physician Federal Desk Reference by Christine B. Fraizer; Paperback 2nd edition (2001), Medicode Inc; ISBN: 1563373971; http://www.amazon.com/exec/obidos/ASIN/1563373971/icongroupinterna Physician’s Desk Reference Supplements Paperback - 300 pages, 53 edition (1999), ISBN: 1563632950; http://www.amazon.com/exec/obidos/ASIN/1563632950/icongroupinterna

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APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or doctor have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to sleep apnea. Finally, at the conclusion of this chapter, we will provide a list of readings on sleep apnea from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine’s (NCCAM) overview of complementary and alternative medicine.

What Is CAM?45 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also known as “preventive,” which means that the practitioner educates and 45

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.

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treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.

What Are the Domains of Alternative Medicine?46 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each. Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are

46

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.

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practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India’s traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body’s defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.

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Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.

Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine’s use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body’s systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.

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Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient’s recovery and that healing is promoted when the body’s energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your doctor who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.47

47

Adapted from http://www.4woman.gov/faq/alternative.htm.

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Is It Okay to Want Both Traditional and Alternative Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a physician or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.

Finding CAM References on Sleep Apnea Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for sleep apnea. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required. National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine’s databases to allow patients to search for articles that specifically relate to sleep apnea and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html. Select “CAM on PubMed.” Enter “sleep apnea” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to sleep apnea: A functional food product for the management of weight. Author(s): Bell SJ, Goodrick GK.

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Source: Critical Reviews in Food Science and Nutrition. 2002 March; 42(2): 163-78. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11934132&dopt=Abstract Acoustically induced cortical arousal increases phasic pharyngeal muscle and diaphragmatic EMG in NREM sleep. Author(s): Carlson DM, Carley DW, Onal E, Lopata M, Basner RC. Source: Journal of Applied Physiology (Bethesda, Md. : 1985). 1994 April; 76(4): 1553-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8045832&dopt=Abstract Altered brainstem sensory processing as assessed by reflex modification procedures in infants at risk for apnea. Author(s): Anday EK, Cohen ME, Daumit G, Hoffman HS. Source: Pediatric Research. 1989 December; 26(6): 576-82. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2602037&dopt=Abstract Alternative medicine and snoring. Author(s): Leo G. Source: Wis Med J. 1997 March; 96(3): 10-1. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9086849&dopt=Abstract An animal model for airway sensory deprivation producing obstructive apnea with postmortem findings of sudden infant death syndrome. Author(s): Abu-Osba YK, Mathew OP, Thach BT. Source: Pediatrics. 1981 December; 68(6): 796-801. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7322715&dopt=Abstract Arousal responses to inspiratory resistive loading during REM and non-REM sleep in normal men after short-term fragmentation/deprivation. Author(s): Gugger M, Keller U, Mathis J. Source: Schweiz Med Wochenschr. 1998 May 2; 128(18): 696-702. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9614333&dopt=Abstract

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Automobile driving in sleep apnea. Author(s): Findley LJ. Source: Prog Clin Biol Res. 1990; 345: 337-43; Discussion 344-5. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2198595&dopt=Abstract Autonomic response to auditory stimulation. Author(s): Anderssen SH, Nicolaisen RB, Gabrielsen GW. Source: Acta Paediatrica (Oslo, Norway : 1992). 1993 November; 82(11): 913-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8111169&dopt=Abstract Behavioral control of abnormal breathing in sleep. Author(s): Badia P, Harsh J, Culpepper J, Shaffer J. Source: Journal of Behavioral Medicine. 1988 December; 11(6): 585-92. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3252050&dopt=Abstract Brainstem auditory evoked potentials in adult and infant sleep apnea syndromes, including sudden infant death syndrome and near-miss for sudden infant death. Author(s): Stockard JJ. Source: Annals of the New York Academy of Sciences. 1982; 388: 443-65. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=6953881&dopt=Abstract Cerebellar Ataxia. Author(s): Perlman SL. Source: Curr Treat Options Neurol. 2000 May; 2(3): 215-224. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11096749&dopt=Abstract Changes in genioglossus muscle activity in obstructive sleep apnea patients with and without snore guard. Author(s): Zhao Y, Zeng X, Fu M, Huang X. Source: Chin J Dent Res. 2000 May; 3(1): 12-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11314334&dopt=Abstract

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Chronobiology and chronotherapy in medicine. Author(s): Kraft M, Martin RJ. Source: Dis Mon. 1995 August; 41(8): 501-75. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7628291&dopt=Abstract Client perceptions of the polysomnography experience and compliance with therapy. Author(s): van de Mortel TF, Laird P, Jarrett C. Source: Contemp Nurse. 2000 June; 9(2): 161-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11855005&dopt=Abstract Conditioned hyperventilation as a factor in animal, infant, and adult apnea: a theoretical analysis of experimental and clinical data. Author(s): Caldwell WE. Source: Genetic, Social, and General Psychology Monographs. 1986 August; 112(3): 325-41. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3770464&dopt=Abstract Controlled trial of hypnotherapy for weight loss in patients with obstructive sleep apnoea. Author(s): Stradling J, Roberts D, Wilson A, Lovelock F. Source: International Journal of Obesity and Related Metabolic Disorders Journal of the International Association for the Study of Obesity. 1998 March; 22(3): 278-81. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9539198&dopt=Abstract Craniomandibular status and function in patients with habitual snoring and obstructive sleep apnoea after nocturnal treatment with a mandibular advancement splint: a 2-year follow-up. Author(s): Bondemark L, Lindman R. Source: European Journal of Orthodontics. 2000 February; 22(1): 53-60. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10721245&dopt=Abstract Current status of medical and surgical therapy for obesity. Author(s): Mun EC, Blackburn GL, Matthews JB.

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Source: Gastroenterology. 2001 February; 120(3): 669-81. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11179243&dopt=Abstract Dental and skeletal changes associated with long-term mandibular advancement. Author(s): Robertson CJ. Source: Sleep. 2001 August 1; 24(5): 531-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11480650&dopt=Abstract Effect of induced transient arousal on obstructive apnea duration. Author(s): Basner RC, Onal E, Carley DW, Stepanski EJ, Lopata M. Source: Journal of Applied Physiology (Bethesda, Md. : 1985). 1995 April; 78(4): 1469-76. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7615457&dopt=Abstract Effects of nasal CPAP on simulated driving performance in patients with obstructive sleep apnoea. Author(s): George CF, Boudreau AC, Smiley A. Source: Thorax. 1997 July; 52(7): 648-53. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9246139&dopt=Abstract Evaluation and management of insomnia in menopause. Author(s): Jones CR, Czajkowski L. Source: Clinical Obstetrics and Gynecology. 2000 March; 43(1): 184-97. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10694999&dopt=Abstract Factors related to the efficacy of an adjustable oral appliance for the treatment of obstructive sleep apnea. Author(s): Liu Y, Lowe AA. Source: Chin J Dent Res. 2000 November; 3(3): 15-23. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11314530&dopt=Abstract First results on daytime submandibular electrostimulation of suprahyoidal muscles to prevent night-time hypopharyngeal collapse in obstructive sleep apnea syndrome.

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Author(s): Wiltfang J, Klotz S, Wiltfang J, Jordan W, Cohrs S, Engelbe W, Hajak G. Source: International Journal of Oral and Maxillofacial Surgery. 1999 February; 28(1): 21-5. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10065643&dopt=Abstract Health care management of adults with Down syndrome. Author(s): Smith DS. Source: American Family Physician. 2001 September 15; 64(6): 1031-8. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11578024&dopt=Abstract Individualizing the approach to treating obesity. Author(s): Ammon PK. Source: The Nurse Practitioner. 1999 February; 24(2): 27-31, 36-8, 41; Quiz 42-3. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10048077&dopt=Abstract Insulin resistance: lifestyle and nutritional interventions. Author(s): Kelly GS. Source: Alternative Medicine Review : a Journal of Clinical Therapeutic. 2000 April; 5(2): 109-32. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10767668&dopt=Abstract Lack of effect of external warming on sleep architecture in sleep apnea/hypopnea syndrome. Author(s): Dowdell WT, Javaheri S. Source: Am Rev Respir Dis. 1992 January; 145(1): 137-40. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1731577&dopt=Abstract Magnetic therapy is ineffective for the treatment of snoring and obstructive sleep apnea syndrome. Author(s): Dexter D Jr. Source: Wis Med J. 1997 March; 96(3): 35-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9086856&dopt=Abstract

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Modification of sleep respiratory patterns by auditory stimulation: indications of a technique for preventing sudden infant death syndrome? Author(s): Stewart MW, Stewart LA. Source: Sleep. 1991 June; 14(3): 241-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1896725&dopt=Abstract Non-CPAP treatment of obstructive sleep apnoea. Author(s): De Backer W. Source: Monaldi Arch Chest Dis. 1998 December; 53(6): 625-9. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10063334&dopt=Abstract Radiofrequency tissue volume reduction of the soft palate in simple snoring. Author(s): Hukins CA, Mitchell IC, Hillman DR. Source: Archives of Otolaryngology--Head & Neck Surgery. 2000 May; 126(5): 602-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10807327&dopt=Abstract Radiofrequency treatment of turbinate hypertrophy in subjects using continuous positive airway pressure: a randomized, double-blind, placebo-controlled clinical pilot trial. Author(s): Powell NB, Zonato AI, Weaver EM, Li K, Troell R, Riley RW, Guilleminault C. Source: The Laryngoscope. 2001 October; 111(10): 1783-90. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11801946&dopt=Abstract Resistive inspiratory muscle training in sleep-disordered breathing of traumatic tetraplegia. Author(s): Wang TG, Wang YH, Tang FT, Lin KH, Lien IN. Source: Archives of Physical Medicine and Rehabilitation. 2002 April; 83(4): 491-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11932850&dopt=Abstract Respiratory and electrocortical responses to acoustic stimulation. Author(s): Carley DW, Applebaum R, Basner RC, Onal E, Lopata M.

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Source: Sleep. 1996 December; 19(10 Suppl): S189-92. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9085507&dopt=Abstract Successful treatment of sleep apnea syndrome by transfusion of "vital energy". Author(s): Zhu SS. Source: Chin Med J (Engl). 1980 April; 93(4): 279-80. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=6768528&dopt=Abstract The art and science of continuous positive airway pressure therapy in obstructive sleep apnea. Author(s): Malhotra A, Ayas NT, Epstein LJ. Source: Current Opinion in Pulmonary Medicine. 2000 November; 6(6): 490-5. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11100958&dopt=Abstract The effects of transcutaneous electrical stimulation during wakefulness and sleep in patients with obstructive sleep apnea. Author(s): Edmonds LC, Daniels BK, Stanson AW, Sheedy PF 3rd, Shepard JW Jr. Source: Am Rev Respir Dis. 1992 October; 146(4): 1030-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1416392&dopt=Abstract Treatment of obstructive sleep apnea syndrome with a Kampo-formula, San'o-shashin-to: a case report. Author(s): Hisanaga A, Saitoh O, Fukuda H, Kurokawa K, Okabe A, Tachibana H, Hagino H, Mita T, Yamashita I, Tsutsumi M, Kurachi M, Itoh T. Source: Psychiatry and Clinical Neurosciences. 1999 April; 53(2): 303-5. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10459719&dopt=Abstract Ventilatory dynamics of transient arousal in patients with obstructive sleep apnea. Author(s): Khoo MC, Shin JJ, Asyali MH, Kim TS, Berry RB.

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Source: Respiration Physiology. 1998 June; 112(3): 291-303. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9749952&dopt=Abstract

Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: Alternative Medicine Foundation, Inc.: http://www.herbmed.org/ AOL: http://search.aol.com/cat.adp?id=169&layer=&from=subcats Chinese Medicine: http://www.newcenturynutrition.com/ drkoop.com : http://www.drkoop.com/InteractiveMedicine/IndexC.html Family Village: http://www.familyvillage.wisc.edu/med_altn.htm Google: http://directory.google.com/Top/Health/Alternative/ Healthnotes: http://www.thedacare.org/healthnotes/ Open Directory Project: http://dmoz.org/Health/Alternative/ TPN.com: http://www.tnp.com/ Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/ WebMD Health: http://my.webmd.com/drugs_and_herbs WellNet: http://www.wellnet.ca/herbsa-c.htm WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html The following is a specific Web list relating to sleep apnea; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: General Overview Sleep Apnea Source: Integrative Medicine Communications; www.onemedicine.com

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Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/SleepA pneacc.html Herbs and Supplements 5-Hydroxytryptophan Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Barbiturates Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Benzodiazepines Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Beta-Blockers Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Caffeine Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Chamomile Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html

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Diazepam Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Eucalyptus Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Primar yPulmonaryHypertensioncc.html Herbal Medicine Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Primar yPulmonaryHypertensioncc.html Hops Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Inositol Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Primar yPulmonaryHypertensioncc.html Insulin Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/SleepA pneacc.html Kava Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Kava Kava

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Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Kola Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Lavender Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Primar yPulmonaryHypertensioncc.html Lavender Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Lemon Balm Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Melatonin Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Mentha Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Rosemary Source: Integrative Medicine Communications; www.onemedicine.com

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Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Primar yPulmonaryHypertensioncc.html Selective Serotonin Reuptake Inhibitors Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Thyme Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Primar yPulmonaryHypertensioncc.html Triazolam Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Valerian Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Related Conditions Amyloidosis Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Amylo idosiscc.html Blood Pressure, High Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Hypert ensioncc.html

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High Blood Pressure Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Hypert ensioncc.html Hypertension Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Hypert ensioncc.html Insomnia Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Obesity Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Obesit ycc.html Pulmonary Hypertension Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Primar yPulmonaryHypertensioncc.html Sleeplessness Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html

General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at:

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www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): Alternative Medicine for Dummies by James Dillard (Author); Audio Cassette, Abridged edition (1998), Harper Audio; ISBN: 0694520659; http://www.amazon.com/exec/obidos/ASIN/0694520659/icongroupinterna Complementary and Alternative Medicine Secrets by W. Kohatsu (Editor); Hardcover (2001), Hanley & Belfus; ISBN: 1560534400; http://www.amazon.com/exec/obidos/ASIN/1560534400/icongroupinterna Dictionary of Alternative Medicine by J. C. Segen; Paperback-2nd edition (2001), Appleton & Lange; ISBN: 0838516211; http://www.amazon.com/exec/obidos/ASIN/0838516211/icongroupinterna Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating by Walter C. Willett, MD, et al; Hardcover - 352 pages (2001), Simon & Schuster; ISBN: 0684863375; http://www.amazon.com/exec/obidos/ASIN/0684863375/icongroupinterna Encyclopedia of Natural Medicine, Revised 2nd Edition by Michael T. Murray, Joseph E. Pizzorno; Paperback - 960 pages, 2nd Rev edition (1997), Prima Publishing; ISBN: 0761511571; http://www.amazon.com/exec/obidos/ASIN/0761511571/icongroupinterna Integrative Medicine: An Introduction to the Art & Science of Healing by Andrew Weil (Author); Audio Cassette, Unabridged edition (2001), Sounds True; ISBN: 1564558541; http://www.amazon.com/exec/obidos/ASIN/1564558541/icongroupinterna New Encyclopedia of Herbs & Their Uses by Deni Bown; Hardcover - 448 pages, Revised edition (2001), DK Publishing; ISBN: 078948031X; http://www.amazon.com/exec/obidos/ASIN/078948031X/icongroupinterna Textbook of Complementary and Alternative Medicine by Wayne B. Jonas; Hardcover (2003), Lippincott, Williams & Wilkins; ISBN: 0683044370; http://www.amazon.com/exec/obidos/ASIN/0683044370/icongroupinterna

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For additional information on complementary and alternative medicine, ask your doctor or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Apnoea: Cessation of breathing. [EU] Chronotherapy: The adaptation of the administration of drugs to circadian rhythms. The concept is based on the response of biological functions to time-related events, such as the low point in epinephrine levels between 10 p.m. and 4 a.m. or the elevated histamine levels between midnight and 4 a.m. The treatment is aimed at supporting normal rhythms or modifying therapy based on known variations in body rhythms. While chronotherapy is commonly used in cancer chemotherapy, it is not restricted to cancer therapy or to chemotherapy. [NIH] Gynecology: A medical-surgical specialty concerned with the physiology and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology. [NIH] Hyperventilation: A state in which there is an increased amount of air entering the pulmonary alveoli (increased alveolar ventilation), resulting in reduction of carbon dioxide tension and eventually leading to alkalosis. [EU] Menopause: The cessation of menstruation in the human female, which begins at about the age of 50. [NIH] Obstetrics: A medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium. [NIH] Reflex: 1; reflected. 2. a reflected action or movement; the sum total of any particular involuntary activity. [EU]

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APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, doctors have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, doctors and healthcare providers may recommend particular dietary supplements to patients with sleep apnea. Any dietary recommendation is based on a patient’s age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with sleep apnea may be given different recommendations. Some recommendations may be directly related to sleep apnea, while others may be more related to the patient’s general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of sleep apnea. We will then show you how to find studies dedicated specifically to nutrition and sleep apnea.

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Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and (6) minerals. Consuming a combination of these elements is considered to be a healthy diet: Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion. Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes. Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products. Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol. Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe. Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains. Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from

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nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs. Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish. Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat. Vitamin C allows the body’s immune system to fight various diseases, strengthens body tissue, and improves the body’s use of iron; food sources for vitamin C include a wide variety of fruits and vegetables. Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products. Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish. Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables. Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains. It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products. Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.

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Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste. Iodine helps regulate the body’s use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat. Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables. Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood. Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products. Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products. Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts. The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your doctor may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:48 DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs. DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium. 48

Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.

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RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.” RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge. What Are Dietary Supplements?49 Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”50 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.51 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where the use of plant products, in particular, has a long tradition. However, the This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 50 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail: [email protected]. 51 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 49

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overwhelming majority of supplements have not been studied scientifically. To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and symposia on scientific topics related to dietary supplements. The ODS often works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail: [email protected]

Finding Studies on Sleep Apnea The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.52 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back periodically as this database is frequently updated. More studies can be 52 Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture.

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found by searching the Full IBIDS Database. Healthcare professionals and researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Search” option that allows you to retrieve up to 100 fully explained references in a comprehensive format. Type “sleep apnea” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following information is typical of that found when using the “Full IBIDS Database” when searching using “sleep apnea” (or a synonym): Association of hypothyroidism and obstructive sleep apnea. Author(s): University of Washington, Seattle; and Group Health Cooperative of Puget Sound, Redmond, Washington, USA. [email protected] Source: Kapur, V K Koepsell, T D deMaine, J Hert, R Sandblom, R E Psaty, B M Am-J-Respir-Crit-Care-Med. 1998 November; 158(5 Pt 1): 1379-83 1073-449X Central sleep apnea-hypopnea syndrome in heart failure: prevalence, impact, and treatment. Author(s): Pulmonary Section, Veterans Administration Medical Center, Cincinnati, Ohio 45220, USA. Source: Javaheri, S Sleepage 1996 December; 19(10 Suppl): S229-31 01618105 Changes in breathing and the pharynx after weight loss in obstructive sleep apnea. Author(s): Pulmonary Division, University of Virginia School of Medicine, Charlottesville 22908. Source: Suratt, P M McTier, R F Findley, L J Pohl, S L Wilhoit, S C Chest. 1987 October; 92(4): 631-7 0012-3692 Clonidine and sleep apnea syndrome interaction: antagonism with yohimbine. Author(s): Department of Emergency Medicine, Western Pennsylvania Hospital, Pittsburgh 15224, USA. Source: Roberge, R J Kimball, E T Rossi, J Warren, J J-Emerg-Med. 1998 Sep-October; 16(5): 727-30 0736-4679 Effect of autonomic blockade on heart rate and blood pressure in sleep apnea syndrome. Author(s): Laboratoire du Sommeil, INSERM CJF 89 09, Hopital A. Beclere, Clamart, France. Source: Januel, B Laude, D Elghozi, J L Escourrou, P Blood-Press. 1995 July; 4(4): 226-31 0803-7051

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Effect of very-low-calorie diets with weight loss on obstructive sleep apnea. Author(s): Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville 22908. Source: Suratt, P M McTier, R F Findley, L J Pohl, S L Wilhoit, S C Am-JClin-Nutr. 1992 July; 56(1 Suppl): 182S-184S 0002-9165 Efficiency of continuous positive airway pressure versus theophylline therapy in sleep apnea: comparative sleep laboratory studies on objective and subjective sleep and awakening quality. Author(s): Division of Sleep Research and Pharmacopsychiatry, Department of Psychiatry, School of Medicine, University of Vienna, Austria. Source: Saletu, B Oberndorfer, S Anderer, P Gruber, G Divos, H Lachner, A Mandl, M Parapatics, S Popp, W Saletu, M Saletu Zyhlarz, G Sertl, K Strobl, R Tschida, U Winkler, A Neuropsychobiology. 1999; 39(3): 151-9 0302-282X Energy expenditure in obstructive sleep apnea. Author(s): Department of Medicine, University of British Columbia, Vancouver, Canada. Source: Ryan, C F Love, L L Buckley, P A Sleepage 1995 April; 18(3): 1807 0161-8105 Four cases of obstructive sleep apnea associated with treatmentresistant mania. Author(s): McLean Hospital, Belmont, MA 02178. Source: Strakowski, S M Hudson, J I Keck, P E Wilson, D R Frankenburg, F R Alpert, J E Teschke, G C Tohen, M J-Clin-Psychiatry. 1991 April; 52(4): 156-8 0160-6689 Impact of obstructive sleep apnea and sleepiness on metabolic and cardivascular risk factors in the Swedish Obese Subjects (SOS) study. Source: Grunstein, R.R. Stenlof, K. Sjostrom, L. Int-j-obes-relat-metabdisord. Avenel, NJ : The Macmillan Press Ltd. June 1995. volume 19 (6) page 410-418. Influence of chronic barbiturate administration on sleep apnea after hypersomnia presentation: case study. Author(s): Department of Psychiatry, University of Western Ontario. [email protected] Source: Takhar, J Bishop, J J-Psychiatry-Neurosci. 2000 September; 25(4): 321-4 1180-4882 Is sleep apnea a predisposing factor for tobacco use? Author(s): Department of Applied and Engineering Statistics, George Mason University, Fairfax VA, USA.

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Source: Schrand, J R Med-Hypotheses. 1996 December; 47(6): 443-8 03069877 Localization of site of obstruction in snorers and patients with obstructive sleep apnea syndrome: a comparison of fiberoptic nasopharyngoscopy and pressure measurements. Author(s): Department of Otorhinolaryngology, Ullevaal University Hospital, Oslo, Norway. Source: Skatvedt, O Acta-Otolaryngol. 1993 March; 113(2): 206-9 00016489 Long-term outcome for obstructive sleep apnea syndrome patients. Mortality. Author(s): Sleep Research Center, Stanford University School of Medicine. Source: Partinen, M Jamieson, A Guilleminault, C Chest. 1988 December; 94(6): 1200-4 0012-3692 Magnetic therapy is ineffective for the treatment of snoring and obstructive sleep apnea syndrome. Author(s): Luther/Midelfort Mayo Health System, Eau Claire, Wisconsin, USA. Source: Dexter, D Wis-Med-J. 1997 March; 96(3): 35-7 0043-6542 Medical treatment of sleep apnea. Author(s): Sleep Disorders Center, St. Boniface General Hospital, Winnipeg, Manitoba, Canada. Source: Wali, S O Kryger, M H Curr-Opin-Pulm-Med. 1995 November; 1(6): 498-503 1078-1641 Nonsurgical management of the obstructive sleep apnea patient. Author(s): Department of Oral and Maxillofacial Surgery, Baylor College of Dentistry, TX, USA. Source: Thornton, W K Roberts, D H J-Oral-Maxillofac-Surg. 1996 September; 54(9): 1103-8 0278-2391 Obesity and weight loss in obstructive sleep apnea: a critical review. Author(s): Department of Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick 08903-0019, USA. Source: Strobel, R J Rosen, R C Sleepage 1996 February; 19(2): 104-15 0161-8105 Obstructive sleep apnea in the Rubinstein-Taybi syndrome. Author(s): Sleep Disorders Center, State University, Milan, Italy. Source: Zucconi, M Ferini Strambi, L Erminio, C Pestalozza, G Smirne, S Respiration. 1993; 60(2): 127-32 0025-7931

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Obstructive sleep apnea syndrome: whom to treat and how to treat. Author(s): Stanford University Medical School. Source: Guilleminault, C Stoohs, R Prog-Clin-Biol-Res. 1990; 345417-25 0361-7742

Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: healthfinder®, HHS’s gateway to health information, including diet and nutrition: http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&page=0 The United States Department of Agriculture’s Web site dedicated to nutrition information: www.nutrition.gov The Food and Drug Administration’s Web site for federal food safety information: www.foodsafety.gov The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/ The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/ Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/ Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/ Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/

Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: AOL: http://search.aol.com/cat.adp?id=174&layer=&from=subcats

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Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html Google: http://directory.google.com/Top/Health/Nutrition/ Healthnotes: http://www.thedacare.org/healthnotes/ Open Directory Project: http://dmoz.org/Health/Nutrition/ Yahoo.com: http://dir.yahoo.com/Health/Nutrition/ WebMD Health: http://my.webmd.com/nutrition WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html The following is a specific Web list relating to sleep apnea; please note that any particular subject below may indicate either a therapeutic use, or a contraindication (potential danger), and does not reflect an official recommendation: Food and Diet Buffalo Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/SleepA pneacc.html Coffee Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Crackers Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Hypertension Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Primar yPulmonaryHypertensioncc.html

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Milk Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/Insom niacc.html Obesity Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/SleepA pneacc.html Sugar Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/SleepA pneacc.html Water Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/SleepA pneacc.html Weight Loss Source: Integrative Medicine Communications; www.onemedicine.com Hyperlink: http://www.drkoop.com/interactivemedicine/ConsConditions/SleepA pneacc.html

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrates: A nutrient that supplies simple or complex. Simple carbohydrates carbohydrates are called starch and compound—containing carbon, hydrogen,

4 calories/gram. They may be are called sugars, and complex fiber (cellulose). An organic and oxygen—that is formed by

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photosynthesis in plants. Carbohydrates are heat producing and are classified as monosaccharides, disaccharides, or polysaccharides. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Fetus: Unborn offspring from 7 or 8 weeks after conception until birth. [NIH] Hypothyroidism: Deficiency of thyroid activity. In adults, it is most common in women and is characterized by decrease in basal metabolic rate, tiredness and lethargy, sensitivity to cold, and menstrual disturbances. If untreated, it progresses to full-blown myxoedema. In infants, severe hypothyroidism leads to cretinism. In juveniles, the manifestations are intermediate, with less severe mental and developmental retardation and only mild symptoms of the adult form. When due to pituitary deficiency of thyrotropin secretion it is called secondary hypothyroidism. [EU] Intestinal: Pertaining to the intestine. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Otorhinolaryngology: That branch of medicine concerned with medical and surgical treatment of the head and neck, including the ears, nose and throat. [EU]

Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Yohimbine: An alkaloid that possesses adrenergic-blocking properties and is used in arteriosclerosis and angina pectoris, formerly used as a local anesthetic and mydriatic and for its purported aphrodisiac properties. [NIH]

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Finding Medical Libraries 221

APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.

Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM’s interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.53

53

Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.

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Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.

Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):54 Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/ Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html California: Gateway Health Library (Sutter Gould Medical Foundation) California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/ 54

Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.

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California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html California: San José PlaneTree Health Library, http://planetreesanjose.org/ California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html California: University of California, Davis. Health Sciences Libraries California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/ Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/ Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/ Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/

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Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/ Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/ Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/ Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/ Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/ Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10 Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml

Finding Medical Libraries 225

Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/ Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp Massachusetts: St. Luke’s Hospital Health Sciences Library (St. Luke’s Hospital), http://www.southcoast.org/library/ Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/ Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/ Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41

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National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/ National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/ Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld/ New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/ New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/ New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/ Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp

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Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/ Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/ Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/ South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/ Texas: Matustik Family Resource Center (Cook Children’s Health Care System), http://www.cookchildrens.com/Matustik_Library.html Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/ Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/

NIH Consensus Statement on the Treatment of Sleep Disorders of Older People 229

APPENDIX E. NIH CONSENSUS STATEMENT ON THE TREATMENT OF SLEEP DISORDERS OF OLDER PEOPLE Overview NIH Consensus Development Conferences are convened to evaluate available scientific information and resolve safety and efficacy issues related to biomedical technology. The resultant NIH Consensus Statements are intended to advance understanding of the technology or issue in question and to be useful to health professionals and the public.55 Each NIH consensus statement is the product of an independent, non-Federal panel of experts and is based on the panel’s assessment of medical knowledge available at the time the statement was written. Therefore, a consensus statement provides a “snapshot in time” of the state of knowledge of the conference topic. The NIH makes the following caveat: “When reading or downloading NIH consensus statements, keep in mind that new knowledge is inevitably accumulating through medical research. Nevertheless, each NIH consensus statement is retained on this website in its original form as a record of the NIH Consensus Development Program.”56 The following concensus statement was posted on the NIH site and not indicated as “out of date” in March 2002. It was originally published, however, in March 1990.57

55 This paragraph is adapted from the NIH: http://odp.od.nih.gov/consensus/cons/cons.htm. 56 Adapted from the NIH: http://odp.od.nih.gov/consensus/cons/consdate.htm. 57 The Treatment of Sleep Disorders of Older People. NIH Consensus Statement Online 1990 Mar 26-28 [cited 2002 February 21];8(3):1-22. http://consensus.nih.gov/cons/078/078_statement.htm

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Abstract The National Institutes of Health Consensus Development Conference on the Treatment of Sleep Disorders of Older People brought together clinical specialists in pulmonology, psychiatry, and psychology, geriatrics, internal medicine, other health care providers, and the public to address the cause, diagnosis, assessment, and specific treatments of sleep disorders of older people. Following 1 1/2 days of presentations by experts and discussion by the audience, a consensus panel weighed the scientific evidence and prepared a consensus statement. Among their findings, the panel concluded that although sleep patterns change during the aging process most older people with sleep disturbances suffer from any of a variety of medical and psychosocial disorders. The panel recommended that the diagnostic evaluation of sleep disorders begin with a careful clinical evaluation performed by an informed primary care physician. When necessary, referrals should be made to individuals or centers with specialized skills and tools for therapy. The panel recognized two types of disorders for which treatment may be beneficial: obstructive sleep apnea and insomnia. The mainstay for treatment for sleep apnea is the use of nasal continuous positive airway pressure. A thorough medical evaluation is essential prior to initiating treatment for insomnia, as its causes may be of psychiatric, pharmacological, or medical origin. The panel recommended that hypnotic medications not be the mainstay of treatment for insomnia as they may have habit forming potential if overused. The full text of the consensus panel’s statement follows.

What Is the Treatment of Sleep Disorders of Older People? The increase in the number of people over 65 and the rise in the proportion of older people represent a marked change in the demographic patterns in this country that will have profound social, economic, medical, and personal consequences. Individuals over 65 constituted 4 percent of the American population in 1900 and nearly 10 percent in 1972. By the year 2000, it is estimated that they will comprise over 13 percent of the population and by 2050 will represent more than 21 percent of Americans. A large proportion of older people are at risk for disturbances of sleep that may be caused by many factors such as retirement and changes in social patterns, death of spouse and close friends, increased use of medications,

NIH Consensus Statement on the Treatment of Sleep Disorders of Older People 231

concurrent diseases and changes in circadian rhythms. While changes in sleep patterns have been viewed as part of the normal aging process, new information indicates that many of these disturbances may be related to pathological processes that are associated with aging. Although the exact numbers are not yet known, it has been estimated that disturbances of sleep afflict more than half of the people 65 and older who live at home and about two-thirds of those who live in long-term care facilities. Problems in sleep and daytime wakefulness disrupt not only the lives of older persons but also those of their families and caregivers. People over 65 years of age now constitute almost 13 percent of the American population but consume over 30 percent of all dispensed prescription drugs, as well as an unknown percentage of over-the-counter medicines. A large proportion of these drugs are sedatives and hypnotic agents, the safety and efficacy of which have not been established for older people. Nor has it been established to what extent drugs contribute to or alleviate problems of sleep. It is necessary to understand the causes of these disorders and to develop better treatment strategies, including non-pharmacological methods. In addition to affecting the quality of life, troubled sleep has been implicated with excess mortality. Controversy also exists concerning the causes, diagnosis, assessment, and specific treatments of sleep disorders in older people. In an effort to assess the current state of knowledge and determine what changes in sleep are clinically important, how sleep disorders are best diagnosed and treated, and how the public can establish good sleep practices, the National Institute on Aging, the Office of Medical Applications of Research, the National Institute of Neurological Disorders and Stroke, and the National Heart, Lung, and Blood Institute of the National Institutes of Health and the National Institute of Mental Health, convened this conference. Following 1-1/2 days of presentations by experts in the relevant fields, a consensus panel consisting of representatives from neurology, psychiatry, internal medicine, geriatric medicine, pulmonology, otolaryngology--head and neck surgery, epidemiology, biostatistics, pharmacology, and the public considered evidence and formulated a consensus statement responding to these key questions: What are the changes in sleep and wakefulness as functions of aging and of diseases of older people? What are the diagnostic criteria that establish clinical abnormalities? Which are clinically and epidemiologically important?

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What are the indications for a diagnostic evaluation? What sequence of assessment methods should be used to determine if the diagnostic criteria are met? What are the indications for the treatment of sleep disorders? What are the common medical practices and lay treatment practices and their health implications? What should the medical profession and general public know about good sleep hygiene and treatment of sleep disorders, and what should be done to increase awareness? What are the directions for future research?

Sleep and Wakefulness of Older People Sleep is a distinctive and essential component of human behavior. Nearly a third of the life of a normal adult is spent sleeping. Sleep is divided into rapid eye movement (REM) and non-REM sleep. REM sleep is characterized by a low amplitude pattern in the EEG, an associated loss of muscle tone, and the presence of rapid eye movements. Non-REM sleep is characterized by sleep spindles and slow wave activity in the EEG. Sleep is differentially distributed into the dark portion of the daily cycle of light and dark. This regulation of sleep reflects basic brain mechanisms that provide the circadian organization of both behavioral and physiological processes. During aging there are typical changes in the pattern of sleep. The amount of time spent in deeper levels of sleep diminishes. There is an associated increase in awakenings during sleep and in the total amount of time spent awake during the night. In part, these changes appear to represent a loss of effective circadian regulation of sleep. In carefully screened, medically healthy, older subjects, there are relatively few individuals who have symptoms related to these changes in sleep and in the distribution of sleep and waking behaviors. Many older individuals, however, suffer from a variety of medical and psychosocial problems and these are very often associated with disturbances of sleep. These include psychiatric illnesses, particularly depression; Alzheimer’s disease and other neurodegenerative diseases; cardiovascular disease; upper airway incompetence; pulmonary disease; arthritis; pain syndromes; prostatic disease; endocrinopathies; and other illnesses.

NIH Consensus Statement on the Treatment of Sleep Disorders of Older People 233

The diagnostic categories that establish clinical abnormalities of sleep arise from two sets of data. The first is derived from evaluation of the patient’s history, which is classified into syndromes as have been described in the International Classification of Sleep Disorders. None of the disorders are specific for older people, but nearly all occur in this population. The second set comes from electrophysiological studies. Both provide valuable information, but each has its own limitations. There is little agreement among workers in the field about what is clinically normal and what is clinically abnormal, except in extreme cases (for example, high values of indices of sleep disordered breathing). Also, measurements are not obtained in a standardized way. Much needs to be learned, and an important first step is to decide upon a standardized approach to data collection. The new classification scheme is an important first step in the standardization process. In the assessment of the behavioral aspects of sleep, standardization is needed before epidemiological subpopulations can be defined and surveyed. The validity (including face validity) and reliability of standardized instruments and settings must be determined before sensitivity, specificity, and prevalence are assessed. Additional considerations are cost and ease of measurement. With standardized, agreed-upon instruments intra- and intersubject variability can be measured and linked with other clinical observations. Standardized approaches to data collection for both the clinician and the researcher are particularly important in the measurement of variations over time. In many situations clinical action is based on an inference that the patient’s condition has changed. If this judgment is guided by a psychometric instrument, then the reliability of the estimated change, in the presence of intrasubject variability, must be established. The rapid and thorough evaluation of new and existing technology will aid in the development of standardized approaches to data collection. The evaluation begins with the specification of the clinical need. Comparisons with competing technology must be made as objectively as possible, and the ideal research design for accomplishing this is the randomized double-blind clinical trial. It is difficult to answer questions about changes in sleep and wakefulness as functions of aging or of disease in older people because basic epidemiologic descriptive studies have not yet been carried out. Studies of the distribution of sleeping patterns and “disorders” need to be conducted in the

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“community” utilizing a representative sampling scheme so that the relationship of sleep patterns to possibly pertinent cultural, demographic, and other variables can be explored. There is a need for epidemiological studies of sleep disorders: international and cross-cultural comparisons and case-control studies may confirm and generate etiological hypotheses. The natural history of certain sleep disorders is not well described: Do they spontaneously remit? What is the relationship to cardiovascular disease and life expectancy? Cohort studies may help advance our understanding of the natural history of these disorders. Similarly, it is difficult to determine which diagnostic criteria are important in establishing clinical abnormalities. The field of sleep disorder research has largely approached this problem by attempting to separate “normal” from “abnormal” or “diseased.” However, population distributions of the phenomena employed as diagnostic criteria (e.g., periodic movements in sleep or apneic episodes) are not well described. Current threshold values are usually not validated; and test characteristics (sensitivity, specificity, predictive values) are largely unavailable. Furthermore, inter- and intraobserver variation in test interpretation has been rarely studied. While the severe forms of clinical entities, such as sleep apnea, are generally accepted and criteria agreed upon, mild and moderate forms are not well distinguished. Study of the distribution of these phenomena in populations, linking them to clinical outcomes, is lacking. For example, persons with a mild degree of periodic movements in sleep or apnea may be asymptomatic and not suffer any appreciable morbidity. It will be difficult to establish diagnostic criteria if the frequency of these events is not linked to natural history studies and eventual health outcomes and functional impairment.

Diagnostic Evaluation Diagnostic evaluation begins with the recognition of a potential disorder by patient history or physician suspicion. Screening questions should include: 1) patient satisfaction with his or her sleep; 2) intrusion of sleep or fatigue into daily activities; and 3) complaint by bed partner or other observers of unusual behavior during sleep. A positive response to these questions should trigger a more detailed history of the onset, severity, duration, and pattern of the complaint, and lead to a differential diagnosis.

NIH Consensus Statement on the Treatment of Sleep Disorders of Older People 235

Three major types of sleep complaints are excessive sleepiness (hypersomnia), difficulty in initiating or maintaining sleep (insomnia), and strange or unusual behavior during sleep (parasomnias). A careful medical history is needed to determine the presence and severity of concomitant disease. The history of snoring, breathing pauses, or periodic movements during sleep is sometimes better described by the bed partner or other observers. Prescribed medications, especially sedatives, alcohol use, and self medication can have a significant effect on sleep and may impair cardiopulmonary mechanisms during sleep. Psychiatric history and evaluation identify anxiety, depression, or major life events which are known to affect sleep habits or hygiene. In some cases the use of a patient sleep log to evaluate sleep/wakefulness patterns will serve to identify rhythmic or circadian disturbances or to document the magnitude of sleep intrusion into daily activities. Appropriate physical examination will depend upon the nature of the complaint and history elicited from the patient. For example, heavy snoring may necessitate a detailed examination of the nose and throat. Appropriate laboratory tests may be similarly indicated. Given additional training and education, primary care physicians should be capable of initial assessment and management of the majority of sleep disorders presenting in the older population. When necessary, referrals should be made to individuals or a center with recognized skills in the indications for and application of more specialized tools, such as polysomnography or multiple sleep latency tests for diagnosis and recommendations for therapy. Polysomnography is indicated when a sleep related breathing disorder is suspected and may be useful for certain behavior or movement disorders during sleep. Polysomnography followed by a multiple sleep latency test is useful for establishing the diagnosis of narcolepsy and for quantitating daytime sleepiness. At present, there are insufficient data to assess the value of polysomnography in the routine evaluation of insomnia, depression, or dementia. Limited monitoring on an ambulatory basis may be useful to assess efficacy of therapy for sleep apnea. Technologic advances, standardization of variables, and cost-effectiveness need to be addressed before incorporating ambulatory monitors into epidemiologic studies or the clinical practice of sleep disorders medicine.

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Treatment of Sleep Disorders The goals of therapy of sleep disorders can be classified as: Reducing morbidity; Reducing excess mortality; and Improving quality of life for patient and family. Sleep disorders have been classified extensively. The major focus of this conference could, however, be summarized as dealing with two primary types of complaints or disorders, for which there is evidence to suggest that treatment is beneficial. These consist of: The hypersomnias, primarily represented by obstructive sleep apnea; and The insomnia complaints, which can be due to a variety of psychiatric and medical disorders. Indications for Treatment of Obstructive Sleep Apnea Obstructive sleep apnea is a potentially reversible cause of daytime hypersomnia, which may be associated with comorbid conditions and even excess mortality. Effective treatment is available for many patients. Development of better and more effective treatment strategies should, however, be encouraged. Treatment is recommended for more severe degrees of this disorder. Objective indices of severity elicited by polysomnography should include a high index of respiratory disturbances per hour, repetitive episodes of hypoxemia, and an abnormally shortened sleep latency. Strict guidelines for therapy have not been adequately validated to dictate thresholds for distinguishing less severely affected patients. At the present time, considerable reliance is made on clinical judgment to initiate a therapeutic trial or regimen. Indications for Treatment of Insomnia Complaints Complaints of insomnia are very common in the older patient. Insomnia is a symptomatic expression of a constellation of medical conditions that are not entirely related one to another. Insomnia may be of psychiatric (e.g., depression, anxiety), physiological (e.g., central apnea, limb movement), pharmacological (e.g., prescribed or unprescribed drugs or alcohol), or of medical origin. It may coexist with other sleep disorders (such as apnea), but this may be merely coincidental.

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Since insomnia has many causes, the indications for treatment are dependent on the etiology. A thorough medical evaluation is essential prior to initiating treatment. Indications for therapy will be driven by the underlying cause and severity of symptoms. Attention was given to periodic movements in sleep which appear to be very common in the older patient. Certain pharmacological treatments appear to be effective in patients who find this condition distressing. There is, however, insufficient evidence at this time to indicate whether or not the disease state or its treatment affect morbidity in the older patient. Moreover, the long-term benefits and risks of treatment of periodic movements in sleep are unknown, and, therefore, further investigations are recommended. Insomnia may also be related to circadian rhythm disorders. Amplitude and phase relationships are often altered in the older person. These changes may produce a variety of somatic complaints and sleep disturbances. Such alterations occur during shift work, transmeridian travel, or changes in daily routine or sleep patterns (earlier arousal and earlier bedtime tendency), or they may occur spontaneously. Therapy should be directed toward appropriate control of the environment and adequate counseling of the patient and the employer. It may include appropriately timed bright light exposure. Insomnia resulting from medical or psychiatric causes should be managed primarily by appropriate treatment of the underlying condition.

Common Medical Practices Insomnia Although hypnotic medication is frequently prescribed by physicians for insomnia and secured either across the counter or “extralegally,” hypnotic medication should not be the mainstay of management for most of the causes of disturbed sleep. Since a large proportion of individuals with chronic insomnia have psychiatric complaints, particularly depression, but also anxiety, panic states, alcoholism, and others, treatment should be directed toward the underlying disorder. In the case of depression the tricyclic antidepressants are frequently useful in the absence of contraindications. One can take advantage of the sedative effect of some of these agents in addition to their

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more specific effect on the depression. Some agents may actually cause sleeplessness and should be used in the morning. Other diseases and conditions which cause or contribute to insomnia, such as congestive heart failure, hyperthyroidism, pulmonary disease, esophageal reflux, and arthritis, should be treated specifically with the reminder that medications such as steroids and theophylline may cause sleep disturbance, as can the timing of administration of diuretics. Pharmacologic therapy may be helpful if it is determined that periodic movements in sleep are contributing to insomnia and require treatment. The long-term benefits of treatment have yet to be determined. Other general measures such as sleep hygiene can be used as adjuncts to treatment of the specific causes of insomnia and tried when the cause is not clear or is unspecified. Sleep hygiene measures include regularization of bedtime (generally later rather than earlier); the use of the bedroom primarily for sleeping and sexual activity; exercise; avoidance of alcohol and caffeine; reduced evening fluid intake; and in the case of esophageal reflux, elevation of the head of the bed. Short-term intermittent use of hypnotics and sedative tricyclics may be useful for temporary problems such as bereavement, dislocation, and situational anxiety. There are no studies that demonstrate their long term effectiveness. Given the changes in drug metabolism associated with increasing age, all medication should be used with caution, especially those with long half-lives. Older people should avoid over-the-counter sleep medication due to their anticholinergic effects and questionable efficacy. LTryptophan (another commonly used over-the-counter sleep-inducing agent) has been associated with eosinophilic myalgia syndrome and has been withdrawn from the market. The role of pharmacological, behavioral, and phototherapeutic management of disorders of circadian rhythm regulation is currently under investigation.

Hypersomnia When treatment is indicated for hypersomnia due to obstructive sleep apnea, certain general measures, if successfully initiated, may suffice. These include weight loss; avoidance of alcohol, sedatives and hypnotics; the avoidance of the supine sleeping position; and management of nasal and nasopharyngeal disease.

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The mainstay of treatment is the use of nasal continuous positive airway pressure (CPAP), which is frequently successful. It and other devices (including tongue retaining and jaw advancing appliances and cervical collars) need further study. Where other measures, including nasal CPAP, fail or are unacceptable, surgical procedures may become an appropriate alternative treatment. Uvulopalatopharyngoplasty has been reported to be successful. There is evidence that the procedure may have better success when tailored to a demonstrated site of obstruction. Tracheostomy may be required if other procedures are unacceptable or fail. In all therapeutic interventions there should be long-term outcome assessment.

Good Sleep Hygiene and Treatment The answer to this question involves defining the target audience, determining what information should be conveyed, and deciding how best to transmit the information. Physicians and medical students, nurses, social workers and counselors, rehabilitation and respiratory therapists, discharge planners, and pharmacists and other allied health professionals are the groups to be approached first. We anticipate particular interest from providers of services to the older people including area agencies on aging, senior centers, and nursing homes. Other special groups that are affected by sleep disorder issues include employers, pharmaceutical companies, members of the legal profession, and developers of technology. Funders of research, both public and private, must be involved in this developing field. Education also must be directed toward decision makers at local, state and national levels, including regulatory and legislative groups. There are also key decision makers in the private sector such as those in the insurance industry and health care systems. Educational efforts must include the very groups we wish to help: the older persons, their families, and caregivers.

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The information to be conveyed will differ in content, style, and depth depending on the audience--professionals, patients, and media. A particular educational emphasis is desirable for new physicians and researchers, even while it is recognized that there are many unanswered questions. Nevertheless there are general concepts that could be useful for all groups. The content should include concepts of sleep physiology and pathophysiology, and assessment and differential diagnosis. Discussion of treatment approaches including technological devices, drugs, and lifestyle should address disadvantages as well as advantages. For audiences unfamiliar with the issue of sleep and the older person, the magnitude of the personal and societal toll in accidents, health, and unhappiness must be conveyed. Other key points include proper use of medications, preventive health measures, and good sleep hygiene practices. Individuals may satisfactorily cope with insomnia, and it may be transient. On the other hand, persistent insomnia may reflect major disease, and competent clinical consultation may be desirable. Imagination and sustained effort are at the heart of the many educational efforts. For health professionals one goal is to include information on sleep in the curriculum of schools--not an easy task. More standard educational efforts include appropriate lay and professional publications, professional conferences, and continuing education. Lay or advocacy groups can contribute to the total educational effort, as well as benefit from it. Reaching the public can be facilitated by utilizing existing networks, for example, state and area agencies on aging, coordinated through the Administration on Aging. There are opportunities for communicating information in newsletters published by churches, hospitals, and senior centers. There is particular need to involve citizen groups who direct their efforts toward the older person. All media groups should be encouraged to discuss these issues. The Public Health Service must take a more active role in educating and disseminating information to the public. Without such effort, this consensus report may not receive the wide dissemination it deserves.

Future Research The conference presentations emphasized the problem of sleep disorders in older age due to the demographic shift in the American population to an increasing proportion in the over-65 age group, and to the public awareness

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of the interest of the medical community in diagnosis and treatment of these disorders. The study of sleep and sleep disorders has advanced rapidly in the past 30 years. This advance has been most prominent in studies of normal sleep throughout the life span. However, the classification, diagnostic criteria, understanding of the basic mechanisms, natural history, and the efficacy of treatment in sleep disorders are still in early stages so that further research in all these areas is necessary. This is particularly true for the older population in whom these conditions may be more frequent and disruptive. It is always difficult to define classification and diagnostic criteria in a relatively new area where clinical descriptions and observations predominate and where the interpretation of objective measures, even with existing and new technology, is hampered. Certainly, large studies of control populations with proper sampling methods are necessary. This is particularly the situation in older populations where controls without confounding disease are more difficult to obtain. It is often necessary in alleviating illness to press forward with clinical descriptions and treatment even without knowledge of the basic mechanisms. However, it is only with elucidation of these mechanisms that rational approaches to therapy can be effected. The study of these disorders in older patients, who often have other diseases, affords some unusual opportunities. For example, how does the dopamine depletion in Parkinson’s disease patients affect sleep architecture and cardiopulmonary adaptation? Also, older patients may take one or more drugs for other conditions, and this may afford an opportunity for clinical observations. There have been extensive studies of sleep mechanisms in experimental animals. Efforts should be made to identify appropriate animal models for sleep disorders. Now it is possible to study old animals, including primates, and these studies should provide insight into the basic mechanisms of sleep changes in aging. The new interest in disordered circadian rhythms as a clinical observation opens up new areas of research. Modern research techniques used in selected human cases might help identify biological markers for some of these disorders. Opportunities for clinical and pathological correlation should be encouraged. The application or development of new research techniques should provide added understanding of the neurobiology of sleep and its disorders.

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The natural history of many sleep disorders has not been well described. Longitudinal studies into older age would clarify the progress of these disorders and their effect on morbidity and mortality. This is also necessary if one is to judge the efficacy of various treatment modalities. Important questions that can only be answered by long-term studies are whether some of the variations noted in the older population are the result of aging or of concomitant disease; whether these variations need to be tested further; and whether these variations are responsible for other medical conditions. This latter point needs clarification because of the questions regarding sleep apnea with oxygen desaturation and various forms of dementia. An important area of study is the disruption of normal circadian rhythms by transmeridian time shifts, dislocation such as moving to a nursing home, and shift work. These may result in sleep disturbances with attendant problems with family, driving, and recreation. It is obvious from the data presented that extensive studies need to be done to settle the question of benefits of treatment in these disorders. Carefully controlled studies of well defined clinical groups will be necessary to establish the benefit of various therapies. It is equally important in clinical trials to look at the efficacy of different means of sleep hygiene practices, not only for therapy but for prevention. Added knowledge about the effectiveness of treatment should spur studies of cost effectiveness of diagnostic methods and therapies. In all the areas mentioned there are many opportunities for basic and clinical research. The enhanced interest in the older population should provide both challenges and opportunities for investigators.

Conclusions and Recommendations There is a need for epidemiologic investigations of sleep disorders: case control, cohort, and cross-cultural studies should be initiated. The information developed in these studies will aid in the understanding of the natural history, etiology, and prevention of sleep disorders. Evaluation of sleep disorders begins with careful clinical evaluation performed by an informed primary care physician. Standardization of clinical measures and assessment of the specificity and sensitivity of diagnostic procedures is essential.

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Advanced skills and diagnostic tools are available and should be applied in appropriate patients. The objective of sleep disorder therapy is to reduce morbidity and mortality and improve the quality of life. Obstructive sleep apnea is a potentially severe and treatable cause of daytime hypersomnia. Restoration of airway competence is the objective in the treatment of severe sleep apnea. Insomnia is a complaint with multiple causes and requires different treatments. Hypnotic medications should not be the mainstay of treatment of insomnia, are overused and have habit forming potential. The value of good sleep hygiene should not be underestimated in the prevention and treatment of insomnia. Widespread knowledge about sleep and its disorders is lacking, and education at all levels is needed. The Public Health Service must take an active role in educating the public. Powerful new techniques, such as brain imaging, molecular biological tools, and neurochemical analyses, should be used in human studies and animal models to explore the basic mechanisms of sleep and sleep disorders. Sleep disorders in older people offer unique opportunities to study integrative neurologic, psychiatric, and cardiopulmonary functions. Current and new therapies and technologies must be evaluated by randomized controlled clinical trials. The Health Care Financing Administration should review current reimbursement policies, and continue to explore clinical data set requirements as these reimbursement policies for sleep disorders evolve.

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APPENDIX F. MORE ON PROBLEM SLEEPINESS Overview58 Everyone feels sleepy at times. However, when sleepiness interferes with daily routines and activities, or reduces the ability to function, it is called “problem sleepiness.” A person can be sleepy without realizing it. For example, a person may not feel sleepy during activities such as talking and listening to music at a party, but the same person can fall asleep while driving home afterward. The following appendix is reproduced and adapted from the National Heart, Lung, and Blood Institute publication dedicated to problem sleepiness.

What Causes Problem Sleepiness? You may have problem sleepiness if you: Consistently do not get enough sleep Get poor quality sleep Fall asleep while driving Struggle to stay awake when inactive such as when watching television or reading Have difficulty paying attention or concentrating at work, school, or home Have performance problems at work or school Adapted from the National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/public/sleep/pslp_fs.pdf. 58

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Are often told by others that you are sleepy Have difficulty remembering Have slowed responses Have difficulty controlling your emotions Must take naps on most days Sleepiness can be due to the body’s natural daily sleep-wake cycles, inadequate sleep, sleep disorders, or certain drugs.

Sleep-Wake Cycle Each day there are two periods when the body experiences a natural tendency toward sleepiness: during the late night hours (generally between midnight and 7 a.m.) and again during the midafternoon (generally between 1 p.m. and 4 p.m.). If people are awake during these times, they have a higher risk of falling asleep unintentionally, especially if they haven’t been getting enough sleep. Inadequate Sleep The amount of sleep needed each night varies among people. Each person needs a particular amount of sleep in order to be fully alert throughout the day. Research has shown that when healthy adults are allowed to sleep unrestricted, the average time slept is 8 to 8.5 hours. Some people need more than that to avoid problem sleepiness; others need less. If a person does not get enough sleep, even on one night, a “sleep debt” begins to build and increases until enough sleep is obtained. Problem sleepiness occurs as the debt accumulates. Many people do not get enough sleep during the work week and then sleep longer on the weekends or days off to reduce their sleep debt. If too much sleep has been lost, sleeping in on the weekend may not completely reverse the effects of not getting enough sleep during the week.

Sleep Disorders Sleep disorders such as sleep apnea, narcolepsy, restless legs syndrome, and insomnia can cause problem sleepiness. Sleep apnea is a serious disorder in which a person’s breathing is interrupted during sleep, causing the

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individual to awaken many times during the night and experience problem sleepiness during the day. People with narcolepsy have excessive sleepiness during the day, even after sleeping enough at night. They may fall asleep at inappropriate times and places. Restless legs syndrome (RLS) causes a person to experience unpleasant sensations in the legs, often described as creeping, crawling, pulling, or painful. These sensations frequently occur in the evening, making it difficult for people with RLS to fall asleep, leading to problem sleepiness during the day. Insomnia is the perception of poor-quality sleep due to difficulty falling asleep, waking up during the night with difficulty returning to sleep, waking up too early in the morning, or unrefreshing sleep. Any of these sleep disorders can cause problem sleepiness.

Medical Conditions/Drugs Certain medical conditions and drugs, including prescription medications, can also disrupt sleep and cause problem sleepiness. Examples include: Chronic illnesses such as asthma, congestive heart failure, rheumatoid arthritis, or any other chronically painful disorder. Some medications to treat high blood pressure, some heart medications, and asthma medications such as theophylline. Alcohol—Although some people use alcohol to help themselves fall asleep, it causes sleep disruption during the night, which can lead to problem sleepiness during the day. Alcohol is also a sedating drug that can, even in small amounts, make a sleepy person much more sleepy and at greater risk for car crashes and performance problems. Caffeine—Whether consumed in coffee, tea, soft drinks, or medications, caffeine makes it harder for many people to fall asleep and stay asleep. Caffeine stays in the body for about 3 to 7 hours, so even when taken earlier in the day it can cause problems with sleep at night. Nicotine from cigarettes or a skin patch is a stimulant and makes it harder to fall asleep and stay asleep.

Problem Sleepiness and Adolescents Many U.S. high school and college students have signs of problem sleepiness, such as: Difficulty getting up for school

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Falling asleep at school Struggling to stay awake while doing homework The need for sleep may be 9 hours or more per night as a person goes through adolescence. At the same time, many teens begin to show a preference for a later bed time, which may be due to a biological change. Teens tend to stay up later but have to get up early for school, resulting in their getting much less sleep than they need. Many factors contribute to problem sleepiness in teens and young adults, but the main causes are not getting enough sleep and irregular sleep schedules. Some of the factors that influence adolescent sleep include: Social activities with peers that lead to later bedtimes Homework to be done in the evenings Early wake-up times due to early school start times Parents being less involved in setting and enforcing bedtimes Employment, sports, or other extracurricular activities that decrease the time available for sleep Teens and young adults who do not get enough sleep are at risk for problems such as: Automobile crashes Poor performance in school and poor grades Depressed moods Problems with peer and adult relationships Many adolescents have part-time jobs in addition to their classes and other activities. High school students who work more than 20 hours per week have more problem sleepiness and may use more caffeine, nicotine, and alcohol than those who work less than 20 hours per week or not at all. Shift Work And Problem Sleepiness About 20 million Americans (20 to 25 percent of workers) perform shift work. Most shift workers get less sleep over 24 hours than day workers. Sleep loss is greatest for night shift workers, those who work early morning shifts, and female shift workers with children at home. About 60 to 70 percent of shift workers have difficulty sleeping and/or problem sleepiness.

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The human sleep-wake system is designed to prepare the body and mind for sleep at night and wakefulness during the day. These natural rhythms make it difficult to sleep during daylight hours and to stay awake during the night hours, even in people who are well rested. It is possible that the human body never completely adjusts to nighttime activity and daytime sleep, even in those who work permanent night shifts. In addition to the sleep-wake system, environmental factors can influence sleepiness in shift workers. Because our society is strongly day-oriented, shift workers who try to sleep during the day are often interrupted by noise, light, telephones, family members, and other distractions. In contrast, the nighttime sleep of day workers is largely protected by social customs that keep noises and interruptions to a minimum. Problem sleepiness in shift workers may result in: Increased risk for automobile crashes, especially while driving home after the night shift Decreased quality of life Decreased productivity (night work performance may be slower and less accurate than day performance) Increased risk of accidents and injuries at work

What Can Help? Sleep—There Is No Substitute! Many people simply do not allow enough time for sleep on a regular basis. A first step may be to evaluate daily activities and sleep-wake patterns to determine how much sleep is obtained. If you are consistently getting less than 8 hours of sleep per night, more sleep may be needed. A good approach is to gradually move to an earlier bedtime. For example, if an extra hour of sleep is needed, try going to bed 15 minutes earlier each night for four nights and then keep the last bedtime. This method will increase the amount of time in bed without causing a sudden change in schedule. However, if work or family schedules do not permit the earlier bedtime, a 30- to 60-minute daily nap may help.

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Medications/Drugs In general, medications do not help problem sleepiness, and some make it worse. Caffeine can reduce sleepiness and increase alertness, but only temporarily. It can also cause problem sleepiness to become worse by interrupting sleep. While alcohol may shorten the time it takes to fall asleep, it can disrupt sleep later in the night, and therefore add to the problem sleepiness. Medications may be prescribed for patients in certain situations. For example, the short-term use of sleeping pills has been shown to be helpful in patients diagnosed with acute insomnia. Long-term use of sleep medication is recommended only for the treatment of specific sleep disorders. If You’re Sleepy—Don’t Drive! A person who is sleepy and drives is at high risk for an automobile crash. Planning ahead may help reduce that risk. For example, the following tips may help when planning a long distance car trip: Get a good night’s sleep before leaving Avoid driving between midnight and 7 a.m. Change drivers often to allow for rest periods Schedule frequent breaks If you are a shift worker, the following may help: Decreasing the amount of night work Increasing the total amount of sleep by adding naps and lengthening the amount of time allotted for sleep Increasing the intensity of light at work Having a predictable schedule of night shifts Eliminating sound and light in the bedroom during daytime sleep Using caffeine (only during the first part of the shift) to promote alertness at night Possibly using prescription sleeping pills to help daytime sleep on an occasional basis (check with your doctor)

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If you think you are getting enough sleep, but still feel sleepy during the day, check with your doctor to be sure your sleepiness is not due to a sleep disorder.

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ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/ Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/ Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as Web MD and (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a) drkoop.com (http://www.drkoop.com/). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to sleep apnea and keep them on file. The NIH, in particular, suggests that patients with sleep apnea visit the following Web sites in the ADAM Medical Encyclopedia:

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Basic Guidelines for Sleep Apnea Central sleep apnea Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003997.htm Obstructive sleep apnea Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000811.htm Signs & Symptoms for Sleep Apnea Apnea Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003069.htm Blood pressure, high Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003082.htm Breath cessation Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003069.htm Cessation of breathing Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003069.htm Confusion Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003205.htm Consciousness, decreased Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003202.htm Decreased consciousness Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003202.htm

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Drowsiness Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003208.htm Edema Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003103.htm Hallucinations Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003258.htm Headaches Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003024.htm Hypoxia Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003215.htm Lethargy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003088.htm Memory loss Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003257.htm No breathing Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003069.htm Obese Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003101.htm Sleepiness Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003208.htm

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Snoring Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003207.htm Somnolence Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003208.htm Swelling, overall Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003103.htm Weight gain Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003084.htm Diagnostics and Tests for Sleep Apnea Arterial blood gases Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003855.htm ECG Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003868.htm Sleep studies Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003932.htm Surgery and Procedures for Sleep Apnea Adenoidectomy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003011.htm Tonsillectomy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/003013.htm

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Tracheostomy Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002955.htm Background Topics for Sleep Apnea Alcohol use Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001944.htm Incidence Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002387.htm Intentional weight loss Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001940.htm Labored breathing Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000007.htm Nasal CPAP Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001916.htm Obstructed airway Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000036.htm Physical examination Web site: http://www.nlm.nih.gov/medlineplus/ency/article/002274.htm Weight management Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001943.htm Weight reduction Web site: http://www.nlm.nih.gov/medlineplus/ency/article/001940.htm

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Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/ Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine

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SLEEP APNEA GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Aberrant: Wandering or deviating from the usual or normal course. [EU] Abscess: A localized collection of pus caused by suppuration buried in tissues, organs, or confined spaces. [EU] Acetylcholine: A neurotransmitter. Acetylcholine in vertebrates is the major transmitter at neuromuscular junctions, autonomic ganglia, parasympathetic effector junctions, a subset of sympathetic effector junctions, and at many sites in the central nervous system. It is generally not used as an administered drug because it is broken down very rapidly by cholinesterases, but it is useful in some ophthalmological applications. [NIH] Adenine: A purine base and a fundamental unit of adenine nucleotides. [NIH] Adenosine: A nucleoside that is composed of adenine and d-ribose. Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. [NIH] Adjuvant: A substance which aids another, such as an auxiliary remedy; in immunology, nonspecific stimulator (e.g., BCG vaccine) of the immune response. [EU] Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Adrenergic: Activated by, characteristic of, or secreting epinephrine or substances with similar activity; the term is applied to those nerve fibres that liberate norepinephrine at a synapse when a nerve impulse passes, i.e., the sympathetic fibres. [EU] Agonist: In anatomy, a prime mover. In pharmacology, a drug that has affinity for and stimulates physiologic activity at cell receptors normally stimulated by naturally occurring substances. [EU] Agoraphobia: Obsessive, persistent, intense fear of open places. [NIH] Airways: Tubes that carry air into and out of the lungs. [NIH] Alimentary: Pertaining to food or nutritive material, or to the organs of

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digestion. [EU] Alkaloid: One of a large group of nitrogenous basis substances found in plants. They are usually very bitter and many are pharmacologically active. Examples are atropine, caffeine, coniine, morphine, nicotine, quinine, strychnine. The term is also applied to synthetic substances (artificial a's) which have structures similar to plant alkaloids, such as procaine. [EU] Alkalosis: A pathologic condition resulting from accumulation of base, or from loss of acid without comparable loss of base in the body fluids, and characterized by decrease in hydrogen ion concentration (increase in pH). [EU]

Allergen: A antigenic substance capable of producing immediate-type hypersensitivity (allergy). [EU] Alveoli: Tiny sac-like air spaces in the lungs where transfer of carbon dioxide from blood into the lungs and oxygen from air into blood takes place. [NIH] Amphetamine: A powerful central nervous system stimulant and sympathomimetic. Amphetamine has multiple mechanisms of action including blocking uptake of adrenergics and dopamine, stimulation of release of monamines, and inhibiting monoamine oxidase. Amphetamine is also a drug of abuse and a psychotomimetic. The l- and the d,l-forms are included here. The l-form has less central nervous system activity but stronger cardiovascular effects. The d-form is dextroamphetamine. [NIH] Anaesthesia: Loss of feeling or sensation. Although the term is used for loss of tactile sensibility, or of any of the other senses, it is applied especially to loss of the sensation of pain, as it is induced to permit performance of surgery or other painful procedures. [EU] Analeptic: A drug which acts as a restorative, such as caffeine, amphetamine, pentylenetetrazol, etc. [EU] Analogous: Resembling or similar in some respects, as in function or appearance, but not in origin or development;. [EU] Anaplasia: Loss of structural differentiation and useful function of neoplastic cells. [NIH] Anastomosis: An opening created by surgical, traumatic or pathological means between two normally separate spaces or organs. [EU] Anatomical: Pertaining to anatomy, or to the structure of the organism. [EU] Anesthesia: A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. [NIH]

Anesthesiology: A specialty concerned with the study of anesthetics and

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anesthesia. [NIH] Anesthetics: Agents that are capable of inducing a total or partial loss of sensation, especially tactile sensation and pain. They may act to induce general anesthesia, in which an unconscious state is achieved, or may act locally to induce numbness or lack of sensation at a targeted site. [NIH] Angina: Chest pain that originates in the heart. [NIH] Ankle: That part of the lower limb directly above the foot. [NIH] Ankylosis: Fixation and immobility of a joint. [NIH] Antibacterial: A substance that destroys bacteria or suppresses their growth or reproduction. [EU] Antibiotic: A drug that kills or inhibits the growth of bacteria. [NIH] Antibodies: Specific proteins produced by the body's immune system that bind with foreign proteins (antigens). [NIH] Anticholinergic: An agent that blocks the parasympathetic nerves. Called also parasympatholytic. [EU] Anticonvulsant: An agent that prevents or relieves convulsions. [EU] Antidepressant: An agent that stimulates the mood of a depressed patient, including tricyclic antidepressants and monoamine oxidase inhibitors. [EU] Antiemetic: An agent that prevents or alleviates nausea and vomiting. Also antinauseant. [EU] Antiepileptic: An agent that combats epilepsy. [EU] Antigens: Substances that are recognized by the immune system and induce an immune reaction. [NIH] Antihistamine: A drug that counteracts the action of histamine. The antihistamines are of two types. The conventional ones, as those used in allergies, block the H1 histamine receptors, whereas the others block the H2 receptors. Called also antihistaminic. [EU] Antitoxin: A purified antiserum from animals (usually horses) immunized by injections of a toxin or toxoid, administered as a passive immunizing agent to neutralize a specific bacterial toxin, e.g., botulinus, tetanus or diphtheria. [EU] Antitussive: An agent that relieves or prevents cough. [EU] Anxiety: The unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, ostensibly resulting from unrecognized intrapsychic conflict. Physiological concomitants include increased heart rate, altered respiration rate, sweating, trembling, weakness, and fatigue; psychological concomitants include feelings of impending danger, powerlessness, apprehension, and tension. [EU]

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Aorta: Blood vessel that delivers oxygen-rich blood from the left ventricle to the body; it is the largest blood vessel in the body. [NIH] Apnea: A transient absence of spontaneous respiration. [NIH] Apnoea: Cessation of breathing. [EU] Arrhythmia: An irregular heartbeat. [NIH] Arterial: Pertaining to an artery or to the arteries. [EU] Arteries: The vessels carrying blood away from the heart. [NIH] Artery: Vessel-carrying blood from the heart to various parts of the body. [NIH]

Aspiration: The act of inhaling. [EU] Asymptomatic: Showing or causing no symptoms. [EU] Ataxia: Failure of muscular coordination; irregularity of muscular action. [EU]

Atrium: One of the two receiving chambers of the heart. The right atrium receives oxygen-poor blood from the body. The left atrium receives oxygenrich blood from the lungs. The plural of atrium is atria. [NIH] Atropine: A toxic alkaloid, originally from Atropa belladonna, but found in other plants, mainly Solanaceae. [NIH] Auditory: Pertaining to the sense of hearing. [EU] Autonomic: Self-controlling; functionally independent. [EU] Autosuggestion: Suggestion coming from the subject himself. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Benzene: Toxic, volatile, flammable liquid hydrocarbon biproduct of coal distillation. It is used as an industrial solvent in paints, varnishes, lacquer thinners, gasoline, etc. Benzene causes central nervous system damage acutely and bone marrow damage chronically and is carcinogenic. It was formerly used as parasiticide. [NIH] Benzodiazepines: A two-ring heterocyclic compound consisting of a benzene ring fused to a diazepine ring. Permitted is any degree of hydrogenation, any substituents and any H-isomer. [NIH] Bereavement: Refers to the whole process of grieving and mourning and is associated with a deep sense of loss and sadness. [NIH] Bilateral: Having two sides, or pertaining to both sides. [EU] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Bionics: The study of systems, particularly electronic systems, which function after the manner of, in a manner characteristic of, or resembling living systems. Also, the science of applying biological techniques and

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principles to the design of electronic systems. [NIH] Biotransformation: The series of chemical alterations of a compound (e.g., a drug) which occur within the body, as by enzymatic activity. [EU] Blastocyst: The mammalian embryo in the post-morula stage in which a fluid-filled cavity, enclosed primarily by trophoblast, contains an inner cell mass which becomes the embryonic disc. [NIH] BMI: Body mass index; the body weight in kilograms divided by the height in meters squared (wt/ht2) used as a practical marker to assess obesity; often referred to as the Quetelet Index. An indicator of optimal weight for health and different from lean mass or percent body fat calculations because it only considers height and weight. [NIH] Bradycardia: Slowness of the heart beat, as evidenced by slowing of the pulse rate to less than 60. [EU] Bronchial: Pertaining to one or more bronchi. [EU] Bronchiectasis: Chronic dilatation of the bronchi marked by fetid breath and paroxysmal coughing, with the expectoration of mucopurulent matter. It may effect the tube uniformly (cylindric b.), or occur in irregular pockets (sacculated b.) or the dilated tubes may have terminal bulbous enlargements (fusiform b.). [EU] Bronchitis: Inflammation of one or more bronchi. [EU] Bruxism: A disorder characterized by grinding and clenching of the teeth. [NIH]

Calculi: An abnormal concretion occurring mostly in the urinary and biliary tracts, usually composed of mineral salts. Also called stones. [NIH] Candidiasis: Infection with a fungus of the genus Candida. It is usually a superficial infection of the moist cutaneous areas of the body, and is generally caused by C. albicans; it most commonly involves the skin (dermatocandidiasis), oral mucous membranes (thrush, def. 1), respiratory tract (bronchocandidiasis), and vagina (vaginitis). Rarely there is a systemic infection or endocarditis. Called also moniliasis, candidosis, oidiomycosis, and formerly blastodendriosis. [EU] Cannula: A tube for insertion into a duct or cavity; during insertion its lumen is usually occupied by a trocar. [EU] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbamazepine: An anticonvulsant used to control grand mal and psychomotor or focal seizures. Its mode of action is not fully understood, but some of its actions resemble those of phenytoin; although there is little chemical resemblance between the two compounds, their three-dimensional structure is similar. [NIH]

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Carbohydrates: A nutrient that supplies 4 calories/gram. They may be simple or complex. Simple carbohydrates are called sugars, and complex carbohydrates are called starch and fiber (cellulose). An organic compound—containing carbon, hydrogen, and oxygen—that is formed by photosynthesis in plants. Carbohydrates are heat producing and are classified as monosaccharides, disaccharides, or polysaccharides. [NIH] Carcinogenic: Producing carcinoma. [EU] Carcinoma: A malignant new growth made up of epithelial cells tending to infiltrate the surrounding tissues and give rise to metastases. [EU] Cardiac: Pertaining to the heart. [EU] Cardiopulmonary: Pertaining to the heart and lungs. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Caudal: Denoting a position more toward the cauda, or tail, than some specified point of reference; same as inferior, in human anatomy. [EU] Cellulose: A polysaccharide with glucose units linked as in cellobiose. It is the chief constituent of plant fibers, cotton being the purest natural form of the substance. As a raw material, it forms the basis for many derivatives used in chromatography, ion exchange materials, explosives manufacturing, and pharmaceutical preparations. [NIH] Cerebellum: Part of the metencephalon that lies in the posterior cranial fossa behind the brain stem. It is concerned with the coordination of movement. [NIH] Cerebral: Of or pertaining of the cerebrum or the brain. [EU] Cerebrovascular: Pertaining to the blood vessels of the cerebrum, or brain. [EU]

Cervical: Pertaining to the neck, or to the neck of any organ or structure. [EU] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Chlorophyll: Porphyrin derivatives containing magnesium that act to convert light energy in photosynthetic organisms. [NIH] Chloroprene: Toxic, possibly carcinogenic, monomer of neoprene, a synthetic rubber; causes damage to skin, lungs, CNS, kidneys, liver, blood cells and fetuses. Synonym: 2-chlorobutadiene. [NIH] Cholesteatoma: A non-neoplastic keratinizing mass with stratified squamous epithelium, frequently occurring in the meninges, central nervous system, bones of the skull, and most commonly in the middle ear and mastoid region. [NIH] Cholesterol: A soft, waxy substance manufactured by the body and used in

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the production of hormones, bile acid, and vitamin D and present in all parts of the body, including the nervous system, muscle, skin, liver, intestines, and heart. Blood cholesterol circulates in the bloodstream. Dietary cholesterol is found in foods of animal origin. [NIH] Cholinergic: Resembling acetylcholine in pharmacological stimulated by or releasing acetylcholine or a related compound. [EU]

action;

Chronotherapy: The adaptation of the administration of drugs to circadian rhythms. The concept is based on the response of biological functions to time-related events, such as the low point in epinephrine levels between 10 p.m. and 4 a.m. or the elevated histamine levels between midnight and 4 a.m. The treatment is aimed at supporting normal rhythms or modifying therapy based on known variations in body rhythms. While chronotherapy is commonly used in cancer chemotherapy, it is not restricted to cancer therapy or to chemotherapy. [NIH] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Coenzyme: An organic nonprotein molecule, frequently a phosphorylated derivative of a water-soluble vitamin, that binds with the protein molecule (apoenzyme) to form the active enzyme (holoenzyme). [EU] Collagen: The protein substance of the white fibres (collagenous fibres) of skin, tendon, bone, cartilage, and all other connective tissue; composed of molecules of tropocollagen (q.v.), it is converted into gelatin by boiling. collagenous pertaining to collagen; forming or producing collagen. [EU] Concomitant: Accompanying; accessory; joined with another. [EU] Confounding: Extraneous variables resulting in outcome effects that obscure or exaggerate the "true" effect of an intervention. [NIH] Convulsion: A violent involuntary contraction or series of contractions of the voluntary muscles. [EU] Coronary: Encircling in the manner of a crown; a term applied to vessels; nerves, ligaments, etc. The term usually denotes the arteries that supply the heart muscle and, by extension, a pathologic involvement of them. [EU] Cortex: The outer layer of an organ or other body structure, as distinguished from the internal substance. [EU] Cortical: Pertaining to or of the nature of a cortex or bark. [EU] Cranial: Pertaining to the cranium, or to the anterior (in animals) or superior (in humans) end of the body. [EU]

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Crowding: Behavior with respect to an excessive number of individuals, human or animal, in relation to available space. [NIH] Curative: Tending to overcome disease and promote recovery. [EU] Cutaneous: Pertaining to the skin; dermal; dermic. [EU] Cyclic: Pertaining to or occurring in a cycle or cycles; the term is applied to chemical compounds that contain a ring of atoms in the nucleus. [EU] Cyst: Any closed cavity or sac; normal or abnormal, lined by epithelium, and especially one that contains a liquid or semisolid material. [EU] Decarboxylation: The removal of a carboxyl group, usually in the form of carbon dioxide, from a chemical compound. [NIH] Defecation: The normal process of elimination of fecal material from the rectum. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Dementia: An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness. [NIH] Demography: Statistical interpretation and description of a population with reference to distribution, composition, or structure. [NIH] Dendrites: Extensions of the nerve cell body. They are short and branched and receive stimuli from other neurons. [NIH] Dentists: Individuals licensed to practice dentistry. [NIH] Dentition: The teeth in the dental arch; ordinarily used to designate the natural teeth in position in their alveoli. [EU] Deprivation: Loss or absence of parts, organs, powers, or things that are needed. [EU] Dermis: A layer of vascular connective tissue underneath the epidermis. The surface of the dermis contains sensitive papillae. Embedded in or beneath the dermis are sweat glands, hair follicles, and sebaceous glands. [NIH]

Diaphragm: The musculofibrous partition that separates the thoracic cavity from the abdominal cavity. Contraction of the diaphragm increases the volume of the thoracic cavity aiding inspiration. [NIH] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Diastole: Period of relaxation of the heart, especially the ventricles. [NIH]

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Diastolic: Of or pertaining to the diastole. [EU] Digestion: The process of breakdown of food for metabolism and use by the body. [NIH] Dilatation: The condition, as of an orifice or tubular structure, of being dilated or stretched beyond the normal dimensions. [EU] Diphenhydramine: A histamine H1 antagonist used as an antiemetic, antitussive, for dermatoses and pruritus, for hypersensitivity reactions, as a hypnotic, an antiparkinson, and as an ingredient in common cold preparations. It has some undesired antimuscarinic and sedative effects. [NIH] Diphtheria: A localized infection of mucous membranes or skin caused by toxigenic strains of corynebacterium diphtheriae. It is characterized by the presence of a pseudomembrane at the site of infection. Diphtheria toxin, produced by C. diphtheriae, can cause myocarditis, polyneuritis, and other systemic toxic effects. [NIH] Disaccharides: Sugars composed of two monosaccharides linked by glycoside bonds. [NIH] Dislocation: The displacement of any part, more especially of a bone. Called also luxation. [EU] Disorientation: The loss of proper bearings, or a state of mental confusion as to time, place, or identity. [EU] Distal: Remote; farther from any point of reference; opposed to proximal. In dentistry, used to designate a position on the dental arch farther from the median line of the jaw. [EU] Dizziness: An imprecise term which may refer to a sense of spatial disorientation, motion of the environment, or lightheadedness. [NIH] Dopamine: A catecholamine neurotransmitter that is found primarily in the basal ganglia of the central nervous system. Major functions include the peripheral inhibition and excitation of certain muscles; cardiac excitation; and metabolic, endocrine and central nervous system actions. [NIH] Dorsal: 1. pertaining to the back or to any dorsum. 2. denoting a position more toward the back surface than some other object of reference; same as posterior in human anatomy; superior in the anatomy of quadrupeds. [EU] Duodenum: The first or proximal portion of the small intestine, extending from the pylorus to the jejunum; so called because it is about 12 fingerbreadths in length. [EU] Dysphagia: Difficulty in swallowing. [EU] Dyspnea: Shortness of breath; difficult or labored breathing. [NIH] ECG: Measurement of electrical activity during heartbeats. [NIH] Edema: Abnormal fluid accumulation in body tissues. [NIH]

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Efficacy: The extent to which a specific intervention, procedure, regimen, or service produces a beneficial result under ideal conditions. Ideally, the determination of efficacy is based on the results of a randomized control trial. [NIH] Effusion: The escape of fluid into a part or tissue, as an exudation or a transudation. [EU] Elastic: Susceptible of resisting and recovering from stretching, compression or distortion applied by a force. [EU] Electrocardiogram: Measurement of electrical activity during heartbeats. [NIH]

Electrolyte: A substance that dissociates into ions when fused or in solution, and thus becomes capable of conducting electricity; an ionic solute. [EU] Embolism: A sudden blocking of an artery by an embolus (clot or a foreign material such as a fat globule) brought to the site by the blood flow. [NIH] Embryology: The study of the development of an organism during the embryonic and fetal stages of life. [NIH] Emphysema: Chronic lung disease in which there is permanent destruction of alveoli. [NIH] Endocarditis: Exudative and proliferative inflammatory alterations of the endocardium, characterized by the presence of vegetations on the surface of the endocardium or in the endocardium itself, and most commonly involving a heart valve, but sometimes affecting the inner lining of the cardiac chambers or the endocardium elsewhere. It may occur as a primary disorder or as a complication of or in association with another disease. [EU] Endocardium: The innermost layer of the heart, comprised of endothelial cells. [NIH] Endocrinology: A subspecialty of internal medicine concerned with the metabolism, physiology, and disorders of the endocrine system. [NIH] Endorphins: One of the three major groups of endogenous opioid peptides. They are large peptides derived from the pro-opiomelanocortin precursor. The known members of this group are alpha-, beta-, and gamma-endorphin. The term endorphin is also sometimes used to refer to all opioid peptides, but the narrower sense is used here; opioid peptides is used for the broader group. [NIH] Endoscopy: Visual inspection of any cavity of the body by means of an endoscope. [EU] Energetic: Exhibiting energy : strenuous; operating with force, vigour, or effect. [EU] Enkephalins: One of the three major families of endogenous opioid peptides. The enkephalins are pentapeptides that are widespread in the

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central and peripheral nervous systems and in the adrenal medulla. [NIH] Enzyme: Substance, made by living cells, that causes specific chemical changes. [NIH] Epidemiological: Relating to, or involving epidemiology. [EU] Epigastric: Pertaining to the epigastrium. [EU] Epithelium: The covering of internal and external surfaces of the body, including the lining of vessels and other small cavities. It consists of cells joined by small amounts of cementing substances. Epithelium is classified into types on the basis of the number of layers deep and the shape of the superficial cells. [EU] Excitation: An act of irritation or stimulation or of responding to a stimulus; the addition of energy, as the excitation of a molecule by absorption of photons. [EU] Exocrine: 1. secreting outwardly, via a duct;. [EU] Extrasystole: A premature contraction of the heart that is independent of the normal rhythm and arises in response to an impulse in some part of the heart other than the sinoatrial node; called also premature beat. [EU] Extremity: A limb; an arm or leg (membrum); sometimes applied specifically to a hand or foot. [EU] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Febrile: Pertaining to or characterized by fever. [EU] Fibrillation: A small, local, involuntary contraction of muscle, invisible under the skin, resulting from spontaneous activation of single muscle cells or muscle fibres. [EU] Fibrosis: Process by which inflamed tissue becomes scarred. [NIH] Fistula: An abnormal passage or communication, usually between two internal organs, or leading from an internal organ to the surface of the body; frequently designated according to the organs or parts with which it communicates, as anovaginal, brochocutaneous, hepatopleural, pulmonoperitoneal, rectovaginal, urethrovaginal, and the like. Such passages are frequently created experimentally for the purpose of obtaining body secretions for physiologic study. [EU] Fluoroscopy: screen. [NIH]

Production of an image when x-rays strike a fluorescent

Fungus: A general term used to denote a group of eukaryotic protists, including mushrooms, yeasts, rusts, moulds, smuts, etc., which are characterized by the absence of chlorophyll and by the presence of a rigid

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cell wall composed of chitin, mannans, and sometimes cellulose. They are usually of simple morphological form or show some reversible cellular specialization, such as the formation of pseudoparenchymatous tissue in the fruiting body of a mushroom. The dimorphic fungi grow, according to environmental conditions, as moulds or yeasts. [EU] Ganglia: Clusters of multipolar neurons surrounded by a capsule of loosely organized connective tissue located outside the central nervous system. [NIH] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Gastroplasty: A surgical procedure that limits the amount of food the stomach can hold by closing off part of the stomach. Food intake is restricted by creating a small pouch at the top of the stomach where the food enters from the esophagus. The pouch initially holds about 1 ounce of food and expands to 2-3 ounces with time. The pouch's lower outlet usually has a diameter of about 1/4 inch. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness. [NIH] Gelatin: A product formed from skin, white connective tissue, or bone collagen. It is used as a protein food adjuvant, plasma substitute, hemostatic, suspending agent in pharmaceutical preparations, and in the manufacturing of capsules and suppositories. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Glycine: A non-essential amino acid. It is found primarily in gelatin and silk fibroin and used therapeutically as a nutrient. It is also a fast inhibitory neurotransmitter. [NIH] Glycoside: Any compound that contains a carbohydrate molecule (sugar), particularly any such natural product in plants, convertible, by hydrolytic cleavage, into sugar and a nonsugar component (aglycone), and named specifically for the sugar contained, as glucoside (glucose), pentoside (pentose), fructoside (fructose) etc. [EU] Gout: Hereditary metabolic disorder characterized by recurrent acute arthritis, hyperuricemia and deposition of sodium urate in and around the joints, sometimes with formation of uric acid calculi. [NIH] Granulomas: Small lumps in tissues caused by inflammation. [NIH]

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Histamine: 1H-Imidazole-4-ethanamine. A depressor amine derived by enzymatic decarboxylation of histidine. It is a powerful stimulant of gastric secretion, a constrictor of bronchial smooth muscle, a vasodilator, and also a centrally acting neurotransmitter. [NIH] Histidine: An essential amino acid important in a number of metabolic processes. It is required for the production of histamine. [NIH] Homeostasis: A tendency to stability in the normal body states (internal environment) of the organism. It is achieved by a system of control mechanisms activated by negative feedback; e.g. a high level of carbon dioxide in extracellular fluid triggers increased pulmonary ventilation, which in turn causes a decrease in carbon dioxide concentration. [EU] Homologous: Corresponding in structure, position, origin, etc., as (a) the feathers of a bird and the scales of a fish, (b) antigen and its specific antibody, (c) allelic chromosomes. [EU] Hormonal: Pertaining to or of the nature of a hormone. [EU] Hormones: Chemical substances having a specific regulatory effect on the activity of a certain organ or organs. The term was originally applied to substances secreted by various endocrine glands and transported in the bloodstream to the target organs. It is sometimes extended to include those substances that are not produced by the endocrine glands but that have similar effects. [NIH] Hydroxylysine: A hydroxylated derivative of the amino acid lysine that is present in certain collagens. [NIH] Hydroxyproline: A hydroxylated form of the imino acid proline. A deficiency in ascorbic acid can result in impaired hydroxyproline formation. [NIH]

Hyperacusis: An abnormally disproportionate increase in the sensation of loudness in response to auditory stimuli of normal volume. Cochlear diseases; vestibulocochlear nerve diseases; facial nerve diseases; stapes surgery; and other disorders may be associated with this condition. [NIH] Hyperlipidemia: An excess of lipids in the blood. [NIH] Hypersensitivity: A state of altered reactivity in which the body reacts with an exaggerated immune response to a foreign substance. Hypersensitivity reactions are classified as immediate or delayed, types I and IV, respectively, in the Gell and Coombs classification (q.v.) of immune responses. [EU] Hypertension: High blood pressure (i.e., abnormally high blood pressure tension involving systolic and/or diastolic levels). The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure defines hypertension as a systolic blood pressure of 140 mm Hg or greater, a diastolic blood pressure of 90 mm Hg or

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greater, or taking hypertensive medication. The cause may be adrenal, benign, essential, Goldblatt's, idiopathic, malignant pate, portal, postpartum, primary, pulmonary, renal or renovascular. [NIH] Hyperthyroidism: 1. excessive functional activity of the thyroid gland. 2. the abnormal condition resulting from hyperthyroidism marked by increased metabolic rate, enlargement of the thyroid gland, rapid heart rate, high blood pressure, and various secondary symptoms. [EU] Hypertrophy: Nutrition) the enlargement or overgrowth of an organ or part due to an increase in size of its constituent cells. [EU] Hyperventilation: A state in which there is an increased amount of air entering the pulmonary alveoli (increased alveolar ventilation), resulting in reduction of carbon dioxide tension and eventually leading to alkalosis. [EU] Hypnotic: A drug that acts to induce sleep. [EU] Hypothyroidism: Deficiency of thyroid activity. In adults, it is most common in women and is characterized by decrease in basal metabolic rate, tiredness and lethargy, sensitivity to cold, and menstrual disturbances. If untreated, it progresses to full-blown myxoedema. In infants, severe hypothyroidism leads to cretinism. In juveniles, the manifestations are intermediate, with less severe mental and developmental retardation and only mild symptoms of the adult form. When due to pituitary deficiency of thyrotropin secretion it is called secondary hypothyroidism. [EU] Hypotonia: A condition of diminished tone of the skeletal muscles; diminished resistance of muscles to passive stretching. [EU] Hypoxia: Too little oxygen available to meet the needs of the body’s tissues. [NIH]

Hysteria: Historical term for a chronic, but fluctuating, disorder beginning in early life and characterized by recurrent and multiple somatic complaints not apparently due to physical illness. This diagnosis is not used in contemporary practice. [NIH] Iatrogenic: Resulting from the activity of physicians. Originally applied to disorders induced in the patient by autosuggestion based on the physician's examination, manner, or discussion, the term is now applied to any adverse condition in a patient occurring as the result of treatment by a physician or surgeon, especially to infections acquired by the patient during the course of treatment. [EU] Idiopathic: Results from an unknown cause. [NIH] Imipramine: The prototypical tricyclic antidepressant. It has been used in major depression, dysthymia, bipolar depression, attention-deficit disorders, agoraphobia, and panic disorders. It has less sedative effect than some other members of this therapeutic group. [NIH]

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Immunization: Protection from disease by administering vaccines that induce the body to form antibodies against infectious agents. [NIH] Implantation: The insertion or grafting into the body of biological, living, inert, or radioactive material. [EU] Incision: 1. cleft, cut, gash. 2. an act or action of incising. [EU] Indicative: That indicates; that points out more or less exactly; that reveals fairly clearly. [EU] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU] Inflammation: Response of the body tissues to injury; typical signs are swelling, redness, and pain. [NIH] Ingestion: The act of taking food, medicines, etc., into the body, by mouth. [EU]

Inhalation: The drawing of air or other substances into the lungs. [EU] Insomnia: Inability to sleep; abnormal wakefulness. [EU] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Intermittent: Occurring at separated intervals; having periods of cessation of activity. [EU] Intervertebral: Situated between two contiguous vertebrae. [EU] Intestines: The section of the alimentary canal from the stomach to the anus. It includes the large intestine and small intestine. [NIH] Intubation: Insertion of a tube into an organ in the body. [NIH] Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Jejunum: That portion of the small intestine which extends from the duodenum to the ileum; called also intestinum jejunum. [EU] Labyrinthitis: Inflammation of the inner ear. [NIH]

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Laryngitis: Inflammation of the larynx, a condition attended with dryness and soreness of the throat, hoarseness, cough and dysphagia. [EU] Laryngoscopy: Examination, therapy or surgery of the interior of the larynx performed with a specially designed endoscope. [NIH] Larynx: An irregularly shaped, musculocartilaginous tubular structure, lined with mucous membrane, located at the top of the trachea and below the root of the tongue and the hyoid bone. It is the essential sphincter guarding the entrance into the trachea and functioning secondarily as the organ of voice. [NIH] Legionella: Gram-negative aerobic rods, isolated from surface water, mud, or thermally polluted lakes or streams. It is pathogenic for man and it has no known soil or animal sources. [NIH] Legionellosis: Infections with bacteria of the genus legionella. [NIH] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Lethal: Deadly, fatal. [EU] Lethargy: Abnormal drowsiness or stupor; a condition of indifference. [EU] Ligament: A band of fibrous tissue that connects bones or cartilages, serving to support and strengthen joints. [EU] Lip: Either of the two fleshy, full-blooded margins of the mouth. [NIH] Lithium: Lithium. An element in the alkali metals family. It has the atomic symbol Li, atomic number 3, and atomic weight 6.94. Salts of lithium are used in treating manic-depressive disorders. [NIH] Localization: 1. the determination of the site or place of any process or lesion. 2. restriction to a circumscribed or limited area. 3. prelocalization. [EU] Locomotion: Movement or the ability to move from one place or another. It can refer to humans, vertebrate or invertebrate animals, and microorganisms. [NIH] Locomotor: Of or pertaining to locomotion; pertaining to or affecting the locomotive apparatus of the body. [EU] Lumen: The cavity or channel within a tube or tubular organ. [EU] Lymph: A transparent, slightly yellow liquid found in the lymphatic vessels. Lymph is collected from tissue fluids throughout the body and returned to the blood via the lymphatic system. [NIH] Malformation: A morphologic defect resulting from an intrinsically abnormal developmental process. [EU] Malignant: Tending to become progressively worse and to result in death. Having the properties of anaplasia, invasion, and metastasis; said of

Glossary 275

tumours. [EU] Mandible: The largest and strongest bone of the face constituting the lower jaw. It supports the lower teeth. [NIH] Mania: Excitement of psychotic proportions manifested by mental and physical hyperactivity, disorganization of behaviour, and elevation of mood. [EU]

Manic: Affected with mania. [EU] Mannans: Polysaccharides consisting of mannose units. [NIH] Maxillary: Pertaining to the maxilla : the irregularly shaped bone that with its fellow forms the upper jaw. [EU] Meiosis: A special method of cell division, occurring in maturation of the germ cells, by means of which each daughter nucleus receives half the number of chromosomes characteristic of the somatic cells of the species. [NIH]

Membrane: Thin, flexible film of proteins and lipids that encloses the contents of a cell; it controls the substances that go into and come out of the cell. Also, a thin layer of tissue that covers the surface or lines the cavity of an organ. [NIH] Menopause: The cessation of menstruation in the human female, which begins at about the age of 50. [NIH] Menstruation: The cyclic, physiologic discharge through the vagina of blood and mucosal tissues from the nonpregnant uterus; it is under hormonal control and normally recurs, usually at approximately four-week intervals, in the absence of pregnancy during the reproductive period (puberty through menopause) of the female of the human and a few species of primates. It is the culmination of the menstrual cycle. [EU] Metastasis: 1. the transfer of disease from one organ or part to another not directly connected with it. It may be due either to the transfer of pathogenic microorganisms (e.g., tubercle bacilli) or to transfer of cells, as in malignant tumours. The capacity to metastasize is a characteristic of all malignant tumours. 2. Pl. metastases. A growth of pathogenic microorganisms or of abnormal cells distant from the site primarily involved by the morbid process. [EU] Microdialysis: A technique for measuring extracellular concentrations of substances in tissues, usually in vivo, by means of a small probe equipped with a semipermeable membrane. Substances may also be introduced into the extracellular space through the membrane. [NIH] Microorganism: A microscopic organism; those of medical interest include bacteria, viruses, fungi and protozoa. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass

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of matter. [EU] Monocytes: Large, phagocytic mononuclear leukocytes produced in the vertebrate bone marrow and released into the blood; contain a large, oval or somewhat indented nucleus surrounded by voluminous cytoplasm and numerous organelles. [NIH] Mononucleosis: The presence of an abnormally large number of mononuclear leucocytes (monocytes) in the blood. The term is often used alone to refer to infectious mononucleosis. [EU] Morphine: The principal alkaloid in opium and the prototype opiate analgesic and narcotic. Morphine has widespread effects in the central nervous system and on smooth muscle. [NIH] Mucopurulent: Containing both mucus and pus. [EU] Mucus: A thick fluid produced by the lining of some organs of the body. [NIH]

Mutagenesis: Process of generating genetic mutations. It may occur spontaneously or be induced by mutagens. [NIH] Mutagens: Chemical agents that increase the rate of genetic mutation by interfering with the function of nucleic acids. A clastogen is a specific mutagen that causes breaks in chromosomes. [NIH] Mycobacterium: An organism of the genus Mycobacterium. [EU] Mydriatic: 1. dilating the pupil. 2. any drug that dilates the pupil. [EU] Nasal: Pertaining to the nose. [EU] Nasopharyngitis: Inflammation of the nasopharynx. [NIH] Nasopharynx: The nasal part of the pharynx, lying above the level of the soft palate. [NIH] Nausea: An unpleasant sensation, vaguely referred to the epigastrium and abdomen, and often culminating in vomiting. [EU] Necrosis: The sum of the morphological changes indicative of cell death and caused by the progressive degradative action of enzymes; it may affect groups of cells or part of a structure or an organ. [EU] Neoplasms: New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. [NIH] Neoplastic: Pertaining to or like a neoplasm (= any new and abnormal growth); pertaining to neoplasia (= the formation of a neoplasm). [EU] Neoprene: An oil-resistant synthetic rubber made by the polymerization of chloroprene. [NIH] Nephrology:

A subspecialty of internal medicine concerned with the

Glossary 277

anatomy, physiology, and pathology of the kidney. [NIH] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neuroanatomy: Study of the anatomy of the nervous system as a specialty or discipline. [NIH] Neurologic: Pertaining to neurology or to the nervous system. [EU] Neurology: A medical specialty concerned with the study of the structures, functions, and diseases of the nervous system. [NIH] Neuromuscular: Pertaining to muscles and nerves. [EU] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Neurons: The basic cellular units of nervous tissue. Each neuron consists of a body, an axon, and dendrites. Their purpose is to receive, conduct, and transmit impulses in the nervous system. [NIH] Neurophysiology: The scientific discipline concerned with the physiology of the nervous system. [NIH] Neurosciences: The scientific disciplines concerned with the embryology, anatomy, physiology, biochemistry, pharmacology, etc., of the nervous sytem. [NIH] Neurotic: 1. pertaining to or characterized by neurosis. 2. a person affected with a neurosis. [EU] Neurotransmitter: Any of a group of substances that are released on excitation from the axon terminal of a presynaptic neuron of the central or peripheral nervous system and travel across the synaptic cleft to either excite or inhibit the target cell. Among the many substances that have the properties of a neurotransmitter are acetylcholine, norepinephrine, epinephrine, dopamine, glycine, y-aminobutyrate, glutamic acid, substance P, enkephalins, endorphins, and serotonin. [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Nicotine: Nicotine is highly toxic alkaloid. It is the prototypical agonist at nicotinic cholinergic receptors where it dramatically stimulates neurons and ultimately blocks synaptic transmission. Nicotine is also important medically because of its presence in tobacco smoke. [NIH] Norepinephrine: Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic

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sympathetic fibers and of the diffuse projection system in the brain arising from the locus ceruleus. It is also found in plants and is used pharmacologically as a sympathomimetic. [NIH] Obstetrics: A medical-surgical specialty concerned with management and care of women during pregnancy, parturition, and the puerperium. [NIH] Ocular: 1. of, pertaining to, or affecting the eye. 2. eyepiece. [EU] Organelles: Specific particles of membrane-bound organized living substances present in eukaryotic cells, such as the mitochondria; the golgi apparatus; endoplasmic reticulum; lysomomes; plastids; and vacuoles. [NIH] Orlistat: A lipase inhibitor used for weight loss. Lipase is an enzyme found in the bowel that assists in lipid absorption by the body. Orlistat blocks this enzyme, reducing the amount of fat the body absorbs by about 30 percent. It is known colloquially as a "fat blocker." Because more oily fat is left in the bowel to be excreted, Orlistat can cause an oily anal leakage and fecal incontinence. Orlistat may not be suitable for people with bowel conditions such as irritable bowel syndrome or Crohn's disease. [NIH] Osteoarthritis: Noninflammatory degenerative joint disease occurring chiefly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain and stiffness. [NIH] Otitis: Inflammation of the ear, which may be marked by pain, fever, abnormalities of hearing, hearing loss, tinnitus, and vertigo. [EU] Otolaryngology: A surgical specialty concerned with the study and treatment of disorders of the ear, nose, and throat. [NIH] Otorhinolaryngology: That branch of medicine concerned with medical and surgical treatment of the head and neck, including the ears, nose and throat. [EU]

Otosclerosis: A pathological condition of the bony labyrinth of the ear, in which there is formation of spongy bone (otospongiosis), especially in front of and posterior to the footplate of the stapes; it may cause bony ankylosis of the stapes, resulting in conductive hearing loss. Cochlear otosclerosis may also develop, resulting in sensorineural hearing loss. [EU] Outpatients: Persons who receive ambulatory care at an outpatient department or clinic without room and board being provided. [NIH] Ovary: Either of the paired glands in the female that produce the female germ cells and secrete some of the female sex hormones. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Overweight: An excess of body weight but not necessarily body fat; a body mass index of 25 to 29.9 kg/m2. [NIH] Ovulation: The discharge of a secondary oocyte from a vesicular follicle of

Glossary 279

the ovary. [EU] Ovum: A female germ cell extruded from the ovary at ovulation. [NIH] Oximetry: The determination of oxygen-hemoglobin saturation of blood either by withdrawing a sample and passing it through a classical photoelectric oximeter or by electrodes attached to some translucent part of the body like finger, earlobe, or skin fold. It includes non-invasive oxygen monitoring by pulse oximetry. [NIH] Oxygenation: To provide with oxygen. [NIH] Pancreas: A mixed exocrine and endocrine gland situated transversely across the posterior abdominal wall in the epigastric and hypochondriac regions. The endocrine portion is comprised of the islets of langerhans, while the exocrine portion is a compound acinar gland that secretes digestive enzymes. [NIH] Paralysis: Loss or impairment of motor function in a part due to lesion of the neural or muscular mechanism; also by analogy, impairment of sensory function (sensory paralysis). In addition to the types named below, paralysis is further distinguished as traumatic, syphilitic, toxic, etc., according to its cause; or as obturator, ulnar, etc., according to the nerve part, or muscle specially affected. [EU] Paroxysmal: Recurring in paroxysms (= spasms or seizures). [EU] Parturition: The act or process of given birth to a child. [EU] Pathogenesis: The cellular events and reactions that occur in the development of disease. [NIH] Pathophysiology: Altered functions in an individual or an organ due to disease. [NIH] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Pelvic: Pertaining to the pelvis. [EU] Pemphigus: A group of chronic, relapsing, sometimes fatal skin diseases characterized clinically by the development of successive crops of vesicles and bullae, histologically by acantholysis, and immunologically by serum autoantibodies directed against antigens in the intracellular zones of the epidermis. The specific disease is usually indicated by a modifying term; but the term pemphigus is often used alone to designate pemphigus vulgaris. [EU] Perinatal: Pertaining to or occurring in the period shortly before and after birth; variously defined as beginning with completion of the twentieth to twenty-eighth week of gestation and ending 7 to 28 days after birth. [EU] Peroxidase: A hemeprotein from leukocytes. Deficiency of this enzyme leads to a hereditary disorder coupled with disseminated moniliasis. It

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catalyzes the conversion of a donor and peroxide to an oxidized donor and water. EC 1.11.1.7. [NIH] Perspiration: Sweating; the functional secretion of sweat. [EU] Pharmacists: Those persons legally qualified by education and training to engage in the practice of pharmacy. [NIH] Pharmacokinetics: The action of drugs in the body over a period of time, including the processes of absorption, distribution, localization in tissues, biotransformation, and excretion. [EU] Pharmacotherapy: A regimen of using appetite suppressant medications to manage obesity by decreasing appetite or increasing the feeling of satiety. These medications decrease appetite by increasing serotonin or catecholamine—two brain chemicals that affect mood and appetite. [NIH] Phenotype: The entire physical, biochemical, and physiological makeup of an individual as determined by his or her genes and by the environment in the broad sense. [NIH] Phenytoin: An anticonvulsant that is used in a wide variety of seizures. It is also an anti-arrhythmic and a muscle relaxant. The mechanism of therapeutic action is not clear, although several cellular actions have been described including effects on ion channels, active transport, and general membrane stabilization. The mechanism of its muscle relaxant effect appears to involve a reduction in the sensitivity of muscle spindles to stretch. Phenytoin has been proposed for several other therapeutic uses, but its use has been limited by its many adverse effects and interactions with other drugs. [NIH] Phonation: The process of producing vocal sounds by means of vocal cords vibrating in an expiratory blast of air. [NIH] Phototransduction: The transducing of light energy to afferent nerve impulses, such as takes place in the retinal rods and cones. After light photons are absorbed by the photopigments, the signal is transmitted to the outer segment membrane by the cyclic GMP second messenger system, where it closes the sodium channels. This channel gating ultimately generates an action potential in the inner retina. [NIH] Polypeptide: A peptide which on hydrolysis yields more than two amino acids; called tripeptides, tetrapeptides, etc. according to the number of amino acids contained. [EU] Posterior: Situated in back of, or in the back part of, or affecting the back or dorsal surface of the body. In lower animals, it refers to the caudal end of the body. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation

Glossary 281

in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Precursor: Something that precedes. In biological processes, a substance from which another, usually more active or mature substance is formed. In clinical medicine, a sign or symptom that heralds another. [EU] Presynaptic: Situated proximal to a synapse, or occurring before the synapse is crossed. [EU] Prevalence: The number of events, e.g., instances of a given disease or other condition, in a given population at a designated time. When used without qualification, the term usually refers to the situation at specific point in time (point prevalence). Prevalence is a number, not a rate. [NIH] Progesterone: Pregn-4-ene-3,20-dione. The principal progestational hormone of the body, secreted by the corpus luteum, adrenal cortex, and placenta. Its chief function is to prepare the uterus for the reception and development of the fertilized ovum. It acts as an antiovulatory agent when administered on days 5-25 of the menstrual cycle. [NIH] Prolapse: 1. the falling down, or sinking, of a part or viscus; procidentia. 2. to undergo such displacement. [EU] Proline: A non-essential amino acid that is synthesized from glutamic acid. It is an essential component of collagen and is important for proper functioning of joints and tendons. [NIH] Prophase: The first phase of cell division, in which the chromosomes become visible, the nucleus starts to lose its identity, the spindle appears, and the centrioles migrate toward opposite poles. [NIH] Prophylaxis: The prevention of disease; preventive treatment. [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Protozoa: A subkingdom consisting of unicellular organisms that are the simplest in the animal kingdom. Most are free living. They range in size from submicroscopic to macroscopic. Protozoa are divided into seven phyla: sarcomastigophora, Labyrinthomorpha, apicomplexa, microspora, ascetospora, myxozoa, and ciliophora. [NIH] Protriptyline: Tricyclic antidepressant similar in action and side effects to imipramine. It may produce excitation. [NIH] Proximal: Nearest; closer to any point of reference; opposed to distal. [EU] Proxy: A person authorized to decide or act for another person, for example, a person having durable power of attorney. [NIH] Pruritus: 1. itching; an unpleasant cutaneous sensation that provokes the

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desire to rub or scratch the skin to obtain relief. 2. any of various conditions marked by itching, the specific site or type being indicated by a modifying term. [EU] Pupil: The aperture in the iris through which light passes. [NIH] Pylorus: The opening in a vertebrate from the stomach into the intestine. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Reflex: 1; reflected. 2. a reflected action or movement; the sum total of any particular involuntary activity. [EU] Reflux: A backward or return flow. [EU] Refractory: Not readily yielding to treatment. [EU] Regurgitation: A backward flowing, as the casting up of undigested food, or the backward flowing of blood into the heart, or between the chambers of the heart when a valve is incompetent. [EU] Relaxant: 1. lessening or reducing tension. 2. an agent that lessens tension. [EU]

Renovascular: Of or pertaining to the blood vessels of the kidneys. [EU] Respiration: Process of exchanging oxygen from the air for carbon dioxide from the body; includes the mechanical process of breathing, gas exchange, and oxygen and carbon dioxide transport to and from the cells. [NIH] Respiratory: Pertaining to respiration. [EU] Rheumatoid: Resembling rheumatism. [EU] Rheumatology: A subspecialty of internal medicine concerned with the study of inflammatory or degenerative processes and metabolic derangement of connective tissue structures which pertain to a variety of musculoskeletal disorders, such as arthritis. [NIH] Rhinitis: Inflammation of the mucous membrane of the nose. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Ribose: A pentose active in biological systems usually in its D-form. [NIH] Sapogenins: The aglucon moiety of a saponin molecule. It may be triterpenoid or steroid, usually spirostan, in nature. [NIH]

Glossary 283

Saponins: Sapogenin glycosides. A type of glycoside widely distributed in plants. Each consists of a sapogenin as the aglycon moiety, and a sugar. The sapogenin may be a steroid or a triterpene and the sugar may be glucose, galactose, a pentose, or a methylpentose. Sapogenins are poisonous towards the lower forms of life and are powerful hemolytics when injected into the blood stream able to dissolve red blood cells at even extreme dilutions. [NIH] Sarcoidosis: An idiopathic systemic inflammatory granulomatous disorder comprised of epithelioid and multinucleated giant cells with little necrosis. It usually invades the lungs with fibrosis and may also involve lymph nodes, skin, liver, spleen, eyes, phalangeal bones, and parotid glands. [NIH] Sciatica: A syndrome characterized by pain radiating from the back into the buttock and into the lower extremity along its posterior or lateral aspect, and most commonly caused by prolapse of the intervertebral disk; the term is also used to refer to pain anywhere along the course of the sciatic nerve. [EU] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Sedative: 1. allaying activity and excitement. 2. an agent that allays excitement. [EU] Seizures: Clinical or subclinical disturbances of cortical function due to a sudden, abnormal, excessive, and disorganized discharge of brain cells. Clinical manifestations include abnormal motor, sensory and psychic phenomena. Recurrent seizures are usually referred to as epilepsy or "seizure disorder." [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Sinusitis: Inflammation of a sinus. The condition may be purulent or nonpurulent, acute or chronic. Depending on the site of involvement it is known as ethmoid, frontal, maxillary, or sphenoid sinusitis. [EU] Skull: The skeleton of the head including the bones of the face and the bones enclosing the brain. [NIH] Snoring: Rough, noisy breathing during sleep, due to vibration of the uvula and soft palate. [NIH] Solvent: 1. dissolving; effecting a solution. 2. a liquid that dissolves or that is capable of dissolving; the component of a solution that is present in greater amount. [EU]

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Somatic: 1. pertaining to or characteristic of the soma or body. 2. pertaining to the body wall in contrast to the viscera. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Sphincter: A ringlike band of muscle fibres that constricts a passage or closes a natural orifice; called also musculus sphincter. [EU] Spirochaetales: An order of slender, flexuous, helically coiled bacteria, with one or more complete turns in the helix. [NIH] Squamous: Scaly, or platelike. [EU] Stabilization: The creation of a stable state. [EU] Standardize: To compare with or conform to a standard; to establish standards. [EU] Steatosis: Fatty degeneration. [EU] Steroid: A group name for lipids that contain a hydrogenated cyclopentanoperhydrophenanthrene ring system. Some of the substances included in this group are progesterone, adrenocortical hormones, the gonadal hormones, cardiac aglycones, bile acids, sterols (such as cholesterol), toad poisons, saponins, and some of the carcinogenic hydrocarbons. [EU] Stimulant: 1. producing stimulation; especially producing stimulation by causing tension on muscle fibre through the nervous tissue. 2. an agent or remedy that produces stimulation. [EU] Stomach: An organ of digestion situated in the left upper quadrant of the abdomen between the termination of the esophagus and the beginning of the duodenum. [NIH] Strychnine: An alkaloid found in the seeds of nux vomica. It is a competitive antagonist at glycine receptors and thus a convulsant. It has been used as an analeptic, in the treatment of nonketotic hyperglycinemia and sleep apnea, and as a rat poison. [NIH] Stupor: Partial or nearly complete unconsciousness, manifested by the subject's responding only to vigorous stimulation. Also, in psychiatry, a disorder marked by reduced responsiveness. [EU]

Glossary 285

Subclinical: Without clinical manifestations; said of the early stage(s) of an infection or other disease or abnormality before symptoms and signs become apparent or detectable by clinical examination or laboratory tests, or of a very mild form of an infection or other disease or abnormality. [EU] Suction: The removal of secretions, gas or fluid from hollow or tubular organs or cavities by means of a tube and a device that acts on negative pressure. [NIH] Suppuration: The formation of pus; the act of becoming converted into and discharging pus. [EU] Surgical: Of, pertaining to, or correctable by surgery. [EU] Sympathomimetic: 1. mimicking the effects of impulses conveyed by adrenergic postganglionic fibres of the sympathetic nervous system. 2. an agent that produces effects similar to those of impulses conveyed by adrenergic postganglionic fibres of the sympathetic nervous system. Called also adrenergic. [EU] Syncope: Fainting; temporary loss of consciousness. [NIH] Synovial: Of pertaining to, or secreting synovia. [EU] Systemic: Relating to a process that affects the body generally; in this instance, the way in which blood is supplied through the aorta to all body organs except the lungs. [NIH] Systolic: Indicating the maximum arterial pressure during contraction of the left ventricle of the heart. [EU] Tachyarrhythmia: Tachycardia associated with an irregularity in the normal heart rhythm. [EU] Tachycardia: Excessive rapidity in the action of the heart; the term is usually applied to a heart rate above 100 per minute and may be qualified as atrial, junctional (nodal), or ventricular, and as paroxysmal. [EU] Tetanus: A disease caused by tetanospasmin, a powerful protein toxin produced by clostridium tetani. Tetanus usually occurs after an acute injury, such as a puncture wound or laceration. Generalized tetanus, the most common form, is characterized by tetanic muscular contractions and hyperreflexia. Localized tetanus presents itself as a mild condition with manifestations restricted to muscles near the wound. It may progress to the generalized form. [NIH] Thrombosis: The formation, development, or presence of a thrombus. [EU] Thrombus: An aggregation of blood factors, primarily platelets and fibrin with entrapment of cellular elements, frequently causing vascular obstruction at the point of its formation. Some authorities thus differentiate thrombus formation from simple coagulation or clot formation. [EU]

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Thyrotropin: A peptide hormone secreted by the anterior pituitary. It promotes the growth of the thyroid gland and stimulates the synthesis of thyroid hormones and the release of thyroxine by the thyroid gland. [NIH] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH] Tinnitus: A noise in the ears, as ringing, buzzing, roaring, clicking, etc. Such sounds may at times be heard by others than the patient. [EU] Tone: 1. the normal degree of vigour and tension; in muscle, the resistance to passive elongation or stretch; tonus. 2. a particular quality of sound or of voice. 3. to make permanent, or to change, the colour of silver stain by chemical treatment, usually with a heavy metal. [EU] Toxic: Pertaining to, due to, or of the nature of a poison or toxin; manifesting the symptoms of severe infection. [EU] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Trachea: The cartilaginous and membranous tube descending from the larynx and branching into the right and left main bronchi. [NIH] Tracheostomy: Surgical formation of an opening into the trachea through the neck, or the opening so created. [NIH] Tracheotomy: Surgical incision of the trachea. [NIH] Transcutaneous: Transdermal. [EU] Transdermal: Entering through the dermis, or skin, as in administration of a drug applied to the skin in ointment or patch form. [EU] Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU] Tremor: An involuntary trembling or quivering. [EU] Treponema: A genus of microorganisms of the order spirochaetales, many of which are pathogenic and parasitic for man. [NIH] Tricyclic: Containing three fused rings or closed chains in the molecular structure. [EU] Tropocollagen: The molecular unit of collagen fibrils that consist of repeating three-stranded polypeptide units arranged head to tail in parallel bundles. It is a right-handed triple helix composed of 2 polypeptide chains. It is rich in glycine, proline, hydroxyproline, and hydroxylysine. [NIH] Tryptophan: An essential amino acid that is necessary for normal growth in infants and for nitrogen balance in adults. It is a precursor serotonin and

Glossary 287

niacin. [NIH] Tumour: 1. swelling, one of the cardinal signs of inflammations; morbid enlargement. 2. a new growth of tissue in which the multiplication of cells is uncontrolled and progressive; called also neoplasm. [EU] Turbinates: The scroll-like bony plates with curved margins on the lateral wall of the nasal cavity. [NIH] Ulcer: A local defect, or excavation, of the surface of an organ or tissue; which is produced by the sloughing of inflammatory necrotic tissue. [EU] Urinary: Pertaining to the urine; containing or secreting urine. [EU] Uterus: The hollow muscular organ in female mammals in which the fertilized ovum normally becomes embedded and in which the developing embryo and fetus is nourished. In the nongravid human, it is a pear-shaped structure; about 3 inches in length, consisting of a body, fundus, isthmus, and cervix. Its cavity opens into the vagina below, and into the uterine tube on either side at the cornu. It is supported by direct attachment to the vagina and by indirect attachment to various other nearby pelvic structures. Called also metra. [EU] Vaccine: A suspension of attenuated or killed microorganisms (bacteria, viruses, or rickettsiae), administered for the prevention, amelioration or treatment of infectious diseases. [EU] Vaginitis: Inflammation of the vagina characterized by pain and a purulent discharge. [NIH] Valerian: Valeriana officinale, an ancient, sedative herb of the large family Valerianaceae. The roots were formerly used to treat hysterias and other neurotic states and are presently used to treat sleep disorders. [NIH] Vasodilator: An agent that widens blood vessels. [NIH] Vein: Vessel-carrying blood from various parts of the body to the heart. [NIH] Venereal: Pertaining or related to or transmitted by sexual contact. [EU] Venous: Of or pertaining to the veins. [EU] Ventilation: The process of exchange of air between the lungs and the atmosphere leading to exchange of gases in the blood. [NIH] Ventricle: One of the two pumping chambers of the heart. The right ventricle receives oxygen-poor blood from the right atrium and pumps it to the lungs through the pulmonary artery. The left ventricle receives oxygenrich blood from the left atrium and pumps it to the body through the aorta. [NIH]

Ventricular: Pertaining to a ventricle. [EU] Vertigo: An illusion of movement; a sensation as if the external world were revolving around the patient (objective vertigo) or as if he himself were

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revolving in space (subjective vertigo). The term is sometimes erroneously used to mean any form of dizziness. [EU] Vestibular: Pertaining to or toward a vestibule. In dental anatomy, used to refer to the tooth surface directed toward the vestibule of the mouth. [EU] Vestibule: A small, oval, bony chamber of the labyrinth. The vestibule contains the utricle and saccule, organs which are part of the balancing apparatus of the ear. [NIH] Viral: Pertaining to, caused by, or of the nature of virus. [EU] Viruses: Minute infectious agents whose genomes are composed of DNA or RNA, but not both. They are characterized by a lack of independent metabolism and the inability to replicate outside living host cells. [NIH] Viscera: Any of the large interior organs in any one of the three great cavities of the body, especially in the abdomen. [NIH] Wakefulness: A state in which there is an enhanced potential for sensitivity and an efficient responsiveness to external stimuli. [NIH] Warfarin: An anticoagulant that acts by inhibiting the synthesis of vitamin K-dependent coagulation factors. Warfarin is indicated for the prophylaxis and/or treatment of venous thrombosis and its extension, pulmonary embolism, and atrial fibrillation with embolization. It is also used as an adjunct in the prophylaxis of systemic embolism after myocardial infarction. Warfarin is also used as a rodenticide. [NIH] Xerostomia: Dryness of the mouth from salivary gland dysfunction, as in Sjögren's syndrome. [EU] Yeasts: A general term for single-celled rounded fungi that reproduce by budding. Brewers' and bakers' yeasts are saccharomyces cerevisiae; therapeutic dried yeast is yeast, dried. [NIH] Yohimbine: An alkaloid that possesses adrenergic-blocking properties and is used in arteriosclerosis and angina pectoris, formerly used as a local anesthetic and mydriatic and for its purported aphrodisiac properties. [NIH] Zygote: The fertilized ovum. [NIH]

Glossary 289

General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinterna Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinterna A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinterna Dorland’s Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinterna Dorland’s Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinterna Dorland’s Pocket Medical Dictionary (Dorland’s Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinterna /103-4193558-7304618 Melloni’s Illustrated Medical Dictionary (Melloni’s Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC PressParthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupinterna Stedman’s Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinterna

290 Sleep Apnea

Stedman’s Medical Dictionary by Thomas Lathrop Stedman, Hardcover 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinterna Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinterna

Index 291

INDEX A Abdomen .....................100, 276, 284, 288 Abdominal......15, 100, 101, 115, 266, 279 Abrupt ..............................................13, 76 Abscess .......................................128, 131 Acetylcholine .........................87, 265, 277 Adenine .........................................86, 259 Adenosine................................80, 86, 259 Adjuvant...............................................270 Adolescence ....47, 60, 135, 248, 259, 279 Adrenergic ...........................219, 285, 288 Adverse .........50, 134, 136, 147, 272, 280 Aerobic ................................................274 Aggravation ...................................97, 101 Agonist.........................................115, 277 Agoraphobia ........................................272 Airways .....73, 95, 98, 107, 109, 112, 113, 131 Alimentary............................................273 Alkaloid .......115, 116, 219, 262, 276, 277, 284, 288 Alkalosis ......................................205, 272 Alveoli ..........115, 134, 205, 266, 268, 272 Amphetamine ......................................260 Anaesthesia.........................................273 Analeptic ......................................116, 284 Analogous............................................111 Anaplasia.............................135, 274, 276 Anastomosis ........................................130 Anatomical.............................84, 118, 128 Anesthesia.............86, 123, 130, 131, 261 Anesthetics ....................................86, 260 Angina .................................128, 219, 288 Ankle....................................144, 145, 146 Ankylosis .....................................135, 278 Antibacterial...................................61, 284 Antibiotic ................................................61 Antibodies............................................273 Anticholinergic .....................................238 Anticonvulsant .............133, 135, 263, 280 Antidepressant.....................116, 272, 281 Antiemetic ......................................87, 267 Antiepileptic ...........................................70 Antigens.................89, 135, 261, 279, 282 Antitoxin.................................................89 Antitussive .....................................87, 267 Anxiety.........................235, 236, 237, 238 Aorta ......................................89, 285, 287 Apnoea ................................193, 194, 196 Arterial .........................................105, 285 Arteries ..........................60, 112, 262, 265

Artery .................... 75, 105, 262, 268, 287 Aspiration ............................................ 131 Asymptomatic ..................................... 234 Ataxia ............................................ 29, 168 Atrium.......................................... 262, 287 Atropine............................................... 260 Auditory............... 128, 134, 192, 196, 271 Autonomic ..................... 98, 213, 259, 277 Autosuggestion ........................... 134, 272 B Bacteria........................... 61, 89, 135, 208 Benign................... 61, 118, 135, 272, 276 Benzene...................................... 132, 262 Benzodiazepines ................................ 131 Bereavement ...................................... 238 Bile ................................ 61, 133, 265, 284 Biliary .................................................. 263 Biochemical................................... 88, 280 Biotransformation................................ 135 Bradycardia................................... 98, 148 Bronchi........................................ 116, 132 Bronchial ............................................. 271 Bronchiectasis .................................... 131 Bronchitis .................................... 127, 150 Bruxism ............................................... 151 C Calculi ........................................... 23, 270 Candidiasis ......................................... 128 Cannula............................................... 107 Capsules ..................................... 211, 270 Carbohydrates .................... 208, 218, 264 Carcinogenic ................. 61, 262, 264, 284 Carcinoma................................... 131, 264 Cardiac....... 61, 74, 81, 93, 98, 105, 107, 108, 109, 149, 267, 268, 284 Cardiopulmonary ..... 17, 47, 74, 235, 241, 243 Cardiovascular . 74, 81, 98, 111, 125, 155, 232, 234, 260 Caudal........................................... 88, 280 Cellulose ............................. 218, 264, 270 Cerebellar ............................................. 29 Cerebral .............................................. 129 Cerebrovascular ................................. 125 Cervical ....................................... 129, 239 Chemotherapy ............................ 205, 265 Chlorophyll .......................................... 269 Chloroprene ................................ 115, 276 Cholesteatoma.................................... 118 Cholesterol... 61, 118, 133, 163, 208, 210, 265, 284

292 Sleep Apnea

Cholinergic.......................77, 83, 115, 277 Chronic .11, 31, 67, 74, 80, 103, 118, 131, 135, 136, 151, 214, 237, 272, 279, 283 Chronotherapy.....................193, 205, 265 Coagulation .........................137, 285, 288 Coal .....................................................262 Collagen ......................130, 133, 265, 286 Collapse.......15, 73, 81, 98, 104, 112, 194 Conception ..........................................219 Concomitant ..................96, 113, 235, 242 Confounding ........................................241 Confusion ............................................267 Consciousness ......34, 87, 136, 254, 266, 285 Coronary................................51, 112, 163 Cortex ..........................................265, 281 Cortical ............................40, 78, 191, 283 Cranial .................................................264 Crowding ...............................................71 Curative .......................................219, 277 Cutaneous ...........................133, 263, 281 Cyclic .....................................88, 275, 280 Cyst .....................................................128 D Decarboxylation...................................271 Degenerative ...........23, 89, 209, 278, 282 Dementia ...............................66, 235, 242 Demography ..........................................68 Dendrites .......................................88, 277 Dentists..................................................75 Dentition ........................................97, 101 Deprivation ....11, 31, 32, 80, 83, 103, 191 Dermis .........................................266, 286 Diaphragm ...........................109, 115, 266 Diarrhea ...............................................208 Diastole................................................267 Diastolic .........................................60, 271 Digestion......................................260, 284 Dilatation......................................132, 263 Disaccharides ..............................219, 264 Dislocation ...........................130, 238, 242 Disorientation...............................133, 267 Distal..............................95, 107, 108, 281 Diurnal ...................................................99 Dizziness .............................118, 136, 288 Dopamine ............................241, 260, 277 Dorsal ............................................88, 280 Duodenum ...........................................273 Dysphagia....................................134, 274 Dyspnea ..............................................131 E Edema .................................128, 130, 131 Efficacy .....48, 60, 72, 194, 229, 231, 235, 238, 241, 242, 268 Effusion................................................131 Elastic ..................................................144

Electrocardiogram............................... 113 Electrolyte ................................... 136, 281 Embolism .................................... 137, 288 Embryology................................... 88, 277 Emphysema ........................................ 127 Endocarditis ................................ 133, 263 Endocardium....................................... 268 Endocrinology ..................................... 205 Endorphins.......................................... 277 Endoscopy .......................................... 130 Enkephalins ................................ 268, 277 Enzyme ................. 61, 119, 265, 278, 279 Epidemiological........................... 233, 234 Epigastric ............................................ 279 Epinephrine......................................... 205 Epithelium ........................... 133, 264, 266 Excitation ............ 116, 267, 269, 277, 281 Exocrine .............................................. 279 Extracellular .................... 80, 87, 271, 275 Extraction .............................................. 84 Extremity..................................... 116, 283 F Facial .............................................. 15, 71 Fatal ...................... 74, 107, 135, 274, 279 Fatigue .................................. 74, 234, 261 Fetus ................................................... 209 Fibrillation.................................... 137, 288 Fibrosis ............................... 131, 136, 283 Fistula ......................................... 118, 270 Fluoroscopy .......................................... 69 Fungus ........................................ 133, 263 G Ganglia........................................ 259, 267 Gastrointestinal................................... 270 Gastroplasty........................................ 140 Gelatin................................. 133, 265, 270 Gestation..................................... 128, 142 Glucose.... 48, 60, 61, 131, 264, 270, 273, 283 Glycine ........................ 116, 277, 284, 286 Glycoside .................................... 267, 283 Gonadal ........................................ 61, 284 Gout ................................................ 19, 20 Granulomas ........................................ 130 H Heartbeat ...................... 12, 114, 148, 262 Hemorrhage .................................. 24, 130 Hepatic.................................................. 48 Histamine ...... 87, 114, 205, 261, 265, 267 Histidine ...................................... 103, 271 Hoarseness................. 118, 127, 134, 274 Hormonal ............................................ 275 Hormones ...... 61, 89, 133, 265, 278, 282, 284, 286 Hydroxylysine ..................................... 286 Hydroxyproline............................ 271, 286

Index 293

Hyperacusis.........................................118 Hyperlipidemia.......................................47 Hypersensitivity ...............86, 87, 260, 267 Hypertension ..47, 51, 60, 74, 97, 98, 102, 105, 109, 112, 147, 163, 271 Hyperthyroidism...........................238, 272 Hypertrophy ...................23, 128, 196, 278 Hyperventilation...................................193 Hypnotic.................87, 230, 231, 237, 267 Hypothyroidism....................213, 219, 272 Hypotonia ........................................29, 34 Hypoxemia...................................106, 236 Hypoxia................................................109 I Iatrogenic .............................................129 Idiopathic ...............61, 136, 147, 272, 283 Immunization .........................................89 Incision ..........................61, 136, 273, 286 Incompetence ......................................232 Incontinence ..................................61, 278 Indicative ...............................46, 111, 276 Infarction ..................74, 81, 112, 137, 288 Inflammation ................................134, 270 Ingestion ..............................................211 Inhalation .............................................127 Insomnia ....... 11, 19, 22, 31, 33, 77, 194, 230, 235, 236, 237, 238, 240, 243, 246, 250 Insulin ..........48, 51, 60, 61, 111, 270, 273 Intermittent.......................46, 92, 105, 238 Intervertebral ...............................116, 283 Intestinal ..............................................208 Intestines .....................................133, 265 Intubation.............................................129 Invasive ...............46, 83, 88, 94, 144, 279 L Labyrinthitis .........................................118 Laryngitis .............................................127 Laryngoscopy ......................................130 Larynx ..................116, 127, 134, 274, 286 Legionellosis........................................131 Lesion ..............................40, 87, 274, 279 Lethal .....................................97, 101, 108 Lethargy.......................................219, 272 Lip ..........................................................30 Lithium ...................................92, 115, 274 Localization............................70, 135, 280 Locomotion ....................................87, 274 Lumen..........................................115, 263 Lymph ..........................................136, 283 M Malignant .......61, 133, 262, 264, 272, 275 Mandible ........71, 72, 75, 96, 97, 101, 102 Mania ...........................................214, 275 Manic ...........................................115, 274 Mannans ..............................................270

Maxillary........................ 97, 101, 136, 283 Membrane ....... 23, 87, 88, 108, 134, 135, 136, 274, 275, 278, 280, 282 Menopause ................................. 194, 275 Menstruation ............................... 205, 275 Metastasis........................... 135, 274, 276 Microdialysis ................................... 78, 80 Molecular . 11, 84, 89, 161, 166, 167, 243, 282, 286 Monocytes................................... 135, 276 Mononucleosis .................... 128, 135, 276 Morphine ............................................. 260 Mucopurulent ...................................... 132 Mucus ................................................. 276 Mutagens ...................................... 87, 276 Mydriatic...................................... 219, 288 N Nasal...... 15, 16, 93, 94, 97, 99, 102, 104, 107, 108, 113, 126, 127, 129, 136, 194, 230, 238, 239, 276, 287 Nasopharyngitis .................................. 128 Nasopharynx............................... 135, 276 Nausea................................................ 261 Necrosis ...................................... 136, 283 Neoplasms.......................... 128, 135, 276 Neoplastic ........................... 133, 260, 264 Neoprene ........................ 94, 95, 144, 264 Nephrology............................................ 73 Neural ..................... 40, 83, 128, 209, 279 Neurologic........................................... 243 Neurology.............................. 61, 231, 277 Neuromuscular ............................. 69, 259 Neuronal ............................................... 80 Neurons .................. 80, 88, 115, 270, 277 Neurotic......................................... 89, 287 Neurotransmitter .. 86, 259, 267, 270, 271, 277 Niacin .................................................. 209 Nicotine ............................... 103, 248, 260 Norepinephrine ........................... 259, 277 O Ocular ................................................... 77 Organelles........................................... 276 Oropharynx ........................... 96, 103, 113 Osteoarthritis .......................... 19, 20, 163 Osteotomy............................................. 71 Otitis.................................................... 118 Otolaryngology............................ 128, 231 Otosclerosis ........................ 118, 135, 278 Ovary .................................................. 279 Overdose ............................................ 209 Overweight................ 12, 19, 20, 109, 163 Ovum .......................... 134, 281, 287, 288 Oximetry................................ 88, 113, 279 P Pancreas....................................... 61, 273

294 Sleep Apnea

Paralysis ................................40, 130, 279 Paroxysmal..........................132, 263, 285 Parturition ....................................205, 278 Pathogenesis.......................................105 Pathologic ..............................................60 Pathophysiology ....................29, 123, 240 Pelvic ...................................100, 101, 287 Pemphigus...........................128, 135, 279 Perspiration .................................144, 145 Pharmacists.........................................239 Pharmacotherapy ........................103, 163 Pharyngitis...........................................128 Phonation ............................................129 Phototransduction..................................77 Placenta...............................................281 Pleura ..................................................131 Pneumonia ............................................28 Polypeptide..........................................286 Posterior ..........69, 97, 100, 101, 116, 135 Postmenopausal..........................151, 153 Postoperative.......................................131 Potassium....................................118, 210 Precursor .....................................268, 286 Preoperative ........................................130 Presynaptic..........................................277 Prevalence..46, 48, 50, 52, 53, 54, 66, 68, 69, 74, 83, 149, 163, 213, 233, 281 Progesterone .................................61, 284 Progressive......................87, 97, 102, 112 Prolapse ......................................116, 283 Proline .........................................271, 286 Prophylaxis ..................................137, 288 Proteins .........78, 115, 208, 210, 261, 275 Protozoa ..............................................275 Protriptyline..........................................103 Proximal.......................107, 115, 267, 281 Proxy .....................................................81 Pruritus ..........................................87, 267 Psychiatric .....78, 230, 232, 236, 237, 243 Psychiatry ......................32, 230, 231, 284 Psychic ..........................................41, 283 Psychology ..........................................230 Psychomotor....................79, 82, 133, 263 Puberty ........................................129, 275 Puerperium ..................................205, 278 Pulmonary ......11, 28, 61, 74, 87, 98, 109, 127, 131, 137, 205, 232, 238, 271, 272, 287, 288 Pulse......................................88, 113, 115 Pupil.....................................................276 Pylorus.................................................267 R Receptor ........................................78, 119 Reflex ..................................................191 Reflux ..........................................127, 238 Refractory ..............................69, 110, 152

Regurgitation ................................ 97, 102 Relaxant...................................... 135, 280 Renovascular ........................................ 61 Respiration....... 23, 83, 97, 98, 101, 103, 104, 123, 124, 129, 261, 262, 282 Respiratory..... 14, 28, 47, 54, 66, 70, 73, 83, 92, 96, 98, 108, 113, 114, 127, 131, 133, 196, 236, 239, 263 Rheumatoid......................................... 247 Rhinitis ........................................ 118, 127 Riboflavin ............................................ 208 Ribose........................................... 86, 259 S Salivation .............................................. 72 Saponins ....................................... 61, 284 Sarcoidosis ......................................... 131 Sciatica ............................................... 100 Secretion............. 219, 271, 272, 280, 283 Sedative .. 87, 89, 237, 238, 267, 272, 287 Seizures ...... 30, 33, 41, 68, 70, 133, 135, 263, 279, 280, 283 Selenium ............................................. 210 Serum ..................................... 67, 89, 135 Sinusitis............... 118, 127, 131, 136, 283 Skeletal ................................. 40, 194, 272 Skull ............................................ 133, 264 Solvent ................................................ 262 Somatic ................. 60, 237, 259, 272, 275 Somnolence .................................... 92, 94 Spasmodic .......................................... 118 Species ................................. 41, 275, 284 Spectrum............................................... 49 Sphincter............................. 134, 274, 284 Squamous................................... 133, 264 Stabilization................................. 135, 280 Standardize........................................... 47 Steatosis ............................................... 48 Steroid................................... 89, 282, 283 Stimulant ............................. 247, 260, 271 Stomach.............. 100, 127, 142, 270, 282 Stroke..... 12, 14, 19, 20, 51, 74, 109, 111, 163 Strychnine ................................... 103, 260 Stupor ................................................. 274 Subclinical..................................... 40, 283 Suction ................................................ 105 Suppuration......................................... 259 Surgical .. 16, 17, 75, 88, 96, 97, 102, 113, 129, 130, 131, 132, 135, 140, 142, 193, 205, 219, 239, 260, 270, 278 Sympathomimetic ....................... 260, 278 Synaptic .............................................. 115 Synovial ........................................ 23, 278 Systemic 74, 98, 133, 136, 137, 263, 267, 283, 288 Systolic.......................................... 60, 271

Index 295

T Tetanus........................................261, 285 Thermoregulation ................................208 Thoracic.........................28, 115, 136, 266 Thrombosis............................24, 137, 288 Thrombus ............................................285 Thyrotropin ..................................219, 272 Thyroxine.....................................210, 286 Tinnitus ................................118, 135, 278 Tolerance.......................................48, 144 Tone .....34, 40, 74, 96, 97, 102, 105, 109, 112, 114, 232, 272 Toxic .40, 87, 89, 115, 209, 219, 262, 264, 267, 277, 279, 283, 286 Toxin ......................78, 136, 261, 285, 286 Trachea .........24, 110, 134, 136, 274, 286 Tracheostomy................94, 110, 141, 153 Tracheotomy........................................129 Transcutaneous.......................67, 86, 197 Transfusion..........................................197 Tremor .................................................168 Tricyclic................................237, 261, 272 Tropocollagen......................................133 Tuberculosis ..........................28, 128, 131 Turbinates............................................129 U Urinary .................................................263

Uterus ......................................... 275, 281 V Vaccine ............................................... 259 Vaginitis ...................................... 133, 263 Vasodilator .......................................... 271 Venous........................................ 137, 288 Ventilation ...... 87, 98, 105, 107, 108, 205, 271, 272 Ventricle ...................... 109, 262, 285, 287 Ventricular..................... 98, 105, 130, 285 Vertebral ............................................. 100 Vertigo................. 118, 135, 136, 278, 287 Vestibular ............................................ 118 Vestibule ..................................... 136, 288 Viral............................................. 128, 131 Viruses ........................................ 275, 287 Viscera ................................................ 284 W Wakefulness ...... 23, 76, 79, 86, 104, 105, 197, 231, 233, 235, 249, 273 X Xerostomia...................................... 71, 72 Y Yeasts ......................................... 269, 288 Yohimbine ........................................... 213

296 Sleep Apnea

Index 297

298 Sleep Apnea