After a successful start to the course, Day 2 began with Allan Pack, MBChB, PhD of the University of Pennsylvania. Allan had given the final talk of Day 1, in which he delivered a thought-provoking lecture on the future of the field of sleep medicine. He has campaigned for a shift for the field, like many others in medicine, to move from performing tests to a more-comprehensive approach to disease management. He persuasively argued for the development of networks to manage patients across the spectrum from initial evaluation to treatment, incorporating the practices of telemedicine and remote monitoring. His talk this morning was a review of key publications over the past year in the field of sleep. There have been studies suggesting a major increase in the prevalence of moderate to severe obstructive sleep apnea; providing insight into the importance of sleep in enabling our brain, heart, and lungs to repair themselves; the link between cancer and sleep apnea (those with frequent drops in blood oxygen levels during sleep); and the specific causes of obstructive sleep apnea that underscore the potential for personalized treatment.
Clete Kushida, MD, PhD from Stanford University has led a number of large studies of positive airway pressure therapy for obstructive sleep apnea, including the recently-completed Apnea Positive Pressure Long-term Efficacy Study (APPLES). APPLES demonstrated little difference in neurocognitive outcomes between actual CPAP and sham placebo CPAP (delivering only 0.5 cm of water pressure), which was certainly surprising to the field. There were improvements in executive function in selected individuals, but overall the benefits were minor. This study has clouded the picture somewhat while underscoring the importance of an individualized approach to treatment.
Advances in snoring and sleep apnea surgery
Today, I spoke about topics that may be familiar to readers of this blog and site: physical examination and identifying the primary factors contributing to snoring and obstructive sleep apnea, selecting procedures to treat what I call the Tongue Region, and new treatments for snoring and obstructive sleep apnea. One of the best parts of being a Co-Director of the course is the ability to choose topics that I truly enjoy and have been at the core of my research. I will not bore everyone with the details of my talks, as they build on courses and lectures I give to physicians around the world. I have been fortunate to work with a number of established and startup medical devices companies, developing and performing the studies that have evaluated their benefits in snoring and sleep apnea.
Andrew Goldberg, MD, MSCE from the University of California, San Francisco delivered a thorough presentation of the treatment options for snoring. Overall, there is a wide range of success rates for various procedures and various types of patients. He later spoke about perioperative management in patients with sleep apnea, after both sleep apnea and non-sleep apnea procedures.
As is true for adults, sleep disordered breathing is becoming more common over time. Anna Meyer, MD, also from the University of California, San Francisco, spoke about guidelines related to tonsillectomy and adenoidectomy for chronic tonsillitis and sleep disordered breathing in children. There are numerous challenges to these guidelines, including recommendations from the American Academy of Pediatrics that all children with suspected sleep disordered breathing need a sleep study; honestly, this is absurd. The problem is that there are not only few sleep centers that are able or want to perform sleep studies in children but also tremendous costs associated with this kind of universal testing. Home sleep studies have not been evaluated for children, so this is not an option. Finally, there are relatively little data to show value in sleep studies for children, questioning whether this specific recommendation is based on science.
Kasey Li, DDS, MD next spoke about maxillofacial surgery, including his preference for maxillomandibular advancement to treat his patients with sleep apnea and potential serious complications of the procedure.
Insight into the hazards of sugar in our diets
Non-communicable diseases have become more of a problem worldwide than infectious diseases, and the United Nations has identified these as a major priority in international health efforts. Robert Lustig, MD of the University of California, San Francisco is one of the world’s leading experts on the risks of sugar in our diets. Simply, his thesis is “a calorie is not a calorie” because some calories cause disease more than others. He presented compelling evidence that sugar is the major risk factor for diabetes, causing 25% of all diabetes worldwide. There are other foodstuffs that are processed similarly, processed in the liver and overwhelming the mitochondria in our bodies: fructose (sugar), transfats, branched chain amino acids (found in corn-fed beef, chicken, and fish), and alcohol. There has been a major push in the scientific community to reduce sugar intake, and the sugar industry has responded. Unfortunately, these responses are not valid in today’s world. He is a force in the ongoing and important debate about taxation of sugary foods, and anyone interested can learn more at www.responsiblefoods.org.
Robson Capasso, MD from Stanford University discussed the array of soft palate surgeries that are available and the strong evidence that they do provide benefit, if not complete resolution by themselves, in obstructive sleep apnea. Mandibular advancement splints (also known as oral appliances or mandibular repositioning devices) can be very effective in many patients with obstructive sleep apnea. Andrew Chan, MBBS, PhD from the University of Sydney discussed their role and the outstanding research related to mandibular advancement splints performed in their center. Ed Weaver, MD, MPH from the University of Washington finished the day with a philosophical discussion of the multidisciplinary approach to snoring and sleep apnea.
I hope everyone enjoyed the course again this year, as I certainly learned quite a bit and enjoyed sharing ideas with colleagues and attendees. I am already looking forward to the next course in Orlando in February 2015.