Management Of Sleep Disorders Research Articles

Management of sleep disorders in the menopausal transition.

The menopausal transition is associated with increasing sleep disorders including sleep apnoea and restless leg syndrome. Insomnia is the most common and is recognised as a core symptom of the menopause. Guidelines to support decision making for women with sleep problems during the menopausal transition are lacking. Sleep problems are associated with negative impacts on healthcare utilisation, quality of life and work productivity. Sleep deprivation is a risk factor for cardiovascular disease, diabetes, obesity and neurobehavioral dysfunction. Declining oestrogen is implicated as a cause of menopausal sleep disruption. Vasomotor symptoms (VMS) and menopausal mood disturbance are also factors in the complex aetiology. VMS commonly precipitate insomnia and, due to their prolonged duration, they often perpetuate the condition. Insomnia in the general population is most effectively treated with cognitive behavioural therapy (CBT) (also effective in the menopausal transition.) The associations of menopausal sleep disturbance with VMS and depression mean that other treatment options must be considered. Existing guidelines outline effectiveness of hormone replacement therapy (HRT), CBT and antidepressants. HRT may indirectly help with sleep disturbance by treating VMS and also via beneficial effect on mood symptoms. The evidence base underpinning menopausal insomnia often references risks associated with HRT that are not in line with current international menopause guidelines. This may influence clinicians managing sleep disorders, leading to hesitation in offering HRT, despite evidence of effectiveness. Viewing sleep symptoms on an axis of menopausal symptoms - towards vasomotor symptoms or towards mood symptoms may help tailor treatment options towards the symptom profile.

Insomnia and circadian sleep disorders in ovarian cancer: Evaluation and management of underestimated modifiable factors potentially contributing to morbidity.

Ovarian cancer is the leading cause of gynaecological cancer deaths and the seventh most commonly diagnosed cancer among women worldwide, so that, as it is related to substantial and increasing disease burden, the management of ovarian cancer survivors should be a priority. Such issues involve prevention and management of emotional distress, anxiety/depressive symptoms, and maintenance of quality of life from initial diagnosis to post-treatment. Within this framework, sleep disturbances, in particular insomnia, are emerging as modifiable determinants of mental health, also contributing to substantial morbidity among cancer, including ovarian cancer. To this aim we conducted a systematic review according to PRISMA guidelines on prevalence and management of insomnia and circadian sleep disorders in ovarian cancer, while selecting 22 papers. Insomnia was evaluated in ovarian cancer and, while circadian sleep disturbances were poorly assessed in ovarian cancer, insomnia increased from 14% to 60% of patients. Insomnia was associated with cancer-related comorbid conditions such as emotional distress, anxiety/depressive symptoms and low quality of life. Despite this evidence, no studies have been conducted about insomnia treatment in ovarian cancer. The burden of insomnia and circadian sleep disorders in patients with ovarian cancer still needs to be addressed, and requires a call to action for the evaluation and management of these potential modifiable factors that might contribute to ovarian cancer morbidity.

Endorsement of: “treatment of adult obstructive sleep apnea with positive airway pressure: an American academy of Sleep Medicine Clinical Practice Guideline” by World Sleep Society

Guidelines for the evaluation and management of sleep disorders from national societies provide recommendations that may be regionally appropriate but may not always be practical or relevant in other parts of the world. A task force of experts from the World Sleep Society’s (WSS) International Sleep Medicine Guidelines Committee and Sleep and Breathing Disorders Taskforce reviewed the American Academy of Sleep Medicine’s Clinical Practice Guideline on the Treatment of Adult Obstructive Sleep Apnea (OSA) with Positive Airway Pressure with respect to its relevance and applicability to the practice of sleep medicine by sleep specialists in various regions of the world. To improve the evaluation of the guideline, surveys were sent by the senior author and the WSS to approximately 800 sleep doctors around the world to query the availability of OSA treatments in their respective region. The task force and the WSS guidelines committee endorsed the AASM’s CPAP guidelines with respect to the indications for PAP therapy, utilization of different PAP modalities, and concurrent strategies to improve outcomes, noting appropriate caveats for universal applicability.

The Relationship Between Primary Sleep Disorders and Temporomandibular Disorders: An 8-Year Nationwide Cohort Study in South Korea.

BackgroundWhile evidence is accumulating to propose a specific contribution of sleep disorders and low quality sleep in the pathogenesis of temporomandibular disorders (TMD), management of primary sleep disorders in the process of preventing and treating TMD still remains scientifically unsupported.ObjectiveTo investigate the association of primary sleep disorders with TMD risk in South Korea.Patients and MethodsThis study was based on the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) of South Korea with 468,882 participants. After excluding participants diagnosed in 2002, those with a diagnosis of a primary sleep disorder in 2003–2005 were recruited. All participants diagnosed with TMD between January 1, 2006 and December 31, 2013 received follow-up. Cox proportional hazards regression was performed to determine the adjusted hazard ratios (aHR) and 95% confidence interval (CI) for TMD according to the presence or absence of a primary sleep disorder diagnosis.ResultsAfter adjusting for all covariates, primary sleep disorder patients had a 44% higher risk for TMD compared with non-sleep disorder participants (aHR 1.44, 95% CI 1.02–2.04). The incidence rate of TMD was nearly twice as high in participants with sleep disorders compared with those without (6.08 vs 3.27, per 104 person-years). In subgroup analysis, an association was observed with those over 60 years old or who frequently exercised physically.ConclusionPrimary sleep disorders could be an important independent risk factor for the initiation and maintenance of TMD. Patients with sleep disorders should be monitored for possible co-occurrence of TMD-related symptoms that could aggravate sleep disorders in turn.

Sleep Disorders and Risk of Motor Vehicle Accident

Driving is a complicated process that demands coordination between a range of neurocognitive functions, including attention, visuo-perception, and appropriate judgment, as well as sensory and motor responses. Therefore, several factors may reduce the driving performance of an individual, such as sleepiness, distraction, overspeeding, alcohol consumption, and sedative drugs, all of which increase the hazard of motor vehicle accidents. Among them, drowsy driving is a major cause of traffic accidents, leading to more serious injuries as compared to other causes of major traffic accidents. Although sleep disorders have been highly associated among drowsy drivers, they are often untreated and unrecognized as a disease. In particular, obstructive sleep apnea and narcolepsy are some sleep disorders that are highly related to traffic accidents. Insomnia, which can cause inadequate sleep duration and promote sedative effects from sleeping pills, may also cause traffic accidents. These conditions are especially applicable to commercial bus or truck drivers, nocturnal workers, and shift workers, who are highly vulnerable to drowsy driving. Therefore, assertive screening and management of sleep disorders are necessary in general private drivers and relevant occupational drivers.

Usages et bon usage des benzodiazépines anxiolytiques et hypnotiques

Since 60 years, benzodiazepines have replaced barbiturates and are now the most prescribed anxiolytic and hypnotic drugs at the international level. France is one of the largest users of benzodiazepines in the world, with more than 13% of its population exposed to this pharmacological class. At the European level, France is in 2nd place just behind Spain. Benzodiazepine use has spread for the management of sleep disorders and anxiety, because of their effectiveness and their relative safety in case of acute intoxication, compared to previous drugs. Epidemiology data show that benzodiazepine use increases with age, and reaches a peak in the elderly. Benzodiazepine use is more common in women (with a ratio of 2 women for one man of the same age). The co-prescription of 2 benzodiazepines at the same time is found in 1 user in 5. Some prescriptions do not comply with the regulations in force, in terms of duration of treatment (15%), dosage and therapeutic indication. However, the evidence of their effectiveness is limited to the legal duration of their prescription, with a risk of reversing the balance of benefits and risks in the instance of prolonged use. The main undesirable effects are due to depressive effects on the central nervous system, and consist of drowsiness, falls, or orthostatic hypotension, which occur during prolonged use, including substance use disorders. Moreover, prolonged use can lead to the occurrence of a withdrawal syndrome, as well as cognitive disorders. In the context of epidemiological overconsumption, this review aims to synthesize the evidence on the risk/benefit ratio of these molecules in their most common indications. Moreover, this article also provides practical rules of good practice, which include in an objective of overall patient care before prescribing anxiolytic or hypnotic benzodiazepines, the reminder of non-medicinal measures such as those of lifestyle, psychotherapy and, if necessary, the use of alternative medicines. If a prescription is initiated, it will then be necessary to choose the minimum effective dosage, the minimum effective duration of treatment, and the molecule which fits the most with recommendations. Finally, deprescribing, a too-often forgotten phase of treatment, allows for a controlled cessation of treatment. Deprescribing should be performed gradually and after evaluation of the patient's degree of pharmacological dependence and of his expectations and motivations. Planned deprescribing also finds its place from the initiation of a treatment, on the basis of a therapeutic alliance with the patient, informed therefore of the benefits and risks of his treatment, and therefore of the resulting modalities such as its limited duration. comprising a decrease in doses until discontinuation. The pharmacist and the prescribing physician are two guarantors of the correct use of benzodiazepines and related drugs. They must work in a coordinated manner and have a common discourse with patients to explain to them, during their initiation, the transient benefits, risks and alternatives to these treatments. These professionals must also support patients in the deprescribing phase, a phase which is too-often overlooked in situations of chronic prescribing.

The Management and Alternative Therapies for Comorbid Sleep Disorders in Epilepsy.

Background There is a complex and interactive relationship between sleep and epilepsy. Sleep disorders are common in patients with epilepsy, and methods for managing sleep disorders in patients with epilepsy are limited.Objective This review addresses the relationship among sleep, sleep disorders, and epilepsy, focusing on the management of sleep disorders in epilepsy, including some complementary and alternative therapies.Methods The terms related to “sleep” and “epilepsy” were searched in “Pubmed” and “Cochrane Library”.Results Sleep stages differently affect both seizures and interictal epileptiform discharges. Seizures disrupt sleep architecture greatly, especially when occurring during sleep in the night. Insomnia and obstructive sleep apnea (OSA) are the most frequent types of comorbid sleep disorders in patients with epilepsy. Pharmacological agents with both anti-convulsant and sedative effects are the priorities for comorbid sleep disorders in epilepsy. Continuous positive airway pressure (CPAP) therapy is the most effective non-pharmacological method to improve OSA and reduce seizures. Complementary and alternative therapies such as Chinese traditional medicine, cognitive behavioral therapy, meditation, yoga, neurofeedback, and acupuncture may have benefits in reducing seizures and improving sleep quality simultaneously by alleviating stress and seizure triggers; however, evidence-based therapies are still deficient.Conclusion Management of sleep disorders in patients with epilepsy is challenging. Large-scale randomized controlled clinical trials are in demand to guide the treatments in the future.

Updated Perspectives on the Management of Sleep Disorders in the Intensive Care Unit.

Sleep disorders and circadian dysrhythmias are extremely prevalent in critically ill patients. Impaired sleep has a variety of etiologies, exhibits a wide range of negative effects and, moreover, might deteriorate the patient’s prognosis. Despite a number of scientific findings and increased awareness, the importance of sleep optimization is still lower on the list of priories in the intensive care unit (ICU). The techniques of measuring and the evaluation of sleep quantity and quality are a great challenge in the ICU setting. The subjective and objective tools of sleep validation continue to suffer from deficiencies. Treatment approaches to improve the critically ill patient’s sleep have focused on non-pharmacologic and pharmacologic strategies with some promising results. But pharmacological interventions alone could not provide sufficient patient benefit. Being aware and knowing of sleep problems and the beneficial effect of the necessary therapies in ICU patients requires greater acceptance. The application of available methods and the development of new methods to prevent sleep disorders in the ICU offer the potential to improve the critically ill patient’s outcome.

Prolonged Effects of the COVID-19 Pandemic on Sleep Medicine Services-Longitudinal Data from the Swedish Sleep Apnea Registry.

The worldwide COVID-19 pandemic has affected the operation of health care systems. The direct impact of obstructive sleep apnea (OSA) on COVID-19 infection outcome remains to be elucidated. However, the coincidence of common risk factors for OSA and severe COVID-19 suggests that patients with OSA receiving positive airway pressure therapy may have an advantage relative to those untreated when confronted with a COVID-19 infection. The ongoing COVID-19 pandemic has led to a substantial reduction of sleep medicine services, and the long-term consequences may be considerable. New strategies for the management of sleep disorders are needed to overcome the current underdiagnosis and delay of treatment.

Recommendations of the Polish Association of Anaesthesia and Intensive Care Nurses on pain monitoring in Intensive Care Units using a Polish version of the Behavioural Pain Scale (BPS)

Abstract Introduction. In 2018, another update of the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobilization and Sleep Disorders in Adult Patients Treated in Intensive Care Units (ICUs) was released. Aim. The study is aimed at presenting current recommendations concerning pain management in patients treated in ICU, and presenting the algorithm of pain assessment and monitoring in patients treated in ICU, using a Polish version of the BPS (Behavioural Pain Scale). The guidelines were prepared based on a systematic review of the literature published in the years 2013-2018. Material and methods. The search for scientific publications was carried out using electronic databases in English and Polish. The following keywords and their combinations were used in the searches: pain, assessment, monitoring, nurse, intensive care, adult patient, unable to communicate. Initially, 758 papers were identified with the use of keywords. After excluding duplicates and preliminary checking and selecting the titles of publications and abstracts, 85 papers were qualified for the analysis of full text. Conclusions. Access to effective pain treatment is a fundamental human right. Recommendations of the Polish Association of Anaesthesia and Intensive Care Nurses, concerning pain monitoring in ICU using a Polish version of the Behavioural Pain Scale (BPS), developed by the Task Force for Practice, are intended to provide a specific guideline for developing effective local pain management strategies in ICU.

SLEEP DISORDERS AND THEIR COMPLEX REHABILITATION USING TRANSCRANIAL MAGNETIC STIMULATION IN POST-STROKE REHABILITATION: STUDY DESIGN

In the Republic of Bashkortostan, a new original study of sleep-in patients in the recovery period of cerebral stroke is planned. One of the goals will be to improve the algorithms of sleep disorders management in complex post-stroke rehabilitation using rhythmic transcranial magnetic stimulation (rTMS). In this paper, we present the design of this study using modern instrumental and clinical technologies for the diagnosis of sleep disorders and rehabilitation. The work will be of practical importance in rehabilitation medicine and neurology for improving the quality of life of patients who have suffered acute cerebral circulatory disorders. We plan to study sleep disorders in patients in the early recovery period of stroke using clinical and polysomnographic techniques, to evaluate the safety and clinical effectiveness of rTMS in the studied patients with sleep disorders, to study the duration of the effects of rTMS on sleep normalization. The successful completion of the study will help to add to algorithms for correcting sleep disorders in post-stroke rehabilitation using transcranial magnetic stimulation.

Lavender for Sleep Disorder Management in Menopausal Women with or without Hypertension: A Systematic and Meta-analysis

Introduction: Regarding the prevalence of sexual problems during menopause and the interest of women in the use of aromatherapy in attenuating the sleep disorders, and due to the lack of comprehensive meta-analysis on the effects of aromatherapy on the sleep disorders, the present study was conducted to determine the effect of lavender on the sleep disorders in postmenopausal women.Material and Methods: The following databases were selected to search systematically the effect of lavender on the quality of sleep in post-menopausal women, including PubMed, Cochrane Library, ISI Web of Science and Scopus, regardless time limit since inception to September 29, 2019. The quality of trials was investigated according to Jadad scale.Results: After combination of the result of four trials, our meta-analysis showed that treatment with lavender was more effective than placebo in respect with improvement of quality of sleep in menopausal women (Standardized Mean Difference=1.098; Confidence Interval 95%: 0.33-1.86; P= 0.005).Conclusion: Considering the effects of lavender essential oil on improving the quality of sleep in postmenopausal and middle-aged women, this medication can be prescribed in the clinics of sleep problems, obstetrics and gynecology.

Knowledge to action: a scoping review of approaches to educate primary care providers in the identification and management of routine sleep disorders.

The referral burden on health care systems for routine sleep disorders could be alleviated by educating primary care providers (PCPs) to diagnose and manage patients with sleep health issues. This requires effective professional education strategies and resources. This scoping review examined the literature on existing approaches to educate PCPs in sleep health management. A comprehensive literature search was conducted across 8 databases to identify citations describing the education of PCPs in diagnosing and managing sleep disorders, specifically insomnia and sleep apnea. A conceptual framework, developed from the knowledge-to-action cycle, was used to analyze citations from a knowledge translation perspective. Searches identified 616 unique citations and after selection criteria were applied, 22 reports were included. Reports spanning 38 years were analyzed using components of the knowledge-to-action cycle to understand how educational interventions were designed, developed, implemented, and evaluated. Interventions involved didactic (32%), active (18%), and blended (41%) approaches, using face-to-face (27%), technology-mediated (45%), and multimodal (5%) delivery. Educational effectiveness was assessed in 73% of reports, most commonly using a pre/post questionnaire (41%). While this scoping review has utility in describing existing educational interventions to upskill PCPs to diagnose and manage sleep disorders, the findings suggest that interventions are often developed without explicitly considering the evidence of best educational practice. Future interventional designs may achieve greater sustained effectiveness by considering characteristics of the target audience, the pedagogical approaches best suited to its needs, and any environmental drivers and barriers that might impede the translation of evidence into practice. King S, Damarell R, Schuwirth L, Vakulin A, Chai-Coetzer CL, McEvoy RD. Knowledge to action: a scoping review of approaches to educate primary care providers in the identification and management of routine sleep disorders. J Clin Sleep Med. 2021;17(11):2307-2324.

Nursing management of anxiety and sleep disorders in patients hospitalized in a cardiac intensive care unit

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac intensive care unit is an environment that induces a high rate of stress, anxiety and sleep disorders in hospitalized patients. All these elements can create an obstacle in the continuity of care and increase cardiovascular risk. Purpose The purpose of our study was to evaluate the anxiety and sleep disorders in patients admitted to the ICUU and to evaluate nurses’ behavior to these disorders. Materials and methods We conducted a descriptive, transversal, observational, prospective study in the cardiology department of Habib Thameur Hospital, which included 37 patients admitted to the ICU and 11 nurses practicing in the department. A questionnaire including two validated scales (HADS-A for anxiety and RCSQ for sleep) was submitted to patients and a self-questionnaire was administered to nurses. Results Patients mean age was 61.24 ± 13.41 years with a sex ratio of 2.36. Eight patients (22%) admitted to the ICU had anxiety disorder. In univariate analysis, female gender and mean hospital stay were significantly associated with anxiety among patients admitted to the ICU. In multivariate analysis, female gender was the only independent factor associated with anxiety at ICU hospitalization (relative risk = 3, 95% confidence interval 2.25-3.37, p = 0.005). Seventeen patients (40%) were afraid of death. The majority of patients (92%, n = 34) felt safe with the health care team. Most patients (92%, n = 34) responded to their visitors (through the window), 97% of whom were family members. Seven patients (19%) had poor sleep. The item with the lowest average was the quality of sleep (53.86 ± 15.65). In univariate analysis, urban living and the average number of sleep hours were significantly associated with poor sleep. Surveillance of vital signs, noise and monitor alarms were the main factors of sleep disturbance. Eleven nurses were included in our study. Seven nurses considered the management of anxiety as not important, and six answered that the management of sleep disorders was not important. The most used medication by nurses to relieve both symptoms was Hydroxyzine tablets. The most common non-medical way to relieve anxiety was privacy. The most common non-medication way to improve sleep was brightness reduction. Conclusion Our study shows that despite the prevalence of anxiety and sleep disorders in patients admitted to the ICU, their care by nurses was not adequate. Specific training on assessment and coping with these disorders could improve nursing care.

Incremental health care utilization and expenditures for sleep disorders in the United States.

To determine the incremental increases in health care utilization and expenditures associated with sleep disorders. Adults with a diagnosis of a sleep disorder (International Classification of Diseases, 10th Revision, code G47.x) within the medical conditions file of the 2018 Medical Expenditure Panel Survey medical conditions file were identified. This dataset was then linked to the consolidated expenditures file and comparisons in health care utilization and expenditures were made between those with and without sleep disorders. Multivariate analyses, adjusted for demographics and comorbidities, were conducted for these comparisons. Overall, 5.6% ± 0.2% of the study population had been diagnosed with a sleep disorder, representing approximately 13.6 ± 0.6 million adults in the United States. Those with sleep disorders were more likely to be non-Hispanic, White, and female, with a higher proportion with public insurance and higher Charlson Comorbidity Scores. Adults with sleep disorders were found to have increased utilization of office visits (16.3 ± 0.8 vs 8.7 ± 0.3, P < .001), emergency room visits (0.52 ± 0.03 vs 0.37 ± 0.02, P < .001), and prescriptions (39.7 ± 1.2 vs 21.9 ± 0.4, P < .001) vs those without sleep disorders. The additional incremental health care expenses for those with sleep disorders were increased in all examined measures: total health care expense ($6,975 ± $800, P < .001), total office-based expenditures ($1,694 ± $277, P < .001), total prescription expenditures ($2,574 ± $364, P < .001), and total self-expenditures for prescriptions ($195 ± $32, P < .001). Sleep disorders are associated with significantly higher rates of health care utilization and expenditures. By using the conservative prevalence estimate found in this study, the overall incremental health care costs of sleep disorders in the United States represents approximately $94.9 billion. Huyett P, Bhattacharyya N. Incremental health care utilization and expenditures for sleep disorders in the United States. J Clin Sleep Med. 2021;17(10):1981-1986.

P126 The effectiveness of pharmacological interventions and cognitive behavioural therapy in improving sleep in fibromyalgia: a systematic review

Abstract Background/Aims Fibromyalgia (FM) is a common yet complex musculoskeletal condition. Sleep disturbance frequently coexists with FM yet optimal management of this important association is unclear. Current standard treatment for FM in general often includes a combination of pharmacological and psychological treatments - most commonly cognitive behavioural therapy (CBT). This systematic review aims to critically appraise the evidence regarding the effectiveness of these treatments at improving sleep in FM. Methods Pre-defined search terms were entered into PubMed, Cochrane CENTRAL, Embase, Medline and CINAHL. Randomised controlled trials (RCTs) studying the effectiveness of any pharmacological intervention or CBT (including electronic CBT) in managing FM-associated sleep disturbances in adults were included. Results Of 682 RCTs identified, 56 (n = 17,005; aged 18-84) met the inclusion criteria: 45 pharmacological studies assessing 24 medications and 11 CBT-based studies. Sleep assessment methods varied between studies, the most common being the visual analogue scale. The most common pharmacological interventions were pregabalin (n = 8) and milnacipran (n = 8), followed by sodium oxybate (n = 4), amitriptyline (n = 4) and fluoxetine (n = 3). Although outcome measures differed across the pregabalin studies, they all showed varying degrees of sleep improvement. Conversely, only 2/8 studies of milnacipran showed improved sleep scores. All 4 studies investigating sodium oxybate showed significant improvements in the Jenkins Sleep Scale. Only 1/4 study analysing amitriptyline and 1/3 assessing fluoxetine showed statistically significant improvement in sleep scores compared to placebo. The remaining 18 pharmacological studies included multiple antidepressants and analgesic agents, with a wide range of efficacy at improving sleep scores. The 11 CBT-based studies typically compared CBT to sleep hygiene or standard pharmacological therapies. Traditional, online and combined CBT methodologies (all n = 4), CBT for insomnia (CBT-I) (n = 7) and/or pain (CBT-P) (n = 4) were all evaluated. Studies conducting CBT-I and CBT-P showed significant improvements in the Pittsburgh Sleep Quality Index and self-reported sleep diaries. Long-term traditional CBT improved sleep in both included studies. One study using multicomponent CBT also showed significant sleep improvements. Only one study assessed online CBT, showing no significant results, though there was a trend towards improved sleep. Conclusion The optimal management of sleep disorders in FM is complex and needs to be tailored to the individual patient. We have shown that there are varying degrees of efficacy throughout a range of commonly used drugs in FM. Unfortunately, lack of consistency in outcome measures between studies makes it difficult to draw definitive conclusions pertaining to superiority between these agents. Conversely, CBT interventions appear to show consistent sleep improvement in FM. It is not clear whether this translates to online variations of CBT. We believe that a longitudinal appraisal of sleep as a primary variable, with robust consistent outcome measures, using pharmacological interventions with CBT would benefit future research. Disclosure A. Pathak: None. I. Brennan: None. R. Amarnani: None. A. Soni: Grants/research support; UCB Prize Fellowship.

Pediatric Obstructive Sleep Apnea Syndrome: Emerging Evidence and Treatment Approach.

OSA pediatric subjects suffer from episodes of upper airway obstruction that can be partial or complete, with atypical sleep patterns and blood-gas level alteration. If poor treated and/or diagnosed, it can cause cardiovascular disease, learning difficulties, behavioural issues, and retardation of growth. In the literature, there are conflicting evidence about OSA assessment and treatment in pediatric age, so the aim of this paper is to highlight the multidisciplinary approach in the management of sleep disorders, stressing the role of the pediatric dentist in both diagnosing and treating the OSAS in children, according to the current evidence of the treatment options effectiveness of the syndrome itself. Conclusions. Scientific evidence shows that OSAS management requires a multidisciplinary approach in order to make an early diagnosis and a correct treatment plan. The orthodontic treatment approach includes orthopedic maxillary expansion and mandibular advancement using intraoral appliances. Hence, the orthodontist and the pediatric dentist play an important role not only in early diagnosis but also in the treatment of pediatric OSAS.

VI. Management of Sleep Disorders in Diabetic Patients

VI. Management of Sleep Disorders in Diabetic Patients

Sleep health management in community pharmacy: Where are we and where should we be heading?

Poor sleep health is now recognised as a significant risk factor for chronic diseases and is associated with considerable comorbidity and mortality. Community pharmacists are primary care clinicians with an integral role in sleep health promotion and chronic sleep disorder management; however, it is unclear to what extent this is currently being undertaken or what the perspectives of Australian community pharmacists regarding their role in sleep health are. To explore community pharmacists' current sleep health practice and perspectives on the potential future of sleep health care in community pharmacy. Qualitative semi-structured interviews were carried out with a maximally varied, convenience-based purposive sample of community pharmacists. Interviews were audio-recorded, transcribed verbatim and subjected to, in sequence; an inductive analysis followed by a deductive approach where the inductively derived thematic structure was used as a framework. Twenty-five community pharmacists from two Australian states were interviewed. Insomnia and obstructive sleep apnea (OSA) were the most frequently encountered sleep disorders in community pharmacy presentations. Four key themes were derived from the data: 1) Preparedness, 2) Approach, 3) Capabilities and 4) What needs to change? All participants reported that their sleep health knowledge was insufficient and emphasized the need for more education and training. Although some were engaged in providing OSA services, none of the participants offered services for insomnia or other sleep disorders. Time/task pressures, low health system/health care professional sleep health recognition/awareness and the lack of standardised pharmacy-specific sleep health management guidelines were commonly cited barriers for sleep health service provision. Community pharmacists commonly manage day-to-day sleep health; however, most expressed a need for increased sleep health recognition/awareness by the health system, targeted education/training for pharmacists and support for the future provision of community pharmacy-delivered sleep health services. With the appropriate implementation strategies, community pharmacists could utilise their availability and accessibility to improve the future of primary care sleep health management.

Impact of EMA regulatory label changes on hydroxyzine initiation, discontinuation and switching to other medicines in Denmark, Scotland, England and the Netherlands: An interrupted time series regression analysis.

Hydroxyzine is indicated for the management of anxiety, skin and sleep disorders. In 2015, the European Medicines Agency (EMA) concluded that hydroxyzine was pro-arrhythmogenic and changes to the product information were implemented in Europe. This study aimed to evaluate their impact in Denmark, Scotland, England and the Netherlands. Quarterly time series analyses measuring hydroxyzine initiation, discontinuation, and switching to other antihistamines, benzodiazepines and antidepressants in Denmark, England, Scotland and the Netherlands from 2009 to 2018. Data were analysed using interrupted time series regression. Hydroxyzine initiation in quarter one 2010 in Denmark, Scotland, England and the Netherlands per 100 000 was: 23.5, 91.5, 35.9 and 34.4 respectively. Regulatory action was associated with a significant: immediate fall in hydroxyzine initiation per 100 000 in England (-12.05, 95%CI -18.47 to -5.63) and Scotland (-19.01, 95%CI -26.99 to -11.02); change to a negative trend in hydroxyzine initiation per 100 000/quarter in England (-1.72, 95%CI -2.69 to -0.75) and Scotland (-2.38, 95%CI -3.32 to -1.44). Regulatory action was associated with a significant: immediate rise in hydroxyzine discontinuation per 100 000 in England (3850, 95%CI 440-7240). No consistent changes were observed in the Netherlands or Denmark. Regulatory action was associated with no switching to other antihistamines, benzodiazepines or antidepressants following hydroxyzine discontinuation in any country. The 2015 EMA regulatory action was associated with heterogeneous impact with reductions in hydroxyzine initiation varying by country. There was limited impact on discontinuation with no strong evidence suggesting unintended consequences of major switching to other antihistamines, benzodiazepines or antidepressants.