First ever world spirometry day

On Thursday October 14^th, free spirometry will be offered world wide. This event will be one of the top opportunities to raise awareness about lung health through the public and the media. The European Respiratory Society and the European Lung Foundation will coordinate the organizing of the event.

Spirometry is the most common method for testing lung function. It is simple, quick and non invasive. The test specifically measures the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled by the lungs. Spirometry is an important tool and is helpful in assessing conditions such as asthma and pulmonary fibrosis and perhaps most importantly chronic obstructive pulmonary disease.

These spirometry events have a dual purpose. On the one hand they have a public health impact enabling many people who have not been tested previously to have their lung function measured. In Berlin approximately 20% of people tested were advised to visit their doctor for further examination. On the other hand, these events provide a focus on lung health and lung disease, facilitating increased public awareness.

The results of six of these events in summary found that in over 12,500 people tested, nearly 20% has some degree of airway obstruction, nearly 50% were smokers and 5% had asthma.

The organizers of these events conclude that spirometry testing is a useful way to detect airway obstruction at an early stage in life, in a large proportion of residents.

On World Spirometry Day, Manse Medical will organize and run an event to offering free spirometry. CareFusion and Bird Heath Care have generously offered support in the way of filters and noseclips for the event.

More details will be posted nearer to the date.

Vanessa

WHAT ARE YOU EATING FOR A GOOD NIGHTS SLEEP?

I recently read a magazine article which focused on sleep and what factors affect our ability to get a good nights rest. We all know that there are many things in our daily life which will have an impact on this area – stress, anxiety, work hours, illness, drugs, exercise, social habits, babies, pain, body temperature, diet, and the list goes on….

I am going to focus in part on food. Research tells us that there are certain foods that can help you get to sleep. This list includes foods such as bananas, nuts and peanut butter, milk, apples, fish, yogurt, cheese (particularly cheddar, Swiss, gruyere), soy products, lettuce (think The Tale of Peter Rabbit and the Flopsy Bunnies – soporific effect) and there are certainly others that I have missed. Why are these foods recommended over others?

The thing that these foods have in common is that they are high in something called tryptophan. Tryptophan is an amino acid which the body cannot make itself but is needed by our nerve cells to make serotonin. Serotonin is a brain neurotransmitter that helps promote feelings of relaxation, calmness and sleepiness. We need enough of this hormone serotonin in our system to get to sleep and this in turn is dependent on our tryptophan levels. Tryptophan is also in competition with other amino acids to reach the brain.

Interestingly, it is NOT recommended that we load ourselves up with these magic sleep inducing foods.

It is important to understand that studies have shown that tryptophan helps with only one phase of our sleep cycle – that of getting to sleep. It won’t necessarily keep you asleep.

Our typical sleep cycle is divided into REM and non- REM sleep. REM (or rapid eye movement) is the stage of sleep when we dream. Non-REM sleep is divided into four stages of sleep – stage 1 being lighter sleep through to progressively deeper stage 4 sleep, followed by REM. This cycle usually takes about 90 - 120 minutes, and we have about 4 or 5 of these cycles a night, with the amount of REM increasing in length with each cycle.

Excess tryptophan has in fact been shown to increase the amount non-REM sleep and actually decrease REM sleep time. Deep sleep is an important time for the body to renew itself and REM sleep an important time for the brain to process and sort information. It is linked to both memory and production of certain neurotransmitters like serotonin and dopamine which directly affect our day time mood.

From my research, there seems to be a general consensus about meals for sleep.
It is recommended that you eat a lighter rather than heavier evening meal about 4 hours prior to your usual bed time so that you body is not working overtime at active digestion.

Evidence shows that eating a small carbohydrate rich snack with tryptophan containing foods (a protein) 1 -2 hours prior to bed to be beneficial. Carbohydrate consumption stimulates the release of insulin which assists in transporting those competing amino acids from the bloodstream, making tryptophan more readily available.
Select your proteins (and portions) wisely as many animal foods high in tryptophan are also high in other amino acids (like tyrosine) which potentially stimulate the brain with the release of adrenalin for example and can have the opposite desired effect.

So that warm glass of milk as a snack before bedtime is a good idea to help you get to sleep but only if you are taking a considered approach to your overall dietary habits (not just focusing on specific foods) and addressing any other potential sleep stressors.
For more information on setting yourself up for a good nights sleep and creating healthy sleep habits, you can download our sleep hygiene recommendations available on our website.

Lisa

A chest x-ray for sore ankles?

A young male patient presents with painful, inflamed ankles and is ordered a chest x-ray. He thinks maybe the doc didn’t quite hear him right.

But possibly his doctor is right on to what is happening and suspects Lofgren’s syndrome (named after Swedish Researcher Sven Lofgren 1910-1978).

This is a type of sub acute sarcoidosis which may present with erythema nodosum (tender red nodules), bilateral hilar adenopathy (enlarged lymph nodes on the border of the lungs), arthritis and fever.

The cause is unknown but environmental triggers have been implicated, combined with a genetic susceptibility. There is variable instances of this disease around the world but you may be more vulnerable if you are Irish, Scandinavian, African or Puerto Rican and less prone if Japanese. There has also been some association with those working in specific professions including health care workers, school teachers, agricultural workers exposed to agricultural dust, insecticides, pesticides and moulds, suppliers of building materials, hardware or gardening materials and firefighters.

Other risk factors are being female (85%), being young to middle age (mean age of disease is 35) and seasonal considerations, with the disease being more common in the spring in the Northern Hemisphere.

The patient may present with arthralgia, cough or shortness of breath, fever or malaise along with erythema nodosum (more likely if female) and bilateral ankle inflammation (more likely if male).

The diagnosis can be made with the assistance of a chest x-ray which will show mediastinal lymphadenopathy or pulmonary infiltration, lung function tests which may indicate decreased forced vital capacity, as well as elevated serum calcium and ACE levels. A lymph node biopsy may also confirm the diagnosis.

Generally the disease has a good prognosis and is usually benign and self limiting over a 6 month to 2 year period. Normal serum ACE levels at diagnosis and a particular HLA type (DRB1*03 positive as opposed to negative which points to a non resolving disease) are good prognostic markers

Management is supportive, with use of non steroidal anti inflammatories and short term bed rest. Occasionally corticosteroids will be given for severe symptoms such as severe arthritis.

Differential diagnoses may include infection, cellulitis, osteomyelitis, gout, polyarthritis, lymphoma, fungal infections, tuberculosis and bronchiogenic carcinoma to name a few.

But just remember that chest x-ray for anyone presenting with inflammatory ankle symptoms.

Irene

Lung cancer chemotherapy - Iressa is back.

Iressa / Gefitinib was the great white hope on the lung cancer scene about 6 years ago, then faded into obscurity for a while. The problem was that the ISEL study did not demonstrate that this oral chemotherapeutic agent ( a tyrosine kinase inhibitor) was better than placebo in terms of survival benefit. There was, however, evidence of tumour response. That is, tumours seemed to get smaller, but people didn't live longer.

Further studies have demonstrated benefit in more select patient groups - much to the relief, I am sure, of AztraZeneca. The drug has recently been licensed in Australia for use in patients with locally advanced or metastatic non-small cell lung cancer if their tumours express activating mutations of the epidermal growth factor (EGFR) tyrosine kinase.

The IPASS trial, conducted in Asia, demonstrated that, in patients with a previous light smoking or non-smoking history, who had mutations of the EGFR tyrosine kinase and who had not received previous chemotherapy, Iressa was superior to a combination of carboplatin/paclitaxel in terms of disease free survival (9.5 vs 6.3 months). The INTEREST trial demonstrated equivalency of Iressa when compared with docetaxal in patients with locally advanced or metastatic NSCLC who had previously received platinum-based chemotherapy.

It's noteworthy that Iressa is now indicated as a first line chemotherapy in appropriately selected patients (ie those meeting the above criteria). Tarceva/Erlotinib, another EGFR tyrosine kinase inhibitor, is still only licensed for patients whose NSCLC has progressed in spite of first-line platinum based chemotherapy (ie second line). As far as I am aware.

It is bound to become more clear, over the next few months / years, exactly which patients do benefit from these medications - and others like them. Perhaps this will even give us a clearer indication of prognosis in patients with lung cancer.

Andrew

To nap or not to nap?

The concept of sleep inertia has presented it's self to me a couple of times in the past few weeks. Once when I mentioned to a sleep scientist that I am like 'a bear with a sore head' if I have a day time nap (the cause most likely sleep inertia). Another time was when I was talking to an emergency services worker, discussing the pro's and con's of napping during night shift. I also saw a promo for a morning show that was airing a segment on 'Napping the key to health and happiness' but I missed watching this.

So what are the pro's and con's of napping?
One of the cons can be sleep inertia. This is especially relevant to emergency services workers who may take naps during night shift. Sleep inertia is bascially a temporary state of lowered arousal occurring immediately after awakening from sleep and producing a temporary decrease in cognitive performance. Sleep inertia can be influenced by factors such as the duration of prior sleep, and the sleep stage prior to awakening. Abrupt awakening during a slow wave sleep (stage 3 and 4) episode produces more sleep inertia than awakening in stage 1 or 2, REM sleep being intermediate. Studies have demonstrated that sleep inertia can last from 1 min to 4 h but usually last around 15 to 30min. The practical implications for those working in our emergency service is that being woken to respond to an immediate emergency gives them no time to recover from the effects of sleep inertia. Being awaken for deep NREM sleep has been shown to decrease reaction time which is highly dangerous for those driving (fire and ambulance crews) and health professionals responding to an emergency.

Conversely, the benefits of a power nap (15 to 30 minutes) have been well document as a way to ward off fatigue and improve cognitive function. There is still a level of sleep inertia but this can be minimised by a short nap (stage 1&2) and having adequate time to 'wake up' after this nap before preforming any important tasks.

Health and Safety recommendations such as these from the Queensland Government reinforce this with recommendations sleep inertia can be minimised for workers who are on-call for emergencies by the following steps;

• Minimising naps taken at work that exceed 40 minutes; and
• Planning for recovery times of up to 30 minutes for workers who may be subject to sleep inertia, before they are to perform hazardous tasks.

Jessica

Home sleep study update

A couple of years ago, in 2008, there was a moment of angst in the sleep-medicine specialist field, when Medicare decreed that they were no longer going to pay for home sleep studies.

At that time, there was no ‘item number’ to cover a home sleep study. The place of home sleep studies in the diagnosis and management of obstructive sleep apnoea, let alone other sleep disorders, had been examined in only a few studies in the literature and there was not a consensus from the community of specialist sleep physicians as to how and when these studies should be done.

Nevertheless, home sleep studies could be done and were being done. Aggressive expansion of home sleep study business models, some industry-driven (ie CPAP companies) and some physician-owned, was occurring. And it was occurring in the country.

From where I sit (that is, in Hamilton) the reason given for this expansion didn’t really hold water. City based specialists and companies were saying that home sleep studies needed to be done because patients such as mine needed access to services. Reading between the lines, that meant that it was easier to stay in the big cities and to negotiate with a chain of pharmacies to put 200 home sleep study devices in towns around the state than to negotiate with hospital administrators to set up state-of-the-art sleep labs, and to back them up with specialist consulting services. The resulting service was limited. The development of skills in regional centres was scant (pharmacy staff trained to put on leads). Medicare fees were drained from the country back to Melbourne, rather than reinvested locally (for example, in a local medical practice or sleep lab). When things got tricky, country people still had to travel to the city to see a sleep specialist. And the impression was given that sleep studies are easy. Like getting your blood pressure checked.

In spite of the above uncertainty, a review of the evidence did suggest that home sleep studies were useful in people with a very high clinical probability of having severe obstructive sleep apnoea. After careful consideration, we decided that it was a service that we should carefully offer, and so we established a handful of home sleep study outlets in our region. We considered the distinctives of our service to be; a sleep specialist reviewed every referral to ensure that a home sleep study is appropriate, prior to authorising performance of the home sleep study; analysis and reporting of the sleep study occur locally (it can’t be assumed that sleep study analysis for home sleep studies in Australia even occurs in Australia any more, with at least one of the major providers of home sleep studies outsourcing analysis of data to sleep scientists in India); the reporting sleep specialist always analyses the raw data (not just the analysis summary provided by the scientist); sleep specialist clinical review is available locally if required.

When Medicare declared a moratorium of sorts on home sleep studies I thought that sounded reasonable. Of course, with substantial business under threat the big providers of home sleep studies negotiated hard for an allowance to continue to provide home sleep studies as they already were. And that permission was granted, in October 2008, although with a much lower fee from medicare for the service, while the whole area was carefully reevaluated.

The Medical Services Advisory Committee has just reported to the Minister for Health after an evaluation of all the literature related to ‘unattended’, or home based, sleep studies. Eighty studies were identified, evaluating home sleep studies performed in ‘non-specialist’ (for example a GP clinic or pharmacy) setting, a ‘referral setting’ (ie referred to a specialist for the study) and a paediatric setting. (14, 60 and 6 studies applicable to each setting respectively).

The document reads:

The Committee recommended funding of Type 2 (unattended) studies in patients >18 years of age once within a 12 month period with the following conditions.
(a) the patient is referred for the investigation by a medical practitioner who has formed a reasonable clinical view that the patient has a high probability of having OSA
*[(b) the necessity for the investigation is determined by a qualified sleep medicine practitioner (as defined in the explanatory notes to the MBS) prior to the investigation;] [*referred study]
(c) a qualified sleep medicine practitioner has:
(i) established quality assurance procedures for the data acquisition; and
(ii) personally analysed the data and written the report;
(d) during a period of sleep, the investigation is a recording of a minimum of seven channels which must include continuous EEG, continuous ECG, airflow, thoraco‐abdominal movement , oxygen saturation; and two or more of EOG, chin EMG and body position.
(e) interpretation and report of the investigation (with analysis of sleep stage, arousals, respiratory events and assessment of clinically significant alterations in heart rate) are provided by a qualified sleep medicine practitioner based on reviewing the parameters recorded under (d) above.


The home sleep study service which we provide, and the business behind it (for example, who reports the sleep study, and how carefully is the data analysed by the sleep specialist, all of which is invisible to the ‘consumer”) meets all of the above requirements. We will continue to provide this service.

A home sleep study service in country towns does not, however, live up to our goal of providing a regional sleep medicine service which is equal to anything available in the major cities. Excellent inpatient sleep laboratories and availability of clinical expertise in sleep medicine (doctors, nurses, psychologists), along with access to therapeutic devices such as CPAP at reasonable prices, are all required. We’ve achieved a lot in this regard over the last 4 to 5 years, but there’s more on the agenda.

Andrew

Chill out and sleep

The title of this blog could refer to a couple of areas of sleep hygiene. One being body temperature and sleep, while the other relaxation and sleep. The former will be discussed.

Body temperature is an important factor in sleep onset. A drop in body temperature normally happens 1 to 1.5 hours prior to falling asleep. As the core body temperature drops (only a matter of .5 to 1 degree) people begin to feel sleepy signaling its time for bed.

One hypothesis is that in some insomniac subjects their core body temperature remains higher than is necessary to initiate and maintain sleep. Studies have been conducted looking at sleep and core body temperature throughout the night. It has been demonstrated that the trough in temperature occurs prior to the longest sleep period and studies with insomniacs show they may may be a limited ability to cool the core body temperature sufficiently for optimal sleep.

What does this means in a particle sense.

• taking a hot bath 90 minutes prior to bed may help reduce core body temperature, as once out of the bath temperature will drop quickly. Make sure this in not immediately prior to bed as there needs to be sufficient time for the bodies temperature to drop.
  
• Avoid strenuous exercise immediately prior to bed
• take notice of when you feel sleepy in the evening and heed these cues

Jessica