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Obstructive sleep apnea (OSA) affects millions of Americans and is estimated to be as prevalent as asthma and diabetes. Given the fact that obesity is a major risk factor for OSA, and given the current global rise in obesity, the prevalence of OSA will increase in the future. Individuals with sleep apnea are often unaware of their sleep disorder. It is usually first recognized as a problem by family members who witness the apneic episodes or is suspected by their primary care doctor because of the individual’s risk factors and symptoms. The vast majority remain undiagnosed and untreated, despite the fact that this serious disorder can have significant consequences. Individuals with untreated OSA can stop breathing hundreds of times a night during their sleep. These apneic events can lead to fragmented sleep that is of poor quality, as the brain arouses briefly in order for the body to resume breathing. Untreated, sleep apnea can have dire health consequences and can increase the risk of hypertension, diabetes, heart disease, and heart failure. OSA management has also become important in a number of comorbid neurological conditions, including epilepsy, stroke, multiple sclerosis, and headache. Diagnosis typically involves use of screening questionnaires, physical exam, and an overnight polysomnography or a portable home study. Treatment options include changes in lifestyle, positive airway pressure, surgery, and dental appliances.

Study Objectives To report at a population level the prevalence of restless legs syndrome, insomnia, and the risk of obstructive sleep apnea in multiple sclerosis patients. Sleep patterns and associations with fatigue and daytime sleepiness were identified. Methods A cross-sectional study was performed using a written survey that was mailed to 11,400 individuals from the Northern California Chapter of the National Multiple Sclerosis (MS) Society Database who self-identified as having MS. The survey included individual questions relating to demographics as well as several standard validated questionnaires related to primary sleep disorders, sleepiness, fatigue severity, and sleep patterns. Results Among the 11,400 surveys mailed out, 2,810 (24.6%) were returned. Of these, 2,375 (84.5%) met the inclusion criteria. Among the completed surveys, 898 (37.8%) screened positive for obstructive sleep apnea, 746 (31.6%) for moderate to severe insomnia, and 866 (36.8%) for restless legs syndrome. In contrast, only 4%, 11%, and 12% of the cohort reported being diagnosed by a health care provider with obstructive sleep apnea, insomnia, and restless legs syndrome, respectively. Excessive daytime sleepiness was noted in 30% of respondents based on the Epworth Sleepiness Scale. More than 60% of the respondents reported an abnormal level of fatigue based on the Fatigue Severity Scale. Both abnormal fatigue and sleepiness scores were associated with screening positive for obstructive sleep apnea, insomnia, and restless legs syndrome. Conclusion A significant percentage of MS subjects in our sample screened positive for one or more sleep disorders. The vast majority of these sleep disorders were undiagnosed. Greater attention to sleep problems in this population is warranted, especially in view of fatigue being the most common and disabling symptom of MS. Citation Brass SD, Li CS, Auerbach S. The underdiagnosis of sleep disorders in patients with multiple sclerosis. J Clin Sleep Med 2014;10(9):1025–1031.

Some patient subsets are at higher risk of sleep apnea, including patients with chronic pain. However, it is unclear whether patients and their caregivers are aware of the possibly increased risk of sleep apnea in this population. Chronic pain is often treated with opioids which may decrease both the central respiratory drive and the patency of the upper airway, potentially contributing to this sleep disorder. Using a self-reporting questionnaire approach in the chronic pain population, this study surveyed patient and caregiver awareness surrounding the risk of sleep apnea. In addition, we looked at the influence of opioid therapy on the prevalence of sleep apnea. Consecutive patients presenting to a pain clinic were invited to participate anonymously in a survey that included the STOP-Bang sleep apnea questionnaire, which assesses patients' knowledge, testing, diagnosis, or treatment of sleep apnea and whether their caregivers had discussed with them their increased risk of sleep apnea and opioid use. Among 305 participating patients, 58.2% (n=173) screened positive for sleep apnea. Among the 202 patients on opioid therapy, 59.2% (116/202) were STOP-Bang positive (score ≥3). However, only 37.5% (n=72/173) of these patients had discussed their risk of sleep apnea with a caregiver and only 30.7% (n=59) underwent testing. Against expectation, opioids did not increase the prevalence of sleep apnea in our study population. Chronic pain patients had a high risk of sleep apnea, regardless of opioid prescription. Most patients were unaware of their increased risk and denied undergoing the necessary testing. Greater attention to screening, testing, and education for sleep apnea needs to be paid in chronic pain patients, especially given the potentially dangerous ramifications of opioid-induced sleep apnea.

Healthcare organizations increasingly aim to become high-reliability organizations (HROs) to ensure patient safety and enhance care quality. Becoming an HRO requires more than operational changes; it necessitates a cultural transformation prioritizing safety and continuous improvement. This review outlines the tactics our organization employed to achieve HRO status, focusing on leadership engagement, safety culture, process improvement strategies, and measurement of progress using a newly created HRO dashboard. Our results indicate significant progress in quality and patient safety, emphasizing the importance of a cohesive strategy encompassing goal-setting, adherence to HRO principles, and effective communication. These efforts have demonstrated the necessity of integrating measurement and strategic planning to drive cultural change and improve patient outcomes.

Purpose This study aims: (1) to identify patients with multiple sclerosis (MS) who are at high risk for obstructive sleep apnea (OSA) by utilizing the STOP-BANG questionnaire and (2) to evaluate the relationship between OSA risk as determined by the STOP-BANG questionnaire and self-reported sleepiness and fatigue using the Epworth Sleepiness Scale (ESS) and the Fatigue Severity Scale (FSS), respectively. Methods A total of 120 consecutive patients presenting to the UC Davis Neurology MS Clinic were invited to participate in an anonymous survey. The exclusion criteria were: age <18 years, indefinite MS diagnosis, or incomplete survey. Results There were 103 subjects included in our study: 42% of subjects ( n  = 43) met the criteria for high-risk OSA, 69% of subjects ( n  = 71) screened high for fatigue (FSS ≥ 4), but only 24 subjects (23%) screened high for excessive daytime sleepiness (ESS > 10). In males, 44% of the variation in ESS scores and 63% in FSS scores were explained by the STOP-BANG components. However, only 17% of the variation in ESS scores and 15% of the variation in FSS scores was explained by the STOP-BANG components in females. Conclusions Over 40% of MS patients were identified as high risk for OSA based on the STOP-BANG questionnaire. The STOP-BANG questionnaire offers clinicians an efficient and objective tool for improving detection of OSA risk in MS patients.

Although continuous positive airway pressure, oral appliances and surgical modifications of the airway are considered as part of the routine management of patients with obstructive sleep apnea, many new and unconventional therapies exist. Many of the trials using these new alternatives have been limited by insufficient data, poor trial design, small sample size, unclear inclusion criteria, lack of randomization, and lack of blinding, and on occasion are biased by retrospective design. Bariatric surgery, positional therapy, auto-titrating positive airway pressure, serotonin agents, wake promoting agents, genioglossus stimulation surgery, supplemental oxygen, nasal dilators, nasal expiratory resistor devices and oropharyngeal exercises will be reviewed. As obstructive sleep apnea impacts the individual and society at large, further research is needed to explore new therapeutic treatment options for obstructive sleep apnea. Therapeutic trials for obstructive sleep apnea must be of rigorous design to prove clinical effectiveness while taking into account both patient satisfaction and cost effectiveness.

A 46-year-old man presented to this hospital with migraine headache, a 4-year history of neurologic events resulting in aphasia and hemiparesis, and a family history of two similarly affected brothers. Neuroimaging studies showed white-matter and deep gray-matter abnormalities. A diagnostic test was performed. A 46-year-old man presented to the hospital with migraine headache, a 4-year history of neurologic events resulting in aphasia and hemiparesis, and a family history of two similarly affected brothers. Presentation of Case A 46-year-old man was seen in the neurology clinic because of hemiparesis, aphasia, and abnormalities on neuroimaging studies. The patient had been well, except for migraine headaches, until 4 years earlier, when right-sided weakness, clumsiness, and slurred speech developed during a period of 24 hours. A neurologist at another hospital found dysarthria and right central facial weakness; decreased muscle tone in the right arm, with strength 4+/5; and normal muscle tone in the right leg, with strength 4+/5. Strength on the left side was normal, with slightly increased tone in the left arm and normal tone in . . .

A 59-year-old man was admitted to this hospital with a 6-month history of chronic daily headache, fever, and myalgia. Dry mouth, polydipsia and polyuria, and pain in the jaws on chewing developed. Neuroimaging studies showed diffuse thickening and enhancement of the dura, extending to the pituitary stalk. Computed tomography revealed calcified nodules in the lungs and spleen. A diagnostic procedure was performed. A 59-year-old man was admitted to the hospital with a 6-month history of chronic daily headache, fever, and myalgia. Neuroimaging studies showed diffuse thickening and enhancement of the dura, extending to the pituitary stalk. Computed tomography revealed calcified nodules in the lungs and spleen. Presentation of Case Dr. Adam B. Cohen (Neurology): A 59-year-old man was admitted to the neurology service of this hospital because of chronic daily headache, fever, and myalgia. Approximately 6 months earlier, the patient had begun having headache, accompanied by muscle spasms, generalized myalgia, weakness, fatigue, difficulty sleeping, and anxiety. The headache was constant, affected both temporal and frontal regions, and was not affected by posture. The temperature rose daily but remained below 37.8°C. Five months before admission to this hospital, he saw his internist at another hospital. The physical examination was normal. Amitriptyline at bedtime was prescribed, without improvement. . . .

Artificial intelligence (AI) is becoming a significant part of healthcare, with the potential to alter the landscape of medicine as we know it. The primary objective of this review is to provide definitions of crucial AI terminology and explore how AI is revolutionizing aspects of healthcare that encompass diagnosis, clinical operations, and treatment. The authors describe a framework to help leaders facilitate the selection and deployment of AI in healthcare. They also discuss the potential challenges of AI, including the regulatory angle, data bias, data accuracy, cost of AI, and how AI can affect healthcare jobs in the future.