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Snooze Newzzz Greetings Fellow Sleep Professionals, I'm sure that you all can agree that time really flies when you are busy, and boy is this fields a busy one! It seems like we just wrapped up the Conference in Sturbridge yesterday, and now everyone is heading for the beach. Hopefully everyone reading this is/was able to attend the conference on the Cape. Thanks to Iain Boyle for coordinating this location! I must admit that I never in a million years thought we would get a hotel rate like this in the summer. Thanks also to those who have stepped forward to speak at the 2005 conference, especially Dr. Sateia! Thanks Lisa for pulling some strings on that one... NEPS is only a few years old and in some ways we have grown by leaps and bounds, in other ways we are moving along slowly. Regardless of the pace, I can report as witness that we are moving in the right direction. Thanks to the hard work of a very dedicated volunteer board and assorted helpers this organization has taken a giant step forward in the past few years. Our mission of providing local educational opportunities for Polysomnographers, and the ability to network and learn from one another is alive and well. We have been working hard to improve/develop the web page and its forum for members to interact. This will be similar to the APT forum, but regional. Good opportunities to network and advertise openings at your sleep facility. Bethany has taken over the web page development as well as the newsletter, and she will undoubtedly do a fantastic job. Unfortunately I have been unable to dedicate much time to NEPS lately and have decided that it is in the organizations best interest to step down. I cannot take credit for this conference at all, but want to make sure that everyone recognizes the efforts of our very active board members. Thanks to Lisa, Chris, Chuck, Tammy, Iain, Alycia, Bethany, Barbara, Loretta, and Patrick. Also thanks to Ray P. for stepping back in. I encourage any one of you interested in getting involved in the NEPS board to contact our active board members. We can always use a fresh perspective... I hope everyone has an excellent conference! Sincerely, Our Web site... get the latest NEPS news on the web! NEPS members Brett Lund, RPSGT and Lisa Gaskin, RPSGT from Capital Region Health Care in Concord, NH, have put together the new NEPS website. If you are interested in posting information on the NEPS website please e-mail info@nepolysomnographic.org. Pediatric Sleep Corner By Patrick Sorensen, RPSGT When most patients are evaluated in a sleep laboratory, the standard monopolar electrode derivations are sufficient for accurate staging of sleep. Yet as more sleep labs are being asked to study infants and children, consideration and attention to a more thorough evaluation of the central nervous system (CNS) during sleep becomes increasingly important. Recording additional electroencephalographic (EEG) channels is important not only for sleep staging but also for the detection of CNS abnormalities that may contribute to, or be solely responsible for, the reason the child is referred to the sleep lab. Recording minimal EEG data during PSG evaluation may cause the clinician to overlook important data that can influence breathing abnormalities, unusual nighttime behaviors and common daytime symptoms such as attention deficit hyperactivity disorder (ADHD) or excessive daytime sleepiness (EDS). Epileptiform activity can fragment sleep in a number of ways and yield symptoms commonly associated with poor sleep. While the primary focus in sleep laboratories is nighttime breathing, those laboratories studying infants and children should also be familiar with the reasons and methodologies for employing an extended EEG montage array, become familiar with common epileptiform activity and be able to accurately interpret these findings to avoid missing or reporting erroneous information in this population. EEG abnormalities in the adult patient are usually known prior to PSG evaluation. However, in children EEG abnormalities may remain undiagnosed because of the sometimes subtle nature of the expression associated with abnormal EEG activity. A patient with EEG discharges may be hyperactive, inattentive or unresponsive and these symptoms can be attributed to other causes including poor sleep-related breathing or movement disorders. While accidental findings are uncommon, they do occur and are felt to be sufficient justification for employing an extended EEG montage. Once previously unknown discharges are discovered, a formal evaluation including an EEG is recommended. In addition to the standard EEG montage where electrodes are placed at A1, A2, O1, O2, C3, and C4 to obtain the monopolar derivations for sleep staging, a simple bipolar EEG montage can also be used to better detect abnormal CNS activity. This typically only requires adding a few more EEG leads. Organizing your montage into an array or chain can be accomplished in a longitudinal, anterior-posterior (front to back) direction or transverse (left to right) derivation. The American EEG Society's Guidelines in EEG-1980 refers to these arrays as longitudinal bipolar (LB) and transverse bipolar (TB). To cover both hemispheres of the brain and localize an electrical event during a sleep study with the minimal amount of lead application, a LB array referred to as a parasagital montage is often sufficient. This montage includes F3-C3, C3-P3 and P3-O1 on the left and F4-C4, C4-P4 and P4-O2 on the right as a standard montage. It is also helpful to record the left parasagital array over the right parasagital array to maintain organization and for accurate interpretation. If unfamiliar with these lead placements, there are many resources available as a reference to help determine placement. Since accuracy in lead placement is critical to the proper interpretation of the EEG, the placement of the EEG leads should always be based on the international "ten-twenty electrode placement system." More commonly seen in the sleep laboratory are patients with known epileptiform activity, or sleep disorders possibly related to EEG abnormalities such as unusual movements during sleep or sleep terrors. For these patients, this activity can usually be adequately monitored with the addition of bilateral mid-temporal leads, T3-T5 and T4-T6 (again, left over right). Using this more extensive montage the clinician is more likely to be able to rule out CNS involvement. While the application of the mid-temporal leads is sufficient in most cases, if a patient's previous EEG is available, that information can also help determine the best montage to use. Since one of the most effective methods for activating epileptiform activity is sleep, employing a thorough EEG montage for sleep studies on children and adults with known CNS abnormality is necessary in order to detect those EEG changes and a relationship, if any, to disordered sleep. Data used for the staging of infant sleep include the combined measurement of the EEG, the electrooculogram (EOG) to record bilateral eye movements, and the electromyogram (EMG) to record facial and intercostal muscle tone. However, because of the special criteria used to define sleep states in infants younger than 6 months old and the unique EEG features for this population, an extended EEG montage is critical and should be standard. An infant PSG montage should also include bilateral mid-temporal EEG electrodes. EEG features specific to infants, such as trace alternant and "brushes," as well as certain epileptiform activity can provide useful information regarding the maturity of the brain and alert clinicians to potential problems in CNS activity. Additionally, certain normal features of the infant EEG, such as rudimentary sleep spindles, are better seen using an extended EEG montage that includes frontal leads. Epileptiform activity can also make scoring the sleep record difficult and good clinical descriptions from technologists performing the study are critical to alert the person scoring the study to perceived state changes. While the descriptive language used for describing EEG activity can seem confusing, there are some basic guidelines that may be useful. EEG characteristics are described in terms of frequencies, voltages and locations. Abnormal frequencies can be faster or slower than healthy individuals of the same age and state. Voltages can be higher or lower and can further be described as continuous, intermittent or paroxysmal (activity that emerges from background with rapid onset, reaching (usually) quite high voltage and ending abruptly). Locations of epileptiform activity can be either generalized (i.e., seen in all areas) or lateralized (i.e., asymmetrical and seen on only one side) or focal (i.e., seen in a restricted area). While there are several EEG abnormalities, main findings can usually be classified as spikes, sharp waves, spike-and-wave complexes and rhythmic hypersynchronous activity. One common sleep stage-related finding is that when many patients with discharges enter REM sleep the discharges are diminished in frequency and or amplitude or are eliminated altogether. For a more thorough explanation and description of abnormal EEG activity, the reference below is suggested.1 Whether performing sleep studies on many children or just a few, knowledge of the reasons and methodology for appropriately monitoring CNS activity is an important aspect for serving this population. Even adult sleep studies on patients with a known seizure disorder should include a montage that will allow the clinician to better visualize any epileptiform activity that may be present. Since epileptiform activity can yield symptoms associated with sleepiness, obtaining the "full picture" by employing a more thorough EEG montage to detect this activity is of vital importance, particularly in the pediatric population where CNS problems may remain undiagnosed. 1. Fundamentals of EEG Technology, Vol.1: Basic Concepts and Methods. Tyner, F., Knott, J., and Mayer, W.B., Raven Press, New York, 1983 Working with Exercise in Mind I found myself in the whirlwind of working the night shift, sleeping during the day, and fitting in laundry, dinner and baths for the kids. I had a routine down pat. Then my doctor sat me down and gave me a heart to heart about adding exercise to my life. I have a herniated disc in my back and the only way to get this thing better is to incorporate daily exercise into my life. Well, being a working mom of 2 kids (the night shift none the less), I thought I was doomed. Where would I find the time to fit in this task? I began brainstorming and started stretching in the morning and in the evening. I had a Yoga ball that I used through my pregnancy and I started using again after the birth while watching TV. At first I was only bouncing on it. I even put my littlest one in my arms and bounced him gently to sleep. It was a great substitute for rocking. I soon found myself becoming very comfortable sitting on this thing. While at work one early morning, I was monitoring a patient listening to the rhythmic loud snoring. I found my eyes starting to close ever so slightly. When this begins, I usually splash water on my face and march in place to get the energy flowing again. Then it hit me. Why can't I bring in my ball and use it during the night at different times to help get my heart pumping and fight off those 4:30am extended eye blinks? With much hazing from my co-workers I began sitting on my ball throughout the night. Of course I felt ridiculous, but could this be the easiest solution for my predicament? I began to perform a series of exercises at 3 different intervals throughout the shift using the same clock that is ticking on the computer screen. The best part is that my eyes never leave the screen, and I am confident that the patient is monitored at all times. I can also make the workout as easy or difficult as I choose. Sometimes I time a set of reps to last as long as an apnea/hypopnea. Or I will do a certain exercise for each stage of sleep (i.e. modified jumping jacks while the pt is in REM). Experts say, "active sitting" on a fitness ball can lead to more movement while sitting because your body must make constant small adjustments to keep you balanced on the ball. So it makes sense that gentle exercise would be a great preventive measure in back care. These small adjustments help circulation to the disks in your spine and can strengthen your back muscles. Also, gentle bouncing on the ball will encourage you to sit with the correct posture and help strengthen your postural muscles. Isn't this the perfect solution? It's been over a year since I have purchased a ball from the physical therapy department ($15, but you can get them at Wal-Mart) and converted it to my only office chair (my coworker has converted as well). The PT department was able to guide me in the correct height of inflation for the ball. The office walls are lined with posters for alternate exercises for strength training of the whole body. I personally concentrate on trunk strengthening. I have a ball stand, which I use with Thera bands. This simulates weights for your arms. I go to work in a sports bra, and love it. I do 300 sit ups each shift and get my last stint of blood pumping exercise right before my patient wakes up, which makes me feel refreshed and awake for my ride home. Your physical Therapy department can give you a list of stretches and exercise for the ball or you can purchase a book, posters or video at most retail stores. I believe this has made a huge improvement for my general health. Nonetheless it keeps kids who visit the office busy. Happy Bouncing... Occupational Opportunities Concord Hospital in Concord, NH, is looking for a night shift polysomnographer. 3-12 hour shifts a week, flexible schedule, and a fun work environment. Excellent benefits and a wonderful place to live and play. Please contact Lisa Gaskin at 603-225-2711 x4189 or e-mail lgaskin@crhc.org. Letter to the Editors Your feedback is greatly appreciated. Let us know how we're doing. Any questions, comments or suggestions for the Snooze Newzzz editors may be directed to: Bethany Lamell, RPSGT And if you're you interested in being a Snooze Newzzz editor or submitting an announcement or article, get in touch with us via e-mail!
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