Okay. We're down to the hearty few. Yes, so kind. Make no problem. Your speakers are permuted in time and arranged by height. So here we go. Today, and I titled my presentation Sleeper Chance to Dream. And let me tell you just a little bit about why I've chosen this topic. I'm involved with medical education event for well over 45 years. The point is, is that we start to see performance of medical students walked in Wayne, depending in the first year. And you could go back to your first year where sleep was looked on as a luxury. And all of a sudden, we start to take a look at how it affects our everyday lives. And so at this point, that's kind of one of the rationales we had to do. Or at least why I chose this topic to present, because I've just seen sleep deprivation and the sorts of things that go on. So going through this, I intend to reference some label and unapproved use of Gabapentum just in a comment. But for full disclosure, I have no interest in that drug financial or otherwise. I'm going to start out with just some initial deal, American Academy of Sleep Medicine. I only put that out because I don't want to confuse with the American Academy of Sports Medicine. This is an actual organization. It's not too far removed from some of the academies that we see pop up all the time. However, this one was in July of 2022. They changed their accreditation standards to include all provider types. Now, I'm just trying to suggest to you that while it was looked on for physicians, it's now health provider now becomes a catch all term. And so anybody who purports to advertise in sleep specialist one way or the other will fall under this academy. Now, one of the things is, is what do we mean by a sleep disorder? And I'm suggesting to you, it depends on who's making the list. The American Academy of Sleep Medicine identifies 80 official sleep disorders. Now, I must tell you that that might have a lot of self-interest in that adversation. The notion here, and I'm going to highlight in red some of these slides because given the hour, some of the things I really need you to be thinking about. First of all, this is a prevalent condition. A third of U.S. citizens, particularly adults, U.S. adults report that they usually get less than the recommended amount of sleep. If you ask them, what is the recommended amount of sleep? They can't tell you. All they know is, is they can't get enough of it. So what I'm really trying to suggest to you here is that getting enough sleep is not a luxury. It's something people need for good health. I'm going to come up with a checklist later on, and you can check yourself relative to these things. Also, sleep disorders can also increase a person's risk for health problems. Particularly, we start talking about the inconvenience of poor sleep and how it really starts to affect our interaction with ourselves, our occupation, and more importantly, with other individuals. So let's talk a little bit about the epidemiology. First of all, I want to point out that if you take a look from 2013 to 2020, there's not a lot of change. So this is a condition which, even though we talk about it, hasn't had the impact of really changing people's behavior. You'll notice that this is age-adjusted. That means that we kind of break it down by age and then sum across those categories so things don't tend to confound each other. But short sleep duration is a little more prevalent among males than females, which to me is a little counterintuitive since females still tend to be the caregiver for a lot of things. And as a result, we keep thinking them maybe being awake a little bit more. But it's really kind of male, and that kind of reflects back on occupation as well. So let's just think just a moment about what are kind of amount of sleep we need as we age. I'm pleased to see it cuts it off at 60 years old because it sees it goes down. I guess at my age, I should probably be getting about two hours more sleep as I look at the degradation across age. But we can see clearly that the infants are 12 to 16 hours, and it goes down to seven or more hours 18 to 60 years old, which I know picks up everything in this room. So the point is, is that how many of you have slept for seven hours last night? Raise your hand. That's great. And I know some of you accumulated those hours during my lecture. So the notion is now that what I'd like to do then is point out in this map, which I was able to pull on the latest information. I'm going to pause for a moment as I speak for you to look at that map, look at the color, and see where the good or bad sort of sleep deprivation lies. These are the short sleep. So as the color gets darker, the percentage goes up just a little bit. So you can kind of see where you are and how your state fits into this overall pattern. Now, let's look at some key sleep disorders. Again, function is who's making the list. CDC recommends or suggests the following are the big four. Insomnia, which I'll speak to, narcolepsy, restless leg syndrome, and sleep apnea. I don't know if I'm going to be able to get to all of the restless leg, but we're certainly going to talk about insomnia. Now, insomnia basically says lack of sleep. Sufferers have a hard time both falling asleep and staying asleep. I don't know if that hits any of you. But the notion is, is we've got sleep apnea, circadian rhythm disorders, which is now going to come up with nauseating frequency in my remarks, movement disorders, parasomnias, and too much sleep. This was posted in 22 out of the Cedars-Sinai criteria, which made it a little more easier to understand. And I've given you the website under my slides. The next we're talking about is just a little bit of neuroanatomy. I'm not going to highlight all of the parts of this. I'm only going to highlight a couple. First, I want to talk about that superchiasmatic nucleus, the SCN. Some of you may remember that from your first year of medical school, neuroanatomy, which many of you, thankfully, you don't have to remember anymore. But anyway, nonetheless, I'm going to talk about that and the pineal gland. Now, the superchiasmatic nucleus, the SCN, is particularly important because of its relationship to something called circadian rhythms. These circadian rhythms really are the light-dark differentiating part of our brain. Most blind people even maintain the ability to sense light and dark, and they're able to then adjust their sleep-wake cycle. Now, I'm going to go over and over about because the sleep cycle, the light versus dark, is going to be your main determiner of what's going on. I want to then come up with just the pineal gland for my remarks because that receives signals from the SCN that increases the hormone melatonin, which helps put one to sleep. Now, we can buy melatonin at aisle six at Costco, and I want to come back because I want to remark on that in a little bit later slides. But melatonin is a natural hormone, which does it, and people have to try to capitalize on that as a sleep aid, and I will comment on that in just a moment. So, I'm saying circadian rhythms out of the SCN and also a little bit in the pineal area is important because we have endogenous circadian rhythms, which are the physical, mental, and behavioral changes that really follow a 24-hour cycle. And these respond primarily to light and dark, and it affects most living things, animals, plants, microbes. Recall that SCN is the one which regulates that. How many of you live in different time zones from where we live now? Most of us? You bet. How many feel a little uneasy when you kind of go back, takes you a little bit to adjust, and that adjustment is the light-dark cycle? Now, all of you, particularly in whether it be military or whatever, I notice the difference is that as they fly around in different areas, you have to allow for adjustments to this. Failure to do so cuts down on efficiency and so on. And also, there's an exogenous contribution to this light-dark cycle, circadian rhythms. And again, these are from the environment, and the word is the German word zeitgeber. And these are things which affect that light-dark cycle to us, like sunlight, temperature, exercise, eating, and drinking patterns. So these are the things we're going to have to pay attention to if we want to try to maximize our circadian rhythms and hence our sleep cycle. And this graph merely tries to show what happens to body temp and what happens to time and the melatonin, which is the light yellow there. And our body temp goes, of course, the bottom, and the sleep cycle goes from sleep to awake. And you can kind of see how it mirrors itself. So as we go through a 24-hour period, we're trying to balance these things internally as well as externally, and that affects our sleep cycle because of the light-dark maneuvering. So in summary, factors that influence your sleep-wake cycle needs are medical conditions, medications, stress, sleep environment, what you eat and drink. Perhaps the greatest influence is exposure to light. Specialized cells in your eyes, of course, are going to adjust to the wake, pardon me, the light, and also to the dark. This tries to trigger things in the SCN, triggers off things in the pineal gland, and there the cycle starts to go. But the thing which is important for us are night shift workers, because they often have trouble falling asleep when they go to bed, and also have trouble staying awake at work because our natural circadian rhythm and sleep-wake cycle is disrupted. And that's why I asked you, when you go back home, what the hell happens? And we have something called daylight savings time. How many felt that that change affected you? Okay, everybody's hand went up, that's pretty decent. And what is it? Again, light. So, and that's going to have some interesting things in just a moment. So in the case of things like jet lag, different time zones, creating a mismatch between their internal clock and the actual clock. Pretty straightforward. Now, a little bit more coming back to that is we talk about sleep stages. We got REM, rapid eye movement sleep, and non-REM sleep. And to tell you the truth, maybe some of us have thought about this, but let's just crystallize just a couple of things. Stage one, non-REM sleep. That's the changeover from wakefulness to sleep. It's during this short period of time, maybe only a few moments, relatively light sleep. Notice that your heart rate, your breathing, your eye movement slow down, your muscles relax. Sometimes you get occasional twitches, and your brain wave begins to slow down from their daytime cycle. Did you remember, just think about last night. Did that somehow kind of cycle that thing through? And then stage two non-REM is light sleep before you enter deeper sleep. Your heartbeat and your breathing tend to slow down again. Muscles relax even more. Body temperature drops. Eye movement stops. Your brain wave activity slows down. You got brief bursts. And then, but you spend more time of your repeated sleep cycles in stage two sleep than in any other sleep stages. This is this, just prior to going down. Stage three is really our period of deep sleep non-REM. You need to feel refreshed in the morning, and that means you've got to enter some stage three sleep to do it. It occurs in longer periods during the first half of the night. Your heartbeat and breathing slow to their lowest levels. Your muscles are relaxed, and it may be difficult to awaken you. Hey, wake up there. We kind of see you kind of, but brain waves become even slower. So this is what, this is kind of a preparatory to really going under. And now we start REM. So you're literally working yourself to the deeper sleep, which makes sense intuitively. And it occurs in the first 90 minutes after falling asleep. So we're rolling through the non-REM, hit that REM area in about 90 minutes. Now look, do your eyes move rapidly from side to side behind your closed eyelids? Mixed frequency brainwave activity becomes closer to that scene in wakefulness. So we're starting to become active, even though we're in deeper sleep. Your breathing becomes faster and irregular. And your heart rate and blood pressure increase to near waking levels, even though we're falling asleep. Most of your dreaming occurs in REM sleep. How many of you dreamt last night? How many remembered it this morning? Yeah, something just wipes out, but there you were. Some can also occur in non-REM sleep, that's stage three, but your arm and leg muscles become temporarily paralyzed, which prevents you from acting out your dreams. You know, how many of you were heroes? You know, you don't wake up, you know, where are you, but you can't move. As you age, you sleep less in REM, and therefore your memory consolidation is most likely requires both non-REM and REM sleep. And some people say, you know, I dreamt last night, I just can't remember it, the details. So in that case, with that as a precursor, light, dark, how are we going to get to sleep? Insomnia is just by definition, a sleep disorder can make it hard to fall asleep or to stay asleep, or cause you to wake up too early and not being able to get back to sleep. Now that I'm telling you, not having you raise your hands, every one of us has gone through. Now, you may still feel tired when you wake up. I just couldn't sleep last night. Now, that's a fine, but now what are we going to do about it? Well, let's think about these common symptoms. How many of you, and this is what I'm not, you do your internal checklist. How many of you were lying awake for a long time before you got to sleep, thinking about stuff? Some people hit the pillow and man, they're down. Other people, oh, what's going on? He says, you know, how many cracks there are in the ceiling. Sleep may be possible for only short amounts of time. Waking up too early in the morning and not getting back to sleep. When you're up, you're up. Poor quality sleep. Difficulty falling or staying asleep for, by definition now, and this now becomes the medical definition. Difficulty falling or staying asleep for at least three nights per week, and it's considered chronic, but occurs three or more nights a week and lasts for three months or longer. Well, look, how many of you had to do nights during your medical school residency? And you remember they were so kind, they were going to give you a two-day, please go in and two days after your rotation so you can readjust. How generous of them. Holy mackerel. I have no idea where they did their training, but that sure as hell never worked for me. And I remember it so vividly because I had to do nights before I had to write part two of my boards. And I'm telling you, you go into that eight o'clock in the morning for that, you remember part two boards, those three-hour sessions? Honest, gravy. You know, you find that maybe I should just take a nap. You know, it's a three-hour, I could take a nap. You know, I put my head down on the desk, I'll just, we have 20 minutes to go, and I'm question 20 of a 200 questions. My gosh, you know, there is no God. I mean, you know, what the hell are you supposed to do? But anyway, that's the adjustment, you know, really getting problems. So age, chances increase as you get older. Stress and anxiety, stressful event, work and family. And many people worry about not being able to fall asleep. And so they stay awake because they're worried about not being able to sleep. Family history, and this I think is not a successful use of some statistics because they suggested it's a genetic disposition. They say it runs in families. And what I'm trying to suggest is I don't think they made a good clean break between that which is habit, that's the way we do things in our family, versus a genetic, when you talk about a genetic disposition for it, that's kind of like a wiring system as opposed to learned behavior. And my reading of that research is it's not as crisp between those two as I think it should be. Environmental occupation, shift or night work, noise or light during the night, uncomfortable temperatures. My point is, is that this really hits all of us, whether in OcMed, aerospace medicine, preventive medicine, but shift work is a big one. And we had a talk last that Naomi asked me to do on shift work, particularly overtime work, and what its effect is. And one of the things it affects is your sleep cycle, and that affects your overall health. Lifestyle problems, changing your normal routine often, experiencing it. And this will be all up on who's on call. Remember, you're doing call and some of you still do call. And still when that happens, you know, the whole thing gets cocked over. Experiencing interruptions in your sleep, such as waking up to care for a baby. And I think they put this together from ASAM, and they should say, and I think that's ill-stated. How about taking care of responsibilities like having a young infant, but more importantly, many of us have had to take care of our parents, guests coming in, whatever the situation is. As people age, their biological needs age, you have to get up to help, whether it's going to the bathroom or toileting or other activities of daily living. So I would rather see that as not necessarily taking care of a baby, but taking care of a dependent. If you understand my terminology, it'd be more of a collective noun. Taking long naps during the day. Some people are used to doing that, and then they can't close their cycle off. Getting too little physical activity during the day. I don't know why we all sit in a chair here for eight hours a day. I don't know where that came from. Anyway, using caffeine, nicotine, alcohol, and I want to put in recreational drugs. We were talking last night around the table over a glass of milk out there, and they were talking about legalizing certain, and I'm using the term recreational pharmacy now, not street drugs, but marijuana. How does that really affect? Because that now is also going to interfere. Receipt drugs, and we were talking about the states having more and more legitimizing that. So I want to put in caffeine, nicotine, alcohol, and recreational drugs. Watching TV or using electronic devices close to your bedtime. How many of you turn your phone off at night? I'll tell you how many. Few. All right? And if you do, good. And then if you turn it off, you worry about maybe I'm going to get a call, so you wake up to check your phone. I have no idea how you're trying to manage this. We're really trying to suggest TVs in the bedroom is not a good thing. Just saying. Particularly watching certain news programs. Yes, sir. Another thing that interrupts sleep at night is leg cramps. The restless leg syndrome. Yeah, that's part two. Different than regular leg cramps. That's true. Also leg cramps. Particularly with diabetics. Yes. Diabetes has a tremendous impact, and those aren't just muscle cramps. Those are neurologic, and the pain involved with those is absolute. How many of you have had these? Neuro. I mean, this is crippling pain, and there's not much you can do about it except kind of grimace. We've had great success in clenching, you know, as you're trying to get through with it. It's very, very painful. Mental health issues, motor disorders, depression, bipolar, anxiety disorders, psychiatric disorders. But physical health as well. Heart conditions, respiratory, neurologic. Probably just our comment, we'll put in diabetes there. Hormonal conditions, particularly thyroid. I'm going to make mention of that in just a moment again. And, of course, arthritis. And, again, I would put in neurologic problems. From my point of view, those diabetic cramps are more neurologic in order than hormonal. Physical health things. You sleep with pain. Medications. And this is the one that we have to do a very careful history on. Some antidepressants, epileptic meds, hypertension meds, steroids, NSAIDs, stimulants, particularly ADHD meds, asthma medications, and National Health Service is the one that came up with this list. I only put it there for completeness and authority. Common causes suggest the following history and physical exam particulars. And this is the one I just want to highlight a couple of things. And these are questions after you do your basic history and physical. How often do you have trouble sleeping? And how long have you had the problem? I will leave you to kind of read through that. I'm only trying to say, have you had any new or longstanding health problems? You taken any medications? People have been taking these so often, they sometimes forget their medications. How many of you had, for example, young women who don't look at oral contraceptives as medication? Anybody do that? I've had several people, they just take it. Anything you take as regular, sometimes they forget to enunciate. I'm just saying that as a general warning. Pregnant or going through menopause. Again, caffeine, nicotine, alcohol, or recreational drugs. Some of you, remember you were usually taught the idea about using illegal drugs. You know, they were thinking heroin, cocaine. And now we're trying to use the term recreational pharmacy or street drugs. It's just a little less loaded in our adjectives. We want to do a standard physical exam to start to see if apnea occludes or enlarged tonsils, enlarged neck circumference, kind of impairs breathing. Basic labs include thyroid indices again, and sometimes we don't do the TSH as part of your basic account. So we're asking you to kind of do your thyroid studies as well. Your additional lab, you can do sleep studies, actigraphy, which is looking at your periods of rest and activity and measures how well you sleep. And this requires you to wear a small motion sensor on your wrist for three to 14 days. Now, let's think about that as a preparatory. So now let's think about how we might want to start to treat this. First of all, yes, sir. Very good point. How many of you have had your tonsils out as a kid? Right. Now, how many get their tonsils out now as kids? It could be lymphoid tissue, right? It's all antibiotics, this kind of stuff. But the point is, when now do we usually do tonsillectomies? 16, 17, 18 years old, adolescents. And as you know, this is not a bloodless surgery at that point. Very, very difficult. And so the notion is you're absolutely right. They now are only looking at tonsillectomies on exceedingly strong indices, one of which is lack of sleep. Absolutely correct. And thank you for that. Now, usually a diary. Now, a sleep diary is a daily record of important sleep. How many people do you think really keep diaries? The answer is it's great for the first week. After that's a little. So we have to get a solution to that. I mean, leaving it, I'm not going to just read that over for you. But you can kind of see what's going on your daily meds, exercise and so on. And I've given you the reference for that. Why am I judging you over that? It's because we end up with electronic sleep diaries. And this is great. Let me just ask again. How many of you own a blood pressure cuff? Okay. 90%. How about temperature? Got it? Super. How about pulse ox? Okay. 15 bucks. If you take a look at what we give our medical students now as their health equipment, they get pulse ox. It's a $15 purchase and they put it in the bag, you know, because I'm writing checks all the time for this stuff. But the point I'm trying to tell you is, is that if you do all of that, no wonder we can do telemedicine. Because all they're going to do your medicine is going to take all your vitals. Well, you can do that now. You know, you go down to aisle six at Kroger's and you buy yourself a thermometer. You know, go to Costco and buy yourself a thermometer. So, the point I'm really trying to get to is this doesn't. Now, let me just give you a warning. If, in fact, you're going to do an electronic diary and somebody didn't have it connected to their beds, warn them. There are certain times you want to turn it off. Are you starting to get the drift here? Call personal time. Some people want to call it connubial bliss. All I want to try to talk about is don't record it. And people say, they don't say, oh, yeah, yeah, we wouldn't want that out, so to speak, you know. Or you can say, we notice that it's not occurring. You know, it can go bad either way you look at it. So, I'm just trying to suggest to you that you tell them to kind of turn it off. Okay. Now, I only grabbed this. I have no interest in this. Don't misunderstand me. Particular brands, but some are doing it on Fitbit watches. They're doing it. I don't want to read too many. I'm not pushing any particular brand. But you can go online, and I will tell you right now, you get more than one page of equipment that you can buy. This is one of the things I'd like you to remember for your own personal use. It's the 10-3-2-1-0. And I'm going to ask you to think about this. Cut out caffeine 10 hours before bed. Don't eat or drink alcohol three hours before bed. Stop working two hours before bed. Get away from your screens one hour before bed. That means phones, TVs, and computers. Let me just stop right now and have you do an own internal check on whether or not you follow this. Okay. I know you don't. But I'm just suggesting to you that you kind of hip pocket this thing and see if it works for you. Yes. Dr. Clark. E-readers. Screens that count E-readers. E-readers. Okay. Isn't that the only blue wave? No. Sir. Isn't it mainly the blue light? It is that. But it's also stimulation. And let's talk about anxiety. Worried about what's going on the next day. You see an article or something that just gets your system going again. So, yes, the idea is not only what you see, but it's also the external stimuli that it gets you internal on those previous slides. Yep. I beg your pardon. Worst thing you can do. Yep. So I'm just going to tell you just to keep that in mind just for your own personal entry. I've given you the link for that as well. Make your bedroom sleep friendly. That means it's cool and quiet. How many of you asked for a blanket in this hotel? Honestly, God, you could hang meat in my room. I mean, it was a little chilling. Got a thermometer over there and it's cold. Yep. Yeah, I did that. Yeah, I did that. It doesn't go up high enough. I knew that thing when I had icicles in my beard. Anyway, the point I'm really trying to suggest to you is it should be cool, should be quiet. Go to sleep, wake cycle around the same time. In other words, to regularize your pattern. Again, caffeine, nicotine, alcohol, and recreational pharmacy. Next, you got to get regular physical activity during your daytime, at least five to six hours before going to bed. Now, regular physical activity becomes one of these definitional problems, but exercising close to bedtime can make it harder to fall asleep. Eat meals at a regular scheduled time and limit how much you drink close to bedtime. And that's only because of retention. You have to get up, men in particular, with prostate problems and so forth. And it's just urinary retention as well. And now, learning new ways to manage stress. Acupuncture, meditation, yoga, sometimes that helps. We have reading a book, listening to soothing music, taking a hot bath. That's stress as opposed to sleep. But removing stress aids in sleep. Certain over-the-counter prescription drugs, you got to be kind of careful of because many of them become stimulants as opposed to sleep aids. Now, and that was done in a, I've given you the reference down below on where that has happened. We've had use for cognitive behavioral therapy for insomnia, six to eight weeks. Some people like it. Primarily, it helps relieve stress. But it's very, very, it's recommended for that. I'll be honest with you, it's done by person, telephone, or online. CBT is now a very, very big part in medical school curriculum for aiding a lot in behavioral problems that come across. Cognitive therapy helps you feel less nervous about sleep. Relaxation, meditation, sleep education, restrictive therapy. I've given you a link for that as well at the bottom. Now, there's a couple of other things. This is the one I want to make sure that we pay attention to, and that is medications. Please try to use these with caution. Usually they're given at night, and the sedative hypnotics become the category of most interest. Only for short periods of time. There are some things which can be quite dependent. Start with the lowest effective dose. Patients must avoid combining these meds with alcohol or other CNS depressants. So you must do a good medical history before this starts. Liver tox, of course, is one of the biggest things we have to worry about. Here are some, and then I had to, you know, on my declaration ahead of time. Zolephalan or Sonata, fast-acting but a very short health life. Use it for patients who have difficulty falling asleep. Escopicoline, which is Lunesta, is slower onset, a little longer duration. Use for patients who have difficulty staying asleep. How many of you have used Triazolam or Halcyon and other, I mean, this is not, this is an older drug. But problems are dose-related, short-term use only. This is really, really, you really got to think twice about using this. It can cause CNS depression. Overseas for the military, we used to go to H&H, Halcyon and a Heineken. Yep, yep. I agree. I remember, the only thing I remember about that was also called HHH. High, hot, hell of a lot. They used to do that for constipation, you remember that? But yeah, I appreciate it. But the question about Halcyon is, man, it works. I just got to, just got to be honest with you, but it's very, it's, it's, it's very dangerous to use. Restoril, avoid the patient with substance abuse problem, but Restoril or Temazepam, same thing as Triazolam. Rosaram, which is a melatonin receptor agonist, avoidant patients with sleep apnea. Remember, we talked about melatonin as being released the pineal gland. Some people say, we're just going to give you a little bit more of it. Be very careful with, you can't do it with people with sleep apnea, because they'll go right through it and have a crash. Guidelines for sedative hypnotic meds, avoid or exercise extreme caution in patients who have substance abuse or substance use history. Please prescribe only on a short-term basis. That means you must bring them back in regularly and do a very detailed history. That diary is critical. Watch for requests for escalating doses. And I was very happy about that opioid lecture that you had yesterday. The same thing that those guidelines apply to this as well. And it was said really, really well there. I don't want to duplicate it. Hypnotic should be discontinued gradually, not cut off quickly. And the lowest effective dose should always be prescribed. You've heard that now from your previous lecturers and from me. You just have to monitor this stuff. Melatonin supplements. Now, I don't want to get on a soapbox about this, but folks, if you just, just for your own use. How many have seen, how many, anybody prescribe melatonin to their patients here? What I'd like you to do is the next time you go to a Costco or Kroger or any, I say Kroger because it's the largest thing, any grocery store that's really well stocked. Please go down and look at in the herbal section, you'll see melatonin. Look at the label because you'll get it in five milligram or 10 milligram doses. I'm trying to. No, you know what, I think we're back cooking with grease. Okay, sir. I'm not going to play because of the time element. Right. So we'll go pick that up later, but I just want to finish a couple of these. Thank you very much. Appreciate it, Jerry. All right. I might have changed your slide. No, no problem. No problem. We're going to get to it. I have no clue what I did. Good job. Okay. Thank you very, very much. I appreciate it. We talked a little bit about Benadryl being a very, very effective, but very dangerous drug. I talked to Dr. Barry, who commented that the number one cause in aerospace medicine for accidents has been the use of Benadryl that will need at least an eight-day. Pardon me, sir? Association. Associated. Excuse me, and thank you for the correction. The notion here then becomes an eight-day layover. We've talked a little bit about Benadryl. As I say, that's a problem. Ambien and others, which while effective, has a tendency to become addictive. Let's go to light therapy. That's always been talked about. They used to sit in front of the light to redo your circadian rhythms and try to get back on. That's got mixed effects, but it has been used and result from a systematic review showed to be effective for sleep problems in general, particularly for circadian outcomes and insomnia symptoms. However, the effect sizes are small to medium. That is to say, I remember when they used to put ads on TV, they used to sit in front of a light for two hours. I'm just saying that the effects are really quite small. The biggest advantage we have, of course, is that it's non-addictive. Second, for short-term insomnia disorders, you should focus on good sleep hygiene or CBT as opposed to medications. Sleep studies are good. History and physical exams combined with sleep studies can assist for proper diagnosis. Remember, this is a definable problem. Medications, if used, should be the lowest effective dose. Please read for potential interactions with medications that the patient is taking. All of us on your cell phones now or on your phones, you can have a PDR. There are several drug interaction programs. Look them up, please. We start to find out new interactions all the time with various changes. Now, I've done this for aerospace medicine. I've come up with some references. And that's because one of the studies I was going to use said, some of these studies is being withheld for security reasons. That's all I had to hear. So I'm only putting this up for read. Some of the questions they were having was, what do you do for people in the modules, you know, in space, where we have, remember I said how the light-dark cycle is really the important one? What are you going to do when you're in 24-hour situations? How do you keep active and so on? And so I'm saying that that really becomes a very interesting research area to look at in the space program. And again, I just put this first one, circadian rhythms in space. That was some of those data apparently were withheld for security reasons. I've given you some additional references on devices for ambulatory monitoring and sleep. And the other one I'm pointing was this great sleep guide for patients. It's really a government publication. It's really good. And it's something that's free. You can give to patients if they need it. Now, my next, and I'm only looking at the time, and I'm going to exceed my time if I got into it. I'll blast through this and be very happy to give this at another, maybe new talk and complete those slides. I'll talk fast through mine. Go ahead, Paul. Sir? I'll talk fast through mine, so get us back on. I'm more worried about the pilot. No, the question that I'm really doing is restless leg syndrome. I was looking across yesterday, and you could see people's legs start to move after they've sat for a few hours. So it's natural, and it's not like I'm putting them to sleep. Maybe I am. But the point I'm really getting to is the fact that restless leg syndrome is a diagnosed area. Basically, it's a leg or arm discomfort, urge to move legs or arms. Usually, it's a bedtime behavioral problem, can go to work, relies on the patient history. I really feel academically cheap going through this this quick. But let me just then come up that you did notice that medication withdrawal is a big problem. And everything I've told you before about medications, you taper slowly, not quickly. It becomes, we do this a lot in our alcohol and drug use discontinuation. Ankylose is a big one, erythromyalgias, leg compartment syndromes. But the big one is medication withdrawal. We have five criterion that we'd like to use, urge or desire to move your legs, usually occurring together with uncomfortable sensation, begin or worsening during periods of rest or inactivity, partially or totally relieved by activity such as stretching, walking, or exercising, and are worse or cold slowly in the evening or at night. But avoid, and you're not solely doing another, that should be medical, not medial. When I spell check this, apparently, I left out the C and they didn't pick it up. And I thought I proofread it and I'm apologizing for the misspelling. And now the one thing I will leave you with is a scale that might help you out. First of all, I've given you the references here, the Hopkins Restless Leg Syndrome Severity Scale, Restless Leg Quality of Life Questionnaire. And that came out of UPenn. So you can stand up and show us your t-shirt. There you go. We have a Penn representative. And then the treatment, of course, is probably exercises, diet, a lot of behavioral issues. This has come from the Cleveland Clinic, which has a specialty in this. And now I'm only going to spend two minutes on this. Many times, because it's so bothersome, there's certain anti-convulsants like gabapentam. But it's not gabapentam that you're going to, it's gabapentam and CARL, which is, Horizon is the brand name. It's on label. It's effective. And gabapentam, per se, is really like Neurontin or Pregabalin, which many of us use. And I'm only saying that that is a problem. That is off-label if you're using it for Restless Leg Syndrome. You with me? Regular is not, is gabapentam and whether Neurontin or Pregabalin is off-label for Restless Leg. And you want to make sure if it's gabapentam, it's the Horizon brand name or, and a CARL is the appendage you have to have. Dopamine agonists, Mirapex or Repironol, which is Requip, is preferred. The other ones are transdermal patches used, but the side effects are really problematic. Try to stay away from those. We talked a little, I think it was mentioned on benzos and clorazepam, diazepam. Those are used. We have to be very careful about that. But remember, low dose opiate narcotics only in severe cases. And I'm going to tell you right now, you've really got to be careful of this. And then iron therapy, if needed, because of the hormonal interactions. Non-pharmacological treatments are very, very good. Minor things have been shown with vitamin C and D, but they've really been small studies on vitamin B12 and E. And I've seen that prescribed a lot. Maybe they've seen it in large scale studies. I don't know if they've used it in the military or not, but the results have not been overwhelming. These suggestions work best in patients with poor nutritional stuff, when you start talking about glucosamine, magnesium, and zinc. There's been a lot of this stuff on the natural products, but the results have not been overwhelming. Very little improvement we've shown with this, okay? It's just, it works for some people, a lot of it is placebo effect, and it's just not as effective as it should be. I'm only going to leave you then with this, which is the Epworth Sleepless Scale. It was available. It's now in part of your handout. It's easy to use. It's freely available. This is how you, zero to five is low normal, six to 10, it gives you the scale. So this is the, it's only because it was easily available online, which is why I chose it. I'm not saying it's the best. It's something you can use, okay? So I'm sorry to blast through those, but I just don't want to get started on something I have to continue inadvertently. So with that in mind, I thank you all for allowing me to speak. It's nice to see old friends and nice to make new ones, and everybody have a very good conference, and I appreciate the opportunity.

sleep deprivation

medical education

sleep disorders

circadian rhythms

insomnia

melatonin

sleep hygiene

cognitive behavioral therapy

Epworth Sleepiness Scale