PUBLICATION OF THE APT
ASSOCIATION OF POLYSOMNOGRAPHIC TECHNOLOGISTS
WINTER/SPRING 2005 • VOLUME 13 • NUMBER 4
First PSG
Licensure Bill
Introduced
Ghrelin
and Sleep
Apnea
2005 Multi-State PSG
Legislative Issues Increase
The Dangers of
Untreated Sleep-Related
Breathing Disorders
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And without sleep, people don’t function well.
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sleepmate.com
W E P U T Y O U F I R S T.
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
THE A2ZZZ MAGAZINE,
EDITORIAL BOARD,
COMMUNICATIONS COMMITTEE
THERESA SHUMARD,
EDITOR-IN-CHIEF,
COMMUNICATIONS DIRECTOR
ASSISTANT EDITOR
ROBERT LINDSEY, MS, RPSGT
APT BOARD OF
DIRECTORS LIAISONS
ROSE ANN ZUMSTEIN, RPSGT
LAURA LINLEY, RCP, RPSGT
CARTOONIST
BARBARA LUDWIG CULL, RPSGT
CORRESPONDENTS
IAIN BOYLE, RPSGT, CANADA
ROGERIO SANTOS DA SILVA,
BRAZIL
WAYNE PEACOCK, RPSGT,
UNITED KINGDOM
ASSOCIATE EDITORS
JOSEPH ANDERSON, RPSGT,
RPFT, CRTT
EDWIN CINTRON, RPSGT
WILLIAM ECKHARDT,
BS, RPSGT
REG HACKSHAW, RPSGT
JOANNE HEBDING, RPSGT
MARY JONES-PARKER, RRT,
RPFT, RPSGT
REGINA PATRICK, RPSGT
JESSICA PILLEY, RPSGT
KIMBERLY TROTTER, RPSGT, MA
SPECIAL PROJECTS
JAYME MATCHINSKI, ESQ.
CYNTHIA MATTICE, RPSGT
TRACY NASCA
ADVERTISING
SCOTT COLE, RPSGT
LAURA LINLEY, RCP, RPSGT
MISSION STATEMENT:
A medium to provide progressive technical information and an
avenue of communication for members, presented in a professional
and constructive manner, to further the goals of, and promote
unity in the Association of Polysomnographic Technologists.
ADVERTISING POLICY
As a service to our membership, The A2Zzz Magazine prints information on
educational programs and products. It is not intended to imply that the programs and products are approved by the Association of Polysomnographic
Technologists (APT) or the Board of Registered Polysomnographic
Technologists (BRPT), or that they are endorsed as a method of preparation
for the BRPT examination. Professional products and services are subject
to approval by The A2Zzz Magazine Editor-in-Chief. Ad inquiries may be
directed by fax to 781/823-4787 or by e-mail to [email protected].
For advertising billing questions, call 708-492-0796.
Advertising rates, specs and info: www.aptweb.org/advertising.asp
ARTICLE SUBMISSIONS GUIDELINES
Research, feature and news manuscript submission guidelines, word limits and e-mail submission instructions may be obtained from the Editor-inChief. All articles subject to standard, blind peer review. Article queries
should be mailed directly to:
Theresa Shumard, Editor-in-Chief • APT Communications Office
PO Box 70 • Mohnton, PA 19540
Phone: 610/796-0788 • Fax: 781/823-4787
E-Mail: [email protected]
Copyright © 2005 by the Association of Polysomnographic Technologists. All
rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy or recording, or any information and retrieval system, without permission in writing from: APT National Office, One Westbrook Corporate Center,
Suite 920, Westchester, IL 60154. Opinions expressed in The A2Zzz
Magazine are not necessarily those of the APT Board of Directors.
In This Issue…
Editorial ....................................................................................6
APT News ..............................................................................6-7
Ghrelin and Sleep Apnea ..............................................................8
Daily Social/Physical Activity Improves Sleep, Cognition in the Elderly....10
The Dangers of Untreated Sleep-Related Breathing Disorders ........12
Legislative Watch — Winter/Spring 2005 ..................................14
Technical Corner ......................................................................15
Modafinil and CPAP Therapy ......................................................16
NewZzz Briefs ..........................................................................18
Seasonal Affective Disorder ........................................................19
You May Be Losing Your Hearing As You Sleep..............................20
Denver, Colorado — The Mile High City....................................22-23
More That Just Skiing and Cows. Really! ......................................30
APT Directory ..........................................................................31
Key Provisions to Consider for a Medical Director Contract ............33
Classified Ads ..........................................................................36
Product Order Form ..................................................................37
Membership Application ............................................................38
SleepLand Calendar ..................................................................40
APT Silver Anniversary
Cookbook…
Celestial
Delectables
PRESENTED BY THE APT
Order form page 37
?
Have you moved?
Changed your email address?
Your phone number?
If you have and have not notified APT, you
can go to the home page of APTWEB to fill in
your updated information (www.APTWEB.org).
You wouldn’t want to miss your
membership benefits!
5
Editorial/APT News
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Editorial
s the Sleep Medicine and Technology Community gears up for its
most prominent event of the year with the concurrent annual
meetings of the Association of Polysomnographic Technologists (APT)
and the Associated Professional Sleep Societies (APSS), there are a
number of other important matters taking place in the organization.
A
2005 Board Of Directors Election:
Call for Nominations
The APT is conducting a call for nominations for the 2005 Board of
Directors election. This year the secretary, treasurer and four directorat-large positions are open. To be considered, individuals must be active
members of the APT. One may either self-nominate or be nominated
(with permission) for any position. Interested candidates are reminded
to consider the time required for such a commitment, which includes
five board meetings requiring weekend travel, regularly scheduled conference calls, and a variety of projects. The individuals elected to the
offices of secretary, treasurer, and director-at-large will serve a two-year
term on the Board of Directors. Criteria and necessary forms for each
position are available for members on APTWEB at www.aptweb.org
2005 APT Awards:
Call for Nominations
The APT is also conducting a call for nominations for the 2005 APT
Awards. APT Members are recognized in a variety of areas for significant contributions to the field. Annually, the APT presents awards along
with industry support for the following: APT Dr. Sharon Keenan Award;
Dr. Elliott D. Weitzman Award; Peter A.
McGregor Award; Dr. Mary Carskadon
Award; Dr. Allen DeVilbiss Award; and the
Dr. German Nino-Murcia Award. Details
about the nomination procedure are available to members on APTWEB at
www.aptweb.org
APT Textbook on
Polysomnographic
Technology
Theresa Shumard
The APT Polysomnographic Technology
Textbook project is fully underway and the organization is excited to work
with Lippincott, Williams, and Wilkins as publisher for this endeavor.
Communications regarding more information about the project will be
made to members.
AASM-ATS-ACCP Letter of Understanding
Supports PsgT as Independent Profession
In a weekly email message to its members, The American Academy
of Sleep Medicine (AASM), informed its members of the following: The
AASM, the American Thoracic Society (ATS) and the American College
of Chest Physicians (ACCP) have signed a united letter of understanding
in support of the independent profession of polysomnographic technology (PsgT) and in opposition to legislation and/or administrative regulations that limit the scope of practice of a PsgT.
continued on page 28
APT 4th Annual Silent Auction
he yearly APT Silent
Auction has been a
popular event at the APT
Annual Meeting since
the event’s inception four
years ago. The auction
will be held again this
year in Denver June 19
to 22, 2005 at the
Westin Hotel. Funds generated by the silent auction promote the APT
educational initiatives.
T
Left to right: Deb Portelli, Clinton, IA, and Cindy
Mack, Baton Rouge, LA, APT 2005 Silent Auction
Coordinators and Lucy Benjamin, Moline, IL, at
last year’s event in Philadelphia.
Popular items that
were donated include
baskets from sleep labs
comprised of gift items native to their state. “It’s a fine way for labs to
be recognized in front of all our colleagues at the meeting,” said Cynthia
Mattice, APT President-Elect and one of the founders of the APT Silent
Auction. Mattice explained that lab names or other donors are
announced at the meeting from the speakers’ podium. Auction items
that arrive early and their donors are also listed on APTWEB prior to the
annual meeting.
Other examples of silent auction items have been bottles of wine,
sleep lab equipment, signed celebrity photos, celestial art, jewelry, spa
6
and beauty products, various electronics including CD & mp3 Players,
books, interactive learning CDs, hats, T-shirts, course registration certificates, various types of gift certificates, and more.
This year's auction coordinators are Deb Portelli, RPSGT, from
Clinton, Iowa, and Cindy Mack, RSPGT, from Baton Rouge, LA. Both have
been actively involved with the silent auction since it began.
“We’re planning something a little special this year,” said Portelli.
“Everyone wearing the APT Sleep Awareness Pin, or who purchases one
at the meeting, and finds Cindy or I personally will be entered into a special drawing. The prize will remain a surprise until the drawing,” she said.
Portelli and Mack are both pictured in the accompanying photo of the
2004 auction.
Those wishing to donate this year should ship the items by May 20,
2005 to:
APT Silent Auction
APT National Office
One Westbrook Corporate Center, Suite 920,
Westchester, IL 60154
Phone 708-492-0796
For questions, please email: [email protected] H
APT News
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Editorial Board Names New
Assistant Editor
he Editorial Board of The A2Zzz Magazine, international print publication of the Association of Polysomnographic Technologists (APT), is
T
pleased to announce the recent appointment of Robert Lindsey, MS, RPSGT
as Assistant Editor. He is Director of Neuromedical Services at The
Regional Sleep Center, at Memorial Health Systems in Chattanooga, TN.
“Robert has already begun serving in his new role, and he has been
wonderful to work with,” said Theresa Shumard, Editor-in-Chief. “The
team is so pleased to have him with us. We’ve got some new and exciting things planned.”
In 1984, Lindsey graduated from the University of Tennessee,
Chattanooga, with a bachelor’s degree in psychology, and in 1987 went on to
earn his master’s in psychology at the same institution. He was also formerly
Co Director at Regional Sleep Centers, and prior to that was a polysomnographic technologist and night supervisor there. Additionally, he was a human
resources compensation/benefits specialist with Memorial Hospital.
Lindsey is a former Adjunct Instructor
of Management for Covenant College’s
Quest Program teaching Human
Resources Management, and Introductory
Psychology. He was also Adjunct
Instructor, Psychology, McKenzie Business
College in Introductory Psychology.
Lindsey became credentialed in
Polysomnographic Technologists in 1996. Robert Lindsey, MS, RPSGT
His article “Isolated Sleep Paralysis in
Healthcare Workers” and a case study, “Nocturnal Seizure Disorder,” have
been published in Sleep Review where he also serves on the Editorial Advisory
Board. He is an active member of the APT and a member of the Reserve
Officers’ Association. He is a retired U.S. Army Reserve Major and Sigma Chi
Fraternity, Alumni Chapter. H
Robert Lindsey may be reached by e-mailing [email protected].
New Legal Columnist Announced
or informational purposes, and an additional benefit to its members,
the Association of Polysomnographic Technologists (APT) and the
F
APT Editorial Board of The A2Zzz Magazine announces a new regular
columnist that will outline possible legal issues for its readership. For
informational purposes, a Chicago attorney, Jayme R. Matchinski, Esq.
will author a new regular column, “Legal Notes,” that will explore regulatory, reimbursement, compliance, operational, and contract issues that
might impact and affect sleep disorder centers and the professionals who
perform and provide sleep studies. (See first column on page 33).
Matchinski will also participate in a workshop sponsored by the APT
Legislative Action Committee (LAC) at the APT Annual Meeting in Denver
on June 21 at the Westin Hotel from 1 pm to 4:45 pm. The APT LAC
Public Policy Workshop titled “Career Regulation of Polysomnographic
Technologists.
Matchinski is a partner with the law firm of Harris Kessler &
Goldstein LLC, in Chicago and concentrates on health care law. She has
counseled sleep disorder centers, physicians, and health care groups
across the U.S. Matchinski concentrates her practice in health care and
corporate law. She focuses her health care practice on regulatory compliance, reimbursement, licensure and certification issues affecting
health care providers, health care transactions, and the purchase, sale,
and formation of health care entities. She has also successfully represented health care providers in reimbursement claims against insurance
carriers and the Center for Medicare & Medicaid Services.
“We are so very pleased to have Ms. Matchinski on the editorial
team,” said Theresa Shumard, The A2Zzz Magazine Editor-in-Chief and
APT LAC Chair. “Jayme brings with her an expertise that is extraordinary
as well as very specialized for our readership at a time when our profession will benefit from it most.”
Matchinski received her law degree from Valparaiso University
School of Law and her bachelor’s degree from Northern Michigan
University. During law school, Matchinski represented clients through
the law school’s Civil Legal Aid Clinic, and she completed externships
with the U.S. EPA, Air & Water Division,
and the Honorable George W. Lindberg,
United States District Court, Northern
District of Illinois. She also participated in
a summer study abroad program at
Ningbo University, People’s Republic of
China, where she studied law and economic policy.
Prior to joining Harris Kessler &
Goldstein, Matchinski practiced in private
law firms and she was a vice president for Jayme R. Matchinski
a national health care consulting firm that
works with hospitals and health care systems. She has worked with physicians, and not-for-profit and for-profit health care systems in the licensure,
certification, legal structuring, and reimbursement structuring of post-acute
venues of care including: sleep disorder centers, rehabilitation hospitals,
long term acute care hospitals, skilled nursing facilities, inpatient and outpatient rehabilitation facilities, nursing homes, and assisted living facilities.
Matchinski has spoken on Optimizing Practice and Reimbursement
Opportunities in Post Hospital Care, Alden Management Services, Inc. and
Ross Laboratories, Nursing and Professional Licensure in Relationship to
Scope of Practice and Liability Issues, Nurse Expo, Medicare Issues for the
Sleep Disorder Center, Midwest Sleep and Neurodiagnostic Institute,
Effective Return-to-Work Strategies, Centre for Labour-Management
Development, Inc., Legal Issues Related to a Sleep Disorder Center,
Midwest Sleep and Neurodiagnostic Institute, Climbing Mt. HIPAA: Steps
You Need to Take to Achieve HIPAA Compliance, American College of
Occupational and Environmental Medicine, and Implications of Change on
Nurse Staffing, Northern Illinois Association of Rehabilitation Nurses.
Matchinski is an active alumna of Valparaiso University School of
Law, participating in the alumni/law student networking program and
professional development programs for law students. Her professional
memberships include the Illinois Association of Healthcare Attorneys and
the American Health Lawyers Association. H
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Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Ghrelin and Sleep Apnea
BY REGINA PATRICK
n 1999, Japanese researchers Masayasu Kojima et al1. discovered the
hormone ghrelin (pronounced “GRELL-in”). Initial studies showed that the
new hormone stimulates the pituitary to release growth hormone. More
recent findings suggest that ghrelin may play a role in sleep apnea.
I
Kojima’s et al. interest in isolating ghrelin was an outgrowth of scientific efforts to find an alternative treatment for pituitary dwarfism
(stunted growth resulting from growth hormone deficiency). An early
treatment for pituitary dwarfism involved using injections of growth hormone derived from animal (e.g., bovine) pituitary. However, animalderived growth hormone did not stimulate growth in humans and scientists soon concluded that successful restoration of growth in pituitary
dwarfs would depend on using human growth hormone.
In 1912, American surgeon Harvey W. Cushing discovered the existence of human growth hormone yet it was not until 1956 that the hope
of using human growth hormone as a treatment for pituitary dwarfism
first appeared feasible. In that year, endocrinologist Maurice S. Raben
purified human growth hormone for the first time. He had extracted the
hormone from the pituitaries of autopsied human cadavers. Two years
later in another first, Raben successfully used cadaver growth hormone
to restore growth in a 17 year old dwarf patient. This success led to the
quick acceptance of cadaver growth hormone as a treatment for growth
hormone deficiency.
Unfortunately, cadaver growth hormone had a drawback: only a
small number of patients could receive treatment since cadaver availability was limited. This availability decreased significantly by the 1970s
as increasingly fewer people were autopsied. This shortage forced scientists to investigate other ways to treat growth hormone deficiency.
A promising option surfaced in 19762 when scientists discovered
that endogenous opioid peptides have the ability (although weak) to stimulate growth hormone release. Scientists quickly worked to modify the
chemical structure of the opioid peptides
with the hope that synthetic derivatives
would more potently stimulate growth
hormone secretion. In 1984, Cyril Y.
Bowers3 and associates reported their
success in creating such a peptide –
GHRP-6. This peptide and others developed later such as hexarelin now make up
a class of drugs called growth hormone
Regina Patrick, RPSGT
secretagogues (GHSs).
GHSs stimulate growth hormone release through growth hormone
secretagogue receptors (GHS-R). These receptors are located on the
outer surface of somatotrophs (growth hormone-secreting cells) in the
pituitary. The secretion process begins when a GHS binds with a small
molecule (i.e., a ligand) and the GHS-ligand complex attaches to a GHSR. Once attached, vesicles within the somatotroph’s cytoplasm migrate
toward and ultimately attach to the inner surface of the somatotroph’s
membrane. The vesicles then release growth hormone into the membrane. The hormone passes through the membrane and exits outside
of the cell.
By 1999, scientists had long known that a GHS needs to bind with
a ligand first in order to stimulate the GHS-R but the nature of the ligand was unknown. To isolate the ligand, Kojima et al. made use of the
fact that the intracellular calcium level rises when a GHS-ligand complex
binds with the GHS-R. Using in vitro CHO cells (Chinese hamster ovary
fibroblasts) for a model, they inserted the GHS-R gene into the cells. The
cells were incubated in a fluorescent dye which binds with calcium and
subjected to extracts of rat brain, lung, heart, kidney, stomach, and
intestine. Afterwards, Kojima et al. observed the CHO cells for changes
in fluorescence. An increase in fluorescence would mean increased
intracellular calcium and hence the that the tissue extract contained the
GHS-ligand complex.
Stomach tissue extract caused the greatest increase
in fluorescence. On learning this, Kojima et al. put stomach tissue extract through several chromatographic
processes (e.g., gel filtration, high performance liquid
chromatography) which isolated the ligand from the GHS
molecule as well as other constituents in the stomach
extract. Once purified, they named the ligand ghrelin
(from “ghre-” an Indo-European root word meaning “to
grow” and the suffix “-in” denoting a chemical substance).
To study the in vivo effects of ghrelin in their study,
Kojima et al. injected the hormone intravenously (IV) into
rats. The rats’ blood levels of growth hormone dramatically rose immediately after injection. From this finding,
they hypothesized that ghrelin is first synthesized in the
stomach, then transported through the bloodstream to
the pituitary, and finally attaches to the GSH-R of pituitary
somatotrophs to stimulate growth hormone release.
In 2000, Yukari Date4 and associates (which included Kojima) proved the hypothesis correct. They
ß
8
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
exposed rat stomach endocrine cells (ECL, EC, D, and X/A-like cells) to
a ghrelin antibody. They then stained the cells and examined them by
light and electron microscopy. Only the X/A-like cells had reacted with
the anti-ghrelin. Date concluded that these cells were the ghrelin-producing cells.
In October 2000, American researchers Matthias Tschöp et al5.
reported that mice and rats, which had been injected daily with ghrelin,
ate more and gained excessive fat tissue. The following year, Tschöp6
performed a human study which examined the effect of ghrelin on obesity. He hypothesized that obese people would have higher levels of ghrelin than lean people since increased food intake and increased fat tissue
in obesity are in keeping with ghrelin’s effects. To test his hypothesis, he
compared the fasting blood level of ghrelin in 14 lean subjects and 16
obese subjects. Contrary to his expectations, fasting ghrelin levels
turned out to be 27% lower in the obese subjects. Tschöp proposes two
reasons for this unexpected result. One, ghrelin may simply be secreted
less in obese people. Two, it may be that ghrelin levels are kept low by
the interplay between it and other hormones that play a role in eating
and metabolism; some research6 suggests that increased levels of leptin (an appetite-suppressing hormone) lowers ghrelin levels.
Studies show that obese people have higher levels of leptin than lean
people. The level of leptin is even higher if the obese person has obstructive sleep apnea (OSA). Interestingly, the leptin level drops drastically
once a person with OSA begins continuous positive airway pressure
(CPAP) treatment. With that in mind, Igor A. Harsch et al7. investigated
whether CPAP treatment would have a similar effect on ghrelin.
They drew fasting blood ghrelin levels from 9 obese severely apneic
untreated OSA subjects and 9 healthy obese controls without OSA. At
baseline, the average ghrelin level of the 9 OSA subjects was 57.9
picograms/micro-liter (57.9 pg/µL) and that of the 9 controls was
10.8 pg/µL.
All of the OSA subjects were then studied in a sleep lab for two
nights with the first night being for CPAP titration and the second night
with CPAP used at its therapeutic pressure. After the second day of
CPAP therapy, bloodwork was redrawn from the OSA subjects. Harsh
et al. found that the OSA subjects’ average ghrelin level had fallen to
19.7 pg/µL.
They were surprised to find such a dramatic decrease in the subjects’ average ghrelin level after only two days of CPAP treatment. They
credit CPAP treatment with reducing ghrelin production but they are
unclear how this occurs. They speculate two possibilities. One, sleep
apnea may impair how lung tissue utilizes ghrelin and CPAP treatment
restores this utilization which is reflected by lowered ghrelin levels. Two,
CPAP restores the normal interplay between neurohormones involved in
respiration allowing the levels of the hormones to drop; ghrelin may be
involved in this neurohormonal interplay.
From a hormone with only one known purpose (to induce growth hormone secretion), ghrelin has become a multi-faceted hormone involved
in metabolism, hunger, and possibly sleep apnea. The latter is just beginning to get scientific focus. Research1 shows that lung tissue contains
the ghrelin receptor (i.e., GHS-R). Yet, ironically, no study has specifically examined its effect on the respiratory drive or pulmonary function.
Potentially, altering how ghrelin functions within the lungs may be useful
in the treatment of OSA. Increasingly, scientists are interested in devel-
oping a drug which can reduce ghrelin’s metabolic effect (i.e., weight
gain). Such a drug would either reduce ghrelin production or act as an
antagonist to block the body’s ability to utilize the hormone. Once successfully developed, the drug could help people with OSA lose weight
more easily and in turn reduce symptoms of sleep apnea. Recent studies show that ghrelin decreases sympathetic activity8. However, its effect
on the sympathetic aspect of the respiration has yet to be studied. It
may be that sleep apnea could be improved by altering ghrelin’s effect
on the sympathetic activity in respiration. Investigation of these potential
uses of ghrelin may lead to improved OSA treatment. H
Notes
1. Kojima M, Hosoda H, Date Y, et al., “Ghrelin is a growth-hormone-releasing acylated peptide from stomach,” Nature, 402:656 – 660, Dec 9, 1999.
2. Hosoda H, Kojima, M, Matsuo H. Kangawa K, “Purification and characterization of rat desGln14-ghrelin, a second endogenous ligand for the growth hormone secretagogue receptor,” Journal of Biological Chemistry, 275(29):21995 – 22000, July 21, 2000.
3. Bowers CY, Momany FA, Reynolds GA, Hong A, “On the in vitro and in vivo activity of a new
synthetic hexapeptide that acts on the pituitary to specifically release growth hormone,”
Endocrinology, 114:1537–1545, 1984.
4. Date Y, Kojima M, Hosoda H, et al., “Ghrelin, a novel growth hormone-releasing acylated
peptide, is synthesized in a distinct endocrine cell type in the gastrointestinal tracts of rats
and humans,” Endocrinology, 141:4255 – 4261, Nov 2000.
5. Tschöp M, Smiley DL, Heiman ML, “Ghrelin induces adiposity in rodents,” Nature,
407(6806):908 – 913, Oct 19, 2000.
6. Tschöp M, Weyer C, Tataranni PA, et al., “Circulating ghrelin levels are decreased in
human obesity,” Diabetes 50:707-709, 2001.
7. Harsch IA, Konturek PC, Koebnick C, et al., “Leptin and ghrelin levels in patients with
obstructive sleep apnoea: Effect of CPAP treatment,” European Respiratory Journal,
22:251 – 257, 2003.
8. Matsumura K, Fujii K, Abe TI, et al., “Central ghrelin modulates sympathetic activity in conscious rabbits,” Hypertension, 40(5):694 – 699, 2002.
POLYSOMNOGRAPHIC TECHNOLOGIST
The Idaho Sleep Disorders Center at St. Luke’s Regional Medical
Center in Boise, Idaho, has two immediate openings for experienced
sleep technologists, full or part-time nights. Our facilities are fully
accredited through the American Academy of Sleep Medicine and
offer competitive wages, benefits and medical insurance. For more
information see our website at www. stlukesonline.org/services/sleep.
Registered (and non-registered PSG Technologists with experience),
Respiratory Therapists and Registered EEG Technicians are encouraged to apply. Applicants should possess excellent patient skills, quality technical and clinical skills and a reliable work history.
Responsibilities include diagnostic testing, CPAP/BiPAP titration and
patient education. An on-the-job nine-week training course is provided.
With its location in Boise, Idaho, the “City of Trees,” St. Luke’s
employees live in a relaxing, family-friendly environment. Situated in
a protected valley at the base of snow-capped mountains, Boise
offers premier skiing at nearby Bogus Basin, and the world-famous
Sun Valley Resort is just a short drive away. Mountain biking, fishing, hiking, kayaking, and golfing are just a few of the activities
available outside your back door. Cultural events abound, including
ballet, theater, summer Shakespeare Festival and musical entertainment, from the symphony to the Gene Harris Jazz Festival.
Interested candidates please fax your resume to 208-706-5383 attn:
Mary Gable, or email to [email protected], or fax your resume to
attn: Jan Greene 208.381.4649, or email to [email protected].
Also, visit our website at www.stlukesonline.org EOE/AA/M/F/V
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Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Daily Social/Physical
Activity Improves Sleep,
Cognition in the Elderly
A study by sleep researchers at Northwestern
University Feinberg School of Medicine suggests
that even short-term exposure to either morning
or evening social and physical activity improves
cognitive performance and subjective sleep quality
in the elderly.
NEWSWISE — More than half of adults over the age of 65 have
trouble sleeping, characterized by both lighter sleep and frequent awakenings during the night. A decline in cognitive function is common with
advanced age, and research has shown that disturbed sleep in younger
adults and in the elderly causes daytime sleepiness and negatively
affects cognitive performance.
Now, a study by sleep researchers at Northwestern University
Feinberg School of Medicine suggests that even short-term exposure to
either morning or evening social and physical activity improves cognitive
performance and subjective sleep quality in the elderly.
The study, by Susan Benloucif, Phyllis Zee, M.D., and colleagues is
described in an article in the Dec. 15 issue of the journal Sleep.
Benloucif is associate professor and Zee is professor in the Ken and
Ruth Davee Department of Neurology and Clinical Neurological Sciences
at Feinberg.
“Many of the
health changes
associated with aging, including the decline in sleep and cognitive abilities, can be attributed to sedentary lifestyles and social disengagement
among older individuals,” Benloucif said.
“Evidence suggests that maintenance of social engagement and
avoidance of social isolation are important factors in maintaining cognitive vitality in old age,” Benloucif said.
Twelve older men and women (between 67 and 86 years) living in
retirement facilities and residential apartments participated in the pilot
study at Northwestern.
All 12 were healthy older adults or adults with chronic but stable
medical conditions and independent in their activities of daily living.
The study consisted of a daily 90-minute session over a 14-day period that included 30 minutes of mild physical activity, 30 minutes of social
interaction and a final 30 minutes of mild to moderate physical activity.
Sessions began with warm-up stretching and mild to moderate physical
activity (walking, stationary upper and lower body exercises), followed by
seated social interaction (talking while playing board or card games). The
final period consisted of mild to moderate physical activity, such as rapid
walking, calisthenics or dancing, ending with a 10-minute cool-down.
Cognitive and psychomotor performance was assessed at the beginning and end of the study. Participants maintained daily sleep diaries in
which bedtime, wake-up time, estimated total sleep time, naps, etc.,
were recorded. Daily activity recordings were obtained via wrist monitors
to verify sleep periods.
Results of the study showed that participation in a short-duration
social and physical activity program improved cognitive performance by
4 to 6 percent and improved subjective sleep quality in older adults.
Future controlled randomized clinical studies of behavioral approaches
are needed to confirm the benefits of increasing social and physical activity levels in older sedentary adults with insomnia, the researchers said.
Collaborating with Benloucif and Zee on the study were Larry Orbeta,
Rosemary Ortiz and Imke Janssen, Northwestern University; Sanford
Finkel, M.D., Geriatric Institute, Council for Jewish Elderly, Chicago; and
Joseph Bleiberg, Neuroscience Research Center, National Rehabilitation
Hospital, Washington, D.C.
The study was supported by grants from the National Institutes of
Health and the Brookdale National Foundation. H
10
WASHINGTON REGIONAL
MEDICAL CENTER
Sleepin’ on
Tulsa Time...
Spring Sleep
Seminar 2005 and
APT Board Review
Tulsa, Okalahoma
Marriott Southern Hills
May 14-16, 2005
Please contact Bill Rivers or Melinda Trimble at:
Phone (479) 713-1272 • Fax (479) 713-1190
Target Audience
Continuing Education Units
Any physician, technologist, or home care practitioner with an
interest in Sleep Medicine or Sleep Disorders.
19.75 CEC’s have been applied for from the Association of
Polysomnographic Technologists and the American Association of
Respiratory Care. There will be a $15.00 charge for CEC’s.
Saturday, May 14, 2005
Continental Breakfast — Vendor Hall
Sponsored by Viasys Corp
8:00 am Welcome — Melinda Trimble RPSGT,
APT Education Chair
8:15 am Sleep Apnea and Diabetes
Dr. Mark Sanders
Sponsored by Respironics
9:30 am Break — Vendor Hall
10:00 am Parasomnias
Dr. David Davis
11:00 am ADHD vs. Sleep Disorders
Dr. Joseph McCarty
12:00 am Lunch — on your own
Vendor hall open
1:30 pm CPAP Compliance
Dr. Robert Gordon
Sponsored by Nellcor Puritan Bennett
2:30pm
General Sleep Disorders and Children
Dr. Joseph McCarty
3:30 pm Pulmonary Disease and Sleep Disorders
Dr. Madhu Kalyan
5:00 pm Wine and Cheese Reception —
Vendor Hall
7:30 am
Sunday, May 15, 2005
Monday May 16, 2005
7:30 am
8:00 am
7:30 am
Refreshments — Vendor Hall
Sleep Mechanisms and Narcolepsy
Dr. David Brown
9:00 am Artifacts and Troubleshooting
Scott Cole RPSGT
Sponsored By Protech
10:00am Break — Vendor Hall
10:30am Non Invasive Ventilation
Debbie Barreto RPSGT
11:30 am Lunch — on your own
Vendor hall open
1:00 pm Sleepy vs. Sleepless Child
Dr. Robert Sheldon
Sponsored by Atlanta School of Sleep Medicine
2:00 pm Taking a Pediatric History
Dr. Robert Sheldon
Sponsored by Atlanta School of Sleep Medicine
3:00 pm Break
3:15 pm Medication Effects
Laura Linley RPSGT
Sponsored by Syntech Solutions
4:15 pm Nocturnal Oxygen Titration
Debbie Barreto RPSGT
8:00 am
9:00 am
10:00 am
10:15 am
11:15 am
12:00 am
1:30 pm
2:30 pm
3:30 pm
3:45 pm
Continental Breakfast — Vendor hall
Sponsored by Seprecor
Sleep Apnea and the Heart
Dr. Maroun Tawk
Sponsored by ResMed
Calculations/Report Generations
Terrence Malloy RPSGT
Sponsored by Atlanta School of Sleep Medicine
Break — Vendor Hall
Amplifier/Signal Filtering Digital vs. Analog
Laura Linley RPSGT
Sponsored by Syntech Solutions
MSLT/MWT
Terrence Malloy RPSGT
Sponsored by Atlanta School of Sleep Medicine
Lunch — On your own
Sleep Stage Scoring
Laura Linley RPSGT
Sponsored by Syntech Solutions
Respiratory Event Scoring
Scott Cole RPSGT
Sponsored by Protech
Break
EKG Arrhythmia
Debbie Barreto RPSGT
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
The Dangers of Untreated Sleep-Related
Breathing Disorders Finally Recognized by
the Mainstream Media?
BY IAIN BOYLE, RPSGT, THE A2ZZZ MAGAZINE CANADIAN CORRESPONDENT
hose of us in the field of sleep medicine have long known about the
dangers of sleep apnea. Now, with the untimely death of a former
football great Reggie White, the dangers seem to be finally getting the
media attention they deserve.
T
Reggie White, a fearsome defensive end for the Green Bay Packers
and Philadelphia Eagles who was one of the great players in NFL history, died recently. He was 43.
The dangers to football
players were first seriously
reported in the New England
Journal of Medicine (NEJM)
in January of 2003, where
the discussion centered
around fit healthy young men
being at a high risk for sleep
related breathing disorders.
We have known that untreated obstructive sleep apnea
(OSA) can lead to life threatening diseases such as
heart disease, hypertension
and stroke. As the prevalence goes further and further to developing bigger,
faster football players (especially linemen), we are going
to see more and more of
Reggie White
these players with sleep
related breathing disorders.
It conjures up visions of football team equipment managers adding CPAP
machines to their players’ equipment list.
The study mentioned in the NEJM was conducted during the summer of 2002, involving more than 300 professional football players.
Players from eight National Football League (NFL) teams, which were
selected at random, were studied for the presence of sleep apnea. In
this research it was found that the presence of sleep apnea among the
players was 14% - nearly five times higher than noted in previous studies of similar aged adults.
When the linemen were looked at as an individual group, the prevalence of sleep apnea in was even higher at 34%.
The general feeling was, even among those of us in the field, that
our patients were mainly male, over 40, and over weight. These findings
significantly challenge this, because these men, even those of a relatively
young age and fit and otherwise thought to be healthy may have widespread sleep related breathing disorders. According to the principal
investator of the study, . Charles George MD, Professor of Medicine at
the University of Western Ontario, (London, Ontario Canada),
Pulmonologist, Fellow of the AASM, and a past President of the
12
Canadian Sleep Society, players are vulnerable to sleep disorders.
“Professional football players have
some of the risk factors associated with
sleep apnea but their age and physical
condition previously would not have suggested a prevalence of the disorder until
they were much older,” Dr. George went
further on to comment, “Many physicians
have never considered such a diagnosis in Iain Boyle, RPSGT
young, healthy individuals because sleep
apnea was previously thought to be associated with middle aged or older
individuals. The study strongly suggests that sleep apnea be considered
as a possible condition for larger patients under 30 years of age.”
With the death of superstar Reggie White, the findings in this study
have once again been brought forward. When contacted about White’s
untimely death, George said, “The recent death of former NFL star
Reggie White highlights the potential for morbidity and mortality from
obstructive sleep apnea. Mr. White was reported to suffer from a number of medical conditions including sleep apnea as well as sarcoidosis.
Both conditions may directly affect the heart but by different mechanisms. Sarcoidosis can shortcircuit the electrical conducting system
leading to arryhthmias , while sleep apnea can produce pressure overload by causing both systemic and pulmonary hypertension. While the
exact cause of death as yet is unclear, it is quite possible that hypoxemia
associated with sleep apnea could facilitate a fatal arrhythmia in a susceptible individual.”
George reiterated that sleep apnea is highly prevalent in professional football players, particularly in the biggest linemen.
Vincent A. Viscomi, MD, Pulmonologist and Dipolmate, ABSM, CoMedical Director of the Regional Sleep Center of Memorial Health Care
System, Chattanooga, TN, a fifteen bed, accredited center, was also
interviewed about Whites death and the link between the two diseases
being fatal. When asked about the initial reports indicating that White
suffered from OSA and sarcoidosis. Regarding what we know about the
two diseases and how they may have contributed to Whites death, ..
Viscomi commented, “I’ve heard that he (White) had sarcoidosis, which
is a disease of the lungs; we don’t know the cause of it, but do know it
starts in the lymph nodes, and can spread out to the lungs OSA may be
more prevalent in football players like Mr. White, who have a neck circumference greater than seventeen inches, and aretherefore more likely to suffer from OSA.”
According to the National Institutes of Health National Heart, Lung
and Blood Institute, sarcoidosis is a disease that causes inflammation of
the body’s tissues. Inflammation is a basic response of the body to injury
and usually causes reddened skin, warmth, swelling, and pain.
Inflammation from sarcoidosis is different. In sarcoidosis, the inflamma-
ß
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
tion produces small lumps (also called nodules or granulomas) in the tissues. The inflammation of sarcoidosis can occur in almost any organ and
always affects more than one. Most often, the inflammation starts in
either the lungs or the lymph nodes (small bean-shaped organs of the
immune system). Once in a while, the inflammation occurs suddenly and
symptoms appear quickly, but usually it develops gradually and only later
produces symptoms.
“The key here is neck size,” Viscomi added. “In a recent study of linebackers and other pro football players from the 2003, the NEJM article (on OSA and linemen) results showed that they (football players), had
a five times higher risk of this (OSA); linebackers aren’t fat, but they have
big necks; and the combination of sarcoidosis and OSA may have put
Reggie White at greater risk for heart attack or stroke”.
It is not just football players, however, that are getting bigger. We
see this prevalence in many sports, however football is the highest visible group. Basketball players, baseball players, and hockey players are
all getting bigger and could be at the same risk level as the football players. The previous studies reveal that it was not just linemen that were
at a higher risk, and the overall risk increase was nearly five times higher than noted in previous studies of similar aged adults.
Perhaps there may be further areas for employment opportunities
for polysomnographic technologists with major sports teams. Recent
incidents certainly suggest that players from sports teams should have
a sleep study if there are any reports of snoring and large neck circumference. As winter rages in parts of North America, a possibly of a proposal for major league baseball to do sleep studies on players at spring
training would certainly seem appropriate and also afford prevention,
and get me out of the cold and snow... H
About the Author
Iain Boyle, RPSGT, gained his RPSGT credentials in 1996 and worked in the Toronto area of
Canada until 2002 when he moved to New Hampshire. He serves on several APT
Committees and is Secretary of the New England Polysomnographic Society, APT’s newest
regional chapter. He is also an officer of the Executive Committee for the Canadian Sleep
Society. His leisure activities include sailing, soccer, Nordic skiing and working on British
sports cars.
Study Shows New
Sleep Drug Has
Promising Results
ephalon Inc. said that a late-stage study found its most recent
drug for excessive sleepiness, armodafinil (Nuvigil), significantly improved wakefulness and the overall clinical condition of
patients. Armodafinil works similarly to the company’s modafinil
(Provigil) tablets, already on the market as a treatment for excessive sleepiness associated with narcolepsy, shift work sleep disorder or obstructive sleep apnea/hypopnea syndrome. The company
said the 12-week study involved about 1,000 patients with one of
those three disorders. In each group, armodafinil significantly
improved sleep latency. The drug also promoted wakefulness later
in the day without impairing sleep, indicating that it continues to
work over a long period, the company said. H
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13
Legislative Watch
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
First PsgT Licensure
Bill Introduced
2005 Multi-State PsgT Legislative
Issues Increase
tate legislative activity related to polysomnographic technology
(PsgT) has recently yielded the introduction of bills with a variety of
S
proposed outcomes. As the Association of Polysomnographic
Technologists (APT) that works on issues to advance the profession such
as establishing competencies, standards, policies, procedures, educating members and improving opportunities for training, access to quality
patient care, the organization has written letters of support of or opposition to policy makers regarding state legislation related to PsgT. The
APT also assists members with necessary information and resources
they need at the state level where polysomnographic procedures are
concerned. The APT is working toward a coalition with other sleep
organizations to address licensure concerns.
The APT supports the concept for measures which exempt PSG professionals from practice acts or that would provide independent licensure. The organization published position papers and model language
documents including “Polysomnographic Technology as a Distinct
Profession,” “Exemption from Existing Respiratory Care Practice Acts,”
“Model State Exemption Language & Definitions,” “Limited Licensure of
Polysomnographic Professionals Under Respiratory Care,” and various
standardized core competency documents related to jobs performed by
PsgTs. All APT documents are available for download in the governmental affairs section of APTWEB at www.aptweb.org
The language recently introduced includes the following outcomes in
various states: PsgT licensure; PsgT exemptions where PSG duties
would be respiratory care (RC) scope of practice; exemption for credentialed PsgTs minus entry pathways for technicians or trainees, and
full exemptions for all PSG professionals. While issues in all states is
being monitored by APT, current attention is being paid to New York,
Illinois, California, Colorado, North Dakota, Montana, New Jersey, North
Carolina, South Carolina, Vermont, Alabama and New Mexico.
The APT Legislative Action Committee (LAC) subcommittee called
“LACWATCH” reviews daily all state legislative activity related to the field,
and provides feedback to the APT Board. While APT monitors legislative
activity on a national level, for the profession to succeed or advance, it’s
important for members to get involved on both national and state grass
root levels. One way to get involved is to join the APT Political Advocacy
Contact Team (PACT). Members may sign up on APTWEB’s governmental affairs section at http://www.aptweb.org/aptaction/index.asp
Members becoming involved on a national and local level is critical
since these issues are timely and of extreme importance. It is necessary
that members provide accurate information to the National Office regarding their grass roots efforts, meetings with state regulatory boards, and
any issues that may arise. The National Office may be reached by calling
(708) 492-0796. or by email at [email protected]
What follows is information about state activity and excerpts from bill
language introduced into some state legislatures:
New Jersey
The first bill for a “Polysomnography Practice Act” in the U.S. was
introduced as New Jersey Senate Bill 2279 (NJ SB 2279). If passed into
14
law after clearing both Houses of the state legislature, SB 2279, which
was introduced January 31, would override a 2003 cease & desist order
that would go into effect in 2006 that was set by the NJ State Board for
RC, the state’s regulatory body for the RC profession. The cease and
desist order provided language that would prohibit non-RC licensed professionals from performing PSG-related duties. After being introduced in
the Senate, SB 2279 was referred to Senate Commerce Committee and
at press time was awaiting subsequent committee readings before it
would be recommended for voting in the Senate, and then, if passed, the
Assembly after additional committee readings.
The New Jersey Association of Sleep Technologists (NJAST) assisted state officials including the NJ Attorney General, the NJ Division of
Consumer Affairs which houses the state’s office of professions, and
several state senators and assemblymen, in drafting language for the bill
based on position papers and model language documents released by
the Association of Polysomnographic Technologists (APT) in order to
maintain national continuity in NJ based on national standards APT sets
for the profession, officials said.
Excerpted language from SB 2279:
NJ Legislature finds and declares that:
Public interest requires the regulation of the practice of
polysomnographers and the establishment of clear licensure
standards for practitioners of the practice of polysomnography
and that the health and welfare of the citizens of this State will
be protected by identifying to the public those individuals who are
qualified and legally authorized to practice polysomnography”
NJ SB2279 language provides for a State PsgT Regulatory Board
composed of:
11 members that are residents of the State, six of whom shall be
licensed technologists who have been actively engaged in the
practice five years; One of whom shall be a qualified medical director, one of whom shall be a physician licensed in this State and
who is a Diplomate of the American Board of Sleep Medicine.
The State PsgT Board would be required to establish criteria & standards for licensure; Review qualification of applicants for licensure;
Insure proper conduct & standards of practice; Issue & renew licenses;
Establish standards for continuing education; Suspend, revoke or decline
to renew licenses.
The entire text for NJ SB 2279 may be found through www.aptweb.org
or www.njleg.state.nj.us/2004/Bills/S2500/2279_I1.PDF
Maryland
Maryland House Bill 1022 (MD HB 1022), the “Maryland
Polysomnography Act,” was introduced February 11 in the Maryland
House of Delegates and is the second licensure bill proposed in the U.S.
slated for the licensure of PsgT professionals. HB 1022 is sponsored by
Democratic Delegate Joanne Benson, a member of the Health
Occupations Subcommittee of the House Health and Government
Operations Committee. The proposal provides for a Polysomnography
Professional Standards Committee to be established under the umbrella of the Maryland State Board of Physicians.
No fiscal impact statement has been officially published, and fees for
PsgT licenses would be determined by state officials.
continued on page 29
Technical Corner
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Technical Corner
BY MARY JONES-PARKER, RRT, RPFT, RPSGT
Question: “Please post some disinfection guidelines for sleep related equipment (EEG leads, CPAP masks). I have had difficulty finding any
federal/state/other documents to reference.”
Answer: I agree wholeheartedly that locating these references can
be a very time consuming task. What would seem to be a relatively simple topic to do an Internet search on in these days of information overload, is in fact not that simple. The answers to your question are scattered all across the Internet.
In 1982, the Centers for Disease Control and Prevention, (the
“CDC”), issued a document entitled “Guideline for Hospital Environmental
Control” to provide specific directions for the selection and use of disinfectants. Three years later, the guideline was revised and the title became
“ Guideline for Hand washing and Hospital Environmental Control, 1985.”
This revised guideline focused on the strategies for disinfecting and sterilizing medical equipment in the health care setting. The shortcoming of
this document was that there were no specific recommendations for the
chemical germicides that should be used on medical equipment or environmental surfaces in health care facilities. Yet another five years would
pass before the Association of Professionals in Infection Control and
Epidemiology would publish specific guidelines to assist healthcare professionals in selecting and using the proper disinfectants.
More recently, back in 2001, the Food and Drug Administration also
entered the picture and made even more guidelines for hospitals and
sleep laboratories to follow as they realized that some items, designed
by the manufacturer for single patient use, (i.e. cpap masks), were being
used over and over again, and, furthermore, not all of the disinfection/reprocessing techniques that were being used were effective.
Equipment that we routinely use for polysomnography testing generally falls into 2 of the three categories of Spaulding criteria, which was
developed back in 1968. (The Spaulding criteria are a way of classifying
medical equipment according to the degree of risk involved in the spread
of infection.) CPAP masks fall into the category of semi critical equipment in as much as masks can come into contact with mucous membranes or skin that is not intact. The EEG electrodes that we use fall into
the noncritical category because the electrodes come into contact with
intact skin, but not necessarily with mucous membranes. Semi critical
items (such as CPAP masks) should be disinfected using a sporicidal
chemical with a short contact time; a sterilant. Noncritical items, (such
as eeg electrodes), may be rendered clean by using a low-level type disinfectant without a label claim for tuberculocidal activity.
• http://www.apic.org (click on link
for practice guidelines)
These websites will help you to locate
more detailed information regarding this
topic, and I recommend that you read
these documents in their entirety. You will
come away with a new appreciation for
Infection control. For example, the APIC
Guideline for Selection and Use of Mary Jones-Parker
Disinfectants article highlights the different properties of bleach, alcohol, gluteraldehyde, and so on. Even though
your goal may be to select a chemical agent that will provide the ultimate
germ protection for your patients, this document will also educate you
about the effect that these chemicals have on you, the end user.
Another noteworthy item that the APIC article points out is the shortcomings of isopropyl alcohol, which most of us in the health care setting
take for granted; especially when we use it to disinfect external surfaces,
such as the stethoscopes that we use to take blood pressures with.
Question: “I wonder about the way to calculate PLM or jerk index.
We use TST as a denominator of jerk or PLM index, while we count jerks
regardless of sleep stage. Is it fair to count all jerks through the nighttime, but only use TST for the calculation?”
Answer: Leg movements are most often reported as an index of
total sleep time. Only movements occurring during sleep are counted for
the index; events occurring during drowsiness before the onset of Stage
I sleep should not be included.
Movements may be included as long as they occur in episodes of 4 or
more movements; movements occurring in isolation should not be included. The time interval between each movement should be greater than 5
seconds, but not greater than 90 seconds from the last movement. (The
average interval between leg movements is 20 to 40 seconds.)
Simultaneous movements in both legs are counted as 1 movement;
movements occurring in both legs are added together in calculating the
index. Some labs report the periodic limb movement-arousal index in
which only movements that are associated with an arousal are included
in the tally, and again, the index is expressed as events per hour of sleep.
It is uncommon to see limb movements during REM sleep. Periodic
limb movements occur most frequently during Stage II sleep, and
decrease in frequency during Stage III/IV sleep. H
You will find that each manufacturer of cpap masks will have different recommendations from one another, but will provide you with the specific information needed for cleaning their masks and the number of times that their
piece of equipment can be used repeatedly before it must be discarded.
Reference
American Sleep Disorders Association. International classification of sleep disorders, revised:
Diagnostic and coding manual. Rochester, Minnesota: American Sleep Disorders Association,
1997, 65-68.
Because space is limited in this column, and the amount of information to be obtained on this topic is so great, I further recommend that
you visit the following websites:
• http://www.fda.gov/cdrh/reuse/1168.html (there is also a link
to this website on the APT website, www.aptweb.org)
• http://www.cdc.gov/ncidod/hip/enviro/guide.htm
About the Author
Mary Jones-Parker works in the Center for Sleep Research in the Department of Sleep and
Respiratory Neurobiology at the University of Pennsylvania, Philadelphia; was the first recipient of the Sleep Multi Media Award for Recent Advances in Polysomnography; past Director
of the Board of Registered Polysomnographic Technologists (BRPT) from 1995-2002 as well
as a past member on the Exam Development Committee; and is a member of the APT
Editorial Board Special Projects Team for The A2Zzz Magazine. Additionally, she is a member of the Education Committee and a Course Director for the Annual APT meeting.
15
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Modafinil and CPAP Therapy
BY WILLIAM ECKHARDT, BS, RPSGT, ASSOCIATE EDITOR
W
e have a dichotomy in regard to treating Obstructive Sleep Apnea
(OSA) patients with Modafinil (Provigil).(1) This is especially true
for those patients treated with Continuous Positive Airway Pressure
(CPAP). Despite this difference of opinion there is a momentum towards
cautious use of Modafinil in the treatment of OSA. This is seen with the US
Food and Drug Administration (FDA) granting Cephalon Inc. the maker of
Provigil (Modafinil) clearance to market this drug to improve wakefulness
in patients with excessive sleepiness associated with shift work sleep disorder and obstructive sleep apnea/hypopnea syndrome. The National
Sleep Foundation (NSF) says that “Provigil should be viewed as a supplementary treatment for the daytime sleepiness related to obstructive sleep
apnea and should not be used as a substitute for the most common treatment for sleep apnea, continuous positive airway pressure, or CPAP.”
cal respiratory disturbances 2. sub clinical arousals 3. adaptation to the device
4. other coexisting sleep disorders. It has
been postulated that there may be permanent alteration of sleep-promoting
mechanisms or permanent changes in
the endogenous waking drive.(5) Another
possibility is that CPAP is effective in opening the airway whereas it does not
reverse other OSA related sequelae as William Eckhardt, BS, RPSGT
effectively. Some data suggest that CPAP
may not benefit the patient as much as previously thought in reference
to daily functioning, cognition and quality of life.
CPAP therapy is considered the preferred therapy for treatment of
OSA at this time.(2) CPAP has proven to lessen the Respiratory
Disturbance Index (RDI) in patients able to tolerate its use. CPAP can
decrease the number and severity of oxygen desaturations, arousals,
and restore normal sleep architecture with proper use. Studies have
demonstrated improved cognitive performance, quality of life and excessive daytime sleepiness (EDS) with the use of CPAP.(2) However some
patients continue to describe daytime hypersomulence despite effective
CPAP therapy. The cause of residual daytime sleepiness in fully titrated
CPAP patients remains unknown.
Studies of modafinil for the treatment of residual daytime sleepiness
in OSA patients treated with CPAP show varying improvement in subjective and objective measurements. Studies have documented improvement
in ESS scores others claiming none. (3,4) MSLT also has had conflicting
outcomes. Interestingly objective measures have shown improvement but
cognitive performance and quality of life showed no significant treatment
related improvements in early studies.(3,4) Also, CPAP use has been
shone to slightly decline with modafinil use in early studies. Later studies
have not validated such a decline in use.(3,4,5) Later studies have shown
both subjective and objective measures of EDS significantly improved with
combined therapy compared to treatment with CPAP and placebo.(2,5)
One study did note a small but significant increase in the arousal index in
patients on combination therapy. Patients in that study started on 200
mg/d and increased to 400 mg/d.(2)
Modafinil, 2-[(diphenylmethylmethyl)-sulfinyl1] acetamide is a wake-promoting drug that is unlike CNS stimulants i.e. amphetamines. Modafinil is
supplied in 100 mg and 200 mg tablets, note that many studies used
doses up to 400 mg. Modafinil does not adversely affect nighttime sleep
and has a low association with adverse cardiovascular events. Adverse
reactions may include headache, infection, nausea, nervousness, anxiety,
rhinitis, and insomnia. In 1998 Cephalon, Inc. received approval from the
U.S. Food and Drug Administration (FDA) to market Modafinil to improve
wakefulness in patients with EDS associated with narcolepsy. Modafinil has
since become the “standard” treatment for EDS in narcolepsy.
EDS has been shown to decrease memory, attention, intellectual
abilities and motor function. Studies using modafinil on narcoleptics
report significant improvements in daytime sleepiness as measured by
the Epworth Sleepiness Scale (ESS), Multiple Sleep Latency Test (MSLT)
and Maintenance of Wakefulness Test (MWT).
In January 2004, Cephalon, Inc. announced that the FDA formally
approved modafinil as a new treatment for the excessive sleepiness
associated with sleep apnea and with shift work. The intent is for use as
additional treatment vs. a first line or replacement therapy. Modafinil has
been shown to be effective adjunctive treatment for OSA patients with
continued daytime sleepiness, improving EDS, sleep-related functional
status, the overall clinical condition and quality of life.(3) Modafinil has
shown no beneficial effect on severity of OSA, arousals, or sleep efficiency. EDS of narcolepsy is of a neurological nature vs. OSA believed to
be due to arousals causing sleep fragmentation.
CPAP therapy does not always effectively normalize sleepiness in the
OSA patient. The reasons for EDS in the CPAP compliant patient with
documented effective titration by Polysomnography may be 1. sub clini16
Modafinil does not treat OSA i.e. the pathophysiology of the airway.
Patients must be encouraged to use their CPAP throughout the night to
prevent sequelae of OSA. It also may be that a decrease in CPAP usage
would out weigh the benefit of the drug therapy in compliant patients wishing to “just take a pill”. It is questionable that modafinil has a place in therapy without CPAP use although there is the opinion that we need to treat
any sleepy driver. Modafinil has been shown to be effective adjunctive treatment of Obstructive Sleep Apnea in patients with continued daytime sleepiness, improving EDS, sleep-related functional status, the overall clinical
condition and quality of life for up to 4 months of combined treatment.(3)
It has been said that the prevalence of residual impairment in daytime
alertness in treated OSA patients may be inaccurate and an underestimate if only “sleepiness” is assessed. Terms such as “lake of energy”,
“tiredness”, or “fatigue” may give us a better picture of the functional
impairment. Again, the mechanism of EDS in OSA is not fully understood.
As stated previously there are those that would treat with drug therapy and those that vehemently oppose such treatment.
Pro’s
• Shows improvement in measures of daytime sleepiness
• CPAP-compliant patients do not alter their CPAP use with Modafinil
therapy. The drug therapy can be re-evaluated in the non-CPAP compliant patients.
• Patients show improvement in quality of live measures
• Modafinil is generally well tolerated
ß
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Con’s
• EDS is an important diagnostic indicator of OSA
• Suppressing EDS with drugs may hide the under-treatment of OSA with
PAP therapy and thereby exacerbate the sequelae of OSA i.e. cor pulmonale, cardiac arrhythmias, hypertension etc.
• May reduce PAP compliance (why do I need a blower when I can take
a pill)
• Could miss the recurrence of OSA in individuals that are treated with
Modafinil
• If effectively treated with PAP why would we need to treat with
Modafinil
• Other causes of insufficient sleep may be missed due to lack of EDS
Modafinil therapy does show improvement in OSA patients with
residual sleepiness. It may indeed be an inappropriate therapy for some
OSA patients i.e. non-compliant or under-treated but others will benefit
from increased quality of life and reduced motor vehicle accidents. The
question does remain however of whether residual sleepiness despite
optimal PAP titration truly exists.
What does this mean to the acquisition technologist? We must do
our best to avoid inadequately titrating or over titrating our patients.
Patients need to be encouraged to use their CPAP device to optimum
therapeutic benefit prior to opting for medication. When this is not satisfactory and levels of sleepiness have considerable negative impact on
health, quality of life, and safety of the patient and others, drug therapy
may be considered a viable albeit debated therapy. H
References
1. Pro/Con Editorials: Modafinil Has a (No) Role in Management of Sleep Apnea Am J Respir
Crit Care Med Vol 167. pp 105-108, 2003
2. Modafinil as Adjunct Therapy for Daytime Sleepiness in Obstructive Sleep Apnea Allan I.
Pack; Jed E. Black; Jonathan R.L. Schwartz; Jean K. Matheson for the U.S. Modafinil in
Obstructive Sleep Apnea Study Group Am J Respir Crit Care Med Vol 164. pp 16751681, 2001
3. Modafinil as Adjunct Therapy for Daytime Sleepiness in Obstructive Sleep Apnea, A 12Week, Open-Label Study Jonathan R. L. Schwartz, MD; Max Hirshkowitz, PhD; Milton K.
Erman, MD; Wolfgang Schmidt-Nowara, MD for the United States Modafinil in OSA Study
Group
4. Randomized, Double-blind, Placebo-controlled Crossover Trial of Modafinil in the Treatment
of Residual Excessive Daytime Sleepiness in the Sleep Apnea/Hypopnea Syndrome Ruth
N. Kingshott; Marjorie Vennelle; Emma L. Coleman; Heather M. Engleman; Thomas W.
Mackay; Neil J. Douglas Am. J. Respir. Crit. Care Med., Vol. 163, Number 4, March
2001, 918-923
5. Effects of Modafinil on sustained attention performance and quality of life in OSA patients
with residual sleepiness while being treated with nCPAP David F. Dinges; Terri E. Weaver
Sleep Medicine 4 (2003) 393-402
About the Author
William W. Eckhardt BS, RPSGT, CRT is the Director of Education at Sleep HealthCenters and
part time professor in Polysomnography at Northern Essex Community College. He is the
2004 recipient of the APT-Dr. Allen DeVilbiss Literary Award for his contributions to The
A2Zzz Magazine. He is also a speaker for sleep-related lectures at national and regional
engagements. He may be reached at [email protected]
17
NewZzz Briefs
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
SleepNet Introduces Holey
Strap! Headgear
New AMA Health
Professions Directory
January 2005, Manchester NH
— SleepNet introduces a new single
size headgear for the IQ nasal
mask. The Holey Strap! headgear
provides a secure and comfortable
foundation with a minimum of surface coverage. The narrow frame
is constructed of breathable “CoolTex”
material, with a moisture wicking interior
surface. Parallel straps at the crown and
below the ears adjust for length with a molded Velcro tab that is easy to reposition without a loss in adherence. The crown strap
adjusts through the frame at three positions
for circumference and angle versatility, adapting to a range of head
shapes and sizes. The Holey Strap! is also available assembled with the
IQ nasal mask. H
The new 2005-2006 edition of the AMA’s
Health Professions Career and Education
Directory is now available. This updated edition
includes information on 6,745 educational programs in 65 professions.
For further information: SleepNet Corporation, www.sleep-net.com, Deidre Christiansen,
[email protected], 1050 Perimeter Rd., Suite 203, Manchester NH 03103, Ph:
(603) 624-1911 x275, Fax: +1 (603) 641-9440
SCMI Adds Managed Care
Consultant to Advisory Team
Duane M. Johnson, PhD, Senior Partner and Co-Founder of Sleep
Center Management Institute (SCMI), is pleased to announce the addition of Mark Misiunas, MPH to the SCMI Advisory Team. Misiunas
brings a wealth of sleep center managed care experience and knowledge
to the consultant/advisory team.
Misiunas, is a managed care expert with a specialization in sleep
medicine. He utilizes his knowledge and expertise to assist sleep diagnostic and treatment professionals in maximizing their revenue potential
and profile with payors. With over twenty years experience in the healthcare industry, Misiunas is uniquely qualified to develop and implement
strategies to assist sleep medicine providers and other healthcare professionals in creating productive partnerships with insurance companies
and other associates to impact their bottom line. Misiunas is a veteran
in the payor contracting and relationship development business with
unique skills in reimbursement analysis, strategy development, and building bridges with key payors.
Through Misiunas, SCMI is able to provide the following additions to
our current menu of advisory services: Revenue enhancement; managed care contracting/contract negotiations; key contact relationship
building with payors; payor strategy development; reimbursement auditing and analysis; contract review; strategic planning; exploration of new
business opportunities; competitive analysis; evaluation of new service
offerings and products; research and development; networking;
addressing payor profiling reports; RFP and RFI responses; IPA management; network development; strategic communications; coordination
of coding audits and coordination of chart reviews. H
For more information on SCMI’s consultative service offerings contact our office at 1-888556-2203 or send email to [email protected].
18
The Directory also includes a useful description of the profession of polysomnographic technology, including the profession’s history, job
duties, required education, and average salary.
As programs begin to be accredited by the
Commission on Accreditation of Allied Health Education Programs,
future editions will list these programs, further raising the profile of the
profession among K-12 students and helping ensure growing awareness
of the opportunities polysomnographic technology offers.
To order a copy of the Directory, call 800 621-8335 or visit
http://tinyurl.com/4wd7p
To receive a copy of the order form, send an e-mail to [email protected]. For fastest service, be sure to specify the phrase “HPCED” in
the e-mail’s subject line. H
Sleep Medicine
Residency Requirements
Now Part of AMA’s
“Green Book”
The new 2005-2006 edition of the Graduate Medical Education
Directory (“Green Book”) will include Program Requirements for
Residency Education in sleep medicine, approved in 2004 by the
Accreditation Council for Graduate Medical Education (ACGME).
This indispensable resource for medical students and medical school
administrators, published annually by the American Medical Association
(AMA), features complete contact information for more than 8,000 programs in 126 specialties/subspecialties.
Sleep medicine programs will be accredited at 1 year in length and
require successful completion of one of the following prerequisite educational programs:
(1)
(2)
(3)
(4)
(5)
3
3
4
4
5
years
years
years
years
years
of
of
of
of
of
internal medicine
pediatrics
psychiatry
neurology
otolaryngology
To request an order form for the Directory, send an e-mail to
[email protected] with the words “single copy” in the subject line.
An auto-reply e-mail will be generated with the order form attached in
Microsoft Word format. Or call AMA Customer Service at 800 6218335. Multiple copy discount information for ten or more copies available. Contact: Paula Coyne, AMA Marketing Fulfillment, 312 464-2518,
e-mail: [email protected]. H
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Seasonal Affective Disorder
BY IAIN BOYLE, RPSGT
easonal Affective Disorder (SAD) was first noted before 1845, but
was not officially named until the early 1980’s. As sunlight has
affected the seasonal activities of animals (i.e., reproductive cycles and
hibernation), SAD may occur in humans due to this seasonal light variation. As seasons change there is a shift in our circadian rhythm. This is
due partly to the changes in sunlight frequency and duration. The result
is having our biological clocks fall out of “step” with our daily schedules.
As the days get shorter the problem may worsen.
S
SAD is a common condition that affects people year after year, and
tends to be worse in January and February. It can vary from being quite
severe, to being a relatively mild problem. Some of the symptoms are:
decreased energy, difficulty waking up in the morning, oversleeping,
overeating (especially sweets and starches); and because of this
overeating and inactivity can lead to weight gain. Often
people with SAD have difficulty concentrating and
getting their work done. They also may withdraw from friends and family and ultimately feel anxious, irritable, and yes — sad.
For many of us working nights in the
sleep center it is probably even more
prevalent amongst sleep medicine technologists. In order to understand this disorder let’s look at the ideology, ways to
prevent it and treatment for.
SAD is caused by three main factors.
The problem could be inadequate exposure to light. Inadequate light exposure may be for non-seasonal reasons; for example, people in basement apartments, windowless
offices, or working nights in poorly
lighted areas. Also, periods of extended
cloudiness any time of the year may cause people
symptoms of SAD. Certain people are also more susceptible to SAD:
those with a family history and women, more than men by a factor of
three to one. People living in the north are also at greater risk for developing SAD, due to less exposure to natural light. Finally, stress combined
with the other two factors can make the symptoms of SAD much worse,
than someone with simply less exposure to light.
To differentiate between normal depression and SAD, one has to
consider the time frame and that season affective disorder is a type of
depression, but occurs regularly. If this occurs in a person regularly at
Thanksgiving, and Christmas; and he or she is usually the life of the party
any other time of the year, then the glum and withdrawn behavior would
be consistent with symptoms of SAD. If you have the symptoms year
after year, and more in the winter than in the summer, chances are you
have SAD as opposed to normal depression.
In people with SAD, sunlight can actually make them less depressed.
While there are many people who do not have symptoms that are bad
enough to warrant going to a doctor, there are those who still feel somewhat down in the winter. Maybe they are less productive or creative or
maybe they just don’t enjoy life as much
during the winter. These people we
describe as having “winter blues” which is
a milder form of SAD. The good news is
that winter blues responds to the same
kind of treatment that is effective for
those with SAD.
Additionally, SAD is more common in
the Northern Climates. For example, in one Iain Boyle, RPSGT
study, SAD occurred in only 1.5% of people
in Sarasota, Florida, but in almost 10% of people in New Hampshire.
SAD does not only happen in the winter season. There are some
people who get depressed every summer year after year. It is believed
that they have difficulty dealing with the heat of summer. SAD can develop in people who previously have not had a problem with it due to
several factors: (always precede a listing like this one with a colon:)
1. Relocation from the south to the
north.
2. Moving a home or office to a new
location that has darker lighting.
3. Children develop SAD as they
grow up. (In girls it typically
appears after puberty.)
4. Anything that blocks the entry of
light into the eyes — for example
cataract development or using
light blockers to promote sleep
when working night shift — can
precipitate SAD.
SAD can affect people of all
ages, including teens. Teens are
commonly affected by SAD, and in
one research study results showed that by the time children get to high
school; approximately 5% have developed SAD. This is about as common
as in adults. It is also worth noting that the winter blues is even more
common than SAD, affecting about 15% of the adult U.S. population. So
if you add the numbers affected by SAD and those affected by the winter blues, about 1 in 5 Americans is affected and could use extra light
in winter. So those of you working nights in the sleep center have not
brought it on, but because of your working hours you are at greater risk.
The holiday season typically presents a special challenge to people with
SAD. Holidays involve many chores and demands. Cards need to be written, gifts purchased and wrapped and the usual round of social events
attended. All of these things can pose major stresses for people with SAD
and can make the symptoms worse. However, it is also worth mentioning
that some people get blues around the holidays for completely different
reasons which appear to be related to emotional reactions to the holidays.
SAD can last up to five or six months of the year. It’s very important
to realize that we’re not dealing with brief holiday blues, but with a concontinued on page 34
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Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
You May Be Losing Your Hearing
As You Sleep
BY REGINA PATRICK
he National Institute on Deafness and Other Communication
Disorders (NIDCD) estimates that 30%-35% of adults over 65
years old and 40%-50% of adults over 75 years old will suffer some
hearing loss. Nevertheless, it is possible to avoid hastening hearing loss
as one ages. One solution may be as simple as treating a bed partner’s
sleep apnea.
T
Two types of hearing loss that commonly occur in adults are presbycusis (age-related hearing loss) and noise-induced
hearing loss. Presbycusis typically affects one’s
ability to hear high-pitched sounds such as the ring
of a phone, ticking of a watch, and children’s or
women’s voices. Noise induced hearing loss initially affects one’s ability to hear a certain range of
high-pitched sounds (e.g., 2.0-4.0 kiloherz
[2,000-4,000 cycles/second]) but a person is still
able to perceive other high pitched sounds but to
a lesser degree than normal. Later, as noise-induced
hearing loss progresses, a person becomes unable to
perceive low-pitched sounds. Both presbycusis and noise-induced hearing loss involve injury to the cochlea. In presbycusis, cochlear structures
are destroyed. In noise-induced hearing loss, cochlear structures are
damaged but not destroyed.
The cochlea is a tapered cone-like structure which coils upon itself
giving it the appearance of a sea shell. The basilar membrane runs the
length of the cochlea. It supports the organ of Corti which contains various types of receptor cells involved in the neurological aspect of hearing: inner hair cells, outer hair cells, inner and outer phalangeal cells,
border cells, and Hansen’s cells. Sound waves cause cochlear fluids
(perilymph and endolymph) to flow back and forth within the cochlea. The
hair cells, which project into endolymph, sway in conjunction with the
fluid’s flow. Each movement of the hair cells transmits a signal to the
cochlear nerve and from there the signal travels to the cochlear nuclei
in the brain to be interpreted as sound.
In noise-induced hearing loss, the hair cells — particularly the outer
hair cells — move about excessively in response to loud noise. This causes them to swell, weaken, and twist. In this condition, the hair cells can
not transmit their signals accurately to the cochlear nerve resulting in
diminished hearing.
In presbycusis, the hair cells die off, the organ of Corti atrophies, the
basilar membrane thickens, and the stria vascularis (a layer of vascular tissue lining the cochlear duct that secretes endolymph) atrophies. Scientists
are not sure why these changes occur but have looked to genetics, diet,
and external factors (e.g., ototoxic drugs, noise) as a cause.
A normal healthy human ear begins to perceive sound at 0 decibels
(dB). Loud noise begins to cause pain at 125 dB (about the loudness of
a car horn if you were standing less than 4 feet away). Damage to inner
ear structures begins at 160 dB (about the loudness of a jet engine at
less than 100 feet). Destruction of inner ear structures occurs at 180
decibels. (The loudest sound possible to measure is 194 dB.) The government agency Occupational Safety and Health Administration (OSHA)1
20
recommends a person wear ear protection (such as ear plugs) at 85 dB and
requires workplaces to provide ear protection to workers at 90 dB.
A light snorer snores at about 38 dB.
Most snorers snore at about 60-70 dB.
Very loud snorers can snore as loud as Regina Patrick, RPSGT
80 decibels — nearly the level at
which OSHA recommends ear protection. Even though
light and moderate levels of snoring are below the
level considered damaging to the ear, snoring may
still play a role hearing loss.
In 1973, Yugoslavian scientist M. Prazic2 was
the first to examine whether snoring contributed to
hearing loss in snorers. He expected that snorers
would have an increased incidence of presbycusis
since snorers are exposed to loud noise repeatedly for
many years. He examined the audiograms of 17 snorers all
of whom were 60 years or older and found that each had presbycusis.
He concluded that their snoring had contributed to their presbycusis.
continued on page 31
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Denver, Colorado — The Mile High City
Site for the 2005 APT & APSS Annual Meetings
BY THERESA SHUMARD, EDITOR-IN-CHIEF
aking a vacation out of your trip to the APT and APSS Annual
Meetings this year for you alone or you and the family? You’re in
for a treat! Denver is an historic Western town and thriving modern City
— all in the same trip. Journey back to the 19th Century and experience
the elegance of historic Larimer Square and the Victorian mansions of
the “Unsinkable Molly Brown” and others.
M
Along the way, you will
pass beautiful Civic Center
Park, the gold-domed State
Capitol, the United States
Mint, the Denver Art Museum
as well as other cultural
attractions and the quiet treelined streets of Denver’s residential neighborhoods.
Another
highlight
is
bustling 17th Street, Denver’s
financial nerve center with its
towering skyscrapers set
against the backdrop of the
Rocky Mountains. The 16th
Street Mall, a multi-million dollar pedestrian mall, is located
just a block away and features
a variety of restaurants, specialty shops and seasonal
activities of all kinds.
Washington Park, one of 200 parks and gardens in Denver, Colorado.
At the end of this journey, you will no longer be a stranger to the Mile
High City!
continued on page 24
Coors Field in Denver, Colorado.
The Royal Gorge is the world’s highest suspension bridge.
22
Denver Performing Arts Complex.
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Denver Trivia
Rocky Mountain National Park is 71 miles northwest of Denver.
Right: Red Rocks
Amphitheatre.
Bottom Left: Ship
Tavern at Brown Palace.
Bottom Right: Garden
of the Gods in Colorado
Springs, an hour south
of Denver.
• In 1935, Louis Ballast melted a slice of
cheese on a hamburger at his Denver
Humpty Dumpty drive-in restaurant,
and patented the invention as the
world’s first “cheeseburger.” The
restaurant is gone today, but there is a
small memorial to this historic dining
event at 2776 North Speer Blvd.(in the
parking lot for Key Bank).
• Denver truly is one mile high. The 15th
step on the west side of the State
Capitol Building is 5,280 feet (1,609
m) above sea level.
• It was on top of nearby Pikes Peak in
1893 that Katherine Lee Bates was
inspired to write the words to “America
the Beautiful.”
• The mountainous area of Colorado is six
times the size of Switzerland and contains 9,600 miles (15,449 km) of fishing
streams, 2,850 lakes and over 1,000
peaks two miles (3,218 km) high.
• The road up 14,260 foot (4,346 m)
high Mount Evans is the highest paved
road in North America — and it is
maintained and operated by Denver
City Parks Department. Denver’s
Mountain Parks Department maintains
20,000 acres of park lands including
its own private buffalo herd and Red
Rocks Amphitheatre — all part of the
largest city park system in the nation.
• In hopes of gaining political favors, local
boosters named the frontier mining
camp on the South Platte River
“Denver” after Kansas Territorial
Governor James Denver. They never
received any favors — by the time they
named the town, Denver had already
resigned.
• There were originally three separate
towns on the current site of Denver,
with three different names. In 1859, in
return for a barrel of whiskey to be
shared by all, the other names were
dropped and the tent and log cabin city
officially became “Denver.”
• Denver is one of the few cities in
history that was not on a road, railroad, lake, navigable river or body of
water when it was founded. Denver
just happened to be where the first few
flakes of gold were found in 1858 and
it was here that the first camp was
made. The first permanent structure
was a saloon. H
23
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Denver, Colorado — The Mile High City
continued from page 22
Description of Denver
Denver is a clean, young and green city with over 200 parks and
dozens of tree-lined boulevards. The architecture reflects the city’s three
boom periods: Victorian, when silver was discovered in Leadville; turn-ofthe-century, when gold was discovered in Cripple Creek; and contemporary, when the energy boom added 16 skyscrapers to the downtown skyline in a three year period, 1980-1983.
Unlike some Western cities, Denver has a central downtown area.
Here, within easy walking distance, are 5,200 hotel rooms, the city’s convention complex, performing arts complex, and a wide variety of shops,
department stores, restaurants, and nightspots. Also within easy walking
distance are some of the city’s top attractions including the Denver Pavilions,
Denver Art Museum and Colorado History Museum. A mile-long pedestrian
mall cuts through the heart of downtown Denver and is surrounded by a
series of parks and plazas that soften the towering skyscrapers and provide
viewpoints from which to see and appreciate the modern architecture.
Lower Downtown (called “LoDo” by locals) is on the northern edge of
downtown Denver and offers one of the nation’s greatest concentrations
of Victorian buildings and warehouses, many of which have been refurbished to house restaurants, art galleries, offices and shops. This is the
center of the city’s brew pubs, with six large brew pubs and micro breweries, each brewing six to eight exclusive beers, all within easy walking
distance of each other. Downtown is also the home of Auraria Campus
where three colleges have over 30,000 students.
24
In May of 1995, Six Flags Elitch Gardens moved to downtown Denver
with a year-round amusement park similar to Copenhagen’s Tivoli
Gardens offering 48 thrill rides, formal gardens, restaurants and shops.
Also in May 1995, downtown Denver unveiled a new 50,000-seat stadium, Coors Field, for the Colorado Rockies, Denver’s Major League
Baseball team. Another large attraction in this area is Colorado’s Ocean
Journey, a large aquarium that features salt and fresh water animal life,
which opened on June 21, 1999.
The Mile High Trail is a series of six walking tours throughout the
downtown area. Maps can be obtained from the Denver Metro
Convention & Visitors Bureau Information Center in the Tabor Center,
located on the 16th Street Mall.
Denver’s Climate
Nothing about Denver is more misunderstood than the city’s climate.
Located just east of a high mountain barrier and a long distance from
any moisture source, Denver has a mild, dry and arid climate. The city
receives only 8-15 inches (20.3-38 cm) of precipitation a year (about
the same as Los Angeles), and records 300 days of sunshine a year —
more annual hours of sun than San Diego or Miami Beach.
Winters are mild with an average daily high of 45° F (7 °C) in February,
warmer than New York, Boston, Chicago or St. Louis. Snow does fall, but
it usually melts in a short time. Golf courses remain open all year and have
been played on as many as 30 days in January. Chinook winds (a wind
blowing down from a mountain that gains heat as it loses elevation) can
bring 60° F (16° C) weather to Denver at any time throughout the winter.
ß
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
In summer, dry relative humidity makes Denver feel cool and comfortable, offering natural air conditioning. Fall is a particularly delightful
time to visit the city and make day excursions to the mountains to view
the colorful changing of the aspens, an event that takes place from midSeptember until mid-October.
Denver’s Museums & Attractions
Denver has some of the finest museums in the West with a wide
variety of historical, western, artistic and horticultural emphasis.
The Black American West Museum tells the forgotten story of
African American cowboys, who made up as many as one third of all the
cowboys on the great cattle drives. Housed in the home of Dr. Justina
Ford, Denver’s first African American doctor, the museum has exhibits,
historic photos and artifacts that tell the story of the many contributions
made by Blacks in settling the West. (303) 292-2566.
Buffalo Bill’s Grave & Museum is filled with memorabilia honoring
the famous frontier scout, showman and Pony Express rider, William F.
Cody. Gun collections and posters from the Wild West Show are some
of the items found here. A beautiful view of the mountains and the plains
is visible from his grave site. (303) 526-0747.
Butterfly Pavilion & Insect Center features a lush tropical forest
filled with up to 1,600 free-flying butterflies. There is also an insect center and gift shop, as well as outdoor gardens and many fun, educational exhibits. (303) 469-5441.
The Children’s Museum of Denver is a unique participatory museum for children and families to experience hands-on, interactive exhibits
and activities. Children can learn to ski on KidSlope, shoot baskets, compare measurements in SizeWise, sample the latest in computer software in CompuLab, and shop in the grocery store. (303) 433-7444.
The Colorado History Museum offers a series of dioramas and
exhibits that trace the colorful history of the Indians, explorers, gold miners, cowboys and pioneers that have called Colorado home. Exhibits
include an outstanding collection of William Henry Jackson photos and a
large diorama of Denver as it appeared in 1860. Call for information on
special exhibits. (303) 866-3670.
Colorado Ocean Journey, opened in June 1999, is a world-class
aquarium that immerses visitors on two journeys, from the Continental
Divide in Colorado to Mexico’s Sea of Cortez, and the other from an
Indonesian rain forest to the Pacific Ocean. The Rocky Mountain West’s
only aquarium will also show visitors how all water and water life are
inter-related. (303) 561-4450.
The Colorado State Capitol stands a mile above sea level with a plaque
on the 15th step to mark the spot that is 5,280 feet (1,609 m) high. The
dome is covered with 200 ounces of pure gold and offers a beautiful view
from the rotunda of the entire Front Range, from Pikes Peak, all the way
north to the Wyoming border, a distance of over 150 miles. Free tours on
weekdays of the beautiful rooms and appointments. (303) 866-2604.
The Coors Brewery offers free tours of the largest single brewery
in the world. Colorado brews more beer than any other state and this
Golden brewery brews more beer than any other place on the planet.
Free tours of the entire complex, from brewing to bottling, with free beer
samples for those over the age of 21. (303) 277-2337.
Denver Art Museum has what is considered to be the finest collection of American Indian art works in the world covering all tribes, as well
as 30,000 other art objects in seven curatorial departments. The
museum celebrated it’s 100th Anniversary in 1993 with newly remodeled Asian, Pre-Columbian and Spanish Colonial galleries and renovated
African and Oceanic galleries. It is the largest art museum between
Kansas City and the West Coast. (720) 865-5000.
The Denver Botanic Gardens has a large conservatory, an alpine
garden with rare tiny flowers, a Japanese tea garden, as well as a water
garden with hundreds of water lilies that bloom in late summer. It is just
one of 506 public gardens in Denver where over 240,000 flowers are
planted each year. (303) 331-4000.
The Denver Museum of Nature & Science is the Rocky Mountain
Region’s leading resource for informal science education. A variety of
engaging exhibits, discussions and activities help Museum visitors celebrate and understand the natural wonders of Colorado, Earth and the
universe. During adventures at the Museum, you’ll learn about current
science topics in the news. Prehistoric Journey transports you back in
time to when dinosaurs ruled the planet. The Museum is also famous
for its interactive children’s discovery centers, Egyptian mummies,
wildlife exhibits, colorful gems and minerals, the Hall of Life health center, awe-inspiring IMAX® films, dynamic temporary exhibits, new scientific discoveries and visionary speakers. (303) 322-7009
Get inspired by space! The Denver Museum of Nature & Science’s
new permanent exhibition, Space Odyssey, debuts June 13, 2003.
Learn about the latest discoveries in space science, experience a stunning close-up view of Mars and talk with an “astronaut” conducting
research on the surface. Visitors can also maneuver a Mars rover and
dock the space shuttle. Also opening June 13, 2003 is the new Gates
Planetarium. The most sophisticated planetarium in the world includes
The Cosmic Atlas(TM), a new digital technology developed by the Denver
Museum of Nature & Science. It is the most accurate 3-D map of the
cosmos ever created.
The Denver Zoo is consistently rated as one of the top 10 in
America with 3,500 animals in lovely spreading grounds in City Park.
“Tropical Discovery,” is a 1.5-acre rainforest under glass in which visitors
feel the sensation of walking through a jungle teeming with wildlife. Other
highlights of the Zoo include “Northern Shores” where you can watch
polar bears swim underwater and Primate Panorama, where visitors
can get as close as 10 feet to over 29 species of monkeys. The Zoo celebrated its 100th anniversary in 1996. (303) 376-4800.
Six Flags Elitch Gardens Theme Park is a hundred-year-old theme
park known for its European atmosphere, elaborate floral gardens, and
thrill rides. In 1995, Elitch Gardens moved to an expanded location in
downtown Denver along the South Platte River with all new rides, gardens, lagoons, restaurants and amusements. (303) 455-4771.
The Molly Brown House honors “Unsinkable Molly Brown,” the heroine of the Titanic disaster with mementos from her life preserved in her
beautiful home on Capitol Hill. Molly was one of the most colorful characters to come from Denver’s gold rush period. While sailing on the
Titanic, she took command of a lifeboat and was credited with putting
down a panic. Her life story was the inspiration for the hit musical and
film, “Unsinkable Molly Brown.” (303) 832-4092.
continued on page 26
25
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Denver, Colorado — The Mile High City
continued from page 25
Red Rocks Amphitheatre is a 9,000-seat natural outdoor arena
carved out of huge, 500-foot (152 m) high, red sandstone cliffs, all overlooking Denver and the plains. With its views and geologic wonders, it’s
one of the world’s most famous concert sites and has played host to
everyone from the Beatles to symphony orchestras. Seventy million
years ago, the rocks were the beach of an ancient inland sea that covered eastern Colorado and Kansas. Today, it’s a wonderful site for hikes,
picnics and concerts.
The U.S Mint Gift Shop is open Mon-Fri from 9:00am to 3:30PM.
The store is located at 333 West Colfax in the Tremont Center across
the street from the mint. The gift shops offers exciting souvenirs and
coin and money-related gifts for the entire family, from traditional Mint
numismatic coin collectibles to clothing, toys, games and accessories.
For more information on the U.S. Mint, visit www.usmint.gov.
Denver’s Cultural Facilities &
Entertainment
The U.S. Mint is where over five billion coins are made each year
and there are free 20 minute tours on weekdays. It is also the second
largest storehouse of gold bullion in the U.S. after Fort Knox. The gift
shop has many unique coins not available anywhere else, and there is a
small museum on the history of money. (303) 844-3582.
With eight theaters offering 10,800 seats, the Denver Performing
Arts Complex is the second largest performing arts center in the nation
(after Lincoln Center in New York) in seating capacity and the largest in
the world under one roof. Located downtown, the four-square block center features: Boettcher Concert Hall, the nation’s first symphony hall inthe-round. The Denver Center Theater Company which won a Tony
Award in 1998 for best regional theatre acting company; the Temple
Buell Theater, a new 2,800-seat Broadway theater that opened in 1991
with Andrew Lloyd Webber’s hit musical, Phantom of the Opera and
hosts other top road attractions such as The Full Monty, Lion King,
Mama Mia and Sunset Boulevard, as well as the world’s first voice
research laboratory. The center is entered under a block-long glass arch
and is noted for its unusual and striking architecture.
Since September 11, tours of the U.S. Mint are limited to groups of
six or less. The tours must be arranged a minimum of two weeks in
advance through your Congressional representative. For information on
how to contact your Representative, www.house.gov. For information on
how to contact your Senator, visit www.senate.gov.
According to Performance Magazine, in 1997 more people attended
performances at the Buell Theatre than at any other 3,000-seat or smaller theatre in the nation. Over 600,000 people paid to see productions at
the Buell in 1997. The Performing Arts Complex had three of the nation’s
top 15 theatres in 1997, with the Auditorium Theatre placing 8th and
Tiny Town is a kid-sized village with dozens of “Old West” buildings,
all built at 1/6 scale in a scenic mountain location. An authentic toy
steam locomotive circles the park giving children and adults a ride past
the miniature town. (303) 790-9393.
2003 Demographic,
Salary & Educational
Needs Survey
Identifies PSG technologist practice
environments, technologist characteristics, compensation, and education.
ß
Sleeping On The Job!
Answers basic questions on site location, design, setup, staffing and more.
Offers resources for locating equipment
and supplies and is highlighted by a
sample Policy and Procedure Manual.
Order form page 37
Order form page 37
“Guardian Sleep” Print
Limited Edition series of
500 color prints (certificate
included). The original
painting was rendered in oil
and mixed media. Available
signed or unsigned.
Order form page 37
26
Show you care by
wearing the new…
Sleep Disorders
Awareness Pin
PRESENTED BY THE APT
Order form page 37
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Boettcher Concert Hall placing 12th. And in 1998, the Denver Center
Theatre Company won a Tony Award for best regional theatre.
The League of American Theatres and Producers in New York
declares Denver to be the 7th best market in North America for gross
revenues from touring Broadway shows after Toronto, Los Angeles,
Chicago, Washington, San Francisco and Boston.
Denver has 30 other theaters and over 100 cinemas and has
always had a long love affair with the arts. When Denver was a wild gold
rush town in the 1870’s, it boasted a theater with sold out performances of MacBeth, long before it had either a school or a hospital.
Cherry Creek Shopping Center is the largest in the Rocky Mountain
region with 140 upscale stores including Saks Fifth Avenue, Neiman
Marcus, Lord & Taylor and Foley’s. Beautiful restaurants, architecture
and events make this a premiere shopping experience.
Larimer Square is a restored section of Denver’s oldest street
where the beautiful Victorian buildings have been restored to house a
collection of art galleries, clothing stores, restaurants, cafes and nightclubs.
The Shops at Tabor Center is a modern complex on the 16th Street
Mall with 80 shops and restaurants in a three-story, glass-covered, greenhouse-like building that offers festive views of downtown and the mountains.
Denver Dining
Denver has over 2,000 restaurants serving all varieties of cuisine.
Area specialties include Rocky Mountain Trout, fresh Colorado beef, and
lamb (Colorado is the fourth largest producer of lamb in the U.S.).
Another popular local dish is buffalo. High in protein, lower in fat, calories and cholesterol than chicken, buffalo is gaining popularity among health
conscious diners and is offered at numerous restaurants in Denver. Among
the restaurants serving buffalo are the historic Buckhorn Exchange, the oldest saloon and restaurant in the city with a unique dining room covered with
500 stuffed animal heads and The Fort, which is housed in a reproduction
of Bent’s Old Fort, a fur trapper’s post on the Santa Fe Trail.
Local residents also enjoy Mexican and Southwestern dishes, served
at dozens of local neighborhood pubs and taverns.
Park Meadows is one of Denver’s newest additions to the shopping
scene. Featuring a Nordstrom, Dillard’s, Foleys and Joslins the shopping
center was created to resemble a ski lodge, complete with a huge center court fireplace.
Denver Pavilions opened in November 1998 and features a
Wolfgang Puck Cafe, Maggiano’s Little Italy, Virgin Records Megastore
and Barnes & Noble Superstore.
Denver Recreation & Sports
With 300 days of sunshine a year, Denver is a sports capital. The
city offers over 450 miles (720 km) of paved, designated bike paths,
including two beautiful stretches through downtown along Cherry Creek
and along the South Platte River. There are over 70 golf courses in the
area, and more than 143 free tennis courts.
Beer Brewing Capital
Colorado produces more beer than any other state. Besides the huge
breweries of Coors and Anheuser-Busch, the Denver area is filled with
micro-breweries and brew pubs, all within walking distance of each other in
downtown Denver. A brew pub is a restaurant that brews the beer right on
the premises and serves beer that is generally not found anywhere else.
On any given day, there are fifty beers available in Denver at small brew
pubs that cannot be found anywhere else in the world. Each brew pub
offers tours and four ounce samplers that let you taste the variety of ales,
porters, stouts and lagers that they produce. While some of the brew pubs
produce what is commonly thought of as “American” style lagers, most of
the beers made are more traditional European and British style ales.
Denver Shopping
As the largest city in a 600-mile (966 km) radius, Denver has always
been the shopping capital of the Rocky Mountain West. The city features
the largest sporting goods store in the world (Gart Brothers Sports
Castle) and the largest independent book store in America with over
400,000 volumes (the Tattered Cover).
The 16th Street Mall is a mile-long pedestrian promenade through
the heart of downtown Denver, lined with shops, department stores and
outdoor cafes. Free buses leave either end as often as every 90 seconds, making this the best spot for “people watching” in the city. In summer, the Mall is decorated with 25,000 flowers including 8,400 impatiens, 6,528 petunias, 648 snapdragons and 370 geraniums.
Cherry Creek North is an eclectic mix of galleries, restaurants,
shops, clothing designers and cafes, all on pleasant tree-lined streets
directly adjacent to the Cherry Creek Shopping Center.
Within an hour and a half drive from Denver, there are opportunities
for skiing, river running, hiking, fishing, camping, horseback riding, sailing or mountain biking.
In June 1997, The Sporting News declared, “The Best Sports City
in 1997 is Denver, where the sun shines 310 days a year and the
sports possibilities are cloudless year-round... Denver comes together
as a unique setting for sports of all kinds. In addition to the Broncos,
Buffs, Nuggets, Avalanche and Rockies, there is every kind of participatory opportunity imaginable.”
Denver has a full compliment of professional sports teams including
the National Football League’s 1998 & 1999 Super Bowl Champion
Denver Broncos, the National Basketball Association’s Denver Nuggets,
Major League Baseball’s Colorado Rockies, and the National Hockey
League’s Colorado Avalanche, who won the 1996 and 2001 Stanley
Cups. Denver also has a professional lacrosse team, Colorado
Mammoth, and an arena sports team, the Colorado Crush. The Rockies
are typical of Denver’s great sports following: their opening game in April
1993 had the highest attendance in baseball history and they went on
to break 11 Major League attendance records, becoming the most popular team ever with 4,483,350 paying fans.
Other spectator sports include the world’s largest rodeo held each
year at the National Western Stock Show in January and pari-mutuel dog
and horse racing.
Half of Colorado is public land open to all forms of recreation with
two national parks, six national monuments, 11 national forests, three
national recreation areas and 30 state parks. H
27
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Editorial
continued from page 6
This defined letter of understanding is undoubtedly critical to current
and future advocacy efforts that will address the efforts of respiratory
therapists to assume administration of diagnostic and therapeutic services in sleep centers and laboratories. Further, the letter is a clarion call
for appropriate recognition of training and certification programs that
ensure PsgTs are the most qualified allied health professionals to provide care and service to patients, and addresses the assurance of quality care and the guarantee of access to care, which is of paramount concern to our patients and the general public. The AASM is appreciative of
support demonstrated by pulmonary medicine and looks forward to
working with both societies and the community. Currently, the AASM is
acting on or exploring issues affecting PsgTs in the following states: New
York, Illinois, California, Colorado, North Dakota, Montana, New Jersey,
North Carolina, South Carolina, Vermont, Alabama and New Mexico.
Journal of Clinical Sleep Medicine Article
Reviews AASM Goals to Ensure Adequate
Numbers of Well-Trained Technologists
In the editorial piece, “Polysomnographic Technologists—Troubled
Waters Ahead?” Epstein discusses that in order to standardize training for
PsgTs, the APT and the AASM along with the Board of Registered
Polysomnographic Technologists formed a Committee on Accreditation for
Polysomnographic Technology (CoA PSG) to set standards and develop
guidelines for PsgT educational programs. The CoA PSG also provides an
accreditation process, and was accepted as a member by the Commission
on Accreditation of Allied Health Education Programs CAAHEP).
“Unfortunately, the development of polysomnographic technology has
created competitive rather than cooperative relationships among technology disciplines,” the editorial states. “In particular, state respiratory
therapy societies have initiated legislative attempts to exclude
polysomnographic technologists (PsgTs) from practicing within their
scope of practice.”
“Excluding PsgTs does an injustice to their training and experience,
hampers the development of sleep medicine and, most importantly, limits quality care for patients with sleep disorders. PsgTs have a long and
well-documented history of expertise and professionalism in sleep medicine that is achieved through training and certification,” Epstein wrote. H
In a pivotal article by Lawrence J. Epstein, M.D., President-Elect,
AASM in the first edition of the Journal of Clinical Sleep Medicine
(JCSM), released in January, discusses the growth of the field of sleep
medicine, the need for qualified PsgTs, and legislative issues that might
prohibit access to quality patient care. The JCSM is only available to
AASM non-members for a short time through www.aasmnet.org
APT 27TH
ANNUAL MEETING
Denver, CO
APT Committee
Openings Available
“The very essence of leadership is that you have to have
vision. You can’t blow an uncertain trumpet.”
—Theodore M. Hesburgh
For more information contact:
Christopher Waring, APT Coordinator
Phone 708-492-0796 • Fax 708-273-9344
[email protected]
28
Westin Tabor Center
June 19-22, 2005
Complete information in early
March at www.aptweb.org
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Legislative Watch
continued from page 14
Excerpts from HB 1022 read:
For the purpose of requiring the State Board of Physicians to
adopt regulations for the licensure and practice of polysomnography; providing that this Act does not limit the rights of certain
individuals to practice certain occupations; authorizing the Board
to set certain fees; establishing the Polysomnography
Professional Standards Committee within the Board; providing
for the membership, powers, and duties of the Committee;
establishing the terms and requirements for certain members of
the Committee; requiring an individual be licensed by the Board
before the individual may practice polysomnography; providing
for the educational requirements for a polysomnographic technician license; providing for the applicant requirements to practice
polysomnography as a polysomnographic trainee; authorizing the
issuance and renewal of certain licenses; providing for the expiration and renewal of certain licenses; authorizing the Board to
deny a license to an applicant, refuse to renew a license, reprimand a licensee, suspend or revoke a license, or impose certain
penalties under certain circumstances; establishing certain
hearing and appeal procedures for polysomnographic technicians; prohibiting certain acts; providing for certain criminal
penalties; requiring that an evaluation of the Committee be performed on or before a certain date; defining certain terms; and
generally relating to the licensure of individuals to practice
polysomnography or to be polysomnographic technicians.
Language for HB 1022 provides that PsgT professionals performance include:
“Evaluating and treating individuals who suffer from sleep disorders as a result of developmental defects, the aging process,
physical injury, disease, or actual or anticipated somatic dysfunction; observing and monitoring physical signs and symptoms, general behavior, and general physical response to
polysomnographic evaluation and determining if initiation, modification, or discontinuation of a treatment regimen is warranted; using evaluation techniques that include limited cardiopulmonary function assessments, the need and effectiveness of
therapeutic modalities and procedures, and the assessment
and evaluation of the need for extended care and home care
procedures, therapy, and equipment; and applying the use of
techniques, equipment, and procedures involved in the administration of polysomnography, including: continuous positive airway pressure or bi-level positive airway pressure titration; supplemental low flow oxygen therapy during polysomnogram;
capnography during polysomnogram; carbon dioxide monitoring; pulse oximetry; ph probe placement and monitoring
esophageal pressure; sleep staging including surface electroencephalography, surface electrooculography, and surface
submental electromyography; surface electromyography of
arms and legs; electrocardiography; respiratory effort including
continued on page 32
Color Print for your Sleep Lab…
Definitions of PsgT professional terms used in the HB 1022 mirror
those defined by the published APT-AASM-BRPT-ASET Job Descriptions
and include:
“Board” means the State Board of Physicians
“Committee” means the Polysomnography Professional
Standards Committee
“Direct Supervision” means the responsibility of a physician or
licensed polysomnographer to exercise on-site direction for a
polysomnographic trainee performing delegated medical acts.
“License” means a license issued by the board.
“Licensed polysomnographic technician” means a polysomnographic technician who is licensed by the board under this title
to practice polysomnography under the supervision of a licensed
physician.
“Licensee” means an individual licensed by the board to practice
polysomnography to the extent determined by the board
“Polysomnographer” means an individual authorized by the board
to practice polysomnography as: a licensed polysomnographic
technician; or a polysomnographic trainee.
“Polysomnographic Trainee” means an individual authorized by the
board to practice polysomnography under the direct supervision
of a licensed physician or a licensed polysomnographic technician.
“Practice Polysomnography” means to analyze, attend, monitor,
or record the physiological data of an individual during sleep or
while awake to assess and diagnose sleep or wake disorders or
other sleep-related disorders, syndromes, or dysfunctions that
may manifest during sleep or may disrupt an individual’s normal
sleep and wake cycle and related activities.
“Practice Polysomnography” includes providing polysomnography
services that are safe, aseptic, preventive, and restorative...
PRESENTED BY THE APT
Order form page 37
29
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
More Than Just Skiing and Cows. Really!
BY CRINTZ SCOTT, RPSGT
f you’ve never been to Denver before, there are probably only a few things
that pop into mind at the mention of the place. Skiing, cowboys, sports
teams, and... well, actually, that’s probably where you got stuck, too.
I
Allow me to dispel some of the myths you may be pondering:
1) No, you can’t ski while you’re here. It’s
June — we do have more than one season around here (most years). In fact,
we probably get more sunshine than
you do — more than 300 days of
tanning weather per year, and the
average temperature during your
stay? How about 70 degrees and
very little humidity! This is Colorado,
though, and you’re bound to hear someone
tell you “If you don’t like the weather, wait a minute”
during your stay. Those crystal clear skies and gentle Spring breeze
can turn into a foot of snow faster than you can remember where you
left that jacket... bring a couple just in case. Also, if you’re planning
any sight-seeing in the high country, be prepared for the change in
altitude and the changes in weather than come with climbing 8,000
feet in 45 minutes through the center of the Rocky Mountains. Read
up on ways to help you acclimate and prevent altitude sickness.
2) You probably won’t have to dodge any wild cows downtown. You
might think that Denver is still a “cow-town”, but don’t let out laid-back
approach to life fool you into assuming we’re a bunch of hayseeds,
dagnabit! Denver is now one of the centers of technological development comparable to the famed Silicon Valley at its height. Home to
more than 2.5 Million at last count, this thriving metropolis boast all
of the amenities that you would expect from a forward-thinking urban
epicenter. From nightlife, world-class dining, a variety of entertainment options and the luxury of retreating to the splendors of the
Rocky Mountains in a short 30 minute drive from the heart of the
city. Trying to escape the frantic-pace of concrete & neon? Denver is
all about options — research day-trips to places like Estes Park,
Boulder, Colorado Springs, or Winter Park, which is host to a thriving tourist industry that caters to the backpacking tent-camper to
four-star mountain spas.
3) There’s more culture than a paint-by-number velvet Elvis. You want
some hi-falutin’ art? We’ve got you covered. From the renowned
Denver Art Museum to the Denver Museum of Nature & Science you
can get as lost in the world of art as a hapless tourist trapped in an
Escher sketch (see ... smart humor). For a look at upcoming exhibits,
visit their web sites at www.DenverArtMuseum.org and
www.DMNS.org, respectively. *Here’s a secret — admission to the
Denver Art Museum is free for residents on Saturdays — what better reason to get out and make some new friends? Looking for a night
of theatre? Only blocks from your hotel is the Denver Performing Arts
Complex, home to world-class productions, symphonic sensations
and a host of events. For a list of performances visit their website at
www.DenverCenter.org. Prefer to cut-loose and rock-out during your
trip? Visit www.ticketmaster.com for a list of upcoming performances at a myriad of venues in the Denver metro area.
30
4) The kids (or the kid in you) might
just have a good time, too. From
Six-Flags Elitch Gardens only minutes
from your hotel, you can wrap your
stomach into a pretzel in dozens of
creative ways. Family Mexican dining
meets a bit of surrealism at Casa
Bonita, something that everyone visiting
Denver should see, experience and
taste (and just watching that South
Park episode doesn’t count!) Where
else can you see rampaging gorillas, cliff divers and a never ending
plate of burritos? No, really — where? Also downtown, ESPN Zone
for all the food, alcohol, videogames and big-screens you can take,
and 12 blocks of shopping with built-in free shuttle service available
right outside the hotel on the 16th Street Mall. Don’t miss the hilarious performances at Rattlebrain Theater. Similar to “Who’s Line Is
It, Anyway?” crossed with Saturday Night Live, these sketch-artists
will have you gasping for breath (remember it is the “Mile High City”)
as you try to stop laughing. Book your seats now by visiting their website at www.RattlebrainTheatre.com.
That’s just a few of the activities going on in Denver during your visit!
So, leave the skis at home but bring the coat, just in case, and prepare
for just about any kind of weather. Check the sites above frequently as
many touring acts have yet to announce dates as of this writing. H
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
You May Be Losing Your Hearing
As You Sleep
continued from page 20
Only within the last six years has Prazic’s experiment begun stimulating other researchers to examine snoring’s effect on hearing loss. In
1999, Victor Hoffstein et al.3 looked for an association between snoring
and presbycusis. They were to conclude that no association existed.
Hoffstein’s study involved 219 subjects; 182 of these were snorers.
They compared each subject’s hearing threshold (i.e., the lowest signal
a person can hear) with his maximum snoring noise level. A subject had
a hearing loss if he could not hear high-pitched sounds greater than
4,000 cycles/second (4.0 kiloherz). Hoffstein et al. found that the hearing threshold of the subjects as a group remained in the normal range
(i.e., below 4.0 kiloherz) throughout the snoring noise range (50-100
dB). When they compared the hearing threshold of mild snorers with
that of loud snorers, they found no statistical difference in threshold.
Hoffstein et al. concluded that snoring does not contribute to presbycusis since the hearing threshold did not increase with increasing snoring
loudness (as would be expected if snoring were causing hearing loss)
and since there was no difference in hearing threshold between loud and
mild snorers.
However, noise-induced hearing loss caused by snoring may be a different matter. Noting that studies such as those of Prazic and Hoffstein
focused only on presbycusis, Canadian doctors Maya G. Sardesai et al.4
examined whether snoring could cause noise-induced hearing loss. Of
particular interest to them was the impact of snoring on a bed partner’s hearing.
They used four couples (i.e., eight subjects) in their study. Each couple was composed of a “snorer” and a “non-snorer.” All eight participants
were given a behavioral audiogram and an otoacoustic emissions (OAE)
test. A behavioral audiogram tests the function of a person’s hearing. It
is used to determine speech perception (i.e., word recognition), hearing
threshold, and the function of the auditory nerve and brain pathways
involved in hearing. An OAE test measures the cochlea’s ability to emit a
signal (i.e., the otoacoustic emission) in response to a test signal.
Hearing loss has occurred if the cochlea does not emit a signal in
response to a 30 dB test signal.
Like Hoffstein, Sardesai et al. could find no correlation between snoring noise and hearing loss in the snorers. All of the bed partners, on the
other hand, had high frequency noise-induced hearing loss in the ear
next to the snorer during sleep. Because of this consistent pattern,
Sardesai et al. concluded that loud snoring can result in noise-induced
hearing loss in the bed partners.
Snorers often suffer from sleep apnea (the cessation of breathing
during sleep) which occurs when pharyngeal tissue collapses into and
blocks the airway. As a result of air blockage, a person will abruptly
arouse for a few seconds to take some deep breaths. It is during the
arousal when snoring occurs. During snoring, pharyngeal tissue partially blocks the airway and flutters with each breath.
Sleep apnea can have potentially serious consequences for a sufferer. Sleep apnea sufferers have an increased risk of gastroesophageal reflux disease; an increased risk of cardiovascular problems
(e.g., hypertension, stroke, congestive heart failure); and increased difficulty with controlling obesity and associated obesity problems.
Additionally, frequent nocturnal arousals from sleep apnea can result in
excessive sleepiness during the day which in turn can jeopardize one’s
ability to function at work or in social situations — a person may find
himself inadvertently dozing at work, in social settings, or at dangerous
times such as while driving. Sleep apnea treatment can counteract
these consequences and, as a double benefit, protect the hearing of a
bed partner. H
References
1. www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9735,
(active as of 1/6/05).
2. Hoffstein V, Haight J, Cole P, Zamel N, “Does snoring contribute to presbycusis?”, American
Journal of Respirtory and Critical Care Medicine, 159(4):1351-1354, April 1999.
3. Hoffstein V, Haight J, Cole P, Zamel N, “Does snoring contribute to presbycusis?”, American
Journal of Respirtory and Critical Care Medicine, 159(4):1351-1354, April 1999.
4. Sardesai MG, AKW Tan, Fitzpatrick M, “Noise-induced hearing loss in snorers and their
bed partners,” Journal of Otolaryngology, 32(3):141-145, June 1, 2003.
APT Directory
APT Offices
APT National Office
Christopher Waring
APT Coordinator
One Westbook Corporate Center
Suite 920
Westchester, IL 60154
Phone 708-492-0796
Fax 708-273-9344
[email protected]
APT Advertising Office
The A2Zzz Magazine &
APTWEB
PO Box 70
Mohnton, PA 19540
610-796-0788
781-823-4787 F
[email protected]
Sleep-Related Organizations
American Academy of Sleep Medicine
One Westbrook Corporate Center
Suite 920
Westchester, IL 60154
Phone 708-492-0930
Fax 708-492-0943
[email protected]
BRPT Management Office
8201 Greensboro Drive, Suite 300
McLean, VA 22102
703-610-9020
703-610-9005 F
[email protected]
www.brpt.org
European Society of Sleep Technologists
Maud Verhelst, ESST Secretary, MCH
Centre for Sleep and Wake Disorders
PO Box 432
2501 CK Den Haag, The Netherlands
+31-70-3303016
+31-70-3882636 F
[email protected]
31
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Word Search
Legislative Watch
BY LAURA LINLEY, APT BOARD LIAISON FOR THE A2ZZZ MAGAZINE
continued from page 29
thoracic and abdominal; plethysmography blood flow; snore
monitoring; and audio video monitoring...”
The Maryland Polysomnography Professional Standards Committee
is proposed to consist of:
Find each of the following words:
MYOCOLONIS
LATENCY
CIRCADIAN RHYTHM
APNEA INDEX
SAWTOOTH WAVES
AC AMPLIFIER
SLEEP PARALYSIS
HYPERCAPNIA
DYSSOMNIA
BIPOLAR
DIURNAL
MONTAGE
solution on page 39
PHASIC
K COMPLEX
ONDINE’S CURSE
MONTAGE
TRACE ALTERNANT
PARADOXICAL SLEEP
Seven members appointed by the board as follows:
Three polysomnographers; three physicians who are board certified in sleep medicine: one of whom is a specialist in psychiatry or
internal medicine; one of whom is a specialist in pulmonary medicine; and one of whom is a specialist in neurology; and one consumer member. The consumer member of the committee: shall
be a member of the general public; may not be or ever have been:
a polysomnographer; any health care professional; or in training
to be a polysomnographer or other health care professional; may
not have a household member who is a health care professional
or is in training to be a health care professional; and may not:
participate or ever have participated in a commercial or professional field related to polysomnography; have a household member who participates in a commercial or professional field related
to polysomnography; have had within 2 years before appointment
a financial interest in a person regulated by the board; or have
had within 2 years before appointment a financial interest in the
provision of goods or services to polysomnographers or to the
field of polysomnography. The term of a member is 3 years...
In addition to the powers set forth elsewhere in this subtitle, the
committee shall:
Develop and recommend to the board regulations to carry out
the provisions of this subtitle; develop and recommend to the
board a code of ethics for the practice of polysomnography for
adoption by the board; develop and recommend to the board
standards of care for the practice of polysomnography; develop
and recommend to the board the requirements for licensure as
a polysomnographer, including:
Criteria for the educational and clinical training of polysomnographers; and criteria for a professional competency examination
and testing of applicants for a license to practice polysomnography; develop and recommend to the board criteria for polysomnographers who are licensed in other states to practice in this
state; evaluate the accreditation status of education programs in
polysomnography for approval by the board; evaluate the credentials of applicants and recommend licensure of applicants who fulfill the requirements for a license to practice polysomnography;
develop and recommend to the board continuing education
requirements for license renewal; provide the board with recommendations concerning the practice of polysomnography; ...
Develop and recommend to the board criteria related to the
practice of polysomnography in the home setting; develop and
recommend to the board criteria for the direction of students in
clinical education programs by licensed polysomnographers;
keep a record of its proceedings; and submit an annual report
to the Board. Except as otherwise provided in this subtitle, an
individual shall be licensed by the board before the individual may
practice polysomnography in this state.
To qualify for a license, an applicant shall be an individual who
meets the requirements of this section. the applicant shall:
continued on page 35
32
Legal Notes
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Key Provisions to Consider for a Medical
Director Contract
BY JAYME R. MATCHINSKI, ESQ., EDITORIAL BOARD, THE A2ZZZ MAGAZINE
EDITOR’S NOTE: For consideration by our readers, this new regular column will discuss regulatory, reimbursement, compliance, operational, and contract issues that may impact and affect sleep disorder
centers and the professionals who perform and provide sleep studies.
The APT publishes this column for its membership for information purposes only. The contents of the column do not constitute legal advice
and do not necessarily reflect the opinions of the APT Board of
Directors or any of its members. The column provides general information, which may or may not be correct, complete or current at the
time of reading. Content is not intended to be used as a substitute for
specific legal advice or opinions. No recipients of content from this column should act or refrain from acting on the basis of content of the
site without seeking appropriate legal advice or other professional
counseling. The APT expressly disclaims all liability relating to actions
taken or not taken based on any or all contents of the publication.
*This first column will focus on key contract provisions that a sleep
disorder center and medical director might consider prior to signing a
contract for medical director services.
he evolving practice of sleep medicine and increasing number of
hospital-based and freestanding sleep disorder centers have
caused many physicians to consider becoming involved in sleep medicine. Physicians have been faced with the possibility of establishing their
own sleep disorder center or becoming the medical director of a sleep
lab owned by another health care provider.
T
In addition to the compensation and related responsibilities which will
most likely be key negotiation points, there are several other issues
which sleep disorder centers and physicians should consider prior to
executing a contract including: private practice, independent contractor
status, clarifications to law, and accreditation issues.
Private Practice
The sleep disorder center and physician should discuss the specific
role and anticipated responsibilities of the medical director. Make sure
that your medical director contract contains a provision which enables
the medical director to continue his private practice separate and apart
from the sleep disorder center if the physician is not an owner of the
center. It is important that the maintenance of a private medical practice will not be considered to be competing with the center when the
physician treats his own patients outside of the sleep disorder center. A
sample private practice provision may include the following language:
Private Practice. Physician shall not be prohibited from carrying on a private practice outside of the Sleep Disorder Center
during the term of this Agreement. Physician acknowledges that
the practice will not conflict with or interfere in any fashion with
the performance of Physician’s obligations under this Agreement.
Independent Contractor Status
The issue as to whether physicians as medical directors are independent contractors or employees for federal income tax purposes has
been addressed by the Justice Department’s Tax Division and continues
to be the source of litigation in several jurisdictions. Inclusion of an independent contractor provision within your contract will help to clarify (but
not insure) the physician’s relationship with the entity which owns and
operates the sleep disorder center. Consider including the following provision within your medical director contract:
Status of Independent Contractor. The services of
Physician are those of an independent contractor practicing the
profession of medicine and specializing in sleep medicine. The
parties do not intend to enter into nor in any way construe this
Agreement to create an agency, employer/employee, partnership or any other relationship between them other than that of
independent contractor. The sole interest and responsibility of
Facility is to assure that the services covered by this Agreement
shall be performed and rendered in a competent, efficient and
satisfactory manner. Physician shall be solely responsible for
compliance with and payment of all taxes of whatever kind including Social Security, Unemployment Compensation, and Worker’s
Compensation in connection with compensation paid for medical
director services hereunder. Facility shall be responsible and
indemnify Physician for tax, interest or penalties associated with
the reclassification of Physician as an employee of Facility.
Clarifications to Law
As the number of sleep studies being ordered and interpreted by
physicians is increasing, reimbursement for such studies is also changing. For example, the Centers for Medicare & Medicaid Services
(“CMS”) issued a revised national coverage determination in 2002 for
Continuous Positive Airway Pressure (“CPAP”) Therapy used in the
treatment of Obstructive Sleep Apnea (“OSA”) which expanded
Medicare coverage for adult patients with OSA. Because coverage
issues will continue to evolve for sleep studies, you should think about
including a provision which addresses what happens to your contract if
there are substantial changes in Medicare reimbursement or other
regulations which impacts the sleep disorder center and physicians’
ability to function and receive reimbursement. The following is an example of such a provision:
Clarifications to Law. In the event there are substantial
changes or clarifications to statutes, regulations or rules, which
materially affect either party’s right to receive Medicare reimbursement for services, or participate in the Medicare Program,
or affects any other significant legal right of either party to this
Agreement, the affected party may, by written notice to the
other party, propose such modifications to this Agreement as
may be necessary to comply with the change or clarification to
law. Upon receipt of the notice, the parties shall engage in good
faith negotiations to reach an agreement regarding any appropriate modifications to this Agreement. Notwithstanding any provisions of this Agreement, if the parties are unable within sixty
(60) days thereafter to agree to appropriate modifications to this
Agreement, either party may terminate this Agreement by providing at least sixty (60) days written notice to the other.
continued on page 36
33
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Seasonal Affective Disorder
continued from page 19
dition that can affect almost half of a person’s life. January and February
tend to be the worst months. There is hope however. Evidence seems
to suggest that for women, SAD improves after menopause. Others
adjust to SAD so well that their symptoms disappear. One study showed
that1/3 of people with SAD reported no longer having symptoms several years after first being diagnosed. Chronic fatigue syndrome, unlike
SAD, affects people all year round. SAD specifically affects people during the dark days. Many of the symptoms of SAD, such as overeating,
weight gain and depression, are not typical of chronic fatigue syndrome.
People with SAD are often either sleepy or fatigued. The first one, as
you know, means drowsy, the other means lacking energy and many
patients have difficulty differentiating between the two. People with SAD can
have either recurrent depression with normal intervening periods or recurrent depression with exaggerated energy and vitality in the spring and summer months. This latter group can also be as a result of bipolar disorder.
People suffering from bipolar disorder need to be extra careful in
using any antidepressants and this includes light therapy because it can
make them over-energized or promote mania in rare cases.
If you have determined that you may have SAD, finding a physician
that knows about SAD should be your first priority. Since the disorder
has only been recently described it may be more difficult to find a physician with experience in treating it. Physicians who do not keep up with
the literature can be surprisingly uninformed about it. If your doctor or
therapist says they don’t believe in SAD or don’t know much about light
therapy, you may want to try someone else.
Treatment of SAD
The first step, obviously, is to get more light. Light therapy alone has
resolved the disorder in 85% of those diagnosed with it. Light therapy is
available in a number of ways. Getting outdoors on a bright winter day,
or bringing more light into the home are two ways almost everyone can
self-help. The best way for people with SAD to predictably and consistently get more light is with special light boxes or fixtures. These are
available through a number of commercial manufacturers; many of
which are accessible through Web sites. There are several commercial
manufacturers who distribute quality light boxes. It is recommended
using a light box from a reputable company rather than trying to create
your own light box.
For those working nights it is best to use the light box either during the
night, or before going into work after the sleep period. This is to prevent
resetting your circadian rhythm before attempting to initiate sleep. The
most difficult months for SAD sufferers are January and February, and
younger persons and women are at higher risk. It is important however to
utilize therapy properly. Sometimes people may need 45 minutes twice a
day of proper bright light therapy. This can be combined with a special
technique that turns the bedside lamp on before waking up. The device is
called Dawn Simulator. The light boxes that are currently used for treatment with light therapy all use artificial light. Generally these are fluorescent lights set in a metal frame behind a plastic diffusing screen. It is very
important to use the right kind of light because staring at incandescent
lights can damage the eyes. So be sure to use a proper light box or the
newer glasses with lights that have become available in recent years.
34
The use of tanning booths is not a way of treating SAD as there are
no good studies of tanning as a treatment for SAD. In fact, the light therapy that is used in treating SAD is not ultraviolet light at all, but visible
light that appears to work by passing through the eyes. In contrast,
when utilizing a tanning salon your eyes are usually covered and the skin
is exposed to ultraviolet light. But some patients with SAD have anecdotally reported a mood lift after such tanning sessions. They can’t be generally recommended, however, because of the risk of skin cancer as a
result of ultraviolet light exposure.
For those that tend to get migraine headaches from bright light,
starting with dimmer lights and gradually increasing the brightness may
decrease the headaches. If that still doesn’t work, antidepressant medicines may help.
Insurance companies sometimes cover the cost of light therapy,
specifically the purchase of a light fixture. But reimbursement is very
much a hit and miss affair. Some of the light box companies will provide
sample letters to your doctor to send to your insurance carrier to help
you get reimbursement.
Other treatments for SAD include exercise, stress management,
dietary control, and vacations in the south.
For those afflicted with SAD, diet may
play an important role. Many people with
SAD have an insatiable appetite for carbohydrates, however it is recommend that
carbohydrates be limited. The trouble is
the more you eat, the more you want and
this of course will lead to weight gain. For
those with SAD it is best that meals be limited to two per day where protein and
salad are predominant, and then by mixing
carbohydrates into the third meal. This is
the essence of most dietary recommendations. There is a connection between eating disorders and SAD as well, more
specifically bulimia (the tendency to binge
eat). People who have this tend to experience worsening symptoms during the winter months, and may benefit from light
therapy. This behavior in a teen girls may
be associated with SAD.
So if you’re affected by SAD, try to purchase a light box. Book a winter vacation in
the Caribbean. Minimize the stresses over
the winter. Get your exercise program in place. When those dark
days hit, you’ll be good and ready. H
About the Author
Iain Boyle, RPSGT, gained his RPSGT credentials in 1996
and worked in the Toronto area of Canada until 2002
when he moved to New Hampshire. He serves on several APT Committees and is Secretary of the New
England Polysomnographic Society, APT’s newest regional chapter. He is also an officer of the Executive
Committee for the Canadian Sleep Society. His
leisure activities include sailing, soccer, Nordic
skiing and working on British sports cars.
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Legislative Watch
continued from page 35
Be of good moral character; be at least 18 years old; and meet
the educational and clinical training requirements established by
the committee.
An applicant for a polysomnographic technician license shall:
Have successfully completed a polysomnography educational
program that includes at least 80 hours of training and teaches
a curriculum that is certified by:
The Council on the Accreditation of Allied Health Education
Programs; the Association of Polysomnographic Technologists;
the American Academy of Sleep Medicine;
the American Society of Electroneurodiagnostic Technologists; or
any other organization approved by the committee; or be a
Registered Polysomnographic Technologist; and provide written
documentation to the board that the individual has successfully
completed competency testing in polysomnography as approved
and defined by the committee in consultation with the
Polysomnographic Community.
To practice polysomnography as a polysomnographic trainee, an
applicant shall provide written documentation to the board: that
a licensed physician or licensed polysomnographic technician will
provide direct supervision over the individual’s practice of
polysomnography; and that the applicant is currently enrolled in
a polysomnography program that includes at least 80 hours of
training and teaches a curriculum that is certified by: The Council
on the Accreditation of Allied Health Education programs; the
Association of Polysomnographic Technologists; the American
Academy of Sleep Medicine; or The American Society of
Electroneurodiagnostic Technologists.
The entire text for MD HB 1022 may be viewed at www.aptweb.org
or http://mlis.state.md.us/2005rs/bills/hb/hb1022f.pdf
The APT was asked by officials of the IL Society for Respiratory Care
(ISRC) to participate in writing the portion of the bill that affects PsgT s
and to provide suggested language for the bill. That verbiage was included in the bill that was introduced.
Colorado Senate Bill 147
While a Colorado Senate bill was introduced that would add an
exemption from the act for sleep technologists engaged in purely evaluative and diagnostic enterprises for the purpose of diagnosing sleep disorders, there is some concern that partial language states that sleep
technologist job procedures fall within the scope of practice of respiratory care. The bill also states that non-credentialed PSG technicians and
trainees would be required to work under the direct supervision of a
licensed respiratory therapist or under the supervision of an individual
exempted from the proposed bill.
The APT has drafted a response to the proposed measure and
addressed it to members of the Colorado State Legislature. In 2003,
the APT released several position papers that state PSG Technology is a
separate and distinct allied health profession. APT supports measures
which exempt PSG professionals from practice acts on the basis of a
professional credentialing process, practicing under physician supervision, or on the basis of demonstrated competency for the specific tasks
in question. APT position statements may be found on the homepage at
www.aptweb.org
The Colorado Respiratory Care Practice Law sunsets this year,
meaning it would automatically terminate unless it is expressly renewed
by the state legislature. While in this process, Colorado Senate Bill 147
(CO SB147) was introduced in the Senate January 31, and assigned to
the Senate Committee on Health and Human Services. At press time,
the bill had passed its third reading but had not gone back to the full
Senate for voting. If the bill passes through both the Senate and House
of Representatives, and is signed into law by Governor Bill Owens, it
would become effective July 1, 2005 and carry through until the next
sunset in 2015.
Illinois
Illinois Senate Bill 139 (IL SB139), a bill that provides for exemption
and amends a regulatory sunset act to extend the repeal of the RC
Practice Act to January 1, 2016. SB 139 language includes:
Recently the Senate Committee on Health and Human Services recommended the following amendment to the bill which may be found on
page 3 of the document,
Eliminates certain exemptions concerning activities of unlicensed
persons who do not represent themselves as respiratory care
practitioners, qualified members of other professional groups,
and organizations or institutions that provide respiratory care
Adds exemptions concerning polysomnographic technologists,
technicians, and trainees.
(a) (III) the practice of respiratory therapy by persons who are
not registered polysomnographic technologists, but such persons shall only practice under the direct supervision of a respiratory therapist or under the supervision of an individual exempted from the provisions of this article pursuant to paragraph (g)
of this subsection (2).
12-41.5-110. Exceptions. (2) This article does not prohibit: The
practice of procedures that fall within the definition of respiratory therapy by certified pulmonary function technologists, registered pulmonary function technologists, registered polysomnographic technologists, or others who hold credentials from a
nationally recognized organization as determined by the director,
including, but not limited to, the national board for respiratory
care; except that the scope of practice of a registered
polysomnographic technologist shall not exceed oxygen titration
and noninvasive positive pressure ventilation titration.”.
Nothing in this Act shall prohibit a polysomnographic technologist, technician, or trainee, as defined by the Association of
Polysomnographic Technologists (APT), from performing activities within the scope of practice adopted by the APT, while under
the direction of a physician licensed in this State
At press time, SB 139 was awaiting committee reading after being
assigned to the IL Licensed Activities Committee on February 3, the date
State Sen. Edward D. Maloney was added as chief co-sponsor of the bill.
On February 1, the bill was filed by State Sen. M. Maggie Crotty, and had
its first readeing, after which time it was referred to the NJ Senate
Rules Committee.
Full language of for SB 147 may be found through www.aptweb.org
or through http://www.leg.state.co.us H
35
Classified Ads
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Chief Polysomnographic Technician
The Sleep Research Center at McLean
Hospital in Belmont, Massachusetts is seeking a qualified, experienced polysomnographic technician for a full time, chief tech
position in our research lab. Candidate must
be mature, detail-oriented and flexible.
Responsibilities include:
• Preparation and monitoring of research subjects for several industrysponsored clinical trials and an NIH-funded study that involves a sleep
deprivation protocol and MR spectroscopy.
• Ability to run standard digital polysomnographic recordings.
• Basic knowledge and skill in the scoring of sleep.
• Administration of questionnaires, cognitive testing with subjects, maintenance of subject charts, data entry.
• Potential trouble shooting of technical issues.
• Some supervision/training of part-time and per-diem techs.
Job Requirements:
• Bachelor’s degree and at least one year of experience in polysomnography.
• RPSGT required.
• Must be detail-oriented and able to interact easily with research subjects and other laboratory personnel.
• Background in a research setting is helpful.
Ideal position for experienced sleep technician who is ready to move
away from nightly CPAP titrations into a more creative, independent position. Salary depends on experience. Please forward resume to: McLean
Hospital, Sleep Research Lab, 115 Mill Street, Belmont, MA 02478
Fax: 617-855-3784.
Registered Polysomnographic
Technologists or Experienced Technicians
Las Vegas, Nevada and Southern Alabama fast-growing, privately-owned
Sleep Diagnostic Centers are seeking Registered Polysomnographic
Technologists or experienced technicians with registry interest. Will train
RRT’s and EEG Techs.
Our Las Vegas center is JCAHO accredited and the Alabama center is
AASM accredited. We have seven centers with 3-5 beds each. In Las
Vegas, our data acquisition equipment is Grass, in Alabama we use
Nihon Khoden. We currently have six RPSGTs on staff and a RPSGT
technical advisor with 15 years of sleep experience. Our Medical
Director is American Board Certified in Sleep Disorders Medicine and is
Stanford University Sleep Fellowship trained.
We are seeking to staff our existing centers and anticipate additional
centers in the near future. We are looking for professionals interested
in growing with our organization. Salary and benefits are commensurate
with experience.
Please send a letter of interest and your resume to [email protected] or
[email protected] or fax to 702-990-7665 ATTN: Rob or Carrie.
ADVERTISING INFORMATION: The APT offers
a full range of advertising products. See the
advertising page on APTWEB, fax 781-823-4787,
or e-mail [email protected] for details.
36
Key Provisions to Consider for a
Medical Director Contract
continued from page 33
Accreditation Standards
The proposed medical director contract should also contain a compliance provision which states that the physician, as medical director of
the sleep disorder center, agrees to comply with all applicable state and
federal laws and regulations, including HIPAA, and the policies and procedures of the sleep disorder center, and that he will provide services in
accordance with applicable accreditation standards.
Many sleep disorder centers seek accreditation as a benchmark for
reimbursement, continued certification and licensure, and as a key element of managed care participation agreements. It is important that the
physician is aware of what his role and duties as the medical director will
be in relation to initial accreditation of the sleep disorder center and
maintenance of such accreditation. The accreditation process will
require the physician to have additional responsibilities and involvement
during the accreditation survey preparation and following the survey to
ensure continued compliance.
Before a sleep disorder center and physician sign a medical director
contract, both parties should make sure that they carefully review all of
the terms of the agreement, including: the private practice, independent
contractor, clarifications to law, and accreditation provisions. H
About the Author
Jayme Matchinski, Esq., a partner with the law firm of Harris Kessler & Goldstein LLC, in
Chicago, concentrates on health care law and has counseled sleep disorder centers, physicians, and health care groups nationally. She can be reached at (312) 280-0111 or
[email protected].
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STUDY GUIDES
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APT Review Course, 2nd Edition (Individual) Intense review preparing for the registry exam. Realtime video alongside
an electronic presentation. Includes CD, booklet and review test to complete and return for 14 CEC credits ..........................$325 / $375
qty______
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APT Review Course, 2nd Edition (Institutional) Intense review preparing for the registry exam. Realtime video alongside
an electronic presentation. Includes CD, booklet and five review tests to complete and return for 14 CEC credits per test......$895 / $895
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Normal and Abnormal Record Flashcards....................................................................................................................................$65 / $85
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BRPT Self Assessment Exam ........................................................................................................................................................$35 / $45
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Current Concepts: Sleep Disorders The first textbook any PSG technologist should own. Covers normal sleep, diagnosis
approaches, sleep disorders classifications and waveform graphics depicting the stages of sleep. No shipping charge! ..............$5 / $10
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2003 Demographic, Salary & Educational Needs Survey
Identifies PSG technologist practice environments, technologist characteristics, compensation, and education ........................$50 / $150
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R&K Scoring Manual Technical Manual Written by A. Rechtschaffen and A. Kales.
Includes standardized terminology, techniques and a scoring system for sleep stages ................................................................$60 / $75
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Artifact and Troubleshooting Guide ..............................................................................................................................................$25 / $35
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Filter Settings and Calibrations: Simple Explanation for a Complex Procedure
Technical article written by Edwin Cintron, RPSGT. No shipping charge! ......................................................................................$10 / $15
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Clinical Practice Guidelines No shipping charge! ..........................................................................................................................$5 / $10
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“Sleeping On the Job!” Answers basic questions on site location, design, setup, staffing and more.
Offers resources for locating equipment and supplies and is highlighted by a sample Policy and Procedure manual ..................$60 / $60
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TECHNICAL/EDUCATIONAL
MEMBERSHIP/GIFTS
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Price (member/non-member)
APT Membership Pin ..............................................................................................................................................................................$30
qty______
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Sleep Disorders Awareness Pin Show you care! Makes a great PSG Technologist Appreciation Week gift ................................$10 / $10
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“Celestial Delectables” Cookbook APT Silver Anniversary cookbook..........................................................................................$25 / $30
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“Guardian Sleep” Print Limited Edition series of 500 color prints (certificate included).
The original painting was rendered in oil and mixed media ..............................................................................$35 Unsigned, $40 Signed
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“Sentries of the Night” Print Color print, measures approximately 8-1/2” x 11” ..........................................................................$8 / $10
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APT Santa Flag Display holiday spirit in your sleep lab! Measures 24” X 36”, vibrant colors. While supplies last! ....................$35 / $45
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APT Denim Shirt High-quality denim shirt featuring the APT logo. Available sizes: M / L / XL / XXL / XXXL ..............................$40 / $40
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Shipping Company/Name and Address __________________________________________________________________________________________
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Or, fax to:
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Please note that the APT does not accept purchase orders or phone orders. The APT accepts no responsibility for loss of product shipped via the US Postal Service. We can ship
via FedEx or UPS 2-Day for a fee of $20.00 within the continental US. Next day delivery is not available. International shipping is available through FedEx, please contact the APT
National Office for a quote.
Rev. 2/05
37
Membership Application
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
Association of Polysomnographic
Technologists
Membership Application
SPECIFIC POLICIES:
1. Membership is open to all individuals interested in sleep medicine.
2. The membership year is January 1 through December 31.
3. All memberships are on an individual basis, including those paid by an employer, and cannot be transferred from one individual to another.
4. Returned check policy: A $25 service fee will be assessed and membership benefits suspended until payment is received.
PLEASE CHECK THOSE WHICH APPLY:
q Active Membership — $75
q APT Membership Pin — $30 + $10 shipping
TOTAL ENCLOSED:_________________
*Check or money order must be in U.S. dollars, drawn on a U.S. bank, and made payable to the APT.
Please see product order form for additional items available.
Name:______________________________________________________________________________________________________________________
First
M. Initial
Last
S.S.#
Home Address:______________________________________________________________________________________________________________
City, State, Zip:________________________________________________________ Phone: ____________________________________________________
Business Name: ____________________________________________________________________________________________________________________________________________________________________
Business Address:__________________________________________________________________________________________________________________
City, State, Zip:________________________________________________________ Phone: ____________________________________________
E-Mail:_______________________________________________________________ Fax: ____________________________________________
Indicate which address should be published in the directory:
q home address q business address
Send correspondence to (please check one):
q home address q business address
Years employed in Sleep Medicine:_____________
Are you an RPSGT?
q No
q Yes
Applicant’s Signature:____________________________________________________ Date:__________________________________________________________________________________________________________________________
Please mail your application and payment to:
APT National Office
One Westbrook Corporate Center, Suite 920
Westchester, IL 60154
q Mastercard
q Visa
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Phone: (708) 492-0796
Fax: (708) 273-9344
Web site: www.aptweb.org
Card Number:_____________________________________ Exp. Date: ____________
Cardholder’s Signature:__________________________________________________________________________________________________________________________________________________________
The Revenue Act of 1987 requires the following statement to be published:
Membership dues are not deductible as charitable contributions.
APT does not discriminate among applicants on the basis of age, sex, race,
religion, national origin, handicap or marital status.
Rev. 2/05
38
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
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sleep professionals.
Multiple locations, good working environment, competitive pay.
• Extensive video demonstrations
• Audio clips and helpful tips
• Competency tests for CEC and CE credits
Modules Include:
Interactive Sleep Scoring
Preparing The Adult Patient For
Polysomnography
Performing A Diagnostic Polysomnogram
Performing A Titration Polysomnogram
Professor Wink™
Polysomnogram Core Program
Sleep Center Management Tools
from puzzle on page 32
Word Search Solution
Business Practices for Sleep Centers
A Guide to Sleep Center/Lab Reimbursement
Quick Quiz!
Call today for pricing and information
1-800-639-5432
Question: Name for a sudden arousal
from NREM sleep with a piercing scream or cry.
Answer: Sleep Terrors
Reference: Hauri, P. Current Concepts Sleep Disorders,
1992, p 37
Question: Name for a maneuver that
generates negative intra-thoracic pressures with
inspiratory effort against an obstructed airway.
Answer: Mueller Maneuver
ONE PARK WEST CIRCLE, SUITE 301 • MIDLOTHIAN, VA 23114
Reference: Shepard, J., Atlas of SLeep Medicine,
1991, p 135
39
SleepLand Calendar
Publication of the Association of Polysomnographic Technologists • Winter/Spring 2005 • www.aptweb.org
SOUTHERN SLEEP SOCIETY March 29-April 2, 2005. Hyatt
Regency New Orleans, New Orleans, LA. Please visit www.southernsleep.net or e-mail [email protected]
WORLD FEDERATION OF SLEEP RESEARCH SOCIETIES (WFSRS)
September 22-26, 2005, New Delhi, India. Please visit www.sleepaus.on.net
NATIONAL POLYSOMNOGRAPHIC
RECOGNITION WEEK, April 4-10, 2005
OF
SOUTHEAST/SOUTHWEST
REGION
ASSOCIATION
POLYSOMNOGRAPHIC TECHNOLOGISTS (SE/SW RAPT) September
23-25, 2005, Biloxi, Mississippi. Please contact [email protected]
Additional information will be available on the website. Please visit sesw.org
TECHNOLOGIST
(PsgT)
MEDTRADE SPRING April 5-7, 2005, Las Vegas Convention Center,
Las Vegas, NV. Please visit www.medtrade.com
FOCUS CONFERENCE April 7-9, 2005, Cleveland Convention
Center, Cleveland, OH. Please visit www.focus.com
ALABAMA ASSOCIATION OF SLEEP PROFESSIONALS May 13-15,
2005, Perdido Beach, AL. Please visit www.aasp.us
APT AND APSS ANNUAL MEETINGS June 18-23, 2005, Colorado
Convention Center, Denver, Co. Please visit www.aptweb.org
APT PUBLIC POLICY WORKSHOP — CAREER REGULATION OF
POLYSOMNOGRAPHIC TECHNOLOGISTS Denver, Colorado, 1 pm to
4:45 pm, Tuesday, June 21 (during APT 2005 Annual Meeting) at the
Denver Westin Tabor Center (APT Hotel). Speakers include William
Dement, MD, Stanford University, and Catherine Dower, JD, Associate
Director at the Health Law & Policy Division of the UCSF Center for the
Health Professions, San Francisco, CA; Frankie Roman, MD, JD, Ohio
Sleep Disorders Center, Canton, OH; and Jayme Matchinski, JD, of the
law firm of Harris, Kessler & Goldstein, Chicago. Admission free. See full
program at www.aptweb.org.
MONTANA REGIONAL SLEEP SEMINAR October 13-15, 2005,
Billings, Montana. Please contact [email protected]
EUROPEAN SLEEP RESEARCH SOCIETY 2006 Meeting is scheduled in Innsbruck, Austria. Please visit ww.esrs.org
Quick Quiz!
Question
What type of montage is recommended in
order to maximize the voltages for recording
EEG during a polysomnographic evaluation?
Answer
Referential montage using contralateral ear
references.
Reference
Rechtschaffen & Kales, A Manual of Standardized Scoring
System for Sleep Stages of Human Subjects, 1968.
Polysomnography Course Coming This Spring!
Our new courses are conducted by a team of the country’s leading experts in polysomnography. Classes start April 5, 2005, at 5:00pm on Tuesdays.
Program Director:
Dr. Veronica Drantz
New innovative course in
the Electroneurodiagnostic
Technology (ENDT)
Program designed to better
serve your patients.
Contact Darren White at:
East-West University
816 S. Michigan Ave.
Chicago, IL 60605
Phone: 312-939-0111
Fax: 312-939-0083
www.eastwest.edu
Alexander Golbin, M.D., PhD
Neuropsychiatrist
American Board of Sleep and
Behavior Medicine Institute
Cassandra Smiley, BS, CRT, RPSGT
Sr. Sleep Research Technologist
University of Chicago
Gary Hansen, B.S., R.PSG.T
Technical Manager
Sleep Disorders Centers
Evanston Northwestern Healthcare
Andre’ Smith BS, RPSGT
Center Director for Sleep
Ventilatory Disorders
University of Illinois Medical Center
Lan Ly, B.S., R.PSG.T
Resource Coordinator
Sleep Disorders Center
Northwestern Memorial Hospital
Nidhi S. Undevia, M.D.
Assistant Professor of Medicine
Div. of Pulmonary & Critical Care Medicine
Loyola University Medical Center
Richard S. Rosenberg, PhD
Senior Director for Science and Research
American Academy of Sleep Medicine
Jaime Villanueva, M.D.
Assistant Professor of Medicine
Pulmonary and Critical Care
Loyola University Medical Center
Stephen H. Sheldon, D.O., F.A.A.P.
Associate Professor of Pediatrics
Northwestern University
Director Sleep Medicine Center
Children’s Memorial Hospital
Lisa F. Wolfe, M.D.
Assistant Professor of Medicine
Northwestern University
Fienberg School of Medicine
Loyola University Medical Center
Prepare for the PSG Registration Exam! Train on State of the Art Sleep Systems!
40
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Toll Free: 877-472-7779 (USA & Canada only)
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