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Non-24–Hour Sleep-Wake Disorder A Case-Based Discussion on Diagnosis and Treatment

Karl Doghramji, MD; Paul P. Doghramji, MD, FAAFP


This activity is jointly provided by Global Education Group and Integritas Communications.

This activity is supported by an educational grant from Vanda Pharmaceuticals.

Faculty

Karl Doghramji, MD
Professor of Psychiatry, Neurology, and Medicine
Medical Director, Jefferson Sleep Disorders Center
Program Director, Fellowship in Sleep Medicine
Thomas Jefferson University
Philadelphia, Pennsylvania

Paul P. Doghramji, MD, FAAFP
Family Physician
Collegeville Family Practice
Medical Director of Health Services
Ursinus College
Collegeville, Pennsylvania

Educational Objectives

Upon completion of this activity, participants will be better prepared to:

  • Diagnose non-24–hour sleep-wake disorder based on presenting symptoms, a comprehensive sleep history, and published diagnostic criteria
  • Tailor therapeutic regimens for patients with non-24–hour sleep-wake disorder, including appropriate combinations of nonpharmacologic and pharmacologic modalities
  • Educate patients with non-24–hour sleep-wake disorder on the deleterious effects of disrupted circadian rhythms, behavioral management strategies, and pharmacologic treatment options

Target Audience

The educational design of this activity addresses the needs of primary care providers (PCPs), sleep specialists, and other clinicians involved in the identification and ongoing treatment of patients with non-24–hour sleep-wake disorder (non-24 disorder).

Statement of Need/Program Overview

Non-24 disorder is characterized by complaints of insomnia and/or excessive daytime sleepiness that result from a progressive desynchronization of the earth’s usual 24-hour light/dark cycle and the individual’s endogenous circadian rhythms.1,2 As many as half of totally blind patients suffer from non-24 disorder, and the incidence of non-24 disorder also appears to be more common than previously appreciated in sighted individuals in their teens and 20s.3,4 Non-24 disorder is underdiagnosed, in part because patients do not proactively discuss sleep-related issues with their healthcare providers, and time-limited clinicians often do not regularly inquire about insomnia or excessive sleepiness.5,6 Moreover, until recently, treatment recommendations were largely based on case series and clinical experience rather than well-designed clinical trials.6,7 This case-based POC101 program will educate clinician-learners regarding the pathophysiologic basis of non-24 disorder, current diagnostic criteria, behavioral approaches to improving sleep hygiene and daily scheduling, and evidence-based pharmacologic interventions.

References

  1. Zee PC, Attarian H, Videnovic A.. Circadian rhythm abnormalities. Continuum (Minneap Minn). 2013;19(1 Sleep Disorders):132-147.
  2. American Academy of Sleep Medicine. International Classification of Sleep Disorders Diagnostic and Coding Manual, Third Edition (ICSD-3). 3rd ed. Westchester, IL: 2014.
  3. Uchiyama M, Lockey SW. Non-24–hour sleep-wake syndrome in sighted and blind patients. Sleep Med Clin. 2015;10(4):495-516.
  4. Hayakawa T, Uchiyama M, Kamei Y, et al. Clinical analyses of sighted patients with non-24–hour sleep-wake syndrome: A study of 57 consecutively diagnosed cases. Sleep. 2005;28(8):945-952.
  5. National Sleep Foundation. 2009 Sleep in America Poll: Health and Safety. Sleep Health. 2009:1(2)e8.
  6. Sorscher AJ. How is your sleep: A neglected topic for health care screening. J Am Board Fam Med. 2008;21(2):141-148.
  7. Auger RR, Burgess HJ, Emens JS, Deriy LV, Thomas SM, Sharkey KM. Clinical practice guideline for the treatment of intrinsic circadian rhythm sleep-wake disorders: advanced sleep-wake phase disorder (ASWPD), delayed sleep-wake phase disorder (DSWPD), non-24–hour sleep-wake rhythm disorder (N24SWD), and irregular sleep-wake rhythm disorder (ISWRD). An update for 2015. J Clin Sleep Med. 2015;11(10):1199-1236.
  8. Lockley SW, Dressman MA, Licamele L, et al. Tasimelteon for non-24–hour sleep–wake disorder in totally blind people (SET and RESET): two multicentre, randomised, double-masked, placebo-controlled phase 3 trials. Lancet. 2015;386(10005):1754-1764.

Physician Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Global Education Group (Global) and Integritas Communications (Integritas). Global is accredited by the ACCME to provide continuing medical education for physicians.

Physician Credit Designation

Global designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Global Contact Information

For information about the accreditation of this program, please contact Global at 303-395-1782 or inquire@globaleducationgroup.com.

Instructions to Receive Credit

In order to receive credit for this activity, the participant must score 70% or better on the posttest and complete the program evaluation.

System Requirements

PC
Microsoft Windows 2000 SE or above.
Flash Player Plugin (v7.0.1.9 or greater)
Internet Explorer (v5.5 or greater), or Firefox
Adobe Acrobat Reader

MAC
MAC OS 10.2.8
Flash Player Plugin (v7.0.1.9 or greater)
Safari
Adobe Acrobat Reader
Internet Explorer is not supported on Macintosh.

Fee Information & Refund/Cancellation Policy

There is no fee for this educational activity.

Disclosure of Conflicts of Interest

Global requires instructors, planners, managers, and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this continuing medical education (CME) activity:

Karl Doghramji, MD  Nothing to disclose

Paul P. Doghramji, MD, FAAFP  Consultant (AstraZeneca, Merck & Co., Inc., Teva Pharmaceutical Industries Ltd.);Speakers Bureau (Merck & Co., Inc., Takeda Pharmaceuticals U.S.A., Inc., Teva Pharmaceutical Industries Ltd.)

The planners and managers reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity:

Lindsay Borvansky     Nothing to disclose
Andrea Funk     Nothing to disclose
Laura Gilsdorf     Nothing to disclose
Jim Kappler, PhD     Nothing to disclose

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Global Education Group (Global) and Integritas Communications do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Click "Begin Activity" to acknowledge that you have reviewed the preamble information for this activity.

Begin Activity

expiration 02/07/2018

type POC101


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1 0.003035 0.003035 0.003035 0.003035
SELECT `event`.`id` AS `t1_c0`, `event`.`group_id` AS `t1_c1`, `event`.`shortAddress` AS `t1_c2`, `event`.`resource_id` AS `t1_c3`, `event`.`type` AS `t1_c4`, `event`.`addType` AS `t1_c5`, `event`.`title` AS `t1_c6`, `event`.`shortDescription` AS `t1_c7`, `event`.`facultyNames` AS `t1_c8`, `event`.`faculty` AS `t1_c9`, `event`.`calendarDate` AS `t1_c10`, `event`.`creditAmount` AS `t1_c11`, `event`.`creditType` AS `t1_c12`, `event`.`shortWhen` AS `t1_c13`, `event`.`fullWhen` AS `t1_c14`, `event`.`venue` AS `t1_c15`, `event`.`shortWhere` AS `t1_c16`, `event`.`fullWhere` AS `t1_c17`, `event`.`createDate` AS `t1_c18`, `event`.`status` AS `t1_c19`, `event`.`description` AS `t1_c20`, `event`.`image` AS `t1_c21`, `event`.`linkout` AS `t1_c22`, `event`.`registrationEnabled` AS `t1_c23`, `event`.`activity_id` AS `t1_c24`, `event`.`adobe_connect_sco` AS `t1_c25`, `event`.`adobe_connect_datetime` AS `t1_c26`, `event`.`users_limit` AS `t1_c27`, `event`.`adobe_connect_duration` AS `t1_c28`, `event`.`calendar_description` AS `t1_c29` FROM `events` `event` WHERE (`event`.`activity_id`=:ypl0)
3 0.002483 0.000828 0.000282 0.001911
SHOW COLUMNS FROM `activities`
1 0.002154 0.002154 0.002154 0.002154
SHOW CREATE TABLE `activities`
1 0.002105 0.002105 0.002105 0.002105
SELECT * FROM `activities` `t` WHERE `t`.`id`=55 LIMIT 1
5 0.001635 0.000327 0.000278 0.000498
SHOW COLUMNS FROM `events`
1 0.001499 0.001499 0.001499 0.001499
SHOW COLUMNS FROM `users`
1 0.001241 0.001241 0.001241 0.001241
SHOW COLUMNS FROM `user_activitiesstatus`
1 0.001151 0.001151 0.001151 0.001151
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
2 0.001140 0.000570 0.000282 0.000858
SHOW COLUMNS FROM `resources`
1 0.001094 0.001094 0.001094 0.001094
SHOW COLUMNS FROM `interactions`
1 0.001039 0.001039 0.001039 0.001039
SHOW COLUMNS FROM `view_log`
1 0.001033 0.001033 0.001033 0.001033
SHOW COLUMNS FROM `questionnaires`
1 0.001024 0.001024 0.001024 0.001024
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
2 0.000975 0.000487 0.000461 0.000514
SELECT `t`.`id` AS `t0_c0`, `t`.`group_id` AS `t0_c1`, `t`.`resource_id` AS `t0_c2`, `t`.`title` AS `t0_c3`, `t`.`type` AS `t0_c4`, `t`.`facultyNames` AS `t0_c5`, `t`.`shortDescription` AS `t0_c6`, `t`.`fullDescription` AS `t0_c7`, `t`.`creditAmount` AS `t0_c8`, `t`.`shortAddress` AS `t0_c9`, `t`.`creditType` AS `t0_c10`, `t`.`startDate` AS `t0_c11`, `t`.`finishDate` AS `t0_c12`, `t`.`sponsors` AS `t0_c13`, `t`.`status` AS `t0_c14`, `t`.`createDate` AS `t0_c15`, `t`.`image` AS `t0_c16`, `t`.`image_featured` AS `t0_c17`, `t`.`archived` AS `t0_c18`, `t`.`managers_list` AS `t0_c19`, `t`.`is_send_pp_email` AS `t0_c20`, `t`.`muvi_sync_date` AS `t0_c21`, `t`.`expert_questions` AS `t0_c22`, `interaction`.`id` AS `t1_c0`, `interaction`.`activity_id` AS `t1_c1`, `interaction`.`title` AS `t1_c2`, `interaction`.`link` AS `t1_c3`, `interaction`.`type` AS `t1_c4`, `interaction`.`status` AS `t1_c5`, `interaction`.`createDate` AS `t1_c6` FROM `activities` `t` LEFT OUTER JOIN `interactions` `interaction` ON (`interaction`.`activity_id`=`t`.`id`) WHERE (`t`.`id`=55)
1 0.000650 0.000650 0.000650 0.000650
SELECT `resource`.`id` AS `t1_c0`, `resource`.`shortAddress` AS `t1_c1`, `resource`.`status` AS `t1_c2`, `resource`.`title` AS `t1_c3`, `resource`.`type` AS `t1_c4`, `resource`.`image` AS `t1_c5`, `resource`.`slides` AS `t1_c6`, `resource`.`linkedResources` AS `t1_c7`, `resource`.`reading` AS `t1_c8`, `resource`.`shortDescription` AS `t1_c9`, `resource`.`fullDescription` AS `t1_c10`, `resource`.`link` AS `t1_c11`, `resource`.`createDate` AS `t1_c12`, `resource`.`archived` AS `t1_c13` FROM `resources` `resource` WHERE (`resource`.`id`=:ypl0)
1 0.000539 0.000539 0.000539 0.000539
SHOW CREATE TABLE `users`
1 0.000478 0.000478 0.000478 0.000478
SELECT `activity_id` AS `c`, COUNT(*) AS `s` FROM `user_activitiesstatus` `t` WHERE (user_id=:user AND isFinished=1) AND (`t`.`activity_id`=55) GROUP BY `activity_id`
1 0.000423 0.000423 0.000423 0.000423
SELECT * FROM `questionnaires` `t` WHERE t.activity_id=:id AND t.type=:type LIMIT 1
1 0.000411 0.000411 0.000411 0.000411
SHOW CREATE TABLE `resources`
1 0.000343 0.000343 0.000343 0.000343
SHOW CREATE TABLE `events`
1 0.000340 0.000340 0.000340 0.000340
SHOW CREATE TABLE `view_log`
1 0.000338 0.000338 0.000338 0.000338
SHOW CREATE TABLE `user_activitiesstatus`
1 0.000282 0.000282 0.000282 0.000282
SHOW CREATE TABLE `interactions`
1 0.000269 0.000269 0.000269 0.000269
SHOW CREATE TABLE `questionnaires`
1 0.000268 0.000268 0.000268 0.000268
# Query Time (s)
0
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
0.000858
1
SHOW COLUMNS FROM `activities`
0.002154
2
SHOW CREATE TABLE `activities`
0.002105
3
SHOW COLUMNS FROM `users`
0.001241
4
SHOW CREATE TABLE `users`
0.000478
5
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
0.000514
6
INSERT INTO `users` (`role`, `sendEmails`, `sendSms`, `source`, `session`, `lastLogin`, `phone`, `createDate`) VALUES (:yp0, :yp1, :yp2, :yp3, :yp4, :yp5, :yp6, :yp7)
0.004831
7
SELECT * FROM `users` `t` WHERE session=:session LIMIT 1
0.000461
8
UPDATE `users` SET `lastLogin`=:yp0 WHERE `users`.`id`=2491918
0.003035
9
SELECT * FROM `activities` `t` WHERE `t`.`id`=55 LIMIT 1
0.000498
10
SHOW COLUMNS FROM `events`
0.001499
11
SHOW CREATE TABLE `events`
0.000340
12
SELECT `event`.`id` AS `t1_c0`, `event`.`group_id` AS `t1_c1`, `event`.`shortAddress` AS `t1_c2`, `event`.`resource_id` AS `t1_c3`, `event`.`type` AS `t1_c4`, `event`.`addType` AS `t1_c5`, `event`.`title` AS `t1_c6`, `event`.`shortDescription` AS `t1_c7`, `event`.`facultyNames` AS `t1_c8`, `event`.`faculty` AS `t1_c9`, `event`.`calendarDate` AS `t1_c10`, `event`.`creditAmount` AS `t1_c11`, `event`.`creditType` AS `t1_c12`, `event`.`shortWhen` AS `t1_c13`, `event`.`fullWhen` AS `t1_c14`, `event`.`venue` AS `t1_c15`, `event`.`shortWhere` AS `t1_c16`, `event`.`fullWhere` AS `t1_c17`, `event`.`createDate` AS `t1_c18`, `event`.`status` AS `t1_c19`, `event`.`description` AS `t1_c20`, `event`.`image` AS `t1_c21`, `event`.`linkout` AS `t1_c22`, `event`.`registrationEnabled` AS `t1_c23`, `event`.`activity_id` AS `t1_c24`, `event`.`adobe_connect_sco` AS `t1_c25`, `event`.`adobe_connect_datetime` AS `t1_c26`, `event`.`users_limit` AS `t1_c27`, `event`.`adobe_connect_duration` AS `t1_c28`, `event`.`calendar_description` AS `t1_c29` FROM `events` `event` WHERE (`event`.`activity_id`=:ypl0)
0.001911
13
select id, status from activities where FIND_IN_SET(:shortAddress, shortAddress)
0.000282
14
SELECT * FROM `activities` `t` WHERE `t`.`id`=55 LIMIT 1
0.000282
15
SELECT `event`.`id` AS `t1_c0`, `event`.`group_id` AS `t1_c1`, `event`.`shortAddress` AS `t1_c2`, `event`.`resource_id` AS `t1_c3`, `event`.`type` AS `t1_c4`, `event`.`addType` AS `t1_c5`, `event`.`title` AS `t1_c6`, `event`.`shortDescription` AS `t1_c7`, `event`.`facultyNames` AS `t1_c8`, `event`.`faculty` AS `t1_c9`, `event`.`calendarDate` AS `t1_c10`, `event`.`creditAmount` AS `t1_c11`, `event`.`creditType` AS `t1_c12`, `event`.`shortWhen` AS `t1_c13`, `event`.`fullWhen` AS `t1_c14`, `event`.`venue` AS `t1_c15`, `event`.`shortWhere` AS `t1_c16`, `event`.`fullWhere` AS `t1_c17`, `event`.`createDate` AS `t1_c18`, `event`.`status` AS `t1_c19`, `event`.`description` AS `t1_c20`, `event`.`image` AS `t1_c21`, `event`.`linkout` AS `t1_c22`, `event`.`registrationEnabled` AS `t1_c23`, `event`.`activity_id` AS `t1_c24`, `event`.`adobe_connect_sco` AS `t1_c25`, `event`.`adobe_connect_datetime` AS `t1_c26`, `event`.`users_limit` AS `t1_c27`, `event`.`adobe_connect_duration` AS `t1_c28`, `event`.`calendar_description` AS `t1_c29` FROM `events` `event` WHERE (`event`.`activity_id`=:ypl0)
0.000290
16
SELECT * FROM `activities` `t` WHERE `t`.`id`=55 LIMIT 1
0.000294
17
UPDATE activities SET archived=1 WHERE finishDate<now();
0.006021
18
SHOW COLUMNS FROM `view_log`
0.001033
19
SHOW CREATE TABLE `view_log`
0.000338
20
INSERT INTO `view_log` (`source`, `unique_id`, `resource_id`, `type`) VALUES (:yp0, :yp1, :yp2, :yp3)
0.003052
21
SHOW COLUMNS FROM `user_activitiesstatus`
0.001151
22
SHOW CREATE TABLE `user_activitiesstatus`
0.000282
23
SHOW COLUMNS FROM `interactions`
0.001039
24
SHOW CREATE TABLE `interactions`
0.000269
25
SELECT `t`.`id` AS `t0_c0`, `t`.`group_id` AS `t0_c1`, `t`.`resource_id` AS `t0_c2`, `t`.`title` AS `t0_c3`, `t`.`type` AS `t0_c4`, `t`.`facultyNames` AS `t0_c5`, `t`.`shortDescription` AS `t0_c6`, `t`.`fullDescription` AS `t0_c7`, `t`.`creditAmount` AS `t0_c8`, `t`.`shortAddress` AS `t0_c9`, `t`.`creditType` AS `t0_c10`, `t`.`startDate` AS `t0_c11`, `t`.`finishDate` AS `t0_c12`, `t`.`sponsors` AS `t0_c13`, `t`.`status` AS `t0_c14`, `t`.`createDate` AS `t0_c15`, `t`.`image` AS `t0_c16`, `t`.`image_featured` AS `t0_c17`, `t`.`archived` AS `t0_c18`, `t`.`managers_list` AS `t0_c19`, `t`.`is_send_pp_email` AS `t0_c20`, `t`.`muvi_sync_date` AS `t0_c21`, `t`.`expert_questions` AS `t0_c22`, `interaction`.`id` AS `t1_c0`, `interaction`.`activity_id` AS `t1_c1`, `interaction`.`title` AS `t1_c2`, `interaction`.`link` AS `t1_c3`, `interaction`.`type` AS `t1_c4`, `interaction`.`status` AS `t1_c5`, `interaction`.`createDate` AS `t1_c6` FROM `activities` `t` LEFT OUTER JOIN `interactions` `interaction` ON (`interaction`.`activity_id`=`t`.`id`) WHERE (`t`.`id`=55)
0.000650
26
SELECT `activity_id` AS `c`, COUNT(*) AS `s` FROM `user_activitiesstatus` `t` WHERE (user_id=:user AND isFinished=1) AND (`t`.`activity_id`=55) GROUP BY `activity_id`
0.000423
27
SELECT `event`.`id` AS `t1_c0`, `event`.`group_id` AS `t1_c1`, `event`.`shortAddress` AS `t1_c2`, `event`.`resource_id` AS `t1_c3`, `event`.`type` AS `t1_c4`, `event`.`addType` AS `t1_c5`, `event`.`title` AS `t1_c6`, `event`.`shortDescription` AS `t1_c7`, `event`.`facultyNames` AS `t1_c8`, `event`.`faculty` AS `t1_c9`, `event`.`calendarDate` AS `t1_c10`, `event`.`creditAmount` AS `t1_c11`, `event`.`creditType` AS `t1_c12`, `event`.`shortWhen` AS `t1_c13`, `event`.`fullWhen` AS `t1_c14`, `event`.`venue` AS `t1_c15`, `event`.`shortWhere` AS `t1_c16`, `event`.`fullWhere` AS `t1_c17`, `event`.`createDate` AS `t1_c18`, `event`.`status` AS `t1_c19`, `event`.`description` AS `t1_c20`, `event`.`image` AS `t1_c21`, `event`.`linkout` AS `t1_c22`, `event`.`registrationEnabled` AS `t1_c23`, `event`.`activity_id` AS `t1_c24`, `event`.`adobe_connect_sco` AS `t1_c25`, `event`.`adobe_connect_datetime` AS `t1_c26`, `event`.`users_limit` AS `t1_c27`, `event`.`adobe_connect_duration` AS `t1_c28`, `event`.`calendar_description` AS `t1_c29` FROM `events` `event` WHERE (`event`.`activity_id`=:ypl0)
0.000282
28
SELECT * FROM `activities` `t` WHERE `t`.`id`=55 LIMIT 1
0.000283
29
SELECT * FROM `activities` `t` WHERE `t`.`id`=55 LIMIT 1
0.000278
30
SHOW COLUMNS FROM `questionnaires`
0.001024
31
SHOW CREATE TABLE `questionnaires`
0.000268
32
SELECT * FROM `questionnaires` `t` WHERE t.activity_id=:id AND t.type=:type LIMIT 1
0.000411
33
SHOW COLUMNS FROM `resources`
0.001094
34
SHOW CREATE TABLE `resources`
0.000343
35
SELECT `resource`.`id` AS `t1_c0`, `resource`.`shortAddress` AS `t1_c1`, `resource`.`status` AS `t1_c2`, `resource`.`title` AS `t1_c3`, `resource`.`type` AS `t1_c4`, `resource`.`image` AS `t1_c5`, `resource`.`slides` AS `t1_c6`, `resource`.`linkedResources` AS `t1_c7`, `resource`.`reading` AS `t1_c8`, `resource`.`shortDescription` AS `t1_c9`, `resource`.`fullDescription` AS `t1_c10`, `resource`.`link` AS `t1_c11`, `resource`.`createDate` AS `t1_c12`, `resource`.`archived` AS `t1_c13` FROM `resources` `resource` WHERE (`resource`.`id`=:ypl0)
0.000539
Log Messages
Message (details) Level Category Time