In the true spirit of the name CONTINUUM, it is my privilege to begin my editorship at the start of the 20th anniversary year of this journal and with the publication of this educationally rich issue on sleep disorders, the production of which was well under way when the editor-in-chief baton was passed to me by Dr Aaron Miller. Dr Alon Avidan, the guest editor for this issue, has assembled an expert faculty to teach us the state of the art of sleep medicine.
This issue begins with an overview by Dr Clifford Saper on the basic neuroanatomy and neurophysiology of sleep and its disorders, an expert explanation of a topic that underlies many of the subsequent clinical discussions. Next, Drs Anita Shelgikar and Ronald Chervin discuss the clinical assessment of patients with sleep disorders, emphasizing important historical clues and examination findings, and elucidate the major diagnostic tests used to evaluate sleep-related symptoms.
Dr David Neubauer discusses chronic insomnia, including a discussion of the nonpharmacologic and pharmacologic management of this most common sleep-related disorder. Drs Samit Malhotra and Clete Kushida discuss the primary hypersomnias of central origin, of which the prototypical disorder is narcolepsy, and provide an approach to their evaluation and management. Drs Lori Panossian and Joseph Daly discuss sleep-disordered breathing, of which sleep apnea is the most prevalent, emphasize the consequences of this disorder in regard to both daytime alertness and overall health, and update us on management approaches.
In their review of nocturnal seizures and the parasomnias, Drs Nancy Foldvary-Schaefer and Zahreddin Alsheikhtaha draw attention to the clinical and pathophysiologic overlap of nocturnal frontal lobe epilepsy with some of the other disorders that present as complex behaviors during sleep and emphasize the importance of video polysomnography with EEG in evaluation of these patients. Drs Phyllis Zee, Hrayr Attarian, and Aleksandar Videnovic discuss the human circadian rhythms and the pathophysiology, clinical manifestations, and management of the increasingly recognized circadian rhythm disorders.
Drs Nathaniel Watson and Mari Viola-Saltzman review the co-occurrence of sleep dysfunction and other neurologic disorders and remind us that sleep-related symptoms may be important harbingers (eg, REM behavior disorder and α-synucleinopathies), integral manifestations (eg, hypnic headache), or risk factors (eg, sleep-disordered breathing and cerebrovascular disease) for neurologic disease. Dr Michael Silber provides a review of sleep-related movement disorders, with an emphasis on restless legs syndrome. His extensive discussion of management of this common, distressing, but treatable condition will be of benefit to our patients. Dr Timothy Hoban reviews sleep disorders in children from infancy to adolescence, a topic of particular clinical interest to readers who care for children; however, given the ubiquitousness of sleep issues in children, this article is a “must read” for those readers with children at home.
In this issue’s Ethical Perspectives article, Drs Stephanie Vertrees and Glen Greenough present a practical analysis of the dilemma of whether to disclose the risk of the possible future development of an α-synucleinopathy to a patient presenting with REM sleep behavior disorder.
This issue features two Practice articles along with a discussion of relevant coding. First, Dr Avidan reviews the history and current status of resident work-hour regulations and the potential effects of sleep deprivation on trainee alertness and patient safety, and presents a sleep medicine perspective on recommendations for countermeasures for sleepiness in trainees. This discussion is applicable to all of our readers, especially since the potential for sleep deprivation in neurologists is not restricted to residency. Next, Dr Douglas Kirsch reviews the growing role of in-home testing for obstructive sleep apnea, including descriptions of patients who may—or may not—be appropriate for in-home testing. Finally, Dr Jennifer Molano reviews diagnostic coding for sleep symptoms and sleep disorders, as well as the appropriate procedural codes for commonly used tests for sleep disorders.
This issue is rich in video material, thanks to the tireless (no pun intended) dedication of Dr Avidan and Dr Marcel Hungs, who gathered videos from international sleep experts to enhance the text. This video material, available to our readers via the online, PDF, or iPad versions of CONTINUUM, provides especial clarity for those disorders that involve movement or sound.
Like all CONTINUUM issues, ample opportunities for CME abound. Drs Douglas Gelb and Adam Kelly have carefully constructed multiple-choice questions based on the material in the core articles. Reading the material, answering the questions, and reviewing the explanatory discussions will assess and enhance your knowledge of the material, and you will be able to earn up to 10 AMA PRA Category 1 CME Credits™. Beginning with this issue we also provide the alternative opportunity to obtain up to 12 AMA PRA Category 1 CME Credits specifically approved by the American Board of Psychiatry and Neurology (ABPN) for self-assessment. Simply submit the Self-Assessment Pretest before reading the material and completing the postreading Multiple-Choice Questions. The Patient Management Problem, written by Dr Michael Thorpy, involves a young woman with excessive daytime sleepiness. By following her case and answering multiple-choice questions corresponding to important diagnostic and therapeutic decision points along her course you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.
Please join me in thanking Dr Avidan and his expert authors who have created a CONTINUUM issue that will be of real benefit to our clinical assessment and management of our patients with sleep-related symptoms.
I also want to personally thank Dr Miller for his mentorship and leadership, and for his 10 devoted years as the editor-in-chief of CONTINUUM, a publication that continued to grow in stature and national and international circulation under his tenure and has impacted the education of neurologists and the care of patients worldwide.
I am extremely pleased to be joining the wonderful AAN editorial team of Andrea Weiss, executive editor, Amanda Tourville, program manager, and Katie Izzo, production editor, who seemingly work round the clock (thanks to the absence of editorial work-hour rules) to create CONTINUUM. I also look forward to working with our expert associate editors, the members of the editorial board, and our publishing experts at Lippincott Williams & Wilkins.
My vision for CONTINUUM is that it will continue to meet the clinical neurology educational needs of all practicing neurologists throughout their careers. To ensure this goal is met, CONTINUUM will continue to publish “core” clinical neurology topics within 3-year curricular cycles, but the number of topics over each cycle will increase from the current 12 to 15 (one issue per year will be “noncore,” for topics less likely to need revisiting within 3 years). I also envision that CONTINUUM will remain an indispensable print reference on each neurologist’s shelf, even as we continue to enhance the unique capabilities of the online and mobile versions.
Finally, on a sad note, I would like to dedicate this issue to the fond memory of Dr Elliott Mancall and his pioneering and visionary work as the founding editor-in-chief of CONTINUUM from 1993 to 2002, who passed away on January 2, 2013. Although I never worked with Dr Mancall professionally, I had the fortunate pleasure of meeting him on several occasions and will always remember a very pleasant walk I took with him to a bookstore on an extended break between examining oral board candidates for the ABPN in 1999. In 1994, Dr Mancall’s and Dr Theodore Munsat’s originally stated editorial vision was for CONTINUUM to “provide our membership with an educational opportunity that will assist them in providing the very best of neurologic care for their patients.”1 We and our patients have greatly benefited from Dr Mancall’s keen vision and his legacy.
—Steven L. Lewis, MD