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A Scientific Approach to Predisposing, Precipitating, and Perpetuating Causes of Sleep Disorders

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John F. Dineen, MD, FCCP, believes that patients want to choose their healthcare providers based on the quality of care provided and their access to it. “The highest quality of care is what we provide at the Lexington Clinic,” says Dineen, “not just in our Sleep Center, but throughout every department.”

Dineen is double board-certified in Internal Medicine/Pulmonary Diseases and in Sleep Medicine. He has been a member of Lexington Clinic since 1983 and director of the clinic’s Sleep Center since 2008. Dineen proudly states that in August 2012, the American Academy of Sleep Medicine (AASM) re-accredited the Lexington Clinic Sleep Center for five years, a testimony he says that, “we adhere to the nationally recognized guidelines that are on the cutting-edge of sleep medicine, and we have the documentation to prove it.”

The staff of the Sleep Center deserves the recognition, says Dineen. All sleep techs are certified for the interpretations of polysomnographs, and he credits partners Craig Knox, MD, PhD, Neurology, and Wayne Colin, MD, DMD, Otolaryngology/ENT, plus the dedicated staff, for ensuring the center’s policies and procedures for patient care, comfort, and safety are upheld.

Attention to details and dedication to high standards of quality are at the core of the success of the Lexington Clinic Sleep Center. “Medicine is moving where industry has been for a long time, putting quality and safety control measures in place across the spectrum of healthcare,” says Dineen. “We have technology and equipment that we, the physicians and staff, must use to interpret the results accurately, for optimum patient care.”

Sleep medicine is developing a scientific basis for diagnosing and treating sleep disorders, just as the specialty has gained recognition and integration into general internal medicine. “The role that good sleep plays in our overall health has come to the forefront, and the development of treatments stem from understanding the patho-physiology of the disorders,” says Dineen.

Dineen cites narcolepsy, excessive daytime sleepiness, and inappropriate periods of uncontrolled sleep, as an example. “We know it is a neurological disease due to a deficiency of hypocretin in the brain. We have identified the neurotransmitters that play a significant role in the manifestation of narcolepsy. We don’t yet have a replacement for the hypocretin, but we can treat the patient with alerting agents. Perhaps, one day we’ll find the replacement therapy,” he says.

Other common sleep disorders such as obstructive sleep apnea (OSA), central apnea, and restless leg syndrome have benefitted from scientific methods that have led to measureable outcome-based treatment.

“There has not been enough scientific understanding of insomnia, but it’s coming,” says Dineen.

Home-based sleep studies are an example of science still in the observation stage, says Dineen, who nevertheless sees some benefit to home-based studies. “The home-based studies are less expensive but they are not as reliable as the overnight, observed, multi-channel polysomnograph, which we employ as the gold standard.”

A positive result for OSA from a home study in which the patient has a history of sleep disorder can confirm a diagnosis, but a negative result does not necessarily mean OSA does not exist. “It’s entirely possible that, without observation, the patient wasn’t properly wearing the device or simply wasn’t asleep,” Dineen states.

Predisposition, Precipitation, & Perpetuation

“The most common elements in sleep disorders are predisposition, precipitation, and perpetuation,” says Dineen. Patients can be predisposed to sleep disorders due to facial or genetic abnormality. A precipitating event such as obesity or smoking can be the catalyst, as well as the perpetuating cause of the affliction. Significant weight loss can eliminate both the precipitating and perpetuating causes, but “we don’t have a pill or a mask that causes weight loss, only a lifestyle change can cure that,” says Dineen.