The tick of an internal clock.
The whoosh of a CPAP machine.
The steady breath of a slumbering child.
We all need good sleep.
Sometimes we obsess over it.
Other times, we fight it.
It’s central to our biology and to our health.
It’s a basic human right.
As the days get longer,
we’re thinking about the essentials:
What happens when we sleep
or when it’s out of reach?
How does medicine help?
And how can we help ourselves?
Illustration by Tiffany Chin
By Lauren Vogel
We spend nearly a third of our lives asleep. But why dedicate so much time to seemingly doing nothing?
Sophocles acknowledged sleep as “the only medicine that gives ease,” while Shakespeare in Macbeth described it as the “balm of hurt minds.” But before the 1950s, sleep was often regarded as little more than an intermission on the mainstage of life.
Today, sleep is better understood as a bustling backstage, and science is beginning to lift the curtain on the crucial actions taking place behind the scenes.
“There are a lot of active processes in sleep, and it’s not wasted time. It’s valuable time for systemic health,” says Brian Murray (MD ’95), a neurology professor at the Temerty Faculty of Medicine and an affiliate scientist with the Hurvitz Brain Sciences Research Program at Sunnybrook Research Institute.
Much of what we know about sleep and health comes from observing what happens when people don’t get enough slumber. It’s something Murray says he experienced “viscerally” in his long on-call hours in medical residency.
Most obvious are the immediate negative effects on mood and attention, which together impair the mental processes that enable us to plan, focus, remember and multitask. “We all know how lousy you feel post-call,” Murray says. “And you need vigilant attention to do any higher-order cognitive function.”
Being awake for 24 hours causes a level of cognitive impairment that’s similar to having a 0.10 per cent blood alcohol concentration — that’s well over Canada’s legal threshold to be charged for DUI. This impairment worsens with chronic sleep loss. And Murray notes that sleep-deprived people, like drunk drivers, “do not have insight into how badly they’re doing as they become progressively impaired.”
We don’t have to experience extreme stretches of sleeplessness to suffer serious effects. Studies show that getting less than seven hours of sleep each night increases the risk for a wide range of health conditions, including obesity, diabetes, hypertension, heart attack and stroke. In addition, it can also lead to mental health disorders, cognitive decline and dementia.
Sleep also appears to be important for immune function and recovery. Inflammation ramps up at night as part of immune system activity that is thought to strengthen the body’s ability to remember and respond to threats. During normal sleep, the body has mechanisms to protect itself against this inflammation. But when sleep is disrupted, inflammation can linger, increasing the risk of cancer and many of the conditions associated with sleep loss.
If you’ve been burning the candle at both ends, it’s possible to quickly pay down a sleep debt. Even one good night’s sleep can restore as much as 80 to 90 per cent of normal cognitive function, Murray says.
“But the real question is: Can you repair whatever immune damage has been done while you were sleep deprived? Have you recovered from the cardiovascular or metabolic stress of sleep loss? Maybe you have misfolded proteins that didn’t get cleared from your brain. It doesn’t hurt you this week, but cumulatively … it adds up.”
With advances in technology, scientists are only now beginning to scratch the surface of what’s happening in the brain during sleep, Murray says. Research combining genetic and neuropsychological data suggests that sleep plays a role in synaptic regulation, particularly in the pruning of irrelevant connections made during the hours in which you’re awake.
“There’s only so much synaptic real estate, so something has to give,” Murray explains. In sleep, the least relevant synaptic connections are washed away, “and the important stuff is relatively strengthened. So sleep seems to be less about learning and more about unlearning.”
The past decade has also seen fascinating research on the glymphatic system — pathways that are thought to open in the brain during sleep to allow cerebrospinal fluid to flow in and clear away debris such as beta-amyloid, a protein associated with Alzheimer’s disease.
“You can think of the glymphatic system as dump trucks removing the garbage that accumulates during waking activity,” says John Peever (PhD ’01), a professor and head of the Laboratory for Sleep Research at the University of Toronto’s Department of Cell & Systems Biology.
This potential explanation for the link between poor sleep and dementia is “elegant and important,” Peever says, adding that it requires further investigation and replication. “We need to dig deeper in this direction to understand what waste is really being cleared, where it comes from and where it’s going.”
Canadian guidelines recommend seven to nine hours of good-quality sleep for adults younger than 65, and seven to eight hours for seniors.
Nearly one in five adults under 65 is getting fewer than the recommended hours of sleep, according to Statistics Canada. Meanwhile, almost one-third of seniors are sleeping more than the recommended hours.
People aged 35 to 49 sleep the least at 7.7 hours per night, on average.
Two-thirds of Canadians aged 18 to 64 report excellent or good sleep quality, with seniors reporting higher quality sleep than those younger than 65, and men reporting better quality sleep than women.
Also, two-thirds of adults under 65 report high variability in sleep duration and wake time because they have different schedules on work and non-work days. Statistics Canada describes this variability as “social jetlag.”
Illustrations by Brian Jiang
By Megan Mueller
If you’ve ever tried to function the day after an all-nighter, you’ve experienced the cognitive consequences of messing with your circadian rhythm.
Sometimes called the “body’s clock,” the circadian rhythm is the biological mechanism that orchestrates our days and our nights. But how does the clock work? What happens when it breaks? And how do you explain early birds and night owls?
“Most of our organs and tissues have clocks within them, arranged in a hierarchy, with a central clock coordinating everything,” says Hai-Ying (Mary) Cheng (MSc ’99 & PhD ’03).
The University of Toronto Mississauga biology researcher studies the cellular mechanisms that regulate biological timing in mammals; how the different parts synchronize to drive biological processes, such as cell division; and what happens when the ensemble plays out of tune, as in the case of disease.
Cheng describes our internal timekeeper as not one, but rather a “symphony” of clocks playing in concert together.
The symphony’s centre stage is shared by three key players. First is adenosine, a neurotransmitter that controls the sleep drive and balances periods of sleep and wakefulness much like the steady tick of a metronome. Next is melatonin, a hormone produced when there’s darkness to create a “sleep gate” that allows a body to fall asleep.
Finally, there is the suprachiasmatic nucleus (SCN), a tiny region in the brain’s hypothalamus that can be thought of as the circadian conductor, waving the baton to keep the clock symphony in time with the beat.
A 2019 study from Cheng’s lab, published in Cell Reports, pinpoints a specific gene, the SOX2, that’s crucial for the SCN to properly conduct the symphony of clocks.
When exposed to controlled lighting conditions, mice missing the SOX2 gene lost their sense of day and night. The typically nocturnal animals developed irregular sleep patterns and displayed weak running activity on exercise wheels, as if they were jet-lagged. According to Cheng, the findings suggest SOX2’s important supporting role in helping SCN regulate the body’s many clocks.
Sometimes the clocks don’t synchronize, so what happens when the symphony plays off-tempo?
It can be bad for our health, says Richard Horner (PGME ’94), a professor in the Department of Medicine and Department of Physiology at the Temerty Faculty of Medicine. Horner, who studies the mechanisms of sleep, sedation and anesthesia, notes that sleep is one of the most important pillars of health, along with nutrition and physical activity.
Missing sleep or sleeping at the wrong time can cause the symphony to lose the beat, as it does with night-shift workers who end their day as the sun is coming up. As Horner explains, numerous studies have shown that the sleep disruption resulting from shift work is associated with an increased incidence of cancer, stroke and diabetes. Shift workers are more likely to experience sleep loss and, as a result, are at increased risk of workplace accidents and motor collisions.
Sleep disruption is also associated with dementia, says neurologist Andrew Lim (PGME ’06 & ’08). As the principal investigator at the Sleep and Brain Health Laboratory at Sunnybrook Health Sciences Centre, Lim is researching how the disruption of circadian and seasonal rhythms may be linked to dementia conditions.
“Our findings suggest that these interrelated rhythms may be an important feature of human brain biology,” says Lim, who is also a professor in the Department of Medicine at Temerty Medicine. “Changes in such rhythms may be consequences of, or contributors to, diseases such as Alzheimer’s disease.”
If the clocks are the orchestra, chronotype decides whether we rise early to sing with the larks or stay up late with the night owls.
Chronotype is influenced by many factors, including genetics, age and exposure to daylight. Purposely changing one’s chronotype is difficult, although it may shift somewhat as we age.
Cheng says chronotype is inherited. Those with the mutant gene for inherited familial advanced sleep phase syndrome will wake up early, while those who inherit familial delayed sleep phase syndrome will stay up late, she explains.
According to Lim, a mix of factors determine our daily schedule. “Roughly 30 per cent of the variance in whether a person is an early bird or a night owl is determined by genetics; the rest, is determined by environmental factors,” says Lim.
“Every living thing takes notice of the rising and setting of the sun,” concludes Horner. “We have the same machinery as plants and other animals. Our circadian clocks have evolved over billions of years.”
According to David Samson, evolution and culture play a significant role in our sleep. The associate professor of evolutionary anthropology and director of the Sleep and Human Evolution Lab at the University of Toronto Mississauga travels the globe to better understand how humans and primates sleep as they do.
In Tanzania, Samson works with the Hadza community, which is considered one of the last hunter-gatherer tribes in Africa. The Hadza live a traditional forager lifestyle, sleeping outdoors on beds of hardened impala skins and blankets.
Researchers theorize that the Hadza’s exposure to natural light and environmental elements may make them more attuned to circadian rhythms than those living in post-industrialized societies. Their sleep behaviour may reveal clues about how early humans slept.
The “sentinel hypothesis” proposes early humans needed someone in the group to stay awake through the night to alert the others to threats of danger.
Hadza sleep patterns appear to bear this out. Samson observed that many Hadza awoke at different times during the night. There were only 18 minutes when all of the adults in the group were asleep at the same time.
Today, we can have light 24 hours a day, indoor beds are the norm and overnight threats are uncommon. Nevertheless, we see communal sleep interruptions similar to those of the Hadza in teenagers who stay up — and sleep in — late; infants who wake through the night as their bleary parents tend to them; and in aging adults who rise for the day in the early morning hours.
Illustration by Shaneela Boodoo
Greg Wells (MSc ’99) believes in the power of naps, especially for those working in health care.
Wells is an expert on human health and performance who studies exercise medicine at The Hospital for Sick Children, and previously held dual appointments as an associate professor with U of T’s Faculty of Kinesiology and Physical Education, and the Temerty Faculty of Medicine’s Department of Anesthesiology and Pain Medicine.
According to Wells, lack of sleep can take a toll on physical and mental health, and negatively impact professional performance. “When you’re tired, you can make bad decisions.”
When life’s demands make it tough to get enough shut-eye at night, naps offer a simple and practical solution. “If your sleep is disrupted, it’s alright to use a nap to catch up,” he says. “It’s definitely something you can do to get through long shifts and perform at a higher level for a longer period of time.”
Timing is everything. To beat a mid-afternoon energy dip, Wells recommends setting an alarm and taking a power nap of no more than 20 minutes to boost alertness and cognition. Waking naturally from a longer nap of 70 to 90 minutes — a full sleep cycle — is best for deeper physical and mental recovery following a sleepless night or intense morning workout, for example.
He warns against the mid-range snooze of 30 to 60 minutes. Waking in the middle of a sleep cycle will leave you feeling tired, rather than refreshed.
“You’ll wake up with sleep inertia, leaving you groggy and feeling horrible for hours afterwards,” Wells says. Exercise, exposure to natural light and a glass of water can help shake the feeling.
We know that caffeine can interfere with sleep, but proponents of the so-called “nappucino” or “espresso nap” claim that caffeine can give a power nap an extra boost.
“If you drink something caffeinated and then close your eyes for 20 minutes, you’ll wake up right as that caffeine surge is in effect.”
Some research suggests this strategy may help shift workers stay alert, but caffeine’s effects on memory and physical performance peak between 30 and 60 minutes after consumption. Wells says the double-benefit, if any, would be short-lived.
A workday doze can improve mood, logical reasoning and reaction time, and employers are taking notice. One MIT study of low-income workers in India found a midday nap boosted productivity by an average of 2.3 per cent.
“Years ago, we never imagined it would be OK to nap at work,” says Wells. “Now we know that napping is beneficial for physical and mental health, and also for performance.”
Most of us don’t have access to soundproof nap pods like those in the offices of nap-friendly employers such as Google and Deloitte, but Wells offers tips gleaned from his own experience.
For napping at work or on the go, Wells recommends a sleep mask and noise-cancelling headphones that help shut out the world and signal that you’re unavailable.
“It’s OK to prioritize sleep,” he continues. “If there’s a chance to grab even five minutes when you’re on a long shift, it can make all the difference.”
Sleep and nutrition are inextricably connected, says Nishta Saxena (MSc ’07), a graduate of the Department of Nutritional Sciences at the Temerty Faculty of Medicine. “The quality of our diet has a huge impact on sleep, and our sleep influences diet. It’s bidirectional.”
Saxena, registered dietitian and founder of Vibrant Nutrition, sympathizes with the challenges of her clients who work in health care and cope with stressful days, unpredictable meal breaks and flipped sleep schedules, not to mention the tempting treats at the nursing station.
“A lack of sleep may mean we are too tired to cook or plan for meals,” she says. “This drives us to choose quick and easy — often processed — foods, or snack or skip meals because we are fatigued.” Convenience foods, which are typically high in sugar, salt or fat, only feed the problem and can lead to low energy and trouble sleeping.
Trendy super foods, such as a shot of tart cherry juice or a handful of almonds at bedtime, are not the answer. “If you’re hoping to improve your sleep, you want a nutrient-rich diet with a broad range of vitamins and minerals,” she says. “Luckily, it’s easy to work this into our day.”
Saxena recommends loading up on foods with sleep-supporting nutrients such as calcium, omega fatty acids and magnesium, a mineral that’s deficient in many North American diets. These nutrients are in foods such as tofu, peas and legumes, along with dairy and calcium-fortified plant-based beverages, dark leafy greens and even dark chocolate. Canned fish — consider trout, mackerel and sardines — can boost serotonin, which is essential for sleep.
Another key step is to take the thinking and planning out of the eating equation by ensuring that a healthy choice is always available. Saxena advises her clients to take shortcuts — subscribe to a prepared meal service or choose grab-and-go produce and salads at the grocery store. They are more expensive but make healthy eating automatic, she says. “You don’t know what’s going to happen on your shift, but you can control what you eat.”
Saxena also advises incrementally decreasing caffeine, sugar and salt, and cutting out snacks at least two hours before bed so the body can rest instead of digest. Sipping on a caffeine-free herbal tea, such as chamomile or valerian root, can signal to the body that the day is winding down.
Little changes can add up quickly, she says. “In a week or two, you could see a dramatic difference in your sleep.”
During sleep, information from the hippocampi moves to other parts of the brain for long-term storage and retrieval. The process is essential to memory and recall, but what happens when the information pathway is damaged?
This is the focus of a case study by Nelly Matorina, a cognitive neuroscience researcher and doctoral student at the University of Toronto. Matorina and colleagues investigated the curious case of CT, a young woman who began experiencing sleep-induced amnesia after surgery to remove a bilateral tumour from her fornices.
Matorina is studying the link between memory and sleep with U of T psychology professor Morgan Barense. As part of the Temerty Faculty of Medicine’s Collaborative Program in Neuroscience, Barense’s Memory & Perception Lab is investigating how the brain supports memory, and what happens when the brain is affected by damage or disease.
While the role of the fornices is not well understood, damage to this C-shaped bundle of nerves can result in anterograde amnesia, which interferes with the ability to learn and retain new information.
Following surgery, 16-year-old CT experienced an unusual form of anterograde amnesia — during the day, she could learn and retain new information, such as what she had eaten for breakfast, but these new memories vanished when she slept.
To test CT’s memory, researchers had her watch episodes of the TV detective series “Poirot.” She was then prompted to recall specific details following a period of wakefulness and again after a nap.
“She could remember several details when she stayed awake, but she couldn’t remember any details at all after a nap,” says Matorina. “This is puzzling because sleep is known to be beneficial for memory consolidation.”
Matorina theorizes that damage to CT’s fornices may interrupt communication between the hippocampi and cerebral cortices.
“This study shows that the fornix plays a critical role in memory processing during sleep, which hasn’t been explored in detail before,” she says.
The results could provide an important clue to dementia-related memory disorders, such as Alzheimer’s disease.
“There’s a possibility sleep may impair memory in other cases of hippocampal system damage,” says Matorina. “For physicians, this means paying attention [in case] someone’s sleep may be impacting their memory.”
By Erin Howe
For many parents, knowing that their children are getting a good night’s sleep would be a dream come true. But what visions await kids when they finally reach the Land of Nod?
In most cases, dreams occur during rapid eye movement (REM) sleep, a stage in the sleep cycle that may start before birth and appears to play a critical role in paediatric development.
When newborns sleep, they spend about half of the sleep cycle in REM sleep, but this drops over time. By adulthood, REM sleep is closer to 20 per cent of the cycle.
One theory for the extended REM sleep of infants is that more REM sleep is needed to support all of the learning and development that take place through the first two years of a child’s life, says Sarah Honaker, an associate professor of paediatrics and psychiatry at Indiana University School of Medicine, where she also directs the Healthy Sleep for Kids research program.
“Brainwave activity during REM sleep is very similar to brainwave activity in an awake state. REM is an important stage of sleep for learning and memory consolidation,” says Honaker.
When a child isn’t getting enough sleep, the brain may compensate with a greater proportion of REM sleep.
This can lead to more vivid dreams and also to nightmares.
Generally, bad dreams aren’t a cause for concern, says Honaker, but if they begin to affect a child’s sleep or daytime behaviour, she advises ensuring that the child is getting enough sleep.
This strategy can reduce the amount of time they spend in the REM stage, manage nightmares, and offer a world of other benefits such as improved cognition, mood and overall health.
Over a 24-hour period, the Canadian Paediatric Society recommends 10 to 13 hours of sleep (including naps) for preschoolers aged three to five, nine to 12 hours for old kids aged six to 12, and eight to 10 hours of shut-eye for teens.
Sleeping in on the weekend might be a sign that a child isn’t getting enough rest, says Honaker.
“Younger children are prone to wake early, so if a young child is waking at 7 a.m. for school and then sleeps until 10 a.m. on the weekends, this suggests that the child may not be getting enough sleep during the school week,” she says.
“This changes in the teen years, though, because there’s a normative delay in circadian rhythms, which means that adolescents become tired later at night and tend to sleep later into the morning. Thus, when teens sleep later on weekends it is hard to know if this is due to sleep deprivation or a delayed circadian timing system that makes it natural to wake later. In many cases, it is both as most teens are sleep deprived due, in part, to early school start-times.”
A child who takes a long time to wake up or whose emotional regulation becomes noticeably worse throughout the day might also not be getting enough sleep.
Honaker notes that in addition to noting “how much” sleep a kid is getting, parents and caregivers should pay attention to “how well” their children sleep.
If a child snores three or more nights per week, she recommends that parents speak with their child’s primary care provider about sleep apnea. Children with the condition are more likely to be sleepy, hyperactive or irritable, even if the clock says they’re getting enough sleep. Kids with sleep apnea are also more likely to have more frequent nightmares.
Sarah Honaker, an associate professor of of paediatrics and psychiatry at Indiana University School of Medicine, spoke with UofTMed about how to help kids rewrite the endings to their less-than-sweet dreams.
Videos by Mark Bennett and Erin Howe
UofTMed spoke with children about their dreams, and brought the stories to life through animations created with artificial intelligence visualization tool Midjourney.
Videos by Mark Bennett and Erin Howe
UofTMed spoke with children about their dreams, and brought the stories to life through animations created with artificial intelligence visualization tool Midjourney.
Photography by Mark Bennett
By Jim Oldfield
How are physicians sleeping, as the world recovers from COVID-19? Very badly, by many measures.
Early in the pandemic, studies showed that physicians and health care workers endured sleep disruptions that were often linked to a surge in critically ill patients and worries about issues such as protective gear and viral exposure.
Today, those concerns have shifted to a clinical workload that’s growing in volume and complexity amid a worsening shortage of health care personnel. And as COVID-19 infections continue, patients are now seeking care for conditions that were untreated during the pandemic.
“The dynamics of the pandemic are different, but the impact on physician sleep health likely hasn’t changed much,” says Mandeep Singh (PGME ’12, ’13 & ’15), an associate professor in the Department of Anesthesiology and Pain Medicine at the Temerty Faculty of Medicine, who gave continuing education and hospital seminars on sleep for front-line workers throughout the pandemic.
“Of course, many physicians were chronically sleep-deprived before COVID-19,” says Singh, who is also a sleep medicine specialist and researcher at University Health Network and Women’s College Hospital.
The history of sleep deprivation among physicians is indeed stark and as old as the medical profession itself. Not only are physicians prone to the same sleep disorders and disruptions as everyone else, they’re at a heightened risk due to night shifts, long hours of stressful work and a professional culture that often prizes patient care over physician well-being.
In the Canadian Medical Association’s recent National Physician Health Survey, over half of physicians and medical learners reported that they are always or often fatigued at work and/or school.
Links between health and physician wellness, and burnout and patient safety have been a growing concern in medicine for over two decades. Many studies during this period have put the rate of physician burnout at about 50 per cent.
In 2020, a large study reported in JAMA Open Network found that sleep impairment is associated with up to double the odds of self-reported, significant medical errors. That same year, the American Academy of Sleep Medicine put out a position statement calling for more study of physician sleep health and ways to improve it, noting that burnout is a serious threat to workforce capacity.
“Medicine needs a culture shift around sleep health, and that is slowly happening,” says Singh. “But the hardest barriers to break are systemic, organizational and cultural, on top of individual sleep patterns. So, there is work to do.”
The urge to keep pushing your body is ingrained in the culture
Resident duty hours are a key issue for physician sleep health. Residents and fellows make up almost one-fifth of the physician workforce in Canada and provide extensive direct care, especially in academic centres. As well, residents inured to sleep deprivation may be inclined to see long hours as normal when they become attending physicians and role models.
Evidence is clear that sleep deprivation impairs physician function, but it’s mixed on whether duty hour limits are a net benefit for resident learning and patient safety. In 2011, Quebec enacted a 16-hour limit on in-hospital shifts. In response to that change and ongoing debate, Canada’s National Steering Committee on Resident Duty Hours in 2014 recommended that shifts be 24 hours only in rare circumstances.
Since then, most provinces and territories have capped shifts at 24 hours plus two for handover, leaving flexibility for medical specialties to develop their own guidelines on both hours and the management of fatigue — two more key principles that the National Steering Committee generated. In 2018, Canada’s Fatigue Risk Management Task Force put out a tool kit emphasizing sleep and wellness, which medical schools and hospitals across the country have adopted.
“There is general consensus on the need to limit duty hours and prioritize sleep and wellness, all of which are increasingly seen as a shared responsibility,” says Julie Maggi (MSc ’04 & PGME ’13), the director of faculty wellness at Temerty Medicine and a staff psychiatrist at St. Michael’s Hospital, Unity Health Toronto. “But we know from our own studies and the literature there are complex reasons why residents work long hours.” Those reasons include inadequate staffing in health centres and the impact on staff who remain in-house when a resident leaves.
By Erin Howe
Frances Howe* woke to the sound of her car scraping against the guardrail. She had fallen asleep at the wheel.
“I was less than an hour into my drive from Richmond Hill to Sudbury,” says Howe, who was heading home after a visit with her daughter and son-in-law. “It was lucky that no other vehicle was involved, and no one was hurt.”
Howe had long suspected that she had a sleep problem. After her husband began complaining about her snoring, Howe spoke to her family physician, who added her name to a months-long wait list for a sleep study.
In 2005, when the collision happened, Howe was just one week away from her scheduled sleep study. “The accident was a huge wake-up call for me,” says Howe, now 71.
***
Howe is among the 2.3 million Canadians to be diagnosed with obstructive sleep apnea (OSA), a condition that causes a person’s airway to briefly collapse, stopping their breathing while they sleep.
The pauses, called apnea events, can last anywhere from 10 seconds to much longer. In severe cases, people may stop breathing hundreds of times a night. As a result, they often feel sleepy, irritable and unable to concentrate during the day. Howe’s experience reflects one of the heightened risks that people with OSA face. Studies show people with unmanaged OSA are significantly more likely to be in a car crash.
Historically, the typical OSA patient was thought to be an older, overweight man. Today we know that other factors such as chronic nasal congestion, jaw structure, narrow airways or a deviated septum, smoking and substance use can also increase the risk of developing the disorder. A less common form of the disorder, called central sleep apnea, prevents the brain from sending the right signals to the person’s breathing muscles.
The stakes for those with sleep apnea are high. In addition to an increased risk of causing a car accident, over time OSA can contribute to cardiovascular problems such as heart failure and stroke, as well as type 2 diabetes, hypertension, depression and anxiety.
***
An estimated 11 million people in Canada have sleep apnea but don’t know it. This is partly because some of the most telling signs are only apparent during sleep.
“If someone doesn’t have a partner who notices and alerts that person to the snoring or gasping, how would they ever know?” asks Frances Chung, a professor in the Department of Anesthesiology and Pain Medicine at the Temerty Faculty of Medicine, and a staff anesthesiologist at University Health Network.
In 2008, Chung developed the STOP-Bang questionnaire, an OSA screening tool that physicians and the general public can use. Her initial goal was to help identify whether patients preparing for surgery might have undiagnosed OSA. The disorder increases the risk of post-operative complications and death.
“People may have respiratory depression or upper airway obstruction as a result of their untreated sleep apnea. So I wanted to find a way to identify these patients quickly to give them better, safer care,” says Chung.
Since its creation, Chung’s eight-question tool has been validated and is now one of the most widely accepted screening tools for OSA around the world.
***
Continuous positive airway pressure (CPAP) is the gold standard treatment for OSA. The machine uses a hose connected to a nosepiece or mask covering the nose or mouth to deliver constant and steady air pressure during sleep. The device can cost between $1,000 and $2,000. Though some provincial health plans provide partial coverage, Chung points out that the remaining expense can still leave therapy out of reach for many.
But money isn’t the only barrier. It is estimated that as many as half of all OSA patients prescribed CPAP therapy no longer use their machine after one year. Many CPAP users find that the mask is uncomfortable, makes them feel claustrophobic and/or leaves their nose dry or irritated.
Rui-lian Jiang knows these issues all too well. While rates of OSA increase with age, Jiang was diagnosed with OSA when he was just 31. He was surprised to learn that during his sleep study, he had frequent apnea events that lasted 45 seconds.
Twelve years ago, when Jiang was diagnosed, he says that the first few weeks of sleep with his new CPAP machine were awful and the mask on his face felt jarring. “There were nights when I would throw the mask across the room in frustration, exhausted and just wanting to fall asleep,” he recalls.
Jiang persevered. Determined to get a better night’s rest, he practised wearing his mask for short periods while watching TV or reading. Eventually, he adjusted and now says he can’t sleep without his CPAP machine. In addition to having a machine at home, Jiang has invested in a smaller device for travel.
Although some people can adapt to wearing a CPAP mask, it’s not possible for everyone. Approximately 40 per cent of patients can’t tolerate the device. Oral appliances can help to reposition a person’s jaw or tongue to keep the airway clear during sleep. But when neither of those treaments work, surgery may be another option.
Josie Xu (PGME ’20) is a lecturer in Temerty Medicine’s Department of Otolaryngology Head and Neck Surgery. Her goal is to use new surgical techniques to help supplement care for patients with OSA. Xu’s clinical focus is on surgery for the upper airway, from the nose to the throat. She is one of only three otolaryngology surgeons in Ontario to specialize in sleep medicine.
In the past, Xu says some patients with OSA were offered a procedure called uvulopalatopharyngoplasty, or UPPP, to remove extra tissue in the throat to open the upper airway. Now there are a broader range of surgical options to address specific anatomical issues. Xu adds that these days, physicians are better able to determine who will — and who won’t — benefit from an operation. Surgery isn’t the right solution for everyone, but when the procedures are appropriately selected and the outcome is good, it can be life-changing.
“Many times after surgery, patients will say, ‘Wow, I finally feel like I’m getting restful sleep. I’m finally dreaming. I’m finally waking up with energy, I’m not falling asleep in the middle of the day, and I feel like my head is clear,’” says Xu, who practises at North York General Hospital and Michael Garron Hospital. “It’s really gratifying to be able to give that to someone.”
Many times after surgery, patients will say, ‘Wow, I finally feel like I’m getting restful sleep…’
As an otolaryngology surgeon, Xu focuses on soft tissue. Her colleague, maxillofacial surgeon Tina Meisami (PGME ’01), treats skeletal structures with procedures to reposition a patient’s jaw to alleviate airway obstruction. The two work together in Meisami’s downtown Toronto office, the first joint surgical sleep clinic in Ontario to offer assessments by soft tissue and maxillofacial experts.
Meisaimi, who is also an assistant professor of dentistry at the University of Toronto, says that early surgical interventions can enhance quality of life, improve life expectancy and prevent the need for expensive care in the future.
“From a health system perspective, there are downstream benefits to providing treatment for people with OSA,” says Meisami, who is the director of sleep medicine at University Health Network’s division of dentistry. “The costs associated with OSA are tremendous.”
***
One way researchers are helping more people access the right treatment is through better testing. When Howe finally got her turn in the sleep lab, a technician adhered several sensors to her scalp, each connected to a wire that transmitted data to a computer. The technician wrapped a strap with another sensor around her chest and clipped a pulse oximeter on her finger. Together, the components measured Howe’s breathing and movement.
But the test felt nothing like an ordinary night’s rest. “I tried not to accidentally pull any of the wires off myself as I tossed, turned and tried to get comfortable,” she remembers. “In the morning, I felt like I’d barely slept a wink.”
Douglas Bradley is part of a team that wants to make testing easier and more accessible to a wider group of people. He is a professor in Temerty Medicine’s Department of Medicine and a senior scientist at KITE, Toronto Rehabilitation Institute’s research centre, where he is also the director of the facility’s sleep research lab.
Over the past 10 years, Bradley and colleagues have worked on creating a less invasive test that allows people to take a sleep study in the comfort of their own bed.
Their diagnostic tool, BresoDX1, includes a sensor with a sticky patch that patients place above their sternum and an oxygen sensor they wear on one finger. The sensor records breathing sounds, movements, body position, oxygen saturation and heart rate while the person sleeps. The information is sent wirelessly to a secure network where it is analyzed and generated into a report for the patient’s physician.
Less obtrusive than a test in a sleep lab, Bradley says BresxoDX1 is more comfortable during slumber. Also, technicians can quickly prepare the kit for the next patient to use, making it a cost-effective, efficient testing option.
“From a physician’s perspective, there’s almost no limit to the number of tests you could send out,” says Bradley.
About half of all sleep studies in the United States are done at home. In Europe, the figure is closer to 75 per cent. In Canada, however, most health care coverage applies only to in-clinic testing.
Bradley hopes that Canada’s provincial and territorial governments will wake up to the benefits of increasing access to sleep studies through home testing.
“Current in-home testing costs about a third of what it does to perform a test in a sleep lab,” he says. “And that’s without accounting for people who don’t have access to a sleep lab in their own communities. Can you imagine the difference at-home testing would have for someone living in Moosonee?”
Photography by Mark Bennett
By Rachel LeBeau
Photography by Mark Bennett
It’s 8 p.m. and Sahil Gupta (PGME ’16 & ’17) has just started his overnight shift as the on-call physician in the emergency department at St. Michael’s Hospital in downtown Toronto. On this frigid February night, Gupta expects to treat patients with flu symptoms and fall injuries from the slippery sidewalks. He also expects to see up to 10 people looking for a warm place to sleep.
This scene plays out in many urban urgent-care centres, says Gupta, a lecturer with the Department of Medicine at the Temerty Faculty of Medicine. Emergency departments “end up being the only place that’s open, or one of the very few places that are open 24 hours, where you can seek warm shelter,” he says.
Federal statistics from 2021 estimate that more than 235,000 people experience homelessness over the course of a year in Canada, and as many as 35,000 have no place to sleep on any given night.
Toronto has 8,000 shelter beds; as well as short- and long-term spaces in hotels, dorm rooms and temporary shelters, but the COVID-19 pandemic pushed the already fraught system to its brink. Emergency shelters in the city have long been operating at capacity. Beds that were closed for pandemic physical distancing measures are slowly returning.
This year, Toronto shelters will turn away between a hundred and two-hundred people a night for lack of space. Many of those turned away are forced to seek out hospitals, bus shelters, public transit or 24-hour restaurants for shelter and sleep.
“People are very, very resilient and very, very creative in finding spaces [to sleep],” says Gupta. “If it’s really cold outside, some will turn to condo lobbies and stairwells where they can find a bit of warmth and rest.”
Michael Smith* is part of the newly unhoused cohort in the economic aftermath of the pandemic. He describes a life that met “all the middle-class checkpoints” — marriage, education, employment and plans to start a family. But in fall 2022, following bad luck, job loss and depleted savings, Smith and his wife found themselves without a stable home.
“We’ve had difficulty finding places to go where we can get more than a couple hours of actual, you know, lying down sleep,” Smith says. Over the winter months, the couple spent their nights in Toronto’s Union Station trying to get some sleep. “That’s one of the biggest problems — just finding somewhere that’s safe and somewhat warm.”
Johnny Wong (PGME ’17) hears this often in his work as a family physician with Street Clinical Outreach for Unsheltered Torontonians. For many of Wong’s patients, shelters are simply not an option. “If I were personally experiencing homelessness, I would choose to sleep outside,” he says.
Shelters are large and crowded with little space between the beds, which may be little more than mats on the floor. Wong’s patients complain about the noise and that lights are left on overnight. They worry that their belongings might be stolen. It’s tough to get any sleep.
The conditions also create an environment that’s ripe for the transmission of COVID-19 and other airborne illnesses, says Wong. A shelter he worked with experienced a 73 per cent test positivity rate for infection during the pandemic’s first wave of the pandemic — alarmingly higher than the provincial average.
Shelter conditions push many people outdoors, but those who bed down outside face other challenges.
The winter months bring frostbite and can cause debilitating swelling and secondary infection in the extremities. The warmer months bring smog, heat exhaustion and dehydration. Harassment from security guards, police officers and members of the public knows no season.
Living in survival mode can lead to or exacerbate mental health and substance use. “People often feel unsafe and surveilled and monitored,” says Gupta. “There’s this hypervigilance that we often see when people experience homelessness. They’re very aware, very on guard, and it can create a lot of mental distress.”
“The strain of not being able to get quality sleep over extended periods not only affects you physically but mentally,” says Smith, adding that it’s often safer and easier to sleep during daylight hours. Sometimes this means finding a spot to rest behind the closed door of a restaurant bathroom stall.
“Street life is not easy,” says Wong. “People are just trying to make it day by day, hour by hour, minute by minute.” Some turn to stimulants, such as crystal meth, to stay alert, he says. “They feel like they have to, to be safe.”
Street drugs can compound the challenges of sleep loss and increase the risk of psychosis. Wong and his team can offer a prescription for an antipsychotic drug or help their patients connect with a shelter.
As the unhoused population grows, so do the casualties. Since the City of Toronto began tracking the deaths of individuals experiencing homelessness in 2018, they have recorded more than 770 deaths. At one point, the average was more than four deaths per week. The Toronto Homeless Memorial Network marks these lives cut short at monthly vigils.
While physicians can prescribe medications, treat infections and offer encouragement, health outcomes can’t improve without addressing the root cause.
“There is no more powerful therapeutic intervention than basic income and housing for all,” says Andrew Boozary (PGME ’18), a primary care physician and the executive director of Population Health and Social Medicine at University Health Network (UHN).
“Income inequality is like a pollution — a social pollution — that makes a less healthy society for everyone,” adds Boozary, who is also an assistant professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation.
There are glimmers of hope. The pandemic showed that governments can move quickly to establish social support programs, such as the Canada Emergency Response Benefit. And some communities are experimenting with new approaches to provide supportive housing.
Later this summer, UHN will open the doors of a new modular building in Toronto’s Parkdale neighbourhood. Led by the United Way in partnership with UHN’s Gattuso Centre for Social Medicine and support from municipal, provincial and federal governments, the facility will provide housing and health care to 51 tenants who will finally have a safe place to sleep.
“If we follow the evidence and focus on what is equitable, the return on investment cannot be matched in anything that we can do in the clinical therapeutic realm,” Boozary concludes.
Matthew Garcia* spoke to photographer Mark Bennett about his experiences with being unhoused.
Since moving to Canada from Columbia in 2021, Garcia has bounced between apartments in Toronto, and moved to a shelter following the end of a relationship in late 2022. While he found staff friendly and helpful, Garcia felt overwhelmed by the noise and lack of privacy. He recently left the shelter for the Allan Gardens encampment where he now sleeps in a tent of his own.
Garcia is waiting for news on the housing application that he submitted months ago. He worries that he may have missed a reply in his inbox. “I have no answer,” he says. “I imagine there are many people on the waiting list.”
“I don’t have many things. I have my laptop to help me get connected to the Internet. I have a phone.
I need to take care of myself and don’t talk to nobody else.”
* Name changed to protect privacy.
By Heather McCall
While growing up in Hong Kong, Raymond Ng (PhD ’86, MD ’88 & PGME ’93) was fascinated by TV medical dramas. One of his favourite activities was setting up his own pretend operating table with couch cushions. He’d use a large sheet of newspaper to cover his imaginary patient, cutting a hole in the paper to isolate where he’d perform the imaginary surgery.
That passion for medicine and imaginative spirit have stayed with Ng throughout his career. Ng moved to Canada with his parents as a preteen. After completing high school, he entered the bachelor of science program at McMaster University with plans to continue in its undergraduate medical program. However, he ultimately decided that the Temerty Faculty of Medicine program at the University of Toronto was a better fit for his learning style and approach.
“It was a structured program with more didactic teaching and more anatomy training, which I found fascinating as a would-be surgeon,” he says. It also had more clinical rotation options that exposed him to many different specialties.
When it came time to choose a surgery specialty, Ng gravitated to the delicate systems of the head and neck. After trying different surgical subspecialties during his final years in medical school, otolaryngology (also known as ear, nose and throat or ENT) was the Goldilocks choice.
Otolaryngology exposed him to both the medical and surgical sides of health care, which early in his career contributed to him heading down two divergent paths — cancer and sleep. It started with cancer research. In 1993, researchers at the Hospital for Sick Children and Mount Sinai Hospital recruited Ng, then an ENT resident at Mount Sinai, to help with a nasopharyngeal cancer (NPC) clinical study. The cancer is prevalent in southern China, and the researchers thought Ng — a native Cantonese speaker with ties to Hong Kong — could help recruit participants, especially from the Greater Toronto Area’s Chinese community.
In researching the disease, he learned that the Epstein-Barr virus (EBV) is an accurate, reliable biomarker for NPC. EBV is a common virus found in over 90 per cent of the global population and is responsible for mononucleosis. In those with NPC, the virus’ DNA presents in unusually high concentrations in the cells, making it useful in detecting NPC.
At the time, the only reliable way to detect NPC was highly invasive — requiring an endoscopy and biopsy, often under general anesthesia. An EBV DNA test existed but was expensive and took many days to process. Ng believed there was an opportunity to develop a more practical, cost-effective and non-invasive test that could yield results in hours.
In 2004, he secured seed funding to launch a research and development project to create and market an early-detection tool that ENT surgeons and family doctors could conveniently use in their office. By 2014, his team had a working prototype kit containing a wand with a small brush at the end to collect a sample from the nasopharynx through the back of the throat, as well as packaging to submit the sample to a lab for EBV DNA measurement.
Clinical trials wrapped up in 2018, the U.S. Food and Drug Administration approved the kit as a Class II medical device, and now it’s used in countries around the world. Ng is working to secure approval in China, where the test is needed most.
If you are inquisitive and care about people, you will always find problems that need solving, and it may lead in very different directions.
Over that same 20-year period, Ng was also practising as a community ENT surgeon in Markham and at the Scarborough Health Network — Centenary Hospital, where he continually encountered patients who suffered from snoring attributed to sleep apnea.
Sleep apnea causes a person’s breathing to stop and start while they slumber. It can disrupt their sleep, leaving them tired throughout the day, and lead to more serious physical and mental health problems.
Obstructive sleep apnea (OSA) is the condition’s most common form, occurring when soft tissue in the back of the throat relaxes and blocks or partially blocks the airway during sleep. OSA patients are typically prescribed a CPAP (continuous positive airway pressure) machine, which pumps air through a tube attached to a facial mask to keep the user’s breathing passages open while they sleep. Unfortunately, nearly 50 per cent or more of OSA patients can’t tolerate the device, and many abandon it altogether.
Listening to his patients’ frustrations, Ng wondered if there was an alternative surgical solution. He sought additional education and training in sleep medicine and was certified as a sleep medicine specialist. Then, he could offer patients with severe OSA the option of surgically removing the excessive soft tissue that was blocking their airway, among other surgical techniques.
Ng was subsequently appointed the medical director of the newly created Division of Sleep Medicine in Temerty Medicine’s Department of Otolaryngology Head and Neck Surgery (OHNS), and tasked with overseeing the training of residents in various aspects of sleep medicine. And in 2007, he founded the Woodbine Steeles Sleep Clinic and began practising with a multidisciplinary team of sleep specialists that includes family physicians, psychiatrists and respirologists to offer comprehensive treatment for various sleep disorders.
He has also been able to give back to Temerty Medicine philanthropically. Ng established student awards that support graduate and postgraduate research projects.
As well, he established an innovation fund with his partner, Wendy Chui. The fund supports awards for OHNS faculty and learners devoted to catalyzing new discoveries, inventions and commercialization strategies.
Ng’s hope is that future generations of head and neck surgeons will, like him, strive to seek innovative solutions, possibly across different subspecialties, to develop commercially viable products that will benefit patients.
“If you’re inquisitive and care about people, you will always find problems that need solving, and it may lead you in very different directions,” he says.
As for what path Ng will follow next, it won’t be too far off the two medical specialties he’s already treading. “I don’t think I’m going to develop a third specialty,” he laughs.
By Deanna Cheng
The best gifts are the ones that have a personal touch, and few gifts are more personal than a legacy gift tied to your core values and experiences.
A legacy gift can take many forms, such as a bequest from an estate or a gift of life insurance, securities or retirement funds. Whatever form it takes, the goal is always the same – to help secure a better and brighter future. Planning for this future is an important step that ensures ongoing support for the organization and causes that are closest to your heart.
Legacy gifts are a key support for the University of Toronto’s Temerty Faculty of Medicine. Thanks to the generosity of alumni, faculty and staff, these gifts play a crucial role in fulfilling the Faculty’s mission to advance health and health care through research and education.
As donors Tanya Williams and Benoit Mulsant demonstrate, this proud tradition continues as new generations in our community take up the cause and plan a legacy that sustains Temerty Medicine’s mission for years to come.
Infertility specialist and reproductive endocrinologist Tanya Williams (MD ’88 & PGME ’93) credits much of her success to the generosity of others – and she is continuing that philanthropic spirt through her own legacy gift.
Williams is a longtime monthly donor to Temerty Medicine. As well, she has made the Faculty a beneficiary of her registered retirement savings plan (RRSP) with the ultimate goal of establishing the Dr. Tanya Williams Scholarship in support of medical students.
This commitment to new generations of medical learners has a deeply personal origin. In 1988, Williams found herself low on funds in the final year of her undergraduate medical studies.
“I ran out of student loans close to the end of medical school,” recalls Williams. “I remember the overwhelming feeling of not knowing what to do. A bursary made all the difference.”
She views giving to Temerty Medicine as a way to support students in similar situations, and a contribution through her estate allows Williams to maximize the impact of her gift.
“My bequest means the funds will grow during my lifetime and go on to serve as many people as possible,” she says. “Donating through my RRSP was a tax-advantageous way to give a larger amount. This way, the scholarship can last well into the future.
“I’m a big believer in education. Helping students with financial need complete their medical training is a way for me to pay it forward.”
As the Labatt Family Chair and a professor in the Department of Psychiatry, Benoit Mulsant is a leading member of the Temerty Medicine community. While he has many responsibilities as an academic chair and clinician-scientist, Mulsant also makes a point of demonstrating leadership through philanthropic support, including a recently committed legacy gift.
“Philanthropy is the engine that generates innovation and discovery in our department,” he says. “As a department chair, I can see the money working – supporting the creation of new curricula and funding important pilot research studies.”
For Mulsant, making a planned gift is a tax-friendly way to give to the future of his field and make a large impact on medicine as a whole.
“I’ve been privileged and fortunate in my career, so now I’m thinking of the next generation,” he says. “My gift will help others do more – to take psychiatry further and help even more patients.”
In making a bequest, Mulsant hopes to inspire others to join him in establishing a lasting legacy.
“I like to think that the gift, and my impact, will continue on for many years in the future,” he says. “In this way, I want to be an example for my children and to those who care about psychiatry.
“The effect of one gift over time can be multiplied tenfold by the new discoveries and innovations it helps fuel. This is the power of philanthropy.”
For more information about estate giving, including how you can designate gifts to specific Temerty Medicine funds or initiatives, please visit uoft.me/med-giving or contact Amy Hopkins, Associate Director, Leadership and Annual Giving, at amy.hopkins@utoronto.ca or 416-559-2731.
In the early 1970s, University of Toronto research psychiatrists Milo Tyndel and Robert Pos investigated new insomnia therapies at a sleep clinic in Toronto General Hospital.
In this 1972 photo from the Toronto Star, nurse Linda Squires prepares a patient for an insomnia therapy called “electro-sleep,” which delivered small electrical impulses to the patient through electrodes connected to a Somlec machine. When coupled with synchronized audio, the therapy was thought to stimulate neural transmitters, induce drowsiness and train the brain to sleep through the night. Electro-sleep therapy offered a potential alternative to barbiturates, which were known to depress the central nervous system and carry the risk of addiction.
Over 10 weeks, patients such as secretary Deana O’Reilly, pictured here, underwent weekly hour-long electro-sleep treatments to achieve a better rest.
Today, the therapy is known as cranial electronic stimulation and is used to manage various conditions, such as pain, stress and anxiety. Tyndel retired the clinic’s Somlec machine in 1973, and it is now part of the collection at the Museum of Health Care at Kingston.
