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Editorials

How Did It Get Late So Soon?. 5-6.
Nancy A. Collop, MD, FAASM

Commentary

Home Portable Sleep Testing Has Gone Global. 7-8.
Karel Calero, MD; William McDowell Anderson, MD

Scientific Investigations

Effects of Suvorexant, an Orexin Receptor Antagonist, on Respiration during Sleep In Patients with Obstructive Sleep Apnea. 9-17.
Hong Sun, MD, PhD1; John Palcza, MS1; Deborah Card, MS1; Adrianna Gipson, MS1; Russell Rosenberg, PhD2; Meir Kryger, MD3; Christopher Lines, PhD1; John A. Wagner, MD, PhD1; Matthew D. Troyer, MD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Suvorexant is a first-in-class orexin receptor antagonist that is approved in the USA and Japan for the treatment of insomnia. Given the coexistence of insomnia and sleep apnea in many patients, it is important to examine the respiratory safety of any new insomnia medication in patients with sleep apnea.

Study Impact: The findings of this study show that a nighttime 40 mg dose of suvorexant (twice the 20 mg maximum daily dose approved in the USA and Japan) does not have clinically meaningful effects on respiration during sleep in patients with mild to moderate obstructive sleep apnea as assessed by mean changes in number of apneas/hypopneas and oxygen saturation. Because there is inter- and intra-individual variability in respiratory effects, suvorexant should be used with caution in patients with compromised respiratory function, and at the lowest effective dose.

Fiber and Saturated Fat Are Associated with Sleep Arousals and Slow Wave Sleep. 19-24.
Marie-Pierre St-Onge, PhD1; Amy Roberts, PhD2; Ari Shechter, PhD1; Arindam Roy Choudhury, PhD3

BRIEF SUMMARY

Current Knowledge/Study Rationale: Research has established a convincing link between short/disrupted sleep duration and food intake. Here we aimed to investigate the effects of dietary intake on subsequent sleep propensity, depth, and architecture.

Study Impact: Few studies have utilized controlled conditions to determine how food intake affects sleep. Current findings—that daytime fat and sugar/fiber content affect nocturnal sleep—imply that diet-based recommendations might be used to improve sleep in those with poor sleep quality.

Evaluation of Bone Mineral Density by Computed Tomography in Patients with Obstructive Sleep Apnea. 25-34.
Satoshi Hamada, MD1; Kohei Ikezoe, MD1; Toyohiro Hirai, MD, PhD1; Tsuyoshi Oguma, MD1; Kiminobu Tanizawa, MD, PhD1; Morito Inouchi, MD, PhD2; Tomohiro Handa, MD, PhD1; Toru Oga, MD, PhD2; Michiaki Mishima, MD, PhD1; Kazuo Chin, MD, PhD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Reports on the relationships between obstructive sleep apnea (OSA) and bone metabolism are conflicting. Bone mineral density (BMD) is usually quantified by dual-energy x-ray absorptiometry, which has limitations in overweight persons. In the present study, we used quantitative CT to examine the relationships between OSA and BMD.

Study Impact: This study showed that BMD in male patients with severe OSA determined by CT images was lower than that in non OSA participants. Also, age, hypertension, and elevation of the alveolar-arterial oxygen pressure difference were significant factors for BMD by CT imaging.

A Comparison of Different Success Definitions in Non-Continuous Positive Airway Pressure Treatment for Obstructive Sleep Apnea Using Cardiopulmonary Coupling. 35-41.
Woo Hyun Lee, MD1; Seung-No Hong, MD2; Hong Joong Kim, MD2; Chae-Seo Rhee, MD2; Chul Hee Lee, MD2; In-Young Yoon, MD3; Jeong-Whun Kim, MD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: There is a need to find a standardized criterion to define the success of non-CPAP treatment for OSA. This study aimed to compare different success criteria of non-CPAP treatment for OSA in terms of sleep quality by using cardiopulmonary coupling.

Study Impact: We propose that a reduction in the AHI greater than 50% may be the optimum value for defining the success of non-CPAP treatment outcome in terms of CPC-based sleep quality. Well-designed studies should be performed in the future to prove that this criterion can be correlated with a satisfactory health outcome in patients with OSA.

Upper Airway Stimulation for Obstructive Sleep Apnea: Self-Reported Outcomes at 24 Months. 43-48.
Ryan J. Soose, MD1; B. Tucker Woodson, MD2; M. Boyd Gillespie, MD3; Joachim T. Maurer, MD4; Nico de Vries, MD5; David L. Steward, MD6; Kingman P. Strohl, MD7; Jonathan Z. Baskin, MD7; Tapan A. Padhya, MD8; M. Safwan Badr, MD9; Ho-sheng Lin, MD9; Olivier M. Vanderveken, MD, PhD10; Sam Mickelson, MD11; Eileen Chasens, PhD12; Patrick J. Strollo, MD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Hypoglossal cranial nerve stimulation therapy consists of a surgically implantable and medically titratable second-line treatment option for obstructive sleep apnea (OSA), and was previously shown to provide safe and effective short-term management for patients who meet specific clinical and anatomical inclusion criteria. Since OSA represents a chronic condition requiring longitudinal care, this study was undertaken to examine the durability of effect of the therapy on patient-centered outcome measures at 24 months after implantation.

Study Impact: This study demonstrates long-term clinically meaningful improvement in snoring, daytime alertness, and sleep-related quality of life with hypoglossal cranial nerve stimulation therapy. The treatment effect size is large and is maintained across a 2 year follow-up period, providing support for consideration of this therapeutic option in selected patients who are unable to adhere to positive pressure therapy.

Article Is Eligible For CME Credits Effects of Blast Exposure on Subjective and Objective Sleep Measures in Combat Veterans with and without PTSD. 49-56.
Ryan P.J. Stocker, PsyD1,2; Benjamin T.E. Paul, MSW1; Oommen Mammen1,2; Hassen Khan, BS1; Marissa A. Cieply, BS1; Anne Germain, PhD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: The potential pervasive effects of blast exposure on subjective and objective sleep measures continue to be a phenomenon that has not been fully investigated. The aim of the present study was to explore the relationships between blast exposure and/or prior mild traumatic brain injury and subjective sleep measures, as well as objective measures of sleep continuity, and non-rapid eye movement (NREM) and rapid eye movements (REM) sleep parameters in a sample of combat-exposed military service members and veterans with and without posttraumatic stress disorder (PTSD), and with no current post-concussive symptoms.

Study Impact: Results of the present study suggests that prior blast exposure or TBI alone, in the absence of current chronic concussive symptoms, does not adversely affect sleep quality, insomnia, disruptive nocturnal behaviors, or objective sleep measures beyond the effects of PTSD. Preliminary observations suggest that attenuation of REM sleep may be an especially sensitive index of central changes resulting from psychological or physical insults. Further investigation is needed to elucidate the of REM sleep mechanisms that may be affected by either or both blast exposure and PTSD.

Sleeping Pill Administration Time and Patient Subjective Satisfaction. 57-62.
Seockhoon Chung, MD, PhD; Soyoung Youn, MD; Kikyoung Yi, MD; Boram Park, MD; Suyeon Lee, MD

BRIEF SUMMARY

Current Knowledge/Study Rationale: Most insomnia patients usually take sleeping pills 30 min before the time when they desire to go to bed, not the time when they should go to bed based on their sleep-wake cycle. The exact time when patients take their sleeping pills may influence the efficacy of these hypnotics. This study was done to investigate the impact of timing on the effectiveness of sleeping pills and patient subjective satisfaction with these drugs.

Study Impact: Patients who were satisfied with their sleeping pills tended to take these hypnotic agents later in the evening than those who were not satisfied. Patients in the satisfied group also spent only 7.2 h until wake up in the morning after taking their sleeping pills, whereas patients in the dissatisfied group spent 9.3 h. We propose that physicians advise patients to take benzodiazepine or nonbenzodiazepine GABA agonists sleeping pills 7 h before their getting- out-of-bed time rather than 30 min before bedtime.

Article Is Eligible For CME Credits Post Hoc Analysis of Data from Two Clinical Trials Evaluating the Minimal Clinically Important Change in International Restless Legs Syndrome Sum Score in Patients with Restless Legs Syndrome (Willis-Ekbom Disease). 63-70.
William G. Ondo, MD1; Frank Grieger, Dipl Stat2; Kimberly Moran, PhD3; Ralf Kohnen, PhD4; Thomas Roth, PhD5

BRIEF SUMMARY

Current Knowledge/Study Rationale: The minimal clinically important change (MCIC) is defined as the minimum change in score that would be perceived as beneficial. This is largely unexplored in restless legs syndrome (RLS). This post hoc analysis of data from two double-blind, randomized clinical studies determined the MCIC for the international restless legs syndrome (IRLS) and restless legs syndrome 6-item questionnaire (RLS-6), two validated patient-reported scales used in the assessment of RLS treatment, in patients with moderate to severe RLS treated with the rotigotine transdermal system.

Study Impact: This post hoc analysis established the MCIC in IRLS and RLS-6 scores related to the ability to discern a clinically relevant improvement in RLS symptoms following treatment with rotigotine. Defining the MCIC for the IRLS and RLS-6 gives clinicians an anchor for determining the effectiveness of RLS therapy, and to better understand the different factors that may influence perceptions of clinical improvement.

Agreement in the Scoring of Respiratory Events Among International Sleep Centers for Home Sleep Testing. 71-77.
Ulysses J. Magalang, MD1; Erna S. Arnardottir, PhD2,3; Ning-Hung Chen, MD4; Peter A. Cistulli, MD, PhD5; Thorarinn Gíslason, MD, PhD2,3; Diane Lim, MD7; Thomas Penzel, PhD6; Richard Schwab, MD7; Sergio Tufik, MD, PhD8; Allan I. Pack, MBChB, PhD7

BRIEF SUMMARY

Current Knowledge/Study Rationale: Home sleep testing (HST) is now commonly used worldwide to confirm the presence of obstructive sleep apnea because it is less labor intensive and less expensive compared to in-laboratory polysomnography (PSG). We previously showed that there was a substantial agreement in the scoring of respiratory events for PSG among international sleep centers, but this has not been studied for HST.

Study Impact: We found a strong agreement in the scoring of the respiratory events for HST among international sleep centers. In association with our previous study, the results suggest that centralized scoring of sleep studies may not be necessary in research collaboration among international sites.

The Effects of Milnacipran on Sleep Disturbance in Fibromyalgia: A Randomized, Double-Blind, Placebo-Controlled, Two-Way Crossover Study. 79-86.
Mansoor Ahmed, MD; Rozina Aamir, MS, MBA; Zahra Jishi, MPH; Martin B. Scharf, PhD

BRIEF SUMMARY

Current Knowledge/Study Rationale: Pain and disturbed sleep are hallmark features of fibromyalgia. The effects of pharmacotherapy on sleep physiology may provide insight into this relationship.

Study Impact: Milnacipran seems to improve sleep by reducing pain. The study suggests the need to evaluate fibromyalgia in a more homogeneous patient population.

Mechanism of Gastroesophageal Reflux in Obstructive Sleep Apnea: Airway Obstruction or Obesity?. 87-94.
Kelly Shepherd, PhD1; William Orr, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: This study compares reflux events during wake and sleep in obese patients with and without OSA and lean individuals with OSA.

Study Impact: This study confirms an important role for obesity, rather than OSA per se in the relationship between OSA and GER.

Performance of a Portable Sleep Monitoring Device in Individuals with High Versus Low Sleep Efficiency. 95-103.
Rachel R. Markwald, PhD1; Sara C. Bessman, MS1; Seth A. Reini, PhD1; Sean P.A. Drummond, PhD2,3

BRIEF SUMMARY

Current Knowledge/Study Rationale: A commercially developed wireless system for monitoring sleep has been utilized as the primary sleep assessment in sleep research studies; however, a previously identified weakness in device performance needs to be further explored. We conducted a study to evaluate the device for sleep/wakefulness identification and sleep staging in a sample of heterogeneous sleep efficiency sleepers.

Study Impact: These findings indicate that the wireless system is useful at sleep staging when high-efficiency sleep is expected and when traditional polysomnography is precluded due to cost or location restrictions. Importantly, although the wireless system performs well at dichotomous sleep/wake identification in lowefficiency sleepers, the sleep stage information becomes less reliable and does not offer any advantages over standard actigraphy for remote monitoring.

The Prevalence of Depression among Untreated Obstructive Sleep Apnea Patients Using a Standardized Psychiatric Interview. 105-112.
Erla Björnsdóttir, MS1,2; Bryndís Benediktsdóttir, MD1,2; Allan I. Pack, PhD3; Erna Sif Arnardottir, PhD1,2; Samuel T. Kuna, PhD3,6; Thorarinn Gíslason, PhD1,2; Brendan T. Keenan, MS3; Greg Maislin, MS, MA3; Jón Fridrik Sigurdsson, PhD1,4,5

BRIEF SUMMARY

Current Knowledge/Study Rationale: Most previous studies have used self-reported questionnaires to assess depression among OSA patients and as a result, overrepresentation of the prevalence is likely to occur due to the frequent symptom overlap between depression and OSA. As a result, it is unclear if OSA and depression express a real comorbidity or only share similar symptoms.

Study Impact: In this study, the prevalence of depression in a sample of patients with untreated OSA assessed with a standardized clinical psychiatric interview is lower than reported in previous studies. Increased awareness of the relationship between depression and OSA and the appropriate use of assessment tools might significantly improve diagnostic accuracy as well as treatment outcome for both depression and OSA.

Special Articles

How Reliable Is Self-Reported Body Position during Sleep?. 127-128.
Kathryn Russo, BS1; Matt T. Bianchi, MD, PhD1,2
The Evolution of the AASM Clinical Practice Guidelines: Another Step Forward. 129-135.
Timothy I. Morgenthaler, MD1; Ludmila Deriy, PhD2; Jonathan L. Heald, MA2; Sherene M. Thomas, PhD2

Case Reports

Mandibular Advancement Device—Emergent Central Sleep Apnea Can Resolve Spontaneously: A Case Report. 137-138.
Arjun Mohan, MD1,2,3; Jennifer Henderson, DO1,2; M. Jeffery Mador, MD1,2
Sleep Related Scratching: A Distinct Parasomnia?. 139-142.
Gaurav Nigam, MD; Muhammad Riaz, MD, MS; Shelley D. Hershner, MD; Cathy A. Goldstein, MD, MS; Ronald D. Chervin, MD, MS

Sleep Medicine Pearls

A 76 Year-Old Woman with Sleep and Waking Stridor, Sleep Talking, Orthostatic Hypotension, and Imbalance. 143-145.
Erik K. St. Louis, MD1,2,3; Ethan J. Duwell, BA1,2,3; Diana M. Orbelo, PhD4; Eduardo E. Benarroch, MD3; Elizabeth A. Coon, MD3; Bradley F. Boeve, MD1,3; Michael H. Silber, MBChB1,3

Journal Club

Adaptive Servo-Ventilation and Central Apnea Associated with Systolic Heart Failure. 147-150.
Shirin Shafazand, MD, MS1; M. Safwan Badr, MD, MBA2
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