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Commentary

CPAP Use: Unmasking the Truth about Interface. 1209-1210.
Rohit Budhiraja, MD1,2; Jessie P. Bakker, BS, MS, PhD1
Perceiving the Misperception. 1211-1212.
Aaron B. Holley, MD
Dentistry and Obstructive Sleep Apnea. 1213-1214.
Carlos Flores-Mir, DDS, DSc, FRCD(C)

Scientific Investigations

Suvorexant in Patients with Insomnia: Pooled Analyses of Three-Month Data from Phase-3 Randomized Controlled Clinical Trials. 1215-1225.
W. Joseph Herring, MD, PhD1; Kathleen M. Connor, MD1; Ellen Snyder, PhD1; Duane B. Snavely, MA1; Ying Zhang, PhD1; Jill Hutzelmann, MS1; Deborah Matzura-Wolfe, BS1; Ruth M. Benca, MD2; Andrew D. Krystal, MD3; James K. Walsh, PhD4; Christopher Lines, PhD1; Thomas Roth, PhD5; David Michelson, MD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Suvorexant is a first-in-class orexin receptor antagonist approved for treating insomnia at a maximum dose of 20 mg. We performed a pooled analysis of suvorexant 20/15 mg, which was evaluated as a secondary objective in Phase-3 clinical trials.

Study Impact: The results of the pooled analysis showed that suvorexant 20/15 mg improved sleep onset and maintenance over 3 months of nightly treatment and was generally safe and well-tolerated. Our analysis validates orexin receptor antagonism as a novel therapeutic approach for treating insomnia.

Article Is Eligible For CME Credits Choosing an Oronasal Mask to Deliver Continuous Positive Airway Pressure May Cause More Upper Airway Obstruction or Lead to Higher Continuous Positive Airway Pressure Requirements than a Nasal Mask in Some Patients: A Case Series. 1227-1232.
Justin R. Ng, MBBS; Vinod Aiyappan, MD; Jeremy Mercer, PhD; Peter G. Catcheside, PhD; Ching Li Chai-Coetzer, MBBS, PhD; R. Doug McEvoy, MD, PhD; Nick Antic, MBBS, PhD

BRIEF SUMMARY

Current Knowledge/Study Rationale: A wide variety of mask interfaces are used to deliver CPAP therapy for patients with OSA, but there is limited literature available to guide the treating physician on the most efficacious mask interface to treat upper airway obstruction (UAO). Four OSA cases are presented demonstrating clinically significant residual UAO with CPAP delivered by an oronasal mask leading to treatment failure, which was corrected by switching to a nasal mask that was set, in two of the four cases, to a substantially lower CPAP pressure.

Study Impact: This is a new case series highlighting this clinical problem and demonstrating that changing from an oronasal mask to a nasal mask led to resolution of the problem. If patients have OSA incompletely controlled by CPAP with evidence of residual UAO or are requiring surprisingly high CPAP pressures to control OSA with an oronasal mask, the choice of mask should be reviewed and consideration be given to a trial of a nasal mask.

Expiratory Positive Airway Pressure for Sleep Apnea after Stroke: A Randomized, Crossover Trial. 1233-1238.
Natalie C. Wheeler, MD1,2; Jeffrey J. Wing, PhD3; Louise M. O'Brien, PhD4; Rebecca Hughes, BA2; Teresa Jacobs, MD2; Edward Claflin, MD5; Ronald D. Chervin, MD, MS1,4; Devin L. Brown, MD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) is widely prevalent after ischemic stroke and is associated with higher mortality and worsened outcomes, but stroke patients as a group may not tolerate conventional continuous positive airway pressure (CPAP). This study was designed to test the effects of nasal expiratory positive airway pressure (EPAP) within this important population.

Study Impact: This study supports the feasibility of diagnostic and clinical interventions for OSA during acute hospitalizations after stroke, but suggests that EPAP is not likely to treat OSA effectively in acute stroke patients intolerant to CPAP. Alternatives to CPAP and EPAP should be identified.

Use of Chest Wall Electromyography to Detect Respiratory Effort during Polysomnography. 1239-1244.
Richard B. Berry, MD1; Scott Ryals, MD1; Ankur Girdhar, MD1; Mary H. Wagner, MD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Recording of surface electromyography (EMG) activity of the chest wall has been used in research studies, but the utility of the technique for detection of respiratory effort during routine clinical polysomnography has not been well documented. This study compared apnea classification using uncalibrated respiratory inductance plethysmography and chest wall EMG.

Study Impact: The study suggests that chest wall EMG using routine clinical techniques can provide useful complementary information to respiratory inductance plethysmography concerning the presence of respiratory effort during apnea.

Article Is Eligible For CME Credits Sleep Fragmentation Does Not Explain Misperception of Latency or Total Sleep Time. 1245-1255.
Austin Saline, BA1; Balaji Goparaju, MS1; Matt T. Bianchi, MD, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Sleep misperception is not uncommon, particularly in patients with insomnia. However, the mechanistic basis remains uncertain, in part because of challenges in quantifying the perception phenotype.

Study Impact: We introduce a novel phenotyping approach that facilitates hypothesis-testing in populations with misperception. Combined with stage-transition analytics, we found no evidence to support the common hypothesis that sleep fragmentation underlies misperception.

Effect of CPAP Therapy on Symptoms of Nocturnal Gastroesophageal Reflux among Patients with Obstructive Sleep Apnea. 1257-1261.
Sadeka Tamanna, MD, MPH1; Douglas Campbell, MD1; Richard Warren, MD1; Mohammad I. Ullah, MD, MPH2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Nocturnal gastroesophageal reflux (nGER) frequently coexists in patients with obstructive sleep apnea (OSA). Previous studies reported some improvement in nGER symptoms with CPAP therapy but no objective measurement of CPAP compliance was documented.

Study Impact: Our study revealed that CPAP therapy with adequate compliance (as documented by the downloaded machine data) helps improve the symptoms of both nocturnal acid reflux and daytime sleepiness. Clinicians should encourage all patients with OSA and nGER to maintain a good CPAP compliance to achieve this benefit.

Oronasal Masks Require a Higher Pressure than Nasal and Nasal Pillow Masks for the Treatment of Obstructive Sleep Apnea. 1263-1268.
Sheetal Deshpande, MBBS1; Simon Joosten, MBBS, BMedSc, FRACP, PhD1,2; Anthony Turton, BSci1; Bradley A. Edwards, PhD3,4; Shane Landry, PhD3; Darren R. Mansfield, MBBS, FRACP, PhD1,4; Garun S. Hamilton, MBBS, FRACP, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: It has been suggested that patients using oronasal masks require a higher CPAP level than those using nasal or nasal pillow masks, but previous literature in the area is conflicting. Our aim was to determine if there is a systematic difference in CPAP requirements according to mask type.

Study Impact: Oronasal mask use is associated with higher CPAP level compared to nasal mask use and this is particularly evident in patients on very high CPAP pressures (≥ 15 cm H2O). There is also a higher residual AHI in patients using oronasal masks and clinicians need to be aware of how this may impact on patient treatment response.

Development of the Pain-Related Beliefs and Attitudes about Sleep (PBAS) Scale for the Assessment and Treatment of Insomnia Comorbid with Chronic Pain. 1269-1277.
Esther F. Afolalu, MSc1; Corran Moore, BSc1; Fatanah Ramlee, MHSc1; Claire E. Goodchild, PhD2; Nicole K.Y. Tang, DPhil1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Maladaptive beliefs about the sleep-pain interaction are possible factors perpetuating pain-related insomnia. This study examined the psychometric properties of the Pain-Related Beliefs and Attitudes about Sleep (PBAS) scale, specifically designed for the assessment and treatment of insomnia comorbid with chronic pain.

Study Impact: Thinking about the interaction between pain and sleep is an integral part of chronic pain patients' insomnia experience. Findings from the current study suggest that the PBAS is a valid and reliable tool for detecting and assessing these unhelpful beliefs, opening up new avenues for research and interventions.

Anthropometric and Dental Measurements in Children with Obstructive Sleep Apnea. 1279-1284.
David F. Smith, MD, PhD1; Nicholas M. Dalesio, MD2,3; James R. Benke, BS3; John A. Petrone, DDS4; Veronica Vigilar, BS5; Aliza P. Cohen, MA1; Stacey L. Ishman, MD, MPH1,6,7

BRIEF SUMMARY

Current Knowledge/Study Rationale: Given the difficulty with acquiring polysomnography based on access and cost, a number of studies have focused on alternative identifiers of OSA in children. Identifiers of interest have focused on physical characteristics that can be evaluated in clinical settings or are less costly to obtain, such as anthropometric and dental measurements.

Study Impact: We present preliminary data for anthropometric and dental measurements in children with OSA compared to nonsnoring control patients. Further, we demonstrate that children with OSA have significantly larger waist and hip circumferences, lower neck-waist ratios, and narrower first and second deciduous and first permanent molar intertooth distances compared to nonsnoring controls.

Adenoidectomy for Obstructive Sleep Apnea in Children. 1285-1291.
Keren Armoni Domany, MD; Elad Dana, MD; Riva Tauman, MD; Guy Gut, MD; Michal Greenfeld, MD; Bat-El Yakir, BSc; Yakov Sivan, MD

BRIEF SUMMARY

Current Knowledge/Study Rationale: Adenotonsillectomy is the recommended treatment for children with obstructive sleep apnea (OSA). Since adenoidectomy may be associated with significantly lower morbidity, mortality and cost, we aimed to investigate whether adenoidectomy alone is a reasonable and appropriate treatment for children with OSA.

Study Impact: In non-obese children with moderate OSA and smaller tonsils, adenoidectomy alone is a reasonable option. Future prospective randomized studies are needed.

Case Reports

Positive Airway Pressure-Induced Conversion of Atrial Fibrillation to Normal Sinus Rhythm in Severe Obstructive Sleep Apnea. 1301-1303.
Harneet K. Walia, MD, FAASM1; Mina K. Chung, MD2; Sally Ibrahim, MD1; Reena Mehra, MD, MS, FCCP, FAASM1,2
Nocturnal Hypermotor Activity during Apnea-Related Arousals. 1305-1307.
Romy Hoque, MD, FAASM1; Lourdes M. DelRosso, MD, FAASM2

Letters to the Editor

Bidirectional Relationship between Obstructive Sleep Apnea (OSA) and Psoriasis: Implications for OSA Therapies?. 1309.
Madhulika A. Gupta, MD, FAASM, RST1; Fiona C. Simpson, HBSc1; Aditya K. Gupta, MD, PhD, FAAD2
Effect of Biological Therapy on the Risk of Sleep Apnea in Patients with Psoriasis. 1311.
Alexander Egeberg, MD, PhD; Lone Skov, MD, PhD, DMSc
ASV in CHF Recommendations Too Restrictive. 1313-1314.
Karin G. Johnson, MD; Douglas C. Johnson, MD
Keep Calm and Debate On. 1315-1316.
R. Nisha Aurora, MD, MHS1; Sabin R. Bista, MD2; Kenneth R. Casey, MD, MPH3; Susmita Chowdhuri, MD4; David A. Kristo, MD5; Jorge M. Mallea, MD6; Kannan Ramar, MD7; James A. Rowley, MD8; Rochelle S. Zak, MD9; Jonathan L. Heald, MA10
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