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Editorial

Payer Perspective of the American Academy of Sleep Medicine Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia. 155-157.
Michael J. Sateia, MD1; William C. Sherrill, MD2; Carolyn Winter-Rosenberg3; Jonathan L. Heald, MA3

Scientific Investigations

Interventional Drug-Induced Sleep Endoscopy: A Novel Technique to Guide Surgical Planning for Obstructive Sleep Apnea. 169-174.
Andrew Jacob Victores, MD; Krista Olson, MD; Masayoshi Takashima, MD, FACS

BRIEF SUMMARY

Current Knowledge/Study Rationale: Determination of the site of upper airway obstruction and selection of the appropriate surgical intervention for obstructive sleep apnea (OSA) can be difficult, especially as the primary area of collapse may induce an artificial secondary area of obstruction. We evaluate the utility of using a nasopharyngeal tube during drug-induced sleep endoscopy (DISE) to simulate the effects of isolated palatal surgery.

Study Impact: Nasopharyngeal tube placement appears to be a useful tool to delineate which patients could benefit from an isolated palatal surgery for OSA as opposed to a more extensive approach. A significant portion of patients who appeared to have multilevel collapse on DISE had complete resolution (35%) of collapse with nasopharyngeal tube placement alone.

Ready-Made Versus Custom-Made Mandibular Repositioning Devices in Sleep Apnea: A Randomized Clinical Trial. 175-182.
Ama Johal, PhD1; Priya Haria, MClinDent1; Seema Manek, MSc1; Easter Joury, PhD1; Renata Riha, MBBS2

BRIEF SUMMARY

Current Knowledge/Study Rationale: The role of mandibular repositioning devices (MRD) in the management of obstructive sleep apnea (OSA) is now recognized. However, data comparing the effectiveness of a custom-made (MRDc) versus ready-made (MRDr) repositioning devices is contradictory and may reflect the inherent limitations in study design.

Study Impact: The present study demonstrates the significant therapeutic benefit of a custom-made MRD, in terms of both clinician-and patient- centered outcomes and highlights the key shortcomings of ready-made MRDs.

Factors Associated with Changes in Invasive and Noninvasive Positive Airway Pressure Therapy Settings during Pediatric Polysomnograms. 183-188.
Suhail Al-Saleh, MBBS, MSc1,2; Priya Sayal, HBSc2; Derek Stephens, MSc3; Joshua Florence1; Aman Sayal1; Adele Baker, RRT1; Faiza Syed, RRT1; Indra Narang, MBBCH, MD1,2; Reshma Amin, MD, MSc1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: The optimal timing of follow-up polysomnograms in children prescribed invasive and noninvasive positive airway pressure therapy for sleep- disordered breathing is an area that has not been well studied. Although there are international guidelines suggesting that polysomnograms should be performed every 6 to 12 mo, this is based on expert opinion rather than the existing literature.

Study Impact: Our data suggest that clinicians should pay particular attention to the type of positive airway pressure therapy, the underlying primary diagnosis, and the time from the initiation of therapy when requesting follow-up positive airway pressure therapy titration studies. Our study is the first to report clinical predictors of changes in technology settings during pediatric polysomnograms, which can begin to be translated into clinical practice and iteratively updated as new literature emerges for this rapidly growing population.

Dynamic Volume Computed Tomography Imaging of the Upper Airway in Obstructive Sleep Apnea. 189-196.
Robert J. Fleck, MD1; Stacey L. Ishman, MD, MPH2,3,4; Sally R. Shott, MD2,4; Ephraim J. Gutmark, PhD, DSc4,5; Keith B. McConnell, MS3; Mohamed Mahmoud, MD1,6; Goutham Mylavarapu, PhD3; Dhananjay R. Subramaniam, MS5; Rhonda Szczesniak, PhD3,7; Raouf S. Amin, MD3,8

BRIEF SUMMARY

Current Knowledge/Study Rationale: Dynamic 3D CT produces a unique 3D dynamic dataset for evaluation of the upper airway for clinical or research use. Dynamic 3D CT can be performed with a radiation dose less than that of a static examination of the exact same anatomy imaged for a facial CT for common clinical indications.

Study Impact: Dynamic 3D CT is an alternative method capable of obtaining a uniquely dynamic 3D dataset for the evaluation of obstructive sleep apnea in patients with persistent, problematic sleep apnea and could be used to guide surgical treatment to result in better outcomes. The effective radiation dose for dynamic 3D CT is equal to or less than that of a facial CT, setting a benchmark for use of the technique.

Exercise, Occupational Activity, and Risk of Sleep Apnea: A Cross-Sectional Study. 197-204.
Roberto P. da Silva, PhD1; Denis Martinez, MD, PhD1,2,3,4; Martina M. Pedroso, MSc1; Camila G. Righi, PhD1; Emerson F. Martins, PhD1; Leticia M.T. Silva, MD4; Maria do Carmo S. Lenz, MD, PhD3; Cintia Z. Fiori, PhD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Programmed physical exercise is associated with less severe OSA. The influence of occupational activity on OSA severity is not completely understood.

Study Impact: The lack of association between OSA and occupational activity suggests the potential importance of programed physical exercise in OSA management.

Are Patients with Childhood Onset of Insomnia and Depression More Difficult to Treat Than Are Those with Adult Onsets of These Disorders? A Report from the TRIAD Study. 205-213.
Jack D. Edinger, PhD1,2; Rachel Manber, PhD3; Daniel J. Buysse, MD4; Andrew D. Krystal, MD2; Michael E. Thase, MD5; Phillip Gehrman, PhD5; Christopher P. Fairholme, PhD6; James Luther, MA7; Stephen Wisniewski, PhD7

BRIEF SUMMARY

Current Knowledge/Study Rationale: Patients with comorbid insomnia and major depression benefit by interventions that simultaneously provide targeted therapies for each of these conditions, yet not all such patients receiving this treatment combination benefit equally from it. The current study was conducted to determine if age of onset of insomnia and depression moderate eventual treatment outcomes when these conditions occur comorbidly.

Study Impact: The study showed that patients with childhood onsets of insomnia and depression show less insomnia and depression improvement with treatment consisting of antidepressant medication and cognitive-behavioral insomnia therapy than do those with adult onsets of both conditions. Results imply that patients with childhood onsets of depression and insomnia may represent a difficult to treat group with treatment needs that go unmet by standard CBT-I/ antidepressant medication protocols.

Nasal Dilator Strip is an Effective Placebo Intervention for Severe Obstructive Sleep Apnea. 215-221.
Fabiana Yagihara, MSc1; Geraldo Lorenzi-Filho, MD, PhD1,2; Rogerio Santos-Silva, PhD, RPSGT1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Randomized controlled trials have shown the effectiveness of continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA), but there are practical difficulties to finding the ideal placebo. The current study sought to evaluate the effects of nasal dilator strip as a placebo intervention compared with CPAP treatment in patients with severe OSA in a randomized controlled crossover protocol.

Study Impact: This study showed high adherence and low levels of difficulty for nasal dilator strip as a placebo intervention in a randomized controlled crossover protocol. Our data indicate that the nasal dilator strip could be used as an alternative placebo intervention in randomized controlled trials of patients with severe OSA, as supported by the absence of effects in clinical sleep outcomes (sleep architecture and respiratory events) compared with CPAP.

Spontaneous Adverse Event Reports Associated with Zolpidem in the United States 2003–2012. 223-234.
Carmen K. Wong, BPharm1; Nathaniel S. Marshall, PhD2,3; Ronald R. Grunstein, MD2; Samuel S. Ho, BPharm1; Romano A. Fois, PhD1; David E. Hibbs, PhD1; Jane R. Hanrahan, PhD1; Bandana Saini, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: The behavioral influence of the media on health scares and stimulated reporting have been studied for a number of medications including the contraceptive pill, vaccinations, paroxetine, and triazolam; however, the impact and consequences of media publicity have been observational and have yet to be rigorously analyzed using robust quantitative pharmacovigilance disproportionality measures.

Study Impact: To our knowledge, this is the first report that thoroughly explores the extent of stimulated reporting of adverse drug reactions associated with zolpidem exposure in the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database using appropriate disproportionality analyses. Analysis of the FAERS data can provide a better profile of the level of adverse events associated with zolpidem and showcase the effect of media publicity during 2006–2009 on adverse event reporting. Drug regulatory bodies should consider this notoriety bias when making drug-related decisions based on adverse event risk.

Normal Morning Melanin-Concentrating Hormone Levels and No Association with Rapid Eye Movement or Non-Rapid Eye Movement Sleep Parameters in Narcolepsy Type 1 and Type 2. 235-243.
Maren Schrölkamp, MSc1,2; Poul J. Jennum, MD, DMedSc3; Steen Gammeltoft, MD, DMedSc1; Anja Holm, PhD1; Birgitte R. Kornum, PhD1; Stine Knudsen, MD, PhD3,4

BRIEF SUMMARY

Current Knowledge/Study Rationale: Hypocretin/orexin neurons interact with the melanin-concentrating hormone (MCH) neurons also located in the hypothalamus. We speculated whether altered MCH function could contribute to the symptoms and sleep abnormalities of narcolepsy.

Study Impact: Our study is the first to systematically collect morning cerebrospinal fluid from patients of both narcolepsy subtypes (narcolepsy type 1, narcolepsy type 2) and healthy controls and measure MCH levels in the samples. We do not find altered morning MCH levels in narcolepsy, regardless of narcolepsy subtype or HCRT-1 status.

Performance of a New Portable Wireless Sleep Monitor. 245-258.
Magdy Younes, MD, FRCPC, PhD1,2; Marc Soiferman, MSc2; Wayne Thompson, RPSGT1; Eleni Giannouli, MD, FRCPC1

BRIEF SUMMARY

Current Knowledge/Study Rationale: The current need for investigating sleep disorders is much greater than can be met by the standard in-laboratory sleep studies. We compared the results of a new portable, wireless, forehead-mounted monitor that utilizes easy-to-apply frontal electrodes with results of in-laboratory full polysomnography in 59 patients with a range of sleep disorders including severe sleep apnea.

Study Impact: We show that EEG signals generated by this monitor are visually indistinguishable from polysomnography signals and, when scored with its automatic system that requires minimal guided editing, produce results in good agreement with manual scoring, and, in addition, provides a continuous index of sleep depth throughout the night (Odds-Ratio-Product). This monitor may make it possible to obtain high quality inexpensive sleep evaluation in the home.

Validation of Polyvinylidene Fluoride Impedance Sensor for Respiratory Event Classification during Polysomnography in Children. 259-265.
Anne G. Griffiths, MD1; Pallavi P. Patwari, MD2; Darius A. Loghmanee, MD3,4; Matthew J. Balog, RSPGT3; Irina Trosman, MD3,4; Stephen H. Sheldon, DO3,4

BRIEF SUMMARY

Current Knowledge/Study Rationale: Current American Academy of Sleep Medicine recommendations include use of respiratory inductance plethysmography belts (RIPb) for detection of respiratory events in children and adults, whereas use of polyvinylidene fluoride belts (PVDFb) is only recommended for adults. With advances in quality of technology, we aimed to determine if PVDFb would be as effective as RIPb in the pediatric population.

Study Impact: Our study directly compares traditional RIPb technology and PVDFb technology for respiratory effort sensing in pediatric patients.

Computerized Cognitive Behavioral Therapy for Insomnia in a Community Health Setting. 267-274.
Seth Feuerstein, MD, JD1,2; Sarah E. Hodges, BA1; Brian Keenaghan, MS2; Andrew Bessette, BS1; Erica Forselius, MS1; Peter T. Morgan, MD, PhD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: The goal of the current study was to explore the feasibility and efficacy of computer-based cognitive-based therapy for insomnia (CBT-I) for patients with comorbid psychiatric diagnoses delivered in a community mental health center setting. Although CBT-I is the gold standard in insomnia treatment, it can be financially and geographically inaccessible for many patients; if shown to be effective, computer-based delivery of CBT-I (cb-CBT-I) has the potential to make treatment accessible for considerably more individuals suffering from insomnia.

Study Impact: The significant improvements in reported sleep suggest that implementing cb-CBT-I treatment in a community mental health center would be a simple, effective, and well-received treatment for improving sleep over a short period of time. These findings further support the current hope that technology-assisted treatments will improve the efficiency and consistency of healthcare delivery.

Article Is Eligible For CME Credits Melatonin Natural Health Products and Supplements: Presence of Serotonin and Significant Variability of Melatonin Content. 275-281.
Lauren A.E. Erland, MSc; Praveen K. Saxena, PhD

BRIEF SUMMARY

Current Knowledge/Study Rationale: Melatonin is an important neurohormone, which mediates circadian rhythms and the sleep cycle; as such, it is a popular and readily available supplement for the treatment and prevention of sleep-related disorders. As these products are often self-prescribed, it is important that labels are informative and representative of the product, i.e., these products are free from contaminants and label claim values for the active ingredient are accurate.

Study Impact: The products examined in this study showed significant variability of melatonin content as compared to labelled values, and a controlled substance, serotonin, was found in a significant portion of the supplements tested. This raises immediate potential health concerns because consumption of these products is at the consumer's discretion and is often based on label information, highlighting the need for both patient education and comprehensive characterization and standardization of melatonin supplements and the methods of their preparation.

Validation of the System One RemStar Auto A-Flex for Obstructive Sleep Apnea Treatment and Detection of Residual Apnea-Hypopnea Index: A European Randomized Trial. 283-290.
Frédéric Gagnadoux, MD, PhD1; Dirk Pevernagie2,3; Poul Jennum4; Nina Lon4; Corinne Loiodice5,6; Renaud Tamisier, MD, PhD5,6; Petra van Mierlo2; Wojciech Trzepizur, MD, PhD1; Martina Neddermann7; Annika Machleit7; Jeffrey Jasko8; Jean Louis Pépin, MD, PhD5,6

BRIEF SUMMARY

Current Knowledge/Study Rationale: Automatically adjusted positive airway pressure (APAP) offers potential clinical advantages when compared to fixed pressure continuous positive airway pressure (CPAP) by adjusting pressure to changes in airflow and providing data about residual respiratory events under treatment. However, algorithms for events detection and automatic pressure adjustments are device specific and have to be evaluated by adequately powered studies.

Study Impact: This European randomized trial demonstrates that APAP with the System One RemStar Auto A-Flex device is as effective as manually titrated fixed-pressure CPAP in abolishing obstructive breathing events with no deleterious effect of pressure adjustments through the night on sleep structure and fragmentation. The System One RemStar Auto A-Flex device has a high accuracy for breathing events detection when compared to full-night polysomnography.

Sleep Disturbances in OEF/OIF/OND Veterans: Associations with PTSD, Personality, and Coping. 291-299.
Mackenzie J. Lind, BS1; Emily Brown, MSW1; Leah Farrell-Carnahan, PhD2; Ruth C. Brown, PhD1; Sage Hawn, MS1,3; Erin Berenz, PhD4; Scott McDonald, PhD2,3,5; Treven Pickett, PsyD2,3,5; Carla Kmett Danielson, PhD6; Suzanne Thomas, PhD6; Ananda B. Amstadter, PhD1,3

BRIEF SUMMARY

Current Knowledge/Study Rationale: Although it is well established that veterans (particularly those with PTSD) have poor sleep and many studies have examined this, few studies have investigated how sleep may differ in a three-group model (controls without trauma exposure, trauma-exposed individuals, and individuals with PTSD). Further, there is a need for more studies that examine correlates of disturbed sleep in veterans, beyond demographics and psychiatric comorbidities.

Study Impact: We have shown that trauma exposure itself may not be an independent risk factor for disturbed sleep in veterans, further emphasizing the importance of targeting sleep in this population. Additionally, neuroticism and substance use coping may also be areas to focus on when addressing disturbed sleep in veterans.

Awakenings? Patient and Hospital Staff Perceptions of Nighttime Disruptions and Their Effect on Patient Sleep. 301-306.
Mila N. Grossman, BS1; Samantha L. Anderson, BA2; Aelaf Worku, MD3; William Marsack, MS4; Nimit Desai, MD2; Ambrosio Tuvilleja, BSN4; Jacqueline Ramos, BSN4; Mary Ann Francisco, MSN4; Cynthia Lafond, PhD4; Jay S. Balachandran, MD5; Babak Mokhlesi, MD, MSc2; Jeanne M. Farnan, MD, MHPE2; David O. Meltzer, MD, PhD2; Vineet M. Arora, MD, MAPP2

BRIEF SUMMARY

Current Knowledge/Study Rationale: This study, to the best of the authors' knowledge, is the first of its kind to examine patients' and providers' perceptions of in-hospital sleep disruptions and the effect of patient-reported sleep disruptions on objective sleep duration. Previous studies focused on noise as the primary disrupter to patient sleep, whereas this study analyzed the effect of a broader spectrum of sleep disruptions on general medicine wards.

Study Impact: This study shows that providers generally agree with patients regarding the factors that are perceived to be most disruptive to patient sleep in the hospital. Further, pain represents the disruption that is most significantly linked to objective sleep loss in the hospital setting, indicating the need for better pain control to improve the inpatient sleeping environment.

Special Articles

Article Is Eligible For CME Credits Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. 307-349.
Michael J. Sateia, MD1; Daniel J. Buysse, MD2; Andrew D. Krystal, MD, MS3; David N. Neubauer, MD4; Jonathan L. Heald, MA5

Case Reports

Orthosomnia: Are Some Patients Taking the Quantified Self Too Far?. 351-354.
Kelly Glazer Baron, PhD, MPH1; Sabra Abbott, MD, PhD2; Nancy Jao, MS2; Natalie Manalo, MD2; Rebecca Mullen, MS2

Sleep Medicine Pearls

An Anxious 17-Year-Old Girl Who Hears Voices Only at Sleep Onset. 355-356.
Lourdes M. DelRosso, MD1; Justin Liegmann, MD2; Romy Hoque, MD3
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