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Scientific Investigations

Midfacial and Dental Changes Associated with Nasal Positive Airway Pressure in Children with Obstructive Sleep Apnea and Craniofacial Conditions. 469-475.
Soleil D. Roberts, DMD, MSD1; Hitesh Kapadia, DDS, PhD1,2; Geoff Greenlee, DDS, MSD, MPH1,2; Maida L. Chen, MD3,4

BRIEF SUMMARY

Current Knowledge/Study Rationale: Prolonged application of orthopedic forces from a nasal positive airway pressure (nPAP) mask used for treatment of pediatric obstructive sleep apnea (OSA) could cause midfacial retrusion in the developing facial skeleton. Since midface retrusion can contribute to decreased airway space, there is a need understand the midfacial effects of nPAP treatment and explore correlations between demographic, medical, and sleep variables with degree of facial change.

Study Impact: Children who were compliant with nPAP for 2.5 years demonstrated facial and dental changes that could exacerbate overall upper airway constriction, potentially worsen sleep symptoms and result in increased therapy with PAP or orthognathic surgery. Sleep specialists should collaborate with their orthodontic colleagues to monitor children undergoing nPAP therapy for signs of midface retrusion, counterclockwise tipping of the palatal plane, and flaring of the maxillary incisors.

Commercial Motor Vehicle Driver Positive Airway Pressure Therapy Adherence in a Sleep Center. 477-485.
Loretta J. Colvin, MS, APRN-BC1,4; Gayla A. Dace, DNP, FNP-BC2; Ryan M. Colvin, MPH3; Joseph Ojile, MD4; Nancy Collop, MD5

BRIEF SUMMARY

Current Knowledge/Study Rationale: Expert consensus panels recommend OSA assessment and treatment for CMV drivers; however, scant data on PAP therapy adherence in CMV drivers have been published. This study evaluates PAP therapy adherence for CMV drivers within a sleep center clinical environment.

Study Impact: Without studies of PAP adherence specifically in CMV driving populations, sleep specialists must extrapolate from published studies in clinical patients. This study provides data on PAP adherence specifically in the CMV driver population.

IGF-1 Levels are Inversely Associated With Metabolic Syndrome in Obstructive Sleep Apnea. 487-493.
Suelem Izumi, MD1; Fernando F. Ribeiro-Filho, MD, PhD2; Gláucia Carneiro, MD, PhD1; Sônia M. Togeiro, MD, PhD3; Sérgio Tufik, MD, PhD3; Maria T. Zanella, MD, PhD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: OSA has been associated with reduced secretion of growth hormone (GH) and IGF-1. Moreover, a growing body of evidence suggests that OSA may contribute to the development of metabolic syndrome. This study examined IGF-1 production and its association with the MS in men with OSA.

Study Impact: The association between OSA and MS has been demonstrated in several studies, and therefore it is important to understand the influence of the GH/IGF-1 system on metabolic changes among patients with OSA. This study aims to understand the independent association of reduced IGF-1 production with increased incidence of MS in patients with OSA.

Article Is Eligible For CME Credits Pre-diagnostic Sleep Duration and Sleep Quality in Relation to Subsequent Cancer Survival. 495-503.
Amanda I. Phipps, PhD1,2; Parveen Bhatti, PhD1,2; Marian L. Neuhouser, PhD1; Chu Chen, PhD1; Tracy E. Crane, RD3; Candyce H. Kroenke, ScD4; Heather Ochs-Balcom, PhD5; Michelle Rissling, PhD6; Beverly M. Snively, PhD7; Marcia L. Stefanick, PhD8; Miriam M. Treggiari, MD9; Nathaniel F. Watson, MD10

BRIEF SUMMARY

Current Knowledge/Study Rationale: Poor sleep quality and short sleep duration have been associated with elevated risk for several cancer types; however, the relationship between sleep and cancer outcomes has not been well characterized. We assessed the association between pre-diagnostic sleep attributes and subsequent cancer survival within the Women's Health Initiative (WHI).

Study Impact: To our knowledge, this is the first study to evaluate the relationship between sleep patterns before cancer diagnosis and subsequent cancer survival. Findings from this study suggest that short sleep duration may be associated with poor breast cancer survival.

A Three-Item Instrument for Measuring Daytime Sleepiness: The Observation and Interview Based Diurnal Sleepiness Inventory (ODSI). 505-512.
Fannie Onen, MD, PhD1,2,3; Christophe Lalanne, PhD2; Victoria M. Pak, MS, PhD3; Nalaka Gooneratne, MD, MSc3,4; Bruno Falissard, MD, PhD2; Saban-Hakki Onen, MD, PhD4,5

BRIEF SUMMARY

Current Knowledge/Study Rationale: Excessive daytime sleepiness is a common problem in older adults yet there are no currently validated scales for measurement of sleepiness in the elderly. The ODSI is a brief, valid, easy-to-administer three-item interviewer-guided tool that can screen for excessive daytime sleepiness. The ODSI score appears to have potential for clinical utility; it is usually 6 or above in patients with OSA syndrome that causes hypersomnolence but averages 3 in healthy controls.

Study Impact: As the clinical diagnosis of OSA is increasingly being made by primary care physicians with limited time to assess behavioral morbidity, the ODSI will be an important method for measuring sleepiness in clinical care.

Effect of Sleep State and Position on Obstructive Respiratory Events Distribution in Adolescent Children. 513-517.
Karim El-Kersh, MD1; Rodrigo Cavallazzi, MD1; Paras M. Patel, MD1; Egambaram Senthilvel, MD, FRCSEd2

BRIEF SUMMARY

Current Knowledge/Study Rationale: The effect of sleep state and position on the distribution of obstructive respiratory events was previously described in young pediatric population. However, there is a paucity of data on this effect in adolescents.

Study Impact: Our study describe the effect of sleep state and position on the distribution of obstructive respiratory events in adolescent population. Our findings help to better understand sleep related breathing disorders in adolescents.

High Adherence to CPAP Treatment Does Not Prevent the Continuation of Weight Gain among Severely Obese OSAS Patients. 519-528.
Minna Myllylä, BM, PhD student1; Samu Kurki, PhD2; Ulla Anttalainen, MD, PhD1,3; Tarja Saaresranta, MD, PhD1,3; Tarja Laitinen, MD, PhD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Obesity is the most common cause of obstructive sleep apnea syndrome (OSAS) in adults. According to current evidence, the proper treatment of OSAS with continuous positive airway pressure (CPAP) does not contribute to weight control. This conclusion, however, is mainly based on two publications that both were limited by follow-up of 6 months.

Study Impact: In a 5-year real-world retrospective survey of one pulmonary clinic, the majority of OSAS patients showed no significant change in their weight or adherence to CPAP treatment. However, the minority of patients who gained weight during the treatment were the youngest and most obese patients at baseline; therefore, the main focus of dietary interventions should be on this patient group to prevent the development of obesity-hypoventilation syndrome later in life.

Influence of a Post-Test Factor on the Results of the Multiple Sleep Latency Test. 529-531.
Jun Tashiro, MD, PhD; Ambra Stefani, MD; Birgit Högl, MD; Elisabeth Brandauer, MD; Werner Poewe, MD; Anna Heidbreder, MD

BRIEF SUMMARY

Current Knowledge/Study Rationale: It is well known that the amount of sleep obtained during the nights prior to the MSLT and other pre-test activities such as shift work and substance use have an influence on the MSLT results. The aim of the present study was to evaluate the potential impact of a post-test factor on the MSLT outcome.

Study Impact: The present study shows that, in contrast to the well-established influence of pre-test factors, post-test factors have only a minor impact on MSLT results.

Effects of Continuous Positive Airway Pressure on Cognitive and Functional Outcome of Stroke Patients with Obstructive Sleep Apnea: A Randomized Controlled Trial. 533-541.
Justine A. Aaronson, PhD1,2; Winni F. Hofman, PhD2; Coen A.M. van Bennekom, MD, PhD1; Tijs van Bezeij, MD1; Joost G. van den Aardweg, MD, PhD3; Erny Groet, MSc1; Wytske A. Kylstra, MSc1; Ben Schmand, PhD2,4

BRIEF SUMMARY

Current Knowledge/Study Rationale: In the general population treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) results in improvement of daily functioning, but the effect of CPAP treatment on stroke recovery is still inconclusive. Therefore, our primary aim was to evaluate the effect of CPAP treatment on the rehabilitation outcome of stroke patients with OSA.

Study Impact: This study indicates that CPAP treatment improves the cognitive outcome of stroke patients with OSA. These beneficial effects offer preliminary evidence for the use of CPAP treatment as part of a rehabilitation program for stroke patients.

Healthcare Use in Individuals with Obesity and Chronic Hypoxemia Treated for Sleep Disordered Breathing. 543-548.
Marcus Povitz, MDCM, MSc1,2; Willis H. Tsai, MD, MSc1,3,4; Sachin R. Pendharkar, MD, MSc1,3,4; Patrick J. Hanly, MD3,4; Matthew T. James, MD, PhD1,3,4

BRIEF SUMMARY

Current Knowledge/Study Rationale: Treatment of both OSA and OHS has been shown to decrease healthcare utilization; however previous studies have studied patients without hypoxemia or significant comorbidities. This study assessed healthcare utilization rates in a cohort of obese hypoxemic individuals.

Study Impact: This study demonstrates the association of treatment adherence with positive airway pressure therapy with reduced hospitalization rates. This reduction may offset the cost of treatment and increase in outpatient visits seen.

Association of Sleep Disordered Breathing with Wake-Up Acute Ischemic Stroke: A Full Polysomnographic Study. 549-554.
Pavel Šiarnik, MD1; Branislav Kollár, MD, PhD1; Zuzana Čarnická, MD1; Pavol Šurda, MD2; Katarína Klobučníková, MD, PhD1; Marek Sýkora, MD, PhD, MSc1,3; Peter Turčáni, MD, PhD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Currently, wake-up stroke patients are excluded from revascularization therapy, so a precise search for predictors and risk factors of wake-up strokes is desirable. The aim of this study was to compare polysomnographic, clinical, and laboratory characteristics of wake-up strokes and non-wake-up strokes with mild-to-moderate severity.

Study Impact: We emphasize the importance of significantly higher frequency of moderate-to-severe sleep apnea syndrome among the wake-up stroke population, as this population is indicated for positive airway pressure therapy. Our results suggest that there seems to be no superior pathomechanism linking sleep disordered breathing with wake-up stroke onset. However, several potential mechanisms including reduction of cerebral blood flow, decreased cardiac output, and baroreceptor and endothelial dysfunction should be investigated in future prospective studies.

Obstructive Sleep Apnea Syndrome in Company Workers: Development of a Two-Step Screening Strategy with a New Questionnaire. 555-564.
Michiel M. Eijsvogel, MSc1; Sytske Wiegersma, MSc2; Winfried Randerath, PhD3; Johan Verbraecken, PhD4; Esther Wegter-Hilbers, MSc5; Job van der Palen, PhD6

BRIEF SUMMARY

Current Knowledge/Study Rationale: In community screening for obstructive sleep apnea syndrome (OSAS) a single or combination of easy to apply test(s) with a high specificity is needed to identify correctly the large numbers of subjects without OSAS and keep the false positive rate as low as possible to avoid unnecessary costly further investigations. A pilot study was performed to develop such a tool with the intention to screen more than 10.000 employees as convincing studies for this type of screening are lacking.

Study Impact: We demonstrated that a combined questionnaire with three outcomes (OSAS unlikely, possible, likely) and applying nasal flow only for the intermediate outcome could make such a screening feasible.

Not Only Sleepwalking But NREM Parasomnia Irrespective of the Type Is Associated with HLA DQB1*05:01. 565-570.
Anna Heidbreder, MD1,2; Birgit Frauscher, MD2; Thomas Mitterling, MD2; Matthias Boentert, MD1; Anja Schirmacher, Dr. rer. nat.1; Paul Hörtnagl, Dr. rer. nat.5; Harald Schennach, PD5; Christina Massoth, MD1; Svenja Happe, MD3; Geert Mayer, MD4; Peter Young, MD1; Birgit Högl, MD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Despite the prevalence and clinical relevance of NREM parasomnias, data on supportive genetic markers are scarce. Whether different types of NREM-parasomnias share the same association with the HLA DQB1 allele as shown for sleepwalking has not been investigated.

Study Impact: HLA DQB1*05:01 was more frequent in all types of NREM parasomnias. In addition, confusional arousals were frequently observed during V-PSG. Our findings therefore support a common genetic background for all types of parasomnias, and corroborate the importance of video-polysomnography in the work-up of parasomnias.

Article Is Eligible For CME Credits Subjective and Objective Measures of Hypersomnolence Demonstrate Divergent Associations with Depression among Participants in the Wisconsin Sleep Cohort Study. 571-578.
David T. Plante, MD1; Laurel A. Finn, MS2; Erika W. Hagen, PhD2; Emmanuel Mignot, MD, PhD3; Paul E. Peppard, PhD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Hypersomnolence plays a significant role in the course of mood disorders, but a reliable objective measure to quantify sleepiness in these patients remains elusive. Because prior studies that have examined objective sleep propensity using the multiple sleep latency test (MSLT) in depressed patients have had limited statistical power, this investigation examined associations between depression and subjective and objective hypersomnolence measures in a large epidemiological cohort study.

Study Impact: Results demonstrated subjective daytime sleepiness and increased habitual sleep duration were associated with an increased odds of depression, but increased sleep propensity on the MSLT was associated with reduced odds of depression. These findings underscore the limitations of the MSLT as a measure of sleepiness in mood disorders.

Psychometric Evaluation of the Ford Insomnia Response to Stress Test (FIRST) in Early Pregnancy. 579-587.
Bizu Gelaye, PhD, MPH1; Qiu-Yue Zhong, MSc1; Yasmin V. Barrios, MPH1; Susan Redline, MD, MPH1,2,3; Christopher L. Drake, PhD4; Michelle A. Williams, ScD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: The Ford Insomnia Response to Stress Test (FIRST) questionnaire has emerged as a broadly used instrument that assesses individual's vulnerability to situational insomnia under stressful conditions. Despite the increased use of the FIRST questionnaire to assess stress-related sleep reactivity in men and non-pregnant women, the instrument has not been used to assess stress-related sleep reactivity in pregnant women.

Study Impact: Our results indicate that the FIRST was found to have good construct validity and internal consistency for assessing vulnerability to insomnia during early pregnancy. Given (1) the high prevalence of insomnia in pregnancy; and (2) that insomnia is associated with substantial adverse maternal and newborn outcomes, the findings may have important clinical implications in maternal-fetal medicine.

Determinants of Behavioral Alertness in Adults with Heart Failure. 589-596.
Ruth Masterson Creber, PhD, MSc, RN1; Victoria M. Pak, PhD, MS, RN2; Miranda Varrasse, MSN, RN3; David F. Dinges, PhD4; Joyce Wald, DO5; Barbara Riegel, PhD, RN3

BRIEF SUMMARY

Current Knowledge/Study Rationale: Poor sleep quality is known to be associated with poor self-care in adults with heart failure. Although self-reported daytime sleepiness is known to be a poor indicator of sleep quality, little is known about the usefulness of objectively measured behavioral alertness as an indicator of sleep quality in heart failure.

Study Impact: This study demonstrated that patients with heart failure demonstrate poor objective behavioral alertness despite reporting not feeling sleepy. In the context of incongruence with self-reported sleep measures, objective measures of behavioral alertness can improve the clinical assessment. Future research should include objective measures of exercise to understand the mechanisms by which exercise improves sleep quality, daytime sleepiness, and behavioral alertness in heart failure.

CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia. 597-606.
Eric Kuhn, PhD1,2; Brandon J. Weiss, PhD1,2; Katherine L. Taylor, MS, MPH1; Julia E. Hoffman, PsyD1; Kelly M. Ramsey, BA1; Rachel Manber, PhD2; Philip Gehrman, PhD3,4; Jill J. Crowley, PhD1; Josef I. Ruzek, PhD1,2; Mickey Trockel, MD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment for chronic insomnia, but patient adherence issues (e.g., dropout, homework non-compliance) can limit its benefits. A smartphone app could help address these issues by making CBT-I procedures more convenient for patients to complete and easier for clinicians to deliver.

Study Impact: CBT-I Coach is a free, publicly available patient-facing smartphone app intended to augment clinician-delivered CBT-I by facilitating the delivery of major CBT-I treatment components, including sleep educational materials, daily sleep diary completion, stimulus control guidelines, sleep restriction procedures, and anxiety management and cognitive therapy tools. Surveys of CBT-I clinicians in the U.S. Department of Veterans Affairs suggest that CBT-I Coach is favorably received in terms of its potential to improve practice and address common adherence issues and that it is being widely used by CBT-I patients.

Respiratory Variability during Sleep in Methadone Maintenance Treatment Patients. 607-616.
Chinh D. Nguyen, PhD1,2; Jong Won Kim, PhD1; Ronald R. Grunstein, MD, PhD1,3; Cindy Thamrin, PhD1; David Wang, PhD1,3,4

BRIEF SUMMARY

Current Knowledge/Study Rationale: Methadone maintenance treatment (MMT) patients have a high prevalence of central sleep apnea and ataxic breathing related to damage to central respiratory rhythm control. However, the quantification of sleep apnea indices requires laborious manual scoring, and ataxic breathing pattern is subjectively judged by visual pattern recognition.

Study Impact: This study showed that MMT patients have a higher respiratory variability during sleep than normal controls population. Semi-automated variability measures are related to apnea indices obtained by manual scoring and may provide a new approach to quantify opioid-related sleep-disordered breathing.

Review Articles

Medium Increased Risk for Central Sleep Apnea but Not Obstructive Sleep Apnea in Long-Term Opioid Users: A Systematic Review and Meta-Analysis. 617-625.
Marie-Lou Filiatrault, RDN, MSc1,2; Jean-Marc Chauny, MD, MSc3,4; Raoul Daoust, MD, MSc3,4; Marie-Pier Roy, RN1,4; Ronald Denis, MD3,5; Gilles Lavigne, DMD, PhD1,5,6

Case Reports

Abnormal Nocturnal Behavior due to Hypoglycemia in a Patient with Type 2 Diabetes. 627-629.
Kwang Ik Yang, MD, PhD1; Hyung Ki Kim, MD, PhD2; Jeehun Baek, MD1; Doh-Eui Kim, MD1; Hyung Kook Park, MD, PhD1
Sleep Disturbances and Nightmares in a Patient Treated with Prazosin. 631-632.
Sam Kosari, BPharm(Hons), PhD; Mark Naunton, BPharm(Hons), PhD
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