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Accepted Papers


Free CPAP Adherence and Readmission: Marker of Health or Cost-Effective Tool?. 161-162.
Lucas M. Donovan, MD; Martha E. Billings, MD, MSc

Scientific Investigations

Autonomic Nervous System Functioning Related to Nocturnal Sleep in Patients With Chronic Fatigue Syndrome Compared to Tired Controls. 163-171.
Maija Orjatsalo, MD1,2; Anniina Alakuijala, MD, PhD1,2; Markku Partinen, MD, PhD2,3


Current Knowledge/Study Rationale: Patients with chronic fatigue syndrome (CFS) often suffer from unrefreshing sleep, even if their sleep recordings show normal sleep stage distribution and sleep microstructure. Heart rate variability is a noninvasive method to assess nocturnal cardiac autonomic nervous system functioning.

Study Impact: Our results suggest that patients with CFS have lower parasympathetic tone in deep sleep and higher sympathetic tone in all sleep stages compared to tired controls. Detachment of parasympathetic tone and deep sleep might be contributing to nonrestorative sleep and even symptoms of cognitive impairment in patients with CFS.

Clinical Trial Enrollment Enrichment in Resource-Constrained Research Environments: Multivariable Apnea Prediction (MAP) Index in SCIP-PA Trial. 173-181.
Hyunju Yang, PhD, RN1; Alexa Watach, PhD, RN1,2; Miranda Varrasse, PhD, RN2,3; Tonya S. King, PhD4; Amy M. Sawyer, PhD, RN1,3


Current Knowledge/Study Rationale: In the current resource-constrained research environment, pre-enrollment screening in studies of obstructive sleep apnea is likely to increase enrollment efficiency and may also reduce protocol resource expenditure. An obstructive sleep apnea screening tool with high predictive utility, Multivariable Apnea Prediction (MAP) index, has been shown to have high clinical predictive utility; however, the use of MAP index for research enrollment enrichment is not well understood.

Study Impact: Results suggest the MAP index can be used for clinical trial enrollment enrichment but consideration of the target population characteristics, including prevalence of obstructive sleep apnea at the study-defined apnea-hypopnea index criterion, sex and age, are important prestudy factors to consider so that the overall utility of employing MAP index as an enrollment enrichment strategy in study settings is optimized.

Free Nonadherence to CPAP Associated With Increased 30-Day Hospital Readmissions. 183-189.
Kimberly K. Truong, MD, MPH1; Rossi De Jardin, BS2; Nahal Massoudi, BS3; Mehrtash Hashemzadeh, MS2; Behrouz Jafari, MD1,2


Current Knowledge/Study Rationale: Although it is well understood that untreated obstructive sleep apnea leads to a variety of worsened health outcomes, it is unclear if this translates into increased 30-day hospital readmissions. This study aimed to determine if nonadherence to continuous positive airway pressure (CPAP) is associated with increased 30-day cardiovascular-cause, pulmonary-cause, or all-cause readmissions.

Study Impact: Our results demonstrate that CPAP adherence is associated with decreased all-cause and cardiovascular-cause 30-day readmissions. This carries important implications because it suggests that CPAP therapy may be an important, modifiable target for reducing hospital readmissions and may affect local, state-based, and national interventions.

Validation of the NoSAS Score for the Screening of Sleep-Disordered Breathing: A Hospital-Based Retrospective Study in China. 191-197.
Cheng Hong, MD1; Riken Chen, MM1,2; Simin Qing, MM1; Ailing Kuang, MM1,3; HuaJing Yang, MB4; Xiaofen Su, MM1; Dongxing Zhao, MD1; Kang Wu, MD1; Nuofu Zhang, MM1


Current Knowledge/Study Rationale: The NoSAS score has been shown to be a reliable screening score for sleep-disordered breathing (SDB) in two population-based cohorts in Switzerland and Brazil. In this study, we aimed to validate the value of NoSAS scores in clinical populations and to compare it with the STOP-Bang, STOP, and Berlin questionnaires, as well as the Epworth Sleepiness Scale for SDB screening.

Study Impact: The NoSAS score is a simple, efficient, and easy method for screening SDB in the clinical setting, especially in moderate to severe SDB, making it appropriate for widespread use.

Activity During Sleep Measured by a Sheet-Shaped Body Vibrometer and the Severity of Atopic Dermatitis in Adults: A Comparison With Wrist Actigraphy. 199-204.
Takamasa Kogure, PhD1,2; Toshiya Ebata, MD, PhD3


Current Knowledge/Study Rationale: Atopic dermatitis is associated with sleep disturbance. Wrist actigraphy devices are used to perform an objective sleep evaluation of patients, but they may underestimate the sleep time because they detect wrist motion due to scratching while sleeping. We compared activity during sleep measured by a sheet-shaped body vibrometer with that measured by wrist actigraphy in adult patients with atopic dermatitis of various severities.

Study Impact: Activity measured by the two devices correlated with the severity of atopic dermatitis. This study suggests that wrist actigraphy is more suited for the scratch evaluation, whereas the sheet-shaped body vibrometer is preferable for the sleep evaluation. However, this finding should be confirmed in a future study using simultaneous in-laboratory polysomnography.

Reliability of the American Academy of Sleep Medicine Rules for Assessing Sleep Depth in Clinical Practice. 205-213.
Magdy Younes, MD, PhD1; Samuel T. Kuna, MD2,3; Allan I. Pack, MBChB, PhD2; James K. Walsh, PhD4; Clete A. Kushida, MD, PhD5; Bethany Staley, RPSGT2; Grace W. Pien, MD, MSCE6


Current Knowledge/Study Rationale: Although interrater variability in sleep stage scoring is well documented, results of such studies are typically given as agreement between technologists in pooled data that include several dozen polysomnograms. The effect of this variability on the accuracy of scoring sleep stages in a single polysomnogram scored by a single technologist, as is the case in clinical practice, is not known.

Study Impact: When 70 polysomnograms were scored by 10 experienced technologists, the amount of time in stage N1 and N3 sleep ranged from very high to very low within almost each record depending on who scored it. Accordingly, when a polysomnogram is scored by a single technologist, dividing non-rapid eye movement sleep into three stages has little value in evaluating sleep depth.

Free Patient-Reported Outcomes in Older Adults With Obstructive Sleep Apnea Treated With Continuous Positive Airway Pressure Therapy. 215-222.
Jennifer Pallansch, BS1; Yiping Li, MD2; James Bena, MS3; Lu Wang, MS3; Nancy Foldvary-Schaefer, DO, MS4


Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) is a chronic disease associated with numerous adverse health and psychosocial outcomes, and the burden of OSA is only increasing with an aging population and a movement away from fee-for-service to performance-based pay. Despite the increasing prevalence of OSA with age, treatment effects in older populations have been inadequately studied.

Study Impact: This study examined the effects of continuous positive airway pressure (CPAP) treatment on sleep-related patient-reported outcomes in older adults to address this disparity and guide current standards of care. Our study demonstrated that elderly patients with OSA have a response to CPAP therapy comparable to that of younger adults and further supports CPAP therapy use in patients older than 60 years.

Restless Legs Syndrome in Iranian People With Type 2 Diabetes Mellitus: The Role in Quality of Life and Quality of Sleep. 223-228.
Leila Modarresnia, MD1; Fatemeh Golgiri, MD1; Nahid Hashemi Madani, MD1; Zahra Emami, PhD1; Kiarash Tanha, MSc2


Current Knowledge/Study Rationale: Restless legs syndrome (RLS) is a common disorder seen in patients with diabetes. This study aimed to determine the prevalence and severity of RSL in a population of patients with diabetes and identify its role in sleep quality and quality of life of these patients.

Study Impact: Having identified the effect of RLS on quality of life and sleep quality of patients with diabetes, we should pay more attention to this issue when determining their treatment plan.

Increased EEG Theta Spectral Power in Sleep in Myotonic Dystrophy Type 1. 229-235.
Joseph Cheung, MD, MS1; Chad Ruoff, MD1; Hyatt Moore, PhD1; Katharine A. Hagerman, PhD2; Jennifer Perez2; Sarada Sakamuri, MD2; Simon C. Warby, PhD3; Emmanuel Mignot, MD, PhD1; John Day, MD, PhD2; Jacinda Sampson, MD, PhD2


Current Knowledge/Study Rationale: Individuals with myotonic dystrophy type 1 (DM1) commonly present with hypersomnolence and sleep-disordered breathing. To better understand sleep dysregulation in DM1, we retrospectively examined power spectra from nocturnal polysomnograms in individuals with DM1 and matched controls.

Study Impact: Differences in sleep electroencephalogram spectral characteristics, specifically theta power, may represent central nervous system changes due to DM1.

Free Evaluating DSM-5 Insomnia Disorder and the Treatment of Sleep Problems in a Psychiatric Population. 237-244.
Lee Seng Esmond Seow, BA1; Swapna Kamal Verma, MBBS, MD2; Yee Ming Mok, MB BCh BAO, DIP, MMed2; Sunita Kumar, MD, FCCP, FAASM3; Sherilyn Chang, BSocSc1; Pratika Satghare, MSc, CRRA1; Aditi Hombali, MPT1; Janhavi Vaingankar, MSc1; Siow Ann Chong, MBBS, MMed, MD1; Mythily Subramaniam, MBBS, MHSM, PhD1


Current Knowledge/Study Rationale: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition distinction into primary and secondary insomnia has been replaced with a unitary diagnosis of insomnia disorder in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), an advocate for its detection and treatment even in the presence of comorbid mental disorders. In view of these changes, the current study aimed to determine the prevalence and correlates of DSM-5 insomnia disorder, and the extent of insomnia management and treatment in a psychiatric population.

Study Impact: Beyond mere symptoms of mental illnesses, our study illustrates that a high proportion of psychiatric patients also suffer from clinically significant insomnia disorder. Evidence from our study is indicative of the need for both clinicians and patients to place greater emphasis on addressing insomnia symptoms in this population.

Nocturnal REM Sleep Without Atonia Is a Diagnostic Biomarker of Pediatric Narcolepsy. 245-252.
Saadoun Bin-Hasan, MBBCH, FRCPC1,2; Aleksandar Videnovic, MD, MSc3,4; Kiran Maski, MD3,5


Current Knowledge/Study Rationale: REM sleep behavior disorder (RBD) and REM sleep without atonia (RWA) are well-described comorbidities in adult populations with narcolepsy, but clinical characteristics in pediatric patients with narcolepsy are less known. We describe clinical characteristics of RBD and RWA in pediatric patients with narcolepsy and determine if a nocturnal RWA index can serve as a diagnostic biomarker for pediatric narcolepsy.

Study Impact: RWA and RBD are important to consider when scoring and interpreting diagnostic sleep studies in pediatric patients with possible narcolepsy. Recognition of the nRWA index as a clinically useful biomarker could help reduce the delay in diagnosis and misdiagnosis of pediatric narcolepsy.

Effects of Coexisting Asthma and Obstructive Sleep Apnea on Sleep Architecture, Oxygen Saturation, and Systemic Inflammation in Women. 253-259.
Fredrik Sundbom, MD1; Christer Janson, MD, PhD1; Andrei Malinovschi, MD, PhD2; Eva Lindberg, MD, PhD1


Current Knowledge/Study Rationale: Both asthma and obstructive sleep apnea (OSA) are strongly associated with poor sleep. The aim was to analyze the effect of asthma, OSA, and the combination of asthma and OSA on objectively measured sleep quality and systemic inflammation.

Study Impact: Coexisting asthma and OSA is associated with poorer sleep quality and more profound nocturnal hypoxemia than either of the conditions alone. Asthma was independently associated with lower oxygen saturation, whereas OSA was not.

Obstructive Sleep Apnea in Patients With Congenital Central Hypoventilation Syndrome Ventilated by Diaphragm Pacing Without Tracheostomy. 261-264.
Annie Wang, MD1; Sheila Kun, RN, MS2; Bonnie Diep, MD1; Sally L. Davidson Ward, MD1,2; Thomas G. Keens, MD1,2; Iris A. Perez, MD1,2


Current Knowledge/Study Rationale: There are limited data on the presence of obstructive sleep apnea in patients receiving diaphragm pacing without tracheostomy. Therefore, we sought to assess whether obstructive sleep apnea occurs in patients with congenital central hypoventilation syndrome who are ventilated by diaphragm pacing, and whether obstructive apneas can be resolved with diaphragm pacer setting changes.

Study Impact: In some centers decannulation has not been performed in patients ventilated by diaphragm pacing due to risk of obstructive sleep apnea; however, this study shows that diaphragm pacing without tracheostomy can be achieved and obstructive sleep apnea can be alleviated.

Influence of Obstructive Sleep Apnea in the Functional Aspects of Patients With Osteoarthritis. 265-270.
Andressa Silva, PhD1; Marco Túlio Mello, PhD1; Paula Regina Serrão, PhD2; Roberta Pitta Luz, PhD3; Franciele Ruiz, PhD3; Lia Rita Bittencourt, PhD3; Sergio Tufik, PhD3; Stela Márcia Mattiello, PhD2


Current Knowledge/Study Rationale: Both obstructive sleep apnea and osteoarthritis are more prevalent in older populations. Thus, knowledge of the association of these two conditions may help impaired patients recover in relation to their functional capacity and the musculoskeletal system.

Study Impact: The current study confirms a relationship between sleep apnea and osteoarthritis that negatively affects functional capacity and the musculoskeletal system. Therefore, these findings are extremely important for clinical practice, because they must be taken into account for the rehabilitation process of patients suffering from musculoskeletal problems.

Review Articles

Hypnosis Intervention Effects on Sleep Outcomes: A Systematic Review. 271-283.
Irina Chamine, PhD1; Rachel Atchley, PhD1; Barry S. Oken, MD, PhD1,2,3

Case Reports

Adult-Onset Sleepwalking Secondary to Hyperthyroidism: Polygraphic Evidence. 285-287.
Loretta Giuliano, MD, MSc1; Daniela Fatuzzo, MD1; Greta Mainieri, MD1; Sandro La Vignera, MD2; Vito Sofia, MD1; Mario Zappia, MD1
Improvement of Neuropathy Symptoms With Treatment of Obstructive Sleep Apnea in a Patient With Charcot-Marie-Tooth Disease. 289-291.
Pinar Polat, MD1; Huong Pham, MD2; Jun Li, MD, PhD2; Kanika Bagai, MD, MSCI2

Letters to the Editor

Free Nurse Practitioners and Physician Assistants Are Qualified to Perform Home Sleep Apnea Test Clinical Evaluations. 293.
Loretta J. Colvin, ACNP-BC1; Ann Cartwright, PA-C2; Neil Freedman, MD3; Ann E. Rogers, PhD, RN, FAASM4; Kimberly D. Vana, DNP, FNP-BC, FNP-C5
Free Nurse Practitioners and Physician Assistants Are Important to the Sleep Team. 295.
Ilene M. Rosen, MD, MS

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