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Free More Than Just a Good Night's Sleep. 709-710.
Scott G. Williams, MD, FAASM1,2; Jacob F. Collen, MD, FAASM2,3; Christopher J. Lettieri, MD, FAASM1,2,3
Free A Requiem for the Clinical Use of the Epworth Sleepiness Scale. 711-712.
Olabimpe Omobomi, MBChB, MSc1; Stuart F. Quan, MD1,2
Free Does a Low Arousal Threshold Equal Low PAP Adherence?. 713-714.
Aaron B. Holley, MD; Robert J. Walter, MD

Scientific Investigations

The Effects of Experimental Sleep Fragmentation and Sleep Deprivation on the Response of the Genioglossus Muscle to Inspiratory Resistive Loads. 715-724.
Jennifer M. Cori, PhD1; Christian L. Nicholas, PhD1,2; Joanne Avraam, PhD1,2; V. Vien Lee, BSc (Hons)1,3; Rachel Schembri, PhD1,3; Melinda L. Jackson, PhD1,2,3; Amy S. Jordan, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Poor sleep is theorized to worsen upper airway dilator muscle responsiveness and subsequently increase upper airway collapsibility in obstructive sleep apnea (OSA). Despite sleep fragmentation being the primary sleep disturbance in OSA, support for this theory comes from studies that have demonstrated reduced dilator muscle responsiveness and increased upper airway collapsibility following sleep deprivation.

Study Impact: This study demonstrated that neither a single night of lack of sleep nor fragmented sleep reduced dilator muscle or ventilatory responsiveness to inspiratory resistive loads in healthy individuals during wakefulness. Should these results persist during sleep following multiple nights of disturbed sleep, they would suggest that fragmented sleep in OSA is unlikely to increase disorder severity via reduced dilator muscle activity.

Use of Chest Wall EMG to Classify Hypopneas as Obstructive or Central. 725-733.
Richard B. Berry, MD1; Scott Ryals, MD1; Mary H. Wagner, MD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications (AASM Scoring Manual) classification of hypopneas as central or obstructive does not utilize chest and abdominal effort signals as they often do not reflect the degree of inspiratory effort. When suitably processed, the surface electromyography (EMG) activity of the chest wall provides a measure of inspiratory effort (CW-EMG-EF) that could potentially be useful for hypopnea classification. This study compared hypopnea classification using AASM Scoring Manual criteria versus the combination of airflow amplitude and CW-EMG-EF.

Study Impact: The study suggests that an inspiratory effort signal derived from the surface chest wall electromyography is useful for classification of hypopneas as obstructive versus central.

Obstructive Sleep Apnea in Community Members Exposed to World Trade Center Dust and Fumes. 735-743.
Shilpi Ahuja, MD1; Zhaoyin Zhu, MS2; Yongzhao Shao, PhD2,3; Kenneth I. Berger, MD1; Joan Reibman, MD1,3; Omer Ahmed, MD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Adverse health effects associated with World Trade Center (WTC) dust exposure in the WTC responder and local community population are well described. An association between aerodigestive disorders and obstructive sleep apnea (OSA) has been reported in responders involved in the rescue and response to the WTC disaster; the relationship to the type of exposure remains unclear. There is even less information available about OSA in the community members who lived or worked in the area surrounding the WTC disaster.

Study Impact: Our study reveals a dose-response relationship between WTC exposure and severity of OSA in community members and highlights the potential role environmental exposures may play in the development of OSA.

Sleep Disturbances in Australian Vietnam Veterans With and Without Posttraumatic Stress Disorder. 745-752.
Timothy Baird, BSc, MBBS, DTM&H, FRACP1; Sarah McLeay, BSc, PhD2; Wendy Harvey, BSc, MBBS, MPH1,2; Rebecca Theal, BSc2; Dayna Law, BSc, MBBS, FRACP1; Robyn O'Sullivan, MBBS, FRACP1; on behalf of the PTSD Initiative

BRIEF SUMMARY

Current Knowledge/Study Rationale: Although sleep disturbance is a hallmark of PTSD, the prevalence of sleep disturbances in the Australian veteran population with PTSD remains uncertain. This study compared trauma-matched Australian Vietnam veterans with and without PTSD, in order to assess the prevalence of a variety of sleep disturbances in this cohort using supervised, structured questionnaires.

Study Impact: Compared to trauma-matched controls, Vietnam veterans with PTSD reported poorer sleep quality and an increased prevalence of a variety of sleep disturbances, including restless legs, limb movements, parasomnias, and OSA. In veterans with PTSD, thorough sleep assessment, including appropriate consideration of polysomnography, is warranted.

Free Obstructive Sleep Apnea is an Independent Risk Factor for Hospital Readmission. 753-758.
Nicholas J. Scalzitti, MD1,2; Peter D. O'Connor, MD1,2; Skyler W. Nielsen, DO2; James K. Aden, PhD3; Matthew S. Brock, MD1,4; David M. Taylor, DO2; Vincent Mysliwiec, MD1; Gregory R. Dion, MD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Obstructive sleep apnea is commonly associated with comorbidities that are known to affect hospital readmission rates. Our study sought to explore whether obstructive sleep apnea itself is a modifiable risk factor for hospital readmission.

Study Impact: This study identifies obstructive sleep apnea as an independent risk factor for hospital readmission. There appears to be inadequate use of positive airway pressure both during hospitalization and after discharge in patients with obstructive sleep apnea.

Free Lack of Resilience Is Related to Stress-Related Sleep Reactivity, Hyperarousal, and Emotion Dysregulation in Insomnia Disorder. 759-766.
Laura Palagini, MD, PhD1; Umberto Moretto, MD1; Martina Novi, MD1; Isabella Masci, MD1; Danila Caruso, MD1; Christopher L. Drake, PhD2; Dieter Riemann, PhD3

BRIEF SUMMARY

Current Knowledge/Study Rationale: According to the diathesis-stress model of insomnia, subjects with insomnia present with a high stress-related sleep reactivity. Resilience is a psychobiological factor that determines an individual's capacity to adapt successfully to stressful events and lower resilience increases vulnerability for the development of mental disorders. The aim was to explore resilience, for the first time in subjects with insomnia, in order to better understand the stress-risk-vulnerability dimension of insomnia.

Study Impact: The study has shown that subjects with insomnia possess low resilience, which was related to high stress-related sleep reactivity, arousal, and emotional dysregulation. This may be helpful in clinical practice for early identification of vulnerable candidates and, by enhancing resilience, for minimizing the extent of insomnia.

Risk of Nephrolithiasis in Patients With Sleep Apnea: A Population-Based Cohort Study. 767-773.
Sheng-Han Tsai, MD1,2; Marshall L. Stoller, MD3; Benjamin A. Sherer, MD3; Zi-Hao Chao, MS4; Tao-Hsin Tung, MD, PhD4,5,6

BRIEF SUMMARY

Current Knowledge/Study Rationale: Although sleep apnea and nephrolithiasis are known to share common risk factors, an association between sleep apnea and stone disease has not been thoroughly investigated. Given the increasing prevalence of both diseases and shared links to metabolic syndrome, identifying nephrolithiasis risk in patients with sleep apnea may provide opportunity for improved counseling and stone prevention.

Study Impact: Sleep apnea is associated with subsequent development of nephrolithiasis. Young male patients with sleep apnea and concomitant comorbidities are at the greatest risk for nephrolithiasis formation.

Insomnia and Nightmares as Markers of Risk for Suicidal Ideation in Young People: Investigating the Role of Defeat and Entrapment. 775-784.
Kirsten Russell, MSc1; Susan Rasmussen, PhD1; Simon C. Hunter, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Insomnia and nightmares confer increased risk for suicidal ideation in young people. However, the psychological processes driving this association are not yet known. This study tested a hypothesized multistep mediational pathway, derived from the Integrated Motivational Volitional Model of Suicidal Behaviour, to further understanding regarding the role of two robust suicide-related constructs, defeat and entrapment, as mediators within the sleep-suicidal ideation relationship in adolescents.

Study Impact: Taken together, analyses supported the hypothesized role of defeat and entrapment, as mediators, driving the psychological pathway from sleep disturbance to suicidal ideation in young people. These findings suggest that suicide risk assessment, prevention, and intervention efforts aimed at young people should consider insomnia, nightmares, defeat, and entrapment as important modifiable clinical targets.

Executive and Visuospatial Dysfunction in Patients With Primary Restless Legs Syndrome/Willis-Ekbom Disease: Study of a Chinese Population. 785-790.
Gen Li, MD; Huidong Tang, MD, PhD; Jie Chen, MD; Xuemei Qi, MD; Shengdi Chen, MD, PhD; Jianfang Ma, MD, PhD

BRIEF SUMMARY

Current Knowledge/Study Rationale: The relationship between restless legs syndrome/Willis-Ekbom disease (RLS/WED) and cognitive dysfunction is unclear; some studies have reported cognitive deficits in patients with RLS/WED and others have not.

Study Impact: This is the first study to investigate cognitive dysfunction in patients with primary RLS/WED in a Chinese population. In this 1:1 matched case-control study, we demonstrated that executive and visuospatial functions were disturbed in Chinese patients with primary RLS/WED.

Clinical Reproducibility of the Epworth Sleepiness Scale for Patients With Suspected Sleep Apnea. 791-795.
Angela J. Campbell, PhD1; Alister M. Neill, MBChB, MD1; Daniel A.R. Scott, MBChB2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Despite being used worldwide in clinical and research settings, assessment of the reproducibility of the Epworth Sleepiness Scale (ESS) score has been limited to normal subjects. In a setting of suspected obstructive sleep apnea, the ESS score is being used for triaging patients for publicly funded assessments from primary care referral in the United Kingdom and New Zealand without knowledge of its reliability throughout a referral pathway. This study aims to document reproducibility of the ESS score in a suspected obstructive sleep apnea population across a diagnostic referral pathway.

Study Impact: In a clinical obstructive sleep apnea referral population, the ESS score is variable when administered sequentially. Given this variability, the ESS should not be used as the sole tool to prioritize patients for obstructive sleep apnea assessment.

Exosomal Cargo Properties, Endothelial Function and Treatment of Obesity Hypoventilation Syndrome: A Proof of Concept Study. 797-807.
Rakesh Bhattacharjee, MD1; Abdelnaby Khalyfa, PhD2; Ahamed A. Khalyfa, BSc2; Babak Mokhlesi, MD, MS3; Leila Kheirandish-Gozal, MD, MSc2; Isaac Almendros, PhD4; Eduard Peris, MSc2; Atul Malhotra, MD5; David Gozal, MD, MBA2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Recent studies show mixed results on the therapeutic benefits of positive airway pressure (PAP) therapy for improving cardiovascular function in adults with sleep-disordered breathing. Few such studies have addressed the early subclinical improvements in cardiovascular function, including endothelial function, which may shed insight into the mechanisms accounting for how PAP therapy can improve cardiovascular disease.

Study Impact: Here, we show that circulating exosomes isolated from patients with obesity hypoventilation syndrome adversely affect naïve endothelial integrity in vitro and such deleterious effects are improved following just 6 weeks of PAP therapy.

Prevalence, Associated Clinical Features, and Impact on Continuous Positive Airway Pressure Use of a Low Respiratory Arousal Threshold Among Male United States Veterans With Obstructive Sleep Apnea. 809-817.
Andrey Zinchuk, MD1; Bradley A. Edwards, PhD2,3; Sangchoon Jeon, PhD4; Brian B. Koo, MD5; John Concato, MD1,6; Scott Sands, PhD7; Andrew Wellman, MD, PhD7; Henry K. Yaggi, MD, MPH1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Studies are lacking in large, clinical populations that examine how the respiratory arousal threshold (ArTH), a key physiological trait involved in the pathogenesis of obstructive sleep apnea (OSA), influences adherence to continuous positive airway pressure (CPAP).

Study Impact: A low ArTH (easy arousability) is a common trait in patients with OSA that is associated with both modifiable (body mass index, medication use) and nonmodifiable factors (age). In specific patient subgroups (eg, nonobese patients), this trait is linked to a marked reduction in long-term CPAP use. Assessment of low ArTH can help identify patients at risk for poor CPAP adherence, and may inform targeted therapy selection to improve CPAP use.

Free Change in Cognition and Other Non-Motor Symptoms With Obstructive Sleep Apnea Treatment in Parkinson Disease. 819-828.
Marta Kaminska, MD, MSc1,2; Victoria P. Mery, MD3; Anne-Louise Lafontaine, MD, MSc4; Ann Robinson1; Andrea Benedetti, PhD1,5; Priti Gros, MD6; R. John Kimoff, MD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Non-motor symptoms of Parkinson disease (PD) include sleep disorders, mood disturbances, progressive cognitive dysfunction frequently leading to dementia, and others. They constitute a prominent source of disability in PD. In the general population, similar symptoms have been linked to obstructive sleep apnea, but cognition has not consistently been found to improve with continuous positive airway pressure (CPAP) treatment.

Study Impact: Individuals with PD and moderate-severe obstructive sleep apnea who used CPAP over a 12-month period showed improved non-motor symptoms, including an overall non-motor symptom score, sleep, anxiety and notably, global cognitive function. The improvement in cognition was associated with baseline reduced cognition and REM sleep behavior disorder. Hence, treating obstructive sleep apnea with CPAP in neurodegenerative disorders such as PD may be beneficial for highly relevant patient outcomes.

Differentiating Single and Multiple Suicide Attempters: What Nightmares Can Tell Us That Other Predictors Cannot. 829-834.
Katrina J. Speed, MS1; Christopher W. Drapeau, PhD1,2; Michael R. Nadorff, PhD1,3

BRIEF SUMMARY

Current Knowledge/Study Rationale: Given continual increases in the suicide rate in the United States, it is critical to improve our understanding of how to assess and treat suicide risk.

Study Impact: This study showed that nightmare frequency differentiated between single and multiple suicide attempters independent of several other risk factors, whereas symptoms of depression, posttraumatic stress disorder, insomnia, and other aspects of nightmares (ie, severity/distress and chronicity) failed to do so. Findings from this study also suggest that assessing nightmare frequency may be important when treating those with nightmares who are at risk of attempting suicide, especially those with a previous suicide attempt. Future research is needed to replicate these findings and assess the efficacy of treating nightmares as a means of reducing suicide risk.

Lack of Worsening of Sleep-Disordered Breathing After Recurrent Stroke in the BASIC Project. 835-839.
Devin L. Brown, MD1; Chengwei Li, MPH1,2; Brisa N. Sánchez, PhD3; Galit Levi Dunietz, PhD4; Ronald D. Chervin, MD, MS4; Erin Case, BA1,2; Nelda M. Garcia, BS1,2; Lynda D. Lisabeth, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: The purpose of the study was to capitalize on a unique opportunity to gain insights into the pathophysiology of post-stroke sleep-disordered breathing. We performed physiological assessments of sleep-disordered breathing longitudinally, in the same subjects, after an index stroke and a recurrent stroke.

Study Impact: This within-person, repeated-measures analysis showed similar sleep-disordered breathing severity after an index and recurrent stroke. These results did not support our hypothesis that recurrent stroke has an incremental negative effect on sleep-disordered breathing severity or prevalence and generates hypotheses about the pathophysiology of the highly prevalent condition of post-stroke sleep apnea.

Ability of the Multisensory Jawbone UP3 to Quantify and Classify Sleep in Patients With Suspected Central Disorders of Hypersomnolence: A Comparison Against Polysomnography and Actigraphy. 841-848.
Jesse D. Cook, BS; Michael L. Prairie, BS; David T. Plante, MD

BRIEF SUMMARY

Current Knowledge/Study Rationale: Consumers are increasingly using commercially available fitness trackers to quantify and classify sleep despite limited empiric data assessing their performance characteristics. These devices may also have clinical utility, particularly in the evaluation of patients with suspected central disorders of hypersomnolence, for which total sleep duration and REM sleep instability are important diagnostic considerations.

Study Impact: Results demonstrate the Jawbone UP3 does not accurately measure sleep duration or identify sleep stages during polysomnography and Multiple Sleep Latency Testing. Thus, this device should not be used for diagnostic purposes in patients with suspected central disorders of hypersomnolence.

Characterizing Decisional Conflict for Caregivers of Children With Obstructive Sleep Apnea Without Tonsillar Hypertrophy. 849-855.
Amy M. Manning, MD1; Angela L. Duggins, RN, BSN2,3; Karin A. Tiemeyer, RN-BC, MSN3; Lisa A. Mullen, MHSA3; Joseph A. Crisalli, MD, MS3; Aliza P. Cohen, MA2; Stacey L. Ishman, MD, MPH1,2,3

BRIEF SUMMARY

Current Knowledge/Study Rationale: Management of children with obstructive sleep apnea (OSA) without tonsillar hypertrophy typically involves an array of possible medical and surgical treatments from which caregivers must choose. Our intent was to examine the degree of decisional conflict (DC) engendered by this process and the relationship between DC, quality of life, and OSA severity.

Study Impact: This is the first study to examine the effect of DC on caregivers of children with OSA without tonsillar hypertrophy. We found that more than 20% of these caregivers experienced high levels of DC regarding their child's treatment for OSA.

Sleep Duration Interacts With Lifestyle Risk Factors and Health Status to Alter Risk of All-Cause Mortality: The Rural Chinese Cohort Study. 857-865.
Feiyan Liu, MD1,2,3; Hongyan Zhang, MD, MPH1; Yu Liu, MD2; Xizhuo Sun, MD2; Zhaoxia Yin, MD2; Honghui Li, MD2; Kunpeng Deng, MD4; Yang Zhao, MD1,2; Bingyuan Wang, MD1,2; Yongcheng Ren, MD1,2; Lu Zhang, MD1,2,5; Junmei Zhou, MM, MPH1,2; Chengyi Han, MM, MPH1,2; Xuejiao Liu, MD1,2,5; Dongdong Zhang, MD1,2,5; Guozhen Chen, BA6; Shihao Hong, BA6; Chongjian Wang, MD, MPH, PhD5; Dongsheng Hu, MD, MPH, PhD1,2,3; Ming Zhang, MD, MPH, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Many studies suggested that sleep duration was associated with all-cause mortality. However, there is a paucity of studies focused on the interrelation between sleep duration and lifestyle factors and health status. In our study, we tried to examine the relationship between sleep duration and all-cause mortality and detect the interrelationship between sleep duration (both short and long) and those factors.

Study Impact: Results of the study indicated that both short and long sleep duration was associated with all-cause mortality and that long sleep duration interacted with low level of physical activity, hypertension, and type 2 diabetes mellitus. Our study of a rural Chinese population has great public health significance and the conclusions could provide useful and important evidence for future intervention programs.

Review Articles

Prevalence of Obstructive Sleep Apnea in Children With Down Syndrome: A Meta-Analysis. 867-875.
Chia-Fan Lee, SLP1; Chia-Hsuan Lee, MD, MPH2,3; Wan-Yi Hsueh, MD4,5,6; Ming-Tzer Lin, MD7,8; Kun-Tai Kang, MD, MPH2,3

Special Articles

Free Consumer Sleep Technology: An American Academy of Sleep Medicine Position Statement. 877-880.
Seema Khosla, MD1; Maryann C. Deak, MD2; Dominic Gault, MD3; Cathy A. Goldstein, MD4; Dennis Hwang, MD5; Younghoon Kwon, MD6; Daniel O'Hearn, MD7; Sharon Schutte-Rodin, MD8; Michael Yurcheshen, MD9; Ilene M. Rosen, MD, MS8; Douglas B. Kirsch, MD10; Ronald D. Chervin, MD, MS4; Kelly A. Carden, MD11; Kannan Ramar, MD12; R. Nisha Aurora, MD13; David A. Kristo, MD14; Raman K. Malhotra, MD15; Jennifer L. Martin, PhD16,17; Eric J. Olson, MD12; Carol L. Rosen, MD18; James A. Rowley, MD19

Durable Medical Equipment

Value and Payment in Sleep Medicine. 881-884.
Emerson M. Wickwire, PhD, FAASM1,2; Tilak Verma, MD, MBA, FAASM3

Case Reports

Stevens-Johnson Syndrome After Armodafinil Use. 885-887.
Steven Holfinger, MD, MS1; Asim Roy, MD2; Markus Schmidt, MD, PhD2,3
Violent Parasomnia With Recurrent Biting and Surgical Interventions: Case Report and Differential Diagnosis. 889-891.
Nilam Danish, MBBS1; Imran S. Khawaja, MBBS, FAASM1,2; Carlos H. Schenck, MD3
The Longest Obstructive Apnea You Have Ever Seen: A Patient With New-Onset Autonomic Dysfunction. 893-895.
Puneet K. Aulakh, MD1; David E. Westerman, MBChB, FCP(SA), FCCP, FAASM2; Raj C. Dedhia, MD, MS3,4

Letters to the Editor

Free The Effects of Sildenafil on the Respiratory System of Patients With Obstructive Sleep Apnea and Erectile Dysfunction. 897-898.
Monica L. Andersen, PhD; Sergio Tufik, MD, PhD
Free The Case for Membership in the AMA. 899.
Alejandro D. Chediak, MD, FAASM1; Patrick J. Strollo, MD, FAASM2
Free Effective Treatment of Insomnia With Mirtazapine Attenuates Concomitant Suicidal Ideation. 901-902.
Kamal Gandotra, MD1,2,3; Peijun Chen, MD, PhD, MPH1,3; George E. Jaskiw, MD1,3; P. Eric Konicki, MD1,3; Kingman P. Strohl, MD2,4

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