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Accepted Papers

Scientific Investigations

Ambivalent Adherence and Nonadherence to Continuous Positive Airway Pressure Devices: A Qualitative Study. 1375-1384.
Dana Zarhin, PhD1; Arie Oksenberg, PhD2


Current Knowledge/Study Rationale: Further research is needed to understand patients' experiences with CPAP use and nonuse. This study contributes to the literature by drawing on in-depth interviews with Jewish-Israeli patients with OSA to examine patients' adherence and nonadherence to CPAP use during the first 18 months after diagnosis.

Study Impact: This study shows that both adherence and nonadherence to CPAP are dynamic processes characterized by patients' ambivalence. Understanding patients' perspectives will help improve the practice of sleep medicine, as it will allow medical practitioners to address patients' concerns directly, and offer useful guidance and assistance. This study highlights the importance of establishing a close long-term follow-up mechanism of all patients regardless of their initial status of CPAP adherence.

Barriers to CPAP Use in India: An Exploratory Study. 1385-1394.
Abhishek Goyal, MD, DM1; Namrata Agarwal2; Abhijit Pakhare, MD3


Current Knowledge/Study Rationale: To our knowledge, this is the first study to report adherence rates to continuous positive airway pressure (CPAP) therapy in India. Furthermore, the barriers preventing the use of CPAP in third world countries need to be identified.

Study Impact: This study shows that cost is the most important barrier to CPAP uptake in patients with obstructive sleep apnea in India. If a patient is able to buy a CPAP device, her adherence is significantly better compared to the rate of CPAP adherence reported in Western countries.

Free Nocturnal Hypoxemia is Associated With Low Testosterone Levels in Overweight Males and Older Men With Normal Weight. 1395-1401.
Alonço Viana, MD, MS1,2,3; Ana Carolina Daflon, MD1,2; Arnaldo Couto, PD, PhD4; Denise Neves, MD, PhD1,5; Maria Helena de Araujo-Melo, MD, PhD1,6; Robson Capasso, MD3


Current Knowledge/Study Rationale: The relationship between obesity, sleep apnea, and testosterone has been widely addressed in multiple studies, describing a negative correlation between polysomnographic parameters (apnea-hypopnea index, oxygen desaturation index and O2 nadir) and testosterone levels, but studies assessing this relationship in a nonobese population with obstructive sleep apnea (OSA) are still needed. Our research evaluated associations between total testosterone (TT) levels in nonobese patients with OSA and overnight polysomnography measurements.

Study Impact: The study demonstrated that, among nonobese men with OSA, being overweight may aggravate the reduction of TT associated with severe hypoxia measured by O2 nadir < 80% and oxygen desaturation index, regardless of apnea-hypopnea index. This association was only observed among normal-weight individuals older than 50 years as well. All normal-weight men with O 2 nadir ≥ 80% presented with normal TT levels.

Changes in Caregiving Status and Intensity and Sleep Characteristics Among High and Low Stressed Older Women. 1403-1410.
Yeonsu Song, PhD, RN1,2; Stephanie L. Harrison, MPH3; Jennifer L. Martin, PhD1,2; Cathy A. Alessi, MD1,2; Sonia Ancoli-Israel, PhD4; Katie L. Stone, PhD3; Lisa Fredman, PhD5


Current Knowledge/Study Rationale: Current knowledge of sleep problems and psychological distress among caregivers are based on cross-sectional studies or subjective sleep measures. We examined associations between change in caregiving role, and subjective and objective sleep characteristics among older community-dwelling women, and explored the potential modifying role of stress on these relationships.

Study Impact: Sleep characteristics were not associated with ceasing caregiving or the intensity of the caregiving role. However, among high-intensity caregivers, those with high stress levels spent significantly longer time in wake after sleep onset than the caregivers with low stress levels. Further studies are needed to examine whether relationship between caregiving-related stress and caregivers' sleep would change over time, particularly those with high level of perceived stress.

Dissociation of Objective and Subjective Daytime Sleepiness and Biomarkers of Systemic Inflammation in Sleep-Disordered Breathing and Systolic Heart Failure. 1411-1422.
Reena Mehra, MD, MS1,2,3; Lu Wang4; Noah Andrews, RPSGT1; W.H. Wilson Tang, MD1,2,3; James B. Young, MD2; Shahrokh Javaheri, MD5; Nancy Foldvary-Schaefer, DO, MS1


Current Knowledge/Study Rationale: The basis for conducting this work is to characterize the inter-relationships of objective and subjective sleepiness and associations with sleep-disordered breathing (SDB) and circulating biomarkers of systemic inflammation in patients with systolic heart failure. Understanding the perception of sleepiness relative to objective sleepiness measures remains an existing knowledge gap that needs to be addressed to inform not only SDB screening and diagnostic approaches in heart failure, but also potentially treatment responsiveness.

Study Impact: We observed novel findings of lack of association (ie, a discordance of measures of objective and subjective sleepiness in systolic heart failure and differential increases in biomarkers of systemic inflammation associated with objective, but not subjective, sleepiness measures). These results are of scientific significance because there are potential clinical implications that need to be verified in larger studies of predictive biochemical signatures discerning physiologic from behavioral sleepiness and also a possible role for screening for sleep disruption and treatment responsiveness in systolic heart failure.

CPAP Adherence is Associated With Attentional Improvements in a Group of Primarily Male Patients With Moderate to Severe OSA. 1423-1428.
Sean Deering, BS1; Lin Liu, PhD1,2; Tania Zamora, BA1; Joanne Hamilton, PhD3; Carl Stepnowsky, PhD1,4


Current Knowledge/Study Rationale: The purpose of this study was to investigate the relationship between CPAP adherence and sustained attention in patients with moderate to severe OSA. Based on findings of previous studies, we predicted that an objective assessment of attention (Psychomotor Vigilance Task) would detect attention-related improvements in behavior resulting from CPAP therapy.

Study Impact: The results of this study show that the more that CPAP therapy is used, the better the patient outcome as measured by the PVT. This finding is of importance because it emphasizes the importance of treatment adherence on a performance-based sleep outcome measure.

The REM Sleep Behavior Disorder Screening Questionnaire: Validation Study of the Korean Version (RBDQ-KR). 1429-1433.
Sooyeoun You, MD1; Hye-Jin Moon, MD1,2; So Young Do1; Yun-Kwok Wing, MD3; Jun-Sang Sunwoo, MD4; Ki-Young Jung, MD, PhD5; Yong Won Cho, MD, PhD1


Current Knowledge/Study Rationale: Several studies have investigated the validity of the Hong Kong version of the rapid eye movement sleep behavior disorder questionnaire (RBDQ-HK) which has been translated into other languages. This study evaluated the usefulness of the Korean version (RBDQ-KR) as a screening tool.

Study Impact: Results of this study demonstrate that RBDQ-KR is a reliable and effective screening tool for diagnosis of rapid eye movement sleep behavior disorder. This study contributes to future research into the sleep disorders and neurodegenerative disease in Korea.

Correlates to Problem Behaviors in Pediatric Narcolepsy: A Pilot Study. 1435-1440.
Althea Robinson Shelton, MD, MPH; Beth Malow, MD, MS


Current Knowledge/Study Rationale: Children with narcolepsy have been shown to have high rates of behavior and psychological problems. This study was performed to define correlations to neuropsychological/behavioral problems in childhood-onset narcolepsy.

Study Impact: Younger children with narcolepsy expressed higher emotional, behavioral, and attention problems than older children with narcolepsy. Sleep physicians need to assess psychological health in their patients with narcolepsy, especially in children, on a routine basis, and refer these patients when needed.

A Longitudinal Follow-Up Study on Multiple Sleep Latency Test and Body Mass Index of Patients With Narcolepsy Type 1 in Korea. 1441-1444.
Yoo Hyun Um, MD, PhD1,2; Tae-Won Kim, MD1,2; Jong-Hyun Jeong, MD, PhD1; Ho-Jun Seo, MD, PhD1; Jin-Hee Han, MD, PhD1; Sung-Min Kim, MD1,2; Ji Hyun Song2; Seung-Chul Hong, MD, PhD1,2


Current Knowledge/Study Rationale: The study was conducted to evaluate the long-term clinical course of patients with narcolepsy type 1. Obesity and validity of the Multiple Sleep Latency Test used to diagnose narcolepsy are key issues discussed in the current study.

Study Impact: This study will help clinicians understand the long-term course of patients with narcolepsy type 1 and further clinicians' focus on crucial issues such as obesity and the diagnostic validity of the Multiple Sleep Latency Test when treating patients with narcolepsy in clinical settings.

Free Improving Sleep for Hospitalized Antepartum Patients: A Non-Randomized Controlled Pilot Study. 1445-1453.
Kathryn A. Lee, RN, CBSM, PhD; Caryl L. Gay, PhD


Current Knowledge/Study Rationale: Women hospitalized for a high-risk pregnancy are vulnerable to poor sleep due to the combination of pregnancy-related sleep disturbance and environmental disturbances common in the hospital setting. Although interventions to optimize sleep for hospitalized antepartum patients are needed, little research has been conducted.

Study Impact: This pilot study demonstrated feasibility and potential efficacy of a behavioral intervention protocol that includes components of sleep hygiene and cognitive behavioral therapy, for improving the sleep of antepartum hospitalized women. Further cost-benefit evaluation is warranted.

Functional Evaluation of Small Fiber Pathways in Primary Restless Legs Syndrome: Aδ Pathway Study. 1455-1462.
Michał Fila, MD, PhD1; Mariusz Stasiołek, MD, PhD2; Adam Markiewicz, MSc2; Andrzej Bogucki, MD, PhD3


Current Knowledge/Study Rationale: Many questions remain that relate to the neurophysiological pathomechanism and the reasons for the occurrence of sensory manifestations in primary restless legs syndrome (RLS). The aim of the study was to evaluate the conduction of main (large and small) sensory pathways in idiopathic RLS, with special attention paid to the conduction of small fibers in the Aδ pathway.

Study Impact: Our study explicitly confirms the presence of dysfunction of the thermonociceptive Aδ pathway. The disability in the central part of small fiber pathways plays a crucial role and is directly related to the occurrence of sensory manifestations in patients with primary RLS. The disturbances in the peripheral part of the Aδ pathway also have an effect on the occurrence of symptoms.

Admission Criteria for Children With Obstructive Sleep Apnea After Adenotonsillectomy: Considerations for Cost. 1463-1472.
David F. Smith, MD, PhD1,2; Charlene P. Spiceland, PhD, CMA, CPA3; Stacey L. Ishman, MD, MPH1,2,4; Branden M. Engorn, MD5; Christopher Donohue, BS5; Paul S. Park, BS5; James R. Benke, BS6; Tiffany Frazee, MD5; Robert H. Brown, MD, MPH7,8; Nicholas M. Dalesio, MD5,6


Current Knowledge/Study Rationale: Postoperative respiratory complications (PRCs) are common among children with obstructive sleep apnea (OSA) after airway surgery. Several published guidelines utilize patient demographics, comorbid diseases, and sleep apnea severity to determine which patients are at highest risk for PRCs. Of the current admission guidelines, none are universally accepted.

Study Impact: We applied three published guidelines as a means to screen a population of children who underwent adenotonsillectomy for OSA to identify those children with PRCs and to determine if the models could be refined to balance patient safety with cost. Although safety should always be considered first, we recognize that cost is a growing concern for patients, physicians, and hospital administrators.

Case Reports

Efficacy of the Addition of a Cervical Collar in the Treatment of Persistent Obstructive Apneas Despite Continuous Positive Airway Pressure. 1473-1476.
Arnaud Prigent, MD1,2; Leo Grassion, MD2,3; Stephanie Guesdon, RN4; Jesus Gonzalez-Bermejo, MD2,5,6
Disordered Consciousness or Disordered Wakefulness? The Importance of Prolonged Polysomnography for the Diagnosis, Drug Therapy, and Rehabilitation of an Unresponsive Patient With Brain Injury. 1477-1481.
Francesca Formica, MD1; Marco Pozzi, PhD1; Paolo Avantaggiato, MD1; Erika Molteni, PhD1; Filippo Arrigoni, MD1; Flavio Giordano, MD3; Emilio Clementi, PhD1,2; Sandra Strazzer, MD1

Sleep Medicine Pearls

Confusing Signals During a Positive Airway Pressure Titration. 1483-1485.
Richard B. Berry, MD1; Scott Ryals, MD1; Mary H. Wagner, MD2

Journal Club

PAP and Cardiovascular Events in Adults With Sleep Apnea: Is PAP Useful?. 1487-1489.
Meghna P. Mansukhani, MD1; Virend K. Somers, MD, PhD2; Shirin Shafazand, MD, MS3

Letters to the Editor

Free Recurrent Hypersomnia and Autonomic Dysregulation in Posttraumatic Stress Disorder. 1491.
Madhulika A. Gupta, MD, FAASM, RST
Free Yogic Pranayama and PAP Therapy: Is There a Connection?. 1493.
Anuj Chandra, MD, DABSM1; Manoj Sharma, MBBS, PhD2

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