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Accepted Papers

Scientific Investigations

Vascular Response During Mental Stress in Sedentary and Physically Active Patients With Obstructive Sleep Apnea. 1463-1470.
Rosyvaldo Ferreira-Silva, MSc1; Thiago T. Goya, MSc2; Eline R.F. Barbosa, MD3; Bruno G. Durante, BS2; Carlos E.L. Araujo, BS2; Geraldo Lorenzi-Filho, MD, PhD3; Linda M. Ueno-Pardi, PhD1


Current Knowledge/Study Rationale: Leisure time physical activity is associated with vascular benefits in several diseases. However, the effect of physical activity on vascular function at rest and during stress in patients with obstructive sleep apnea is unknown.

Study Impact: Among patients with moderate to severe obstructive sleep apnea and no comorbidities, moderate physical activity during leisure time (approximately 4 h/wk) is associated with better vascular function at rest and during stress than in sedentary patients. Physical activity may protect vascular function in patients with obstructive sleep apnea.

Prevalence of Obstructive Sleep Apnea and Obesity Among Middle-Aged Women: Implications for Exercise Capacity. 1471-1475.
Martinha Millianny Barros de Carvalho, RpT1; Ricardo Quental Coutinho, MD2; Isly Maria L. Barros, MD, PhD2; Laura O.B.F. Costa, MD, PhD2; Ana Kelley L. Medeiros, RN1; Thais C. Lustosa, RpT1; Carolina A. Medeiros, RN1; Marcus Vinícius França, RpT1; Tarcya L.G. Couto, RpT1; Ulisses R. Montarroyos, PhD3; Virend K. Somers, MD, PhD4; Rodrigo Pinto Pedrosa, MD, PhD1,5


Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) and obesity may both impair exercise capacity, which is an important cardiovascular risk predictor.

Study Impact: Our study showed an interaction between obesity and OSA in exercise functional capacity, suggesting that OSA and obesity may together contribute to reduce functional capacity, resulting in heightened cardiovascular risk in middle-aged women.

Obesity Hypoventilation Syndrome: Early Detection of Nocturnal-Only Hypercapnia in an Obese Population. 1477-1484.
Sheila Sivam, MD; Brendon Yee, MBChB, PhD; Keith Wong, MBBS, PhD; David Wang, PhD; Ronald Grunstein, MD, PhD; Amanda Piper, PhD


Current Knowledge/Study Rationale: The prevalence and clinical predictors of obesity-related sleep hypoventilation (ORSH) without daytime hypercapnia is unknown. Detection and multimodal management of patients at this stage may potentially prevent the development of advanced obesity hypoventilation syndrome and its related complications.

Study Impact: Our study demonstrates that stages I/II ORSH and stages III/IV obesity hypoventilation syndrome have a similar prevalence in a tertiary sleep referral center setting, with awake oxygen saturation and partial pressure of carbon dioxide obtained in a supine position shown to be the best predictors for nocturnal-only hypoventilation. Simple measures using supine positioning help predict sleep hypoventilation in a morbidly obese population, where ORSH is underrecognized.

Free Race, Sex, Age, and Regional Differences in the Association of Obstructive Sleep Apnea With Atrial Fibrillation: Reasons for Geographic and Racial Differences in Stroke Study. 1485-1493.
Lama Ghazi, MD1; Aleena Bennett, MS2; Megan E. Petrov, PhD3; Virginia J. Howard, PhD4; Monika M. Safford, MD5; Elsayed Z. Soliman, MD, MSC, MS6; Stephen P. Glasser, MD7


Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) is prevalent among 32% to 49% of patients with atrial fibrillation (AF) and has been associated with increased cardiovascular risk including several AF risk factors; this association may differ by race, sex, age, and region. We explored the association between AF and OSA risk in the REGARDS cohort and assessed whether this association differed by race, sex, age, or region.

Study Impact: Individuals at high risk for OSA have increased prevalence of AF and after multivariable adjustment this association remained significant in blacks but not in whites. This study showed that this association did not differ by sex, region, or age as previously presumed; understanding this association will be key to reducing the burden of AF.

Home Sleep Apnea Testing is a Feasible and Accurate Method to Diagnose Obstructive Sleep Apnea in Stroke Patients During In-Hospital Rehabilitation. 1495-1501.
Michael T. Saletu, MD1,2; Stefan T. Kotzian, MSc1; Angela Schwarzinger, MSc1; Sandra Haider, PhD1; Josef Spatt, MD1; Bernd Saletu, MD3


Current Knowledge/Study Rationale: In stroke patients, current American Academy of Sleep Medicine guidelines still recommend attended polysomnography (PSG) for the diagnosis of obstructive sleep apnea (OSA). During in-hospital stroke rehabilitation, home sleep apnea testing (HSAT) might be a viable alternative to facilitate the decision of whether or not to initiate continuous positive airway pressure therapy.

Study Impact: The current findings confirm a good feasibility and sufficient accuracy of HSAT attached in a stroke rehabilitation unit. Wake time periods and arousals not evaluated by HSAT showed no relevant influence in apnea-hypopnea index classification and night-to-night variability was acceptable. Therefore, HSAT is an alternative to PSG in stroke patients during in-hospital rehabilitation to diagnose OSA.

Frequency of Past and Current Psychiatric Disorders in Patients Referred for Polysomnography: A Pilot Study. 1503-1507.
Morgane Pradines, MD1; Marc Rey, MD2; Rémy Dumas, MD1; Wadih Rhondali, MD3; Patrick Lemoine, MD4; Jean-Michel Azorin, MD5; Christian Vedie, MD1


Current Knowledge/Study Rationale: Many studies have already shown that sleep disorders are very common among patients with psychiatric disorders. Conversely, this study evaluated psychiatric disorders among patients with a sleep complaint.

Study Impact: This study found a high frequency of past and current psychiatric disorders among patients with a sleep complaint. It demonstrates the importance of trying to understand the sleep complaint even if polysomnography does not show evidence of any common sleep disorder.

CPAP Therapy Delays Cardiovagal Reactivation and Decreases Arterial Renin-Angiotensin System Activity in Humans With Obstructive Sleep Apnea. 1509-1520.
David D.M. Nicholl, MD, MSc1,2; Patrick J. Hanly, MD1,3,4; Ann A. Zalucky, MD, MSc1,2; Michelle C. Mann, PhD1,2; Jennifer M. MacRae, MD, MSc1,2,5; Marc J. Poulin, PhD, DPhil2,4,6,7,8; George B. Handley, RRT9; Darlene Y. Sola, RN, BScN1,2; Sofia B. Ahmed, MD, MMSc1,2,5


Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) is associated with increased cardiovascular risk and bradyarrhythmias, including alterations in heart rate variability and arterial stiffness, both validated markers of cardiovascular risk, though the mechanisms remain elusive. Whether adherent continuous positive airway pressure (CPAP) therapy in men and women with OSA is associated with improved measures of cardiovascular risk in response to a stressor remains unknown.

Study Impact: In men and women with OSA, adherent CPAP therapy was associated with (1) delayed cardiovagal reactivation after exposure to an angiotensin II stressor and (2) reduced vascular renin-angiotensin system activity. These findings support a role for the renin-angiotensin system in mediating OSA-induced hypertension and cardiovascular disease and highlight an important mechanism by which CPAP may eradicate bradyarrhythmias during sleep and convey cardiovascular protection.

Gout and the Risk of Incident Obstructive Sleep Apnea in Adults 65 Years or Older: An Observational Study. 1521-1527.
Jasvinder A. Singh, MBBS, MPH1,2,3; John D. Cleveland, MS2


Current Knowledge/Study Rationale: Both gout and obstructive sleep apnea (OSA) are associated with cardiovascular disease and the metabolic syndrome. Emerging data indicate that inflammation and/or oxidative stress may play a role in the pathogenesis of OSA. We investigated whether gout was associated with an increase in the risk of new/incident OSA in adults 65 years or older.

Study Impact: Gout was independently associated with a twofold higher risk of the development of OSA, after adjusting for demographics, comorbidity, and common cardiovascular and gout medications. This indicates that when it coexists with other OSA risk factors, a diagnosis of gout may trigger screening for OSA. Future studies should attempt to replicate this finding for this patient population and elucidate the mechanistic underpinnings of this association.

Insomnia and Regulation of Sleep-Wake Cycle With Drugs Among Adolescent Risky Drinkers. 1529-1537.
Tina Lam, PhD1; Rowan P. Ogeil, PhD2; Steve Allsop, PhD1; Tanya Chikritzhs, PhD1; Jane Fischer, PhD3; Richard Midford, PhD4; William Gilmore, MSc1; Simon Lenton, PhD1; Wenbin Liang, PhD1; Belinda Lloyd, PhD2; Alexandra Aiken, MPH5; Richard Mattick, PhD5; Lucinda Burns, PhD5; Dan I. Lubman, PhD2


Current Knowledge/Study Rationale: There is a bidirectional relationship between sleep disturbance and alcohol and other drug-related problems. To date, however, there has been limited exploration of the experience of adolescents engaging in risky drinking with sleep problems, and their use of drugs to regulate their sleep-wake cycle.

Study Impact: Controlling for various psychological and behavioral confounders, use of drugs specifically identified as sleep/wake aids was associated with higher odds of insomnia among teenagers in the risky drinking group. Contrary to their intended function of regulating sleep-wake cycles, these drugs may actually be compounding sleeping problems. Interventions to improve sleep quality may have positive flow-on effects in other health areas such as heavy alcohol use.

The Association Between Adherence to Positive Airway Pressure Therapy and Long-Term Outcomes in Patients With Obesity Hypoventilation Syndrome: A Prospective Observational Study. 1539-1550.
Izolde Bouloukaki, MD, PhD; Charalampos Mermigkis, MD, PhD; Stylianos Michelakis, MD; Violeta Moniaki, RN; Eleni Mauroudi, RN; Nikolaos Tzanakis, MD, PhD; Sophia E. Schiza, MD, PhD


Current Knowledge/Study Rationale: There are limited data concerning the effect of long-term effects of positive airway pressure (PAP) therapy on survival and functional status in individuals with obesity hypoventilation syndrome (OHS). This study aimed to assess the role of different levels of adherence and long-term effects of PAP therapy on gas exchange, sleepiness, quality of life, depressive symptoms, and all-cause mortality in patients with OHS after 2 years of PAP therapy.

Study Impact: Our results show that PAP therapy for ≥ 6 h/night, at least for a 2-year period in patients with OHS, resulted in significant improvements of arterial blood gases, quality of life, cardiovascular morbidity, and mortality. Clinicians should encourage PAP adherence to provide a significant improvement in clinical status and gas exchange of these patients.

Sleep-Disordered Breathing is Associated With Increased Mortality in Hospitalized Infants With Congenital Heart Disease. 1551-1558.
Daniel Combs, MD1,2,3; Grant Skrepnek, PhD, RPh4; Michael D. Seckeler, MD, MSc5; Brent J. Barber, MD5; Wayne J. Morgan, MD1; Sairam Parthasarathy, MD2,3


Current Knowledge/Study Rationale: Sleep-disordered breathing is known to have adverse cardiovascular effects in children and adults. It has been shown to be associated with increased risk of mortality in adults with cardiac disease, but there are no hospital outcomes data published for children.

Study Impact: Sleep-disordered breathing is associated with increased mortality, length of stay, and hospital charges in infants with congenital heart disease. Sleep-disordered breathing may represent a modifiable risk factor for mortality in this population.

Pediatric Obstructive Sleep Apnea is Associated With Changes in the Oral Microbiome and Urinary Metabolomics Profile: A Pilot Study. 1559-1567.
Huajun Xu, MD, PhD1,2,3; Xiaoyan Li, MD4; Xiaojiao Zheng, PhD5; Yunyan Xia, MD1,2,3; Yiqun Fu, MD1,2,3; Xinyi Li, MD1,2,3; Yingjun Qian, MD, PhD1,2,3; Jianyin Zou, MD, PhD1,2,3; Aihua Zhao, PhD5; Jian Guan, MD, PhD1,2,3; Meizhen Gu, MD4; Hongliang Yi, MD, PhD1,2,3; Wei Jia, PhD5,6; Shankai Yin, MD, PhD1,2,3


Current Knowledge/Study Rationale: The oral microbiota has been suggested to be associated with several systemic diseases, but little is known about whether the structure and composition of the oral microbiota are perturbed in pediatric obstructive sleep apnea (OSA). To date, there have been no clinical studies using metabolomics approaches to evaluate metabolic status in pediatric OSA. This study was performed to investigate the oral microbiome and urinary metabolomics profile in OSA.

Study Impact: Five genera and 57 metabolites were different between OSA and controls. These alterations suggest perturbation of metabolic status and functional alterations in the oral microbiota in pediatric OSA, supporting the hypothesis that changes in the oral microbiome may represent a new mechanism leading to or exacerbating OSA-related metabolic disorders.

Respiratory-Related Leg Movements of Sleep Are Associated With Serotonergic Antidepressants But Not Bupropion. 1569-1576.
Catherine A. McCall, MD1; John W. Winkelman, MD, PhD2


Current Knowledge/Study Rationale: Selective serotonin reuptake inhibitors (SSRIs), but not bupropion, are associated with increased periodic limb movements. It was not known whether these medications also increase respiratory-related leg movements, which may further increase sleep fragmentation and cardiovascular risk in patients with obstructive sleep apnea (OSA).

Study Impact: This study demonstrates that leg movements associated with respiratory events occur more frequently in patients with OSA taking SSRIs relative to bupropion or no antidepressant. These results may aid in guiding selection of a nonserotonergic antidepressant such as bupropion in this population to minimize treatment-emergent insomnia and elevated sympathetic activity.

Detailed Polysomnography in Australian Vietnam Veterans With and Without Posttraumatic Stress Disorder. 1577-1586.
Timothy Baird, BSc, MBBS, DTMH, FRACP1,2; Rebecca Theal, BSc(Hons)3; Sarah Gleeson, MBBS, FRACP1,2; Sarah McLeay, BSc(Hons), PhD3,4; Robyn O'Sullivan, MBBS, FRACP1,2; Sarah McLeay, BSc(Hons), PhD1; Wendy Harvey, BSc(Hons), MBBS, MPH1; Madeline Romaniuk, GradDipPsych, BBehSc(Hons), DPsych(Clinical)1,2; Darrell Crawford, MBBS, FRACP, MD1,3,4; David Colquhoun, MBBS, FRACP1,3,4; Ross McD Young, PhD1,5; Miriam Dwyer, BSc, HDipEd1; John Gibson, MBBS, FRANZCP1,4; Robyn O'Sullivan, MBBS, FRACP1,3,4; Graham Cooksley, MBBS, MD, FRACP1,3; Christopher Strakosch, MD, FRACP1,3,4; Rachel Thomson, MBBS, GradDipClinEpi, PhD, FRACP1,3,4; Joanne Voisey, BSc(Hons), PhD1,2; Bruce Lawford, MBBS, FRANZCP, FAChAM (RACP)1,2,3,4


Current Knowledge/Study Rationale: Although sleep disturbances are characteristic of posttraumatic stress disorder (PTSD), limited studies have objectively assessed sleep and obstructive sleep apnea risk in veterans with PTSD compared to trauma-exposed control patients. This study examined the prevalence of sleep disorders in a cohort of matched trauma-exposed Australian Vietnam veterans (VV) with and without PTSD using detailed polysomnography.

Study Impact: Compared to trauma-exposed control patients, Australian VV with PTSD demonstrated no difference in the prevalence of objective sleep disorders including obstructive sleep apnea and periodic limb movements. This study suggests that despite the high incidence of self-reported sleep disturbances, VV with PTSD may have a similar prevalence of polysomnography-diagnosed sleep disorders to trauma-exposed controls.

Total Sleep Time Interacts With Age to Predict Cognitive Performance Among Adults. 1587-1594.
Brian S. Mohlenhoff, MD1,2,3; Philip S. Insel, MS2,4,5; R. Scott Mackin, PhD1,2,5; Thomas C. Neylan, MD1,3; Derek Flenniken2,5; Rachel Nosheny, PhD2,5; Anne Richards, MD, MPH1,3; Paul Maruff, PhD6,7; Michael W. Weiner, MD1,2,3,4


Current Knowledge/Study Rationale: Sleep durations that are comparatively short and long have been associated with poorer cognitive performance but little is known about how total sleep time interacts with other risk factors for poorer cognitive performance. Furthermore, most studies to date have considered only short or long sleep durations, not both.

Study Impact: For the first time, we show that individuals who were concerned about their memory and reported short and long sleep durations performed significantly worse on standardized tests of memory and attention than their peers who reported mid-range sleep durations. Additionally, after excluding subjects with dementia, older individuals who reported short and long sleep durations performed significantly worse on a standardized test of attention than their peers who reported mid-range sleep durations, raising the possibility that older adults are especially susceptible to the effects of irregular sleep durations.

Free Gray Matter Changes Following Cognitive Behavioral Therapy for Patients With Comorbid Fibromyalgia and Insomnia: A Pilot Study. 1595-1603.
Christina S. McCrae, PhD1; Jennifer M. Mundt, PhD2; Ashley F. Curtis, PhD1; Jason G. Craggs, PhD1; Andrew M. O'Shea, MSc3; Roland Staud, MD4; Richard B. Berry, MD5; William M. Perlstein, PhD3; Michael E. Robinson, PhD3


Current Knowledge/Study Rationale: Insomnia commonly occurs in patients with fibromyalgia. The extent to which gray matter changes may be affected by treatment for chronic pain and insomnia is unknown.

Study Impact: Results from the current pilot study suggest that cognitive behavioral therapy for insomnia may lead to slowing or reversal of cortical atrophy in neural regions associated with central sensitization of pain.

Review Articles

Free Digital Health and Sleep-Disordered Breathing: A Systematic Review and Meta-Analysis. 1605-1620.
Talita Rosa, MD, MS1; Kersti Bellardi, MS2; Alonço Viana, MD, MS3; Yifei Ma, MS4; Robson Capasso, MD5


Current Knowledge/Study Rationale: The current diagnostic resources available are not meeting the clinical demand for the evaluation of people suffering from sleep-disordered breathing. The use of novel tools and mobile technology has the potential to increase access to diagnostic tools, but the accuracy of such devices in diagnosing sleep-disordered breathing is unknown.

Study Impact: The study is the first to assess the literature to show the potential use of novel tools and mobile technology in screening for sleep-disordered breathing in adults. The study evidences the need for further evaluation of such devices in the home environment.

Case Reports

Sleep-Related Rhythmic Sound From the Vocal Cords: A Possible Atypical Form of NREM Parasomnia. 1621-1624.
Paola Proserpio, MD1; Anna Esposito, PhD2; Dante Facchetti, MD2; Carlo Alberto Tassinari, MD3; Lino Nobili, MD, PhD1,4
Pseudo Status Cataplecticus in Narcolepsy Type 1. 1625-1627.
Candace N. Meinen, DO; Kelsey M. Smith, MD; Jan-Mendelt Tillema, MD; Suresh Kotagal, MD

Sleep Medicine Pearls

An Unusual Cause of Obstructive Sleep Apnea in a Man With Spinal Muscular Atrophy Type III. 1628-1630.
Shuk-Kuen Chau, FHKAM, FHKCPaed; Cheuk-Lam Lau, MRCPCH; So-Lun Lee, FHKAM, FHKCPaed
Asthma Exacerbation in the Spouse of a Patient With Obstructive Sleep Apnea. 1631-1632.
Mirna Ayache, MD, MPH1; Patricia Kellner, MD2; Ambrose Chiang, MD1

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