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Accepted Papers


Free Overnight Pulse Oximetry Unwoven. 497-498.
Peter C. Gay, MD, FAASM
Free The Future of the Sleep Lab: It's Complicated. 499-500.
Jeremy E. Orr, MD; Pamela N. DeYoung, RPSGT; Robert L. Owens, MD
Free Getting Personal with Down Syndrome and Obstructive Sleep Apnea. 501-502.
Benjamin H. Hughes, MD

Scientific Investigations

Heart Rate Variability Responses of Individuals With and Without Saline-Induced Obstructive Sleep Apnea. 503-510.
Daniel Vena, MASc1,2; T. Douglas Bradley, MD1,3; Philip J. Millar, PhD4,5; John S. Floras, MD, DPhil3,4; Jonathan Rubianto1; Bojan Gavrilovic, MASc1; Elisa Perger, MD1; Azadeh Yadollahi, PhD1,2


Current Knowledge/Study Rationale: Development of obstructive sleep apnea postoperatively has been attributed to the fluid overloaded state of patients during the postoperative period. Postoperative obstructive sleep apnea increases the risk for the development of cardiovascular events after surgery, which may be attributed to altered cardiac autonomic regulation caused by obstructive events.

Study Impact: Using measures of heart rate variability, we demonstrated that individuals in whom obstructive sleep apnea developed through fluid overload via saline infusion experienced reduced heart rate variability, consistent with vagal withdrawal, compared to those without saline-induced obstructive sleep apnea. In this context, alterations in cardiac autonomic regulation associated with obstructive sleep apnea may add to postoperative risk for cardiovascular events.

Free Role of Positive Airway Pressure Therapy for Obstructive Sleep Apnea in Patients With Stroke: A Randomized Controlled Trial. 511-521.
Anupama Gupta, PhD1; Garima Shukla, DM1; Mohammed Afsar, M Phil1; Shivani Poornima, M Phil1; Ravindra M. Pandey, PhD2; Vinay Goyal, DM1; Achal Srivastava, DM1; Deepti Vibha, DM1; Madhuri Behari, DM1


Current Knowledge/Study Rationale: Stroke is a common cause of death and disability and obstructive sleep apnea (OSA) is an independent risk factor for stroke. The objective of this study was to assess the effect of continuous positive airway pressure (CPAP) treatment in prevention of new vascular events among patients with stroke and OSA. We included patients presenting with their first-ever stroke after 6 weeks of ictus. Patients with stroke and OSA were randomized to CPAP and non-CPAP treatment groups.

Study Impact: At 1 year from randomization, a nonsignificantly higher number of new vascular events occurred in the non-CPAP group and significantly better stroke outcomes were observed in the CPAP group.

Reference Data for Polysomnography-Measured and Subjective Sleep in Healthy Adults. 523-532.
Elisabeth Hertenstein, PhD1; Agata Gabryelska1,2; Kai Spiegelhalder, MD PhD1; Christoph Nissen, MD1,3,4; Anna F. Johann, MSc1,5; Roza Umarova, MD1,4; Dieter Riemann, PhD1; Chiara Baglioni, PhD1; Bernd Feige, PhD1


Current Knowledge/Study Rationale: A classification of sleep parameters as normal or pathologic is important in order to detect disorders and need for treatment. Such a classification is difficult because clear cutoffs are not available for many parameters.

Study Impact: With our set of normative data of a sample of 206 healthy adults, comprising polysomnography parameters, spectral analytic data, and subjective sleep estimations for 2 consecutive nights, we provide an orientation and guidance for sleep clinicians. However, in light of high interindividual and intraindividual variation within sleep variables, we are far from being able to derive and establish clear cutoff values for healthy versus unhealthy sleep.

Sleep Patterns in Chinese Preschool Children: A Population-Based Study. 533-540.
Ran Wu, MA1,2; Guang-Hai Wang, PhD3; Hong Zhu, MA2; Fan Jiang, MD, PhD3; Chun-Lei Jiang, MD, PhD1


Current Knowledge/Study Rationale: To date there have been a limited number of population-based studies that have comprehensively examined sleep patterns specific to preschool children in mainland China. We sought to assess normal sleep patterns in Chinese preschool children and cross-cultural differences among China and other countries, and estimate the prevalence of insufficient sleep and delayed weekend sleep pattern.

Study Impact: Age- and region-specific variability of sleep patterns is reported as well as insufficient sleep and delayed weekend sleep pattern in Chinese preschool children. We found that the cross-cultural difference of sleep patterns was in temporal placement rather than sleep duration.

High Interrater Reliability of Overnight Pulse Oximetry Interpretation Among Inexperienced Physicians Using a Structured Template. 541-548.
Mirna Ayache, MD, MPH1,2; Kingman P. Strohl, MD1,2


Current Knowledge/Study Rationale: There are no professional guidelines or formal training of pulmonary and critical care (PCC) fellows in overnight pulse oximetry (OPO) interpretation. Therefore, it is not surprising that there is significant variation and poor reliability across PCC physicians' interpretation of this relatively common test.

Study Impact: This study provides a tool (a comprehensive structured template for OPO interpretation) to reduce variation and produce a reliable interpretation of OPO by physicians without sleep training or experience in OPO interpretation. Implementation of this tool will help physicians across the country to systematically interpret OPO tests within its limitations.

Gestational Obstructive Sleep Apnea: Biomarker Screening Models and Lack of Postpartum Resolution. 549-555.
Linda M. Street, MD1; Carol A. Aschenbrenner, MA2; Timothy T. Houle, PhD3; Clark W. Pinyan, MD, MPH4; James C. Eisenach, MD2


Current Knowledge/Study Rationale: Obstructive sleep apnea is common during pregnancy but postpartum persistence and course are unknown. Additionally, current screening methods for gestational sleep apnea are poor.

Study Impact: As knowledge about incidence and ramifications of obstructive sleep apnea in pregnancy for both the mother and infant continues to grow, it becomes increasingly important to identify a feasible screen for gestational sleep apnea. Additionally, knowledge of the expected postpartum course is important for advising women on appropriate postpartum follow-up.

Free The Association Between Vitamin D Level and Restless Legs Syndrome: A Population-Based Case-Control Study. 557-564.
Siraj Wali, FRCPC1; Samah Alsafadi, MD, MScPH2; Bahaa Abaalkhail, DrPH2; Iman Ramadan, DrPH2; Badr Abulhamail, MD1; Moaiyyad Kousa, MD1; Reem Alshamrani, MD1; Hanan Faruqui, MD1; Abdulaziz Faruqui, MD1; Mohamed Alama, MD1; Mohamed Hamed, MD1


Current Knowledge/Study Rationale: Most evidence to date suggests that brain dopaminergic dysfunction plays a key role in the development of restless legs syndrome (RLS), and vitamin D is essential for the function of the dopaminergic system. Nonetheless, few studies have examined the relationship between vitamin D and RLS. The current study is the first population-based case-control study to assess the association between RLS and vitamin D levels using an adequate sample size of patients with RLS.

Study Impact: The data show an inverse association between vitamin D levels and RLS. Therefore, vitamin D deficiency should be considered in the management of patients with RLS.

Effects of Bedroom Environmental Conditions on the Severity of Obstructive Sleep Apnea. 565-573.
Sattamat Lappharat, PhD1; Nutta Taneepanichskul, PhD1; Sirimon Reutrakul, MD2,3; Naricha Chirakalwasan, MD4,5


Current Knowledge/Study Rationale: Particulate matter has been linked to obstructive sleep apnea (OSA), but the influence of indoor environmental conditions, particularly in bedrooms on severity of OSA, has not been well studied. The association of indoor environmental conditions with OSA severity is investigated in this study.

Study Impact: An increase in PM10 concentrations is associated with more severe OSA as measured by an apnea-hypopnea index and respiratory disturbance index. Reduction in exposure to particulate matter may lessen the severity of OSA.

Evaluation of a Trial Period With a Sleep Position Trainer in Patients With Positional Sleep Apnea. 575-583.
Jolien Beyers, MBS1,2; Marijke Dieltjens, MBS, PhD1,2,3; Chloé Kastoer, MD1,2; Lynn Opdebeeck, MBS2; An N. Boudewyns, MD, PhD1,2; Ilse De Volder, MD4,5; Ann Van Gastel, MD4,5; Johan A. Verbraecken, MD, PhD2,4,6; Wilfried A. De Backer, MD, PhD2,4,6; Marc J. Braem, DDS, PhD2,3; Paul H. Van de Heyning, MD, PhD1,2; Olivier M. Vanderveken, MD, PhD1,2,4


Current Knowledge/Study Rationale: In more than 50% of patients with obstructive sleep apnea (OSA), it is possible that the disorder is position dependent, which is called positional OSA (POSA). Positional therapy is a noninvasive treatment option for POSA. In the past, treatment of POSA was hampered by a low adherence rate to devices aimed to reduce sleep time in the supine position.

Study Impact: In the current study, patients with POSA were given a 1-month trial period with a sleep position trainer (SPT). We found that treatment of POSA with the SPT was effective and that patients were highly adherent to this treatment. Furthermore, we stress the importance of the trial period so that patients who will not benefit from SPT treatment can avoid purchasing the device.

The Validity of a New Consumer-Targeted Wrist Device in Sleep Measurement: An Overnight Comparison Against Polysomnography in Children and Adolescents. 585-591.
Anu-Katriina Pesonen, PhD; Liisa Kuula, MA


Current Knowledge/Study Rationale: The validity of consumer-targeted accelerometers in measuring sleep is little studied. Most validation studies focus only on devices designed for research use, though sleep-tracking devices are widely used among consumers. This study compared two wrist-worn devices (Polar Electro Oy and Philips Respironics Actiwatch 2) against polysomnography in children and adolescents.

Study Impact: Both wrist-worn devices had high sensitivity, but specificity was generally higher for the Polar fitness tracker than for the Actiwatch 2. The Polar fitness tracker measures sleep at a level generally accepted in clinical and research contexts.

Ambulatory Surgery Has Minimal Impact on Sleep Parameters: A Prospective Observational Trial. 593-602.
Arlene J. Hudson, MD, MA1; Robert J. Walter, MD, DHCE2; John Flynn, MD3; Dale F. Szpisjak, MD, MPH1; Cara Olsen, DrPH4; Matthew Rodgers, MD2; Vincent F. Capaldi, ScM, MD2; Brent McDuffie, MSN3; Christopher J. Lettieri, MD2


Current Knowledge/Study Rationale: Although the presence of obstructive sleep apnea (OSA) has been shown to be an independent risk factor for adverse outcomes among inpatients, several small studies among ambulatory surgical patients have not demonstrated an increase in perioperative risk. We aimed to study serial perioperative sleep parameter data among ambulatory surgical patients with and without OSA to evaluate the effect surgery and anesthesia may impose on this large surgical population.

Study Impact: Surgery and anesthesia had minimal effect on sleep parameters and there was no increase in adverse outcomes observed among patients with either treated or untreated OSA. Given the high prevalence of OSA observed in the ambulatory surgical population, further study exploring the effect of OSA on sleep parameters and outcomes is warranted.

Diagnostic and Treatment Challenges of Sighted Non–24-Hour Sleep-Wake Disorder. 603-613.
Roneil G. Malkani, MD, MS; Sabra M. Abbott, MD, PhD; Kathryn J. Reid, PhD; Phyllis C. Zee, MD, PhD


Current Knowledge/Study Rationale: Non–24-hour sleep-wake disorder in sighted people is uncommon, often overlooked, and severely affects daily function and quality of life. We aimed to highlight the challenges in diagnosis and circadian-based treatment of non–24-hour sleep-wake disorder with bright light exposure and melatonin in a clinical setting.

Study Impact: Although timed melatonin and bright light therapy is effective to entrain the sleep-wake rhythm, it requires frequent physician-patient contact, and long-term patient adherence to treatment is low. This study highlights the need for understanding the pathophysiology of this disorder, to develop clinical tools for diagnosis and treatment planning, and to develop and test a targeted and effective long-term therapeutic strategy.

Reliability and Validity of the Functional Outcomes of Sleep Questionnaire – Spanish Short Version (FOSQ-10SV) in Peruvian Patients With Obstructive Sleep Apnea. 615-621.
Jorge Rey de Castro, MSc, MD1,2; Edmundo Rosales-Mayor, MSc, MD3,4; Terri E. Weaver, PhD, RN5


Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) is a chronic disease that affects quality of life (QOL). Thus, we evaluated the reliability and validity of a Spanish short version of the Functional Outcomes of Sleep Questionnaire (FOSQ-10SV) in a clinical population of Peruvian patients suspected to have OSA.

Study Impact: The FOSQ-10SV has an internal validity and construct validity in patients with OSA. The FOSQ-10SV has the sensitivity to change in patients with OSA who started continuous positive airway pressure treatment.

Sleep Disorders and Their Management in Children With Ehlers-Danlos Syndrome Referred to Sleep Clinics. 623-629.
Keren Armoni Domany, MD1,2; Sumalee Hantragool, MD1,3; David F. Smith, MD, PhD1,4,5; Yuanfang Xu, MS6; Monir Hossain, PhD6; Narong Simakajornboon, MD1


Current Knowledge/Study Rationale: There is evidence of a high frequency of sleep problems in adults with Ehlers-Danlos syndrome (EDS); specifically, high rates of obstructive sleep apnea (OSA), low sleep quality, and periodic limb movement disorder (PLMD). However, no data exist regarding OSA and other sleep disorders as well as their management in children with EDS.

Study Impact: Our data suggest that a high prevalence of sleep disorders, specifically OSA, insomnia, circadian rhythm disorders, PLMD, and hypersomnia already exist by late childhood in children with EDS referred to sleep clinics, and that specific management can improve quality of life. Hence, a high index of suspicion for sleep disorders is necessary in this population.

Free Analyses of the Complexity of Patients Undergoing Attended Polysomnography in the Era of Home Sleep Apnea Tests. 631-639.
Brendon Colaco, MBBS1,2; Daniel Herold, RPSGT1; Matthew Johnson, MPH3; Daniel Roellinger3; James M. Naessens, ScD3,4; Timothy I. Morgenthaler, MD, FAASM1,2


Current Knowledge/Study Rationale: There have been no prior studies specifically evaluating the complexity of patients undergoing polysomnography over time. However, several factors may be increasing complexity of such patients: (1) home sleep apnea tests draw less complex patients away from attended polysomnography, (2) greater percentages of patients seeking medical care have multiple chronic health conditions, and (3) advances in the type of respiratory support devices employed by sleep medicine specialists are capable of supporting more complex patient needs. Study Impact: Our data demonstrate that the complexity of patients being studied increased by nearly 30% and that care requirements increase with complexity measures. This trend suggests the need for higher levels of training and special equipment, with potential resultant increased costs of attended polysomnography tests in the future.

Integrating the Divided Nasal Cannula Into Routine Polysomnography to Assess Nasal Cycle: Feasibility and Effect on Outcomes. 641-650.
Marcelo Scapuccin, MD1,2; Logan Schneider, MD3; Nur Rashid, MD1,4; Soroush Zaghi, MD1; Talita Rosa, MD1; Yung-an Tsuo, MD1,5; Stanley Liu, MD1; Paulo Lazarini, MD2; Robson Capasso, MD1; Chad Ruoff, MD3


Current Knowledge/Study Rationale: The phenomenon that underlies the alternation of congestion and decongestion of nasal airways, producing a relative change in resistance between one side of the nasal passage and the other, is called the nasal cycle. It is well known that body position can influence nasal airway resistance and respiratory events.

Study Impact: In our study, we replaced the undivided nasal cannula with a divided nasal cannula during polysomnography, allowing us to replicate past nasal cycle findings and search for other associations between the nasal cycle and traditional polysomnographic measures.

The Role of Functional Respiratory Imaging in Treatment Selection of Children With Obstructive Sleep Apnea and Down Syndrome. 651-659.
Monique A.L.J. Slaats, MD1; Dieter Loterman, MSc2; Cedric van Holsbeke, MSc, PhD2; Wim Vos, MSc, PhD2; Kim Van Hoorenbeeck, MD, PhD1; Jan de Backer, MSc, PhD2; Wilfried de Backer, MD, PhD3; Marek Wojciechowski, MD1; An Boudewyns, MD, PhD1; Stijn Verhulst, MD, PhD4


Current Knowledge/Study Rationale: The complexity of the pathogenesis of obstructive sleep apnea (OSA) in children with Down syndrome (DS) is illustrated by a prevalence of residual OSA after adenotonsillectomy. The most common causes of persistent OSA in DS include macroglossia, glossoptosis, recurrent enlargement of the adenoid, tonsils, and enlarged lingual tonsils; however, there are still children who have these risk factors and benefit from adenotonsillectomy (decrease of greater than 50% in obstructive apnea-hypopnea index).

Study Impact: This is the first study that investigated whether upper airway imaging combined with computational fluid dynamics could influence treatment selection after adenotonsillectomy in these children. This study suggests that upper airway imaging could probably provide objective values for treatment selection by creating cutoff values of volumes below the tonsils.

Review Articles

Associations Between Neuropsychological, Neurobehavioral and Emotional Functioning and Either Narcolepsy or Idiopathic Hypersomnia in Children and Adolescents. 661-674.
Beris Ludwig, BS (Hons), BEd, MEd1,2; Simon Smith, BS (Hons), MS, PhD1; Helen Heussler, MBBS, PhD1,2,3

Special Articles

Did René Descartes Have Exploding Head Syndrome?. 675-678.
Abidemi Idowu Otaiku, BSc (Hons) AKC
Free Medical Cannabis and the Treatment of Obstructive Sleep Apnea: An American Academy of Sleep Medicine Position Statement. 679-681.
Kannan Ramar, MD1; Ilene M. Rosen, MD, MS2; Douglas B. Kirsch, MD3; Ronald D. Chervin, MD, MS4; Kelly A. Carden, MD5; R. Nisha Aurora, MD6; David A. Kristo, MD7; Raman K. Malhotra, MD8; Jennifer L. Martin, PhD9,10; Eric J. Olson, MD1; Carol L. Rosen, MD11; James A. Rowley, MD12
Free The Risk of Fatigue and Sleepiness in the Ridesharing Industry: An American Academy of Sleep Medicine Position Statement. 683-685.
Michael Berneking, MD1; Ilene M. Rosen, MD, MS2; Douglas B. Kirsch, MD3; Ronald D. Chervin, MD, MS4; Kelly A. Carden, MD5; Kannan Ramar, MD6; R. Nisha Aurora, MD7; David A. Kristo, MD8; Raman K. Malhotra, MD9; Jennifer L. Martin, PhD10,11; Eric J. Olson, MD6; Carol L. Rosen, MD12; James A. Rowley, MD13; Indira Gurubhagavatula, MD, MPH2,14

Case Reports

Melatonin-Responsive Complex Nocturnal Visual Hallucinations. 687-691.
Liudmila Lysenko, MD1; Sushanth Bhat, MD2
Dissociative Identity Disorder CPAP Adherence: An Uncommon Factor in Obstructive Sleep Apnea. 693-695.
Kamal Gandotra, MD1; Joseph Golish, MD2; Carl Rosenberg1; Kingman Strohl, MD1,3
Segmental Hair Testing of Triazolam to Unmask a Suspected Case of Idiopathic Recurrent Stupor. 697-699.
Emanuela Postiglione, MD1; Elena Antelmi, MD, PhD1,2; Monica Moresco, MSc1; Simona Pichini, PhD3; Fabio Pizza, MD, PhD1,2; Giuseppe Plazzi, MD, PhD1,2; Francesco Paolo Busardò, MD, PhD4,5
Tooth Movement Associated With CPAP Therapy. 701-702.
Benjamin T. Pliska, DDS, MS; Fernanda R. Almeida, PhD

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