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Scientific Investigations

Free Simplifying the Screening of Obstructive Sleep Apnea With a 2-Item Model, No-Apnea: A Cross-Sectional Study. 1097-1107.
Ricardo L.M. Duarte, MD, MSc1,2; Marcelo F. Rabahi, MD, PhD3; Flavio J. Magalhães-da-Silveira, MD1; Tiago S. de Oliveira-e-Sá, MD4,5; Fernanda C.Q. Mello, MD, PhD2; David Gozal, MD, MBA6


Current Knowledge/Study Rationale: There are several clinical questionnaires for screening of obstructive sleep apnea (OSA), aiming to find the patients at high risk for this disease, which is often undiagnosed. These questionnaires often use subjective data related to sleep, which often requires bed partner information, reducing their practical applicability.

Study Impact: The No-Apnea, a practical model with only two variables (neck circumference and age) may be useful to identify patients at high risk for OSA, indicating home sleep studies and reducing long waiting lines found in several sleep laboratories, especially in primary care settings and when limited resources constrain referral evaluation. When compared to STOP-BANG (an 8-item model) and NoSAS (a 5-item model), the No-Apnea (a 2-item model) had similar performance characteristics.

Adropin and Inflammation Biomarker Levels in Male Patients With Obstructive Sleep Apnea: A Link With Glucose Metabolism and Sleep Parameters. 1109-1118.
Josko Bozic, MD, PhD1,2; Josip A. Borovac, MD, BSc1; Tea Galic, DMD, PhD2,3; Tina Ticinovic Kurir, MD, PhD1; Daniela Supe-Domic, PhD4; Zoran Dogas, MD, PhD2,5,6


Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) is a complex sleep disorder that is marked by cardiometabolic, autonomic, and inflammatory dysregulation. Adropin is a novel biopeptide that is implicated in energy homeostasis regulation and protective cardiometabolic activity. The rationale of this study was, therefore, to investigate plasma adropin levels among patients with OSA in comparison with healthy controls.

Study Impact: This study demonstrated that adropin levels in plasma were decreased in patients with OSA in comparison with controls and reflected disease severity. Moreover, adropin showed a good discriminatory power for OSA status and a significant negative correlation with certain indices of systemic inflammation, glucose metabolism, and polysomnographic parameters of sleep, suggesting its pathophysiological link with multiple dimensions of this complex disorder.

Obstructive Sleep Apnea in Cardiac Rehabilitation Patients. 1119-1126.
David Hupin, MD, PhD1,2; Vincent Pichot, PhD1,2; Mathieu Berger, MSc2; Emilia Sforza, MD, PhD1,2; Jérémy Raffin, MSc2; Cécile Lietar3; Erkan Poyraz3; Delphine Maudoux1,2; Jean-Claude Barthelemy, MD, PhD1,2; Frédéric Roche, MD, PhD1,2


Current Knowledge/Study Rationale: The value of treatment with continuous positive airway pressure in patients with symptomatic coronary artery disease (daytime sleepiness and/or 2 clinical symptoms with apnea-hypopnea index ≥ 20 events/h) appears to be established; however, treatment with continuous positive airway pressure in patients with asymptomatic coronary artery disease (with apnea-hypopnea index > 30 events/h) may be too demanding. Therefore, it would be interesting to suggest other treatment modalities, and physical activity appears to be such an alternative.

Study Impact: Severe obstructive sleep apnea is improved by cardiac rehabilitation among patients with coronary artery disease. The autonomic nervous system regulation by physical activity might be a key in alternative therapy for obstructive sleep apnea.

Sleep Disturbances in Midlife Women at the Cusp of the Menopausal Transition. 1127-1133.
Holly J. Jones, PhD, RN, CFNP1; Rochelle Zak, MD2; Kathryn A. Lee, PhD, RN, CBSM3


Current Knowledge/Study Rationale: Research about sleep disturbance in midlife women has primarily focused on differences associated with the transition from perimenopause to postmenopause. Factors associated with sleep disturbance during the premenopause stage just prior to the menopausal transition have not been as extensively explored. Using descriptive and multivariate statistical analyses, causes of sleep disturbance and differences in sleep duration among late premenopausal women were compared to those of women in early perimenopause.

Study Impact: This study identifies some of the salient factors that contribute to poor sleep quality in the premenopausal and perimenopausal reproductive stages, such as nocturia and feeling too hot. Awareness of these potential risks factors for sleep disturbance can improve clinical assessment, preventive interventions, and treatments.

Responsiveness of Veterans Affairs Health Care System to Zolpidem Safety Warnings. 1135-1141.
Hyungjin Myra Kim, ScD1,2; Lauren B. Gerlach, DO3; Matheos Yosef, PhD2; Claire Stano, MA2; Deirdre A. Conroy, PhD3; Marcia Valenstein, MD2,3; Paul N. Pfeiffer, MD2,3; Anne E. Sales, PhD, RN3,4; Kara Zivin, PhD2,3


Current Knowledge/Study Rationale: Sedative hypnotic medications are routinely prescribed for insomnia treatment, but have been associated with morning-after impairment risks. We evaluated responsiveness to two safety warnings recommending against high-dose zolpidem use in Veterans Health Administration facilities—a 2007 Veterans Administration warning and a 2013 Food and Drug Administration (FDA) warning.

Study Impact: Higher-than-recommended dose use decreased after each warning. Almost 50% of females, however, were using a high dose in 2014. In contrast, overall zolpidem use increased more than fourfold between 2007 and 2013, but decreased after the 2013 FDA warning in both sexes. Policies were effective in decreasing high dose use. Different strategies to communicate the warnings and understanding of patients, particularly women, that use a high dose should be examined.

Craniofacial Phenotyping in Chinese and Caucasian Patients With Sleep Apnea: Influence of Ethnicity and Sex. 1143-1151.
Kate Sutherland, PhD1,2; Richard W.W. Lee, MBBS, PhD3,4; Tat On Chan, MSc, RPSGT5; Susanna Ng, MBChB5; David S. Hui, MBBS, MD5; Peter A. Cistulli, MBBS, PhD1,2


Current Knowledge/Study Rationale: We have previously shown craniofacial photography to predict obstructive sleep apnea (OSA) risk in sleep clinic populations of different ethnicity. However, direct interethnic and sex comparisons of craniofacial risk factors in OSA are limited.

Study Impact: This study provides evidence that ethnicity and sex influence facial phenotypes associated with OSA risk and that craniofacial photography can be used as a tool to assess phenotypic differences in large samples.

Positive Airway Pressure Therapy Is Challenging for Patients With Epilepsy. 1153-1159.
Véronique Latreille, PhD; Ellen J. Bubrick, MD; Milena Pavlova, MD


Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) is common in patients with epilepsy, and treatment adherence issues are confronted daily. Positive airway pressure (PAP) adherence may be even more challenging for patients with epilepsy than those who are healthy, but this has not been examined systematically.

Study Impact: Not only are patients with epilepsy less adherent to PAP therapy, but they are also more likely to have a higher number of residual apneas following PAP treatment. This finding is of potential high relevance to clinical practice, especially given the relationship between seizures and central apneas, and possibly associated risk of sudden unexpected death in epilepsy.

Changes in Sleep Characteristics and Breathing Parameters During Sleep in Early and Late Pregnancy. 1161-1168.
Bilgay Izci-Balserak, PhD1; Brendan T. Keenan, MS2; Charles Corbitt, MS2; Beth Staley, BA2; Michael Perlis, PhD2; Grace W. Pien, MD, MSCE3


Current Knowledge/Study Rationale: Sleep patterns differ during pregnancy. Few studies have objectively evaluated sleep characteristics during pregnancy or investigated the relationship between changes in EEG bands and SDB.

Study Impact: This study measured changes in sleep characteristics that included EEG frequency bands from early to late pregnancy. This study also indicated that the level of delta power from early to late pregnancy may decrease with increased severity of SDB. Alterations in sleep architecture have been shown to increase the risk of obesity, diabetes, and cardiovascular complications. Thus, decreased sleep duration and changes in sleep architecture during pregnancy may adversely affect maternal and infant outcomes. The current study increases knowledge and awareness about changes in sleep characteristics related to pregnancy and sleep disturbances among antenatal care providers. This knowledge may contribute to better health outcomes for mothers and their children.

Quantitative Analysis of Thoracoabdominal Asynchrony in Pediatric Polysomnography. 1169-1176.
Jason Z. Bronstein, MD1; Li Xie, ScM2; Thomas H. Shaffer, MSE, PhD3; Aaron Chidekel, MD1; Robert Heinle, MD1


Current Knowledge/Study Rationale: Current practice is to use polysomnographic respiratory inductance plethysmography data qualitatively, though there is untapped potential to use easily calculable quantitative measures for further information on thoracoabdominal asynchrony and airway obstruction during pediatric polysomnography in common clinical groups. This study was performed to demonstrate feasibility of these methods and utility of the measures.

Study Impact: This study provides evidence that average phase angle in non-rapid eye movement and rapid eye movement sleep correlates with indices of obstructive sleep apnea. This study quantifies the difference in asynchrony between non-rapid eye movement and rapid eye movement sleep. Average phase angle is a feasible measure in pediatric polysomnography.

Sleep Disturbances in Traumatic Brain Injury: Associations With Sensory Sensitivity. 1177-1186.
Jonathan E. Elliott, PhD1,2; Ryan A. Opel, BS1; Kris B. Weymann, PhD, RN1,3; Alex Q. Chau1; Melissa A. Papesh, PhD1; Megan L. Callahan, PsyD1; Daniel Storzbach, PhD1,2,4; Miranda M. Lim, MD, PhD1,2,5,6,7


Current Knowledge/Study Rationale: Traumatic brain injury (TBI) is common in Veterans and is often independently associated with persistent sleep disturbances as well as sensory (ie, light and noise) sensitivity. The current study sought to correlate sensory sensitivity with sleep disturbances in Veterans with TBI who have undergone in-laboratory polysomnography.

Study Impact: In Veterans with TBI, sensory sensitivity was strongly correlated with sleep disturbances and posttraumatic stress disorder symptom severity, and insomnia severity was the strongest predictor of this relationship. Furthermore, sensory sensitivity was associated with an increased mean heart rate during sleep, even after controlling for posttraumatic stress disorder status. These data suggest the underlying mechanism of the sleep-sensory relationship could be due in part to comorbid posttraumatic stress disorder and autonomic hyperarousal.

Continued Presence of Period Limb Movements During REM Sleep in Patients With Chronic Static Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS). 1187-1192.
Jonathan D. Santoro, MD1; Jennifer Frankovich, MD2; Sumit Bhargava, MD3


Current Knowledge/Study Rationale: Patients with pediatric acute-onset neuropsychiatric syndrome (PANS) have been shown to have sleep dysregulation with previously established elevations in periodic limb movements and rapid eye movement sleep without atonia during early phases of the disease.

Study Impact: This study identifies continued presence of periodic limb movements and rapid eye movement sleep without atonia in patients with chronic static PANS. Continued sleep disturbances after presentation and treatment in patients in chronic static PANS may be a contributing factor in prolonged symptomatology of this disease process.

Free Cognitive Behavioral Therapy for Insomnia Reduces Fear of Sleep in Individuals With Posttraumatic Stress Disorder. 1193-1203.
Jennifer C. Kanady, PhD1,2,3; Lisa S. Talbot, PhD1,2; Shira Maguen, PhD1,2; Laura D. Straus, PhD1,2,3; Anne Richards, MD1,2; Leslie Ruoff, BS1; Thomas J. Metzler, MA1; Thomas C. Neylan, MD1,2


Current Knowledge/Study Rationale: Fear of sleep may be contributing to the bidirectional relationship between sleep disturbance and posttraumatic stress disorder (PTSD) symptoms. This is the first study to examine fear of sleep in individuals with PTSD and insomnia using standard objective and subjective measures and a therapeutic manipulation of sleep.

Study Impact: Results from our study demonstrate that fear of sleep is related to sleep disturbance symptoms characteristic of PTSD (eg, nightmares, disruptive behaviors during sleep), rather than classic insomnia symptoms (eg, difficulty staying asleep). Despite not being a treatment target and not being related to insomnia symptoms, fear of sleep decreased following cognitive behavioral therapy for insomnia (CBT-I), further demonstrating the usefulness of CBT-I in a PTSD sample.

Accuracy of Patient Perception of Supine Sleep. 1205-1208.
Peter D. Wallbridge, MBBS1,2; Thomas J. Churchward, RPSGT1,2; Christopher J. Worsnop, MBBS, PhD1,2


Current Knowledge/Study Rationale: Obstructive sleep apnea is frequently more severe in the supine position. When discussing treatment options with patients their perception of the amount of time spent supine while asleep may affect the decision-making process, and this study aims to ascertain the accuracy of perceived supine sleep.

Study Impact: This study shows that recall of supine sleep has a good positive predictive value with a poor negative predictive value, with wide limits of agreement for duration of time spent supine. This may assist clinicians when discussing perceived usual sleep patterns with their patients.

Review Articles

Free Use of Actigraphy for the Evaluation of Sleep Disorders and Circadian Rhythm Sleep-Wake Disorders: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. 1209-1230.
Michael T. Smith, MA, PhD1; Christina S. McCrae, PhD2; Joseph Cheung, MD, MS3; Jennifer L. Martin, PhD4,5; Christopher G. Harrod, MS6; Jonathan L. Heald, MA6; Kelly A. Carden, MD7

Special Articles

Free Use of Actigraphy for the Evaluation of Sleep Disorders and Circadian Rhythm Sleep-Wake Disorders: An American Academy of Sleep Medicine Clinical Practice Guideline. 1231-1237.
Michael T. Smith, MA, PhD1; Christina S. McCrae, PhD2; Joseph Cheung, MD, MS3; Jennifer L. Martin, PhD4,5; Christopher G. Harrod, MS6; Jonathan L. Heald, MA6; Kelly A. Carden, MD7
Free Evaluation of Clinical Tools to Screen and Assess for Obstructive Sleep Apnea. 1239-1244.
Charlene Gamaldo, MD1; Luis Buenaver, PhD1; Oleg Chernyshev, MD, PhD2; Stephen Derose, MD, MSHS3; Reena Mehra, MD, MS4; Kimberly Vana, DNP5; Harneet K. Walia, MD4; Vanessa Gonzalez, MPH6; Indira Gurubhagavatula, MD, MPH7,8
Free Polysomnography for Obstructive Sleep Apnea Should Include Arousal-Based Scoring: An American Academy of Sleep Medicine Position Statement. 1245-1247.
Raman K. Malhotra, MD1; Douglas B. Kirsch, MD2; David A. Kristo, MD3; Eric J. Olson, MD4; Rashmi N. Aurora, MD, MHS5; Kelly A. Carden, MD, MBA6; Ronald D. Chervin, MD, MS7; Jennifer L. Martin, PhD8,9; Kannan Ramar, MD4; Carol L. Rosen, MD10; James A. Rowley, MD11; Ilene M. Rosen, MD, MS12

Emerging Technologies

Free A Pilot Study of Impulse Radio Ultra Wideband Radar Technology as a New Tool for Sleep Assessment. 1249-1254.
Ståle Pallesen, PhD1,2; Janne Grønli, PhD3; Kenneth Myhre, MSc4; Frode Moen, PhD5; Bjørn Bjorvatn, PhD2,6; Ingar Hanssen, MSc7; Hanne Siri A. Heglum, MSc7

Sleep Medicine Pearls

Abnormal Pulse Oximetry Signal. 1255-1256.
Lois E. Krahn, MD; Ann Petersen, CNP; Bernie W. Miller, RCP, RPSGT, CSM; Matthew Lizak, RCP, RPSGT; Philip Lyng, MD

Case Reports

Severe Chronic Abuse of Zolpidem in Refractory Insomnia. 1257-1259.
Giacomo Chiaro, MD1; Anna Castelnovo, MD1; Giovanni Bianco, MD1; Piermario Maffei, MD2; Mauro Manconi, MD, PhD1
Sleep-Related Eating Disorder (SRED): Paradoxical Effect of Clonazepam. 1261-1263.
Debabrata Ghosh, MD1; Abigail M. Petrecca2; Abdul Latif Khuhro, MD1
A Case of Non-24-Hour Sleep-Wake Rhythm Disorder Treated With a Low Dose of Ramelteon and Behavioral Education. 1265-1267.
Akiko Watanabe, MD, PhD; Marina Hirose, MD, PhD; Chiaki Arakawa, MD, PhD; Nakao Iwata, MD, PhD; Tsuyoshi Kitajima, MD, PhD

Letters to the Editor

Free Sleep Education for College Students: The Time Is Now. 1269.
Stuart F. Quan, MD; Pallas S. Ziporyn, AB; Charles A. Czeisler, PhD, MD
Free Sleep Education for College Students. 1271-1272.
Shelley Hershner, MD1; Louise M. O'Brien, PhD, MS1,2,3
Free Measurement of Mefloquine Exposure in Studies of Veterans' Sleep Disorders. 1273-1274.
Remington L. Nevin, MD, MPH, DrPH
Free Nightmares in United States Military Personnel Are Multifactorial and Require Further Study. 1275-1276.
Jennifer L. Creamer, MD1; Matthew S. Brock, MD2; Vincent Mysliwiec, MD2

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