Sleep_Disorders RSS : Gourt

Asleep at the Wheel?

Truck drivers who routinely get too little sleep or suffer from sleep apnea show signs of fatigue and impaired performance that can make them a hazard on the road, according to a major new study by Penn Sleep Centers researchers. The study results, entitled “Impaired Performance in Commercial Drivers: Role of Sleep Apnea and Short Sleep Duration,” were published in the August 15th issue of the American Journal of Respiratory and Critical Care Medicine.

Sleep Apnea and Heart Disease

Along with the epidemic of obesity, the incidence of sleep apnea has risen at an alarming rate. The most common form, known as obstructive sleep apnea (OSA), is caused by extra tissue in the upper airway that collapses and literally blocks the airflow to the lungs. The risk factors for OSA include male sex (women’s risk increases after menopause), obesity, and neck size greater than 17 inches. The symptoms of sleep apnea include fatigue, early morning headaches, snoring, falling asleep during the daytime, depression and witnessed episodes of irregular breathing while sleeping.

Cognitive-Behavioral Treatment of Insomnia

Insomnia is the most prevalent sleep disorder, representing one of the most common complaints reported to doctors by their patients. In an effort to provide non-pharmacologic treatment options for insomnia, research and clinical practice have focused on developing cognitive- behavior treatments as an alternative.

Do Flies and Worms Sleep?

Can you tell if a fly is asleep? This is precisely the question asked seven years ago by Dr. Joan Hendricks, who is now the Dean of the School of Veterinary Medicine at the University of Pennsylvania. In collaboration with Dr. Amita Sehgal and Dr. Allan Pack of the Penn Center for Sleep and Respiratory Neurobiology (CSRN), Dr. Hendricks wanted to determine if the fruit fly Drosophila melanogaster, an animal used since the early 1900s for genetic studies in biology, has a sleeplike state much as we do. But unlike human studies, where one can measure brain electrical activity to distinguish sleep from the waking state, one cannot easily measure fly brain waves. Instead, Dr. Hendricks used behavioral measures.

Advice for Sleepy Students

Each fall, Grace Pien, MD in the University of Pennsylvania Division of Sleep Medicine sees teenagers being brought into her office by parents. The teens complain about difficulty falling asleep at night. After several follow-up questions, Pien often determines that these patients suffer from a sleep disorder called delayed sleep phase syndrome (DSPS) - when the body's circadian rhythm delays the urge to sleep until much later than what is considered to be a normal bedtime.

New Headquarters for Penn Sleep

In April of this year, the practices and sleep laboratory facilities of the Penn Sleep Centers at the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center were merged into a single new site at 3624 Market St. which serves as headquarters for the Penn Sleep Centers. This newly renovated facility provides pleasant and spacious areas for both patients and staff.

Let Her Sleep…But How Much?

A commentary on Miller et al. Gender differences in the cross-sectional relationships between sleep duration and markers of inflammation: Whitehall II study. Sleep 2009;32:857-64.

Autonomic Arousals in Sleep Related Breathing Disorders: A Link Between Daytime Somnolence and Hypertension?

Factual Errors in Brooks and Peever’s Rebuttal to Critiques

Sleep and Depression in Postpartum Women: A Population-Based Study

Study Objectives:(1) To describe the prevalence of and risk factors for postpartum maternal sleep problems and depressive symptoms simultaneously, (2) identify factors independently associated with either condition, and (3) explore associations between specific postpartum sleep components and depression. Design: Cross-sectional. Setting: Population-based. Participants: All women (n = 4191) who had delivered at Stavanger University Hospital from October 2005 to September 2006 were mailed a questionnaire seven weeks postpartum. The response rate was 68% (n = 2830). Interventions: None. Measurements and results: Sleep was measured using the Pittsburgh Sleep Quality Index (PSQI), and depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS). The prevalence of sleep problems, defined as PSQI > 5, was 57.7%, and the prevalence of depression, defined as EPDS ≥ 10, was 16.5%. The mean self-reported nightly sleep duration was 6.5 hours and sleep efficiency 73%. Depression, previous sleep problems, being primiparous, not exclusively breastfeeding, or having a younger or male infant were factors associated with poor postpartum sleep quality. Poor sleep was also associated with depression when adjusted for other significant risk factors for depression, such as poor partner relationship, previous depression, depression during pregnancy and stressful life events. Sleep disturbances and subjective sleep quality were the aspects of sleep most strongly associated with depression. Conclusions: Poor sleep was associated with depression independently of other risk factors. Poor sleep may increase the risk of depression in some women, but as previously known risk factors were also associated, mothers diagnosed with postpartum depression are not merely reporting symptoms of chronic sleep deprivation. Keywords: Postpartum, sleep, depression, PSQI, EPDS

Gender Differences in the Cross-Sectional Relationships Between Sleep Duration and Markers of Inflammation: Whitehall II Study

Objective: To examine the relationships between sleep and inflammatory markers because these may be important in the development of cardiovascular disease. Methods and Results: The relationship between self-reported sleep duration and interleukin-6 (IL-6) (n = 4642) and high-sensitivity C-reactive protein (hs-CRP) (n = 4677) was examined in individuals from the Whitehall II study. Following multiple adjustments, there were no overall linear or nonlinear trends between sleep duration and IL-6. However, in women but not men (interaction P < 0.05), levels of IL-6 tended to be lower in individuals who slept 8 hours (11% [95% confidence interval 4 to 17]) as compared to 7 hours. With hs-CRP, in the adjusted model, there was no association between hs-CRP and sleep duration in men. However, there was a significant nonlinear association in women, the level of hs-CRP being significantly higher in women short sleepers (5 hours or less) after multiple adjustments (P = 0.04) (interaction P < 0.05). Conclusions: No significant variation in inflammatory markers with sleep duration was observed in men. By contrast, both IL-6 and hs-CRP levels varied with sleep duration in women. The observed pattern of variation was different according to the inflammatory marker observed. Further longitudinal studies are required to fully investigate possible temporal relationships between short sleep and markers of inflammation. Keywords: Inflammation, Sleep, Cardiovascular disease

Estradiol and Progesterone Modulate Spontaneous Sleep Patterns and Recovery from Sleep Deprivation in Ovariectomized Rats

Study Objectives: Women undergo hormonal changes both naturally during their lives and as a result of sex hormone treatments. The objective of this study was to gain more knowledge about how these hormones affect sleep and responses to sleep loss. Design: Rats were ovariectomized and implanted subcutaneously with Silastic capsules containing oil vehicle, 17β-estradiol and/or progesterone. After 2 weeks, sleep/wake states were recorded during a 24-h baseline period, 6 h of total sleep deprivation induced by gentle handling during the light phase, and an 18-h recovery period. Measurements and Results: At baseline and particularly in the dark phase, ovariectomized rats treated with estradiol or estradiol plus progesterone spent more time awake at the expense of non-rapid eye movement sleep (NREMS) and/or REMS, whereas those given progesterone alone spent less time in REMS than ovariectomized rats receiving no hormones. Following sleep deprivation, all rats showed rebound increases in NREMS and REMS, but the relative increase in REMS was larger in females receiving hormones, especially high estradiol. In contrast, the normal increase in NREMS EEG delta power (an index of NREMS intensity) during recovery was attenuated by all hormone treatments. Conclusions: Estradiol promotes arousal in the active phase in sleep-satiated rats, but after sleep loss, both estradiol and progesterone selectively facilitate REMS rebound while reducing NREMS intensity. These results indicate that effects of ovarian hormones on recovery sleep differ from those on spontaneous sleep. The hormonal modulation of recovery sleep architecture may affect recovery of sleep related functions after sleep loss. Keywords: Ovariectomy; female sex hormones; sleep homeostasis; REM sleep; EEG delta power

Potentiating Effect of Eszopiclone on GABAA Receptor-Mediated Responses in Pedunculopontine Neurons

The pedunculopontine nucleus (PPN) is part of the cholinergic arm of the reticular activating system, which is mostly active during waking and REM sleep. GABAergic modulation of this area appears to regulate sleep-wake cycles. Eszopiclone (ESZ), a nonbenzodiazepine hypnotic agent, appears to modulate GABAergic receptors. However, the action site of ESZ in the brain is still unresolved. We tested the hypothesis that ESZ acts by potentiating GABAA receptors on PPN neurons. Whole-cell voltage clamp recordings were performed on PPN neurons in 7-15 day rat brainstem slices, and the potentiating effects of ESZ on the responses to the GABAA receptor agonist isoguvacine (IGV), and on GABAA receptor-mediated inhibitory post-synaptic currents (IPSCs), were determined. In the presence of tetrodotoxin, ESZ (1) increased the amplitude of the outward current induced by IGV, (2) increased its duration, and (3) enhanced the IGV-induced decrease in input resistance (Rin). The GABAA receptor antagonist gabazine (GBZ) blocked these effects. ESZ alone did not induce detectable currents or change Rin at a holding potential of −60 mV, but when held at 0 mV, ESZ induced an outward current in 13/21 PPN cells, an effect blocked by GBZ. ESZ also increased the amplitude (n = 18/21), duration (n = 17/21), and frequency (n = 13/15) of IPSCs. ESZ may potentiate GABAA inhibition in the PPN via pre- and post-synaptic modulation, which may underlie the hypnotic effects of ESZ. The differential effects of ESZ on both pre- and post-synaptic sites may partially explain why it has less significant side effects compared to other hypnotic agents. Keywords: GABAA receptor, pedunculopontine nucleus, sleep, waking

GABAergic Antagonism of the Central Nucleus of the Amygdala Attenuates Reductions in Rapid Eye Movement Sleep After Inescapable Footshock Stress

Study Objectives: Rapid eye movement sleep (REM) appears to be especially susceptible to the effects of stress; inescapable footshock stress (IS) can produce reductions in REM that can occur without recovery sleep. The amygdala has well-established roles in stress and emotion; the central nucleus of the amygdala (CNA) projects to REM regulatory regions in the brainstem and has been found to play a key role in the regulation of REM. The objective of this study was to determine whether the reduction in REM induced by IS could be regulated by CNA and brainstem regions. Design: The GABAergic agonist muscimol (MUS) and GABAergic antagonist bicuculline (BIC) were microinjected into CNA before IS, and sleep was recorded for 20 h. In a second experiment using the same manipulations, sleep was recorded for 2 h, after which the rats were killed to evaluate Fos expression (a marker of neuronal activity) in the locus coeruleus (LC), a brainstem REM regulatory region. Setting: NA. Patients or Participants: The subjects were male, outbred Wistar rats. Interventions: The rats were surgically implanted with standard electrodes or with telemetry transmitters for determining arousal state. Measurements and Results: IS preceded by control or MUS microinjections selectively reduced REM and increased Fos expression in LC. By comparison, microinjection of BIC into CNA prior to IS attenuated both the reduction in REM and Fos expression in LC to levels seen in non-shocked controls. Conclusions: The results suggest that the effects of IS on REM may involve local GABAergic inhibition in CNA and activation of LC. Keywords: GABA, footshock, stress, REM sleep, central amygdala, locus coeruleus

Prevalent Hypertension and Stroke in the Sleep Heart Health Study: Association with an ECG-derived Spectrographic Marker of Cardiopulmonary Coupling

Study Objectives: The electrocardiogram (ECG)-based sleep spectrogram generates a map of cardiopulmonary coupling based on heart rate variability and respiration derived from QRS amplitude variations. A distinct spectrographic phenotype, designated as narrow-band elevated low frequency coupling (e-LFCNB), has been associated with central apneas and periodic breathing and predicts sleep laboratory failure of continuous positive airway pressure therapy. This study assesses, at a population level, the associations of this spectrographic biomarker with prevalent cardiovascular disease using the Sleep Heart Health Study (SHHS)-I dataset. Design: Retrospective analysis of the Sleep Heart Health Study-I dataset. Setting: Laboratory for complex physiologic signals analysis. Measurements and Results: The fully-automated ECG-derived sleep spectrogram technique was applied to 5247 (of the original 6441) polysomnograms from the SHHS-I. Associations were estimated with use of various drugs and pathologies including prevalent hypertension and cardiovascular and cerebrovascular disease. Increasing with age and more common in males, e-LFCNB is also associated with greater severity of sleep apnea and fragmented sleep. After adjustment for potential confounders, an independent association with prevalent hypertension and stroke was found. Conclusions: An ECG-derived spectrographic marker related to low frequency cardiopulmonary coupling is associated with greater sleep apnea severity. Whether this biomarker is solely a sign of more severe disease or whether it reflects primary alterations in sleep apnea pathophysiology (which may either cause or result from sleep apnea) is unknown. This ECG-based spectral marker is associated with a higher prevalence of hypertension and stroke. Keywords: ECG, cardiopulmonary coupling, Sleep Heart Health Study, sleep spectrogram, hypertension stroke

Neurobehavioral Performance in Young Adults Living on a 28-h Day for 6 Weeks

Objectives: Performance on many cognitive tasks varies with time awake and with circadian phase, and the forced desynchrony (FD) protocol can be used to separate these influences on performance. Some performance tasks show practice effects, whereas the Psychomotor Vigilance Task (PVT) has been reported not to show such effects. We aimed to compare performance on the PVT and on an addition test (ADD) across a 6-week FD study, to determine whether practice effects were present and to analyze the circadian and wake-dependent modulation of the 2 measures. Design and Setting: A 47-day FD study conducted at the Brigham and Women’s Hospital General Clinical Research Center. Participants: Eleven healthy adults (mean age: 24.4 years, 2 women). Measurements and Results: For 2 baseline days and across 6 weeks of FD, we gave a test battery (ADD, PVT, self-rating of effort and performance) every 2 hours. During FD, there was a significant (P < 0.0001) improvement in ADD performance (more correct calculations completed), whereas PVT performance (mean reaction time, fastest 10% reaction times, lapses) significantly (P < 0.0001) declined week by week. Subjective ratings of PVT performance indicated that subjects felt their performance improved across the study (P < 0.0001), but their rating of whether they could have performed better with greater effort did not change across the study (P > 0.05). Conclusions: The decline in PVT performance suggests a cumulative effect of sleep loss across the 6-week study. Subjects did not accurately detect their declining PVT performance, and a motivational factor could not explain this decline. Keywords: Alertness, PVT, cognitive throughput, forced desynchrony

Development of the FOSQ-10: A Short Version of the Functional Outcomes of Sleep Questionnaire

Introduction: The Functional Outcomes of Sleep Questionnaire (FOSQ), has been used in research and clinical practice to measure the impact of daytime sleepiness on activities of daily living. The purpose of this study was to develop a shorter version of the instrument (FOSQ-10) that may be more easily implemented in clinical practice. Methods: Data from a study of CPAP-treated obstructive sleep apnea (OSA) patients (Sample 1) (n = 155, AHI = 63 ± 31) were used to develop the FOSQ-10. Of the 30 original FOSQ items, 10 questions representing each of the 5 subscales were selected if they had a normal distribution of responses and the largest pre- to post-treatment effect size. The psychometric properties of the instrument were then evaluated with data from a second, independent sample of CPAP-treated OSA patients (n = 51 AH I = 51 ± 28). Results: Internal consistency of the FOSQ-10 was α = 0.87. Pre-treatment correlations of the 2 scales was r = 0.96. After 3 months of treatment the correlation was r = 0.97 (P < 0.0001). Subscales were also highly correlated at baseline and following treatment. Effect sizes for both instruments were highly correlated and indicated ability to measure meaningful change. Differences were observed between scores on the FOSQ-10 for normal controls and OSA patients. Conclusions: The FOSQ-10 is a psychometrically strong instrument that performs similarly to the long version. The rapidly completed and easily scored FOSQ-10 shows promise for application in the clinical setting. Keywords: Functional status, sleepiness, outcome measure, sleep disorders, CPAP, nasal continuous positive airway pressure, sleep apnea, quality of life

Developmental Emergence of Power-Law Wake Behavior Depends Upon the Functional Integrity of the Locus Coeruleus

Study Objectives: Daily amounts of sleep and wakefulness are accumulated in discrete bouts that exhibit distinct statistical properties.In adult mammals, sleep bout durations follow an exponential distribution whereas wake bout durations follow a power-law distribution. In infant Norway rats, however, wake bouts initially follow an exponential distribution and only transition to a power-law distribution beginning around postnatal day 15 (P15). Here we test the hypothesis that the locus coeruleus (LC), one of several wake-active nuclei in the brainstem, contributes to this developmental transition. Design: At P7, rats were injected subcutaneously with saline orDSP-4, a neurotoxin that targets noradrenergic (NA) LC terminals. Then, at P21, sleep and wakefulness during the day and night were monitored. The effectiveness of DSP-4 treatment was verified by measuring NA, dopamine (DA), and serotonin (5-HT) concentration in cortical and non-cortical tissue using high performance liquid chromatography. Results: In relation to controls, subjects treated with DSP-4 exhibited significant reductions only in cortical and non-cortical NA concentration. Consistent with our hypothesis, the wake bout durations of DSP-4 subjects more closely followed an exponentialdistribution, whereas those of control subjects followed the expected power-law distribution. Sleep bout distributions were unaffected by DSP-4. Conclusions: These results suggest that the fundamental developmental transition in the statistical structure of wake bout durations is effected in part by changes in noradrenergic LC functioning. Considered within the domain of network theory, the hub-like connectivity of the LC may have important implications for the maintenance of network function in the face of random or targeted neural degeneration. Keywords: Wakefulness, DSP-4, power-law, noradrenaline, locus coeruleus, rat, development, circadian rhythms

Model-Based Assessment of Cardiovascular Autonomic Control in Children with Obstructive Sleep Apnea

Study Objectives: To quantitatively assess daytime autonomic cardiovascular control in pediatric subjects with and without obstructive sleep apnea syndrome (OSAS). Design: Respiration, R-R intervals, and noninvasive continuous blood pressure were monitored in awake subjects in the supine and standing postures, as well as during cold face stimulation. Setting: Sleep disorders laboratory in a hospital setting. Participants: Ten pediatric patients (age 11.4 ± 3.6 years) with moderate to severe OSAS (obstructive apnea-hypopnea index = 21.0 ± 6.6/ h) before treatment and 10 age-matched normal control subjects (age 11.5 ± 3.7 years). Measurements and Results: Spectral analysis of heart rate variability revealed that high-frequency power was similar and the ratio of low- to high-frequency power was lower in subjects with OSAS vs control subjects. The closed-loop minimal model allowed heart rate variability to be partitioned into a component mediated by respiratory-cardiac coupling and a baroreflex component, whereas blood pressure variability was assumed to result from the direct effects of respiration and fluctuations in cardiac output. Baroreflex gain was lower in subjects with OSAS vs control subjects. Under orthostatic stress, respiratory-cardiac coupling gain decreased in both subject groups, but baroreflex gain decreased only in controls. The model was extended to incorporate time-varying parameter changes for analysis of the data collected during cold face stimulation: cardiac output gain increased in controls but remained unchanged in OSAS. Conclusions: Our findings suggest thatvagal modulation of the heart remains relatively normal in pediatric subjects with OSAS. However, baseline cardiovascular sympathetic activity is elevated, and reactivity to autonomic challenges is impaired. Keywords: pediatric sleep disordered breathing, autonomic nervous system, mathematical model, respiratory sinus arrhythmia, baroreflex

Simple Four-Variable Screening Tool for Identification of Patients with Sleep-Disordered Breathing

Objectives: To aid in the identification of patients with moderate-to-severe sleep-disordered breathing (SDB), we developed and validated a simple screening tool applicable to both clinical and community settings. Methods: Logistic regression analysis was used to develop an integer-based risk scoring system. The participants in this derivation study included 132 patients visiting one of 2 hospitals in Japan, and 175 residents of a rural town. The participants in the present validation study included 308 employees of a company in Japan who were undergoing a health check. Results: The screening tool consisted of only 4 variables: sex, blood pressure level, body mass index, and self-reported snoring. This tool (screening score) gave an area under the receiver operating characteristic curve (ROC) of 0.90, sensitivity of 0.93, and specificity of 0.66, using a cutoff point of 11. Predicted and observed prevalence proportions in the validation dataset were in close agreement across the entire spectrum ofrisk scores. In the validation dataset, the area under the ROC for moderate-to-severe SDB and severe SDB were 0.78 and 0.85, respectively. The diagnostic performance of this tool did not significantly differ from that of previous, more complex tools. Conclusion: These findings suggest that our screening scoring system is a valid tool for the identification and assessment of moderate-to-severe SDB. With knowledge of only 4 easily ascertainable variables, which are routinely checked during daily clinical practice or mass health screening, moderate-to-severe SDB can be easily detected in clinical and public health settings. Keywords: Sleep-disordered breathing, screening, sensitivity, specificity, validation

Obstructive Sleep Apnea in New Zealand Adults: Prevalence and Risk Factors Among Māori and Non-Māori

Study Objectives: Examine the distribution of symptoms and risk factors, and estimate the prevalence of obstructive sleep apnea (OSA) among Māori and non-Māori New Zealanders. Design: Mail-out survey to a stratified random sample from the electoral roll of 10,000 people aged 30-59 y, and overnight MESAM IV monitoring during sleep of a similarly aged stratified random sample of 364 people from the Wellington electoral roll. Setting: Nationwide survey of OSA symptoms (71% response rate) and regional home-based measurement of respiratory disturbance index (RDI, 4% oxygen desaturations/h of sleep, plus bursts of snoring or ≥ 10/min increase in heart rate). Participants: Sample designs aimed for equal numbers of Māori and non-Māori participants, men and women, and participants in each decade of age. Interventions: N/A Measurements and results: Māori were more likely than non-Māori to report OSAS risk factors and symptoms. After controlling for sex and age, Māoriwere 4.3 times more likely to have RDI ≥ 15 (95% CI = 1.3–13.9). Ethnicity was not an independent risk factor after controlling for body mass index (BMI) and neck circumference. The prevalence of OSAS (RDI ≥ 5 and ESS > 10) was conservatively estimated to be 4.4% for Māori men, 4.1% for non-Māori men, 2.0% for Māori women, and 0.7% for non-Māori women. Conclusions: The national survey and the regional monitoring study indicate a higher prevalence of OSA among Māori and among men. The higher prevalence among Māori appears to be attributable to recognized risk factors, notably body habitus. In addition to increased prevention and treatment services, strategies are needed to reduce ethnic disparities in OSAS prevalence. Keywords: Obstructive sleep apnea syndrome, gender, ethnicity, Māori, socioeconomic deprivation

In-Situ Mechanical Characteristics of the Tongue are not Altered in the Obese Zucker Rat

Study Objectives: Obese Zucker rats have more collapsible isolated upper airways, compared with their lean counterparts. The functional characteristics of the tongue as a potential mechanism for the enhanced upper airway collapsibility in the obese Zucker rat are unknown. This study measured the functional characteristics of the tongue muscle in lean and obese Zucker rats. Design: In-situ tongue force (twitch and peak) and fatigability were measured in anesthetized obese and lean Zucker rats. Setting: Animal housing facility at the University of Buffalo. Subjects: Eight lean and eight obese Zucker rats. Intervention: Tongue force and fatigability were measured before, during, and following cocontraction of the tongue protrudor and retractor muscles via direct stimulation of the common hypoglossal nerve. Measurements and Results: Obese rats were significantly heavier than their lean counterparts (718 ± 101 gm vs. 545 ± 32, P < 0.05). Total force production at all stimulation frequencies was not different between lean and obese Zucker rats before or after fatigue (P = 0.436). Forces were significantly reduced at the end of the 5-minute stimulation period (P < 0.001) and returned to baseline within 1 minute after fatigue in both lean and obese rats. At the end of the fatigue protocol, tongue force averaged 63.3% ± 13.8% and 72.3% ± 17.8% of the initial force in obese and lean rats respectively (P = 0.85). Conclusion: Obesity does not alter the in-situ force production of the tongue muscle. Thus, increases in collapsibility of the isolated upper airway previously noted in obese Zucker rats cannot be ascribed to upper airway muscle dysfunction or enhanced fatigability. Keywords: Obstructive sleep apnea, pharyngeal muscle, upper airway, muscle, Zucker rat

Basal Metabolic Rate in Narcoleptic Patients

Study Objectives: We investigated basal metabolic rate (BMR) and energy expenditure (EE) in narcoleptic patients and in BMI- and age-matched controls in order to explore the hypothesis that a reduced BMR or EE plays a role in narcolepsy-associated obesity. Design: Control group design with comparison of EE and BMR. EE was determined by indirect calorimetry using the Deltatrac Metabolic Monitor system. BMR was calculated from the oxygen consumption (VO2) and the carbon dioxide consumption (VCO2)measurements after 12 hours of fasting in the morning. Participants: 13 narcoleptic patients and 30 controls. Results: BMR and EE were not significantly reduced when all subjects were included into the analysis. Subgroup analysis revealed that only non-obese narcoleptics, but not obese narcoleptics had reduced BMRs in comparison to the BMI matched controls. Conclusion: Our study suggests that EE plays a role in narcolepsy associated obesity. We propose that narcolepsy may lead to a shift of individual BMI set points. Keywords: Narcolepsy, obesity, basal metabolic rate, energy expenditure, indirect calorimetry

Sleep technologist performance: a call for standardization and performance feedback

Sleep technologist performance: a call for standardization and performance feedback Content Type Journal ArticleCategory EditorialDOI 10.1007/s11325-009-0272-4Authors Reena Mehra, University Hospitals Case Medical Center Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine Cleveland OH USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Standardization of quality assurance for sleep technologist: a model

Abstract Introduction Since the last decade, there has been a tremendous growth of sleep centers in the US to meet the increasing need of diagnosing and treating sleep disorders. However, this unregulated growth has resulted in tremendous variance in the quality of sleep centers across the nation. The American Academy of Sleep Medicine, in an attempt to provide a benchmark standard, has introduced a voluntary accreditation process, part of which involves assessment of technical quality parameters. However, measuring technical quality is not easy. Hypothesis We undertook a study to determine if the implementation of point system and schematic feedback on technologist performance can result in improvement and tracking of their performance. Materials and methods We randomly reviewed 100 charts from the preimplementation phase as control and 1,739 charts from the post implementation of the point system phase as study group. Results There was a statistically significant difference in the score among technologist between the control and study groups with the average being 75 ± 4.12 and 87.53 ± 0.91, respectively, with a p value being 0.0001. Conclusion Evaluating the performance of the sleep technologist can be a way to track and monitor their performance in a standardized way and to identify weakness at an earlier stage. We present a system, which we have developed and implemented at our sleep center, as a possible model of assessing and subsequently standardizing technical quality for polysomnography. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0271-5Authors Salim Surani, Baylor College of Medicine Houston TX USARaymond Aguillar, Torr Sleep Center Corpus Christi TX USARoy Aguillar, Torr Sleep Center Corpus Christi TX USAShyam Subramanian, Baylor College of Medicine Houston TX USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Efficacy of a modified mandibular advancement device for a totally edentulous patient with severe obstructive sleep apnea

Abstract Background It has been asserted that the success rate of oral appliances was more satisfactory for mild to moderate obstructive sleep apnea (OSA) than severe ones; besides, there is a lack of literature about mandibular advancement device (MAD) application for edentulous patients with OSA. Report This clinical case shows fabrication method and treatment efficacy of a modified MAD, which is aiming to displace bulky masseter muscles laterally, to provide more space for tongue on totally edentulous patient with severe OSA. Content Type Journal ArticleCategory Case ReportDOI 10.1007/s11325-009-0273-3Authors Bulent Pıskın, Van Military Hospital Department of Dental Service Van TurkeyFatih Sentut, Van Military Hospital Department of Dental Service Van TurkeyHaldun Sevketbeyoglu, Van Military Hospital Department of Chest Disease Van TurkeyHakan Avsever, Gulhane Military Medical Academy Center of Dental Sciences Ankara TurkeyKaan Gunduz, Gulhane Military Medical Academy Center of Dental Sciences Ankara TurkeyMurat Kose, Divan Hayat Hospital Department of Otorhinolaryngology Van TurkeyDemet Oguz, Van Military Hospital Department of Dental Service Van TurkeySezai Uyar, Van Military Hospital Department of the Psychiatry Service Van Turkey Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

American Academy of Dental Sleep Medicine Continuing Education Offerings

American Academy of Dental Sleep Medicine Continuing Education Offerings Content Type Journal ArticleCategory CMEDOI 10.1007/s11325-009-0274-2 Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512 Journal Volume Volume 13 Journal Issue Volume 13, Number 3 / August, 2009

18th Annual Meeting of the American Academy of Dental Sleep Medicine, Seattle, WA, USA, 5–7 June 2009

18th Annual Meeting of the American Academy of Dental Sleep Medicine, Seattle, WA, USA, 5–7 June 2009 Content Type Journal ArticleCategory AbstractsDOI 10.1007/s11325-009-0267-1 Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512 Journal Volume Volume 13 Journal Issue Volume 13, Number 3 / August, 2009

Are the adverse effects of body position in patients with obstructive sleep apnea dependent on sleep stage?

Abstract Purpose The purpose of the study was to determine if the adverse effect of body position on obstructive sleep apnea (OSA) is worsened during rapid eye movement (REM) sleep and if patients with OSA decrease the time spent supine during REM sleep. Methods Overnight polysomnography from 80 sequential patients referred to Buffalo VA Sleep Lab for suspected OSA were analyzed with 20 patients in each of the following groups: normal with apnea–hypopnea indices (AHI) <5/h, mild (AHI, 5–< 15/h), moderate (AHI, 15–<30/h), and severe (AHI, >30/h). We used extended Cox models with the Anderson–Gill modification for multiple events with two time varying covariates: sleep stage and body position. Generalized estimating equations with logit link were used to take into account correlated data within each patient for the relation between sleep stage and body position. Results The hazard ratios for events in REM vs non-REM sleep was significant for the normal, mild, and moderate groups only: 1.71 (95% CI 1.4–2.08), 1.45 (95% CI 1.22–1.73), 1.28 (95% CI 1.1–1.5), respectively. The hazard ratio for events in the supine vs non-supine position was significant for the mild and moderate groups only: 1.25 (95% CI 1.02–1.52) and 1.24 (95% CI 1.04–1.47), respectively. The addition of an interaction effect between sleep stage and body position was not statistically significant for any group. The odds ratios of sleeping in supine position for REM vs non-REM sleep were 0.47 (95% CI 0.27–0.82) for moderate OSA group and 0.54 (95% CI 0.3–0.95) for severe OSA. Conclusion In summary, we found significant effects of both sleep stage and body position in mild and moderate but not severe OSA. Patients with moderate and severe OSA were less likely to spend time in the supine position during REM compared with non-rapid eye movement sleep. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0269-zAuthors M. Jeffery Mador, University of Buffalo Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine Buffalo NY USAYoungmi Choi, University of Buffalo Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine Buffalo NY USAAbid Bhat, University of Buffalo Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine Buffalo NY USAJacek Dmochowski, University of North Carolina Department of Mathematics and Statistics Charlotte NC USAMark Braun, Buffalo VAMC Buffalo NY USAV. A. Gottumukkala, University of Buffalo Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine Buffalo NY USABrydon J. Grant, University of Buffalo Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine Buffalo NY USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Home diagnosis of obstructive sleep apnoea in coronary patients: validity of a simplified device automated analysis

Abstract Introduction Our aim was to evaluate a type 3 portable simplified device as a screening tool for obstructive sleep apnoea (OSA) in coronary patients. Materials and methods In 50 patients selected independently from sleep complaints, we compared the number of respiratory events per hour of valid recording time counted automatically by the device and the number counted manually per hour of sleep on polysomnography performed at home during the same night. Results Five patients were excluded because of technical failures. Estimated OSA prevalences (95% confidence interval) for apnoea/hypopnoea index (AHI) cut-offs ≥5, ≥15, and ≥30 by polysomnography were 0.93 (0.81–0.98), 0.69 (0.53–0.81), and 0.27 (0.15–0.42), respectively. The device would have correctly diagnosed 75% of patients with severe OSA (AHI ≥30 by polysomnography) and would have classified the remaining 25% as having moderate OSA. Discussion This ambulatory device may prove valuable in reducing the costs of diagnosing and managing OSA in coronary patients. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0275-1Authors Carole Planès, Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Service d’Explorations Fonctionnelles Multidisciplinaire 9 Av Charles de Gaulle 92104 Boulogne FranceMichel Leroy, Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Service d’Explorations Fonctionnelles Multidisciplinaire 9 Av Charles de Gaulle 92104 Boulogne FranceNajette Bouach Khalil, Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Service d’Explorations Fonctionnelles Multidisciplinaire 9 Av Charles de Gaulle 92104 Boulogne FranceRami El Mahmoud, Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Service de Cardiologie Boulogne-Billancourt FranceFranck Digne, Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Service de Cardiologie Boulogne-Billancourt FranceFlorence de Roquefeuil, Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Service de Cardiologie Boulogne-Billancourt FranceBernadette Raffestin, Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Service d’Explorations Fonctionnelles Multidisciplinaire 9 Av Charles de Gaulle 92104 Boulogne France Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Diurnal variability of C-reactive protein in obstructive sleep apnea

Abstract Objective The objective of this study is to examine the diurnal variability of C-reactive protein (CRP) in obstructive sleep apnea (OSA). Methods and measurements Participants included 44 women and men with untreated OSA (mean apnea/hypopnea index = 37.5, SD ± 28) and 23 healthy adults with no OSA. Sleep was monitored with polysomnography in the University of California San Diego General Clinical Research Center. Over a 24-h period, blood was collected every 2 h, and CRP levels were determined. Results Adjusting for age, gender, and body mass index, a significant group by time interaction showed that patients with OSA had higher CRP levels during the daytime (8:00 a.m.–8:00 p.m.) versus the nighttime (10:00 p.m. until 6:00 p.m.; p < 0.001). Non-apneics showed no significant change in CRP levels during the 24 h. Conclusions The findings indicate that sleep apnea patients have disproportionately elevated CRP levels in the day versus the nighttime, possibly as a result of carryover effects of nighttime arousal into the daytime. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0268-0Authors Paul J. Mills, University of California, San Diego Department of Psychiatry 9500 Gilman Drive La Jolla CA 92093-0804 USALoki Natarajan, University of California, San Diego Department of Family and Preventive Medicine La Jolla CA USARoland von Känel, University Hospital Department of General Internal Medicine Geneva SwitzerlandSonia Ancoli-Israel, University of California, San Diego Department of Psychiatry 9500 Gilman Drive La Jolla CA 92093-0804 USAJoel E. Dimsdale, University of California, San Diego Department of Psychiatry 9500 Gilman Drive La Jolla CA 92093-0804 USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Refractory cluster headache in a patient with bruxism and obstructive sleep apnea: a case report

Abstract Introduction This is a case report of a 39-year-old patient with a 14-year history of clinically refractory cluster headache (CH), also presenting obstructive sleep apnea (OSA) and complaining of tooth-grinding during sleep. Discussion Treatment of OSA with an intra-oral device allowed an immediate reduction in frequency and intensity of CH events. Furthermore, CH attacks did not occur during the 12-month follow-up period. Content Type Journal ArticleCategory Case ReportDOI 10.1007/s11325-009-0265-3Authors Ana Laura Polizel Ranieri, University of Sao Paulo Dentistry Division of the Central Institute, Hospital das Clínicas, School of Medicine São Paulo BrazilSergio Tufik, Universidade Federal de São Paulo Department of Psychobiology São Paulo BrazilJosé Tadeu Tesseroli de Siqueira, Universidade Federal de São Paulo Department of Psychobiology São Paulo Brazil Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Sleep apnea in adult myotonic dystrophy patients who have no excessive daytime sleepiness

Abstract Purpose Sleep apnea is common in myotonic dystrophy (MD) and may cause respiratory failure. Most of the sleep studies have been performed in patients with excessive daytime sleepiness (EDS), which is a characteristic and strong predictor of sleep apnea. Therefore, we investigated the prevalence of sleep apnea in adult MD patients who have no EDS. Materials and methods Epworth Sleepiness Scale was used to exclude EDS and a score over 10 was accepted as an indicator of EDS. Sleep studies of 17 adult MD patients with the Epworth sleepiness scale score ≤10 were retrospectively reviewed. Spirometry (n = 16) and daytime arterial blood gasses were used to evaluate the relationship with nocturnal parameters. Results On admission to the outpatient chest clinic, seven patients had normal spirometry, and ten had daytime hypercapnia and/or hypoxemia. All but one had sleep apnea (apnea–hypopnea index ≥5 events/h of sleep; mild in five, moderate in seven, and severe in four). Hypopneas were more common than apneas (16.9 ± 13.2 events/h vs. 4.6 ± 4.1events/h). Nocturnal desaturation episodes were very frequent (oxygen desaturation index, 19.7 ± 20.3/h of sleep). Three patients had central sleep apnea and 13 had obstructive sleep apnea. Body mass index, spirometry parameters (FVC and FEV1) and arterial oxygen tension were moderately correlated with nocturnal oxygenation parameters. Apnea–hypopnea index showed moderate correlation with spirometry parameters (FVC and FEV1). Conclusion Sleep apnea and oxygen desaturations are very common in MD patients who report no excessive daytime sleepiness. Daytime lung function parameters are not sufficiently reliable for screening sleep apnea. Therefore, we recommend routine polysomnography in MD patients. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0270-6Authors Esen Kiyan, Istanbul University Department of Pulmonary Diseases, Istanbul Faculty of Medicine Istanbul TurkeyGulfer Okumus, Istanbul University Department of Pulmonary Diseases, Istanbul Faculty of Medicine Istanbul TurkeyCaglar Cuhadaroglu, Istanbul University Department of Pulmonary Diseases, Istanbul Faculty of Medicine Istanbul TurkeyFeza Deymeer, Istanbul University Department of Neurology, Istanbul Faculty of Medicine Istanbul Turkey Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Elevated economic burden in obstructive lung disease patients with concomitant sleep apnea syndrome

Abstract Purpose The purpose of this study is to examine the incremental economic burden of sleep apnea syndrome (SAS) among individuals with concomitant asthma, chronic obstructive pulmonary disease (COPD), or both (i.e., asthma/COPD). Methods Maryland Medicaid claims data were used to identify beneficiaries with asthma (n = 3,072), COPD (n = 3,455), or both (n = 2,604). We compared patient’s baseline characteristics by SAS and stratified the analyses by disease cohort to examine the effect of SAS on medical utilization and cost. Results SAS was more prevalent among beneficiaries with asthma/COPD (6.72%) than beneficiaries with COPD alone (2.87%) or asthma alone (2.15%). Asthma/COPD and COPD beneficiaries with SAS had more medical service claims (p < 0.001) and higher medical cost than beneficiaries without SAS: 5,773 and4,155 in excess costs among asthma/COPD (p = 0.037) and COPD patients (p = 0.035), respectively. Medical utilization and cost did not differ by SAS in asthma patients (p = 0.567). Conclusions SAS may add additional economic burden on beneficiaries who already have COPD or asthma/COPD. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0266-2Authors Fadia T. Shaya, University of Maryland Department of Pharmaceutical Health Services Research, School of Pharmacy 220 Arch Street, 12th Floor Baltimore MD 21201 USAPei-Jung Lin, University of Maryland Department of Pharmaceutical Health Services Research, School of Pharmacy 220 Arch Street, 12th Floor Baltimore MD 21201 USAMohammad H. Aljawadi, University of Maryland Department of Pharmaceutical Health Services Research, School of Pharmacy 220 Arch Street, 12th Floor Baltimore MD 21201 USASteven M. Scharf, University of Maryland Sleep Disorders Center Division of Pulmonary and Critical Care Medicine Baltimore MD USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

The economic burden of medical care in general and sleep apnea syndrome in particular

The economic burden of medical care in general and sleep apnea syndrome in particular Content Type Journal ArticleCategory EditorialDOI 10.1007/s11325-009-0264-4Authors Vidya Krishnan, MetroHealth Medical Center Division of Pulmonary, Critical Care and Sleep Medicine Room BG3-37, 2500 MetroHealth Drive Cleveland OH 44109 USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Inspiratory airflow dynamics during sleep in irritable bowel syndrome: a pilot study

Abstract Purpose This study is a preliminary test of the hypothesis that the pathophysiology of irritable bowel syndrome (IBS) derives from pharyngeal collapse during sleep. Materials and methods We studied inspiratory airflow dynamics during sleep in 12 lean females with IBS and 12 healthy female controls matched for age and obesity. A standard clinical polysomnogram (airflow measured with a nasal/oral pressure catheter) was performed to assess the impact of pharyngeal collapse on the participants’ natural sleep. A second polysomnogram with a pneumotachograph and a supraglottic pressure catheter to measure airflow and effort was performed to compare the maximal inspiratory airflow and effort and the prevalence of inspiratory airflow limitation (IFL) during supine stage 2 sleep between groups. Results During clinical polysomnography, IBS participants did not differ significantly from controls in sleep architecture or respiration. The difference in apnea–hypopnea index between IBS participants and controls, however, approached statistical significance (2.8 ± 2.7 vs 1.1 ± 1.5, respectively; p = 0.079). Although nine of the 12 IBS participants had a prevalence of IFL of at least 33% during supine stage 2 sleep, they did not differ from controls in maximal inspiratory airflow, inspiratory effort, or the prevalence of IFL. Controls, however, differed from IBS participants in having their prevalence of IFL during stage 2 sleep positively correlated with age (r = 0.86; p = 0.0003) while IBS participants demonstrated no relationship between the prevalence of IFL and age. Conclusions Our findings, while less than definitive, suggest a prevalence pattern of pharyngeal collapse during sleep among females with IBS that differs from that of healthy females, providing necessary background to inform further work on the relationship of pharyngeal collapse during sleep to IBS. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0262-6Authors Avram R. Gold, Stony Brook University School of Medicine Division of Pulmonary/Critical Care Medicine Stony Brook NY 11794 USAJoan E. Broderick, Stony Brook University School of Medicine Department of Psychiatry and Behavioral Sciences Stony Brook NY 11794 USAMohammad M. Amin, Stony Brook University School of Medicine Division of Pulmonary/Critical Care Medicine Stony Brook NY 11794 USAMorris S. Gold, Novartis Consumer Health Parsippany NJ USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Overlap syndrome: an indication for sleep studies?

Abstract Background The coexistence of obstructive sleep apnea (OSA) and chronic obstructive pulmonary diseases (COPD) is known as overlap syndrome (OS); it occurs in 10–20% of patients with OSA. Patients with OS have a higher risk of pulmonary hypertension and worse nocturnal hypoxemia than those with either disease alone. Differences may be seen according to severity of COPD, anthropometric measures, and polysomnography (PSG) features of patients. Recent studies have suggested that long-term use of continuous positive airway pressure for OSA is associated with worsening of coexistent COPD. This stresses the importance of identifying this subgroup of patients in order to provide adequate therapy. Objectives This study aims to describe the presence of OS among subjects at our institution and study its association to daytime hypercapnia, nocturnal hypoxemia, and severity of OSA and of COPD. Methods We reviewed the records of patients who underwent PSG and pulmonary function test (PFT) at our center since 2002. Data gathered from PSG and PFTs included respiratory disturbance index (RDI), apnea index, lowest nocturnal desaturation, forced expiratory volume in 1 s (FEV1), FEV1/forced vital capacity ratio, arterial blood gasses, and anthropometric measures. Results Five hundred forty-seven records were reviewed, but only 73 met all inclusion criteria for analysis. Thirty-six patients had COPD, 52 had OSA, and 29 had OS. The mean predicted FEV1 percent of all subjects was 80%, and the mean diurnal partial pressure of carbon dioxide (pCO2) was 39 mmHg. There were no significant differences in average pCO2 or RDI between subjects with OSA and OS. In all subjects, hypercapnia significantly correlated with worse RDI (p = 0.01) and with worse nocturnal desaturation (p = 0.01). During rapid eye movement (REM) sleep, those with FEV1 less than 80% predicted had higher RDI than those with higher FEV1 (p = 0.010). Conclusion In these preliminary results, the prevalence of OS in our population is similar to that previously reported. Daytime hypercapnia correlated with the more severe sleep-disordered breathing (SDB) and worse nocturnal hypoxemia in all subjects. Severity of obstructive ventilatory impairment is associated with worse SDB during REM sleep. Randomized trials to determine if PSGs are indicated in all patients with severe COPD should be considered. This is an ongoing study. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0263-5Authors Marjery N. López-Acevedo, VA Caribbean Healthcare System Pulmonary and Critical Care Fellowship Training Program San Juan Puerto RicoAlfonso Torres-Palacios, VA Caribbean Healthcare System Pulmonary and Critical Care Fellowship Training Program San Juan Puerto RicoMaria Elena Ocasio-Tascón, VA Caribbean Healthcare System Pulmonary and Critical Care Fellowship Training Program San Juan Puerto RicoZulmari Campos-Santiago, VA Caribbean Healthcare System Pulmonary and Critical Care Fellowship Training Program San Juan Puerto RicoWilliam Rodríguez-Cintrón, San Juan Veterans Affair Medical Center Pulmonary/Critical Care Medicine Section 10 Casia St San Juan 00921-3201 Puerto Rico Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

A novel method for the evaluation and treatment of obstructive sleep apnea in four adults with complex congenital heart disease and Fontan repairs

Abstract Introduction Advances in cardiac diagnosis, medical therapy, and surgery have resulted in greater survival for patients with congenital heart disease (CHD). As a result, increasing numbers of CHD patients are surviving to adulthood with little knowledge regarding the consequences of comorbid medical conditions. Obstructive sleep apnea (OSA) is common and associated with hypertension, heart failure, and arrhythmias. Adults with certain types of CHD are at a higher risk for these and other cardiovascular complications than the general population. Therefore, OSA in adults with CHD may have a greater adverse impact on cardiovascular health than in the general population. Materials and methods We report four patients with CHD and OSA. All had conditions resulting in a hypoplastic right ventricle causing a single ventricle physiology, and all were treated surgically with a Fontan repair. Results and discussion Because of their unique cardiac physiology, our cases were at risk for a further decrease in cardiac output and systemic perfusion with the application of continuous positive airway pressure (CPAP) therapy for OSA. We describe a method of identifying safe CPAP thresholds in the cardiac catheterization laboratory prior to titration of CPAP in the sleep laboratory in these patients. Content Type Journal ArticleCategory Case ReportDOI 10.1007/s11325-009-0260-8Authors Nathaniel F. Watson, University of Washington Department of Neurology Seattle WA 98104-2499 USATheodore Bushnell, University of Washington Department of Neurology Seattle WA 98104-2499 USAThomas K. Jones, University of Washington Division of Pediatric Cardiology, Department of Pediatrics Seattle WA 98104-2499 USAKaren Stout, University of Washington Division of Cardiology, Department of Medicine Seattle WA 98104-2499 USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Impact of microarousal associated with increased negative esophageal pressure in sleep-disordered breathing

Abstract Purpose “Microarousals” during sleep have not been analyzed systematically. We investigated the importance of “microarousals” (lasting 1.5–3 s). Methods Standard polysomnography including esophageal pressure (Pes) assessment was performed on ten patients (aged 54.0 ± 5.0 years) with respiratory effort-related arousal ≥5/h. We measured the number of arousals per hour (American Sleep Disorders Association (ASDA) arousal index) and the number of microarousals lasting 1.5–3 s per hour (mASDA arousal index). On the night after the baseline sleep study, we performed overnight continuous positive airway pressure (CPAP) titration. Results mASDA arousals, characterized by lower Pes values, were observed more frequently in patients with sleep-disordered breathing. The Pes results did not differ significantly between ASDA and mASDA arousals (−15.6 ± −5.0 vs −15.0 ± −4.4 cmH2O). mASDA arousals were significantly improved by CPAP treatment (mASDA arousals, 82.6 ± 60.1 vs 6.0 ± 1.4/h). Conclusions mASDA arousals were characterized by an increase in Pes. mASDA arousals are thus key to our understanding of clinical manifestations in patients with sleep-disordered breathing. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0256-4Authors Mayo Sukegawa, Nagoya University School of Health Sciences Department of Medical Technology 1-1-20 Daiko-minami, Higashi-ku Nagoya Aichi 461-8673 JapanAkiko Noda, Nagoya University School of Health Sciences Department of Medical Technology 1-1-20 Daiko-minami, Higashi-ku Nagoya Aichi 461-8673 JapanYoshinari Yasuda, Nagoya University Hospital Department of Nephrology Nagoya JapanSeiichi Nakata, Nagoya University Graduate School of Medicine Department of Otorhinolaryngology Nagoya JapanTatsuki Sugiura, Nagoya University Graduate School of Medicine Department of Psychiatry Nagoya JapanSeiko Miyata, Nagoya University School of Health Sciences Department of Medical Technology 1-1-20 Daiko-minami, Higashi-ku Nagoya Aichi 461-8673 JapanKumiko Honda, Nagoya University School of Health Sciences Department of Medical Technology 1-1-20 Daiko-minami, Higashi-ku Nagoya Aichi 461-8673 JapanYoshinori Hasegawa, Nagoya University Graduate School of Medicine Department of Respiratory Medicine Nagoya JapanTsutomu Nakashima, Nagoya University Graduate School of Medicine Department of Otorhinolaryngology Nagoya JapanYasuo Koike, Nagoya University School of Health Sciences Department of Medical Technology 1-1-20 Daiko-minami, Higashi-ku Nagoya Aichi 461-8673 Japan Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Systematic assessment of the impact of oral appliance therapy on the temporomandibular joint during treatment of obstructive sleep apnea: long-term evaluation

Abstract Objective The aim of the present study was to evaluate the symptoms of temporomandibular dysfunction (TMD) in patients with obstructive sleep apnea treated with long-term use of an oral appliance (OA) using a questionnaire based on the Helkimo Anamnestic Dysfunction Index. A further aim of the study was to evaluate the presence of daytime sleepiness using the Epworth Sleep Scale (ESS) and otologic symptoms. Materials and methods Polysomnograms of 34 patients were performed at baseline and after 6 months of OA use. As follow-up, the patients were contacted by telephone interview to answer the same questionnaires after 36.0 ± 17.0 months. Results and discussion The intensity of TMD symptoms decreased significantly throughout treatment (p < 0.01). ESS values improved from 12.2 ± 5.0 to 6.9 ± 2.6 (p ≤ 0.05). Tinnitus was present in nine patients at baseline and decreased in intensity in seven patients by the final assessment while remaining at the same level in two patients. Conclusions We conclude that long-term usage of an OA does not cause impairment to the temporomandibular joint. The Helkimo and otologic indexes are simple and useful in long-term patient follow-up. There was a long-term improvement in the ESS values over the years analyzed. A follow-up program could increase compliance by motivating patients to use the device regularly. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0257-3Authors Lílian C. Giannasi, University of Vale do Paraíba Institute of Research and Development IP&D São Paulo BrazilFernanda R. Almeida, University of Vancouver Vancouver CanadaMárcio Magini, University of Vale do Paraíba Institute of Research and Development IP&D São Paulo BrazilMaricília S. Costa, University of Vale do Paraíba Institute of Research and Development IP&D São Paulo BrazilCláudia S. de Oliveira, Nove de Julho University Sleep Laboratory, Rehabilitation Sciences Master’s Program São Paulo BrazilJúlio César Mendes de Oliveira, Nove de Julho University Sleep Laboratory, Rehabilitation Sciences Master’s Program São Paulo BrazilSandra Kalil Bussadori, Nove de Julho University Sleep Laboratory, Rehabilitation Sciences Master’s Program São Paulo BrazilLuis Vicente F. de Oliveira, Nove de Julho University Sleep Laboratory, Rehabilitation Sciences Master’s Program São Paulo Brazil Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Obstructive sleep apnea in familial partial lipodystrophy type 2 with atypical skin findings and vascular disease

Abstract Introduction A number of metabolic conditions have been associated with Obstructive Sleep Apnea Syndrome (OSAS). Familial partial lipodystrophy type 2 (FPLD2), one of the few rare genetic disorders affecting total body fat redistribution, is one of those conditions. Case report In this case report the authors detail OSAS associated with FPLD2 with atypical dermatological and systemic manifestations. Content Type Journal ArticleCategory Case ReportDOI 10.1007/s11325-009-0261-7Authors Kumar Patel, University of Vermont College of Medicine and Fletcher Allen Health Care Departments of Neurology Burlington VT USADebra Roseman, University of Vermont College of Medicine and Fletcher Allen Health Care Department of Internal Medicine Burlington VT USAHeather Burbank, University of Vermont College of Medicine and Fletcher Allen Health Care Department of Radiology Burlington VT USAHrayr Attarian, University of Vermont College of Medicine and Fletcher Allen Health Care Departments of Neurology Burlington VT USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Comparison of hypopnea definitions in lean patients with known obstructive sleep apnea hypopnea syndrome (OSAHS)

Abstract Study objectives In the interest of improving inter-rater reliability and standardization between sleep laboratories, hypopnea definitions were recently changed to place less emphasis on arousal scoring and more emphasis on oxygen desaturations. We sought to determine whether these changes would affect detection and treatment of OSAHS in lean patients—a group known to desaturate less-than-obese patients. Methods Thirty-five lean subjects (15 male, 20 women, five post-menopausal) diagnosed OSAHS and a documented benefit from treatment had diagnostic polysomnograms (PSG) originally scored using the American Academy of Sleep Medicine (AASM) rule from 1999 (referred to as “Rule C”). These patients had appropriate clinical care based on those results. PSG records were then re-scored in a randomized and blinded fashion utilizing hypopnea Rule A and B of the 2007 AASM guidelines. Results Baseline mean (SD) apnea hypopnea indices (AHI) for rules A, B, and C were 6.4 (3.1), 20.6 (8.2), and 26.9 (7.3), respectively (p < 0.0001). Mean (SD) BMI was 24.4 (1.0). By design, all subjects were treatment responders. Eighty-six percent with CPAP, 83% with oral appliance, and 100% with surgical intervention reported resolution of their initial daytime or sleep complaint. Post-treatment AHIs for rules A, B, and C were 0.8 (0.9), 1.8 (1.2) and 2.3 (1.6; p < 0.001). In all three scoring conditions, the AHI was reduced significantly with treatment (p < 0.001). A repeated measures ANOVA of the difference between scoring methods indicated statistically significant differences between all three strategies at both pre- and post-treatment (p < 0.001). Sleepiness on the Epworth sleepiness scale decreased from a mean of 10.9 (2.3) to 5.7 (1.3) with treatment (p < 0.001). This change in subjective rating of sleepiness was more strongly correlated with rules B and C (r = 0.6) and more modestly correlated with Rule A scoring (r = 0.4). Conclusion Response to treatment was more tightly correlated with arousal based scoring rules B and C in this group of lean subjects. The1999 hypopnea rule was used at baseline to detect this cohort of patients with OSAHS that ultimately benefitted from treatment. Rule B detected OSAHS and correlated well with response to treatment, but many more were categorized as mild (5 < AHI < 15) at baseline. Since 40% of the subjects had an AHI less than 5 with Rule A, lack of sensitivity should be considered before applying Rule A to the scoring of sleep studies in lean patients. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0253-7Authors C. Guilleminault, Stanford University Sleep Medicine Clinic Stanford CA USAC. C. Hagen, Oregon Health and Science University Sleep Disorders Program 3181 SW Sam Jackson Rd, CR-139 Portland OR 97239 USAN. T. Huynh, Stanford University Sleep Medicine Clinic Stanford CA USA Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Pro-atherogenic cytokine profile of patients with suspected obstructive sleep apnea

Abstract Purpose Systemic inflammation is important in the pathogenesis of cardiovascular disease (CVD). We sought to characterize the systemic inflammatory profile associated with obstructive sleep apnea (OSA). Methods Adult patients referred for suspected OSA at the University of British Columbia Hospital Sleep Disorders Program were recruited for our study. Patients using HMG CoA inhibitors or a history of CVD were excluded. Fasting serum samples were obtained the morning after their diagnostic polysomnograms. Samples were tested for the following circulating inflammatory mediators: interferon gamma; interleukins 1B, 6, and 8; intercellular and vascular cell adhesion molecules (sICAM-1 and sVCAM-1); and leptin using a multiplex Luminex System. Results There were 176 patients; 68% were male, mean age = 50 ± (SD) 11 years, mean apnea/hyponea index (AHI) = 22.9 ± 22/h, mean desaturation (i.e. % of sleep time spent below an oxyhemoglobin saturation of 90%) = 5.4% ± 15, and mean body mass index (BMI) = 32.2 ± 8 kg/m2. In univariate analyses, only leptin, sVCAM-1, and sICAM-1 were significantly associated with indices of OSA severity (i.e. AHI and/or desaturation). In multivariate linear regression analyses that controlled for BMI, gender, age, and current smoking; desaturation persisted as a significant independent predictor for elevated sVCAM-1 and leptin. Conclusions We did not find significant associations between OSA and markers of activated innate immunity (IL-1B, 6, and 8). However, OSA severity was independently associated with serum levels of sVCAM-1 and leptin; these may represent mechanisms involved in the pathogenesis of OSA-related CVD. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s11325-009-0259-1Authors Nabil Al Lawati, University of British Columbia Vancouver BC CanadaAlan Mulgrew, University of British Columbia Vancouver BC CanadaRupi Cheema, University of British Columbia Hospital Sleep Disorders Program Vancouver BC CanadaStephan vanEeden, St Pauls Hospital iCAPTURE Center Vancouver BC CanadaArsalan Butt, University of British Columbia Hospital Sleep Disorders Program Vancouver BC CanadaJohn Fleetham, University of British Columbia Vancouver BC CanadaFrank Ryan, University of British Columbia Vancouver BC CanadaNajib Ayas, University of British Columbia Vancouver BC Canada Journal Sleep and BreathingOnline ISSN 1522-1709Print ISSN 1520-9512

Commentary from the Italian Association of Sleep Medicine on the AASM manual for the scoring of sleep and associated events: For debate and discussion.

Related Articles Commentary from the Italian Association of Sleep Medicine on the AASM manual for the scoring of sleep and associated events: For debate and discussion. Sleep Med. 2009 Jun 27; Authors: Parrino L, Ferri R, Zucconi M, Fanfulla F In 2007, the American Academy of Sleep Medicine (AASM) completed a new manual for the scoring of sleep and associated events. The AASM manual is divided into separate sections relative to the parameters reported for polysomnography. The present commentary, accomplished by a Task Force of the Italian Association of Sleep Medicine, focuses on sleep scoring data, arousal rules, movement and respiratory events. Comparisons with the previous Rechtschaffen and Kales system are detailed and a number of methodological weaknesses are pointed out. Major comments address the 30-s scoring epochs, the restrictive approach to arousals and EEG activating patterns, the incomplete quantification of motor events and the thresholds for the definition of hypopnea. Since the new AASM manual is an iterative process, proposals for discussion and re-examination of the agreed criteria with other national and international organizations are encouraged. PMID: 19564132 [PubMed - as supplied by publisher]