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Accepted Papers

Scientific Investigations

Prevalence and Mimics of Kleine-Levin Syndrome: A Survey in French-Speaking Switzerland. 1083-1087.
Oussama Habra, BM1; Raphaël Heinzer, MD, MPH1; Jose Haba-Rubio, MD1; Andrea O. Rossetti, MD1,2


Current Knowledge/Study Rationale: Kleine-Levin syndrome (KLS) is a rare disease of uncertain prevalence, for which no recognized biological marker has been identified making its diagnosis difficult. The aim of our study was to estimate the prevalence of KLS in French-speaking Switzerland, and to characterize the typical clinical presentation of these patients as compared to patients with mimicking diagnoses.

Study Impact: This study estimates the prevalence of KLS at 3.19 per million, which is moderately higher than previously published. Compared to confirmed KLS cases, patients with mimicking conditions tend to be older at disease onset, show no gender predominance, report less frequently precipitating factors and have a higher prevalence of psychiatric disorders.

Prevalence and Characteristics of Periodic Limb Movements during Sleep in Korean Adult Patients with Restless Legs Syndrome. 1089-1097.
Jung-won Shin1,2; Yong Seo Koo3; Byeong Uk Lee1; Won Chul Shin4; Sang Kun Lee1; Yong Won Cho, MD, PhD5; Ki-Young Jung, MD, PhD1


Current Knowledge/Study Rationale: Although it is generally known that restless legs syndrome (RLS) is associated with periodic limb movements during sleep (PLMS) in up to 90%, current knowledge of prevalence of PLMS in RLS is limited, especially in Asia. Therefore, we investigated prevalence and characteristics of PLMS in Korean patients with RLS.

Study Impact: The prevalence of PLMS in Korean patients was lower than that reported in patients from western countries, whereas independent factors associated with PLMS and the characteristics of periodic limb movement structure were not different from those in patients from western countries. The low prevalence of PLMS in the Korean population may be explained by genetic factors, including ethnic and gender differences.

Prolonged Eyelid Closure Episodes during Sleep Deprivation in Professional Drivers. 1099-1103.
Pasquale K. Alvaro, PhD1,2; Melinda L. Jackson, PhD1,3; David J. Berlowitz, PhD1,4; Philip Swann, PhD5; Mark E. Howard, PhD1,2,4


Current Knowledge/Study Rationale: Measures of eyelid closure episodes accurately reflect drowsiness in drivers, but most ocular devices of eyelid closure episodes use average blink duration. Averaged data may conceal variability in duration of eyelid closure episodes, and more prolonged episodes indicate more extreme drowsiness.

Study Impact: This study identified increasing frequency and duration of prolonged eyelid closure lasting up to 18 seconds after 17–23 hours of sleep deprivation, both emphasizing the substantial risk of driving after acute sleep deprivation and the necessity for ocular based alertness monitors to detect these prolonged episodes.

Pain Intensity and Opioid Utilization in Response to CPAP Therapy in Veterans with Obstructive Sleep Apnea on Chronic Opioid Treatment. 1105-1111.
Philippe Jaoude, MD1,2; Ashima Lal, MD1; Leah Vermont, MS1,2; Jahan Porhomayon, MD1,4; Ali A. El-Solh, MD, MPH1,2,3,4


Current Knowledge/Study Rationale: There is a bidirectional relationship between sleep apnea and chronic pain. The aim of the study is to determine the effect of CPAP on pain intensity and opioids use in opioid-treated veterans with OSA.

Study Impact: Pain intensity was the only determinant of CPAP adherence. The results underscore pain management as a part of multidisciplinary approach to improve CPAP adherence.

Article Is Eligible For CME Credits Mandibular Advancement Device as a Comparable Treatment to Nasal Continuous Positive Airway Pressure for Positional Obstructive Sleep Apnea. 1113-1119.
Yoshikazu Takaesu, PhD1; Satoru Tsuiki, PhD2,4,5; Mina Kobayashi, PhD2,4; Yoko Komada, PhD2,3,4; Hideaki Nakayama, PhD6; Yuichi Inoue, PhD2,3,4


Current Knowledge/Study Rationale: Positional obstructive sleep apnea (P-OSA) is a clinically common phenotype of OSA, which can be treated effectively with mandibular advancement devices (MADs). Therefore, the authors hypothesized that the efficacy of a MAD is comparable to that of nasal continuous positive airway pressure (nCPAP) in P-OSA patients.

Study Impact: This is the first demonstration that a MAD is as efficacious as nCPAP for P-OSA patients. MAD treatment for this specific phenotype may be a promising patient-tailored and first-line approach to OSA.

Psychometric Evaluation of the PSQI in U.S. College Students. 1121-1129.
Jessica R. Dietch, MS1; Daniel J. Taylor, PhD, D,ABSM, CBSM1; Kevin Sethi, PhD1; Kimberly Kelly, PhD1; Adam D. Bramoweth, PhD2; Brandy M. Roane, PhD, CBSM3


Current Knowledge/Study Rationale: The Pittsburgh Sleep Quality Index (PSQI) is a self-report questionnaire that is widely used by clinicians and researchers to broadly assess several dimensions of sleep, but it has never been validated in U.S. college students. The current study aimed to assess which aspects of sleep and psychosocial factors the PSQI can accurately measure in U.S. college students, examine the diagnostic accuracy of the PSQI for Insomnia Disorder, and provide recommendations about the uses and limitations of the PSQI in this population.

Study Impact: If the PSQI is to be used in a college population as an insomnia screening tool, a cutoff score ≥ 6 is recommended in order to maintain high sensitivity of the test and maximize the diagnostic accuracy. The PSQI may be a good screening tool, but is not a substitute for sleep disorder diagnoses established through a clinical interview performed by an experienced sleep clinician—and users of the PSQI in populations with a history of psychiatric illness should exercise caution in interpretation.

Sleep/Wake Modulation of Polysomnographic Patterns has Prognostic Value in Pediatric Unresponsive Wakefulness Syndrome. 1131-1141.
Erika Molteni, PhD1; Paolo Avantaggiato, MD1; Francesca Formica, MD1; Valentina Pastore, PhD1; Katia Colombo, PhD1; Sara Galbiati, MD1; Filippo Arrigoni, MD2; Sandra Strazzer, MD1


Current Knowledge/Study Rationale: Despite the difficulties in applying the classic criteria for sleep staging, previous studies observed behavioral, but no electrophysiological, sleep-wake patterns in adult patients in a vegetative state, while they found near-to-normal patterns of sleep in adults in a minimally conscious state; unfortunately, such evidences have never been validated in pediatric cohorts, as only two pediatric case studies can be traced back in literature. The goal of the current study is to provide a quantitative depiction of sleep-wake alternation in pediatric patients with unresponsive wakefulness syndrome.

Study Impact: The report extends to the pediatric age previous findings about a possible predictive role of polysomnography in the determination of clinical outcome in adults in a UWS. Our work confirms that pediatric patients exiting from coma and lingering in a UWS experience power increase in the delta frequency band during sleep, and decreased alpha, sigma, and beta activities; we also demonstrate the consistent gain in outcome prediction due to the employment of the Sleep Patterns for Pediatric Unresponsive Wakefulness Syndrome scale.

Effect of Antihypertensive Medications on the Severity of Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. 1143-1151.
Kiran Khurshid, MD1; Jonathan Yabes, PhD2; Patricia M. Weiss, MLIS3; Sushma Dharia, MD4; Lee Brown, MD4; Mark Unruh, MD, MS5; Manisha Jhamb, MD, MPH1


Current Knowledge/Study Rationale: Increasing evidence suggests that hypertension (HTN) exacerbates obstructive sleep apnea (OSA). It is thus plausible that intensive treatment of HTN may improve OSA severity, either by volume control (by promoting diuresis or suppressing aldosterone), stabilization of upper airway muscles, or perhaps because of some direct effect of antihypertensive medications

Study Impact: Out of more than 27,000 studies screened, only 11 evaluated the effect of antihypertensive treatment on objective OSA severity, thus revealing a critical need for more research in this area. Our meta-analysis suggests that treatment with antihypertensive agents confers a statistically significant, albeit small, reduction in the severity of OSA, which may be more pronounced with the use of diuretics.

Residual Events during Use of CPAP: Prevalence, Predictors, and Detection Accuracy. 1153-1158.
Joel Reiter, MD1,2; Bashar Zleik, MD1,3; Mihaela Bazalakova, MD, PhD1,4; Pankaj Mehta, MD1,5; Robert Joseph Thomas, MD, MMSc1


Current Knowledge/Study Rationale: Initiation and adjustment of PAP devices in automatic mode is generally accepted as the standard of care for treatment of OSA without significant comorbidities. Device settings are adjusted remotely, based on event data from these devices; however, waveform data available is seldom reviewed. We sought to compare automatically detected versus manually scored events to analyze the accuracy of devices and identify predictors of residual AHIFLOW.

Study Impact: It is demonstrated that direct review of device generated flow data identifies inadequate control, otherwise missed with sole review of automatic device detection indices. The baseline study central sleep apnea index is the main predictor of high AHIFLOW.

Effectiveness of Oral Appliances in Obstructive Sleep Apnea with Respiratory Arousals. 1159-1165.
Pia Nerfeldt, MD, PhD; Danielle Friberg, MD, PhD


Current Knowledge/Study Rationale: Polysomnography (PSG) rather than of home sleep study, could be justified by diagnosing obstructive sleep apnea (OSA) in patients with mainly respiratory arousals and evaluating their treatment outcome. This clinical study aimed to compare treatment adherence and success with an oral appliance (OA) between patients with mostly arousals and patients also with oxygen desaturations. If so, this would justify the costs of PSG and OA.

Study Impact: High OA treatment adherence and success in patients with mainly arousals strengthens the motivation for use of PSG and OA treatment in this subgroup of OSA patients.

Article Is Eligible For CME Credits Management of Snoring and Sleep Apnea in Australian Primary Care: The BEACH Study (2000–2014). 1167-1173.
Nathan E. Cross, BSc (Hons)1; Christopher M. Harrison, PhD3; Brendon J. Yee, MBChB, PhD1,4; Ronald R. Grunstein, MD, PhD1,4; Keith K.H. Wong, MBBS, PhD1,4; Helena C. Britt, PhD3; Nathaniel S. Marshall, PhD1,2


Current Knowledge/Study Rationale: The epidemiology of obstructive sleep apnoea (OSA) in the general population and patients seen in tertiary care has been well described; however, the risk factors between the two differ in strength. Our current study aims to characterize the management of snoring and OSA in general practice in Australia to determine if there has been any change in the rate of management and how patients are being managed.

Study Impact: The management rate for OSA tripled from 2000 to 2014, illustrating the significant rise in patients seeking treatment for the sleep disorder. Also of note is the finding that the traditional view of the OSA patient being male has changed in general practice as the sex ratio of males to females has shrunk from 4:1 to approximately 2:1.

Review Articles

Quality Assessment of Systematic Reviews on the Efficacy of Oral Appliance Therapy for Adult and Pediatric Sleep-Disordered Breathing. 1175-1183.
Thikriat S. Al-Jewair, BDS, MBA, MSc, MS, FRCDC1; Balgis O. Gaffar, BDS, MS2; Carlos Flores-Mir, DDS, DSc, FRCDC3


Current Knowledge/Study Rationale: Evidence from SRs should be used to generate practice guidelines and to support task forces conclusions for day-to-day clinical management use. The objective of this study was to assess the methodological quality of SRs on the efficacy of OA therapy in the management of pediatric and adult SDB.

Study Impact: Potential variability in the methodology and reporting in the included SRs may limit the validity of the conclusions and eventually the clinical decisions made. Therefore, consideration of the methodological quality of such evidence before clinical decision-making is of paramount importance.

Special Articles

Quality Measure for Screening for Adult Obstructive Sleep Apnea by Primary Care Physicians. 1185-1187.
Rashmi N. Aurora, MD, FAASM1; Stuart F. Quan, MD, FAASM2,3

Case Reports

Parasomnia Overlap Disorder with Sexual Behaviors during Sleep in a Patient with Obstructive Sleep Apnea. 1189-1191.
Rodolfo Soca, MD1; Joseph C. Keenan, MD2; Carlos H. Schenck, MD3

Letters to the Editor

Alternatives to Clonazepam in REM Behavior Disorder Treatment. 1193.
Jesús Escribá, MD; Blanca Hoyo, PhD
Seeking Good Alternatives to Clonazepam: Suggestions for Future Treatment Trials in REM Sleep Behavior Disorder. 1195-1196.
Yuichi Esaki, MD, PhD; Tsuyoshi Kitajima, MD, PhD
Criminal Law and Parasomnias: Some Legal Clarifications. 1197-1198.
John Rumbold, PhD (Medico-legal)1; Ian Morrison, PhD2; Renata Riha, MD3
And the Doctor Answers: “Dream, Dream, I Will Be the Guardian of Your Breathing…”. 1199-1201.
Claudio Rabec, MD1; Jésus Gonzalez-Bermejo, MD2; Christophe Perrin, MD, PhD3; Bruno Langevin, MD4; Jean-Louis Pepin, MD, PhD5; Daniel Rodenstein, MD, PhD6; Jean Paul Janssens, MD, PhD7
And the Doctor Continues: “…But I Have to Choose My Gear Wisely”. 1203-1204.
Bart Vrijsen, PT, MSc1,2; Bertien Buyse, MD, PhD1,3; Dries Testelmans, MD, PhD1,3
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