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Accepted Papers

Consensus Statement

Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine. 785-786.
Shalini Paruthi, MD1; Lee J. Brooks, MD2,3; Carolyn D'Ambrosio, MD4; Wendy A. Hall, PhD, RN5; Suresh Kotagal, MD6; Robin M. Lloyd, MD6; Beth A. Malow, MD, MS7; Kiran Maski, MD8; Cynthia Nichols, PhD9; Stuart F. Quan, MD10; Carol L. Rosen, MD11; Matthew M. Troester, DO12; Merrill S. Wise, MD13


“Please, sir, I want some more.”. 787-788.
Michael P. Coppola, MD

Scientific Investigations

Nocturia, Insomnia Symptoms and Mortality among Older Men: The Health, Aging and Body Composition Study. 789-796.
Yohannes W. Endeshaw, MD, MPH1; Ann V. Schwartz, PhD, MPH2; Katie Stone, PhD3; Paolo Caserotti, PhD4; Tamara Harris, MD, MS5; Stephen Smagula, PhD6; Suzanne Satterfield, MD, DrPH7


Current Knowledge/Study Rationale: Nocturia is a common complaint among older adults and associated with sleep related complaints, as well as higher morbidity burden and mortality rate. In this study, we examine if the association between nocturia and mortality is independent of insomnia symptoms, prevalent diabetes mellitus and cardiovascular morbidity.

Study Impact: Results of the study indicate that the association between 3 or more nocturia episodes and mortality is independent of insomnia symptoms and this association may be partly explained by prevalent diabetes mellitus and cardiovascular morbidity. These findings underscore the importance of these morbidities on the association between frequent nocturia episodes and higher mortality rate.

Examining the Variability of Sleep Patterns during Treatment for Chronic Insomnia: Application of a Location-Scale Mixed Model. 797-804.
Jason C. Ong, PhD1; Donald Hedeker, PhD2; James K. Wyatt, PhD1; Rachel Manber, PhD3


Current Knowledge/Study Rationale: Sleep disturbance can vary considerably across nights but traditional statistical methods are not optimized to examine both the mean and variability of sleep patterns. We used a novel statistical technique called the location-scale mixed model to simultaneously analyze the mean and intra-individual variability (IIV) on sleep diary data collected for a randomized controlled trial for chronic insomnia.

Study Impact: Mindfulness-based stress reduction (MBSR) and mindfulness-based therapy for insomnia (MBTI) exhibited different patterns of change on mean levels and IIV of sleep efficiency during the course of treatment compared to the control condition. The location-scale mixed model can serve as an efficient statistical technique for analyzing intensive longitudinal sleep data.

Low Prevalence of Sleep Disorders in Demyelinating Disease in a Northern Tenerife Population. 805-811.
Montserrat González-Platas, PhD1; Javier González-Platas, PhD2; Moises Bermúdez-Hernández, BS1; Maria Yaiza Pérez-Martín, PhD1; Cristina Croissier-Elías, BS1; Pedro Javier Pérez-Lorensu, BS1


Current Knowledge/Study Rationale: Our goal was to indentify the presence of sleep problems in the study population with the objective to refer the patients to a specialist in sleep disorders for their treatment. We endeavored to confirm that sleep disorders are as prevalent as those described in the literature to determine if the measuring instruments used are useful for its detection.

Study Impact: There is a significant the low prevalence of sleep disorders in the population in our study compared with other studies. This illustrates the importance of avoiding biases in the selection of the sample and to not specifically select those patients having explicit complaints of sleep problems.

Article Is Eligible For CME Credits Clinical Relevance of Sleep Duration: Results from a Cross-Sectional Analysis Using NHANES. 813-819.
M. Soledad Cepeda, MD, PhD1; Paul Stang, PhD1; Clair Blacketer, MPH1; Justine M. Kent, MD2; Gayle M. Wittenberg, PhD3


Current Knowledge/Study Rationale: The importance of sleep duration needs to be further elucidated. We sought to assess the clinical relevance of sleep duration in a representative sample of the US population. This is a cross-sectional analysis of subjects in the US National Health and Nutrition Examination Surveys.

Study Impact: We found that better health is associated with longer duration of sleep. Fewer hours of sleep resulted in greater BMI and cardiovascular risk. A difference of 30 minutes of sleep is associated with a substantive change in clinical well-being.

Psychometric Comparison of the Full and Abbreviated Versions of the Dysfunctional Beliefs and Attitudes about Sleep Scale. 821-828.
Ka-Fai Chung, MBBS, MRCPsych1; Fiona Yan-Yee Ho, MPhil2; Wing-Fai Yeung, PhD3


Current Knowledge/Study Rationale: The different versions of the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) have limited comparison and summary of the findings across studies. We aimed to examine which version and which subscales had better psychometric properties.

Study Impact: The DBAS-16 possesses better internal consistency, a reproducible factor structure, strong concurrent validity, and sensitivity to change. Future studies should consider the DBAS-16 as a better option to quantify sleep-related cognitions in research settings.

Article Is Eligible For CME Credits The Association between Nocturnal Cardiac Arrhythmias and Sleep-Disordered Breathing: The DREAM Study. 829-837.
Bernardo J. Selim, MD1; Brian B. Koo, MD2; Li Qin, PhD3; Sangchoon Jeon, PhD4; Christine Won, MD5; Nancy S. Redeker, PhD4; Rachel J. Lampert, MD6; John P. Concato, MD7,10; Dawn M. Bravata, MD8; Jared Ferguson, BS8; Kingman Strohl, MD9; Adam Bennett5; Andrey Zinchuk, MD5,7,10; Henry K. Yaggi, MD5,7,10


Current Knowledge/Study Rationale: The association between sleep-disordered breathing (SDB) and cardiac arrhythmias has been examined in community-based with self-reported morbidities but not in clinic-based populations that tend to have more severe sleep-disordered breathing and higher rates of cardiovascular comorbidity.

Study Impact: The association between SDB and nocturnal cardiac arrhythmia may, in part, explain the observed increased risk in nocturnal sudden death among patients with sleep apnea. Understanding the nature of the association between sleep apnea and cardiac arrhythmias also has the potential to change the practice of polysomnographic interpretation, leading to a more systematic approach to the detection and quantifications of cardiac events.

Does Postural Rigidity Decrease during REM Sleep without Atonia in Parkinson Disease?. 839-847.
Dario Arnaldi, MD1,2; Alice Latimier, MS3; Smaranda Leu-Semenescu, MD1,3; Fabrizio De Carli, MPhys4; Marie Vidailhet, MD, PhD3,5; Isabelle Arnulf, MD, PhD1,3


Current Knowledge/Study Rationale: In patients with Parkinson disease (PD), despite the rigidity and the bradykinesia, movements are rapid and not slow during rapid eye movement (REM) sleep behavior disorder (RBD). It is unclear whether wake postural rigidity is attenuated during REM sleep without atonia in patients with PDs.

Study Impact: Both PD-related (rigidity) and RBD-related (REM sleep without atonia) muscle hypertonia coexist during REM sleep suggesting that some rapid RBD movements likely occur against a rigid postural tone. This finding provides new information about postural rigidity and RBD in PD.

Predicting CPAP Use and Treatment Outcomes Using Composite Indices of Sleep Apnea Severity. 849-854.
Karthik Balakrishnan, MD, MPH1; Kathryn T. James, PA, MPH2,3; Edward M. Weaver, MD, MPH2,3,4,5


Current Knowledge/Study Rationale: The daily and long-term benefits of continuous positive airway pressure (CPAP) are dependent on patient use of the therapy. Although individual measures of sleep apnea severity and disease burden (e.g., apneahypopnea index and Epworth Sleepiness Scale) predict CPAP use and outcome, we investigated whether a multivariable composite measure that integrated subjective and objective measures of sleep apnea severity was a more robust predictor.

Study Impact: Composite measures of sleep apnea severity have value in prospectively predicting objective adherence to CPAP treatment and subjective treatment outcomes. They retain the predictive value of apnea-hypopnea index and Epworth Sleepiness Scale for some outcomes while better predicting others, particularly changes in disease-specific quality of life.

Short-Term Variability in Apnea-Hypopnea Index during Extended Home Portable Monitoring. 855-863.
Bharati Prasad, MD, MS1,2,3; Sarah Usmani, MD1; Alana D. Steffen, PhD4; Hans P.A. Van Dongen, PhD5; Francis M. Pack, RN6; Inna Strakovsky, MPH6; Bethany Staley, RPSGT6; David Dinges, PhD6,7; Greg Maislin, MS, MA6; Allan I. Pack, MBChB, PhD6; Terri E. Weaver, PhD, RN, FAAN1,2,8


Current Knowledge/Study Rationale: This study was undertaken to determine night-to-night variability in expression of obstructive sleep apnea (OSA) during extended home portable monitoring.

Study Impact: This study extends our knowledge of night-to-night variability in OSA by demonstrating that patients with mild OSA are more likely to exhibit night to night variability in their apnea-hypopnea index and time of recording in hypoxemia on home portable monitoring. This is important for management and prognostication of mild OSA.

A Relationship between Periodic Limb Movements in Sleep and High Nocturnal Blood Pressure Values in Patients with Insomnia. 865-869.
Mariusz Sieminski, PhD1; Markku Partinen, Prof2


Current Knowledge/Study Rationale: Epidemiologic data show that insomnia is related to an increased risk of hypertension and polysomnographic data show that periodic limb movements lead to an increase in blood pressure. The purpose of this study was to verify whether periodic limb movements are related to increased nocturnal blood pressure values in patients with insomnia.

Study Impact: Periodic limb movements may be a treatable cause of increased blood pressure in patients with insomnia. Therefore, treatment of periodic limb movements is one possible method by which to decrease blood pressure in patients with insomnia, leading to an improvement in the vascular risk profile of this population.

Population-Based Study of Sleep Apnea in Pregnancy and Maternal and Infant Outcomes. 871-877.
Yu Sun Bin, PhD1,2; Peter A. Cistulli, MD, PhD2,3,4; Jane B. Ford, PhD1,2


Current Knowledge/Study Rationale: The evidence for an impact of sleep apnea on pregnancy is limited by weak study designs with small clinical samples and poor measurement of sleep apnea. The current study aimed to examine if clinically significant sleep apnea is prospectively associated with maternal and infant outcomes in a population-based cohort.

Study Impact: The study provides evidence that sleep apnea increases risks for a number of pregnancy outcomes. The findings, together with the greater literature, suggest a large-scale intervention study is needed to determine if treatment of sleep apnea can fully ameliorate these risks.

Correlates of Pediatric CPAP Adherence. 879-884.
Stephen M.M. Hawkins, MD1,2; Emily L. Jensen, BS3,4; Stacey L. Simon, PhD1,2; Norman R. Friedman, MD3,4


Current Knowledge/Study Rationale: Pediatric obstructive sleep apnea is plagued by poor adherence to CPAP therapy. We found that female sex and diagnosis of developmental delay were associated with improved adherence; adherence was not associated with age, medical complexity, OSA severity, CPAP factors, or other diagnoses.

Study Impact: This study reinforces the need to identify populations at risk for poor adherence to CPAP therapy, to bolster CPAP desensitization efforts, and to develop CPAP alternatives. It is also provides justification for tailoring pediatric OSA treatment to the individual, as opposed to utilizing a “one-size-fits-all” approach.

Staging Sleep in Polysomnograms: Analysis of Inter-Scorer Variability. 885-894.
Magdy Younes, MD1,2,3; Jill Raneri, RPSGT2; Patrick Hanly, MD2


Current Knowledge/Study Rationale: Inter-scorer variability in scoring polysomnograms is a well-recognized problem that impacts the diagnosis and management of sleep disorders and confounds interpretation of outcome studies. We wished to determine whether differences between highly qualified technologists in scoring sleep are related to inattention errors, scoring bias, or to the signals in a number of epochs being difficult to score definitively with current guidelines (equivocal epochs).

Study Impact: We found that inattention errors and bias contribute little, while the vast majority of scoring differences between qualified technologists result from the presence of a large number of equivocal epochs that can legitimately be assigned any of two, or even three, sleep stages by competent technologists. These findings suggest that digital identification of key staging variables (e.g., spindles, delta wave duration, objective sleep depth) is needed if inter-scorer variability is to be minimized and that better training or fine-tuning of the scoring guidelines are not likely to be effective.

Increased Motor Activity During REM Sleep Is Linked with Dopamine Function in Idiopathic REM Sleep Behavior Disorder and Parkinson Disease. 895-903.
Marielle Zoetmulder, MSc, PhD1,2,3; Miki Nikolic, MSc, PhD4; Heidi Biernat, MD1; Lise Korbo, MD1; Lars Friberg, MD5; Poul Jennum, Prof2,3


Current Knowledge/Study Rationale: The pathophysiology of RBD in PD is unclear. Although degeneration of the nigrostriatal dopaminergic system is characteristic for daytime motor function in PD, only few studies have investigated this system in motor function, atonia, during sleep. This study investigated the relation between the nigrostriatal dopamine system and EMG-activity during sleep in iRBD and PD.

Study Impact: We show in this study that increased EMG-activity during REM/NREM sleep is at least partly linked to the dopaminergic system in iRBD and PD. However, further studies are needed to elucidate possible mechanisms and pathways.

Case Reports

Altered Sleep Spindles in Delayed Encephalopathy after Acute Carbon Monoxide Poisoning. 913-915.
Takuya Yoshiike, MD, PhD1; Masaki Nishida, MD, PhD1; Kazuyoshi Yagishita, MD, PhD2; Tadashi Nariai, MD, PhD3; Kenji Ishii, MD, PhD4; Toru Nishikawa, MD, PhD1
Can We Assess Pulsus Paradoxus through Polysomnography in a Patient with Chronic Obstructive Pulmonary Disease and Sleep-Disordered Breathing?. 917-919.
Cesar Liendo, MD1,2; Ashtaad Dalal, MD1,2; Esther Hinds, MD1,2; Samreena Sara, MD1,2; Oleg Chernyshev, MD1,2; Swathi Nutakki, MD1,2; Jorge Rey de Castro, MD3; Andrew Chesson, MD1

Sleep Medicine Pearls

A 7-Year-Old Boy with Intractable Seizures and Snoring. 920-923.
Casandra Arevalo, MD1; Lourdes M. DelRosso, MD1; Ilya Khaytin, MD2; Lawrence Brown, MD2

Board Review Corner

Frightening Spells at Night. 925-927.
Aaron M. Carlson, MD1; Jeffrey Young, PhD2; Alon Avidan, MD, MPH1,3
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