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Commentary

A Snapshot in Time: Subjective-Objective Discrepancies during In-Lab Polysomnography. 1437-1438.
Scott G. Williams, MD1; Emerson M. Wickwire, PhD2,3; Carla York, PhD4
Duration Isn't Everything. Healthy Sleep in Children and Teens: Duration, Individual Need and Timing. 1439-1441.
Daniel S. Lewin, PhD1; Amy R. Wolfson, PhD2; Edward O. Bixler, PhD3; Mary A. Carskadon, PhD4,5

Scientific Investigations

Validation of a Wireless, Self-Application, Ambulatory Electroencephalographic Sleep Monitoring Device in Healthy Volunteers. 1443-1451.
Patrick H. Finan, PhD1; Jessica M. Richards2; Charlene E. Gamaldo1; Dingfen Han1; Jeannie Marie Leoutsakos1; Rachel Salas1; Michael R. Irwin3; Michael T. Smith1

BRIEF SUMMARY

Current Knowledge/Study Rationale: This study was conducted to evaluate the validity of a wireless self-application electroencephalographic device for the assessment of sleep architecture and continuity. For this validation study, we compared the Sleep Profiler to the gold standard polysomnography.

Study Impact: This study impacts the field by demonstrating that an ambulatory sleep EEG device can be used to assess sleep architecture and continuity with acceptable comparability to the gold standard laboratory procedure, polysomnography. As the field moves away from brick-and-mortar sleep labs and toward ambulatory assessment, a self-application device like the Sleep Profiler holds promise for both research and clinical care.

Pharmacokinetics of a Novel Zolpidem Nasal Spray for Rapid Management of Insomnia: First Trial in Humans. 1453-1459.
Cheng-Tai Li, MD, PhD1; Tung-Ping Su, MD, PhD1; Yanfeng Wang, PhD2; Benjamin Lee, PharmD2; Melvin Toh, MD2; Tony Ho, PhD2

BRIEF SUMMARY

Current Knowledge/Study Rationale: In order to provide an alternative and effective approach for administering zolpidem other than the conventional oral dosage form, an intranasal formulation, zolpidem nasal spray (ZNS), is developed and evaluated in healthy volunteers. Our preliminary animal studies in rats and dogs indicated that the nasal absorption of zolpidem tartrate was rapid and efficient, with significantly higher drug concentration and faster absorption in animal plasma as well as good local tolerability in terms of minimal nasal irritation; if successfully developed, this novel nasal formulation can become a unique medication suitable for as-needed or intermittent use in subjects with sleep initiation difficulty and middle-of-the-night awakening.

Study Impact: This is the first study that evaluates the pharmacokinetic parameters of a novel zolpidem nasal spray in healthy volunteers. Our results indicate that zolpidem was rapidly absorbed and eliminated after intranasal administration of ZNS, with dose proportionality found at the evaluated range of doses; intranasal exposure of zolpidem was generally higher in female subjects than that in male subjects, and ZNS is safe, well tolerated, and warranted for further clinical development.

Article Is Eligible For CME Credits Does Subjective Sleep Affect Bone Mineral Density in Older People with Minimal Health Disorders? The PROOF Cohort. 1461-1469.
Saint Martin Magali, PhD1,3; Labeix Pierre, MSc1; Garet Martin, PhD1; Thomas Thierry, MD2; Barthélémy Jean-Claude, MD, PhD1; Collet Philippe, MD2; Roche Frédéric, MD, PhD1; Sforza Emilia, MD, PhD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Osteoporosis is a risk factor for fracture in the elderly. The role of short or long sleep time may affect the risk of osteoporosis.

Study Impact: In older people, long sleep duration might be a major factor of osteoporosis risk. Clinicians should consider the role of sleep on bone metabolism in order to educate patients to have not only an increased physical activity but also reduced sleep duration.

High Prevalence of Orthostatic Dysregulation among Circadian Rhythm Disorder Patients. 1471-1476.
Akiko Tsuchiya, MD, PhD1; Tsuyoshi Kitajima, MD, PhD1; Satoe Tomita, MD, PhD1,2; Yuichi Esaki, MD, PhD1; Marina Hirose, MD, PhD1; Nakao Iwata, MD, PhD1

BRIEF SUMMARY

Current Knowledge/Study Rationale: Circadian rhythm sleep disorders (CRSDs) and orthostatic dysregulation (OD) have many common clinical characteristics, including association with school refusal of adolescence. However, the prevalence of OD in patients with CRSD has not been examined.

Study Impact: The overall prevalence of OD in patients with CRSD was 57.9%, and prevalence of OD was 70% in those aged under 20 years. This result suggests some relationship between CRSD and OD.

Standing Balance and Spatiotemporal Aspects of Gait Are Impaired Upon Nocturnal Awakening in Healthy Late Middle-Aged and Older Adults. 1477-1486.
Amanda L. McBean, PhD1,2; Raymond P. Najjar, PhD1,2,3; Ronald A. Schuchard, PhD2,4; Courtney D. Hall, PhD5,6; Cheng-Ann Wang, BA2; Ban Ku, MS2; Jamie M. Zeitzer, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Approximately one-third of adults older than 65 y experience at least one fall each year, and over one-fourth of these falls occur during the night. This study was conducted to determine whether midsleep arousals impair gait and standing balance, and whether changes in the lighting environment during the midsleep arousal could affect gait and standing balance.

Study Impact: This is to our knowledge the first study to report impairment of several aspects of both standing balance and gait during midsleep awakenings among healthy late middle-aged and older adults. This impairment is not ameliorated by exposure to room lighting, when compared to dim light.

Nasal Resistance Is Elevated in People with Tetraplegia and Is Reduced by Topical Sympathomimetic Administration. 1487-1492.
Laura Gainche, MSc1,2; David J. Berlowitz, PhD1,2; Mariannick LeGuen, MD1; Warren R. Ruehland, BSc hons1,2; Fergal J. O'Donoghue, MD, PhD1,2; John Trinder, PhD2; Marnie Graco, MPh1; Rachel Schembri, PhD1; Danny J. Eckert, PhD3; Peter D. Rochford, Grad Dip Bio Instr1; Amy S. Jordan, PhD1,2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Patients with tetraplegia often report nasal congestion and suffer from obstructive sleep apnea (OSA). High nasal resistance contributes to OSA in the able-bodied and may therefore predispose people with tetraplegia to the condition. Until now, nasal resistance has not previously been documented in tetraplegia.

Study Impact: This paper found that nasal resistance was higher in patients with tetraplegia and OSA compared to OSA alone and was reduced with topical phenylephrine, possibly providing a reason and a line of therapy for OSA in tetraplegia.

Associations of Parent Health Behaviors and Parenting Practices with Sleep Duration in Overweight and Obese Children. 1493-1498.
Corinna J. Rea, MD, MPH1,2; Renata L. Smith, MPH2,3; Elsie M. Taveras, MD, MPH2,4

BRIEF SUMMARY

Current Knowledge/Study Rationale: Several child health behaviors have been associated with insufficient sleep, but little is known about the associations of parents' own health behaviors and parenting practices with sleep duration among their school-age children.

Study Impact: Parent sleep duration and confidence in ability to help children get adequate sleep are associated with increased child sleep duration. This study suggests that family-targeted interventions may be an effective approach to increase child sleep duration and thus improve child health outcomes.

Urine Toxicology in Adults Evaluated for a Central Hypersomnia and How the Results Modify the Physician's Diagnosis. 1499-1505.
Christopher A. Kosky, MBBS, FRCP1,2; Anastasios Bonakis, MD2,3; Arthee Yogendran, MBBS1,2; Gihan Hettiarachchi, MBBS2,4; Paul I. Dargan, MD5,6; Adrian J. Williams, MBBS, FRCP2

BRIEF SUMMARY

Current Knowledge/Study Rationale: Drugs and substances have been shown to cause hypersomnia, but little is known about their effects in patients being evaluated for excessive daytime sleepiness. In this study urine drug testing by gas chromatography-mass spectrometry was performed in adult patients undergoing clinical assessment and a multiple sleep latency test (MSLT) for a suspected central hypersomnia.

Study Impact: The study found drugs and substances are frequent among patients being evaluated for hypersomnia and if undetected, may confound the MSLT results and the physician's diagnosis. The results of this study support routine drug testing of patients undergoing assessment for a central hypersomnia.

Outcomes Associated with Early Postoperative Noninvasive Ventilation in Bariatric Surgical Patients with Sleep Apnea. 1507-1516.
Mihaela S. Stefan, MD, PhD1,2,3; Nicholas S. Hill, MD4; Karthik Raghunathan, MD, MPH5; Xiaoxia Liu, MS1; Penelope S. Pekow, PhD1,6; Stavros G. Memtsoudis, MD, PhD7; Satya Krishna Ramachandran, MD8; Peter K. Lindenauer, MD, MSc1,2,3

BRIEF SUMMARY

Current Knowledge/Study Rationale: Several professional societies including the American Society of Anesthesiology recommend routine postoperative use of noninvasive ventilation (NIV) in patients with OSA who were using it preoperatively and early initiation of NIV for postoperative hypoxemia. However evidence on whether prophylactic postoperative NIV improves outcomes in patients with OSA is weak.

Study Impact: In this large observational study, we found that one in five patients with OSA undergoing bariatric surgery received early NIV, and the rates of NIV use varied largely across the hospitals. Although we could not make a clear distinction between prophylactic use of NIV and early treatment of respiratory deterioration, our results suggest that early use of NIV was not associated with better outcomes, including intubation and mortality rates.

Sleep Misperception in Chronic Insomnia Patients with Obstructive Sleep Apnea Syndrome: Implications for Clinical Assessment. 1517-1525.
Su Jung Choi, PhD1,2; Sooyeon Suh, PhD3,4; Jason Ong, PhD5; Eun Yeon Joo, MD, PhD2,6

BRIEF SUMMARY

Current Knowledge/Study Rationale: Although sleep perception may vary in patients with insomnia and obstructive sleep apnea (OSA), it is unknown how sleep perception changes when patients have both comorbid conditions. The objective of this study was to investigate differences in sleep perception and self-reported habitual sleep duration in four groups—patients with insomnia, obstructive sleep apnea (OSA), patients with both insomnia and OSA, and those without diagnosed OSA or insomnia.

Study Impact: Patients with insomnia, regardless of OSA status, have lower sleep perception and showed smaller discrepancy between objective sleep time and habitual sleep duration compared to patients with OSA or good sleepers. This suggests that sleep studies may be necessary in patients with insomnia for tailoring proper treatment based on insomnia subtype.

Surgical Maxillary Advancement Increases Upper Airway Volume in Skeletal Class III Patients: A Cone Beam Computed Tomography-Based Study. 1527-1533.
Henrique Damian Rosário, DDs, MSc, PhD1; Bruno Gomes de Oliveira, DDS2; Daniela Daufenback Pompeo, DDS, MSc, PhD3; Paulo Henrique Luiz de Freitas, DDS, PhD4; Luiz Renato Paranhos, DDS, PhD4

BRIEF SUMMARY

Current Knowledge/Study Rationale: To date, few studies investigated the volumetric changes of the upper airway that occur following surgical advancement of the maxilla by means of three-dimensional imaging techniques. This study used cone-beam computed tomography to verify whether surgical advancement of the maxilla affects upper airway volume and to determine associations of any existing volume changes with sex and age.

Study Impact: By showing that maxillary advancement resulted in significant volumetric increase of the upper airway in nearly half the study's subjects, our results strengthen the role of isolated maxillary advancement as a fair alternative for the treatment of skeletal class III patients with OSA.

Special Articles

Jack London's Sleep. 1545-1547.
Meir Kryger, MD, FRCPC
Article Is Eligible For CME Credits Consensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion. 1549-1561.
Shalini Paruthi, MD, Moderator1; 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

Sleep Medicine Pearls

An Unexpected Polysomnogram Finding. 1567-1569.
Brian N. Palen, MD1,2; Lucas M. Donovan, MD2; Elizabeth C. Parsons, MD1,2

Letters to the Editor

Impact of Sleep-Disordered Breathing on Postoperative Outcomes: Another Brick in the Wall. 1571.
Antonio Maria Esquinas, MD, PhD, FCCP1; Luca Salvatore De Santo, MD, FESC2,3
Obstructive Sleep Apnea: A Risk Factor of Cardiac Valve Replacement Surgery. 1573-1575.
Ning Ding1; Bu-Qing Ni2; Hong Wang1; Shi-Jiang Zhang, PhD, MD2; Xi-Long Zhang, PhD, MD1
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