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Accepted Papers

Scientific Investigations

Effects of Yoga and Aerobic Exercise on Actigraphic Sleep Parameters in Menopausal Women with Hot Flashes. 11-18.
Diana Taibi Buchanan, PhD, RN1; Carol A. Landis, PhD, RN1; Chancellor Hohensee, MA2; Katherine A. Guthrie, PhD2; Julie L. Otte, PhD, RN3; Misti Paudel, PhD, MPH4; Garnet L. Anderson, PhD2; Bette Caan, DrPH5; Ellen W. Freeman, PhD6; Hadine Joffe, MD, MSc7; Andrea Z. LaCroix, PhD8; Katherine M. Newton, PhD9; Susan D. Reed, MD, MPH10; Kristine E. Ensrud, MD, MPH11,12


Current Knowledge/Study Rationale: Yoga and exercise have been suggested as useful non-pharmacological treatments for midlife women experiencing sleep disturbance, but evidence regarding efficacy remains mixed and inconclusive. This study reports actigraphic sleep outcomes from a randomized controlled trial comparing 12 w of yoga, aerobic exercise, or usual care in women experiencing the menopausal transition or postmenopause with hot flashes.

Study Impact: Sleep disturbances were shown on baseline actigraphy sleep measures; however, yoga and aerobic exercise interventions did not significantly affect sleep measures. The limited body of current evidence does not support the efficacy of yoga or aerobic exercise for reducing sleep disturbance in women during the menopause transition or postmenopause with hot flashes. Future research should explore other approaches for improving sleep quality, such as cognitive behavioral therapy for insomnia.

Vitamin D Improves Selected Metabolic Parameters but Not Neuropsychological or Quality of Life Indices in OSA: A Pilot Study. 19-26.
Conor P. Kerley, PhD1,2; Katrina Hutchinson, MD3,4; Jessica Bramham, PhD5; Aisling McGowan, MSc1; John Faul, MD1; Liam Cormican, MD1


Current Knowledge/Study Rationale: Low vitamin D levels are common in subjects with obstructive sleep apnea and correlate with multiple cardiometabolic parameters. There is evidence the supplementing with vitamin D may improve several physiological, biochemical and subjective features of obstructive sleep apnea.

Study Impact: We present the first report of vitamin D supplementation in obstructive sleep apnea where 15 weeks of daily vitamin D supplementation at 4,000 IU/day decreased low-density lipoprotein cholesterol and systemic inflammation (lipoprotein-associated phospholipase A2). Our pilot study is limited by small sample size and heterogeneous study sample, but may serve to increase knowledge and work in this area.

Ventilatory Cycle Measurements and Loop Gain in Central Apnea in Mining Drivers Exposed to Intermittent Altitude. 27-32.
Jorge Rey de Castro, MD, MSc1; Alicia Liendo, BA, BMS2; Oswaldo Ortiz, MD3; Edmundo Rosales-Mayor, MD, MSc4; César Liendo, MD5


Current Knowledge/Study Rationale: A respiratory polygraph was done on miners working at 2,020 meters' altitude. The prevalence of central sleep apnea in those workers was higher than expected for that level of altitude. We hypothesize that the intermittent exposure to a higher working altitude and residing in a lower altitude area preclude the acquisition of acclimatization, which may predispose to developing high altitude central sleep apnea.

Study Impact: These central apneas have the characteristics of idiopathic central apnea (non-cardiogenic) and have a high loop gain; also, there was a significant direct correlation between the central apnea severity and the loop gain values.

Association between Sleep Duration and Self-Reported Health Status: Findings from the Bhutan's Gross National Happiness Study. 33-38.
Gyambo Sithey, MSc1; Li Ming Wen, PhD1,2; Patrick Kelly, PhD1; Mu Li, PhD1


Current Knowledge/Study Rationale: The association between sleep duration and self-reported health status has been mostly investigated in developed countries; results were inconsistent. To our knowledge, this is the first study using the nationally representative survey data to investigate the association between sleep duration and self-reported health status in a developing country setting.

Study Impact: We found that both shorter and longer sleep durations were associated with poor self-reported health status. This finding is significant as it highlights sleep duration as an emerging lifestyle related health risk behaviour even in a developing country.

Reliability of Actigraphy and Subjective Sleep Measurements in Adults: The Design of Sleep Assessments. 39-47.
Katarina Aili, PhD1; Sofia Åström-Paulsson, MD2; Ulrich Stoetzer, PhD3; Magnus Svartengren, MD, PhD2; Lena Hillert, MD, PhD1


Current Knowledge/Study Rationale: Previous research indicates that sleep may be a feasible marker to use when evaluating interventions targeting stress-related ill health at workplaces. The knowledge of how many nights of actigraphy measured sleep that is required for a reliable measure of sleep is however scarce.

Study Impact: This study contributes with methodologically new knowledge of the reliability of repeated measurements of sleep. Knowledge of which, is helpful when planning and performing sleep measurements in both research and clinical settings.

Increased Mortality in Relation to Insomnia and Obstructive Sleep Apnea in Korean Patients Studied with Nocturnal Polysomnography. 49-56.
Jae-Won Choi, MD1; Ji Soo Song2; Yu Jin Lee, MD, PhD1; Tae-Bin Won, MD, PhD3; Do-Un Jeong, MD, PhD1


Current Knowledge/Study Rationale: Most previous mortality studies of OSA and insomnia have been conducted without consideration of other sleep disorders, and reports concerning insomnia have relied heavily on subjective symptoms or questionnaires. In this study, to overcome these shortcomings, we excluded all other sleep disorders and objectively determined insomnia by nocturnal polysomnography.

Study Impact: Severe OSA was associated significantly with all-cause mortality and cardiovascular mortality, and insomnia showed a significant correlation with deaths due to cardiovascular causes. These results suggest that early screening and efficient treatment are needed not only for OSA, but also for insomnia.

Article Is Eligible For CME Credits Treatment of OSA with CPAP Is Associated with Improvement in PTSD Symptoms among Veterans. 57-63.
Jeremy E. Orr, MD1; Carolina Smales, BS2; Thomas H. Alexander, MD, MHSc2,3; Carl Stepnowsky, PhD2; Giora Pillar, MD4; Atul Malhotra, MD1; Kathleen F. Sarmiento, MD1,2


Current Knowledge/Study Rationale: Recent research has revealed an association between OSA and PTSD, although the significance of this association is unclear. We sought to determine if treatment of OSA with CPAP could improve PTSD symptoms.

Study Impact: CPAP appears to improve a variety of symptoms related to PTSD, with greatest improvements in those with better compliance. Future research is needed to elucidate the mechanistic link between PTSD and OSA, and to optimize patient compliance with CPAP.

Cerebral Microbleeds on MRI in Patients with Obstructive Sleep Apnea. 65-72.
Dae Lim Koo, MD, PhD1; Jun Yup Kim, MD1; Jae-Sung Lim, MD, MSc2; Hyung-Min Kwon, MD, PhD1; Hyunwoo Nam, MD, PhD1


Current Knowledge/Study Rationale: Cerebral microbleeds are considered as a surrogate marker of overt stroke. Obstructive sleep apnea is known to increase the risk of stroke and death, but the significance of cerebral microbleeds has not been well investigated in patients with obstructive sleep apnea.

Study Impact: Moderate-to-severe obstructive sleep apnea is associated with the presence of cerebral microbleeds, and higher apnea-hypopnea index is correlated with more cerebral microbleeds. Preemptive stroke evaluations and preventive treatment may be necessary in patients with moderate-to-severe OSA.

Article Is Eligible For CME Credits Unanticipated Nocturnal Oxygen Requirement during Positive Pressure Therapy for Sleep Apnea and Medical Comorbidities. 73-79.
Safal Shetty, MD1,2; Aaron Fernandes, MD1,2; Sarah Patel, MD1,2; Daniel Combs, MD3; Michael A. Grandner, PhD, MTR, CBSM4; Sairam Parthasarathy, MD1,2,5


Current Knowledge/Study Rationale: Home-based management of sleep-disordered breathing (SDB) generally excludes patients with significant medical comorbidities (such as severe chronic obstructive pulmonary disease, congestive heart failure, and morbid obesity), but such an approach lacks scientific evidence. Moreover, patients prescribed home sleep studies and automatic positive airway pressure (PAP) therapies may not be completely assessed for supplemental oxygen therapy needs in addition to PAP therapy.

Study Impact: We tested a clinical prediction rule of less than two determinants (age older than 50 y, morbid obesity, chronic obstructive pulmonary disease, and postural SpO2 desaturation higher than 5%) that had excellent negative predictive value for need for unanticipated oxygen supplementation that could assist in appropriate triage of patients through home-based (portable) over laboratory-based management pathways for their SDB.

Obstructive Sleep Apnea without Obesity Is Common and Difficult to Treat: Evidence for a Distinct Pathophysiological Phenotype. 81-88.
Emma L. Gray, MBBS, MPH1; David K. McKenzie, FRACP, PhD1,2; Danny J. Eckert, PhD2


Current Knowledge/Study Rationale: Obesity can cause anatomical obstruction of the upper airway and is a well-established risk factor for OSA. However, the proportion of patients with OSA who are not obese, their response to existing therapies (i.e. continuous positive airway pressure) and whether these patients have different pathophysiological mechanisms leading to airway obstruction has been minimally investigated.

Study Impact: More than half of the population referred to an academic teaching hospital sleep clinic for suspected OSA was not obese and these patients were difficult to treat with current therapies. Nonobese patients with OSA were more likely to have a low respiratory arousal threshold, suggesting that nonanatomical pathophysiological causes of OSA are particularly important in nonobese patients with OSA, which has implications for treatment.

Effect of Mineral and Bone Metabolism on Restless Legs Syndrome in Hemodialysis Patients. 89-94.
Precil D.M.M. Neves, MD1; Fabiana G. Graciolli, PhD1; Ivone B. Oliveira, MS1; Ramaiane A. Bridi, MD1; Rosa M.A. Moysés, MD, PhD1,2; Rosilene M. Elias, MD, PhD1


Current Knowledge/Study Rationale: Restless legs syndrome (RLS) is a sleep disorder with high prevalence among patients on hemodialysis, for which the underlying mechanism is still unknown. This current study evaluated the role of chronic kidney disease-mineral and bone disorders (CKD-MBD) on RLS among patients on hemodialysis.

Study Impact: This study provides a new perspective on the physiopathology of RLS among patients on hemodialysis by showing that: (a) Factors of iron metabolism are associated with CKD-MBD; (b) CKD-MBD factors such as phosphate and 25(OH)-vitamin D correlated with iron metabolism (transferrin saturation); and (c) RLS in patients on hemodialysis may be related to hyperphosphatemia, high levels of fibroblast growth factor-23 (FGF-23), and high levels of parathyroid hormone.

A Randomized, Crossover Trial of a Novel Sound-to-Sleep Mattress Technology in Children with Autism and Sleep Difficulties. 95-104.
Thomas W. Frazier, PhD1; Jyoti Krishna, MD2; Eric Klingemier, BA1; Mary Beukemann1; Rawan Nawabit1; Sally Ibrahim, MD1


Current Knowledge/Study Rationale: Children with autism have significant sleep difficulties that impact the child's functioning and overall caregiver and family life. The present study was conducted to examine whether a novel mattress technology improved sleep in children with autism who also have significant sleep difficulties.

Study Impact: The sound-to-sleep mattress technology was well tolerated and improved some measures of sleep in children with autism. If supported in future trials, this technology may be a safe, effective adjunct or second-line treatment of sleep difficulties in children with autism.

Symptoms of Restless Legs Syndrome in Biological Caregivers of Children with Autism Spectrum Disorders. 105-113.
Maureen Russell, PhD1; Carol Baldwin, PhD1; Darya McClain, PhD1; Nicole Matthews, PhD2; Christopher Smith, PhD2; Stuart F. Quan, MD3,4


Current Knowledge/Study Rationale: Restless legs syndrome is a sleep disorder known to have strong heritability and is often associated with other health conditions. RLS may be under-diagnosed in the biological caregivers of children with ASD, and RLS may contribute to poorer sleep quality in these caregivers.

Study Impact: This study suggests that biological caregivers of children with ASD may be at risk for RLS and poorer mental health. Education of caregivers concerning sleep hygiene and possible sleep disruptors in their own sleep and in the sleep of their children with ASD is vital.

Eszopiclone and Zolpidem Do Not Affect the Prevalence of the Low Arousal Threshold Phenotype. 115-119.
Patrick R. Smith, DO1; Karen L. Sheikh, BA2; Camille Costan-Toth, MD3; Derek Forsthoefel, MD1; Edward Bridges, MD1; Teotimo F. Andrada, MS1; LTC Aaron B. Holley, MD1


Current Knowledge/Study Rationale: The non benzodiazepine sedative hypnotic eszopiclone increases the respiratory arousal threshold in small studies of patients with severe OSA. We sought to determine whether zolpidem and eszopiclone affect the arousal threshold in a large cohort of patients with mild-to-moderate disease.

Study Impact: After adjustment for pretest probability of OSA, patients who received zolpidem or eszopiclone prior to PSG were just as likely to have a low arousal threshold as those who were not premedicated. Our study suggests that for non-selected patients with mild-to-moderate disease, neither drug is likely to increase the arousal threshold.

Effect of Manual Editing of Total Recording Time: Implications for Home Sleep Apnea Testing. 121-126.
Ying Y. Zhao, MD, MPH1,2; Jia Weng, PhD1; Daniel R. Mobley, RPSGT, CCSH1; Rui Wang, PhD1,3; Younghoon Kwon, MD4; Phyllis C. Zee, MD, PhD5; Pamela L. Lutsey, PhD, MPH6; Susan Redline, MD, MPH1,2,7


Current Knowledge/Study Rationale: Home sleep apnea tests and automated scoring platforms are frequently used for the diagnosis of sleep-disordered breathing. How the apnea-hypopnea index on automatically scored sleep studies compare to manually edited studies or the gold standard polysomnography is unknown.

Study Impact: Our study shows that compared to polysomnography, sleep studies scored without manual editing of total recording time overestimate the total sleep time and consequently underestimate the apnea-hypopnea index. Manual editing of total recording time can improve the accuracy of the apnea-hypopnea index and the classification of sleep-disordered breathing.

Special Articles

The Past Is Prologue: The Future of Sleep Medicine. 127-135.
Nathaniel F. Watson, MD, MSc, FAASM; Ilene M. Rosen, MD, MSc, FAASM; Ronald D. Chervin, MD, MS, FAASM

Case Reports

Fragile X and Obstructive Sleep Apnea Syndrome: Case Presentation and Management Challenges. 137-138.
Courtney Curran, BS; Swarnalata Debbarma, MD, MPH; Karim Sedky, MD, MSc

Sleep Medicine Pearls

An 18-Year-Old Woman with Prolonged Eyes Closed Unresponsiveness during Multiple Sleep Latency Testing. 139-143.
Romy Hoque, MD1; Victoria Olvera, NP1; Lourdes M. DelRosso, MD2
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