Narcolepsy type 1

Although being the second most common cause of disabling daytime sleepiness in the world, narcolepsy in India is seldom diagnosed. So far, only two cases had been reported. This is the case of narcolepsy in a 15-year-old female student struggling in her scholastic pursuit because of the disease.

Clinical and Polysomnographic Correlates of Subjective Sleepiness in Mild Obstructive Sleep Apnea

Purpose

The decision to treat mild obstructive sleep apnea (OSA) often hinges on the presence of subjective daytime sleepiness. This study was done to identify clinical and polysomnographic features which correlate with subjective sleepiness in mild OSA.

Methods

Utilizing data from the Apnea Positive Pressure Long-term Efficacy Study, 199 participants with mild OSA were identified. Participants were grouped as "sleepy" or "non-sleepy" based on their responses to a question regarding excessive daytime sleepiness, and Epworth Sleepiness Scores. We compared demographic, clinical and baseline polysomnographic data between the groups.

Results

The prevalence of subjective sleepiness was 74.4%. The sleepy group was younger (46.1 ± 12.6 vs. 53.3 ± 13.1 years, p=0.001), reported lower quality of life (4.5 ± 0.69 vs. 4.9 ± 0.61, p=0.0002), had higher depression scores (5.4 ± 4.7 vs. 3.1 ± 3.5, p=0.003) and reported more naps per week (2.6 ± 2.9 vs. 1.3 ± 1.9, p=0.01). Total sleep time and sleep efficiency were notably higher in the sleepy (254.2 ± 106 vs. 220.4 ± 114 min, p=0.08) and (80.2 ± 12.6 vs. 75.7 ± 14.9 %, p=0.06), approaching statistical significance. The non-sleepy group had slightly higher apnea hypopnea index (AHI: 12.2 ± 1.5 vs. 11.2 ± 2.4 events/hour, p=0.01) and worse desaturation indices.

Conclusions

Subjective sleepiness in mild OSA is associated with younger age, worsened mood and quality of life. This study suggests that evidence of increased sleep drive on polysomnography may correlate with subjective sleepiness in mild OSA.

An Epworth Sleep Score ≥11 is associated with emergency operative birth and poor neonatal composite outcome at term

BACKGROUND

During pregnancy, the Epworth Sleepiness Scale can be used as a surrogate marker for maternal sleep-disordered breathing, a condition that is becoming increasingly prevalent in obstetric populations and is associated with a multitude of pregnancy complications.

AIMS

The aim of this observational study was to investigate the relationship between the Epworth Sleepiness Scale score and indication and mode of delivery during pregnancy.

MATERIALS AND METHODS

The Epworth Sleepiness Scale was completed by 178 women at Mater Mothers' Hospital, Brisbane, Australia.

RESULTS

Women with a score ≥11 were less likely to achieve a spontaneous vaginal delivery (aOR 0.43, 95% CI 0.21-0.88, P = 0.02), and were more likely to have an instrumental (aOR 2.81, 95% CI 1.30-6.08, P = 0.01) or any operative birth (instrumental and caesarean section aOR 2.32, 95% CI 1.14-4.71, P = 0.02). These women were also more likely to have an operative birth for intrapartum fetal compromise (aOR 2.62, 95% CI 1.21-5.69, P = 0.015), as well as an infant with poor neonatal outcomes (aOR 2.77, 95% CI 1.09-7.03, P = 0.03).

CONCLUSIONS

These results show that symptoms of sleep-disordered breathing are associated with emergency operative birth, particularly when the indication for operative birth was intrapartum fetal compromise.

A Cross-Recurrence Analysis of the Pupil Size Fluctuations in Steady Scotopic Conditions

Pupil size fluctuations during stationary scotopic conditions may convey information about the cortical state activity at rest. An important link between neuronal network state modulation and pupil fluctuations is the cholinergic and noradrenergic neuromodulatory tone, which is active at cortical level and in the peripheral terminals of the autonomic nervous system (ANS). This work aimed at studying the low- and high-frequency coupled oscillators in the autonomic spectrum (0–0.45 Hz) which, reportedly, drive the spontaneous pupillary fluctuations. To assess the interaction between the oscillators, we focused on the patterns of their trajectories in the phase-space. Firstly, the frequency spectrum of the pupil signal was determined by empirical mode decomposition. Secondly, cross-recurrence quantification analysis was used to unfold the non-linear dynamics. The global and local patterns of recurrence of the trajectories were estimated by two parameters: determinism and entropy. An elliptic region in the entropy-determinism plane (95% prediction area) yielded health-related values of entropy and determinism. We hypothesize that the data points inside the ellipse would likely represent balanced activity in the ANS. Interestingly, the Epworth Sleepiness Scale scores scaled up along with the entropy and determinism parameters. Although other non-linear methods like Short Time Fourier Transform and wavelets are usually applied for analyzing the pupillary oscillations, they rely on strong assumptions like the stationarity of the signal or the a priori knowledge of the shape of the single basis wave. Instead, the cross-recurrence analysis of the non-linear dynamics of the pupil size oscillations is an adaptable diagnostic tool for identifying the different weight of the autonomic nervous system components in the modulation of pupil size changes at rest in non-luminance conditions.

Scoring of Hypersomnolence and Fatigue in Patients With Obstructive Sleep Apnea Treated With a Titratable Custom-Made Mandibular Advancement Device

STUDY OBJECTIVES

The objective of this study was to measure fatigue and hypersomnolence in patients with obstructive sleep apnea (OSA) treated with a mandibular advancement device (MAD), using Epworth Sleepiness Scale (ESS) for hypersomnolence and Checklist Individual Strength questionnaire (CIS20R) for fatigue.

METHODS

This was a single-center, prospective cohort study. A total of 58 patients with OSA filled out ESS and CIS20R questionnaires at baseline and after 3 months of MAD treatment. A total of 39 full datasets were collected. Statistical analysis for reliability of the questionnaires, comparison between baseline and 3-month follow-up, correlation between the changes in the values of the two questionnaires, and changes in apnea-hypopnea index (AHI) were performed.

RESULTS

CIS20R showed excellent reliability in this patient group at baseline and 3-month follow-up (Cronbach α = .97), ESS showed a marginally good reliability (Cronbach α = .82). The CIS20R (82/140) expressed high levels of fatigue at baseline, and ESS showed a normal level of daytime sleepiness. AHI, ESS, and CIS20R were significantly reduced under MAD treatment. A significant correlation between ESS and CIS20R was observed. No significant correlation between any of the questionnaires and the change in AHI was found.

CONCLUSIONS

The CIS20R questionnaire results showed a high level of fatigue in the patients with OSA, and the questionnaire can be used to evaluate changes in fatigue due to MAD treatment after 3 months. The ESS failed to show similar characteristics. Therefore, a combination of ESS for hypersomnolence with CIS20R for fatigue is proposed for the follow-up of patients with OSA treated with MAD.

The relationship between anxiety, depression, daytime sleepiness in the REM-related mild OSAS and the NREM-related mild OSAS

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is a common form of sleep-related respiratory disease characterized by recurrent blockages in the upper airway. Rapid eye movement (REM)-related OSAS is a condition in which apneas and hypopneas are more common during REM sleep. We investigated whether there was any difference between REM-related mild OSAS group and NREM-related mild OSAS group in terms of anxiety, depression, and daytime sleepiness.

METHODS

A total of 166 patients with mild OSAS (72 patients with REM-related and 94 NREM-related OSAS) participated in the study. Hospital Anxiety-Depression Scale (HADS) and Epworth Sleepiness Scale (ESS) questionnaires were completed by both groups.

RESULTS

Anxiety and depression scores were significantly higher in patients with REM-related OSAS in comparison to the NREM-related OSAS group (p = 0.01, p = 0.02 respectively). There was no statistically significant difference between the two groups in terms of ESS scores (p = 0.60).

CONCLUSION

The results of our study suggest that patients with REM-related OSAS have higher rates of depression and anxiety compared to non-REM-related OSAS patients and this may adversely affect quality of life. It may be possible to prevent psychiatric complications, such as depression and anxiety, by administering treatments that reduce REM sleep duration and intensity in patients with REM-related OSAS.

Sleep questionnaires for the screening of obstructive sleep apnea in patients with type 2 diabetes mellitus compared with non-diabetic patients

BACKGROUND

Several tools have been used to screen for obstructive sleep apnea (OSA). Evaluation of the predictive performance of different questionnaires is essential in patients with type 2 diabetes mellitus (T2DM) because the prevalence of OSA in this population is high. The aim of this study was to evaluate different sleep questionnaires to identify T2DM patients with OSA, and to compare the predictive values of these questionnaires with a matched sample of non-diabetic patients.

METHODS

The study was a retrospective study of two patients groups (n = 350 with T2DM, n = 350 without T2DM) visiting a sleep clinic and matched by age, gender, body mass index, and the apnea-hypopnea index (AHI). Symptoms of OSA and Epworth Sleepiness Scale (ESS), STOP-Bang, Berlin questionnaire, and Athens insomnia scale (AIS) scores were compared, and sleep studies were performed.

RESULTS

Diabetic patients with OSA complained more frequently of nocturia (P = 0.025), morning headaches (P = 0.04), restless sleep (P = 0.002), and leg movements (P = 0.01) than non-diabetic patients with OSA. Most predictive values of the sleep questionnaires did not differ significantly between the two groups; however, the AIS was higher only in T2DM women (P = 0.01). In both groups, the Berlin and STOP-Bang questionnaires had the highest sensitivity. The ESS had the highest specificity in T2DM patients and the STOP and S-B questionnaires had the highest specificity in non-diabetics.

CONCLUSIONS

The predictive performance of the questionnaires was similar in both groups, especially in the case of moderate and severe OSA.

The relationship between sleep disturbances and quality of life in elderly patients with hypertension

Purpose

Sleep disorders, such as insomnia with objective short sleep duration, are associated with increased risk of hypertension. The objective of the study was to evaluate the effects of insomnia and daytime sleepiness on the quality of life (QOL) among elderly hypertensive patients.

Patients and methods

This cross-sectional study covered 100 patients with hypertension. All participants completed standardized questionnaires, such as the Epworth Sleepiness Scale (ESS), the Athens Insomnia Scale (AIS), and the World Health Organization Quality of Life-Brief (WHOQOL-BREF), and clinical data were obtained from patients' medical records.

Results

We showed that more than half of the patients experienced insomnia (AIS score ≥6) and 39% experienced daytime sleepiness. Daytime sleepiness was negatively associated with perceived QOL (r=-0.478, P<0.001). It was also shown that insomnia might be influenced by older age (P<0.001), occupational activity (P=0.011), overweight (body mass index [BMI] 25-30) (P=0.042), and longer duration of illness (P=0.049) among hypertensive patients.

Conclusion

Sleep problems have a significant negative impact on the QOL in patients with hypertension, especially in the physical domain of the QOL questionnaire. The occurrence of sleep problems in patients with hypertension is influenced by older age, primary education, overweight, occupational activity, and longer duration of illness.

Relationship between Daytime Sleepiness and Health Utility in Patients after Cardiac Surgery: A Preliminary Study

Background Daytime sleepiness can be assessed by the Epworth Sleepiness Scale (ESS), which is widely used in the field of sleep medicine as a subjective measure of a patient's sleepiness. Also, health utility assessed by the mean Short-Form Six-Dimension (SF-6D) score, one of several preference-based utility measures, is an important measure in health care. We aimed to examine age-related differences in daytime sleepiness and health utility and their relationship in patients 5 months after cardiac surgery. Methods; This cross-sectional study assessed 51 consecutive cardiac surgery patients who were divided into a middle-aged (<65 years, n = 29) and older-age group (≥65 years, n = 22). The mean ESS and SF-6D utility scores were measured at 5 months after cardiac surgery and compared. In addition, the relationship between ESS and SF-6D utility scores were assessed. Results; There were no significant differences between the middle-aged and older-aged groups in either the mean ESS (5.14 ± 2.96 vs. 4.05 ± 3.23, p = 0.22) or SF-6D utility (0.72 ± 0.14 vs. 0.71 ± 0.10, p = 0.76) scores. However, there was a negative correlation between both values in all of the patients after cardiac surgery (r = -0.41, p = 0.003). Conclusions; Although there were no age-related differences in the ESS and SF-6D utility values between the two groups, there was a negative correlation between these values in all patients at 5 months after cardiac surgery. This suggested that sleepiness is associated with decreased utility scores in patients at 5 months after cardiac surgery.

Screening extremely obese pregnant women for obstructive sleep apnea

BACKGROUND

Obesity is prevalent among pregnant women in the United States; obstructive sleep apnea is highly comorbid with obesity and is associated with adverse pregnancy outcomes. Screening for obstructive sleep apnea in pregnant women has remained a challenge because of a lack of validated screening tools.

OBJECTIVE

The purpose of this study was to evaluate established obstructive sleep apnea screening tools, a sleepiness scale, and individual component items in a cohort of pregnant women with extreme obesity in mid pregnancy with the use of objective testing to determine obstructive sleep apnea status and to describe the prevalence of obstructive sleep apnea among women with extreme obesity.

STUDY DESIGN

Adult pregnant subjects, between 24 and 35 weeks gestation, with a body mass index ≥40 kg/m² at the time of enrollment completed obstructive sleep apnea screening tools (Berlin Questionnaire, American Society of Anesthesiologists checklist, and STOP-BANG questionnaire) and the Epworth Sleepiness Scale; they also underwent physical examination of the neck, mouth, and airway. The published obstructive sleep apnea in pregnancy prediction score was calculated for each subject. Obstructive sleep apnea status for each subject was determined by the results of an overnight, unattended type III home sleep apnea test.

RESULTS

Twenty-four percent of pregnant women with extreme obesity had obstructive sleep apnea on home sleep apnea testing in mid pregnancy (Apnea-Hypopnea Index, ≥5 events per hour]. Established obstructive sleep apnea screening tools performed very poorly to screen for obstructive sleep apnea in this cohort. Age, body mass index, neck circumference, frequently witnessed apneas, and highly likely to fall asleep while driving were associated most strongly with obstructive sleep apnea status in this cohort.

CONCLUSION

We found that 24% of pregnant women with body mass index ≥40 kg/m² between 24 and 35 weeks gestation have obstructive sleep apnea, defined as Apnea-Hypopnea Index ≥5 events per hour on an overnight type III home sleep apnea test. We found the Berlin Questionnaire, American Society of Anesthesiologists checklist, STOP-BANG, obstructive sleep apnea in pregnancy score by Facco et al, and the Epworth Sleepiness Scale were not useful screening tools for obstructive sleep apnea in a cohort of obese pregnant women. However, age, body mass index, neck circumference, frequently witnessed apneas, and likely to fall asleep while driving were associated with obstructive sleep apnea in this cohort. Further studies are needed to adjust the criteria and thresholds within the available screening tools to better predict obstructive sleep apnea in pregnant women with obesity.

The Epworth Sleepiness Scale: Validation of One-Dimensional Factor Structure in a Large Clinical Sample

STUDY OBJECTIVES

The Epworth Sleepiness Scale (ESS) is used by clinicians and researchers to determine level of daytime sleepiness. The number of factors included in the scale has been debated. Our study objective was to clarify the dimensionality of the ESS using a large clinical sample.

METHODS

A retrospective cohort study included all patients presenting for care in a tertiary care sleep disorders center who answered all items on the ESS from January 8, 2008 to September 28, 2012. Dimensionality was assessed using scree plot, eigenvalues, factor loadings, principal factor analysis, and confirmatory factor analysis. Multigroup confirmatory factor analysis (MGCFA) evaluated dimensionality within 10 subgroups of clinical interest.

RESULTS

The mean age of the 10,785 study participants was 50 (± 15) years with 49% female, and 81% white. The one-factor solution explained 63% of the variability in responses with high factor loadings (> .67 for all 8 items). The scree plot identified one factor with eigenvalue > 1. Results of confirmatory factor analysis demonstrated a one-factor solution had acceptable goodness of fit as assessed by root mean square error of approximation of .094 (90% confidence interval: .089-.099). MGCFA confirmed measurement invariance within all 10 demographic and clinical subgroups.

CONCLUSIONS

Our study confirmed the unidimensionality of the ESS in a large diverse clinical population. Results from this study can be used to justify the interpretation of the ESS within clinical populations, and supports valid comparisons between groups based on the ESS. Future studies are warranted to further understand the items comprising the ESS and potentially eliminate redundant items for increased efficiency in clinical settings.

Psychometric analysis of Epworth Sleepiness Scale and its correlation with Pittsburgh sleep quality index in poor sleepers among Indian university students

Background The Epworth Sleepiness Scale (ESS) is an 8-item scale to detect excessive daytime sleepiness. Although its psychometric properties are well established on a number of populations the same has not been done for an Indian population, hence this study was designed to cover this knowledge gap. Aims The purpose of this study was to establish the test-retest reliability, validity and internal consistency of the ESS and its correlation with the Pittsburgh Sleep Quality Index (PSQI) in poor sleepers in India. Materials and methods Twenty-five poor sleepers were randomly chosen from a university population. All the subjects were administered the two scales on the test day and the same was repeated after 1 week, which was the retest. Statistical analysis Intraclass coefficient (ICC) and standard error of measurement (SEM) were calculated for the reliability which was further supported by the Bland-Altman graph and a scatterplot. Cronbach's alpha and Pearson's coefficient were calculated for internal consistency and correlation, respectively. Results Twenty-five poor sleepers with mean age 25.24 ± 7.04 years were recruited. The test-retest reliability for ESS displayed good reliability (ICC2,1: 0.86) which was supported by the Bland-Altman graph and the scatterplot. Cronbach's alpha was reported as 0.86 and Pearson's coefficient was r: 0.62, p-value: 0.001. Conclusion The results suggest that the ESS has good internal consistency and test-retest reliability for a university population of poor sleepers in India.

Serum Levels of Melatonin and Sleep Evaluation Scales in the Diagnosis of Sleep Disorders in Patients with Idiopathic Parkinson's Disease

Introduction

Sleep disturbances, such as difficulty in initiation of sleep, decrease in total sleep duration and efficacy, frequent awakenings, and increased daytime sleepiness are among the most common non-motor symptoms in patients with idiopathic Parkinson's disease (PD). However, patients usually do not consider these symptoms as important as their motor symptoms, and do not complain. We aimed to investigate PD patients for subtle sleep disturbances using sleep evaluation scales, and to evaluate the relationship between these tests and the serum levels of melatonin during night-sleep.

Methods

A total of 40 PD patients (19, female), older than 50 years, registered in our "Movement Disorders Out-patient Clinic", and 40 healthy, age and sex-matched control subjects (20, female) were included in the study. All subjects were assessed using Pittsburg Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Serum melatonin levels during night-sleep were measured in blood samples taken at 00:00 and 05:00 hours in every subject. Both groups were compared for demographical data, sleep evaluation scales and serum levels of melatonin.

Results

Patients with PD had significantly higher scores in PSQI and ESS than the healthy controls (p<0.001). Although the serum melatonin levels at two different time points during night sleep were lower in PD patients than the controls, these differences did not reach statistical significance (p=0.104 at 00:00 am, p=0.528 at 05:00 am). There was no significant correlation between the PSQI scores and serum melatonin levels in patient group (p>0.05). However, there was a significant but weak correlation (r=-0.353, p=0.025) between ESS scores and the serum melatonin levels measured at 05:00 hours in patients, but not between the melatonin levels measured at 00:00 hours.

Conclusion

Sleep evaluation questionnaires such as, PSQI and ESS, can provide useful information in PD patients with mild sleep disturbances. However, serum melatonin levels alone were not helpful in diagnosing the sleep disorders.

The prevalence of restless leg syndrome among pregnant Saudi women

Objectives:

Restless legs syndrome (RLS) is common among pregnant women, but it has not been documented in pregnant Saudi Arabian women. The main purpose of this study was to estimate the extent of the prevalence of RLS and identify both the associated factors and the associated risk factors among pregnant Saudi women.

Methods:

A cross-sectional study was conducted among pregnant women visiting obstetric clinics at King Abdulaziz Medical City in Riyadh (KAMC-Riyadh) over the period from June 1 to November 1, 2014. We interviewed the participants and collected demographic data, number of pregnancies, duration of pregnancy, comorbidities, and symptoms of RLS. The diagnosis of RLS is based on the four criteria designated by the International RLS Study Group.

Results:

The total number of participants enrolled was 517, and the mean age was 30.11 ± 5.42 years. The prevalence of RLS was 21.3% (110/517) (95% confidence interval [CI]: 17.83%-25.06%). RLS symptoms were more common among women in the third trimester (24.1%) compared to the second trimester (14.3%) and first trimester (13.6%), P = 0.043. The stepwise multivariate logistic model identified insomnia (odds ratio [OR]: 3.6, 95% CI: 2.167–6.017, P = 0.001), and poor sleep quality (OR: 4.9, 95% CI: 1.473-16.454, P = 0.010) were associated with RLS.

Conclusion:

RLS occurs in two of ten pregnant women visiting obstetric clinics at KAMC-Riyadh and is strongly associated with insomnia and poor sleep quality. Studies are needed to explore the causality of these associations.

Sleep onset insomnia, daytime sleepiness and sleep duration in relationship to Toxoplasma gondii IgG seropositivity and serointensity

Toxoplasma gondii (T. gondii) infects central nervous tissue and is kept in relative dormancy by a healthy immune system. Sleep disturbances have been found to precipitate mental illness, suicidal behavior and car accidents, which have been previously linked to T. gondii as well. We speculated that if sleep disruption, particularly insomnia, would mediate, at least partly, the link between T. gondii infection and related behavioral dysregulation, then we would be able to identify significant associations between sleep disruption and T. gondii. The mechanisms for such an association may involve dopamine (DA) production by T. gondii, or collateral effects of immune activation necessary to keep T. gondii in check. Sleep questionnaires from 2031 Old Order Amish were analyzed in relationship to T. gondii-IgG antibodies measured by enzyme-linked immunosorbent assay (ELISA). Toxoplasma gondii seropositivity and serointensity were not associated with any of the sleep latency variables or Epworth Sleepiness Scale (ESS). A secondary analysis identified, after adjustment for age group, a statistical trend toward shorter sleep duration in seropositive men (p = 0.07). In conclusion, it is unlikely that sleep disruption mediates links between T. gondii and mental illness or behavioral dysregulation. Trending gender differences in associations between T. gondii and shorter sleep need further investigation.

Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis

Objective Up to 75% of patients with chronic rhinosinusitis (CRS) suffer with poor sleep quality and reduced quality of life. Endoscopic sinus surgery has demonstrated encouraging results in improving sleep function. The aim of this systematic review is to assess the change in sleep quality after surgery for CRS. Data Sources PubMed, Web of Science, EMBASE. Review Methods An electronic search was conducted with the keywords "sinusitis" or "rhinosinusitis" and "sleep." Studies were included only when adults underwent endoscopic sinus surgery and were evaluated pre- and postoperatively by the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Apnea-Hypopnea Index (AHI), the sleep domain of Sino-Nasal Outcome Test-22, or the sleep domain of Rhinosinusitis Disability Index. Results The database search yielded 1939 studies, of which 7 remained after dual-investigator screening. The standardized mean differences (95% CI) for the ESS, PSQI, and AHI were -0.94 (-1.63 to -0.26), -0.80 (-1.46 to -0.14), and -0.20 (-0.32 to -0.07), indicating large, moderate to large, and small improvements, respectively. All analyses displayed high heterogeneity ( I² = 95%-99%). Conclusion Sleep quality, as measured by the ESS and PSQI surveys, shows substantial improvement after surgery for CRS, with smaller improvement seen for AHI. Generalizability of our results is limited by high heterogeneity among studies and by broad confidence intervals that cannot exclude small to trivial changes. The findings of this meta-analysis provide insight into the effect of CRS-related endoscopic sinus surgery on sleep quality, which should guide future research direction and counseling of patients in the clinical setting.

Wake up to sleep: The effects of lacosamide on daytime sleepiness in adults with epilepsy

OBJECTIVE

The objective of the study was to investigate the effects of lacosamide (LCM) on daytime sleepiness ascertained by the Epworth Sleepiness Scale (ESS) in adults with focal epilepsy in a randomized, controlled design.

METHODS

Subjects taking ≤2 AEDs for ≥4weeks underwent polysomnography with EEG followed by the maintenance of wakefulness test (MWT) and completed the ESS and other patient-reported outcomes (PROs) at baseline, LCM 200mg/day, and LCM 400mg/day (Visit 4; V4). Primary endpoint was ESS change (V4 to baseline) between LCM and placebo. Noninferiority test on ESS used a one-sided t-test based on a hypothesized difference of 4-point change between groups. Superiority test used a two-sided t-test to investigate the difference in change in PROs and MWT mean sleep latency (MSL) between groups. Fifty-five subjects provided 80% power to show noninferiority of LCM assuming 10% dropout.

RESULTS

Fifty-two subjects (mean age: 43.5±13.2years, 69% female, median monthly seizure frequency: 1 [0, 4.0]) participated. Baseline group characteristics including age, sex, ethnicity, standardized AED dose, seizure frequency, and ESS were similar. Abnormal baseline ESS scores were found in 35% of subjects. Noninferiority test found a ≤4-point increase in ESS (mean [95% CI]) in LCM subjects vs. placebo (-1.2 [-2.9, 0.53] vs. -1.1 [-5.2, 3.0], p=0.027) at V4. No significant difference in change in PROs, MSL, seizure frequency, or AED standardized dose was observed between groups.

SIGNIFICANCE

Our interventional trial found that LCM is not a major contributor to daytime sleepiness based on subjective and objective measures. Inclusion of sleepiness measures in AED trials is warranted given the high prevalence of sleep-wake complaints in people with epilepsy.

Verifying the Relative Efficacy between Continuous Positive Airway Pressure Therapy and Its Alternatives for Obstructive Sleep Apnea: A Network Meta-analysis

Obstructive sleep apnea (OSA) is a common breathing disorder, and continuous positive airway pressure (CPAP) therapy together with its alternatives has been developed to treat this disease. This network meta-analysis (NMA) was aimed to compare the efficacy of treatments for OSA. Cochrane Library, MEDLINE, and Embase were searched for eligible studies. A conventional and NMA was carried out to compare all therapies. Sleeping characteristics, including Apnea–Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), arterial oxygen saturation, and arousal index (AI), and changes of blood pressure were selected as outcomes. A total of 84 studies were finally included after rigorous screenings. For the primary outcomes of AHI and ESS, the value of auto-adjusting positive airway pressure (APAP), CPAP, and oral appliance (OA) all showed statistically reduction compared with inactive control (IC). Similar observation was obtained in AI, with treatments of the three active interventions. A lower effect of IC in SaO₂ was exhibited when compared with APAP, CPAP, and OA. Similar statistically significant results were presented in 24 h systolic blood pressure and 24 h DBP when comparing with CPAP. Our NMA identified CPAP as the most efficacious treatment for OSA patients after the evaluation of sleeping characteristics and blood pressures. In addition, more clinical trials are needed for further investigation due to the existence of inconsistency observed in this study.

Subjective and Objective Assessment of Hypersomnolence

This article describes clinical approaches to assessing sleepiness. Subjective sleep scales are used in clinical settings but have significant limitations. Likewise, objective tools may have prohibitive expense, and practical administration considerations may prohibit regular use. Gold standard tests include the multiple sleep latency test and maintenance of wakefulness test. These studies are criticized for a variety of reasons but are useful in appropriate clinical context. New tools suggest novel ways to assess sleepiness and will likely be more prominent in clinical assessments over time. This article outlines subjective scales and objective tools and suggests situations where particular instruments may be appropriate.

Screening Commercial Vehicle Drivers for Obstructive Sleep Apnea: Tools, Barriers, and Recommendations

Obstructive sleep apnea (OSA) is a disorder characterized by a cessation of breathing during sleep, leading to poor sleep patterns and daytime somnolence. Daytime somnolence is of particular concern for commercial vehicle drivers, whose crash risk increases 50% with untreated OSA. The process of diagnosing and treating OSA in commercial drivers begins with effective and consistent screening. Therefore, the researchers screened drivers with both the STOP-Bang Questionnaire and the Obstructive Sleep Apnea Evaluation Worksheet (OSAEW) and compared the two tools. Drivers screening positive on the STOP-Bang Questionnaire, OSAEW, and both questionnaires were 28%, 23%, and 13%, respectively. Sleep study referrals were made for 50 drivers; 12 drivers were scheduled for sleep tests within 3 months. Health care provider referral rates for drivers screening at high risk (37%) and commercial driver monitoring rates (24%) were both low. Recommendations to improve OSA screening and testing practices include Federal Motor Carrier Safety Administration-mandated screening and referral guidelines, employee-facilitated sleep testing, and OSA awareness campaigns.

A Sleep Position Trainer for positional sleep apnea: a randomized, controlled trial

We tested the effect of the Sleep Position Trainer, a vibrational device, for positional sleep apnea in an open, randomized controlled trial with 101 patients, where 52 patients were allocated to Sleep Position Trainer and 49 patients to a non-treatment control group for 2 months (Part 1). All patients were then followed as a cohort for a period of 6 months with use of the Sleep Position Trainer (Part 2). The participants were assessed with polygraphy at entry, and after 2 and 6 months. The mean apnea-hypopnea index supine was 35 per h (SD, 18) in the Sleep Position Trainer group and 38 per h (SD, 15) in the control group at entry. In a per protocol analysis, the mean total apnea-hypopnea index at entry and after 2 months in the Sleep Position Trainer group was 18 per h (SD, 10) and 10 per h (SD, 9; P < 0.001) versus 20 per h (SD, 9) and 18 per h (SD, 10; NS) in the control group. The mean supine sleep time decreased from 47% (SD, 22) to 17% (SD, 18; P < 0.001) in the Sleep Position Trainer group after 2 months. In the control group, the mean supine sleep time was 48% (SD, 20) at entry and 39% (SD, 21; NS) after 2 months. The positive effect of Sleep Position Trainer was maintained in all patients treated with Sleep Position Trainer after 6 months. Daytime sleepiness improved after 6 months. Compliance with the Sleep Position Trainer device during the first 2 months, defined as use of Sleep Position Trainer >4 h per night for all weekdays, was 75.5% (SD 21.2). The discontinuation rate was 28.8 and 49.4% after 2 and 6 months, respectively.

[Association between subjective and objective sleepiness in obstructive sleep apnea hypopnea syndrome patients]

Objective: To examine the association between subjective sleepiness and objective sleepiness in Chinese obstructive sleep apnea hypopnea syndrome (OSAHS) patients. Methods: A total of 1 660 patients meeting the diagnostic criteria of OSAHS based on overnight polysomnography from West China Hospital, Sichuan University in the period from Jul 2010 to Jul 2014 were enrolled in the study. The Epworth Sleepiness Scale (ESS) and Multiple Sleep Latency Test (MSLT) were to evaluate subjective and objective sleepiness, respectively. The subjects were categorized into quartiles [A (0-4) (n=406), B (5-7) (n=325), C (8-12) (n=443), D(13-24) (n=486) groups] based on the ESS score distribution. Survival analysis was used to characterize the association between the ESS score and the mean sleep latency (MSL). Results: The apnea hypopnea index (AHI) in D group was higher than other three groups [(58.7±26.1) vs (36.8±24.2), (42.6±26.7), (45.7±26.6) events/h, all P<0.05]. The mean sleep latency in D group was shorter than other three groups [(8.0±4.6) vs (10.9±4.4), (10.3±4.8), (9.4±4.5) min, all P<0.05]. The Kaplan-Meier survivor functions across the ESS score quartiles were distinct and fourth quartiles were progressively associated with a greater tendency for falling asleep (χ(2)=77.76, P<0.001 by Log-rank test) in the daytime (The percentages of awaking patients in fourth quartiles were progressively lower at the same time). The adjusted hazard ratios for sleep onset during the MSLT for the group B, C and D were 1.05 (95%CI: 0.90-1.22), 1.22 (95%CI: 1.07-1.40), and 1.38 (95%CI: 1.20-1.60), respectively, comparing to group A. Conclusion: Subjective report of daytime sleepiness is consistent with the objective sleepiness in OSAHS patients.

The influence of hypertension on daytime sleepiness in obstructive sleep apnea

Daytime sleepiness is a common symptom among hypertensive patients. The aim of this study was to determine subjective sleepiness assessed by Epworth Sleepiness Scale (ESS) and to asses sleep architecture in 304 patients with arterial hypertension. All patients underwent a standardized diagnostic overnight, polysomnography. The control group consisted of 67 normotensives. The hypertensive patients had a decreased sleep efficiency, mean and minimum oxygen saturation levels, and increased apnea/hypopnea index and oxygen desaturation index compared with normotensive patients. The lower ratio of N3 sleep, higher of N2 sleep, and decreased sleep efficiency was observed in hypertensives without obstructive sleep apnea (OSA). In the moderate to severe OSA groups, the total ESS score was significantly lower in hypertensives compared with normotensives. The ESS scores decreased with age in hypertensives, but not in normotensives. The study showed that ESS total score is lower in hypertensives than in normotensives with OSA, making the OSA more difficult to suspect. Thus, the low ESS score in hypertensives should not discourage further evaluation.

Effect of adherence on daytime sleepiness, fatigue, depression and sleep quality in the obstructive sleep apnea/hypopnea syndrome patients undertaking nasal continuous positive airway pressure therapy

OBJECTIVES

The aims of this study were to describe changes in day- and nighttime symptoms and the adherence to nasal continuous positive airway pressure (nCPAP) during the first 3-month nCPAP therapy among newly diagnosed patients with obstructive sleep apnea/hypopnea syndrome (OSAS) and to identify the effect of adherence on the changes in day- and nighttime symptoms during the first 3 months.

METHODS

Newly diagnosed OSAS patients were consecutively recruited from March to August 2013. Baseline clinical information and measures of the Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Zung's Self-Rating Depression Scale (SDS) and the Pittsburgh Sleep Quality Index (PSQI) at baseline and the end of 3rd, 6th, 9th and 12th week of therapy were collected. Twelve weeks' adherence was calculated as the average of each 3-week period. Mixed model was used to explore the effect of adherence to nCPAP therapy on ESS, FSS, SDS and PSQI in each 3-week phase.

RESULTS

Seventy-six patients completed the 12-week follow-up. The mixed-effects models showed that under the control of therapy phase adherence in the range of <4 hours per night, using nCPAP could independently improve daytime sleepiness, in terms of ESS (coefficient, [95% confidence interval] unit; -4.49 [-5.62, -3.36]). Adherence at 4-6 hours per night could independently improve all variables of day- and nighttime symptoms included in this study, namely ESS -6.69 (-7.40, -5.99), FSS -6.02 (-7.14, -4.91), SDS -2.40 (-2.95, -1.85) and PSQI -0.20 (-0.52, -0.12). Further improvement in symptoms could be achieved at ≥6 hours per night using nCPAP, which was ESS -8.35 (-9.26, -7.44), FSS -10.30 (-11.78, -8.83), SDS -4.42 (-5.15, -3.68) and PSQI -0.40 (-0.82, -0.02). The interaction between adherence level and therapy phase was not significant in day- and nighttime symptoms.

CONCLUSION

The effect of adherence on the above-mentioned symptoms is stable through the first 3 months. Under the control of therapy phase, the nCPAP therapy effectively improves day- and nighttime symptoms with ≥4 hours adherence, and the patients can achieve a further improvement with ≥6 hours adherence.