Journal of Clinical Sleep Medicine最新文献

Telehealth use greatly expanded under the Centers for Medicare and Medicaid Services (CMS) waivers at the start of the COVID-19 pandemic; however, the uncertainty and limitations of continued coverage risks loss of this momentum. Permanent coverage with adequate reimbursement is essential for the long-term acceptance and expansion of telehealth services. Telehealth supports both the current and future need for sleep health management by expanding patient access, increasing clinician efficiency, improving patient safety, and addressing health care equity. Sleep medicine is an ideal field for telehealth due to limited provider access, safety concerns with sleepy patients, availability of remote patient monitoring for treatment management, and the minimal need for repeated physical examinations. Telehealth is non-inferior for delivery of cognitive behavioral therapy for insomnia (CBT-I) and can enhance obstructive sleep apnea (OSA) treatment adherence. It is the position of the American Academy of Sleep Medicine (AASM) that telehealth is an essential tool for the provision of high quality, patient-centered care for patients with sleep disorders. We encourage all stakeholders including legislators, policymakers, clinicians, and patients to work together to address payment models, interstate care, technology access, prescribing practices, and ongoing research to ensure that sleep telehealth services are permanently available and accessible for all patients seeking sleep medicine care.

Study objectives: Catathrenia has been classified as a sleep-related breathing disorder variant in the third edition of the International Classification of Sleep Disorders, but its validity remains unverified. We analyzed the clinical descriptive variables and polysomnographic findings of catathrenia and discussed the similarities and differences to those of obstructive sleep apnea (OSA), non-REM parasomnias, and sleep bruxism (SB).

Methods: A retrospective analysis was conducted on 47 patients diagnosed with nocturnal groaning through polysomnography. We examined sex, body mass index, age at symptom onset, weekly symptom frequency, and presence/absence of comorbidities, including OSA, periodic limb movement disorder, non-REM parasomnia, and SB. The groaning event (GE) index was calculated according to sleep position and sleep stage.

Results: The distribution of patients with catathrenia did not show sex difference (male/female = 20:27), body mass index was 20.6 ± 3.0 kg/m², and age of onset was 18.2 ± 7.4 years. The GE index was higher in stages N1 and R than in stage N3 and in the supine position than in the lateral position. There were no cases complicated with non-REM parasomnia, but the complication of SB was observed in 30% of the participants, and SB events appeared immediately before or during the interictal period of the GE episodes in these cases.

Conclusions: Given the clinical background, posture- and sleep stage-dependent appearance of GEs, and the relatively high complication rate of SB, catathrenia pathogenesis may be heterogeneous or comprise elements of different sleep disorders.

Study objectives: Sleep disturbances in "long COVID" are common, but the associations between the severity of sleep problems and the severity of COVID infection are unclear. We evaluated the prevalence, persistence, comorbidities, and clinical effects of insomnia following recovery from acute COVID-19 infection in a COVID-specific clinic.

Methods: Inpatients discharged after COVID infection and outpatients referred for persistent post-COVID symptoms were surveyed on insomnia severity (Insomnia Severity Index, ISI), other neuropsychological symptoms, cardiopulmonary symptoms and physiological functions (6 minute walk distance and others), and functional outcome and quality of life (QOL). Multivariable regression models evaluated the severity of ISI against independent variables.

Results: A total of 280 patients met criteria at the initial visit. The prevalence of significant insomnia at the initial visit was 50% and 42% at the subsequent visit (obtained in 78 of the 280 patients). Lower age, female sex, non-white race, and non-Hispanic ethnicity were significantly associated with worse initial ISI scores. More severe symptoms of anxiety and depression were strong correlates with worse ISI scores. Interval improvements in insomnia severity correlated with improvements in anxiety and post-traumatic stress disorder (PTSD) scores. Physiological sequelae of infection did not correlate with insomnia at any stage.

Conclusions: Initial and persistent insomnia is common in long COVID. Treatment for insomnia with the use of evidence based approaches (such as cognitive behavioral therapy for insomnia) may best suit this particular post-COVID symptom.

Study objectives: Insomnia and sleep problems are common in pregnancy and have potentially negative impacts on both parental and infant health. This study examined the sleeping for two adaptation of cognitive behavioral therapy for insomnia (CBT-I) in pregnancy.

Methods: A parallel (1:1) randomized controlled trial evaluated CBT-I (n=32) compared to a treatment as usual (TAU) waitlist (n=32) among pregnant individuals from Alberta, Canada experiencing insomnia. Five weekly individual sessions of CBT-I pivoted from in-person delivery to telehealth due to COVID-19 pandemic physical distancing regulations. Insomnia symptom severity (primary outcome), insomnia diagnosis by structured interview, self-reported sleep problems, as well as sleep parameters measured by diary and actigraphy, were assessed pre-treatment at 12-28 weeks gestation (T1), one-week post-treatment (T2), and six months postpartum (T3). Birth information (secondary outcomes) were collected via delivery record and parent report of infant sleep (exploratory outcome) was taken at T3.

Results: Multilevel modeling using an intention-to-treat approach showed that CBT-I was associated with a decrease in insomnia symptoms and improved sleep quality across time compared to TAU. The CBT-I group had fewer diagnoses of insomnia post-treatment, but the difference did not reach statistical significance until 6-months postpartum. Participants with worse sleep quality at baseline benefitted substantially more from CBT-I vs. TAU waitlist.

Conclusions: CBT-I delivered in pregnancy can reduce symptoms of insomnia and improve sleep quality, which could in turn minimize risk of negative consequences for birthing parent and infant health.

Clinical trial registration: Registry: ClinicalTrials.gov; Identifier: NCT03918057; Name: Sleeping for Two: RCT of CBT-Insomnia in Pregnancy; URL: https://www.clinicaltrials.gov/study/NCT03301727.

Study objectives: Obstructive sleep apnea (OSA) is associated with cognitive impairment; however, the underlying mechanisms remain incompletely understood. OSA is characterized by periods of interrupted ventilation ("ventilatory burden (VB)"), leading to hypoxemia ("hypoxic burden (HB)") and/or arousal ("arousal burden (AB)") from sleep. While hypoxemia is considered a key mechanism underlying white matter injury, its measurement has been limited. In our primary analysis, we assessed the association of HB, a quantitative measure of hypoxemia, with white matter hyperintensity volume (WMH_v), a marker of small vessel disease, and compared with that of VB and AB (quantitative measures of ventilatory deficit and arousals).

Methods: Data from participants in the Multi-Ethnic Study of Atherosclerosis with full polysomnograms (PSG) and brain MRI were analyzed. HB was defined as the total area under the oxygen desaturation curve per hour of sleep, while VB was defined as the event-specific area under the ventilation signal and AB was defined as the normalized cumulative duration of all arousals. The primary outcome was WMH_v, with other MRI measures considered secondary outcomes.

Results: The analysis included PSGs from 587 participants (age: 65.5±8.2 years). In the fully adjusted model, each 1 standard deviation (SD) increase in HB was associated with a 0.09 SD increase in WMH_v (p=0.023), after adjusting for demographics, study site, and comorbidities. In contrast, VB, AB, and conventional OSA measures were not associated with outcomes.

Conclusions: Hypoxic burden was associated with white matter hyperintensity volume in a racially/ethnically diverse cohort of older individuals with a high prevalence of OSA.

Study objectives: To describe similarities and differences in OSA care pathways and their impact on patients in Australia and Canada, including among urban versus rural participants.

Methods: In this secondary data analysis of patient surveys exploring OSA care in Australia and Canada, we recruited adults with a prior diagnosis of OSA from market research companies, social media, and patient-facing medical associations. Residential postal codes were used to classify participants as urban or rural. Survey domains included wait times and travel distances for care, providers, and treatments.

Results: Data from 589 Canadians (21% rural; 42% female, mean [SD] age = 57 [13] years) and 412 Australians (38% rural; 45% female, mean [SD] age = 58 [14] years) with OSA were included. Participants in both countries most commonly sought initial care for suspected OSA from a primary care practitioner. Canadian participants waited longer to seek care than Australian participants (37% vs 51% within 12 months of symptom onset). Wait times for diagnostic testing were longer in Canada (59% vs 76% within 3 months of initial assessment), especially in urban settings (58% vs 78%). In both countries, >80% of participants were offered positive airway pressure (PAP) therapy. Overall, a greater variety of treatments were offered and used by Australian participants.

Conclusions: Greater access to diagnostic testing and a greater variety of treatments were found in Australia compared to Canada. Further research is needed to determine if reduced diagnostic wait times and presentation of increased therapy options found in Australia translate into better patient outcomes.

The botulinum toxin (BT) is US Food and Drug Administration-approved for therapeutic applications in different medical conditions. However, BT is not considered an obstructive sleep apnea (OSA) therapy. OSA is characterized by recurrent airway collapse during sleep, leading to intermittent hypoxia, hypercapnia, and arousal. The application of BT in pharyngeal and masticatory musculature can reduce its constrictive activity, attenuating the obstructions. We present the first case report of a 38-year-old man with severe OSA syndrome who underwent a BT infiltration in palatoglossal, stylohyoid, and masseter muscles bilaterally to treat OSA itself. He had significant clinical and polysomnographic improvement during the muscle afferent block by intramuscular injection of BT, without adverse effects.

Study objectives: Disrupted nighttime sleep (DNS) and sleep instability are common in children and adolescents with Narcolepsy Type 1 (NT1), but optimal objective sleep measures have not been determined. We compared self-reported and objective sleep measures between young people with NT1 and healthy controls (HC) and test the hypotheses that the Wake/N1 Index is the best objective measure of perceived nocturnal wakings vs. other DNS measures reported in the literature and is associated with daytime functional problems.

Methods: N=26 HC and N=27 NT1 participants ages 8-21 years completed a 15-item habitual sleep quality survey and an in-lab polysomnogram. We compared group survey responses and performed stepwise regression of sleep quality and instability measures with a survey question ("During the night, I wake more than once"). Last, we used logistic regression to identify associations between the Wake/N1 Index with daytime functional concerns across groups.

Results: Compared to HC, NT1 participants reported more frequent restless sleep, nighttime moaning/groaning/talking, tossing and turning, and nocturnal wakings (all p's < 0.01), but no greater difficulties in falling asleep or returning back to sleep. Across groups, self-reported waking from sleep was associated with increased Wake/N1 Index and SSRI/SNRI use. The Wake/N1 Index was associated with daytime fatigue but no other behavioral or cognitive concerns.

Conclusions: DNS is a multi-factorial complaint that differs from insomnia. We believe the Wake/N1 Index is a useful sleep instability measure that should be helpful in research and as a treatment target in clinical practice, especially for fatigue concerns.

Central sleep apnea (CSA) is commonly encountered among patients with sleep-disordered breathing, however its clinical consequences are less well-characterized. We therefore convened an expert panel to discuss the common presentations of CSA, as well as challenges and knowledge gaps in the diagnosis and management of CSA. The panel identified several key research priorities essential for advancing our understanding of the disorder. Within the diagnostic realm, panel members discussed the utility of multi-night assessments, and importance of the development and validation of novel metrics and automated assessments for differentiating central versus obstructive hypopneas, such that their impact on clinical outcomes and management may be better evaluated. The panel also discussed the current therapeutic landscape for the management of CSA and agreed that therapies should primarily aim to alleviate sleep-related symptoms, after optimizing treatment to address the underlying cause. Most importantly, the panel concluded that there is a need to further investigate the clinical consequences of CSA, as well as the implications of therapy on clinical outcomes, particularly among those who are asymptomatic. Future research should focus on endo-phenotyping central events for a better mechanistic understanding of the disease, validating novel diagnostic methods for implementation in routine clinical practice, as well as the use of combination therapy and comparative effectiveness trials in elucidating the most efficacious interventions for managing CSA.