Journal of Clinical Sleep Medicine最新文献

Study objectives: Hypoglossal nerve stimulator (HGNS) is a common treatment for obstructive sleep apnea. Objective assessment of HGNS efficacy measures apnea-hypopnea index (AHI) by multiamplitude titration polysomnography (tPSG) and/or a single amplitude, full-night type 3 home sleep study (eHST). Both tests have been used to determine efficacy despite significantly different protocols. This project's aim was to determine differences in objective outcomes in HGNS patients who underwent both tPSG and eHST postoperatively.

Methods: Data from 379 consecutive HGNS patients were retrospectively reviewed. Inclusion requirements were a preoperative sleep study, a postoperative tPSG, and then an eHST, which at our institution is a type 3 home study. AHI mean and differences were calculated. Wilcoxon rank sum tests were used to analyze differences between tPSG and eHST. Sher₁₅ criteria (postoperative AHI ≤ 15 events/h and ≥ 50% reduction from baseline) were calculated and compared by χ² tests.

Results: Ultimately 61 patients met inclusion criteria with an average preoperative AHI = 33.2 events/h. When comparing the patient's tPSG vs eHST, tPSG AHI was significantly lower (AHI = 8.8 events/h vs AHI = 17.6 events/h; respectively, P < .001). There was also a difference in the percentage of patients that met Sher₁₅ criteria when using tPSG (80.3%) vs eHST AHI (45.9%).

Conclusions: HGNS patient's postoperative tPSG AHI was significantly lower than their eHST outcome. This work highlights the importance of reporting the type of postoperative study used in evaluating HGNS efficacy and the need for single amplitude, full-night studies to assess HGNS efficacy more accurately.

Citation: Kaffenberger TM, Sina EM, Hambach B, et al. How we measure hypoglossal nerve stimulator outcome matters: titration vs single amplitude efficacy sleep studies. J Clin Sleep Med. 2025;21(1):47-53.

Study objectives: Optimal cutoff values of oximetry indices that differentiate obstructive sleep apnea (OSA) from primary snoring (PS) are not well-established. Our study aimed to assess the utility of overnight oximetry indices in differentiating PS from OSA and assessing OSA severity, compared to polysomnography, in children with suspected OSA.

Methods: This was a retrospective study of children (1-18 years of age) with snoring who underwent polysomnography. Patients with Down syndrome, craniofacial anomalies, known genetic syndromes, neuromuscular conditions, or a central apnea index ≥ 5 were excluded. Demographic data, polysomnography variables, and oximetry indices (eg, oxygen desaturation index [ODI₃, defined as number of ≥ 3% desaturation episodes/h of artifact-free recording time, and SpO₂ nadir]) were collected.

Results: Of 1,203 children (mean age 9.1 ± 3.9 years, 67.7% males), 91.8% (847/923) ≤ 12 years and 84.3% (236/280) > 12 years of age had OSA. The optimal cutoff of ODI₃ for differentiating PS from OSA was 2.4 (sensitivity [Se]: 78.8% [75.9-81.6%]; specificity [Sp]: 80.5% [69.9-88.7%]) in children ≤ 12 years of age and 3.6 (Se: 71.1% [64.8-76.8%]; Sp: 91.1% [78.8-97.5%]) in children > 12 years of age. The optimal cutoffs of ODI₃ for differentiating PS from mild, moderate, and severe OSA categories were 2.0 (Se: 70.1% [65.3-74.5%]; Sp: 70.1% [58.6-80.0%]), 3.7 (Se: 82.3% [76.6-87.1%]; Sp: 94.8% [87.2-98.6%]), and 4.3 (Se: 99.1% [96.8-99.9%]; Sp: 98.7% [93.0-100.0%]) in children ≤ 12 years of age and 1.9 (Se: 78.8% [75.9-81.6%]; Sp: 80.5% [69.9-88.7%]), 4.1 (Se: 85.4% [72.2-93.9%]; Sp: 91.1% [78.8-97.5%]), and 6.9 (Se: 98.4% [91.2-100.0%]; Sp: 97.8% [88.2-99.9%]) in children > 12 years of age, respectively.

Conclusions: This study provides optimal cutoff values for ODI₃ in differentiating PS from OSA and assessing OSA severity in children. Because oximetry is cheaper and widely available, ODI₃ has the potential to be incorporated into cost-effective clinical decision-making algorithms, especially in resource-limited settings.

Citation: Koh YQ, Sultana R, Pugalenthi A, et al. Utility of overnight oximetry indices in the evaluation of children with snoring and suspected obstructive sleep apnea. J Clin Sleep Med. 2025;21(1):109-121.

Study objectives: Seizures are rare in rapid eye movement (REM) sleep. However, seizures sometimes occur in REM sleep, and a small number of focal epilepsy patients display their maximum rate of interictal epileptiform discharges in REM sleep. We sought to systematically identify and characterize seizures in REM sleep.

Methods: We reviewed all admissions to the epilepsy monitoring unit at the Winnipeg Health Sciences Center over 12 months in 2014-2015. American Academy of Sleep Medicine sleep-stage scoring was initially applied in the standard 30-second epochs. Then, to capture sudden changes in sleep-wake state on shorter timescales that are associated with seizure formation and propagation, we rescored ictal and peri-ictal electroencephalography epochs every 1 second. Patients found to have seizures in REM sleep were subject to chart review spanning 3 years pre- and postadmission.

Results: REM sleep seizures occurred in 3 of 63 patients admitted to the epilepsy monitoring unit. Notably, 1 patient exhibited continuous epileptiform activity, consistent with focal nonconvulsive electrographic status epilepticus, throughout REM sleep cycles for each night of her admission. Otherwise, discrete REM sleep seizures constituted a small fraction of the other patients' total seizures (range 5.0-8.3%), occurred shortly after REM sleep onset from stage N2 sleep, and were manifest as minor epileptic arousals.

Conclusions: Our results confirm that REM sleep seizures are rare, while highlighting outliers who widen the known spectrum of heterogeneous sleep effects on seizures/epilepsy. We also report, to our knowledge, the first case of paradoxical status epilepticus in REM sleep.

Citation: McLeod GA, Szelemej PA, Toutant D, McKenzie MB, Ng MC. Dreams interrupted: characteristics of REM sleep-associated seizures and status epilepticus. J Clin Sleep Med. 2025;21(1):23-32.

Study objectives: Patients with obstructive sleep apnea often require the use of a continuous positive airway pressure (CPAP) machine. However, some patients experience issues using CPAP after receiving a dacryocystorhinostomy (DCR) for epiphora. This review aims to assess these complications and the potential interventions.

Methods: A systematic literature search was conducted in March 2023 with the PubMed, EMBASE, Web of Science, and Scopus databases. Since most of the studies were case reports and lacked quantitative results, a narrative review was done.

Results: Fourteen studies were included for review, representing 49 patients. During nightly CPAP use, 77.6% (38/49) of patients experienced air regurgitation onto the ocular surface via the tear drainage passage constructed by DCR. The interventions attempted could be categorized into (1) CPAP changes or (2) ophthalmic management. CPAP changes included changing the CPAP mask (successful in 5/6 patients), modifying the pressure or incorporating heated humidifier tubing (2/8 successes), changing the ventilation mode (1/3 successes), and switching to a CPAP alternative (1/2 successes). Ophthalmic management included eye plugs (3/3 successes), eye lubricants (2/6 successes), an eye patch (1/2 successes), and removal of the Lester Jones tube placed during DCR (1/1 successes). After trying these interventions, 36.7% (18/49) of patients continued to experience symptoms and opted to discontinue CPAP therapy.

Conclusions: CPAP-related issues after DCR are common and can be difficult to treat. There are a variety of techniques to improve CPAP use and adherence after DCR.

Citation: Sahoo A, Kreibich E, Tabor M, Sharma A. CPAP complications after dacryocystorhinostomy: a narrative review. J Clin Sleep Med. 2025;21(1):201-206.

Introduction: This systematic review provides supporting evidence for the accompanying clinical practice guideline on the treatment of restless legs syndrome and periodic limb movement disorder.

Methods: The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of pharmacological or nonpharmacological treatment to no treatment to improve patient-important outcomes. Statistical analyses were performed to determine the clinical significance of using various interventions to treat restless legs syndrome and periodic limb movement disorder in adults and children. The Grading of Recommendations Assessment, Development, and Evaluation process was used to assess the evidence for making recommendations.

Results: The literature search resulted in 3,631 studies out of which 148 studies provided data suitable for statistical analyses. The task force provided a detailed summary of the evidence along with the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

Citation: Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2025;21(1):153-199.

Study objectives: Serum ferritin levels are used to determine the need for iron supplementation in patients with restless legs syndrome. The purpose of this study was to determine whether immunoassay measurement of serum ferritin yields varying levels according to different manufacturers' assays, with resultant variation in cutoff values.

Methods: We compared serum ferritin levels using 116 clinical samples assessed by the Beckman and Roche methods.

Results: Although there was a high correlation between results obtained from the 2 methods (R² = 0.99), the absolute values differed. The equivalent ferritin measures determined by the Beckman and Roche methods were 50 μg/dl, 83 μg/dl; 75 μg/dl, 121 μg/dl; 100 μg/dl, 158 μg/dl; and 300 μg/dl, 457 μg/dl.

Conclusions: It is uncertain which assays were used to measure serum ferritin in the seminal studies on which current guidelines for iron therapy for restless legs syndrome are based. In view of this uncertainty, as well as the limited data on which current recommendations are based, clinicians should be flexible in using recommended serum ferritin cutoff values, also using percentage of transferrin saturation. Assuming that Beckman or equivalent assays were used, centers using the Roche method need to adjust the cutoffs for administration of oral iron and intravenous iron recommended by current practice guidelines to avoid withholding treatment for restless legs syndrome patients who might benefit from iron supplementation.

Citation: Silber MH, Block DR, St. Louis EK. Serum ferritin measurements differ according to the assay used: implications for iron therapy in restless legs syndrome. J Clin Sleep Med. 2025;21(1):65-67.

Study objectives: Temporomandibular disorders (TMDs) were linked to poor sleep on the Pittsburgh Sleep Quality Index (PSQI), whereas polysomnography revealed no major sleep disturbances, implying sleep state misperception. This study investigates sleep state misperception in TMD and control participants; correlates sleep state misperception with objective short sleep duration (SSD), depression symptoms, daytime sleepiness, and orofacial pain; and compares objective SSD between the groups.

Methods: General linear models were used to compare second-night polysomnography total sleep time, sleep latency, sleep efficiency (SE), and wake after sleep onset with homologous PSQI-derived variables in 124 women with myofascial TMD and 46 age and body mass index matched controls. PSQI variables were regressed onto objective SSD, depression symptoms, daytime sleepiness, and pain. Lastly, objective SSD was related to TMD presence.

Results: Compared to controls, TMD cases misperceived SE (P = .02); depression symptoms explained PSQI-derived SE (P = .002) and mediated the effect of pain (P < .001). PSQI variables were unrelated to respective polysomnography measures or objective SSD, except a significant self-reported-objective correlation in SE among controls only (P = .002). Objective SSD was more frequent in TMD cases (P = .02, odds ratio = 2.95), but it was unrelated to depression symptoms, daytime sleepiness, or prepolysomnography pain.

Conclusions: The study demonstrates misperception of SE among TMD cases, which was accounted for by depression symptoms. Objective SSD nearly tripled in TMD cases; however, it was unrelated to PSQI variables, depression, daytime sleepiness, or pain, suggesting that sleep state misperception and objective SSD are 2 independent sleep features in TMD.

Citation: Chan C, Dubrovsky B, Bouchard M, Tartter VC, Raphael KG. Sleep misperception in women with myofascial temporomandibular disorder. J Clin Sleep Med. 2025;21(1):55-64.