Economic implications of sleep disorders

Sleep disturbances are associated with greater healthcare utilization in children with autism spectrum disorder

BACKGROUND

Sleep disturbances are frequently reported in children with autism spectrum disorder (ASD) and are associated with the severity of co-occurring symptoms. This study's aim was to examine the extent of healthcare utilization and clinical outcomes associated with sleep disturbances in children with ASD.

STUDY DESIGN

A retrospective, cross-sectional study of 541 children with ASD from the Azrieli National Center for Autism and Neurodevelopment Research (ANCAN) whose parents completed the Children's Sleep Habits Questionnaire (CSHQ). Children with a total CSHQ score ≥ 48 were defined as having sleep disturbances. Sociodemographic characteristics, ASD diagnostic measures, chronic co-occurring conditions, medication usage, hospitalizations, visits to the emergency room (ER), and visits to specialists were compared in ASD children with and without sleep disturbances. Multivariate logistic regression models were then used to assess the independent association of sleep disturbances with clinical characteristics and healthcare utilization.

RESULTS

Of the 541 children with ASD, 257 (47.5%) had sleep disturbances. Children with sleep disturbances exhibited higher rates of multiple (≥ 3) co-occurring conditions (19.1% vs. 12.7%; p = 0.0414) and prescribed medications (45.5% vs. 32.7%; p = 0.0031) than other children. Finally, ASD children with sleep disturbances were 1.72 and 2.71 times more likely to visit the ER and be hospitalized than their counterparts (aOR = 1.72; 99%CI = 1.01-2.95; and aOR = 2.71; 99%CI = 1.10-6.67, respectively).

CONCLUSIONS

Our findings suggest that sleep disturbances are associated with greater healthcare utilization among children with ASD. Further studies could examine whether treating sleep disturbances in children with ASD yields additional clinical benefits beyond improvements in sleep.

A social-ecological examination of sleep among Airmen in technical training

Inadequate sleep is an on-going risk to the health and mission readiness of U.S. Armed Forces, with estimates of sleep problems high above U.S. civilian populations. Intervening early in the career of active duty Air Force personnel (or "Airmen") with education and the establishment of healthy behaviors may prevent short and long term-detriments of sleep problems. This paper describes the results of a qualitative study seeking to understand the facilitators and barriers to achieving good sleep in a technical training school during the first year of entry into the United States Air Force. Using the social ecological framework and content analysis, three focus groups with Airmen were conducted to explore themes at the individual, social, environmental, and organizational/policy level. Overall, results indicated a cohort motivated to achieve good sleep, and also struggling with a number of barriers across each level. This paper highlights opportunities for population health interventions during technical training aimed at supporting Airmen in developing healthy sleep behaviors early in the course of their career.

Elevated prevalence and treatment of sleep disorders from 2011 to 2020: a nationwide population-based retrospective cohort study in Korea

OBJECTIVES

This study used National Health Insurance claims data from Korea to report the prevalence of sleep disorders and treatment status, including traditional Korean medicine, in the last 10 years.

METHODS

This is a retrospective cohort study in Korea. All diagnosis and prescription data, including herbal medicine claims, from the Health Insurance Review and Assessment Service from 2011 to 2020 were reviewed. Prevalence estimation, direct medical expenses and prescribed amounts for sleep disorders were recorded.

RESULTS

The prevalence of sleep disorders increased from 3 867 975 (7.62%) in 2011 to 7 446 846 (14.41%) in 2020, nearly doubling over 10 years. Insomnia was observed in 91.44% (n=9 011 692) of the patients. The mean number of hospital visits per patient for sleep disorders was 11.5 (±26.62). Benzodiazepines are the most commonly prescribed medications for sleep disorders, and gamma-isoyosan is the most frequently prescribed herbal medicine.

CONCLUSIONS

Sleep disorders are continuously increasing, as is the use of medical services-personal and social medical expenses are also increasing accordingly. Sleep disorders should be recognised as a significant health problem that needs to be actively addressed to improve quality of life.

Preceding Night Sleep Quality and Atrial Fibrillation Episodes in the I-STOP-AFIB Randomized Trial

BACKGROUND

Chronic sleep disruption is associated with incident atrial fibrillation (AF), but it is unclear whether poor sleep quality acutely triggers AF.

OBJECTIVES

The aim of this study was to characterize the relationship between a given night's sleep quality and the risk of a discrete AF episode.

METHODS

Patients with symptomatic paroxysmal AF in the I-STOP-AFIB (Individualized Studies of Triggers of Paroxysmal Atrial Fibrillation) trial reported sleep quality on a daily basis. Participants were also queried daily regarding AF episodes and were provided smartphone-based mobile electrocardiograms (ECGs) (KardiaMobile, AliveCor).

RESULTS

Using 15,755 days of data from 419 patients, worse sleep quality on any given night was associated with a 15% greater odds of a self-reported AF episode the next day (OR: 1.15; 95% CI: 1.10-1.20; P < 0.0001) after adjustment for the day of the week. No statistically significant associations between worsening sleep quality and mobile ECG-confirmed AF events were observed (OR: 1.04; 95% CI: 0.95-1.13; P = 0.43), although substantially fewer of these mobile ECG-confirmed events may have limited statistical power. Poor sleep was also associated with longer self-reported AF episodes, with each progressive category of worsening sleep associated with 16 (95% CI: 12-21; P < 0.001) more minutes of AF the next day.

CONCLUSIONS

Poor sleep was associated with an immediately heightened risk for self-reported AF episodes, and a dose-response relationship existed such that progressively worse sleep was associated with longer episodes of AF the next day. These data suggest that sleep quality may be a potentially modifiable trigger relevant to the near-term risk of a discrete AF episode.

Melatonin Ameliorates Neuropsychiatric Behaviors, Gut Microbiome, and Microbiota-Derived Metabolites in Rats with Chronic Sleep Deprivation

With the increasing prevalence of sleep deprivation (SD)-related disorders, the effective treatment of sleep disorders has become a critical health research topic. Thus, we hypothesized and investigated the effectiveness of a 3-week melatonin intervention on neuropsychiatric behavioral responses mediated throughout melatonin receptors, gut microbiota, and lipid metabolites in rats with chronic SD. Eighteen 6-week-old Wistar rats were used and divided into the control grup (C, n = 6), SD group (n = 6), and melatonin-supplemented group (SDM, n = 6). During weeks 0 to 6, animals were provided with the AIN-93M diet and free access to water. Four-week chronic SD was conducted from weeks 7 to 10. Exogenous melatonin administration (10 mg/kg BW) was injected intraperitoneally 1 h before the daily administration of SD for 3 weeks in the SDM group. SD rats exhibited anxiety-like behavior, depression-like behavior, and cognitive impairment. Exogenous melatonin administration ameliorated neuropsychiatric behaviors induced by chronic SD. Analysis of fecal metabolites indicated that melatonin may influence brain messaging through the microbiota-gut-brain axis by increasing the production of short-chain fatty acids (SCFA) and decreasing the production of secondary bile acids (SBA). Four-week SD reduced the cerebral cortex expression of MT1, but not in the colon. Chronic SD led to anxiety and depression-like behaviors and cognitive decline, as well as the reduced intestinal level of SCFAs and the enhanced intestinal level of SBAs in rats. In this work, we confirmed our hypothesis that a 3-week melatonin intervention on neuropsychiatric behavioral response mediated throughout melatonin receptors, gut microbiota, and lipid metabolites in rats with chronic SD.

A Novel Clinical Tool to Detect Severe Obstructive Sleep Apnea

Purpose

Obstructive sleep apnea (OSA) is a disease with high morbidity and is associated with adverse health outcomes. Screening potential severe OSA patients will improve the quality of patient management and prognosis, while the accuracy and feasibility of existing screening tools are not so satisfactory. The purpose of this study is to develop and validate a well-feasible clinical predictive model for screening potential severe OSA patients.

Patients and Methods

We performed a retrospective cohort study including 1920 adults with overnight polysomnography among which 979 cases were diagnosed with severe OSA. Based on demography, symptoms, and hematological data, a multivariate logistic regression model was constructed and cross-validated and then a nomogram was developed to identify severe OSA. Moreover, we compared the performance of our model with the most commonly used screening tool, Stop-Bang Questionnaire (SBQ), among patients who completed the questionnaires.

Results

Severe OSA was associated with male, BMI≥ 28 kg/m2, high blood pressure, choke, sleepiness, apnea, white blood cell count ≥9.5×109/L, hemoglobin ≥175g/L, triglycerides ≥1.7 mmol/L. The AUC of the final model was 0.76 (95% CI: 0.74-0.78), with sensitivity and specificity under the optimal threshold selected by maximizing Youden Index of 73% and 66%. Among patients having the information of SBQ, the AUC of our model was statistically significantly greater than that of SBQ (0.78 vs 0.66, P = 0.002).

Conclusion

Based on common clinical examination of admission, we develop a novel model and a nomogram for identifying severe OSA from inpatient with suspected OSA, which provides physicians with a visual and easy-to-use tool for screening severe OSA.

Clarifying sleep characteristics and analyzing risk factors of sleep disorders to promote a predictive, preventive, and personalized medicine in patients with burn scars

Purpose

This study assessed sleep quality in patients with burn scars and investigated risk factors of sleep disorders to guide clinical therapy. From the strategy of predictive, preventive, and personalized medicine (PPPM/3PM), we proposed that risk assessment based on clinical indicators could prompt primary prediction, targeted prevention, and personalized interventions to improve the management of sleep disorders present in patients with burn scars.

Methods

This retrospective study recruited patients with burn scars and healthy volunteers from the Shanghai Burn Treatment Center between 2017 and 2022. Relevant information and data, including demographic characteristics, scar evaluation, and sleep quality, were obtained through the hospital information system, classical scar scale, and self-report questionnaires. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and monitored using a cardiopulmonary-coupled electrocardiograph. Pain and pruritus were assessed using the visual analog scale (VAS). Scar appearance was assessed using the modified Vancouver scar scale (mVSS).

Results

The sample was comprised of 128 hypertrophic scar (HS) patients, with 61.7% males, a mean age of 41.1 ± 11.6 years, and burn area of 46.2 ± 27.9% total body surface area (TBSA). Patients with PSQI ≥ 7 accounted for 76.6%, and the global PSQI score was 9.4 ± 4.1. Objective sleep data showed that initial enter deep sleep time, light sleep time, awakening time, light sleep efficiency, and sleep apnea index were higher but deep sleep time, sleep efficiency, and deep sleep efficiency were lower in HS patients than that in healthy controls. Preliminary univariate analysis showed that age, hyperplasia time of scar, narrow airway, microstomia, VAS for pain and pruritus, and mVSS total (comprised of pigmentation, vascularity, height and pliability) were associated with the PSQI score (p < 0.1). Multivariable linear regression showed narrow airway, VAS for pain and pruritus, and mVSS specifically height, were the risk factors for PSQI score (p < 0.1).

Conclusions

This study model identified that narrow airway, pain, pruritus and scar appearance specifically height may provide excellent predictors for sleep disorders in HS patients. Our results provided a basis for the predictive diagnostics, targeted prevention, and individualized therapy of somnipathy predisposition and progression of HS patients in the setting of PPPM/3PM health care system, which contributed to a paradigm shift from reactive cure to advanced therapy.

The association between sleep disorders on employment and income among adults in the United States

STUDY OBJECTIVES

To examine the association between sleep disorders, employment status, and income among US adults aged 18-64 years.

METHODS

The 2018-2019 Medical Expenditure Panel Survey medical conditions file was queried for adults aged 18-64 years with a diagnosis of a sleep disorder (International Classification of Diseases, 10th Revision, code G47.x) and linked to the household dataset. Comparisons in rates of wage, supplemental, and social security income as well as mean wage income were made between those with and without sleep disorders. Multivariate analyses, adjusting for demographics and comorbidities, were conducted.

RESULTS

A sleep disorder was diagnosed in 4.4% ± 0.2% of the study population (approximately 8.8 ± 0.4 million adults aged 18-64 years in the United States; mean age 46.9 years, 55.8% female). Adults with sleep disorders were less likely to have wage income from employment (adjusted odds ratio 0.5, 95% confidence interval 0.4-0.6, P < .001) and more likely to have Supplemental Security (1.8, 1.4-2.4, P < .001) and Social Security income (2.0, 1.6-2.4, P < .001) compared with those without sleep disorders. Among wage-earning adults, those with sleep disorders had $2,496 less mean annual wage income compared with those without a sleep disorder ($20,445 vs $22,941, P = .007), adjusting for demographics and comorbidities.

CONCLUSIONS

There are significantly higher indirect costs associated with sleep disorders. This study specifically demonstrates lower employment rates, lower wages, and higher welfare income utilization among those with sleep disorders despite using a very conservative estimate of sleep disorder prevalence.

CITATION

Huyett P, Bhattacharyya N. The association between sleep disorders, employment, and income among adults in the United States. J Clin Sleep Med. 2022;18(8):1967-1972.

Vitamin D Supplementation and Sleep: A Systematic Review and Meta-Analysis of Intervention Studies

Background: Vitamin D deficiency is associated with sleep disorders and poor sleep quality. Whether vitamin D supplementation (VDS) helps resolve these problems remains unclear. Objective: To systematically review the effect of VDS on sleep quantity, quality, and disorders, and perform a meta-analysis of available data. Methods: The reporting of this review followed the PRISMA statement. VDS human interventions studies that reported on sleep quality, quantity, or disorders were included. Medline, CINAHL, EMBASE, PsycInfo, the Cochrane Library, Clinicaltrials.gov, and the ICTRP were searched, in addition to the references of the included articles and previous relevant reviews, without language or time restrictions. Included studies were critically appraised, findings were narratively synthesized, and a meta-analysis was conducted. Furthermore, the overall certainty of the evidence was assessed. Results: A total of 19 studies were included (13 randomized controlled trials (RCTs), 1 opportunistic addition to an RCT, 4 pre−post studies, and 1 pre−post study analyzed as a case series); 3 RCTs were meta-analyses. The risk of bias was generally low. Pre−post studies showed a significant improvement in sleep quality with VDS. Similarly, the results of the meta-analysis revealed a statistically significant decrease in the Pittsburgh Sleep Quality Index with VDS compared with placebo (mean difference, −2.33 (95% CI, −3.09, −1.57); p < 0.001; I2 = 0%), with a moderate certainty of evidence. The results regarding the effect of VDS on sleep-related impairment, difficulty, and disorders, as well as sleepiness and restless legs syndrome, were not unanimous. Conclusions: VDS is promising in improving sleep quality; however, its effect on sleep quantity and disorders needs to be further investigated.

A jerk-based algorithm ACCEL for the accurate classification of sleep–wake states from arm acceleration

Arm acceleration data have been used to measure sleep–wake rhythmicity. Although several methods have been developed for the accurate classification of sleep–wake episodes, a method with both high sensitivity and specificity has not been fully established. In this study, we developed an algorithm, named ACceleration-based Classification and Estimation of Long-term sleep–wake cycles (ACCEL) that classifies sleep and wake episodes using only raw accelerometer data, without relying on device-specific functions. The algorithm uses a derivative of triaxial acceleration (jerk), which can reduce individual differences in the variability of acceleration data. Applying a machine learning algorithm to the jerk data achieved sleep–wake classification with a high sensitivity (>90%) and specificity (>80%). A jerk-based analysis also succeeded in recording periodic activities consistent with pulse waves. Therefore, the ACCEL algorithm will be a useful method for large-scale sleep measurement using simple accelerometers in real-world settings.

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An algorithm for sleep-wake classification based on arm acceleration is presented

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The algorithm only uses a derivative of triaxial arm acceleration (jerk)

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The algorithm can accurately detect temporal awake during sleep

Automated Scoring of Respiratory Events in Sleep with a Single Effort Belt and Deep Neural Networks

OBJECTIVE

Automatic detection and analysis of respiratory events in sleep using a single respiratory effort belt and deep learning.

METHODS

Using 9,656 polysomnography recordings from the Massachusetts General Hospital (MGH), we trained a neural network (WaveNet) to detect obstructive apnea, central apnea, hypopnea and respiratory-effort related arousals. Performance evaluation included event-based analysis and apnea-hypopnea index (AHI) stratification. The model was further evaluated on a public dataset, the Sleep-Heart-Health-Study-1, containing 8,455 polysomnographic recordings.

RESULTS

For binary apnea event detection in the MGH dataset, the neural network obtained a sensitivity of 68%, a specificity of 98%, a precision of 65%, a F1-score of 67%, and an area under the curve for the receiver operating characteristics curve and precision-recall curve of 0.93 and 0.71, respectively. AHI prediction resulted in a mean difference of 0.417.8 and a r² of 0.90. For the multiclass task, we obtained varying performances: 84% of all labeled central apneas were correctly classified, whereas this metric was 51% for obstructive apneas, 40% for respiratory effort related arousals and 23% for hypopneas.

CONCLUSION

Our fully automated method can detect respiratory events and assess the AHI accurately. Differentiation of event types is more difficult and may reflect in part the complexity of human respiratory output and some degree of arbitrariness in the criteria used during manual annotation.

SIGNIFICANCE

The current gold standard of diagnosing sleep-disordered breathing, using polysomnography and manual analysis, is time-consuming, expensive, and only applicable in dedicated clinical environments. Automated analysis using a single effort belt signal overcomes these limitations.

High-dose Vitamin D Supplementation and Improvement in Cognitive Abilities, Insomnia, and Daytime Sleepiness in Adolescent Girls

Introduction:

Vitamin D may affect the modulation of signaling pathways in the central nervous system. We aimed to evaluate the effect of high-dose vitamin D supplementation on neuropsychological functions in female adolescents.

Methods:

We studied the effects of 9 weeks of vitamin D supplementation (50000 IU vitamin D3 [cholecalciferol]/week) on cognitive abilities and sleep disorders in 940 adolescent girls.

Results:

Oral vitamin D supplementation improved cognitive abilities, including memory, inhibitory control, selective attention, decision making, planning, sustained attention, and cognitive flexibility in healthy adolescent girls (P<0.001). The prevalence of subjects with insomnia after intervention fell from 15.0% to 11.3%. Similar results were also found for the prevalence of sleepiness (15.6% reduced to 14.7%), or cases with both insomnia and sleepiness (8.0% reduced to 6.1%; P<0.05).

Conclusion:

High dose of vitamin D can improve cognitive abilities and alleviate insomnia and daytime sleepiness in adolescent girls. Further investigations are required on different population groups (age and gender) to determine the sustainability of these effects. The value of vitamin D therapy in other neurological disorders would also be of research interest.

Incremental health care utilization and expenditures for sleep disorders in the United States

STUDY OBJECTIVES

To determine the incremental increases in health care utilization and expenditures associated with sleep disorders.

METHODS

Adults with a diagnosis of a sleep disorder (International Classification of Diseases, 10th Revision, code G47.x) within the medical conditions file of the 2018 Medical Expenditure Panel Survey medical conditions file were identified. This dataset was then linked to the consolidated expenditures file and comparisons in health care utilization and expenditures were made between those with and without sleep disorders. Multivariate analyses, adjusted for demographics and comorbidities, were conducted for these comparisons.

RESULTS

Overall, 5.6% ± 0.2% of the study population had been diagnosed with a sleep disorder, representing approximately 13.6 ± 0.6 million adults in the United States. Those with sleep disorders were more likely to be non-Hispanic, White, and female, with a higher proportion with public insurance and higher Charlson Comorbidity Scores. Adults with sleep disorders were found to have increased utilization of office visits (16.3 ± 0.8 vs 8.7 ± 0.3, P < .001), emergency room visits (0.52 ± 0.03 vs 0.37 ± 0.02, P < .001), and prescriptions (39.7 ± 1.2 vs 21.9 ± 0.4, P < .001) vs those without sleep disorders. The additional incremental health care expenses for those with sleep disorders were increased in all examined measures: total health care expense ($6,975 ± $800, P < .001), total office-based expenditures ($1,694 ± $277, P < .001), total prescription expenditures ($2,574 ± $364, P < .001), and total self-expenditures for prescriptions ($195 ± $32, P < .001).

CONCLUSIONS

Sleep disorders are associated with significantly higher rates of health care utilization and expenditures. By using the conservative prevalence estimate found in this study, the overall incremental health care costs of sleep disorders in the United States represents approximately $94.9 billion.

CITATION

Huyett P, Bhattacharyya N. Incremental health care utilization and expenditures for sleep disorders in the United States. J Clin Sleep Med. 2021;17(10):1981-1986.

Effect of exercise training on improving sleep disturbances: a systematic review and meta-analysis of randomized control trials

OBJECTIVES

Exercise training has beneficial effects on various aspects of health. This study aimed to investigate the effect of exercise training on the improvement of sleep disturbances using systematic review and meta-analysis of randomized control trials.

METHOD

Four indexes of scientific information including PubMed, Web of Science, Scopus, and the Cochrane library were selected and all manuscripts of these sources were searched in English until January 2021. The studies were screened and finally, the studies were entered into meta-analysis and the Standardized Mean Difference (SMD) was calculated, and the analyzes were performed based on the random effects method. Publication bias and heterogeneity were examined in all analyzes.

RESULT

A total of 32 studies were included in the meta-analysis. Meta-analysis showed that exercise training is effective in improving sleep quality (SMD = -0.85 and confidence interval (CI) was -1.16-0.54; P < 0.001). Exercise training improving insomnia (SMD = -0.87 and CI was -1.68-0.06; P = 0.036). Exercise training improves sleepiness (SMD = -0.38 and CI was -0.68-0.07; P = 0.016), obstructive sleep apnea (SMD = -0.40 and CI was -0.67-0.14; P = 0.003) and restless legs syndrome (SMD = -1.02 and CI was -1.56-0.49; P < 0.001).

DISCUSSION

Exercise training has beneficial effects on a variety of sleep disturbances and therefore it can be said that providing the necessary conditions for exercise training can play a major role in promoting health, especially since this type of intervention is a non-pharmacological intervention.

Employer-mandated obstructive sleep apnea treatment and healthcare cost savings among truckers

OBJECTIVE

To evaluate the effect of an employer-mandated obstructive sleep apnea (OSA) diagnosis and treatment program on non-OSA-program trucker medical insurance claim costs.

METHODS

Retrospective cohort analysis; cohorts constructed by matching (randomly, with replacement) Screen-positive Controls (drivers with insurance screened as likely to have OSA, but not yet diagnosed) with Diagnosed drivers (n = 1,516; cases = 1,224, OSA Negatives = 292), on two factors affecting exposure to medical claims: experience level at hire and weeks of job tenure at the Diagnosed driver's polysomnogram (PSG) date (the "matching date"). All cases received auto-adjusting positive airway pressure (APAP) treatment and were grouped by objective treatment adherence data: any "Positive Adherence" (n = 932) versus "No Adherence" (n = 292). Bootstrap resampling produced a difference-in-differences estimate of aggregate non-OSA-program medical insurance claim cost savings for 100 Diagnosed drivers as compared to 100 Screen-positive Controls before and after the PSG/matching date, over an 18-month period. A two-part multivariate statistical model was used to set exposures and demographics/anthropometrics equal across sub-groups, and to generate a difference-in-differences comparison across periods that identified the effect of OSA treatment on per-member per-month (PMPM) costs of an individual driver, separately from cost differences associated with adherence choice.

RESULTS

Eighteen-month non-OSA-program medical claim costs savings from diagnosing (and treating as required) 100 Screen-positive Controls: $153,042 (95% CI: -$5,352, $330,525). Model-estimated effect of treatment on those adhering to APAP: -$441 PMPM (95% CI: -$861, -$21).

CONCLUSIONS

Results suggest a carrier-based mandatory OSA program generates substantial savings in non-OSA-program medical insurance claim costs.

Estimation of national stress index using socioeconomic antecedents - a case of MIMIC model

Developed economies are at the forefront of facing the brunt of non-communicable diseases (NCD). The majority of the health expenditures are routed in managing obesity and mental disorder-related patients, and there is a fall in the productivity of the distressed and NCD prone labour. Several indicators of stress are used in literature to assess its implications. However, empirically no database has maintained the longitudinal data of national stress level. This study focused on constructing the socioeconomic antecedent of non-communicable stress which is leading to several NCDs. For this Multiple Indicator and Multiple Causes (MIMIC) model is utilized for 151 countries between 2008 and 2018. The results show that macroeconomic conditions, trade, and environmental quality follow fundamentals in explaining stress. While, national stress index is a significant source of smoking and mental disorder prevalence.

Quality of Life and Psychological Impact in Patients with Atopic Dermatitis

Atopic dermatitis (AD) is a dermatological disorder that affects patients' mental health and psychological state in complex ways. The importance of understanding the entire scope of this burden is well recognized, but there is limited comprehensive information about the resulting stress on adult patients with AD. This study aimed to determine the degree of psychological stress in patients with AD compared to healthy participants. A total of 352 adult patients participated in this cross-sectional study-174 with AD and 178 healthy participants. Demographic and clinical data were collected. Itch and sleep disturbance were assessed using a numeric rating scale and a visual analogue scale. The 20-item Toronto Alexithymia Scale (TAS-20) and Beck Depression Inventory (BDI) questionnaires were administered to assess the symptoms of alexithymia and depression. Quality of life (QOL) was assessed in AD patients using the Dermatology Quality Index. In our study, we found high TAS-20 and BDI scores among patients with AD. The prevalence of alexithymic personality features was 56.3% in patients with AD versus 21.3% in healthy controls (p < 0.001). Based on BDI scoring (BDI-21 > 13), depression was suspected in a significantly higher number of patients with AD than in the control group (56.9% (99/174) vs. 15.7% (28/178); p < 0.0001). Eczema Area and Severity Index (EASI) score did not show any significant correlations with psychological parameters. Among clinical parameters, only sleep disturbance was positively correlated with depression (R = 0.307, p < 0.005). Our data show that the severity index score as a representative factor of skin involvement has a limited role in predicting the effect of skin diseases on mental status. Screening and assessment for psychiatric disorders, QOL, and sleep disturbance in patients with atopic dermatitis cannot be neglected by physicians and they should be treated in clinical practice with the consideration of psychosomatic approaches.

Study Protocol on the Validation of the Quality of Sleep Data from Xiaomi Domestic Wristbands

(1) Background: Sleep disorders are a common problem for public health since they are considered potential triggers and predictors of some mental and physical diseases. Evaluating the sleep quality of a person may be a first step to prevent further health issues that diminish their independence and quality of life. Polysomnography (PSG) is the “gold standard” for sleep studies, but this technique presents some drawbacks. Thus, this study intends to assess the capability of the new Xiaomi Mi Smart Band 5 to be used as a tool for sleep self-assessment. (2) Methods: This study will be an observational and prospective study set at the sleep unit of a hospital in A Coruña, Spain. Forty-three participants who meet the inclusion criteria will be asked to participate. Specific statistical methods will be used to analyze the data collected using the Xiaomi Mi Smart Band 5 and PSG. (3) Discussion: This study offers a promising approach to assess whether the Xiaomi Mi Smart Band 5 correctly records our sleep. Even though these devices are not expected to replace PSG, they may be used as an initial evaluation tool for users to manage their own sleep quality and, if necessary, consult a health professional. Further, the device may help users make simple changes to their habits to improve other health issues as well. Trial registration: NCT04568408 (Registered 23 September 2020).

Knowledge about obstructive sleep apnea among medical undergraduate students: A long way to go!

OBJECTIVE

The aim is to study the knowledge and attitude of medical undergraduate students regarding obstructive sleep apnea (OSA).

MATERIALS AND METHODS

This cross-sectional study involved 324 medical undergraduate students in clinical semesters. Knowledge and attitude regarding adult OSA were assessed using the obstructive sleep apnea knowledge and attitude (OSAKA), and to evaluate the same about childhood OSA, OSAKA-KIDS was used.

RESULTS

Results showed that the study population was not informed about OSA among adults as well as kids. Most of the participants could recognize that snoring was a common symptom of adult OSA but failed to identify the association between childhood OSA and hyperactivity. The participants had a good knowledge about the pathophysiology of OSA. More than 80% of students reported that OSA is an important disorder and that these patients should be identified.

CONCLUSION

Medical undergraduates are poorly informed about OSA.

Self-reported poor sleep on multiple dimensions is associated with higher total health care costs in older men

STUDY OBJECTIVES

To estimate the association of self-reported poor sleep in multiple dimensions with health care costs in older men.

METHODS

Participants were 1,413 men (mean [SD] age 76.5 [5.7] years) enrolled in both the Outcomes of Sleep Disorders in Older Men (MrOS Sleep) study and Medicare Fee-for-Service. Poor sleep was characterized at the baseline MrOS Sleep visit on five dimensions (satisfaction, daytime sleepiness, timing, latency, and duration). Health care costs and utilization were ascertained over 3 years of follow-up using Medicare Claims.

RESULTS

Median (interquartile range [IQR]) annualized total health care costs (2018 US dollars) rose from $3,616 (IQR 1,523-7,875) for those with no impaired sleep dimensions to $4,416 (IQR 1,854-11,343) for men with two impaired sleep dimensions and $5,819 (IQR 1,936-15,569) for those with at least three impaired sleep dimensions. After multivariable adjustment, the ratio of total health care costs (CR) was significantly higher for men with two (1.24, 95% confidence interval [CI] 1.03- to 1.48) and men with at least three impaired sleep dimensions (1.78, 95% CI 1.42 to 2.23) vs. those with no impaired sleep dimensions. After excluding 101 men who died during the 3-year follow-up period, these associations were attenuated and not significant (CR 1.22, 95% CI 0.98 to 1.53 for men ≥3 impaired sleep dimensions vs. none).

CONCLUSIONS

Self-reported poor sleep on multiple dimensions is associated with higher subsequent total health care costs in older men, but this may be due to higher mortality and increased health care costs toward the end of life among those with poor sleep health.

Low-dose melatonin for sleep disturbances in early-stage cirrhosis: A randomized, placebo-controlled, cross-over trial

Background and aim

Melatonin is used to treat sleep disturbances (SDs). The aim of this study was to investigate the safety and efficacy of low‐dose melatonin for SDs in early‐stage cirrhosis.

Methods

In a single‐center, randomized, double‐blind, placebo‐controlled, cross‐over clinical trial, patients with early‐stage (Child‐Turcotte‐Pugh [CTP] class A or B) cirrhosis with SDs, without hepatic encephalopathy, were randomized to placebo or 3 mg of melatonin for 2 weeks. After 2 weeks, the patients were given a washout period of 1 week and crossed over to melatonin or placebo for a further 2 weeks. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to measure sleep quality and daytime sleepiness, respectively. Analysis of results was based on intention to treat, and linear mixed‐effect models were used to evaluate the effect of melatonin. Analysis was conducted using R‐programming language 3.5.1.

Results

Seventy one patients were recruited (mean age: 61.9 ± 8.7 years, males: 46 [64.8%], and CTP Class A = 52 [73.2%] and Class B = 19 [26.8%]). Sixty patients completed the study (mean age: 61.7 ± 8.8 years, males: 40 [66.6%], and CTP Class A = 45 [75.0%] and Class‐B = 15 [25.0%]). Two patients dropped out due to adverse events. Nine patients were lost to follow up. Patients given melatonin had a significantly lower PSQI and ESS compared to both pretreatment (P < 0.001) and postplacebo scores (P < 0.001). Incidence of adverse events was similar (two each of abdominal pain, one each of headache, one each of dizziness) in both groups.

Conclusion

Melatonin seems safe and effective for use in patients with SDs in early‐stage cirrhosis in the short term. However, larger and longer‐term studies to assess efficacy and safety are required before its clinical use can be recommended.

Sex differences in measures of central sensitization and pain sensitivity to experimental sleep disruption: implications for sex differences in chronic pain

Study Objectives

Females demonstrate heightened central sensitization (CS), a risk factor for chronic pain characterized by enhanced responsivity of central nervous system nociceptors to normal or subthreshold input. Sleep disruption increases pain sensitivity, but sex has rarely been evaluated as a moderator and few experiments have measured CS. We evaluated whether two nights of sleep disruption alter CS measures of secondary hyperalgesia and mechanical temporal summation in a sex-dependent manner. We also evaluated differences in measures of pain sensitivity.

Methods

Seventy-nine healthy adults (female n = 46) participated in a randomized crossover experiment comparing two consecutive nights of eight pseudorandomly distributed forced awakenings (FA [-200 min sleep time]) against two nights of undisturbed sleep (US). We conducted sensory testing the mornings following Night 2; the heat-capsaicin pain model was used to induce secondary hyperalgesia.

Results

FA reduced total sleep time (REM and NREM Stage 3) more profoundly in males. We observed divergent, sex-dependent effects of FA on secondary hyperalgesia and temporal summation. FA significantly increased secondary hyperalgesia in males and significantly increased temporal summation in females. Sex differences were not attributable to differential sleep loss in males. FA also significantly reduced heat-pain threshold and cold pressor pain tolerance, independently of sex.

Conclusions

Sleep disruption enhances different pain facilitatory measures of CS in males and females suggesting that sleep disturbance may increase risk for chronic pain in males and females via distinct pathways. Findings have implications for understanding sex differences in chronic pain and investigating sleep in chronic pain prevention efforts.

Atopic Dermatitis in Adults

Atopic dermatitis (AD) was once thought to be a benign childhood disease that remitted with increasing age. However, recent studies have transformed the understanding of AD, particularly in adult patients. AD is common in adults and can lead to substantial disability by negatively affecting sleep, mental health, and quality of life. There seem to be different genetic, immunologic, and epidemiologic risk factors for AD in adults than in children. This article examines the pathophysiology, epidemiology, heterogeneous clinical presentation, burden, diagnosis, and treatment of adult AD.

Expert-level sleep scoring with deep neural networks

Objectives

Scoring laboratory polysomnography (PSG) data remains a manual task of visually annotating 3 primary categories: sleep stages, sleep disordered breathing, and limb movements. Attempts to automate this process have been hampered by the complexity of PSG signals and physiological heterogeneity between patients. Deep neural networks, which have recently achieved expert-level performance for other complex medical tasks, are ideally suited to PSG scoring, given sufficient training data.

Methods

We used a combination of deep recurrent and convolutional neural networks (RCNN) for supervised learning of clinical labels designating sleep stages, sleep apnea events, and limb movements. The data for testing and training were derived from 10 000 clinical PSGs and 5804 research PSGs.

Results

When trained on the clinical dataset, the RCNN reproduces PSG diagnostic scoring for sleep staging, sleep apnea, and limb movements with accuracies of 87.6%, 88.2% and 84.7% on held-out test data, a level of performance comparable to human experts. The RCNN model performs equally well when tested on the independent research PSG database. Only small reductions in accuracy were noted when training on limited channels to mimic at-home monitoring devices: frontal leads only for sleep staging, and thoracic belt signals only for the apnea-hypopnea index.

Conclusions

By creating accurate deep learning models for sleep scoring, our work opens the path toward broader and more timely access to sleep diagnostics. Accurate scoring automation can improve the utility and efficiency of in-lab and at-home approaches to sleep diagnostics, potentially extending the reach of sleep expertise beyond specialty clinics.

Absenteeism and Delay to Work Due to Sleep Disorders in the Turkish Adult Population: A Questionnaire-Based National Survey

Sleep problems may have negative effects on work-life balance, overall health, and safety. We aimed to investigate the association between sleep disorders and absenteeism and delay to work (being late or tardy) among the working adult population. The study was conducted by using data from a large survey of working adults who participated in the Turkish Adult Population Epidemiology of Sleep Study (TAPES) managed by Turkish Sleep Medicine Society (TSMS). Secondary analyses was employed to examine absenteeism and delay to work and their associations with sleep problems, including sleepiness by Epworth Sleepiness Scale (ESS), parasomnias, sleep apnea (by Berlin Questionnaire), sleep quality (by Pittsburgh Sleep Quality Index), and restless leg. History of any absenteeism and delay to work was observed in 276 (18%) and 443 (29%) out of 1,533 working adults, respectively. In the multivariate analyses, absenteeism was associated with younger age, female gender and poor sleep quality, while delay to work was associated with younger age, poor sleep quality, parasomnia, and sleepiness. In the presence of absenteeism and delay to work, sleep disorders including sleepiness, poor sleep quality, and parasomnia should be considered. Such evaluation may improve worker well-being and provide some additional benefits in terms of increasing productivity and lowering work-related costs.

Patient preference survey: are patients willing to delay surgery if obstructive sleep apnea is suspected?

BACKGROUND

Screening and optimizing patients for OSA in the perioperative period may reduce postoperative complications. However, sleep studies can be difficult to obtain before surgery. Previous surveys reported that the majority of sleep physicians would delay surgery to diagnose and manage OSA, but most anesthesiologists would not. While disagreements exist, the importance of shared decision making and patient preferences have never been studied on this topic. It is unknown whether patients with suspected OSA, when given information about OSA, would be willing to delay surgery to diagnose and manage their condition preoperatively.

METHODS

This study consisted of a self-administered questionnaire that surveyed patients, patient relatives, or any accompanying members. The survey was conducted in the preoperative clinic or in the perioperative patient and family waiting area at two hospitals in Canada and in the United States. A hypothetical scenario was used: participants were given information about OSA, and asked about their preferences regarding preoperative management should they be at risk for OSA in the setting of pending elective surgery. The objective of this study was to determine whether respondents preferred to 1) proceed with surgery as planned, 2) delay surgery to ensure the medical condition of OSA is diagnosed and optimized, or 3) let his/her physician decide.

RESULTS

The final survey contained 19 questions and the survey was conducted from June 2016 to September 2016. Four hundred and seventy-three surveys were collected. Forty-four percent of respondents, when given information about OSA, preferred to delay surgery pending a sleep study and treatment. Forty percent of respondents who preferred to delay surgery would tolerate delaying up to two months.

CONCLUSION

Increasing emphasis and significant value has been placed on shared-decision making between patients and physicians. Educating patients about the risks of OSA and incorporating patient preferences into the perioperative management of OSA may be warranted.

Using coffee to compensate for poor sleep: Impact on vigilance and implications for workplace performance

Poor sleep negatively impacts vigilance and is associated with reduced well-being and work productivity. While many individuals depend on caffeine to counteract the cognitive consequences of poor sleep and restore optimal work performance, few studies have naturalistically evaluated this strategy. This study examined the effects of coffee on vigilance, comparing individuals based on recent sleep quality. Sixty-nine participants completed two randomized, counterbalanced trials consisting of 237 ml water or coffee (100 mg caffeine), followed by a continuous performance test assessing vigilance at 30, 90, and 120 min. While coffee improved and stabilized reaction time at all three assessments regardless of recent sleep history, its effects on omission and commission errors were seen only at 90 min; coffee increased commission errors and only partially reduced omission errors in individuals reporting poor sleep quality. The use of coffee to combat poor sleep may therefore be detrimental in situations requiring inhibitory control.

Associations between atopic dermatitis and other disorders

Atopic dermatitis is a heterogeneous, chronic, and inflammatory skin disease that is associated with a profound symptom burden. Recent studies have demonstrated associations between atopic dermatitis and a number of multi-organ and systemic disorders. The origin of these comorbid conditions is likely multifactorial, with combined effects of skin-barrier disruption, immune dysregulation, intense symptoms, and iatrogenic complications. Some of these comorbid conditions appear to be related to the underlying severity of atopic dermatitis and inadequate disease control. This review will summarize recent developments in the understanding of the comorbid health disorders associated with atopic dermatitis, particularly infections, sleep disturbances, and cardiovascular disease.

Enduring sleep complaints predict health problems: a six-year follow-up of the survey of health and retirement in Europe

OBJECTIVES

Sleep complaints are common and enduring among old people. The study aimed to extend current knowledge by exploring the effects of episodic versus chronic sleep complaints on a range of physical and mental health outcomes.

METHODS

Older adults (N = 8934, mean age = 64) who participated in Waves 1, 2 and 4 of the Survey of Health, Ageing and Retirement in Europe (SHARE) reported sleep and health outcome measures. Episodic sleep complaints, in the first or in the second wave and chronic sleep complaints, in both waves were recorded. Outcomes in Wave 4 included physical symptoms, difficulties in activities of daily living and low quality of life.

RESULTS

Logistic regressions examined whether episodic and chronic sleep complaints at W1 and W2 predict W4 health outcomes. Chronic sleep complaints predicted worse outcomes, compared to no sleep difficulties and to episodic sleep complaints, even after adjusting for demographic characteristics and previous levels of health.

CONCLUSION

Sleep complaints and mainly chronic sleep complaints are related to elevated risk of future health and functional problems. Caregivers are encouraged to address sleep complaints and provide their older patients with help before sleep complaints become persistent.

Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea

Supplemental Digital Content is available in the text.

The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients’ conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.

The relationship between serum vitamin D levels and sleep quality in fixed day indoor field workers in the electronics manufacturing industry in Korea

Background

Although recent studies have investigated the influence of vitamin D on sleep patterns, there is a lack of research on the relationship between vitamin D and sleep patterns in Korean workers. This study focused on the relationship between serum vitamin D levels and sleep in fixed day indoor field workers in the electronics manufacturing industry in Korea.

Methods

The 1472 subjects who were included in this study were selected from fixed day workers in the electronics manufacturing industry who had received a worker’s special health examination at a hospital in Changwon, South Gyeongsang Province between January 2015 and December 2015. Nighttime workers and those who showed symptoms of depression were excluded from this study. The sociodemographic and lifestyle variables of the participants were investigated, including age, sex, marital status, level of education, body mass index, smoking habits, alcohol consumption habits, and regular exercise. Work-related factors were evaluated, such as employee tenure and occupational stress. Serum 25-hydroxyvitamin D was measured as an indicator of vitamin D levels, and quality of sleep was evaluated using the Pittsburgh Sleep Quality Index (PSQI) translated into Korean.

Results

The subjects had a mean serum vitamin D level of 13.70 ± 5.93 ng/mL. Vitamin D deficiency, defined as a serum vitamin D level of <10 ng/mL, was found in 24.8% of males and significantly more frequently in females (47.6%). Poor sleep quality was reported by 19.8% of participants with serum vitamin D levels ≥10 ng/mL and by 21.7% of those with serum vitamin D levels <10 ng/mL, which was a significant difference (P = .007). Multiple logistic regression analysis adjusting for significant variables found that poor sleep quality was more likely in those with vitamin D deficiency than those with higher serum vitamin D levels (odds ratio = 1.36; 95% CI, 1.01–1.82). A comparison of serum vitamin D levels and PSQI components showed that the mean scores for subjective sleep quality, sleep latency, and sleep duration were significantly higher in the vitamin D-deficient participants, indicating that the vitamin D-deficient participants had poorer sleep quality.

Conclusions

This study investigated serum vitamin D levels in fixed day indoor field workers in the manufacturing industry in Korea and analyzed the relationship of vitamin D deficiency with sleep quality. A significant correlation was found between serum vitamin D deficiency and poor sleep quality. Based on the results of this study, sleep disorder management for workers can be improved by providing regular examinations checking their serum vitamin D levels and supplying vitamin D to workers with serum vitamin D deficiency to enhance their quality of sleep.

American Academy of Sleep Medicine (AASM) Position Paper for the Use of Telemedicine for the Diagnosis and Treatment of Sleep Disorders

The American Academy of Sleep Medicine's (AASM) Taskforce on Sleep Telemedicine supports telemedicine as a means of advancing patient health by improving access to the expertise of Board-Certified Sleep Medicine Specialists. However, such access improvement needs to be anchored in attention to quality and value in diagnosing and treating sleep disorders. Telemedicine is also useful to promote professionalism through patient care coordination and communication between other specialties and sleep medicine. Many of the principles and key concepts adopted here are based on U.S. industry standards, with special consideration given to the body of work by the American Telemedicine Association (http://www.americantelemed.org/), and abide by standards endorsed by the American Medical Association (http://www.ama-assn.org/). Practitioners who wish to integrate sleep telemedicine into their practice should have a clear understanding of the salient issues, key terminology, and the following recommendations from the AASM. The Taskforce recommends the following: • Clinical care standards for telemedicine services should mirror those of live office visits, including all aspects of diagnosis and treatment decisions as would be reasonably expected in traditional office-based encounters. • Clinical judgment should be exercised when determining the scope and extent of telemedicine applications in the diagnosis and treatment of specific patients and sleep disorders. • Live Interactive Telemedicine for sleep disorders, if utilized in a manner consistent with the principles outlined in this document, should be recognized and reimbursed in a manner competitive or comparable with traditional in-person visits. • Roles, expectations, and responsibilities of providers involved in the delivery of sleep telemedicine should be defined, including those at originating sites and distant sites. • The practice of telemedicine should aim to promote a care model in which sleep specialists, patients, primary care providers, and other members of the healthcare team aim to improve the value of healthcare delivery in a coordinated fashion. • Appropriate technical standards should be upheld throughout the telemedicine care delivery process, at both the originating and distant sites, and specifically meet the standards set forth by the Health Insurance Portability and Accountability Act (HIPAA). • Methods that aim to improve the utility of telemedicine exist and should be explored, including the utilization of patient presenters, local resources and providers, adjunct testing, and add-on technologies. • Quality Assurance processes should be in place for telemedicine care delivery models that aim to capture process measures, patient outcomes, and patient/provider experiences with the model(s) employed. • Time for data management, quality processes, and other aspects of care delivery related to telemedicine encounters should be recognized in value-based care delivery models. • The use of telemedicine services and its equipment should adhere to strict professional and ethical standards so as not to violate the intent of the telemedicine interaction while aiming to improve overall patient access, quality, and/or value of care. • When billing for telemedicine services, it is recommended that patients, providers, and others rendering services understand payor reimbursements, and that there be financial transparency throughout the process. • Telemedicine utilization for sleep medicine is likely to rapidly expand, as are broader telehealth applications in general; further research into the impact and outcomes of these are needed. This document serves as a resource by defining issues and terminology and explaining recommendations. However, it is not intended to supersede regulatory or credentialing recommendations and guidelines. It is intended to support and be consistent with professional and ethical standards of the profession.

Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure

BACKGROUND

Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease.

OBJECTIVES

(1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH.

TOMADO

A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY.

META-ANALYSIS

A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)].

LONG-TERM COST-EFFECTIVENESS

An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2.

CONCLUSIONS

Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates.

TRIAL REGISTRATION

This trial is registered as ISRCTN02309506.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.

Melatonin, the Hormone of Darkness: From Sleep Promotion to Ebola Treatment

Melatonin is a hormone secreted by the enigmatic pineal gland in response to darkness, hence the name hormone of darkness. It has generated a great deal of interest as a therapeutic modality for various diseases particularly sleep disorders. This pleiotropic molecule has anti-inflammatory, antioxidant and anticoagulopathic properties in addition to its endothelial protective effects. In this article we discuss melatonin secretion and mechanisms of action as well as therapeutic rationale. We also highlight the potential utility of melatonin in the deadly modern-day Ebola epidemic.

Biomarkers associated with obstructive sleep apnea: A scoping review

The overall validity of biomarkers in the diagnosis of obstructive sleep apnea (OSA) remains unclear. We conducted a scoping review to provide assessments of biomarkers characteristics in the context of obstructive sleep apnea (OSA) and to identify gaps in the literature. A scoping review of studies in humans without age restriction that evaluated the potential diagnostic value of biological markers (blood, exhaled breath condensate, salivary, and urinary) in the OSA diagnosis was undertaken. Retained articles were those focused on the identification of biomarkers in subjects with OSA, the latter being confirmed with a full overnight or home-based polysomnography (PSG). Search strategies for six different databases were developed. The methodology of selected studies was classified using an adaptation of the evidence quality criteria from the American Academy of Pediatrics. Additionally the biomarkers were classified according to their potential clinical application. We identified 572 relevant studies, of which 117 met the inclusion criteria. Eighty-two studies were conducted in adults, 34 studies involved children, and one study had a sample composed of both adults and children. Most of the studies evaluated blood biomarkers. Potential diagnostic biomarkers were found in nine pediatric studies and in 58 adults studies. Only nine studies reported sensitivity and specificity, which varied substantially from 43% to 100%, and from 45% to 100%, respectively. Studies in adults have focused on the investigation of IL-6, TNF-α and hsCRP. There was no specific biomarker that was tested by a majority of authors in pediatric studies, and combinatorial urine biomarker approaches have shown preliminary promising results. In adults IL-6 and IL-10 seem to have a favorable potential to become a good biomarker to identify OSA.

Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study

Sleep disturbances are associated with poor health outcomes in adults. However, little is known about the sleep disturbances that occur in adult eczema. We studied the association between adult eczema and sleep disturbance and their impact on overall health and health care utilization. We used the 2012 National Health Interview Survey, a cross-sectional questionnaire of 34,613 adults. Eczema was associated with higher odds of fatigue (odds ratio (95% confidence interval): 2.97 (2.65-3.34)), regular daytime sleepiness (2.66 (2.34-3.01)), and regular insomnia (2.36 (2.11-2.64)), even after controlling for sleep duration, history of allergic disease, sociodemographics, and body mass index. There were significant interactions between eczema and fatigue, sleepiness, and insomnia as predictors of poorer overall health status, number of sick days, and doctor visits, such that eczema and each of the sleep symptoms were associated with higher odds of poorer outcomes than either eczema or sleep symptoms alone. Latent class analysis was used and identified five classes of fatigue, sleep disturbances, and allergic disorders. Two classes had high probabilities of eczema: one with high probabilities of asthma, hay fever, food allergy, and multiple sleep symptoms and the other with intermediate probability of insomnia alone. Future studies are warranted to better characterize sleep loss in eczema and develop strategies for treatment and prevention.

A comparison of screening methods for sleep disorders in Australian community pharmacies: a randomized controlled trial

BACKGROUND

Community pharmacies may potentially assist in screening for chronic conditions such as sleep disorders, which remain both under-diagnosed and untreated. We aimed to compare a subjective risk-assessment-only questionnaire (RAO) for common sleep disorder screening against the same risk-assessment questionnaire plus a nasal flow monitor as an objective marker of possible underlying obstructive sleep apnea (OSA) (RA+) in a community pharmacy setting. The primary outcome was the number of participants identified in RAO or RA+ group who were likely to have and consequently be diagnosed with OSA. Further outcomes included the number of participants identified as being at risk for, referred for, taking-up referral for, and then diagnosed with OSA, insomnia, and/or restless legs syndrome (RLS) in either group.

METHODS

In a cluster-randomized trial, participants were recruited through 23 community pharmacies. Using validated instruments, 325 (RAO = 152, RA+ = 173) participants were screened for OSA, insomnia, and RLS.

FINDINGS

218 (67%) participants were at risk of OSA, insomnia or RLS and these participants were referred to their primary physician. The proportion of screened participants identified as being at risk of OSA was significantly higher in the RA+ group (36% in RAO vs. 66% in RA+, OR 3.4, 95% CI (1.8-6.5), p<0.001). A 12-month follow-up was completed in 125 RAO and 155 RA+ participants. Actual referral uptake was 34% RAO, 26% RA+, OR 4.4, 95% CI (1.4-19.2), p = 0.31. The OSA diagnosis rate was higher in the RA+ arm (p = 0.01). To yield a single additional confirmed OSA diagnosis, 16 people would need to be screened using the RA+ protocol.

CONCLUSIONS

These results demonstrate that utilising either screening method is feasible in identifying individuals in the community pharmacy setting who are likely to have OSA, insomnia and/or RLS. Secondly, adding an objective marker of OSA to a questionnaire-based prediction tool resulted in more confirmed OSA diagnoses.

TRIAL REGISTRATION

ACTR.org.au ACTRN12608000628347.

Obstructive sleep apnea is associated with higher healthcare utilization in elderly patients

BACKGROUND

Obstructive sleep apnea (OSA) is an important cause of morbidity in the elderly population. Limited data are available regarding the healthcare utilization and predisposing conditions related to OSA in the elderly. Our aim was to evaluate the healthcare utilization and the conditions associated with new and chronic diagnosis of OSA in a large cohort of elderly patients in the Veterans Health Administration (VHA).

MATERIALS AND METHODS

This retrospective cohort study used inpatient and outpatient VHA data to identify the individuals diagnosed with OSA using ICD-9 codes during the fiscal years 2003-2005. Primary outcomes were emergency department (ED) visits and hospitalizations. Multivariable logistic regression analysis was performed to identify the demographic and clinical characteristics associated with new and chronic diagnosis of OSA.

RESULTS

Of 1,867,876 elderly veterans having 2 years of care, 82,178 (4.4%) were diagnosed with OSA. Individuals with OSA were younger and more likely to have chronic diseases than those without OSA. Individuals with chronic OSA were more likely to have diagnoses of congestive heart failure (CHF), pulmonary circulation disorders, COPD, and obesity and less likely to have diagnoses of hypertension, osteoarthritis, and stroke than individuals with newly diagnosed OSA. The proportion of patients with new OSA diagnosis who required at least one ED visit was higher than the proportion of chronic OSA and no OSA patients (37%, 32%, and 15%, respectively; P-value <0.05). The proportion of new OSA patients who required at least one hospitalization was also higher than the proportion of chronic OSA and no OSA patients (24%, 17%, and 7%, respectively; P-value <0.05).

CONCLUSION

Patients with OSA had a higher incidence of healthcare utilization compared to patients without OSA. New OSA patients had a higher rate of healthcare utilization in the year of diagnosis compared to chronic patients and patients without OSA. Early OSA recognition may reduce healthcare utilization in these patients.

Sleep disturbances and glucoregulation in patients with type 2 diabetes

We investigated the frequency of sleep disturbances and the association between sleep disturbances and glucoregulation in type 2 diabetic patients. The frequency of sleep disturbances in 614 type 2 diabetic patients was investigated using validated sleep questionnaires. There were 381 male and 233 female patients. The mean age was 59.7 ± 11.1 yr; the mean body mass index was 24.9 ± 4.4 kg/m(2); the mean HbA1c was 7.8% ± 1.5%; and the mean duration of diabetes was 10.3 ± 8.4 yr. The questionnaires revealed insomnia in 48.2% of the patients while 8.5% reported excessive daytime sleepiness. A total of 49% of the patients was poor sleepers, while 28.5% had depression. Multivariate logistic regression analysis showed that there was no significant association between HbA1c and other sleep disturbances, such as poor sleep, insomnia, and short duration of sleep. Sleep disturbances were very common in patients with type 2 diabetes mellitus, whereas there was no association between poor or short sleep and glucoregulation. Awareness and identifying sleep complaints in such patients are necessary to improve their quality of daily life.

Association of naso-Oro-pharyngeal structures with the sleep architecture in suspected obstructive sleep apnea

The study was conducted to find out the association of various naso-oro-pharyngeal structures with sleep macro-architecture in suspected obstructive sleep apnea subjects. Study included 51 subjects with suspected obstructive sleep apnea. Subjects with possible central apnea and those consuming any substance that can affect sleep architecture were excluded. Level I polysomnography was performed after thorough physical examination. Overnight study was scored in 30 s epochs to find out the polysomnographic variables. Surgical treatment was offered wherever indicated. Subjects with moderate to severe obstructive sleep apnea were manually titrated on CPAP with the polysomnogram. SPSS v 17.0 was used for statistical analysis. We did not find any difference in the sleep architecture between genders. Sleep Efficiency was better in subjects with dental overjet, dental attrition, high tongue base, macroglossia, lesser oral cavity volume, edematous uvula, increased submental fat, hypertrophied facial muscles and Mallampatti grade III-IV. Shorter Sleep Latency was seen in subjects with tender TMJ and Mallampatti Gr III-IV. REM latency was shorter in subjects with high tongue base, macroglossia and hypertrophied muscles of mastication. Increased REM was observed in subjects with high tongue base, edematous uvula and tender TMJ. Enlarged tonsils had reversed effect with poor sleep efficiency, increased REM latency and decreased REM. CPAP therapy (N = 20) lessened awake time, decreased N2 and increased REM. Oro-pharyngeal structures affect the sleep architecture in suspected OSA subjects. Nasal structures do not affect the sleep architecture in these subjects and enlarged tonsils have opposite effect. Sleep architecture changes on the titration night with CPAP.