A randomized, double-blind clinical trial comparing continuous positive airway pressure with a novel bilevel pressure system for treatment of obstructive sleep apnea syndrome

STUDY OBJECTIVES: To obtain efficacy, objective compliance, and self-assessment data from obstructive sleep apnea syndrome (OSAS) patients treated with continuous positive airway pressure (CPAP) or a novel bilevel (NBL) therapy. DESIGN: Randomized, controlled, double-blind trial. SETTING: Home treatment after diagnosis and titration by split-night polysomnography (PSG) in a sleep laboratory. PATIENTS: Twenty-seven adults (22 men) newly referred for suspected OSAS but without concomitant medical or sleep disorders. INTERVENTIONS: If the subject's apnea-hypopnea index was greater than 10 and less than 100, the CPAP was titrated during PSG and then followed by NBL titration. Treatment was randomly and blindly set to either CPAP or NBL mode for 1 month. MEASUREMENTS & RESULTS: There were no significant baseline group differences in age, body mass index, apnea-hypopnea index (mean +/- SD, CPAP group vs NBL group of 46.1 +/- 23.1/hour vs 41.8 +/- 25.8), CPAP requirement, or scores on the Epworth Sleepiness Scale and Functional Outcomes of Sleep Questionnaire. Treatment with CPAP and NBL equivalently reduced the apnea-hypopnea index during the laboratory titration (7.6 +/- 11.9/hour vs. 3.7 +/- 4.4, respectively). At 1 month, there were no significant group compliance differences as determined by percentage of nights with at least 4 hours of use (CPAP, 80.5 +/- 24 vs NBL, 77.6 +/- 24.8) and hours of use per night (CPAP, 5.6 +/- 1.4 hours/night vs NBL, 5.6 +/- 1.7). Similar improvements were seen in scores on the Epworth Sleepiness Scale and Functional Outcomes of Sleep Questionnaire. CONCLUSIONS: The NBL appeared to be as effective as CPAP for the treatment of OSAS but offered no advantages in patients receiving first-time therapy for OSAS.     

Utilization of healthcare resources in obstructive sleep apnea syndrome: a 5-year follow-up study in men using CPAP

STUDY OBJECTIVES: Patients with untreated obstructive sleep apnea syndrome (OSAS) have higher healthcare utilization than matched controls. However, the long-term impact of continuous positive airway pressure (CPAP) use on healthcare utilization is unknown. DESIGN: Retrospective observational cohort study. SUBJECTS: There were 342 eligible men with OSAS and matched controls on whom there were utilization data for 5 years prior to initial OSAS diagnosis and for the 5 years on CPAP treatment of the cases. INTERVENTIONS: Patients were treated with CPAP. RESULTS: Patients with OSAS were typical cases (mean +/- SD): age, 48.2 +/- 0.6 years; body mass index, 35.6 +/- 0.4 kg/m2; Epworth Sleepiness Scale score, 14.2 +/- 0.3; apnea-hypopnea index, 47.1 +/- 1.8 events per hour. The number of physician visits were higher by 3.46 +/- 0.2 (95% confidence interval [CI]: 2.57 to 4.36) in cases in the year before diagnosis, compared with the fifth year before diagnosis, then decreased over the next 5 years by 1.03 +/- 0.49 (95% CI: -1.99 to -0.07)(P<.0001). Physician fees, in Canadian dollars, were higher by dollars 148.65 +/- dollars 27.27 (95% CI: 95.12 to 202.10) in cases in the year before diagnosis, compared with the fifth year before diagnosis, and then decreased over the next 5 years by dollars 13.92 +/- dollars 27.94(95%CI: -68.68 to 40.83)(P=.0009). Preexisting ischemic heart disease at the time of OSAS diagnosis predicted about a 5-fold increase in healthcare utilization between the second and fifth year of treatment. CONCLUSIONS: Treatment of OSAS reversed the trend of increasing healthcare utilization seen prior to diagnosis. Preexisting ischemic heart disease results in a negative impact on healthcare utilization. CPAP results in a long-term health benefit, as measured by the use of healthcare services.     

The clinical predictors of sleepiness correlated with the multiple sleep latency test in an Asian Singapore population

STUDY OBJECTIVES: To explore the clinical predictors of sleepiness as objectively determined by the Multiple Sleep Latency Test with the Epworth Sleepiness Scale, age, body mass index, and overnight polysomnographic parameters at a tertiary referral center Sleep Disorders Unit. DESIGN: Retrospective, consecutive case series review. SETTING: A multidisciplinary sleep disorders unit in Singapore General Hospital, a tertiary-care university-affiliated hospital. PATIENTS: 72 consecutive patients evaluated for sleep disorders with overnight polysomnograms and Multiple Sleep Latency Tests between March 2002 and September 2002. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Mean sleep latency on the Multiple Sleep Latency Test was 9.0 +/- 4.4 minutes, and mean Epworth Sleepiness Scale score was 10.8 +/- 5.8. On univariate analysis, mean sleep latency on the Multiple Sleep Latency Test showed a significant negative correlation with the Epworth Sleepiness Scale score, apnea-hypopnea index, body mass index, arousal index, and time spent below 90% oxygen saturation during overnight polysomnography. After performing multiple linear regression, only Epworth Sleepiness Scale score and apnea-hypopnea index remained significantly correlated (P = .039 and P = .008, respectively). An Epworth Sleepiness Scale score of 8 or above predicted a mean sleep latency on the Multiple Sleep Latency Test of less than 10 minutes with a sensitivity of 73.9% and specificity of 50.0%. CONCLUSIONS: The Epworth Sleepiness Scale and apnea-hypopnea index are useful predictors of sleepiness in our Asian Singapore population.     

Prediction of uvulopalatopharyngoplasty outcome: anatomy-based staging system versus severity-based staging system

STUDY OBJECTIVE: To evaluate and compare outcomes of uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea/hypopnea syndrome (OSAHS) using anatomy- and severity-based staging systems. DESIGN: Prospective design with a retrospective review. SETTING: A tertiary-care, sleep disorder referral center. PATIENTS: In total, 110 patients with OSAHS (105 men, 5 women; mean age, 43 years; apnea-hypopnea index, 44.4 +/- 28.8 events per hour; body mass index, 27.1 +/- 3.3 kg/m2). MEASUREMENTS: An anatomy-based staging system (stages I-IV) was used to classify patients with OSAHS by examining tongue-palate position, tonsil size, body mass index, and craniofacial deformities. Patients were also classified as having mild, moderate, moderate-severe, or severe OSAHS based on preoperative apnea-hypopnea index from polysomnography (a severity-based staging system). Surgical success was defined as a 50% or greater reduction in the apnea-hypopnea index and a postoperative apnea-hypopnea index of less than 20 events per hour. INTERVENTION: UPPP was performed in all patients. RESULTS: The overall success rate of UPPP was 78%. Success rates for mild (90%), moderate (73%), moderate-severe (81%), and severe (74%) diseases were similar (p = .10). Conversely, success rates for patients with anatomy-based stages I, II, III, and IV were 100%, 96%, 65%, and 20%, respectively; these rates were significantly different (p < .001). Changes in apnea-hypopnea index were significantly correlated with Friedman tongue position (FTP) (r = -0.33, p = .0004) and tonsil size (r = -0.37, p < .0001). The FTP (odds ratio = 0.43, SE = 0.13, p = .005, 95% confidence interval = 0.24-0.78) and tonsil size (odds ratio = 3.13, SE = 1.53, p = .02, 95% confidence interval = 1.20-8.17), but not the severity-based staging (odds ratio = 0.77, SE = 0.18, p = .283, 95% confidence interval = 0.49-1.23), were predictive of surgical success. CONCLUSION: The anatomy-based staging system predicted UPPP outcomes more effectively than did the severity-based staging. The anatomy-based staging system facilitates good case-selection information for counseling patients before UPPP surgery.     

Efficacy and cost of home-initiated auto-nCPAP versus conventional nCPAP

STUDY OBJECTIVES: To compare in a multicenter prospective study the efficacy and cost of conventional nasal continuous positive airway pressure (nCPAP) initiated at the sleep laboratory versus auto-nCPAP initiated at home. DESIGN: Patients with severe obstructive sleep apnea syndrome (OSAS) were randomized to treatment with either the REM+ auto device in constant mode at the effective pressure determined by titration at the sleep laboratory (n=17) or the REM+ auto device in automatic mode initiated at the patients home by a nurse (n=18). After 2 months, the efficacy and cost of nCPAP therapy and the time from diagnosis to nCPAP were evaluated. All values are reported as means +/- SD. PATIENTS: Thirty-five subjects with newly diagnosed OSAS (8 women and 27 men, mean age: 54.3 +/- 10.6 years, apnea-hypopnea index (AHI) 58.1 +/- 14.0 h(-1)). INTERVENTIONS: N/A MEASUREMENTS AND RESULTS: Both treatments were used properly and induced similar decreases in the AHI (7.6 +/- 6.9 vs. 10.4 +/ -12.5 h(-1) for auto-nCPAP and conventional nCPAP, respectively; NS) and Epworth Sleepiness score (from 15.5 +/- 4.7 to 7.5 +/- 3.4 vs. 14.7 +/- 3.9 to 7.6 +/- 3.4 for auto-nCPAP and conventional nCPAP, respectively; NS). With auto-nCPAP initiated at home, the time from diagnosis to final adjustment of nCPAP was shorter (16.3 +/- 5.0 vs. 47.2 +/- 46.5 days with conventional nCPAP, P < 0.02) and the cost was lower (1,263 +/- 352 vs. 1720+/-455 E, respectively; P < 0.05). CONCLUSIONS: Treatment of OSAS with auto-nCPAP initiated at home is effective and reliable and reduces the time from diagnosis to therapy and the cost of treatment.     

Sleep habits and accident risk among truck drivers: a cross-sectional study in Argentina

Road accidents are a major cause of death, and sleep deprivation affects driving skills. We conducted a cross-sectional study to evaluate sleep habits and accident risk in long-haul truck drivers in Buenos Aires, Argentina. Questionnaires regarding sleep habits, snoring, and daytime sleepiness were administered, and a limited physical examination was performed. We obtained 738 complete answers (response rate 85%). Mean sleep hours during working days was 3.76 (SD 2.40). Mean driving hours was 15.9 (SD 5.60) per day. Frequent sleepiness while driving was reported by 43.7% of responders. Sleepiness while driving was associated with Epworth Sleepiness Scale values >10 (odds ratio 1.85, 95% confidence interval = 1.20-2.85). Snoring was reportea by 71% of drivers and was frequent in 43.8%. Snoring more than 3 times a week (odds ratio 1.73, 95% confidence interval = 1.23-2.44), sleepiness while driving (OR 1.92, 95% confidence interval = 1.08-1.96), and Epworth Sleepiness Scale score > 10 (odds ratio 2.53, 95% confidence interval = 1.61-3.97) were independently associated with reporting of accidents or near accidents. Sleep deprivation and long driving shifts were prevalent in our study. Accident risk was associated with frequent snoring, daytime sleepiness, and reporting of sleepiness at the wheel. This study highlights the need of improving working conditions in this highly exposed population.     

Auto-adjusting versus fixed positive pressure therapy in mild to moderate obstructive sleep apnoea

STUDY OBJECTIVES: To determine if auto-adjusting positive airway pressure (APAP) would be better tolerated on the basis of delivering a lower mean pressure in patients with mild to moderate obstructive sleep apnoea syndrome (OSAS). DESIGN: Patients spent 8 weeks on continuous positive airway pressure (CPAP) and 8 weeks on APAP in a randomized crossover design. SETTING: Respiratory Sleep Disorders Unit in a University Hospital and the patient's home. PARTICIPANTS: Twenty-nine patients with newly diagnosed mild to moderate OSAS (apnoea-hypopnoea frequency of 5-30 events/hour) were studied. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Overnight polysomnography and Epworth Sleepiness Scale were recorded at baseline and at the end of each treatment period in addition to patient preference for device, side effects, and objective compliance. No differences were found in polysomnographic variables or Epworth Sleepiness Scale scores between the 2 treatment modes, but all variables were significantly improved from baseline values. Mean APAP pressure levels were significantly lower than CPAP (6.3 +/- 1.4 vs 8.1 +/- 1.7 cm H2O, p < .001). Patient compliance was similar with both treatments. More patients requiring higher fixed pressure (> or = 8cm H2O) preferred APAP, whereas those requiring lower pressure (< 8 cm H2O) preferred CPAP (p = .03). Follow-up after 18 months of therapy indicated that 76% of subjects continued to be compliant, with a nightly use of 5.8 +/- 1.9 hours per night, despite high levels of minor side effects. CONCLUSIONS: APAP and CPAP are equally effective in managing patients with mild to moderate OSAS, but device preference may be influenced by fixed pressure requirements.     

Associations between gender and measures of daytime somnolence in the Sleep Heart Health Study

STUDY OBJECTIVES: To examine the relationship of gender to subjective measures of sleepiness, including the Epworth Sleepiness Scale (ESS), in a community-based population. DESIGN: A cross-sectional study. SETTING/PARTICIPANTS: Multicenter Sleep Heart Health Study participants (N = 6.440, 52% women) recruited from ongoing cohort studies. INTERVENTIONS: N/A. MEASUREMENTS: Scores from the ESS, Sleep Heart Health Study daytime sleepiness and feeling unrested questions, polysomnography results (respiratory disturbance index at 4% desaturation), as well as data on difficulty initiating and maintaining sleep, insufficient sleep, sedative use, alcohol use, cardiovascular or respiratory disease, frequent awakening due to leg cramps. RESULTS: Women reported feeling sleepy as often as men did (odds ratio [OR] = 1.06; confidence interval [CI], 0.86-1.32), but women were less likely to have an ESS score > 10 (adjusted OR = 0.77; CI, 0.66-0.90) and more likely to report feeling unrested (adjusted OR = 1.39; CI, 1.14-1.69) than men. In men, the ESS score was more strongly correlated with reports of feeling unrested or sleepy compared to women. CONCLUSIONS: Men and women answer questions on sleepiness differently. Findings indicate that using the ESS to detect subjective sleepiness is more likely to identify men with sleepiness. Since the ESS is more strongly related to other subjective measures in men, the ESS may be a more sensitive measure of subjective sleepiness in men than in women.     

Long-term efficacy of fixed CPAP recommended by Autoset for OSAS

The Autoset autotitration system (Resmed, Australia) was designed as an aid for determination of the effective level of CPAP. Two studies have shown that the 95% pressure centile during a night with Autoset, after excluding any periods with severe leak (P95), was well correlated with the pressure determined manually according to the reference method. However, the suitability of P95 under Autoset for treatment with conventional CPAP needed to be evaluated outside of the context of titration. The objective of this study was to measure the compliance and efficacy of CPAP at P95 determined by Autoset, after 3 months. Twenty-four patients who had undergone routine autotitration by Autoset under polysomnographic control in the laboratory for previously untreated OSAS were evaluated after 3 months of treatment with CPAP at P95. This evaluation was based on compliance, daily usage, determined by reading the hourly counter, Epworth sleepiness score and home respiratory recording under CPAP. Polysomnography under Autoset showed a significant reduction of abnormal respiratory events (apnea-hypopnea index (AHI): 5.7 (+/-4.6) vs 69.6 (+/-29.8) n/h; p<0.001). P95 was between 8.5 and 15 cm H2O (mean: 11.2 (+/-1.6)). Two patients were lost to follow-up. At 3 months, 18 out of 22 (82%) patients declared that they were still using their machine with a daily usage of 5.25 (+/-1.82) h. The Epworth sleepiness scale was significantly decreased (5 (+/-4.1) vs 11.4 (+/-5.4); p<0.05). P95 recommended by Autoset remained effective on abnormal respiratory events with a low AHI (4.1 (+/-3.2) n/h) and a low 4% oxygen desaturation index (3.6 (+/-4.5) n/h) under CPAP. This study confirms the efficacy of autotitration and the suitability of P95 determined by Autoset for long-term treatment by conventional CPAP at home.     

Classification algorithms for predicting sleepiness and sleep apnea severity

Identifying predictors of subjective sleepiness and severity of sleep apnea are important yet challenging goals in sleep medicine. Classification algorithms may provide insights, especially when large data sets are available. We analyzed polysomnography and clinical features available from the Sleep Heart Health Study. The Epworth Sleepiness Scale and the apnea-hypopnea index were the targets of three classifiers: k-nearest neighbor, naive Bayes and support vector machine algorithms. Classification was based on up to 26 features including demographics, polysomnogram, and electrocardiogram (spectrogram). Naive Bayes was best for predicting abnormal Epworth class (0-10 versus 11-24), although prediction was weak: polysomnogram features had 16.7% sensitivity and 88.8% specificity; spectrogram features had 5.3% sensitivity and 96.5% specificity. The support vector machine performed similarly to naive Bayes for predicting sleep apnea class (0-5 versus >5): 59.0% sensitivity and 74.5% specificity using clinical features and 43.4% sensitivity and 83.5% specificity using spectrographic features compared with the naive Bayes classifier, which had 57.5% sensitivity and 73.7% specificity (clinical), and 39.0% sensitivity and 82.7% specificity (spectrogram). Mutual information analysis confirmed the minimal dependency of the Epworth score on any feature, while the apnea-hypopnea index showed modest dependency on body mass index, arousal index, oxygenation and spectrogram features. Apnea classification was modestly accurate, using either clinical or spectrogram features, and showed lower sensitivity and higher specificity than common sleep apnea screening tools. Thus, clinical prediction of sleep apnea may be feasible with easily obtained demographic and electrocardiographic analysis, but the utility of the Epworth is questioned by its minimal relation to clinical, electrocardiographic, or polysomnographic features.     

Variation in symptoms of sleep-disordered breathing with race and ethnicity: the Sleep Heart Health Study

STUDY OBJECTIVES: To examine the relation of sleep-related symptoms to race and ethnicity in a diverse sample of middle-aged and older men and women. DESIGN: Cross-sectional questionnaire survey. SETTING: In the initial phase of the Sleep Heart Health Study, men and women enrolled in participating epidemiologic cohort studies were surveyed. PARTICIPANTS: 13,194 men and women 40 years of age and older, including 11,517 non-Hispanic white, 648 black, 643 American Indian, 296 Hispanic, and 90 Asian-Pacific Islander. INTERVENTIONS: Not applicable. MEASUREMENTS AND RESULTS: After adjustment for BMI and other factors, frequent snoring was more common among Hispanic women (odds ratio (OR) = 2.25, 95% confidence interval (CI) = 1.48, 3.42) and black women (OR = 1.55, 95% Ci = 1.13, 2.13) than among non-Hispanic white women. Hispanic men were significantly more likely to report frequent snoring than non-Hispanic white men (OR = 2.30, 95% CI = 1.43, 3.69). Black, American Indian, and Asian men did not differ significantly from white men in snoring prevalence. American Indian women were significantly more likely to report breathing pauses during sleep than their white, non-Hispanic counterparts (OR = 1.52, 95% CI 1.03, 2.24), although polysomnography data on a subset of the sample suggested that the association between this symptom reported on questionnaire and objective evidence of sleep-disordered breathing may be weaker among American Indians than among other groups. Mean Epworth Sleepiness Scale scores were slightly higher in black men and women than in their white, non-hispanic counterparts. CONCLUSIONS: Frequent snoring was more common among black and Hispanic women and Hispanic men than among their white non-Hispanic counterparts, even after adjusting for BMI and other factors. Further research including polysomnography and objective measurements of sleepiness is needed to assess the physiologic and clinical significance of these findings.     

Associations between sleep disturbances,mental health outcomes and burnout in firefighters,and the mediating role of sleep during overnight work: A cross‐sectional study

This study investigated whether sleep disorder risk and mental health outcomes in firefighters were associated with burnout, particularly emotional exhaustion, and examined the mediating role of sleep at work in these relationships. A secondary aim was to investigate associations between habitual sleep characteristics and burnout. North American firefighters (n = 6,307) completed the Maslach Burnout Inventory (emotional exhaustion, depersonalisation, personal accomplishment), and were screened for sleep disorders and self‐reported current mental health conditions and sleep characteristics. Multiple logistic regression analyses examined associations between sleep, mental health outcomes and burnout. Firefighters screening positive for a sleep disorder, particularly insomnia, had increased risk of emotional exhaustion (adjusted odds ratio 3.78, 95% confidence interval 2.97–4.79). Firefighters self‐reporting a current mental health condition were at greater risk of emotional exhaustion (adjusted odds ratio 3.45, 95% confidence interval 2.79–4.27). Sleep during overnight work mediated the impact of having a sleep disorder and mental health condition on high burnout. Sleepiness and sleep deficit (difference between required and actual sleep), even in firefighters without sleep disorder risk, were associated with depersonalisation (adjusted odds ratio 1.65, 95% confidence interval 1.34–2.03 and adjusted odds ratio 1.29, 95% confidence interval 1.06–1.57, respectively) and low personal accomplishment (adjusted odds ratio 1.25, 95% confidence interval 1.07–1.47 and adjusted odds ratio 1.17, 95% confidence interval 1.01–1.35, respectively). Sleep and mental health problems were associated with increased risk of burnout in firefighters, and sleep during overnight work mediated these relationships. The results suggest the need to examine the effectiveness of occupational interventions that improve the opportunity for sleep, together with screening for and treating sleep disorders, to reduce burnout risk.     

Fatigue and sleep disturbance in adult survivors of childhood cancer: a report from the childhood cancer survivor study (CCSS)

STUDY OBJECTIVE: To examine the prevalence of and risk factors for fatigue and sleep disturbance among adult survivors of childhood cancer. DESIGN: Retrospective cohort of childhood cancer survivors. SETTING: Twenty-six academic institutions treating childhood cancer. PARTICIPANTS: Two thousand six hundred forty-five survivors of childhood acute lymphocytic leukemia, central nervous system tumors, Hodgkin lymphoma, soft-tissue sarcomas, or bone tumors diagnosed before age 21, surviving at least 5 years from diagnosis, and a 500-sibling comparison group. MEASUREMENTS: Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue), Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale. RESULTS: Significant differences were found between survivors and siblings on the Functional Assessment of Chronic Illness Therapy-Fatigue (40.8 vs 42.0, P < 0.02), Pittsburgh Sleep Quality Index (6.1 vs 5.5, P < 0.004), and Epworth Sleepiness Scale (6.2 vs 5.4, P < 0.001). Nineteen percent of survivors were in the most fatigued range, 16.7% reported disrupted sleep, and 14% increased daytime sleepiness. Survivors with a history of radiation therapy were more likely to be fatigued (odds ratio 1.7, 95% confidence interval 1.3-2.3), yet without significantly different mean scores. Female sex, congestive heart failure, pulmonary fibrosis, depression, and being unmarried significantly predicted more fatigue, whereas obesity and an infant in the house predicted more daytime sleepiness. Similar sociodemographic predictors were also identified among the siblings. CONCLUSION: Because of the large sample size, we detected more objectively reported fatigue, sleep disturbance, and daytime sleepiness among adult survivors of childhood cancer. However, the clinical significance of these differences is questionable. Predictors of fatigue and poor sleep were similar in both survivors and the siblings.     

Gender differences in morbidity and health care utilization among adult obstructive sleep apnea patients

STUDY OBJECTIVE: To explore gender differences in morbidity and total health care utilization 5 years prior to diagnosis of obstructive sleep apnea (OSA). DESIGN: Case-control study; patients were recruited between January 2001 and April 2003. SETTING: Two university-affiliated sleep laboratories. PATIENTS: 289 women (22-81 years) with OSA were matched with 289 men with OSA for age, body mass index (BMI), and apnea-hypopnea index (AHI). All OSA patients were matched 1:1 with healthy controls by age, geographic area, and primary physician. MEASUREMENTS AND RESULTS: Women with OSA compared to men with OSA have lower perceived health status and Functional Outcomes of Sleep Questionnaire score (54.5% vs. 28.4%, P <0.05 and 67.5+/-21.4 vs. 76+/-20.1, P <0.05, respectively). Compared to men with OSA, women with OSA have higher risk of hypothyroidism (OR 4.7; 95% CI, 2.3-10) and arthropathy (OR 1.6, 95% CI, 1.1-2.2) and lower risk for CVD (OR 0.7; 95% CI, 0.5-0.91). Compared to controls, both women and men with OSA had 1.8 times higher 5-year total costs (P <0.0001). Compared to men with OSA, expenditures for women with OSA are 1.3 times higher (P <0.0001). The multiple logistic regression (adjusting for BMI, AHI) revealed that age (OR 1.04; 95% CI, 1.01-1.07), antipsychotic and anxiolytic drugs (OR 2.3; 95% CI, 1.2-4.4), and asthma (OR 2.4; 95% CI, 1.1-5.6) are independent determinants for "most costly" OSA women. CONCLUSION: Compared to men with similar OSA severity, women are heavier users of health care resources. Low FOSQ score and poor perceived health status in addition to overuse of psychoactive drugs are associated with high health care utilization among women with OSA.     

The cyclic alternating pattern demonstrates increased sleep instability and correlates with fatigue and sleepiness in adults with upper airway resistance syndrome

OBJECTIVE: To clarify the relationship between sleep instability and subjective complaints in patients with upper airway resistance syndrome (UARS). METHODS: Thirty subjects (15 women) with UARS and 30 age- and sex-matched controls in a prospective, single-blind, case-control study. Blinded cyclic alternating pattern (CAP) electroencephalogram analysis and scales of fatigue and sleepiness were completed. ANALYSIS: Mann-Whitney U tests for independent, nonparametric variables between groups and chi2 tests for nonparametric variables with defined standard values. RESULTS: Patients with UARS had significantly more complaints of fatigue and sleepiness, compared with controls, demonstrated on their Fatigue Severity Scale (P < 0.001) and Epworth Sleepiness Scale (P < 0.001). By design, the mean apnea-hypopnea index was normal in both groups, whereas the respiratory disturbance index was greater in patients with UARS than in those without (14.5 +/- 3.0 vs 9 +/- 5.2, respectively [P < 0.001]). CAP analysis demonstrated abnormal non-rapid eye movement sleep with abnormally increased CAP rate, electroencephalogram arousals, A2 index, and A3 index. Decreased A1 index in controls was consistent with their more normal progression of sleep. CAP rate correlated with both the Epworth Sleepiness Scale (r = 0.38, P < 0.01) and the Fatigue Severity Scale (r = 0.51, P < 0.0001), and there was a positive trend between the Fatigue Severity Scale and phase A2 index (r = 0.29, P < 0.05). CONCLUSION: Compared with age- and sex-matched controls, patients with UARS have higher electroencephalogram arousal indexes and important non-rapid eye movement sleep disturbances that correlate with subjective symptoms of sleepiness and fatigue. These disturbances are identifiable with sensitive measures such as CAP analysis but not with traditional diagnostic scoring systems.     

Communication and coping as predictors of fertility problem stress: cohort study of 816 participants who did not achieve a delivery after 12 months of fertility treatment

BACKGROUND: We investigated coping strategies and communication strategies as predictors of fertility problem stress 12 months after start of fertility treatment. METHODS: We used a prospective, longitudinal cohort design including 2250 people beginning fertility treatment with a 12-month follow-up. Data were based on self-administered questionnaires measuring communication with partner and with other people, coping strategies: active-avoidance coping, active-confronting coping, passive-avoidance coping, meaning-based coping, and fertility problem stress. The study population included those participants (n = 816, men and women) who had not achieved pregnancy by assisted reproduction or delivery at follow-up. RESULTS: Among both men and women, difficulties in partner communication predicted high fertility problem stress (odds ratio for women, 3.47, 95% confidence interval 2.09-5.76; odds ratio for men, 3.69, 95% confidence interval 2.09-6.43). Active-avoidance coping (e.g. avoiding being with pregnant women or children, turning to work to take their mind off things) was a significant predictor of high fertility problem stress. Among men, high use of active-confronting coping (e.g. letting feelings out, asking other people for advice, seeking social support) predicted low fertility problem stress in the marital domain (odds ratio 0.53, 95% confidence interval 0.28-1.00). Among women, medium or high use of meaning-based coping significantly predicted low fertility problem stress in the personal and marital domain. CONCLUSION: The study provides information about where to intervene with fertility patients in order to reduce their stress after medically unsuccessful treatment.     

A randomized crossover efficacy trial of oral CPAP (Oracle) compared with nasal CPAP in the management of obstructive sleep apnea

STUDY OBJECTIVES: To determine the therapeutic efficacy and viability of a novel oral interface for continuous positive airway pressure (CPAP) compared with conventional nasal interfaces. DESIGN: A randomized single-blind crossover study. SETTING: Hospital-based sleep laboratory. PATIENTS OR PARTICIPANTS: 21 CPAP-na?ve patients with obstructive sleep apnea (baseline apnea-hypopnea index, 85 +/- 36) Interventions: Nasal CPAP and oral CPAP MEASUREMENTS AND RESULTS: Patients were each treated for two 4-week periods using nasal CPAP and oral CPAP. The CPAP titrations were undertaken at the start of each treatment arm. Outcome measures were recorded at baseline and at the end of each treatment arm. These included polysomnography variables, CPAP compliance, subjective sleepiness, obstructive sleep apnea symptom ratings, and adverse effects. There were no significant differences between oral and nasal interfaces for the on-CPAP frequency of apneas and hypopneas (mean difference, nasal-oral [95%CI] = -4.6[-10.1-1.0]/h; P = 0.06) or arousals (-3.0 [-7.8-1.8]/h; P = 0.23). There were also no statistically significant differences between interfaces for scores on the Epworth Sleepiness Scale (-0.7 [-3.1-1.7]; P = 0.20), obstructive sleep apnea symptoms (-7.7 [-17.7-2.4]; P = 0.052), CPAP compliance (0.3 [-0.5-1.1] h/night; P = 0.50), CPAP pressure (0.05 [-0.66-0.76] cmH20; P = 0.73), CPAP side effects scores (-2.0 [-5.3-1.4]; P = 0.23), or mask preference (P = 0.407). In addition, both nasal and oral interfaces significantly improved polysomnographic variables, Epworth Sleepiness Scale scores, obstructive sleep apnea symptoms, and CPAP compliance from baseline (all P < 0.05). CONCLUSIONS: This preliminary study indicates that oral CPAP has similar efficacy to traditionally applied nasal CPAP in treating obstructive sleep apnea. Additional large studies are required to determine the range of clinical situations where oral CPAP is indicated.     

Sleep habits and insomnia in a sample of elderly persons in China

STUDY OBJECTIVES: To examine sleep habits, insomnia, and hypnotic use in the elderly in China. DESIGN AND SETTING: A cross-sectional survey in 5 cities of Shandong, mainland China in 1997. PARTICIPANTS: Among 1,820 individuals aged 65 and older who were sampled, 1,679 (92.2%) were interviewed at home, including 770 men and 909 women. MEASUREMENTS: Asleep and demographic questionnaire that included the Pittsburgh Sleep Quality Index was used for interviews. RESULTS: Average bedtime of participants was 9:18 PM (SD = 2.2 hours), and morning rise time was 5:42 AM (SD = 1.0 hour). Reported night sleep duration was 7.1 hours (SD = 1.6) without age and sex differences. Regular napping was more common in men than in women (44.2% vs 28.0%). Of the sample, 32.9% reported frequent insomnia symptoms, and 8.9% had insomnia symptoms with daytime consequences. Multivariate analysis indicated that age 75 years and older (odds ratio = 2.0), female sex (odds ratio = 1.4), unmarried status (odds ratio = 1.7), frequent napping (odds ratio = 1.5), and poor perceived health (odds ratio, = 2.1) were associated with elevated risks for insomnia. Hypnotic use during the past month was reported by 6.5% of the sample; women were 2 times as likely as men to use hypnotics. CONCLUSION: Sleep patterns in Chinese elderly may be characterized by going to bed early and waking up early. Insomnia symptoms are as common among Chinese as among Western elderly. Further study is warranted to examine the association between insomnia and aging per se in Chinese elderly.     

The reliability of the Epworth Sleepiness Score in a sleep clinic population

Despite the Epworth Sleepiness Score being widely used, there are limited studies of its reliability in clinical practice. The aim of this study was to assess the reliability of the Epworth Sleepiness Score in a clinical population. The study included patients referred to Middlemore Hospital sleep service between October and November 2014, aged over 17 years, with at least two Epworth Sleepiness Score measurements at up to three different points on the diagnostic pathway: on General Practitioner referral (GP Epworth Sleepiness Score); at overnight oximetry assessment (Oximetry Epworth Sleepiness Score); and at a specialist clinic (Specialist Epworth Sleepiness Score). No treatment was administered between scores. One‐hundred and thirty‐three patients were included in the study. There was a median of 91 days from GP Epworth Sleepiness Score to Oximetry Epworth Sleepiness Score, and 11 days from Oximetry Epworth Sleepiness Score to Specialist Epworth Sleepiness Score. There was poor test–retest reliability between GP Epworth Sleepiness Score and Specialist Epworth Sleepiness Score; 72.4% and 17.8% of patients had an absolute difference of more than 2 and 8 Epworth Sleepiness Score points, respectively. A Bland–Altman plot of mean Epworth Sleepiness Score versus the difference between GP Epworth Sleepiness Score and Specialist Epworth Sleepiness Score demonstrated a wide scatter of data and 95% confidence interval for the difference in Epworth Sleepiness Score for an individual patient of ?14 to +10. There was similar variability between GP Epworth Sleepiness Score and Oximetry Epworth Sleepiness Score. The reliability of the Epworth Sleepiness Score is unproven in clinical settings. This study shows poor test–retest reliability of Epworth Sleepiness Score, particularly between primary and secondary care, arguing against the use of Epworth Sleepiness Score for clinical decision‐making or prioritisation of services without first assessing the reliability of the Epworth Sleepiness Score in the relevant clinical population.