Average Epworth Sleepiness Scale Research Articles

0835 Elucidating the Effect of Sleep Apnea on Cognitive Health: A Preliminary Report

Abstract Introduction We aim to determine the cognitive domains associated with obstructive sleep apnea (OSA) age-related brain atrophy in a sample of middle-aged to older males. Methods We evaluated consecutive treatment naïve male OSA patients (AHI≥15) without dementia, stroke or heart disease (infarction, heart failure), from March to November of 2019. We obtained demographic variables, vascular risk factors, the Epworth sleepiness scale (ESS) and the Pittsburgh sleep quality index (PSQI). We also obtained computerized neurocognitive testing with the Go-NoGo Response Inhibition Test, Stroop Interference Test, Catch Game Test, Staged Information Processing Speed Test, Verbal Memory Test and Non-Verbal Memory Test. We derived domain-specific Z-scores age and education adjusted for global cognition, memory, attention, processing speed and executive function. Pearson correlation was used to evaluate bivariate associations between the sleep exposures and neurocognitive outcomes. Linear regression was used to evaluate associations between AHI and neurocognitive domains, adjusting for the ESS. Results A total of 15 participants 40 to 76 years of age, 73% of Hispanic/Latino background, completed neurocognitive testing. The average ESS was 8.2±6.0, PSQI=5.7±4.9, and AHI=48.9±25.5. Hypertension was seen in 66% and diabetes in 27%. The AHI was correlated with global cognition (r= -0.66; p=0.008), memory (r= -0.73; p=0.002) and attention (r= -0.67; p =0.007), but not executive function or processing speed. In addition, the AHI correlated with verbal memory (r= -0.76; p=0.001), but not with non-verbal memory. In adjusted models, the AHI was associated with global cognition (β= -0.60; p=0.05) and decreased memory (β= -0.85; p=0.006). However, the association with attention was explained by the ESS. The PSQI was not correlate with the cognitive domains. Conclusion In this pilot-study, the AHI was associated with decreased global cognition, and verbal memory accounting for sleepiness. Findings suggest the left-hippocampus as a region vulnerable to early age-related brain loss in OSA. Support Scientific Advisory Committee, Pilot grant, Miller School of Medicine; R21AG056952; R21HL140437.

0647 The Effect of CPAP on the Blood Flow to the Brain: A Preliminary Report

Abstract Introduction We aim to determine the effect of positive airway pressure (PAP) on total cerebral blood flow in a sample of middle-aged to older male patients with obstructive sleep apnea (OSA). Methods We evaluated consecutive treatment-naïve male OSA patients with Apnea hypopnea Index (AHI)≥15, from January to November of 2019. We obtained demographic variables, vascular risk factors, the Epworth sleepiness scale (ESS) and the Pittsburgh sleep quality index (PSQI). Brain magnetic resonance imaging (MRI) consisted of high resolution anatomical imaging and velocity encoded phase contrast MRI to measure volumetric blood flow rate to the brain, or the total cerebral blood flow (tCBF), by summation of the flow rate through the two internal carotid and vertebral arteries. Positive airway pressure at various pressures was provided during the MRI, while subjects were awake, starting at 0 cm H20, then 5 cmH20, 10, 15, and 20 cmH20. Each setting was applied for six minutes. Two subjects did not tolerate pressure setting of 20 cmH2O. Results We had a total of 11 participants’ age 40-73 years, 70% Hispanic/Latino background. The average ESS was 8.2±6.0, PSQI=5.7±4.9, and AHI=48.9±25.5. Five of the subjects had hypertension and a quarter had diabetes. In all subjects total CBF monotonically decreased with increasing PAP. The initial decreases in total CBF (PAP from 0 to 5 and 5 to 10) where significantly larger than the decrease in the higher pressure range. In two subjects the total decrease in tCBF was nearly 50%. The average tCBF was 682.3 mL/min at 0 cmH20 and 506.3 ml/min at 20 cmH20. Conclusion Incremental increases in PAP lead to substantial decrease in tCBF during wake. Substantial decrease in tCBF is possibly explained by decreasing end tidal CO2 pressure. The specific physiologic cause and the neurologic impact of prolonged decreased tCBF during CPAP therapy needs to be further investigated. Support Scientific Advisory Committee, Pilot grant, Miller School of Medicine; R21AG056952; R21HL140437; Jazz-Pharmaceutical.

0609 Sleep Phenotypes in Middle-Aged and Older Hispanics/Latinos. Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Abstract Introduction Identifying sleep phenotypes in the diverse and understudied US Hispanic/Latino population is critical to developing interventions and mitigating distal clinical outcomes (e.g. dementias). Methods Using latent class analyses (LCA), we identify empirically derived and clinically meaningful sleep phenotypes using data on community dwelling middle-aged/older adults (ages ≥45-years) from the HCHS/SOL (2008-2011) - Investigation of Neurocognitive Aging (n=6,377). Sleep variables used included Apnea/Hypopnea Index (AHI), percent time SpO2<90%, Epworth Sleepiness Scale (ESS), Women’s Health Initiative Insomnia Rating Scale (WHIIRS), self-reported average sleep duration, restless legs symptoms, napping frequency, and sleep quality. Results Mean (M) age was 56.4±8.1 years, and 54.7% were female. Average AHI, ESS, WHIIRS, and sleep duration were 8.7±13.1, 6.0±5.0, 7.6±5.5, and 7.8±1.4, respectively, and 25.8% had zero percent time SpO2 <90%. Fit statistics indicated that a four-class solution provided the best data fit. The derived classes, adjusting for age, sex, income, and acculturation, corresponded with four clinically meaningful groups: (1) 28.8% were asymptomatic [(M) AHI=0.8; (M) ESS=5.6; (M)WHIIRS=7.6; (M) sleep duration=7.8; 0% SpO2<90%=74.1%], (2) 25.7 % were asymptomatic mild sleep apnea [(M) AHI=6.2; (M) ESS=3.8; (M) WHIIRS=2.9; (M) sleep duration=7.8; 0% SpO2<90%=8.8%], (3) 19.4% were symptomatic sleep apnea [(M) AHI=25.6; (M) ESS=8.5; (M) WHIIRS=7.2; (M) sleep duration=7.7; 0% SpO2<90%= 0.5%], and (4) 26.1% were insomnia [(M) AHI=5.7; (M) ESS=6.7; (M) WHIIRS=13.0; (M) sleep duration=7.8; 0% SpO2<90%=10.3%]. Classification into groups 3 and 4 were primarily driven by elevated AHI and WHIIRS scores, respectively. The distribution of scores in the derived groups suggest variations relative to current clinical thresholds. Conclusion We identified 4-groups using LCA in a community-based sample of diverse U.S. Hispanic/Latino adults. Better characterization of sleep phenotypes for Hispanics/Latinos can help in developing targeted interventions studies and ameliorate health disparities. Support 5R01AG048642-05; R21AG056952; R21HL140437.

0756 A One Year Observational Early Access Pitolisant Study of Excessive Daytime Sleepiness in Narcolepsy

Abstract Introduction Pitolisant is a H3 receptor antagonist/inverse agonist that has been FDA approved for excessive daytime sleepiness in narcolepsy at doses of either 17.8 mg or 35.6 mg per day. Methods 13 patients (3 males and 10 females) were studied having an average age of 46.8 years, with the majority receiving a dose of 35.6 mg Pitolisant. One patient received 17.8 mg throughout the year, and another advanced after 6 months to the 35.6 mg dose due to hepatic issues. 12 of the patients were Caucasian and one was Asian. 100% of the patients had co-existing sleep and psychiatric disorders. 46% had co-existing sleep apnea and were on CPAP/BIPAP. 38.5% had a history of a head injury. 84.6% of the patients had associated cataplexy, 38% had sleep paralysis, 92% had disrupted nocturnal sleep, and 46% had hypnogogic hallucinations. Throughout the year the patients were monitored using the Epworth Sleepiness Scale (ESS). Nine patients completed the 12-month ESS scales. 12/13 were on other medications to treat narcolepsy prior to starting Pitolisant. 6/13 were on sodium oxybate, 7/13 were on an antidepressant, and 11/13 were on either a stimulant, modafanil, or armodafanil. Only one patient was on Pitolisant alone. Results The patient’s average ESS score at onset was 16.2 Statistically significant findings using paired t-tests were documented. After one-month ESS scores decreased to an average of 13.2 (t=2.38, 9df, P=.04). At 3 months it was 12.4 (t=2.81, 10df, P=.02), at 6 months it was 12.75 (t=4.69, 11df, P<.001) and at 12 months the average score was 13.11 (t=2.55, 8df, P=.03) documenting clinically meaningful decrease of ESS by >/= 3 points. Three patients had ESS scores </=10 at 12 months. Conclusion Improvement on ESS was documented at one month and sustained for one year in patients diagnosed with having narcolepsy both with and without cataplexy. Support **No support was given for this study. Dr. Stultz is a speaker for Harmony Biosciences and has served on their advisory committee. She is also a speaker for Jazz Pharmaceuticals.

Clinical utility of the Epworth sleepiness scale.

The Epworth sleepiness scale (ESS) is a widely used tool which has been validated as a measure of sleepiness. However, the scores within individual patients referred for clinical sleep services vary considerably which may limit the clinical use of the ESS. We sought to determine the test-retest reliability of the ESS if scores were classified as either normal or sleepy. We measured the ESS in patients presenting to our sleep center at a clinical visit and again when a sleep study was done. Demographic and clinical information was extracted from the electronic medical record. Average ESS scores were similar on 2 administrations, mean (SD) of 9.8 (5.4) and 10.2 (6.2). Bland-Altman analysis showed upper and lower limits of agreement of 7.5 and - 6.7, respectively. No demographic or clinical variables were identified which contributed to the intra-individual variability. Of the patients who presented with an initial ESS < 11, 80% had a second ESS < 11. Of the patients who presented with an initial ESS ≥ 11, 89% had a second ESS ≥ 11. Cohen's kappa for the two administrations of the ESS was 0.67 (95% CI of 0.51-0.83). Using previously published reports, we calculated Cohen's kappa for polysomnographic determination of the apnea-hypopnea index (AHI) with values ranging from 0.26 to 0.69. Individual ESS scores varied considerably within individual patients, but with classification into either normal or sleepy, the test-retest reliability was substantial and in line with other clinical measures including polysomnographic determination of the AHI.

Social Jet-Lag in Tertiary Students Following a Modern Curriculum with Few Time-Tabled Contact Hours: A Pilot Study.

Social jet-lag (SJL) impairs academic performance, specifically for late chronotypes faced with early start times. Most modern tertiary educational systems have fewer time-tabled contact hours and consequently fewer early starts, which may limit SJL. We performed a pilot study of SJL in a convenience sample of students from Maastricht University, where problem-based learning (PBL) is implemented throughout the curricula. PBL is a modern curriculum, with only few contact hours and student-driven learning, comprising substantial amounts of self-study. Fifty-two students kept a detailed sleep diary for one week, and completed the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS). Participants were divided into early and late sleepers based on a ranking of their reported sleeping times, combined with a single question on their self-reported chronotype. Late sleepers (for brevity: “Owls”; n = 22) had later midpoint-sleep (5:14 ± 0:11 on weekdays; 5:50 ± 0:07 on weekend days) than early sleepers (for brevity: “Larks”; n = 11, 3:21 ± 0:05 on weekdays; 3:41 ± 0:06 on weekend days, F = 10.8, p = 0.003). The difference between the midpoint of sleep on weekdays and weekend days was comparable for Larks and Owls (F = 1.5; p = 0.22). SJL (0:53 ± 0:06, T = 1.4; p = 0.16), total sleep duration (7:58 ± 0:08; p = 0.07), and PSQI score (4.7 ± 0.3, U = 137; p = 0.56) were comparable for Larks and Owls. Average ESS score was higher in Larks (10.7 ± 0.96) than in Owls (7.0 ± 0.72; U = 52; p = 0.007). Within this pilot study of students engaged in a problem-based learning curriculum, Owls have no selective disadvantage compared to Larks concerning sleep.

Management of Excessive Daytime Sleepiness in Narcolepsy With Baclofen

BackgroundNarcolepsy is a disabling sleep-wake disorder characterized by the pentad symptoms of excessive daytime sleepiness, sleep paralysis, sleep fragmentation, sleep-related hallucinations, and cataplexy. There is no curative therapy for narcolepsy. Treatment is therefore symptom directed. Symptom management is generally directed at improving excessive daytime sleepiness, sleep fragmentation, and cataplexy. First-line treatment for excessive daytime sleepiness is typically daily use of wake-promoting agents, such as modafinil or armodafinil, or stimulant therapy, such as methylphenidate or amphetamines. Alternatively, sodium oxybate can be used nightly for improved cataplexy, sleep consolidation, and following day wakefulness. These therapies can be limited in some patients because of inadequate efficacy, poor tolerability, or side effects. MethodsWe describe five narcolepsy patients with severe excessive daytime sleepiness who had an inadequate response or experienced side effects with the initial therapies but had a positive response to treatment with baclofen. ResultsThese patients reported subjective improvement in sleep maintenance without fragmentation and daytime sleepiness. Average Epworth Sleepiness Scale assessment before treatment was 15.8 with post-treatment assessment being 10.4 (P < 0.05). ConclusionsBaclofen may be an effective treatment for excessive daytime sleepiness and sleep fragmentation in narcolepsy and warrants further study.

Clinical Reproducibility of the Epworth Sleepiness Scale for Patients With Suspected Sleep Apnea.

To determine the reproducibility of the Epworth Sleepiness Scale (ESS) score in a clinical population referred for diagnostic testing with suspected obstructive sleep apnea. A retrospective audit of patients referred for a diagnostic sleep study with suspected sleep apnea was undertaken. Data collection was two 3-month time periods from January to March in 2012 and 2014. To evaluate reproducibility, the ESS score at primary care referral was compared to the ESS score at first specialist assessment/sleep assessment. The proportion of scores changing by more than 2, 3, 5, or 7 points was determined. Data were analyzed using Bland-Altman plots and paired t tests. A total of 154 patients (68% male) with a mean ± standard deviation age of 51 ± 13 years, body mass index 36 ± 10 kg/m2, and apnea-hypopnea index 43 ± 40 events/h were included. The average ESS score change was -0.2 with a standard deviation of 3.9 reflecting a wide scatter. A difference between the sequential ESS scores of 5 or more was seen in 21% of subjects. In a clinical obstructive sleep apnea referral population, the ESS score was variable when administered sequentially. Given this variability the ESS should not be used as the sole tool to prioritize patients for obstructive sleep apnea assessment. A commentary on this article appears in this issue on page 711.

An Initial Report of Sleep Disorders in Women in the U.S. Military.

Sleep disorders are increasingly recognized in active duty service members (ADSM). While there are multiple studies in male ADSM, there are limited data regarding sleep disorders in women in the military. The purpose of this study was to characterize sleep disorders in female ADSM referred for clinical evaluation to provide a better understanding of this unique population. We conducted a retrospective review of female ADSM who underwent a sleep medicine evaluation and an attended polysomnogram (PSG). Demographic and polysomnogram variables, as well as medical records, were reviewed. Associated illnesses to include post-traumatic stress disorder, pain disorders, anxiety, and depression, were recorded. The cohort consisted of 101 women. The average age was 33.9 ± 9.0 years and body mass index was 27.3 ± 4.5, with an average Epworth Sleepiness Scale score of 12.9 ± 5.2, and Insomnia Severity Index score of 17.6 ± 5.7. Overall, 36.6% were diagnosed with insomnia only, 14.9% with obstructive sleep apnea (OSA) only, and 34.7% met diagnostic criteria for both insomnia and OSA. The average apnea-hypopnea index for the entire cohort was 5.37 ± 7.04/h whereas it was 10.34 ± 3.14/h for those meeting diagnostic criteria for OSA. The women referred for sleep evaluations had the following rates of associated illnesses: pain disorders (59.4%), anxiety (48.5%), depression (46.5%), and post-traumatic stress disorder (21.8%). For patients with OSA, the relative risk of having post-traumatic stress disorder was 2.72 (95% confidence interval 1.16-6.39). Women in the U.S. military who have sleep disorders have a high rate of behavioral medicine and pain disorders. Interestingly, nearly 50% of active duty females referred for a sleep study have OSA while not necessarily manifesting the typical signs of obesity or increased age. The reasons for this finding are not completely understood, though factors related to military service may potentially contribute. The findings from our study indicate a need for increased awareness and evaluation of sleep disorders in women in the military, especially those with behavioral medicine disorders.

Lingual tonsillectomy with palatal surgery for the treatment of obstructive sleep apnea in adults: a systematic review and meta-analysis.

To conduct a systematic review and meta-analysis to evaluate effects of lingual tonsillectomy with palatal surgery as a combined procedure for the treatment of obstructive sleep apnea (OSA) in adults. Data source: a comprehensive search of MEDLINE, Scopus, Ovid, Web of Science, and the Cochrane Library was performed through November 2017. Manual searches and subject matter expert input were also obtained. This review includes studies assessing efficacy of lingual tonsillectomy with palatal surgery as a combined procedure for the treatment of OSA in adults, who had multilevel obstruction including lingual tonsil hypertrophy, in which apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) were reported. A total of four studies (107 patients) met our inclusion criteria. Pooled random effects analysis demonstrated a statistically significant improvement of polysomnographic respiratory events postoperatively, with average AHI reduction of 18.51 events per hour, [95% confidence interval (CI) (- 31.72, - 5.31); P = 0.006] and increase in minimal arterial oxygen saturation of 5.26 [95% CI (0.10, 10.42); P = 0.05]. The result also showed that the procedures significantly improved sleepiness resulting in an average Epworth Sleepiness Scale (ESS) reduction of 5.44 [95% CI (- 8.69, - 2.18); P = 0.001]. A combination of lingual tonsillectomy with palatal surgery may offer benefits in a selected group of OSA adults, in terms of apnea/hypopnea index, minimal arterial oxygen saturation and Epworth Sleepiness Scale. Data were based on meta-analysis of all case series with 2-6months' follow-up.

Sleep disturbances in restless legs syndrome

Background/Aim. Resteless legs syndrome (RLS) is chronical neurological disorder characterized by urge to move legs that is usually accompanied by unpleasant sensations in the lower extremities. Sleep disturbance is one of the main accompanying symptoms of RLS which exists in approximatelly 90% of patients. Impairment of sleep is related to daily sleepiness, depressive and anxiety disorders. The aim of this study was to detect frequency and characterisitics of sleep-related symptoms in patients with RLS, and its impairrment to daily sleepiness, fatique, anxiety and depression. Methods. We have examinated 94 patients with RLS. The diagnose of RLS was based on questionnaire with 4 specific questions according to the International Restless Legs Syndrome Study Group (IRLSSG) criteria updated in 2003. Severity of symptoms was astimated with IRLSSG Rating Scale, depression and anxiety with Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS) and sleepiness with Epworth Sleepiness scale (ESS). We astimated sleep characteristics and disturbances with specific questionnaire. Results. In our study 79.9% of patients had sleep-related symptoms. Average sleep duration was 6.50 ? 1.42 hours, with average frequency of awakening 2.34 ? 1.69 times per night. Average ESS score was 5.12 ? 4.08 (0?17). Patients with more severe symptoms had higher degree of sleepiness (p = 0.005). Patients with higher symptoms frequency, significantly more often had sleep disturbance (p = 0.016), tiredness and daily sleepiness (p = 0.001). Daily sleepiness (ESS) also significantly correlates with depression (p &lt; 0.05) and anxiety (p = 0.012). Conclusion. Our results confirm that sleep disturbances are one of the key accompanying symptoms of RLS which cause daily sleepiness, tiredness, depression and anxiety. Therefore, their early recognition and appropriate treatment must be a priority in RLS patients.

Agreement between Epworth Sleepiness Scale and objective sleep parameters in patients with excessive daytime sleepiness

Obstructive sleep apnea (OSA) is a disease with a broad social impact. Excessive daytime sleepiness raises suspicion of OSA and together with polysomnography (PSG) is the basis for diagnosis. The Epworth Sleepiness Scale (ESS) is used for objective assessment of daytime sleepiness. Many authors underline a high predictive value of this scale in selecting patients at risk of OSA. Moreover, there is a high agreement between the ESS and PSG. However, some authors oppose the use of this scale. We wanted to verify this issue based on our own data. We enrolled 120 patients who were referred to the Polysomnographic Laboratory, Department of Otolaryngology, Medical University of Warsaw with a suspicion of obstructive sleep apnea. All patients filled out the Epworth Sleepiness Scale. Overnight PSG was performed with 14-channel recordings (Grassm USA), including EEG, EMG, and recordings of the movements of the chest and abdomen. Airflow through the airways was recorded with a nasal-oral temperature probe. PSG was assessed automatically and manually; sleep stages were coded manually for each 30-second interval by a technician. Severity of OSA was assessed based on AHI. There were 96 patients with confirmed OSA and a control group of 24 patients with exclusion of OSA but with different disorders causing excessive daytime sleepiness. The average ESS scores were not significantly different between the subgroups, between genders, and in patients with different severity of OSA. ESS scores did not correlate significantly with any of the tested PSG parameters. In conclusion, the ESS should be used as an additional and only ancillary tool in assessing patients with suspected OSA.

Sleep quality and disturbances in patients with different-sized rotator cuff tear.

The literature is unanimous in saying that shoulder pain, due to rotator cuff tear (RCT), may be mostly at night; to our knowledge, this statement is not supported by scientific evidence. Our aim was to investigate sleep quality and disturbances in patient with RCT and in a control group. A case-control design study was used. We enrolled 324 consecutive patients (Group A) (156M-168F, mean age±SD: 64.94±6.97; range 47-74) who underwent arthroscopic rotator cuff repair. Tear size was determined intraoperatively. The control group (Group B) included 184 subjects (80M-104F, mean age±SD=63.34±6.26; range 44-75) with no RCT. All participants were submitted to two standardized self-reported questionnaires evaluating sleep quality and disturbances: the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS). Data were submitted to statistics. We found no significant differences between the two groups according to both PSQI (Group A: 5.22±2.59; Group B: 5.21±2.39) and ESS (Group A: 2.59±2.54; Group B: 5.76±2.63), p>0.05. Patients with small tears had average PSQI and ESS higher than patients with large and massive lesions (p<0.005). Pearson's test showed that tear severity was negatively correlated with both sleep latency (r 2=-0.35, β=0.069, p<0.005) and sleep disturbances (r 2=-0.65, β=0.053, p<0.001). RCT is only one of the responsible causes for sleep disturbance in middle-aged and elderly subjects. Patients with small tears have a poorer sleep quality with respect to those with a more severe tear; particularly, they not only take more time to fall asleep, but also have a more disturbed sleep compared to patients with large and massive tears. III.

Utility of polygraphic studies for sleep apnea screening in the setting of tertiary care hypertension outpatient clinic

Background: Prevalence of obstructive sleep apnea (OSA) in patients with hypertension outnumbers the prevalence reported in the general population. Concurrently, majority of patients remain undiagnosed. Given the fact that untreated OSA contributes to ineffective hypotensive treatment, and higher rate of complications is ascribed to hypertension, early OSA diagnosis and its elimination constitutes one of the key clinical goals. Polysomnography comprises a golden standard in sleep apnea diagnosis, however it is a time-consuming and expensive procedure which requires hospitalization. Therefore, we assessed the utility of simplified polygraphic (PG) studies in the OSA screening of patients with hypertension requiring regular tertiary care. Material and methods: The study was conducted in the Outpatient Tertiary Care Clinic of the Medical University Hospital of Gdansk. We enrolled consecutive patients regardless of OSA symptoms presence (n = 243), as well as patients with OSA suspicion (n = 75). A total of 318 patients (39% females) were subjected to ambulatory, one night polygraphic study (ApneaLink™). The following signals were recorded: airflow (pressure cannula), respiratory movements, and pulse oximetry. Additionally, anthropometrics, Epworth Sleepiness Scale (ESS), selected clinical symptoms, and drug-regimen were recorded. Results: Three hundred and eight (97%) patients completed the study (10 dropouts due to study failure). Patients were 57.7 ± 11.5 years old, had BMI = 30.0 ± 5.0 kg/m 2 , and average ESS = 5.7 ± 4.6. 65.3% of all patients were characterized by AHI ≥ 5 (62.2% vs. 74.7% in Random vs. Symptomatic group, respectively; P = 0.49), whereas 27.6% of patients were diagnosed with AHI ≥ 15 (23.6% in Random group and 40.0% in Symptomatic group). In logistic regression analysis, nocturia (> 2) increased the odds of AHI ≥ 30 diagnosis approximately 3.5 times in a fully adjusted model. Conclusions: Our results justify routine polygraphic screening of hypertensive patients requiring tertiary care. Abridged medical history may substantially increase the odds for positive screening.

Diode endovascular laser treatment in venous malformations of the upper aerodigestive tract.

Venous malformations of the upper aerodigestive tract can cause pain, dysphagia, obstructive sleep apnea, and rarely bleeding. We studied 980-nm diode endovenous laser therapy. This is a 2007-2014 retrospective study in our vascular anomalies center. Data on patients' clinical history, polysomnography, magnetic resonance imaging, and treatment were collected. Patients were contacted for Epworth Sleepiness Scale and Eating Assessment Tool (EAT-10) scores to evaluate sleepiness and dysphagia before and after laser therapy. We included 32 patients (mean age 41 years) presenting with obstructive sleep apnea (n=18) and dysphagia (n=13). With a mean follow-up of 39 months, average Epworth Sleepiness Scale score fell from 17.3 to 10.4 (p=0.015), EAT-10 score from 8.2 to 3.5 (p=0.002) and apnea-hypopnea index from 47.5 to 24.7 (p=0.01). Of the sleep apnea patients, 89% required continuous positive airway pressure before and 50% afterward (p=0.016). Diode endovascular laser treatment seems to be a safe and effective treatment option in venous malformations of the upper airways.

Validation of the Arabic version of the Epworth Sleepiness Scale

BackgroundThe Epworth Sleepiness Scale (ESS) is a questionnaire widely used in developed countries to measure daytime sleepiness and diagnose sleep disorders. ObjectiveThis study aimed to develop an ESS questionnaire for the Arabic population (ArESS), to determine ArESS internal consistency, and to measure ArESS test–retest reproducibility. It also investigated whether the normal range of ESS scores of healthy people in different cultures are similar. MethodsThe original ESS questionnaire was translated from English to Arabic and back-translated to English. In both the English and Arabic translations of the survey, ESS consists of eight different situations. The subject was asked to rate the chance of dozing in each situation on a scale of 0–3 with total scores ranging between 0 (normal sleep) and 24 (very sleepy). An Arabic translation of the ESS questionnaire was administered to 90 healthy subjects. ResultsItem analysis revealed high internal consistency within ArESS questionnaire (Cronbach’s alpha=0.86 in the initial test, and 0.89 in the retest). The test–retest intra-class correlation coefficient (ICC) shows that the test–retest reliability was substantially high: ICC=0.86 (95% confidence interval: 0.789–0.909, p-value<0.001). The difference in ArESS scores between the initial test and retest was not significantly different from zero (average difference=−0.19, t=−0.51, df=89, p-value=0.611). In this study, the averages of the ESS scores (6.3±4.7, range 0–20 in the initial test and 6.5±5.3, range 0–20 in the retest) are considered high in Western cultures. ConclusionsThe study shows that the ArESS is a valid and reliable tool that can be used in Arabic-speaking populations to measure daytime sleepiness. The current study has shown that the average ESS score of healthy Arabian subjects is significantly higher than in Western cultures.

Treatment of Obstructive Sleep Apnea Syndrome with Nasal Positive Airway Pressure Improves Golf Performance

Obstructive sleep apnea syndrome (OSAS) is associated with impairment of cognitive function, and improvement is often noted with treatment. Golf is a sport that requires a range of cognitive skills. We evaluated the impact of nasal positive airway pressure (PAP) therapy on the handicap index (HI) of golfers with OSAS. Golfers underwent a nocturnal polysomnogram (NPSG) to determine whether they had significant OSAS (respiratory disturbance index > 15). Twelve subjects with a positive NPSG were treated with PAP. HI, an Epworth Sleepiness Scale (ESS), and sleep questionnaire (SQ) were submitted upon study entry. After 20 rounds of golf on PAP treatment, the HI was recalculated, and the questionnaires were repeated. A matched control group composed of non-OSAS subjects was studied to assess the impact of the study construct on HI, ESS, and SQ. Statistical comparisons between pre- and post-PAP treatment were calculated. The control subjects demonstrated no significant change in HI, ESS, or SQ during this study, while the OSAS group demonstrated a significant drop in average HI (11.3%, p = 0.01), ESS, (p = 0.01), and SQ (p = 0.003). Among the more skilled golfers (defined as HI ≤ 12), the average HI dropped by an even greater degree (31.5%). Average utilization of PAP was 91.4% based on data card reporting. Treatment of OSAS with PAP enhanced performance in golfers with this condition. Treatment adherence was unusually high in this study. Non-medical performance improvement may be a strong motivator for selected subjects with OSAS to seek treatment and maximize adherence.

Effects of the new Accreditation Council for Graduate Medical Education work hour rules on surgical interns: a prospective study in a community teaching hospital

BackgroundOn July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) eliminated 30-hour call in an attempt to improve resident wakefulness. We surveyed interns on the Newton Wellesley Hospital (NWH) surgery service before and after the transition from Q4 overnight call to a night float schedule. MethodsFor 15 weeks, interns completed weekly surveys including the Epworth Sleepiness Scale (ESS). The service changed to a night float schedule after 3 weeks (ie, first to 3–4 and then to 6 nights in a row). ResultsThe average ESS score rose from 9.8 ± 5.2 to 14.9 ± 3.1 and 14.4 ± 4.5 (P = .042) on the 3/4 and 6/1 schedules, respectively. Interns were more likely to be abnormally tired on either night float schedule (relative risk = 2.86; 95% confidence interval, 1.17–6.97, P = .029). ConclusionsThe new ACGME work hours increased the ESS scores among interns at NWH and caused interns to be more tired than interns on the Q4 schedule. This is likely caused by the multiple nights of poor sleep without a post-call day to make up sleep.

The Effect of Acute Sleep Deprivation and Fatigue in Cardiovascular Perfusion Students: A Mixed Methods Study

Sleep deprivation as a result of long working hours has been associated with an increased risk of adverse events in healthcare professions but not in cardiovascular perfusion. The purpose of this study is to investigate the impact of sleep deprivation on cardiovascular perfusion students. Testing with highfidelity simulation after 24 hours of sleep deprivation allowed investigators to assess user competency and the effect of fatigue on performance. After informed consent, seven senior perfusion students were enrolled in the study (three declined to participate). The qualitative portion of the study included a focus group session, whereas the quantitative portion included administration of questionnaires, including the Epworth Sleepiness Scale (ESS) and the Stanford Sleepiness Scale (SSS), as well as clinical skills assessment using high-fidelity simulation. Subjects were assessed at three different intervals of sleep deprivation over a 24-hour period: baseline (6:00am), 12 hours (6:00pm), 16 hours (10:00pm), and 24 hours (6:00am) of wakefulness. During each scenario, normally monitored bypass parameters, including mean arterial pressure, activated clotting times, partial pressures of oxygen, partial pressures of carbon dioxide, and venous flow, were manipulated, and the subjects were required to return the parameters to normal levels. In addition, the scenario required calculation of the final protamine dose (using a dose–response curve) and detection of electrocardiography changes. Each task was varied at the different simulation sessions to decrease the effect of learning. Despite any lack of sleep, we hypothesized that, because of repetition, the times to complete the task would decrease at each session. We also hypothesized that the ESS and SSS scores would increase over time. We expected that the students would anticipate which tasks were being evaluated and would react more quickly. The average ESS scores progressively increased at each time period: baseline, 12 hours, 16 hours, and 24 hours. At 24 hours, the ESS and SSS scores were the greatest and the standard deviation was low, suggesting that fatigue affected all participants. During the clinical task evaluations, a “flattening effect” on the learning curve over time was observed. Tasks that required a higher level of cognition had prolonged completion times. Sleep deprivation significantly affects clinical performance as assessed with high-fidelity simulation. To optimize patient and clinician safety, it is important that the question of length of working time be investigated further.

The Prevalence and Natural History of Complex Sleep Apnea

Central sleep apnea (CSA) may occasionally occur in patients with obstructive sleep apnea during titration with a continuous positive airway pressure (CPAP) device. To determine the prevalence and the natural history of CPAP-emergent CSA. This is a retrospective study of 1286 patients with a diagnosis of OSAwho underwent titration with a positive airway device during a 1-year period. Patients were seen in consultation and underwent full-night attended polysomnography followed by full-night attended CPAP titration. Four weeks after CPAP therapy, patients returned to the clinic for follow-up, and objective adherence to CPAP was recorded. In patients who had CSA on CPAP, a second full-night attended CPAP titration was recommended. Eighty-four of the 1286 patients developed a central apnea index (CAI) of 5 or greater per hour while on CPAP. The incidence of CSA varied from 3% to 10% monthly, with an overall incidence of 6.5%. Forty-two of the 84 patients returned for a second CPAP titration. In 33 patients, CSA was eliminated. In each of the remaining 9 patients, the CAI remained at 5 or greater per hour, with an average of 13 per hour. These patients characteristically had the most severe OSA, and 5 had a CAI of 5 or more per hour at baseline. Two of the 9 patients were on opioids In this large retrospective study of 1286 patients with a diagnosis of OSA, 6.5% had CPAP-emergent or persistent CSA. However, CPAP-emergent CSA was generally transitory and was eliminated within 8 weeks after CPAP therapy. The prevalence of CPAP-persistent CSA was about 1.5%. Severity of OSA, a CAI of 5 or greater per hour, and use of opioids were potential risk factors.