Publications by authors named "Max Hirshkowitz"

65 Publications

Healthcare utilization after elective surgery in patients with obstructive sleep apnea - analysis of a nationwide data set.

Sleep Med 2021 Feb 26;81:294-299. Epub 2021 Feb 26.

Medical Care Line, Section of Pulmonary, Critical Care and Sleep Medicine, Michael E. DeBakey VA Medical Center, Houston, TX, USA; Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA.

Background: Obstructive sleep apnea is prevalent among those undergoing elective surgery and likely introduces a risk of adverse outcomes. To understand its impact, we aimed to compare healthcare utilization in postsurgical patients with obstructive sleep apnea compared to controls matched on the surgical care environment.

Methods: This is a retrospective case-control cohort study using a nationwide database. Among patients undergoing elective surgical procedures during 2009-2014, we compared patients with obstructive sleep apnea with those without obstructive sleep apnea. The two cohorts were matched based on age, sex, type of surgery, performing surgeon, the hospital where the procedure was performed, and various All-Patient-Refined Diagnosis-Related-Groups severity indices. The primary effect of interest was short-term healthcare utilization. We also compared long-term hospital admissions, intensive care unit admissions, emergency room visits and outpatient visits.

Results: 47,719 subjects and controls were matched on a 1:1 basis. As the subjects were matched, the two groups did not differ on age, percent female, and various Diagnosis-Related-Groups severity indices. The obstructive sleep apnea group had more comorbid conditions and a higher Elixhauser index. Short-term healthcare utilization measured by the length of stay and mortality related to index procedure did not increase in the sleep apnea group. In hierarchical logistical regression analysis, the presence of sleep apnea predicted higher long-term health care utilization.

Conclusions: Our data suggests that the presence of sleep apnea was not associated with increased post elective surgical length of stay and mortality; however, the presence of obstructive sleep apnea was associated with long-term health care utilization.
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http://dx.doi.org/10.1016/j.sleep.2021.02.044DOI Listing
February 2021

Non-respiratory complaints are main reasons for disturbed sleep post lung transplant.

Sleep Med 2020 06 27;70:106-110. Epub 2019 Nov 27.

Michael E. DeBakey VA Medical Center, Section of Pulmonary, Sleep, and Critical Care Medicine, USA. Electronic address:

Background: Poor sleep is prevalent in lung transplant recipients and affects quality of life negatively. To improve quality of sleep, it's important to identify the causes of poor sleep. We conducted a survey to identify the reasons for poor sleep quality in the recipients.

Methods: We surveyed lung transplant recipients (2003-2010) at Baylor College of Medicine/The Methodist Hospital lung transplant center. We used a compilation of questionnaires, including the Pittsburgh Sleep Quality Index (PSQI), Berlin Questionnaire, Epworth Sleepiness Scale (ESS) and Short Form 36 (SF36). Descriptive analysis was performed on the responses.

Results: Of the 167 participants, 54 responded (32.3%) with mean age 60.6 years (SD 9.8), 48% male, and a mean post-transplant body mass index (BMI) of 27 (SD 4.7). The responders reported a long mean sleep latency of 33.2 min (SD 32.5), poor sleep quality (74% with PSQI score > 5), excessive daytime sleepiness (ESS > 9 in 29%), poor physical QOL with SF36 mean score of 41.3 (SD 9.4), and high risk for OSA (48.2%). About 30% and 72% reported sleep initiation and maintenance insomnia, respectively. The poor sleep quality was due to "getup to go to bathroom" (85%), "cough or snore loudly" (33%), "have pain" (27.8%), and "feel too cold" (27.8%). Furthermore, 5% reported "Can't breathe comfortably" as reason for poor sleep.

Conclusions: The recipients reported poor sleep and quality of life. The non-respiratory complaints were important factors for poor sleep. Attention to these factors may help to outline better management strategies to improve sleep in lung transplant recipients.
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http://dx.doi.org/10.1016/j.sleep.2019.11.1243DOI Listing
June 2020

Getting more from less.

Authors:
Max Hirshkowitz

Sleep Med 2020 03 5;67:248. Epub 2019 Jan 5.

Division of Public Mental Health and Population Sciences, School of Medicine, Stanford University, Stanford, CA, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA. Electronic address:

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http://dx.doi.org/10.1016/j.sleep.2019.01.001DOI Listing
March 2020

The role of home sleep testing for evaluation of patients with excessive daytime sleepiness: focus on obstructive sleep apnea and narcolepsy.

Sleep Med 2019 04 28;56:80-89. Epub 2019 Jan 28.

Yale Pulmonary and Critical Care Medicine, New Haven, CT, USA. Electronic address:

Excessive daytime sleepiness (EDS) is a common complaint in the general population, which may be associated with a wide range of sleep disorders and other medical conditions. Narcolepsy is a sleep disorder characterized primarily by EDS, which involves a substantial burden of illness but is often overlooked or misdiagnosed. In addition to identifying low cerebrospinal fluid (CSF) hypocretin (orexin) levels, evaluation for narcolepsy requires in-laboratory polysomnography (PSG). Polysomnography is the gold standard for diagnosis of obstructive sleep apnea (OSA) as well as other sleep disorders. However, the use of home sleep apnea testing (HSAT) to screen for OSA in adults with EDS has increased greatly based on its lower cost, lower technical complexity, and greater convenience, versus PSG. The most commonly used, types 3 and 4, portable monitors for HSAT lack capability for electroencephalogram recording, which is necessary for the diagnosis of narcolepsy and other sleep disorders and is provided by PSG. These limitations, combined with the increased use of HSAT for evaluation of EDS, may further exacerbate the under-recognition of narcolepsy and other hypersomnias, either as primary or comorbid disorders with OSA. Adherence to expert consensus guidelines for use of HSAT is essential. Differential clinical characteristics of patients with narcolepsy and OSA may help guide correct diagnosis. Continued EDS in patients diagnosed and treated for OSA may indicate comorbid narcolepsy or another sleep disorder. Although HSAT may diagnose OSA in appropriately selected patients, it cannot rule out or diagnose narcolepsy. Therefore, at present, PSG and MSLT remain the cornerstone for narcolepsy diagnosis.
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http://dx.doi.org/10.1016/j.sleep.2019.01.014DOI Listing
April 2019

The National Sleep Foundation's Sleep Satisfaction Tool.

Sleep Health 2019 02 19;5(1):5-11. Epub 2018 Oct 19.

Division of Public Mental Health and Population Sciences, School of Medicine, Stanford University, Stanford, CA, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

Objectives: The National Sleep Foundation (NSF) sought to test, refine, and add statistical rigor to its previously described provisional Sleep Satisfaction Tool (SST). The tool assesses the general population's sleep satisfaction.

Design: In 2017, NSF created a provisional tool through systematic literature review and an expert consensus panel process. This tool was expanded, refined, and tested through an open-ended survey, 2 rounds of cognitive testing, and a national survey of a random sample of Internet users (aged 18-90). Factor analysis and final consensus panel voting produced the robust SST.

Results: The exploratory, open-ended surveying for identifying additional factors important to the public led to question formulation around mind relaxation. Cognitive testing yielded significant refinement to question and response option formatting. Factor analysis of questions from field testing indicated loading on one construct identified as "sleep satisfaction." The final 9-item SST demonstrated strong reliability and internal validity with overall SST scores of 56/100 (higher scores indicating greater sleep satisfaction). Individual SST item mean scores ranged from 39 to 66, and overall SST scores varied substantially across demographic groups.

Conclusions: NSF used a series of development and validation tests on its provisional SST, producing a novel and reliable research tool that measures the general population's sleep satisfaction. The SST is a short, reliable, nonclinical assessment that expands the set of tools available to researchers that implements the individual, social, and environmental factors related to sleep satisfaction. Further research will explore refined scoring methods along with factor weighting and use within different populations.
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http://dx.doi.org/10.1016/j.sleh.2018.10.003DOI Listing
February 2019

A provisional tool for the measurement of sleep satisfaction.

Sleep Health 2018 02 18;4(1):6-12. Epub 2017 Dec 18.

Division of Public Mental Health and Population Sciences, School of Medicine, Stanford University, Stanford, CA, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

Objectives: The goal of this project was to provisionally identify the basic elements of sleep satisfaction within the general population.

Methods: The National Sleep Foundation conducted a systematic literature review and identified 495 published articles evaluating potential indicators of sleep satisfaction. The National Sleep Foundation then convened an expert panel ("Panel"), provided full-text articles and summaries, and used a modified RAND appropriateness method with three total rounds of voting to determine the appropriateness of indicators for sleep satisfaction.

Results: The literature review revealed no tools or measures of sleep satisfaction (not dissatisfaction) applied to the general population and directly associated with good health. Nonetheless, a variety of sleep factors were extracted from the extant sleep research literature. Panel members voted on these indicators: sleep environmental factors; and sleep initiation and maintenance parameters. Using these indicators, the Panel constructed provisional questions for measuring sleep satisfaction.

Conclusions: The Panel determined that appropriate sleep satisfaction elements include how an individual feels (a) about their sleep, (b) immediately after their sleep, and (c) during the subsequent day. Additionally, appropriate environmental elements include (a) bedding comfort, (b) bedroom temperature, and (c) noise and light in the bedroom. How one feels with (a) the time it takes to fall asleep, (b) the ease with which one falls back to sleep after awakening during a sleep period, (c) the amount of sleep on weekdays and weekends, as well as how undisturbed one's sleep is also were determined to be appropriate contributors to sleep satisfaction. Finally, the Panel agreed that whether an individual desired to change anything about their sleep, is a relevant question.
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http://dx.doi.org/10.1016/j.sleh.2017.11.002DOI Listing
February 2018

The National Sleep Foundation's Sleep Health Index.

Sleep Health 2017 08 20;3(4):234-240. Epub 2017 Jun 20.

National Sleep Foundation, Arlington, VA; Baylor College of Medicine, Houston, TX; Stanford University, Stanford, CA.

Objectives: A validated survey instrument to assess general sleep health would be a useful research tool, particularly when objective measures of sleep are not feasible. Thus, the National Sleep Foundation spearheaded the development of the Sleep Health Index (SHI).

Design: The development of the SHI began with a task force of experts who identified key sleep domains and questions. An initial draft of the survey was created and questions were refined using cognitive testing and pretesting. The resulting 28-question survey was administered via random-sample telephone interviews to nationally representative samples of adults in 2014 (n=1253) and 2015 (n=1250). These data were combined to create the index. A factor analysis linked 14 questions to 3 discrete domains: sleep quality, sleep duration, and disordered sleep. These were assembled as sub-indices, then combined to form the overall SHI, with scores ranging from 0 to 100 (higher score reflects better sleep health).

Results: Americans earned an overall SHI score of 76/100, with sub-index scores of 81/100 in disordered sleep, 79/100 in sleep duration, and 68/100 in sleep quality. In regression analyses, the strongest independent predictors of sleep health were self-reported stress (β=-0.26) and overall health (β=0.26), which were also the strongest predictors of sleep quality (β=-0.32 and β=0.27 respectively).

Conclusions: The current 12-item SHI is a valid, reliable research tool that robustly measures 3 separate but related elements of sleep health-duration, quality, and disorders-and assesses the sleep health status of adults in the United States.
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http://dx.doi.org/10.1016/j.sleh.2017.05.011DOI Listing
August 2017

Indexing America's sleep health.

Authors:
Max Hirshkowitz

Sleep Health 2017 08 19;3(4):232-233. Epub 2017 Jun 19.

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http://dx.doi.org/10.1016/j.sleh.2017.06.001DOI Listing
August 2017

National Sleep Foundation's sleep quality recommendations: first report.

Sleep Health 2017 02 23;3(1):6-19. Epub 2016 Dec 23.

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.

Objectives: To provide evidence-based recommendations and guidance to the public regarding indicators of good sleep quality across the life-span.

Methods: The National Sleep Foundation assembled a panel of experts from the sleep community and representatives appointed by stakeholder organizations (Sleep Quality Consensus Panel). A systematic literature review identified 277 studies meeting inclusion criteria. Abstracts and full-text articles were provided to the panelists for review and discussion. A modified Delphi RAND/UCLA Appropriateness Method with 3 rounds of voting was used to determine agreement.

Results: For most of the sleep continuity variables (sleep latency, number of awakenings >5minutes, wake after sleep onset, and sleep efficiency), the panel members agreed that these measures were appropriate indicators of good sleep quality across the life-span. However, overall, there was less or no consensus regarding sleep architecture or nap-related variables as elements of good sleep quality.

Conclusions: There is consensus among experts regarding some indicators of sleep quality among otherwise healthy individuals. Education and public health initiatives regarding good sleep quality will require sustained and collaborative efforts from multiple stakeholders. Future research should explore how sleep architecture and naps relate to sleep quality. Implications and limitations of the consensus recommendations are discussed.
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http://dx.doi.org/10.1016/j.sleh.2016.11.006DOI Listing
February 2017

Polysomnography Challenges.

Authors:
Max Hirshkowitz

Sleep Med Clin 2016 Dec 27;11(4):403-411. Epub 2016 Oct 27.

Division of Public Mental Health and Population Sciences, School of Medicine, Stanford University, 3430 Bayshore Road, Palo Alto, CA 94303, USA; Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA. Electronic address:

Polysomnography provided a means to objectively study sleep. Initial challenges were technical; the next challenge was overcoming communication difficulties and lack of standardization. The new specialty, sleep medicine, created a huge demand for laboratory polysomnography. By the early 2000s, home sleep testing and treatment devices made inroads into clinical sleep practice. The economic consequence was shrinking demand for clinical laboratory polysomnography. Therefore, polysomnography must now find new directions, approaches, and purpose. Engineering challenges remain, and the "new" polysomnography needs to revisit some of the original questions about sleep, including what constitutes optimal sleep quantity, timing, and quality.
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http://dx.doi.org/10.1016/j.jsmc.2016.07.002DOI Listing
December 2016

Sleep-deprived motor vehicle operators are unfit to drive: a multidisciplinary expert consensus statement on drowsy driving.

Sleep Health 2016 Jun 10;2(2):94-99. Epub 2016 May 10.

Division of Public Mental Health and Population Sciences, School of Medicine, Stanford University, Stanford, CA, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

Objectives: This article presents the consensus findings of the National Sleep Foundation Drowsy Driving Consensus Working Group, which was an expert panel assembled to establish a consensus statement regarding sleep-related driving impairment.

Methods: The National Sleep Foundation assembled a expert panel comprised of experts from the sleep community and experts appointed by stakeholder organizations. A systematic literature review identified 346 studies that were abstracted and provided to the panelists for review. A modified Delphi RAND/UCLA Appropriateness Method with 2 rounds of voting was used to reach consensus.

Results: A final consensus was reached that sleep deprivation renders motorists unfit to drive a motor vehicle. After reviewing growing evidence of impairment and increased crash risk among drivers who obtained less than optimal sleep duration in the preceding 24 hours, the panelists recognized the need for public policy guidance as to when it is certainly unsafe to drive. Toward this end, the panelists agreed upon the following expert consensus statement: "Drivers who have slept for two hours or less in the preceding 24 hours are not fit to operate a motor vehicle." Panelists further agreed that most healthy drivers would likely be impaired with only 3 to 5 hours of sleep during the prior 24 hours.

Conclusions: There is consensus among experts that healthy individuals who have slept for 2 hours or less in the preceding 24 hours are too impaired to safely operate a motor vehicle. Prevention of drowsy driving will require sustained and collaborative effort from multiple stakeholders. Implications and limitations of the consensus recommendations are discussed.
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http://dx.doi.org/10.1016/j.sleh.2016.04.003DOI Listing
June 2016

Can You Hear Me Now?

J Clin Sleep Med 2016 05 15;12(5):641-2. Epub 2016 May 15.

Consulting Professor, Division of Public Mental Health and Population Sciences, School of Medicine, Stanford University, Stanford, CA.

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http://dx.doi.org/10.5664/jcsm.5780DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4865547PMC
May 2016

Obstructive Sleep Apnea Is Not Associated with Higher Health Care Use after Colonoscopy under Conscious Sedation.

Ann Am Thorac Soc 2016 Mar;13(3):419-24

1 Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine.

Rationale: The use of sedation allows medical procedures to be performed outside the operating room while ensuring patient comfort and a controlled environment to increase the yield of the procedure. There is concern about a higher risk of adverse events with use of sedation in patients with obstructive sleep apnea.

Objectives: We aimed to determine if the presence of obstructive sleep apnea increased the risk of hospitalization and/or health care use after patients received moderate conscious sedation for an elective, ambulatory colonoscopy.

Methods: We conducted a retrospective case-control database and chart review study. We compared hospital admissions, intensive care unit (ICU) admissions, and emergency room visits at 24 hours, 7 days, and 30 days in patients with obstructive sleep apnea (n = 3,860) and without obstructive sleep apnea (n = 2,374) who had undergone an elective, ambulatory colonoscopy with sedation.

Measurements And Main Results: We found no significant differences in hospital admissions, ICU admissions, or emergency room visits between the two groups at any time point within the 30 days following the procedures. In a sensitivity analysis in which we compared 827 individuals with polysomnographically confirmed sleep apnea with control subjects, there was still no difference in hospital admissions, ICU admissions, or emergency room visits in the 30 days after receiving sedation for the procedure. Outcomes were not different in individuals with various severities of obstructive sleep apnea.

Conclusions: The presence of obstructive sleep apnea was not associated with increased early hospital admissions, ICU admissions, or emergency room visits after colonoscopy with sedation.
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http://dx.doi.org/10.1513/AnnalsATS.201510-664OCDOI Listing
March 2016

National Sleep Foundation's updated sleep duration recommendations: final report.

Sleep Health 2015 Dec 31;1(4):233-243. Epub 2015 Oct 31.

Division of Sleep Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.

Objective: To make scientifically sound and practical recommendations for daily sleep duration across the life span.

Methods: The National Sleep Foundation convened a multidisciplinary expert panel (Panel) with broad representation from leading stakeholder organizations. The Panel evaluated the latest scientific evidence and participated in a formal consensus and voting process. Then, the RAND/UCLA Appropriateness Method was used to formulate sleep duration recommendations.

Results: The Panel made sleep duration recommendations for 9 age groups. Sleep duration ranges, expressed as hours of sleep per day, were designated as recommended, may be appropriate, or not recommended. Recommended sleep durations are as follows: 14-17 hours for newborns, 12-15 hours for infants, 11-14 hours for toddlers, 10-13 hours for preschoolers, 9-11 hours for school-aged children, and 8-10 hours for teenagers. Seven to 9 hours is recommended for young adults and adults, and 7-8 hours of sleep is recommended for older adults. The self-designated basis for duration selection and critical discussions are also provided.

Conclusions: Consensus for sleep duration recommendations was reached for specific age groupings. Consensus using a multidisciplinary expert Panel lends robust credibility to the results. Finally, limitations and caveats of these recommendations are discussed.
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http://dx.doi.org/10.1016/j.sleh.2015.10.004DOI Listing
December 2015

Arthur Spielman: in memoriam (1947-2015).

Authors:
Max Hirshkowitz

Sleep Health 2015 Dec 23;1(4):226. Epub 2015 Oct 23.

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http://dx.doi.org/10.1016/j.sleh.2015.09.009DOI Listing
December 2015

Realizing sleep health?

Authors:
Max Hirshkowitz

Sleep Health 2015 Sep 10;1(3):145. Epub 2015 Aug 10.

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http://dx.doi.org/10.1016/j.sleh.2015.07.001DOI Listing
September 2015

Sleep Medicine and Psychiatric Disorders in Children.

Sleep Med Clin 2015 Jun;10(2):xiii-xiv

Baylor College of Medicine, Houston, TX, USA; Stanford University School of Medicine, Palo Alto, CA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jsmc.2015.04.001DOI Listing
June 2015

Sleep and Psychiatry in Adults.

Sleep Med Clin 2015 Mar;10(1):xiii-xiv

Baylor College of Medicine, Houston, TX, USA; Stanford University School of Medicine, Palo Alto, CA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jsmc.2014.12.001DOI Listing
March 2015

National Sleep Foundation's sleep time duration recommendations: methodology and results summary.

Sleep Health 2015 Mar 8;1(1):40-43. Epub 2015 Jan 8.

Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA.

Objective: The objective was to conduct a scientifically rigorous update to the National Sleep Foundation's sleep duration recommendations.

Methods: The National Sleep Foundation convened an 18-member multidisciplinary expert panel, representing 12 stakeholder organizations, to evaluate scientific literature concerning sleep duration recommendations. We determined expert recommendations for sufficient sleep durations across the lifespan using the RAND/UCLA Appropriateness Method.

Results: The panel agreed that, for healthy individuals with normal sleep, the appropriate sleep duration for newborns is between 14 and 17 hours, infants between 12 and 15 hours, toddlers between 11 and 14 hours, preschoolers between 10 and 13 hours, and school-aged children between 9 and 11 hours. For teenagers, 8 to 10 hours was considered appropriate, 7 to 9 hours for young adults and adults, and 7 to 8 hours of sleep for older adults.

Conclusions: Sufficient sleep duration requirements vary across the lifespan and from person to person. The recommendations reported here represent guidelines for healthy individuals and those not suffering from a sleep disorder. Sleep durations outside the recommended range may be appropriate, but deviating far from the normal range is rare. Individuals who habitually sleep outside the normal range may be exhibiting signs or symptoms of serious health problems or, if done volitionally, may be compromising their health and well-being.
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http://dx.doi.org/10.1016/j.sleh.2014.12.010DOI Listing
March 2015

Sitting and television viewing: novel risk factors for sleep disturbance and apnea risk? results from the 2013 National Sleep Foundation Sleep in America Poll.

Chest 2015 Mar;147(3):728-734

Sleep Center, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX.

Background: Excess sitting is emerging as a novel risk factor for cardiovascular disease, diabetes, mental illness, and all-cause mortality. Physical activity, distinct from sitting, is associated with better sleep and lower risk for OSA, yet relationships among sitting behaviors and sleep/OSA remain unknown. We examined whether total sitting time and sitting while viewing television were associated with sleep duration and quality, OSA risk, and sleepiness.

Methods: The 2013 National Sleep Foundation Sleep in America Poll was a cross-sectional study of 1,000 adults aged 23 to 60 years. Total sitting time, time watching television while sitting, sleep duration and quality, OSA risk, and daytime sleepiness were assessed.

Results: After adjusting for confounding factors (including BMI and physical activity), each additional hour per day of total sitting was associated with greater odds of poor sleep quality (OR [95% CI] = 1.06 [1.01, 1.11]) but not with other sleep metrics (including sleep duration), OSA risk, or daytime sleepiness. For television viewing while sitting, each additional hour per day was associated with greater odds of long sleep onset latency (≥ 30 min) (OR = 1.15 [1.04, 1.27]), waking up too early in the morning (OR = 1.12 [1.03, 1.23]), poor sleep quality (OR = 1.12 [1.02, 1.24]), and "high risk" for OSA (OR = 1.15 [1.04, 1.28]). Based upon an interaction analysis, regular physical activity was protective against OSA risk associated with television viewing (P = .04).

Conclusions: Excess sitting was associated with relatively poor sleep quality. Sitting while watching television was associated with relatively poor sleep quality and OSA risk and may be an important risk factor for sleep disturbance and apnea risk.
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http://dx.doi.org/10.1378/chest.14-1187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364317PMC
March 2015

Polysomnography: understanding this technology's past might guide future developments.

Authors:
Max Hirshkowitz

IEEE Pulse 2014 Sep-Oct;5(5):26-8

Hans Berger published the first human electroencephalograph (EEG) recording in 1924 [1]. He used a device called the string galvanometer to record brain waves on a light-sensitive plate. The fluctuating potential difference from the scalp oscillated at eight to 13 cycles per second (alpha rhythm) when an individual closed his or her eyes and remained relaxed but awake. Berger noted that when a person fell asleep, the alpha rhythm disappeared. Amazingly, to this day, the alpha rhythm disappearance remains the primary marker for defining sleep onset. Years later, Carl Ludwig invented a kymograph (the ?wave writer?) that used a stylus to record electroencephalographic oscillation on a rotating drum. Later, an alternative approach evolved so that the brain wave recordings were inked onto a roll or fan-folded continuous paper strip moving at a constant speed. Mechanical engineers gradually improved the drive mechanisms for moving paper by using rotating sprockets, pinch rollers, and pressure plates. Gear mechanisms were also incorporated to permit speed changes.
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http://dx.doi.org/10.1109/MPUL.2014.2339291DOI Listing
June 2015

A telemedicine program for diagnosis and management of sleep-disordered breathing: the fast-track for sleep apnea tele-sleep program.

Semin Respir Crit Care Med 2014 Oct 29;35(5):560-70. Epub 2014 Oct 29.

Department of Medicine, Baylor College of Medicine, Houston, Texas.

The objective of this study was to facilitate access to sleep health care for veterans. We designed and implemented a Telehealth program for diagnosing and treating sleep-related breathing disorders (SRBDs). Building on our ongoing out-of-laboratory "Fast Track for Sleep Apnea" program, procedures were modified to accommodate remote operations. This Tele-sleep program was set up at the medical center's community-based outpatient clinics. Home sleep testing and positive airway pressure device technological advances enabled realizing this application for Telehealth. In addition to obtaining appropriated teleconferencing equipment, the program involved implementing systematic processes for (1) six types of clinic visits, (2) training remote-site personnel, (3) making recommendations for inventory management, and (4) evaluating patient satisfaction. Over the past year, we have updated and refined our procedures to optimize program performance and efficiency. To achieve the next step, that is, increasing program scale beyond its current state (e.g., to region-wide), we will need to further develop and formalize quality control indicators to more efficiently monitor operations. The program has helped relieve clinical load at the central sleep program, improved local access to sleep care for veterans, and improved patient satisfaction with health care for SRBDs.
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http://dx.doi.org/10.1055/s-0034-1390069DOI Listing
October 2014

Does nighttime exercise really disturb sleep? Results from the 2013 National Sleep Foundation Sleep in America Poll.

Sleep Med 2014 Jul;15(7):755-61

Objective: To assess the relationship between sleep, time of exercise, and intensity of exercise in a large American sample.

Methods: The 2013 National Sleep Foundation Sleep in America Poll was a cross-sectional study of 1000 adults stratified by age (23–60 years) and U.S. geographical region. Sleep outcomes included self-reported sleep quality, total sleep time, sleep latency, and waking unrefreshed. Exercise timing was characterized as morning (>8 h before bed), afternoon (4–8 h before bed), or evening (<4 h before bed). Exercise intensity was assessed with a modified version of the International Physical Activity Questionnaire.

Results: After adjustment for confounders, evening moderate or vigorous exercisers did not differ in any of the reported sleep metrics compared to non-exercisers. Morning vigorous exercisers had the most favorable sleep outcomes, including greater likelihood of reporting good sleep quality (OR = 1.88, p < .001) and lower likelihood of waking unrefreshed (OR = 0.56, p = .03). Most individuals who performed vigorous evening exercise believed that their sleep was of equal or better quality (97%) and duration (98%) on days they exercised.

Conclusion: Evening exercise was not associated with worse sleep. These findings add to the growing body of evidence that sleep hygiene recommendations should not discourage evening exercise.
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http://dx.doi.org/10.1016/j.sleep.2014.01.008DOI Listing
July 2014

Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: The Apnea Positive Pressure Long-term Efficacy Study (APPLES).

Sleep 2012 Dec 1;35(12):1593-602. Epub 2012 Dec 1.

Stanford University, Stanford, CA, USA.

Study Objective: To determine the neurocognitive effects of continuous positive airway pressure (CPAP) therapy on patients with obstructive sleep apnea (OSA).

Design, Setting, And Participants: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) was a 6-month, randomized, double-blind, 2-arm, sham-controlled, multicenter trial conducted at 5 U.S. university, hospital, or private practices. Of 1,516 participants enrolled, 1,105 were randomized, and 1,098 participants diagnosed with OSA contributed to the analysis of the primary outcome measures.

Intervention: Active or sham CPAP MEASUREMENTS: THREE NEUROCOGNITIVE VARIABLES, EACH REPRESENTING A NEUROCOGNITIVE DOMAIN: Pathfinder Number Test-Total Time (attention and psychomotor function [A/P]), Buschke Selective Reminding Test-Sum Recall (learning and memory [L/M]), and Sustained Working Memory Test-Overall Mid-Day Score (executive and frontal-lobe function [E/F])

Results: The primary neurocognitive analyses showed a difference between groups for only the E/F variable at the 2 month CPAP visit, but no difference at the 6 month CPAP visit or for the A/P or L/M variables at either the 2 or 6 month visits. When stratified by measures of OSA severity (AHI or oxygen saturation parameters), the primary E/F variable and one secondary E/F neurocognitive variable revealed transient differences between study arms for those with the most severe OSA. Participants in the active CPAP group had a significantly greater ability to remain awake whether measured subjectively by the Epworth Sleepiness Scale or objectively by the maintenance of wakefulness test.

Conclusions: CPAP treatment improved both subjectively and objectively measured sleepiness, especially in individuals with severe OSA (AHI > 30). CPAP use resulted in mild, transient improvement in the most sensitive measures of executive and frontal-lobe function for those with severe disease, which suggests the existence of a complex OSA-neurocognitive relationship.

Clinical Trial Information: Registered at clinicaltrials.gov. Identifier: NCT00051363.

Citation: Kushida CA; Nichols DA; Holmes TH; Quan SF; Walsh JK; Gottlieb DJ; Simon RD; Guilleminault C; White DP; Goodwin JL; Schweitzer PK; Leary EB; Hyde PR; Hirshkowitz M; Green S; McEvoy LK; Chan C; Gevins A; Kay GG; Bloch DA; Crabtree T; Demen WC. Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the Apnea Positive Pressure Long-term Efficacy Study (APPLES). SLEEP 2012;35(12):1593-1602.
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http://dx.doi.org/10.5665/sleep.2226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3490352PMC
December 2012

Weight and metabolic effects of CPAP in obstructive sleep apnea patients with obesity.

Respir Res 2011 Jun 15;12(1):80. Epub 2011 Jun 15.

Division of Pulmonary, Critical Care and Sleep Medicine, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77025, USA.

Background: Obstructive sleep apnea (OSA) is associated with obesity, insulin resistance (IR) and diabetes. Continuous positive airway pressure (CPAP) rapidly mitigates OSA in obese subjects but its metabolic effects are not well-characterized. We postulated that CPAP will decrease IR, ghrelin and resistin and increase adiponectin levels in this setting.

Methods: In a pre- and post-treatment, within-subject design, insulin and appetite-regulating hormones were assayed in 20 obese subjects with OSA before and after 6 months of CPAP use. Primary outcome measures included glucose, insulin, and IR levels. Other measures included ghrelin, leptin, adiponectin and resistin levels. Body weight change were recorded and used to examine the relationship between glucose regulation and appetite-regulating hormones.

Results: CPAP effectively improved hypoxia. However, subjects had increased insulin and IR. Fasting ghrelin decreased significantly while leptin, adiponectin and resistin remained unchanged. Forty percent of patients gained weight significantly. Changes in body weight directly correlated with changes in insulin and IR. Ghrelin changes inversely correlated with changes in IR but did not change as a function of weight.

Conclusions: Weight change rather than elimination of hypoxia modulated alterations in IR in obese patients with OSA during the first six months of CPAP therapy.
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http://dx.doi.org/10.1186/1465-9921-12-80DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146428PMC
June 2011

The association between obstructive sleep apnea and neurocognitive performance--the Apnea Positive Pressure Long-term Efficacy Study (APPLES).

Sleep 2011 Mar 1;34(3):303-314B. Epub 2011 Mar 1.

Arizona Respiratory Center, University of Arizona, Tucson, AZ, USA.

Study Objectives: To determine associations between obstructive sleep apnea (OSA) and neurocognitive performance in a large cohort of adults.

Study Design: Cross-sectional analyses of polysomnographic and neurocognitive data from 1204 adult participants with a clinical diagnosis of obstructive sleep apnea (OSA) in the Apnea Positive Pressure Long-term Efficacy Study (APPLES), assessed at baseline before randomization to either continuous positive airway pressure (CPAP) or sham CPAP.

Measurements: Sleep and respiratory indices obtained by laboratory polysomnography and several measures of neurocognitive performance.

Results: Weak correlations were found for both the apnea hypopnea index (AHI) and several indices of oxygen desaturation and neurocognitive performance in unadjusted analyses. After adjustment for level of education, ethnicity, and gender, there was no association between the AHI and neurocognitive performance. However, severity of oxygen desaturation was weakly associated with worse neurocognitive performance on some measures of intelligence, attention, and processing speed.

Conclusions: The impact of OSA on neurocognitive performance is small for many individuals with this condition and is most related to the severity of hypoxemia.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041706PMC
http://dx.doi.org/10.1093/sleep/34.3.303DOI Listing
March 2011

Characteristics of insomnia in a primary care setting: EQUINOX survey of 5293 insomniacs from 10 countries.

Sleep Med 2010 Dec 18;11(10):987-98. Epub 2010 Nov 18.

Université Paris Descartes, APHP, Centre du Sommeil et de la Vigilance, Hôtel Dieu de Paris, 75004 Paris, France.

Objective: To describe the characteristics of insomnia in primary care physicians' (PCPs') practices in 10 countries and to understand how the difficulty of maintaining sleep (DMS) was or was not associated with other insomnia symptoms such as difficulty initiating sleep (DIS), early morning awakenings (EMA) or nonrestorative sleep (NRS) in PCPs patients with insomnia.

Methods: International, noninterventional, cross-sectional, observational survey conducted in a primary care setting in subjects complaining of sleep disturbances in 10 countries. A questionnaire based on DSM-IV and ICSD criteria was administered.

Results: Thirteen thousand one hundred twenty-four subjects were enrolled by 647 physicians; 5293 of them (32.6%) had insomnia and were surveyed. The population was predominantly female (63.9%) with a mean age of 47.8±15.3 years; 39.9% of these patients have already been treated for sleep difficulties. Combination of all types of insomnia symptoms (DIS+DMS+EMA+NRS) was the most frequently reported combination (38.6% of the subjects), while the percentage of subjects presenting with only one type of insomnia symptom (DIS, DMS, EMA or NRS) was very low: 3%, 1.8%, 0.9% and 1.4% respectively. DMS was on average the most commonly reported insomnia symptom (80.2%). Multiple logistic regression showed that DMS, EMA and NRS symptoms were significantly linked with each other and also to other insomnia criteria (sleep satisfaction, sleep quality, sleep duration, number of hours of sleep, frequency of insomnia symptoms, wake up rested / unrested and non restorative sleep).

Conclusions: Patients visiting PCPs with insomnia are likely to present with severe and poly-symptomatic insomnia.
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http://dx.doi.org/10.1016/j.sleep.2010.04.019DOI Listing
December 2010

Sleep and genitourinary systems: physiology and disorders.

Handb Clin Neurol 2011 ;98:355-62

Michael E. DeBakey Veterans Affairs Medical Center Sleep Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

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http://dx.doi.org/10.1016/B978-0-444-52006-7.00022-8DOI Listing
March 2011