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The effects of untreated obstructive sleep apnea (OSA) on cardiopulmonary function remain unclear. Cardiorespiratory fitness (CRF), commonly reflected by VO(2) max measured during cardiopulmonary exercise testing, has gained popularity in evaluating numerous cardiopulmonary conditions and may provide a novel means of identifying OSA patients with the most clinically significant disease. This emerging testing modality provides simultaneous assessment of respiratory and cardiovascular function with results helping uncover evidence of evolving pathology in either organ system. In this review, we highlight the current state of the literature in regard to OSA and CRF with a specific focus on changes in cardiovascular function that have been previously noted. While OSA does not appear to limit respiratory function during exercise, studies seem to suggest an abnormal cardiovascular exercise response in this population including decreased cardiac output, a blunted heart rate response (ie, chronotropic incompetence), and exaggerated blood pressure response. Surprisingly, despite these observed changes in the cardiovascular response to exercise, results involving VO(2) max in OSA remain inconclusive. This is reflected by VO(2) max studies involving middle-aged OSA patients showing both normal and reduced CRF. As prior studies have not extensively characterized oxygen desaturation burden, we propose that reductions in VO(2) max may exist in OSA patients with only the most significant disease (as reflected by nocturnal hypoxia). Further characterizing this relationship remains important as some research suggests that positive airway pressure therapy or aerobic exercise may improve CRF in patients with OSA. In conclusion, while it likely that severe OSA, via an abnormal cardiovascular response to exercise, is associated with decreased CRF, further study is clearly warranted to include determining if OSA with decreased CRF is associated with increased morbidity or mortality. CITATION: Powell TA, Mysliwiec V, Brock MS, Morris MJ. OSA and cardiorespiratory fitness: a review. J Clin Sleep Med. 2022;18(1):279–288.

ObjectiveTo test the hypothesis that reduced slow-wave sleep, or N3 sleep, which is thought to underlie the restorative functions of sleep, is associated with MRI markers of brain aging, we evaluated this relationship in the community-based Framingham Heart Study Offspring cohort using polysomnography and brain MRI.MethodsWe studied 492 participants (age 58.8 ± 8.8 years, 49.4% male) free of neurological diseases who completed a brain MRI scan and in-home overnight polysomnography to assess slow-wave sleep (absolute duration and percentage of total sleep). Volumes of total brain, total cortical, frontal cortical, subcortical gray matter, hippocampus, and white matter hyperintensities were investigated as a percentage of intracranial volume, and the presence of covert brain infarcts was evaluated. Linear and logistic regression models were adjusted for age, age squared, sex, time interval between polysomnography and MRI (3.3 ± 1.0 years), APOE ε4 carrier status, stroke risk factors, sleeping pill use, body mass index, and depression.ResultsLess slow-wave sleep was associated with lower cortical brain volume (absolute duration, β [standard error] = 0.20 [0.08], p = 0.015; percentage, 0.16 [0.08], p = 0.044), lower subcortical brain volume (percentage, 0.03 [0.02], p = 0.034), and higher white matter hyperintensities volume (absolute duration, −0.12 [0.05], p = 0.010; percentage, −0.10 [0.04], p = 0.033). Slow-wave sleep duration was not associated with hippocampal volume or the presence of covert brain infarcts.ConclusionLoss of slow-wave sleep might facilitate accelerated brain aging, as evidence by its association with MRI markers suggestive of brain atrophy and injury. Alternatively, subtle injuries and accelerated aging might reduce the ability of the brain to produce slow-wave sleep.

In 2017 the Veterans Administration (VA) and Department of Defense (DOD) launched development of clinical practice guidelines (CPGs) for the diagnosis and treatment of sleep disorders, with the goal of informing and improving patient care. The guideline development process followed GRADE methodology, considering studies and systematic reviews published over the 10-year period prior to guideline development. A total of 41 recommendations were made,18 related to the diagnosis and treatment of obstructive sleep apnea (OSA) and 23 regarding chronic insomnia disorder. In contrast to other published guidelines, the VA DoD CPGs provide a comprehensive approach to diagnosis and management of the two most common sleep disorders, including a discussion of the sequencing of diagnostic approaches and treatment options. Regarding OSA, strong recommendations were made for follow-up evaluation after non-diagnostic home sleep apnea tests, positive airway pressure therapy as first-line treatment, and the incorporation of supportive, educational and behavioral interventions for patients at high risk for PAP therapy non-adherence due to comorbid conditions. Strong recommendations were also made for the use of cognitive-behavioral therapy for insomnia and against the use of kava (an herbal supplement) in the treatment of chronic insomnia disorder. These guidelines, while intended to directly inform care within VA and DOD, are broadly relevant to the practice of sleep medicine. The majority of scientific evidence was based on studies of non-military, non-veteran populations. The CPG is a major milestone for the VA and DOD in recognizing the importance of evidence-based treatments for sleep disorders in military personnel and veterans. CITATION: Martin JL, Mysliwiec V, Chowdhuri S, Ulmer CS. The Veterans Administration and Department of Defense clinical practice guidelines for the diagnosis and management of sleep disorders: what does this mean for the practice of sleep medicine? J Clin Sleep Med. 2020;16(8):1377–1381.

While forehead cooling has been studied in patients with insomnia in the absence of comorbid medical/psychiatric disorders, it has never been evaluated in patients with insomnia in the presence of co-morbid medical/psychiatric disorders. Veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions received 4-week open-label, in-home, nightly treatment with a forehead cooling device (14–16 °C) along with personalized sleep hygiene following baseline assessments. Pre- and post-treatment, participants completed the Insomnia Severity Index (ISI), the Generalized Anxiety Disorder 7-item scale (GAD-7), and the Patient Health Questionnaire 9-item scale (PHQ-9). Participants recorded daily sleep and anxiety/arousal symptoms. Of 24 veterans (20 men, 42.2 ± 9.5 years), 17 (71%) had marked insomnia severity improvement (a decrease of > 8 on the ISI) and 10 (42%) participants scored 7 or below on the ISI at post-treatment reflecting remission. Participants reported reductions in sleep onset latency (SOL) (F = 12.9, p < 0.001), and wakefulness after sleep onset (WASO) (F = 8.4, p < 0.001) across treatment. They also had significant reductions in insomnia severity (t = 10.04, p < 0.001), anxiety (t = 3.59, p = 0.002), and depression (t = 7.75, p < 0.001) from pre- to post-treatment. This pilot study shows that 4-week nightly use of a forehead cooling device produces improvements in insomnia, anxiety, and depressive symptoms in veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions. Controlled studies are warranted to determine the role of this therapy in the management of insomnia in veterans. Not required as a small sample size feasibility study.

Description In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions. Methods In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

Mild traumatic brain injuries (mTBI) are a pervasive concern for military personnel. Determining the impact of injury severity, including loss of consciousness (LOC) may provide important insights into the risk of psychological symptoms and inflammation commonly witnessed in military personnel and veterans following mTBI. US military personnel and veterans were categorized into three groups; TBI with LOC (n = 36), TBI without LOC (n = 25), Controls (n = 82). Participants reported their history of mTBI, psychological symptoms (post-traumatic stress disorder [PTSD] and depression), health-related quality of life (HRQOL), and underwent a blood draw. ANCOVA models which controlled for insomnia status and combat exposure indicated that both mTBI groups (with/without LOC) reported significantly greater depression and PTSD symptoms compared to controls; however, they did not differ from each other. The mTBI with LOC did report greater pain than both controls and mTBI without LOC. The TBI with LOC group also had significantly elevated IL-6 concentrations than both TBI without LOC and control groups. Within the mTBI groups, increased TNFα concentrations were associated with greater PTSD symptoms. These findings indicate that sustaining an mTBI, with or without LOC is detrimental for psychological wellbeing. However, LOC may be involved in perceptions of pain and concentrations of IL-6.

Study Objectives:Studies of older and less active patients with obstructive sleep apnea (OSA) have reported decreased exercise capacity as measured by peak oxygen uptake (VO2 max) during cardiopulm...

The military lifestyle often includes continuous operations whether in training or deployed environments. These stressful environments present unique challenges for service members attempting to achieve consolidated, restorative sleep. The significant mental and physical derangements caused by degraded metabolic, cardiovascular, skeletomuscular, and cognitive health often result from insufficient sleep and/or circadian misalignment. Insufficient sleep and resulting fatigue compromises personal safety, mission success, and even national security. In the long-term, chronic insufficient sleep and circadian rhythm disorders have been associated with other sleep disorders (e.g., insomnia, obstructive sleep apnea, and parasomnias). Other physiologic and psychologic diagnoses such as post-traumatic stress disorder, cardiovascular disease, and dementia have also been associated with chronic, insufficient sleep. Increased co-morbidity and mortality are compounded by traumatic brain injury resulting from blunt trauma, blast exposure, and highly physically demanding tasks under load. We present the current state of science in human and animal models specific to service members during- and post-military career. We focus on mission requirements of night shift work, sustained operations, and rapid re-entrainment to time zones. We then propose targeted pharmacological and non-pharmacological countermeasures to optimize performance that are mission- and symptom-specific. We recognize a critical gap in research involving service members, but provide tailored interventions for military health care providers based on the large body of research in health care and public service workers.

Patients with obstructive sleep apnea (OSA) commonly report residual excessive daytime sleepiness (EDS) despite treatment with positive airway pressure (PAP). The present study aimed to determine whether patients presenting with subjective sleepiness after treatment with PAP therapy had objective evidence of residual sleepiness.We conducted a retrospective analysis of 29 adults with OSA on PAP therapy who underwent a standardized evaluation for EDS. Patients were evaluated with the Epworth Sleepiness Scale (ESS) and attend an in-lab polysomnogram (PSG) with PAP followed by a multiple sleep latency test (MSLT).Our cohort consisted of 23 men (79%) and 6 women (21%) with a mean age of 40.7 years. All patients were subjectively sleepy with an ESS score of 10 and met minimal PAP usage of 4 h a night for at least 70% of nights with a residual apnea-hypopnea index (AHI) ≤ 10. On MSLT, 31% of patients had an average sleep onset latency (SOL) 8 min, 35% had a SOL between 8 and 11 min, and 35% had SOL 11 min.After optimizing PAP therapy and sleep in patients with OSA and residual EDS, the majority were found to have objective findings of an abnormally short SOL on MSLT. This is further evidence that there is a distinct OSA phenotype that will have persistent EDS despite appropriate treatment of their sleep-disordered breathing. Objective testing to quantify the degree of sleepiness is recommended for OSA patients with residual EDS.

Historically, scientific knowledge gaps—including a lack of information regarding the minimum amount of sleep needed to sustain nominally adequate, militarily relevant performance, and nescience of the potential impact of chronic sleep restriction on health and psychological well-being—have hindered decision-making vis-a-vis sleep/alertness management in operational environments. However, against a backdrop of increasing awareness of the importance of sleep for sustaining both performance and health, military researchers are currently doing the following: (1) developing a comprehensive, individualized sleep/alertness management system to optimize the general effectiveness of military personnel (ie, without regard to the potential relationship between sleep and specific aspects of military performance, thus sidestepping what has historically been an impediment to development of such a system); and (2) investigating the prevalence, potentially unique etiology (eg, resulting from the interaction of long-term exposure to combat-related stressors and sleep restriction), and treatment of sleep disorders and comorbidities in the military population.

Introduction According to the American Academy of Sleep Medicine (AASM) guidelines, split-night polysomnography (SN-PSG) is an acceptable alternative to full-night PSG (FN-PSG) and may be considered in patients with an apnea-hypopnea index (AHI) ≥20/hr within the first 2 hours of the study. While SN-PSGs are an accurate approximation of moderate-to-severe obstructive sleep apnea (OSA), there remains the potential to misclassify the severity of sleep disordered breathing. Risks associated with the misclassification of OSA severity may be significant in high-risk professions such as active duty service members (ADSMs). The purpose of our study was to determine the accuracy of split-night polysomnography (SN-PSG) in a cohort of ADSMs. Materials and methods We conducted a retrospective review of ADSMs undergoing FN-PSG with approval by our institution's Department of Clinical Investigation. FN-PSG data were processed using t-test, ANOVA, Chi-Squared, and logistical regression using JMP v12.0 to obtain partial-night data for the first 2 and 3 hours of recording. Significance was established with p-value less than 0.05. OSA severity was determined by calculating the AHI of each subject's FN-PSG and SN-PSG. Results Three-hundred patients were included in the study. Overall 79% were male with a mean age of 37.6 ± 8.4 years and mean BMI of 28.5 ± 3.3 kg/m2. Of our cohort, 112 patients (37%) would have qualified for a SN-PSG, of which 94 (84%) were appropriately classified and 18 patients (16%) were misclassified. Conclusions In the relatively young, non-obese ADSM population, the majority did not qualify for a SN-PSG. The 3-hour SN-PSG accurately determined OSA severity in those with moderate-severe OSA; however, some patients with mild OSA would have been misclassified which can result in unnecessary duty limitations. A SN-PSG may not be ideal for this population.

INTRODUCTION: We evaluated whether insomnia symptom severity was associated with cognitive function, and whether this relationship was modified by biomarkers associated with Alzheimer’s disease risk. METHODS: We examined insomnia symptoms and neuropsychological performance 3.4 years later in 511 dementia-free Framingham Heart Study participants (62.65 ± 8.7 years, 50.9% male). Additionally, we explored insomnia symptoms combined with self-reported short habitual sleep duration and effect modification by apolipoprotein E (APOE) ε4 allele status. RESULTS: More severe insomnia symptoms were associated with lower performance on global cognition, and immediate and delayed Logical Memory recall, especially when insomnia symptoms were combined with short sleep duration. The association between insomnia symptoms and poorer memory recall was more pronounced in APOE ε4 allele carriers. DISCUSSION: Insomnia symptom severity was associated with worse subsequent global cognitive and memory performance, which was especially apparent in APOE ε4 allele carriers, suggesting that poor sleep might be particularly detrimental when the brain is already vulnerable to neurodegeneration.

STUDY OBJECTIVES: Military personnel frequently experience sleep difficulties, but little is known regarding which military or life events most impact their sleep. The Military Service Sleep Assessment (MSSA) was developed to assess the impact of initial military training, first duty assignment, permanent change of station, deployments, redeployments, and stressful life events on sleep. This study presents an initial psychometric evaluation of the MSSA and descriptive data in a cohort of service members. METHODS: The MSSA was administered to 194 service members in a military sleep disorders clinic as part of a larger study. RESULTS: Average sleep quality on the MSSA was 2.14 (on a Likert scale, with 1 indicating low and 5 indicating high sleep quality), and 72.7% (n = 140) of participants rated their sleep quality as low to low average. The events most reported to negatively impact sleep were stressful life events (41.8%), followed by deployments (40.6%). Military leadership position (24.7%) and birth/adoption of a child (9.7%) were the most frequently reported stressful life events to negatively impact sleep. There were no significant differences in current sleep quality among service members with a history of deployment compared with service members who had not deployed. CONCLUSIONS: The MSSA is the first military-specific sleep questionnaire. This instrument provides insights into the events during a service member’s career, beyond deployments, which precipitate and perpetuate sleep disturbances and likely chronic sleep disorders. Further evaluation of the MSSA in nontreatment-seeking military populations and veterans is required. CITATION: Mysliwiec V, Pruiksma KE, Brock MS, et al. The Military Service Sleep Assessment: an instrument to assess factors precipitating sleep disturbances in U.S. military personnel. J Clin Sleep Med. 2021;17(7):1401–1409.

Background Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment. Methods This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™’s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM’s sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM’s sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group. Discussion Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members. Trial registration ClinicalTrials.gov NCT04366284. Registered on 28 April 2020.

Study Objectives Epidemiologic studies of obstructive sleep apnea (OSA) and insomnia in the U.S. military are limited. The primary aim of this study was to report and compare OSA and insomnia diagnoses in active duty the United States military service members. Method Data and service branch densities used to derive the expected rates of diagnoses on insomnia and OSA were drawn from the Defense Medical Epidemiology Database. Single sample chi-square goodness of fit tests and independent samples t-tests were conducted to address the aims of the study. Results Between 2005 and 2019, incidence rates of OSA and insomnia increased from 11 to 333 and 6 to 272 (per 10,000), respectively. Service members in the Air Force, Navy, and Marines were diagnosed with insomnia and OSA below expected rates, while those in the Army had higher than expected rates (p < .001). Female service members were underdiagnosed in both disorders (p < .001). Comparison of diagnoses following the transition from ICD 9 to 10 codes revealed significant differences in the amounts of OSA diagnoses only (p < .05). Conclusion Since 2005, incidence rates of OSA and insomnia have markedly increased across all branches of the U.S. military. Despite similar requirements for overall physical and mental health and resilience, service members in the Army had higher rates of insomnia and OSA. This unexpected finding may relate to inherent differences in the branches of the military or the role of the Army in combat operations. Future studies utilizing military-specific data and directed interventions are required to reverse this negative trend.

Sleep disturbances, posttraumatic stress disorder, and traumatic brain injury are highly prevalent in military personnel and veterans. These disorders can negatively impact military performance. Although literature evaluating how posttraumatic stress disorder and traumatic brain injury directly impact military performance is limited, there is evidence supporting that these disorders negatively impact cognitive and social functioning. What is not clear is if impaired performance results from these entities individually, or a combination of each. Further research using standardized evaluations for the clinical disorders and metrics of military performance is required to assess the overall performance decrements related to these disorders.

The article of record as published may be found at https://doi.org/10.1093/oso/9780190455132.003.0010 This chapter explores the influence of sleep on human performance and well-being. A general discussion of the role of sleep in humans is followed by a description of the functions of various stages of sleep. The authors explore causal factors of insufficient sleep and inventory known effects of sleep restriction on human performance. They then describe the particular challenges of fatigue and sleep deprivation in military operational environments. The efficacy of fatigue countermeasures and alertness aids commonly used in military settings is presented. The chapter concludes with an argument for more deliberately protecting and promoting sleep, particularly in vulnerable populations such as shiftworkers.

IntroductionIn the United States (U.S.), approximately 35% of adults sleep less than 7 hours per night. The relationship between social media use and insufficient sleep has not thoroughly been examined among adults. The purpose of this study was to determine if social media use is associated with insufficient sleep among a sample of U.S. Army Soldiers.MethodsThis study surveyed 9,052 U.S. Soldiers in 2018 via a self-administered online questionnaire. Using multivariable logistic regression, we examined the association between social media use (ResultsOverall, 54.9% of Soldiers reported insufficient sleep. There was no significant relationship between excessive social media use and insufficient sleep in the multivariable logistic regression (OR: 1.03; CI: 0.87–1.23). The covariates of sex, race/ethnicity, rank, hazardous alcohol consumption, anxiety, and depression were significantly associated with insufficient sleep. Soldiers who reported symptoms of anxiety were more than twice as likely (OR: 2.11; CI: 1.65–2.70) to report insufficient sleep than Soldiers without signs of anxiety. Additionally, Soldiers who reported depressive symptoms were 85% (OR: 1.85; CI: 1.44–2.37) more likely to experience insufficient sleep than Soldiers without signs of depression.ConclusionSufficient sleep is essential to ensuring mission readiness and preventing accidental morbidity and mortality among Soldiers. The findings of this analysis do not suggest a link between extended social media use and insufficient sleep. However, though previously uninvestigated, Soldiers reporting symptoms of anxiety and depression were more likely to experience insufficient sleep compared to unafflicted Soldiers. Therefore developing a culture that encourages Soldiers to seek necessary behavioral health screening and care could be a key primary strategy to promote adequate sleep.

Comorbid insomnia and sleep apnea (COMISA) is prevalent and carries significant morbidity but lacks a standardized diagnostic and therapeutic approach. Through a critical evaluation of the literature, we propose a novel approach to COMISA that incorporates the underlying etiology and existence of different phenotypes in this disorder. A low arousal threshold and/or hyperarousability may underlie the development of COMISA. Pretreatment symptoms may serve as baseline predictors of response to positive airway pressure therapy in COMISA and differentiate insomnia secondary to OSA from independent insomnia. A variety of therapeutic strategies for COMISA have been put forward with evidence supporting the use of monotherapy or combined therapy in the appropriate clinical setting. Patients with either OSA or insomnia must be effectively screened for both disorders based on presenting symptoms and response to therapy. Recognition of the underlying etiology of COMISA and the different COMISA phenotypes can guide therapy.

Sleep disturbances are endemic in military personnel with nonclinical populations averaging 6 hours of sleep. The Pittsburgh Sleep Quality Index (PSQI), however, has not been validated in this popu...

Hospital readmissions are an important metric of quality and safety. This study seeks to characterize the relationship between readmissions and obstructive sleep apnea (OSA). A better understanding of this relationship could be utilized to develop preventative measures and reduce readmission rates.A retrospective review of patients discharged over a 24-month period to a Department of Defense hospital was conducted. Medical records review provided demographic data, presence of OSA and comorbid diseases, and whether readmission occurred within 30 days of discharge. Statistical analysis assessed risk factors for readmission, and multivariate analysis was performed. Next, 125 readmitted patients with OSA were randomly selected for detailed chart review and compared to a matched cohort that was not readmitted.Of 22,261 unique patients discharged, 1,899 (8.5%) were readmitted. Patients with OSA had a readmission rate of 11.4% versus 7.6% for patients without OSA (This study found OSA to be an independent risk factor for readmission within 30 days of discharge. PAP therapy appears to be underutilized in patients with known OSA. Additional studies are needed to define the relationship between OSA, PAP adherence, and hospital readmission.

Military personnel experience posttraumatic stress disorder (PTSD), which is associated with differential DNA methylation across the whole genome. However, the relationship between these DNA methylation patterns and clinically relevant increases in PTSD severity is not yet clearly understood. The purpose of this study was to identify differences in DNA methylation associated with PTSD symptoms and investigate DNA methylation changes related to increases in the severity of PTSD in military personnel. In this pilot study, a cross-sectional comparison was made between military personnel with PTSD (n = 8) and combat-matched controls without PTSD (n = 6). Symptom measures were obtained, and genome-wide DNA methylation was measured using methylated DNA immunoprecipitation (MeDIP-seq) from whole blood samples at baseline and 3 months later. A longitudinal comparison measured DNA methylation changes in military personnel with clinically relevant increases in PTSD symptoms between time points (PTSD onset) and compared methylation patterns to controls with no clinical changes in PTSD. In military personnel with elevated PTSD symptoms 3 months following baseline, 119 genes exhibited reduced methylation and 8 genes exhibited increased methylation. Genes with reduced methylation in the PTSD-onset group relate to the canonical pathways of netrin signaling, Wnt/Ca+ pathway, and axonal guidance signaling. These gene pathways relate to neurological disorders, and the current findings suggest that these epigenetic changes potentially relate to PTSD symptomology. This study provides some novel insights into the role of epigenetic changes in PTSD symptoms and the progression of PTSD symptoms in military personnel.

The article of record as published may be found at http://dx.doi.org/10.1093/milmed/usx116 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. Materials and Methods: 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. Results: 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). Conclusions: 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.

Idiopathic rapid eye movement sleep behavior disorder is characterized by vocalizations and complex motor behaviors during sleep. We report a case of a 44-year-old male with a 20-year history of dream enactment behavior that was incidentally captured on a polysomnogram during an evaluation for obstructive sleep apnea. Genetic testing found the patient had a homozygous deletion for one of the five tandem repeats in exon 18 of the PER3 gene. This case highlights a potential genetic basis for idiopathic rapid eye movement sleep behavior disorder. CITATION: Brock MS, Shirley S, Rohena L, Moore BA, Mysliwiec V. Unexpected finding of idiopathic REM sleep behavior disorder in a young healthy male with snoring: a case report. J Clin Sleep Med. 2019;15(9):1369–1371.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

The purpose of this study is to compare sleep disorders between male and female military personnel. Comorbid behavioral health disorders and chronic pain were also studied in relation to sleep disorders.We conducted a retrospective review of military personnel who underwent a sleep medicine evaluation and an in-laboratory attended polysomnography. Initial sleep questionnaires, demographics, polysomnographic variables, and comorbid disorders of interest were reviewed and compared for each sex.All patients were referred to the Wilford Hall Ambulatory Surgical Center Sleep Disorders Center for evaluation of sleep disturbance.Our cohort consisted of 209 military personnel with 51.7% men. The cohort was relatively young with a mean age of 34.3 years. Men had a significantly higher body mass index at 29.4 vs 27.3 in women.Insomnia was diagnosed in 72 women and 41 men (P.001), whereas obstructive sleep apnea (OSA) was diagnosed in 92 men and 50 women (P.001). Depression and anxiety were more common in women. Women had an average of 1.76 ± 1.36 comorbid conditions compared with 1.08 ± 1.19 in men. In patients diagnosed with both insomnia and OSA, women were more likely to have post-traumatic stress disorder, depression, and anxiety. Neither the Epworth Sleepiness Scale (12.8 ± 4.88) nor the Insomnia Severity Index (16.9 ± 5.33) differed between sexes.Gender-related differences in sleep disorders are present in active-duty personnel. Behavioral health disorders were frequent comorbid disorders, and women diagnosed with both insomnia and OSA manifested greater psychiatric comorbidity. The frequent association between sleep and behavioral health disorders in military personnel requires further study.

Introduction Sleep is an essential biological function and the disruption of sleep has deleterious consequences. Military personnel experience unique stressors related to their service, elevating the risk of developing sleep disorders. The etiologies and impact of sleep disorders on military women’s health is poorly understood. This study is the first to prospectively assess whether military women with insomnia, obstructive sleep apnea (OSA), or comorbid insomnia and OSA (COMISA) have different gender roles, military service-associated factors, and biological characteristics than military men with the same disorders. Methods This is a prospective observational study of military personnel with sleep disturbances. The study will evaluate women and men matched for sleep disorder. Participants will complete an evaluation to include polysomnography (PSG), sleep questionnaires and validated clinical assessments of associated disorders of interest. The baseline demographics, questionnaire, and PSG results will be analyzed to assess for commonalities or differences between genders. Results We have enrolled 45 patients (24% female). Males had a higher BMI (29.1) than females (26). Males were also older (38) than females (35). The leading diagnosis in males was OSA (44%) and insomnia in females (64%). In males, the apnea-hypopnea index (AHI) was 11.3/hr, arousal index (ARI) was 20/hr, and sleep efficiency (SE) was 86.5%. Total sleep time (TST), wake after sleep onset (WASO), and sleep onset latency (SOL) were 364.6, 40.9, and 12.6 minutes, respectively. In females, the average AHI was 6.6/hr, ARI was 15/hr, and SE was 87.2%. Their TST, WASO, and SOL were 359, 44, and 12.6 minutes, respectively. Conclusion Military personnel are at increased risk of sleep disorders. Literature comparing male and female characteristics and sleep disorders is scarce. In this study, baseline demographics were similar in both groups but insomnia was the leading diagnosis for women. This emphasizes the importance of adequate recognition and treatment of insomnia in this group. Support This study is supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health.

Exposure to elevated concentrations of respirable particulate matter ( 10 μm) may influence sleep-disordered breathing. Burn pits as utilized by the US military in the Middle East until 2011 produced elevated particle matter concentrations. We seek to determine if subjective exposure to burn pits during deployment affects prevalence or severity of obstructive sleep apnea (OSA) in military personnel.As part of a prospective observational study of previously deployed military personnel with exertional dyspnea (n = 145), all patients underwent pulmonary function testing, screening for burn pit exposure, and if warranted by questionnaires, overnight polysomnography. A total of 100 patients completed all testing. For analysis, patients were classified into a burn pit exposure group (45 patients) and a no exposure group (55 patients). Additional analyses were performed on those endorsing burn pit maintenance during deployment (25 patients) and those with 12 h of daily exposure (17 patients).The prevalence of OSA, defined by apnea-hypopnea index (AHI) 5/h, was similarly high in both groups (69% vs. 71%, p = 0.83). Surprisingly, the mean AHI was lower in the exposed group (12.8/h vs. 19.7/h, p = 0.04) while nadir of oxygen saturation was similar (87% vs. 86%, p = 0.39). Subgroup analyses revealed similar findings in those who performed burn pit maintenance (prevalence = 80%, p = 0.58; AHI = 14.8, p = 0.16) and those with 12 h of daily exposure (prevalence = 88%, p = 0.33; AHI = 18.0, p = 0.62).Subjective burn pit exposure does not appear to influence OSA development in previously deployed military personnel. Given the high rate of OSA in this cohort, continued investigation of deployment exposures which may influence sleep-disordered breathing is recommended.

Insomnia is one of the most frequent sleep complaints among veterans and military personnel. This retrospective study investigated whether cognitive-behavioral therapy for insomnia (CBT-I) improved sleep and reduced insomnia symptoms in an active duty military population. The study consisted of 98 military personnel (mean age = 31.0, SD = 7.4; 70% male) who experienced insomnia and completed CBT-I in a military sleep disorders clinic. Assessments of sleep were completed analyzing pre- and posttreatment variables from the sleep diary, Insomnia Severity Index (ISI), and Epworth Sleepiness Scale (ESS). At baseline, the mean ISI was 16.63 (SD = 4.36) with a total sleep time (TST) of approximately 5.90 hr (SD = 1.32). After CBT-I, the ISI was 14.50 (SD = 5.19) and TST was 5.62 hr (SD = 1.32). There was no significant change over time for patients who received fewer than 4 sessions, but change over time was significant for patients who received 4 or more sessions. Over the course of treatment, patients' overall sleep improved across metrics with 20% achieving clinically meaningful improvement in insomnia symptoms. CBT-I improves insomnia symptoms in some military personnel. However, everyone does not respond successfully to CBT-I treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Following traumatic experiences, patients can develop trauma-associated nightmares, autonomic hyperactivity, and disruptive nocturnal behaviors that transcend the established definition of nightmares. Trauma-associated sleep disorder (TSD) is a proposed parasomnia that encompasses these symptoms. In this chapter we present a case of a 45-year-old active duty soldier who developed post-traumatic stress disorder and severe sleep disturbances following multiple deployments. On most nights he suffers from replicative nightmares about his deployment experiences with associated night sweats, tachypnea, and tachycardia as well as vocalizations, defensive posturing, and violent thrashing. Polysomnography was notable for the presence of rapid eye movement (REM) sleep without atonia as well as relative tachycardia and limb movements during REM sleep. He was treated with prazosin, which reduced the severity of his nightmares and disruptive nocturnal behaviors. The differential diagnosis for his sleep disturbances is presented with the conclusion that current nosology cannot account for his constellation of symptoms and TSD likely has unique neurobiological underpinnings. Recognizing TSD as a distinct parasomnia is paramount to address the severe nocturnal manifestations of this disease.

IntroductionExcessive daytime sleepiness affects an estimated 20% of the general population. While the prevalence of sleepiness in the military is largely unknown, it is well established that short sleep duration is endemic. The reasons for this include: the demanding nature of their duties, shift work and 24-hour duty periods, deployments and exigencies of military service as well as sleep disorders. The Epworth Sleepiness Scale (ESS) is the most widely used sleep questionnaire and provides a self-assessment of daytime sleepiness. To date the clinical utility of this questionnaire in differentiating sleep disorders in military patients with sleep disorders has never been evaluated.Materials and MethodsThe primary aim of this manuscript was to assess if Epworth Sleepiness Scale (ESS) scores differed between military personnel with insomnia, obstructive sleep apnea (OSA), comorbid insomnia/obstructive sleep apnea (COMISA), and a group with neither insomnia nor obstructive sleep apnea (NISA). This study assessed the clinical utility of the ESS in differentiating sleep disorders amongst a sample (N = 488) of U.S. military personnel with insomnia (n = 92), OSA (n = 142), COMISA (n = 221), and a NISA group (n = 33) which served as the control population.ResultsIn the present sample, 68.4% of service members reported excessive daytime sleepiness (EDS) with an ESS > 10. ESS scores differed between military personnel with COMISA (13.5 ± 4.83) and those with OSA only (11.5 ± 4.08; p < 0.001) and the NISA group (9.46 ± 4.84; p < 0.001). Also, ESS scores differed between patients with insomnia only (13.0 ± 4.84) and the NISA group (p < 0.01).ConclusionsOverall, the ESS had poor ability to differentiate sleep disorders. In military personnel, the ESS appears elevated in the most common sleep disorders, likely due to their insufficient sleep, and does not help to differentiate OSA from insomnia. Further studies are required to validate this questionnaire and determine an appropriate threshold value for abnormal sleepiness in the military population.

Active duty service members (ADSM) are a unique population at risk for complex health issues; among the most frequent are sleep disorders. Sleep disturbances are prevalent, debilitating, and persistent in ADSM following combat deployments. Multiple factors associated with deployment and combat operations place ADSM at risk for acute sleep disturbances. If untreated, acute sleep disturbances can become chronic sleep disorders that result in physical and mental impairments and decreased military readiness. Sleep disorders are frequently comorbid with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). However, they are independent clinical disorders which require specific therapy. The consequences of sleep disorders are increasingly recognized in both ADSM and veterans and pose an unprecedented challenge to medical providers who care for these populations.

Disturbed sleep is one of the most common complaints following traumatic brain injury (TBI) and worsens morbidity and long-term sequelae. Further, sleep and TBI share neurophysiologic underpinnings with direct relevance to recovery from TBI. As such, disturbed sleep and clinical sleep disorders represent modifiable treatment targets to improve outcomes in TBI. This paper presents key findings from a national working group on sleep and TBI, with a specific focus on the testing and development of sleep-related therapeutic interventions for mild TBI (mTBI). First, mTBI and sleep physiology are briefly reviewed. Next, essential empirical and clinical questions and knowledge gaps are addressed. Finally, actionable recommendations are offered to guide active and efficient collaboration between academic, industry, and governmental stakeholders.

Sleep disorders (SD) have a complex aetiology, and socioeconomic status (SES) as determined by social class, household income, ethnicity and education plays an important role in their development. As SD are associated with cognitive impairment and mood disorders, they in turn impact SES. Socioeconomic status also influences allostatic load caused by chronic accumulation of stress throughout life. Environmental and psychological stressors have a direct effect on SD, and they are modulated by SES, in combination with comorbidities like obesity and cardiovascular disease. This review explores the recent theories about the influence of SES on the development of SD in the general population, whether or not occurring with comorbidities, and also focusses on the interplay between socioeconomic status, circadian rhythms, aging and clinical outcomes like metabolic diseases and cancer.

STUDY OBJECTIVES: To evaluate prevalence of sedative hypnotic medications and their potential indication among active duty service members (ADSM) and non-ADSM receiving care in the Military Health System (MHS). METHODS: Using a retrospective cohort study design, we extracted data on sedative hypnotic medications (benzodiazepine receptor agonists, benzodiazepines, sedating antidepressants, and melatonin receptor agonist) dispensed from January 2009 to December 2015. Prevalence was defined as ≥ 1 dispensing per patient per year whereas chronic episode was categorized as ≥ 90 days of continuous therapy. Chi square statistics, odds ratios, and 95% confidence intervals were calculated to assess meaningful differences between ADSM and non-ADSM. RESULTS: Mean age at dispensing was 33.5 years in ADSM compared to 59.1 years in non-ADSM. Of all drugs dispensed, 79.2% (n = 2.4 million) were to male ADSM compared to 34.5% (11.5 million) to male non-ADSM. Zolpidem and trazodone were the two most frequently used medications, comprising more than 75% of all prescriptions. Age- and sex-adjusted prevalence peaked at 8.1% in 2013 for ADSM and at 4.9% in 2012 for non-ADSM and remained stable thereafter for both groups. Most episodes for ADSM (81.0%) and non-ADSM (65.0%) were acute or intermittent. ADSM were significantly more likely to have a sleep-related diagnosis associated with their episode than non-ADSM (odds ratio 2.35, 95% confidence interval 2.33–2.36), most frequently insomnia. CONCLUSIONS: ADSM had a 2% to 3% higher adjusted prevalence of sedative hypnotic medications than non-ADSM. The use of sedative hypnotics in the young ADSM population highlights the need for military-appropriate sleep practices and novel interventions to mitigate sleep disturbances and chronic sleep disorders in this population. CITATION: Thelus Jean R, Hou Y, Masterson J, Kress A, Mysliwiec V. Prescription patterns of sedative hypnotic medications in the Military Health System. J Clin Sleep Med. 2019;15(6):873–879.

Sleep disturbances are common in United States military personnel. Despite their exposure to combat and trauma, little is known about nightmares in this population. The purpose of this study was to describe the prevalence and associated clinical and polysomnographic characteristics of nightmares in United States military personnel with sleep disturbances.Retrospective review of 500 active duty United States military personnel who underwent a sleep medicine evaluation and polysomnography at our sleep center. The Pittsburgh Sleep Quality Index and the Pittsburgh Sleep Quality Index-Addendum were used to characterize clinically significant nightmares. Subjective and objective sleep attributes were compared between groups.At least weekly nightmares were present in 31.2%; yet, only 3.9% reported nightmares as a reason for evaluation. Trauma-related nightmares occurred in 60% of those patients with nightmares. Patients with nightmares had increased sleep onset latency (SOL) and rapid eye movement (REM) sleep latency (mean SOL/REM sleep latency 16.6/145 minutes,Clinically significant nightmares are highly prevalent in United States military personnel with sleep disturbances. Nightmares are associated with both subjective and objective sleep disturbances and are frequently comorbid with other sleep and mental health disorders.A commentary on this article appears in this issue on page 303.

Trauma associated sleep disorder (TSD) is likely a novel REM sleep related parasomnia which develops after trauma associated with sleep deprivation and/or disruption. Patients present with trauma related nightmares and disruptive nocturnal behaviors. These are the most profound sleep disturbances incited by trauma but are not well characterized. This may in part result from their rare occurrence in monitored settings, which contrasts distinctly with patient’s self-reported nocturnal experiences. Disruptive nocturnal behaviors consisting of vocalizations, autonomic discharges of tachycardia, tachypnea, night sweats, and non-specific movements as well as dream enactment behavior are reported. Recognizing the clinical features of TSD and classifying it as a distinct parasomnia are paramount to treating the extreme nocturnal distress characteristic of this disorder.

Introduction In 2013, the U.S. Army Surgeon General implemented the Performance Triad (P3), an educational initiative to improve health-related behaviors of soldiers throughout the U.S. Army. The components of P3 are Sleep, Activity, and Nutrition with tenet behaviors for each component. This study reports the results of the 2015 U.S. Army Medical Corps survey regarding physician knowledge and adherence to the tenet behaviors of P3. Methods In 2015, an anonymous survey was sent to all active duty U.S. Army physicians to assess demographic information, work hours, and knowledge of and adherence to P3. The survey assessed the tenets of P3 with questions about the following topics: obtaining 8 h of sleep per day; performing at least 2 d of resistance training and 1 day of agility training per week; re-fueling 30-60 min after exercise; incorporating at least 150 min of moderate and 75 min of vigorous aerobic exercise per week; going caffeine free 6 h before bedtime; eating at least 8 servings of fruits and vegetables per day; and getting 15,000 steps per day. For each question, there were four response options which ranged from "Always" to "Never." A positive response to the questionnaire was defined as answering frequently or always. The responses were analyzed by comparison of several physician categories utilizing descriptive statistics and multivariable analysis. Results Surveys were completed by 1,003 of approximately 4,500 U.S. Army physicians. 79.1% of the respondents were male. Staff physicians made up 834 (83.6%) of the respondents compared with 164 (16.4%) physicians in training. Overall 25% of respondents were adherent to the sleep tenet, 45% to the exercise tenet, and 38% to the nutrition tenet. Reported work hours were significantly higher in physicians in training compared with staff physicians (p < 0.001). About 28.4% of staff reported a positive response to obtaining at least 8 h of sleep per night, compared with 12.7% of residents/fellows. In multivariable analyses, better sleep was associated with being a staff physician [odds ratio 2.4 (95% confidence interval 1.40-4.13)], working fewer hours per week [1.75 (1.37-2.25)], and belief in supervisor adherence to P3 [2.04 (1.59-2.56)]. Increased exercise was associated with male gender [2.09 (1.45-3.02)], being a staff physician [1.63 (1.09-2.43)], and belief in supervisor adherence to P3 [1.43 (1.18-1.75)]. Positive response to the nutrition tenet was associated with belief in supervisor adherence to P3 [1.23 (1.01-1.49)]. Conclusion Overall, U.S. Army physicians are most adherent to the exercise tenet and least adherent to the sleep tenet of P3; this is consistent with the military culture. Work hours seem to affect wellness behaviors. Specifically, physicians who work fewer hours are more likely to report obtaining 8 h of sleep per day and exercise on a regular basis. Importantly, belief in supervisor adherence to P3 was associated with better adherence to P3, suggesting that physician leadership has a positive effect on wellness behaviors. This suggests a role for similar wellness programs in civilian healthcare institutions. Future research should also include changes in health system policies to motivate physician wellness behaviors.

BACKGROUND: Up to one-third of deployed military personnel sustain a traumatic brain injury (TBI). TBIs and the stress of deployment contribute to the vulnerability for chronic sleep disturbance, resulting in high rates of insomnia diagnoses as well as symptoms of posttraumatic stress disorder (PTSD), depression, and declines in health-related quality of life (HRQOL). Inflammation is associated with insomnia; however, the impact of sleep changes on comorbid symptoms and inflammation in this population is unknown. METHODS: In this study, we examined the relationship between reported sleep changes and the provision of the standard of care, which could include one or more of the following: cognitive behavioral therapy (CBT), medications, and continuous positive airway pressure (CPAP). We compared the following: (a) the group with a decrease in the Pittsburgh Sleep Quality Index (PSQI; restorative sleep) and (b) the group with no change or increase in PSQI (no change). Independent t tests and chi-square tests were used to compare the groups on demographic and clinical characteristics, and mixed between-within subjects analysis of variance tests were used to determine the effect of group differences on changes in comorbid symptoms. Linear regression models were used to examine the role of inflammation in changes in symptoms and HRQOL. RESULTS: The sample included 70 recently deployed military personnel with TBI, seeking care for sleep disturbances. Thirty-seven participants reported restorative sleep and 33 reported no sleep changes or worse sleep. The two groups did not differ in demographic characteristics or clinical symptoms at baseline. The TBI + restored sleep group had significant reductions in PTSD and depression over the 3-month period, whereas the TBI + no change group had a slight increase in both PTSD and depression. The TBI + restored sleep group also had significant changes in HRQOL, including the following HRQOL subcomponents: physical functioning, role limitations in physical health, social functioning, emotional well-being, energy/fatigue, and general health perceptions. In a linear regression model using a forced entry method, the dependent variable of change in C-reactive protein (CRP) concentrations was significantly related to changes in PTSD symptoms and HRQOL in the TBI + restored sleep group, with R(2) = 0.43, F33,3 = 8.31, p CONCLUSIONS: Military personnel with TBIs who have a reduction in insomnia symptoms following a standard-of-care treatment report less severe symptoms of depression and PTSD and improved HRQOL, which relate to decreased plasma concentrations of CRP. These findings suggest that treatment for sleep disturbances in this TBI + military population is associated with improvements in health and decreases in inflammation. The contributions of inflammation-induced changes in PTSD and depression in sleep disturbances in TBI + military personnel require further study. Language: en

Background Deployed military personnel are vulnerable to chronic sleep disturbance, which is highly comorbid with post-traumatic stress disorder (PTSD) and depression, as well as declines in health-related quality of life (HRQOL). Inflammation is associated with HRQOL declines and sleep-related comorbidities; however, the impact of sleep changes on comorbid symptoms and inflammation in this population is unknown. Methods In this observational study, we examined the relationship between reported sleep changes and concentrations of inflammatory biomarkers, interleukin 6 (IL-6), and C-reactive protein (CRP) in peripheral blood. The sample was dichotomized into two groups: (1) decrease in Pittsburgh Sleep Quality Index (PSQI; restorative sleep) and (2) no change or increase in PSQI (no change). Mixed between–within subjects analysis of variance tests were used to determine group differences on changes of inflammation and comorbid symptoms. Results In our sample of 66 recently deployed military personnel with insomnia, 34 participants reported restorative sleep whereas 32 reported no sleep changes. The two groups did not differ in demographic or clinical characteristics, with the exception of PTSD diagnosis at baseline. The restorative sleep group had significant reductions in CRP concentrations and depression symptoms, as well as reduced fatigue and improvements in emotional well-being, social functioning, and physical functioning at follow-up. Conclusions Military personnel who report sleep restoration after deployment have reduced CRP concentrations, decreased severity of depression, and improved HRQOL. These findings suggest that treatment for sleep disturbances may be associated with improvements in mental and physical health, thereby supporting continued study in this line of research.

The article of record as published may be found at http://dx.doi.org/10.1016/j.sleep.2017.11.1121 Obstructive sleep apnea (OSA) is characterized by apneas and hypopneas that result in hypoxia, cerebral hypoperfusion, endothelial dysfunction, inflammation, and oxidative stress. These pathophysiologic processes likely contribute to neuronal damage. Tau is a protein that stabilizes microtubules and, along with amyloid beta (Ab), is associated with neurodegenerative processes. We sought to determine if tau and other biomarkers of inflammation were related to OSA severity. Concentrations of tau, Ab40, Ab42, c-reactive protein (CRP), TNF-a, interleukin (IL)-6, and IL-10 were measured in blood and compared between participants with moderate-severe OSA (n 1⁄4 28), those with mild OSA (n 1⁄4 22), and healthy controls (n 1⁄4 24). The cohort included relatively young, primarily male active duty military personnel without a history of traumatic brain injury or neurodegenerative disease. Total biomarker concentrations were determined from plasma samples using an ultra-sensitive detection method, SimoaTM, and CRP was assayed by ELISA. Total tau and IL-6 concentrations were elevated in participants with moderate-severe OSA, with a mean apnea-hypopnea index (AHI) of 26.1/h, compared to those with mild OSA (mean AHI 8.6/h) and healthy controls (mean AHI 2.1/h). Tau concentrations were also significantly correlated with the AHI (r 1⁄4 0.342, p 1⁄4 0.004). Our findings show that tau is elevated in the blood of young patients with moderate-severe OSA, suggesting that this degree of sleep-disordered breathing is a contributing factor in the development of neurodegenerative disorders. The finding of increased IL-6 further suggests that inflammatory biomarkers are present early in the course of this chronic disease.

Background Narcolepsy is a chronic primary sleep disorder, characterized by excessive daytime sleepiness and sleep dysfunction with or without cataplexy. Narcolepsy is uncommon, with a low prevalence rate which makes it difficult to diagnose definitively without a complex series of tests and a detailed history. The aim of this study was to review patients referred to a tertiary sleep centre who had been labelled with a diagnosis of narcolepsy prior to referral in order to assess if the diagnosis was accurate, and if not, to determine the cause of diagnostic misattribution. Methods All patients seen at a sleep centre from 2007–2013 (n = 551) who underwent detailed objective testing including an MSLT PSG, as well as wearing an actigraphy watch and completing a sleep diary for 2 weeks, were assessed for a pre-referral and final diagnosis of narcolepsy. Results Of the 41 directly referred patients with a diagnostic label of narcolepsy, 19 (46 %) were subsequently confirmed to have narcolepsy on objective testing and assessment by a sleep physician using ICSD-2 criteria. Conclusions The diagnosis of narcolepsy was incorrectly attributed to almost 50 % of patients labelled with a diagnosis of narcolepsy who were referred for further opinion by a variety of specialists and generalists. Accurate diagnosis of narcolepsy is critical for many reasons, such as the impact it has on quality of life, driving, employment, insurance and pregnancy in women as well as medication management.

To characterize the clinical, polysomnographic and treatment responses of patients with disruptive nocturnal behaviors (DNB) and nightmares following traumatic experiences.A case series of four young male, active duty U.S. Army Soldiers who presented with DNB and trauma related nightmares. Patients underwent a clinical evaluation in a sleep medicine clinic, attended overnight polysomnogram (PSG) and received treatment. We report pertinent clinical and PSG findings from our patients and review prior literature on sleep disturbances in trauma survivors.DNB ranged from vocalizations, somnambulism to combative behaviors that injured bed partners. Nightmares were replays of the patient's traumatic experiences. All patients had REM without atonia during polysomnography; one patient had DNB and a nightmare captured during REM sleep. Prazosin improved DNB and nightmares in all patients.We propose Trauma associated Sleep Disorder (TSD) as a unique sleep disorder encompassing the clinical features, PSG findings, and treatment responses of patients with DNB, nightmares, and REM without atonia after trauma.

Military personnel who have combat exposures are at increased risk for the service-related disorders of post-traumatic stress disorder (PTSD), depression, sleep disturbances and decreased health related quality of life (HRQOL). Those with a traumatic brain injury (TBI) are at even greater risk. Inflammation is associated with these disorders and may underlie the risk for health declines. We evaluated 110 recently deployed, military personnel presenting with sleep disturbances for service-related disorders (TBI, PTSD, and depression) as well as HRQOL. ANOVA models were used to examine differences among military personnel with two or more service-related disorders (high comorbid group), or one or no disorders (low comorbid group). Logistic regression models were used to determine associations among interleukin-6 (IL-6) to HRQOL and service-related disorders. Approximately one-third of the sample had two or more service-related disorders. HRQOL was lower and IL-6 concentrations were higher in military personnel with PTSD or depression, with the most profound differences in those with more service-related disorders, regardless of sleep disorder. Having symptoms of depression and PTSD resulted in a 3.5-fold risk to be in the lower quartile of HRQOL and the highest quartile of IL-6. In a linear regression model, 41% of the relationship between HRQOL and IL-6 concentrations was mediated by PTSD and depression. Military personnel with PTSD and depression are at high risk for lower HRQOL, and higher IL-6 concentrations. Comprehensive treatment is required to address co-occurring service-related disorders in military personnel to promote health and well-being.