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Background Although insomnia is common in patients with low back pain (LBP), it is unknown whether commonly used self-report sleep measures are sufficiently accurate to screen for insomnia in the LBP population. This study investigated the discriminatory properties of the Pittsburgh Sleep Quality Index (Pittsburgh questionnaire), Insomnia Severity Index (Insomnia index), Epworth Sleepiness Scale (Epworth scale) and the sleep item of the Roland and Morris Disability Questionnaire (Roland item) to detect insomnia in patients with LBP by comparing their accuracy to detect insomnia to a sleep diary. The study also aimed to determine the clinical optimal cut-off scores of the questionnaires to detect insomnia in the LBP population. Methods Seventy nine patients with LBP completed the four self-reported questionnaires and a sleep diary for 7 consecutive nights. The accuracy of the questionnaires was evaluated using Receiver Operator Characteristic (ROC) curves with the Area Under the Curve (AUC) used to examine each test’s accuracy to discriminate participants with insomnia from those without insomnia. Results The Pittsburgh questionnaire and Insomnia index had moderate accuracy to detect insomnia (AUC = 0.79, 95% CI = 0.68 to 0.87 and AUC = 0.78, 95% CI = 0.67 to 0.86 respectively), whereas the Epworth scale and the Roland item were not found to be accurate discriminators (AUC = 0.53, 95% CI = 0. 41 to 0.64 and AUC = 0.64, 95% CI = 0.53 to 0.75 respectively). The cut-off score of > 6 for the Pittsburgh questionnaire and the cut-off point of > 14 for the Insomnia index provided optimal sensitivity and specificity for the detection of insomnia. Conclusions The Pittsburgh questionnaire and Insomnia index had similar ability to screen for insomnia in patients with low back pain.

Most people's experiences of poor sleep are memorable, because sleeplessness and its daytime consequences are unpleasant. There are those, however, for whom insomnia is the norm. Persistent and severe sleep disturbance affects at least one in 10 adults and one in five older adults, thus representing a considerable public health concern. Sleep disruption is central to a number of medical and psychiatric disorders, and insomnia is usually treated by general practitioners. Therefore differential diagnosis is important, and respiratory physicians, neurologists, psychiatrists, and clinical psychologists need to be involved. The purpose of this chapter is to summarize current understanding of the insomnias, their appraisal, and treatment. Particular emphasis will be placed upon evidence-based practical management.

RATIONALE: Placebo responses are complex psychobiological phenomena and often involve patient expectation of benefit. With continuous positive airway pressure (CPAP) treatment of obstructive sleep apnoea, greater hours of CPAP use are associated with reduced sleepiness. However, these open-label studies have not controlled for patient expectation of benefit derived from their knowledge of hours of device use. OBJECTIVES: To investigate the relative effectiveness of the use of real or placebo CPAP on daytime sleepiness. METHODS: Patient-level meta-analysis combining data on sleepiness measured by the Epworth Sleepiness Scale from three randomised placebo-controlled crossover trials. Mixed model analysis of variance was used to quantify the effects of real versus placebo device treatment, usage, their interaction and regression to the mean. MEASUREMENTS AND MAIN RESULTS: Duration of real and placebo CPAP use was correlated within patients (r=0.53, p

Objectives This study aimed to explore the unique experiences of people with obstructive sleep apnoea (OSA) who source their treatment through community pharmacies. Methods A qualitative study employing the phenomenological approach was used. In-depth semi-structured interviews with a purposive convenience sample of 20 participants were conducted. Twenty participants were recruited from community pharmacies offering continuous positive airways pressure (CPAP) device provision and a teaching hospital in Sydney, Australia. Interviews were digitally recorded and transcribed verbatim, coded using Nvivo8 software and analysed based on the ‘framework’ method. Key findings The quality and delivery of information at diagnosis was reported to have been inappropriate for participants' personal needs. Many barriers emerged in regards to CPAP use, consistent with current literature. Participants' self-reported individual styles, coping practices and health beliefs appeared to be the most influential factors in CPAP uptake and adherence, regardless of mechanical advancements and environmental support. High satisfaction was expressed with CPAP obtainment from pharmacy services listing convenience and good service as notable characteristics. Conclusions Community pharmacies have the potential to increase OSA awareness and improve optimal usage of CPAP. Psychosocial based models of adherence intervention could potentially be implemented through CPAP providers, including the community pharmacy, to address some of these factors which impede CPAP adherence.

An important function of the healthy nose is the ability to adjust nasal patency in response to stimuli such as a change in posture between sitting and supine. We hypothesised that the regulation of nasal patency would be impaired in patients with asthma and mild rhinitis and that it could be improved by reducing nasal inflammation with a topical nasal steroid. This is a randomised, placebo-controlled, double-blind, cross-over study comprising 19 subjects with well-controlled asthma and a history of rhinitis without current treatment. The subjects were randomised to fluticasone propionate aqueous nasal spray (Beconase(®)), 200 μg daily, or placebo (FESS(®) saline nasal spray), for 6 weeks in a cross-over design with a 4-week wash-out between treatments. Nasal patency was measured with acoustic rhinometry, while sitting and supine and with peak nasal inspiratory flow (PNIF). Treatment response was also monitored with spirometry, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), Short Form-36 (SF-36), and The Pittsburgh Sleep Quality Index. The minimal cross-sectional area remained unchanged between sitting and supine at baseline and after placebo but after fluticasone propionate there was a significant decrease. PNIF, RQLQ and SF-36 improved after fluticasone propionate, whereas sleep quality did not change. In well-controlled asthma and mild rhinitis, nasal steroid treatment normalised the neurovascular response to posture in the nasal mucosa and improved health-related quality of life. An impaired ability to regulate nasal patency could be a marker of upper airway inflammation in patients with asthma that can be measured non-invasively.

Publisher Summary Cognitive behavioral therapy to increase adherence to continuous positive airway is used to provide information about obstructive sleep apnea (OSA), to educate the patient on the most effective treatment, continuous positive airway pressure (CPAP), and to educate the individual on the medical and psychiatric risks when OSA is not treated. Most sleep laboratories provide basic information about OSA, and then introduce patients to the numerous CPAP machines and masks available on the market. Anecdotal evidence suggests that many patients come away from these sessions feeling confused and unsure of what health benefits they will actually achieve from using a CPAP machine when it seems both foreign and personally invasive. There are a few initial contraindications for the use of psychoeducation to enhance adherence to CPAP. Even the patient with a previous history of claustrophobia can be slowly guided until he or she learns to feel comfortable with the mask. This takes time as the patient learns to manage the equipment, knowing that the control comes from gaining confidence with use. Other more physical difficulties, such as sinusitis, leaks, skin irritations, can be overcome in most instances, provided that the patient seeks help and is heard by sleep laboratory staff. For some groups, there may be a cultural barrier to the uptake and adherence of CPAP.

Objective It is known that many people with insomnia choose to self medicate and present at community pharmacies, particularly in cases of acute insomnia. The objective of this study is to investigate how community pharmacists respond to complaints of acute insomnia from people who seek self treatment and determine the factors affecting this response. Setting Community pharmacies in New South Wales, Australia. Method A simulated patient study was conducted in 100 randomly selected pharmacies located in Newcastle and Sydney, Australia. A standardized scenario of acute sleep onset insomnia and a scoring system was used in each pharmacy. Main outcome measures Main outcome measures included supply/non supply of an over the counter sleep aid to the simulated patient, and scores for pharmacists for skills in eliciting information prior to supply of medication (Pre Supply Score), counseling about medication (Supply Score), or about sleep (Sleep Score). Results Of the 100 pharmacies, upon simulated patient presentation, 96% supplied a product, the remaining 4% referred to a physician. Non-pharmacological advice was provided in 42%. Pharmacists scored highly on advice provided with supply of a medication (Supply scores/4, 3.1 ± 0.9), but lower on skills in eliciting information prior to supply (Pre-supply score/8, 3.6 ± 1.9) and sleep related counselling (Sleep Score/9, 2.1 ± 1.7). Lower estimated pharmacist age, being in a chain type pharmacy, and having a visible symbol of quality accreditation were found to significantly improve (P

To assess the prevalence of treatment and diagnosis of snoring and sleep apnea in the population of New South Wales Australia.Postal survey of 10,000 people randomly selected from the electoral roll, half aged 18 to 24 and half aged 25 to 64, with telephone follow-up for some nonresponders. Weighted prevalences are reported.The overall response rate was 35.6% (18-24 n = 1421 and 25-64 n = 1879). One hundred and fifty-nine respondents reported seeking medical help for snoring or sleep apnea (6.3%, 95% confidence interval 5.46-7.12%), with 133 of these being aged 25 to 64. Fifty-one respondents reported subsequent treatment (2.0%; 95% CI 1.49-2.43), with some reporting more than 1 treatment. Continuous positive airway pressure was received in 17 cases, mandibular advancement splints in 9 cases, and upper airway or nasal surgery in 31 cases. Eighty-six reported receiving an overnight sleep study (polysomnography). Most surgical patients did not report having their sleep measured with a sleep study (22/31).The population of New South Wales has had the longest potential exposure to continuous positive airway pressure. However, few of those in even the middle-aged group reported ever being recommended continuous positive airway pressure treatment. It is more common to have a surgical intervention for snoring or sleep apnea. Surprisingly, most surgical patients do not report any associated sleep study to quantify their snoring or sleep apnea or measure the efficacy of surgery. Since a substantial proportion of patients who experience snoring and sleep apnea are not assessed via a sleep study, it is necessary to increase awareness of undergoing such clinical procedures.

Aims: The aim of this study was to provide the first population-based descriptions of typical sleep duration and the prevalence of chronic sleep restriction and chronic sleepiness in community-dwelling Australian adults. Methods: Ten thousand subjects randomly selected from the New South Wales electoral roll, half aged 18–24 years and the other half aged 25–64 years were posted a questionnaire asking about sleep behaviour, sleepiness and sleep disorders. Results: Responses were received from 3300 subjects (35.6% response rate). The mean ± standard deviation of sleep duration was 7.25 ± 1.48 h/night during the week and 7.53 ± 2.01 h/night in the weekends. Of the working age group, 18.4% reported sleeping less than 6.5 h/night. Chronic daytime sleepiness was present in 11.7%. Logistic modelling indicated that the independent risk factors for excessive daytime sleepiness were being older, sleeping less than 6.5 h per night during the week, getting qualitatively insufficient sleep, having at least one symptom of insomnia and lacking enthusiasm (marker of depression). Conclusion: In New South Wales almost one-fifth of the people are chronically sleep restricted and 11.7% are chronically sleepy. Chronic sleepiness was most commonly associated with voluntarily short sleep durations and symptoms of insomnia and depression. If the experimentally observed health effects of sleep restriction also operate at a population level, this prevalence of chronic sleep restriction is likely to have a significant influence on public health in Australia.

PURPOSE: The purpose of this study was to determine the prevalence, number, and distribution of musculoskeletal injuries among young, recreational, female dancers before and after dancing in pointe shoes and to explore possible risk factors. METHODS: Thirty-one female, nonprofessional ballet dancers, eight to 20 years of age, were recruited from two dance studios in London, Ontario. Participants completed a descriptive questionnaire and reliable examiners performed stress, stability, and laxity tests. RESULTS: The prevalence of instability for nonpointe and pointe groups was 0% and 8% for the knee and 17% and 3% for the ankle, respectively (a nonsignificant difference). The mean number of painful sites was 1.3 (SD = 1.9) and 2.9 (SD = 2.1) for nonpointe and pointe groups, respectively (p = 0.04). The only variable that, in part, predicted the number of painful sites was the number of years of having danced ballet. CONCLUSIONS: The generalizability of these results is limited by the small sample size. Additional prospective research with larger samples, inclusion of dancers who are just beginning to dance in pointe shoes, and consideration of level of exposure and the intensity of both dancing and other physical activity is indicated before prevention programs can be planned and tested. Language: en

Adults with cystic fibrosis (CF) are susceptible to hypoxemia, hypercapnia, arousal from sleep, and neurobehavioral impairment.We hypothesized that pulmonary exacerbations would adversely affect sleep and neurobehavioral performance.Patients with exacerbations (cases) had sleep studies and neurobehavioral testing before and after inpatient intravenous therapy. Adults with stable CF underwent the same testing procedures (control subjects).When clinically stable, cases and control subjects had similar lung function, intelligence, and body mass index. Among cases, treatment of an exacerbation improved lung function, quality of life, mood, sleepiness, and activation. Cases spent more time awake after sleep onset (p = 0.02), less time in REM sleep (p = 0.03), and were more hypoxemic than control subjects when unwell. The severity of hypoxemia correlated with lung function. On admission, cases had slower throughput than control subjects in the serial addition and subtraction task (cases, 16 +/- 4, vs. control subjects, 17 +/- 3; F[1, 36] = 5.15, p = 0.03) and a slower response time on the digit symbol substitution task (F[1, 36] = 11.91, p = 0.001), which persisted after treatment (F[1, 36] = 8.48, p = 0.006). Cases experienced significant improvements in sleep efficiency, amount of REM sleep, and hypoxia with treatment. Their performance in the serial addition and subtraction task, psychomotor vigilance task, and simulated driving task also improved with treatment. Sex modified the effect of an exacerbation on some aspects of performance.Exacerbations of lung disease in adults with CF adversely affect sleep and tests of neurobehavioral performance regardless of underlying disease severity. The implications for performance in daily life need further evaluation because patients often delay admission to hospital to fulfill study or work commitments.

Background and purpose: Obstructive sleep apnea (OSA) is associated with intermittent hypoxia and cognitive decrements. As the hippocampus is particularly susceptible to hypoxia, we hypothesized that it may show biochemical abnormalities, and they may relate to apnea severity. Patients and methods: Eight males with OSA and five age-matched controls underwent neurocognitive testing before and after polysomnography and proton magnetic resonance spectra were obtained from the left hippocampal area of all subjects. Results: In the left hippocampal area, N-acetyl-containing/creatine-containing compounds was significantly increased in OSA (PZ0.04). Inspection of these compounds with respect to the water resonance indicated that this was most likely due to a decrease in creatine-containing compounds rather than any change in N-acetyl-containing compounds. Lower levels of hippocampal creatine-containing compounds were correlated with worse OSA severity and neurocognitive performance. Conclusions: We suggest the changes in creatine levels in the hippocampal area represent adjustments to brain bioenergetics, similar to those seen in ischemic preconditioning, and may reflect the different susceptibility of these tissues to hypoxic damage in OSA. q 2004 Elsevier B.V. All rights reserved.

STUDY OBJECTIVES To empirically derive and evaluate potential clusters of Insomnia Disorder through cluster analysis from polysomnography (PSG). We hypothesized that clusters would differ on neurocognitive performance, sleep-onset measures of quantitative (q)-EEG and heart rate variability (HRV). METHODS Research volunteers with Insomnia Disorder (DSM-5) completed a neurocognitive assessment and overnight PSG measures of total sleep time (TST), wake time after sleep onset (WASO), and sleep onset latency (SOL) were used to determine clusters. RESULTS From 96 volunteers with Insomnia Disorder, cluster analysis derived at least two clusters from objective sleep parameters: Insomnia with normal objective sleep duration (I-NSD: n = 53) and Insomnia with short sleep duration (I-SSD: n = 43). At sleep onset, differences in HRV between I-NSD and I-SSD clusters suggest attenuated parasympathetic activity in I-SSD (P < 0.05). Preliminary work suggested three clusters by retaining the I-NSD and splitting the I-SSD cluster into two: I-SSD A (n = 29): defined by high WASO and I-SSD B (n = 14): a second I-SSD cluster with high SOL and medium WASO. The I-SSD B cluster performed worse than I-SSD A and I-NSD for sustained attention (P ≤ 0.05). In an exploratory analysis, q-EEG revealed reduced spectral power also in I-SSD B before (Delta, Alpha, Beta-1) and after sleep-onset (Beta-2) compared to I-SSD A and I-NSD (P ≤ 0.05). CONCLUSIONS Two insomnia clusters derived from cluster analysis differ in sleep onset HRV. Preliminary data suggest evidence for three clusters in insomnia with differences for sustained attention and sleep-onset q-EEG. CLINICAL TRIAL REGISTRATION Insomnia 100 sleep study: Australia New Zealand Clinical Trials Registry (ANZCTR) identification number 12612000049875. URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=347742.