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Objective/background: A historic cohort single-center study of kidney transplant recipients with graft loss examined the associations between sleep apnea and two transplant outcomes, death with a functioning graft (DWFG), and graft survival time., Patient/methods: Adult patients who received transplants and experienced graft failure or DWFG from January 1, 1997 to January 1, 2017 constituted the cohort (n = 322). Data for the study were obtained by merging two secondary data sources: the Organ Procurement and Transplantation Network (OPTN) database and the transplant center's medical records. A Cox regression modeled the association of diagnosed sleep apnea, stratified by year-of transplant surgery, with graft survival time. Using backward elimination, this model was adjusted for recipient age, race/ethnicity, gender, functional status, donor age, and antigen mismatch., Results: No statistically significant differences were found for proportions of DWFG in those with, versus without, sleep apnea, informing our censoring approach. When examining graft survival time, the Cox regression model was stratified given a sleep apnea and year-of-transplant interaction (p < 0.01, adjusted model). For patients transplanted between 1997 and 2008, sleep apnea was statistically significantly associated with a decreased risk of graft failure or cardiovascular-related DWFG [adjusted Hazard Ratio (aHR) = 0.63, 95%CI, 0.42-0.94]. For patients transplanted between 2009 and 2017, sleep apnea statistically significantly increased the risk of graft failure or cardiovascular-related DWFG (aHR = 2.61, 95%CI, 1.13-6.00)., Conclusions: In a cohort of transplant recipients with graft loss, sleep apnea increased the risk of graft loss nearly three-fold among patients transplanted between 2009 and 2017. Similar DWFG proportions by sleep apnea presence indicate this risk is likely driven by renal failure, not mortality. Further research on whether treatment of sleep apnea can improve graft survival is warranted., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Sleep apnea increases risk of driving crashes when left untreated. This study examined the driving performance decrements of untreated, undiagnosed sleep apnea drivers compared with healthy controls in a monotonous highway driving simulator task. It was hypothesized that the sleep apnea group would perform worse during a driving simulator test compared with the control group. A significant group by time interaction occurred indicating that sleep apnea participants' performance degraded more quickly over the course of the drive. In contrast with previous studies, this sleep apnea group did not include sleep disorder center patients, but rather community volunteers whose screening indicated a significant apnea/hypopnea index of 15 or greater. There may be inherent differences between patients and nonpatients with sleep apnea, as patients may have a more significant impact on their quality of life, causing them to seek treatment. Still, the results are clear that although the sleep apnea group drove similarly to the control group at the start of the drive, they are sensitive to time on task effects. These results support the need to diagnose and treat sleep apnea., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

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., (Copyright © 2015 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Sleep dysfunction is a highly prevalent condition that has long been implicated in accelerating disease states characterized by having an inflammatory component such as systemic lupus erythematosus, HIV, and multiple sclerosis. Inflammatory bowel disease (IBD) is a chronic, debilitating disease that is characterized by waxing and waning symptoms, which are a direct result of increased circulating inflammatory cytokines. Recent studies have demonstrated sleep dysfunction and the disruption of the circadian rhythm to result in an upregulation of inflammatory cytokines. Not only does this pose a potential trigger for disease flares but also an increased risk of malignancy in this subset of patients. This begs to question whether or not there is a therapeutic role of sleep cycle and circadian rhythm optimization in the prevention of IBD flares. Further research is needed to clarify the role of sleep dysfunction and alterations of the circadian rhythm in modifying disease activity and also in reducing the risk of malignancy in patients suffering from IBD.

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., (Copyright © 2015 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Background and Objective: Early high school start times (EHSST) may lead to sleep loss in adolescents ("teens"), thus resulting in higher crash rates. (Vorona et al., 2011). In this study, we examined two other adjacent Virginia counties for the two years subsequent to the above-mentioned study. We again hypothesized that teens from jurisdictions with EHSST (versus later) experience higher crash rates., Methods: Virginia Department of Motor Vehicles supplied de-identified aggregate data on weekday crashes and time-of-day for 16-18 year old (teen) and adult drivers for school years 2009-2010 and 2010-2011 in Henrico and Chesterfield Counties. Teen crash rates for counties with early versus later school start-times were compared using two-sample Z-tests and these compared to adult crash rates using pair-wise tests., Results: Henrico teens manifested a statistically higher crash rate of 48.8/1000 licensed drivers versus Chesterfield's 37.9/1000 (p = 0.04) for 2009-2010. For 2010-2011, HC 16-17 year old teens demonstrated a statistically significant higher crash rate (53.2/1000 versus 42.0/1000), while for 16-18 teens a similar trend was found, albeit nonsignificant (p = 0.09). Crash peaks occurred 1 hour earlier in the morning and 2 hours earlier in the afternoon in Chesterfield, consistent with commute times. Post hoc analyses found significantly more run-off road crashes to the right (potentially sleep-related) in Chesterfield teens. Adult crash rates and traffic congestion did not differ between counties., Conclusions: Higher teen crash rates occurred in jurisdictions with EHSST, as in our prior study. This study contributes to and extends existing data on preventable teen crashes and high school start times., (© 2014 American Academy of Sleep Medicine.)

Our patient presented with repetitive, self-limited bouts of forceful hiccups in sleep. Eszopiclone, a commonly prescribed hypnotic, appeared to cause these intermittent hiccups. This case is a reminder that eszopiclone may cause this adverse effect, and that it may be the bed partner and not the patient who furnishes critical sleep medicine history.

Numerous medical disorders, including obstructive sleep apnea, may cause nocturnal diaphoresis. Previous work has associated severe obstructive sleep apnea with nocturnal diaphoresis. This case report is of import as our patient with severe nocturnal diaphoresis manifested only mild sleep apnea, and, for years, his nocturnal diaphoresis was ascribed to other causes, i.e., first prostate cancer and then follicular B-cell lymphoma. Additionally, it was the nocturnal diaphoresis and not more common symptoms of obstructive sleep apnea, such as snoring, that led to the definitive diagnosis of his sleep apnea and then to treatment with a gratifying resolution of his onerous symptom.

Study Objectives: Early high school start times may contribute to insufficient sleep leading to increased teen crash rate. Virginia Beach (VB) and Chesapeake are adjacent, demographically similar cities. VB high schools start 75-80 minutes earlier than Chesapeake's. We hypothesized that VB teens would manifest a higher crash rate than Chesapeake teens., Methods: The Virginia Department of Motor Vehicles (DMV) provided de-identified, aggregate 2008 and 2007 data for weekday crashes and crash times in VB and Chesapeake for drivers aged 16-18 years ("teens"), and provided 2008 and 2007 crash data for all drivers. Data allowed comparisons of VB versus Chesapeake crash rates for teens (overall and hour-by-hour), and teens versus all other ages. We compared AM and PM traffic congestion (peak hours) in the two cities., Results: In 2008, there were 12,916 and 8,459 Virginia Beach and Chesapeake 16- to 18-year-old drivers, respectively. For VB and Chesapeake, teen drivers' crash rates in 2008 were 65.8/1000 and 46.6/1000 (p < 0.001), respectively, and in 2007 were 71.2/1000 and 55.6/1000. Teen drivers' crash peaks in the morning occurred one hour earlier in VB than Chesapeake, consistent with school commute time. Congestion data for VB and Chesapeake did not explain the different crash rates., Conclusions: A significantly increased teen crash rate for both 2008 and 2007 occurred in VB, the city with earlier high school start times. Future studies using individual level data may clarify if sleep restriction, circadian dyssynchrony, and sleep inertia might contribute to this increased crash rate.

Residents on call experience decreased total sleep time (TST) and increased dysphoria. This study monitored changes in mood and sleepiness for 3 post-call days. Fifty-two internal medicine residents participated in the study. The residents wore actigraphs for the 4 to 9 days of the study. Each morning resident completed mood scales, a sleepiness scale, and estimated their prior night TST. The residents were on a 1-in-4 schedule. Call decreased subjective- and actigraphy-derived TST to less than 4 hr. During the 3 days post call, mood measures improved. Tension, depression, and anxiety stabilized on the first post-call day following the first night of off-call sleep during which the residents obtained about 7 hr of sleep. Vigor, fatigue, and confusion stabilized on the second post-call day. The Epworth Sleepiness Scale dropped to less than 11 after 1 post-call night and continued to decrease up to 3 post-call days. The effects of call linger past the first recovery night. For these residents, recovery sleep appeared inadequate, and the negative effects of call persisted across succeeding off-call days. Thus, for these residents on a 1-in-4 schedule, call affects their mood for much of the time when off call and potentially their personal and professional interactions during this period as well.

This article surveyed attending physicians on their work hours, sleep schedule, daytime sleepiness, and the perceived relation of these factors to patient safety, quality of care, and personal well-being. Physicians answered demographic and workload questions and attitudinal questions regarding work-hour limitations; the Epworth Sleepiness Scale (ESS) was used to measure subjective sleepiness, and an 18-item Impact Questionnaire was also used. Of 180 participants, 41 (23%) attending physicians manifested abnormal ESS scores (11 or greater). Private practice- and surgically-based subspecialties had higher ESS scores. Reduced sleep, but not hours worked, was associated with increased sleepiness. Sleepy physicians were more likely to associate sleep loss with medical errors and driving impairment. Sleepiness may be attenuated by education regarding consequences of insufficient sleep and institution of effective countermeasures.

A chinstrap alone improved severe obstructive sleep apnea as well as or better than the use of CPAP.

The objective of this study was to examine heart rate variability (HRV) among sleep stages in obstructive sleep apnea (OSA) patients. The study was retrospective within subjects and examined the sleep stages and HRV in relation to OSA, age, body mass index (BMI), and sex. Data collected during diagnostic polysomnograms were used in this study. There were 105 clinical patients undergoing polysomnography for suspected OSA. We sampled the electrocardiogram (ECG) from wakefulness, stage 2, and REM sleep and analyzed for frequency domain HRV. Sampled epochs were free of apnea and arousals. Heart rate variability decreased with age. Total frequency variability (TF) and low frequency variability (LF) in wakefulness and REM sleep increased as apnea severity increased. Measures of TF, LF, and the LF/HF ratio were greatest in REM sleep. There was less LF and TF in Stage REM sleep in patients with higher BMI. In conclusion, the decrease in HRV with aging is a robust finding that occurs even in a clinical sleep apnea population. However, apnea does not mimic aging effects on the heart because HRV increased as apnea severity increased. The decrease in HRV during REM sleep in the obese apnea patients suggests the possibility of an autonomic dysfunction in this subgroup.

This study compared driving simulation performance after night call and after being off call in 22 medical residents and 1 medical student in a prospective within-subjects counterbalanced design. The results demonstrated an unexpected interaction between call and sex wherein men performed more poorly after night call than women as measured by lane variance and crash frequency. Secondary measures, including caffeine, actigraphy, and subjective total sleep time, did not differ between men and women. Collectively, results of this study and others suggest that medical residents are at risk when driving after a night on call and support the need for resident education to address sleep needs, consequences of sleep disruption, postcall recovery sleep, and countermeasures that may reduce residents' driving risks.

Background: Studies suggest obstructive sleep apnea syndrome (OSAS) frequently manifests in patients with gastroesophageal reflux disease (GERD) and that there may be a causal relationship., Aim: To determine the relationship between OSAS and symptoms of GERD., Methods: Consecutive patients referred to the Sleep Disorders Center (SDC) 18 years and older with polysomnographically defined OSAS were evaluated prospectively for GERD using a validated symptoms questionnaire. The GERD and OSAS relationship was assessed by 1) determining frequency of GERD in patients with and without OSAS; 2) ascertaining the relationship between OSAS severity categories and presence of GERD; 3) examining GERD score in relation to those factors that might affect both GERD and OSAS, e.g. obesity., Results: One thousand and twenty-three SDC patients met entry criteria. Amongst participants, GERD was common (29% of women and 17% of males) and OSAS extremely common (58% of women and 80% of males). GERD score did not correlate with OSAS variables. The severity of OSAS did not influence the prevalence of GERD., Conclusion: In a large group of patients referred to a sleep disorders center, there was no relationship between OSAS and GERD symptoms. Also, there was no relationship between the severity of OSAS and the likelihood of GERD symptoms.

Background: Insufficient sleep and obesity are common in the United States. Restricted sleep causes important neurocognitive changes, including excessive daytime sleepiness and altered mood. This may result in work-related injuries and automotive crashes. Evidence links sleep loss to hormonal changes that could result in obesity. This article examines the association between restricted sleep and obesity in a heterogeneous adult primary care population., Methods: A total of 1001 patients from 4 primary care practices participated in this prospective study. Patients completed a questionnaire administered by a nurse or study coordinator concerning demographics, medical problems, sleep habits, and sleep disorders. Professional staff measured height and weight in the office. The relationship between body mass index (BMI) and reported total sleep time per 24 hours was analyzed after categorizing patients according to their BMI (calculated as weight in kilograms divided by the square of height in meters) as being of normal weight (<25), overweight (25-29.9), obese (30-39.9), or extremely obese (> or =40)., Results: Analyzable forms from 924 patients aged between 18 and 91 years indicated that (1) the mean BMI was 30; (2) women slept more than men; (3) overweight and obese patients slept less than patients with a normal BMI (patients reported less sleep in a nearly linear relationship from the normal through the obese group); and (4) this trend of decreasing sleep time was reversed in the extremely obese patients., Conclusions: This study found that reduced amounts of sleep are associated with overweight and obese status. Interventions manipulating total sleep time could elucidate a cause-and-effect relationship between insufficient sleep and obesity.

Background: There is little information on the prevalence of pathological sleep disorders in patients with gastro-oesophageal reflux disease and whether pharmacological treatment of patients with gastro-oesophageal reflux disease will lead to improvement in sleep., Aims: This pilot study determined the prevalence of sleep disorder in patients with erosive gastro-oesophageal reflux disease, correlated subjective (questionnaire) and objective (actigraphy - a watch worn on the wrist that monitors motion to help differentiate sleep from awake states) assessment of sleep dysfunction and determined whether therapeutic resolution of oesophageal symptoms was associated with an improvement in sleep., Methods: Eighteen patients with erosive gastro-oesophageal reflux disease received esomeprazole 40 mg once daily for 8 weeks. Assessments at 0, 4 and 8 weeks included: Gastrointestinal Symptoms Rating Scale, Pittsburgh Sleep Quality Index questionnaire and ambulatory wrist actigraphy., Results: Unrecognized sleep disturbance occurred in 81% of this cohort of patients with gastro-oesophageal reflux disease and erosive oesophagitis. Median reflux syndrome score (heartburn and acid regurgitation) on Gastrointestinal Symptoms Rating Scale decreased from 2 at baseline to 0 at weeks 4 and 8 (P

Study Objectives: Weight loss improves obstructive sleep apnea (OSA), and clinicians regularly recommend dieting to their patients with OSA; however, many morbidly obese patients may be unable to lose weight without medical or surgical intervention. Gastric bypass surgery (GB) facilitates weight loss for morbidly obese patients. Studies show GB will improve symptoms associated with OSA, but little is known regarding the long-term effects of GB on this population., Design: Historical, retrospective, cohort study., Setting: Sleep Disorders Center, Sentara Norfolk General Hospital, Norfolk, VA., Participants: A list of subjects who underwent vertical Roux-en-Y GB was cross-referenced with the Sleep Disorders Center at Sentara Norfolk General Hospital to identify patients with a diagnosis of OSA during the preoperative evaluation prior to undergoing GB., Interventions: GB., Measurements: Our primary end point was the respiratory disturbance index (RDI). Secondary variables were body mass index (BMI), mean oxygen saturation, low oxygen saturation, a standardized depression scale, and the continuous positive airway pressure (CPAP) requirement., Results: Thirty-four subjects with a diagnosis of OSA prior to GB were identified. Of these, 28 subjects were located and offered follow-up polysomnography after GB. Eight subjects returned for repeat polysomnography. The subjects were re-evaluated an average of 28 months after GB. Seven subjects had a lower BMI after GB. Mean BMI was reduced by 31% (p = 0.001). The mean decrease in RDI was 75% (p = 0.01), and five of the eight subjects no longer required nasal CPAP. Mean nocturnal oxygen saturation improved from 95 to 97% (p = 0.04)., Conclusions: Weight reduction following GB is associated with significant improvements in sleep apnea indexes an average of 28 months after GB. Re-evaluation after GB is necessary to identify and treat those patients who, despite subjective improvement, may continue to require CPAP for residual OSA.

Obstructive sleep apnea syndrome may disguise the presence of other less common but equally important etiologies of sleepiness in patients presenting to sleep disorder specialists. In this case report the authors detail how multiple polysomnograms performed over 6 years eventually suggested that a patient had both obstructive sleep apnea and narcolepsy.

Obstructive sleep apnea syndrome leads to an increased risk of motor vehicle accidents through multiple pathways. Sleep apnea and motor vehicle crashes are common, and motor vehicle collisions are the leading causes of death amongst accidents. Therefore, the clinician charged with the care of apneic patients must address the issue of safe driving. Some recent evidence reveals that driving simulator technology may discriminate apneic drivers from control drivers as well as those apneics at a lesser risk for automobile crashes. This same tool demonstrates an improvement in driving capabilities to baseline when patients with sleep apnea are treated with nasal continuous positive airway pressure and that this improvement may occur rapidly. The prevention of driving accidents in patients with sleep apnea appears cost effective. Educating the patient with sleep apnea about sleepy driving and objective documentation of treatment efficacy are important in reducing the likelihood of accidents., (Copyright 2002 Lippincott Williams & Wilkins, Inc.)