Incidence of chronic respiratory conditions among oil spill responders: Five years of follow-up in the Deepwater Horizon Oil Spill Coast Guard Cohort study.

BACKGROUND: Over ten years after the Deepwater Horizon (DWH) oil spill, our understanding of long term respiratory health risks associated with oil spill response exposures is limited. We conducted a prospective analysis in a cohort of U.S. Coast Guard personnel with universal military healthcare. METHODS: For all active duty cohort members (N = 45,193) in the DWH Oil Spill Coast Guard Cohort Study we obtained medical encounter data from October 01, 2007 to September 30, 2015 (i.e., ~2.5 years pre-spill; ~5.5 years post-spill). We used Cox Proportional Hazards regressions to calculate adjusted hazard ratios (aHR), comparing risks for incident respiratory conditions/symptoms (2010-2015) for: responders vs. non-responders; responders reporting crude oil exposure, any inhalation of crude oil vapors, and being in the vicinity of burning crude oil versus responders without those exposures. We also evaluated self-reported crude oil and oil dispersant exposures, combined. Within-responder comparisons were adjusted for age, sex, and smoking. RESULTS: While elevated aHRs for responder/non-responder comparisons were generally weak, within-responder comparisons showed stronger risks with exposure to crude oil. Notably, for responders reporting exposure to crude oil via inhalation, there were elevated risks for allsinusitis (aHR = 1.48; 95%CI, 1.06-2.06), unspecified chronic sinusitis (aHR = 1.55; 95%CI, 1.08-2.22), chronic obstructive pulmonary disease (COPD) and other allied conditions (aHR = 1.43; 95%CI, 1.00-2.06), and dyspnea and respiratory abnormalities (aHR = 1.29; 95%CI, 1.00-1.67); there was a suggestion of elevated risk for diseases classified as asthma and reactive airway diseases (aHR = 1.18; 95%CI, 0.98-1.41), including the specific condition, asthma (aHR = 1.35; 95%CI, 0.80-2.27), the symptom, shortness of breath (aHR = 1.50; 95%CI, 0.89-2.54), and the overall classification of chronic respiratory conditions (aHR = 1.18; 95%CI, 0.98-1.43). Exposure to both crude oil and dispersant was positively associated with elevated risk for shortness of breath (HR = 2.24; 95%CI, 1.09-4.64). CONCLUSIONS: Among active duty Coast Guard personnel, oil spill clean-up exposures were associated with moderately increased risk for longer term respiratory conditions.

Obstructive sleep apnea and cardiovascular disease, a story of confounders!

Obstructive sleep apnea (OSA) syndrome is increasingly common among middle aged and older adults and is frequently linked to most cardiovascular diseases (CVD). Sleep-disordered breathing and CVD share a number of common risk factors and comorbid conditions including obesity, male gender, advancing age, metabolic syndrome, and hypertension. OSA appears to be associated with worsened CVD outcomes, sleep-related symptoms, quality of life, and risk of motor vehicle accidents. Demonstrating a cause-and-effect relationship between CVD and OSA has been challenging due to shared comorbidities. Strong evidence demonstrating clinically significant benefit for OSA treatments on OSA-related CVD outcomes are limited. In this review, we evaluate potential pathophysiologic mechanisms that link OSA to CVD and focus on specific treatments for OSA, including positive airway pressure (PAP), dental devices, and surgeries with regard to OSA-related CVD outcomes.

A randomized, placebo-controlled trial using a novel PAP delivery platform to treat patients with OSA and comorbid PTSD.

PURPOSE: Positive airway pressure (PAP) adherence is poor in comorbid OSA/PTSD. SensAwake™ (SA) is a wake-sensing PAP algorithm that lowers pressure when wake is detected. We compared auto-PAP (aPAP) with and without SA for comorbid OSA/PTSD. METHODS: Prospective, randomized crossover study comparing aPAP to aPAP + SA. We enrolled patients with OSA/PTSD who were PAP naïve. Four weeks after randomization, the patients were crossed over to the alternate treatment group, with final follow-up at eight weeks. Sleep questionnaires (ESS, ISI, FSS, and FOSQ-10) were assessed at baseline and follow-up. RESULTS: We enrolled 85 patients with OSA/PTSD. aPAP reduced AHI to < 5/h in both groups. Our primary endpoint, average hours of aPAP adherence (total) after 4 weeks, was significantly increased in the SA group in our intention-to-treat (ITT) analysis (ß = 1.13 (95% CI 0.16-2.1); p = 0.02), after adjustment for ESS differences at baseline. After adjustment for ESS, SA (ITT analysis) also showed significant improvement in percentage of nights used for ≥ 4 h (ß = 14.9 (95% CI 1.02-28.9); p = 0.04). There were trends toward an increase in percentage nights used total (ß = 17.4 (95% CI - 0.1 to 34.9); p = 0.05), average hours of aPAP adherence (nights used) (ß = 1.04 (95% CI - 0.07 to 2.1); p = 0.07), and regular use (OR = 7.5 (95% CI 0.9-64.7); p = 0.07) after adjustment for ESS at baseline. After adjustment for ESS and days to cross over, SA by actual assignment did not show any effect on adherence variables. The ESS, ISI, FSS, and FOSQ-10 all showed significant improvements with PAP, but there were no differences in the magnitude of improvement in any score between groups. CONCLUSIONS: Adherence to aPAP may be improved with the addition of SA and deserves further study. SA is as effective as standard aPAP for normalizing the AHI and improving sleep-related symptoms. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT02549508 https://clinicaltrials.gov/ct2/show/NCT02549508?term=NCT02549508&rank=1 "Comparison Study Using APAP With and Without SensAwake in Patients With OSA and PTSD".

Detection of sleep-disordered breathing with ambulatory Holter monitoring.

PURPOSE: Obstructive sleep apnea (OSA) syndrome is a common condition that can impact clinical outcomes among patients with cardiovascular disease. Screening all subjects with heart disease via polysomnography (PSG) is costly and resource-limited. We sought to compare a Holter monitor-based algorithm to detect OSA to in-laboratory polysomnography (PSG). METHODS: Prospective cohort study of patients undergoing in-laboratory attended PSG for the evaluation of OSA. A standard 12-lead Holter monitor was attached to patients at the initiation of PSG. Holter-derived respiratory disturbance index (HDRDI) was extracted from the respiratory myogram, based on detecting skeletal muscle "noise" detected on the baseline. Apneic and hypopneic episodes were identified by comparing sudden changes in the myogram to abrupt increases in heart rate. The HDRDI was compared with the PSG-derived apnea-hypopnea index (PDAHI). RESULTS: Thirty patients underwent simultaneous Holter monitoring and overnight diagnostic PSG. An ROC curve for peak HDRDI was 0.79 (95% CI 0.61, 0.97) for OSA, with sensitivity of 94.4% and specificity of 54.5%. A cutoff value of HDRDI < 10 appeared to identify those individuals without clinically significant sleep-disordered breathing. CONCLUSION: Holter-derived respiration detected OSA comparable to PSG. Further study is warranted to determine its utility for screening and diagnosing OSA in appropriately selected patients.

The impact of combat deployment on asthma diagnosis and severity.

OBJECTIVES: Environmental exposures during military deployments to Iraq and Afghanistan may lead to higher rates of respiratory complaints and diagnoses. This study investigates whether there is a relationship between rates of asthma diagnosis and severity associated with military deployment. METHODS: Retrospective review of active duty Army personnel underwent fitness for duty evaluation (Medical Evaluation Board) for asthma. The electronic medical record was reviewed for onset of diagnosis (pre- or post-deployment), disease severity, screening spirometry, bronchodilator response and bronchoprovocation testing. We compared patients with and without a history of combat deployment to Operations Iraqi Freedom/Enduring Freedom. RESULTS: Four hundred consecutive Army personnel with a clinical diagnosis of asthma were evaluated. Equal numbers of patients had deployed (48.5%) versus never deployed (51.5%). Of those who deployed, 98 (24.5%) were diagnosed post-deployment. The diagnosis of asthma was objectively confirmed in 74.8% of patients by obstructive screening spirometry, bronchodilator response, and/or methacholine challenge testing. There were no significant differences in spirometry between deployers and non-deployers or based on pre- and post-deployment diagnosis. Similarly, asthma severity classification did not differ between deployed and non-deployed service members, or by pre- and post-deployment diagnosis status. CONCLUSIONS: Among active duty military personnel with career limiting asthma, there is no significant relationship between rates of diagnosis or severity based on history of deployment to Southwest Asia.

Sleep disorders in combat-related PTSD.

PURPOSE: We sought to assess the rate of sleep complaints and sleep disorders among active duty soldiers with deployment-related PTSD and to determine whether any clinical features differentiated those with sleep disorders. METHODS: Retrospective review of consecutive soldiers diagnosed with PTSD. We recorded subjective measures of sleep and polysomnographic data. We compared clinical and demographic variables including psychoactive medication use, psychiatric comorbidity, and combat-related traumatic injury with the presence of sleep disorders. RESULTS: One hundred thirty patients were included (91.5 % male, mean age of 35.1 ± 10.6 years, mean body mass index (BMI) 28.9 ± 4.4 Kg/m(2)). About 88.5 % had comorbid depression, with the majority (96.2 %) taking psychoactive medications (mean 3.4 ± 1.6 medications per patient). Over half of the cohort suffered combat-related traumatic physical injuries (54.6 %). The obstructive sleep apnea syndrome (OSAS) was diagnosed in 67.3 % (80 % of the cohort underwent polysomnography), with a mean apnea hypopnea index of 24.1 ± 22.8 events/hour and a mean oxygen saturation nadir of 84.2 ± 5.7 %. OSAS was significantly more common in the non-injured soldiers (72.9 vs. 38.0 %, p < 0.001). In multivariate analysis, absence of physical injury showed a trend towards predicting OSAS. CONCLUSIONS: Sleep complaints are common among soldiers with PTSD. We observed significantly higher rates of OSAS among those without physical injuries, raising the possibility that underlying sleep-disordered breathing is a risk factor for the development of PTSD. This potential association requires further validation.

The impact of sleep on soldier performance.

The military population is particularly vulnerable to a multitude of sleep-related disorders owing to the type of work performed by active duty servicemembers (ADSMs). Inadequate sleep, due to insufficient quantity or quality, is increasingly recognized as a public health concern. Traditionally, ADSMs have been encouraged that they can adapt to insufficient sleep just as the body adapts to physical training, but there is a substantial body of scientific literature which argues that this is not possible. Additionally, the military work environment creates unique challenges with respect to treatment options for common sleep disorders like obstructive sleep apnea, restless legs syndrome, and parasomnias. This review highlights sleep disorders which are prevalent in the modern military force and discusses the impact of poor sleep on overall performance. Medical treatments and recommendations for unit leaders are also discussed.

Exploring sleep duration and clinical reasoning process in resident physicians: a thematic analysis.

STUDY OBJECTIVES: Connecting resident physician work hours and sleep deprivation to adverse outcomes has been difficult. Our study explores clinical reasoning rather than outcomes. Diagnostic errors are a leading cause of medical error and may result from deficits in clinical reasoning. We used simulated cases to explore relationships between sleep duration and diagnostic reasoning. METHODS: Residents were recruited for a 2-month study (inpatient/outpatient). Each participant's sleep was tracked (sleep diary/actigraphy). At the end of each month, residents watched 2 brief simulated clinical encounters and performed "think alouds" of their clinical reasoning. In each session, 1 video was straightforward and the other video contained distracting contextual factors. Sessions were recorded, transcribed, and interpreted. We conducted a thematic analysis using a constant comparative approach. Themes were compared based on sleep duration and contextual factors. RESULTS: Residents (n = 17) slept more during outpatient compared with inpatient months (450.5 ± 7.13 vs 425.6 ± 10.78 hours, P = .02). We found the following diagnostic reasoning themes: uncertainty, disorganized knowledge, error, semantic incompetence, emotional content, and organized knowledge. Themes reflecting suboptimal clinical reasoning (disorganized knowledge, error, semantic incompetence, uncertainty) were observed more in cases with contextual factors (distractors). "Think alouds" from cases with contextual factors following sleep restriction had a greater number of themes concerning for problematic diagnostic reasoning. CONCLUSIONS: Residents obtained significantly more sleep during outpatient compared with inpatient months. Several negative clinical reasoning themes emerged with less sleep combined with cases containing contextual distractors. Our findings reinforce the importance of adequate sleep and supervision in house officers, particularly in cases with distracting elements. CITATION: Collen J, Durning S, Berk J, Mang J, Alcover K, Jung E. Exploring sleep duration and clinical reasoning process in resident physicians: a thematic analysis. J Clin Sleep Med. 2024;20(8):1279-1289.

From trenches to technology: a narrative review of sleep medicine in the military.

Diagnoses of military-relevant sleep disorders have increased substantially since the terrorist attacks of September 11, 2001. The cause of this increase appears to be complicated and multifactorial, with military and civilian populations clearly differing with respect to both the nature and distribution of sleep disorders diagnoses. In part, these differences may be attributable to the fact that a majority of service members are chronically sleep-restricted-an unavoidable consequence of continuous and sustained military operations that "set the stage" for development of specific sleep disorders. The purpose of this narrative review is to describe the military relevance of several common sleep disorders, assess the extent to which these disorders currently constitute a burden on the military health care system, and suggest strategies to alleviate that burden. The military health care system does not have enough sleep medicine providers to address the immediate and long-term consequences of sleep disorders in military personnel. Digital technologies and education packages can be leveraged to improve access to care. CITATION: Thomas CL, Carr K, Yang F, et al. From trenches to technology: a narrative review of sleep medicine in the military. J Clin Sleep Med. 2024;20(6):973-981.

Association of Biomarkers of Neuronal Injury and Inflammation With Insomnia Trajectories After Traumatic Brain Injury: A TRACK-TBI Study.

BACKGROUND AND OBJECTIVES: Insomnia affects about one-third of patients with traumatic brain injury and is associated with worsened outcomes after injury. We hypothesized that higher levels of plasma neuroinflammation biomarkers at the time of TBI would be associated with worse 12-month insomnia trajectories. METHODS: Participants were prospectively enrolled from 18 level-1 trauma centers participating in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study from February 26, 2014, to August 8, 2018. Plasma glial fibrillary acidic protein (GFAP), high-sensitivity C-reactive protein (hsCRP), S100b, neuron-specific enolase (NSE), and ubiquitin carboxyl-terminal hydrolase-L1 (UCH-L1) were collected on days 1 (D1) and 14 (D14) after TBI. The insomnia severity index was collected at 2 weeks, 3, 6, and 12 months postinjury. Participants were classified into insomnia trajectory classes based on a latent class model. We assessed the association of biomarkers with insomnia trajectories, controlling for medical and psychological comorbidities and demographics. RESULTS: Two thousand twenty-two individuals with TBI were studied. Elevations in D1 hsCRP were associated with persistent insomnia (severe, odds ratio [OR] = 1.33 [1.11, 1.59], p = 0.002; mild, OR = 1.10 [1.02, 1.19], p = 0.011). Similarly, D14 hsCRP elevations were associated with persistent insomnia (severe, OR = 1.27 [1.02, 1.59], p = 0.03). Of interest, D1 GFAP was lower in persistent severe insomnia (median [Q1, Q3]: 154 [19, 445] pg/mL) compared with resolving mild (491 [154, 1,423], p < 0.001) and persistent mild (344 [79, 1,287], p < 0.001). D14 GFAP was similarly lower in persistent (11.8 [6.4, 19.4], p = 0.001) and resolving (13.9 [10.3, 20.7], p = 0.011) severe insomnia compared with resolving mild (20.6 [12.4, 39.6]. Accordingly, increases in D1 GFAP were associated with reduced likelihood of having persistent severe (OR = 0.76 [95% CI 0.63-0.92], p = 0.004) and persistent mild (OR = 0.88 [0.81, 0.96], p = 0.003) compared with mild resolving insomnia. No differences were found with other biomarkers. DISCUSSION: Elevated plasma hsCRP and, surprisingly, lower GFAP were associated with adverse insomnia trajectories after TBI. Results support future prospective studies to examine their utility in guiding insomnia care after TBI. Further work is needed to explore potential mechanistic connections between GFAP levels and the adverse insomnia trajectories.

A 2022 Survey of Commercially Available Smartphone Apps for Sleep: Most Enhance Sleep.

Commercially available smartphone apps represent an ever-evolving and fast-growing market. Our review systematically surveyed currently available commercial sleep smartphone apps to provide details to inform both providers and patients alike, in addition to the healthy consumer market. Most current sleep apps offer a free version and are designed to be used while awake, prior to sleep, and focus on the enhancement of sleep, rather than measurement, by targeting sleep latency using auditory stimuli. Sleep apps could be considered a possible strategy for patients and consumers to improve their sleep, although further validation of specific apps is recommended.

Traumatic Brain Injury, Sleep, and Melatonin-Intrinsic Changes with Therapeutic Potential.

Traumatic brain injury (TBI) is one of the most prevalent causes of morbidity in the United States and is associated with numerous chronic sequelae long after the point of injury. One of the most common long-term complaints in patients with TBI is sleep dysfunction. It is reported that alterations in melatonin follow TBI and may be linked with various sleep and circadian disorders directly (via cellular signaling) or indirectly (via free radicals and inflammatory signaling). Work over the past two decades has contributed to our understanding of the role of melatonin as a sleep regulator and neuroprotective anti-inflammatory agent. Although there is increasing interest in the treatment of insomnia following TBI, a lack of standardization and rigor in melatonin research has left behind a trail of non-generalizable data and ambiguous treatment recommendations. This narrative review describes the underlying biochemical properties of melatonin as they are relevant to TBI. We also discuss potential benefits and a path forward regarding the therapeutic management of TBI with melatonin treatment, including its role as a neuroprotectant, a somnogen, and a modulator of the circadian rhythm.

Outcomes Associated With Intensive Care and Organ Support Among Patients With COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Accurate accounting of coronavirus disease 2019 (COVID-19) critical care outcomes has important implications for health care delivery. RESEARCH QUESTION: We aimed to determine critical care and organ support outcomes of intensive care unit (ICU) COVID-19 patients and whether they varied depending on the completeness of study follow-up or admission time period. STUDY DESIGN AND METHODS: We conducted a systematic review and meta-analysis of reports describing ICU, mechanical ventilation (MV), renal replacement therapy (RRT), and extracorporeal membrane oxygenation (ECMO) mortality. A search was conducted using PubMed, Embase, and Cochrane databases.We included English language observational studies of COVID-19 patients, reporting ICU admission, MV, and ICU case fatality, published from December 1, 2019 to December 31, 2020. We excluded reports of less than 5 ICU patients and pediatric populations. Study characteristics, patient demographics, and outcomes were extracted from each article. Subgroup meta-analyses were performed based on the admission end date and the completeness of data. RESULTS: Of 6,778 generated articles, 145 were retained for inclusion (n = 60,357 patients). Case fatality rates across all studies were 34.0% (95% CI = 30.7%, 37.5%, P < 0.001) for ICU deaths, 47.9% (95% CI = 41.6%, 54.2%, P < 0.001) for MV deaths, 58.7% (95% CI = 50.0%, 67.2%, P < 0.001) for RRT deaths, and 43.3% (95% CI = 31.4%, 55.4%, P < 0.001) for extracorporeal membrane oxygenation deaths. There was no statistically significant difference in ICU and organ support outcomes between studies with complete follow-up versus studies without complete follow-up. Case fatality rates for ICU, MV, and RRT deaths were significantly higher in studies with patients admitted before April 31st 2020. INTERPRETATION: Coronavirus disease 2019 critical care outcomes have significantly improved since the start of the pandemic. Intensive care unit outcomes should be evaluated contextually (study quality, data completeness, and time) for the most accurate reporting and to effectively guide mortality predictions.

Economic Impact of Insufficient and Disturbed Sleep in the Workplace.

OBJECTIVE: Insufficient and disturbed sleep are associated with significant morbidity among working-age adults. Poor sleep results in negative health outcomes and increases economic costs to employers. The current systematic review surveyed the peer-reviewed scientific literature and aggregated scientific evidence of sleep-related economic burdens borne by employers. METHODS: A systematic review was performed to identify peer-reviewed, English language studies evaluating the economic impact of insufficient and disturbed sleep among adult employee populations. An exhaustive literature search was performed using keywords related to sleep, economics, and the workplace. Included were scientific studies (randomized controlled trials, cohort and case control studies, cross-sectional and longitudinal studies) examining specific employee populations with relevant sleep and economic outcomes. Each included study was evaluated for risk of bias and relevant data was extracted and summarized. RESULTS: Sleep problems among employee populations are associated with worsened workplace outcomes, such as presenteeism, absenteeism, and accidents. Sleep problems also increased costs to employers, ranging from US$322 to US$1967 per employee. Interventions to improve sleep, such as the use of blue-light filtering glasses, strategic shift scheduling, and targeted interventions to treat insomnia, may improve workplace outcomes and reduce costs. CONCLUSIONS: This review synthesizes the existing data regarding the negative impacts of insufficient and disturbed sleep on the workplace, suggesting that employers have an economic stake in their employees' sleep. TRIAL REGISTRATION: PROSPERO: CRD42021224212.

Intensive Care and Organ Support Related Mortality in Patients With COVID-19: A Systematic Review and Meta-Analysis.

To perform a systematic review and meta-analysis to generate estimates of mortality in patients with COVID-19 that required hospitalization, ICU admission, and organ support. DATA SOURCES: A systematic search of PubMed, Embase, and the Cochrane databases was conducted up to December 31, 2021. STUDY SELECTION: Previously peer-reviewed observational studies that reported ICU, mechanical ventilation (MV), renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO)-related mortality among greater than or equal to 100 individual patients. DATA EXTRACTION: Random-effects meta-analysis was used to generate pooled estimates of case fatality rates (CFRs) for in-hospital, ICU, MV, RRT, and ECMO-related mortality. ICU-related mortality was additionally analyzed by the study country of origin. Sensitivity analyses of CFR were assessed based on completeness of follow-up data, by year, and when only studies judged to be of high quality were included. DATA SYNTHESIS: One hundred fifty-seven studies evaluating 948,309 patients were included. The CFR for in-hospital mortality, ICU mortality, MV, RRT, and ECMO were 25.9% (95% CI: 24.0-27.8%), 37.3% (95% CI: 34.6-40.1%), 51.6% (95% CI: 46.1-57.0%), 66.1% (95% CI: 59.7-72.2%), and 58.0% (95% CI: 46.9-68.9%), respectively. MV (52.7%, 95% CI: 47.5-58.0% vs 31.3%, 95% CI: 16.1-48.9%; p = 0.023) and RRT-related mortality (66.7%, 95% CI: 60.1-73.0% vs 50.3%, 95% CI: 42.4-58.2%; p = 0.003) decreased from 2020 to 2021. CONCLUSIONS: We present updated estimates of CFR for patients hospitalized and requiring intensive care for the management of COVID-19. Although mortality remain high and varies considerably worldwide, we found the CFR in patients supported with MV significantly improved since 2020.

Patient Engagement and Provider Effectiveness of a Novel Sleep Telehealth Platform and Remote Monitoring Assessment in the US Military: Pilot Study Providing Evidence-Based Sleep Treatment Recommendations.

BACKGROUND: Sleep problems are common and costly in the US military. Yet, within the military health system, there is a gross shortage of trained specialist providers to address sleep problems. As a result, demand for sleep medicine care far exceeds the available supply. Telehealth including telemedicine, mobile health, and wearables represents promising approaches to increase access to high-quality and cost-effective care. OBJECTIVE: The purpose of this study was to evaluate patient engagement and provider perceived effectiveness of a novel sleep telehealth platform and remote monitoring assessment in the US military. The platform includes a desktop web portal, native mobile app, and integrated wearable sensors (ie, a commercial off-the-shelf sleep tracker [Fitbit]). The goal of the remote monitoring assessment was to provide evidence-based sleep treatment recommendations to patients and providers. METHODS: Patients with sleep problems were recruited from the Internal Medicine clinic at Walter Reed National Military Medical Center. Patients completed intensive remote monitoring assessments over 10 days (including a baseline intake questionnaire, daily sleep diaries, and 2 daily symptom surveys), and wore a Fitbit sleep tracker. Following the remote monitoring period, patients received assessment results and personalized sleep education in the mobile app. In parallel, providers received a provisional patient assessment report in an editable electronic document format. Patient engagement was assessed via behavioral adherence metrics that were determined a priori. Patients also completed a brief survey regarding ease of completion. Provider effectiveness was assessed via an anonymous survey. RESULTS: In total, 35 patients with sleep problems participated in the study. There were no dropouts. Results indicated a high level of engagement with the sleep telehealth platform, with all participants having completed the baseline remote assessment, reviewed their personalized sleep assessment report, and completed the satisfaction survey. Patients completed 95.1% of sleep diaries and 95.3% of symptom surveys over 10 days. Patients reported high levels of satisfaction with most aspects of the remote monitoring assessment. In total, 24 primary care providers also participated and completed the anonymous survey. The results indicate high levels of perceived effectiveness and identified important potential benefits from adopting a sleep telehealth approach throughout the US military health care system. CONCLUSIONS: Military patients with sleep problems and military primary care providers demonstrated high levels of engagement and satisfaction with a novel sleep telehealth platform and remote monitoring assessment. Sleep telehealth approaches represent a potential pathway to increase access to evidence-based sleep medicine care in the US military. Further evaluation is warranted.

Association Between Insomnia and Mental Health and Neurocognitive Outcomes Following Traumatic Brain Injury.

We previously described five trajectories of insomnia (each defined by a distinct pattern of insomnia severity over 12 months following traumatic brain injury [TBI]). Our objective in the present study was to estimate the association between insomnia trajectory status and trajectories of mental health and neurocognitive outcomes during the 12 months after TBI. In this study, participants included N = 2022 adults from the Federal Inter-agency Traumatic Brain Injury Repository database and Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. The following outcome measures were assessed serially at 2 weeks, and 3, 6, and 12 months post-injury: Insomnia Severity Index, Patient Health Questionnaire, Post-Traumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Patient Reported Outcomes Measurement Information System-Pain, and Quality of Life After Brain Injury-Overall Scale. Neurocognitive performance was assessed at 2 weeks, and 6 and 12 months using the Wechsler Adult Intelligence Scales Processing Speed Index and the Trails Making Test Parts A and B. Results indicated that greater insomnia severity was associated with greater abnormality in mental health, quality of life, and neuropsychological testing outcomes. The pattern of insomnia over time tracked the temporal pattern of all these outcomes for all but a very small number of participants. Notably, severe insomnia at 3 or 6 months post-TBI was a risk factor for poor recovery at 12 months post-injury. In conclusion, in this well-characterized sample of individuals with TBI, insomnia severity generally tracked severity of depression, pain, PTSD, quality of life, and neurocognitive outcomes over 12 months post-injury. More intensive sleep assessment is needed to elucidate the nature of these relationships and to help inform best strategies for intervention.

International Consensus Statement on Obstructive Sleep Apnea.

BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Performance comparison of peripheral arterial tonometry-based testing and polysomnography to diagnose obstructive sleep apnea in military personnel.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is increasingly common among military personnel, but diagnostic capabilities are challenged by limited capability for polysomnography (PSG). We sought to evaluate the diagnostic properties of peripheral arterial tonometry (PAT)-based home sleep apnea testing (HSAT) to accurately identify and classify OSA among active-duty military personnel. METHODS: This study was a retrospective review of all patients suspected of having OSA who completed an initial PAT-based HSAT followed by confirmatory PSG within 120 days. The diagnostic properties of a PAT-based, HSAT-derived apnea-hypopnea index (AHI) vs a PSG-derived AHI were assessed. RESULTS: Two hundred eight matched pairs of asynchronous studies were analyzed. The prevalence of OSA was 63.5%. PAT-based HSAT overdiagnosed 27.4% of patients with OSA and underdiagnosed 46.6% of patients with OSA. The majority (n = 116, 55.8%) of patients changed OSA severity classification (absent, mild, moderate, severe) after PSG. OSA severity classification concordance between PAT-based HSAT and PSG was observed in 53.4%, 40.5%, 28.6%, and 40.0% of patients with absent, mild, moderate, and severe OSA, respectively. Receiver operating characteristic curve analysis showed an area under the curve of 0.715 and a proposed PAT-based, HSAT-derived AHI cutoff score for OSA diagnosis of 9.0 events/h. This PAT-based, HSAT-derived AHI provided a 52% sensitivity, 83% specificity, 84% positive predictive value, and 50% negative predictive value. Bland-Altman plots showed an unacceptable degree of agreement between PAT-based, HSAT-derived AHI and AHI. CONCLUSIONS: There is significant discordance between PAT-based HSAT and PSG among active-duty military personnel evaluated for OSA. PAT-based HSAT may have limited utility for diagnosing OSA and grading severity in this unique patient population. CITATION: O'Reilly BM, Wang Q, Collen J, Matsangas P, Colombo CJ, Mysliwiec V. Performance comparison of peripheral arterial tonometry-based testing and polysomnography to diagnose obstructive sleep apnea in military personnel. J Clin Sleep Med. 2022;18(6):1523-1530.

Central disorders of hypersomnolence: diagnostic discrepancies between military and civilian sleep centers.

STUDY OBJECTIVES: The majority of active-duty service members obtain insufficient sleep, which can influence diagnostic evaluations for sleep disorders, including disorders of hypersomnolence. An incorrect diagnosis of hypersomnia may be career ending for military service or lead to inappropriate medical care. This study was conducted to assess the rates at which narcolepsy (Nc) and idiopathic hypersomnia (IH) are diagnosed by military vs civilian sleep disorders centers. METHODS: This retrospective study utilized claims data from the Military Health System Data Repository. The analyses compared diagnostic rates of military personnel by provider type-either civilian provider or military provider-from January 1, 2016 to December 31, 2019. Three diagnostic categories for Nc and IH: Nc or IH, Nc only, and IH only, were assessed with multivariate logistic regression models. RESULTS: We found that among service members evaluated for a sleep disorder, the odds ratios of a positive diagnosis at a civilian facility vs a military facility for Nc or IH was 2.1, for Nc only was 2.1, and IH only was 2.0 over the 4-year period. CONCLUSIONS: Civilian sleep specialists were twice as likely to diagnose central disorders of hypersomnolence compared to military specialists. Raising awareness about this discrepancy is critical given the occupational and patient care-related implications of misdiagnoses. CITATION: Thomas CL, Vattikuti S, Shaha D, et al. Central disorders of hypersomnolence: diagnostic discrepancies between military and civilian sleep centers. J Clin Sleep Med. 2022;18(10):2433-2441.