Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy.

OBJECTIVE/HYPOTHESIS: The ADHERE Registry is a multicenter prospective observational study following outcomes of upper airway stimulation (UAS) therapy in patients who have failed continuous positive airway pressure therapy for obstructive sleep apnea (OSA). The aim of this registry and purpose of this article were to examine the outcomes of patients receiving UAS for treatment of OSA. STUDY DESIGN: Cohort Study. METHODS: Demographic and sleep study data collection occurred at baseline, implantation visit, post-titration (6 months), and final visit (12 months). Patient and physician reported outcomes were also collected. Post hoc univariate and multivariate analysis was used to identify predictors of therapy response, defined as ≥50% decrease in Apnea-Hypopnea Index (AHI) and AHI ≤20 at the 12-month visit. RESULTS: The registry has enrolled 1,017 patients from October 2016 through February 2019. Thus far, 640 patients have completed their 6-month follow-up and 382 have completed the 12-month follow-up. After 12 months, median AHI was reduced from 32.8 (interquartile range [IQR], 23.6-45.0) to 9.5 (IQR, 4.0-18.5); mean, 35.8 ± 15.4 to 14.2 ± 15.0, P < .0001. Epworth Sleepiness Scale was similarly improved from 11.0 (IQR, 7-16) to 7.0 (IQR, 4-11); mean, 11.4 ± 5.6 to 7.2 ± 4.8, P < .0001. Therapy usage was 5.6 ± 2.1 hours per night after 12 months. In a multivariate model, only female sex and lower baseline body mass index remained as significant predictors of therapy response. CONCLUSIONS: Across a multi-institutional study, UAS therapy continues to show significant improvement in subjective and objective OSA outcomes. This analysis shows that the therapy effect is durable and adherence is high. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:1333-1338, 2020.

Drowsy Driving Considerations in Non-Commercial Drivers for the Sleep Physician.

ABSTRACT: The sleep physician faces many challenges in the assessment of drowsy driving. The following article reviews current clinical evaluation methods and legal considerations at the state level in the United States.

Early feasibility of hypoglossal nerve upper airway stimulator in patients with cardiac implantable electronic devices and continuous positive airway pressure-intolerant severe obstructive sleep apnea.

BACKGROUND: Implantable hypoglossal nerve upper airway stimulation (HNS) is a novel strategy approved by the US Food and Drug Administration for the management of moderate-to-severe obstructive sleep apnea (OSA) in patients with continuous positive airway pressure therapy intolerance or failure. Because of the proximity of a cardiac implantable electronic device (CIED) to this stimulator, interaction between these devices is theoretically possible. OBJECTIVE: The purpose of this study was to assess interactions between an implantable HNS device and a CIED. METHODS: We retrospectively analyzed 14 ad hoc patients with continuous positive airway pressure-intolerant, moderate-to-severe OSA and pre-existing transvenous CIEDs undergoing HNS implantation (Inspire II, Inspire Medical Systems). We assessed these devices for their pre and postimplant OSA outcomes and for possible device-device interaction. All patients were followed up for 1 year. RESULTS: Of the 14 patients, 9 had a pacemaker (8 dual-chamber, 1 single-chamber), 4 had an implantable cardioverter-defibrillator (2 dual-chamber, 1 single-chamber), and 1 had a cardiac resynchronization therapy device. All the HNS devices were implanted on the opposite side of the CIED. All CIEDs were programmed bipolar. HNS were programmed either unipolar or bipolar. During implant, intraoperative testing was performed to confirm that bipolar and unipolar HNS stimulation did not impact CIED sensing. During the follow-up period, no oversensing episodes were noted on the CIEDs. CONCLUSION: In this early experience, simultaneous use of a novel hypoglossal nerve upper airway stimulation device with transvenous CIEDs seems to be safe, effective, and without any device-device interactions.

Modified Genioglossal Advancement for Isolated Treatment of Obstructive Sleep Apnea.

INTRODUCTION: Genioglossal advancement is a surgical procedure for obstructive sleep apnea (OSA) that has lost favor as a primary treatment strategy. The authors describe utilization of a modified genioglossal advancement (MGA), combining a geniotubercle advancement via sliding genioplasty and a glossopexy. METHODS: A retrospective review was performed. Preoperative and postoperative apnea-hypopnea indices (AHIs) were compared to determine OSA treatment success. RESULTS: Five patients underwent MGA. Three subjects had preoperative and postoperative AHI scores which improved from 61, 28, and 19 (mean = 36) to 4.5, 2, and 6.3 (mean = 4.3), respectively. Two subjects had incomplete data for comparison. All subjects had an acceptable esthetic outcome. DISCUSSION: In properly selected subjects, MGA can alleviate OSA and provide improved esthetic outcomes.

Experience with telehealth for sleep monitoring and sleep laboratory management.

In 2009, we established a pilot telehealth service to a sleep laboratory in Garden City, Kansas, approximately 600 km from the Kansas University Medical Center. Videoconferencing was used for polysomnography (PSG) study follow-up, patient monitoring and sleep laboratory medical management. It allowed the sleep specialist to treat patients and collaborate with sleep laboratory personnel from a distance without extensive travel. In the first six months the telemedicine clinic was held on six occasions. There were 18 new patient evaluations and four follow up visits. The most common diagnosis was obstructive sleep apnoea. The videoconferencing equipment and the intraoral camera worked well. Interviewing and examining patients via telemedicine was very similar to doing it in-person. Telemedicine was effective for the physician-patient interaction and for visualizing airway structures. Although more research is needed, the use of videoconferencing for sleep study follow-up and laboratory oversight appears very promising.

Insurance status and patient behavior with asthma medications.

Few studies have measured patients' asthma medication compliance, medication costs, and insurance status. We used a questionnaire assessing details of asthma, medications used, patient costs, and methods used to reduce medication costs to assess these factors. Patients in outpatient clinics, emergency rooms, and inpatient units of two urban Chicago hospitals who had a history of asthma and an age of 18 years or older were eligible for the study. Two hundred subjects completed the questionnaire of which 54 (27%) were self-pay/uninsured, 54 (27%) had public aid, and 92 (46%) had insurance. The public aid group had a significantly higher rate of emergency room services. Eighty-four (42% of all participants) had no costs, including no copayment to obtain their antiasthma medications. Self-pay/uninsured patients more commonly reported delaying filling a prescription, failure to fill a prescription, and taking less than recommended doses than the other two groups. Self-pay/uninsured patients also more commonly reported choosing their pharmacy on the basis of medication costs. Participants with public aid reported their physicians inquired about insurance status, estimated medication costs, advised measures to reduce costs, and gave them free medication samples less often than the other two groups. In conclusion, patients report different methods to reduce their medication costs that vary according to their insurance status. Advice on methods to reduce medication costs and being supplied with medication samples also varied by insurance status according to participants' report.