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The differential diagnosis of narcolepsy type 1, a rare, chronic, central disorder of hypersomnolence, is challenging due to overlapping symptoms with other hypersomnolence disorders. While recent years have seen significant growth in our understanding of nocturnal polysomnography narcolepsy type 1 features, there remains a need for improving methods to differentiate narcolepsy type 1 nighttime sleep features from those of individuals without narcolepsy type 1. We aimed to develop a machine learning framework for identifying sleep features to discriminate narcolepsy type 1 from clinical controls, narcolepsy type 2 and idiopathic hypersomnia. The population included polysomnography data from 350 drug-free individuals (114 narcolepsy type 1, 90 narcolepsy type 2, 105 idiopathic hypersomnia, and 41 clinical controls) collected at the National Reference Centers for Narcolepsy in Montpelier, France. Several sets of nocturnal sleep features were explored, as well as the value of time-resolving sleep architecture by analysing sleep per quarter-night. Several patterns of nighttime sleep evolution emerged that differed between narcolepsy type 1, clinical controls, narcolepsy type 2 and idiopathic hypersomnia, with increased nighttime instability observed in patients with narcolepsy type 1. Using machine learning models, we identified rapid eye movement sleep onset as the best single polysomnography feature to distinguish narcolepsy type 1 from controls, narcolepsy type 2 and idiopathic hypersomnia. By combining multiple feature sets capturing different aspects of sleep across quarter-night periods, we were able to further improve between-group discrimination and could identify the most discriminative sleep features. Our results highlight salient polysomnography features and the relevance of assessing their time-dependent changes during sleep that could aid diagnosis and measure the impact of novel therapeutics in future clinical trials.

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BACKGROUND AND AIM: We aim to conduct a systematic review and determine the association between obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD). METHODS: Literature search for eligible studies was performed across major databases. The main endpoint was to assess the association between GERD and OSA. Subgroup analyses were performed to determine this strength of the association stratified by the diagnostic tools used for OSA (nocturnal polysomnogram or Berlin questionnaire) and GERD (validated reflux questionnaire or esophagogastroduodenoscopy). We also compared sleep efficiency, apnea hypopnea index, oxygen desaturation index, and Epworth Sleepiness Scale in OSA patients with or without GERD. Results were pooled together using Reviewer Manager 5.4. RESULTS: Six studies involving 2950 patients with either GERD or OSA were included in the pooled analysis. Our findings suggest that there was a statistically significant unidirectional association between GERD and OSA (odds ratio [OR] = 1.53, P = 0.0001). Subgroup analyses redemonstrated an OSA-GERD association irrespective of the tools used for diagnosing either GERD or OSA (P = 0.24 and P = 0.82, respectively). Sensitivity analyses demonstrated the same association after controlling for gender (OR = 1.63), BMI (OR = 1.81), smoking (OR = 1.45), and alcohol consumption (OR = 1.79). In patients with OSA, there were no statistically significant differences between patients with or without GERD in terms of apnea hypopnea index (P = 0.30), sleep efficiency (P = 0.67), oxygen desaturation index (P = 0.39), and Epworth Sleepiness Scale (P = 0.07). CONCLUSION: There exists an association between OSA and GERD that is independent of the modalities used for screening or diagnosing both disorders. However, the presence of GERD did not affect the severity of OSA.

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BACKGROUND: Delayed sleep-wake phase disorder (DSWPD) is a chronic condition with a multifactorial etiology that primarily affects adolescents, significantly influencing their quality of life. In clinical practice, the contribution of intrinsic and behavioral factors is difficult to determine. The aim of our study was to compare data from clinical interviews, sleep diaries, actigraphy, and nocturnal polysomnography (PSG) in a cohort of adolescents with DSWPD and to assess psychiatric/neurodevelopmental comorbidity. METHODS: Thirty-one patients (22 male; mean age 15.4 ± 2.2 years, range 12 to 19 years) with a diagnosis of DSWPD based on detailed history, sleep diary, and actigraphy underwent nocturnal polysomnography (PSG) and neurological, psychological, and psychiatric examination. RESULTS: Attention-deficit/hyperactivity disorder (ADHD) was present in 14 cases (45%), specific learning difficulties in nine (29%), and mood disorder (anxiety/depression) in 16 patients (52%). PSG revealed sleep-onset delay in only 12 (38%) cases. No differences in clinical data or psychiatric comorbidity between the group with sleep delay and the group with normal sleep onset were detected. Decreased total sleep time, sleep efficiency, rapid eye movement (REM) sleep, and prolonged REM sleep latency were observed in patients with delayed sleep onset. CONCLUSIONS: PSG showed delayed sleep timing in only 38% of patients with a diagnosis of DSWPD based on diagnostic criteria of the International Classification of Sleep Disorders. We suggest that PSG can provide useful information regarding the prevailing etiology (biological versus behavioral) if dim light melatonin onset testing is not available.

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OBJECTIVE: Rhinoplasty can reduce nasal airways' resistance. This study evaluates the effects of rhinoplasty on sleep quality, daytime drowsiness, and obstructive sleep apnea (OSA). METHODS: In this prospective cohort study, 80 rhinoplasty candidates were examined before and six months after rhinoplasty to evaluate symptom changes. STOP-BANG, Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS) questionnaires, and nocturnal polysomnography were used, respectively, to screen for OSA, assess sleep quality, assess daytime drowsiness, and confirm results. RESULTS: Seventeen men (21.2%) and 63 women (78.8%) were studied. PSQI results showed an increase only in post-operative sleep disturbance items (p = 0.04). STOP-BANG showed an increase in apnea (p = 0.06) and a decrease in snoring (p = 0.06), which were both insignificant. The polysomnography tests confirmed the results of the questionnaires. CONCLUSION: Contrary to popular belief, rhinoplasty does not increase snoring, sleep disorders, or apnea.

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BACKGROUND: Patients with cerebral palsy and other static encephalopathies (CP) are known to be at increased risk of sleep-related breathing disorders (SRBD). Few studies have reviewed whether intrathecal baclofen (ITB) can contribute to SRBD. OBJECTIVE: To assess the prevalence of SRBD in patients with CP receiving ITB by using nocturnal polysomnography (NPSG). METHODS: We performed a retrospective chart review of patients receiving ITB who had NPSG at Children's Hospital Colorado (CHCO) and Seattle Children's Hospital (SCH) from 1995 to 2019. The Gross Motor Function Classification System (GMFCS) measured the severity of motor disability. Screening sleep questionnaires collected subjective data and NPSG provided objective data of SRBD. RESULTS: All patients except one were GMFCS 4 or 5 with median age at ITB pump placement of 9.7 years. The screening questionnaire for SRBD detected one or more nighttime symptoms in > 82% of all patient groups. Pre-ITB criteria for a SRBD was met in 83% of patients at CHCO and 91% at SCH. Post-ITB prevalence remained similarly high. CONCLUSIONS: NPSG identified a high prevalence of SRBD in these cohorts from CHCO and SCH. Our study showed neither improvement nor worsening of SRBD in patients receiving ITB.

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Leber hereditary optic neuropathy and Dominant optic atrophy are associated with a selective loss of retinal ganglion cells (RGC). A subtype of RGC is responsible for light-dependent physiological processes. The aim of our study was to evaluate both subjective and objective sleep parameters in 36 (18 males; mean age 33.8 ± 16.7) symptomatic/asymptomatic subjects with Leber hereditary optic neuropathy and dominant optic atrophy. The Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS) and nocturnal polysomnography were used to assess sleep disturbances and sleep quality. The questionnaires indicated significantly worse sleep quality (PSQI > 5; average 7.7 ± 3.8) in 21 (70%) and excessive daytime sleepiness (ESS > 10; average 6.3 ± 5.8) in six (20%) individuals. Nocturnal polysomnography has not revealed any significant changes of sleep structure. Rapid eye movement (REM) sleep without atonia was observed in two patients with Leber hereditary optic neuropathy. Obstructive sleep apnea was noted in eight cases. No correlation between subjective and polysomnographic data and no differences between symptomatic and asymptomatic groups were observed. None of the subjects fulfilled criteria for a circadian sleep disorder. In both symptomatic and asymptomatic individuals, a subjective decrease of the quality of sleep and wakefulness was noted without any correlation on polysomnography.

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OBJECTIVE: To clarify the differences in quantitative electroencephalographic (EEG) measures and their relation to clinical symptoms among narcolepsy-spectrum disorders. METHODS: The enrolled patients were: 28 with narcolepsy with cataplexy (NA-CA); 16 with NA without cataplexy (NA w/o CA) and HLA-DRB1*1501/DQB1*0602 positive (NA w/o CA HLA+); 22 with NA w/o CA and HLA negative (NA w/o CA HLA-); and 22 with idiopathic hypersomnia without long sleep time (IHS w/o LST). Nocturnal polysomnography (n-PSG) and quantitative EEG evaluation, as well as the Multiple Sleep Latency test (MSLT), were conducted for all patients. RESULTS: Patients with NA-CA or NA w/o CA HLA+ showed lower alpha power, higher delta and theta power during wakefulness, and higher alpha and beta power during rapid eye movement (REM) sleep, compared to those with NA w/o CA HLA- or IHS w/o LST. The former two groups also showed lower sleep efficiency and a higher rate of positivity of REM-related symptoms than the other two groups. CONCLUSIONS: In narcolepsy, the presence of cataplexy and HLA positivity are associated with EEG slowing during wakefulness and increased fast EEG activity during REM sleep, REM-related symptoms and disrupted nocturnal sleep in narcolepsy.

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OBJECTIVES: Fibromyalgia (FM) and rheumatoid arthritis (RA) are associated with sleep disturbance and daytime sleepiness. We sought to determine whether sleep homeostatic mechanisms are blunted in FM by assessing the effects of reduced time in bed (4h) on next day sleepiness and recovery sleep. METHODS: Fifty women (18 with FM, 16 with RA, and 16 HC) had a baseline 8h time-in-bed (TIB) and Multiple Sleep Latency Test (MSLT) the following day, and 3-7 days later bedtime was reduced (4h) followed by MSLT and an 8h TIB recovery night. RESULTS: Following reduced bedtime the MSLT was reduced relative to baseline in the FM group by an amount (4.3+/-4.8 min) similar to that of the RA (3.1+/-5.2 min) and HC (4.8 +/-3.1 min) groups. Relative to the baseline on the recovery night the FM group showed increased sleep efficiency (83.7+/-7.8 to 88.1+/-9.2%) relative to the RA (83.9+/-8.6 to 80.9+/-13.3%) and HC (90.1+/-5.0 to 87.4+/-7.6%) groups due primarily to reduced wake after sleep onset. The groups did not differ in recovery night sleep stages with the exception that the FM group showed REM rebound (21.6+/-6.5 to 25.2+/-6.0%), which was not found in the RA (20.4+/-7.4 to 17.8+/-6.5%) or HC (16.6+/-6.6 to 17.5+/-6.0%) groups. CONCLUSIONS: Compared to RA and HC, people with FM responded to reduced bedtime with a comparable increase in sleepiness and greater recovery sleep efficiency, suggesting that homeostatic sleep mechanisms are functional in FM. People with FM uniquely showed REM rebound on recovery from reduced bedtime suggesting underlying REM pressure.

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The authors evaluated basic sleep architecture and non-rapid eye movement (NREM) sleep alterations in drug-naïve attention-deficit/hyperactivity disorder (ADHD) children without psychiatric or other comorbidities. This cross-sectional case-control study included 28 drug-naïve children with ADHD and 15 healthy controls. This subjective studies revealed that children with ADHD had a worse sleep quality and increased daytime sleepiness. Polysomnography data showed that the sleep macrostructure was not significantly different in children with ADHD. Sleep microstructure was altered in ADHD children by means of reduced total cyclic alternating pattern rate and duration of cyclic alternating pattern sequences. This reduction was associated with a selective decrease of A1 index during stage 2 NREM. SpO2 in total sleep was slightly decreased; however, the incidence of sleep disordered breathing showed no significant difference. The authors suggest that cyclic alternating pattern scoring would provide a further insight to obtain a better understanding of the sleep structure in children with ADHD.

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Borderline personality disorder (BPD) is characterized by identity and interpersonal problem, affective dysregulation and pervasive severe impulsivity. Although sleep disturbances are not primary symptoms of BPD, they are important aspects of this disorder. However, clinicians and researchers did not give much attention to the sleep symptoms of BPD yet. Measured by nocturnal polysomnography, increased sleep latency as well as reduced total sleep time and sleep efficiency, and 'depression-like' REM abnormalities (i.e., reduced REM latency and increased REM density) are found in BPD patients. Co-morbid sleep disorders such as chronic insomnia, nightmare disorder or circadian rhythm sleep disorder associated with BPD have been reported. Clinicians should focus on the sleep complaints of BPD patients, and carefully manage such symptoms with sleep hygiene education, cognitive psychotherapy or light therapy.

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A 63-year-old female with obstructive sleep apnea syndrome (OSAS) presented with clinical features indistinguishable from paradoxical insomnia (PI). Her main complaint was chronic insomnia. Her subjective sleep latency was 2-3 h, subjective sleep time was less than 3 h, despite spending 8 h in bed, and she reported near constant awareness of her surroundings while lying in bed. Her body mass index (BMI) was 22.67 kg/m(2), and her neck circumference was 34.5 cm. Nocturnal polysomnography (NPSG) findings indicated severe OSAS. Her total sleep time (TST) was 359 min, sleep latency 13 min, and her apnea/hypopnea index (AHI) was 74.6/h. The aim of this report is to evaluate the association between PI and OSAS cases confirmed by NPSG.

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A 63-year-old female with obstructive sleep apnea syndrome (OSAS) presented with clinical features indistinguishable from paradoxical insomnia (PI). Her main complaint was chronic insomnia. Her subjective sleep latency was 2-3 h, subjective sleep time was less than 3 h, despite spending 8 h in bed, and she reported near constant awareness of her surroundings while lying in bed. Her body mass index (BMI) was 22.67 kg/m2, and her neck circumference was 34.5 cm. Nocturnal polysomnography (NPSG) findings indicated severe OSAS. Her total sleep time (TST) was 359 min, sleep latency 13 min, and her apnea/hypopnea index (AHI) was 74.6/h. The aim of this report is to evaluate the association between PI and OSAS cases confirmed by NPSG.

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OBJECTIVES: A few studies have compared REM sleep-dependent obstructive sleep apnea syndrome (REM-OSA) with sleep stage non-dependent apnea syndrome (SND-OSA). Despite that REM-OSA might be more common in women than men, no studies have examined the probable characteristics of women patients with obstructive sleep apnea syndrome (OSAS). This study aimed at finding out the characteristics of REM-OSA in women by comparing it with SND-OSA. METHODS: Fifty-three subjects diagnosed as OSAS (AHI>5; AHI: apnea-hypopnea index) with nocturnal polysomnography at the Center for Sleep and Chronobiology of the Seoul National University Hospital between October 2004 and February 2006 were studied. Of them, 44 subjects with OSAS severity of mild (52 and AHI-NR<15 (AHI-R: AHI during REM sleep, AHI-NR: AHI during non-REM sleep). We compared REM-OSA group with SND-OSA as well as the criteria-determined REM-OSA cases with the visually-determined ones. RESULTS: Among 44 subjects, 28 persons (63.6%) turned out to have REM-OSA by our criteria and 24 persons (54.5%) by visual determination. Statistically significant differences (p<0.05) were found between REM-OSA and SND-OSA groups in AHI, hypopnea index, total sleep time, total wake time, sleep efficiency index, percents of stage 1, 2 and REM sleep, and REM latency. Percent of stage REM sleep (%REM) turned out to have influence on AHI ratio (AHI-R/AHI-NR) (B=0.537, p=0.002). REM-OSA was likely to be diagnosed in milder severity of OSAS (chi-square=13.117, p<0.001) and those with higher %REM (chi-square=11.325, p=0.001). There was no significant difference between the criteria-determined and the visually-determined cases of REM-OSA. CONCLUSION: We suggest that REM-OSA and SND-OSA patients be differentiated in terms of pathophysiology and treatment strategies. Visual determination of REM-OSA might be useful as the screening procedure of REM-OSA. Further studies on women with OSAS and REM-OSA need to be done.

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OBJECTIVES: Sleep disturbances are very common in hemodialysis (HD) patients with chronic renal failure (CRF). This study aimed to examine the characteristics of sleep disturbances, and to illustrate the relationship of sleep parameters with clinical parameters reflecting metabolic dysfunction in HD patients with CRF. METHODS: The Epworth Sleepiness Scale (ESS) and Sleep Disorders Questionnaire (SDQ) were administered in 26 HD patients with CRF. For fifteen patients with the risk of sleep disorder, nocturnal polysomnographic study (NPSG) and blood sampling were done. RESULTS: Among 15 patients, 14 patients (93%) were diagnosed as sleep disorders, sleep breathing disorder or periodic limb movements in sleep. Uric acid (UA) was positively correlated with sleep efficiency (r=0.571), and negatively correlated with waking after sleep onset, the amount of stage 1 sleep, and respiratory disturbance index (r=-0.515, -0.564, -0.646). Interleukin-6 was positively correlated with obstructive apnea index (r=0.661). CONCLUSION: In our study, the difficulty in maintaining sleep was found in HD patients with CRF. It also showed that increased UA was associated with improved sleep maintenance and decreased breathing disturbance during sleep. This might be related with antioxidant effect of UA in CRF. Further studies on total CRF patients including those without the risk of sleep disorder are necessary.

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