A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia : main outcomes from the MATRICS study

Study Objectives -- To investigate treatment models using cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia. Methods -- 121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home setup and CBT-I was delivered in four individual sessions. The primary outcome measure was PAP adherence across the first 90 days, with regular PAP use (≥4 h on ≥70% of nights during a 30-day period) serving as the clinical endpoint. The secondary outcome measures were the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) with good sleeper (PSQI 7) serving as the clinical endpoints. Results -- No significant differences were found between the concomitant treatment arms and PAP only on PAP adherence measures, including the percentage of participants who met the clinical endpoint. Compared to PAP alone, the concomitant treatment arms reported a significantly greater reduction from baseline on the ISI (p = .0009) and had a greater percentage of participants who were good sleepers (p = .044) and remitters (p = .008). No significant differences were found between the sequential and concurrent treatment models on any outcome measure. Conclusions -- The findings from this study indicate that combining CBT-I with PAP is superior to PAP alone on insomnia outcomes but does not significantly improve adherence to PAP

Morning and Evening Blue-Enriched Light Exposure Alters Metabolic Function in Normal Weight Adults

<div><p>Increasing evidence points to associations between light-dark exposure patterns, feeding behavior, and metabolism. This study aimed to determine the acute effects of 3 hours of morning versus evening blue-enriched light exposure compared to dim light on hunger, metabolic function, and physiological arousal. Nineteen healthy adults completed this 4-day inpatient protocol under dim light conditions (<20lux). Participants were randomized to 3 hours of blue-enriched light exposure on Day 3 starting either 0.5 hours after wake (n = 9; morning group) or 10.5 hours after wake (n = 10; evening group). All participants remained in dim light on Day 2 to serve as their baseline. Subjective hunger and sleepiness scales were collected hourly. Blood was sampled at 30-minute intervals for 4 hours in association with the light exposure period for glucose, insulin, cortisol, leptin, and ghrelin. Homeostatic model assessment of insulin resistance (HOMA-IR) and area under the curve (AUC) for insulin, glucose, HOMA-IR and cortisol were calculated. Comparisons relative to baseline were done using t-tests and repeated measures ANOVAs. In both the morning and evening groups, insulin total area, HOMA-IR, and HOMA-IR AUC were increased and subjective sleepiness was reduced with blue-enriched light compared to dim light. The evening group, but not the morning group, had significantly higher glucose peak value during blue-enriched light exposure compared to dim light. There were no other significant differences between the morning or the evening groups in response to blue-enriched light exposure. Blue-enriched light exposure acutely alters glucose metabolism and sleepiness, however the mechanisms behind this relationship and its impacts on hunger and appetite regulation remain unclear. These results provide further support for a role of environmental light exposure in the regulation of metabolism.</p></div

Glucose, insulin, and HOMA-IR in dim versus blue-enriched morning and evening light.

<p>Glucose levels (A-B), insulin levels (C-D), and homeostatic model assessment of insulin resistance (E-F) during dim light (dotted line on line plots and grey bar on bar graph) compared to blue-enriched light (solid line on line plots and black bar on bar graph) for morning (n = 9; n = 8 for insulin and HOMA-IR) and evening (n = 10) participants. Grey shading on line plots indicates specified light exposure condition; M on line plots denote meal given 1 or 11 hours after wake for morning and evening participants, respectively. Results are plotted as mean ± standard error. *p<0.05, **p<0.01.</p

Glucose, insulin, HOMA-IR, and cortisol between conditions (dim versus blue-enriched light) within each group and between groups (morning versus evening).

<p>Glucose, insulin, HOMA-IR, and cortisol between conditions (dim versus blue-enriched light) within each group and between groups (morning versus evening).</p

Hunger in dim versus blue-enriched morning and evening light.

<p>Subjective hunger composite scores (A-B) and component scores (C-J) during dim light (dotted line) compared to blue-enriched light (solid line) for morning (left panels; n = 9) and evening (right panels; n = 10) participants. Grey shading indicates specified light exposure condition; M denotes meal given 1 or 11 hours after wake for morning and evening participants, respectively. Results are plotted as mean ± standard error.</p

Morning and Evening Blue-Enriched Light Exposure Alters Metabolic Function in Normal Weight Adults - Fig 1

<p><b>Schematic representation of the experimental protocol for morning (A) and evening (B) light exposure.</b> Participants arrived in the early evening of Day 1 (not shown) and began dim light < 20 lux (light grey shading) on Day 2 during 16 hours of wake and < 3 lux (dark grey shading) during 8 hours of sleep. Fixed isocaloric meals were given 1, 5, and 11 hours after wake. On both Days 2 and 3, questionnaires (VASH and KSS) were collected hourly during wake and blood was drawn (black circles) at 30-minute intervals 0.5–4.5 hours after wake for morning light exposure participants (A) and 10.5–14.5 hours after wake for evening light exposure participants (B). Participants were exposed to 3 hours of blue-enriched light (hashed shading on Day 3) starting 0.5 hours after wake for morning light exposure participants (A) and starting 10.5 hours after wake for evening light exposure participants (B) compared to dim light (Day 2). Participants were discharged on Day 4 (not shown). Abbreviations: VASH–visual analogue scale for hunger, KSS–Karolinska Sleepiness Scale.</p

Change from baseline (prior to start of light exposure) in leptin and ghrelin measures, between conditions (dim versus blue-enriched light) within each group and between groups (morning versus evening).

<p>Change from baseline (prior to start of light exposure) in leptin and ghrelin measures, between conditions (dim versus blue-enriched light) within each group and between groups (morning versus evening).</p

Sleepiness and cortisol in dim versus blue-enriched morning and evening light.

<p>Subjective sleepiness (A-B) and cortisol levels (C-D) during dim light (dotted line) compared to blue-enriched light (solid line) for participants in the morning (n = 8 for sleepiness and n = 9 for cortisol) and evening (n = 9 for sleepiness and n = 10 for cortisol) groups. Grey shading indicates specified light exposure condition; M denotes meal given 1 or 11 hours after wake for morning and evening participants, respectively. Results are plotted as mean ± standard error.</p

Management of REM sleep behavior disorder: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.

This systematic review provides supporting evidence for a clinical practice guideline for the management of rapid eye movement (REM) sleep behavior disorder in adults and children. The American Academy of Sleep Medicine commissioned a task force of 7 experts in sleep medicine. A systematic review was conducted to identify randomized controlled trials and observational studies that addressed interventions for the management of REM sleep behavior disorder in adults and children. Statistical analyses were performed to determine the clinical significance of critical and important outcomes. Finally, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations. The literature search identified 4,690 studies; 148 studies provided data suitable for statistical analyses; evidence for 45 interventions is presented. The task force provided a detailed summary of the evidence assessing the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.CitationHowell M, Avidan AY, Foldvary-Schaefer N, et&nbsp;al. Management of REM sleep behavior disorder: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2023;19(4):769-810