Alec B. Platt

Sleep symptoms, race/ethnicity, and socioeconomic position.

STUDY OBJECTIVES Growing evidence indicates sleep is a major public health issue. Race/ethnicity and socioeconomics may contribute to sleep problems. This study assessed whether sleep symptoms were more prevalent among minorities and/or the socioeconomically disadvantaged. DESIGN Cross-sectional. SETTING Epidemiologic survey. PATIENTS OR PARTICIPANTS 2007-2008 National Health and Nutrition Examination Survey (N = 4,081). INTERVENTIONS None. MEASUREMENTS AND RESULTS Sociodemographics included age, sex, race/ethnicity, marital status, and immigration. Socioeconomics included poverty, education, private insurance, and food insecurity. Sleep symptoms assessed were sleep latency > 30 min, difficulty falling asleep, sleep maintenance difficulties, early morning awakenings, non-restorative sleep, daytime sleepiness, snorting/gasping, and snoring. Decreased reported problems for most symptoms were found among minorities, immigrants, and lower education levels. In general, in fully adjusted models, long sleep latency was associated with female gender, being black/African American, lower education attainment, no private insurance, and food insecurity. Difficulty falling asleep, sleep maintenance difficulties, early morning awakenings, and non-restorative sleep were also associated with female gender and food insecurity. Daytime sleepiness was seen in female and divorced respondents. Snorting/gasping was more prevalent among male, other-Hispanic/Latino, and 9(th)- to 11(th)-grade-level respondents. Snoring was prevalent among male, other-Hispanic/Latino, less-educated, and food-insecure respondents. CONCLUSIONS Sleep symptoms were associated with multiple sociodemographic and economic factors, though these relationships differed by predictor and sleep outcome. Also, reports depended on question wording.

Risk factors for nonadherence to warfarin: results from the IN-RANGE study†‡

Warfarin is widely used to prevent stroke and venous thromboembolism despite its narrow therapeutic window. Warfarin nonadherence is a substantial problem, but risk factors have not been well elucidated.

Can We Predict Daily Adherence to Warfarin?: Results From the International Normalized Ratio Adherence and Genetics (IN-RANGE) Study

BACKGROUND Warfarin is the primary therapy to prevent stroke and venous thromboembolism. Significant periods of nonadherence frequently go unreported by patients and undetected by providers. Currently, no comprehensive screening tool exists to help providers assess the risk of nonadherence at the time of initiation of warfarin therapy. METHODS This article reports on a prospective cohort study of adults initiating warfarin therapy at two anticoagulation clinics (university- and Veterans Affairs-affiliated). Nonadherence, defined by failure to record a correct daily pill bottle opening, was measured daily by electronic pill cap monitoring. A multivariable logistic regression model was used to develop a point system to predict daily nonadherence to warfarin. RESULTS We followed 114 subjects for a median of 141 days. Median nonadherence of the participants was 14.4% (interquartile range [IQR], 5.8-33.8). A point system, based on nine demographic, clinical, and psychosocial factors, distinguished those demonstrating low vs high levels of nonadherence: four points or fewer, median nonadherence 5.8% (IQR, 2.3-14.1); five points, 9.1% (IQR, 5.9-28.6); six points, 14.5% (IQR, 7.1-24.1); seven points, 14.7% (IQR, 7.0-34.7); and eight points or more, 29.3% (IQR, 15.5-41.9). The model produces a c-statistic of 0.66 (95% CI, 0.61-0.71), suggesting modest discriminating ability to predict day-level warfarin nonadherence. CONCLUSIONS Poor adherence to warfarin is common. A screening tool based on nine demographic, clinical, and psychosocial factors, if further validated in other patient populations, may help to identify groups of patients at lower risk for nonadherence so that intensified efforts at increased monitoring and intervention can be focused on higher-risk patients.

Hits and misses: screening commercial drivers for obstructive sleep apnea using guidelines recommended by a joint task force.

Objective:To evaluate joint task force criteria-based screening for severe obstructive sleep apnea (s-OSA) in commercial drivers. Methods:Among a community-based cohort of licensed commercial vehicle drivers, we assessed utility of the joint task force criteria. We conducted full, 14-channel overnight polysomnography in all drivers, defining s-OSA as an apnea–hypopnea index of 30 or more per hour. Results:One hundred of 104 drivers with successful polysomnography studies were predominantly obese (median body mass index = 32.8 kg/m2; interquartile range = 26.8 to 37.4) and had a median apnea—hypopnea index of 20.6 per hour (interquartile range = 10.0 to 34.2). Examination-based criteria were more effective (sensitivity = 80%; negative posttest probability [nPTP] = 17%) than symptom-based criteria (sensitivity = 63%; nPTP = 23%). Examination and symptom-based criteria combined had high sensitivity (97%) and low nPTP (7%), but poor specificity (19%). Conclusions:Examination-based criteria missed 20% of s-OSA cases. Combining examination with confidentially reported symptoms improved sensitivity but required confirmatory polysomnography in 86%, supporting universal screening of all drivers.