Grigg-Damberger, in a recent review, 3 noted that there have been few complaints about the new scoring system. Moser and colleagues 4 found signifi cant differences in stage scores with the AASM Manual. Stages N1 and N3 were increased, whereas stage N2 was decreased with the new scoring as compared to the old. Scorers were drawn from a pool of 30 experienced sleep experts. Danker-Hopfe and colleagues found that use of the AASM Manual resulted in slightly improved inter-rater reliability to 82.0% compared to 80.6% using R & K rules. 5 Her study was based on 72 recordings that were scored with both methods by a pool of 7 experienced scorers.The AASM inter-scorer reliability (ISR) program was developed to aid sleep centers in fulfi lling accreditation standards. The standards require that a sample of randomly chosen records be scored by the center director and each of the technologists involved in record scoring. As a means of achieving this standard, the AASM ISR program provides a record each

A systematic literature review and meta-analyses (where appropriate) were performed to update the previous AASM practice parameters on the treatments, both dopaminergic and other, of RLS and PLMD. A considerable amount of literature has been published since these previous reviews were performed, necessitating an update of the corresponding practice parameters. Therapies with a STANDARD level of recommendation include pramipexole and ropinirole. Therapies with a GUIDELINE level of recommendation include levodopa with dopa decarboxylase inhibitor, opioids, gabapentin enacarbil, and cabergoline (which has additional caveats for use). Therapies with an OPTION level of recommendation include carbamazepine, gabapentin, pregabalin, clonidine, and for patients with low ferritin levels, iron supplementation. The committee recommends a STANDARD AGAINST the use of pergolide because of the risks of heart valve damage. Therapies for RLS secondary to ESRD, neuropathy, and superficial venous insufficiency are discussed. Lastly, therapies for PLMD are reviewed. However, it should be mentioned that because PLMD therapy typically mimics RLS therapy, the primary focus of this review is therapy for idiopathic RLS.

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Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD) -rotigotine. Rotigotine was originally approved by the US Food and Drug Administration (FDA) for the treatment of signs and symptoms associated with early stage idiopathic Parkinson's disease. Additionally, rotigotine had been shown in clinical trials to be effective for the treatment of moderate-to-severe RLS. In 2008, rotigotine was withdrawn from the US market due to concerns about inconsistent absorption from the patch; therefore, rotigotine was not an FDA-approved treatment option for RLS or PLMD when the 2012 update was accepted for publication. Thus, despite high level evidence supporting the efficacy of this drug for the treatment of moderate-to-severe RLS, the Standards of Practice Committee (SPC) made no recommendation regarding the use of rotigotine in the setting of RLS.The issue of drug absorption was subsequently resolved by the manufacturer, and the new formulation of rotigotine received FDA approval in April 2012. Rotigotine is currently FDA approved both for the treatment of signs and symptoms associ- LETTER TO THE EDITOR

Study Objectives: The American Academy of Sleep Medicine (AASM) Inter-scorer Reliability program provides a unique opportunity to compare a large number of scorers with varied levels of experience to determine agreement in the scoring of respiratory events. The objective of this paper is to examine areas of disagreement to inform future revisions of the AASM Manual for the Scoring of Sleep and Associated Events. Methods: The sample included 15 monthly records, 200 epochs each. The number of scorers increased steadily during the period of data collection, reaching more than 3,600 scorers by the fi nal record. Scorers were asked to identify whether an obstructive, mixed, or central apnea; a hypopnea; or no event was seen in each of the 200 epochs. The "correct" respiratory event score was defi ned as the score endorsed by the most scorers. Percentage agreement with the majority score was determined for each epoch and the mean agreement determined. Results:The overall agreement for scoring of respiratory events was 93.9% (κ = 0.92). There was very high agreement on epochs without respiratory events (97.4%), and the majority score for most of the epochs (87.8%) was no event. For the 364 epochs scored as having a respiratory event, overall agreement that some type of respiratory event occurred was 88.4% (κ = 0.77). The agreement for epochs scored as obstructive apnea by the majority was 77.1% (κ = 0.71), and the most common disagreement was hypopnea rather than obstructive apnea (14.4%). The agreement for hypopnea was 65.4% (κ = 0.57), with 16.4% scoring no event and 14.8% scoring obstructive apnea. The agreement for central apnea was 52.4% (κ = 0.41). A single epoch was scored as a mixed apnea by a plurality of scorers. Conclusions:The study demonstrated excellent agreement among a large sample of scorers for epochs with no respiratory events. Agreement for some type of event was good, but disagreements in scoring of apnea vs. hypopnea and type of apnea were common. A limitation of the analysis is that most of the records had normal breathing. A review of controversial events yielded no consistent bias that might be resolved by a change of scoring rules. I dentifi cation of respiratory events during sleep is critical to the diagnosis of sleep related breathing disorders, especially obstructive sleep apnea.1 Rules are provided by the AASM Manual for the Scoring of Sleep and Associated Events 2 (the Manual) and require not only identifi cation of events but classifi cation of types. Apnea types include obstructive, mixed, and central events. In addition, apneas are distinguished from hypopneas, defi ned as a partial decrease of air fl ow as measured using a nasal pressure transducer.Studies have attempted to assess scoring reliability for respiratory events, often employing non-standard techniques. A widely cited study published before the Manual used data from home sleep testing relying on a single nasal thermistor. 3The study defi ned apneas as a 75% or greater reduction of fl ow amplitude and hypopneas as a 30% or ...