Obstructive sleep apnoea and type 2 diabetes mellitus: a bidirectional association

Obstructive Sleep Apnea as a Risk Factor of Insulin Resistance in Nondiabetic Adults

OBJECTIVE

The aim of this research was to assess the relationship between prevalence and severity of obstructive sleep apnea (OSA) and insulin resistance among patients with increased risk of OSA without diabetes mellitus.

METHOD AND MATERIALS

our study group involved 102 individuals with suspected OSA, mean age 53.02 ± 12.37 years. Data on medical history, medication usage, sleep habits, sleep quality and daytime sleepiness, were obtained using questionnaires. All patients underwent standardized full night polysomnography. Serum fasting insulin and glucose concentration were analyzed, the homeostatic model assessment-insulin resistance (HOMA-IR) index was calculated.

RESULTS

polysomnographic study indicated that in the group with OSA mean values of apnea-hypopnea index (AHI), oxygen desaturation index (ODI), duration of SpO₂ < 90% and average desaturation drop were significantly higher compared to the group without OSA, while the minimum SpO2 was significantly lower. The carbohydrate metabolism parameters did not differ within those groups. Significantly higher fasting insulin concentration and HOMA-IR index were found in the group with AHI ≥ 15 compared to the group with AHI < 15 and in the group with AHI ≥ 30 compared to the group with AHI < 30. Higher AHI and ODI were independent risk factors for higher fasting insulin concentration and higher HOMA-IR index. Increased duration of SpO2 < 90% was an independent risk factor for higher fasting glucose concentration.

CONCLUSIONS

Individuals with moderate to severe OSA without diabetes mellitus had a higher prevalence of insulin resistance.

Role of physical activity and fitness on sleep in sedentary middle-aged adults: the FIT-AGEING study

The association of physical activity and fitness with sleep still remains unclear since there is a lack of studies in this field of research using objective measurements of these variables. This study aimed to investigate the association of objectively-measured sedentariness, physical activity levels, and physical fitness with sleep quantity and quality in sedentary middle-aged adults. A total of 74 volunteers (52.7% women; aged 53.7 ± 5.1) were recruited for the present study. Cardiorespiratory fitness was measured through a maximal treadmill test, and muscular strength by extension and flexion peak torque, and by the hand grip test. Physical activity and objective sleep parameters were determined through accelerometry, and subjective sleep by the Pittsburgh Sleep Quality Index (PSQI). Reduced levels of sedentariness, greater VO_2max, and greater muscular strength were positively related to improved objective sleep quantity and quality (all P ≤ 0.05). Furthermore, higher levels of overall physical activity, VO_2max, and muscular strength were related to better subjective sleep quantity and quality (all P ≤ 0.05). Reduced sedentariness and increased physical activity and fitness may be a potential prevention and/or treatment pathway to reduce sleep disturbances and, in general, to improve patients physical and psychological health for a successful aging process.

Association of Hypertriglyceridemic Waist Phenotype with Obstructive Sleep Apnea: A Cross-Sectional Study

OBJECTIVE

Hypertriglyceridemic waist (HTGW) phenotype is an independent risk factor for metabolic disorders. Although obstructive sleep apnea (OSA) is associated with metabolic disorders, it is unclear whether there is an association between HTGW phenotype and OSA.

METHODS

We enrolled consecutive participants presenting to a sleep center in Shanghai, China. Full-night polysomnography was performed, and serum triglyceride (TG) levels and waist circumference (WC) were calculated. HTGW phenotype was defined as increased WC (men > 90 cm, women > 80 cm) and elevated TG levels (> 1.7 mmol/L). Participants were classified into four groups: normal TG with normal WC (NTNW); normal TG with increased WC (NTGW); elevated TG with normal WC (HTNW); and elevated TG with enlarged WC, namely HTGW. The relationships between HTGW phenotypes and OSA were assessed using binary (apnea hypopnea index, [AHI]≥5/hr) and multinomial logistic regression analyses (clinical AHI severity categories).

RESULTS

We included 3190 participants in this cross-sectional study. Compared to the NTNW phenotype, participants with NTGW and HTGW phenotypes had the significantly higher risk of OSA (AHI ≥5/hr, odds ratio [OR] = 2.51, 95% confidence interval [CI] = 1.91-3.31; OR = 3.76, 95% CI = 2.67-5.31, respectively), after adjustment for confounders. In subgroup analyses categorised by age, sex, and BMI, the aforementioned associations remained significant. The association between the NTGW, HTGW phenotype and OSA risk remained significant across the OSA severity groups. Multinomial logistic regression also revealed that the mild (OR = 1.63, 95% CI = 1.07-2.50), moderate (OR = 1.875, 95% CI = 1.22-2.88), and severe OSA (OR = 3.18, 95% CI = 2.14-4.73) were associated with HTGW phenotype.

CONCLUSION

Both NTGW and HTGW phenotype were positively associated with OSA risk in all subgroups. Further longitudinal follow-up studies are needed to determine the causal link and prognostic role of these metabolic factors.

Diabetes in late-life schizophrenia: Prevalence, factors, and association with clinical symptoms

OBJECTIVE

The prevalence of diabetes mellitus has been found to be higher in patients with schizophrenia. Older patients are the fastest-growing segment of the schizophrenia population. However, few studies have explored diabetes in older patients with schizophrenia. Therefore, this study aimed to determine the prevalence and characteristics of factors associated with diabetes in Chinese patients with late-life schizophrenia (LLS), which has not been reported in previous studies.

METHODS

A total of 289 inpatients aged 60 or above who met the DSM-IV criteria for schizophrenia were recruited. The severity of psychopathology was assessed by the Positive and Negative Syndrome Scale (PANSS). Diabetes was diagnosed by fasting blood glucose tests, or oral glucose tolerance tests.

RESULTS

The overall prevalence of diabetes in LLS patients was 25.3%. The prevalence of diabetes in female patients was significantly higher than that in male patients (35% vs. 21.53%). Other factors associated with diabetes included higher BMI, greater waistline (only for males), higher levels of triglyceride, and more severe positive symptoms.

CONCLUSION

These results indicate that the prevalence of diabetes in LLS patients is similar to that in the age-matched general population. Female gender, excess weight and abdominal obesity, dyslipidemia, and clinical symptoms can be potential risk factors of diabetes in the LLS patient group.

Association of parameters of nocturnal hypoxemia with diabetic microvascular complications: A cross-sectional study

AIMS

To examine the association between obstructive sleep apnea (OSA)-related nocturnal hypoxemia parameters and diabetic microvascular complications in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 463 Chinese patients with T2DM underwent overnight polysomnography, followed by diagnosis of diabetic microvascular complications including diabetic peripheral neuropathy (DPN), diabetic retinopathy (DR) and diabetic nephropathy (DN). Parameters of nocturnal hypoxemia, including apnea-hypopnea index (AHI), oxygen desaturation index (ODI), time spent with SpO₂ < 90% (T90%) or <85% (T85%), mean SpO₂ and lowest SpO₂, were recorded.

RESULTS

AHI was independently associated with higher odds of DPN (OR 1.19; 95% CI, 1.05-1.36; P = 0.008) after adjustment for possible confounders. Moreover, patients with severe OSA (AHI ≥ 30 events/h) had higher likelihood of having DPN than those with mild OSA (OR 2.36; 95% CI, 1.31-4.25; P = 0.004). When combining DPN, DR and DN into an overall diabetic microvascular complication index, AHI was also independently associated with higher odds of having any diabetic microvascular complication (OR 1.21; 95% CI, 1.06-1.38; P = 0.006).

CONCLUSIONS

The AHI may be the OSA-related index that most strongly reflects the association of OSA and diabetic microvascular complications, compared with other OSA-related hypoxemia parameters.

Dynamic changes in nocturnal blood glucose levels are associated with sleep-related features in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) has a bidirectional relationship with insulin resistance conditions; however, the mechanism remains unclear. This study aimed to compare dynamic nocturnal glucose changes among patients with OSA of varying levels of severity and evaluate temporal changes associated with the cardinal features of OSA (sympathetic hyperactivation, intermittent hypoxemia, and sleep fragmentation) in nondiabetic subjects. Nocturnal glucose was measured with a continuous glucose monitoring device every 5 min during polysomnography (PSG). The OSA features were evaluated using heart rate variability (HRV), minimum saturation, and electroencephalography. Eleven subjects with moderate to severe OSA and 12 subjects with no or mild OSA were evaluated. Those with moderate to severe OSA showed an increasing trend in blood glucose levels after sleep onset, whereas those without or with mild OSA showed a decreasing trend (F = 8.933, p < 0.001). Delta band power also showed different trends during sleep between the two groups (F = 2.991, p = 0.009), and minimum saturation remained lower in the moderate to severe OSA group than in the no or mild OSA group. High degrees of coupling between nocturnal glucose levels and each OSA feature were observed. Altered trends in nocturnal glucose in moderate to severe OSA may reflect glucose intolerance and result in metabolic consequences. Managing the features of sleep-related OSA may have implications for metabolic management in the future.

Usefulness of Cathepsin S to Predict Risk for Obstructive Sleep Apnea among Patients with Type 2 Diabetes

Background

Obstructive sleep apnea (OSA) was highly prevalent in patients with type 2 diabetes (T2D). Cathepsin S (CTSS), a cysteine protease, is involved in the inflammatory activity in T2D and hypoxia conditions. The aim of the study was to evaluate whether CTSS could be involved in the inflammatory reaction of OSA in patients with T2D.

Methods

We included 158 participants in this study matched for age, gender, and body mass index in 4 groups (control, non-OSA&T2D, OSA&non-T2D, and OSA&T2D). After overnight polysomnography, we collected the clinical data including anthropometrical characteristics, blood pressure, and fasting blood samples in the morning. Plasma CTSS concentration was evaluated using the human Magnetic Luminex Assay.

Results

Compared with the control group, both the non-OSA&T2D group and the OSA&non-T2D group showed higher CTSS levels. Plasma CTSS expression was significantly increased in subjects with OSA&T2D compared to subjects with non-OSA&T2D. The OSA&T2D group had higher CTSS levels than the OSA&non-T2D group, but there were no statistically significant differences. Plasma CTSS levels showed significant correlation with the apnea-hypopnea index (AHI) (r = 0.559, P < 0.001) and plasma fasting blood glucose (r = 0.427, P < 0.001). After adjusting confounding factors, plasma CTSS levels were independently associated with the AHI (Beta: 0.386, 95% confidence intervals (CI): 21.988 to 57.781; P < 0.001). Furthermore, we confirmed the higher pinpoint accuracy of plasma CTSS in the diagnosis of OSA (area under the curve: 0.868).

Conclusions

Plasma CTSS expression was significantly elevated in the OSA&T2D group and was independently associated with the AHI; it could be a biomarker with a positive diagnostic value on diagnosing OSA among patients with T2D.

Insights into Friedman stage II and III OSA patients through drug-induced sleep endoscopy

Background

The Friedman staging is a classic system to predict outcomes of obstructive sleep apnea (OSA) surgery. Increasing stage indicates more severe upper airway (UA) obstruction and worse surgical successful rate. In previous studies, the UA obstruction between stages were usually assessed based on awake examination. Drug-induced sleep endoscopy (DISE) is a new method that can evaluate airway collapse characteristics during sleep. Therefore, we planned to compare Friedman staging and DISE findings and fulfill the knowledge gap on the correlation between awake and sedated UA examination.

Methods

Retrospective case series study that assessed patients with OSA who underwent DISE. Subjects were classified to stage II and stage III groups based on Friedman staging system. UA collapse characteristics based on velum, oropharynx, tongue base, epiglottis (VOTE) classification, including single/multiple obstruction sites, single/combined upper and lower obstruction levels, collapse degree and patterns in different sites, and surgical results among the groups were analyzed.

Results

A total of 175 cases were analyzed. No significant differences were found in baseline measurements between groups. Stage III patients (n=102) had a higher proportion (74.5%) with 3 or 4 obstruction sites than stage II (57.5%, n=73). Velum (V) + oropharynx (O) + tongue base (T) was the most common multi-sites combined obstruction pattern with 33% in stage II and 37% in stage III, isolated lower level obstruction was the least with 6% and 4%, respectively. No significant differences were found in obstruction sites and levels. 106 patients underwent surgeries and 33 had post-surgical sleep study, 73.7% and 63.6% response rate were found in stage II and III with no significant difference.

Conclusions

Upper and lower combined obstruction was the main pattern of collapse in both, Friedman stage II and III patients. Patients with OSA and Friedman stage III had more than 2 sites of obstruction than stage II patients.

Effect of Type 2 Diabetes Mellitus on the Hypoxia-Inducible Factor 1-Alpha Expression. Is There a Relationship with the Clock Genes?

Limited reports exist on the relationships between regulation of oxygen homeostasis and circadian clock genes in type 2 diabetes. We examined whether the expression of Hypoxia-Inducible Factor-1α (HIF-1α) and HIF-2α relates to changes in the expression of clock genes (Period homolog proteins (PER)1, PER2, PER3, Retinoid-related orphan receptor alpha (RORA), Aryl hydrocarbon receptor nuclear translocator-like protein 1 (ARNTL), Circadian locomotor output cycles kaput (CLOCK), and Cryptochrome proteins (CRY) 1 and CRY2) in patients with type 2 diabetes. A total of 129 subjects were evaluated in this cross-sectional study (48% with diabetes). The gene expression was measured by polymerase chain reaction. The lactate and pyruvate levels were used as surrogate of the hypoxia induced anaerobic glycolysis activity. Patients with diabetes showed an increased plasma concentration of both lactate (2102.1 ± 688.2 vs. 1730.4 ± 694.4 uM/L, p = 0.013) and pyruvate (61.9 ± 25.6 vs. 50.3 ± 23.1 uM/L, p = 0.026) in comparison to controls. However, this finding was accompanied by a blunted HIF-1α expression (1.1 (0.2 to 5.0) vs. 1.7 (0.4 to 9.2) arbitrary units (AU), p ≤ 0.001). Patients with diabetes also showed a significant reduction of all assessed clock genes’ expression. Univariate analysis showed that HIF-1α and almost all clock genes were significantly and negatively correlated with HbA1c concentration. In addition, positive correlations between HIF-1α and the clock genes were observed. The stepwise multivariate regression analysis showed that HbA1c and clock genes independently predicted the expression of HIF-1α. Type 2 diabetes modifies the expression of HIF-1α and clock genes, which correlates with the degree of metabolic control.

Is Sleep Associated with the S-Klotho Anti-Aging Protein in Sedentary Middle-Aged Adults? The FIT-AGEING Study

Sleep and Klotho have both been closely related to the ageing process, both playing a substantial role in the endocrine and immune systems and, thereby, in oxidative stress and chronic inflammation. However, there are no studies elucidating the relationship between sleep and Klotho. Therefore, this study investigated the association of sleep quantity and quality with the shed form of the α-Klotho gene (S-Klotho plasma levels) in sedentary middle-aged adults. A total of 74 volunteers (52.7% women; aged 53.7 ± 5.1) were recruited for the present study. Objective sleep quality parameters (total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE)) were determined using a wrist-worn accelerometer over seven consecutive days, and the subjective sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI; higher scores indicate worse sleep quality). The S-Klotho plasma levels were measured in the ethylenediaminetetraacetic acid plasma using a solid-phase sandwich enzyme-linked immunosorbent assay. Objective sleep parameters were associated with the S-Klotho plasma levels only after including the age, fat mass percentage, and lean mass index as covariates. A direct relationship was observed between the subjective sleep quality (inverse of PSQI scores) and the S-Klotho plasma levels in sedentary middle-aged adults. Improving sleep quantity and quality could be considered an anti-aging therapeutic approach for the prevention, slowing, and even reversal of the physiological decline and degenerative pathologies that are certainly related to the aging process.

Low long-term mortality in patients with sleep apnoea and positive airway pressure therapy: analysis of a large German healthcare database

Background

There are limited data on long-term mortality in sleep apnoea (SA) patients with and without positive airway pressure (PAP) therapy. This retrospective cohort study investigated long-term hospitalisation and mortality rates in SA patients from a German statutory health insurance (SHI) database who did versus did not receive PAP therapy.

Methods

Patients had continuous insurance coverage from 01 January 2008 to 31 December 2013, complete medical records and ≥1 SA-related diagnosis in 2009. Those receiving PAP were matched with a control group not treated with PAP. Outcomes (hospitalisations including stays in the sleep laboratory) were compared between groups the year prior to and the 4 years after SA diagnosis. Mortality was assessed in the 4 years after SA diagnosis.

Results

2176 PAP therapy recipients were matched with 2176 controls. The PAP group had a higher rate of hospitalisation in the year before SA diagnosis than the control group (80.2% vs. 26.6%; p = 0.0016). After diagnosis, the PAP group had a higher hospitalisation rate only in year 1 (p < 0.05), and average length of stay per hospitalisation was lower in the PAP group (p < 0.05 vs. control at years 1, 2 and 4). Cumulative all-cause mortality after year 3 (3.4% vs. 4.6%; p = 0.0287) and after year 4 (4.8% vs. 6.5%; p = 0.0175) was significantly lower in SA patients receiving PAP versus controls (relative risk reduction for death after 4 years: 25.5%).

Conclusion

This real-world cohort study showed an association between long-term PAP therapy use and lower mortality, a higher rate of hospitalisations before and shorter hospital stays after treatment initiation.

Acute pulmonary embolism in patients with obstructive sleep apnea: frequency, hospital outcomes, and recurrence

STUDY OBJECTIVES

The objectives of this study were to assess the effect of obstructive sleep apnea (OSA) on the risk of acute pulmonary embolism (PE), hospital outcomes including mortality, and PE recurrence.

METHODS

We retrospectively enrolled adult patients, admitted to Mayo Clinic Hospital in Rochester, Minnesota, within a 5-year period (2009-2013). We compared frequency of PE, hospital mortality, and secondary outcomes in patients with OSA versus patients without OSA. We assessed risk of PE recurrence in relation to compliance with OSA therapy.

RESULTS

Of 25,038 patients, 3,184 (13%) had OSA and 283 (1.1%) experienced PE. Frequency of PE in patients with and without OSA was 2.4% versus 0.9% (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.9-3.3; P < .001). OSA was independently associated with increased risk of PE after adjusting for demographics and comorbidities (OR, 1.44; 95% CI, 1.07-1.9; P = .017). Adjusted hospital mortality was increased in patients with PE (OR, 2.88; 95% CI, 1.7-4.9; P < .001) but not in patients with OSA (OR, 0.98; 95% CI, 0.7-1.4, P = .92). OSA was not a significant determining factor for mortality in patients who experienced a PE (OR, 0.56; 95% CI, 0.1.1-2.78; P = .47), adjusting for demographics, PE severity, and Charlson comorbidity index. Adjusted risk of PE recurrence was greater in patients with OSA compared with patients without OSA (OR, 2.21; 95% CI, 1.05-4.68; P < .04). The patients compliant with OSA therapy had a lower rate of PE recurrence (16% vs 32%; P = not significant).

CONCLUSIONS

Although OSA significantly increases risk of acute PE occurrence and recurrences, related hospital mortality was not greater in patients with OSA compared with those without OSA. OSA therapy might have a modifying effect on PE recurrence.

Inspiratory Muscle Training in Obstructive Sleep Apnea Associating Diabetic Peripheral Neuropathy: A Randomized Control Study

Objective

This work is aimed at assessing the effects of inspiratory muscle training on lung functions, inspiratory muscle strength, and aerobic capacity in diabetic peripheral neuropathy (DPN) patients with obstructive sleep apnea (OSA).

Methods

A randomized control study was performed on 55 patients diagnosed with DPN and OSA. They were assigned to the training group (IMT, n = 28) and placebo training group (P-IMT, n = 27). Inspiratory muscle strength, lung functions, and aerobic capacity were evaluated before and after 12 weeks postintervention. An electronic inspiratory muscle trainer was conducted, 30 min a session, three times a week for 12 consecutive weeks.

Results

From seventy-four patients, 55 have completed the study program. A significant improvement was observed in inspiratory muscle strength (p < 0.05) in the IMT group while no changes were observed in the P-IMT group (p > 0.05). No changes were observed in the lung function in the two groups (p > 0.05). Also, VO₂max and VCO₂max changed significantly after training in the IMT group (p < 0.05) while no changes were observed in the P-IMT group (p > 0.05). Other cardiopulmonary exercise tests did not show any significant change in both groups (p > 0.05).

Conclusions

Based on the outcomes of the study, it was found that inspiratory muscle training improves inspiratory muscle strength and aerobic capacity without a notable effect on lung functions for diabetic patients suffering from DPN and OSA.

Diabetes and respiratory system including tuberculosis - challenges

Diabetes mellitus is a common disorder associated with systemic inflammation and oxidative stress affecting various organ systems leading to microvascular (retinopathy, nephropathy and neuropathy) and macrovascular (myocardial infarction, stroke, peripheral vascular disease) complications. Although the impact of diabetes on lung functions has been previously reported, especially in asthma and COPD, the lung has not been described as a common target organ in diabetes and this has important medical, social and financial consequences in our already overburdened healthcare system. The underlying mechanism and pathophysiology of such an association have rarely been described in the literature. This review aims to discuss the effects of diabetes on lungs, probable mechanisms by which hyperglycemia may affect lung functions and mechanisms by which respiratory diseases can lead to onset, or worsening of pre-existing hyperglycemia with inherited challenges in the management.

Effect of Glucose Improvement on Nocturnal Sleep Breathing Parameters in Patients with Type 2 Diabetes: The Candy Dreams Study

Type 2 diabetes exerts a negative impact on sleep breathing. It is unknown whether a long-term improvement in glycemic control ameliorates this effect. We conducted an interventional study with 35 patients with type 2 diabetes and obstructive sleep apnea (OSA) to explore this. At home, sleep breathing parameters were assessed at baseline and after a 4-month period in which antidiabetic therapy was intensified. Patients who decreased their body mass index ≥2kg/m² were excluded. Those with an HbA1c reduction ≥0.5% were considered good responders (n = 24). After the follow-up, good responders exhibited an improvement in the apnea–hypopnea index (AHI: 26-1 (95% IC: 8.6–95.0) vs. 20.0 (4.0–62.4) events/hour, p = 0.002) and in time with oxygen saturation below 90% (CT90: 13.3 (0.4–69.0) vs. 8.1 (0.4–71.2) %, p = 0.002). No changes were observed in the group of non–responders (p = 0.722 and p = 0.138, respectively). The percentage of moderate and severe OSA decreased among good responders (p = 0.040). In the wider population, the change in HbA1c correlated positively to decreases in AHI (r = 0.358, p = 0.035) and negatively to increases in the minimum arterial oxygen saturation (r = −0.386, p = 0.039). Stepwise multivariate regression analysis showed that baseline AHI and the absolute change in HbA1c independently predicted decreased AHI (R² = 0.496). The improvement of glycemic control exerts beneficial effects on sleep breathing parameters in type 2 diabetes, which cannot be attributed merely to weight loss.

Associations between ankle-brachial index, diabetes, and sleep apnea in the Hispanic community health study/study of Latinos (HCHS/SOL) database

BACKGROUND

Sleep apnea and diabetes mellitus (DM) negatively impact cardiovascular health. One important indicator of cardiovascular health is the Ankle-Brachial Index (ABI). Either low ABI or high ABI are signs of peripheral vascular impairment. Impaired vascular health and DM, together, might provoke sleep apnea; however, information regarding these relationships is limited. Therefore, this study aimed to investigate the association between ABI, DM status, and severity of obstructive sleep apnea in people of Hispanic/Latino descent who are diverse in culture, environmental exposures, nativity, socioeconomic status, and disease burden.

METHODS

A cross sectional analysis from a multi-center epidemiologic study, Hispanic Community Health Study/Study of Latinos, was utilized and included 3779 participants (mean age 55.32 ± 7.67, females 57.9%). The sample was divided into 4 groups based on the American Diabetes Association diagnostic guidelines (no DM or DM), and the ABI status (normal and abnormal). Multiple linear regression analysis was used to determine the association of the four groups and other independent variables with severity of sleep apnea measured by apnea-hypopnea index. Kruskal-Wallis H test was used for comparisons between groups for the apnea-hypopnea index. The significant level was set at 0.01.

RESULTS

There were significant differences between groups in the mean of apnea-hypopnea index (P < 0.001; no DM + normal ABI = 5.42 ± 9.66, no DM + abnormal ABI = 7.11 ± 11.63, DM + normal ABI = 10.99 ± 15.16, DM + abnormal ABI = 12.81 ± 17.80). Linear regression showed that DM and abnormal ABI were significantly associated with severe sleep apnea (β = 3.25, P = 0.001) after controlling for age, sex, BMI, income, education, alcohol use, cigarette use, hypertension or related medication, stroke and statin use.

CONCLUSION

These findings suggest that people with DM and abnormal ABI were more likely to have high apnea-hypopnea index compared to the other groups. We observed gradual increasing in the severity of sleep apnea from low abnormality groups to high abnormality groups for Hispanic/Latino. Further work should elucidate the association of DM, abnormal ABI and sleep apnea with longer term outcomes, and replicate this work in different populations.

The Somatotropic Axis in the Sleep Apnea-Obesity Comorbid Duo

Background: Growth hormone (GH) stimulates the production of insulin-like growth factor 1 (IGF-1) in most tissues and together GH and IGF-1 profoundly impact adipose tissue deposition, glucose metabolism and cardiovascular function. A low serum IGF-I level has been reported as being associated with obstructive sleep apnea (OSA) and might be one of the mechanisms underlying cardio-metabolic risk in OSA patients. Methods: In a multicenter national study, 817 patients consulting for suspicion of OSA (OSA confirmed for 567 patients) underwent serum IGF-1 measurements. We analyzed the association between an IGF-1 level below the median value of the population and variables related to cardio-metabolic risk: body mass index (BMI) and waist circumference, apnea hypopnea index (AHI), cholesterol and triglycerides (expressed as median and divided into quartiles for continuous variables). Results: After adjustment for age and gender, low IGF-1 levels were associated with increased BMI and AHI (Odds ratios (OR) = 2.83; p < 0.0001 and OR = 3.03, p < 0.0001 for Quartile 4 vs. Quartile1, respectively), with elevated cholesterol levels (OR = 1.36, p = 0.0444), and elevated triglyceride levels (OR = 1.36; p = 0.0008). Conclusions: Both adiposity and sleep apnea synergistically predict low levels of IGF-1 and thus could together contribute toward cardio-metabolic risk. Further work are needed to confirm whether IGF-1 levels allow grading severity and predicting response to treatments to aim at a personalized medicine for patients suffering from OSA.

Review of Ginseng Anti-Diabetic Studies

Ginseng is one of the most valuable and commonly used Chinese medicines not only in ancient China but also worldwide. Ginsenosides, also known as saponins or triterpenoids, are thought to be responsible for the beneficial effects of ginseng. In this review, we summarize recent publications on anti-diabetic studies of ginseng extracts and ginsenosides in cells, animals, and humans. It seems that the anti-diabetic effect of ginseng is positive for type 2 diabetic patients but has no significant impact on prediabetes or healthy adults. Regulation of insulin secretion, glucose uptake, anti-oxidative stress, and anti-inflammatory pathways may be the mechanisms involved with ginseng's anti-diabetic effects. Taken together, this summary provides evidence for the anti-diabetes effects of ginseng extracts and ginsenosides as well as the underlying mechanisms of their impact on diabetes.

Ruiz J, Buela-Casal G. Anxiety and Depression in Patients with Obstructive Sleep Apnoea before and after Continuous Positive Airway Pressure: The ADIPOSA Study

The prevalence and treatment response of depression and anxiety symptoms in obstructive sleep apnoea (OSA), although widely addressed in research and clinical settings, still remain unclear due to overlapping symptoms. The ADIPOSA study sought to elucidate the presence of non-overlapping symptoms of depression and anxiety in patients with moderate to severe OSA before and after continuous positive airway pressure (CPAP) treatment. Forty-eight adults aged 18-80 (68.75% men) with moderate to severe OSA were enrolled in this twelve-week longitudinal single-arm trial and completed a full-night ambulatory sleep diagnostic test and an assessment of cognitive-affective depression and anxiety symptoms using the Beck-Depression Inventory-Fast Screen (BDI-FS), the State-Trait Depression Inventory (IDER) and the State-Trait Anxiety Inventory (STAI). We found no cognitive-affective depression or anxiety symptoms of clinical relevance at baseline. The amelioration of depression and anxiety symptoms after CPAP use was only statistically significant when considering anxiety-trait (p < 0.01; d = 0.296) and euthymia (p < 0.05; d = 0.402), the distinctive component of depression. Although dysthymia or high negative affect remained unchanged, CPAP may be effective at reducing the lack of positive affect, a well-established health-protective factor. However, not until depression and anxiety disorders related to OSA are accurately measured in clinical and research settings will it be possible to obtain robust conclusions on the occurrence and amelioration of these symptoms after treatment.

Diabetes Mellitus and Chronic Obstructive Pulmonary Disease: An Overview

Chronic obstructive pulmonary disease (COPD) is a common disease with an increasing prevalence, characterised by persistent respiratory symptoms and airflow limitation. Apart from cigarette smoking, certain occupational and environmental exposures, low socioeconomic status and genetic factors may contribute to the pathogenesis of COPD. Comorbidities, e. g. diabetes mellitus (DM), can negatively affect quality of life, COPD outcomes and cardiovascular risk. The present narrative review considers the potential links between COPD and DM, such as systemic inflammation, oxidative stress, hypoxaemia and hyperglycaemia. The effects of antidiabetic drugs on lung function and COPD outcomes, as well as the possibility of common therapeutic modalities are also briefly considered. Further research is needed in this field to elucidate these relationships as well as their potential clinical implications in daily practice.

Obstructive sleep apnoea in Type 2 diabetes mellitus: increased risk for overweight as well as obese people included in a national primary care database analysis

AIMS

To determine obstructive sleep apnoea prevalence in people with Type 2 or Type 1 diabetes in a national primary care setting, stratified by BMI category, and to explore the relationship between patient characteristics and obstructive sleep apnoea.

METHODS

Using the Royal College of General Practitioners Research and Surveillance Centre database, a cross-sectional analysis was conducted. Diabetes type was identified using a seven-step algorithm and was grouped by Type 2 diabetes, Type 1 diabetes and no diabetes. The clinical characteristics of these groups were analysed, BMI-stratified obstructive sleep apnoea prevalence rates were calculated, and a multilevel logistic regression analysis was completed on the Type 2 diabetes group.

RESULTS

Analysis of 1 275 461 adult records in the Royal College of General Practitioners Research and Surveillance Centre network showed that obstructive sleep apnoea was prevalent in 0.7%. In people with Type 2 diabetes, obstructive sleep apnoea prevalence increased with each increasing BMI category, from 0.5% in those of normal weight to 9.6% in those in the highest obesity class. By comparison, obstructive sleep apnoea prevalence rates for these BMI categories in Type 1 diabetes were 0.3% and 4.3%, and in those without diabetes 1.2% and 3.9%, respectively. Obstructive sleep apnoea was more prevalent in men than women in both diabetes types. When known risk factors were adjusted for, there were increased odds ratios for obstructive sleep apnoea in people with Type 2 diabetes in the overweight and higher BMI categories.

CONCLUSIONS

Obstructive sleep apnoea was reported in people with both types of diabetes across the range of overweight categories and not simply in the highest obesity class.

Does Continuous Positive Airway Pressure Therapy in Patients with Obstructive Sleep Apnea Improves Uric Acid? A Meta-Analysis

Purpose

The efficacy of obstructive sleep apnea (OSA) therapy with continuous positive airway pressure (CPAP) on uric acid (UA) yielded conflicting results. This meta-analysis was performed to assess whether OSA treatment with CPAP could reduce UA levels.

Methods

The Web of Science, Cochrane Library, Embase, and PubMed were searched before March 2019. Information of patients, study design, and pre- and post-CPAP treatment of UA was utilized for analysis. The overall effects were analyzed via the standardized mean difference (SMD) with a 95% confidence interval (CI). Five studies were obtained and the meta-analysis was performed using Stata 12.0 and Review Manager 5.2.

Results

A total of 5 studies with 6 cohorts (2 RCT and 3 observational studies) involving 270 patients were pooled into meta-analysis. There was no change of UA levels before and after CPAP treatment in OSA patients (SMD = ‐0.20, 95% CI: -0.78 to 0.37, Z = 0.69, p = 0.49). Subgroup analysis showed that the outcomes were not affected by age of patients, gender distribution, baseline body mass index, daily duration, duration of CPAP treatment, sample size, and study design.

Conclusions

This meta-analysis revealed that CPAP treatment has no effect on UA in OSA patients. Further well-designed, large-scale randomized controlled trials are required to address this issue.

The Impact of Antidepressants on the Risk of Developing Obstructive Sleep Apnea in Posttraumatic Stress Disorder: A Nationwide Cohort Study in Taiwan

STUDY OBJECTIVES

The association between posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) has been reported inconsistently, and the association between antidepressant use and the risk of developing OSA in patients with PTSD has not been previously studied. Therefore, we used the Longitudinal National Health Insurance Database (LHID) to investigate the impact of PTSD and antidepressant use on the risk of OSA development.

METHODS

Identified from the LHID, 2,316 individuals aged ≥ 18 years with PTSD, but with no history of OSA, and 23,160 control individuals matched for age, sex, obesity and index date were enrolled between 2000 and 2015 and followed up until the end of 2015 to identify the development of OSA. A two-tailed Bonferroni-corrected P < .00038 (.05/13) was considered statistically significant as we examined 13 antidepressants.

RESULTS

Individuals with PTSD had increased risk of developing OSA (adjusted hazard ratio 4.672, 95% confidence interval 2.246-9.787, P < .001) after adjusting for demographic data, medical comorbidities, and medication. Treatment with antidepressants was not significantly associated with an increased risk of developing OSA compared to no antidepressant treatment.

CONCLUSIONS

Asian patients with PTSD had increased risk of developing OSA, and treatment with antidepressants did not play a key role in increasing the risk of OSA development. Further studies are required to investigate the underlying mechanisms of PTSD and the roles of antidepressants on the risk of developing OSA.

CITATION

Lin C-E, Chung C-H, Chen L-F, Chien W-C, Chou P-H. The impact of antidepressants on the risk of developing obstructive sleep apnea in posttraumatic stress disorder: a nationwide cohort study in taiwan. J Clin Sleep Med. 2019;15(9):1233-1241.

Cardiometabolic correlates of sleep-disordered breathing in renal transplant children

Sleep-disordered breathing, a prevalent condition among adult renal transplant (RTx) recipients, has become an established independent risk factor of MetS, and furthermore, it might contribute to increased CV risk. Despite the proven correlations in adults, there is a lack of evidence for its significance in the pediatric RTx population. In this study, we aimed at assessing the prevalence and the clinical correlates of SDB in RTx children. Data of 13 patients (age [mean ± SD]: 14.2 ± 2.7 years) were analyzed. SDB was evaluated by PSG, as severity score OAHI was applied. Carbohydrate metabolism was characterized by OGTT, whereas CV status was studied by ABPM. Three composite end-points were calculated as sum of z-scores: daytime systolic and diastolic BP; nighttime systolic and diastolic BP; and glucose and insulin levels at 120 minutes. Eight patients (61.5%) were diagnosed with SDB of whom five patients (38.5%) had moderate or severe SDB. In linear regression analysis, OAHI during REM was associated with the CV variables (daytime BP P = 0.032, ß = 0.748; nighttime BP P = 0.041, ß = 0.715), and the correlations remained significant after adjustments for BMI. However, we did not confirm a significant association with the metabolic variables. The prevalence of SDB was high, and its severity during REM was a predictor of the BP suggesting that RTx children with SDB might be at risk of developing CV complications, especially HTN similarly to adults.

A new sensitive and accurate model to predict moderate to severe obstructive sleep apnea in patients with obesity

Obstructive sleep apnea (OSA) has a high prevalence in patients with obesity. Only patients with clinical symptoms of OSA are admitted to polysomnography; however, many patients with OSA are asymptomatic. We aimed to create and validate a population-based risk score that predicts the severity of OSA in patients with obesity.We here report the cross-sectional analysis at baseline of an ongoing study investigating the long-term effect of bariatric surgery on OSA. One-hundred sixty-one patients of the Obesity Center of the Catholic University Hospital in Rome, Italy were included in the study. The patients underwent overnight cardiorespiratory monitoring, blood chemistry analyses, hepatic ultrasound, and anthropometric measurements. The patients were divided into 2 groups according OSA severity assessed by the apnea-hypopnea index (AHI): AHI < 15 = no or mild and AHI ≥ 15 moderate to severe OSA. A statistical prediction model was created and validated. C statistics was used to evaluate the discrimination performance of the model.The prevalence of OSA was 96.3% with 74.5% of the subjects having moderate/severe OSA. Sex, body mass index, diabetes, and age were included in the final prediction model that had excellent discrimination ability (C statistics equals to 83%). An OSA risk chart score for clinical use was created.Patients with severe obesity are at a very high risk for moderate or severe OSA in particular if they are men, older, more obese, and/or with type 2 diabetes. The OSA risk chart can be useful for general practitioners and patients as well as for bariatric surgeons to select patients with high risk of moderate to severe OSA for further polysomnography.

Obstructive Sleep Apnea Is Associated With Altered Glycemic Patterns in Pregnant Women With Obesity

OBJECTIVE

Often unrecognized, obstructive sleep apnea (OSA) worsens over pregnancy and is associated with poorer perinatal outcomes. The association between OSA in late pregnancy and metabolic biomarkers remains poorly understood. We tested the hypothesis that OSA in pregnant women with obesity is positively correlated with 24-hour patterns of glycemia and IR despite controlling for diet.

DESIGN

Pregnant women (32 to 34 weeks' gestation; body mass index, 30 to 40 kg/m2) wore a continuous glucose monitor for 3 days. OSA was measured in-home by WatchPAT 200™ [apnea hypopnea index (AHI), oxygen desaturation index (ODI; number per hour)]. Fasting blood was collected followed by a 2-hour, 75-g, oral glucose tolerance test to measure IR. Association between AHI and 24-hour glucose area under the curve (AUC) was the powered outcome.

RESULTS

Of 18 women (29.4 ± 1.4 years of age [mean ± SEM]), 12 (67%) had an AHI ≥5 (mild OSA). AHI and ODI were correlated with 24-hour glucose AUC (r = 0.50 to 0.54; P ≤ 0.03) and mean 24-hour glucose (r = 0.55 to 0.59; P ≤ 0.02). AHI and ODI were correlated with estimated hepatic IR (r = 0.59 to 0.74; P < 0.01), fasting free fatty acids (fFFAs; r = 0.53 to 0.56; P < 0.05), and waking cortisol (r = 0.49 to 0.64; P < 0.05).

CONCLUSIONS

Mild OSA is common in pregnant women with obesity and correlated with increased glycemic profiles, fFFAs, and estimates of hepatic IR. OSA is a potentially treatable target to optimize maternal glycemia and metabolism, fetal fuel supply, and pregnancy outcomes.

Combination therapy with mandibular advancement and expiratory positive airway pressure valves reduces obstructive sleep apnea severity

Study Objectives

Mandibular advancement splint (MAS) therapy is a well-tolerated alternative to continuous positive airway pressure for obstructive sleep apnea (OSA). Other therapies, including nasal expiratory positive airway pressure (EPAP) valves, can also reduce OSA severity. However, >50% of patients have an incomplete or no therapeutic response with either therapy alone and thus remain at risk of adverse health outcomes. Combining these therapies may yield greater efficacy to provide a therapeutic solution for many incomplete/nonresponders to MAS therapy. Thus, this study evaluated the efficacy of combination therapy with MAS plus EPAP in incomplete/nonresponders to MAS alone.

Methods

Twenty-two people with OSA (apnea–hypopnea index [AHI] = 22 [13, 42] events/hr), who were incomplete/nonresponders (residual AHI > 5 events/hr) on an initial split-night polysomnography with a novel MAS device containing an oral airway, completed an additional split-night polysomnography with MAS + oral EPAP valve and MAS + oral and nasal EPAP valves (order randomized).

Results

Compared with MAS alone, MAS + oral EPAP significantly reduced the median total AHI, with further reductions with the MAS + oral/nasal EPAP combination (15 [10, 34] vs. 10 [7, 21] vs. 7 [3, 13] events/hr, p < 0.01). Larger reductions occurred in supine nonrapid eye movement AHI with MAS + oral/nasal EPAP combination therapy (ΔAHI = 23 events/hr, p < 0.01). OSA resolved (AHI < 5 events/hr) with MAS + oral/nasal EPAP in nine individuals and 13 had ≥50% reduction in AHI from no MAS. However, sleep efficiency was lower with MAS + oral/nasal EPAP versus MAS alone or MAS + oral EPAP (78 ± 19 vs. 87 ± 10 and 88 ± 10% respectively, p < 0.05).

Conclusions

Combination therapy with a novel MAS device and simple oral or oro-nasal EPAP valves reduces OSA severity to therapeutic levels for a substantial proportion of incomplete/nonresponders to MAS therapy alone.

Clinical Trials

Name: Targeted combination therapy: Physiological mechanistic studies to inform treatment for obstructive sleep apnea (OSA)

URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372279 Registration: ACTRN12617000492358 (Part C)

Sleep-Disordered Breathing and Idiopathic Normal-Pressure Hydrocephalus: Recent Pathophysiological Advances

Purpose of Review

Idiopathic normal-pressure hydrocephalus (iNPH) is characterized clinically by ventriculomegaly, abnormal gait, falls, incontinence, and cognitive decline. This article reviews recent advances in the pathophysiology of iNPH concerning sleep-disordered breathing (SDB) and glymphatic circulation during deep sleep.

Recent Findings

The authors found iNPH frequently associated with obstructive sleep apnea (OSA). A critical factor in iNPH is intracranial venous hypertension delaying drainage of cerebrospinal fluid (CSF) into the cerebral venous sinuses. CSF-venous blood circulates in the jugular veins and finally drains into the heart. During SDB, repeated reflex attempts to breathe induce strong respiratory efforts against a closed glottis thereby increasing the negative intrathoracic pressure. This causes atrial distortion and decreases venous return to the heart resulting in retrograde intracranial venous hypertension. Additionally, repeated awakenings from OSA impede sleep-associated circulation of interstitial CSF into the glymphatic circulation contributing to hydrocephalus.

Summary

Sleep has become a critical element in the cognitive changes of aging including iNPH.

The Interlinked Rising Epidemic of Insufficient Sleep and Diabetes Mellitus

For healthy existence, humans need to spend one-third of their time sleeping. Any qualitative or quantitative disturbances in sleep would result in an increased prevalence of obesity, metabolic disorders, diabetes, cardiovascular diseases, and hypertension. The paper aims to highlight the growing global problem of insufficient sleep and its significant impact on the rising incidence of diabetes mellitus. An extensive literature search was done in all major databases for "insufficient sleep" and "Diabetes Mellitus" for this review. Shorter (<6 h) and longer (>9 h) durations of sleep have been adversely related to insulin resistance. Though the relation between insufficient sleep and diabetes mellitus is more or less understood, little is known about how oversleeping or hypersomnia (10⁻12 h) increases the risk of diabetes. The relationship between sleep disturbances and diabetes is dual-sided, as chronic sleep disturbances would elevate the risk of developing insulin resistance, while diabetes would worsen the quality of sleep. Both the qualitative and quantitative disturbances in sleep significantly increase the risk of developing diabetes, which is supported by numerous community-based and hospital-based epidemiological studies discussed in this review. Obstructive sleep apnea is one of the most common sleep disorders and is characterized by chronic intermittent hypoxia and increased sympathetic activity, thus leading to a higher prevalence of diabetes. Sleep therapy may serve as a low-cost method for fighting against the rising epidemic of diabetes.

Obstructive sleep apnea and comorbidities: a dangerous liaison

Obstructive sleep apnea (OSA) is a highly prevalent disease, and is traditionally associated with increased cardiovascular risk. The role of comorbidities in OSA patients has emerged recently, and new conditions significantly associated with OSA are increasingly reported. A high comorbidity burden worsens prognosis, but some data suggest that CPAP might be protective especially in patients with comorbidities. Aim of this narrative review is to provide an update on recent studies, with special attention to cardiovascular and cerebrovascular comorbidities, the metabolic syndrome and type 2 diabetes, asthma, COPD and cancer. Better phenotypic characterization of OSA patients, including comorbidities, will help to provide better individualized care. The unsatisfactory adherence to CPAP in patients without daytime sleepiness should prompt clinicians to examine the overall risk profile of each patient in order to identify subjects at high risk for worse prognosis and provide the optimal treatment not only for OSA, but also for comorbidities.

Elevated obstructive sleep apnoea risk score is associated with poor healing of diabetic foot ulcers: a prospective cohort study

AIMS

To assess the prevalence of risk factors for obstructive sleep apnoea in people with diabetic foot ulcers and to determine whether this risk predicts diabetic foot ulcer healing.

METHODS

We studied 94 consecutive people (69% men) with diabetic foot ulcers (Type 2 diabetes, n=66, Type 1 diabetes, n=28) attending a university hospital foot unit. All participants were screened for obstructive sleep apnoea using the STOP-BANG questionnaire, with a score ≥4 identifying high risk of obstructive sleep apnoea. The primary outcome was poor diabetic foot ulcer healing, defined as diabetic foot ulcer recurrence (diabetic foot ulcers which healed and re-ulcerated in same anatomical position) and/or diabetic foot ulcer persistence (no evidence of healing on clinical examination). All participants were evaluated at 12 months.

RESULTS

Of the 94 participants, 60 (64%) had a STOP-BANG score ≥4. Over 12 months, 27 participants with a score ≥4 had poor diabetic foot ulcer healing as compared to seven with a score <4 (45% vs 20.5%; P=0.025). A STOP-BANG score ≥4 significantly increased the relative risk of poor healing more than twofold, independently of other risk factors in multivariable analyses.

CONCLUSIONS

There is a high prevalence of features and risk of obstructive sleep apnoea in people with diabetic foot ulcers. A STOP-BANG score ≥4 predicts poor diabetic foot ulcer healing. Obstructive sleep apnoea may be a potential, modifiable risk factor/treatment target to improve diabetic foot ulcer outcomes.

Sleep, Health, and Metabolism in Midlife Women and Menopause: Food for Thought

Sleep and metabolism are essential components of health. Metabolic health depends largely on individual's lifestyle. Disturbances in sleep health, such as changes in sleep patterns that are associated with menopause/reproductive aging and chronologic aging, may have metabolic health consequences. Sleep restriction and age-related changes in sleep and circadian rhythms may influence changes in appetite and reproductive hormones, energy expenditure, and body adiposity. In this article, the authors describe how menopause-related sleep disturbance may affect eating behavior patterns, immunometabolism, immunometabolic dysfunction, and associations between sleep and metabolic outcomes.

Idiopathic normal-pressure hydrocephalus and obstructive sleep apnea are frequently associated: A prospective cohort study

BACKGROUND

Idiopathic normal-pressure hydrocephalus (iNPH) is defined by ventriculomegaly, cognitive decline, urinary incontinence and gait problems. Vascular risk factors (VRF) are associated with iNPH but obstructive sleep apnea (OSA) -a well-known independent VRF- is seldom mentioned.

METHODS

We investigated the presence of sleep-disordered breathing in a prospective cohort of 31 consecutive unselected patients with iNPH using sleep questionnaires and nocturnal polysomnography (PSG).

RESULTS

We found OSA in 90·3% (28/31) patients with iNPH; all had undiagnosed sleep abnormalities (snoring, awakenings, nocturia) and excessive daytime sleepiness (Epworth scale = 11·4 ± 6·4; normal <8). Nocturnal PSG showed moderate-to-severe OSA in 25 patients (80·6%) with mean apnea-hypopnea index (AHI) 31·6 ± 23·6/h; mean respiratory distress index (RDI) 34·5/h; and, mean SaO₂ desaturation at nadir, 82·2 ± 7·5%. The observed OSA prevalence is statistically significant: 90·3%, 95%CI 74·3-97·5; p = 0·000007. Other VRF included overweight body-mass index (BMI >25- < 30 kg/m²) in 59%, hyperhomocysteinemia 57%, hypertension 43%, hyperlipidemia 39%, diabetes 32%, smoking 21%, coronary disease 18%, and previous stroke 10%.

CONCLUSION

Abnormal sleep breathing is frequently associated with iNPH. Validation in larger series is required but we suggest including sleep evaluation in patients suspected of iNPH.

A Population-Based Study of the Bidirectional Association Between Obstructive Sleep Apnea and Type 2 Diabetes in Three Prospective U.S. Cohorts

OBJECTIVE

Multiple lines of evidence support a complex relationship between obstructive sleep apnea (OSA) and diabetes. However, no population-based study has evaluated the potential bidirectional association between these two highly prevalent disorders.

RESEARCH DESIGN AND METHODS

We followed 146,519 participants from the Nurses' Health Study (NHS; 2002-2012), Nurses' Health Study II (NHSII; 1995-2013), and Health Professionals Follow-up Study (HPFS; 1996-2012) who were free of diabetes, cardiovascular disease, and cancer at baseline. Cox proportional hazards models were used to estimate hazard ratios (HRs) for developing diabetes according to OSA status. In parallel, we used similar approaches to estimate risk of developing OSA according to diabetes status among 151,194 participants free of OSA, cardiovascular disease, and cancer at baseline. In all three cohorts, diagnoses of diabetes and OSA were identified by validated self-reports.

RESULTS

Similar results were observed across the three cohorts. In the pooled analysis, 9,029 incident diabetes cases were identified during follow-up. After accounting for potential confounders, the HR (95% CI) for diabetes was 2.06 (1.86, 2.28) comparing those with versus without OSA. The association was attenuated but remained statistically significant after further adjusting for waist circumference and BMI (HR 1.37 [95% CI 1.24, 1.53]), with the highest diabetes risk observed for OSA concomitant with sleepiness (1.78 [1.13, 2.82]). In the second analysis, we documented 9,364 incident OSA cases during follow-up. Compared with those without diabetes, the multivariable HR (95% CI) for OSA was 1.53 (1.32, 1.77) in individuals with diabetes. Adjustment for BMI and waist circumference attenuated the association (1.08 [1.00, 1.16]); however, an increased risk was observed among those with diabetes who used insulin compared with those without diabetes (1.43 [1.11, 1.83]), particularly among women (1.60 [1.34, 1.89]).

CONCLUSIONS

OSA is independently associated with an increased risk of diabetes, whereas insulin-treated diabetes is independently associated with a higher risk of OSA, particularly in women. Clinical awareness of this bidirectional association may improve prevention and treatment of both diseases. Future research aimed at elucidating the mechanisms that underlie each association may identify novel intervention targets.

Association between serum level of advanced glycation end products and obstructive sleep apnea-hypopnea syndrome: a meta-analysis

Objective

This meta-analysis was performed to assess the difference in the serum level of advanced glycation end products (AGEs) between patients with obstructive sleep apnea–hypopnea syndrome (OSAHS) and controls.

Methods

A systematic literature search was performed using PubMed, Elsevier, SCI, Wanfang, Weipu, and China National Knowledge Internet. Eligible studies that reported the serum AGE level in patients with OSAHS were identified by two reviewers. Review Manager version 5.2 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) and R version 3.10 (www.r-project.org) were employed for data synthesis.

Results

Five studies involving 670 subjects were identified. The meta-analysis showed that the mean serum AGE level in the OSAHS group was 0.98 mmol/L higher than those in the control group (95% confidence interval, 0.69–1.27).

Conclusions

This meta-analysis showed that the serum AGE level was elevated in patients with OSAHS. This finding suggests that AGEs may play an important role in insulin resistance in OSAHS and serve as a biomarker for patients with OSAHS with a high risk of type 2 diabetes mellitus.

Maternal Weight, Snoring, and Hypertension: Potential Pathways of Associations

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are linked to excessive maternal weight and frequent snoring. However, pathways between maternal excessive weight, pregnancy-onset snoring, and HDP are only partially estimated. We examined and quantified the total and direct associations between excessive maternal weight and incident HDP and their indirect pathway through pregnancy-onset snoring.

METHODS

Third trimester pregnant women enrolled from prenatal clinics of a large tertiary medical center. Sleep data were collected through a questionnaire. Demographic and pregnancy information and first trimester maternal weight were abstracted from medical charts. After exclusion of women with prepregnancy hypertension and/or chronic snoring, causal mediation analysis was used to estimate the total and direct association between maternal weight and incident HDP and their indirect association through pregnancy-onset snoring. The proportion of the mediated association through pregnancy-onset snoring from the total association of maternal weight and HDP was also quantified.

RESULTS

After excluding those with chronic hypertension and/or snoring, the final sample included 1,333 pregnant women. In adjusted analysis, excessive maternal weight was directly associated with incident HDP; odds ratio (OR) = 1.87 (95% confidence interval (CI) 1.30, 2.70). Pregnancy-onset snoring significantly mediated the association between maternal weight and incident HDP; OR = 1.08 (95% CI 1.01, 1.17). The mediated pathway accounted for 15% of the total association between maternal weight and incident HDP.

CONCLUSIONS

Pregnancy-onset snoring mediates the association between maternal weight and incident HDP in women without prepregnancy snoring or hypertension. These findings demonstrate the relative contributions of excessive maternal weight and pregnancy-onset snoring to incident HDP.

Sleep disturbances in diabetic peripheral neuropathy patients: a clinical and polysomnographic study

Background

Disordered sleep breathing is a common complication of diabetic peripheral neuropathy (DPN) manifested by excessive daytime sleepiness, morning headache, morning dizziness, cognitive decline, and mood changes.

Methods

This study was performed on 30 non-obese type 2 diabetic patients; 20 with clinically evident DPN and 10 without. Ten age-, sex-, and body mass index-matched healthy control subjects were also included. Patients and control were subjected to history taking, neurological examination, glycated hemoglobin, and clinical assessment of the sensori-motor manifestations by the neuropathy symptom score and neuropathy disability score. The autonomic nervous system was evaluated clinically by the systolic blood pressure response to standing and heart rate response to each of standing, Valsalva, and deep breath. Finally, sleep was assessed by one-night polysomnogram (PSG) followed by multiple sleep latency test in the next day.

Results

The study showed significant increase in sleep apnea syndromes in diabetic peripheral neuropathy patients compared to diabetic neuropathy free patients and healthy control (p < 0.0001). The sleep apnea was mainly obstructive and to a little extent mixed (obstructive/central) sleep apnea. The severity of sleep PSG abnormalities was positively correlated with the severities of sensory, motor, and autonomic manifestations.

Conclusions

Non-obese type 2 diabetic patients complicated by peripheral neuropathy especially those having dysautonomia are at increased risk of developing sleep disordered breathing resulting in their excessive daytime sleepiness, decreased productivity, and poor glycemic control.

Disturbed sleep and diabetes: A potential nexus of dementia risk

Type 2 diabetes (T2D) and sleep disturbance (e.g., insomnia, sleep-disordered breathing) are prevalent conditions among older adults that are associated with cognitive decline and dementia, including Alzheimer's disease (AD). Importantly, disturbed sleep is associated with alterations in insulin sensitivity and glucose metabolism, and may increase the risk of T2D, and T2D-related complications (e.g., pain, nocturia) can negatively affect sleep. Despite these associations, little is known about how interactions between T2D and sleep disturbance might alter cognitive trajectories or the pathological changes that underlie dementia. Here, we review links among T2D, sleep disturbance, cognitive decline and dementia-including preclinical and clinical AD-and identify gaps in the literature, that if addressed, could have significant implications for the prevention of poor cognitive outcomes.

A Case of Concomitant Obstructive Sleep Apnea and Non-Alcoholic Steatohepatitis Treated With CPAP Therapy

Obstructive sleep apnea syndrome is a disorder of sleep breathing that is a result of recurrent and intermittent hypoxia during sleep induced by the repeated partial or complete collapse of the upper airway, eventually causing chronic intermittent hypoxia. Non-alcoholic fatty liver disease is divided into non-alcoholic fatty liver and non-alcoholic steatohepatitis. Animal and human studies showed that obesity is associated with chronic liver hypoxia, even in the presence of systemic normoxia causing inflammation and release of cytokines. A "two-hit" model has been proposed. The first hit is characterized by insulin resistance and excess hepatic lipid accumulation secondary to abnormal fatty acid metabolism. Oxidative stress and inflammation are thought to comprise the second hit. Gold standard for the diagnosis of non-alcoholic steatohepatitis is a liver biopsy. Many clinical scores and non-invasive tools are used for the diagnosis of non-alcoholic steatohepatitis. Conservative management with lifestyle modifications including diet, exercise and weight loss remains the therapy of choice today. We present a case report of a 39-year-old man who was diagnosed with concomitant non-alcoholic steatohepatitis and severe obstructive sleep apnea. He was started treatment with continuous positive airway pressure and demonstrated excellent adherence to therapy for 6 years, with concomitant obstructive sleep apnea and non-alcoholic steatohepatitis which reversed with prolonged optimal continuous positive airway pressure therapy. Physical examination remained unremarkable except for morbid obesity. His abdominal girth, as well as body mass index, remained unchanged. After 6 years of optimal continuous positive airway pressure therapy, liver enzymes and relevant lipid panel normalized, suggesting reversal of non-alcoholic steatohepatitis.

Relationship between obstructive sleep apnoea syndrome and essential hypertension: a dose-response meta-analysis

OBJECTIVE

The objective of this study was to summarize the evidence regarding the relationship between obstructive sleep apnoea syndrome (OSAS) and the risk of essential hypertension.

METHODS

The study was a dose-response meta-analysis of observational studies. The PubMed, Embase, CNKI, VIP and CBM databases were searched to collect relative studies examining the relationship between OSAS and the risk of essential hypertension. Studies were retrieved from database establishment through September 2016, and new literature published between September 2016 and May 2017 was later supplemented. Linear and non-linear dose-response models were used to assess the relationship between apnoea-hypopnea index (AHI), which was used to reflect the severity of OSAS, and the risk of essential hypertension. Stata 13.0 was used for the meta-analysis.

RESULTS

Six prospective cohort studies and one case-control study were included, for a total sample size of 6098. The dose-response meta-analysis showed that a high AHI significantly increased the risk of essential hypertension compared with a low AHI (odds ratio (OR) = 1.77, 95% confidence interval (CI) (1.30, 2.41), p = 0.001). The linear dose-response meta-analysis showed that the risk of essential hypertension increased by 17% for every 10 events/h increase in the AHI (OR = 1.17, 95% CI (1.07, 1.27), p = 0.001), and the results of the non-linear dose-response meta-analysis showed that the risk of essential hypertension increased with increasing AHI value.

CONCLUSION

A potential dose-response relationship exists between the severity of OSAS and the risk of essential hypertension. This relationship should be considered when developing prevention measures for essential hypertension.

Sex differences in the associations of obstructive sleep apnoea with epidemiological factors

Despite the well-known male predominance in the prevalence of obstructive sleep apnoea (OSA), sex differences in the associations between OSA and a comprehensive range of epidemiological factors remain less clear.We examined the prevalence of self-reported OSA in 143 326 females (age 48-93 years) from the Nurses' Health Study (NHS) and NHS-II and 22 896 males from the Health Professionals Follow-up Study (age 65-101 years) in 2012-2013. Multivariable logistic regression was used to estimate the sex-specific prevalence odds ratios (pOR) and 95% confidence intervals of OSA by demographic, anthropometric, lifestyle and comorbidity factors.The overall prevalence of self-reported OSA was 6.4% in females and 13.8% in males. After mutual adjustment, the associations of OSA with physical inactivity, hypertension and daytime sleepiness were stronger in females, whereas the associations with waist circumference and witnessed apnoea were stronger in males (p-heterogeneity <0.01). There were qualitative sex differences in the associations with age (pOR per 5-year increment in females 0.95, 95% CI 0.94-0.96, and males 1.04, 1.01-1.08; p-heterogeneity <0.0001) and marital status (pOR for married versus other in females 0.85, 95% CI 0.81-0.89, and males 1.11, 0.99-1.25; p-heterogeneity <0.0001).Substantial sex differences exist in the associations with various factors, suggesting sex-specific mechanisms in OSA.

Sleep deprivation disrupts the lacrimal system and induces dry eye disease

Sleep deficiency is a common public health problem associated with many diseases, such as obesity and cardiovascular disease. In this study, we established a sleep deprivation (SD) mouse model using a 'stick over water' method and observed the effect of sleep deficiency on ocular surface health. We found that SD decreased aqueous tear secretion; increased corneal epithelial cell defects, corneal sensitivity, and apoptosis; and induced squamous metaplasia of the corneal epithelium. These pathological changes mimic the typical features of dry eye. However, there was no obvious corneal inflammation and conjunctival goblet cell change after SD for 10 days. Meanwhile, lacrimal gland hypertrophy along with abnormal lipid metabolites, secretory proteins and free amino-acid profiles became apparent as the SD duration increased. Furthermore, the ocular surface changes induced by SD for 10 days were largely reversed after 14 days of rest. We conclude that SD compromises lacrimal system function and induces dry eye. These findings will benefit the clinical diagnosis and treatment of sleep-disorder-related ocular surface diseases.