Obstructive sleep apnoea syndrome

Multimodal data integration for enhanced longitudinal prediction for cardiac and cerebrovascular events following initial diagnosis of obstructive sleep apnea syndrome

Background

Obstructive sleep apnea syndrome (OSAS), a prevalent condition, often coexists with intricate metabolic issues and is frequently associated with negative cardiovascular outcomes. We developed a longitudinal prediction model integrating multimodal data for cardiovascular risk stratification of patients with an initial diagnosis of OSAS.

Methods

We reviewed the data of patients with new-onset OSAS who underwent diagnostic polysomnography between 2018-19. Patients were treated using standard treatment regimens according to clinical practice guidelines.

Results

Over a median follow-up of 32 months, 98/729 participants (13.4%) experienced our composite outcome. At a ratio of 7:3, cases were randomly divided into development (n = 510) and validation (n = 219) cohorts. A prediction nomogram was created using six clinical factors - sex, age, diabetes mellitus, history of coronary artery disease, triglyceride-glucose index, and apnea-hypopnea index. The prediction nomogram showed excellent discriminatory power, based on Harrell's C-index values of 0.826 (95% confidence interval (CI) = 0.779-0.873) for the development cohort and 0.877 (95% CI = 0.824-0.93) for the validation cohort. Moreover, comparing the predicted and observed major adverse cardiac and cerebrovascular events in both development and validation cohorts indicated that the prediction nomogram was well-calibrated. Decision curve analysis demonstrated the good clinical applicability of the prediction nomogram.

Conclusions

Our findings demonstrated the construction of an innovative visualisation tool that utilises various types of data to predict poor outcomes in Chinese patients diagnosed with OSAS, providing accurate and personalised therapy.

Registration

Chinese Clinical Trial Registry ChiCTR2300075727.

Evaluation of bi-directional causal association between obstructive sleep apnoea syndrome and diabetic microangiopathy: a Mendelian randomization study

Background

The relationship between obstructive sleep apnea syndrome (OSAS) and diabetic microangiopathy remains controversial.

Objective

This study aimed to use bidirectional two-sample Mendelian Randomization (MR) to assess the causal relationship between OSAS and diabetic microangiopathy.

Methods

First, we used the Linkage Disequilibrium Score Regression(LDSC) analysis to assess the genetic correlation. Then, the bidirectional two-sample MR study was conducted in two stages: OSAS and lung function-related indicators (forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)) were investigated as exposures, with diabetic microangiopathy as the outcome in the first stage, and genetic tools were used as proxy variables for OSAS and lung function-related measures in the second step. Genome-wide association study data came from the open GWAS database. We used Inverse-Variance Weighted (IVW), MR-Egger regression, Weighted median, Simple mode, and Weighted mode for effect estimation and pleiotropy testing. We also performed sensitivity analyses to test the robustness of the results. Furthermore, we performed multivariate and mediation MR analyses.

Results

In the LDSC analysis, We found a genetic correlation between OSAS, FVC, FEV 1, and diabetic microangiopathy. In the MR analysis, based on IVW analysis, genetically predicted OSAS was positively correlated with the incidence of diabetic retinopathy (DR), diabetic kidney disease (DKD), and diabetic neuropathy (DN). In the subgroup analysis of DR, there was a significant causal relationship between OSAS and background diabetic retinopathy (BDR) and proliferative diabetic retinopathy (PDR). The reverse MR did not show a correlation between the incidence of diabetic microangiopathy and OSAS. Reduced FVC had a potential causal relationship with increased incidence of DR and PDR. Reduced FEV1 had a potential causal relationship with the increased incidence of BDR, PDR, and DKD. Multivariate MR analysis showed that the association between OSAS and diabetic microangiopathy remained significant after adjusting for confounding factors. However, we did not find the significant mediating factors.

Conclusion

Our results suggest that OSAS may be a cause of the development of diabetic microangiopathy, and OSAS may also be associated with a high risk of diabetic microangiopathy, providing a reference for a better understanding of the prevention of diabetic microangiopathy.

Association Between Sleep Apnea Treatment and Health Care Resource Use in Patients With Atrial Fibrillation

BACKGROUND

Obstructive sleep apnea (OSA) contributes to the generation, recurrence, and perpetuation of atrial fibrillation, and it is associated with worse outcomes. Little is known about the economic impact of OSA therapy in atrial fibrillation. This retrospective cohort study assessed the impact of positive airway pressure (PAP) therapy adherence on health care resource use and costs in patients with OSA and atrial fibrillation.

METHODS AND RESULTS

Insurance claims data for ≥1 year before sleep testing and 2 years after device setup were linked with objective PAP therapy use data. PAP adherence was defined from an extension of the US Medicare 90-day definition. Inverse probability of treatment weighting was used to create covariate-balanced PAP adherence groups to mitigate confounding. Of 5867 patients (32% women; mean age, 62.7 years), 41% were adherent, 38% were intermediate, and 21% were nonadherent. Mean±SD number of all-cause emergency department visits (0.61±1.21 versus 0.77±1.55 [P=0.023] versus 0.95±1.90 [P<0.001]), all-cause hospitalizations (0.19±0.69 versus 0.24±0.72 [P=0.002] versus 0.34±1.16 [P<0.001]), and cardiac-related hospitalizations (0.06±0.26 versus 0.09±0.41 [P=0.023] versus 0.10±0.44 [P=0.004]) were significantly lower in adherent versus intermediate and nonadherent patients, as were all-cause inpatient costs ($2200±$8054 versus $3274±$12 065 [P=0.002] versus $4483±$16 499 [P<0.001]). All-cause emergency department costs were significantly lower in adherent and intermediate versus nonadherent patients ($499±$1229 and $563±$1292 versus $691±$1652 [P<0.001 and P=0.002], respectively).

CONCLUSIONS

These data suggest clinical and economic benefits of PAP therapy in patients with concomitant OSA and atrial fibrillation. This supports the value of diagnosing and managing OSA and highlights the need for strategies to enhance PAP adherence in this population.

Obstructive Sleep Apnea in Pregnancy: A Comprehensive Review of Maternal and Fetal Implications

Obstructive sleep apnea (OSA) is a prevalent yet underdiagnosed condition in pregnancy, associated with various maternal and fetal complications. This review synthesizes the current evidence on the epidemiology, pathophysiology, and neurological consequences of OSA in pregnancy, along with the potential management strategies. Articles were sourced from the PubMed, EMBASE, and Cochrane databases until 2023. Our comprehensive review highlights that the incidence of OSA increases during pregnancy due to physiological changes such as weight gain and hormonal fluctuations. OSA in pregnancy is linked with gestational hypertension, pre-eclampsia, gestational diabetes, and potential adverse fetal outcomes such as intrauterine growth restriction and preterm birth. Continuous positive airway pressure (CPAP) therapy remains the most effective management strategy for pregnant women with OSA. However, adherence to CPAP therapy is often suboptimal. This comprehensive review underscores the importance of the early recognition, timely diagnosis, and effective management of OSA in pregnancy to improve both maternal and fetal outcomes. Future research should focus on enhancing screening strategies and improving adherence to CPAP therapy in this population.

The Future of Telemedicine for Obstructive Sleep Apnea Treatment: A Narrative Review

Obstructive sleep apnea is a common type of sleep-disordered breathing associated with multiple comorbidities. Nearly a billion people are estimated to have obstructive sleep apnea, which carries a substantial economic burden, but under-diagnosis is still a problem. Continuous positive airway pressure (CPAP) is the first-line treatment for OSAS. Telemedicine-based interventions (TM) have been evaluated to improve access to diagnosis, increase CPAP adherence, and contribute to easing the follow-up process, allowing healthcare facilities to provide patient-centered care. This narrative review summarizes the evidence available regarding the potential future of telemedicine in the management pathway of OSA. The potential of home sleep studies to improve OSA diagnosis and the importance of remote monitoring for tracking treatment adherence and failure and to contribute to developing patient engagement tools will be presented. Further studies are needed to explore the impact of shifting from teleconsultations to collaborative care models where patients are placed at the center of their care.

Three-Dimensional Comparative Changes in the Pharyngeal Airway of Patients with Cleft after Two-Jaw Orthognathic Surgery

BACKGROUND

The present study evaluated the three-dimensional changes of the pharyngeal airway after orthognathic surgery (OGS) in patients with unilateral and bilateral clefts, and in unilateral cleft patients with and without pharyngeal flap (PF).

METHODS

Forty-five patients with unilateral or bilateral clefts undergoing OGS were enrolled. Cone-beam computed tomographic images were obtained before and after OGS. We measured the pharyngeal airway volumes, minimal cross-sectional area, and the horizontal displacement of facial landmarks.

RESULTS

The patients with bilateral cleft exhibited smaller initial velopharyngeal volume (unilateral, 8623 mm 3 ; bilateral, 7781 mm 3 ; P = 0.211), whereas the velopharyngeal volume increased significantly with a median of 744 mm 3 after OGS ( P = 0.031). The median horizontal displacement of A point was 2.9 and 2.6 mm among the patients with unilateral and bilateral clefts, respectively ( P = 0.276), and the median horizontal displacement of B point was -2.9 and -3.3 mm among patients with unilateral and bilateral clefts, respectively ( P = 0.618). The unilateral cleft patients with PF exhibited lower initial velopharyngeal volume (patients with a history of PF surgery, 7582 mm 3 ; patients without a history of PF surgery, 8756 mm 3 ; P = 0.129) and a lower increase in velopharyngeal volume (patients with a history of PF surgery, 437 mm 3 ; patients without a history of PF surgery, 627 mm 3 ; P = 0.739) after OGS.

CONCLUSIONS

Midface hypoplasia and the decrease in the velopharyngeal volume were more prominent among the bilateral cleft patients and the unilateral cleft patients with PF. After OGS, the velopharyngeal volume increased considerably among the bilateral cleft patients, but no considerable differences were noted among the unilateral cleft patients with PF.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Mandibular Jaw Movement Automated Analysis for Oral Appliance Monitoring in Obstructive Sleep Apnea: A Prospective Cohort Study

Rationale: Oral appliances are second-line treatments after continuous positive airway pressure for obstructive sleep apnea (OSA) management. However, the need for oral appliance titration limits their use as a result of monitoring challenges to assess the treatment effect on OSA. Objectives: To assess the validity of mandibular jaw movement (MJM) automated analysis compared with polysomnography (PSG) and polygraphy (PG) in evaluating the effect of oral appliance treatment and the effectiveness of MJM monitoring for oral appliance titration at home in patients with OSA. Methods: This observational, prospective study included 135 patients with OSA eligible for oral appliance therapy. The primary outcome was the apnea-hypopnea index (AHI), measured through in-laboratory PSG/PG and MJM-based technology. Additionally, MJM monitoring at home was conducted at regular intervals during the titration process. The agreement between PSG/PG and MJM automated analysis was revaluated using Bland-Altman analysis. Changes in AHI during the home-based oral appliance titration process were evaluated using a generalized linear mixed model and a generalized estimating equation model. Results: The automated MJM analysis demonstrated strong agreement with PG in assessing AHI at the end of titration, with a median bias of 0.24/h (limits of agreement, -11.2 to 12.8/h). The improvement of AHI from baseline in response to oral appliance treatment was consistent across three evaluation conditions: in-laboratory PG (-59.6%; 95% confidence interval, -59.8% to -59.5%), in-laboratory automated MJM analysis (-59.2%; -65.2% to -52.2%), and at-home automated MJM analysis (-59.7%; -67.4% to -50.2%). Conclusions: Incorporating MJM automated analysis into the oral appliance titration process has the potential to optimize oral appliance therapy outcomes for OSA.

Adherence to continuous positive airway pressure therapy in patients with spinal cord injury and obstructive sleep apnea: trajectories and predictors

PURPOSE

To identify specific determinants of non-adherence or cessation of continuous positive airway pressure (CPAP) therapy in a population of patients with spinal cord injuries (SCI).

METHODS

Retrospective analysis of data from patients with SCI who underwent a full night supervised polysomnography between 2015 and 2021 and presented with moderate to severe obstructive sleep apnea (OSA) and for whom CPAP was indicated. Adherence was studied at 1, 6, and 12 months. Univariate and multivariate analyses were performed to identify factors associated with non-adherence (< 4 h per night or CPAP cessation). Factors studied were demographic and disease-related data and both subjective and objective sleep parameters.

RESULTS

A total of 60 patients were included (40% cervical SCI). In univariate analysis, the only predictive parameters of non-adherence observed at 1, 6, and 12 months were the average use of CPAP on the 1st night (p = 0.02) and over the 1st week (p ≤ 0.001). A complete lesion (AIS-A) was predictive of non-adherence at 1 and 6 months (p = 0.02 at 6 months), while mask leakage was associated with non-adherence at 12 months (p = 0.02). Upper limb autonomy and the presence of family caregivers did not appear to be protective. In multivariate analysis, only the average use in the first week remained predictive of adherence (> 4 h) in the short, medium and long term.

CONCLUSION

In patients with SCI and OSA, the 1st week of CPAP treatment seems to be determinant of short-, medium-, and long-term CPAP adherence. Support for SCI patients from the start of treatment is essential and may help avoid treatment failures.

Patient motivation ranked by caregivers at continuous positive airway pressure initiation is predictive of adherence and 1-year therapy termination rate

PURPOSE

In patients diagnosed with obstructive sleep apnea (OSA), continuous positive airway pressure therapy (CPAP) is effective in reducing symptoms and improving quality of life. However, poor mid- to long-term adherence and high termination rates are a problem. We asked whether or not patient motivation at CPAP initiation was associated with 15-day and 1-year CPAP adherence and termination rates.

METHODS

In this nationwide multicenter observational study, individual patient motivation for achieving CPAP adherence was subjectively evaluated at the time of CPAP set-up by the home-care provider's technician on a simple scale (low, average, good, very good). Then, adherence and CPAP termination rates were objectively monitored via the home-care provider's CPAP remote monitoring platform at 15 days and 1 year.

RESULTS

A total of 10,450 adults with OSA initiating CPAP were included by 36 centers. CPAP adherence at day 15 was significantly different between the low and the very good motivation groups: 5.4 [3.2; 6.9] hours and 6.0 [4.2; 7.3] hours per night respectively. In the 72.0% of patients using CPAP at 1 year, CPAP adherence was 5.2 [3.1; 6.7] and 5.5 [4.0; 7.0] hours per night in the groups with low and very good motivation respectively. Therapy termination rates at 1 year were 14.6% in the low motivation group and 8.0% in the very good motivation group.

CONCLUSION

Our study suggests that motivation of patients with OSA estimated by caregivers at CPAP initiation using a simple four-item ranking is associated with CPAP adherence and primary therapy termination rates during the first year of treatment.

Guidelines for the assessment and management of residual sleepiness in obstructive apnea-hypopnea syndrome: Endorsed by the French Sleep Research and Medicine Society (SFRMS) and the French Speaking Society of Respiratory Diseases (SPLF)

Excessive daytime sleepiness (EDS) is frequent among patients with obstructive sleep apnea hypopnea syndrome (OSAHS) and can persist despite the optimal correction of respiratory events (apnea, hypopnea and respiratory efforts), using continuous positive airway pressure (CPAP) or mandibular advancement device. Symptoms like apathy and fatigue may be mistaken for EDS. In addition, EDS has multi-factorial origin, which makes its evaluation complex. The marketing authorization [Autorisation de Mise sur le Marché (AMM)] for two wake-promoting agents (solriamfetol and pitolisant) raises several practical issues for clinicians. This consensus paper presents recommendations of good clinical practice to identify and evaluate EDS in this context, and to manage and follow-up the patients. It was conducted under the mandate of the French Societies for sleep medicine and for pneumology [Société Française de Recherche et de Médecine du Sommeil (SFRMS) and Société de Pneumologie de Langue Française (SPLF)]. A management algorithm is suggested, as well as a list of conditions during which the patient should be referred to a sleep center or a sleep specialist. The benefit/risk balance of a wake-promoting drug in residual EDS in OSAHS patients must be regularly reevaluated, especially in elderly patients with increased cardiovascular and psychiatric disorders risks. This consensus is based on the scientific knowledge at the time of the publication and may be revised according to their evolution.

Hypoxaemia and risk of asphyxia during underground work in artisanal cobalt mines

BACKGROUND

More than half the cobalt needed for vehicle electrification originates from the southern part of the Democratic Republic of the Congo (DRC), with a substantial part being extracted by artisanal miners.

AIMS

To investigate oxygen saturation during underground work among cobalt artisanal miners.

METHODS

In a field survey, we measured oxygen saturation (SpO2) and heart rate by pulse oximetry in 86 miners from two underground mines and 24 miners from a surface mine at four different time points: before descent into the mine (T1), at 50 minutes in the mine (T2), upon leaving the shaft (T3), and 10 minutes after having left the mine (T4).

RESULTS

Miners working underground (-36 to -112 meters) were somewhat older (34.8 ± 6.7 years) than those working in the surface mine (32.0 ± 6.5 years), and they worked more hours daily (12.6 ± 1.2 hours) than controls (9.0 ± 0.0 hours). All participants had SpO2 >95% at T1 and T4. At T2, SpO2 dropped below 93% and 80% in 35% and 10% underground miners, respectively; SpO2 was still <93% at T3 in 13%. SpO2 remained stable among surface miners. Later, we showed that underground ambient oxygen levels decreased well below 21% in several pits.

CONCLUSIONS

Pulse oximetry revealed relevant hypoxaemia during underground work in a substantial proportion of artisanal miners. Such hypoxaemia without evidence of underlying cardiovascular disease is indicative of low ambient oxygen, due to insufficient mine ventilation. This may cause deaths from asphyxia. The hazards of low ambient oxygen in artisanal mines must be prevented by appropriate technical measures ensuring the supply of sufficient fresh air.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

[Use of murine models for the study of obstructive sleep apnea syndrome in Down syndrome]

Down syndrome (DS), or trisomy 21, is a genetic disorder caused by the presence of an extra copy of chromosome 21, leading to various characteristic physical features as well as developmental and cognitive delays. Obstructive sleep apnea syndrome (OSAS) is a common disorder in both adult and pediatric patients with DS. Several characteristics of DS may contribute to the development or worsening of OSAS. Numerous murine models of DS exist. A number of studies have explored apneas and the risk of upper airway obstruction in these models, but up until now, only in adulthood.

Real-time visualization of dextran extravasation in intermittent hypoxia mice using noninvasive SWIR imaging

Imaging tools are crucial for studying the vascular network and its barrier function in various physiopathological conditions. Shortwave infrared (SWIR) window optical imaging allows noninvasive, in-depth exploration. We applied SWIR imaging, combined with vessel segmentation and deep learning analyses, to study real-time dextran probe extravasation in mice experiencing intermittent hypoxia (IH)-a characteristic of obstructive sleep apnea associated with potential cardiovascular alterations due to early vascular permeability. Evidence for permeability in this context is limited, making our investigation significant. C57Bl/6 mice were exposed to normoxia or intermittent hypoxia for 14 days. Then SWIR imaging between 1,250 and 1,700 nm was performed on the saphenous artery and vein and on the surrounding tissue after intravenous injection of labeled dextrans of two different sizes (10 or 70 kDa). Postprocessing and segmentation of the SWIR images were conducted using deep learning treatment. We monitored high-resolution signals, distinguishing arteries, veins, and surrounding tissues. In the saphenous artery and vein, after 70-kD dextran injection, tissue/vessel ratio was higher after intermittent hypoxia (IH) than normoxia (N) over 500 seconds (P < 0.05). However, the ratio was similar in N and IH after 10-kD dextran injection. The SWIR imaging technique allows noninvasive, real-time monitoring of dextran extravasation in vivo. Dextran 70 extravasation is increased after exposure to IH, suggesting an increased vessel permeability in this mice model of obstructive sleep apnea.NEW & NOTEWORTHY We demonstrate that SWIR imaging technique is a useful tool to monitor real-time dextran extravasation from vessels in vivo, with a high resolution. We report for the first time an increased real-time dextran (70 kD) extravasation in mice exposed to intermittent hypoxia for 14 days compared with normoxic controls.

Risk of Sarcopenia and Osteoporosis in Elderly Male Patients with Obstructive Sleep Apnea Syndrome: A Multicenter Study

The aim of this study was to assess the risk of sarcopenia and osteoporosis in elderly patients with obstructive sleep apnea syndrome (OSAS). We recruited both OSAS patients and non-OSAS subjects from multiple centers and evaluated their skeletal muscle index (SMI), bone mineral density (BMD), and inflammatory factors. All participants underwent polysomnography (PSG) testing, handgrip strength testing, chest CT, and dual-energy x-ray BMD testing. Based on the PSG diagnosis results, the participants were divided into a control group and an OSAS group. The analysis results revealed a higher incidence of sarcopenia in the OSAS group (χ2 = 22.367; P = 0.000) and osteoporosis (χ2 = 11.730a; P = 0.001). There were statistically significant differences in BMI (P = 0.000), grip strength (P = 0.000), SMI (P = 0.000), bone density (P = 0.000) and vitamin D (P = 0.000). The independent sample t test results showed that there was no statistical difference between IL-6 (P = 0.247) and CRP (P = 0.246). Considering the potential impact of body weight on the observed indicators, we employed covariance analysis to calculate the modified P value for each observation indicator. The findings demonstrated that the grip strength, IL-6, and CRP levels in the OSAS group were significantly higher compared to the control group. Conversely, the SMI, bone density, and Vitamin D levels were found to be significantly lower in the OSAS group than in the control group. These results suggest a higher likelihood of sarcopenia and osteoporosis among OSAS patients. Further studies should be conducted in larger study populations.

Control of breathing by orexinergic signaling in the nucleus tractus solitarii

Orexin signaling plays a facilitatory role in respiration. Abnormalities in orexin levels correlate with disordered breathing patterns and impaired central respiratory chemoreception. Nucleus tractus solitarii (NTS) neurons expressing the transcription factor Phox2b contribute to the chemoreceptive regulation of respiration. However, the extent to which orexinergic signaling modulates respiratory activity in these Phox2b-expressing NTS neurons remains unclear. In the present study, the injection of orexin A into the NTS significantly increased the firing rate of the phrenic nerve. Further analysis using fluorescence in situ hybridization and immunohistochemistry revealed that orexin 1 receptors (OX1Rs) were primarily located in the ventrolateral subdivision of the NTS and expressed in 25% of Phox2b-expressing neurons. Additionally, electrophysiological recordings showed that exposure to orexin A increased the spontaneous firing rate of Phox2b-expressing neurons. Immunostaining experiments with cFos revealed that the OX1R-residing Phox2b-expressing neurons were activated by an 8% CO2 stimulus. Crucially, OX1R knockdown in these NTS neurons notably blunted the ventilatory response to 8% CO2, alongside an increase in sigh-related apneas. In conclusion, orexinergic signaling in the NTS facilitates breathing through the activation of OX1Rs, which induces the depolarization of Phox2b-expressing neurons. OX1Rs are essential for the involvement of Phox2b-expressing NTS neurons in the hypercapnic ventilatory response.

Does Aesthetic Osseous Genioplasty Impact Upper Airway Volume?

BACKGROUND

Although maxillomandibular advancement is the treatment of choice for obstructive sleep apnea syndrome (OSAS) in the presence of underlying maxillomandibular complex hypoplasia, there is still a gap in the literature regarding the impact of genioplasty upon upper airway volume (UAV).

OBJECTIVES

The aim of this study was to evaluate the impact of isolated osseous genioplasty upon UAV.

METHODS

A retrospective analysis of all patients subjected to isolated osseous genioplasty between July 2015 and July 2022 was conducted. Cone-beam computed tomography was performed preoperatively and postoperatively to assess the chin and hyoid 3-dimensional (3D) spatial position and UAV changes after surgery.

RESULTS

A total of 44 patients were included in the study. Regarding surgical movements of the chin, almost all patients received a sagittal movement (n = 42; 39 forward and 3 backward), while in 8 patients a vertical movement (5 upward and 3 downward) was applied, and in 6 patients the chin was centered. Statistically significant increases in total UAV (P = .014) and at the level of the oropharynx (P = .004) were observed. Specifically, chin centering, upward and forward movements enlarged the oropharynx volume (P = .006, .043 and .065, respectively). Chin advancement enlarged the hypopharynx volume (P = .032), as did upward movement of the hyoid bone (P < .001).

CONCLUSIONS

Results of the study suggest that aesthetic osseous genioplasty impacts the UAV: each 3D spatial chin movement differently impacts the upper airway by enlarging or narrowing it. However, further studies addressing the apnea-hypopnea index are required to assess its effectiveness in treating OSAS.

LEVEL OF EVIDENCE: 4

The relationship between the systemic immune-inflammation index and obstructive sleep apnea

AIM

To investigate the predictive value of the systemic immune-inflammation index (SII) in patients with obstructive sleep apnea (OSA).

MATERIAL AND METHODS

Patients diagnosed with OSA formed the patient group, and those with a normal polysomnography (PSG) result formed the control group. The neutrophil, thrombocyte, monocyte, and lymphocyte counts obtained from the hemogram were used to calculate the neutrophil-to-lymphocyte ratio (NLR), thrombocyte-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), and the SII values. The two groups were compared with respect to the NLR, PLR, MLR, and SII values. Correlations were examined between the PSG parameters and the NLR, PLR, MLR, and SII values in the patient group.

RESULTS

Evaluation included 146 subjects with 85 in the patient group and 61 in the control group. Statistically significantly higher SII and NLR values were found in the patient group (p = 0.037, p < 0.05; p = 0.015, p < 0.05). A statistically significant negative correlation was observed between the SII and the lowest O2 saturation measurements (r =  - 0.246; p = 0.003; p < 0.01). A statistically significant negative correlation was found between the NLR and the lowest O2 saturation measurement (r =  - 0.255; p = 0.002; p < 0.01). The cutoff value for SII was found to be 290, with 84.7% sensitivity and 29.5% specificity. A cutoff value of 1.71 for NLR was determined to have 61.2% sensitivity and 60.7% specificity.

CONCLUSION

SII may be a new, rapid, low-cost, and easy-to-measure biomarker for the prediction of obstructive sleep apnea.

The effects of disease severity and comorbidity on oxidative stress biomarkers in obstructive sleep apnea

PURPOSE

Ischemia-modified albumin (IMA), total oxidant status (TOS), and total antioxidant status (TAS) are biomarkers used to evaluate oxidative stress status in various diseases including obstructive sleep apnea (OSA). In this study, we investigated the effects of disease severity and comorbidity on IMA, TOS and TAS levels in OSA.

METHODS

Patients with severe OSA (no-comorbidity, one comorbidity, and multiple comorbidities) and mild-moderate OSA (no-comorbidity, one and multiple comorbidities), and healthy controls were included in the study. Polysomnography was applied to all cases and blood samples were taken from each participant at the same time of day. ELISA was used to measure IMA levels in serum samples and colorimetric commercial kits were used to perform TOS and TAS analyses. In addition, routine biochemical analyses were performed on all serum samples.

RESULTS

A total of 74 patients and 14 healthy controls were enrolled. There was no statistically significant difference between the disease groups according to gender, smoking status, age, body mass index (BMI), HDL, T3, T4, TSH, and B12 (p > 0.05). As the severity of OSA and comorbidities increased, IMA, TOS, apnea-hypopnea index (AHI), desaturation index (T90), cholesterol, LDL, triglyceride, AST, and CRP values increased significantly (p < 0.05). On the other hand, TAS, minimum desaturation, and mean desaturation values decreased significantly (p < 0.05).

CONCLUSIONS

We concluded that IMA, TOS, and TAS levels may indicate OSA-related oxidative stress, but as the severity of OSA increases and with the presence of comorbidity, IMA and TOS levels may increase and TAS levels decrease. These findings suggest that disease severity and presence/absence of comorbidity should be considered in studies on OSA.

Association of the TNF-α-308G>A gene polymorphism with left ventricular geometry and functional abnormalities in obstructive sleep apnea subjects

OBJECTIVE

Tumor necrosis factor-α (TNF-α) can induce left ventricular remodeling. In this study, we investigated whether the TNF-α-308G>A polymorphism is associated with left ventricular geometry (LVG) and left ventricular functional abnormalities in obstructive sleep apnea (OSA) subjects.

METHODS

Two hundred and seventy-eight subjects were enrolled. Echocardiography and genetic data were assessed in all patients. Geometric patterns of the left ventricle were determined from the relative wall thickness and left ventricular mass index (LVMI). Genetic analysis for the TNF-α-308G>A SNP rs1800629 was identified by Sanger sequencing. The correlations of the TNF-α-308G>A polymorphism with LVG and left ventricular function were analyzed by difference analysis and logistic regression.

RESULTS

The chi-square test showed that there were differences in genotype distributions among the four groups (p = 0.033), such that the frequency of GA+AA genotypes was significantly higher in the concentric hypertrophy group than in the normal geometry group (p < 0.05). Independent sample T tests showed that the GA+AA genotypes had higher IVST, LVPWT, LVMI, E/e' values, and lower e' values than those of the GG genotype (p < 0.05). Logistic regression analysis showed that the TNF-α-308G>A polymorphism was independently correlated with eccentric hypertrophy (OR = 2.456, p = 0.047) and concentric hypertrophy (OR = 2.456, p = 0.047).

CONCLUSION

In OSA patients, the TNF-α-308G>A polymorphism was linked to LVG and abnormal left ventricular diastolic function, suggesting that the TNF-α-308G>A polymorphism may have an important influence on LVG alterations.

The Emergence of Inpatient Sleep Medicine: Screening for Sleep Disordered Breathing to Reduce the Burden of Cardiovascular Disease

Purpose of Review

Treatment of obstructive sleep apnea (OSA) has historically been centered on outpatients given sleep testing is performed on an outpatient basis. Much of this practice originates from insurers only covering sleep testing on an outpatient basis. Over the last decade, there have been innovations made in the portability of sleep monitors which have allowed sleep testing on inpatients to be facilitated. There is also emerging data that inpatient sleep testing may reduce readmissions and healthcare costs in certain cardiovascular conditions. Accordingly, this review aims to provide comprehensive coverage of recent advances in the practice of inpatient sleep medicine and its effect on reducing the burden of cardiovascular disease.

Recent Findings

Chief cardiovascular diseases that intersect with OSA in inpatients are stroke, atrial fibrillation, and heart failure. There is data from the National Inpatient Sample comparing arrhythmia burdens in patients with OSA and HFpEF showing that OSA patients have higher mortality rates, hospital durations, and medical costs. Also, OSA is associated with higher burdens of arrhythmia. It is currently unknown whether treatment of inpatients with PAP therapy lowers the occurrence of arrhythmias. Recent data suggests that costs for heart failure patients with OSA that are readmitted are higher than those for heart failure patients without OSA. A recent analysis of patients with HFpEF (heart failure with preserved ejection fraction) and OSA showed that the PAP adherent patients had fewer healthcare related costs, lower readmission rates, and fewer emergency room visits than those that were nonadherent. In broader terms, rapid initiation of PAP therapy in a large administration database query of 23 million Medicare patients appears to reduce annual healthcare costs and reduce readmissions although further study is required.

Summary

OSA is globally underdiagnosed, with an estimated one billion individuals affected. OSA's pathogenesis involves a combination of risk factors, such as obesity, age, and increased neck circumference that contribute to fragmented sleep patterns and in turn, numerous cardiovascular comorbidities, such as stroke, atrial fibrillation, and coronary artery disease. Recently, inpatient sleep medicine programs have emerged as a promising avenue for improving diagnosis, patient safety, and potentially reducing readmissions. Integrating inpatient sleep medicine into healthcare systems to address the significant health and economic burden associated with undiagnosed OSA. Improved coverage of inpatient sleep testing and services will be a key driver of addressing inpatient gaps in sleep medicine care. The current research findings provide a bedrock from which further investigations may proceed in a prospective and randomized, controlled fashion to further clarify the effects of treatment of OSA on cardiovascular outcomes of inpatients.

Pharmacological interventions for the treatment of obstructive sleep apnea syndrome

Obstructive Sleep Apnea Syndrome (OSAS) affects 13-33% of males and 6-9% of females globally and poses significant treatment challenges, including poor adherence to Continuous Positive Airway Pressure (CPAP) and residual excessive sleepiness (RES). This review aims to elucidate the emerging interest in pharmacological treatments for OSAS, focusing on recent advancements in this area. A thorough analysis of extensive clinical trials involving various drugs, including selective dopamine reuptake inhibitors, selective norepinephrine inhibitors, combined antimuscarinic agents, and orexin agonists, was conducted. These trials focused on ameliorating respiratory metrics and enhancing sleep quality in individuals affected by OSAS. The studied pharmacological agents showed potential in improving primary outcomes, notably the apnea-hypopnea index (AHI) and the Epworth sleepiness scale (ESS). These improvements suggest enhanced sleep quality and symptom management in OSAS patients. With a deeper understanding of OSAS, pharmacological interventions are emerging as a promising direction for its effective management. This review provides a comprehensive overview of the current state of drug research in OSAS, highlighting the potential of these treatments in addressing the disorder's complex challenges.

Evaluate the Relationship Between Obstructive Sleep Apnea and Metabolic Syndrome in Real-World Data

Objective

Obstructive sleep apnea (OSA) is a disorder characterized by disruption in breathing and hypoventilation. In parallel, metabolic syndrome (MetS) mainly co-occur with OSA, however, their association has not been fully elucidated. Therefore, this study aimed to reveal the relationship between OSA and MetS using data from the National Health And Nutrition Examination Survey (NHANES) database and pooled data from Genome-Wide Association Studies (GWAS).

Material and Methods

Data from the National Health and Nutrition Examination Survey and pooled data from genome-wide association analysis (GWAS) were used univariate and multivariate logistic regression analyses were carried out to evaluate the correlation between OSA and MetS, and multivariate logistic regression models were utilized for adjusting for potential confounders. Two-sample Mendelian randomization (MR) was used to assess the causal relationship between OSA and MetS. The variance-weighted inverse method was employed as the main method of analysis.

Results

A positive relationship of OSA with Mets was evidenced by multivariate logistic regression analysis, and OSA was associated with higher incidence rates of all-cause and cardiovascular mortality. OSA is strongly associated with abdominal obesity, hypertension, hyperglycemia, high triglycerides, and low HDL. Furthermore, except for hypertriglyceridemia, MR analysis indicated that genetically driven OSA was causally associated with a higher risk of MetS.

Conclusion

The positive relationship of OSA with Mets was revealed, and higher incidence rates of all-cause mortality and cardiovascular mortality were noted to be correlated with OSA. MR analysis further confirmed the causal relationship of OSA with MetS and cardiovascular disease.

Knowledge and Attitudes of Obstructive Sleep Apnea among Jordanian Otolaryngologists: A Cross-Sectional Study

Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder that affects almost one billion individuals worldwide. An estimated 16.8% of adults in Jordan have been diagnosed with OSA. Given the importance of management of OSA by otolaryngologists, we assessed the knowledge and attitudes of Jordanian otolaryngologists in managing OSA in adult and pediatric patients. A survey, conducted anonymously online, was sent present otolaryngology residents and specialist in Jordan, in the English language. The participants were given the OSA Knowledge and Attitude questionnaire (OSAKA, OSAKA-KIDS), which have been previously validated. Data were obtained and then analyzed via SPSS software. A total of 140 residents and specialist of otolaryngology were selected. A significant difference in OSAKA scores were found between otolaryngologists under 30 years of age and those above, with higher scores for the older age group. The proportion of specialists who 'agreed' or 'strongly agreed' they are confident in their ability to manage patients with OSA was significantly higher that junior residents (73.8% vs 33.3%; p = 0.008). More than 10 years at practice was associated with statistically significant higher levels of knowledge towards OSAKA scale (AOR = 0.09; p = 0.044). Additionally, being a senior resident was significantly associated with more knowledge towards OSAKA-KIDS scale (AOR = 0.19; p = 0.03). Otolaryngology residents and specialists' knowledge of OSA was very good. Further improving in the level of the knowledge toward OSA among the otolaryngology resident doctors should be implemented as possible by following the updated guidelines for the diagnosis and management OSA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04180-8.

Gender Differences in Prevalence of Sleepy Driving Among Young Drivers in Saudi Arabia

Introduction

Sleepy driving is associated with Motor Vehicles Accidents (MVAs). In Saudi Arabia, previous studies have addressed this association among men only. Therefore, the aim of this study was to compare the prevalence of sleepy driving and associated factors between genders.

Methods

In a cross-sectional study design, we offered a self-administered online questionnaire to 3272 participants from different regions of Saudi Arabia. The questionnaire included 46 questions covering sociodemographics, driving habits, sleeping habits, Epworth Sleepiness Scale, and Berlin questionnaire to assess the risk of sleep apnea. Univariable and multivariable logistic regression analyses were used to determine the significant factors associated with self-reported sleepy driving, defined as operating a motor vehicle while feeling sleepy in the preceding six months.

Results

Of the 3272 invitees, 2958 (90%) completed the questionnaire, of which 1414 (48%) were women. The prevalence of sleepy driving in the preceding six months was 42% (men: 50% and women 32%, p<0.001). Specifically, participants reported the following: 12% had had to stop their vehicle due to sleepiness (men: 16.2% and women 7%, p<0.001), 12.4% reported near-miss accidents (men: 16.2% and women: 8.2%, p<0.001) and 4.2% reported an accident due to sleepiness (men: 4.3% and women: 4%, p=0.645). In multivariable analysis, being male, younger age, use of any type of medications, shift working, working more than 12 hours per day, driving duration of 3-5 hours per day, driving experience of more than 2 years, excessive daytime sleepiness and risk of having obstructive sleep apnea were all associated with increased likelihood of falling asleep while driving in the preceding 6 months.

Conclusion

Sleepy driving and MVA are prevalent in both gender but was higher in men. Future public health initiatives should particularly focus on men, since men reported a greater likelihood of both sleep-related MVA and "near miss" events.

Functional recovery after ischemic stroke: Impact of different sleep health parameters

Sleep disturbances after ischaemic stroke include alterations of sleep architecture, obstructive sleep apnea, restless legs syndrome, daytime sleepiness and insomnia. Our aim was to explore their impacts on functional outcomes at month 3 after stroke, and to assess the benefit of continuous positive airway pressure in patients with severe obstructive sleep apnea. Ninety patients with supra-tentorial ischaemic stroke underwent clinical screening for sleep disorders and polysomnography at day 15 ± 4 after stroke in a multisite study. Patients with severe obstructive apnea (apnea-hypopnea index ≥ 30 per hr) were randomized into two groups: continuous positive airway pressure-treated and sham (1:1 ratio). Functional independence was assessed with the Barthel Index at month 3 after stroke in function of apnea-hypopnea index severity and treatment group. Secondary objectives were disability (modified Rankin score) and National Institute of Health Stroke Scale according to apnea-hypopnea index. Sixty-one patients (71.8 years, 42.6% men) completed the study: 51 (83.6%) had obstructive apnea (21.3% severe apnea), 10 (16.7%) daytime sleepiness, 13 (24.1%) insomnia, 3 (5.7%) depression, and 20 (34.5%) restless legs syndrome. Barthel Index, modified Rankin score and Stroke Scale were similar at baseline and 3 months post-stroke in the different obstructive sleep apnea groups. Changes at 3 months in those three scores were similar in continuous positive airway pressure versus sham-continuous positive airway pressure patients. In patients with worse clinical outcomes at month 3, mean nocturnal oxygen saturation was lower whereas there was no association with apnea-hypopnea index. Poorer outcomes at 3 months were also associated with insomnia, restless legs syndrome, depressive symptoms, and decreased total sleep time and rapid eye movement sleep.

CPAP resumption after a first termination and impact on all-cause mortality in France

BACKGROUND

Continuation of continuous positive airway pressure (CPAP) therapy after initial prescription has been shown to reduce all-cause mortality versus therapy termination. However, there is a lack of data on the rates and impact of resuming CPAP in patients with obstructive sleep apnoea (OSA). This analysis determined the prevalence of CPAP resumption in the year after termination, characterised determinants of CPAP resumption, and examined the impact of CPAP resumption on all-cause mortality.

METHODS

French national health insurance reimbursement system data for adults aged ≥18 years were used. CPAP prescription was identified by specific treatment codes. Patients who resumed CPAP after first therapy termination and continued to use CPAP for 1 year were matched with those who resumed CPAP then terminated therapy for a second time.

RESULTS

Out of 103 091 individuals with a first CPAP termination, 26% resumed CPAP over the next 12 months, and 65% of these were still using CPAP 1 year later. Significant predictors of CPAP continuation after resumption included male sex, hypertension and CPAP prescription by a pulmonologist. In the matched population, the risk of all-cause death was 38% lower in individuals who continued using CPAP after therapy resumption versus those who had a second therapy discontinuation (hazard ratio 0.62, 95% CI 0.48-0.79; p=0.0001).

CONCLUSION

These data suggest that individuals with OSA who fail initial therapy with CPAP should be offered a second trial with the device to ensure that effective therapy is not withheld from those who might benefit.

A Systematic Review and Meta-Analysis of Mean Platelet Volume and Platelet Distribution Width in Patients with Obstructive Sleep Apnoea Syndrome

Obstructive sleep apnoea syndrome (OSAS) is a highly prevalent yet underestimated disorder caused by the complete or partial obstruction of the upper airways. Although polysomnography is the gold standard for OSAS diagnosis, there is an active search for easily accessible biomarkers of disease presence and severity, particularly those reflecting morphological changes in specific blood cells. We investigated the associations between the presence and severity of OSAS, continuous positive airway pressure (CPAP) treatment, mean platelet volume (MPV), and platelet distribution width (PDW), routinely assessed as part of the complete blood count. From 262 retrieved records from PubMed, the Web of Science, Scopus, and Google Scholar, 31 manuscripts were selected for a final analysis, 30 investigating MPV and 15 investigating PDW. MPV was not statistically different between OSAS patients and healthy controls; however, it progressively increased with disease severity. By contrast, OSAS patients had significantly higher PDW values than controls (SMD = 0.40, 95% CI: 0.25 to 0.56; p ˂ 0.001), and the difference increased with disease severity. In a univariate meta-regression, there were significant associations between the MPV and publication year, the apnoea-hypopnea index, and diabetes mellitus, while no associations were observed with the PDW. No significant between-group differences were observed in the subgroup analyses. These data suggest that PDW, and to a lesser extent, MPV, are potential biomarkers of OSAS and require further research to ascertain their pathophysiological significance (PROSPERO, CRD42023459413).

Triglyceride-glucose index and obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) has a bidirectional association with metabolic syndrome, and insulin resistance (IR). The triglyceride-glucose (TyG) index could be a simply calculated marker of IR in OSA. However, its clinical application appears still limited. Hence, this systematic review and meta-analysis aimed to respond to this question by analyzing all the existing studies showing an association between OSA and the TyG index.

METHODS

Four online databases, including PubMed, Scopus, the Web of Science, and Embase were searched for studies evaluating the TyG index in OSA. After screening and data extraction, a random-effect meta-analysis was performed to compare the TyG index in OSA patients vs. healthy controls by calculating standardized mean difference (SMD) and 95% confidence interval (CI) and pooling the area under the curves (AUCs) for diagnosis of OSA based on this index.

RESULTS

Ten studies involving 16,726 individuals were included in the current systematic review. Meta-analysis indicated that there was a significantly higher TyG index in patients with OSA, compared with the healthy controls (SMD 0.856, 95% CI 0.579 to 1.132, P < 0.001). Also, TyG had a diagnostic ability for OSA representing a pooled AUC of 0.681 (95% CI 0.627 to 0.735). However, based on the two studies' findings, no difference between different severities of OSA was observed. Finally, our data showed that the TyG index is a good potential predictor of adverse outcomes in these patients.

CONCLUSION

Our study revealed that the TyG index is an easy-to-measure marker of IR for assessing OSA, both in diagnosis and prognosis. Our study supports its implementation in routine practice to help clinicians in decision-making and patient stratification.

GC-MS-based metabolomics of volatile organic compounds in exhaled breath: applications in health and disease. A review

Exhaled breath analysis, with particular emphasis on volatile organic compounds, represents a growing area of clinical research due to its obvious advantages over other diagnostic tests. Numerous pathologies have been extensively investigated for the identification of specific biomarkers in exhalates through metabolomics. However, the transference of breath tests to clinics remains limited, mainly due to deficiency in methodological standardization. Critical steps include the selection of breath sample types, collection devices, and enrichment techniques. GC-MS is the reference analytical technique for the analysis of volatile organic compounds in exhalates, especially during the biomarker discovery phase in metabolomics. This review comprehensively examines and compares metabolomic studies focusing on cancer, lung diseases, and infectious diseases. In addition to delving into the experimental designs reported, it also provides a critical discussion of the methodological aspects, ranging from the experimental design and sample collection to the identification of potential pathology-specific biomarkers.

Relevance Between Reduction of SpO2 and Parasympathetic Nervous Activity During Sleep

Sleep apnea syndrome (SAS) is associated with cardiopulmonary and dental nasopharyngeal diseases. The blood oxygen saturation (SpO2) detected using pulse oximetry is a diagnostic screening method for SAS. SAS severity is assessed using the oxygen desaturation index (ODI), which measures the number of times the SpO2 decreases by more than 3% for longer than 10 s. This study investigated the association between reduced SpO2 and parasympathetic nervous system activity (PSNA) during night sleep in young adults (n = 63; aged 20-32 years). Changes in PSNA were measured every minute for 24 h during a free-moving day using an ActiveTracer accelerometer. Pulse oximetry was performed simultaneously during sleep. All participants had significantly lower PSNA when the SpO2 decreased by 3% or more than when it did not. There were no significant differences in PSNA when an ODI cutoff of 5 events/h was used. However, participants with an ODI >5 events/h had significantly lower PSNA during normal SpO2 than those with an ODI <5 events/h, suggesting an association between SpO2 desaturation and PSNA decline during sleep. A high ODI may indicate reduced PSNA levels during sleep, affecting sleep efficiency. Treatment aimed at reducing the ODI may improve sleep quality, even in young adults.

Breath biomarkers in Non-Carcinogenic diseases

The analysis of volatile organic compounds (VOCs) from human matrices like breath, perspiration, and urine has received increasing attention from academic and medical researchers worldwide. These biological-borne VOCs molecules have characteristics that can be directly related to physiologic and pathophysiologic metabolic processes. In this work, gathers a total of 292 analytes that have been identified as potential biomarkers for the diagnosis of various non-carcinogenic diseases. Herein we review the advances in VOCs with a focus on breath biomarkers and their potential role as minimally invasive tools to improve diagnosis prognosis and therapeutic monitoring.

Persistent sleep-disordered breathing independently contributes to metabolic syndrome in prepubertal children

BACKGROUND

Obstructive sleep apnea (OSA) is a risk factor for metabolic syndrome (MetS) in adults, but its association in prepubertal children is still questionable due to the relatively limited cardiometabolic data available and the phenotypic heterogeneity.

OBJECTIVE

To identify the role of OSA as a potential mediator of MetS in prepubertal children.

METHODS

A total of 255 prepubertal children from the Childhood Adenotonsillectomy Trial were included, with standardized measurements taken before OSA treatment and 7 months later. MetS was defined if three or more of the following criteria were present: adiposity, high blood pressure, elevated glycemia, and dyslipidemia. A causal mediation analysis was conducted to assess the effect of OSA treatment on MetS.

RESULTS

OSA treatment significantly impacted MetS, with the apnea-hypopnea index emerging as mediator (p = .02). This mediation role was not detected for any of the individual risk factors that define MetS. We further found that the relationship between MetS and OSA is ascribable to respiratory disturbance caused by the apnea episodes, while systemic inflammation as measured by C-reactive protein, is mediated by desaturation events and fragmented sleep. In terms of evolution, patients with MetS were significantly more likely to recover after OSA treatment (odds ratio = 2.56, 95% confidence interval [CI] 1.20-5.46; risk ratio = 2.06, 95% CI 1.19-3.54) than the opposite, patients without MetS to develop it.

CONCLUSION

The findings point to a causal role of OSA in the development of metabolic dysfunction, suggesting that persistent OSA may increase the risk of MetS in prepubertal children. This mediation role implies a need for developing screening for MetS in children presenting OSA symptoms.

The Overlap Syndrome: A Combination of Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea

Chronic obstructive pulmonary disease (COPD) is a severe lung disease that results in persistent and progressively worsening airflow obstruction due to abnormalities in the airway and alveoli. Obstructive sleep apnea (OSA) is a critical condition characterized by obstructive apneas, hypopneas, and respiratory effort-related arousals. These events occur due to the repetitive collapse of the upper airway during sleep, and it is essential to address this condition. These two conditions, when co-occur, are known as overlap syndrome (OS), which is associated with a higher likelihood of morbidity and mortality compared to either condition alone. Effective management of overlap syndrome is critical to maintain normal oxygen levels during sleep and reduce the incidence of hypoxemia and hypoventilation while improving sleep quality. Positive pressure ventilation is a standard technique used to effectively lower hospitalizations, emergency room visits, moderate and severe exacerbations, and related healthcare expenses in patients diagnosed with COPD and OSA. Despite the lack of literature on overlap syndrome, it is imperative to understand that this condition requires prompt and effective management to prevent further complications. Therefore, this review provides a detailed discussion highlighting the importance of proactive measures to manage overlap syndrome.

Continuous positive airway pressure treatment improves bone mineral density in men affected by severe obstructive sleep apnea syndrome

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) and low bone mineral density (BMD) are 2 prevalent conditions with a significant negative impact on patients' well-being and quality of life. Recent research has shown low BMD at different bone sites in male patients with OSA. Although the efficacy of continuous positive airway pressure (CPAP) treatment for OSA has been widely demonstrated, the evidence for understanding its impact on BMD and other bone-related outcomes is insufficient. The aim of this observational study was to investigate the effect of 12 months of CPAP treatment on lumbar and femur BMD and bone-related serum biomarkers in male patients with severe OSA.

METHODS

Sixty patients (mean age: 55.1 ± 9.9 years) were consecutively included and underwent BMD measurement with dual-energy x-ray absorptiometry at baseline and after 12 months of CPAP treatment. Vitamin D, parathyroid hormone, and calcium serum levels were examined at the same time points.

RESULTS

A significant increase in BMD in the L1 (P < .001, d = 0.27) and L2 (P < .001, d = 0.26) vertebrae was observed after CPAP treatment, along with an increase in vitamin D (P < .001, d = 0.71) and calcium (P < .001, d = 0.73) levels and a decrease in parathyroid hormone levels (P < .001, d = 0.60). The increase in BMD in L1 was significantly correlated with the decrease in parathyroid hormone serum levels (r = -.50, P < .001).

CONCLUSIONS

Overall, these findings showed that beneficial OSA treatment might restore bone health and support CPAP treatment as a feasible strategy to improve BMD in male patients with severe OSA. Accordingly, diagnosing and targeting OSA may be warranted in the treatment of male patients with undetermined osteopenia and osteoporosis.

CITATION

Carpi M, Cordella A, Placidi F, et al. Continuous positive airway pressure treatment improves bone mineral density in men affected by severe obstructive sleep apnea syndrome. J Clin Sleep Med. 2024;20(1):67-73.

Exploring the potential relationships among obstructive sleep apnea, erectile dysfunction, and gut microbiota: a narrative review

INTRODUCTION

Poor sleep quality is closely associated with comorbidities affecting a multitude of organ systems. Among the sleep disorders in the population, there has recently been an increase in the prevalence of obstructive sleep apnea (OSA), which has particularly affected men. The intermittent hypoxia and sleep fragmentation associated with OSA can result in the manifestation or aggravation of a number of pathophysiologic conditions, including the impairment of reproductive function in men and women. In this context, erectile dysfunction (ED) is of particular concern. Other consequences of OSA are changes in the gastrointestinal microbiota, with the resultant dysbiosis having potentially harmful consequences that promote downstream exacerbation of various comorbidities.

OBJECTIVES

This narrative review aims to explore the potential relationships among ED, gut microbiota, and OSA.

METHODS

A search of the relevant literature was performed in the PubMed, Embase, Medline, and Web of Science databases.

RESULTS

Sleep is important for regulating the body's functions, and sleep deprivation can negatively affect health. OSA can damage organic functions, including reproductive function, and can lead to ED. Restoring the microbiota and improving sleep can help to improve sexual function or reverse ED and enhance other associated conditions mediated through the gut-brain axis relationship. Probiotics and prebiotics can be used as supportive strategies in the prevention and treatment of OSA, as they help to reduce systemic inflammation and improve intestinal barrier function.

CONCLUSION

A good diet, a healthy lifestyle, and proper bowel function are essential in controlling depression and several other pathologies. Modulating the gut microbiota through probiotics and prebiotics can provide a viable strategy for developing new therapeutic options in treating many conditions. A better understanding of these a priori unrelated phenomena would foster our understanding of the effects of OSA on human fertility and how changes in gut microbiota may play a role.

Respiratory event index underestimates severity of sleep apnea compared to apnea-hypopnea index

Polygraphy (PG) is often used to diagnose obstructive sleep apnea (OSA). However, it does not use electroencephalography, and therefore cannot estimate sleep time or score arousals and related hypopneas. Consequently, the PG-derived respiratory event index (REI) differs from the polysomnography (PSG)-derived apnea-hypopnea index (AHI). In this study, we comprehensively analyzed the differences between AHI and REI. Conventional AHI and REI were calculated based on total sleep time (TST) and total analyzed time (TAT), respectively, from two different PSG datasets (n = 1561). Moreover, TAT-based AHI (AHITAT) and TST-based REI (REITST) were calculated. These indices were compared keeping AHI as the gold standard. The REI, AHITAT, and REITST were significantly lower than AHI (p < 0.0001, p ≤ 0.002, and p ≤ 0.01, respectively). The total classification accuracy of OSA severity based on REI was 42.1% and 72.8% for two datasets. Based on AHITAT, the accuracies were 68.4% and 85.9%, and based on REITST, they were 65.9% and 88.5% compared to AHI. AHI was most correlated with REITST (r = 0.98 and r = 0.99 for the datasets) and least with REI (r = 0.92 and r = 0.97). Compared to AHI, REI had the largest mean absolute errors (13.9 and 6.7) and REITST the lowest (5.9 and 1.9). REI had the lowest sensitivities (42.1% and 72.8%) and specificities (80.7% and 90.9%) in both datasets. Based on these present results, REI underestimates AHI. Furthermore, these results indicate that arousal-related hypopneas are an important measure for accurately classifying OSA severity.

Obstructive sleep apnoea-hypopnoea syndrome

Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a common disorder characterised by repetitive episodes of the complete or partial collapse of the pharyngeal airway during sleep. This results in cessation (apnoea) or reduction (hypopnoea) of airflow, leading to oxygen desaturation and sleep fragmentation. An individual's disposition to develop OSAHS depends on the collapsibility of a segment of the upper airway. The degree of collapsibility can be quantified by the balance between occluding or extraluminal pressures of the surrounding tissues. Patients can experience snoring, unrefreshing sleep, witnessed apnoeas, waking with a choking sensation and excessive daytime sleepiness. OSAHS has a broad range of consequences, including cardiovascular, metabolic, and neurocognitive sequelae. Treatment options include lifestyle measures, in particular weight loss, and strategies to maintain upper airway patency overnight, including continuous positive airway pressure, mandibular advancement devices and positional modifiers.

A mediation analysis of metabolic and inflammatory factors in the severe sleep apnea-coronary heart disease association

BACKGROUND

It is unclear whether metabolic and inflammatory factors mediate the association between severe sleep apnea and coronary heart disease (CHD) in observational studies based on the large-scale population. This study aims to assess the association between severe sleep apnea and CHD and to explore the extent to which this association is mediated by metabolic factors and C-reactive protein (CRP).

METHODS

In UK Biobank, 213 442 CHD-free (mean age: 55.00) adults were followed up for 15 years to detect incident CHD. Metabolic factors included hyperglycemia, hypertension, dyslipidemia, hypertriglyceridemia, and hyperuricemia. A higher CRP concentration level was defined as a cutoff point of >3.0 mg/l. Data were analyzed using Cox proportional hazards models and the generalized structural equation model.

RESULTS

During follow-up, 9278 participants developed incident CHD (4.3%). The multi-adjusted hazard ratio and 95% confidence interval of CHD related to severe sleep apnea were 1.76 (1.44-2.15). In the mediation analysis, the strongest indirect association was for dyslipidemia, accounting for 20.8% of the association between severe sleep apnea and CHD (β = 0.22, 95% confidence interval = 0.16-0.28), followed by hypertriglyceridemia (12.3%). The proportion of mediation increased to 29.1% when CRP was added to the metabolic mediators.

CONCLUSIONS

Severe sleep apnea was associated with an increased risk of CHD. Lipid factors might play an essential role in the severe sleep apnea-CHD relationship. CRP increased the magnitude of mediation effects of overall metabolic factors. What is already known on this topic It is unknown whether the association between severe sleep apnea and CHD among the large population-based cohort study. Evidence on the mediating effect of metabolic and inflammatory factors in the severe sleep apnea-CHD association remains unclear. What this study adds Lipid factors were the biggest mediation driver in the severe sleep apnea-CHD path. C-reactive protein increased the magnitude of mediation effects of overall metabolic factors. How this study might affect research, practice or policy Investigating mediation analyses not only enhances comprehension of the pathophysiological connection between severe sleep apnea and CHD but also offers valuable insights into preventing CHD.

Effects of smoking on sleep architecture and ventilatory parameters including apneas: Results of the Tab-OSA study

Background

The interaction between smoking and sleep seems appears to be bidirectional, but few studies evaluated the impact of smoking and its cessation on objective sleep parameters. In this context, this new study aimed to assess the impact of smoking and its cessation on sleep architecture and on ventilatory sleep parameters, particularly the presence of sleep apnea syndrome (apnea-hypopnea index (AHI)≥15). Methods: Patients hospitalized for polysomnographic sleep exploration were compared according to their smoking status: active smokers (AS), former smokers (FS), non-smokers (NoNi). Psychiatric and non-psychiatric co-morbidities and treatment or substance use were taken into account in the analyses.

Results

A total of 170 participants were included (N = 37 FS, 39 AS, 86 NoNi). A significant decrease in the mean nocturnal O2 saturation was observed for FS and AS compared to NoNi. No differences were found regarding AHI. Regarding sleep architecture, we observed a significant decrease in the slow wave sleep duration for AS compared to NoNi, and interestingly not between FS and NoNi.

Conclusion

This study suggests that current smokers suffer from alterations in both sleep architecture and ventilatory parameters, the later appears to persist even after smoking cessation.

Prognostic implications of obstructive sleep apnea in patients with acute coronary syndrome stratified by homocysteine level: a prospective cohort study

BACKGROUND

Sporadic studies have examined the impact of OSA on ACS patients by homocysteine (Hcy) level. This study attempted to comprehensively evaluate the effects of the interaction between Hcy and OSA on long-term cardiovascular outcomes in ACS patients.

METHODS

In this prospective, large-scale cohort study, 2160 patients admitted for ACS were recruited to undergo overnight sleep monitoring. OSA was diagnosed when apnea-hypopnea index ≥ 15 events/h. Patients with normohomocysteinemia (NHcy) were defined as having serum Hcy ≤ 15 μmol/L, and the others had hyperhomocysteinemia (HHcy). The primary endpoint was major adverse cerebrocardiovascular event (MACCE), a composite of cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization and hospitalization for unstable angina and heart failure.

RESULTS

A total of 1553 eligible ACS patients (average age: 56.3 ± 10.5 years) were enrolled, among which 819 (52.7%) had OSA, and 988 (63.6%) were with NHcy. OSA did not significantly affect the level of Hcy. During a median follow-up of 2.9 (1.6, 3.5) years, after adjustment for clinical confounders, OSA was associated with increased risk for MACCE occurrence versus non-OSA ones in ACS patients with NHcy (adjusted hazard ratio [HR] = 1.36, 95% confidence interval [CI] 1.02-1.83, P = 0.039), but not in those with HHcy (adjusted HR = 0.92, 95%CI 0.62-1.36, P = 0.668). There was an absence of interaction between homocysteine level and OSA in relation to MACCE (interaction P = 0.106).

CONCLUSIONS

OSA was independently associated with worse prognosis in ACS patients with NHcy. Our study emphasized the necessity to identify potential presence of OSA in such a population.

TRIAL REGISTRATION

ClinicalTrials.gov; Number: NCT03362385; URL: www.

CLINICALTRIALS

gov .

Impact of CPAP Therapy on the Autonomic Nervous System

Obstructive sleep apnea (OSA) is a significant risk factor for cardiovascular disease (CVD) with increasing prevalence. An important mechanism of CVD development is a dysregulation of the autonomic nervous system (ANS). This prospective and controlled cohort study aimed to investigate ANS function in OSA including the response to long-term continuous positive airway pressure (CPAP) therapy by analyzing 24 h Holter electrocardiogram and 24 h Holter ambulatory blood pressure recording parameters. The study enrolled 57 patients who were newly diagnosed with severe OSA. After 6 months of CPAP therapy, 37 patients had a good therapy adherence (usage of CPAP device >4 h per night), and their data were analyzed. The difference in nocturnal diastolic blood pressure values before and after CPAP therapy reached statistical significance (76 (68-84) vs. 74 (63-80) mmHg, p = 0.0439). Lower nocturnal values after CPAP therapy of SDNN (101.5 vs. 95 ms, p = 0.0492) and RMSSD (29.5 vs. 26 ms, p = 0.0193) were found. An increase in diurnal spectral power (1742 vs. 2112 ms2, p = 0.0282) and a decrease in nocturnal spectral power (3256 vs. 2124 ms2, p = 0.0097), nocturnal VLF band (2493 vs. 1485.4 ms2, p = 0.0176), nocturnal LF band (638.7 vs. 473 ms2, p = 0.0097), and nocturnal HF band (234.9 vs. 135.7 ms2, p = 0.0319) was found. The results showed an imbalance of the ANS with a sympathetic predominance, especially during the night hours and in those with arterial hypertension. The impact of CPAP therapy on the improvement in ANS parameters was more pronounced at night, in men, and those with arterial hypertension.

The immune response to arterial damage in a mouse model of intermittent hypoxia: a transcriptomics analysis

PURPOSE

Mice can develop arterial damage and even atherosclerosis under intermittent hypoxia (IH); however, the specific mechanism of arterial damage induced by IH remains unclear. Hence, this research aimed to illustrate the underlying mechanism linking IH to arterial injury.

MATERIALS AND METHODS

The differential gene expression of the thoracic aorta under normoxia or IH mice was analyzed utilizing RNA sequencing. Furthermore, GO, KEGG pathway, and CIBERSORT analyses were carried out. For verification of the expression of candidate genes affected by IH, quantitative RT-qPCR (qRT-PCR) was conducted. Immunohistochemical (IHC) staining revealed immune cell infiltration in the thoracic aorta.

RESULTS

The thickness of the intima-media of the mouse aorta was increased, and the fiber structure was disordered under IH. Transcriptomics analysis showed that in the aorta, 1137 upregulated genes and 707 downregulated genes were affected by IH, significantly related to the activation of the immune system and cell adhesion. Furthermore, B cell infiltration around the aorta was observed under IH.

CONCLUSIONS

IH might lead to structural changes in the aorta by activating the immune response and enhancing cell adhesion.

Adaptive responses to chronic intermittent hypoxia: contributions from the European Sleep Apnoea Database (ESADA) Cohort

Obstructive sleep apnoea (OSA) is a common disease in the general population, and is associated with increased cardiovascular risk and several comorbidities. Obesity favours upper airway collapsibility, but other pathophysiological traits have been identified, i.e. upper airway muscle activity, modulation of the respiratory drive, and the arousal threshold. OSA causes chronic intermittent hypoxia, inflammatory activation and autonomic imbalance with diurnal and nocturnal sympathetic hyperactivity. Disentangling so many components to investigate the pathogenesis of OSA's consequences is very hard clinically. However, albeit imperfect, clinical medicine constitutes a major source of inspiration for basic research, and a mutual exchange of information is essential between clinicians and physiologists to improve our understanding of disease states. OSA is no exception, and this narrative review will summarize the results of clinical studies performed over the years by the European Sleep Apnoea Database (ESADA) Study Group, to explore the variables linked to markers of intermittent hypoxia as opposed to the traditional assessment of OSA severity based on the frequency of respiratory events during sleep (the Apnoea Hypopnoea Index). The results of the clinical studies indicate that intermittent hypoxia variables are associated with several comorbidities, although evidence of a cause-effect relationship is still missing in many cases. It is also possible that adaptive rather than maladaptive responses could be evoked by intermittent hypoxia. The intensity, duration and frequency of intermittent hypoxia episodes causing adaptive rather than maladaptive responses, and their clinical implications, deserve further investigation.

Obstructive sleep apnea promotes the progression of lung cancer by modulating cancer cell invasion and cancer-associated fibroblast activation via TGFβ signaling

OBJECTIVE

Obstructive sleep apnea (OSA) is associated with severity of pneumonia; however, the mechanism by which OSA promotes lung cancer progression is unclear.

METHODS

Twenty-five lung cancer patients were recruited to investigate the relationship between OSA and cancer-associated fibroblast (CAFs) activation. Lung cancer cells (A549) and WI38 fibroblast cells were used to explore the hypoxia-induced TGFβ expression using qPCR, Western blot, and ELISA. Wound healing and transwell assays were performed to evaluate cancer cell migration and invasion. A549 or A549-Luc + WI38 xenograft mouse models were established to detect the intermittent hypoxia (IH) associated with lung tumor growth and epithelial-mesenchymal transition (EMT) in vivo.

RESULTS

OSA promotes CAF activation and enrichment in lung cancer patients. Hypoxia (OSA-like treatment) activated TGFβ signaling in both lung cancer cells and fibroblasts, which promoted cancer cell migration and invasion, and enriched CAFs. IH promoted the progression and EMT process of lung cancer xenograft tumor. Co-inoculation of lung cancer cells and fibroblast cells could further promote lung cancer progression.

CONCLUSIONS

IH promotes lung cancer progression by upregulating TGFβ signaling, promoting lung cancer cell migration, and increasing the CAF activation and proportion of lung tumors.

Possible genetic cross-talk between Down syndrome and obstructive sleep apnea revealed by transcriptomic analysis

PURPOSE

Down syndrome (DS) is linked to a higher prevalence of obstructive sleep apnea (OSA) than in the general population, which in turn contributes to worse cognitive impairment in DS. However, the shared pathogenic mechanisms for DS and OSA remain incompletely illustrated. This study was designed to decipher the genetic cross-talk between DS and OSA by bioinformatics approach.

METHODS

Transcriptomic datasets of DS (GSE59630) and OSA (GSE135917) were accessed from the Gene Expression Omnibus (GEO) repository. After screening out the common differentially expressed genes (DEGs) for DS and OSA, gene ontology (GO) functional enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were carried out. A protein-protein interaction (PPI) network was then constructed to determine essential modules and hub genes. Finally, based on hub genes, transcriptional factor (TF)-gene interaction and TF-miRNA regulatory networks were constructed.

RESULTS

DS and OSA showed 229 DEGs. Functional analyses revealed how oxidative stress and inflammatory response were critical in the progression of DS and OSA. Ten significant hub genes were identified, including TLR4, SOD1, IGF1, FGF2, NFE2L2, PECAM1, S100A8, S100A9, FCGR3A, and KCNA1, which were candidate targets for DS and OSA.

CONCLUSIONS

We found that DS and OSA display similarities in their pathogenesis. Key genes and signaling pathways revealed to be in common between the two conditions could lead us to new therapeutic targets for DS and OSA.

Unveiling the sleep-cardiovascular connection: Novel perspectives and interventions-A narrative review

Introduction

Sleep is an important neurophysiological condition that is intricately linked to general health, laying the basis for both physiological and psychological well-being. A thorough examination of sleep disorders and cardiovascular health demonstrates their deep relationship, emphasizing the numerous diagnostic tools and treatment techniques available.

Aim

This study aims to examine the impact, mechanisms, diagnostic techniques, treatment strategies, implications, and healthcare interventions of the sleep-cardiovascular connection, to better understand the relationship between sleep disorders and cardiovascular health.

Methods

The paper reviews key studies conducted from 2015-till date, investigating the impact of sleep disorders on the cardiovascular system. It looked into data relating to cardiovascular outcomes based on the degree of sleep disorders, considered potential confounding factors, and addressed current research constraints.

Results

The findings highlight a strong link between sleep problems and poor cardiovascular outcomes. Emerging diagnostic tools, such as enhanced sleep-related technology and biomarkers, open up new avenues for determining the impact of sleep disturbances on cardiovascular health. In addition, the research discusses several treatment options, ranging from cognitive behavioral therapy to pharmaceutical therapies, and their potential benefits in addressing sleep-related cardiovascular risks.

Conclusion

The complex association between sleep disturbances and cardiovascular health emphasizes the need to recognize sleep as a critical component of overall well-being. Thus collaboration among medical disciplines, as well as individualized therapies, are critical to improving patient care. Moreover, Understanding and managing the consequences of sleep problems on cardiovascular health can lead to more effective interventions, better outcomes, and improved public health as research advances.

The role of cone-beam computed tomography in the radiographic evaluation of obstructive sleep apnea: A review article

The apnea-hypopnea index is widely regarded as a measure of the severity of obstructive sleep apnea (OSA), a condition characterized by recurrent episodes of apnea or hypopnea during sleep that induce airway collapse. OSA is a catastrophic problem due to the wide range of health issues it can cause, including cardiovascular disease and memory loss. This review was conducted to clarify the roles of various imaging modalities, particularly cone-beam computed tomography (CBCT), in the diagnosis of and preoperative planning for OSA. Unfortunately, 2-dimensional imaging techniques yield insufficient data for a comprehensive diagnosis, given the complex anatomy of the airway. Three-dimensional (3D) imaging is favored as it more accurately represents the patient's airway structure. Although computed tomography and magnetic resonance imaging can depict the actual 3D airway architecture, their use is limited by factors such as high radiation dose and noise associated with the scans. This review indicates that CBCT is a low-radiation imaging technique that can be used to incidentally identify patients with OSA, thereby facilitating early referral and ultimately enhancing the accuracy of surgical outcome predictions.

EEG Power Spectral Density in NREM Sleep is Associated with the Degree of Hypoxia in Patients with Obstructive Sleep Apnea

Purpose

Obstructive sleep apnea (OSA) is a prevalent sleep-related breathing disorder. Research conducted on patients with OSA using electroencephalography (EEG) has revealed a noticeable shift in the overnight polysomnography (PSG) power spectrum. To better quantify the effects of OSA on brain function and to identify the most reliable predictors of pathological cortical activation, this study quantified the PSG power and its association with the degree of hypoxia in OSA patients.

Patients and Methods

This retrospective study recruited 93 patients with OSA. OSA patients were divided into three groups based on their apnea-hypopnea index (AHI) scores. The clinical characteristics and sleep macrostructure of these patients were examined, followed by an analysis of PSG signals. Power spectral density (PSD) in five frequency bands was analyzed during nonrapid eye movement (NREM) sleep, rapid eye movement (REM) sleep, and wakefulness. Finally, correlation analysis was conducted to assess the relationships among PSD, PSG parameters, and serum levels of S100β and uric acid.

Results

Obstructive sleep apnea occurred during both the NREM and REM sleep phases. Except for a decrease in the duration of N2 sleep and an increase in the microarousal index, there were no significant differences in sleep architecture based on disease severity. Compared to the mild OSA group, the theta and alpha band PSD in the frontal and occipital regions during NREM sleep and wakefulness were significantly decreased in the moderate and severe OSA groups. Correlation analysis revealed that theta PSD in N1 and N3 stages were negatively correlated the AHI, oxygen desaturation index, SaO2<90% and microarousal index.

Conclusion

These findings imply that patients with more severe OSA exhibited considerable NREM hypoxia and abnormal brain activity in the frontal and occipital regions. Therefore, sleep EEG oscillation may be a useful neurophysiological indicator for assessing brain function and disease severity in patients with OSA.