Longitudinal study of moderate weight change and sleep-disordered breathing

Biochemical Markers and Obstructive Sleep Apnea Risk in Individuals After Long-Term Bariatric Surgery

BACKGROUND

Individuals who have undergone long-term bariatric surgery may be at increased obstructive sleep apnea (OSA) risk. The purpose of this study was to estimate the frequency of OSA risk and its associations, via biochemical markers, in patients who have undergone long-term bariatric surgery.

METHODS

This cross-sectional study evaluated patients after 5 years or more post Roux-en-Y gastric bypass. Biochemical markers, anthropometrics, and OSA risk, via the STOP-Bang score screening tool, were evaluated. Independent Student t, Pearson's chi-squared, or correlation tests were applied, according to total OSA risk score groups or its isolated components.

RESULTS

Among the 77 patients evaluated (88.3% female; body mass index = 32.7 ± 5.8 kg/ m²; postoperative time = 9.9 ± 3.1 years), 36 were at risk for OSA. OSA risk score was positively correlated to high-sensitivity C-reactive protein levels (r² = 0.270; p = 0.025), triglycerides (r² = 0.338, p = 0.004), total cholesterol (r² = 0,262; p = 0,028), and HbA1c (r² = 0.332; p = 0.005). Compared to each counterpart, basal insulin and triglycerides were higher among those who self-reported witnessed apnea (12.8 ± 6.5 vs 8.1 ± 3.8, p = 0.013; 136.4 ± 41.1 vs 88.5 ± 34.8, p = 0.001, respectively), while levels of total cholesterol and LDL-C were higher in participants who reported tiredness (183.9 ± 27.0 vs 164.8 ± 33.4, p = 0.005; 105.9 ± 24.4 vs 92.0 ± 26.6, p = 0.018). Participants with snoring also had higher levels of triglycerides (107 ± 41.1 vs 83.7 ± 33.9, p = 0.010).

CONCLUSIONS

OSA risk was highly prevalent among patients who had undergone long-term bariatric surgery, as noted via increased STOP-Bang scores, as were isolated components related to inflammatory markers and lipid and glycemic profile.

The Relationship between Cellphone Usage on the Physical and Mental Wellbeing of University Students: A Cross-Sectional Study

(1) Background: The study aims to examine the use of cell phones on physical and mental health status and their impact on personality among university students. (2) Methods: A cross-sectional study was conducted using a semi-structured questionnaire. The association of physical and mental health variables with the demographic variables was examined using Pearson’s correlation and χ2-test. The binary logistic regression model was further used to predict the probabilities of negative impact on personality due to excessive use of cell phones. (3) Results: A total of 400 participants participated with a mean age of 24.45 ± 3.45 years. The average eye strain was more in High cell phone users HCPU than in LCPU and that difference was significant p = 0.000. The average neck pain was more in (HCPU) than Low cell phone users (LCPU) and there was a significant difference between the two groups with p = 0.006. The average weight gain was more in HCPU than LCPU and that difference was significant p = 0.000. Considering back pain, back pain was found more in HCPU as compared to LCPU with a statistical difference at p = 0.027. Cell phone usage significantly correlated with eye strain (r = 0.577, p = 0.000), neck pain (r = 0.543, p = 0.000), back pain (r = 0.611, p = 0.000), weight gain (r = 0.423, p = 0.000), depression (r = 0.430, p = 0.000), loneliness (r = −0.276, p = 0.002), and mood disorder (r = 0.608, p = 0.000). Eye strain, neck pain, and back pain was observed more in HCPU than in LCPU. HCPU felt they gained more weight when compared to the respondents in the LCPU group. HCPU felt more changes in mood and feeling low when compared to the LCPU, while LCPU group felt more lonelier when compared to the HCPU group. (4) Conclusions: The study highlights a significant association between excess use of cell phones and negative effects on physical and mental health wellbeing. Based on the results, it is recommended that more physical activities and alternative to minimize cell phone usage should be planned for the students. Public health policy makers and stakeholder need to address the ill effects of excessive use of cell phones through novel policies., especially young students, and alternatives to reduce their cell phone activities.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Association between obstructive sleep apnea and cardiovascular diseases

Obstructive sleep apnea (OSA) is a common respiratory disorder characterized by partial obstruction of upper respiratory tract and repetitive cessation of breathing during sleep. The etiology behind OSA is associated with the occurrence of intermittent hypoxemia, recurrent arousals and intrathoracic pressure swings. These contributing factors may turn on various signaling mechanisms including elevated sympathetic tone, oxidative stress, inflammation, endothelial dysfunction, cardiovascular variability, abnormal coagulation and metabolic defect ( e.g., insulin resistance, leptin resistance and altered hepatic metabolism). Given its close tie with major cardiovascular risk factors, OSA is commonly linked to the pathogenesis of a wide array of cardiovascular diseases (CVDs) including hypertension, heart failure, arrhythmias, coronary artery disease, stroke, cerebrovascular disease and pulmonary hypertension (PH). The current standard treatment for OSA using adequate nasal continuous positive airway pressure (CPAP) confers a significant reduction in cardiovascular morbidity. Nonetheless, despite the availability of effective therapy, patients with CVDs are still deemed highly vulnerable to OSA and related adverse clinical outcomes. A better understanding of the etiology of OSA along with early diagnosis should be essential for this undertreated disorder in the clinical setting.

Prevalence and associated factors of obstructive sleep apnea in refractory hypertension

BACKGROUND

Refractory hypertension (RfHT) and obstructive sleep apnea (OSA) share common pathophysiological mechanisms and probably are intrinsically associated, but their prevalence, clinical profile, and polysomnography (PSG) pattern remain misunderstood.

OBJECTIVE

To describe OSA prevalence and PSG pattern of patients with RfHT in a large cohort of resistant hypertension (RHT).

METHODS

This is a cross-sectional study involving 418 RHT patients (30.9% male; mean age of 62.5 ± 9.9 years) who were submitted to full-night PSG. RfHT was defined as uncontrolled ambulatory blood pressure monitoring using five or more antihypertensive drugs, including spironolactone. Bivariate analysis compared RHT and RfHT and multivariate analysis was performed to assess the independent correlates of OSA.

RESULTS

A total of 90 patients (21.5%) were diagnosed with RfHT (26.7% male; mean age of 58.5 ± 8.3 years). In comparison with resistant ones, RfHT patients were younger, with higher smoking and previous cardiovascular diseases prevalence, especially stroke. There was no difference regarding anthropometric measures. OSA prevalence (80.0 vs. 82.9%) and moderate/severe OSA (51.1 vs. 57.0%) were similar in both groups as well as apnea-hypopnea index. In its turn, refractory hypertensive patients presented better sleep efficiency (78 vs. 71%), with higher total sleep time (315 vs. 281 min) and lower sleep latency (11 vs. 17 min). There was no difference regarding rapid eye movement sleep, oxygen saturation, microarousals index, and periodic limb movement.

CONCLUSION

In this large RHT cohort, resistant and refractory hypertensive patients have similar OSA prevalence, although refractory ones, which by definition use spironolactone, are younger and apparently have a better sleep pattern.

Association of Preoperative Sleep-Disordered Breathing With Functional Status After Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy

Background

Sleep-disordered breathing (SDB) is a risk factor for heart failure symptoms in patients with hypertrophic cardiomyopathy (HCM). However, the relationship between preoperative SDB and postoperative functional status after septal myectomy (SM) is unknown. In this study, we investigated the association of preoperative SDB with late self-reported health status among patients undergoing SM for obstructive HCM.

Methods

Prior to SM, an overnight pulse oximetry test was used to measure oxygen desaturation index (ODI), which indicates the average number of desaturation episodes with at least 4% of drops in oxygen level from baseline per hour of sleep. Patients reported postoperative function through a questionnaire-based survey completed 3-5 years following SM.

Results

We analyzed 264 patients who underwent transaortic SM from November 2005 through April 2016. On predischarge transthoracic echocardiography post-procedure, no significant difference was present in the extent of mitral valve regurgitation (P = 0.524), left ventricular outflow tract gradient (P = 0.405), or septal thickness (P = 0.744) related to ODI. At 3 to 5 years after their operation, 236 patients (89%) reported good or excellent health. Approximately 18% (n = 48) and 8% (n = 22) of the cohort continued to experience exertional dyspnea and chest tightness, respectively, on walking 2 blocks or less. A greater ODI was not an independent predictor of worse health status or residual symptoms.

Conclusions

Relief of left ventricular outflow tract obstruction in patients with obstructive HCM improves symptoms, with 89% of patients reporting good or excellent health. Preoperative SDB is not significantly associated with late functional status after septal myectomy.

Progression of Obstructive Sleep Apnea Syndrome in Pediatric Patients with Prader-Willi Syndrome

Obstructive sleep apnea syndrome (OSAS) is one of the most common comorbidities in patients with Prader-Willi syndrome (PWS) and causes significant consequences. This observational study was conducted to investigate the progression of OSAS in pediatric patients with PWS, who had not undergone upper airway surgery, through a longitudinal follow-up of their annual polysomnography results. Annual body mass index (BMI), BMI z-score, sleep efficiency and stages, central apnea index (CAI), obstructive apnea-hypopnea index (OAHI), and oxygen saturation nadir values were longitudinally analyzed. At enrollment, of 22 patients (10 boys and 12 girls) aged 11.7 ± 3.9 years, 20 had OSAS. During the 4-year follow-up, only two patients had a spontaneous resolution of OSAS. The average BMI and BMI z-score increased gradually, but CAI and OAHI showed no significant differences. After statistical adjustment for sex, age, genotype, growth hormone use, and BMI z-score, OAHI was associated with the BMI z-score and deletion genotype. In conclusion, OSAS is common in patients with PWS, and rarely resolved spontaneously. Watchful waiting may not be the best OSAS management strategy. Weight maintenance and careful selection of surgical candidates are important for OSAS treatment in patients with PWS.

Treatment options in obstructive sleep apnea

Treatment of OSA with CPAP is currently the recommended treatment and has the greatest evidence of efficacy on AHI, symptoms and comorbidities. Symptomatic patients with moderate-severe OSA generally have good adherence to CPAP therapy, while those with mild OSA, female, young and generally paucisymptomatic, have lower CPAP adherence, especially in the medium and long term. The recent identification of different clinical and pathophysiological phenotypes of OSA has paved the way for alternative treatments to CPAP, leading to an increasingly personalized therapy. Weight loss and lifestyle modifications are highly recommended in all obese or overweight patients. Mandibular advancement devices (MAD), positional therapy (PT) and hypoglossal nerve stimulation (HSN) are recent and personalized alternative therapies on which there is promising and encouraging data but with still little strong scientific evidence. The purpose of this review is to compare the efficacy, adherence and costs of various therapeutic options for OSA patients in the light of recent evidence and to provide useful guidance for specialists.

Holistic care for obstructive sleep apnea (OSA) with an emphasis on restoring nasal breathing: A review and perspective

Obstructive sleep apnea (OSA) is characterized by partial or complete airway blockage during sleep. Nocturnal nasal obstruction usually leads to mouth breathing while sleeping, which worsens sleep apnea by aggravating tongue base and lateral pharyngeal wall collapse. The pathogenesis of OSA is multifactorial, and the precipitating factors vary significantly among individuals. Although continuous positive airway pressure (CPAP) is considered the first-line therapy for OSA, its adherence rate remains a challenge. Oral appliances are more suitable for simple snorers or patients with mild OSA. Maxillomandibular advancement (MMA) is highly effective for treating those with mandibular retrognathia and moderate-to-severe OSA. Intrapharyngeal surgeries yield favorable outcomes in patients with large tonsils and low tongue resting position (Friedman Stage I); however, their efficacy declines with time. Each therapy has its own strength and weakness; thus, the principle of multimodality treatment should be adopted. Nasal surgery plays an indispensable role in the holistic care for OSA. In addition to alleviating nasal congestion, nasal surgery significantly reduces snoring intensity and daytime sleepiness, which improves the quality of life of patients with OSA. Although it significantly reduces the respiratory disturbance index, its effect on the apnea-hypopnea index remains controversial. A combination of nasal surgery and multilevel pharyngeal surgery may result in better prognosis. Nasal surgery can significantly reduce the therapeutic pressure and improve the CPAP compliance of patients undergoing CPAP therapy. In conclusion, multimodality treatment and holistic care for OSA should involve nasal surgery for optimizing treatment outcomes.

Can Weight Loss Improve the Cardiovascular Outcomes of Patients with Obesity and Obstructive Sleep Apnea?

Cardiovascular events are the primary cause of mortality in patients with obstructive sleep apnea and obesity. The rising prevalence of obstructive sleep apnea in recent decades has been linked to increasing rates of obesity. Obstructive sleep apnea has also been linked with many different cardiovascular diseases including coronary artery disease, stroke, heart failure, hypertension, and atrial fibrillation. Obesity is an increasing health concern globally, in part because obesity complications such as hypertension, diabetes, and obstructive sleep apnea increase the risk of cardiovascular diseases. More than 10% weight loss may be required to prevent or reverse obesity complications. Treatment approaches to obesity include nutritional therapy, exercise therapy, pharmacotherapy, and surgical therapies. This review intends to identify the effects of weight loss on cardiovascular outcomes in patients with obesity and obstructive sleep apnea. Despite the strong association between cardiovascular diseases and obstructive sleep apnea, randomized trials have failed to demonstrate that treatment of obstructive sleep apnea reduces cardiovascular events, even in patients with established cardiovascular diseases. Weight loss in patients with obstructive sleep apnea improves HbA1c, systolic blood pressure, HDL cholesterol, and triglycerides, but thus far no changes in cardiovascular events have been shown. The combination of weight loss with continuous positive airway pressure (CPAP) appears more beneficial than either treatment in isolation. Large well-controlled trials in patients with obstructive sleep apnea to assess the effects of different weight reduction programs on cardiovascular disease are still needed.

Current and Novel Treatment Options for OSA

Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy.

The analysis of individual pathophysiological composition opens new directions towards personalised treatment of OSA, focusing not only on pharyngeal dilation, but also on technical or pharmaceutical interventions on muscle function or breathing regulationhttps://bit.ly/3sayhkd

Twenty-four hour urine parameters in nephrolithiasis patients with obstructive sleep apnea syndrome

Objective:

To study 24-hour urine metabolic abnormalities in patients with obstructive sleep apnea syndrome (OSAS), diagnosed by polysomnography. The purpose was to identify whether OSAS is independently associated with a distinctive set of 24-hour urine studies in a cohort of stone formers.

Patients and Methods:

Using our institutional stone database (2013–2017), 1132 consecutive patients with 24-hour urine collections were identified. After applying our exclusion criteria, the final cohort consisted of 376 patients of which 45 patients had OSAS. Descriptive statistics were used to compare 24-hour urine parameters between patients with and without OSAS. Logistic regression models were used to assess the association between OSAS and 24-hour urine parameters.

Results:

On univariate analysis, patients with OSAS were older (57.7 versus 48.2, p < 0.001) with a higher body mass index (BMI) (35 versus 27.8, p < 0.001), and higher likelihood of diabetes mellitus (DM) (57.8 versus 10.6%, p < 0.001) and hypertension (HTN) (60% versus 23.9%, p < 0.001). Patients with OSAS had higher 24-hour total amount of urine volume (2018 versus 1818 ml, p = 0.03), calcium (279.7 versus 208 mg, p = 0.02), oxalate (41.6 versus 31.3 mg, p < 0.001), yet lower 24-hour urine pH (5.75 versus 6.03, p = 0.001). On multivariable linear regression analysis, OSAS did not affect any of the 24-hour urinary parameters.

Conclusion:

OSAS is a prevalent comorbidity among nephrolithiasis patients. We found no major differences in 24-hour urine parameters between nephrolithiasis patients with OSAS and those without OSAS. Further study is needed to determine whether the severity of OSAS and compliance with treatment play a role in the pathogenesis of stone formation.

Level of evidence:

2b

The effects of long-term continuous positive airway pressure on apnea-hypopnea index change following short-term that withdrawal in patients with obstructive sleep apnea

The effect of long‐term continuous positive airway pressure (CPAP) treatment on apnea–hypopnea index (AHI) after CPAP withdrawal remains unclear, especially in obstructive sleep apnea (OSA) patients screened from the population. To examine that, 1241 civil servants who participated in the annual physical examination were screened for OSA between September and December 2017. Screened OSA firstly underwent 1‐week CPAP adherence assessment. Then, patients with good CPAP adherence would be freely provided CPAP to continued treatment. All OSA patients were followed for 2 years. At study end, all OSA patients underwent home sleep testing (HST) again within 1 week of CPAP withdrawal. The effect of 2‐year CPAP treatment on OSA severity was investigated by using linear regression and multinominal logistic regression. In total, 103 OSA patients were screened, including 41 cases (39.8%) in CPAP treatment group and 62 cases (60.2%) in non‐CPAP treatment group. At 2‐year follow‐up, compared with baseline, in CPAP treatment group, following CPAP withdrawal, a significant decrease in AHI was observed in patients with severe OSA (P = 0.014); in non‐CPAP treatment group, a significant increase in AHI was observed in patients with moderate OSA (P = 0.028). After adjustment for confounding factors, multivariate linear regression showed that △AHI was negatively associated with CPAP treatment (β = −4.930, 95% confidence interval [CI] [−9.361, −0.500], P = 0.030). Multinominal logistic regression showed that the AHI of patients not treated with CPAP tended to be unchanged or worsened with the AHI improvement group as a reference (OR [odds ration] [95% CI], 4.555 [1.307, 15.875], P = 0.017; 6.536 [1.171, 36.478], P = 0.032). In conclusion, active OSA screening and long‐term CPAP intervention may improve the severity of severe OSA patients following short‐term CPAP withdrawal in the general population.

Seizures and Sleep: Not such strange bedfellows

It has long been recognised that sleep and deprivation of it have important consequences for cortical excitability, the electroencephalogram and seizure control. However, in the management of people with epilepsy, it is also important to recognise that epilepsy and its treatment may also have significant implications for sleep. Lack of consideration for this bidirectional relationship between sleep and epilepsy may have negative consequences on individuals’ seizure control, quality of life, and other aspects of their health.

Dose-response relationship between weight loss and improvements in obstructive sleep apnea severity after a diet/lifestyle interventions: secondary analyses of the "MIMOSA" randomized clinical trial

STUDY OBJECTIVES

Lifestyle-induced weight loss is a complementary therapeutic approach for obstructive sleep apnea (OSA). We aimed at identifying the dose-response relationship between weight loss and OSA severity improvement.

METHODS

This is a secondary analysis of a 6-month clinical trial in 180 adult, overweight/obese moderate-to-severe OSA patients. Participants were randomized to a standard care, a Mediterranean diet, or a Mediterranean lifestyle arm. All patients were prescribed with continuous positive airway pressure (CPAP), while intervention arms additionally participated in a weight-loss dietary/lifestyle intervention. Based on percent change in weight at 6 months, participants were categorized into a weight-stable/gain (WS/GG) group or 3 weight-loss groups (WLG): < 5%WLG, 5%-10%WLG, and ≥ 10%WLG. Polysomnographic data and OSA symptoms were evaluated preintervention and postintervention.

RESULTS

Respiratory events and oximetry indices improved only in patients who lost weight and improvements were proportional to the degree of weight loss. Median percent change in apnea-hypopnea index (AHI) was -11.7%, - 37.9%, and - 49.3% in the < 5%WLG, 5%-10%WLG, and ≥ 10%WLG, respectively (P < .001). Compared to the WS/GG, the age-, sex-, baseline-, and CPAP use-adjusted relative risk (95% confidence interval) of severe OSA (AHI ≥ 30 events/h) was 0.45 (0.23-0.87) in the 5%-10%WLG and 0.32 (0.17-0.64) in the ≥ 10%WLG; the risk was also lower in the ≥ 10%WLG vs the < 5%WLG (0.42 [0.22-0.82]). Insomnia and daytime sleepiness also improved more in participants exhibiting ≥ 5% weight loss.

CONCLUSIONS

Even a < 5% weight loss can reduce respiratory events, but a ≥ 5% and ideally ≥ 10% weight loss is necessary for reducing the prevalence of severe OSA.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Mediterranean Diet/Lifestyle Intervention in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT02515357; Identifier: NCT02515357.

CITATION

Georgoulis M, Yiannakouris N, Kechribari I, et al. Dose-response relationship between weight loss and improvements in obstructive sleep apnea severity after a diet/lifestyle intervention: secondary analyses of the "MIMOSA" randomized clinical trial. J Clin Sleep Med. 2022;18(5):1251-1261.

Socioeconomic factors do not predict sleep apnea in a population sample from Mecklenburg-Western Pomerania, Germany

PURPOSE

Socioeconomic factors are known to modulate health. Concerning sleep apnea, influences of income, education, work, and living in a partnership are established. However, results differ between national and ethnic groups. Results also differ between various clinical studies and population-based approaches. The goal of our study was to determine if such factors can be verified in the population of Pomerania, Germany.

METHODS

A subgroup from the participants of the population-based Study of Health in Pomerania volunteered for an overnight polysomnography. Their data were subjected to an ordinal regressions analysis with age, sex, body mass index (BMI), income, education, work, and life partner as predictors for the apnea-hypopnea index.

RESULTS

Among the subgroup (N = 1209) from the population-based study (N = 4420), significant effects were found for age, sex, and BMI. There were no significant effects for any of the socioeconomic factors.

CONCLUSION

Significant effects for well-established factors as age, sex, and BMI show that our study design has sufficient power to verify meaningful associations with sleep apnea. The lack of significant effects for the socioeconomic factors suggests their clinical irrelevance in the tested population.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

.

Improving Bed Utilization in a Cohort of Bariatric Surgical Patients Using a Perioperative Obstructive Sleep Apnea Treatment and Bed Triage Protocol

BACKGROUND

Postoperative bariatric management often includes high-intensity monitoring for respiratory complications since > 70% of patients have obstructive sleep apnea. Given the increasing number of bariatric surgeries, there is a need to determine safe and cost-effective processes for postoperative care.The objective of this study was to determine if a novel triage and perioperative management guideline reduces postoperative monitoring and costs following bariatric surgery.

METHODS

Using a pre-post design, this is a retrospective analysis of 501 patients who had bariatric surgery. Half the patients were managed with usual care, and the other half received obstructive sleep apnea screening and treatment of moderate/severe obstructive sleep apnea with perioperative continuous positive airway pressure. The intervention group was triaged preoperatively to a postoperative nursing location based on risk factors.

RESULTS

There were no significant differences in demographics, comorbidities, frequency, or severity of OSA between groups. In the intervention group, there were fewer admissions to the intensive care unit (2.0% vs 9.1%; p < 0.01) and high acuity unit (9.6% vs 18.3%; p < 0.01). The length of stay was shorter in the intervention group (1.3 vs 2.3 days; p < 0.01) with a 50% reduction in costs. There were no statistically significant differences in the incidence of postoperative respiratory and non-respiratory complications between the two groups.

CONCLUSIONS

Most postoperative bariatric surgery patients can be safely managed on the surgical ward with monitoring of routine vitals alone if patients with moderate/severe obstructive sleep apnea receive perioperative continuous positive airway pressure.

The Impact of Sleep-Disordered Breathing on Ghrelin, Obestatin, and Leptin Profiles in Patients with Obesity or Overweight

Background: The impact of concomitant obesity and sleep disorders on neuropeptides related to energy balance is poorly understood. The aim of this study was to assess the nocturnal profile of total ghrelin, obestatin, and leptin in patients with elevated BMI and to investigate the impact of breathing-related sleep disorders on these hormone levels. Methods: The study involved 58 patients with suspicion of obstructive sleep apnea (OSA). Patients underwent anthropometric and sleep examination and measurements of night ghrelin, leptin, and obestatin levels. Results: In patients with OSA (n = 46), recognized on the basis of sleep examination outcomes, the correlation of anthropometric measurements with parameters of sleep disorders and ghrelin levels was observed, contrary to the control group (n = 12). In the OSA group, levels of ghrelin were significantly lower than in the control group at 5:00 and 7:00. Levels of leptin in the OSA group were also lower than those in the control groups (not statistically significant). Profiles of obestatin in both groups were similar. Conclusions: Our results confirm the relationship between obesity and sleep-disordered breathing. Both these disorders affect ghrelin levels—parameters of obesity negatively correlate with hormone concentration, and OSA seems to lower ghrelin values in the second half of the night.

High quality and anti-inflammatory diets and a healthy lifestyle are associated with lower sleep apnea risk

STUDY OBJECTIVES

Most studies on diet and sleep apnea focus on calorie restriction. Here we investigate potential associations between dietary quality [healthy eating index (HEI), dietary inflammatory index (DII)] and overall healthy lifestyle with sleep apnea risk.

METHODS

National Health and Nutrition Examination Survey data (waves 2005-2008, and 2015-2018; N=14,210) were used to determine HEI, DII and their quintiles, with the fifth quintile indicating highest adherence to each dietary construct. A healthy lifestyle score was determined using diet, smoking, alcohol intake and physical activity level. STOP-BANG questionnaire was used to define sleep apnea risk. Generalized linear regression models with binomial family and logit link were used to investigate potential associations. The models were adjusted for socioeconomic status, lifestyle factors and chronic conditions.

RESULTS

Prevalence of high sleep apnea risk was 25.1%. Higher DII was positively associated with sleep apnea (odds ratio (OR)_{Q5 vs. Q1}=1.55; 95% CI: 1.24-1.94; p for trend <0.001) whereas higher HEI was associated with reduced sleep apnea risk (OR_{Q5 VS. Q1}=0.72: 0.59-0.88; p for trend=0.007). Higher healthy lifestyle score was also associated with decreased odds of sleep apnea (p for trend <0.001). There was a significant interaction between healthy lifestyle and sex with sleep apnea risk (p for interaction=0.049) whereby females with higher healthy lifestyle scores had lower risk of sleep apnea versus males.

CONCLUSIONS

Higher quality and anti-inflammatory diets and a healthier overall lifestyle are associated with lower sleep apnea risk. These findings underline the importance of strategies to improve overall diet quality and promote healthy behavior, not just calorie restriction, to reduce sleep apnea risk.

The effect of 4-h versus 6-h time restricted feeding on sleep quality, duration, insomnia severity and obstructive sleep apnea in adults with obesity

BACKGROUND

Time restricted feeding (TRF) involves deliberately restricting the times during which energy is ingested. Preliminary findings suggest that 8-10-h TRF improves sleep. However, the effects of shorter TRF windows (4-6 h) on sleep, remain unknown.

AIMS

This study compared the effects of 4-h versus 6-h TRF on sleep quality, duration, insomnia severity and the risk of obstructive sleep apnea.

METHODS

Adults with obesity (n = 49) were randomized into one of three groups: 4-h TRF (eating only between 3 and 7 p.m.), 6-h TRF (eating only between 1 and 7 p.m.), or a control group (no meal timing restrictions) for 8 weeks.

RESULTS

After 8 weeks, body weight decreased (p < 0.001) similarly by 4-h TRF (-3.9 ± 0.4 kg) and 6-h TRF (-3.4 ± 0.4 kg), versus controls. Sleep quality, measured by the Pittsburgh Sleep Quality Index (PSQI), did not change by 4-h TRF (baseline: 5.9 ± 0.7; week 8: 4.8 ± 0.6) or 6-h TRF (baseline: 6.4 ± 0.8; week 8: 5.3 ± 0.9), versus controls. Wake time, bedtime, sleep duration and sleep onset latency also remained unchanged. Insomnia severity did not change by 4-h TRF (baseline: 4.4 ± 1.0; week 8: 4.7 ± 0.9) or 6-h TRF (baseline: 8.3 ± 1.2; week 8: 5.5 ± 1.1), versus controls. Percent of participants reporting obstructive sleep apnea symptoms did not change by 4-h TRF (baseline: 44%; week 8: 25%) or 6-h TRF (baseline: 47%; week 8: 20%), versus controls.

CONCLUSION

These findings suggest that 4- and 6-h TRF have no effect on sleep quality, duration, insomnia severity, or the risk of obstructive sleep apnea.

Evaluation and Management of Secondary Hypertension

Hypertension is a major cause of cardiovascular morbidity and mortality globally. Many patients with hypertension have secondary causes of hypertension that merit further evaluation. For example, secondary hypertension can result in target organ damage to the heart, kidneys, and brain independent of the effects of blood pressure. Several causes benefit from targeted therapies to supplement first-line antihypertensive agents. However, secondary hypertension is often underrecognized. The goal of this review is to highlight optimal approaches to the diagnosis and management of common causes of secondary hypertension, including primary aldosteronism, renovascular hypertension, obstructive sleep apnea, and drug-induced hypertension.

Economic evaluation of CPAP therapy for obstructive sleep apnea: a scoping review and evidence map

PURPOSE

To synthesize findings of economic evaluations investigating cost-effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) and of strategies of organization of care related to CPAP therapy.

METHODS

Scoping review with searches conducted in MEDLINE, CRD, LILACS, and Embase in August 2020. Eligible studies were economic evaluations comparing CPAP to other alternative or assessing strategies of care for CPAP therapy. Results were presented narratively, and incremental cost-effectiveness ratios (ICER) were presented in evidence maps.

RESULTS

Of 34 studies, 3 concluded that CPAP is less costly and more effective when compared to usual care. Most studies indicated that CPAP is associated with better health outcomes, but at higher prices. ICER ranged from USD 316 to 98,793 per quality-adjusted life years (QALY) gained (median 16,499; IQR 8267 to 33,119). One study concluded that CPAP is more costly and less effective, when treatment is applied to all patients, regardless of disease severity. Variability of ICER was mainly due to definition of population and applied time horizons. When CPAP was compared to mandibular advancement device, ICER ranged from USD 21,153 to 361,028 (median 89,671; IQR 26,829 to 295,983), which represents the investment in CPAP therapy required to obtain one extra QALY. Three studies assessed the effects of organizing CPAP therapy in primary care, which was cost-effective or cost-saving.

CONCLUSIONS

Compared to usual care, CPAP is cost-effective after the second year of treatment, when indicated for moderate-to-severe OSA. CPAP therapy may be even more cost-effective by using different strategies of organization of care. These findings may inform decision making related to CPAP reimbursement in health systems.

CLINICAL TRIAL REGISTRATION NUMBER

Not applicable.

Comparison of anatomic and aerodynamic characteristics of the upper airway among edentulous mild, moderate, and severe obstructive sleep apnea in older adults

STUDY OBJECTIVES

First, to compare the upper airway's anatomic and aerodynamic characteristics of the edentulous older adults who experience mild, moderate, and severe obstructive sleep apnea (OSA). Second, to examine the correlation between the severity of OSA and the anatomic and aerodynamic characteristic(s) of the upper airway in these edentulous individuals.

METHODS

NewTom5G cone beam computed tomography scans of 58 edentulous individuals with mild, moderate, and severe OSA were included in this analysis. 1) Computational models of the upper airway were reconstructed based on cone beam computed tomography images and the anatomical and aerodynamic characteristics of the upper airway were examined by an observer blind to OSA severity. 2) Pearson correlation analysis was used to determine the correlation between apnea-hypopnea index and the anatomic and aerodynamic characteristics of the upper airway.

RESULTS

Compared with edentulous patients with mild and moderate OSA, those with severe OSA have a more hourglass-shaped upper airway. The severity of OSA, namely, apnea-hypopnea index, was significantly correlated with the length, shape, and minimum cross-sectional area of the upper airway. During inspiration, the mean velocity of the airflow within the upper airway of the edentulous patients with severe OSA was higher than that of patients with mild and moderate OSA. During both inspiration and expiration, apnea-hypopnea index was found to be significantly correlated with maximum velocity (P = .05) and airway resistance (P = .024, 0.038).

CONCLUSIONS

The edentulous patients with severe OSA have a more hourglass-shaped upper airway. The findings also suggest that, during inspiration, the airflow travels faster in edentulous patients with severe OSA than in those with mild or moderate OSA.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: The Effect of Nocturnal Wear of Dentures on Sleep and Oral Health Related Quality of Life; URL: https://clinicaltrials.gov/ct2/show/NCT01868295; Identifier: NCT01868295.

CITATION

Chen H, Elham E, Li Y, et al. Comparison of anatomic and aerodynamic characteristics of the upper airway among edentulous mild, moderate, and severe obstructive sleep apnea in older adults. J Clin Sleep Med. 2022;18(3):759-768.

The Relationship Between Obstructive Sleep Apnea (OSA) and Gastroesophageal Reflux Disease (GERD) in Inpatient Settings: A Nationwide Study

Introduction: Several studies identified a link between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA). GERD is a condition in which acid reflux from the stomach to the esophagus causes troublesome symptoms. On the other hand, OSA is defined as a sleep-related breathing disorder in which airflow significantly decreases or ceases due to upper airway obstruction, leading to arousal from sleep. OSA was found to be associated with GERD. In this study, we aim to study the characteristics and concurrent risk factors associated with GERD and OSA in a large population-based study.

Methods: Patients with the diagnosis of GERD were extracted from the National Inpatient Database (NIS) for the years 2016 to 2019. Patients' age, gender, race, and hospital information, including region and bed size, were extracted and considered as baseline characteristics. The comorbidities included are hypertension (HTN), atrial fibrillation (AFib), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pulmonary hypertension (PHTN), obesity, and smoking. Patients younger than 18 years old were excluded from this study. 

Results: Out of 22,677,620 patients with the diagnosis of GERD, 12.21% had a concurrent diagnosis of OSA (compared to 4.79% in patients without GERD, p-value <0.001). The mean age of patients with GERD and OSA was 64.47 years vs 65.42 years in patients without OSA (p-value <0.001). The GERD and OSA group had almost identical gender distribution compared to the GERD only group, as it was predominantly female patients. The white and black races were slightly more prevalent in the GERD and OSA group compared to the GERD only group. Regarding comorbidities, the prevalence of obesity was more clear in the GERD and OSA group. It was noted that the group of patients who carry a diagnosis of GERD and OSA have more prevalence of diabetes (DM), hypertension (HTN), obesity, atrial fibrillation (Afib), congestive heart failure (CHF), and pulmonary hypertension (PHTN). Patients with GERD and OSA were 21% less likely to be older than 65 years rather than younger (95% CI: 0.79-0.8, p-value <0.001), 35% less likely to be females (95% CI: 0.65-0.65, p-value <0.001), and 22% less likely to be non-white (95% CI: 0.77-0.8, p-value <0.001). Obesity was found to be the strongest association with this population, followed by PHTN, CHF, DM, HTN, Afib, and lastly smoking.

Conclusion: Patients with GERD and OSA were found more likely to be female, white, living in the southern part of the United States, obese, diabetes mellitus type 2, and being active smokers. 

Combined application of pharyngeal volume and minimal cross-sectional area may be helpful in screening persons suspected of obstructive sleep apnea (OSA)

BACKGROUND

Obstructive sleep apnea (OSA) is a common disease that seriously affects human health and daily life. However, the gold standard for its diagnosis, polysomnography (PSG), is expensive resulting in inadequate diagnosis of this disease in primary clinics. Therefore, a simple and rapid method for initial screening for OSA is needed. Acoustic pharyngometry (APh) is an FDA-approved noninvasive method that is gradually being applied to screening for OSA.

MATERIALS AND METHODS

In this study, we applied analysis with receiver operating characteristic (ROC) curves to explore how APh may play a greater role in the screening of subjects with suspected OSA. Patients admitted into the departments of otolaryngology at our hospital from March 2017 to May 2019 were recruited into the study. All subjects underwent PSG monitor and were separated into two groups according to the apnea-hypopnea index (AHI) from the PSG results: OSA group (AHI ≥ 5) and control group (AHI < 5). APh measurements and other indicators of the subjects, including age, height, and weight; Epworth Sleepiness Scale (ESS) score; and the pharynx examination, including the degree of tonsil enlargement and tongue hypertrophy, were also be recorded.

RESULTS

The t-test results showed that almost all indicators except age and height have significant differences between the OSA group and control group. Subjects with OSA had greater weight, BMI, ESS, higher degree of tonsil enlargement, and tongue hypertrophy, while they had smaller minimal cross-sectional area (mCSA) and pharyngeal volume than the subjects in control group. The correlation analysis revealed that pharyngeal volume and mCSA were two helpful indicators to screen for OSA. Furthermore, we established the ROC curve and calculated the combining predictors (combining predictors = pharyngeal volume + mCSA * (- 2.347)/(- 0.225)). The area under the ROC curve (AUC) of combining predictors was 0.917 (95% CI 0.842-0.991, P < 0.001), which was higher than combinations of other two independent indicators. The cutoff point of combining predictors was found to be 59.84 (AUC = 0.917, sensitivity = 0.80, 1-specificity = 0.06, P < 0.001).

CONCLUSIONS

These findings suggest that APh is a simple, rapid, and economical detection method which may be useful in screening for OSA, especially in communities and primary clinics where PSG cannot be performed.

Management of Obstructive Sleep Apnea in Patients With Heart Failure

Sleep apnea is traditionally classified as obstructive sleep apnea (OSA), which occurs when the upper airway collapses due to the relaxation of oropharyngeal musculature, and central sleep apnea occurs when the brainstem cannot stimulate breathing. Most sleep apnea in patients with heart failure (HF) results from coexisting OSA and central sleep apnea (CSA), or complex sleep apnea syndrome. OSA and CSA are common in HF and can be involved in its progression by exposure to the heart to intermittent hypoxia, increased preload and afterload, activating sympathetic, and decreased vascular endothelial function. A majority of treatments have been investigated in patients with CSA and HF; however, less or short-term randomized trials demonstrated whether treating OSA in patients with HF could improve morbidity and mortality. OSA could directly influence the patient's recovery. This review will focus on past and present studies on the various therapies for OSA in patients with HF and summarize CSA treatment options for reasons of reference and completeness. More specifically, the treatment covered include surgical and non-surgical treatments and reported the positive and negative consequences for these treatment options, highlighting possible implications for clinical practice and future research directions.

Smoking Obstructive Sleep Apnea: Arguments for a Distinctive Phenotype and a Personalized Intervention

Background: This is the first study that aims to define smoking, with obstructive sleep apnea (OSA), as a phenotype (SOSA). Moreover, we wanted to demonstrate the deleterious effects of the continuation of smoking on OSA. Methods: The cross-sectional study highlighted four dimensions of SOSA: the demographic and anthropometric features, the symptoms, the comorbidities, and the sleep study parameters. This study compared these characteristics between current smokers (CS), those who have never smoked (NS), and ex-smokers (ES) with OSA. Results: More men (83.95% in CS, versus 66.67% in NS) and an earlier onset of OSA (average age = 50.05 in CS, versus 52.26 in NS, p = 0.04) were recorded among CS. The distinguishing symptom of CS was daytime sleepiness, with an Epworth score that was significantly higher than in NS. Chronic obstructive pulmonary disease (COPD) was significantly more prevalent in CS (38.27%) than in NS (1.51%) (p < 0.001). The severity of OSA, consisting of a higher apnea-hypopnea index, a higher oxygen desaturation index, and a longer time spent below 90% oxygen saturation during sleep was significantly influenced by smoking. Conclusions: The SOSA phenotype includes younger male patients with a higher waist circumference, suggesting central obesity. They have a higher prevalence of COPD and a greater severity of OSA, in correlation with the number of pack-years of smoking.

Obstructive Sleep Apnea Syndrome Comorbidity Phenotypes in Primary Health Care Patients in Northern Greece

Background: Obstructive sleep apnea syndrome (OSAS) is a significant public health issue. In the general population, the prevalence varies from 10% to 50%. We aimed to phenotype comorbidities in OSAS patients referred to the primary health care (PHC) system. Methods: We enrolled 1496 patients referred to the PHC system for any respiratory- or sleep-related issue from November 2015 to September 2017. Some patients underwent polysomnography (PSG) evaluation in order to establish OSAS diagnosis. The final study population comprised 136 patients, and the Charlson comorbidity index was assessed. Categorical principal component analysis and TwoStep clustering was used to identify distinct clusters in the study population. Results: The analysis revealed three clusters: the first with moderate OSAS, obesity and a high ESS score without significant comorbidities; the second with severe OSAS, severe obesity with comorbidities and the highest ESS score; and the third with severe OSAS and obesity without comorbidities but with a high ESS score. The clusters differed in age (p < 0.005), apnea–hypopnea index, oxygen desaturation index, arousal index and respiratory and desaturation arousal index (p < 0.001). Conclusions: Predictive comorbidity models may aid the early diagnosis of patients at risk in the context of PHC and pave the way for personalized treatment.

Overview of the Role of Pharmacological Management of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) remains a prominent disease state characterized by the recurrent collapse of the upper airway while sleeping. To date, current treatment may include continuous positive airway pressure (CPAP), lifestyle changes, behavioral modification, mandibular advancement devices, and surgical treatment. However, due to the desire for a more convenient mode of management, pharmacological treatment has been thoroughly investigated as a means for a potential alternative in OSA treatment. OSA can be distinguished into various endotypic or phenotypic classes, allowing pharmacological treatment to better target the root cause or symptoms of OSA. Some medications available for use include antidepressants, CNS stimulants, nasal decongestants, carbonic anhydrase inhibitors, and potassium channel blockers. This review will cover the findings of currently available and future study medications that could potentially play a role in OSA therapy.

Differences in Symptoms and Severity of Obstructive Sleep Apnea between Black and White Patients

Rationale: Prior work suggests that Black patients have more severe obstructive sleep apnea (OSA) upon clinical presentation. However, the extent to which this may reflect differences in symptoms or other standard measures of OSA risk is unclear. Objectives: We assessed for racial disparities in OSA characteristics at time of initial clinical diagnosis. Methods: Data from 890 newly diagnosed patients with OSA at an urban academic sleep center were included in this analysis. All patients completed a standardized questionnaire on demographics and sleep-related symptoms and underwent laboratory polysomnography. Symptom severity at the time of evaluation was compared across race and sex. Results: Black men were underrepresented in the sleep lab, making up only 15.8% of the cohort and 31.3% of Black participants (P < 0.001). Despite this, Black men had the most severe OSA with a mean apnea hypopnea index of 52.4 ± 39.4 events/hour, compared with 39.0 ± 28.9 in White men, 33.4 ± 32.3 in Black women, and 26.2 ± 23.8 in White women (P < 0.001 for test of homogeneity). Black men also had the greatest burden of OSA symptoms with the highest mean Epworth Sleepiness Scale score (12.2 ± 5.9 versus 9.4 ± 5.2 in White men, 11.2 ± 5.9, in Black women, and 9.8 ± 5.6 in White women; P < 0.001). Compared with White men, Black men were 1.61 (95% CI [1.04-2.51]) times more likely to have witnessed apneas and 1.56 (95% CI [1.00-2.46]) times more likely to have drowsy driving at the time of OSA diagnosis. Conclusions: At the time of clinical diagnosis, Black men have greater disease severity, suggesting delay in diagnosis. Further, the greater burden of classic OSA symptoms suggests the delayed diagnosis of OSA in Black men is not due to atypical presentation. Further research is needed to identify why screening methods for OSA are not equitably implemented in the care of Black men.

Leptin: A Potential Link Between Obstructive Sleep Apnea and Obesity

Chronic intermittent hypoxia (CIH), a pathophysiological manifestation of obstructive sleep apnea (OSA), is strongly correlated with obesity, as patients with the disease experience weight gain while exhibiting elevated plasma levels of leptin. This study was done to determine whether a relationship may exist between CIH and obesity, and body energy balance and leptin signaling during CIH. Sprague-Dawley rats were exposed to 96 days of CIH or normoxic control conditions, and were assessed for measures of body weight, food and water intake, and food conversion efficiency. At the completion of the study leptin sensitivity, locomotor activity, fat pad mass and plasma leptin levels were determined within each group. Additionally, the hypothalamic arcuate nucleus (ARC) was isolated and assessed for changes in the expression of proteins associated with leptin receptor signaling. CIH animals were found to have reduced locomotor activity and food conversion efficiency. Additionally, the CIH group had increased food and water intake over the study period and had a higher body weight compared to normoxic controls at the end of the study. Basal plasma concentrations of leptin were significantly elevated in CIH exposed animals. To test whether a resistance to leptin may have occurred in the CIH animals due to the elevated plasma levels of leptin, an acute exogenous (ip) leptin (0.04 mg/kg carrier-free recombinant rat leptin) injection was administered to the normoxic and CIH exposed animals. Leptin injections into the normoxic controls reduced their food intake, whereas CIH animals did not alter their food intake compared to vehicle injected CIH animals. Within ARC, CIH animals had reduced protein expression of the short form of the obese (leptin) receptor (isoform OBR₁₀₀) and showed a trend toward an elevated protein expression of the long form of obese (leptin) receptor (OBRb). In addition, pro-opiomelanocortin (POMC) protein expression was reduced, but increased expression of the phosphorylated extracellular-signal-regulated kinase 1/2 (pERK1/2) and of the suppressor of cytokine signaling 3 (SOCS3) proteins was observed in the CIH group, with little change in phosphorylated signal transducer and activator of transcription 3 (pSTAT3). Taken together, these data suggest that long-term exposure to CIH, as seen in obstructive sleep apnea, may contribute to a state of leptin resistance promoting an increase in body weight.

Predictors and outcomes of obstructive sleep apnea in patients with chronic obstructive pulmonary disease in China

BACKGROUND

"Overlap syndrome" refers to obstructive sleep apnea (OSA) combined with chronic obstructive pulmonary disease (COPD), and has poorer outcomes than either condition alone. We aimed to evaluate the prevalence and possible predictors of overlap syndrome and its association with clinical outcomes in patients with COPD.

METHODS

We assessed the modified Medical Research Council dyspnea scale (mMRC), Epworth sleepiness scale (ESS), COPD assessment test (CAT), Hospital Anxiety and Depression Scale (HADS), Charlson Comorbidity Index (CCI), and STOP-Bang questionnaire (SBQ) and performed spirometry and full overnight polysomnography in all patients. An apnea-hypopnea index (AHI) ≥ 5 events per hour was considered to indicate OSA. Risk factors for OSA in COPD patients were identified by univariate and multivariate logistic regression analyses.

RESULTS

A total of 556 patients (66%) had an AHI ≥ 5 events per hour. There were no significant differences in age, sex ratio, mMRC score, smoking index, number of acute exacerbations and hospitalizations in the last year, and prevalence of cor pulmonale between the two groups (all p > 0.05). Body mass index (BMI), neck circumference, CAT score, CCI, ESS, HADS, and SBQ scores, forced expiratory volume (FEV)1, FEV1% pred, FEV1/forced vital capacity ratio, and prevalence of hypertension, coronary heart disease, and diabetes were all significantly higher and the prevalence of severe COPD was significantly lower in the COPD-OSA group compared with the COPD group (p < 0.05). BMI, neck circumference, ESS, CAT, CCI, HADS, hypertension, and diabetes were independent risk factors for OSA in COPD patients (p < 0.05). SBQ could be used for OSA screening in patients with COPD. Patients with severe COPD had a lower risk of OSA compared with patients with mild or moderate COPD (β =  - 0.459, odds ratio = 0.632, 95% confidence interval 0.401-0.997, p = 0.048).

CONCLUSION

Patients with overlap syndrome had a poorer quality of life, more daytime sleepiness, and a higher prevalence of hypertension and diabetes than patients with COPD alone. BMI, neck circumference, ESS, CAT, CCI, HADS, hypertension, and diabetes were independent risk factors for OSA in patients with COPD. The risk of OSA was lower in patients with severe, compared with mild or moderate COPD.

Emerging Treatments for Insomnia, Sleep Apnea, and Restless Leg Syndrome Among Dialysis Patients

Sleep disturbances are highly prevalent in patients with predialysis chronic kidney disease, end-stage kidney disease, and after a kidney transplant. They contribute to impairment in daily function and are associated with a high burden of physical and psychiatric symptoms, decreased quality of life, and increased morbidity and mortality. Sleep disturbances also may precipitate and accelerate kidney disease progression. They often evolve across the spectrum of kidney dysfunction and may persist or re-emerge in kidney transplant recipients. Investigation into the multifaceted and dynamic relationships between sleep disturbance and chronic kidney disease requires consideration of myriad contributors including the progression of kidney disease itself, the role of treatment via dialysis and kidney transplant, psychosocial factors, and underlying sleep disorders. Despite sleep disturbance being identified as a priority to address by patients and caregivers, sleep disorders including insomnia, sleep apnea, and restless leg syndrome remain under-recognized and undertreated, and innovation in their management remains modest. In this article, we review the relationships between sleep disturbance and kidney disease, the impact of sleep disturbance and sleep disorders on symptom burden and mental health, and treatment opportunities that may address overlapping symptoms across the spectrum of kidney disease and that could improve patient-related and clinical outcomes.

STOP-BANG screener vs objective obstructive sleep apnea testing among younger veterans with PTSD and insomnia: STOP-BANG does not sufficiently detect risk

STUDY OBJECTIVES

Posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) cooccur even in veterans who are younger with lower body mass index. The STOP-BANG screener for OSA relies heavily on high blood pressure, age, and body mass index and may not generalize to veterans with PTSD. The inability to effectively screen veterans for OSA is problematic given negative outcomes of untreated OSA.

METHODS

Our study compared the STOP-BANG to objective OSA diagnostic testing in 48 younger veterans (mean age 43.7 years; 43.8% Caucasian; 20.8% female) seeking treatment for PTSD and insomnia. Apnea-hypopnea events per hour (apnea-hypopnea index), recorded by NOX T3 sleep monitors, were used to diagnose OSA (apnea-hypopnea index ≥ 5 events/h). Logistic regressions examined how STOP-BANG cut-off scores (≥ 3 and ≥ 5) classified OSA status (apnea-hypopnea index ≥ 5 events/h). Follow-up chi-square goodness-of-fit tests examined single-item STOP-BANG performance in the OSA-positive subsample (n = 28).

RESULTS

The STOP-BANG (≥ 3) had good sensitivity (92.6%) but poor specificity (47.6%) and negative (0.16) and positive (1.77) likelihood ratios. The STOP-BANG (≥ 5) led to improved specificity (76.19%), but sensitivity (37.04%) and positive (1.56)/negative likelihood ratios (0.83) were poor. Single-item OSA subgroup analyses revealed that body mass index, age, and neck circumference performed poorly, while tiredness and sex performed well.

CONCLUSIONS

Findings suggest that the STOP-BANG correctly diagnosed OSA in some veterans but missed OSA in large number of younger veterans with PTSD. This suggests objective diagnostic OSA testing is needed in veterans with PTSD. Future research is needed to develop more accurate OSA screening measures in this population.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Integrated CBT-I on PE and PTSD Outcomes (Impact Study); URL: https://www.clinicaltrials.gov/ct2/show/NCT02774642; Identifier: NCT02774642.

CITATION

Lyons R, Barbir LA, Owens R, Colvonen PJ. STOP-BANG screener vs objective obstructive sleep apnea testing among younger veterans with PTSD and insomnia: STOP-BANG does not sufficiently detect risk. J Clin Sleep Med. 2022;18(1):67-73.

Obesity-related kidney disease: Beyond hypertension and insulin-resistance

Chronic kidney disease (CKD) causes considerable morbidity, mortality, and health expenditures worldwide. Obesity is a significant risk factor for CKD development, partially explained by the high prevalence of diabetes mellitus and hypertension in obese patients. However, adipocytes also possess potent endocrine functions, secreting a myriad of cytokines and adipokines that contribute to insulin resistance and induce a chronic low-grade inflammatory state thereby damaging the kidney. CKD development itself is associated with various metabolic alterations that exacerbate adipose tissue dysfunction and insulin resistance. This adipose-renal axis is a major focus of current research, given the rising incidence of CKD and obesity. Cellular senescence is a biologic hallmark of aging, and age is another significant risk factor for obesity and CKD. An elevated senescent cell burden in adipose tissue predicts renal dysfunction in animal models, and senotherapies may alleviate these phenotypes. In this review, we discuss the direct mechanisms by which adipose tissue contributes to CKD development, emphasizing the potential clinical importance of such pathways in augmenting the care of CKD.

Obesity and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is characterized by upper airway collapse during sleep. Chronic intermittent hypoxia, sleep fragmentation, and inflammatory activation are the main pathophysiological mechanisms of OSA. OSA is highly prevalent in obese patients and may contribute to cardiometabolic risk by exerting detrimental effects on adipose tissue metabolism and potentiating the adipose tissue dysfunction typically found in obesity. This chapter will provide an update on: (a) the epidemiological studies linking obesity and OSA; (b) the studies exploring the effects of intermittent hypoxia and sleep fragmentation on the adipose tissue; (c) the effects of OSA treatment with continuous positive airway pressure (CPAP) on metabolic derangements; and (d) current research on new anti-diabetic drugs that could be useful in the treatment of obese OSA patients.

Association of Dietary Behaviors with Poor Sleep Quality and Increased Risk of Obstructive Sleep Apnea in Korean Military Service Members

PURPOSE

Sleep quality among military service members is important for enhancing their capabilities and preventing psychiatric problems. We aimed to explore the association of dietary behaviors with poor sleep quality and increased risk of obstructive sleep apnea (OSA) in military men on active duty.

PATIENTS AND METHODS

A large-scale multi-site cross-sectional survey was conducted in five units of the Republic of Korea's army. Poor sleep quality and increased risk of OSA were defined using the Pittsburgh sleep quality index (PSQI) and Berlin Questionnaire, respectively. Information on dietary behaviors, including the frequency of skipping breakfast, eating snacks, consuming a night meal, and overeating, were collected.

RESULTS

From August 2021 to September 2021, 4389 male respondents, mean age (20.8 ± 1.3 years), completed the survey; 2579 (58.8%) were assessed as having poor sleep quality, and 614 (14.0%) increased risk of OSA. After adjusting for lifestyle and occupational covariates, skipping breakfast 1-2 times weekly was associated with an increased likelihood of experiencing poor sleep quality, compared with not skipping breakfast (odds ratio: 1.23 [95% CI 1.02-1.47]). Eating night meals 5-6 times weekly was also associated with poor sleep quality (odds ratio: 5.54 [95% CI 2.49-14.18]). In addition, skipping breakfast daily (odds ratio: 2.28 [95% CI 1.27-4.03]) and eating night meals daily (odds ratio: 2.30 [95% CI 1.21-4.22]) were related to an increased risk of OSA.

CONCLUSION

Dietary behaviors appear to be related to poor sleep quality and a high risk of OSA. To improve sleep quality, dietary factors could be considered when promoting health programs for military personnel in further research.

Surfactant protein D concentration in a pediatric population with suspected sleep disorder

Obstructive sleep apnea (OSA) affects between 2% and 4% in children and there is a search for new biomarkers that can be useful both in the diagnosis and in the evolution of the disease. The surfactant protein D (SP-D) is a collection that is part of the innate immune system exerting an anti-inflammatory and antimicrobial effect. Thus, the objective of this study was to evaluate the concentration of SP-D in the suspect OSA pediatric population. A total of 178 children were recruited in this prospective study. Blood samples, sleep parameters, feeding habits, anthropometric, sociodemographic, and family data were collected. Specific biochemical determinations were made, and the plasmatic concentrations of SP-D were measured by enzyme-linked immunosorbent assay. We found no statistical correlation between the SP-D concentration and the apnea-hypopnea index (AHI) from the data. Nevertheless, the changes in SP-D levels could be correlated to a large extent by the arousals that often go along with hypopneas (r = -0.258, p = 0.011 unadjusted; r = -0.258, p = 0.014 adjusted by age and body mass inded [BMI] Z-score). Intermittent hypoxia was correlated with C-reactive protein levels (r = 0.547, p < 0.001 unadjusted; r = 0.542, p < 0.001 adjusted by age and BMI Z-score). Although AHI and SP-D did not appear to correlate, a secondary analysis suggests that sleep fragmentation, which is produced by arousals, may do, and further research is needed to determine the mechanisms by which changes in SP-D occur in OSA.

Comorbidities associated with high-risk obstructive sleep apnea based on the STOP-BANG questionnaire: a nationwide population-based study

BACKGROUND/AIMS

We investigated the prevalence, associated factors, and comorbidities of high-risk obstructive sleep apnea (OSA) as determined by the STOP-BANG questionnaire in a Korean adult population.

METHODS

Data were obtained from 7,650 adults (aged ≥ 40 years) who participated in the Korea National Health and Nutrition Examination Survey (2019-2020). Multiple logistic regression analyses were used to evaluate the association of socioeconomic status, lifestyle related factors, and comorbidities with high-risk OSA (STOP-BANG score, 5-8).

RESULTS

The prevalence of high-risk OSA according to the STOP-BANG questionnaire was 12.0 %. Older age, male, current smoking, heavy alcohol consumption, and more comorbidities were associated with higher STOP-BANG scores. In multivariable adjusted analysis, diabetes mellitus (DM) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.25 to 1.97), hypertension (OR, 4.81; 95% CI, 3.88 to 5.97), and obesity (OR, 2.02; 95% CI, 1.60 to 2.56) were associated with high risk of OSA, and when hypertension, DM, and obesity were combined, the risk increased synergistically (OR, 3.88; 95% CI, 2.94 to 5.11).

CONCLUSION

According to the STOP-BANG questionnaire, the high risk of OSA was more common in males, and was associated with chronic metabolic disease, particularly in those with DM, hypertension, and obesity combined. Active OSA screening, prevention, and management may be beneficial to improving health outcomes related to OSA in these populations.

Airway morphology and its influence on OSA severity and surgical intervention: a retrospective study

Introduction: The aim was to assess the relationship between airway morphology and surgical intervention in a cohort of patients presenting with increased body mass index (BMI) and a confirmed diagnosis of obstructive sleep apnoea (OSA). A secondary aim was to revisit the relationship between morphology and OSA severity.

Methods: A retrospective analysis was conducted of pre-operative maxillofacial 3D-CT scans of thirty-two patients with a confirmed diagnosis of OSA who received treatment from an ear nose and throat specialist (ENT). Lateral cephalograms were imported into Quick Ceph Studio (Quick Ceph Systems Inc, San Diego, CA, USA) after which linear and angular measurements of selected hard and soft tissues were obtained. 3D-CT images were loaded into the software program 3dMDVultus (3dMD) which permitted 3D visualisation of the airway. Measurements were repeated 3 times on the images of six patients after an interval of two weeks to establish the intraclass correlation coefficient (ICC) for intra-examiner accuracy and reliability. Logistic regression was applied to determine the relationships between morphology, OSA and surgical treatments.

Results: A positive correlation was found between age and the apnoea-hypopnea index (AHI). Morphological measurements of the airway did not exhibit a positive relationship with OSA severity. Posterior airway space at the level of the uvula and tongue, the length of the soft palate and position of the hyoid bone were significantly associated with BMI. No variables were found to be correlated with uvulopalatopharyngoplasty (UPPP) surgery. Notwithstanding, airway length and posterior airway space at the level of the uvula tip were significantly associated with tongue channelling.

Conclusions: Radiographic airway assessment is an invaluable and opportunistic tool for screening OSA but requires judicial use in its prescription and interpretation. There is little correlation between OSA severity and airway morphology and between surgical intervention and morphology. Additional factors need to be considered before a treatment modality is considered and is best managed in a multidisciplinary setting.

Prevalence and Characteristics of Erectile Dysfunction in Obstructive Sleep Apnea Patients

BACKGROUND

Obstructive sleep apnea (OSA) is a common and severe social problem. Erectile dysfunction (ED) is an important health concern. The prevalence of OSA with ED is increasing, which significantly affects the quality of life and work efficiency of patients. However, the mechanism underlying the comorbidity of these two diseases remains unclear.

OBJECTIVES

(1) Investigate the prevalence of OSA with ED; (2) analyze the correlation between OSA and ED; and (3) explore the treatment response to and possible mechanism of uvulapalatopharyngoplasty (UPPP) in patients with OSA and ED. This study aims to provide a theoretical basis for the clinical diagnosis and comprehensive treatment of OSA with ED and improve prevention and treatment strategies.

MATERIALS AND METHODS

In total, 135 subjects were enrolled in the study. Clinical data, polysomnography, the ESS score, Beck anxiety score, Beck depression score, IIEF-5 score and ASEX score were recorded before UPPP and 6 months after UPPP. Sex hormones were measured for all subjects using a Roche electrochemiluminescence analyzer.

RESULT

The prevalence of OSA with ED was 64.52%, and the prevalence of severe OSA with ED was 73.02%. The prevalence of OSA with ED increased with age, BMI and apnea-hypopnea index (AHI) value. Among polysomnography indicators, minimum oxygen saturation and average oxygen saturation may predict the occurrence of OSA with ED. Improving the patient's anxiety and depression is very important for treating OSA with ED. Sex hormone levels were not significantly correlated with the occurrence of OSA with ED.

CONCLUSION

ED is a common symptom of OSA patients. This study showed that sex hormone levels in OSA patients with ED were not significantly correlated with the condition, but further investigation of this relationship is worthwhile. It is recommended that the free and combined types of sex hormones be further distinguished during testing because the free type is the active form. UPPP surgical treatment is effective for OSA with ED, and its possible mechanism is protection of the peripheral nerves of the sex organs by improving nighttime hypoxia and arousal.