The association between sleep and diabetes outcomes - A systematic review

Assessing the level of device-measured physical activity according to insomnia symptoms in 1,354 individuals with diabetes: the HUNT Study, Norway

Background

Insomnia symptoms that influence daytime functioning are common among adults with type 2 diabetes. However, no previous study has examined if levels of physical activity differ among adults with diabetes with and without insomnia symptoms. Thus, the aim of this study was to assess the difference in total physical activity (TPA) and moderate-to-vigorous physical activity (MVPA) levels in individuals with diabetes with and without insomnia symptoms.

Methods

This cross-sectional study included 1,354 participants with any type of diabetes who participated in the Norwegian HUNT4 Study, 2017-19. Participants were defined to have 'insomnia symptoms' if they reported difficulty initiating and/or maintaining sleep ≥ 3 nights/week during the last 3 months. MVPA (defined as moderate/brisk walking [> 4.0 km/h], running, and cycling), and TPA (MVPA including slow walking [≤ 4.0 km/h]) were determined from two accelerometers worn on the thigh and lower back. Analyses were stratified by age and sex.

Results

The median age was 67 years and 491 (36%) had insomnia symptoms and 37 (3%) had insomnia disorder. Among women, 28% with one or more insomnia symptoms fulfilled the recommended minimum level of physical activity, as compared to 34% in women without insomnia symptoms. The corresponding proportions in men were 48% and 45%. Women above 65 years with insomnia symptoms performed less TPA (-73 min/week, 95% CI -122 to -24) and MVPA (-33 min/week, 95% CI -50 to -15), compared to women without insomnia symptoms in the same age group. There was no clear difference in physical activity levels according to insomnia symptoms in men or women below 65 years. Women and men with insomnia disorder had substantially lower TPA (women: -192 min/week, 95% CI -278 to -106; men: -276 min/week, 95% CI -369 to -193) and MVPA (women: -37 min/week, 95% CI -63 to -11; men: -67 min/week, 95% CI -83 to -50) than those without insomnia symptoms.

Conclusions

This study showed that women above 65 years with insomnia symptoms and individuals with insomnia disorder performed less physical activity, suggesting that these subgroups may suffer from additional challenges that prevent them from engaging in regular physical activity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44167-024-00066-4.

Sleep disorders in younger and middle-older age adults with newly diagnosed type 2 diabetes mellitus: A retrospective cohort study in >1million individuals

AIMS

To explore the 5-year incidence and relative rates of sleep disorders in younger (16-≤40 years) and middle-older (=>40 years) age adults with and without newly diagnosed type 2 diabetes.

METHODS

This retrospective, observational cohort study utilised data from the US Collaborative Network within the TriNetX database. We compared 5-year cumulative incidence of sleep disorders in younger (n = 110,088) and middle-older populations (n = 1,185,961).

RESULTS

The absolute risk of developing any type of sleep disorder was greater in individuals with type 2 diabetes vs. those without. Over the 5-year follow-up period, 14.2 % of younger adults and 18.5 % of middle-older age adults with newly diagnosed type 2 diabetes developed any form of sleep disorder, compared to 4.5 % and 7.9 % propensity matched individuals without diabetes. We observed a more pronounced relative rate across the observed sleep disorders in younger adults.

CONCLUSIONS

The 5-year risk of sleep disorders is higher in those with newly diagnosed type 2 diabetes vs. those without. A higher absolute risk was seen in middle-older adults, but relative rates were consistently higher in younger adults with type 2 diabetes. Sleep should be regularly discussed as part of a holistic approach to diabetes care, particularly in those aged ≤40.

Obstructive sleep apnea mediates genetic risk of Diabetes Mellitus: The Hispanic Community Health Study/Study of Latinos

Objective

We sought to evaluate whether obstructive sleep apnea (OSA), and other sleep disorders, increase genetic risk of developing diabetes mellitus (DM).

Research Design and Methods

Using GWAS summary statistics from the DIAGRAM consortium and Million Veteran Program, we developed multi-ancestry Type 2 Diabetes (T2D) polygenic risk scores (T2D-PRSs) useful in admixed Hispanic/Latino individuals. We estimated the association of the T2D-PRS with cross-sectional and incident DM in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). We conducted a mediation analysis with T2D-PRSs as an exposure, incident DM as an outcome, and OSA as a mediator. Additionally, we performed Mendelian randomization (MR) analysis to assess the causal relationship between T2D and OSA.

Results

Of 12,342 HCHS/SOL participants, at baseline, 48.4% were normoglycemic, 36.6% were hyperglycemic, and 15% had diabetes, and 50.9% identified as female. Mean age was 41.5, and mean BMI was 29.4. T2D-PRSs was strongly associated with baseline DM and with incident DM. At baseline, a 1 SD increase in the primary T2D-PRS had DM adjusted odds ratio (OR) = 2.67, 95% CI [2.40; 2.97] and a higher incident DM rate (incident rate ratio (IRR) = 2.02, 95% CI [1.75; 2.33]). In a stratified analysis based on OSA severity categories the associations were stronger in individuals with mild OSA compared to those with moderate to severe OSA. Mediation analysis suggested that OSA mediates the T2D-PRS association with DM. In two-sample MR analysis, T2D-PRS had a causal effect on OSA, OR = 1.03, 95% CI [1.01; 1.05], and OSA had a causal effect on T2D, with OR = 2.34, 95% CI [1.59; 3.44].

Conclusions

OSA likely mediates genetic effects on T2D.

Gut microbiota and sleep: Interaction mechanisms and therapeutic prospects

Sleep is crucial for wellness, and emerging research reveals a profound connection to gut microbiota. This review explores the bidirectional relationship between gut microbiota and sleep, exploring the mechanisms involved and the therapeutic opportunities it presents. The gut-brain axis serves as a conduit for the crosstalk between gut microbiota and the central nervous system, with dysbiosis in the microbiota impairing sleep quality and vice versa. Diet, circadian rhythms, and immune modulation all play a part. Specific gut bacteria, like Lactobacillus and Bifidobacterium, enhance sleep through serotonin and gamma-aminobutyric acid production, exemplifying direct microbiome influence. Conversely, sleep deprivation reduces beneficial bacteria, exacerbating dysbiosis. Probiotics, prebiotics, postbiotics, and fecal transplants show therapeutic potential, backed by animal and human research, yet require further study on safety and long-term effects. Unraveling this intricate link paves the way for tailored sleep therapies, utilizing microbiome manipulation to improve sleep and health. Accelerated research is essential to fully tap into this promising field for sleep disorder management.

Neurexan Prescription Is Associated with Lower Risk of Sleep Disorder Recurrence and Depression Prevalence as Compared to Z-Drugs and Benzodiazepines: A Retrospective Database Analysis in Germany

Real-world evidence on the association between natural medicinal products and the recurrence of sleep disorders is currently limited, particularly when compared to the evidence reported for prescription hypnotics. In a retrospective cohort analysis, we investigated patients with sleep disorders prescribed either the natural medicinal product Neurexan (Nx4), benzodiazepines, or nonbenzodiazepines (Z-drugs) using the IQVIA Disease Analyzer database, which encompasses electronic medical records nationwide in Germany. A 1:1 matching procedure based on age, sex, prevalent depression, anxiety or adjustment disorder, and the number of medical consultations in the past 12 months resulted in four cohorts: patients prescribed Nx4 were matched with those prescribed Z-drugs (two cohorts with 8594 matched patients each), and another cohort of patients prescribed Nx4 were matched with those prescribed benzodiazepines (7779 matched pairs). Results from multivariable-adjusted Cox regression models demonstrated that Nx4 was associated with a significantly lower risk of recurrent sleep disorder diagnosis within 30-365 days after prescription compared to both Z-drugs (HR = 0.65, 95%CI = 0.60-0.70, p < 0.001) and benzodiazepines (HR = 0.85, 95%CI = 0.79-0.93, p < 0.001). Additionally, Nx4 was associated with a lower prevalence of depression compared to Z-drugs (HR = 0.90, 95%CI = 0.83-0.98, p = 0.020) and benzodiazepines (HR = 0.89, 95%CI = 0.82-0.97, p = 0.009). These findings suggest an association between Nx4 and improved sleep and mental health outcomes. However, due to inherent limitations in the study design, the causality of this relationship cannot be stated.

The effect of lavender and rosemary aromatherapy application on cognitive functions, anxiety, and sleep quality in the elderly with diabetes

OBJECTIVE

This study aimed to determine the effects of aromatherapy use on cognitive function, anxiety, and sleep quality in the elderly with diabetes.

METHODS

The study was conducted with 63 participants aged 65 and over. Participants were randomly divided into three groups: lavender, rosemary and control groups. The intervention continued for four weeks. Data was collected using the Blessed Orientation Concentration Test, State-Trait Anxiety Scale, and Pittsburgh Sleep Quality Scale. Data were analyzed using One-Way ANOVA, Mann-Whitney U/Kruskal-Wallis, Wilcoxon and Friedman tests.

RESULTS

In both intervention groups, the 4th week scores of cognitive functions, anxiety, and sleep quality after aromatherapy were significant compared to the baseline scores. In the control group, state anxiety scores were significantly higher in the 2nd and 4th weeks compared to the initial scores.

CONCLUSIONS

Inhaling lavender and rosemary has been observed to improve cognitive function and sleep quality and reduce anxiety levels. The effects of the essential oils used in the research were evaluated over four weeks. It is thought that studying for a longer period and with more samples would be beneficial. There is a need for studies examining its effects, especially in the elderly with diabetes.

Sleep Apnea and Atrial Fibrillation: Clinical Features and Screening Diagnostic Options

INTRODUCTION

Obstructive sleep apnea (OSA) is associated with an increased risk of hypertension, coronary artery disease, heart failure (HF), and atrial fibrillation (AF).

MATERIALS AND METHODS

A total of 179 patients aged 34-81 years were included in the study. The median age was 63 years (interquartile range: 56-69 years). Of these patients, 105 (58.7%) were men, and 74 (41.3%) were women; there were cases of paroxysmal (n = 99), persistent (n = 64), and permanent AF (n = 16). All patients underwent investigations including respiratory sleep monitoring, echocardiography, and 24 h Holter electrocardiography monitoring. Statistical analyses were performed using IBM SPSS Statistics 26.0.

RESULTS

OSA was detected in 131 (73.2%) patients. In patients with OSA, paroxysmal AF was commonest (n = 65), followed by persistent AF (n = 51) and permanent AF (n = 15). The patients with sleep apnea had increased body mass index (33.6 kg/m2; p = 0.02), waist circumference (114 cm; p < 0.001), and neck circumference (42 cm; p < 0.001) values. HF (OR 2.9; 95% CI: 1.4-5.9; p = 0.004) and type 2 diabetes (OR 3.6; 95% CI: 1.5-8.3; p = 0.001) were more common in patients with AF and OSA. The STOP-BANG scale (AUC = 0.706 ± 0.044; 95% CI: 0.619-0.792; p < 0.001) and the Berlin questionnaire (AUC = 0.699 ± 0.044; 95% CI: 0.614-0.785) had a higher predictive ability for identifying sleep apnea.

CONCLUSIONS

Patients with AF demonstrate a high prevalence of OSA and an increased association with cardiovascular comorbidities. The STOP-BANG scale and the Berlin questionnaire can be used to screen for OSA in patients with AF.

The effect of exercise on sleep habits of children with type 1 diabetic: a randomized clinical trial

BACKGROUND

Adequate sleep and exercise are important components of the human lifestyle. Paying attention to these two factors is very important to improve the condition of children with type 1 diabetes. Therefore, this study aimed to investigate the effect of exercise on sleep habits in children with type 1 diabetes.

MATERIAL & METHODS

62 children with type 1 diabetes participated in this clinical trial. They will be divided into the intervention group (31) and the control group (31). Sleep habits were measured using the Children's Sleep Habits Questionnaire (CSHQ). All children's parents completed the CSHQ. The intervention for the experimental group consisted of 8 weeks of regular exercise program. The exercise program was prepared as an educational video and provided to parents. Paired sample t-test and ANCOVA test were used with SPSS 23.

RESULTS

62 children with an average age of 9.32 ± 2.02 were studied. Fifty-four and eight% of the children were girls and the rest were boys. The analysis of the variance test showed a significant difference (F = 144.72, P ≤ 0.01) between the average score of the sleep habits of the control group (62.45 ± 5.12) and the experimental group (47.06 ± 4.39).

CONCLUSION

Sleep habits in the experimental group improved after 8 weeks of exercise training using educational videos. Exercise as a non-pharmacological treatment is an effective way to manage diabetes and improve sleep quality in diabetic children.

Sleep quality of patients with diabetes mellitus: association with anxiety trait and state

OBJECTIVE

To assess sleep quality and the association of trait and state anxiety in patients with diabetes mellitus.

METHOD

A cross-sectional, quantitative, and analytical study was conducted between January and April 2022, at the reference center for hypertension and diabetes in Rio Verde, Goiás, with 81 patients. The Pittsburgh Sleep Quality Index and State-Trait Anxiety Inventory were used for data collection. Analyses included the Student's t-test and multivariate logistic regression analysis.

RESULTS

Of patients, 64.2% reported poor sleep quality. There were significant differences in trait anxiety levels between patients with good and poor sleep quality. Trait anxiety was associated with sleep quality, with an increase in the trait anxiety score increasing the chances of poor sleep quality.

CONCLUSION

A significant proportion of the sample had poor sleep quality, and trait anxiety was found to be associated with this condition.

Factors Associated With Poor Sleep Quality Among Primary Healthcare Workers During the SARS-CoV-2 Pandemic

INTRODUCTION

Sleep is one of the most important activities for health and the processes related to the central nervous system. Healthcare workers commonly present alterations in the sleep-wake cycle due to complex work schedules because 24-hour attention to the population is required in public health institutions. The increase in care needs caused by the COVID-19 pandemic caused changes in work schedules; as in Mexico, the number of patients requiring consultation in all public health units increased. Chronic partial sleep deprivation (< 7 hours of sleep in the 24-hour cycle) is the most frequent sleep alteration in Mexican health workers. However, it has not been explored whether work modifications due to the pandemic had an impact on the sleep quality of workers.

OBJECTIVE

We aimed to describe the prevalence of poor sleep quality and the associated factors in workers (clinical and non-clinical) of a primary care medical unit.

MATERIAL AND METHODS

We conducted an analytical and cross-sectional study during November and December 2022. We used the following tools for studying clinical and non-clinical staff working at a family medicine primary care unit: Pittsburgh Sleep Quality Index, Hamilton Anxiety Scale, Beck Depression Inventory, Maslach Burnout Inventory, and Graffar-Méndez-Castellanos socioeconomic level scale, as well as a data collection sheet and a survey of workers' knowledge, attitudes, fears, and needs regarding COVID-19.

RESULTS

A total of 233 workers were surveyed. The prevalence of poor sleep quality was 56.7%. A higher score on the Beck Depression Inventory (OR: 1.21, CI 95%: 1.13-1.29), being a doctor (OR: 3.48, CI 95%: 1.5-8.01), and frequent alcohol consumption (OR: 2.4, CI 95%: 1.13-5.2) were identified as risk factors for poor sleep quality. A lower score in the depersonalization dimension of the Maslach Burnout Inventory (OR: 0.5, CI 95%: 0.26-0.99) was identified as a protective factor for poor sleep quality.

CONCLUSIONS

During the pandemic, the stress of health workers increased due to work alterations that were necessary to treat the greatest number of patients, so their quality of sleep decreased. Unfortunately, the mental health of healthcare workers is often under-assessed in many institutions. Thus, it is relevant to identify risk factors for alterations (especially those of sleep), since by identifying the target population, comprehensive interventions can be carried out, which can reduce the prevalence of burnout, anxiety, and depression, but if not addressed, the alterations can lead to inadequate care for users of health units.

Self-reported sleep characteristics are linked to type 2 diabetes in middle-aged and elderly individuals: a cross-sectional study based on NHANES

OBJECTIVE

This study was aimed to evaluate the link between sleep characteristics and type 2 diabetes of middle-aged and elderly individuals.

METHODS

Twenty thousand four hundred ninety-seven individuals enrolled in National Health and Nutritional Examination Survey (NHANES) form periods of 2005-2008 were included in this study, and 3965 individuals aged 45 years and older with complete data were detected. Variables related to sleep characteristics were analyzed by univariate analysis to identify the risk factors of type 2 diabetes, the logistic regression model was used to test for the tendency across the sections of sleep duration, and the link between sleep duration and risk of type 2 diabetes was manifested as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Six hundred ninety-four individuals with type 2 diabetes were identified and enrolled in the type 2 diabetes group, while the remaining individuals (n = 3271) were enrolled in the non-type 2 diabetes group. Individuals in the type 2 diabetes group (63.9 ± 10.2) were older than those in the non-type 2 diabetes group (61.2 ± 11.5, P < 0.001). Factors of taking longer time to fall asleep (P < 0.001), sleeping less (≤ 4 h) or more (≥ 9 h) (P < 0.001), having trouble in falling asleep (P = 0.001), frequent snoring (P < 0.001), frequent sleep apnea (P < 0.001), frequent nighttime awakenings (P = 0.004), and frequent excessive daytime sleepiness (P < 0.001) were linked to the risk of type 2 diabetes.

CONCLUSION

Our study revealed that sleep characteristics were closely linked to type 2 diabetes in middle-aged and elderly individuals, and a longer sleep duration might have protective effects against type 2 diabetes, but it should be constrained within 9 h/night.

Development of generalizable automatic sleep staging using heart rate and movement based on large databases

Purpose

With the advancement of deep neural networks in biosignals processing, the performance of automatic sleep staging algorithms has improved significantly. However, sleep staging using only non-electroencephalogram features has not been as successful, especially following the current American Association of Sleep Medicine (AASM) standards. This study presents a fine-tuning based approach to widely generalizable automatic sleep staging using heart rate and movement features trained and validated on large databases of polysomnography.

Methods

A deep neural network is used to predict sleep stages using heart rate and movement features. The model is optimized on a dataset of 8731 nights of polysomnography recordings labeled using the Rechtschaffen & Kales scoring system, and fine-tuned to a smaller dataset of 1641 AASM-labeled recordings. The model prior to and after fine-tuning is validated on two AASM-labeled external datasets totaling 1183 recordings. In order to measure the performance of the model, the output of the optimized model is compared to reference expert-labeled sleep stages using accuracy and Cohen's κ as key metrics.

Results

The fine-tuned model showed accuracy of 76.6% with Cohen's κ of 0.606 in one of the external validation datasets, outperforming a previously reported result, and showed accuracy of 81.0% with Cohen's κ of 0.673 in another external validation dataset.

Conclusion

These results indicate that the proposed model is generalizable and effective in predicting sleep stages using features which can be extracted from non-contact sleep monitors. This holds valuable implications for future development of home sleep evaluation systems.

Job Stress and Sleep Disturbances Among Career Firefighters in Northern California

OBJECT

This study examined the association between job stress and sleep disturbance among career firefighters.

METHODS

A cross-sectional survey study was conducted with 154 career firefighters working in Northern California, US job stress was measured using the short form of the Effort-Reward Imbalance questionnaire and sleep was measured with the Patient-Reported Outcomes Measurement Information System Sleep Disturbance.

RESULTS

Approximately 75% experienced sleep disturbance. For firefighters' job stress, high effort (odds ratio [OR] = 3.68; 95% confidence interval [CI]: 1.25-10.80), high effort-reward ratio (OR = 3.55; 95% CI: 1.23-10.23), and high overcommitment (OR = 9.09; 95% CI: 2.30-35.85) were significantly associated with increased likelihood of sleep disturbance, after adjustment for other factors.

CONCLUSIONS

Job stress significantly affected firefighters' sleep health, suggesting the need to design effective health promotion interventions to reduce job stress and improve sleep quality for these public service workers.

Effects of outdoor artificial light at night on human health and behavior: A literature review

The quality of life of human beings has improved tremendously through improved productivity, convenience, safety, and livability due to nighttime lights that illuminate outdoor work, leisure, and mobility. Recently, however, concerns have been growing over outdoor artificial light at night (ALAN) and its effects on human beings as well as ecosystems including animals and plants. This literature review aims to deliver a critical overview of the findings and the areas for future research on the effects of outdoor ALAN on human health and behaviors. Through a narrative literature review, we found that scientific research crucially lacks studies on the effects of outdoor ALAN on human behaviors and health, including social interaction, which may be more widespread compared to what is recognized so far. This review also highlights the importance of investigating the causal and complex relationships between outdoor ALAN, health, and behaviors with sleep as a key mediating factor. We elucidate that outdoor ALAN has both positive and negative effects on human life. Therefore, it is important for societies to be able to access facts and evidence about these effects to plan, agree to, and realize the optimal usage of nighttime lighting that balances its merits and demerits. Researchers in related areas of study must investigate and deliver the science of outdoor ALAN to various stakeholders, such as citizens, policymakers, urban and landscape planners, relevant practitioners, and industries. We believe that our review improves the understanding of outdoor ALAN in relation to human life and contributes to sustainable and thriving societies.

Relationship between nonrestorative sleep with short sleep duration and diabetes mellitus comorbid among a Japanese occupational population

Objective

Nonrestorative sleep (NRS) is one of the symptoms of insomnia and is clearly more associated with objective indices, such as sleep stability, sleep fragmentation, and inflammatory responses, than other insomnia symptoms. However, the link between NRS and diabetes mellitus is poorly understood. Therefore, the prevalence of NRS in workers and the relationships between NRS and diabetes were investigated.

Methods

The results of a single year's medical examinations were investigated for 26,144 Japanese active office workers who were 30 to 59 years old. NRS was investigated using a personal computer in a medical interview. Furthermore, the relationships between NRS and diabetes comorbidity in addition to sleep duration were also analyzed.

Results

The mean age of the subjects was 47.9 ± 7.3 years old, and the proportion of subjects with NRS was 26%. The presence of NRS together with a sleep duration ≤ 5 h or a sleep duration of 6 h was an independent comorbid factor for diabetes compared with the absence of NRS together with a sleep duration of 7 h (odds ratio [OR] 1.34; 95% confidence interval [CI] 1.14-1.58; P < 0.001; and OR 1.25; 95% CI 1.04-1.48; P = 0.015).

Conclusion

NRS in active workers may contribute to the development of diabetes even if the workers have the same short sleep durations as other workers without NRS.

Self-Reported Sleep Disturbance is an Independent Predictor of All-Cause Mortality and Respiratory Disease Mortality in US Adults: A Population-Based Prospective Cohort Study

Objective: Self-reported sleep disturbance is common but its association with mortality has rarely been investigated. Methods: This prospective cohort analysis included 41,257 participants enrolled in the National Health and Nutrition Examination Survey from 2005 to 2018. Self-reported sleep disturbance in the present study refers to the patients who have ever consulted doctors or other professionals for trouble sleeping. Univariate and multivariate survey-weighted Cox proportional hazards models were used to evaluate the association of self-reported sleep disturbance with all-cause and disease-specific mortality. Results: Approximately 27.0% of US adults were estimated to have self-reported sleep disturbance. After adjusting for all sociodemographic variables, health behavioral factors, and common comorbidities, participants with self-reported sleep disturbance tend to have higher all-cause mortality risk with a hazard ratio (HR) of 1.17 (95% CI, 1.04-1.32) and chronic lower respiratory disease mortality risk (HR, 1.88; 95% CI, 1.26-2.80), but not cardiovascular disease mortality risk (HR, 1.19; 95% CI, 0.96-1.46) and cancer mortality risk (HR, 1.10; 95% CI, 0.90-1.35). Conclusion: Self-reported sleep disturbance could be associated with higher mortality in adults, and may need to be paid more attention in public health management.

Mendelian randomization reveals no associations of genetically-predicted obstructive sleep apnea with the risk of type 2 diabetes, nonalcoholic fatty liver disease, and coronary heart disease

BACKGROUND

Obstructive sleep apnea (OSA) has been reported to affect cardiometabolic diseases. However, whether such association is causal is still unknown. Here, we attempt to explore the effect of OSA on type 2 diabetes (T2D), nonalcoholic fatty liver disease (NAFLD) and coronary heart disease (CHD).

METHODS

Genetic variants associated with OSA were requested from a published genome-wide association study (GWAS) and those qualified ones were selected as instrumental variables (IV). Then, the IV-outcome associations were acquired from T2D, NAFLD and CHD GWAS consortia separately. The Mendelian randomization (MR) was designed to estimate the associations of genetically-predicted OSA on T2D, NAFLD and CHD respectively, using the inverse-variance weighted (IVW) method. We applied the Bonferroni method to adjust the p-value. Besides, MR-Egger regression and weighted median methods were adopted as a supplement to IVW. The Cochran's Q value was used to evaluate heterogeneity and the MR-Egger intercept was utilized to assess horizontal pleiotropy, together with MR-PRESSO. The leave-one-out sensitivity analysis was carried out as well.

RESULTS

No MR estimate reached the Bonferroni threshold (p < 0.017). Although the odds ratio of T2D was 3.58 (95% confidence interval (CI) [1.06, 12.11], IVW-p-value = 0.040) using 4 SNPs, such causal association turned insignificant after the removal of SNP rs9937053 located in FTO [OR = 1.30 [0.68, 2.50], IVW p = 0.432]. Besides, we did not find that the predisposition to OSA was associated with CHD [OR = 1.16 [0.70, 1.91], IVW p = 0.560] using 4 SNPs.

CONCLUSION

This MR study reveals that genetic liability to OSA might not be associated with the risk of T2D after the removal of obesity-related instruments. Besides, no causal association was observed between NAFLD and CHD. Further studies should be carried out to verify our findings.

Consequences of Sleep Deprivation in Adult Diabetes Mellitus Type 2 Patients: An Integrative Review

BACKGROUND: Sleep deprivation in individuals with diabetes mellitus type 2 is more prevalent than in ordinary people. At present, the adverse effects of diabetes type 2 people with sleep disorders and sleep deprivation on blood sugar control are irrefutable. Thorough assessments covering the whole structure should be of concern in health-care treatment. It is precipitated and delivered to the physical, mental health, and social environment, but no systematic review or minimal data were published. Furthermore, it may significantly affect the system more than existing research. AIM: An integrative review aims to clarify the results or consequences of sleep disturbance/deprivation or insomnia symptoms among diabetes mellitus type 2 patients. METHODS: The writers implemented a literature search in PubMed, CINAHL, and Medline using the terms DM type 2, insomnia, adult, effect, DM, sleep disturbance, sleep disorder, and a consequence between 2012 and 2022. Inclusion criteria selected through considering the entire article, and providing an abstract, were 20 articles. RESULTS: Integrative data extraction and information were analyzed thematically. Identified were nine ideas: Association with blood sugar control, blood pressure control, risk of CVD, diabetes self-care behavior, weight gained and Obstructive Sleep Apnea (OSA), lifestyle and physical activity, mood/depression and anxiety symptoms, daily calories distribution, cholesterol/triglyceride, and liver enzyme levels. CONCLUSION: The adverse effects of sleep deprivation in type 2 diabetes significantly affect all pathophysiologically, mentally, and lifestyle modifications, including diabetes self-care. Therefore, to highlight the importance of promoting optimum sleep in diabetes type2 patients, a health-care system is inevitably as necessary as diet and exercise management.

Sleep, cardiovascular risk factors, and kidney function: The Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVES

Examine the associations of sleep measures with kidney function changes over time among individuals from a community-based study.

METHODS

The sample includes 1657 participants (287 with chronic kidney disease [CKD]) in the Multi-Ethnic Study of Atherosclerosis Sleep Cohort (mean age: 57.7 years, male: 46.0%). We examined associations between a large set of sleep variables (polysomnography, actigraphy, and questionnaires) and cardiovascular disease risk factors and changes in estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio over approximately 5 years using high-dimensional regression. We investigated the modifying effect of sleep on the associations between cardiovascular disease risk factors and kidney function.

RESULTS

Sleep metrics predicted kidney function decline only among individuals with baseline CKD. Among this group, eGFR decline was associated with decreased stage N3 sleep (0.32 mL/min/1.73 m2/y per 10% decrease in N3, p < .001); increased actigraphy napping frequency (beta: -0.20 [-0.30, -0.07]); and actigraphy sleep midpoint trajectory in early morning (ref: midnight, beta: -0.84 [-1.19, -0.50]). Urinary albumin-to-creatinine ratio increase was associated with high wake bouts trajectory (ref: low, beta: 0.97 [0.28, 1.67]) and increased sleep-related hypoxemia (oxygen saturation %time<90 [≥5%], beta: 2.17 [1.26, 3.08]). Sleep metrics--N3 sleep, naps, and midpoint trajectory--significantly modified associations between hemoglobin A1C and eGFR decline.

CONCLUSIONS

Reduced deep sleep, daytime napping, increased wake bouts, delayed sleep rhythms, and overnight hypoxemia are associated with longitudinal kidney function decline, with effects most apparent in individuals with CKD. Deep sleep, napping, and sleep timing modified the association between hemoglobin A1C and kidney function.

The burden and risks of emerging complications of diabetes mellitus

The traditional complications of diabetes mellitus are well known and continue to pose a considerable burden on millions of people living with diabetes mellitus. However, advances in the management of diabetes mellitus and, consequently, longer life expectancies, have resulted in the emergence of evidence of the existence of a different set of lesser-acknowledged diabetes mellitus complications. With declining mortality from vascular disease, which once accounted for more than 50% of deaths amongst people with diabetes mellitus, cancer and dementia now comprise the leading causes of death in people with diabetes mellitus in some countries or regions. Additionally, studies have demonstrated notable links between diabetes mellitus and a broad range of comorbidities, including cognitive decline, functional disability, affective disorders, obstructive sleep apnoea and liver disease, and have refined our understanding of the association between diabetes mellitus and infection. However, no published review currently synthesizes this evidence to provide an in-depth discussion of the burden and risks of these emerging complications. This Review summarizes information from systematic reviews and major cohort studies regarding emerging complications of type 1 and type 2 diabetes mellitus to identify and quantify associations, highlight gaps and discrepancies in the evidence, and consider implications for the future management of diabetes mellitus.

Sleep of Healthcare Workers During the COVID-19 Pandemic and the Role of Atypical Work Schedules: A Scoping Review

The COVID-19 pandemic has negatively impacted the well-being of healthcare workers (HCWs). HCWs are highly exposed to shift work and their work schedules have been subject to increasing unpredictability since the start of the pandemic. This review aims to: (1) map the studies providing information about factors associated with sleep characteristics in HCWs working in the context of the COVID-19 pandemic during the first and second waves and (2) examine the state of the evidence base in terms of the availability of information on the influence of atypical work schedules. A literature search was performed in PubMed. Studies containing information about factors (demographic; psychological; occupational; COVID-19-specific; work schedule; lifestyle; medical; or other) associated with various sleep characteristics among HCWs working in the context of the COVID-19 pandemic were included. Particular attention was paid to the availability of information on the role of atypical work schedules on HCW sleep. Fifty-seven articles met the inclusion criteria. Most studies were reports of quantitative cross-sectional surveys using self-report measures. Associations between female sex, frontline HCW status, psychological factors, and poorer sleep were observed. Six studies included a measure of shift work in their analyses, 5 of which reported an association between shift work status and sleep. A wide range of factors were investigated, with female sex, frontline HCW status, and psychological factors repeatedly demonstrating associations with poorer sleep. Sleep was predominantly measured in terms of self-reported sleep quality or insomnia symptoms. Few studies investigated the influence of atypical work schedules on HCW sleep in the context of the COVID-19 pandemic. Research on this topic is lacking in terms of reliable and consistent measurements of sleep outcomes, longitudinal data, and knowledge about the influence of covariates such atypical work schedules, comorbidity, and medical history on HCW sleep.

Potential Therapeutic Applications of Natural Compounds in Diabetes-Associated Periodontitis

Diabetes mellitus (DM) is a major worldwide health burden. DM is a metabolic disease characterized by chronic hyperglycemia, and if left untreated, can lead to various complications. Individuals with uncontrolled DM are more susceptible to periodontitis due to both a hyper-inflammatory host response and an impaired immune response. Periodontitis, on the other hand, may exacerbate DM by increasing both local and systemic inflammatory components of DM-related complications. The current standard for periodontal treatment in diabetes-associated periodontitis (DP) focuses mostly on reducing bacterial load and less on controlling the excessive host response, and hence, may not be able to resolve DP completely. Over the past decade, natural compounds have emerged as an adjunct approach for modulating the host immune response with the hope of curing DP. The anti-oxidant, anti-inflammatory, and anti-diabetic characteristics of natural substances are well-known, and they can be found in regularly consumed foods and drinks, as well as plants. The pathophysiology of DP and the treatment benefits of various bioactive extracts for DP will be covered in this review.

Perceived sleep quality: a comparison between hospital nurses and student nurses

BACKGROUND

The prevalence of poor sleep quality is high among nurses, and affects them physically and psychologically as well as organisational functioning. However, evidence on equipping student nurses with good sleep practices that could mitigate poor sleep as they transition into the nursing workforce is lacking.

AIM

This study compared the prevalence and quality of good sleep among hospital nurses and student nurses.

METHODS

A descriptive cross-sectional study of 130 hospital nurses and 130 student nurses in Brunei was carried out. Sleep quality was assessed using the Pittsburgh Sleep Quality index. Multiple logistic regression was applied.

RESULTS

Hospital nurses were 4.29 times more likely to experience poor sleep than student nurses. Those who were overweight were 2.35 times more likely to have poor sleep quality than those with a healthy weight. Although students had significantly good sleep latency, needing less time to fall asleep, they experienced significantly more sleep disturbances, shorter sleep duration and less sleep efficiency.

CONCLUSION

The prevalence of poor sleep quality among nurses in Brunei is higher than global estimates. Stakeholders such as nursing leaders, nursing educators and healthcare policymakers should prepare student nurses and help existing nurses by formulating strategies to promote working schedules and rosters that minimise circadian disruption.

Obstructive Sleep Apnea and Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia, increasing with age and comorbidities. Obstructive sleep apnea (OSA) is a chronic sleep disorder more common in older men. It has been shown that OSA is linked to AF. Nonetheless, the prevalence of OSA in patients with AF remains unknown because OSA is significantly underdiagnosed. This review, including 54,271 patients, carried out a meta-analysis to investigate the association between OSA and AF. We also performed a meta-regression to explore cofactors influencing this correlation. A strong link was found between these two disorders. The incidence of AF is 88% higher in patients with OSA. Age and hypertension independently strengthened this association, indicating that OSA treatment could help reduce AF recurrence. Further research is needed to confirm these findings. Atrial Fibrillation (AF) is the most common arrhythmia, increasing with age and comorbidities. Obstructive sleep apnea (OSA) is a regulatory respiratory disorder of partial or complete collapse of the upper airways during sleep leading to recurrent pauses in breathing. OSA is more common in older men. Evidence exists that OSA is linked to AF. Nonetheless, the prevalence of OSA in patients with AF remains unknown because OSA is underdiagnosed. In order to investigate the incidence of AF in OSA patients, we carried out a meta-analysis including 20 scientific studies with a total of 54,271 subjects. AF was present in 4801 patients of whom 2203 (45.9%) had OSA and 2598 (54.1%) did not. Of a total of 21,074 patients with OSA, 2203 (10.5%) had AF and 18,871 (89.5%) did not. The incidence of AF was 88% higher in patients with OSA. We performed a meta-regression to explore interacting factors potentially influencing the occurrence of AF in OSA. Older age and hypertension independently strengthened this association. The clinical significance of our results is that patients with OSA should be referred early to the cardiologist. Further research is needed for the definition of the mechanisms of association between AF and OSA.

Association Between Diabetic Retinopathy and Insomnia Risk: A Nationwide Population-Based Study

BACKGROUND

Previous studies have suggested a close link between sleep disturbances and diabetic retinopathy (DR). However, to date, no confirmatory findings have been reported. We aimed to explore the risk of insomnia in DR by considering demographic factors and diabetes mellitus (DM)-related variables.

METHODS

A nationwide population-based cohort of 2,206,619 patients with type 2 diabetes from the Korean National Insurance Service Database was followed up for insomnia incidence. DR, non-proliferative DR (NPDR), and proliferative DR (PDR) were defined according to ICD-10 codes. The interactive effects of sex, age, and DM-related variables were analyzed to evaluate their impact on insomnia risk in DR.

RESULTS

Compared with the non-DR group, insomnia risk was increased in the DR [(adjusted hazard ratio (aHR): 1.125, 95% confidence interval (CI):1.108-1.142), NPDR (aHR:1.117, 95% CI:1.099-1.134), and PDR (aHR:1.205, 95% CI: 1.156-1.256), even after controlling for comorbidities, lifestyle factors, and DM-related variables. The men and youngest age groups (<40 years) were most vulnerable to insomnia risk. Sex, age, DM duration, and chronic kidney disease (CKD) status exerted interactive effects with DR status in increasing the insomnia risk. In the PDR group, sex, age, DM duration, insulin therapy status, and CKD status exerted interactive effects that increased the risk of insomnia.

CONCLUSION

Insomnia risk is significantly higher in patients with DR, and clinical attention is warranted.

Association Between Poor Sleep Quality and Glycemic Control in Adult Patients with Diabetes Referred to Endocrinology Clinic of Guilan: A Cross-sectional Study

BACKGROUND

Diabetes is a prevalent chronic medical comorbid condition worldwide. Diabetes mellitus is associated with various sleep disorders.

OBJECTIVES

We aimed to determine the prevalence of poor sleep and the main factors of sleep interruptions in patients with diabetes mellitus. We further evaluated the association of sleep interruptions with glycemic control in this cohort.

METHODS

We conducted a cross-sectional study on 266 patients with type 1 and type 2 diabetes recruited from a university outpatient endocrinology clinic. Patients completed a checklist including demographic and disease-related characteristics in addition to the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep quality. Using the PSQI cutoff score of 5, we created two subgroups of good sleepers (GS) and poor sleepers (PS).

RESULTS

Our results showed that good sleeper and poor sleeper patients with diabetes were significantly different regarding sex, employment status, BMI, presence of diabetes-related complications, HbA1c, and 2-hour postprandial blood sugar (2HPPBS) (all significant at P < 0.05). The most prevalent factors of sleep interruptions were "waking up to use a bathroom", "feeling hot", "pain", "having coughs or snores", and "bad dreams". Among the subjective factors of sleep interruption, problems with sleep initiation, maintenance, or early morning awakenings in addition to having pain or respiratory problems such as coughing or snoring had the most significant associations with HbA1c.

CONCLUSIONS

Our study showed significant subjective sleep disturbances (both quality and quantity) in patients with diabetes mellitus (both type I and II) and its association with diabetes control. We further identified the main factors that led to sleep interruptions in this cohort.

Comorbid obstructive sleep apnea and insomnia and its associations with mood and diabetes-related distress in type 2 diabetes mellitus

STUDY OBJECTIVES

Previous research suggests that obstructive sleep apnea (OSA) and insomnia frequently co-exist and are prevalent in persons with type 2 diabetes mellitus (T2DM). This study compared mood and diabetes-related distress among OSA, insomnia, and comorbid OSA and insomnia (OSA+I) groups in persons with T2DM.

METHODS

A secondary analysis was conducted with baseline data from two independent randomized controlled trials evaluating the efficacy of OSA and insomnia treatment. The pooled sample (N=224) included participants with OSA only (n=68 [30.4%]), insomnia only (n=107 [47.8%]), and OSA and insomnia (OSA+I; n=49 [21.9%]). OSA was defined as an apnea-hypopnea index ≥ 15 events per hour; insomnia defined as an Insomnia Severity Index score ≥ 15. Mood was measured by the Profile of Mood States total and subscale scores; diabetes-related distress was assessed by the Problem Areas in Diabetes. One-way analysis of covariance and multivariate analysis of covariance were conducted, controlling for demographic characteristics and restless leg syndrome.

RESULTS

The insomnia group had on average significantly higher scores for total mood disturbance (insomnia vs. OSA= 45.32 vs. 32.15, p=.049), tension-anxiety (insomnia vs. OSA= 12.64 vs. 9.47, p=.008), and confusion-bewilderment (insomnia vs. OSA= 9.45 vs. 7.46, p=.036) than OSA group. The OSA+I group had on average significantly greater diabetes-related distress than OSA group (OSA+I vs. OSA= 40.61 vs. 30.97, p=.036).

CONCLUSIONS

Insomnia may have greater impact on mood disturbance and diabetes-related distress than OSA in persons with T2DM. In particular, comorbid insomnia may contribute to greater diabetes-related distress in persons with T2DM and OSA.

A Blanket Accommodative Sleep Posture Classification System Using an Infrared Depth Camera: A Deep Learning Approach with Synthetic Augmentation of Blanket Conditions

Surveillance of sleeping posture is essential for bed-ridden patients or individuals at-risk of falling out of bed. Existing sleep posture monitoring and classification systems may not be able to accommodate the covering of a blanket, which represents a barrier to conducting pragmatic studies. The objective of this study was to develop an unobtrusive sleep posture classification that could accommodate the use of a blanket. The system uses an infrared depth camera for data acquisition and a convolutional neural network to classify sleeping postures. We recruited 66 participants (40 men and 26 women) to perform seven major sleeping postures (supine, prone (head left and right), log (left and right) and fetal (left and right)) under four blanket conditions (thick, medium, thin, and no blanket). Data augmentation was conducted by affine transformation and data fusion, generating additional blanket conditions with the original dataset. Coarse-grained (four-posture) and fine-grained (seven-posture) classifiers were trained using two fully connected network layers. For the coarse classification, the log and fetal postures were merged into a side-lying class and the prone class (head left and right) was pooled. The results show a drop of overall F1-score by 8.2% when switching to the fine-grained classifier. In addition, compared to no blanket, a thick blanket reduced the overall F1-scores by 3.5% and 8.9% for the coarse- and fine-grained classifiers, respectively; meanwhile, the lowest performance was seen in classifying the log (right) posture under a thick blanket, with an F1-score of 72.0%. In conclusion, we developed a system that can classify seven types of common sleeping postures under blankets and achieved an F1-score of 88.9%.

Associations of impaired glucose tolerance and sleep disorders with mortality among the US general population

INTRODUCTION

Sleep disorders and short sleep duration are common symptoms among people with diabetes. However, the evidence is limited about the associations of post-challenge hyperglycemia and sleep quality or quantity with all-cause mortality in the US general population.

RESEARCH DESIGN AND METHODS

Our study included 8795 adults from the National Health and Nutrition Examination Survey 2005-2014. Mortality data were ascertained through 2015. Multivariable Cox proportional-hazards models were used to estimate adjusted HRs (aHRs) for all-cause mortality according to 2-hour plasma glucose levels during the 75 g oral glucose tolerance test-normal glucose tolerance (NGT), <140 mg/dL; impaired glucose tolerance (IGT), 140-199 mg/dL; and diabetes, ≥200 mg/dL. We then examined the associations of glucose tolerance status and self-reported physician-diagnosed sleep disorders (yes vs no) or sleep duration (<7 vs ≥7 hours) with all-cause mortality.

RESULTS

During follow-up (median, 5.6 years), the diabetes group had a higher risk of all-cause mortality compared with the NGT group (aHR (95% CI)=1.93 (1.41 to 2.64)), but not the IGT group (aHR (95% CI)=1.19 (0.90 to 1.59)). When we categorized participants according to glucose tolerance status and sleep disorders, the IGT group with sleep disorders had a higher risk of all-cause mortality (aHR (95% CI)=2.03 (1.24 to 3.34)) compared with the NGT group without sleep disorders. Both diabetes groups with and without sleep disorders also showed high mortality risks. The results were consistent when we used sleep duration instead of sleep disorders.

CONCLUSIONS

Using the most updated US national data, we found a high risk of all-cause mortality among individuals with IGT having sleep disorders or short sleep duration as well as those with diabetes. Future investigations are needed to identify whether and what kind of sleep management is beneficial for people with impaired glucose metabolism to prevent early death.

Covid-19 and changes in sleep health in the Blackfeet Community

We examined changes in psychological outcomes related to the COVID-19 pandemic (ie psychological stress, perceived control, and perceived ability to cope) and changes in sleep health in the American Indian Blackfeet community over 4 months (August 24, 2020-November 30, 2020). American Indian adults residing on the Blackfeet reservation (n = 167) completed measures of perceived control over contracting COVID-19, perceived ability to cope with pandemic stressors, psychological stress linked to the pandemic, and a measure of sleep health each month. Linear-effects mixed models were used to examine changes in our outcomes. Community members who reported more control over contracting the virus had better sleep health relative to those who reported less control (B = 0.72, SE = 0.29, p = 0.015). Further, during months when individuals felt they had more control over contracting the virus compared to their average perceived control levels, they had better sleep health relative to their own average (B = 1.06, SE = 0.13, p < 0.001). Average sleep health was the lowest in October, 2020, the month during which COVID-19 incidence was at its highest on the reservation. Declines in sleep health linked to low levels of control over contracting COVID-19 may exacerbate high incidence of chronic mental and physical health conditions in tribal communities. Interventions which highlight strategies known to reduce risk of contracting the virus, may increase perceived control and sleep health, and thus may improve downstream health outcomes for this at-risk population.

Association between comorbid sleep apnoea-hypopnoea syndrome and prognosis of intensive care patients: a retrospective cohort study

OBJECTIVE

In this study, we investigated the association between comorbid sleep apnoea-hypopnoea syndrome (SAHS) and the prognosis of patients in an intensive care unit (ICU) to determine whether this relationship varies between different disease subgroups.

METHODS

We conducted a retrospective cohort study using publicly available information from the critical care database Medical Information Mart for Intensive Care III. Adults (≥18 years of age) who attended the ICU for the first time were enrolled. Demographic information and clinical data were obtained from each patient. The primary outcome was 30-day mortality after ICU admission, and the secondary outcomes were in-hospital and ICU mortality. Multivariate logistic regression and Cox regression analyses were used to examine the associations between SAHS comorbidities and the research outcomes. Propensity score matching was used to adjust for potential confounding variables.

RESULTS

Of the 32 989 patients enrolled, 1918 (5.81%) were diagnosed with SAHS as a comorbid condition. Patients with SAHS had a significantly lower 30-day mortality rate compared with those without SAHS (5.27% vs 13.65%, respectively; p<0.001). The frequency of chronic obstructive pulmonary disease, cerebral disease, cardiovascular disease, hypertension, diabetes mellitus and renal failure was significantly different between the two groups. Patients with SAHS demonstrated significantly longer survival compared with patients without SAHS. Multivariate Cox proportional hazards regression identified a significant relationship between SAHS and mortality within 30 days (adjusted HR=0.610, 95% CI 0.499 to 0.747, p<0.0001).

CONCLUSION

SAHS as a comorbid condition decreases the risk of 30-day mortality, in-hospital mortality and ICU mortality among ICU patients.

Botanical characteristics, phytochemistry and related biological activities of Rosa roxburghii Tratt fruit, and its potential use in functional foods: a review

Due to the growing global population, reduction in arable land and effects of climate change, incongruity between food supply and demand has become increasingly severe. Nowadays, with awareness of the elementary nutrients required for human growth, increasing attention is being paid to the health and medical functions of food. Along with increased food production achieved by modern agricultural techniques, underutilised functional foods are an important strategy for solving food security problems and maintaining the nutritional quality of the human diet. Rosa roxburghii Tratt (RRT) is a natural fruit that contains unique functional and nutritional constituents, which are characterised by a high anti-oxidant potential. This review summarises the biological characteristics, chemical composition, health-promoting properties and development status of RRT products to inspire investigations on the use of RRT fruit as a functional food, dietary supplement and pharmaceutical additive. The nutrients and functional ingredients of RRT fruit are described in detail to provide more reference information for nutritionists and pharmacists.

Association of sleep-disordered breathing and wound healing in patients with diabetic foot ulcers

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) is prevalent and associated with an increased risk of morbidity and mortality. However, whether SDB has an adverse impact on wound healing in patients with diabetic foot ulcers (DFUs) is uncertain. The purpose of this study was to investigate the association of SDB with wound healing in patients with DFUs.

METHODS

A total of 167 patients with DFUs were enrolled between July 2013 and June 2019 at West China Hospital (Chengdu, China) to assess the association of SDB with wound healing, ulcer recurrence, and all-cause mortality.

RESULTS

Whereas there was no significant association between apnea-hypopnea index (AHI) and wound healing, total sleep time (per hour: hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.01-1.30; P = .029), sleep efficiency (per 10%: HR, 1.20; 95% CI, 1.04-1.37; P = .012), and wakefulness after sleep onset (per 30 minutes: HR, 0.89; 95% CI, 0.82-0.97; P = .008) were associated with wound healing. Total sleep time (per hour: odds ratio, 0.71; 95% CI, 0.51-0.97; P = .035) and sleep efficiency (per 10%: odds ratio, 0.68; 95% CI, 0.47-0.97; P = .033) were also associated with ulcer recurrence. Mean oxygen saturation (per 3%: HR, 0.68; 95% CI, 0.49-0.94; P = .021) and percentage of sleep time with oxygen saturation < 90% (per 10%: HR, 1.25; 95% CI, 1.03-1.53; P = .026) were significantly associated with mortality.

CONCLUSIONS

SDB is highly prevalent in patients with DFUs but its severity, as conventionally measured by AHI, is not associated with wound healing. Sleep fragmentation and hypoxemia are stronger predictors of poor wound healing, high ulcer recurrence, and increased risk of death in patients with DFUs.

The role of obstructive sleep apnea on the prognosis of pulmonary embolism: a systemic review and meta-analysis

PURPOSE

The relationship between obstructive sleep apnea (OSA) and pulmonary embolism (PE) has been reported by some studies but the underlying mechanism remains unclear. We aimed to systematically assess the role of OSA on the disease prognosis of PE.

METHODS

We searched for studies on the relationship of OSA and the prognosis of PE published up to February 2020 among PubMed, Web of Science, EMBASE, and Cochrane Library databases. Two independent reviewers conducted the process of study search and screening, quality assessment, and data extraction. Meta-analysis was carried out using RevMan 5.3.

RESULTS

A total of 9 articles were included, and the funnel plots suggested no evidence of publication bias among studies. The results showed that compared to PE patients without OSA, the PE patients with moderate-severe OSA were more likely to be high-risk type (OR = 1.96, 95% CI [1.14, 3.34]) and with higher index of disease severity (sPESI: OR = 2.29, 95% CI [1.50, 3.47]; PAOI%: MD = 13.52, 95% CI [7.2, 19.83]). The prevalence of recurrent PE was higher in PE patients with OSA than those without OSA (RR = 3.87, 95% CI [1.65, 9.07]). However, there was no significant difference in right ventricle to left ventricle short-axis diameter (MD = 0.08, 95% CI [- 0.06, 0.21]), length of hospital stay (MD = 1.03, 95% CI [- 1.11, 3.17]), or prevalence of deep vein thrombosis (OR = 0.87, 95% CI [0.48, 1.57]). Sensitivity and subgroup analysis showed that the pooled outcomes were stable.

CONCLUSION

OSA, especially moderate-severe OSA, was a risk factor for high-risk PE and recurrent PE. However, the current evidence showed that the length of hospital stay is not influenced by OSA.

Sleep Characteristics in Diabetic Patients Depending on the Occurrence of Neuropathic Pain and Related Factors

This study aims to compare the sleep characteristics (structure and quality) in patients with type-2 diabetes mellitus with and without diabetic neuropathic pain (DNP), and to investigate the relationship of sensory phenotypes, anxiety, and depression with sleep quality in DNP patients. A cross-sectional study was performed in patients with type-2 diabetes mellitus and neuropathy. Patients were classified into two groups-with or without neuropathic pain-according to the "Douleur Neuropathique-4 (DN4)" scale. Sleep characteristics and quality (Medical Outcomes Study-MOS-sleep), pain phenotype (Neuropathic Pain Symptom Inventory-NPSI), mood status (Hospital Anxiety and Depression scale-HADS), pain intensity (Visual Analogue Scale-VAS), and quality of life (SF-12v2) were measured. The sample included 130 patients (65 with DNP). The mean scores in all the dimensions of the MOS-sleep scale were higher (more disturbances) in the DNP patients. Higher scores in anxiety or depression, greater intensity of pain or a higher score in the paroxysmal pain phenotype were associated with lower sleep quality in DNP patients. A shorter duration of the diabetes and lower levels of glycated hemoglobin were also associated with lower sleep quality. The results show the relationship between DNP and sleep quality, and the importance of assessing sensory phenotypes and mental comorbidities in these patients. Taking these factors into consideration, to adopt a multimodal approach is necessary to achieve better clinical results.

Effectiveness of acceptance and commitment therapy (ACT) on depression and sleep quality in painful diabetic neuropathy: a randomized clinical trial

Background

Neuropathic pain is a complicated phenomenon in patients with diabetes. These patients have many problems, especially depression and Sleep disturbance. This study aimed to assess the effectiveness of Acceptance and Commitment Therapy on depression and Sleep disturbance in patients with painful diabetic neuropathy.

Methods

The current paper was conducted according to the clinical trial method with 50 participants. Participants were separated into intervention and control groups randomly. Based on the diagnosis of neurologists, all participants received standard medications to regulate neuropathic pain. The intervention group received ACT for eight sessions. The results were evaluated in the pre-test, post-test, and follow-up. The tools used were the Pittsburgh sleep quality index (PSQI) and Beck's depression inventory. Statistical analysis includes descriptive statistics, and repeated-measures (ANOVA) conducted by SPSS (version 26) software. Results: Results showed that in the intervention group, the treatment led to improved depressive symptoms (F = 6.81, P < 0.05). Besides, for sleep quality, treatment in all subscales, except for the Hypnotic medicine subscale, significantly improved the intervention group's situations. It was also observed that the overall quality of sleep in the ACT group showed a more significant improvement (P < 0.05). All the above results remained the same until the end of the follow-up period (P < 0.05).

Conclusion

ACT, as a complementary treatment, can improve the psychiatric symptoms and problems in people with neuropathic pain. Therefore, it is necessary to include psychotherapy services along with medical treatment in outpatient and hospitalization units.

Trial registration number

IRCT201802050388630N4. Registered in 02/05/2018.