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Balk EM, Adam GP, D’Ambrosio CM. Large variability in definitions of sleep apnea indices used in clinical studies. J Clin Sleep Med 2024; 20:461-468. [PMID: 38054476 PMCID: PMC11019218 DOI: 10.5664/jcsm.10918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/07/2023]
Abstract
STUDY OBJECTIVES We explored the variability of sleep apnea indices and definitions of obstructive sleep apnea in clinical studies of continuous positive airway pressure. METHODS In a systematic review of the long-term clinical effects of continuous positive airway pressure, we noted variability across studies in how sleep apnea was defined. We, thus, sought to quantify the heterogeneity. RESULTS Across 57 comparative studies of long-term clinical outcomes of continuous positive airway pressure, only 40% fully and explicitly reported their definitions of apnea and hypopnea. Most studies defined apnea as 100% airflow cessation, but a minority used 90% or even down to 75% thresholds. Almost half of the studies defined hypopnea as ≥ 50% airflow cessation, but the majority used 30% or even 25% thresholds. Similarly, about half of the studies used a 4% desaturation threshold to define oxygen desaturation and about half used a 3% threshold, with 2 studies using both thresholds for different purposes. Randomized trials were no more consistent or better-reported than observational studies. Studies that cited published criteria generally reported definitions that were different from the cited criteria. CONCLUSIONS The criteria used to define sleep apnea indices (apnea, hypopnea, and oxygen desaturation) were highly variable, even among studies stating that definitions were based on the same standard criteria. It was often difficult to discern the actual criteria used. The great variability across studies and lack of transparency about their sleep study methods hampers the interpretability and utility of the studies and calls into question whether studies are generalizable from one setting to another. CITATION Balk EM, Adam GP, D'Ambrosio CM. Large variability in definitions of sleep apnea indices used in clinical studies. J Clin Sleep Med. 2024;20(3):461-468.
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Affiliation(s)
- Ethan M. Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Gaelen P. Adam
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Carolyn M. D’Ambrosio
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut
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2
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Grossmann M, Jayasena CN, Anawalt BD. Approach to the Patient: The Evaluation and Management of Men ≥50 Years With Low Serum Testosterone Concentration. J Clin Endocrinol Metab 2023; 108:e871-e884. [PMID: 36995891 PMCID: PMC10438885 DOI: 10.1210/clinem/dgad180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
Although testosterone replacement in men with classic hypogonadism due to an identified pathology of the hypothalamic-pituitary-testicular axis is uncontroversial, the role of testosterone treatment for men with age-related declines in circulating testosterone is unclear. This is due to the lack of large, long-term testosterone therapy trials assessing definitive clinical endpoints. However, men ≥50 years of age, particularly those who have a body mass index >25 kg/m2 and multiple comorbidities, commonly present with clinical features of androgen deficiency and low serum testosterone concentrations. Clinicians are faced with the question whether to initiate testosterone therapy, a difficult dilemma that entails a benefit-risk analysis with limited evidence from clinical trials. Using a case scenario, we present a practical approach to the clinical assessment and management of such men.
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Affiliation(s)
- Mathis Grossmann
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Victoria 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria 3084, Australia
| | - Channa N Jayasena
- Section of Investigative Medicine, Imperial College London, London SW7 2AZ, UK
| | - Bradley D Anawalt
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
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3
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Lv R, Liu X, Zhang Y, Dong N, Wang X, He Y, Yue H, Yin Q. Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome. Signal Transduct Target Ther 2023; 8:218. [PMID: 37230968 DOI: 10.1038/s41392-023-01496-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.
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Affiliation(s)
- Renjun Lv
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xueying Liu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Yue Zhang
- Department of Geriatrics, the 2nd Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Na Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xiao Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yao He
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Hongmei Yue
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
| | - Qingqing Yin
- Department of Geriatric Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
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4
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Alonso-Isa M, García-Gómez B, González-Ginel I, García-Rayo-Encina C, Del Prado Caro-González M, Medina-Polo J, García-Rojo E, Romero-Otero J. Conservative Non-surgical Options for Erectile Dysfunction. Curr Urol Rep 2023; 24:75-104. [PMID: 36445614 DOI: 10.1007/s11934-022-01137-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW This study aimed to review recent evidence on conservative non-surgical options for erectile dysfunction (ED) in men. A narrative review of the literature was performed. A comprehensive search in the MEDLINE, Embase, and Cochrane databases was done. Papers in English language, published from May 2017 until May 2022, were included. Papers reporting basic research or animal research were excluded, as long as reviews or meta-analyses. Congress reports, clinical cases, or clinical trials protocols with no results were also excluded. RECENT FINDINGS We found a multitude of different treatment modalities for ED. We must take into account the type of patient, their comorbidities, the origin of their ED, and its severity in order to reproduce effective results using these therapies. Some of the treatments show good results with a good level of evidence (new IPDE5 formulations, intracavernous injections, shock wave therapy, hormonal theraphy, psycho-sexual theraphy). However, others (some new molecules, stem cell theraphy, platelet-rich plasma injections, oxygenation-based therapy, nutraceuticals), although some of them present promising results, require randomized studies with a larger number of patients and a longer follow-up time to be able to establish firm recommendations. Regarding the conservative treatment of erectile dysfunction, in recent years, some therapies have been consolidated as effective and safe for certain types of patients. On the other hand, other treatment modalities, although promising, still lack the evidence and the necessary follow-up to be recommended in daily practice.
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Affiliation(s)
- Manuel Alonso-Isa
- Department of Urology, Hospital Universitario 12 Octubre, Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain
- Department of Urology, HM Hospitales (Montepríncipe, Puerta del Sur, Sanchinarro), Madrid, Spain
- ROC Clinic, Madrid, Spain
| | - Borja García-Gómez
- Department of Urology, Hospital Universitario 12 Octubre, Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain
- Department of Urology, HM Hospitales (Montepríncipe, Puerta del Sur, Sanchinarro), Madrid, Spain
- ROC Clinic, Madrid, Spain
| | - Ignacio González-Ginel
- Department of Urology, Hospital Universitario 12 Octubre, Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain
| | - Clara García-Rayo-Encina
- Department of Urology, Hospital Universitario 12 Octubre, Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain
| | - María Del Prado Caro-González
- Department of Urology, Hospital Universitario 12 Octubre, Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain
| | - José Medina-Polo
- Department of Urology, Hospital Universitario 12 Octubre, Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain
- Department of Urology, HM Hospitales (Montepríncipe, Puerta del Sur, Sanchinarro), Madrid, Spain
- ROC Clinic, Madrid, Spain
| | - Esther García-Rojo
- Department of Urology, HM Hospitales (Montepríncipe, Puerta del Sur, Sanchinarro), Madrid, Spain
- ROC Clinic, Madrid, Spain
| | - Javier Romero-Otero
- Department of Urology, HM Hospitales (Montepríncipe, Puerta del Sur, Sanchinarro), Madrid, Spain.
- ROC Clinic, Madrid, Spain.
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5
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Pivonello R, Auriemma RS, Delli Veneri A, Dassie F, Lorusso R, Ragonese M, Liotta M, Sala E, Zarino B, Lai E, Urbani C, Bogazzi F, Mantovani G, Cannavò S, Maffei P, Chiodini P, Colao A. Global psychological assessment with the evaluation of life and sleep quality and sexual and cognitive function in a large number of patients with acromegaly: a cross-sectional study. Eur J Endocrinol 2022; 187:823-845. [PMID: 36165745 PMCID: PMC9782455 DOI: 10.1530/eje-22-0263] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 09/27/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Acromegaly is associated with somatic disfigurements which impair self-perception of well-being and quality of life. Nowadays, limited data are available on the interplay between hormonal excess and psychological discomfort. The study aimed at investigating the psychological profile, sleep quality, sexual function, cognitive functions, and quality of life in patients with acromegaly. METHODS In 223 acromegaly patients from 5 referral centres, global psychological profile, sleep quality, sexual function, cognitive function, and quality of life were investigated. RESULTS Depression was found in ~30% of patients, and anxiety in two-thirds, together with severe discomfort in body image mainly in women. Obstructive sleep apnoea syndrome risk and sleep disorders were found in >50% of patients and daily sleepiness in ~20%. Sexual dysfunction was reported in most of the patients, with the most severe impairment in women. Cognitive functions were compromised in ~10% of cases. Disease duration and patient's age and gender were the main determinants of these psychopathological conditions. Depression (P = 0.047), somatic-affective mood lowering (P = 0.021), state (P < 0.001) and trait (P = 0.013) anxiety, and body image distortion in body uneasiness test A (P < 0.001) and B (P = 0.006) were significantly worsened in patients <45 years and slightly worsened in those with disease duration less than 2 years. Male (P < 0.001) and female (P < 0.001) sexual function scores were significantly worsened in patients aged >64 years and slightly worsened in those with disease duration for more than 10 years, particularly in presence of cardiometabolic and respiratory complications. Cognitive symptoms were slightly worsened in older patients and in those with long disease duration. CONCLUSIONS Acromegaly is associated with a relevant impairment of psychological profile persisting despite remission and long-term medical treatment.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, ‘Federico II’ University, Naples, Italy
- Correspondence should be addressed to R Pivonello;
| | - Renata Simona Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Alessandra Delli Veneri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Francesca Dassie
- Department of Medicine, Clinica Medica 3^, University of Padua, Padua, Italy
| | - Riccardina Lorusso
- Department of Medicine, Clinica Medica 3^, University of Padua, Padua, Italy
| | - Marta Ragonese
- Endocrine Unit, University Hospital ‘G. Martino’, Messina, Italy
| | - Marco Liotta
- Endocrine Unit, University Hospital ‘G. Martino’, Messina, Italy
| | | | - Barbara Zarino
- Neurosurgery Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Lai
- Psychology Unit, Department of Surgical, Medical, Molecular, and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Claudio Urbani
- Endocrinology II Unit, Department of Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Fausto Bogazzi
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giovanna Mantovani
- Endocrinology Unit
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Pietro Maffei
- Department of Medicine, Clinica Medica 3^, University of Padua, Padua, Italy
| | - Paolo Chiodini
- Medical Statistic Unit, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, ‘Federico II’ University, Naples, Italy
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6
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The Impact of Transoral Robotic Surgery on Erectile Dysfunction and Lower Urinary Tract Symptoms in Male Patients with Moderate-to-Severe Obstructive Sleep Apnea. Healthcare (Basel) 2022; 10:healthcare10091633. [PMID: 36141245 PMCID: PMC9498748 DOI: 10.3390/healthcare10091633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Obstructive sleep apnea (OSA), lower urinary tract symptoms (LUTS), and erectile dysfunction (ED) are chronic conditions that seriously affect middle-aged men. This study aimed to evaluate the changes in the presence of these conditions after transoral robotic surgery (TORS) for OSA. This prospective observational study recruited 48 men with moderate-to-severe OSA (mean age 40.6 ± 8.1 years) who underwent TORS from October 2019 to November 2021 at a tertiary center. Baseline polysomnographic parameters, Epworth Sleepiness Scale (ESS), and demographic characteristics were measured. The evaluations of LUTS and ED were based on self-administered International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) questionnaires, respectively, before TORS. The treatment outcomes were assessed three months postoperatively in the patients undergoing TORS due to moderate-to-severe OSA. There was significant Apnea-Hypopnea Index (AHI) reduction from 53.10 ± 25.77 to 31.66 ± 20.34 three months after undergoing TORS (p < 0.001). There was also a significant decrease in the total IPSS score (5.06 ± 5.42 at baseline to 2.98 ± 2.71 at three months postoperatively, p = 0.001), the storage domain, and the voiding domain (p < 0.05). The ED also improved significantly, as seen in the IIEF score (20.98 ± 3.32 to 22.17± 3.60, p = 0.007). The reduction of AHI was associated with changes in body weight and the lowest oxygen saturation (SpO2) levels during sleep (rho = 0.395, p = 0.005; rho = 0.526, p < 0.001, respectively). However, the reduction in AHI was not significantly associated with improvement in IPSS or IIEF scores (p > 0.05). For men with moderate-to-severe OSA, TORS can significantly improve the polysomnography parameters, sleep-related questionnaire scores, and quality of life, and alleviate ED and LUTS. AHI reduction is not a crucial factor for ED and LUTS improvement after TORS for OSA, especially in ED.
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7
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Cantone E, Massanova M, Crocetto F, Barone B, Esposito F, Arcaniolo D, Corlianò F, Romano L, Motta G, Celia A. The relationship between obstructive sleep apnoea and erectile dysfunction: An underdiagnosed link? A prospective cross-sectional study. Andrologia 2022; 54:e14504. [PMID: 35817418 PMCID: PMC9539465 DOI: 10.1111/and.14504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/06/2022] [Accepted: 06/12/2022] [Indexed: 01/04/2023] Open
Abstract
This cross‐sectional study aimed to investigate the prevalence and clinical characteristics of erectile dysfunction in patients with obstructive sleep apnoea. We enrolled 133 male patients with suspected obstructive sleep apnoea. Ear, nose and throat evaluation, laboratory tests, body mass index, Epworth sleepiness scale, 5‐international index of erectile function, overnight ambulatory polygraphy and drug‐induced sleep endoscopy patterns were assessed. Eighty patients reported obstructive sleep apnoea. 60% (n = 48) reported erectile dysfunction. Statistically significant correlations were found between 5‐International Index of Erectile Function and age, hypertension, diabetes, Epworth sleepiness scale, apnoea‐hypopnea index score, O2 saturation‐nadir, and oxygen desaturation index. Age, diabetes and O2 saturation‐nadir were independent predictors of erectile function. Epworth sleepiness scale, apnoea‐hypopnea index score, O2 saturation‐nadir, oxygen desaturation index and albumin were higher compared to patients without erectile dysfunction. No statistically significant differences were reported for drug‐induced sleep endoscopy patterns and erectile dysfunction. Patients with obstructive sleep apnoea were at significant risk of having erectile dysfunction. Males with obstructive sleep apnoea should be investigated for erectile dysfunction.
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Affiliation(s)
- Elena Cantone
- Department of Neuroscience, Reproductive Sciences and Dentistry - ENT Section, University "Federico II", AOU "Federico II", Naples, Italy.,Head and Neck Department, UOC Otorhinolaryngology, AOU "Federico II", Naples, Italy
| | - Matteo Massanova
- Department of Urology, Southend University Hospital NHS Foundation Trust, Southend-On-Sea, UK
| | - Felice Crocetto
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Biagio Barone
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Fabio Esposito
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Davide Arcaniolo
- Department of Woman, Child and General and Specialized Surgery, Urology Unit, University of Campania "Luigi Vanvitelli,", Naples, Italy
| | | | - Luigi Romano
- Department of ENT, San Bassiano Hospital, Vicenza, Italy
| | - Gaetano Motta
- Department of Mental and Physical Health and Preventive Medicine, Head and Neck Surgery Unit, University of Campania "Luigi Vanvitelli,", Naples, Italy
| | - Antonio Celia
- Department of Urology, San Bassiano Hospital, Vicenza, Italy
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8
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Gu Y, Wu C, Qin F, Yuan J. Erectile Dysfunction and Obstructive Sleep Apnea: A Review. Front Psychiatry 2022; 13:766639. [PMID: 35693968 PMCID: PMC9178074 DOI: 10.3389/fpsyt.2022.766639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Erectile dysfunction (ED) is a disease with a wide scope of etiologies. Obstructive sleep apnea (OSA) is considered one of the risk factors for ED and is less studied. A growing lot of evidence show an association between OSA and ED. This study provides an updated review of the relationship between ED and OSA and the possible physiological mechanisms of ED in patients with OSA based on the current evidence. In clinical interviews, patients with ED may benefit from a sleep evaluation. However, further clinical investigations and more basic research are needed to illustrate the relationship between ED and OSA.
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Affiliation(s)
- Yiwei Gu
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu, China.,Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - ChangJing Wu
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Qin
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Jiuhong Yuan
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu, China.,Department of Urology, West China Hospital, Sichuan University, Chengdu, China
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9
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Feng C, Yang Y, Chen L, Guo R, Liu H, Li C, Wang Y, Dong P, Li Y. Prevalence and Characteristics of Erectile Dysfunction in Obstructive Sleep Apnea Patients. Front Endocrinol (Lausanne) 2022; 13:812974. [PMID: 35250871 PMCID: PMC8896119 DOI: 10.3389/fendo.2022.812974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/12/2022] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Chen Feng
- Department of Otolaryngology Head and Neck Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Otorhinolaryngology, Qilu Hospital, Shandong University Cheeloo College of Medicine, Jinan, China
- NHC Key Laboratory of Otorhinolaryngology (Shandong University), Jinan, China
| | - Yan Yang
- Department of Otorhinolaryngology, Qilu Hospital, Shandong University Cheeloo College of Medicine, Jinan, China
- NHC Key Laboratory of Otorhinolaryngology (Shandong University), Jinan, China
| | - Lixiao Chen
- Department of Otolaryngology Head and Neck Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ruixiang Guo
- Department of Otorhinolaryngology, Qilu Hospital, Shandong University Cheeloo College of Medicine, Jinan, China
- NHC Key Laboratory of Otorhinolaryngology (Shandong University), Jinan, China
| | - Huayang Liu
- Department of Otorhinolaryngology, Qilu Hospital, Shandong University Cheeloo College of Medicine, Jinan, China
- NHC Key Laboratory of Otorhinolaryngology (Shandong University), Jinan, China
| | - Chaojie Li
- Department of Otorhinolaryngology, Qilu Hospital, Shandong University Cheeloo College of Medicine, Jinan, China
- NHC Key Laboratory of Otorhinolaryngology (Shandong University), Jinan, China
| | - Yan Wang
- Department of Otorhinolaryngology, Qilu Hospital, Shandong University Cheeloo College of Medicine, Jinan, China
- NHC Key Laboratory of Otorhinolaryngology (Shandong University), Jinan, China
| | - Pin Dong
- Department of Otolaryngology Head and Neck Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- *Correspondence: Pin Dong, ; Yanzhong Li,
| | - Yanzhong Li
- Department of Otorhinolaryngology, Qilu Hospital, Shandong University Cheeloo College of Medicine, Jinan, China
- NHC Key Laboratory of Otorhinolaryngology (Shandong University), Jinan, China
- *Correspondence: Pin Dong, ; Yanzhong Li,
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10
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Reynor A, McArdle N, Shenoy B, Dhaliwal SS, Rea SC, Walsh J, Eastwood PR, Maddison K, Hillman DR, Ling I, Keenan BT, Maislin G, Magalang U, Pack AI, Mazzotti DR, Lee CH, Singh B. Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients? Sleep 2021; 45:6421415. [PMID: 34739082 PMCID: PMC9891109 DOI: 10.1093/sleep/zsab264] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/26/2021] [Indexed: 02/04/2023] Open
Abstract
STUDY OBJECTIVES Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic. METHODS Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified. RESULTS Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities. CONCLUSIONS A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.
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Affiliation(s)
- Ayesha Reynor
- Centre for Sleep Science, School of Human Sciences, University of Western Australia, Crawley, WA, Australia,Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Nigel McArdle
- Centre for Sleep Science, School of Human Sciences, University of Western Australia, Crawley, WA, Australia,Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia,West Australian Sleep Disorders Research Institute, Nedlands, WA, Australia
| | - Bindiya Shenoy
- Centre for Sleep Science, School of Human Sciences, University of Western Australia, Crawley, WA, Australia
| | - Satvinder S Dhaliwal
- Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia,Curtin Health Innovation Research Institute, Faculty of Health Sciences, B305, Curtin University, Bentley, WA, Australia,Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia,Duke-NUS Medical School, National University of Singapore, Singapore,Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Minden, Pulau Pinang, Malaysia
| | - Siobhan C Rea
- Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Jennifer Walsh
- Centre for Sleep Science, School of Human Sciences, University of Western Australia, Crawley, WA, Australia,Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia,West Australian Sleep Disorders Research Institute, Nedlands, WA, Australia
| | - Peter R Eastwood
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Kathleen Maddison
- Centre for Sleep Science, School of Human Sciences, University of Western Australia, Crawley, WA, Australia,Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia,West Australian Sleep Disorders Research Institute, Nedlands, WA, Australia
| | - David R Hillman
- Centre for Sleep Science, School of Human Sciences, University of Western Australia, Crawley, WA, Australia,West Australian Sleep Disorders Research Institute, Nedlands, WA, Australia
| | - Ivan Ling
- Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia,West Australian Sleep Disorders Research Institute, Nedlands, WA, Australia
| | - Brendan T Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Greg Maislin
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ulysses Magalang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Allan I Pack
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Diego R Mazzotti
- Division of Medical Informatics, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Chi-Hang Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Department of Cardiology, National University Heart Centre, Singapore
| | - Bhajan Singh
- Corresponding author. Bhajan Singh, Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA 6015, Australia.
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Ye G, Yin H, Chen T, Chen H, Cui L, Zhang X. FENet: A Frequency Extraction Network for Obstructive Sleep Apnea Detection. IEEE J Biomed Health Inform 2021; 25:2848-2856. [PMID: 33434137 DOI: 10.1109/jbhi.2021.3050113] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Obstructive Sleep Apnea (OSA) is a highly prevalent but inconspicuous disease that seriously jeopardizes the health of human beings. Polysomnography (PSG), the gold standard of detecting OSA, requires multiple specialized sensors for signal collection, hence patients have to physically visit hospitals and bear the costly treatment for a single detection. Recently, many single-sensor alternatives have been proposed to improve the cost efficiency and convenience. Among these methods, solutions based on RR-interval (i.e., the interval between two consecutive pulses) signals reach a satisfactory balance among comfort, portability and detection accuracy. In this paper, we advance RR-interval based OSA detection by considering its real-world practicality from energy perspectives. As photoplethysmogram (PPG) pulse sensors are commonly equipped on smart wrist-worn wearable devices (e.g., smart watches and wristbands), the energy efficiency of the detection model is crucial to fully support an overnight observation on patients. This creates challenges as the PPG sensors are unable to keep collecting continuous signals due to the limited battery capacity on smart wrist-worn devices. Therefore, we propose a novel Frequency Extraction Network (FENet), which can extract features from different frequency bands of the input RR-interval signals and generate continuous detection results with downsampled, discontinuous RR-interval signals. With the help of the one-to-multiple structure, FENet requires only one-third of the operation time of the PPG sensor, thus sharply cutting down the energy consumption and enabling overnight diagnosis. Experimental results on real OSA datasets reveal the state-of-the-art performance of FENet.
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Singh B. Physiology May Be the Key: Cardiovascular Risk Stratification in Obstructive Sleep Apnea. Am J Respir Crit Care Med 2021; 203:1458-1460. [PMID: 33651665 PMCID: PMC8483224 DOI: 10.1164/rccm.202101-0145ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Bhajan Singh
- Department of Pulmonary Physiology Sir Charles Gairdner Hospital Nedlands, Western Australia, Australia.,West Australian Sleep Disorders Research Institute QE II Medical Centre Nedlands, Western Australia, Australia and.,School of Human Sciences University of Western Australia Crawley, Western Australia, Australia
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Abstract
: Sexual health is an integral part of overall health, and an active and healthy sexual life is an essential aspect of a good life quality. Cardiovascular disease and sexual health share common risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, obesity, and smoking) and common mediating mechanisms (endothelial dysfunction, subclinical inflammation, and atherosclerosis). This generated a shift of thinking about the pathophysiology and subsequently the management of sexual dysfunction. The introduction of phosphodiesterase type 5 inhibitors revolutionized the management of sexual dysfunction in men. This article will focus on erectile dysfunction and its association with arterial hypertension. This update of the position paper was created by the Working Group on Sexual Dysfunction and Arterial Hypertension of the European Society of Hypertension. This working group has been very active during the last years in promoting the familiarization of hypertension specialists and related physicians with erectile dysfunction, through numerous lectures in national and international meetings, a position paper, newsletters, guidelines, and a book specifically addressing erectile dysfunction in hypertensive patients. It was noted that erectile dysfunction precedes the development of coronary artery disease. The artery size hypothesis has been proposed as a potential explanation for this observation. This hypothesis seeks to explain the differing manifestation of the same vascular condition, based on the size of the vessels. Clinical presentations of the atherosclerotic and/or endothelium disease in the penile arteries might precede the corresponding manifestations from larger arteries. Treated hypertensive patients are more likely to have sexual dysfunction compared with untreated ones, suggesting a detrimental role of antihypertensive treatment on erectile function. The occurrence of erectile dysfunction seems to be related to undesirable effects of antihypertensive drugs on the penile tissue. Available information points toward divergent effects of antihypertensive drugs on erectile function, with diuretics and beta-blockers possessing the worst profile and angiotensin receptor blockers and nebivolol the best profile.
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14
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Yang Z, Du G, Ma L, Lv Y, Zhao Y, Yau TO. Continuous positive airway pressure therapy in obstructive sleep apnoea patients with erectile dysfunction-A meta-analysis. CLINICAL RESPIRATORY JOURNAL 2020; 15:163-168. [PMID: 32975905 DOI: 10.1111/crj.13280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 09/11/2020] [Accepted: 09/14/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Erectile dysfunction (ED) with obstructive sleep apnoea (OSA) is a relatively common issue for men. A number of clinical studies have demonstrated that continuous positive airway pressure (CPAP) therapy may effectively alleviate ED symptoms from patients with OSA. METHODS PubMed, MEDLINE, EMBASE and Cochrane Library databases were utilised and searched for the relevant studies up to September 2, 2019. The International Index of Erectile Function 5 (IIEF-5) scoring system from the patients before and after receiving their CPAP therapy were collected according to the strict inclusion and exclusion criteria. REVMEN 5.3 software was applied for the meta-analysis. RESULTS A total of seven publications consisted of 206 ED patients with OSA were included in the study. ED patients with OSA received CPAP treatment were significantly improved based on the IIEF-5 scores [Weighted Mean Difference (WMD) = 1.14, 95% confidence interval (CI) = 0.89-1.38, z = 9.09, p < 0.0001].Our research found that the high heterogeneity is mainly due to Zhang's data, with a higher apnoea-hypopnea index (AHI) compared to the other included studies. A moderate heterogeneity (I2 = 54%, P = 0.05) was found after removal of Zhang's data. CONCLUSION The results suggest that continuous positive airway pressure therapy relive erectile dysfunction symptoms in patients with obstructive sleep apnoea. However, further evidence is needed due to the insufficient number of included patients and high heterogeneity.
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Affiliation(s)
- Zhihao Yang
- School of Information Engineering and Automation, Kunming University of Science, and Technology, Kunming, China
| | - Guodong Du
- School of Information Engineering and Automation, Kunming University of Science, and Technology, Kunming, China
- Department of Artificial Intelligence, Xiamen University, Xiamen, China
| | - Lei Ma
- School of Information Engineering and Automation, Kunming University of Science, and Technology, Kunming, China
| | - Yunhui Lv
- Sleep Medicine Centre, First People's Hospital of Yunnan Province, Kunming, China
| | - Yang Zhao
- School of Information Engineering and Automation, Kunming University of Science, and Technology, Kunming, China
| | - Tung On Yau
- John van Geest Cancer Research Centre, School of Sciences and Technology, Nottingham Trent University, Nottingham, UK
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15
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Andersen ML, Tufik S. A Review of Sleep Disturbance and Sexual Function: the Effect of Sleep Apnea on Erectile Function. CURRENT SLEEP MEDICINE REPORTS 2020. [DOI: 10.1007/s40675-020-00171-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Li Z, Fang Z, Xing N, Zhu S, Fan Y. The effect of CPAP and PDE5i on erectile function in men with obstructive sleep apnea and erectile dysfunction: A systematic review and meta-analysis. Sleep Med Rev 2019; 48:101217. [PMID: 31715462 DOI: 10.1016/j.smrv.2019.101217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/20/2019] [Accepted: 09/22/2019] [Indexed: 12/19/2022]
Abstract
Growing evidence has shown that obstructive sleep apnea (OSA) and erectile dysfunction (ED) often coexist. However, the effect of continuous positive airway pressure (CPAP) on erectile function remains controversial. The objective of this review was to clarify the anti-ED effect of CPAP and further compare the efficacy between CPAP, phosphodiesterase type 5 inhibitors (PDE5i) and combination therapy on erectile function in OSA patients concurrent ED. Literature search was performed up to December 1st, 2018 and 26 studies were included in the review. Results showed that CPAP significantly ameliorated the international index of erectile function (IIEF) score, total erectile events (TEE) and nocturnal penile rigidity (NPR), while no significant improvements in nocturnal penile tumescence circumference (NPTC). Moreover, CPAP was inferior to PDE5i in improving IIEF-erectile function, IIEF-intercourse satisfaction, NPTC, successful attempted intercourses rate (SAIR) and erectile dysfunction inventory of treatment satisfaction-question one (EDITS-Q1), while CPAP and PDE5i were of equal efficacy in other domains of IIEF and NPR. Interestingly, CPAP was more effective in improving TEE. Furthermore, CPAP combined with PDE5i was superior to CPAP alone in improving IIEF score, SAIR, and TEE. This review provided promising insights about CPAP-based ED treatment for OSA patients.
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Affiliation(s)
- Zeyan Li
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, PR China
| | - Zhiqing Fang
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, PR China
| | - Naidong Xing
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, PR China
| | - Shiqin Zhu
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250012, PR China.
| | - Yidong Fan
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, PR China.
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Liu PY. A Clinical Perspective of Sleep and Andrological Health: Assessment, Treatment Considerations, and Future Research. J Clin Endocrinol Metab 2019; 104:4398-4417. [PMID: 31042277 PMCID: PMC6735730 DOI: 10.1210/jc.2019-00683] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/25/2019] [Indexed: 12/29/2022]
Abstract
CONTEXT Sleep that is insufficient, misaligned, or disrupted causes hypersomnolence and neuropsychological deficits, adversely affects cardiometabolic health, and is increasingly recognized to impair other biological processes that lead to conditions important to men, such as hypogonadism, erectile dysfunction, and infertility. EVIDENCE ACQUISITION Literature review from 1970 to December 2018. EVIDENCE SYNTHESIS High-quality and complementary epidemiological and interventional studies establish that abnormal sleep is associated with increased mortality, hypertension, and other cardiometabolic disorders (insufficient, disrupted, and misaligned sleep), as well as reduced fecundity and total sperm count (insufficient sleep), erectile dysfunction (disrupted sleep), and low testosterone (both). Circadian misalignment shifts the peak of testosterone's diurnal rhythm to occur soon after waking up, irrespective of the biological clock time, but it does not change the mean concentration. Preliminary studies show that extending sleep in individuals who are chronically sleep deprived may become a strategy to reduce insulin resistance and hypertension. Continuous positive airway pressure therapy can improve erectile function, and possibly systemic testosterone exposure, but only when used adherently by men with obstructive sleep apnea. Both high-dose and replacement-dose testosterone therapies modestly worsen sleep-disordered breathing, but they also improve cardiometabolic function and sexual desire. Persistence of either the adverse or beneficial outcomes over the longer term requires further investigation. CONCLUSIONS Sleep is increasingly recognized to be essential for healthy living. Establishing the effect of abnormal sleep, and of improving sleep, on andrological issues of prime interest to men will promote prioritization of sleep, and may thereby improve overall long-term health outcomes.
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Affiliation(s)
- Peter Y Liu
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
- Correspondence and Reprint Requests: Peter Y. Liu, PhD, Division of Endocrinology and Metabolism, Department of Medicine, Harbor UCLA Medical Center and Los Angeles Biomedical Research Institute, 1124 West Carson Street, Box 446, Torrance, California 90502. E-mail:
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Effects of continuous positive airway pressure therapy on daytime and nighttime arterial blood pressure in patients with severe obstructive sleep apnea and endothelial dysfunction. Sleep Breath 2019; 24:941-951. [DOI: 10.1007/s11325-019-01926-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/14/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
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