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Lin J, Hou X, Liu Y, Cai Y, Pan J, Liao J. Elevated peripheral glutamate and upregulated expression of NMDA receptor NR1 subunit in insomnia disorder. Front Psychiatry 2024; 15:1436024. [PMID: 39435127 PMCID: PMC11491378 DOI: 10.3389/fpsyt.2024.1436024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 09/18/2024] [Indexed: 10/23/2024] Open
Abstract
Background The present study explored the serum glutamate (Glu), glutamine (Gln), glutamic acid dehydrogenase (GAD) concentrations and the mRNA expression levels of the N-methyl-D-aspartate receptor (NMDAR) NR1 subunit in the peripheral blood of patients with insomnia disorder (ID). To our knowledge, this is the first study showing an increase in the mRNA expression levels of the NMDAR NR1 subunit in patients with ID. Methods This study included 30 ID patients and 30 matched healthy controls. We investigated the demographic and illness information and assessed subjective sleep quality using the Pittsburgh Sleep Quality Index. The Hamilton Depression Scale-17 and Hamilton Anxiety Scale were used to evaluate the patients' symptoms of depression and anxiety, respectively. The quantifications of Glu, Gln and GAD concentrations were performed by Enzyme-linked immunosorbent assay (ELISA). Real-time PCR was used to detect the mRNA expression levels of the NMDAR NR1 subunit in peripheral blood. Results Compared with the healthy control group, the serum Glu concentrations and the mRNA expression levels of the NMDAR NR1 subunit in the ID group were significantly higher. However, there was no significant difference in Gln and GAD between the two groups. The receiver operating characteristic (ROC) analysis showed that the mRNA expression levels of the NMDAR NR1 subunit could distinguish ID patients from healthy individuals (area under the curve: 0.758; sensitivity: 73.3%; specificity: 76.7%). A negative correlation was found between the mRNA expression levels of the NMDAR NR1 subunit for age, total duration of illness, and age of first onset in the ID group, whereas a positive correlation was detected for daytime dysfunction. Conclusion Glutamatergic neurotransmission was abnormal in ID patients. Additionally, the mRNA expression levels of the NMDAR NR1 subunit appeared to have potential as a clinical biomarker for ID. However, the sample size of our study was limited, and future studies with larger sample sizes are needed to further validate and explore the mechanisms involved and to assess the reliability of the biomarker.
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Affiliation(s)
- Jingjing Lin
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
- Department of Psychiatry, Sleep Medicine Centre, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Xiaohui Hou
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Yaxi Liu
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
- Department of Psychiatry, Sleep Medicine Centre, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Yixian Cai
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
- Department of Psychiatry, Sleep Medicine Centre, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Jiyang Pan
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
- Department of Psychiatry, Sleep Medicine Centre, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Jiwu Liao
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
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Aquino G, Benz F, Dressle RJ, Gemignani A, Alfì G, Palagini L, Spiegelhalder K, Riemann D, Feige B. Towards the neurobiology of insomnia: A systematic review of neuroimaging studies. Sleep Med Rev 2024; 73:101878. [PMID: 38056381 DOI: 10.1016/j.smrv.2023.101878] [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: 11/25/2022] [Revised: 11/03/2023] [Accepted: 11/10/2023] [Indexed: 12/08/2023]
Abstract
Insomnia disorder signifies a major public health concern. The development of neuroimaging techniques has permitted to investigate brain mechanisms at a structural and functional level. The present systematic review aims at shedding light on functional, structural, and metabolic substrates of insomnia disorder by integrating the available published neuroimaging data. The databases PubMed, PsycARTICLES, PsycINFO, CINAHL and Web of Science were searched for case-control studies comparing neuroimaging data from insomnia patients and healthy controls. 85 articles were judged as eligible. For every observed finding of each study, the effect size was calculated from standardised mean differences, statistic parameters and figures, showing a marked heterogeneity that precluded a comprehensive quantitative analysis. From a qualitative point of view, considering the findings of significant group differences in the reported regions across the articles, this review highlights the major involvement of the anterior cingulate cortex, thalamus, insula, precuneus and middle frontal gyrus, thus supporting some central themes in the debate on the neurobiology of and offering interesting insights into the psychophysiology of sleep in this disorder.
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Affiliation(s)
- Giulia Aquino
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine - University of Pisa, Pisa, Italy.
| | - Fee Benz
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Raphael J Dressle
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Angelo Gemignani
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine - University of Pisa, Pisa, Italy
| | - Gaspare Alfì
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine - University of Pisa, Pisa, Italy
| | - Laura Palagini
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Kai Spiegelhalder
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dieter Riemann
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd Feige
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Nyhuis CC, Fernandez-Mendoza J. Insomnia nosology: a systematic review and critical appraisal of historical diagnostic categories and current phenotypes. J Sleep Res 2023; 32:e13910. [PMID: 37122153 DOI: 10.1111/jsr.13910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 05/02/2023]
Abstract
Insomnia nosology has significantly evolved since the Diagnostic and Statistical Manual (DSM)-III-R first distinguished between 'primary' and 'secondary' insomnia. Prior International Classification of Sleep Disorders (ICSD) nosology 'split' diagnostic phenotypes to address insomnia's heterogeneity and the DSM nosology 'lumped' them into primary insomnia, while both systems assumed causality for insomnia secondary to health conditions. In this systematic review, we discuss the historical phenotypes in prior insomnia nosology, present findings for currently proposed insomnia phenotypes based on more robust approaches, and critically appraise the most relevant ones. Electronic databases PsychINFO, PubMED, Web of Science, and references of eligible articles, were accessed to find diagnostic manuals, literature on insomnia phenotypes, including systematic reviews or meta-analysis, and assessments of the reliability or validity of insomnia diagnoses, identifying 184 articles. The data show that previous insomnia diagnoses lacked reliability and validity, leading current DSM-5-TR and ICSD-3 nosology to 'lump' phenotypes into a single diagnosis comorbid with health conditions. However, at least two new, robust insomnia phenotyping approaches were identified. One approach is multidimensional-multimethod and provides evidence for self-reported insomnia with objective short versus normal sleep duration linked to clinically relevant outcomes, while the other is multidimensional and provides evidence for two to five clusters (phenotypes) based on self-reported trait, state, and/or life-history data. Some approaches still need replication to better support whether their findings identify true phenotypes or simply different patterns of symptomatology. Regardless, these phenotyping efforts aim at improving insomnia nosology both as a classification system and as a mechanism to guide treatment.
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Affiliation(s)
- Casandra C Nyhuis
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry and Behavioral Health, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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Liu Y, Rao K, Li Z, Huang C. Improvement of neurological recovery in the insomnia rats by Warming Yang Strategy through targeting SIRT4 by inhibiting inflammation and apoptosis. Immun Inflamm Dis 2023; 11:e964. [PMID: 37647454 PMCID: PMC10408374 DOI: 10.1002/iid3.964] [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: 12/24/2022] [Revised: 03/24/2023] [Accepted: 07/17/2023] [Indexed: 09/01/2023] Open
Abstract
The incidence rate of insomnia is increasing, but the mechanism of it remains unclear. Warming Yang Strategy (WY) is a kind of Traditional Chinese Medicine, and it is proved to be effective in treating insomnia patients. The insomnia animal was established with chlorophenylalanine (PCPA). Morris water maze and open field test were performed to evaluate the influence of WY on the neurological recovery of insomnia rats. TUNEL staining and flow cytometry were used to measure apoptosis level. WY promoted the neurological recovery in the insomnia rats through Morris water maze and open field test evaluation. The increase of γ-aminobutyric acid, dopamine, 5-hydroxytryptamine, and norepinephrine caused by WY was suppressed by siSIRT4. The decrease of apoptosis and inflammation factors expression induced by WY was promoted by siRNA-SIRT4 (siSIRT4). WY improve neurological recovery in the insomnia rats through SIRT4 by inhibiting inflammation and apoptosis. This research might provide a novel insight for the prevention and treatment of insomnia through targeting SIRT4.
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Affiliation(s)
- Yuanyuan Liu
- Department of Cardiology, Jiangxi Provincial People's HospitalThe First Affiliated Hospital of Nanchang Medical CollegeNanchangChina
| | - Kaihua Rao
- Department of NeurologyAffiliated Hospital of Jiangxi University of Traditional Chinese MedicineNanchangChina
| | - Zhengfeng Li
- Department of EndocrinologyAffiliated Hospital of Jiangxi University of Traditional Chinese MedicineNanchangChina
| | - Chunhua Huang
- Department of NeurologyAffiliated Hospital of Jiangxi University of Traditional Chinese MedicineNanchangChina
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Lee DW, Kwon JI, Heo H, Woo CW, Yu NH, Kim KW, Woo DC. Cerebral Glutamate Alterations Using Chemical Exchange Saturation Transfer Imaging in a Rat Model of Lipopolysaccharide-Induced Sepsis. Metabolites 2023; 13:metabo13050636. [PMID: 37233677 DOI: 10.3390/metabo13050636] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/26/2023] [Accepted: 05/06/2023] [Indexed: 05/27/2023] Open
Abstract
Glutamate-weighted chemical exchange saturation transfer (GluCEST) is a useful imaging tool to detect glutamate signal alterations caused by neuroinflammation. This study aimed to visualize and quantitatively evaluate hippocampal glutamate alterations in a rat model of sepsis-induced brain injury using GluCEST and proton magnetic resonance spectroscopy (1H-MRS). Twenty-one Sprague Dawley rats were divided into three groups (sepsis-induced groups (SEP05, n = 7 and SEP10, n = 7) and controls (n = 7)). Sepsis was induced through a single intraperitoneal injection of lipopolysaccharide (LPS) at a dose of 5 mg/kg (SEP05) or 10 mg/kg (SEP10). GluCEST values and 1H-MRS concentrations in the hippocampal region were quantified using conventional magnetization transfer ratio asymmetry and a water scaling method, respectively. In addition, we examined immunohistochemical and immunofluorescence staining to observe the immune response and activity in the hippocampal region after LPS exposure. The GluCEST and 1H-MRS results showed that GluCEST values and glutamate concentrations were significantly higher in sepsis-induced rats than those in controls as the LPS dose increased. GluCEST imaging may be a helpful technique for defining biomarkers to estimate glutamate-related metabolism in sepsis-associated diseases.
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Affiliation(s)
- Do-Wan Lee
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Jae-Im Kwon
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
- Nonclinical Research Center, QuBEST BIO Inc., Giheung-gu, Yongin-si 17015, Gyeonggi-do, Republic of Korea
| | - Hwon Heo
- Department of Convergence Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Chul-Woong Woo
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Na Hee Yu
- Nonclinical Research Center, QuBEST BIO Inc., Giheung-gu, Yongin-si 17015, Gyeonggi-do, Republic of Korea
| | - Kyung Won Kim
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Dong-Cheol Woo
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
- Department of Convergence Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Republic of Korea
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Ren D, Jiang B, Guo Z. Insomnia disorder with objective short sleep duration (ISS) phenotype and cognitive performance: a systematic review and meta-analysis. Neurol Sci 2023. [PMID: 36867277 DOI: 10.1007/s10072-023-06692-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
OBJECTIVE Insomnia disorder with objective short sleep duration (ISS) has been considered as a biologically severe subtype. The aim of this meta-analysis was to reveal the association of the ISS phenotype and cognitive performance. METHODS We searched PubMed, EMBASE, and the Cochrane Library for studies that observed an association of cognitive performance and insomnia with objective short sleep duration (ISS) phenotype. The "metafor" and "MAd" packages in R software (version 4.2.0) were used to calculate the unbiased standardized mean difference (Hedge's g), which was adjusted so that a negative value indicated worse cognitive performance. RESULTS The pooled analysis with 1339 participants revealed that the ISS phenotype was associated with overall cognitive impairments (Hedges' g = - 0.56 [- 0.89, - 0.23]), as well as specific cognitive domains including attention (Hedges' g = - 0.86 [- 1.25, - 0.47]), memory (Hedges' g = - 0.47 [- 0.82, - 0.12]), and executive function (Hedges' g = - 0.39 [- 0.76, - 0.02]). However, cognitive performance was not significantly different between insomnia disorder with objective normal sleep duration (INS) and good sleepers (p > .05). CONCLUSION Insomnia disorder with the ISS phenotype, but not the INS phenotype, was associated with cognitive impairments, suggesting the possible utility of treating the ISS phenotype to improve cognitive performance.
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Affiliation(s)
- Dongmei Ren
- Department of Psychology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Binghu Jiang
- Institute of Brain Function, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Zhiwei Guo
- Institute of Brain Function, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, 637000, Sichuan, China
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7
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Insomnia with objective short sleep duration in women with temporomandibular joint disorder: quantitative sensory testing, inflammation and clinical pain profiles. Sleep Med 2022; 90:26-35. [PMID: 35091170 PMCID: PMC8923986 DOI: 10.1016/j.sleep.2022.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/12/2021] [Accepted: 01/04/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES/BACKGROUND Temporomandibular joint disorder (TMD) is a disabling facial pain syndrome with a high prevalence of insomnia that primarily affects women. Insomnia with objective short sleep duration (ISSD) is an emerging phenotype linked to cardiometabolic morbidity and increased mortality. The present report examines the association of ISSD on clinical and laboratory pain and systemic inflammation in TMD. METHODS We collected baseline data from 128 women with TMD and insomnia as part of a clinical trial evaluating psychological interventions for sleep and pain. Participants completed self-report questionnaires, one-night polysomnography, a two-week actigraphy assessment, quantitative sensory testing (QST) to assess cold pain tolerance, pain sensitivity and central sensitization and circulating Interleukin-6 levels were measured to assess systemic inflammation. RESULTS 24.2% (n = 31) of the sample met criteria for ISSD [polysomnography (sleep duration <6 h)]. Compared to those with insomnia and normal sleep duration, ISSD were older (40.4 vs. 34.9,p < 0.05) and a greater proportion self-identified as Black (48.4% vs 11.3%,p < 0.001). Multivariate regressions revealed that ISSD endorsed higher self-report pain severity and functional limitation of the jaw. ISSD also demonstrated increased generalized pain sensitivity, enhanced central sensitization, cold pressor tolerance and higher resting interleukin-6 levels. CONCLUSIONS This is the first study to characterize the ISSD phenotype in a chronic pain sample and expand the scope of its negative health outcomes to chronic pain. ISSD may be an important chronic pain phenotype associated with a more severe clinical and laboratory pain profile, and future studies should focus on implications for treatment response and disease trajectory. CLINICAL TRIAL ClinicalTrials.gov Identifier: NCT01794624.
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Vgontzas AN, Fernandez-Mendoza J, Lenker KP, Basta M, Bixler EO, Chrousos GP. Hypothalamic-pituitary-adrenal (HPA) axis response to exogenous corticotropin-releasing hormone (CRH) is attenuated in men with chronic insomnia. J Sleep Res 2021; 31:e13526. [PMID: 34825417 DOI: 10.1111/jsr.13526] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 12/23/2022]
Abstract
Although insomnia is by far the most common sleep disorder, our understanding of its neurobiology is limited. Insomnia, particularly when associated with objective sleep disturbance, has been associated with activation of the hypothalamic-pituitary-adrenal axis. The objective of this experimental study was to compare the response of the hypothalamic-pituitary-adrenal axis to ovine corticotropin-releasing hormone, a stress test, in men with insomnia versus controls. Circulating adrenocorticotropic hormone and cortisol levels were assayed before (-30 min, -15 min), at (0 min) and after (+5 min, +15 min, +30 min, +60 min, +90 min, +120 min) exogenous ovine corticotropin-releasing hormone administration in 23 men (11 insomnia, 12 controls), who underwent four consecutive nights of in-lab polysomnography. Men with insomnia compared with controls demonstrated markedly and significantly shorter total sleep time (368.4 ± 8.99 min versus 411.61 ± 8.61 min; p < 0.01) and lower sleep efficiency (76.77 ± 1.80% versus 86.04 ± 1.72%; p < 0.01) on polysomnography, and showed decreased adrenocorticotropic hormone and cortisol levels after ovine corticotropin-releasing hormone administration. Adrenocorticotropic hormone levels at 15 min and 30 min were significantly lower in men with insomnia than in controls (p < 0.05). Similarly, the peak levels of cortisol at +60 min, and the total and net area under the curve levels of this hormone were significantly lower in men with insomnia than controls (all p < 0.01). Adrenocorticotropic hormone and cortisol response to ovine corticotropin-releasing hormone administration was attenuated in men with insomnia associated with objective sleep disturbance, suggesting that objectively defined insomnia subtypes have a disrupted hypothalamic-pituitary-adrenal axis function and highlight the need to develop treatments targeting the underlying hypothalamic-pituitary-adrenal axis dysregulation.
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Affiliation(s)
- Alexandros N Vgontzas
- Sleep Research & Treatment Center, Penn State Health Milton S. Hershey Medical Center, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Julio Fernandez-Mendoza
- Sleep Research & Treatment Center, Penn State Health Milton S. Hershey Medical Center, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Kristina Puzino Lenker
- Sleep Research & Treatment Center, Penn State Health Milton S. Hershey Medical Center, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Maria Basta
- Department of Psychiatry, University of Crete, University Hospital of Heraklion, Heraklion, Greece
| | - Edward O Bixler
- Sleep Research & Treatment Center, Penn State Health Milton S. Hershey Medical Center, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - George P Chrousos
- Aghia Sophia Children's Hospital, Medical School, University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Vakulin A, Green MA, D'Rozario AL, Stevens D, Openshaw H, Bartlett D, Wong K, McEvoy RD, Grunstein RR, Rae CD. Brain mitochondrial dysfunction and driving simulator performance in untreated obstructive sleep apnea. J Sleep Res 2021; 31:e13482. [PMID: 34528315 DOI: 10.1111/jsr.13482] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022]
Abstract
It is challenging to determine which patients with obstructive sleep apnea (OSA) have impaired driving ability. Vulnerability to this neurobehavioral impairment may be explained by lower brain metabolites levels involved in mitochondrial metabolism. This study compared markers of brain energy metabolism in OSA patients identified as vulnerable vs resistant to driving impairment following extended wakefulness. 44 patients with moderate-severe OSA underwent 28hr extended wakefulness with three 90min driving simulation assessments. Using a two-step cluster analysis, objective driving data (steering deviation and crashes) from the 2nd driving assessment (22.5 h awake) was used to categorise patients into vulnerable (poor driving, n = 21) or resistant groups (good driving, n = 23). 1 H magnetic resonance spectra were acquired at baseline using two scan sequences (short echo PRESS and longer echo-time asymmetric PRESS), focusing on key metabolites, creatine, glutamate, N-acetylaspartate (NAA) in the hippocampus, anterior cingulate cortex and left orbito-frontal cortex. Based on cluster analysis, the vulnerable group had impaired driving performance compared with the resistant group and had lower levels of creatine (PRESS p = ns, APRESS p = 0.039), glutamate, (PRESS p < 0.01, APRESS p < 0.01), NAA (PRESS p = 0.038, APRESS p = 0.035) exclusively in the left orbito-frontal cortex. Adjusted analysis, higher glutamate was associated with a 21% (PRESS) and 36% (APRESS) reduced risk of vulnerable classification. Brain mitochondrial bioenergetics in the frontal brain regions are impaired in OSA patients who are vulnerable to driving impairment following sleep loss. These findings provide a potential way to identify at risk OSA phenotype when assessing fitness to drive, but this requires confirmation in larger future studies.
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Affiliation(s)
- Andrew Vakulin
- Adelaide Institute for Sleep Health/FHMRI Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - Michael A Green
- Neuroscience Research Australia, Sydney, New South Wales, Australia.,School of Medical Sciences, The University of New South Wales, Sydney, New South Wales, Australia
| | - Angela L D'Rozario
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - David Stevens
- Adelaide Institute for Sleep Health/FHMRI Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Centre for Nutritional and Gastrointestinal Diseases, SAHMRI, Adelaide, South Australia, Australia
| | - Hannah Openshaw
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - Delwyn Bartlett
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Keith Wong
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health/FHMRI Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Ronald R Grunstein
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia
| | - Caroline D Rae
- Neuroscience Research Australia, Sydney, New South Wales, Australia.,School of Medical Sciences, The University of New South Wales, Sydney, New South Wales, Australia
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The cerebral mechanism of acupuncture for chronic insomnia with gastrointestinal disorder: protocol for a randomized controlled trial. Trials 2021; 22:386. [PMID: 34098994 PMCID: PMC8186179 DOI: 10.1186/s13063-021-05332-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 05/19/2021] [Indexed: 11/20/2022] Open
Abstract
Background Many patients with chronic insomnia disorder (CID) have gastrointestinal (GI) symptoms. First-line insomnia medications do not treat GI problems. Acupuncture has a comprehensive regulative action on both CID and GI disorder and is receiving increasing attention. Recent studies indicate that both CID and GI diseases may cause abnormal brain activity. However, the neurological mechanism underlying the effect of acupuncture on such diseases is still unclear. The aim of this study is to explore the pathological mechanisms of CID with GI discomfort, as well as the main response characteristics of acupuncture treatment from multiple perspectives using multimodal magnetic resonance imaging (MRI). Methods A total of 60 participants with CID and GI disorders will be randomly divided into two groups (real acupuncture group and sham acupuncture group; ratio of 1:1). Patients will receive 20 sessions (five sessions per week) of real acupuncture treatment or sham acupuncture treatment. The primary outcome is the aggregate score on the Pittsburgh Sleep Quality Index. Secondary outcomes are scores on the Gastrointestinal Symptom Rating Scale, Self-Rating Anxiety Scale, and Self-Rating Depression Scale. Multimodal MRI scans and clinical assessments will be performed both at baseline and post-treatment. Another 30 age-, sex-, and education-matched healthy subjects will be recruited as controls and will receive MRI scans and clinical evaluations. Discussion This study aims to provide scientific evidence for the mechanism of acupuncture in treating CID with GI disorder using multimodal MRI imaging data on brain structure, function, and metabolism. Trial registration Chinese Clinical Trial Registry, ChiCTR1800017092 (URL: http://www.chictr.org.cn/showproj.aspx?proj=27173). Registered on July 11, 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05332-3.
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Benson KL, Bottary R, Schoerning L, Baer L, Gonenc A, Eric Jensen J, Winkelman JW. 1H MRS Measurement of Cortical GABA and Glutamate in Primary Insomnia and Major Depressive Disorder: Relationship to Sleep Quality and Depression Severity. J Affect Disord 2020; 274:624-631. [PMID: 32663996 PMCID: PMC10662933 DOI: 10.1016/j.jad.2020.05.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 04/13/2020] [Accepted: 05/10/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Both Major Depressive Disorder (MDD) and Primary Insomnia (PI) have been linked to deficiencies in cortical γ-aminobutyric acid (GABA) and glutamate (Glu) thus suggesting a shared neurobiological link between these two conditions. The extent to which comorbid insomnia contributes to GABAergic or glutamatergic deficiencies in MDD remains unclear. METHODS We used single-voxel proton magnetic resonance spectroscopy (1H MRS) at 4 Tesla to examine GABA+ and Glu relative to creatine (Cr) in the dorsal anterior cingulate cortex (dACC) and in the parieto-occipital cortex (POC) of 51 non-medicated adults with MDD, 24 adults with Primary Insomnia (PI), and 25 age- and sex-matched good sleeper controls (HC). Measures of depression severity and subjective and objective sleep quality were compared with 1H MRS metabolite measures. RESULTS MDD subjects exhibited a 15% decrease in Glu/Cr in the dACC compared to HC. Within the MDD group, there was a trend inverse correlation between dACC Glu/Cr and anhedonia ratings. We observed no significant association between measures of sleep quality with dACC Glu/Cr in those with MDD. LIMITATIONS The protocol and data interpretation would have been enhanced by the recruitment of MDD subjects with a broader range of affect severity and a more comprehensive assessment of clinical features. CONCLUSIONS These findings support the role of cortical glutamatergic mechanisms in the pathophysiology of MDD. Insomnia severity did not further contribute to the relative deficiency of glutamatergic measures in MDD.
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Affiliation(s)
- Kathleen L Benson
- McLean Imaging Center, McLean Hospital, Belmont, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Ryan Bottary
- Cognitive and Affective Neuroscience Laboratory, Department of Psychology, Boston College, Chestnut Hill, MA, USA
| | - Laura Schoerning
- University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Lee Baer
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Atilla Gonenc
- McLean Imaging Center, McLean Hospital, Belmont, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - J Eric Jensen
- McLean Imaging Center, McLean Hospital, Belmont, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - John W Winkelman
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Departments of Psychiatry and Neurology, Massachusetts General Hospital, Boston, MA, USA.
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12
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Honma A, Revell VL, Gunn PJ, Davies SK, Middleton B, Raynaud FI, Skene DJ. Effect of acute total sleep deprivation on plasma melatonin, cortisol and metabolite rhythms in females. Eur J Neurosci 2020; 51:366-378. [PMID: 30929284 PMCID: PMC7027445 DOI: 10.1111/ejn.14411] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/21/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022]
Abstract
Disruption to sleep and circadian rhythms can impact on metabolism. The study aimed to investigate the effect of acute sleep deprivation on plasma melatonin, cortisol and metabolites, to increase understanding of the metabolic pathways involved in sleep/wake regulation processes. Twelve healthy young female participants remained in controlled laboratory conditions for ~92 hr with respect to posture, meals and environmental light (18:00-23:00 hr and 07:00-09:00 hr <8 lux; 23:00-07:00 hr 0 lux (sleep opportunity) or <8 lux (continuous wakefulness); 09:00-18:00 hr ~90 lux). Regular blood samples were collected for 70 hr for plasma melatonin and cortisol, and targeted liquid chromatography-mass spectrometry metabolomics. Timepoints between 00:00 and 06:00 hr for day 1 (baseline sleep), day 2 (sleep deprivation) and day 3 (recovery sleep) were analysed. Cosinor analysis and MetaCycle analysis were performed for detection of rhythmicity. Night-time melatonin levels were significantly increased during sleep deprivation and returned to baseline levels during recovery sleep. No significant differences were observed in cortisol levels. Of 130 plasma metabolites quantified, 41 metabolites were significantly altered across the study nights, with the majority decreasing during sleep deprivation, most notably phosphatidylcholines. In cosinor analysis, 58 metabolites maintained their rhythmicity across the study days, with the majority showing a phase advance during acute sleep deprivation. This observation differs to that previously reported for males. Our study is the first of metabolic profiling in females during sleep deprivation and recovery sleep, and offers a novel view of human sleep/wake regulation and sex differences.
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Affiliation(s)
- Aya Honma
- ChronobiologyFaculty of Health and Medical SciencesUniversity of SurreyGuildfordUK
| | | | - Pippa J. Gunn
- ChronobiologyFaculty of Health and Medical SciencesUniversity of SurreyGuildfordUK
- Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Sarah K. Davies
- ChronobiologyFaculty of Health and Medical SciencesUniversity of SurreyGuildfordUK
- Department of Surgery and CancerImperial College LondonLondonUK
| | - Benita Middleton
- ChronobiologyFaculty of Health and Medical SciencesUniversity of SurreyGuildfordUK
| | - Florence I. Raynaud
- Cancer Research UK Cancer Therapeutics UnitDivision of Cancer TherapeuticsThe Institute of Cancer ResearchLondonUK
| | - Debra J. Skene
- ChronobiologyFaculty of Health and Medical SciencesUniversity of SurreyGuildfordUK
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D'Rozario AL, Bartlett DJ, Wong KKH, Sach T, Yang Q, Grunstein RR, Rae CD. Brain bioenergetics during resting wakefulness are related to neurobehavioral deficits in severe obstructive sleep apnea: a 31P magnetic resonance spectroscopy study. Sleep 2019; 41:5026697. [PMID: 29868772 DOI: 10.1093/sleep/zsy117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Indexed: 11/15/2022] Open
Abstract
Study Objectives Obstructive sleep apnea (OSA) is a well-established cause of impaired daytime functioning. However, there is a complex inter-individual variability in neurobehavioral performance in OSA patients. We previously reported compromised brain bioenergetics during apneic sleep in severe OSA. In this study, we investigate whether brain bioenergetics during resting wakefulness are related to neurobehavioral performance. Methods Patients attended the sleep laboratory in the evening and were kept awake over-night. Repeated testing on the 10-minute psychomotor vigilance task (PVT, at 9 pm, 11 pm, 1 am, 3 am, 5 am) and 30-minute AusEd driving simulator task (9 pm and 5 am) was performed. Brain bioenergetics (inorganic phosphate/adenosine triphosphate ratio, Pi/ATP) were measured in the temporal lobe during resting wakefulness at 7 am in a 1.5T MRI scanner using phosphorus magnetic resonance spectroscopy (31P MRS). Results Fifteen males with severe OSA (age 47.7 ± 10.4 years, body mass index [BMI] 34 ± 6.6 kg/m2, apnea hypopnea index [AHI] 79.7 ± 21.8/hour) were investigated. A higher Pi/ATP ratio in the brain (lower phosphorylation potential) was correlated with worse PVT and driving simulator performance across the testing period (PVT lapses: r = 0.632, r2 = 0.399, p = 0.012; and AusEd braking reaction time: r = 0.609, p = 0.016). In contrast, the conventional AHI measure of disease severity was not significantly correlated with performance (PVT lapses: r = -0.084, p = 0.8; and AusEd braking reaction time: r = -0.326, p = 0.2). Conclusions Lower phosphorylation potential was associated with worse performance. Compromised brain bioenergetics may in part underlie the neurobehavioral deficits in untreated OSA. We speculate that better brain bioenergetics may explain why some OSA patients are relatively asymptomatic compared with others.
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Affiliation(s)
- Angela L D'Rozario
- CIRUS, Woolcock Institute of Medical Research, University of Sydney and Sydney Health Partners, Sydney, New South Wales, Australia
- School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Delwyn J Bartlett
- CIRUS, Woolcock Institute of Medical Research, University of Sydney and Sydney Health Partners, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Keith K H Wong
- CIRUS, Woolcock Institute of Medical Research, University of Sydney and Sydney Health Partners, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Respiratory and Sleep Disorders Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Toos Sach
- Rayscan Imaging, Goulburn St, Liverpool, New South Wales, Australia
| | - Qiao Yang
- CIRUS, Woolcock Institute of Medical Research, University of Sydney and Sydney Health Partners, Sydney, New South Wales, Australia
| | - Ronald R Grunstein
- CIRUS, Woolcock Institute of Medical Research, University of Sydney and Sydney Health Partners, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Respiratory and Sleep Disorders Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Caroline D Rae
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
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14
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Lee D, Woo C, Kwon J, Chae YJ, Ham SJ, Suh J, Kim S, Kim JK, Kim KW, Woo D, Lee D. Cerebral mapping of glutamate using chemical exchange saturation transfer imaging in a rat model of stress‐induced sleep disturbance at 7.0T. J Magn Reson Imaging 2019; 50:1866-1872. [DOI: 10.1002/jmri.26769] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 01/28/2023] Open
Affiliation(s)
- Dong‐Hoon Lee
- Faculty of Health Sciences and Brain & Mind CentreUniversity of Sydney Sydney Australia
| | - Chul‐Woong Woo
- Convergence Medicine Research CenterAsan Institute for Life Sciences Asan Medical Center, Seoul Republic of Korea
| | - Jae‐Im Kwon
- Convergence Medicine Research CenterAsan Institute for Life Sciences Asan Medical Center, Seoul Republic of Korea
| | - Yeon Ji Chae
- Department of Convergence MedicineAsan Medical orcidCenter, University of Ulsan College of Medicine Seoul Republic of Korea
| | - Su Jung Ham
- Center for Bioimaging of New Drug DevelopmentAsan Institute for Life Sciences, Asan Medical Center Seoul Republic of Korea
| | - Ji‐Yeon Suh
- Research Institute of RadiologyAsan Medical Center, University of Ulsan College of Medicine Seoul South Korea
| | - Sang‐Tae Kim
- Convergence Medicine Research CenterAsan Institute for Life Sciences Asan Medical Center, Seoul Republic of Korea
| | - Jeong Kon Kim
- Department of RadiologyAsan Medical Center, University of Ulsan College of Medicine Seoul Republic of Korea
| | - Kyung Won Kim
- Department of RadiologyAsan Medical Center, University of Ulsan College of Medicine Seoul Republic of Korea
| | - Dong‐Cheol Woo
- Convergence Medicine Research CenterAsan Institute for Life Sciences Asan Medical Center, Seoul Republic of Korea
- Department of Convergence MedicineAsan Medical orcidCenter, University of Ulsan College of Medicine Seoul Republic of Korea
| | - Do‐Wan Lee
- Convergence Medicine Research CenterAsan Institute for Life Sciences Asan Medical Center, Seoul Republic of Korea
- Center for Bioimaging of New Drug DevelopmentAsan Institute for Life Sciences, Asan Medical Center Seoul Republic of Korea
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15
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Khassawneh BY, Bathgate CJ, Tsai SC, Edinger JD. Neurocognitive performance in insomnia disorder: The impact of hyperarousal and short sleep duration. J Sleep Res 2018; 27:e12747. [PMID: 30069961 DOI: 10.1111/jsr.12747] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 12/27/2022]
Abstract
Given the recent evidence on the association between hyperarousal in insomnia disorder and neurocognitive deficits, we aimed to examine the effect of short sleep duration on neurocognitive reaction time tests in insomnia disorder sufferers. We recruited subjects with insomnia disorder (n = 35, mean age = 40.6 years) who scored ≥29 on a Hyperarousal Scale, and a group of controls (n = 54, mean age = 31.5 years) who had no sleep disorders and scored <26 on the Hyperarousal Scale. Participants completed two in-home polysomnograms and four daytime trials of neurocognitive tests, including simple reaction time, choice reaction time, big circle-little circle, rapid visual information processing, attention switching task, and spatial working memory tests. Total sleep time divided study cohorts into subgroups of short (total sleep time <6 hr) and normal (total sleep time ≥6 hr) sleepers. ANCOVA showed a significant interaction between participant type (insomnia disorder versus controls) and sleep duration (short versus normal) for spatial working memory-latency (p = 0.020) and spatial working memory-errors (p = 0.025). The short-sleeping insomnia disorder group had longer spatial working memory-latencies and more spatial working memory-errors than did normal-sleeping controls. Regardless of sleep duration, those with insomnia disorder had more attentional deficits with longer attention switching task-latency (p = 0.011) and more attention switching task-incorrect trials (p = 0.015) than the control group. Normal-sleepers only had longer attention switching task-latency than short-sleepers (p = 0.004). A phenotype of insomnia disorder with hyperarousal and short sleep duration is associated with daytime cognitive deficits in complex attentional and spatial working memory tasks.
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Affiliation(s)
- Basheer Y Khassawneh
- Jordan University of Science and Technology, Irbid, Jordan.,National Jewish Health, Denver, Colorado
| | | | | | - Jack D Edinger
- National Jewish Health, Denver, Colorado.,Duke University Medical Center, Durham, North Carolina
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16
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Bertisch SM, Pollock BD, Mittleman MA, Buysse DJ, Bazzano LA, Gottlieb DJ, Redline S. Insomnia with objective short sleep duration and risk of incident cardiovascular disease and all-cause mortality: Sleep Heart Health Study. Sleep 2018; 41:4924334. [PMID: 29522193 PMCID: PMC5995202 DOI: 10.1093/sleep/zsy047] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 12/29/2017] [Indexed: 01/22/2023] Open
Abstract
Study Objectives To quantify the association between insomnia or poor sleep with objective short sleep duration and incident cardiovascular disease (CVD) and mortality in the general population. Methods We conducted a time-to-event analysis of Sleep Heart Health Study data. Questionnaires and at-home polysomnography (PSG) were performed between 1994 and 1998. Participants were followed for a median of 11.4 years (Q1-Q3, 8.8-12.4 years) until death or last contact. The primary exposure was insomnia or poor sleep with short sleep defined as follows: difficulty falling asleep, difficulty returning to sleep, early morning awakenings, or sleeping pill use, 16-30 nights per month; and total sleep of <6 hr on PSG. We used proportional hazard models to estimate the association between insomnia or poor sleep with short sleep and CVD, as well as all-cause mortality. Results Among 4994 participants (mean age: 64.0 ± 11.1 years), 14.1 per cent reported insomnia or poor sleep, of which 50.3 per cent slept <6 hr. Among 4437 CVD-free participants at baseline, we observed 818 incident CVD events. After propensity adjustment, there was a 29 per cent higher risk of incident CVD in the insomnia or poor sleep with short sleep group compared with the reference group (HR: 1.29, 95% CI: 1.00, 1.66), but neither the insomnia or poor sleep only nor short sleep only groups were associated with higher incident CVD. Insomnia or poor sleep with objective short sleep was not associated with all-cause mortality (HR: 1.07, 95% CI: 0.86, 1.33). Conclusions Insomnia or poor sleep with PSG-short sleep was associated with higher risk of incident CVD. Future studies should evaluate the impact of interventions to improve insomnia with PSG-short sleep on CVD.
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Affiliation(s)
- Suzanne M Bertisch
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Benjamin D Pollock
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
- Department of Epidemiology, Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, TX
- Robbins Institute for Health Policy and Leadership, Baylor University, Waco, TX
| | - Murray A Mittleman
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lydia A Bazzano
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Daniel J Gottlieb
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
- VA Boston Healthcare System, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Susan Redline
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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