Obesity, obstructive sleep apnoea and metabolic syndrome

Knowledge and attitude regarding obstructive sleep apnoea among medical and dental practitioners working in North-Eastern Peninsular Malaysia: A comparative cross-sectional study

BACKGROUND

Obstructive Sleep Apnea (OSA) is a temporary airflow obstruction during periods of sleep. Patients with OSA often suffer from poor work performance, compromised sleep quality, and low quality of life which may lead to a life-threatening event. Adequate knowledge and a positive attitude toward OSA among medical and dental practitioners are crucial to the initial diagnosis and treatment.

OBJECTIVE

This study aimed to identify the differences in knowledge and attitude toward OSA between medical and dental practitioners working in North-Eastern Peninsular Malaysia.

METHODS

A comparative cross-sectional study was performed from February 2020 to February 2021. A total of fifty-two medical practitioners and fifty-two dental practitioners working at university-based outpatient clinics, government health clinics, and oral health clinics located in Kelantan State of Malaysia participated in the study, and data were collected by the structured questionnaire including sociodemographic inquiry and OSAKA questionnaire by non-probability stratified random sampling. The Mann-Whitney U test was used to compare knowledge and attitude scores between the two groups.

RESULTS

The mean age of the respondents was 34.6 years. The current study shows that 92.3% of medical doctors and 96.1% of dental doctors were able to correctly answer the question "Most of the patients with OSA snore" a significant finding in our study. Only 1% of medical professionals could answer seventeen questions correctly with a median score of 11, and only 1% of dental professionals could answer sixteen questions correctly with a median score of 9. None of them could provide an accurate answer to all the knowledge questions. Medical and dental practitioners exhibited different knowledge levels on OSA (z- statistics=-4.39, U = 827.00 with p <  0.05, and effect size, r = 0.61). However, no significant differences were found in total knowledge score by gender (p-value>0.05), ethnicity (p-value>0.05), total service years (p-value>0.05), and training attended. In addition, significant differences in attitude levels between medical and dental practitioners have been observed (z-statistics=-3.42, U = 725.00 with p <  0.05, and effect size, r = 0.47). Nevertheless, no significant differences have been seen in total attitude score by ethnicity (p-value >  0.05), total service years (p-value >  0.05), attending training on OSA (p-value >  0.05), and professional status (p-value >  0.05) except gender (p-value <  0.05).

CONCLUSION

A Significant difference is evident concerning knowledge and attitude toward OSA diagnosis and management between medical and dental practitioners working in North-Eastern Peninsular Malaysia. Medical practitioners in this study recorded a higher knowledge and attitude score compared to dental practitioners.

Combined impact of sleep and obesity on female infertility in the NHANES 2017-2020

BACKGROUND

Sleep health and obesity may affect the risk of female infertility. However, few studies focused on the interaction of obesity and sleep health on the female infertility risk. This study aimed to evaluate the combined impact of trouble sleeping / sleep duration and overweight/obesity/ abdominal obesity on the risk of female infertility.

METHODS

The data for this cross-sectional study was obtained from National Health and Nutritional Examination Survey, which provided information on trouble sleeping, sleep duration, overweight/obesity, abdominal obesity, and confounding factors. Adopted weighted univariate and multivariate logistic regression models to explore the relationship between trouble sleeping, sleep duration, overweight/obesity, abdominal obesity, and the risk of infertility, respectively, and the combined effect of trouble sleeping and overweight/obesity, trouble sleeping and abdominal obesity, sleep duration and overweight/obesity, sleep duration and abdominal obesity, on the female infertility risk.

RESULTS

This study included a total of 1,577 women, and 191 were diagnosed with infertility. Women with infertility had a higher proportion of people with overweight/obesity, abdominal obesity, sleep duration ≤ 7 h and trouble sleeping than those with non-infertility. The result indicated that trouble sleeping [odds ratio (OR) = 2.25, 95% confidence intervals (CI): 1.49-3.39], sleep duration ≤ 7 h (OR = 1.59, 95% CI: 1.03-2.48), and the combined impact of abdominal obesity and trouble sleeping (OR = 2.18, 95% CI: 1.28-3.72), abdominal obesity and sleep duration ≤ 7 h (OR = 2.00, 95% CI: 1.17-3.40), overweight/obesity and trouble sleeping (OR = 2.29, 95% CI: 1.24-4.26), and overweight/obesity and sleep duration ≤ 7 h (OR = 1.88, 95% CI: 1.01-3.49) were associated with increased odds of infertility, respectively.

CONCLUSION

There was combined effects of trouble sleeping/sleep duration ≤ 7 h and overweight/obesity/ abdominal obesity on increased odds of female infertility.

Sleep status of older adults with sleep apnoea syndrome may vary by body mass index

Obesity and ageing are the most important risk factors for sleep apnoea syndrome (SAS); however, the role of body mass index (BMI) on sleep status in healthy older adults is unclear. To explore sleep parameters according to BMI among active older adults, we cross-sectionally examined the relationship between sleep-related parameters and BMI in 32 Japanese adults aged from 83 to 95 years without long-term care who were unaware of having SAS. Correlation and linear regression analyses were performed. Moderate or severe SAS prevalence was high in both those with low (68.8%) and high (68.8%) BMI. A higher increase in apnoea-hypopnoea index (AHI) was negatively correlated with sleep depth in the high-BMI group. In the low-BMI group, the number of awakenings and age were positively correlated with AHI. Older adults may have SAS regardless of their BMI, and the sleep status of patients with SAS may vary by BMI.

Use of Edibles as Effective Tools in Myofunctional Therapy: A Pilot Study

AIM

The aim of this retrospective study is to explore the introduction of edible spread cream and small candies as tools to improve motivation and compliance in young children undergoing myofunctional therapy, with the purpose of optimizing oral functions, including swallowing.

METHODS

Six patients, one female and five males, between the ages of 7 and 14 years, presenting with atypical swallowing, were evaluated and treated at the clinic of the University of L'Aquila. The patients included in the study were randomly divided into two groups and were treated with two different treatment protocols: Group A: traditional myofunctional therapy and traditional tools; Group B: same exercises as group A, but with edible tools (spreadable cream and small candies).

RESULTS

As expected, the two patients who used edible tools demonstrated increased motivation and collaboration during myofunctional therapy.

CONCLUSIONS

Patient compliance, especially in very young patients, limits the effectiveness of myofunctional therapy; therefore, creative solutions are needed to achieve greater cooperation, and edible tools can play a significant part in retraining correct swallowing. Although the sample of this pilot study is small, the results suggest that using actual edible tools in myofunctional therapy could increase compliance and provide better results in myofunctional therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association between hypoxic burden and common cardiometabolic diseases in patients with severe obstructive sleep apnea

PURPOSE

To determine the possible associations between total sleep time spent with arterial oxygen saturation < 90% (T90) and comorbid cardiometabolic diseases (CMDs) in patients with severe obstructive sleep apnea (OSA).

METHODS

A retrospective review of the chart was conducted in patients with severe OSA diagnosed by in-lab polysomnography (PSG) between January 2018 and December 2019 at Siriraj Hospital. The patients were divided into two groups: hypoxic (T90 ≥ 10%) and nonhypoxic (T90 < 10%). The association between common CMDs including hypertension (HT), type 2 diabetes mellitus (T2DM), and impaired fasting glucose (IFG) was investigated and compared between the two groups.

RESULTS

Data were collected from 450 patients with severe OSA, 289 males/161 females with a mean age of 53.5 ± 14.2 years and an apnea-hypopnea index (AHI) of 49.6 events/h. Among these, 114 patients (25.3%) were defined as the hypoxic group (T90 ≥ 10%). When compared between the hypoxic and nonhypoxic groups, the patients in the hypoxic group were significantly younger and more obese, and had a higher proportion of male patients. The majority of patients (80%) had at least one CMD; however, the most common comorbidities significantly associated with hypoxic OSA (T90 ≥ 10%) were HT and IFG.

CONCLUSION

Hypoxic burden is significantly associated with an increased prevalence of HT and IFG in patients with severe OSA. T90 may be potentially useful for predicting CMDs in these patients. However, prospective studies are still required.

Waist to height ratio as a simple tool for predicting mortality: a systematic review and meta-analysis

BACKGROUND

The association of central obesity with higher rates of mortality is not well studied. This study evaluates the association between waist-to-height ratio (WHtR), as a measure of central obesity, with mortality.

METHODS

Documents were retrieved from PubMed, Web of Science, Scopus, and Google Scholar databases until May 2022. Data were extracted from cohort studies reporting effect size (hazard ratio (HR)) regarding the association between WHtR as a continuous (per 1 SD increment) or categorical (highest/lowest) measure and all-cause and cause-specific mortality. Screening of included studies was performed independently by two authors. Moreover, the quality assessment of included studies was performed based on the Newcastle-Ottawa assessment scale. Finally, random effect meta-analysis was performed to pool the data, and the outcomes' certainty level was assess based on the GRADE criteria.

RESULTS

Of the 815 initial studies, 20 were included in the meta-analysis. Random effect meta-analysis showed that in the general population, the all-cause mortality HRs for categorical and continuous measurements of WHtR increased significantly by 23% (HR:1.23; 95% CI: 1.04-1.41) and 16% (HR:1.16; 95% CI: 1.07-1.25), respectively. Moreover, the hazard of cardiovascular (CVD) mortality increased significantly for categorical and continuous measurements of WHtR by 39% (HR:1.39; 95% CI: 1.18-1.59) and 19% (HR:1.19; 95% CI: 1.07-1.31). The quality assessment score of all included studies was high.

CONCLUSIONS

Higher levels of WHtR, indicating central obesity, were associated with an increased hazard of CVD and all-cause mortality. This measure can be used in the clinical setting as a simple tool for predicting mortality.

Non-Cardiotoxic Tetradecanoic Acid-2,4-Dinitrophenol Ester Nanomicelles in Microneedles Exert Potent Anti-Obesity Effect by Regulating Adipocyte Browning and Lipogenesis

Sustained oral uncoupler 2,4-dinitrophenol (DNP) administration exerts prominent anti-obesity effects, but the adipose tissue off-target disadvantage leads to systemic adverse effects. A novel non-cardiotoxicity DNP delivery method using a biocompatible microneedles patch containing the amphiphilic tetradecanoic acid-DNP ester (TADNP) is described, which is synthesized via esterification on the phenolic hydroxyl of DNP. The TADNP is self-assembled as nanomicelles, which enhance the endocytosis rate of DNP by adipocytes and its permeation in isolated adipose tissues. The microenvironment of adipose tissues promotes the massive release of DNP and plasma and simulated gastrointestinal fluids. The microneedles-delivered TADNP nanomicelles (MN-TADNP) effectively deliver DNP in treated adipose tissues and reduce DNP content in off-target organs. Both oral and MN patch-delivered TADNP micelles effectively exert anti-obesity effects in a mouse model of high-fat diet-induced obesity; and noteworthily, MN-TADNP exhibit more satisfactory biosafety than oral administration. Here, a smart MN patch loaded with tetradecanoic acid-modified DNP is reported, which enhances its accumulation in adipose tissues and exerts an anti-obesity effect without causing any systemic toxicity.

Mitochondria in hypoxic pulmonary hypertension, roles and the potential targets

Mitochondria are the centrol hub for cellular energy metabolisms. They regulate fuel metabolism by oxygen levels, participate in physiological signaling pathways, and act as oxygen sensors. Once oxygen deprived, the fuel utilizations can be switched from mitochondrial oxidative phosphorylation to glycolysis for ATP production. Notably, mitochondria can also adapt to hypoxia by making various functional and phenotypes changes to meet the demanding of oxygen levels. Hypoxic pulmonary hypertension is a life-threatening disease, but its exact pathgenesis mechanism is still unclear and there is no effective treatment available until now. Ample of evidence indicated that mitochondria play key factor in the development of hypoxic pulmonary hypertension. By hypoxia-inducible factors, multiple cells sense and transmit hypoxia signals, which then control the expression of various metabolic genes. This activation of hypoxia-inducible factors considered associations with crosstalk between hypoxia and altered mitochondrial metabolism, which plays an important role in the development of hypoxic pulmonary hypertension. Here, we review the molecular mechanisms of how hypoxia affects mitochondrial function, including mitochondrial biosynthesis, reactive oxygen homeostasis, and mitochondrial dynamics, to explore the potential of improving mitochondrial function as a strategy for treating hypoxic pulmonary hypertension.

The association between biomarker angiopoietin-like protein five and obstructive sleep apnea in patients undergoing bariatric surgery

PURPOSE

Obstructive sleep apnea (OSA) is prevalent in the bariatric population. OSA should be recognized in patients undergoing bariatric surgery preoperatively to prevent peri- and post-operative complications. Lipid metabolism-related biomarkers are associated with OSA. Triglyceride metabolism is, among others, regulated by angiopoietin-like protein five (ANGPTL5). We aimed to evaluate the level of ANGPTL5 in patients with OSA of different severity levels before and after bariatric surgery.

METHODS

We performed a single-center prospective cohort study including a consecutive series of patients who underwent bariatric surgery. We collected the clinical data, polysomnography (PSG) or polygraphy (PG) parameters, and plasma derived via venipuncture before and 6 to 12 months after surgery. Lipid profile, glucose levels, and ANGPTL5 levels were assessed. ANGPTL5 levels were measured using an enzyme-linked immunosorbent assay (ELISA).

RESULTS

The study included 88 patients for analysis. The patients were divided into two subgroups: no or mild OSA (apnea-hypopnea index (AHI) < 15 events/hour, n = 57) and moderate-to-severe OSA (AHI ≥ 15 events/hour, n = 31). The ANGPTL5 level was higher in the moderate-to-severe OSA group (20.5 [15.6, 26.5] ng/mL) compared to the no or mild OSA group (16.3 [12.5, 19.4] ng/mL) (p = 0.008). A significant positive correlation was observed between ANGPTL5 and AHI (ρ = 0.256, p = 0.017), apnea index (AI) (ρ = 0.318, p = 0.003), and triglyceride levels (ρ = 0.240, p = 0.025). ANGPTL5 levels were reduced significantly after bariatric surgery in both moderate-to-severe OSA (15.6 [10.3, 18.7] ng/mL) and no or mild OSA (13.4 [9.2, 15.8] ng/mL) groups, though to a lower level in the group without or mild OSA. Post-surgery, the significant positive correlation between ANGPTL5 and AHI (ρ = 0.210, p = 0.047), AI (ρ = 0.230, p = 0.034), and triglyceride (ρ = 0.397, p < 0.001) remained.

CONCLUSION

The data showed increased levels of ANGPTL5 in patients with moderate-to-severe OSA. Both AHI and ANGPTL5 levels decreased significantly after bariatric surgery. We also report an association between ANGPTL5 levels and OSA severity.

Effect of renal denervation on cardiac remodelling and function in rats with chronic intermittent hypoxia

Chronic intermittent hypoxia (CIH) mimicking obstructive sleep apnea elicits divergent outcomes in the cardiovascular systems. The effect of renal denervation (RDN) on the heart during CIH remains unclear. We aimed to explore the effect of RDN on cardiac remodelling in rats exposed to CIH and to discuss the underlying mechanisms. Adult Sprague Dawley rats were divided into four groups: control, control+RDN, CIH (CIH exposure for 6 weeks, nadir of 5%-7% to peak of 21% O2, 20 cycles/h, 8 h/day) and CIH+ RDN group. Echocardiography, cardiac fibrosis, left ventricle (LV) expressions of nuclear factor-E2-related factor 2 (Nrf2)/heme oxygenase-1 (HO-1) pathway and inflammatory factors were tested at the end of the study. Cardiac structural remodelling and dysfunction were induced by CIH and attenuated by RDN. Myocardial fibrosis was more severe in the CIH group than in the control group and improved in the CIH + RDN group. Sympathetic activity reflected by tyrosine hydroxylase (TH) expression and noradrenaline were significantly elevated after CIH but blunted by RDN. CIH downregulated LV protein expressions of Nrf2 and HO-1, which was activated by RDN. The downstream of Nrf2/HO-1, such as NQO1 and SOD expression, elevated following RDN. RDN also decreased the mRNA expression of IL-1β and IL-6. Notably, control+RDN did not affect cardiac remodelling and Nrf2/HO-1 compared with the control. Taken together, we found that RDN exerted cardio-protective effects in a rat model of CIH involving Nrf2/HO-1 pathway and inflammation.

Keep it simple: A novel technique for measuring airflow using a wireless patch

OBJECTIVES

Despite the growing use of home sleep testing for obstructive sleep apnea (OSA), there are significant barriers that make it difficult for patients. This study aimed to evaluate a new set of wireless patches for the detection of OSA as compared to polysomnography (PSG) respiratory signals. Safety was also evaluated.

METHODS

Patients (n = 25; mean age = 51.3; SD = 15.6) undergoing standard PSG evaluation for OSA wore 2 device patches applied on the chest and abdomen to provide surrogates of respiratory effort and derived airflow. Two sets of respiratory data (with common SpO2 and heart rate as a reference from PSG) were created, one from PSG and one from the device patches. Data were scored by a Registered Polysomnographic Technologist. Linear regression analyses and Bland-Altman plots were used to compare the two derived apnea-hypopnea indices (AHI). Bench testing was performed to determine whether the device patch respiratory signal accuracy remained consistent for different body characteristics.

RESULTS

There was a significant correlation for AHI between the device patch and PSG (r = 0.979; P < .001; 95% CI 0.952, 1.00). There were also significant correlations between PSG and the device patch for supine AHI (r = 0.866, P < .001, 95% CI 0.610, 0.965) and nonsupine AHI (r = 0.983; <0.001, 95% CI 0.954, 1.00). No differences in respiratory signal accuracy were found with bench testing comparison groups.

CONCLUSIONS

These preliminary results suggest that the device patch may be an effective way to measure respiratory dynamics, including derived airflow, to evaluate OSA. Results show promise as a new innovative method for home sleep testing.

Relationship between obstructive sleep apnea, insulin resistance, and metabolic syndrome: a nationwide population-based survey

We aimed to identify the association between obstructive sleep apnea (OSA), insulin resistance (IR), and metabolic syndrome (MetS) in a nationwide population-based sample. A total of 7,900 adults with information on the STOP-Bang score and MetS (3,341 men and 4,469 women) were identified from the dataset of the Korea National Health and Nutrition Examination Survey 2019-2020. The association between OSA, IR, MetS, and its components was estimated using complex sample logistic regression analysis with adjustments for age, body mass index, residence, smoking status, alcohol consumption, household income, education, and the presence of diabetes. Participants with a high OSA score were more likely to have IR (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.96-3.95 in men and OR 2.64, 95% CI 0.55-12.80 in women), MetS (OR 6.05, 95% CI 4.23-8.69 in men and OR 4.20, 95% CI 1.23-15.70 in women), and components of MetS, compared to individuals with a low OSA score. Compared to premenopausal women, postmenopausal women had a more intense association between OSA and IR (OR 1.78, 95% CI 0.13-24.43 for premenopausal women and OR 3.64, 95% CI 0.60-22.28 for postmenopausal women) and MetS (OR 2.58, 95% CI 0.23-29.55 for premenopausal women and OR 5.36, 95% CI 1.42-20.21 for postmenopausal women). OSA was associated with abdominal obesity and hypertension in premenopausal women, while all components of MetS were associated with OSA in postmenopausal women. Further studies are necessary to elucidate the underlying mechanisms of these findings.

Detection of obstructive sleep apnea in young patients suffering from coronary artery disease by performing portable polysomnography studies

Background

Obstructive sleep apnea (OSA) is known to be an important contributory factor of coronary artery disease (CAD), but the extent of contribution of OSA in young patients suffering from CAD is not known. Thus, with an aim to detect OSA in young patients suffering from CAD by performing portable polysomnography (PSG), the present study was carried out at a tertiary care chest center.

Methods

A prospective study was carried out from June 2015 to June 2018, wherein 100 consecutive young (age less than 40 years), non-smoking patients with angiographically confirmed CAD, with no identifiable risk factors for cardiovascular diseases except obesity, were subjected to level 3 portable PSG studies.

Results

Of 100 patients with CAD, 80% had OSA (24% with mild OSA, 28% with moderate OSA, and 28% with severe OSA). Body weight and severity of OSA showed a significant correlation with a P-value of 0.033. SPSS software was used for statistical analysis. The categorical variables were compared using Fischer's exact test.

Conclusion

The study detected a significant number of young patients with angiographically confirmed CAD having OSA. A significant correlation was also observed between weight and severity of OSA, suggesting that overweight patients and patients with obesity have higher grades of OSA.

The Case for Early Use of Glucagon-like Peptide-1 Receptor Agonists in Obstructive Sleep Apnea Patients with Comorbid Diabetes and Metabolic Syndrome

Patients with obstructive sleep apnea (OSA) have high rates of co-occurring type 2 diabetes, hypertension, obesity, stroke, congestive heart failure, and accelerated atherosclerotic cardiovascular diseases. These conditions frequently require multiple medications, raising the risk of polypharmacy, adverse drug-drug and drug-disease interactions, decreased quality of life, and increased healthcare cost in these patients. The current review of extant literature presents evidence supporting glucagon-like peptide-1 receptor agonists (GLP-1RA) as one pharmacologic intervention that provides a "one-stop shop" for OSA patients because of the multiple effects GLP-1RA has on comorbidities (e.g., hypertension, diabetes, obesity, metabolic syndrome, and atherosclerotic cardiovascular diseases) that commonly co-occur with OSA. Examples of glucagon-like peptide-1 receptor agonists approved by the FDA for diabetes (some of which are also approved for obesity) are liraglutide, exenatide, lixisenatide, dulaglutide, semaglutide, and albiglutide. Prescribing of GLP-1RAs to address these multiple co-occurring conditions has enormous potential to reduce polypharmacy, cost, and adverse drug events, and to improve quality of life for patients living with OSA and diabetes. We thus strongly advocate for increased and early use of GLP-1RA in OSA patients with co-occurring diabetes and other cardiometabolic conditions common in OSA.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Associations of Chronic Diabetes Complications and Cardiovascular Risk with the Risk of Obstructive Sleep Apnea in Patients with Type 2 Diabetes

Background: Type 2 diabetes mellitus (T2DM) is associated with increased mortality and morbidity, including cardiovascular diseases and obstructive sleep apnea (OSA). The aim of this study was to assess the associations between cardiovascular risk, chronic diabetes complications and the risk of OSA in adult patients with T2DM. Methods: The study included 529 patients with T2DM in whom moderate-to-severe OSA risk was assessed using the STOP-Bang questionnaire, dividing the subjects into two groups: group 1: STOP-Bang score <5, and group 2: STOP-Bang score ≥5, respectively. In all the subjects, cardiovascular risk was assessed using the UKPDS risk engine. Statistical analysis was performed using SPSS 26.0, the results being statistically significant if p value was <0.05. Results: 59% of the subjects scored ≥5 on the STOP-Bang questionnaire. We recorded statistically significant differences between the two groups regarding diabetes duration, HbA1c, HOMA-IR, albuminuria, as well as cardiovascular risk at 10 years for both coronary heart disease (CHD) and stroke (p < 0.05). Furthermore, through logistic regression, adjusting for confounding factors, we demonstrated that the STOP-Bang score ≥ 5 is a risk factor for 10-year fatal and nonfatal CHD risk. Conclusions: It is extremely important to screen and diagnose OSA in patients with T2DM, in order to improve the primary and secondary prevention of cardiovascular events in these patients.

Sleep Problems Mediate the Relationship Between Psychosocial Stress and Pain Facilitation in Native Americans: A Structural Equation Modeling Analysis from the Oklahoma Study of Native American Pain Risk

BACKGROUND

Native Americans (NAs) are more likely to experience chronic pain than non-Hispanic Whites (NHWs); however, the proximate causes predisposing NAs to chronic pain remain elusive. Likely due to centuries of adversity, discrimination, and marginalization, NAs report greater psychological stress than NHWs, which may place them at risk for sleep problems, a well-established risk factor for chronic pain onset.

PURPOSE

This study examined the effects of psychological stress and sleep problems on subjective and physiological measures of pain processing in NAs and NHWs.

METHODS

Structural equation modeling was used to determine whether ethnicity (NA or NHW) was associated with psychological stress or sleep problems and whether these variables were related to conditioned pain modulation of pain perception (CPM-pain) and the nociceptive flexion reflex (CPM-NFR), temporal summation of pain (TS-pain) and NFR (TS-NFR), and pain tolerance in a sample of 302 (153 NAs) pain-free participants.

RESULTS

NAs experienced more psychological stress (Estimate = 0.027, p = .009) and sleep problems (Estimate = 1.375, p = .015) than NHWs. When controlling for age, sex, physical activity, BMI, and general health, NA ethnicity was no longer related to greater sleep problems. Psychological stress was also related to sleep problems (Estimate = 30.173, p = <.001) and psychological stress promoted sleep problems in NAs (indirect effect = 0.802, p = .014). In turn, sleep problems were associated with greater TS-pain (Estimate = 0.714, p = .004), but not other pain measures.

CONCLUSIONS

Sleep problems may contribute to chronic pain risk by facilitating pain perception without affecting facilitation of spinal neurons or endogenous inhibition of nociceptive processes. Since psychological stress promoted pain facilitation via enhanced sleep problems, efforts to reduce psychological stress and sleep problems among NAs may improve health outcomes.

Getting More from the Sleep Recording

Sleep studies have typically followed criteria established many decades ago, but emerging technologies allow signal analyses that go far beyond the scoring rules for manual analysis of sleep recordings. These technologies may apply to the analysis of signals obtained in standard polysomnography in addition to novel signals more recently developed that provide both direct and indirect measures of sleep and breathing in the ambulatory setting. Automated analysis of signals such as electroencephalogram and oxygen saturation, in addition to heart rate and rhythm, provides a wealth of additional information on sleep and breathing disturbances and their potential for comorbidity.

Predictive Value of Clinical and Questionnaire Based Screening Tools of Obstructive Sleep Apnea in Patients With Type 2 Diabetes Mellitus

Background

Obstructive sleep apnea (OSA) is a major health problem for people with type 2 diabetes mellitus (DM2) and is associated with poorer glycemic control. Early detection is critical to proper management. In this study, we planned to assess and compare the diagnostic accuracy of various OSA screening tools in patients with DM2.

Methods

In this cross-sectional study, we consecutively recruited 58 patients with DM2, presenting to the endocrinology department of Services Hospital Lahore between February 2020 to March 2021. Along with demographic and anthropometric measurements, including BMI and neck circumference, participants answered the snoring, tiredness, observed apnea, high blood pressure - BMI, age, neck circumference, and gender (STOP-BANG) questionnaire, Berlin questionnaire, and Epworth sleepiness scale. All participants then underwent an overnight, level 3 polysomnography.

Results

The overall prevalence of OSA, diagnosed by overnight polysomnography, was 65.5% in type 2 diabeticDM2 patients. The STOP-BANG questionnaire had the highest sensitivity for mild, moderate, and severe OSA i.e., 84.2%, 90.3%, and 100% respectively. Berlin questionnaire also had 100% sensitivity for severe OSA and was most specific for mild and moderate OSA (70% and 63% respectively) whereas the Epworth sleepiness scale had the highest specificity of 53.3% for severe OSA.

Conclusion

This study shows that OSA is highly prevalent in DM2 patients in Pakistan. The STOP-BANG and Berlin questionnaire proved to be effective screening tools, especially for severe OSA. Results of our study should encourage the routine use of these questionnaires in clinical practice, to help in the early identification of OSA in diabetics.

FASSNet: fast apnea syndrome screening neural network based on single-lead electrocardiogram for wearable devices

Objective. Sleep apnea (SA) is a chronic condition that fragments sleep and results in intermittent hypoxemia, which in long run leads to cardiovascular diseases like stroke. Diagnosis of SA through polysomnography is costly, inconvenient, and has long waiting list. Wearable devices provide a low-cost solution to the ambulatory detection of SA syndrome for undiagnosed patients. One of the wearables are the ones based on minute-by-minute analysis of single-lead electrocardiogram (ECG) signal. Processing ECG segments online at wearables contributes to memory conservation and privacy protection in long-term SA monitoring, and light-weight models are required due to stringent computation resource.Approach.We propose fast apnea syndrome screening neural network (FASSNet), an effective end-to-end neural network to perform minute-apnea event detection. Low-frequency components of filtered ECG spectrogram are selected as input. The model initially processes the spectrogram via convolution blocks. Bidirectional long-short-term memory blocks are used along the frequency axis to complement position information of frequency bands. Layer normalisation is implemented to retain in-epoch information since apnea periods have variable lengths. Experiments were carried out on 70 recordings of Apnea-ECG database, where each 60 s ECG segment is manually labelled as an apnea or normal minute by technician. Both ten-fold and patient-agnostic validation protocols are adopted.Main results.FASSNet is light-weighted, since its value of model parameters and multiply accumulates are 0.06% and 28.33% of those of an AlexNet benchmark, respectively. Meanwhile, FASSNet achieves an accuracy of 87.09%, a sensitivity of 77.96%, a specificity of 91.74%, and an F1 score of 81.61% in apnea event detection. Its accuracy of diagnosing SA syndrome severity exceeds 90% under the patient-agnostic protocol.Significance:FASSNet is a computationally efficient and accurate neural network for wearables to detect SA events and estimate SA severity based on minute-level diagnosis.

Slow-wave sleep and obstructive sleep apnea in patients with type 2 diabetes mellitus

PURPOSE

This study aimed to analyze sleep architecture and obstructive sleep apnea (OSA) in patients with type 2 diabetes and clarify the association between sleep characteristics and glycemic control.

METHODS

All participants underwent metabolism-related laboratory testing and a cross-sectional analysis of nocturnal polysomnography for sleep parameter analysis. Data were analyzed using the chi-squared test, a one-way analysis of variance, and Kruskal-Wallis test to compare the differences among three groups (type 2 diabetes, prediabetes, and control groups). The prevalence of OSA was evaluated using descriptive statistics and comparing the group divided into HbA1c quartiles. Univariate and multivariate linear regression analyses were used to determine factors associated with glycemic control.

RESULTS

Of 75 study participants (age 57.3 ± 4.1 years, 32 men), there were 25 participants each in the type 2 diabetes, prediabetes, and control groups. Participants with type 2 diabetes had significantly decreased slow-wave sleep duration (77.9 ± 30.0 min, p = 0.026) and shortened rapid eye movement sleep latency (median 75 min, p = 0.018) compared with those in the prediabetes and control groups. Forty-five participants (60%) had OSA (apnea-hypopnea index ≥ 5/h), 18 of whom were in the type 2 diabetes group. The prevalence of OSA in this group was 72%. The prevalence of moderate-to-severe OSA was significantly higher in the type 2 diabetes group than in the control group (p = 0.025) and in groups with HbA1c levels of > 6.7% than in groups with HbA1c levels of < 5.3% (p = 0.007). Multiple regression analysis showed that dyslipidemia (β = 0.179, p = 0.000) and slow-wave sleep duration (β =  - 0.113, p = 0.008) were independently associated with the HbA1c level.

CONCLUSION

Our results suggest that increasing slow-wave sleep is positively associated with glycemic control.

Prevalence of Metabolic Syndrome and Its Parameters and Their Correlations With Psoriasis Duration, Severity, and Sleep Quality In Psoriasis Patients: A Cross-Sectional Study

Background

Psoriasis is an inflammatory skin disease that may lead to comorbidities, including metabolic syndrome (MS).

Objective

We determined the prevalence of MS and its correlation with psoriasis duration, severity, and sleep quality in psoriasis patients.

Methods

A total of 112 subjects with chronic plaque psoriasis were studied. Demographics, MS parameters, disease duration, severity, and sleep quality were examined. The Psoriasis Area and Severity Index (PASI) and the Pittsburgh Sleep Quality Index (PSQI) were used to assess psoriasis severity and sleep quality, respectively. Presence of MS and its correlations with psoriasis duration, severity and sleep quality were investigated.

Results

Of 112 patients, 76 (67.8%) were diagnosed with MS. Of all patients, 74.1% had a high PASI, and 84.8% had a high PSQI. The mean values of psoriasis duration, body mass index, waist circumference, fasting glucose, HOMA-IR, triglyceride levels, blood pressure, PSQI, sleep latency, and daytime sleep dysfunction were significantly higher in the MS group than non-MS group, whereas the mean HDL level was lower. The prevalences of MS, high fasting glucose, and low HDL were significantly higher among female, but not male, patients with severe psoriasis (PASI >10) than those without severe psoriasis. Disease duration, high body mass index, waist circumference, blood pressure, fasting glucose, HOMA-IR, triglyceride levels, low HDL, and poor sleep quality were significantly correlated with the presence of MS. However, only waist circumference, fasting glucose, blood pressure, and low HDL were predictive of the development of MS.

Conclusions

MS is common among psoriasis patients, and especially in females with advanced psoriasis, high fasting glucose, and low HDL levels. Besides diagnostic criteria of MS, a long duration of psoriasis, poor sleep quality and high-HOMA-IR correlate with the development of MS. High fasting glucose and low HDL levels may facilitate MS development in association with psoriasis severity in females.

The relationship between metabolic syndrome and obstructive sleep apnea syndrome: a nationwide population-based study

There has been a need for research on the association between metabolic syndrome (MetS) and obstructive sleep apnea syndrome (OSAS) using large data such as nationwide population-based data that adjusts important confounding factors. Therefore, we investigated the relationship between MetS and OSAS. The data source we used was the National Health Insurance Service claims database managed by the Republic of Korea government, in which 10,113,560 individuals were enrolled in 2009 and followed up until 2018. The independent association of MetS with the risk of OSAS was determined using a Cox proportional hazards model with adjustment for age, sex, smoking status, alcohol consumption, regular physical exercise, and body mass index. Our results showed that MetS were strongly associated to OSAS which was adjusted for several confounding factors. Also, we found men, increased waist circumference and increased triglyceride are important risk factors for OSAS.

Fibromyalgia and obesity: A comprehensive systematic review and meta-analysis

INTRODUCTION

Obesity has been associated with several complications, including musculoskeletal disorders. Aim of the present systematic review was to identify all available evidence on the relationship between fibromyalgia (FM) and obesity, including epidemiological association, impact of obesity on FM severity and effect of weight loss strategies on FM symptoms.

METHODS

MedLine, Cochrane Central Register of Controlled Trials and Web of Science databases were searched up to September 2020 to identify eligible articles. Data from studies reporting the prevalence of obesity in FM patients were pooled using a random-effects model.

RESULTS

After removal of duplicate records, 393 studies proceeded to review. A total of 41 articles were deemed eligible for inclusion in final synthesis. Quality assessment revealed that the overall risk of bias was high. The overall prevalence of obesity in FM was 35.7% (95% CI: 31.8 - 39.9%), with higher figures reported for USA. The majority of studies included demonstrated that obesity is associated with different domains of the disorder, including composite measures of activity, pain severity, tender point count, stiffness, fatigue, physical functioning/disability, sleep, cognitive dysfunction, and quality of life; the strength of correlation was weak on average. Inconsistent data were available regarding the correlation with depression and anxiety. Only few studies addressed the effect of therapeutic weight loss in FM, either by bariatric surgery, diet/exercise combination or behavioral weight loss, providing preliminary evidence for a potential benefit of weight loss in ameliorating FM symptoms.

CONCLUSIONS

Available data support a potential interplay between obesity and FM-related symptoms. Weight management should be encouraged in patients with FM.

Insights into interplay of immunopathophysiological events and molecular mechanistic cascades in psoriasis and its associated comorbidities

Psoriasis is an inflammatory skin disease with complex pathogenesis and multiple etiological factors. Besides the essential role of autoreactive T cells and constellation of cytokines, the discovery of IL-23/Th17 axis as a central signaling pathway has unraveled the mechanism of accelerated inflammation in psoriasis. This has provided insights into psoriasis pathogenesis and revolutionized the development of effective biological therapies. Moreover, genome-wide association studies have identified several candidate genes and susceptibility loci associated with this disease. Although involvement of cellular innate and adaptive immune responses and dysregulation of immune cells have been implicated in psoriasis initiation and maintenance, there is still a lack of unifying mechanism for understanding the pathogenesis of this disease. Emerging evidence suggests that psoriasis is a high-mortality disease with additional burden of comorbidities, which adversely affects the treatment response and overall quality of life of patients. Furthermore, changing trends of psoriasis-associated comorbidities and shared patterns of genetic susceptibility, risk factors and pathophysiological mechanisms manifest psoriasis as a multifactorial systemic disease. This review highlights the recent progress in understanding the crucial role of different immune cells, proinflammatory cytokines and microRNAs in psoriasis pathogenesis. In addition, we comprehensively discuss the involvement of various complex signaling pathways and their interplay with immune cell markers to comprehend the underlying pathophysiological mechanism, which may lead to exploration of new therapeutic targets and development of novel treatment strategies to reduce the disastrous nature of psoriasis and associated comorbidities.

Risk of mortality among patients with moderate to severe obstructive sleep apnea and diabetes mellitus: results from the SantOSA cohort

INTRODUCTION

Patients with obstructive sleep apnea (OSA) and comorbid diabetes mellitus (DM) are reported to have an increased risk of cardiovascular (CV) outcomes; however, data on CV mortality are scant.

AIM

This study aimed to evaluate if patients with comorbid OSA and DM have an increased risk of CV mortality that is higher than the two diseases in isolation.

METHODS

In this prospective cohort study, we included patients referred for a sleep study with and without DM at baseline. We developed four study groups as follows: group 1 (reference group), OSA (-) DM (-); group 2, OSA (-) DM (+); group 3, OSA (+) DM (-); group 4, OSA (+) DM (+). Intergroup differences were evaluated using the t test and χ² test, and multivariate analysis was performed using logistic regression. The incidence rates of CV mortality were calculated using the Kaplan-Meier (log-rank) model, and adjusted HRs were calculated using the Cox regression model.

RESULTS

A total of 1447 patients were included in the analysis-group 1: 441 participants; group 2: 141 participants; group 3: 736 participants; group 4: 151 participants. The mean follow-up was 5 years. The association between OSA + DM showed an independent risk of incident CV mortality (HR 2.37, CI 1.16-4.82, p = 0.02) and an increased prevalence of coronary heart disease (OR 3.44, CI 1.73-5.59, p < 0.01). In addition, T90% was also associated with CV mortality.

CONCLUSION

The coexistence of OSA + DM was associated with an independent risk of CV mortality. In addition, T90% was also associated with CV mortality.

Association of Hypertriglyceridemic Waist Phenotype with Obstructive Sleep Apnea: A Cross-Sectional Study

OBJECTIVE

Hypertriglyceridemic waist (HTGW) phenotype is an independent risk factor for metabolic disorders. Although obstructive sleep apnea (OSA) is associated with metabolic disorders, it is unclear whether there is an association between HTGW phenotype and OSA.

METHODS

We enrolled consecutive participants presenting to a sleep center in Shanghai, China. Full-night polysomnography was performed, and serum triglyceride (TG) levels and waist circumference (WC) were calculated. HTGW phenotype was defined as increased WC (men > 90 cm, women > 80 cm) and elevated TG levels (> 1.7 mmol/L). Participants were classified into four groups: normal TG with normal WC (NTNW); normal TG with increased WC (NTGW); elevated TG with normal WC (HTNW); and elevated TG with enlarged WC, namely HTGW. The relationships between HTGW phenotypes and OSA were assessed using binary (apnea hypopnea index, [AHI]≥5/hr) and multinomial logistic regression analyses (clinical AHI severity categories).

RESULTS

We included 3190 participants in this cross-sectional study. Compared to the NTNW phenotype, participants with NTGW and HTGW phenotypes had the significantly higher risk of OSA (AHI ≥5/hr, odds ratio [OR] = 2.51, 95% confidence interval [CI] = 1.91-3.31; OR = 3.76, 95% CI = 2.67-5.31, respectively), after adjustment for confounders. In subgroup analyses categorised by age, sex, and BMI, the aforementioned associations remained significant. The association between the NTGW, HTGW phenotype and OSA risk remained significant across the OSA severity groups. Multinomial logistic regression also revealed that the mild (OR = 1.63, 95% CI = 1.07-2.50), moderate (OR = 1.875, 95% CI = 1.22-2.88), and severe OSA (OR = 3.18, 95% CI = 2.14-4.73) were associated with HTGW phenotype.

CONCLUSION

Both NTGW and HTGW phenotype were positively associated with OSA risk in all subgroups. Further longitudinal follow-up studies are needed to determine the causal link and prognostic role of these metabolic factors.

Obstructive Sleep Apnea and Incident Cancer: A Large Retrospective Multicenter Clinical Cohort Study

BACKGROUND

To examine the association between the severity of obstructive sleep apnea (OSA) and nocturnal hypoxemia with incident cancer.

METHODS

This was a multicenter retrospective clinical cohort study using linked clinical and provincial health administrative data on consecutive adults who underwent a diagnostic sleep study between 1994 and 2017 in four academic hospitals (Canada) who were free of cancer at baseline. Cancer status was derived from the Ontario Cancer Registry. Cox cause-specific regressions were utilized to address the objective and to calculate the 10-year absolute risk difference (ARD) in the marginal probability of incident cancer and the number needed to harm (NNH).

RESULTS

Of 33,997 individuals considered, 33,711 with no missing OSA severity were included: median age, 50 years; 58% male; and 23% with severe OSA (apnea-hypopnea index >30). Of the 18,458 individuals with information on sleep time spent with oxygen saturation (SaO₂) <90%, 5% spent >30% of sleep with SaO₂ <90% (severe nocturnal hypoxemia). Over a median of 7 years, 2,498 of 33,711 (7%) individuals developed cancer, with an incidence rate of 10.3 (10.0-10.8) per 1,000 person-years. Controlling for confounders, severe OSA was associated with a 15% increased hazard of developing cancer compared with no OSA (HR = 1.15, 1.02-1.30; ARD = 1.28%, 0.20-2.37; and NNH = 78). Severe hypoxemia was associated with about 30% increased hazard (HR = 1.32, 1.08-1.61; ARD = 2.38%, 0.47-4.31; and NNH = 42).

CONCLUSIONS

In a large cohort of individuals with suspected OSA free of cancer at baseline, the severity of OSA and nocturnal hypoxemia was independently associated with incident cancer.

IMPACT

These findings suggest the need for more targeted cancer risk awareness in individuals with OSA.

Technologic advances in the assessment and management of obstructive sleep apnoea beyond the apnoea-hypopnoea index: a narrative review

Obstructive sleep apnoea (OSA) is a growing and serious worldwide health problem with significant health and socioeconomic consequences. Current diagnostic testing strategies are limited by cost, access to resources and over reliance on one measure, namely the apnoea-hypopnoea frequency per hour (AHI). Recent evidence supports moving away from the AHI as the principle measure of OSA severity towards a more personalised approach to OSA diagnosis and treatment that includes phenotypic and biological traits. Novel advances in technology include the use of signals such as heart rate variability (HRV), oximetry and peripheral arterial tonometry (PAT) as alternative or additional measures. Ubiquitous use of smartphones and developments in wearable technology have also led to increased availability of applications and devices to facilitate home screening of at-risk populations, although current evidence indicates relatively poor accuracy in comparison with the traditional gold standard polysomnography (PSG). In this review, we evaluate the current strategies for diagnosing OSA in the context of their limitations, potential physiological targets as alternatives to AHI and the role of novel technology in OSA. We also evaluate the current evidence for using newer technologies in OSA diagnosis, the physiological targets such as smartphone applications and wearable technology. Future developments in OSA diagnosis and assessment will likely focus increasingly on systemic effects of sleep disordered breathing (SDB) such as changes in nocturnal oxygen and blood pressure (BP); and may also include other factors such as circulating biomarkers. These developments will likely require a re-evaluation of the diagnostic and grading criteria for clinically significant OSA.

Targeted Metabolomics Analysis on Obstructive Sleep Apnea Patients after Multilevel Sleep Surgery

BACKGROUND

Obstructive sleep apnea (OSA) is caused by partial or complete obstruction of the upper airways. Corrective surgeries aim at removing obstructions in the nasopharynx, oropharynx, and hypopharynx. OSA is associated with an increased risk of various metabolic diseases. Our objective was to evaluate the effect of surgery on the plasma metabolome.

METHODS

This study included 39 OSA patients who underwent Multilevel Sleep Surgery (MLS). Clinical and anthropometric measures were taken at baseline and five months after surgery.

RESULTS

The mean Apnea-Hypopnea Index (AHI) significantly dropped from 22.0 ± 18.5 events/hour to 8.97 ± 9.57 events/hour (p-Value < 0.001). Epworth's sleepiness Score (ESS) dropped from 12.8 ± 6.23 to 2.95 ± 2.40 (p-Value < 0.001), indicating the success of the surgery in treating OSA. Plasma levels of metabolites, phosphocholines (PC) PC.41.5, PC.42.3, ceremide (Cer) Cer.44.0, and triglyceride (TG) TG.53.6, TG.55.6 and TG.56.8 were decreased (p-Value < 0.05), whereas lysophosphatidylcholines (LPC) 20.0 and PC.39.3 were increased (p-Value < 0.05) after surgery.

CONCLUSION

This study highlights the success of MLS in treating OSA. Treatment of OSA resulted in an improvement of the metabolic status that was characterized by decreased TG, PCs, and Cer metabolites after surgery, indicating that the success of the surgery positively impacted the metabolic status of these patients.

Performance of brief ICF-sleep disorders and obesity core set in obstructive sleep apnea patients

BACKGROUND

Clinical questionnaires are mainly applied as screening tools for identification of the Obstructive sleep apnea (OSA) patients. Little attention has been paid to assess the body functions and health status of the patients. International Classification of Functioning, Disability and Health (ICF) was designed for better understanding and describing functioning and disability of patients. This study adopted the Brief ICF-Sleep Disorders and Obesity Core Set to evaluate the impairment of functioning and health status of OSA patients.

METHODS

Five hundred ninety-two participants were enrolled in this cross-sectional study. Data were collected using Brief ICF-Sleep Disorders and Obesity Core Set Polysomnography was performed and basic characteristics of the patients were recorded.

RESULTS

The scores for the component Body Functions and Code b130, b134, b140, b440, b530, s330, d160, d240, d450 of the two core sets were significantly different among the patients divided by apnea-hypopnea index (AHI) or oxygen saturation (SaO2) nadir, but the frequency of code s330, d160, d240, d450 was low. The Body Functions component of the both sets were closely related to neck circumference (NC), body mass index (BMI), apnea-hypopnea index (AHI) of the OSA patients. Body Functions of the Brief ICF-Sleep Disorders performed better with a threshold of 4 with sensitivity, specificity and area under the receiver operating characteristic curve (AUC) as 0.62, 0.74, 0.68(AHI ≥ 5), 0.69, 0.63, 0.66 (AHI ≥ 15), 0.75, 0.56, 0.66 (AHI ≥ 30), 0.56, 0.70, 0.63 (SaO2 nadir≤90%), 0.67, 0.66, 0.66 (SaO2 nadir<85%), 0.71, 0.59, 0.65 (SaO2 nadir<80%), separately.

CONCLUSION

The Body Functions component of both two sets could be an evaluation tool of impairment of body functions for OSA patients. The Brief ICF-Sleep Disorders Body Functions component performed better with a threshold of 4 and might provide a new insight for physicians to assess OSA patients.

Rethinking the association between overweight/obesity and ADHD in children: a longitudinal and psychosocial perspective

OBJECTIVE

This study examines the association between attention-deficit/hyperactivity disorder (ADHD) and overweight/obesity in a large-scale longitudinal study of children, while controlling for a range of psychosocial factors.

METHOD

Data were obtained from Growing Up in Ireland, a nationally representative and longitudinal study of approximately 6500 children who were assessed at 9 and 13 years of age. Body mass index (BMI) was determined using measured height and weight, ADHD status was determined by parent reports of professional diagnoses and ADHD symptoms were measured using the Strengths and Difficulties Questionnaire (SDQ).

RESULTS

The associations between ADHD status, ADHD symptoms (SDQ) and BMI category at age 9 and 13 years were evaluated using logistic regression. Adjustments were made for child factors (sex, developmental coordination disorder, emotional symptoms, conduct problems, birth weight and exercise) and parental factors (socio-economic status, parental BMI, parental depression, and maternal smoking and alcohol use during pregnancy). Logistic regression indicated that ADHD status was not associated with BMI category at 9 or at 13 years of age, but children with ADHD at 9 years were significantly more likely to be overweight/obese at 13 years than those without ADHD. However, when other child and parental factors were adjusted for, ADHD status was no longer significantly associated with weight status. Female sex, low levels of exercise, overweight/obese parents and prenatal smoking during pregnancy consistently increased the odds of childhood overweight/obesity.

CONCLUSIONS

While ADHD and overweight/obesity co-occur in general populations, this relationship is largely explained by a variety of psychosocial factors.

The Evaluation of Autonomic Arousals in Scoring Sleep Respiratory Disturbances with Polysomnography and Portable Monitor Devices: A Proof of Concept Study

BACKGROUND

Autonomic arousals can be considered as surrogates of electroencephalography (EEG) arousals when calculating respiratory disturbance index (RDI). The main objective of this proof of concept study was to evaluate the use of heart rate acceleration (HRa) arousals associated with sleep respiratory events in a population undergoing full polysomnography (type 1) and in another undergoing portable monitor study (type 3). Our hypothesis is that when compared to other commonly used indexes, RDI based on HRa will capture more events in both types of recording.

MATERIALS AND METHODS

A retrospective analysis was performed in two different populations of patients with suspected OSA: a) 72 patients undergoing one night of type 1 recording and b) 79 patients undergoing one night of type 3 recording. Variables for type 1 were 4% oxygen desaturation index (ODI), apnea/hypopnea index (AHI), RDI based on EEG arousals (RDIe), and RDI based on HRa with threshold of 5bpm (RDIa5). For type 3, variables were 4% ODI, AHI, and RDIa5 (it is not possible to calculate RDIe due to the absence of EEG). Calculated data were 1) Mean values for each sleep disturbance index in type 1 and 3 recordings; 2) Frequency of migration from lower to higher OSA severity categories using RDIa5 in comparison to AHI (thresholds: ≥5/h mild, ≥15/h moderate, ≥30/h severe); and 3) Bland-Altman plots to assess agreement between AHI vs RDIe and RDIa5 in type 1 population, and AHI vs RDIa5 in type 3 populations.

RESULTS

More respiratory disturbance events were captured with RDIa5 index in both type 1 and type 3 recordings when compared to the other indexes. In type 1 recording, when using RDIa5 37% of patients classified as not having OSA with AHI were now identified as having OSA, and a total of 59% migrated to higher severity categories. In type 3 recording, similar results were obtained, as 37% of patients classified as not having OSA with AHI were now identified as having OSA using RDIa5, and a total of 55% patients migrated to higher severity categories. Mean differences for RDIa5 and AHI in type 1 and 3 populations were similar.

CONCLUSION

The use of autonomic arousals such as HRa can help to detect more respiratory disturbance events when compared to other indexes, being a variable that may help to capture borderline mild cases. This becomes especially relevant in type 3 recordings. Future research is needed to determine its validity, optimization, and its clinical significance.

Examination of the Relationship Between Metabolic Syndrome and Obstructive Sleep Apnea in Iranian Patients with Type 2 Diabetes: A Case-Control Study

INTRODUCTION

Obstructive sleep apnea (OSA) is a common risk factor for metabolic syndrome (MS) that increases the chance of cardiovascular disease, stroke, and mortality. Many studies have been conducted on this matter, but the results are still conflicting. The aim of the present study was to examine the relationship between metabolic syndrome (MS) and obstructive sleep apnea (OSA) in Iranian patients with type 2 diabetes (T2D).

PATIENTS AND METHODS

This matched case-control study was conducted with 190 patients with T2D in Sanandaj, Iran. The data were selected using the demographic questionnaire, clinical and anthropometric measures, the Berlin Questionnaire (BQ), and the National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATP III). Participants were divided into two groups of high risk of OSA (experimental) and low risk of OSA (control). The data were analyzed using Stata, version 14.

RESULTS

The frequency of MS was higher in the OSA group than the control group (81.1% vs 70.5%), but the group difference was not statistically significant (p=0.127). The results of crude and age-sex adjusted logistic regression analysis revealed no significant association between OSA and the other variables under study (P>0.05). Sensitivity analysis and external adjustment for BMI showed no significant relationship between OSA and the other variables under study (P=0.319).

CONCLUSION

In the present study, no significant association was found between metabolic syndrome (MS) and obstructive sleep apnea (OSA) in patients with T2D; therefore, more studies should be conducted on this subject.

Sleep apnoea among Australian Aboriginal and non-Aboriginal patients in the Northern Territory of Australia—a comparative study

Australian Aboriginal and Torres Straight Islanders (ATSI) are noted to have a higher burden of chronic health conditions. However, there is a paucity of data on obstructive sleep apnoea (OSA) in this population. In this retrospective study, we evaluated the clinical and polysomnographic (PSG) characteristics of ATSI and non-ATSI adult patients who underwent diagnostic PSG between 2011 and 2015. There were a total of 3078 patients. Of the total, 403 (13%) were of ATSI origin. Among those of ATSI origin, 61% were male and 39% females, while among the non-ATSI cohort, 66% were males. The median age was 47.8 years in ATSI and 51.5 years in the non-ATSI cohort. In the combined cohort, body mass index was more than 30 kg/m2 (61%), hypertension (14.4%), diabetes (17.8%), and heart disease (23.3%). The ATSI patients had higher rates of class III obesity (27 vs. 15%), hypertension (26 vs. 14%), cardiac disease (34 vs. 23%), and diabetes (37 vs. 17%). Among all the study participants, the PSG confirmed 83.7% of the patients had an apnoea–hypopnea index (AHI) more than 5/h, mild (AHI 5–15/h) in 28.4%, moderate (AHI 15–30/h) in 22.3%, and severe (AHI &gt; 30/h) in 33.0%. Among the ATSI patients, 46% had severe OSA. The median total AHI value was higher in the ATSI population (25, interquartile range [IQR]: 11–58) compared to the non-ATSI (17, IQR: 7–36), and in rural/remote population (19, IQR: 8–42) compared to urban (17, IQR: 7–37). This trend was similar for NREM (non-rapid eye movement)-AHI and REM (rapid eye movement)-AHI scores, although statistically significant difference was found only with ATSI status. In the combined cohort the probability of (OR = 1.62, 95% CI: 1.32–2.00, p &lt; 0.001) of severe OSA was 62% higher in individual with hypertension, however, when stratified by ATSI status, the association was only significant in the non-ATSI population (OR = 1.53 95% CI: 1.21–1.94, p &lt; 0.001). The odds of severe AHI was also significantly associated with heart disease (1.37; 95% CI: 1.14,1.63, p &lt; 0.001), diabetes (1.74; 95% CI: 1.43,2.10; p &lt; 0.001) and smoking (1.28; 95% CI: 1.09,1.50, p = 0.0023) in the overall study cohort. In both ATSI and non-ATSI patients, body mass index, neck circumference, sleep efficiency, wake after sleep onset, and respiratory arousal index were significantly higher and independently associated with severe AHI.

Role of Obesity in Otorhinolaryngologic Diseases

PURPOSE OF REVIEW

Obesity is a major public health problem associated with various diseases. Improving obesity control and achieving greater patient satisfaction are critical unmet needs. Various otorhinolaryngologic diseases can have negative effects on quality of life or actual health status depending on their type. Over the past decade, the relationship between obesity and otorhinolaryngologic conditions has been investigated. The purpose of this review was to discuss the relationship between obesity and otorhinolaryngological diseases.

RECENT FINDINGS

This is a narrative review on the current state of incidence, effects, and associated mechanisms between obesity and otorhinolaryngologic diseases. In various otologic diseases, otitis media (OM) and hearing loss (HL) are associated with obesity. In rhinologic parts, chronic rhinosinusitis (CRS) and obstructive sleep apnea (OSA) were significantly associated with obesity. Most of these diseases are reported to have higher susceptibility and severity as body mass index (BMI) increases. However, the incidence of head and neck cancer (HNC) was inversely associated with obesity, especially central adiposity. The relevance of obesity in laryngopharyngeal reflux disease (LPR) and allergic rhinitis (AR) has yet to be clarified, and this remains controversial. This review provides a comprehensive overview of the current state of incidence, effects, and associated mechanisms between obesity and otorhinolaryngologic diseases. Various otorhinolaryngological diseases are related to obesity. As obesity can be a negative risk factor in these otorhinolaryngologic diseases, early diagnosis and treatment of these diseases in obese patients will be critical.

Effects of CPAP on the transcriptional signatures in patients with obstructive sleep apnea via coexpression network analysis

A growing number of studies provide epidemiological evidence linking obstructive sleep apnea (OSA) with a number of chronic disorders. Transcriptional analyses have been conducted to analyze the gene expression data. However, the weighted gene coexpression network analysis (WGCNA) method has not been applied to determine the transcriptional consequence of continuous positive airway pressure (CPAP) therapy in patients with severe OSA. The aim of this study was to identify key pathways and genes in patients with OSA that are influenced by CPAP treatment and uncover/unveil potential molecular mechanisms using WGCNA. We analyzed the microarray data of OSA (GSE 49800) listed in the Gene Expression Omnibus database. Coexpression modules were constructed using WGCNA. In addition, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analysis were also conducted. After the initial data processing, 5101 expressed gene profiles were identified. Next, a weighted gene coexpression network was established and 16 modules of coexpressed genes were identified. The interaction analysis demonstrated a relative independence of gene expression in these modules. The black module, tan module, midnightblue module, pink module, and greenyellow module were significantly associated with the alterations in circulating leukocyte gene expression at baseline and after exposure to CPAP. The five hub genes were considered to be candidate OSA-related genes after CPAP treatment. Functional enrichment analysis revealed that steroid biosynthesis, amino sugar and nucleotide sugar metabolism, protein processing in the endoplasmic reticulum, and the insulin signaling pathway play critical roles in the development of OSA in circulating leukocyte gene expression at baseline and after exposure to CPAP. Using this new systems biology approach, we identified several genes and pathways that appear to be critical to OSA after CPAP treatment, and these findings provide a better understanding of OSA pathogenesis.

Obstructive sleep apnea and comorbidities: a dangerous liaison

Obstructive sleep apnea (OSA) is a highly prevalent disease, and is traditionally associated with increased cardiovascular risk. The role of comorbidities in OSA patients has emerged recently, and new conditions significantly associated with OSA are increasingly reported. A high comorbidity burden worsens prognosis, but some data suggest that CPAP might be protective especially in patients with comorbidities. Aim of this narrative review is to provide an update on recent studies, with special attention to cardiovascular and cerebrovascular comorbidities, the metabolic syndrome and type 2 diabetes, asthma, COPD and cancer. Better phenotypic characterization of OSA patients, including comorbidities, will help to provide better individualized care. The unsatisfactory adherence to CPAP in patients without daytime sleepiness should prompt clinicians to examine the overall risk profile of each patient in order to identify subjects at high risk for worse prognosis and provide the optimal treatment not only for OSA, but also for comorbidities.

Comparative Abilities of Body Mass Index, Waist Circumference, Abdominal Volume Index, Body Adiposity Index, and Conicity Index as Predictive Screening Tools for Metabolic Syndrome among Apparently Healthy Ghanaian Adults

The prevalence of the metabolic syndrome (MetS) continues to increase. There is therefore the need for early detection to avert possible adverse outcomes. Several anthropometric methods have been suggested to predict MetS, but no consensus has been reached on which is best. The aim of the study was to explore the comparative abilities of conicity index, body adiposity index, abdominal volume index, body mass index, and waist circumference in predicting cardiometabolic risk among apparently healthy adults in the Tamale metropolis. This study was a cross sectional study conducted from September 2017 to January 2018, among one hundred sixty (160) apparently healthy normoglycemic normotensive adults. A self-designed questionnaire was administered to gather sociodemographic data. Anthropometric and haemodynamic measurements were also taken. Blood samples were collected for fasting blood glucose (FBG) and lipid profile. MetS was classified using the harmonised criteria as indicated by the joint interim statement (JIS). Of 160 participants, 42.5% were male and 57.5% were female. Body mass index (BMI) and waist circumference (WC) associated better with MetS and other cardiovascular risk factors. Generally, BMI and WC showed largest area under curves (AUCs) than abdominal volume index (AVI), body adiposity index (BAI), and conicity index (CI) in predicting MetS and its components. Upon gender stratification, AVI and CI had the larger AUCs in females whiles BMI remained the superior index in males. Whiles BMI and WC remained useful parameters, they were not useful in predicting MetS and its components in the female population in this study.

Air-splinting Maneuver During Flexible Bronchoscopy: A Cross-sectional Study

BACKGROUND

Magazine's maneuver was developed for ease of insertion of the flexible bronchoscope, on encountering a closed lumen at the nasopharynx-oropharynx junction. The purposes of this study were to find the frequency of occurrence of such luminal closures and to compare the efficacy of Magazine's maneuver, with other variations of the maneuver, in improving visualization of the upper airway.

MATERIALS AND METHODS

Patients aged 18 years and above who were undergoing flexible bronchoscopy were included, and their demographic and clinical data were noted. The bronchoscope was inserted using the transnasal approach, and, at the junction of nasopharynx with oropharynx, the patency of the lumen between the soft palate and the posterior pharyngeal wall was recorded. The subjects were instructed to perform 4 variations of the maneuver. Observations at each variation were recorded as lumen open or closed; if the lumen was open, the size was noted as small or large and whether it closed during expiration.

RESULTS

Among 443 subjects, obstruction at the nasopharynx-oropharynx junction was observed, at baseline, in 105 (23.7%); whereas 338 (76.3%) had an open lumen. An open lumen was observed during nose and mouth breathing in 294 (66.4%) subjects, and, when head-tilt chin-lift was added to it, it was observed in 303 (68.4%). During Magazine's maneuver the lumen remained open in all 443 (100%) subjects. Half of the subjects (n=8) with body mass index >30 and one-third (n=29) above 65 years of age had luminal closure at baseline.

CONCLUSION

Magazine's maneuver opens up the obstruction at the nasopharynx-oropharynx junction, whereas mouth and nose breathing mostly fails to do so. Adding head-tilt chin-lift to either of the 2 breathing techniques does not provide any additional benefit.

Upper airway stimulation in obstructive sleep apnea improves glucose metabolism and reduces hedonic drive for food

Upper airway stimulation is a new and effective second-line treatment for obstructive sleep apnea, but possible consequences on glucose metabolism and central regulation of food intake are unclear. Twenty patients were prospectively studied before and 12 months after obstructive sleep apnea treatment by upper airway stimulation. Respiratory parameters and daytime sleepiness were assessed to document effectiveness of treatment. Glucose metabolism was assessed by the oral glucose tolerance test, and hedonic versus homeostatic drive to eat was characterized. At 12 months, upper airway stimulation significantly improved measures of obstructive sleep apnea (all p < 0.01). Despite no change in body weight, fasting C-peptide insulin resistance index (p = 0.01) as well as insulin and C-peptide levels at 60 min during the oral glucose tolerance test (p < 0.02) were reduced. Hedonic drive to eat was strongly reduced (p < 0.05), while leptin and ghrelin remained unchanged (p > 0.15). Upper airway stimulation is effective in treatment of obstructive sleep apnea and improves glucose metabolism. Reduced hedonic drive to eat might contribute to these metabolic improvements. These promising findings are in need for long-term controlled evaluation of metabolic sequelae of upper airway stimulation and to mechanistically evaluate the metabolic benefits of upper airway stimulation in patients with obstructive sleep apnea.