Models of intermittent hypoxia and obstructive sleep apnea: molecular pathways and their contribution to cancer

Changes in appetite during acute passive intermittent and continuous hypoxemia in postprandial and fasting states: A combined analysis of four laboratory-based randomized crossover trials

Hypoxemia occurs during exposure to high altitude (continuous hypoxemia) or in the context of breathing disorders such as obstructive sleep apnea (OSA; intermittent hypoxemia). Growing evidence demonstrates that hypoxemia induces an anorexigenic effect on appetite; however, few studies have assessed hypoxemia-related reductions in appetite during acute passive exposures and during intermittent hypoxemia. This study thus pooled together four same-single-site randomized crossover trials using simulated models of high altitude (fraction of inspired oxygen = 0.1200, ∼5000 m) and moderate OSA (∼15 hypoxemic cycles per hour, ∼85 oxyhemoglobin saturation). Changes in appetite were evaluated during 6 h of passive normoxia and intermittent or continuous hypoxemia in postprandial or fasting states among healthy young adults (n = 40) and middle-aged individuals living with OSA (n = 7). Our results demonstrate that (1) acute passive intermittent hypoxemia leads to statistically significant, but likely not clinically significant reductions in appetite in the postprandial state, (2) the anorexigenic effect of acute passive hypoxemia on appetite is not consistent across hypoxemic methods and nutritional states, and (3) variations in individual factors may influence appetite responses during normoxia and hypoxemia. These findings indicate that the effect of acute passive hypoxemia on appetite is heterogeneous, particularly across different hypoxemic methods and nutritional states.

State of the art: Alternative overlap syndrome-asthma and obstructive sleep apnea

In the general population, Bronchial Asthma (BA) and Obstructive Sleep Apnea (OSA) are among the most prevalent chronic respiratory disorders. Significant epidemiologic connections and complex pathogenetic pathways link these disorders via complex interactions at genetic, epigenetic, and environmental levels. The coexistence of BA and OSA in an individual likely represents a distinct syndrome, that is, a collection of clinical manifestations attributable to several mechanisms and pathobiological signatures. To avoid terminological confusion, this association has been named alternative overlap syndrome (vs overlap syndrome represented by the chronic obstructive pulmonary disease-OSA association). This comprehensive review summarizes the complex, often bidirectional links between the constituents of the alternative overlap syndrome. Cross-sectional, population, or clinic-based studies are unlikely to elucidate causality or directionality in these relationships. Even longitudinal epidemiological evaluations in BA cohorts developing over time OSA, or OSA cohorts developing BA during follow-up cannot exclude time factors or causal influence of other known or unknown mediators. As such, a lot of pathophysiological interactions described here have suggestive evidence, biological plausibility, potential or actual directionality. By showcasing existing evidence and current knowledge gaps, the hope is that deliberate, focused, and collaborative efforts in the near-future will be geared toward opportunities to shine light on the unknowns and accelerate discovery in this field of health, clinical care, education, research, and scholarly endeavors.

Does obstructive sleep apnea increase the risk of cancer and cancer mortality in combined community-based cohorts?

Obstructive sleep apnea (OSA) has been linked to cancer in several clinical and community-based cohorts. The effect in community-based studies free of clinical referral bias needs to be replicated. In this observational prospective cohort study, we pooled data from three community-based prospective cohorts (Uppsala Sleep and Health in Men cohort [UMEN]; Sleep and health in women [SHE]; Men Androgen Inflammation Lifestyle Environment and Stress Cohort [MAILES]; nTotal = 1467). All cohorts had objective data on obstructive sleep apnea and registry linkage data on cancer and cancer mortality. Analyses for different obstructive sleep apnea measures (apnea-hypopnea index [AHI], oxygen desaturation index [ODI], and minimal saturation) as risk factors for cancer incidence (all cancers) were performed using Cox proportional hazards models (follow-up 5-16 years). We did not find an overall increased risk of cancer after adjustment for age, sex, and BMI (HRAHI [95% CI] = 1.00 [0.98; 1.01] and HRODI [95% CI] = 0.99 [0.97; 1.01]). Stratifying by daytime sleepiness did not influence the association. Cancer mortality was not significantly associated with obstructive sleep apnea. Taken together, we did not observe an overall increased risk of cancer or cancer mortality in relation to obstructive sleep apnea, however, our confidence limits remain wide for important diagnostic categories of sleep apnea severity. The relationship between obstructive sleep apnea and cancer needs further investigation in a comprehensive multi-cohort approach with greater statistical precision. For future studies we may need to find and then combine every community-based cohort study that can provide a definitive answer to the question on the risk of cancer from obstructive sleep apnea in the general population.

An integrated bioinformatics analysis to identify the shared biomarkers in patients with obstructive sleep apnea syndrome and nonalcoholic fatty liver disease

Background

Obstructive sleep apnea (OSA) syndrome and nonalcoholic fatty liver disease (NAFLD) have been shown to have a close association in previous studies, but their pathogeneses are unclear. This study explores the molecular mechanisms associated with the pathogenesis of OSA and NAFLD and identifies key predictive genes.

Methods

Using the Gene Expression Omnibus (GEO) database, we obtained gene expression profiles GSE38792 for OSA and GSE89632 for NAFLD and related clinical characteristics. Mitochondrial unfolded protein response-related genes (UPRmtRGs) were acquired by collating and collecting UPRmtRGs from the GeneCards database and relevant literature from PubMed. The differentially expressed genes (DEGs) associated with OSA and NAFLD were identified using differential expression analysis. Gene Set Enrichment Analysis (GSEA) was conducted for signaling pathway enrichment analysis of related disease genes. Based on the STRING database, protein-protein interaction (PPI) analysis was performed on differentially co-expressed genes (Co-DEGs), and the Cytoscape software (version 3.9.1) was used to visualize the PPI network model. In addition, the GeneMANIA website was used to predict and construct the functional similar genes of the selected Co-DEGs. Key predictor genes were analyzed using the receiver operating characteristic (ROC) curve.

Results

The intersection of differentially expressed genes shared between OSA and NAFLD-related gene expression profiles with UPRmtRGs yielded four Co-DEGs: ASS1, HDAC2, SIRT3, and VEGFA. GSEA obtained the relevant enrichment signaling pathways for OSA and NAFLD. PPI network results showed that all four Co-DEGs interacted (except for ASS1 and HDAC2). Ultimately, key predictor genes were selected in the ROC curve, including HDAC2 (OSA: AUC = 0.812; NAFLD: AUC = 0.729), SIRT3 (OSA: AUC = 0.775; NAFLD: AUC = 0.750), and VEGFA (OSA: AUC = 0.812; NAFLD: AUC = 0.861) (they have a high degree of accuracy in predicting whether a subject will develop two diseases).

Conclusion

In this study, four co-expression differential genes for OSA and NAFLD were obtained, and they can predict the occurrence of both diseases. Transcriptional mechanisms involved in OSA and NAFLD interactions may be better understood by exploring these key genes. Simultaneously, this study provides potential diagnostic and therapeutic markers for patients with OSA and NAFLD.

Prevalence of obstructive sleep apnoea syndrome in oncological patients: A systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnoea syndrome (OSAS) has garnered increasing attention in recent years due to its potential association with cancer. This systematic review and meta-analysis aimed to assess the prevalence of OSAS in cancer patients through a comprehensive analysis of existing literature.

METHODS

This systematic review and meta-analysis, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, aimed to evaluate the prevalence of OSAS in cancer patients. A comprehensive search of electronic databases was performed to identify relevant studies published up to September 2021. Eligible studies reporting on the prevalence of OSAS in cancer patients, encompassing various study designs, were included in the analysis. Pooled estimates of the odds ratios (OR) with 95% confidence intervals (CIs) were calculated using a random effects model. Heterogeneity among the studies was assessed using the I2 statistic.

RESULTS

Seventeen studies fulfilled the inclusion criteria and were subsequently included in the review. The prevalence of OSAS in cancer patients was estimated to have an overall OR of 0.80 (95% CI: 0.75-0.85). In comparison with non-cancer patients, cancer patients had a statistically significant greater risk of OSAS, as indicated by the total estimated RR for the prevalence of OSAS in cancer patients, which was 0.89 (95% CI: 0.86-0.92). Nonetheless, there was a significant amount of heterogeneity (I2 = 96%) among the studies.

CONCLUSION

The overall data analysed in this review indicates that patients with cancer had far reduced likelihood of developing OSAS than individuals without cancer. However, the significant variation across the included studies highlights the need for additional investigation to fully clarify the complex association between OSAS and cancer incidence. These results emphasise how critical it is to identify OSAS as a possible comorbidity in cancer patients, one that should be taken into account for clinical management and ongoing research.

Knowledge and Attitudes Toward Obstructive Sleep Apnea Among Korean Pulmonologists: A Nationwide Survey

BACKGROUND

Obstructive sleep apnea (OSA) significantly impacts cardiovascular, metabolic, and respiratory health. In Korea, OSA patients are treated by specialists in internal medicine, otolaryngology, neurology, and psychiatry, but the participation rate of pulmonologists in OSA management is relatively low compared to other specialties. This study investigated the knowledge and attitudes about OSA among Korean pulmonologists.

MATERIALS AND METHODS

An online survey was conducted, targeting respiratory specialists listed in the Korean Academy of Tuberculosis and Respiratory Diseases directory. The survey used the validated "Obstructive Sleep Apnea Knowledge and Attitudes" (OSAKA) questionnaire, which consists of questions about knowledge and attitudes on OSA. To maximize participation, email invitations were sent three times to the target audience.

RESULTS

Out of 634 queried pulmonologists, 127 (20%) responded to the survey. The mean age of respondents was 45.4 ± 8.6 years. The respondents' years of specialty acquisition ranged from the 1980s to the 2010s. Additionally, 74 (58.3%) held a doctor's degree, and 96 (75.6%) worked in hospitals with a sleep center. Furthermore, 71 (55.9%) of the pulmonologists reported having experience with OSA patients. Pulmonologists with experience managing OSA patients had significantly higher knowledge and attitude scores compared to those without such experience. Interestingly, older respondents and those who completed their pulmonology training earlier had higher attitude scores. In addition, the knowledge score significantly correlated with responses to the five items of the attitude questionnaire.

CONCLUSION

This study provides valuable insights into the knowledge and attitudes of Korean pulmonologists regarding OSA. The findings indicate that their knowledge levels are comparable to or better than those in previous studies. These results underscore the need for targeted educational programs and practical training, especially for younger pulmonologists, to enhance their proficiency in managing OSA and to encourage a more active role in its treatment.

Contribution of Obstructive Sleep Apnea to Asthmatic Airway Inflammation and Impact of Its Treatment on the Course of Asthma

Asthma and obstructive sleep apnea (OSA) are very common respiratory disorders in the general population. Beyond their high prevalence, shared risk factors, and genetic linkages, bidirectional relationships between asthma and OSA exist, each disorder affecting the other's presence and severity. The author reviews here some of the salient links between constituents of the alternative overlap syndrome, that is, OSA comorbid with asthma, with an emphasis on the effects of OSA or its treatment on inflammation in asthma. In the directional relationship from OSA toward asthma, beyond direct influences, multiple factors and comorbidities seem to contribute.

Oscillatory Hypoxia Can Induce Senescence of Adipose-Derived Mesenchymal Stromal Cells Potentiating Invasive Transformation of Breast Epithelial Cells

Obesity is strongly associated with occurrence, metastasis, and resistance to therapy in breast cancers, which also exhibit high adipose content in the tumor microenvironment. Adipose tissue-derived mesenchymal stromal cells (ASCs) are recruited to breast cancer by many mechanisms, including hypoxia, and contribute to metastatic transition of the cancer. Breast cancers are characterized by regions of hypoxia, which can be temporally unstable owing to a mismatch between oxygen supply and consumption. Using a high-sensitivity nanopatterned stromal invasion assay, we found that ASCs could promote stromal invasion of not only breast cancer cell lines but also MCF10A1, a cell line derived from untransformed breast epithelium. RNA sequencing of MCF10A1 cells conditioned with medium from ASCs revealed upregulation of genes associated with increased cell migration, chemotaxis, and metastasis. Furthermore, we found that fluctuating or oscillating hypoxia could induce senescence in ASCs, which could result in an increased invasive potential in the treated MCF10A1 cells. These findings highlight the complex interplay within the breast cancer microenvironment, hypoxia, and the role of ASCs in transforming even non-cancerous breast epithelium toward an invasive phenotype, providing insights into early metastatic events.

Murine Pro-Inflammatory Responses to Acute and Sustained Intermittent Hypoxia: Implications for Obstructive Sleep Apnea Research

OBJECTIVES

Obstructive sleep apnea (OSA) is characterized by chronic systemic inflammation; however, the mechanisms underlying these pathologic consequences are incompletely understood. Our objective was to determine the effects of short- versus long-term exposure to intermittent hypoxia (IH) on pro-inflammatory mediators within vulnerable organs impacted by OSA.

STUDY DESIGN

Experimental animal study.

METHODS

A total of 8-10 week old C57BL/6J mice were exposed to normoxic or IH conditions for 7 days (short-term) or 6 weeks (long-term) under 12 h light, 12 h dark cycles. After exposure, multiple tissues were collected over a 24 h period. These tissues were processed and evaluated for gene expression and protein levels of pro-inflammatory mediators from peripheral tissues.

RESULTS

We observed a global decrease in immune response pathways in the heart, lung, and liver compared with other peripheral organs after short-term exposure to IH. Although there were tissue-specific alterations in the gene expression of pro-inflammatory mediators, with down-regulation in the lung and up-regulation in the heart, we also observed reduced protein levels of pro-inflammatory mediators in the serum, lung, and heart following short-term exposure to IH. Long-term exposure to IH resulted in an overall increase in the levels of inflammatory mediators in the serum, lung, and heart.

CONCLUSIONS

We demonstrated novel, longitudinal changes in the inflammatory cascade in a mouse model of OSA. The duration of exposure to IH led to significant variability of inflammatory responses within blood and cardiopulmonary tissues. Our findings further elucidate how inflammatory responses change over the course of the disease in vulnerable organs.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:S1-S11, 2024.

Hypoxia Induces Alterations in the Circadian Rhythm in Patients with Chronic Respiratory Diseases

The function of the circadian cycle is to determine the natural 24 h biological rhythm, which includes physiological, metabolic, and hormonal changes that occur daily in the body. This cycle is controlled by an internal biological clock that is present in the body's tissues and helps regulate various processes such as sleeping, eating, and others. Interestingly, animal models have provided enough evidence to assume that the alteration in the circadian system leads to the appearance of numerous diseases. Alterations in breathing patterns in lung diseases can modify oxygenation and the circadian cycles; however, the response mechanisms to hypoxia and their relationship with the clock genes are not fully understood. Hypoxia is a condition in which the lack of adequate oxygenation promotes adaptation mechanisms and is related to several genes that regulate the circadian cycles, the latter because hypoxia alters the production of melatonin and brain physiology. Additionally, the lack of oxygen alters the expression of clock genes, leading to an alteration in the regularity and precision of the circadian cycle. In this sense, hypoxia is a hallmark of a wide variety of lung diseases. In the present work, we intended to review the functional repercussions of hypoxia in the presence of asthma, chronic obstructive sleep apnea, lung cancer, idiopathic pulmonary fibrosis, obstructive sleep apnea, influenza, and COVID-19 and its repercussions on the circadian cycles.

Are sleep disorders associated with the risk of gastrointestinal cancer?-A case-control study

PURPOSE

Sleep disorders are among the most common health problems worldwide and are linked to a variety of physical and mental health problems. Recently, there has been increasing evidence of an association between sleep disorders and cancer risk. We aimed to investigate this association specifically for cancers of the gastrointestinal (GI) tract.

METHODS

Using the DA database (IQVIA), adult patients diagnosed with GI cancer between January 2010 and December 2022 were retrospectively compared to a 1:1 propensity score-matched cohort of patients without cancer. The outcome of the study was the association between sleep disorders and subsequent diagnosis of GI cancer. To determine whether sleep disorders were more common in patients with GI cancer than in patients without GI cancer, logistic regression models were used to estimate odds ratios (ORs) with 95% confidence intervals (95% CI).

RESULTS

After matching, 37,161 cases with GI cancer and 37,161 controls without cancer were available for analysis. No association with cancer was found for sleep disorders in the overall history before the index date (OR 1.04; 95% CI 0.96-1.12), but considering sleep disorders documented within 1 year before the index date showed a positive association with GI cancer overall (OR 1.20; 95% CI 1.08-1.34). Stratified analyses by cancer site revealed higher odds of sleep disorders prior to diagnosis of gastric, pancreatic, and colorectal cancer.

CONCLUSION

Our findings suggest that sleep disorders might be indicative of short-term health outcomes, including GI cancer, suggesting a role for sleep disorder screening in the context of cancer prevention efforts.

Intermittent Hypoxia Mediates Cancer Development and Progression Through HIF-1 and miRNA Regulation

INTRODUCTION

There is still a debate for the link between obstructive sleep apnoea (OSA) and cancer. The mechanisms underlying this causality are poorly understood. Several miRNAs are involved in cancer development and progression with expression being influenced by hypoxia. The aims of this work were (i) to compare miRNAs expression in controls versus patients affected by OSA without or with cancer (ONCO-OSA) and (ii) in colorectal cancer cells exposed to intermittent hypoxia (IH), to evaluate miRNAs impact on tumor progression in vitro.

METHODS

We detected miRNAs by qRT-PCR in patients' sera and in CaCo2 cells exposed to 2-32h of IH with or without acriflavine (ACF), a HIF-1 inhibitor. Viability and transwell invasion test were applied to investigate the proliferation and migration of CaCo2 exposed to IH and treated with miRNA inhibitors or acriflavine. HIF-1α activity was evaluated in CaCo2 cells after IH.

RESULTS

The levels of miR-21, miR-26a and miR-210 increased in OSA and ONCO-OSA patients compared to controls. MiR-23b increased in ONCO-OSA patients, and miR-27b and miR-145 increased in OSA but not ONCO-OSA patients. MiR-21, miR-26a, miR-23b and miR-210 increased in cells after IH. IH stimulated cell proliferation and migration. This effect was reduced after either miRNA inhibition or acriflavine treatment. MiRNA inhibition reduces HIF-1α gene expression. Conversely, acriflavine reduced the expression of these miRNAs.

CONCLUSIONS

We identified a signature of miRNAs, induced by the IH environment. They could be implicated in cancer development and progression through a regulatory loop involving HIF-1.

Intermittent Hypoxia Promotes TAM-Induced Glycolysis in Laryngeal Cancer Cells via Regulation of HK1 Expression through Activation of ZBTB10

Obstructive sleep apnea (OSA), characterized by intermittent hypoxia (IH), may increase the risk of cancer development and a poor cancer prognosis. TAMs of the M2 phenotype, together with the intermittent hypoxic environment within the tumor, drive tumor aggressiveness. However, the mechanism of TAMs in IH remains unclear. In our study, IH induced the recruitment of macrophages, and IH-induced M2-like TAMs promoted glycolysis in laryngeal cancer cells through hexokinase 1. The hexokinase inhibitor 2-deoxy-D-glucose and HK1 shRNA were applied to verify this finding, confirming that M2-like TAMs enhanced glycolysis in laryngeal cancer cells through HK1 under intermittent hypoxic conditions. Comprehensive RNA-seq analysis disclosed a marked elevation in the expression levels of the transcription factor ZBTB10, while evaluation of a laryngeal cancer patient tissue microarray demonstrated a positive correlation between ZBTB10 and HK1 expression in laryngeal carcinoma. Knockdown of ZBTB10 decreased HK1 expression, and overexpression of ZBTB10 increased HK1 expression in both laryngeal cancer cells and 293T cells. The luciferase reporter assay and Chromatin immunoprecipitation assay confirmed that ZBTB10 directly bound to the promoter region of HK1 and regulated the transcriptional activity of HK1. Finally, the CLEC3B level of the M2 supernatant is significantly higher in the IH group and showed a protumor effect on Hep2 cells. As ZBTB10-mediated regulation of HK1 affects glycolysis in laryngeal cancer, our findings may provide new potential therapeutic targets for laryngeal cancer.

Associations among sleep-disordered breathing, sleep quality, and lung cancer in Korean patients

PURPOSE

Intermittent hypoxia and sleep fragmentation, two main features of sleep-disordered breathing (SDB), have been shown to increase the aggressiveness of lung cancer, mainly in animal and in vitro studies. However, the association between SDB and lung cancer has not been well described in human studies. In this study, we investigated the associations among SDB, sleep quality, and lung cancer in Korean patients.

METHODS

Patients with histologically diagnosed lung cancer performed a home sleep apnea test. Sleep questionnaires including the Epworth Sleepiness Scale (ESS), Insomnia Severity Index, and Pittsburgh Sleep Quality Index were also administered. Clinical information related to lung cancer was collected during the study.

RESULTS

Sixty-nine patients were enrolled, 31 of whom were poor sleepers. The overall prevalence of SDB was 57% and that of moderate to severe SDB was 27%. Underlying chronic obstructive pulmonary disease (COPD) and smoking history were significantly more frequent in patients with moderate to severe SDB compared to patients without or with mild SDB. No significant differences were observed in the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), or time with oxygen saturation < 90% (T90) according to cancer cell types, mutations, stages, and survival. However, small-cell lung cancer patients showed a trend toward higher AHI, ODI, and T90 values.

CONCLUSION

The prevalence of SDB and proportion of poor sleepers were high in Korean patients with lung cancer. Paying more attention to sleep status may be helpful for patients with COPD, a smoking history, and small-cell lung cancer.

Incidence disparities of obstructive sleep apnea-associated lung cancer by gender; Korean National Health Insurance data analysis

Introduction

Obstructive sleep apnea (OSA) is known to increase the risk of various cancers. By analyzing the Korea National Health Insurance Service (KNHIS) registry, the impact of OSA on the lung cancer incidence was analyzed in a retrospective cohort group.

Methods

A retrospective cohort of adult patients newly registered with OSA in the KNHIS data from 2007 to 2017 was included and observed until December 2019 (12 years). The main outcome measure was newly diagnosed lung cancer. The control group was set with age and sex that matched those in the OSA group.

Results

The hazard ratio (HR) of OSA for lung cancer incidence showed a significantly reduced HR of 0.87 (95% CI, 0.82-0.93). The observed significance of this finding was limited to male OSA patients [HR, 0.84 (95% CI, 0.78-0.90)], while no significant association was found in female OSA patients [HR, 1.05 (95% CI, 0.91-1.21)], irrespective of their age.

Discussion

OSA patients have a lower risk of developing lung cancer, but this risk reduction is gender-specific, as female OSA patients do not show a reduction in hazard ratio.

How to study sleep apneas in mouse models of human pathology

Sleep apnea, the most widespread sleep-related breathing disorder (SBD), consists of recurrent episodes of breathing cessation during sleep. This condition can be classified as either central (CSA) or obstructive (OSA) sleep apnea, with the latest being the most common and toxic. Due to the complexity of living organisms, animal models and, particularly, mice still represent an essential tool for the study of SBD. In the present review we first discuss the methodological pros and cons in the use of whole-body plethysmography to coupling respiratory and sleep measurements and to characterize CSA and OSA in mice; then, we draw an updated and objective picture of the methods used so far in the study of sleep apnea in mice. Most of the studies present in the literature used intermittent hypoxia to mimic OSA in mice and to investigate consequent pathological correlates. On the contrary, few studies using genetic manipulation or high-fat diets investigated the pathogenesis or potential treatments of sleep apnea. To date, mice lacking orexins, hemeoxygenase-2, monoamine oxidase A, Phox2b or Cdkl5 can be considered validated mouse models of sleep apnea. Moreover, genetically- or diet-induced obese mice, and mice recapitulating Down syndrome were proposed as OSA models. In conclusion, our review shows that despite the growing interest in the field and the need of new therapeutical approaches, technical complexity and inter-study variability strongly limit the availability of validated mouse of sleep apnea, which are essential in biomedical research.

Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.

Obstructive Sleep Apnea - Influence on the Cardiovascular System and Cognition

Kardiovaskuläre und kognitive Erkrankungen sind ebenso wie die obstruktive Schlafapnoe sehr häufige Krankheiten mit einer erheblichen Beeinträchtigung der Lebensqualität und einer deutlichen sozioökonomischen Bedeutung. Die Auswirkungen einer unbehandelten obstruktiven Schlafapnoe (OSA) auf das kardiovaskuläre und kognitive Erkrankungsrisiko und die Therapieeffekte einer OSA sind für die meisten kardiovaskulären und kognitiven Folgeerkrankungen wissenschaftlich nachgewiesen. Für die klinische Praxis besteht ein deutlicher Bedarf nach mehr Interdisziplinarität. Aus schlafmedizinischer Sicht müssen bei der Therapieindikation das individuelle kardiovaskuläre und kognitive Risiko berücksichtigt und kognitive Erkrankungen bei der Beurteilung der Therapieintoleranz und residuellen Symptomatik beachtet werden. Aus internistischer Sicht sollte bei Patienten mit schlecht einstellbarem Hypertonus, Vorhofflimmern, koronarer Herzkrankheit und Schlaganfall die Abklärung einer OSA in die Diagnostik integriert werden. Bei Patienten mit milder kognitiver Beeinträchtigung, Alzheimer-Krankheit und Depression können sich die typischen Symptome wie Fatigue, Tagesmüdigkeit und Reduktion der kognitiven Leistungen mit OSA-Symptomen überschneiden. Die Diagnostik einer OSA sollte in die Abklärung dieser Krankheitsbilder integriert werden, da eine Therapie der OSA die kognitiven Beeinträchtigungen reduzieren und die Lebensqualität verbessern kann.

Obstructive sleep apnea in a mouse model is associated with tissue-specific transcriptomic changes in circadian rhythmicity and mean 24-hour gene expression

Intermittent hypoxia (IH) is a major clinical feature of obstructive sleep apnea (OSA). The mechanisms that become dysregulated after periods of exposure to IH are unclear, particularly in the early stages of disease. The circadian clock governs a wide array of biological functions and is intimately associated with stabilization of hypoxia-inducible factors (HIFs) under hypoxic conditions. In patients, IH occurs during the sleep phase of the 24-hour sleep-wake cycle, potentially affecting their circadian rhythms. Alterations in the circadian clock have the potential to accelerate pathological processes, including other comorbid conditions that can be associated with chronic, untreated OSA. We hypothesized that changes in the circadian clock would manifest differently in those organs and systems known to be impacted by OSA. Using an IH model to represent OSA, we evaluated circadian rhythmicity and mean 24-hour expression of the transcriptome in 6 different mouse tissues, including the liver, lung, kidney, muscle, heart, and cerebellum, after a 7-day exposure to IH. We found that transcriptomic changes within cardiopulmonary tissues were more affected by IH than other tissues. Also, IH exposure resulted in an overall increase in core body temperature. Our findings demonstrate a relationship between early exposure to IH and changes in specific physiological outcomes. This study provides insight into the early pathophysiological mechanisms associated with IH.

Differential Impact of Intermittent vs. Sustained Hypoxia on HIF-1, VEGF and Proliferation of HepG2 Cells

Obstructive sleep apnea (OSA) is an emerging risk factor for cancer occurrence and progression, mainly mediated by intermittent hypoxia (IH). Systemic IH, a main landmark of OSA, and local sustained hypoxia (SH), a classical feature at the core of tumors, may act separately or synergistically on tumor cells. Our aim was to compare the respective consequences of intermittent and sustained hypoxia on HIF-1, endothelin-1 and VEGF expression and on cell proliferation and migration in HepG2 liver tumor cells. Wound healing, spheroid expansion, proliferation and migration were evaluated in HepG2 cells following IH or SH exposure. The HIF-1α, endothelin-1 and VEGF protein levels and/or mRNA expression were assessed, as were the effects of HIF-1 (acriflavine), endothelin-1 (macitentan) and VEGF (pazopanib) inhibition. Both SH and IH stimulated wound healing, spheroid expansion and proliferation of HepG2 cells. HIF-1 and VEGF, but not endothelin-1, expression increased with IH exposure but not with SH exposure. Acriflavine prevented the effects of both IH and SH, and pazopanib blocked those of IH but not those of SH. Macitentan had no impact. Thus, IH and SH stimulate hepatic cancer cell proliferation via distinct signaling pathways that may act synergistically in OSA patients with cancer, leading to enhanced tumor progression.

Global research on cancer and sleep: A bibliometric and visual analysis of the last two decades

Objective

The study aimed to analyze the research status, hotspots, and frontiers of global research on cancer and sleep through bibliometrics and provide references and guidance for future research.

Methods

The literature regarding cancer and sleep from 2002 to 2022 was searched from the Web of Science Core Collection (WoSCC) database. CiteSpace 5.6.R3 was performed for visualization analysis.

Results

A total of 1,172 publications were identified. The number of publications in the field has gradually increased over the past two decades. The United States had the most prominent contributions. Taipei Medical University and the University of California, San Francisco, and David Gozal were the most prolific institutions and author, respectively. The most published academic journal was Supportive Care in Cancer. The research hotspots can be summarized into the symptom cluster intervention for cancer survivors and the association between cancer and melatonin and/or obstructive sleep apnea (OSA). The complex interaction between cancer and sleep disruption and the influencing factors of sleep quality may be the emerging trends of research.

Conclusion

This study systematically analyzed the hotspots and frontiers in the field of cancer and sleep and called for strengthening cooperation among countries, institutions, and authors. In addition, intervention measures for the cancer symptom cluster, the bioavailability of exogenous melatonin, the causal relationship between OSA and cancer, the mechanism of tumor-induced sleep disruption, the dose–response relationship between sleep duration and cancer risk, and the path relationship between sleep quality influencing factors may be the focus of future research.

Is obstructive sleep apnea a circadian rhythm disorder?

Obstructive sleep apnea is the most common sleep-related breathing disorder worldwide and remains underdiagnosed. Its multiple associated comorbidities contribute to a decreased quality of life and work performance as well as an increased risk of death. Standard treatment seems to have limited effects on cardiovascular and metabolic aspects of the disease, emphasising the need for early diagnosis and additional therapeutic approaches. Recent evidence suggests that the dysregulation of circadian rhythms, processes with endogenous rhythmicity that are adjusted to the environment through various cues, is involved in the pathogenesis of comorbidities. In patients with obstructive sleep apnea, altered circadian gene expression patterns have been demonstrated. Obstructive respiratory events may promote circadian dysregulation through the effects of sleep disturbance and intermittent hypoxia, with subsequent inflammation and disruption of neural and hormonal homeostasis. In this review, current knowledge on obstructive sleep apnea, circadian rhythm regulation, and circadian rhythm sleep disorders is summarised. Studies that connect obstructive sleep apnea to circadian rhythm abnormalities are critically evaluated. Furthermore, pathogenetic mechanisms that may underlie this association, most notably hypoxia signalling, are presented. A bidirectional relationship between obstructive sleep apnea and circadian rhythm dysregulation is proposed. Approaching obstructive sleep apnea as a circadian rhythm disorder may prove beneficial for the development of new, personalised diagnostic, therapeutic and prognostic tools. However, further studies are needed before the clinical approach to obstructive sleep apnea includes targeting the circadian system.

Adipocytokines in obstructive sleep apnea: A systematic review and meta-analysis

BACKGROUND AND AIM

Adipocytokines play an important role in obstructive sleep apnea (OSA) by mediating inflammatory responses. Previous studies have reported that OSA is related to a change in the serum levels of adipocytokines; however, the results are still controversial. This meta-analysis aimed to assess the relationship between OSA and circulating level of adipocytokines in adults and children.

METHODS

A comprehensive search was conducted in databases of Medline/PubMed and Scopus for pertinent articles published since their inception to July 2022. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were used to assess the strength of the relationship between the concentrations of adipocytokines with OSA.

RESULTS

In the overall analysis, contrary to IL-10, which showed a significant reduction, IL-1β, IL-4, IL-8, IL-17, and IFN- gamma showed higher levels in OSA patients in comparison with control groups (p <0.05). For adults, IL-1β, IL-8, IL-17, IL-18, vaspin, visfatin, and chemerin were linked to a greater serum levels in patients with OSA, while, IL-5 and IL-10 were detected significantly lower in adults with OSA in comparison with healthy adults (p <0.05). In children with OSA, the serum levels of IL-4, IL-8, IL-12, IL-17, IL-23, and IFN-gamma were significantly higher than healthy children (p <0.05).

CONCLUSION

The levels of inflammatory markers were found to be higher in OSA patients compared with control individuals, suggesting that adipocytokines may contribute to the pathology of OSA.

Intermittent hypoxia treatments cause cellular priming in human microglia

Obstructive sleep apnoea syndrome (OSAS) is a sleep-disordered breathing characterized by nocturnal collapses of the upper airway resulting in cycles of blood oxygen partial pressure oscillations, which lead to tissue and cell damage due to intermittent hypoxia (IH) episodes. Since OSAS-derived IH may lead to cognitive impairment through not fully cleared mechanisms, herein we developed a new in vitro model mimicking IH conditions to shed light on its molecular effects on microglial cells, with particular attention to the inflammatory response. The in vitro model was set-up and validated by measuring the hypoxic state, HIF-1α levels, oxidative stress by ROS production and mitochondrial activity by MTS assay. Then, the mRNA and protein levels of certain inflammatory markers (NF-κB and interleukin 6 (IL-6)) after different IH treatment protocols were investigated. The IH treatments followed by a normoxic period were not able to produce a high inflammatory state in human microglial cells. Nevertheless, microglia appeared to be in a state characterized by increased expression of NF-κB and markers related to a primed phenotype. The microglia exposed to IH cycles and stimulated with exogenous IL-1β resulted in an exaggerated inflammatory response with increased NF-κB and IL-6 expression, suggesting a role for primed microglia in OSAS-driven neuroinflammation.

A novel OSA-related model of intermittent hypoxia in endothelial cells under flow reveals pronounced inflammatory pathway activation

Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder characterized by recurrent episodes of upper airway obstruction and subsequent hypoxia. In patients with OSA, severity and number of these hypoxic events positively correlate with the extent of associated cardiovascular pathology. The molecular mechanisms underlying intermittent hypoxia (IH)-driven cardiovascular disease in OSA, however, remain poorly understood-partly due to the lack of adequate experimental models. Here, we present a novel experimental approach that utilizes primary human endothelial cells cultivated under shear stress. Oxygen partial pressure dynamics were adopted in our in vitro model according to the desaturation-reoxygenation patterns identified in polysomnographic data of severe OSA patients (n = 10, with 892 severe desaturations, SpO₂<80%). Using western blot analysis, we detected a robust activation of the two major inflammatory pathways ERK and NF-κB in endothelial cells, whereas no HIF1α and HIF2α protein stabilization was observed. In line with these findings, mRNA and protein expression of the pro-inflammatory adhesion and signaling molecule ICAM-1 and the chemokine CCL2 were significantly increased. Hence, we established a novel in vitro model for deciphering OSA-elicited effects on the vascular endothelium. First data obtained in this model point to the endothelial activation of pro-inflammatory rather than hypoxia-associated pathways in OSA. Future studies in this model might contribute to the development of targeted strategies against OSA-induced, secondary cardiovascular disease.

Obstructive Sleep Apnea: A Look towards Micro-RNAs as Biomarkers of the Future

Sleep-disordered breathing (SDB) includes a broad spectrum of diseases, of which obstructive sleep apnea syndrome (OSA) is the most clinically significant manifestation. OSA is a respiratory disorder characterized by episodes of complete or partial obstruction of the upper airways that disturb ventilation and sleep architecture. In recent years, interest in the clinical implications of OSA seems to have increased, probably due to the numerous studies that have shown the existence of an important correlation between OSA and cardiovascular, dysmetabolic, and neoplastic changes. The guidelines currently available highlight the importance of diagnosis and effective treatment for OSA, underlining the need for new biomarkers that are useful in clinical practice, feasible, and reproducible to guide medical decision making. In this review, we intend to provide an overview of the potential role of microRNAs as new indicators for OSA management. MicroRNAs (miRNAs) are small non-coding RNA molecules that play an important role in RNA silencing and regulation of gene expression at the post-transcriptional level. These can bind specifically to their target genes by forming silencing complexes, thus inducing degradation or altered gene expression. A wide range of miRNAs have been extensively studied in a variety of diseases including cancer, and recently, miRNAs have been shown to have enormous potential to function as diagnostic and clinical biomarkers of disease. This review includes recent studies that establish the inevitable role of miRNAs in the pathogenesis of OSA.

Experimental Modeling of Damaging and Protective Hypoxia of the Mammalian Brain

Currently, there is a new surge of interest in the problem of hypoxia, almost lost in recent decades. Due to the fact that the circle of competent specialists in this field has significantly narrowed, it is necessary to carry out an intensive exchange of knowledge. In order to inform a wide range of interested researchers and doctors, this review summarizes the current understanding of hypoxia, its pathogenic and adaptogenic consequences, as well as key physiological and molecular mechanisms that implement the response to hypoxia at various levels-from cellular to organismic. The review presents a modern classification of forms of hypoxia, the understanding of which is necessary for the formation of a scientifically based approach to experimental modeling of hypoxic states. An analysis of the literature covering the history and current level of hypoxia modeling in mammals and human experiments, including methods for creating moderate hypoxia used to increase the resistance of the nervous system to severe forms of hypoxia and other extreme factors, is carried out. Special attention is paid to the discussion of the features and limitations of various approaches to the creation of hypoxia, as well as the disclosure of the potential for the practical application of moderate hypoxic effects in medicine.

Carbonic Anhydrase IX as a Marker of Disease Severity in Obstructive Sleep Apnea

Background and Objectives: Carbonic anhydrase (CA) enzymes are a family of metalloenzymes that contain a zinc ion in their active sites. CA enzymes have been implied in important situations such as CO2 transport, pH regulation, and oncogenesis. CA-IX is a transmembrane glycoprotein and stimulates the expression of hypoxia-inducible factor-1 (HIF-1) CA-IX. This study aimed to determine serum CA-IX levels in OSA patients in whom intermittent hypoxia is important and to investigate the relationship between serum CA-IX levels and disease severity. Materials and Methods: The study included 88 people who applied to Malatya Turgut Özal University Training and Research Hospital Sleep Disorders Center without a history of respiratory disease, malignancy, and smoking. Patients were divided into three groups: control (AHI < 5, n = 31), mild−moderate OSA (AHI = 5−30, n = 27) and severe OSA (AHI > 30, n = 30). The analysis of the data included in the research was carried out with the SPSS (IBM Statistics 25, NY, USA). The Shapiro−Wilk Test was used to check whether the data included in the study had a normal distribution. Comparisons were made with ANOVA in multivariate groups and the t-test in bivariate groups. ANCOVA was applied to determine the effect of the CA-IX parameter for OSA by controlling the effect of independent variables. The differentiation in CA-IX and OSA groups was analyzed regardless of BMI, age, gender, and laboratory variables. ROC analysis was applied to determine the parameter cut-off point. Sensitivity, specificity, and cut-off were calculated, and the area under the curve (AUC) value was calculated. Results: Serum CA-IX levels were 126.3 ± 24.5 pg/mL in the control group, 184.6 ± 59.1 pg/mL in the mild−moderate OSA group, and 332.0 ± 39.7 pg/mL in the severe OSA group. Serum CA-IX levels were found to be higher in the severe OSA group compared to the mild−moderate OSA group and control group and higher in the mild−moderate OSA group compared to the control group (p < 0.001, p < 0.001, p < 0.001, respectively). In addition, a negative correlation between CA-IX and minimum SaO2 and mean SaO2 (r = −0.371, p = 0.004; r = −0.319, p = 0.017, respectively). A positive correlation between CA-IX and desaturation index (CT90) was found (r = 0.369, p = 0.005). A positive correlation was found between CA-IX and CRP (r = 0.340, p = 0.010). When evaluated by ROC curve analysis, the area under the curve (AUC) value was determined as 0.940 (95% CI 0.322−0.557; p < 0.001). When the cut-off value for CA-IX was taken as 254.5 pg/mL, it was found to have 96.7% sensitivity and 94.8% specificity in demonstrating severe OSA. Conclusions: Our study found that serum CA-IX value was higher in OSA patients than in control patients, and this elevation was associated with hypoxemia and inflammation. CA-IX value can be a fast, precise, and useful biomarker to predict OSA.

The impact of macrophages on endothelial cells is potentiated by cycling hypoxia: Enhanced tumor inflammation and metastasis

Cycling hypoxia (cyH), neo-angiogenesis, and tumor-associated macrophages are key features of the tumor microenvironment. In this study, we demonstrate that cyH potentiates the induction by unpolarized and M1-like macrophages of endothelial inflammatory phenotype and adhesiveness for monocytes and cancer cells. This process triggers a positive feedback loop sustaining tumor inflammation. This work opens the door for innovative therapeutic strategies to treat tumor inflammation and metastasis.

In cancers, the interaction between macrophages and endothelial cells (ECs) regulates tumor inflammation and metastasis. These cells are both affected by cycling hypoxia (cyH), also called intermittent hypoxia, a feature of the tumor microenvironment. cyH is also known to favor tumor inflammation and metastasis. Nonetheless, the potential impact of cyH on the dialog between macrophages and ECs is still unknown. In this work, the effects of unpolarized, M1-like, and M2-like macrophages exposed to normoxia, chronic hypoxia (chH), and cyH on endothelial adhesion molecule expression, pro-inflammatory gene expression, and EC adhesiveness for monocytes and cancer cells were investigated. cyH increased the ability of unpolarized and M1-like macrophages to induce EC inflammation and to increase the expression of the EC endothelial adhesion molecule ICAM1, respectively. Unpolarized, M1-like, and M2-like macrophages were all able to promote EC adhesive properties toward cancer cells. Furthermore, the ability of macrophages (mostly M1-like) to shift EC phenotype toward one allowing cancer cell and monocyte adhesion onto ECs was potentiated by cyH. These effects were specific to cyH because they were not observed with chH. Together, these results show that cyH amplifies the effects of macrophages on ECs, which may promote tumor inflammation and metastasis.

The Role of Inflammation in Cognitive Impairment of Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) has become a major worldwide public health concern, given its global prevalence. It has clear links with multiple comorbidities and mortality. Cognitive impairment is one related comorbidity causing great pressure on individuals and society. The clinical manifestations of cognitive impairment in OSAS include decline in attention/vigilance, verbal–visual memory loss, visuospatial/structural ability impairment, and executive dysfunction. It has been proven that chronic intermittent hypoxia (CIH) may be a main cause of cognitive impairment in OSAS. Inflammation plays important roles in CIH-induced cognitive dysfunction. Furthermore, the nuclear factor kappa B and hypoxia-inducible factor 1 alpha pathways play significant roles in this inflammatory mechanism. Continuous positive airway pressure is an effective therapy for OSAS; however, its effect on cognitive impairment is suboptimal. Therefore, in this review, we address the role inflammation plays in the development of neuro-impairment in OSAS and the association between OSAS and cognitive impairment to provide an overview of its pathophysiology. We believe that furthering the understanding of the inflammatory mechanisms involved in OSAS-associated cognitive impairment could lead to the development of appropriate and effective therapy.

Intermittent hypoxia enhances the expression of hypoxia inducible factor HIF1A through histone demethylation

The cellular response to hypoxia is regulated through enzymatic oxygen sensors, including the prolyl hydroxylases, which control degradation of the well-known hypoxia inducible factors (HIFs). Other enzymatic oxygen sensors have been recently identified, including members of the KDM histone demethylase family. Little is known about how different oxygen-sensing pathways interact and if this varies depending on the form of hypoxia, such as chronic or intermittent. In this study, we investigated how two proposed cellular oxygen-sensing systems, HIF-1 and KDM4A, KDM4B, and KDM4C, respond in cells exposed to rapid forms of intermittent hypoxia (minutes) and compared to chronic hypoxia (hours). We found that intermittent hypoxia increases HIF-1α protein through a pathway distinct from chronic hypoxia, involving the KDM4A, KDM4B, and KDM4C histone lysine demethylases. Intermittent hypoxia increases the quantity and activity of KDM4A, KDM4B, and KDM4C, resulting in a decrease in histone 3 lysine 9 (H3K9) trimethylation near the HIF1A locus. We demonstrate that this contrasts with chronic hypoxia, which decreases KDM4A, KDM4B, and KDM4C activity, leading to hypertrimethylation of H3K9 globally and at the HIF1A locus. Altogether, we found that demethylation of histones bound to the HIF1A gene in intermittent hypoxia increases HIF1A mRNA expression, which has the downstream effect of increasing overall HIF-1 activity and expression of HIF target genes. This study highlights how multiple oxygen-sensing pathways can interact to regulate and fine tune the cellular hypoxic response depending on the period and length of hypoxia.

Identification of arterial oxygen intermittency in oximetry data

In patients with kidney failure treated by hemodialysis, intradialytic arterial oxygen saturation (SaO₂) time series present intermittent high-frequency high-amplitude oximetry patterns (IHHOP), which correlate with observed sleep-associated breathing disturbances. A new method for identifying such intermittent patterns is proposed. The method is based on the analysis of recurrence in the time series through the quantification of an optimal recurrence threshold ([Formula: see text]). New time series for the value of [Formula: see text] were constructed using a rolling window scheme, which allowed for real-time identification of the occurrence of IHHOPs. The results for the optimal recurrence threshold were confronted with standard metrics used in studies of obstructive sleep apnea, namely the oxygen desaturation index (ODI) and oxygen desaturation density (ODD). A high correlation between [Formula: see text] and the ODD was observed. Using the value of the ODI as a surrogate to the apnea-hypopnea index (AHI), it was shown that the value of [Formula: see text] distinguishes occurrences of sleep apnea with great accuracy. When subjected to binary classifiers, this newly proposed metric has great power for predicting the occurrences of sleep apnea-related events, as can be seen by the larger than 0.90 AUC observed in the ROC curve. Therefore, the optimal threshold [Formula: see text] from recurrence analysis can be used as a metric to quantify the occurrence of abnormal behaviors in the arterial oxygen saturation time series.

Chronic intermittent hypoxia, a hallmark of obstructive sleep apnea, promotes 4T1 breast cancer development through endothelin-1 receptors

The association between obstructive sleep apnea (OSA) and cancer is still debated and data are scarce regarding the link between OSA and breast cancer progression. Since conclusive epidemiological studies require large sample sizes and sufficient duration of exposure before incident cancer occurrence, basic science studies represent the most promising approach to appropriately address the topic. Here we assessed the impact of intermittent hypoxia (IH), the major hallmark of OSA, on the development of breast cancer and explored the specific involvement of the endothelin signaling pathway. Original in vitro and in vivo models were used where 3D-spheroids or cultures of murine 4T1 breast cancer cells were submitted to IH cycles, and nude NMRI mice, orthotopically implanted with 4T1 cells, were submitted to chronic IH exposure before and after implantation. The role of the endothelin-1 in promoting cancer cell development was investigated using the dual endothelin receptor antagonist, macitentan. In vitro exposure to IH significantly increased 4T1 cell proliferation and migration. Meta-analysis of 4 independent in vivo experiments showed that chronic IH exposure promoted tumor growth, assessed by caliper measurement (overall standardized mean difference: 1.00 [0.45-1.55], p < 0.001), bioluminescence imaging (1.65 [0.59-2.71]; p < 0.01) and tumor weight (0.86 [0.31-1.41], p < 0.01), and enhanced metastatic pulmonary expansion (0.77 [0.12-1.42]; p = 0.01). Both in vitro and in vivo tumor-promoting effects of IH were reversed by macitentan. Overall, these findings demonstrate that chronic intermittent hypoxia exposure promotes breast cancer growth and malignancy and that dual endothelin receptor blockade prevents intermittent hypoxia-induced tumor development.

Macrophage polarization in hypoxia and ischemia/reperfusion: Insights into the role of energetic metabolism

Macrophages, the key cells of innate immunity, possess wide phenotypical and functional heterogeneity. In vitro studies showed that microenvironment signals could induce the so-called polarization of macrophages into two phenotypes: classically activated macrophages (M1) or alternatively activated macrophages (M2). Functionally, they are considered as proinflammatory and anti-inflammatory/pro-regenerative, respectively. However, in vivo studies into macrophage states revealed a continuum of phenotypes from M1 to M2 state instead of the clearly distinguished extreme phenotypes. An important role in determining the type of polarization of macrophages is played by energy metabolism, including the activity of oxidative phosphorylation. In this regard, hypoxia and ischemia that affect cellular energetics can modulate macrophage polarization. Here, we overview the data on macrophage polarization during metabolic shift-associated pathologies including ischemia and ischemia/reperfusion in various organs and discuss the role of energy metabolism potentially triggering the macrophage polarization.

Effects of Intermittent Hypoxia in Training Regimes and in Obstructive Sleep Apnea on Aging Biomarkers and Age-Related Diseases: A Systematic Review

Several studies have assessed the effects of intermittent hypoxia-normoxia training (IHNT), intermittent hypoxia-hyperoxia training (IHHT), and obstructive sleep apnea (OSA) on aging and age-related diseases in humans; however, the results remain contradictory. Therefore, this review aims to systematically summarize the available studies on the effects of IHNT, IHHT, and OSA on aging and age-related diseases. Relevant studies were searched from PubMed, Google Scholar, Cochrane Library databases, and through manual searching from reference lists of eligible studies. A total of 38 eligible studies were included in this systematic review. IHHT and IHNT provide positive effects on several age-related parameters including quality of life, cognitive and physical functions, plasma level of glucose and cholesterol/LDL, systolic blood pressure, red blood cells, and inflammation. Moreover, moderate intermittent hypoxia induces telomerase reverse transcriptase (TERT) activity and telomere stabilization, delays induction of senescence-associated markers expression and senescence-associated β-galactosidase, upregulates pluripotent marker (Oct4), activates a metabolic shift, and raises resistance to pro-apoptotic stimuli. On the contrary, intermittent hypoxia in OSA causes hypertension, metabolic syndrome, vascular function impairment, quality of life and cognitive scores reduction, advanced brain aging, increase in insulin resistance, plasma hydrogen peroxide, GSH, IL-6, hsCRP, leptin, and leukocyte telomere shortening. Thus, it can be speculated that the main factor that determines the direction of the intermittent hypoxia action is the intensity and duration of exposure. There is no direct study to prove that IHNT/IHHT actually increases life expectancy in humans. Therefore, further study is needed to investigate the actual effect of IHNT/IHHT on aging in humans.

Systematic Review Registration

www.crd.york.ac.uk/prospero, identifier CRD42022298499.

OSA and Chronic Respiratory Disease: Mechanisms and Epidemiology

Obstructive sleep apnea (OSA) is a highly prevalent disorder that has profound implications on the outcomes of patients with chronic lung disease. The hallmark of OSA is a collapse of the oropharynx resulting in a transient reduction in airflow, large intrathoracic pressure swings, and intermittent hypoxia and hypercapnia. The subsequent cytokine-mediated inflammatory cascade, coupled with tractional lung injury, damages the lungs and may worsen several conditions, including chronic obstructive pulmonary disease, asthma, interstitial lung disease, and pulmonary hypertension. Further complicating this is the sleep fragmentation and deterioration of sleep quality that occurs because of OSA, which can compound the fatigue and physical exhaustion often experienced by patients due to their chronic lung disease. For patients with many pulmonary disorders, the available evidence suggests that the prompt recognition and treatment of sleep-disordered breathing improves their quality of life and may also alter the course of their illness. However, more robust studies are needed to truly understand this relationship and the impacts of confounding comorbidities such as obesity and gastroesophageal reflux disease. Clinicians taking care of patients with chronic pulmonary disease should screen and treat patients for OSA, given the complex bidirectional relationship OSA has with chronic lung disease.

Endothelial Dysfunction and Cardiovascular Risk in Obstructive Sleep Apnea: A Review Article

Obstructive sleep apnea (OSA) is a respiratory condition during sleep caused by repeated pauses in breathing due to upper airway obstruction. It is estimated that OSA affects 30% of the population, but only 10% are well diagnosed due to the absence of a well-defined symptomatology and poor screening tools for early diagnosis. OSA is associated to an endothelial dysfunction inducing several biological responses such as hypoxia, hypercapnia and oxidative stress, among others. OSA also triggers respiratory, nervous, metabolic, humoral and immunity system activations that increase the possibility of suffering a cardiovascular (CV) disease. In this review, we expose different studies that show the relationship between OSA and endothelial dysfunction and its association with CV pathologies like hypertension, and we define the most well-known treatments and their limitations. Additionally, we describe the potential future directions in OSA research, and we report clinical features such as endothelial progenitor cell alterations that could act as biomarkers for the development of new diagnostic tools and target therapies.

A cross-sectional study of obstructive sleep apnea in patients with colorectal cancer

BACKGROUND

The association between colorectal cancer (CRC) and obstructive sleep apnoea (OSA) has been attracting increasing attention. several studies had confirmed that OSA increases the risk of CRC onset. However, the findings of studies on the morbidity of OSA in patients with CRC were unclear. Therefore, this study aimed to investigate the morbidity of OSA in patients with CRC as well as the association between the clinicopathological characteristics of OSA and CRC.

METHODS

A total of 414 patients with a pathological diagnosis of CRC from 1 January, 2020 to 30 December, 2020 were included in this study. Demographic characteristics, clinical information, and tumor characteristics of participants were collected; sleep was monitored using a wearable oximeter and via sleep quality questionnaire. The oxygen desaturation index (ODI) was used to classify OSA severity so that the diagnostic criteria for OSA were set based on the ODI as 0-5 (normal) and ≥5 (abnormal). After correcting for confounding factors, a logistic regression analysis was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) for the factors affecting the tumor lymph node stage (N stage).

RESULTS

A total of 402 patients with CRC were included in this study, including 225 (55.97%) men and 177 (44.03%) women. The mean ODI value of participants was 3.40±8.17. The morbidity of OSA among the patients with CRC having ODI ≥5 was 16.17%. A comparison between the normal and abnormal ODI value groups revealed that the high proportion of abnormal ODI was related to higher N stage (P<0.05). Logistic regression analysis revealed a correlation of ODI values and age to the N stage. Specifically, CRC patients with an abnormal ODI had a higher risk of lymph node metastasis compared to those with normal ODI (OR =1.915, 95% CI: 1.025 to 3.579). Moreover, patients with CRC aged ≥65 years had a higher risk of lymph node metastasis compared to those aged <65 years (OR =2.190, 95% CI: 1.163 to 4.125).

CONCLUSIONS

CRC patients with abnormal ODI are susceptible to OSA. Additionally, abnormal ODI and age ≥65 years are relevant factors for the N2 stage.

The Incidence of Cancer Is Increased in Hospitalized Adult Patients With Obstructive Sleep Apnea in China: A Retrospective Cohort Study

Background

The association between obstructive sleep apnea (OSA) and the incidence and mortality of cancer remain unclear, especially in Asian populations. Thus, this study was conducted to explore the relationship between OSA and the incidence and mortality of cancer in hospitalized patients.

Methods

This retrospective cohort study evaluated inpatients from Guangdong Provincial People’s Hospital for suspected OSA between January 2005 and December 2015. Cancer incidence, all-cause mortality, and cancer mortality and were determined using data from the hospital information system and Centers for Disease Control. Between-group comparisons were carried out by performing a chi-square test and analysis of variance. Kaplan–Meier analysis and the Cox proportional risk model were applied to investigate the association between OSA and cancer incidence and mortality.

Results

Of the 4,623 hospitalized patients included, 3,786 (81.9%) patients were diagnosed with OSA. After a median follow-up of 9.1 years (interquartile range, 9.79–11.44), the incidence of cancer was 6.6% (251/3,786), with lung cancer having the highest incidence at 1.6% (60/3,786). The mortality rate of OSA patients was higher than that of non-OSA patients (16.83% vs.12.78%, p=0.008), but the relationship between apnea-hypopnea index (AHI), oxygen saturation less than 90% (TSat90), and cancer mortality was not statistically significant (p>0.05).The mortality rate for all types of cancer was 2.8% (105/3,786), with lung cancer having the highest mortality rate at 0.8% (32/3,786). The cumulative incidence of cancer in the severe OSA group was 8.2%, which was higher than that in the normal, mild, and moderate OSA groups (P=0.010). Further, the Cox proportional risk regression model showed a progressive enhancement in the risk of cancer incidence as the AHI increased (adjusted hazard ratio [HR]: 1.009 [95% confidence interval (CI): 1.003–1.016], P=0.005). Based on subgroup analysis, the risk of cancer increased as the AHI increased in patients aged <65 years (adjusted HR: 1.019 [95% CI: 1.007–1.031], P=0.002). In addition, the cancer incidence was significantly higher in the severe OSA group than in the normal, mild, and moderate OSA groups (adjusted HR: 2.825 [95% CI: 1.358–5.878], P=0.019).

Conclusion

The incidence of cancer is higher in patients with OSA than in non-OSA patients and is significantly positively associated with the severity of OSA. Particularly, for OSA patients aged <65 years, lung cancer is the main cause of death in those with new-onset cancer. Mortality was higher in OSA patients than in non-OSA patients.

Cancer and obstructive sleep apnea: An updated meta-analysis

OBJECTIVE

The relationship between cancers and obstructive sleep apnea (OSA) has been discussed for decades. However, the previous meta-analysis led to opposite conclusions. To further investigate this controversial issue, we performed this systematic review and meta-analysis update.

METHODS

PubMed, Embase, and the Cochrane Library were systematically searched and studies on "cancer and OSA" were all included. Two reviewers independently searched articles, extracted data, and assessed the quality of included studies. Moreover, the overall incidence of cancer and OSA in corresponding populations was calculated.

RESULTS

Of the 1434 titles identified, 22 articles involving more than 32.1 million patients were included in this meta-analysis. An overall incidence of OSA positive individuals in cancer was 46 (95%CI, 27-67)%, and the prevalence of cancers in OSA patients reached 1.53 (95%CI, 1.01-2.31) times higher than non-OSA individuals.

CONCLUSION

This meta-analysis indicated that there was a high prevalence of OSA in cancer patients, and individuals with OSA were more likely to develop tumors, and the incidence was related to the severity of OSA.

Evaluation of Intraoperative End-Tidal Carbon Dioxide Change Relates to Length Hospitalisation in Peridiaphragmatic Surgery: A Pilot Study

Intraoperative evaluation is deeply changed using many new tools, both invasive and non-invasive. Peripheral oxygen saturation percentage (SpO2) is the more reliable method for a non-invasive monitoring of patient's blood oxygen concentration. Capnography (using end-tidal CO2 (EtCO2)) evaluation is an immediate and continuous non-invasive monitoring of carbon dioxide (CO2) in the breathing that provides important information on circulatory status and ventilation.Aim of this study is to perform a preliminary analysis of oxygen change during surgery exploring its possible influence on post-operative evolution.

METHODS AND RESULTS

Intraoperative evaluation of SpO2 and EtCO2 was performed. Change in each parameter was categorised as 1 point for each five-point variation from baseline value (∆SpO2 as 1 point for each 5%, ∆EtCO2 as 1 point for each 5 mmHg). For each patient, the length of stay (LOS) in the intensive care unit (ICU), total hospitalisation, duration of intervention, surgical risk and complications were recorded.

RESULTS

We analysed 93 consecutive patients (43 males and 40 females, aged 66.35 ± 9.79 years) that underwent peridiaphragmatic surgery. Forty patients (48.19%) presented complications after surgery. There was no statistically significant difference in age, duration of intervention and length of stay in ICU between complicated and non-complicated patients. As expected, patients with complications present an increased hospitalisation time compared to uncomplicated cases (14.69 ± 11.41 days vs 10.70 ± 6.28 days; p < 0.05). ∆EtCO2 was significantly increased (p < 0.05) in complicated compared to non-complicated. No differences were found in ∆SpO2 between the two groups. Considering the whole population, ∆EtCO2 presents a significant direct correlation to surgical risk, hospitalisation and duration of intervention.

CONCLUSION

∆EtCO2 may be related to possible complications after surgery and hospitalisation. An important comparison between SpO2 and EtCO2 and strict monitoring with an intraoperative arterial blood gas (ABG) sample during the main steps of surgery could bring some essential information to understand oxygen changes in intra- and post-operative evolution. However, a further validation analysis is needed before the approach can be used extensively in daily clinical settings.

The Association of Obstructive Sleep Apnea With Breast Cancer Incidence and Mortality: A Systematic Review and Meta-analysis

Purpose

Emerging evidence from animal models suggests that intermittent hypoxia due to obstructive sleep apnea (OSA) is a risk factor for breast cancer. Despite their biological plausibility, human epidemiological studies have reported conflicting results. Therefore, we conducted a meta-analysis to delineate this relationship.

Methods

We searched the PubMed, Embase, Scopus, and Cochrane Library databases for eligible studies from inception until June 6, 2021. Two reviewers selected randomized trials or observational studies reporting the association between OSA and breast cancer incidence compared with those without OSA. Two reviewers extracted relevant data and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and Newcastle-Ottawa Scale (NOS). We pooled the maximally covariate-adjusted hazard ratios (HRs) using a random-effects inverse variance-weighted meta-analysis and performed pre-specified subgroup analyses.

Results

We included six studies out of 1,707 records, comprising a combined cohort of 5,165,200 patients. All studies used the International Classification of Diseases codes to classify OSA and breast cancer. OSA patients had a 36% increased breast cancer risk (HR, 1.36; 95% confidence interval [CI], 1.03–1.80; N = 6, I² = 96%) compared to those without OSA. Most studies adjusted for confounders, such as age, sex, obesity, diabetes mellitus, alcohol use, and hypertension. Subgroup analyses for studies with (1) multivariate adjustment and (2) at least five years of follow-up yielded HRs of 1.35 (95% CI, 0.98–1.87; N = 5, I² = 96%) and 1.57 (95% CI, 1.14–2.18; N = 4; I² = 90%), respectively. One Mendelian randomization study suggested a causal relationship, with a two-fold increase in the odds of breast cancer in patients with OSA.

Conclusion

This meta-analysis suggested that OSA is a risk factor for breast cancer. Future studies should explore the dose-response relationship between OSA and breast cancer, and whether treatment may mitigate breast cancer risk or progression.

MiR-142-3p as an Indicator of OSA Severity Predicts Prognosis in Lung Adenocarcinoma with OSA

PURPOSE

The aim was to explore the correlation between Obstructive sleep apnea (OSA) and Lung adenocarcinoma malignant prognosis and evaluate the miR-142-3p was used as an OSA severity indicator to predict the prognosis of Lung adenocarcinoma patients.

METHODS

This study comprised of 21 diagnosed lung adenocarcinoma patients with or without OSA. The sleep-related variables and tumor pathology were recorded. Hypoxia-inducible factor-1α (HIF1α) and ki67 expression were analyzed by immunohistochemistry in tumor samples. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to assess the level of miR-142-3p.

RESULTS

Lung adenocarcinoma with OSA showed higher apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and the lower lowest pulse oxygen saturation (LS_PO₂) compared to Lung adenocarcinoma without OSA (P<0.05), and patients with severer OSA have an advanced TNM stage (P=0.004) and metastasis rate (p=0.032). In addition, OSA may down-regulate the miR-142-3p expression in patients with Lung adenocarcinoma, and the patients with low miR-142-3p expression exhibited severe OSA. MiR-142-3p levels significantly decreased in the advanced TNM stage (p=0.015), and the expression of miR-142-3p was negatively associated with AHI (r= -0.505, p=0.020), ODI (r= -0.513, p=0.017).

CONCLUSION

OSA severity may increase Lung adenocarcinoma malignant prognosis. OSA may down-regulate the expression of miR-42-3p. The expression of miR-142-3p was inversely correlated with AHI and ODI as a surrogate of OSA severity. Additionally, the low miR-142-3p expression level was significantly associated with advanced TNM stage in Lung adenocarcinoma patients.

Obstructive Sleep Apnea as an Acceleration Trigger of Cellular Senescence Processes through Telomere Shortening

Obstructive sleep apnea (OSA) is chronic disorder which is characterized by recurrent pauses of breathing during sleep which leads to hypoxia and its two main pathological sequelae: oxidative stress and chronic inflammation. Both are also associated with cellular senescence. As OSA patients present with higher prevalence of age-related disorders, such as atrial hypertension or diabetes mellitus type 2, a relationship between OSA and accelerated aging is observable. Furthermore, it has been established that these OSA are associated with telomere shortening. This process in OSA is likely caused by increased oxidative DNA damage due to increased reactive oxygen species levels, DNA repair disruptions, hypoxia, chronic inflammation, and circadian clock disturbances. The aim of the review is to summarize study outcomes on changes in leukocyte telomere length (LTL) in OSA patients and describe possible molecular mechanisms which connect cellular senescence and the pathophysiology of OSA. The majority of OSA patients are characterized by LTL attrition due to oxidative stress, hypoxia and inflammation, which make a kind of positive feedback loop, and circadian clock disturbance.

The association of obstructive sleep apnea with melanoma incidence and mortality: a meta-analysis of 5,276,451 patients

BACKGROUND

Melanoma is the most aggressive and lethal form of skin cancer. While emerging in-vivo evidence suggests that intermittent hypoxia, a hallmark feature of obstructive sleep apnea (OSA), may induce melanoma tumorigenesis, the epidemiological association between OSA and melanoma has been inconsistent.

METHODS

We performed a literature search of PubMed, Embase, Scopus and Cochrane Library from inception until 6 June 2021. Two reviewers independently selected randomized trials or observational studies that reported the association of OSA with melanoma incidence or mortality in adults, in comparison to participants with no OSA. Two reviewers independently extracted relevant data and assessed the quality of evidence using the GRADE framework and the Newcastle-Ottawa Scale (NOS). We pooled data using an inverse variance-weighted meta-analysis and ran pre-specified subgrourp analyses.

RESULTS

The meta-analysis included six studies out of 1897 records, comprising a combined cohort of 5,276,451 patients. All studies were adjusted for covariates, with majority of studies adjusting for age (N=5) and sex (N = 4). Compared to those without OSA, patients with OSA had 71% higher pooled hazards of melanoma (HR = 1.71; 95% CI: 1.08-2.69, I² = 99%). Subgroup analyses for studies with (1) median follow-up duration of at least five years, (2) prospective study design, (3) adjustment for obesity yielded HRs of 1.88 (95%CI:1.32-2.67, N = 5), 1.11 (95%CI:0.77-1.60, N = 2) and 1.52 (95%CI:0.75-3.08, N = 3) respectively. One study investigating the relationship between OSA and melanoma mortality detected no association. There were insufficient studies to assess publication bias.

CONCLUSIONS

Meta-analysis of mainly retrospective observational studies, with significant heterogeneity, suggests increased melanoma incidence in OSA patients. Future studies should prospectively explore the differential risk of melanoma for varying OSA severity, and whether timely OSA treatment may mitigate this risk.

Polysomnographic Markers of Obstructive Sleep Apnea Severity and Cancer-Related Mortality: A Large Retrospective Multicenter Clinical Cohort Study

RATIONALE

The evidence for an association between cancer survival and obstructive sleep apnea (OSA) remains under-explored.

OBJECTIVES

To evaluate an association between markers of OSA severity (respiratory disturbances, hypoxemia, and sleep fragmentation) and cancer-related mortality in individuals with previously diagnosed cancer.

METHODS

We conducted a multicenter retrospective 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 Canadian academic hospitals and were previously diagnosed with cancer through the Ontario Cancer Registry. Multivariable cause-specific Cox regressions were utilized to address the research objective.

RESULTS

We included 2,222 subjects. Over a median follow-up time of 5.6 years (IQR: 2.7-9.1), 261/2,222 (11.7%) individuals with prevalent cancer died from cancer-related causes, which accounted for 44.2% (261/590) of all-cause death. Controlling for age, sex, alcohol use disorder, prior heart failure, COPD, hypertension, diabetes, treatment for OSA, clinic site, year of the sleep study, and time since the cancer diagnosis, measures of hypoxemia and sleep fragmentation, but not apnea-hypopnea index were significantly associated with the cancer-specific mortality: % time spent with SaO2 <90% (HR per 5% increase: 1.05; 95% CI: 1.01-1.09); mean SaO2 (HR per 3% increase: 0.79; 0.68-0.92); and % of Stage 1 Sleep (HR per 16% increase: 1.27; 1.07-1.51).

CONCLUSION

In a large clinical cohort of adults with suspected OSA and previously diagnosed cancer, measures of nocturnal hypoxemia and sleep fragmentation as markers of OSA severity were significantly associated with cancer-related mortality, suggesting the need for more targeted risk awareness.

Interleukin-8 concentrations in obstructive sleep apnea syndrome: a systematic review and meta-analysis

Interleukin (IL)-8 has been shown to play an important role in obstructive sleep apnea syndrome (OSAS). However, its role in OSAS development is still controversial. This meta-analysis was to explore the correlation between interleukin (IL)-8 concentration and OSAS. Database (from the inception to July 2021) searches on PubMed, Web of Science, Medline, EMBASE, and Cochrane Library were conducted for studies analyzing the correlation between IL-8 concentration and OSAS, regardless of the language of publication. Standardized mean difference (SMD) and 95% confidence intervals (CI) were used to analyze any prospective association between IL-8 concentration and OSAS. A total of 25 eligible studies, including 2301 participants and 1123 controls, were included in this meta-analysis. The included studies evaluating the association between serum IL-8 concentration and OSAS indicated that adults and children with OSAS had elevated serum concentrations of IL-8 compared with controls (SMD = 0.997, 95% CI = 0.437–1.517, P < 0.001; SMD = 0.431, 95% CI = 0.104–0.759, P = 0.01). Categorization of the study population into subgroups according to body mass index, apnea–hypopnea index (AHI), ethnicity, and sample size also showed that individuals with OSAS had elevated serum concentrations of IL-8 compared with controls. Additionally, the results demonstrated that the higher the AHI, higher was the IL-8 concentration. Similar results were observed in the literature on the association between plasma IL-8 concentration and OSAS. This meta-analysis verified that compared with controls, children and adults with OSAS have significantly elevated IL-8 concentrations.

Does timing matter in radiotherapy of hepatocellular carcinoma? An experimental study in mice

This study investigates whether a chronotherapeutic treatment of hepatocellular carcinoma (HCC) may improve treatment efficacy and mitigate side effects on non-tumoral liver (NTL). HCC was induced in Per2::luc mice which were irradiated at four time points of the day. Proliferation and DNA-double strand breaks were analyzed in irradiated and nonirradiated animals by detection of Ki67 and γ-H2AX. Prior to whole animal experiments, organotypic slice cultures were investigated to determine the dosage to be used in whole animal experiments. Irradiation was most effective at the proliferation peaks in HCC at ZT02 (early inactivity phase) and ZT20 (late activity phase). Irradiation effects on NTL were minimal at ZT20. As compared with NTL, nonirradiated HCC revealed disruption in daily variation and downregulation of all investigated clock genes except Per1. Irradiation affected rhythmic clock gene expression in NTL and HCC at all ZTs except at ZT20 (late activity phase). Irradiation at ZT20 had no effect on total leukocyte numbers. Our results indicate ZT20 as the optimal time point for irradiation of HCC in mice at which the ratio between efficacy of tumor treatment and toxic side effects was maximal. Translational studies are now needed to evaluate whether the late activity phase is the optimal time point for irradiation of HCC in man.

Sleep-disordered breathing and risk of the breast cancer: A meta-analysis of cohort studies

BACKGROUND

Sleep-disordered breathing (SDB) has been related to a higher risk of breast cancer whereas the results of previous studies are inconsistent. We, therefore, performed a meta-analysis to evaluate the association between SDB and subsequent risk of breast cancer in women.

METHODS

Cohort studies that investigated the temporal relationship between SDB and breast cancer incidence were obtained via search of PubMed, Embase and Web of Science from inception to 30 January 2021. Only studies with multivariate analyses were included. A fixed or a randomised effect model was applied according to the heterogeneity.

RESULTS

Eight cohort studies with 1 398 113 women were included. Pooled results with a randomised-effect model showed that compared with women without SDB at baseline, women with SDB had a significantly increased risk of breast cancer (risk ratio [RR]: 1.36, 95% confidence interval [CI]: 1.08 to 1.71, P = .01) with significant heterogeneity (P for Cochrane's Q test < .001, I²  = 95%). Subgroup analyses showed that SDB seemed to confer a more remarkably increased risk of breast cancer in elderly women (RR: 3.00, 95% CI: 1.33 to 6.76, P = .008) than that in non-elderly women (RR: 1.15, 95% CI: 1.02 to 1.29, P = .02; P for subgroup difference = .04). However, the association was not significantly affected by country of the study, study design, diagnostic strategy for SDB or adjustment of obesity (P for subgroup analyses all > .05).

CONCLUSIONS

SDB may be an independent risk factor for breast cancer in women, particularly in elderly females.

Intergenic SNPs in Obstructive Sleep Apnea Syndrome: Revealing Metabolic, Oxidative Stress and Immune-Related Pathways

There is strong evidence supporting the contribution of genetic factors to obstructive sleep apnea syndrome (OSAHS) susceptibility. In the current study we analyzed both in a clinical cohort and in silico, four single nucleotide polymorphisms SNPs, rs999944, rs75108997, rs35329661 and rs116133558 that have been associated with OSAHS. In 102 patients with OSAHS and 50 healthy volunteers, genetic testing of the above polymorphisms was performed. Polymorphism rs116133558 was invariant in our study population, whereas polymorphism rs35329661 was more than 95% invariant. Polymorphism rs999944 displayed significant (>5%) variance in our study population and was used in the binary logistic regression model. In silico analyses of the mechanism by which these three SNPs may affect the pathophysiology of OSAHS revealed a transcriptomic network of 274 genes. This network was involved in multiple cancer-associated gene signatures, as well as the adipogenesis pathway. This study, uncover a regulatory network in OSAHS using transcriptional targets of intergenic SNPs, and map their contributions in the pathophysiology of the syndrome on the interplay between adipocytokine signaling and cancer-related transcriptional dysregulation.