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Stepney D, Attarian HP, Knutson KL. Association between severity of obstructive sleep apnea and its common symptoms varies by race, ethnicity, and sex. J Clin Sleep Med 2023; 19:1727-1733. [PMID: 37786380 PMCID: PMC10545998 DOI: 10.5664/jcsm.10660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 10/04/2023]
Abstract
STUDY OBJECTIVES The US Preventive Services Task Force recently released guidelines suggesting little evidence of benefit to screening asymptomatic adults for obstructive sleep apnea (OSA). Our goal was to provide important context to this statement. Specifically, we examined associations between common OSA symptoms, excessive daytime sleepiness and snoring, and OSA severity for different racial/ethnic and sex groups. METHODS Analyses were performed on 2 samples. One combined 2 observational studies that included full polysomnography, the Epworth Sleepiness Scale (ESS), and questions about snoring (mean [standard deviation] age 39 [15.2] years). The second sample was the Multi-Ethnic Study of Atherosclerosis study of older adults (mean [standard deviation] age 69 [9.1] years), which also included polysomnography, ESS and a question about snoring. Apnea-hypopnea index represented OSA severity. For each racial/ethnic-sex group we estimated correlations between apnea-hypopnea index and ESS and the sensitivity and specificity of excessive daytime sleepiness (ESS >10) or frequent snoring to predict moderate-to-severe OSA (apnea-hypopnea index >15 events/h). RESULTS A weak significant correlation between OSA severity and ESS was found only in White men in the first sample and Black men in the second sample. Screening tool characteristics for ESS and snoring were poor except for moderate specificity in some racial/ethnic-sex groups. CONCLUSIONS Excessive daytime sleepiness and snoring are commonly used to identify symptomatic patients. Our results suggest that the accuracy of these symptoms to identify OSA varies by race/ethnicity and sex. Therefore, focus on common symptoms as an OSA screen could systematically leave out certain patient populations who would benefit from treatment. CITATION Stepney D, Attarian HP, Knutson KL. Association between severity of obstructive sleep apnea and its common symptoms varies by race, ethnicity, and sex. J Clin Sleep Med. 2023;19(10):1727-1733.
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Affiliation(s)
- David Stepney
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hrayr P. Attarian
- Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristen L. Knutson
- Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Anderson DJ, Aucoin A, Toups CR, Cormier D, McDonald M, Hasoon J, Viswanath O, Kaye AD, Urits I. Lower Urinary Tract Symptoms in Depression: A Review. Health Psychol Res 2023; 11:81040. [PMID: 37465591 PMCID: PMC10351871 DOI: 10.52965/001c.81040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Lower Urinary Tract Symptoms (LUTS) are frequently present in the general population as patients age with approximately a third of individuals experiencing LUTS during their lifetime. LUTS can be further defined as having any of the following symptoms: urinary hesitancy, straining, nocturia, increased urination frequency, and dysuria. LUTS has the potential for patients to contribute their symptoms to what can normally occur as we age. This can lead to a decrease in patients seeking care and could negatively impact patients' health-related quality of life (HRQL). In conjunction with LUTS, we obtained from our analysis that LUTS and depression are closely related and worsening depressive symptoms may increase the severity of LUTS. We also discerned three categories of factors that can yield major depression namely adversity, internalizing, and externalizing factors. Within these categories, trauma, social support, genetic factors, and minimal education appeared to increase the risk of depression in patients. With the recent increase in mental health awareness and more access to mental health care amid the COVID-19 Pandemic, further screening, and collaboration between providers to treat both urological and psychiatric symptoms could improve patient outcomes. It is important for providers to have an increased understanding of the mental and physical impact both LUTS and depression can have on patients' wellbeing. This has the potential to help patients be more open about their symptoms with the aim of better addressing LUTS and depression to positively impact their HRQL.
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Affiliation(s)
| | - Alise Aucoin
- Department of Anesthesiology Louisiana State University Health
| | - Colton R Toups
- Department of Anesthesiology Louisiana State University Health
| | - Devin Cormier
- Department of Anesthesiology Louisiana State University Health
| | | | - Jamal Hasoon
- Department of Anesthesia, Critical Care, and Pain Medicine Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Omar Viswanath
- Department of Anesthesia, Critical Care, and Pain Medicine Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Alan D Kaye
- Department of Anesthesiology Louisiana State University Health
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Chen YC, Lin IC, Su MC, Hsu PY, Hsiao CC, Hsu TY, Liou CW, Chen YM, Chin CH, Wang TY, Chang JC, Lin YY, Lee CP, Lin MC. Autophagy impairment in patients with obstructive sleep apnea modulates intermittent hypoxia-induced oxidative stress and cell apoptosis via hypermethylation of the ATG5 gene promoter region. Eur J Med Res 2023; 28:82. [PMID: 36805797 PMCID: PMC9936724 DOI: 10.1186/s40001-023-01051-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/07/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Autophagy is a catabolic process that recycles damaged organelles and acts as a pro-survival mechanism, but little is known about autophagy dysfunction and epigenetic regulation in patients with obstructive sleep apnea (OSA). METHODS Protein/gene expressions and DNA methylation levels of the autophagy-related genes (ATG) were examined in blood leukocytes from 64 patients with treatment-naïve OSA and 24 subjects with primary snoring (PS). RESULTS LC3B protein expression of blood monocytes, and ATG5 protein expression of blood neutrophils were decreased in OSA patients versus PS subjects, while p62 protein expression of cytotoxic T cell was increased, particularly in those with nocturia. ATG5, ULK1, and BECN1 gene expressions of peripheral blood mononuclear cells were decreased in OSA patients versus PS subjects. LC3B gene promoter regions were hypermethylated in OSA patients, particularly in those with excessive daytime sleepiness, while ATG5 gene promoter regions were hypermethylated in those with morning headache or memory impairment. LC3B protein expression of blood monocytes and DNA methylation levels of the LC3B gene promoter region were negatively and positively correlated with apnea hyponea index, respectively. In vitro intermittent hypoxia with re-oxygenation exposure to human THP-1/HUVEC cell lines resulted in LC3B/ATG5/ULK1/BECN1 down-regulations and p62 up-regulation along with increased apoptosis and oxidative stress, while rapamycin and umbilical cord-mesenchymal stem cell treatment reversed these abnormalities through de-methylation of the ATG5 gene promoter. CONCLUSIONS Impaired autophagy activity in OSA patients was regulated by aberrant DNA methylation, correlated with clinical phenotypes, and contributed to increased cell apoptosis and oxidative stress. Autophagy enhancers may be novel therapeutics for OSA-related neurocognitive dysfunction.
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Affiliation(s)
- Yung-Che Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301, Taiwan. .,Department of Medicine, College of Medicine, Chang Gung University, Taouyan, 33302, Taiwan. .,Sleep Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301, Taiwan.
| | - I-Chun Lin
- grid.145695.a0000 0004 1798 0922Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, 83301 Taiwan
| | - Mao-Chang Su
- grid.145695.a0000 0004 1798 0922Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan ,grid.145695.a0000 0004 1798 0922Sleep Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan ,grid.418428.3Chang Gung University of Science and Technology, Chiayi, 61363 Taiwan
| | - Po-Yuan Hsu
- grid.145695.a0000 0004 1798 0922Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan
| | - Chang-Chun Hsiao
- grid.145695.a0000 0004 1798 0922Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan ,grid.145695.a0000 0004 1798 0922Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taouyan, 33302 Taiwan
| | - Te-Yao Hsu
- grid.145695.a0000 0004 1798 0922Department of Obstetrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, 83301 Taiwan
| | - Chia-Wei Liou
- grid.145695.a0000 0004 1798 0922Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, 83301 Taiwan
| | - Yu-Mu Chen
- grid.145695.a0000 0004 1798 0922Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan ,grid.145695.a0000 0004 1798 0922Sleep Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan
| | - Chien-Hung Chin
- grid.145695.a0000 0004 1798 0922Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan ,grid.145695.a0000 0004 1798 0922Sleep Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan
| | - Ting-Ya Wang
- grid.145695.a0000 0004 1798 0922Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan
| | - Jen-Chieh Chang
- grid.413804.aGenomics and Proteomics Core Lab, Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 83301 Taiwan
| | - Yong-Yong Lin
- grid.145695.a0000 0004 1798 0922Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan
| | - Chiu-Ping Lee
- grid.145695.a0000 0004 1798 0922Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301 Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301, Taiwan. .,Department of Medicine, College of Medicine, Chang Gung University, Taouyan, 33302, Taiwan. .,Sleep Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Ta-Pei Rd, Niao-Sung District, Kaohsiung, 83301, Taiwan.
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Votteler S, Knaack L, Janicki J, Fink GR, Burghaus L. Sex differences in polysomnographic findings in patients with obstructive sleep apnea. Sleep Med 2023; 101:429-436. [PMID: 36516599 DOI: 10.1016/j.sleep.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/23/2022] [Accepted: 11/25/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Sex differences in the clinical findings and the polysomnographic presentation of patients with obstructive sleep apnea (OSA) are compelling current research issues. For example, patients suffering from obstructive sleep apnea are predominantly male. While women are older than men and tend to have a higher body mass index, men typically present with a more severe form of obstructive sleep apnea. Using polysomnography, we investigated a German cohort, subdivided per severity levels of obstructive sleep apnea (apnea-hypopnea index: ≥5 to < 15/h (mild), ≥15 to < 30/h (moderate), and ≥30/h (severe)) to provide a detailed analysis of breathing and sleep parameters, accounting for body position effects and severity of illness. A deeper understanding of sex differences may allow targeted diagnosis and treatment adjustment. PATIENTS AND METHODS This retrospective study included a cohort of 1242 German patients (940 male, 302 female) who underwent overnight polysomnography at the private sleep laboratory "Intersom Köln", Center for Sleep Medicine and Sleep Research. In 1125 subjects (878 male, 247 female), obstructive sleep apnea was diagnosed. All patients were examined between January 01, 2018 and December 31, 2020, comparing anthropometric, sleep morphological, and respiratory polysomnographic findings. RESULTS Female patients with obstructive sleep apnea were significantly older than male patients (60.9 ± 12.3 vs. 56.9 ± 12.5 years, P < .001), also among OSA subgroups per OSA severity. The body mass index was similar in male and female patients (29.6 ± 5.1 vs. 29.2 ± 7.3 kg/m2, P > .05), including the three subgroups. Men were more likely to have severe obstructive sleep apnea (46.9%) than women (35.2%). Women exhibited a higher proportion of slow-wave sleep than men (129.4 ± 52.8 vs. 104.2 ± 53.2 min; P < .001). The apnea-hypopnea index of total sleep time was significantly greater in male than female patients (32.9 ± 21.2 vs. 27.2 ± 20.2 per hour; P < .001). Female patients had a higher apnea-hypopnea index during rapid-eye-movement (REM) sleep (34.0 ± 23.8 vs. 31.8 ± 22.3 per hour; P = .171). A statistically significant difference in the apnea-hypopnea index during REM sleep between sexes was found when the obstructive sleep apnea severity was considered. Women had a lower apnea-hypopnea index in non-rapid eye-movement (NREM) sleep than men (25.7 ± 21.1 vs. 32.7 ± 22.3 per hour; P < .001). The oxygen desaturation index (29.9 ± 20.3 vs. 22.4 ± 19.4%; P < .001) and an oxygen desaturation below 90% (9.4 ± 14.0 vs. 6.8 ± 11.7%; P = .003) was greater in men than in women. In severe obstructive sleep apnea, the oxygen desaturation index was similar between the sexes (45.0 ± 17.8 vs. 41.1 ± 20.9%; P = .077). Male patients showed a higher supine apnea-hypopnea-index than female patients. (45.7 ± 26.7 vs 36.1 ± 22.7 per hour; P < .001). CONCLUSION The present noninvasive, retrospective registry study is the first to examine sex differences in OSA in such a large German population in terms of respiratory and sleep parameters, taking into account the effects of body position and severity of the disease. We could confirm and extend observations from previous studies. Female patients were significantly older than the male patients. The apnea-hypopnea index was higher in male than in female patients. Women showed a higher apnea-hypopnea index in REM sleep and a lower one in NREM sleep. Men were desaturated more often and were more affected by supine-dependent obstructive sleep apnea than women. Contrary to the literature, there were no significant differences in body mass index (BMI) between the sexes. With increasing age and BMI, the gender differences become less significant.
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Affiliation(s)
- Sinje Votteler
- Sleep Laboratory "Intersom Köln" Center for Sleep Medicine and Sleep Research, Im Mediapark 4D, Cologne, 50670, Germany; Department of Neurology, Faculty of Medicine and University Hospital, Cologne, 50937, Germany.
| | - Lennart Knaack
- Sleep Laboratory "Intersom Köln" Center for Sleep Medicine and Sleep Research, Im Mediapark 4D, Cologne, 50670, Germany.
| | - Jaroslaw Janicki
- Sleep Laboratory "Intersom Köln" Center for Sleep Medicine and Sleep Research, Im Mediapark 4D, Cologne, 50670, Germany.
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine and University Hospital, Cologne, 50937, Germany; Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich, Jülich, 52428, Germany.
| | - Lothar Burghaus
- Department of Neurology, Faculty of Medicine and University Hospital, Cologne, 50937, Germany; Department of Neurology, Heilig-Geist-Hospital, Graseggerstraße 105, Cologne, Germany.
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Ahmad T, Khan M, Al-Omari B. Mapping the global literature output on nocturia: A bibliometric and visualized analysis. Medicine (Baltimore) 2022; 101:e29455. [PMID: 35945764 PMCID: PMC9351897 DOI: 10.1097/md.0000000000029455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE This study aims to facilitate researchers' and clinicians' understanding of research frontiers and trends in nocturia. It explores the scientific research outcomes and key bibliometric indices and plots global research on nocturia. METHODS A bibliometric retrospective study was designed, and an online search was conducted in the Web of Science Core Collection database using the potential search keywords related to nocturia in the title field with some specific filtration. HistCite™ and VOSviewer software for windows were used to analyze the data obtained for authors, journals, countries, institutions, keywords, and visualization mapping. RESULTS The initial search retrieved 1479 hits. A total of 1445 publications were included in the final analysis. Of these, 43.53% were published as articles. The most studied area in nocturia is urology nephrology. The most productive year was 2019 (n = 121, citations = 335), and the most prolific author, both in terms of publications (n = 97) and citations (1658) was Weiss JP. The most cited journal in nocturia research was the Journal of Urology (n = 293, citations = 3050). The most widely used keyword in nocturia publications was nocturia (n = 1249). Visualization mapping shows that the USA was the most influential and highly cited country in nocturia research. CONCLUSION This study showed that there has been an increasing research trend in nocturia over the past few years. The current findings provide important empirical evidence for researchers, clinicians, and physicians to understand research frontiers and trends, achievements, collaborative networks, and hotspot research topics in the research field of nocturia.
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Affiliation(s)
- Tauseef Ahmad
- Department of Epidemiology and Health Statistics, School of Public Health, Southeast University, Nanjing 210096, China
- Vanke School of Public Health, Tsinghua University, Beijing 100084, China
| | - Muhammad Khan
- Department of Biotechnology and Genetic Engineering, Hazara University, Mansehra, 21120, Khyber Pakhtunkhwa, Islamic Republic of Pakistan
| | - Basem Al-Omari
- Department of Epidemiology and Population Health, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
- KU Research and Data Intelligence Support Center (RDISC) AW 8474000331, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- *Correspondence: Basem Al-Omari, Department of Epidemiology and Population Health, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates (e-mail: )
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Chung YH, Kim JR, Choi SJ, Joo EY. Prevalence and predictive factors of nocturia in patients with obstructive sleep apnea syndrome: A retrospective cross-sectional study. PLoS One 2022; 17:e0267441. [PMID: 35476719 PMCID: PMC9045637 DOI: 10.1371/journal.pone.0267441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/09/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives Many patients with obstructive sleep apnea syndrome (OSAS) have nocturia. However, the predictive index of nocturia in patients with OSAS is currently not well known. We aimed to investigate the prevalence of nocturia in patients with OSAS and determine the factors that could predict nocturia in these patients. Methods In this retrospective cross-sectional study, we enrolled 1,264 untreated patients with OSAS (Apnea-Hypopnea Index, AHI ≥5/h on polysomnography [PSG]) from January 2017 to January 2020. Participants completed the Beck Depression Inventory-II (BDI-II), Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and Epworth Sleepiness Scale. Participants were divided by sex and then subdivided into nocturia and non-nocturia groups according to the following question, “Do you go to the bathroom two times or more during your sleep?” Participants’ characteristics and underlying disease were investigated, and all information, including PSG data, was compared between the two groups using the t-test or chi-square test. Results Overall, 35.2% (337/958) of male participants with OSAS and 59.8% (183/306) of female participants with OSAS had nocturia. The nocturia group was older; scored higher on the BDI-II, PSQI, and ISI; and had more underlying disease in both sexes. There was no difference in the AHI between the two groups among both sexes, but the hypoxia-related PSG parameters and sleep quality parameters, such as higher 90% oxygen desaturation index (90% ODI), lesser N3 sleep, and higher wakefulness after sleep onset, were worse among male participants with OSAS in the nocturia group than in the non-nocturia group. In multivariate logistic analysis, 90% ODI was an independent risk factor associated with nocturia in male participants with OSAS. Conclusions Considerable number of patients with OSAS had nocturia and poor sleep quality. Nocturia should be evaluated in male OSAS patients with severe hypoxia observed during sleep.
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Affiliation(s)
- Yeon Hak Chung
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Rim Kim
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Su Jung Choi
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Graduate School of Clinical Nursing Science, Sungkyunkwan University, Seoul, Korea
| | - Eun Yeon Joo
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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