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Momcilovic D, Reznakova B, Bosse F, Begrich C, Bernhardt C, Hamiko M, Bakhtiary F, Nickenig G, Skowasch D, Pizarro C. Sleep-disordered breathing and lung function abnormalities in adults with congenital heart disease. Sleep Breath 2024; 28:241-250. [PMID: 37552390 PMCID: PMC10954938 DOI: 10.1007/s11325-023-02899-w] [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: 01/05/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE Advances in treatment enables most patients with congenital heart diseases (CHD) to survive into adulthood, implying the need to address comorbid conditions in this growing cohort of patients. The aim of this study was to evaluate the prevalence of sleep-disordered breathing (SDB) and lung function abnormalities in patients with adult congenital heart disease (ACHD). METHODS Patients with ACHD underwent level 3 sleep testing (Embletta MPR polygraphy) and pulmonary function testing. Results were stratified by the underlying haemodynamic ACHD lesion group. RESULTS Patients with ACHD (n = 100) were middle-aged (42.3 ± 14.6 years), 54% male and slightly overweight (BMI 25.9 ± 5.5 kg/m2). Polygraphy revealed a prevalence of sleep apnoea of 39% with 15% of patients presenting with predominantly obstructive apnoeic episodes, while 23% of patients presenting primarily with central sleep apnoea. The distribution of mild, moderate, and severe sleep apnoea in the total study population was 26%, 7% and 6%, respectively. Comparison of apnoea-hypopnoea index, presence of sleep apnoea, and apnoea severity did not offer significant differences between the four ACHD lesion groups (p = 0.29, p = 0.41 and p = 0.18, respectively). Pulmonary function testing revealed obstructive lung disease in 19 of 100 patients. Concomitant chronic obstructive pulmonary disease and obstructive sleep apnoea were diagnosed in 3% of patients and were associated with profound nocturnal desaturation. CONCLUSION The findings suggest a mild propensity amongst patients with ACHD to develop SDB that seems to be unaffected by the specific underlying congenital lesion.
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Affiliation(s)
- D Momcilovic
- Department of Internal Medicine II - Cardiology, Pneumology, Angiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - B Reznakova
- Department of Internal Medicine II - Cardiology, Pneumology, Angiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - F Bosse
- Department of Internal Medicine II - Cardiology, Pneumology, Angiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - C Begrich
- Department of Internal Medicine II - Cardiology, Pneumology, Angiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - C Bernhardt
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - M Hamiko
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - F Bakhtiary
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - G Nickenig
- Department of Internal Medicine II - Cardiology, Pneumology, Angiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - D Skowasch
- Department of Internal Medicine II - Cardiology, Pneumology, Angiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Carmen Pizarro
- Department of Internal Medicine II - Cardiology, Pneumology, Angiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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Barroso-García V, Fernández-Poyatos M, Sahelices B, Álvarez D, Gozal D, Hornero R, Gutiérrez-Tobal GC. Prediction of the Sleep Apnea Severity Using 2D-Convolutional Neural Networks and Respiratory Effort Signals. Diagnostics (Basel) 2023; 13:3187. [PMID: 37892008 PMCID: PMC10605440 DOI: 10.3390/diagnostics13203187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/30/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
The high prevalence of sleep apnea and the limitations of polysomnography have prompted the investigation of strategies aimed at automated diagnosis using a restricted number of physiological measures. This study aimed to demonstrate that thoracic (THO) and abdominal (ABD) movement signals are useful for accurately estimating the severity of sleep apnea, even if central respiratory events are present. Thus, we developed 2D-convolutional neural networks (CNNs) jointly using THO and ABD to automatically estimate sleep apnea severity and evaluate the central event contribution. Our proposal achieved an intraclass correlation coefficient (ICC) = 0.75 and a root mean square error (RMSE) = 10.33 events/h when estimating the apnea-hypopnea index, and ICC = 0.83 and RMSE = 0.95 events/h when estimating the central apnea index. The CNN obtained accuracies of 94.98%, 79.82%, and 81.60% for 5, 15, and 30 events/h when evaluating the complete apnea hypopnea index. The model improved when the nature of the events was central: 98.72% and 99.74% accuracy for 5 and 15 events/h. Hence, the information extracted from these signals using CNNs could be a powerful tool to diagnose sleep apnea, especially in subjects with a high density of central apnea events.
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Affiliation(s)
- Verónica Barroso-García
- Biomedical Engineering Group, University of Valladolid, 47011 Valladolid, Spain; (M.F.-P.); (D.Á.); (R.H.); (G.C.G.-T.)
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 47011 Valladolid, Spain
| | - Marta Fernández-Poyatos
- Biomedical Engineering Group, University of Valladolid, 47011 Valladolid, Spain; (M.F.-P.); (D.Á.); (R.H.); (G.C.G.-T.)
| | - Benjamín Sahelices
- Electronic Devices and Materials Characterization Group, Department of Computer Science, University of Valladolid, 47011 Valladolid, Spain;
| | - Daniel Álvarez
- Biomedical Engineering Group, University of Valladolid, 47011 Valladolid, Spain; (M.F.-P.); (D.Á.); (R.H.); (G.C.G.-T.)
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 47011 Valladolid, Spain
| | - David Gozal
- Office of The Dean, Joan C. Edwards School of Medicine, Marshall University, 1600 Medical Center Drive, Huntington, WV 25701, USA;
| | - Roberto Hornero
- Biomedical Engineering Group, University of Valladolid, 47011 Valladolid, Spain; (M.F.-P.); (D.Á.); (R.H.); (G.C.G.-T.)
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 47011 Valladolid, Spain
| | - Gonzalo C. Gutiérrez-Tobal
- Biomedical Engineering Group, University of Valladolid, 47011 Valladolid, Spain; (M.F.-P.); (D.Á.); (R.H.); (G.C.G.-T.)
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 47011 Valladolid, Spain
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Schneider G. Obstructive Sleep Apnea - Influence on the Cardiovascular System and Cognition. Laryngorhinootologie 2023; 102:S101-S114. [PMID: 37130534 PMCID: PMC10184569 DOI: 10.1055/a-1963-9957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
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.
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Huang HH, Ma KSK, Wu MY, Hung YM, Tsao CH, Wei JCC, Wen WS, Wang YH, Hung SY, Chao MM. Patients with obstructive sleep apnea are at great risk of flavor disorders: a 15-year population-based cohort study. Clin Oral Investig 2023; 27:183-192. [PMID: 36129542 DOI: 10.1007/s00784-022-04707-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/30/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Obstructive sleep apnea (OSA) results from upper airway remodeling, which has been suggested to alter sensory and motor neuron function due to hypoxia or snore vibration. This study investigated whether OSA was associated with the risk of flavor disorder (FD). MATERIALS AND METHODS Seven thousand and eight hundred sixty-five patients with OSA and 7865 propensity score-matched controls without OSA were enrolled between 1999 and 2013 through a nationwide cohort study. The propensity score matching was based on age, sex, comorbidities including hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), asthma, ankylosing spondylitis, and Charlson comorbidity index, and co-medications during the study period, including statins and angiotensin-converting enzyme (ACE) inhibitors. The adjusted hazard ratio (aHR) of incident FD following OSA was derived using a Cox proportional hazard model. A log-rank test was used to evaluate the time-dependent effect of OSA on FD. Age, sex, comorbidities, and co-medications were stratified to identify subgroups susceptible to OSA-associated FD. RESULTS Patients with OSA were at a significantly great risk of FD (aHR = 1.91, 95% CI = 1.08-3.38), which was time-dependent (log-rank test p = 0.013). Likewise, patients with hyperlipidemia were at a significant great risk of FD (aHR = 2.99, 95% CI = 1.33-6.69). Subgroup analysis revealed that female patients with OSA were at higher risks of FD (aHR = 2.39, 95%CI = 1.05-5.47). CONCLUSIONS Patients with OSA were at significantly great risk of incident FD during the 15-year follow-up period, especially in female patients with OSA. CLINICAL RELEVANCE Timely interventions for OSA may prevent OSA-associated FD.
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Affiliation(s)
- Hsin-Hsin Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Kevin Sheng-Kai Ma
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Graduate Institute of Biomedical Electronics and Bioinformatics, College of Electrical Engineering & Computer Science, National Taiwan University, Taipei, Taiwan
| | - Min-You Wu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yao-Min Hung
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chien-Han Tsao
- Department of Otolaryngology, Chung Shan Medical University Hospital, Taichung, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
| | - James Cheng-Chung Wei
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan. .,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan.
| | - Wei-Sheng Wen
- Department of Otolaryngology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
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Bin Heyat MB, Akhtar F, Sultana A, Tumrani S, Teelhawod BN, Abbasi R, Amjad Kamal M, Muaad AY, Lai D, Wu K. Role of Oxidative Stress and Inflammation in Insomnia Sleep Disorder and Cardiovascular Diseases: Herbal Antioxidants and Anti-inflammatory Coupled with Insomnia Detection using Machine Learning. Curr Pharm Des 2022; 28:3618-3636. [PMID: 36464881 DOI: 10.2174/1381612829666221201161636] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/20/2022] [Accepted: 10/27/2022] [Indexed: 12/07/2022]
Abstract
Insomnia is well-known as trouble in sleeping and enormously influences human life due to the shortage of sleep. Reactive Oxygen Species (ROS) accrue in neurons during the waking state, and sleep has a defensive role against oxidative damage and dissipates ROS in the brain. In contrast, insomnia is the source of inequity between ROS generation and removal by an endogenous antioxidant defense system. The relationship between insomnia, depression, and anxiety disorders damages the cardiovascular systems' immune mechanisms and functions. Traditionally, polysomnography is used in the diagnosis of insomnia. This technique is complex, with a long time overhead. In this work, we have proposed a novel machine learning-based automatic detection system using the R-R intervals extracted from a single-lead electrocardiograph (ECG). Additionally, we aimed to explore the role of oxidative stress and inflammation in sleeping disorders and cardiovascular diseases, antioxidants' effects, and the psychopharmacological effect of herbal medicine. This work has been carried out in steps, which include collecting the ECG signal for normal and insomnia subjects, analyzing the signal, and finally, automatic classification. We used two approaches, including subjects (normal and insomnia), two sleep stages, i.e., wake and rapid eye movement, and three Machine Learning (ML)-based classifiers to complete the classification. A total number of 3000 ECG segments were collected from 18 subjects. Furthermore, using the theranostics approach, the role of mitochondrial dysfunction causing oxidative stress and inflammatory response in insomnia and cardiovascular diseases was explored. The data from various databases on the mechanism of action of different herbal medicines in insomnia and cardiovascular diseases with antioxidant and antidepressant activities were also retrieved. Random Forest (RF) classifier has shown the highest accuracy (subjects: 87.10% and sleep stage: 88.30%) compared to the Decision Tree (DT) and Support Vector Machine (SVM). The results revealed that the suggested method could perform well in classifying the subjects and sleep stages. Additionally, a random forest machine learning-based classifier could be helpful in the clinical discovery of sleep complications, including insomnia. The evidence retrieved from the databases showed that herbal medicine contains numerous phytochemical bioactives and has multimodal cellular mechanisms of action, viz., antioxidant, anti-inflammatory, vasorelaxant, detoxifier, antidepressant, anxiolytic, and cell-rejuvenator properties. Other herbal medicines have a GABA-A receptor agonist effect. Hence, we recommend that the theranostics approach has potential and can be adopted for future research to improve the quality of life of humans.
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Affiliation(s)
- Md Belal Bin Heyat
- IoT Research Center, College of Computer Science and Software Engineering, Shenzhen University, Shenzhen, Guangdong 518060, China
| | - Faijan Akhtar
- School of Computer Science and Engineering, University of Electronic Science and Technology of China, Chengdu, Sichuan 611731, China
| | - Arshiya Sultana
- Department of Ilmul Qabalat wa Amraze Niswan, National Institute of Unani Medicine, Ministry of AYUSH, Bengaluru, Karnataka, India
| | - Saifullah Tumrani
- Department of Computer Science, Bahria University, Karachi 75260, Pakistan
| | - Bibi Nushrina Teelhawod
- School of Information and Software Engineering, University of Electronic Science and Technology of China, Chengdu, Sichuan 610054, China
| | - Rashid Abbasi
- Key Laboratory of Advanced Perception and Intelligent Control of High-end Equipment of Ministry of Education, School of Electrical Engineering, Anhui Polytechnic University, Wuhu 241000, China
| | - Mohammad Amjad Kamal
- Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.,King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia.,Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh.,Enzymoics, Novel Global Community Educational Foundation, Hebersham, NSW 2770, Australia
| | - Abdullah Y Muaad
- Department of Studies in Computer Science, University of Mysore, Manasagangothri, Mysore 570006, India.,Sana'a Community College, Sana'a 5695, Yemen
| | - Dakun Lai
- BMI-EP Laboratory, School of Electronic Science and Engineering, University of Electronic Science and Technology of China, Chengdu, Sichuan 610054, China
| | - Kaishun Wu
- IoT Research Center, College of Computer Science and Software Engineering, Shenzhen University, Shenzhen, Guangdong 518060, China
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Pan W, Xia L, Liu L, Gu L, Xiang M, Zhang H, Wei X, Yang Z, Zhou X, Li J, Zeng D, Jiang J. Increased diastolic blood pressure and apnea time contribute to the poor apnea and hypopnea index and life quality of primary snoring: a cohort study combined with external validation. Sleep Biol Rhythms 2022; 20:561-568. [PMID: 38468624 PMCID: PMC10899998 DOI: 10.1007/s41105-022-00402-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
Obstructive sleep apnea hypoventilation syndrome (OSAHS) is a common sleep breathing disorder closely associated with cardiovascular disease. However, the respiratory sleep and related cardiovascular parameters on the apnea and hypopnea index (AHI) and life quality of primary snoring are unclear. We launched a cohort study focused on the association between respiratory sleep and cardiovascular-related parameters and apnea and hypopnea index, incorporating data from 218 patients with primary snoring in our medical center between Jun 1, 2015, and Apr 1, 2016. Thirty patients from Sichuan Cancer Hospital were used for validation. Patients with longer apnea time were more likely to progress to higher AHI (> 30) than controls (OR = 5.66, 95% CI = [2.79, 11.97], p < 0.001). Similarly, if patients have a higher value of diastolic blood pressure, they will also have a higher AHI (> 30) (HR [95% CI] = 3.42 [1.14, 13.65], p = 0.043). According to multivariate analysis, longest apnea time, the mean percentage of SaO2, and neckline length were independent risk factors of overall survival. A predictive model developed based on these factors above yielded a favorable agreement (C-index = 0.872) on the calibration curve. Thirty patients conducted external validation from Sichuan Cancer Hospital, displaying an AUC of 0.833 (0.782-0.884). Increased diastolic blood pressure and apnea time affect AHI level. An AHI prediction model based on these factors above can help clinicians predict the risk of high AHI events.
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Affiliation(s)
- Wenying Pan
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
| | - Lei Xia
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
| | - Lingling Liu
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
| | - Ling Gu
- Department of Medicine, Respiratory, Emergency, and Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Mengqi Xiang
- Department of Medical Oncology, Sichuan Cancer Hospital, Medical School of, University of Electronic Science and Technology of China, Chengdu, China
| | - Huachuan Zhang
- Department of Thoracic Surgery, Sichuan Cancer Hospital, Medical School of, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoying Wei
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
| | - Zhenyu Yang
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
| | - Xiaoli Zhou
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
| | - Jing Li
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
| | - Daxiong Zeng
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
| | - Junhong Jiang
- Department of Medicine, Respiratory, Emergency and Intensive Care Medicine, The Affiliated Dushu Lake Hospital of Soochow University, Suzhou, 215006 China
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Johnson DA, Ohanele C, Alcántara C, Jackson CL. The Need for Social and Environmental Determinants of Health Research to Understand and Intervene on Racial/Ethnic Disparities in Obstructive Sleep Apnea. Clin Chest Med 2022; 43:199-216. [PMID: 35659019 DOI: 10.1016/j.ccm.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Obstructive sleep apnea (OSA), a sleep-disordered breathing (SDB) disorder, affects at least 25 million adults in the United States and is associated with increased risk for hypertension, diabetes, and cardiovascular disease (CVD). Racial/ethnic minorities have a disproportionate burden of OSA along with the health sequelae associated with this condition. Despite supporting evidence of racial/ethnic disparities, few studies have investigated SDB including OSA among minoritized racial/ethnic groups. In this scoping review of the literature, the authors summarize current findings related to racial/ethnic disparities in OSA, identified social and environmental determinants of health, treatment inequities, and promising evidence-based interventions and conclude with future research directions.
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Affiliation(s)
- Dayna A Johnson
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, CNR Room 3025, Atlanta, GA 30322, USA.
| | - Chidinma Ohanele
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, CNR Room 3025, Atlanta, GA 30322, USA
| | - Carmela Alcántara
- School of Social Work, Columbia University, 1255 Amsterdam Avenue, Room 917, New York, NY 10027, USA
| | - Chandra L Jackson
- Epidemiology Branch, Social and Environmental Determinants of Health Equity, National Institute of Environmental Health Sciences, National Institutes of Health, 111 T.W. Alexander Drive, Room A327, Research Triangle Park, 27709 Post: P.O. Box 12233, Mail Drop A3-05, NC 27709, USA; Intramural Program, Department of Health and Human Services, National Institute on Minority Health and Health Disparities, Bethesda, MD, USA
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8
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Study on Mechanism of Invigorating Qi and Promoting Blood Circulation in Treatment of Angiogenesis after Myocardial Infarction Using Network Pharmacology. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:5093486. [PMID: 35656461 PMCID: PMC9152384 DOI: 10.1155/2022/5093486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/29/2022] [Indexed: 12/05/2022]
Abstract
Objective This article aims to explore the impact and mechanism of invigorating qi and promoting blood circulation (IQPBC) on angiogenesis after myocardial infarction (AMI) by using network pharmacology approach. Methods First, IQPBC was searched on the traditional Chinese medicine systems pharmacology database and analysis platform (TCMSP), and the main active ingredients and targets of IQPBC were screened and obtained. Second, by virtue of GeneCards and Online Mendelian Inheritance in Man (OMIM) databases, the targets related to AMI are screened and then obtained. Then, the intersection targets between IQPBC and AMI can be obtained by using online tool Venny 2.1.0. Third, based on the STRING database, the interaction of target proteins is established and some key targets can be analyzed and obtained. Finally, the IQPBC-AMI interaction network is constructed by using Cytoscape, and Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses are executed by DAVID and OmicShare databases. Results 143 intersection targets between IQPBC and AMI are obtained. Besides, key active ingredients, namely, quercetin, tanshinone, kaempferol, and luteolin, are shown. Furthermore, AKT1, VEGFA, STAT3, HIF-1α, and other 10 key targets are obtained. A total of 752 enrichment results are acquired by using GO analysis. KEGG pathway enrichment analysis shows 241 signaling pathways, focusing on cancer, fluid shear stress and atherosclerosis, and TNF and PI3K/AKT signaling pathways. Conclusion This article studies the potential targets and signaling pathways of IQPBC drugs acting on AMI via the network pharmacology approach, which better illustrates the effect and mechanism, and provides some good ideas for the following mechanism research studies.
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Halioua B, Chelli C, Misery L, Taieb J, Taieb C. Sleep Disorders and Psoriasis: An Update. Acta Derm Venereol 2022; 102:adv00699. [PMID: 35191513 PMCID: PMC9574693 DOI: 10.2340/actadv.v102.1991] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Psoriasis alters patients’ quality of life. Among the disorders associated with psoriasis, sleep disorders are common, although they are not directly assessed by most quality-of-life scores. Thus, the specific evaluation of sleep disorders using dedicated scores is necessary, especially because such disorders alter patients;’ physical and psychological health. The relationship between psoriasis and sleep disorders has been shown in numerous studies, but has not yet been fully elucidated. The aim of this study was to update knowledge of sleep disorders in patients with psoriasis, through a review of the scientific literature since 1980. This work covers several topics of interest, such as sleep assessment methods, the prevalence of sleep disorders in patients with psoriasis, factors predictive of sleep disorders in patients with psoriasis, the impact of sleep disorders on comorbidities and quality of life, pathogenic mechanisms, obstructive sleep apnoea and restless leg syndromes, and the impact of biotherapy treatments on sleep disorders in patients with psoriasis.
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10
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Gutiérrez-Tobal GC, Álvarez D, Vaquerizo-Villar F, Crespo A, Kheirandish-Gozal L, Gozal D, del Campo F, Hornero R. Ensemble-learning regression to estimate sleep apnea severity using at-home oximetry in adults. Appl Soft Comput 2021. [DOI: 10.1016/j.asoc.2021.107827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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11
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Pai PY, Lin YY, Yu SH, Lin CY, Liou YF, Wu XB, Wong JKS, Huang CY, Lee SD. Angiotensin II receptor blocker irbesartan attenuates sleep apnea-induced cardiac apoptosis and enhances cardiac survival and Sirtuin 1 upregulation. Sleep Breath 2021; 26:1161-1172. [PMID: 34626328 DOI: 10.1007/s11325-021-02499-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 09/17/2021] [Accepted: 09/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to investigate whether or not angiotensin II type 1 receptor blocker irbesartan (ARB) with a partial agonist of PPAR-γ could protect against chronic nocturnal intermittent hypoxia (CIH)-induced cardiac Fas/FasL-mediated to mitochondria-mediated apoptosis. METHODS Sprague-Dawley rats were in a normoxic control group (CON-G), or rats were in a chronic nocturnal intermittent hypoxia group (HP-G, from 3 to 7% oxygen versus 21% oxygen per forty seconds cycle, nocturnally 8 h per day for 1 month), or rats were in a chronic nocturnal intermittent hypoxia group pretreated with ARB (50 mg/kg/day, S.C.) (ARB-HP-G). Echocardiography, H&E staining, TUNEL staining, and Western blotting were measured in the left ventricle. RESULTS Hypoxia-induced SIRT1 degradation, Fas receptors, FADD, active caspase-8 and caspase-3 (Fas/FasL apoptotic pathway) and Bax, tBid, active caspase-9 and -3 (mitochondrial apoptotic pathway) and TUNEL-positive apoptosis were reduced in ARB-HP-G when compared with HP-G. IGF-I, IGF1 receptor, p-PI3k, p-Akt, Bcl2, and Bcl-XL (IGF1/PI3K/AKT pro-survival pathway) were increased in ARB-HP-G compared to HP-G. CONCLUSIONS Our findings suggest that the ARB may prevent cardiac Fas/FasL to mitochondrial apoptotic pathways and enhance cardiac IGF1/PI3K/AKT pro-survival pathway in the sleep apnea model associated with JNK de-activation and SIRT1 upregulation. ARB prevents chronic sleep apnea-enhanced cardiac apoptosis via enhancing survival pathways.
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Affiliation(s)
- Pei-Ying Pai
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yi-Yuan Lin
- Department of Exercise and Health Science, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Shao-Hong Yu
- College of Rehabilitation, Shandong University of Traditional Chinese Medicine, Shandong, China
| | - Ching-Yuang Lin
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
- Clinical Immunology Center, China Medical University Hospital, Taichung, Taiwan
| | - Yi-Fan Liou
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Xu-Bo Wu
- Department of Rehabilitation, Seventh People's Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - James K S Wong
- Department of Cardiology, Asia University Hospital, Taichung, Taiwan
| | - Chih-Yang Huang
- Graduate Institute of Chinese Medical Science, China Medical University, Taichung, Taiwan
- Department of Biotechnology, Asia University, Taichung, Taiwan
- Cardiovascular and Mitochondrial Related Disease Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Shin-Da Lee
- Department of Rehabilitation, Seventh People's Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China.
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
- Department of Physical Therapy, Asia University, Taichung, Taiwan.
- Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung, Taichung, 40402, Taiwan.
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12
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Abstract
Es hat sich viel getan in der Welt der Schlafmedizin in der Kardiologie, weshalb eine vollwertige Überarbeitung des Positionspapiers „Schlafmedizin in der Kardiologie“ erforderlich wurde. In der aktuellen neuartigen Version finden sich nicht nur alle verfügbaren Studien, Literaturstellen und Updates zu Pathophysiologie, Diagnostik- und Therapieempfehlungen, sondern auch Ausblicke auf neue Entwicklungen und zukünftige Forschungserkenntnisse. Dieses überarbeitete Positionspapier gibt Empfehlungen für Diagnostik und Therapie von Patienten mit kardiovaskulären Erkrankungen mit schlafassoziierten Atmungsstörungen und erteilt darüber hinaus einen fundierten Überblick über verfügbare Therapien und Evidenzen, gibt aber ebenso Ratschläge wie mit Komorbiditäten umzugehen ist. Insbesondere enthält dieses überarbeitete Positionspapier aktualisierte Stellungnahmen zu schlafassoziierten Atmungsstörungen bei Patienten mit koronarer Herzerkrankung, Herzinsuffizienz, arterieller Hypertonie, aber auch für Patienten mit Vorhofflimmern. Darüber hinaus finden sich erstmals Empfehlungen zur Telemedizin als eigenes, neues Kapitel. Dieses Positionspapier bietet Kardiologen sowie Ärzten in der Behandlung von kardiovaskulären Patienten die Möglichkeit einer evidenzbasierten Behandlung der wachsend bedeutsamen und mit zunehmender Aufmerksamkeit behafteten Komorbidität schlafassoziierter Atmungsstörungen. Und nicht zuletzt besteht mit diesem neuen Positionspapier eine enge Verknüpfung mit dem neuen Curriculum Schlafmedizin der Deutschen Gesellschaft für Kardiologie, weshalb dieses Positionspapier eine Orientierung für die erworbenen Fähigkeiten des Curriculums im Umgang von kardiovaskulären Patienten mit schlafassoziierten Atmungsstörungen darstellt.
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Chen Y, Chen Y, Wen F, He Z, Niu W, Ren C, Li N, Wang Q, Ren Y, Liang C. Does continuous positive airway pressure therapy benefit patients with coronary artery disease and obstructive sleep apnea? A systematic review and meta-analysis. Clin Cardiol 2021; 44:1041-1049. [PMID: 34145595 PMCID: PMC8364731 DOI: 10.1002/clc.23669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/30/2021] [Accepted: 06/03/2021] [Indexed: 12/04/2022] Open
Abstract
The prevalent co‐morbidity of coronary artery disease (CAD) and obstructive sleep apnea (OSA) has attracted great interest. However, effects of continuous positive airway pressure (CPAP) in patients with OSA and CAD for cardiovascular outcomes and deaths are still controversial. Usage of CPAP among patients with CAD and OSA could decrease the risk of cardiovascular events and death in adults. PubMed, EMBASE, Web of science, and Cochrane Library were systematically searched. Studies that described association of CPAP treatment with cardiovascular events in CAD and OSA patients were included. The main outcome was the major adverse cardiovascular events (MACE), including all‐cause death, cardiovascular death, myocardial infarction (MI), stroke, and repeat revascularization. Summary relative risks (risk ratios [RRs]) and 95% confidence intervals (CIs) of outcomes were pooled and heterogeneity was assessed with the I2 statistic. Nine studies enrolling 2590 participants with OSA and CAD were included and extracted data. There was significant association of CPAP with reduced risk of MACE (RR, 0.73, 95% CI [0.55, 0.96]), particularly among those with AHI less than 30 events/h (RR, 0.43, 95% CI [0.22, 0.84]). Similarly, the same result was found in all‐cause death (RR, 0.66, 95% CI, [0.46, 0.94]) and cardiovascular death (RR, 0.495, 95% CI [0.292, 0.838]). Our data suggested that CPAP usage, compared to usual care, was associated with reduced risks of cardiovascular outcomes or death in patients with OSA and CAD, particularly in the subgroup with AHI less than 30 events/h, which still needs further studies to confirm.
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Affiliation(s)
- Yasha Chen
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Yihong Chen
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Feng Wen
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Zhiqing He
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Wenhao Niu
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Changzhen Ren
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Na Li
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Qinqin Wang
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Yusheng Ren
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Chun Liang
- Department of Cardiology, Shanghai Changzheng Hospital, Navy Medical University, Shanghai, China
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14
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Wang J, Xu H, Yuan J, Guo C, Hu F, Yang W, Song L, Luo X, Liu R, Cui J, Liu S, Chun Y, Qiao S. Association Between Obstructive Sleep Apnea and Metabolic Abnormalities in Patients With Hypertrophic Cardiomyopathy. J Clin Endocrinol Metab 2021; 106:e2309-e2321. [PMID: 33420791 DOI: 10.1210/clinem/dgab015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Metabolic abnormalities have been associated with long-term cardiac mortality in patients with hypertrophic cardiomyopathy (HCM). Obstructive sleep apnea (OSA) is a risk factor for metabolic abnormalities in general populations, but association between OSA and metabolic abnormalities in HCM is still undefined. This study aimed to investigate the relationship between OSA and metabolic dysfunction in a large series of patients with HCM. METHODS A total of 587 patients with HCM who underwent sleep evaluations at Fuwai Hospital were included. Data from clinical characteristics, polysomnography studies, and metabolic measurements were collected. RESULTS OSA was present in 344 patients (58.6%). Patients with OSA were older, more often male, and had more clinical comorbidities. Body mass index, blood pressure, fasting glucose, and triglycerides all increased (all P < 0.001) and high-density lipoprotein cholesterol decreased (P = 0.046) with the severity of OSA. In multivariate analysis, moderate to severe OSA and Log (apnea-hypopnea index + 1) were independently associated with obesity (odds ratio [OR], 2.42; 95% CI, 1.48-3.95 and OR, 1.60; 95% CI, 1.31-1.95), elevated blood pressure (OR, 1.99; 95% CI, 1.42-3.26 and OR, 1.31; 95% CI, 1.08-1.60), and elevated triglycerides (OR, 1.71; 95% CI, 1.05-2.78 and OR, 1.24; 95% CI, 1.02-1.51 but not elevated fasting glucose (OR, 0.88; 95% CI, 0.50-1.52 and OR, 1.02; 95% CI, 0.82-1.28) or reduced high-density lipoprotein cholesterol (OR, 1.30; 95% CI, 0.83-2.04 and OR, 1.06; 95% CI, 0.89-1.27). CONCLUSIONS Severity of OSA is independently associated with some profiles of metabolic abnormalities. Clinical trials are required to determine whether OSA treatment improves metabolic abnormalities and long-term outcomes in patients with HCM.
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Affiliation(s)
- Juan Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Haobo Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jiansong Yuan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Chao Guo
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Fenghuan Hu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Weixian Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Lei Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xiaoliang Luo
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Rong Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jingang Cui
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Shengwen Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yushi Chun
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Shubin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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15
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Tavares L, Lador A, Valderrábano M. Sleep Apnea and Atrial Fibrillation: Role of the Cardiac Autonomic Nervous System. Methodist Debakey Cardiovasc J 2021; 17:49-52. [PMID: 34104320 DOI: 10.14797/zyut2951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Sleep apnea is highly associated with atrial fibrillation (AF), and both diseases are highly prevalent in the United States. The mechanistic underpinnings that contribute to their association remain uncertain, but numerous possible mechanisms have been proposed, including dysfunction of the cardiac autonomic nervous system (ANS). Studies have reported that apnea induces hyperactivity of the ANS, leading to increases in AF susceptibility. This review compiles the latest evidence on the role of the ANS in sleep-apnea-induced AF.
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Affiliation(s)
- Liliana Tavares
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Adi Lador
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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16
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Riaz S, Bhatti H, Sampat PJ, Dhamoon A. The Converging Pathologies of Obstructive Sleep Apnea and Atrial Arrhythmias. Cureus 2020; 12:e9388. [PMID: 32754415 PMCID: PMC7386049 DOI: 10.7759/cureus.9388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/25/2020] [Indexed: 11/05/2022] Open
Abstract
Obstructive sleep apnea (OSA) is highly prevalent in the United States (US). Along with epidemic rates of obesity, the rate of OSA cases is also on the rise. OSA is associated with multiple chronic health conditions, including hypertension, diabetes, stroke, myocardial ischemia, and heart rhythm disturbances. OSA is commonly treated with continuous positive airway pressure (CPAP) therapy. Several reports indicate that effective treatment of OSA can reduce the risk of cardiovascular diseases, including cardiac arrhythmias, especially atrial fibrillation (AF). CPAP therapy helps to maintain sinus rhythm after interventions such as electrical cardioversion and catheter ablation in patients with AF. However, more data is required to establish a relationship between OSA and other atrial arrhythmias as well to evaluate the effect of CPAP. This review will compile the latest evidence on the pathophysiology, management, and treatment of atrial arrhythmias associated with OSA.
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Affiliation(s)
- Sana Riaz
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Harneet Bhatti
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Parth J Sampat
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Amit Dhamoon
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
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17
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Wang J, Xu H, Guo C, Duan X, Hu F, Yang W, Cui J, Song L, Chun Y, Yuan J, Qiao S. Association between severity of obstructive sleep apnea and high-sensitivity C-reactive protein in patients with hypertrophic obstructive cardiomyopathy. Clin Cardiol 2020; 43:803-811. [PMID: 32458487 PMCID: PMC7368348 DOI: 10.1002/clc.23385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/26/2020] [Accepted: 05/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background Obstructive sleep apnea (OSA) is highly prevalent in patients with hypertrophic obstructive cardiomyopathy (HOCM). Inflammatory responses are increased in patients with OSA, meanwhile, inflammation is also associated with adverse outcomes in HOCM. Hypothesis To investigate the association between severity of OSA and high‐sensitivity C‐reactive protein (hs‐CRP) in patients with HOCM. Methods Three hundred and ninteen patients with HOCM who underwent sleep evaluations at Fuwai Hospital were retrospectively included between February 2010 and December 2018. Data from baseline clinical characteristics and polysomnography studies were collected. Results OSA was present in 168 (52.7%). Patients with OSA were older, more likely to be male, had a higher body mass index and more clinical comorbidities. Patients with OSA had enlarged left ventricular diameter and similar left ventricular outflow tract obstruction compared with those without. In multivariate logistic analysis, apnea‐hypopnea index (OR, 1.024; 95% CI, 1.005‐1.044; P = .014), oxygen desaturation index (OR, 1.025; 95% CI, 1.004‐1.046; P = .018) and lowest oxygen saturation (OR, 0.951; 95% CI, 0.915‐0.989; P = .011) were independently associated with high risk hs‐CRP (>3 mg/L) after adjusting for confounders. In addition, decreasing lowest oxygen saturation (β = −.159, P = .004) was also independently correlated with increasing hs‐CRP concentrations in multivariate linear analysis after adjusting for confounders. Conclusions Severity of OSA was independently associated with elevated hs‐CRP levels in patients with HOCM. Further studies are needed to evaluate the effects of treating OSA on hs‐CRP as well as clinical outcomes in these patients.
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Affiliation(s)
- Juan Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Haobo Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Chao Guo
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xin Duan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Fenghuan Hu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Weixian Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jingang Cui
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Lei Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yushi Chun
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jiansong Yuan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Shubin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Park KM, Kim SY, Sung D, Kim H, Kim BN, Park S, Jung KI, Park MH. The relationship between risk of obstructive sleep apnea and other sleep problems, depression, and anxiety in adolescents from a community sample. Psychiatry Res 2019; 280:112504. [PMID: 31401289 DOI: 10.1016/j.psychres.2019.112504] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 01/16/2023]
Abstract
Obstructive sleep apnea (OSA) is highly related to mental health problems, such as depression and anxiety. However, previous studies on OSA and depression and anxiety have mostly been conducted in the adult population. We aimed to (1) screen for risk of OSA in a sample of adolescents from the general population using self-report questionnaires and (2) examine whether there are differences between the high- and low-risk groups for OSA in depressive and anxiety symptoms, self-esteem, and sleep-related variables. The data of 793 students (age range: 12-17 years old) were analyzed. The participants were assigned to the high-risk (n = 202, 25.5%) or the low-risk group (n = 591, 74.5%) of OSA. The participants in the high-risk group had more severe anxiety symptoms, lower self-esteem, insomnia, excessive daytime sleepiness, and higher BMI compared those in the low-risk group. This study shows that it is possible to efficiently screen for risks of various problems associated with OSA in adolescents using an easy and simple screening tool.
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Affiliation(s)
- Kyu-Myoung Park
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Shin-Young Kim
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dajung Sung
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyemin Kim
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bung-Nyun Kim
- Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Subin Park
- Department of Research Planning, National Center for Mental Health, Seoul, Republic of Korea
| | - Kyu-In Jung
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min-Hyeon Park
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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19
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Fujioka K, Perdomo C, Malhotra M. Effect of lorcaserin on weight reduction in persons with obstructive sleep apnea (OSA): a combined subgroup analysis from three randomized, controlled clinical trials. Obes Sci Pract 2019; 5:238-245. [PMID: 31275597 PMCID: PMC6587310 DOI: 10.1002/osp4.340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 03/08/2019] [Accepted: 03/17/2019] [Indexed: 12/30/2022] Open
Abstract
STUDY OBJECTIVES To evaluate weight loss with lorcaserin in persons with obstructive sleep apnea (OSA). METHODS This retrospective analysis evaluated weight loss of lorcaserin (10 mg twice daily) versus placebo in persons with obesity or overweight persons with OSA from a pooled database of three randomized, controlled trials. Primary end points were reductions in the baseline body weight of ≥5% and ≥10% at year 1 and overall weight change at year 1. Changes in heart rate and blood pressure were also evaluated. RESULTS A total of 336 persons with OSA were identified in the overall pooled population (N = 6,636). At year 1, more patients receiving lorcaserin lost ≥5% (47.2% lorcaserin vs. 25.6% placebo; p < 0.0001) and 10% (22.2% lorcaserin vs. 13.1% placebo; p < 0.0354) of their baseline body weight. Weight loss at year 1 was 6.4 kg versus 3.5 kg in the lorcaserin and placebo groups, respectively (p < 0.0001). Similar results were observed for change in blood pressure and heart rate, with responders having larger benefits. Weight loss was similar between persons with and without OSA. CONCLUSIONS In this retrospective analysis, persons with OSA showed significant and meaningful weight loss, blood pressure and heart rate reductions in patients treated with lorcaserin versus placebo. Persons with OSA lost just as much weight as those without OSA. Health care providers can expect persons with OSA to lose weight by diet, exercise and the weight loss medication lorcaserin comparable with persons without OSA. Further prospective research is warranted to evaluate impact of weight loss on OSA and overall outcomes for patients.
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Affiliation(s)
- K. Fujioka
- Department of Diabetes and EndocrinologyScripps ClinicSan DiegoCAUSA
| | - C. Perdomo
- Neurology Business GroupEisai Inc.Woodcliff LakeNJUSA
| | - M. Malhotra
- Neurology Business GroupEisai Inc.Woodcliff LakeNJUSA
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20
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Román GC, Jackson RE, Fung SH, Zhang YJ, Verma AK. Sleep-Disordered Breathing and Idiopathic Normal-Pressure Hydrocephalus: Recent Pathophysiological Advances. Curr Neurol Neurosci Rep 2019; 19:39. [PMID: 31144048 PMCID: PMC6541578 DOI: 10.1007/s11910-019-0952-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose of Review Idiopathic normal-pressure hydrocephalus (iNPH) is characterized clinically by ventriculomegaly, abnormal gait, falls, incontinence, and cognitive decline. This article reviews recent advances in the pathophysiology of iNPH concerning sleep-disordered breathing (SDB) and glymphatic circulation during deep sleep. Recent Findings The authors found iNPH frequently associated with obstructive sleep apnea (OSA). A critical factor in iNPH is intracranial venous hypertension delaying drainage of cerebrospinal fluid (CSF) into the cerebral venous sinuses. CSF-venous blood circulates in the jugular veins and finally drains into the heart. During SDB, repeated reflex attempts to breathe induce strong respiratory efforts against a closed glottis thereby increasing the negative intrathoracic pressure. This causes atrial distortion and decreases venous return to the heart resulting in retrograde intracranial venous hypertension. Additionally, repeated awakenings from OSA impede sleep-associated circulation of interstitial CSF into the glymphatic circulation contributing to hydrocephalus. Summary Sleep has become a critical element in the cognitive changes of aging including iNPH.
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Affiliation(s)
- Gustavo C Román
- Department of Neurology, Methodist Neurological Institute and Houston Methodist Hospital Research Institute for Academic Medicine, Houston, TX, USA. .,Department of Neurology, Weill Cornell Medical College, Cornell University, New York, NY, USA.
| | - Robert E Jackson
- Department of Medicine, Houston Methodist Hospital and Houston Research Institute for Academic Medicine, Houston, TX, USA.,Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Steve H Fung
- Department of Radiology MRI Core, Houston Methodist Hospital and Methodist Research Institute for Academic Medicine, Houston, TX, USA.,Department of Radiology Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Y Jonathan Zhang
- Department of Neurosurgery, Methodist Neurological Institute and Houston Methodist Hospital Research Institute for Academic Medicine, Houston, TX, USA.,Department of Neurosurgery, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Aparajitha K Verma
- Department of Neurology, Methodist Neurological Institute and Houston Methodist Hospital Research Institute for Academic Medicine, Houston, TX, USA.,Department of Neurology, Weill Cornell Medical College, Cornell University, New York, NY, USA.,Sleep Laboratory Houston Methodist Hospital, Houston, TX, USA
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Madsen MT, Huang C, Zangger G, Zwisler ADO, Gögenur I. Sleep Disturbances in Patients With Coronary Heart Disease: A Systematic Review. J Clin Sleep Med 2019; 15:489-504. [PMID: 30853047 DOI: 10.5664/jcsm.7684] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 01/08/2019] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVES Investigation into sleep and coronary heart disease (CHD) has predominantly been focused on sleep disturbances as a risk factor for developing CHD. Objectively measured and self-reported sleep at a patient level has only been sparsely and not systematically reported. Therefore, we set out to review the literature for studies using objectively measured and self-reported sleep in patients with CHD. The review focuses on patients with acute coronary syndrome (ACS) and stable CHD. METHODS A systematic review performed in four databases adhering to the PRISMA guidelines applying a qualitative synthesis of evidence. RESULTS Following ACS, we found sleep architecture to be significantly disturbed with changes normalizing over a period of up to 6 months. With increasing severity of CHD, sleep disturbances were more pronounced; however, the modulating effects of sleep-disordered breathing and ejection fraction on sleep in patients with CHD are conflicting. Overall, studies were predominantly cross-sectional in design and of low methodological quality. Polysomnography was the predominant outcome assessment tool and validated self-reported assessment tools were limited. CONCLUSIONS Future investigations in sleep and CHD applying both a longitudinal design and investigating objective and self-reported sleep assessments are warranted. SYSTEMATIC REVIEW REGISTRATION Registry: PROSPERO, Title: Sleep measures in relation to coronary heart disease: a systematic review, Identifier: CRD42017056377, URL: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=56377.
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Affiliation(s)
- Michael Tilling Madsen
- Center for Surgical Science, Zealand University Hospital, Denmark.,Department of Emergency, Zealand University Hospital, Denmark
| | - Chenxi Huang
- Center for Surgical Science, Zealand University Hospital, Denmark
| | - Graziella Zangger
- REHPA - Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital and University of Southern Denmark, Denmark
| | - Ann Dorthe Olsen Zwisler
- REHPA - Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital and University of Southern Denmark, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Denmark
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Gutierrez-Tobal GC, Alvarez D, Crespo A, del Campo F, Hornero R. Evaluation of Machine-Learning Approaches to Estimate Sleep Apnea Severity From At-Home Oximetry Recordings. IEEE J Biomed Health Inform 2019; 23:882-892. [DOI: 10.1109/jbhi.2018.2823384] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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TNFRSF11B: A potential plasma biomarker for diagnosis of obstructive sleep apnea. Clin Chim Acta 2018; 490:39-45. [PMID: 30562485 DOI: 10.1016/j.cca.2018.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/27/2018] [Accepted: 12/14/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) was characterized by chronic intermittent hypoxia, which was an independent risk factor for endothelial dysfunction. Circulating TNFRSF11B might play an important role in promoting endothelial cells dysfunction. We explored the role of plasma TNFRSF11B as a potential mechanism of endothelial dysfunction in OSA patients. METHODS The study population consisted of 120 patients with varying severity of OSA and 40 control subjects. Plasma TNFRSF11B levels were measured using human Magnetic Luminex assay. RESULTS Our data showed that plasma TNFRSF11B levels were significantly higher in patients with OSA. After adjusting confounding factors, plasma TNFRSF11B levels were independently associated with the presence of OSA (Beta:0.434, 95% CI: 664.096 to 1076.247; P < 0.001) and plasma TNFRSF11B levels were positively associated with the apnea-hypopnea index (Beta:0.486, 95% CI: 0.007 to 0.017; P < 0.001). Furthermore, plasma TNFRSF11B showed higher discriminatory accuracy in predicting the presence of OSA (AUC:0.964). CONCLUSIONS Plasma TNFRSF11B levels were significantly associated with the presence of OSA and its severity. TNFRSF11B could be a plasma biomarker with a positive diagnostic value for premature vascular endothelial dysfunction in patients with OSA.
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Fan Z, Lu X, Long H, Li T, Zhang Y. The association of hemocyte profile and obstructive sleep apnea. J Clin Lab Anal 2018; 33:e22680. [PMID: 30246267 DOI: 10.1002/jcla.22680] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/20/2018] [Accepted: 08/27/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The hemocyte profile is one of the most frequently requested clinical laboratory tests. However, the analysis of blood cell indexes of obstructive sleep apnea (OSA) patients in previous studies was not comprehensive. And, this study aimed to fully analyze the blood routine in OSA patients. METHODS A retrospective study was conducted on 1087 male patients, who were admitted to the sleep center of Nanfang Hospital from May 2013 to February 2018. According to the apnea hypopnea index (AHI), patients were divided into four groups: control group (AHI < 5, n = 135), mild OSA (5 ≦ AHI < 15, n = 185), moderate OSA (15 ≦ AHI < 30, n = 171), and severe OSA (AHI ≧ 30, n = 596). Data collected included sleep parameters, complete blood routine, body mass index (BMI), age, and comorbidities. RESULTS In our study, leukocytes, neutrophils, lymphocytes, monocytes, eosinophils, basophils, erythrocytes, hemoglobin, hematocrit, platelets, MPV, and PDW-SD were statistically significant among the four groups based on AHI (P < 0.05), but no significant differences were found in MCV, RDW-SD, N/L, and P/L ratio (P > 0.05). Neutrophils, lymphocytes, monocytes, eosinophils, basophils, hemoglobin, hematocrit, platelets, and MPV were significantly correlated with AHI. Moreover, multiple linear regression analysis demonstrated that hematocrit (β = 73.254, P = 0.001), neutrophils (β = 1.414, P = 0.012), and lymphocytes (β = 4.228, P < 0.001) were independently associated with AHI. CONCLUSION Neutrophils, lymphocytes, and hematocrit were independently associated with OSA severity. And combining these three blood cell indicators could contribute to the diagnosis of OSA.
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Affiliation(s)
- Zeqin Fan
- Sleep Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoxia Lu
- Sleep Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hong Long
- Sleep Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Taoping Li
- Sleep Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanhong Zhang
- Health Care Center, Guangdong Entry-exit Inspection and Quarantine Bureau, Guangzhou, China
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Urtnasan E, Park JU, Lee KJ. Multiclass classification of obstructive sleep apnea/hypopnea based on a convolutional neural network from a single-lead electrocardiogram. Physiol Meas 2018; 39:065003. [PMID: 29794342 DOI: 10.1088/1361-6579/aac7b7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In this paper, we propose a convolutional neural network (CNN)-based deep learning architecture for multiclass classification of obstructive sleep apnea and hypopnea (OSAH) using single-lead electrocardiogram (ECG) recordings. OSAH is the most common sleep-related breathing disorder. Many subjects who suffer from OSAH remain undiagnosed; thus, early detection of OSAH is important. APPROACH In this study, automatic classification of three classes-normal, hypopnea, and apnea-based on a CNN is performed. An optimal six-layer CNN model is trained on a training dataset (45 096 events) and evaluated on a test dataset (11 274 events). The training set (69 subjects) and test set (17 subjects) were collected from 86 subjects with length of approximately 6 h and segmented into 10 s durations. MAIN RESULTS The proposed CNN model reaches a mean [Formula: see text]-score of 93.0 for the training dataset and 87.0 for the test dataset. SIGNIFICANCE Thus, proposed deep learning architecture achieved a high performance for multiclass classification of OSAH using single-lead ECG recordings. The proposed method can be employed in screening of patients suspected of having OSAH.
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Affiliation(s)
- Erdenebayar Urtnasan
- Department of Biomedical Engineering, College of Health Science, Yonsei University, Wonju-si, Gangwon-do 26493, Republic of Korea
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Johnson DA, Billings ME, Hale L. Environmental Determinants of Insufficient Sleep and Sleep Disorders: Implications for Population Health. CURR EPIDEMIOL REP 2018; 5:61-69. [PMID: 29984131 PMCID: PMC6033330 DOI: 10.1007/s40471-018-0139-y] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Sleep is important for overall health and well-being. Insufficient sleep and sleep disorders are highly prevalent among adults and children and therefore a public health burden, particularly because poor sleep is associated with adverse health outcomes. Emerging evidence has demonstrated that environmental factors at the household- and neighborhood-level can alter healthy sleep. This paper will (1) review recent literature on the environmental determinants of sleep among adults as well as children and adolescents; and (2) discuss the opportunities and challenges for advancing research on the environment and sleep. RECENT FINDINGS Epidemiologic research has shown that social features of environments, family, social cohesion, safety, noise, and neighborhood disorder can shape and/or impact sleep patterns; and physical features such as light, noise, traffic, pollution, and walkability can also influence sleep and is related to sleep disorders among adults and children. Prior research has mainly measured one aspect of the environment, relied on self-reported sleep, which does not correlate well with objective measures, and investigated cross-sectional associations. Although most studies are conducted among non-Hispanic white populations, there is growing evidence that indicates that minority populations are particularly vulnerable to the effects of the environment on insufficient sleep and sleep disorders. SUMMARY There is clear evidence that environmental factors are associated with insufficient sleep and sleep disorders. However, more research is warranted to evaluate how and which environmental factors contribute to sleep health. Interventions that target changes in the environment to promote healthy sleep should be developed, tested, and evaluated as a possible pathway for ameliorating sleep health disparities and subsequently health disparities.
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Affiliation(s)
- Dayna A. Johnson
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School
| | - Martha E. Billings
- Division of Pulmonary, Critical Care & Sleep Medicine, University of Washington
| | - Lauren Hale
- Department of Family, Population, and Preventive Medicine, Stony Brook University School of Medicine
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Automated Detection of Obstructive Sleep Apnea Events from a Single-Lead Electrocardiogram Using a Convolutional Neural Network. J Med Syst 2018; 42:104. [DOI: 10.1007/s10916-018-0963-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
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Smith JR, Sutterfield SL, Baumfalk DR, Didier KD, Hammer SM, Caldwell JT, Ade CJ. Left ventricular strain rate is reduced during voluntary apnea in healthy humans. J Appl Physiol (1985) 2017; 123:1730-1737. [PMID: 28912359 DOI: 10.1152/japplphysiol.00327.2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
During an apneic event, sympathetic nerve activity increases resulting in subsequent increases in left ventricular (LV) afterload and myocardial work. It is unknown how cardiac mechanics are acutely impacted by the increased myocardial work during an apneic event. Ten healthy individuals (23 ± 3 yr) performed multiple voluntary end-expiratory apnea (VEEA) maneuvers exposed to room air, while a subset ( n = 7) completed multiple VEEA exposed to hyperoxic air (100% [Formula: see text]). Beat-by-beat blood pressure, heart rate, and stroke volume were measured continuously. Effective arterial elastance (EA) was calculated as an index of cardiac afterload, and myocardial work was calculated as the rate pressure product (RPP). Tissue Doppler echocardiography was used to measure LV tissue velocities, deformation via strain, and strain rate (SR). Systolic blood pressure (Δ18 ± 13 mmHg, P < 0.01), EA (Δ0.13 ± 0.10 mmHg/ml, P < 0.01), and RPP (Δ9 ± 10 beats/min × mmHg 10-2, P < 0.01) significantly increased with room air VEEA. This occurred in parallel with decreases in peak longitudinal systolic (Δ-0.62 ± 0.41 cm/s, P < 0.01) and early LV filling (Δ-2.81 ± 1.99 cm/s, P < 0.01) myocardial velocities. Longitudinal SR (Δ-0.30 ± 0.32 1/s, P = 0.01) was significantly decreased during room air VEEA. VEEA with hyperoxia did not alter ( P > 0.18) EA or RPP and attenuated the systolic blood pressure response compared with room air. Myocardial velocities and LV strain rate response to VEEA were unchanged ( P = 0.30) with hyperoxia. Consistent with our hypotheses, VEEA-induced increases in EA and myocardial work impact LV mechanics, which may depend, in part, on stimulation of peripheral chemoreceptors. NEW & NOTEWORTHY Transient increases in arterial blood pressure and systemic vascular resistance occur during sleep apnea events and may contribute to the associated daytime hypertension and risk of overt cardiovascular disease. To date, the link between this apnea pressor response and acute changes in left ventricular function remains poorly understood. We demonstrate that in parallel to increases in cardiac afterload a depressed left ventricular systolic function occurs at end apnea.
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Affiliation(s)
- Joshua R Smith
- Department of Kinesiology, Kansas State University , Manhattan, Kansas
| | | | - Dryden R Baumfalk
- Department of Kinesiology, Kansas State University , Manhattan, Kansas
| | - Kaylin D Didier
- Department of Kinesiology, Kansas State University , Manhattan, Kansas
| | - Shane M Hammer
- Department of Kinesiology, Kansas State University , Manhattan, Kansas
| | - Jacob T Caldwell
- Department of Kinesiology, Kansas State University , Manhattan, Kansas
| | - Carl J Ade
- Department of Kinesiology, Kansas State University , Manhattan, Kansas
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Hong SN, Yun HC, Yoo JH, Lee SH. Association Between Hypercoagulability and Severe Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2017; 143:996-1002. [PMID: 28817760 DOI: 10.1001/jamaoto.2017.1367] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance Obstructive sleep apnea (OSA) is related to the increased risk of cardiovascular disease. Although the pathogenesis of this association remains unclear, an alteration in coagulability is suspected as a link. Objective To investigate the association between the severity of OSA and blood coagulability. Design, Setting, and Participants A retrospective cohort study conducted at a tertiary care university hospital evaluated 146 patients with OSA from January 1, 2009, to July 31, 2015. The participants were divided into 4 groups according to the severity of OSA: control, mild, moderate, and severe. Main Outcomes and Measures Association between the severity of OSA and coagulation test results, including platelet count, bleeding time, prothrombin time (PT) in seconds and as international normalized ratio (INR), and activated partial thromboplastin time. Results Of the 146 patients, 135 (92.5%) were men; mean (SD) age was 34.8 (11.1) years. The control group included 41 (28.1%) patients; mild OSA, 32 (21.9%); moderate OSA, 30 (20.5%); and severe OSA, 43 (29.5%). Significant correlations were found between the apnea-hypopnea index and the PT seconds (Spearman r coefficient, -0.30; 95% CI, -0.44 to -0.14) and PT INR (Spearman r coefficient, -0.30; 95% CI, -0.44 to -0.14). There were significant differences between the OSA severity groups for PT seconds for the control group (mean, 11.26 [0.78] seconds) vs the moderate OSA group (10.74 [0.62] seconds; mean difference [MD], 0.52; 95% CI, 0.27 to 1.01) and the severe OSA group (10.67 [0.77] seconds; MD, 0.59; 95% CI, 0.14 to 1.03). Significant differences were also noted in PT INR between the control group (1.00 [0.07]) vs the moderate OSA group (0.95 [0.05]; MD, 0.04; 95% CI, 0.01 to 0.07) and the severe OSA group (0.94 [0.07]; MD, 0.05; 95% CI, 0.02 to 0.08). However, there was no significant difference between the control and mild OSA groups in PT seconds. Conclusions and Relevance These results suggest that patients with moderate to severe OSA have elevated blood coagulability markers compared with healthy individuals, which may contribute to the occurrence of cardiovascular complications.
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Affiliation(s)
- Seung-No Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
| | - Hee-Chul Yun
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
| | - Joon Hyuk Yoo
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
| | - Seung Hoon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
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Wang N, Chang Y, Chen L, Guo YJ, Zhao YS, Guo QH, Ji ES. Tanshinone IIA protects against chronic intermittent hypoxia-induced myocardial injury via activating the endothelin 1 pathway. Biomed Pharmacother 2017; 95:1013-1020. [PMID: 28922718 DOI: 10.1016/j.biopha.2017.08.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 07/19/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023] Open
Abstract
Tanshinone IIA (Tan IIA) may exert significant protective effects against heart oxidative stress damage in obstructive sleep apnoea (OSA) syndrome. Chronic intermittent hypoxia (CIH)-triggered left ventricular dysfunction is used in a rat model to mimic CIH in OSA patients. 48 rats were randomly divided into three groups: normal control (NC) group, CIH group and CIH+Tan IIA group with 16 rats in each group. At the end of experiment (day 21), the blood pressure, Plasma ET-1 and NO content, hemodynamic indexes, heart histology, myocardial apoptosis as well as the expression of eNOS, ET-1, ETA receptor and ETB receptor were compared among different groups. Tan IIA was able to inhibit the increase of blood pressure induced by CIH. Meanwhile, rat cardiac function in Tan IIA group was evaluated by hemodynamic indexes, histopathological examination. Higher ventricular eNOS activity was induced by Tan IIA with a reduction in both ET-1 and ETA receptor expression. However, Tan IIA largely inhibited the decrease of ETB receptor expression. This study demonstrated that Tan IIA has the potential to benefit rat heart against CIH via endothelin system.
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Affiliation(s)
- Na Wang
- Department of Physiology, Hebei University of Chinese Medicine, Shijiazhuang, Hebei, People's Republic of China
| | - Yue Chang
- Department of Physiology, Hebei University of Chinese Medicine, Shijiazhuang, Hebei, People's Republic of China
| | - Lingling Chen
- Department of Pharmacology, Hebei University of Chinese Medicine, Shijiazhuang, Hebei, People's Republic of China
| | - Ya-Jing Guo
- Department of Physiology, Hebei University of Chinese Medicine, Shijiazhuang, Hebei, People's Republic of China
| | - Ya-Shuo Zhao
- Department of Physiology, Hebei University of Chinese Medicine, Shijiazhuang, Hebei, People's Republic of China
| | - Qiu-Hong Guo
- Department of Pharmacology, Hebei University of Chinese Medicine, Shijiazhuang, Hebei, People's Republic of China
| | - En-Sheng Ji
- Department of Physiology, Hebei University of Chinese Medicine, Shijiazhuang, Hebei, People's Republic of China.
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Fernandez-Bustamante A, Bartels K, Clavijo C, Scott BK, Kacmar R, Bullard K, Moss AFD, Henderson W, Juarez-Colunga E, Jameson L. Preoperatively Screened Obstructive Sleep Apnea Is Associated With Worse Postoperative Outcomes Than Previously Diagnosed Obstructive Sleep Apnea. Anesth Analg 2017; 125:593-602. [PMID: 28682951 DOI: 10.1213/ane.0000000000002241] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) affects up to 26% of US adults, is often undiagnosed, and increases perioperative morbidity. We hypothesized that patients screened on the day of surgery as moderate/high risk for OSA (S-OSA) present similar perioperative respiratory complications, hospital use, and mortality than patients with previously diagnosed OSA (D-OSA). Second, we hypothesized that both OSA groups have more respiratory complications than No-OSA patients. METHODS The electronic medical database from 1 academic and 2 community hospitals was retrospectively queried to identify adults undergoing nonemergent inpatient surgery (January 1, 2012, to December 31, 2014). Based on the day-of-surgery preoperative assessment and STOP-BANG (Snoring, Tiredness, Observed apnea during sleep, high blood Pressure, Body mass index >35, Age >50 years, thick Neck, Gender male) score, they were classified as D-OSA, S-OSA, or No-OSA. Perioperative respiratory events and interventions, hospital use, and mortality were measured. The primary outcome composite (adverse respiratory events [AREs]) included perioperative hypoxemic events and difficult airway management. Hypoxemic event was defined as peripheral saturation of oxygen (SpO2) <90% by continuous pulse oximetry for ≥3 minutes, or if validated and/or manually entered into the medical chart. Hypoxemia was classified as mild (lowest SpO2 86%-89%) or moderate/severe (lowest SpO2 ≤85%). Secondary outcomes included postoperative respiratory interventions, intensive care unit admission, hospital length of stay, and 30-day and 1-year all-cause mortality. Outcomes were compared using linear and logistic regression analyses. RESULTS A total of 28,912 patients were assessed: 3432 (11.9%) D-OSA; 1546 (5.3%) S-OSA; and 23,934 (82.8%) No-OSA patients. At least 1 ARE was present in 68.0% of S-OSA; 71.0% of D-OSA; and 52.1% of No-OSA patients (unadjusted P < .001), primarily ≥1 moderate/severe hypoxemic event after discharge from the postanesthesia care unit (PACU; 39.9% in S-OSA; 39.5% in D-OSA; and 27.1% in No-OSA patients). S-OSA patients compared to D-OSA patients presented lower rates of moderate/severe hypoxemia in the PACU but similar intraoperatively and postoperatively, higher difficult mask ventilation rates, and similar difficult intubation reports. After adjusting for demographic, health, and surgical differences and hospital type, the likelihood of ≥1 ARE was not different in S-OSA and D-OSA patients (adjusted odds ratio 0.90 [99% confidence interval, 0.75-1.09]; P = .15). S-OSA patients compared to D-OSA patients had significantly increased postoperative reintubation, mechanical ventilation, direct intensive care unit admission after surgery, hospital length of stay, and 30-day all-cause mortality. CONCLUSIONS Patients classified as S-OSA have similar rates of AREs to D-OSA patients, but increased postoperative respiratory interventions, hospital use, and 30-day all-cause mortality. These worse postoperative outcomes in S-OSA patients than D-OSA patients could reflect the lack of awareness and appropriate management of this bedside S-OSA diagnosis after PACU discharge. Multidisciplinary interventions are needed for these high-risk patients.
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Affiliation(s)
- Ana Fernandez-Bustamante
- From the *Department of Anesthesiology and †Adult and Child Center for Health Outcomes and Delivery Science, University of Colorado Denver, Denver, Colorado
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Gutierrez-Tobal GC, de Frutos J, Alvarez D, Vaquerizo-Villar F, Barroso-Garcia V, Crespo A, Del Campo F, Hornero R. A Bayesian neural network approach to compare the spectral information from nasal pressure and thermistor airflow in the automatic sleep apnea severity estimation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:3741-3744. [PMID: 29060711 DOI: 10.1109/embc.2017.8037670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In the sleep apnea-hypopnea syndrome (SAHS) context, airflow signal plays a key role for the simplification of the diagnostic process. It is measured during the standard diagnostic test by the acquisition of two simultaneous sensors: a nasal prong pressure (NPP) and a thermistor (TH). The current study focuses on the comparison of their spectral content to help in the automatic SAHS-severity estimation. The spectral analysis of 315 NPP and corresponding TH recordings is firstly proposed to characterize the conventional band of interest for SAHS (0.025-0.050 Hz.). A magnitude squared coherence analysis is also conducted to quantify possible differences in the frequency components of airflow from both sensors. Then, a feature selection stage is implemented to assess the relevance and redundancy of the information extracted from the spectrum of NPP and TH airflow. Finally, a multiclass Bayesian multi-layer perceptron (BY-MLP) was used to perform an automatic estimation of SAHS severity (no-SAHS, mild, moderate, and severe), by the use of the selected spectral features from: airflow NPP alone, airflow TH alone, and both sensors jointly. The highest diagnostic performance was reached by BY-MLP only trained with NPP spectral features, reaching Cohen's κ = 0.498 in the overall four-class classification task. It also achieved 91.3%, 84.9%, and 83.3% of accuracy in the binary evaluation of the 3 apnea-hypopnea index cut-offs (5, 15, and 30 events/hour) that define the four SAHS degrees. Our results suggest that TH sensor might be not necessary for SAHS severity estimation if an automatic comprehensive characterization approach is adopted to simplify the diagnostic process.
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Bianchi MT, Goparaju B. Potential Underestimation of Sleep Apnea Severity by At-Home Kits: Rescoring In-Laboratory Polysomnography Without Sleep Staging. J Clin Sleep Med 2017; 13:551-555. [PMID: 28095966 DOI: 10.5664/jcsm.6540] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 12/09/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Home sleep apnea testing (HSAT) is increasingly available for diagnosing obstructive sleep apnea (OSA). One key limitation of most HSAT involves the lack of sleep staging, such that the respiratory event index is calculated using the total recording time (TRT) rather than total sleep time (TST). METHODS We performed a retrospective analysis of n = 838 diagnostic polysomnography (PSG) nights from our center; n = 444 with OSA (4% rule, apneahypopnea index (AHI) ≥ 5), and n = 394 with AHI < 5. We recalculated the AHI using time in bed (TIB) instead of TST, to assess the predicted underestimation risk of OSA severity. RESULTS Of all the patients with OSA, 26.4% would be reclassified as having less severe or no OSA after recalculating the AHI using TIB rather than TST. Of the n = 275 with mild OSA, 18.5% would be reclassified as not having OSA. The risk of underestimation was higher in those with moderate or severe OSA. Of the n = 119 moderate OSA cases, 40.3% would be reclassified as mild, and of the n = 50 severe OSA cases, 36.0% would be reclassified as moderate. Age strongly correlated with the degree of underestimation of the AHI, because age was significantly correlated with time awake during PSG. CONCLUSIONS The risk of sleep apnea underestimation is predicted to be substantial in a tertiary sleep center population. Phenotyping errors included risk of falsely negative results (from mild to normal), as well as category errors: moderate or severe moving to mild or moderate severity, respectively. Clinicians should recognize this underestimation limitation, which directly affects diagnostic phenotyping and thus therapeutic decisions. COMMENTARY A commentary on this article appears in this issue on page 531.
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Affiliation(s)
- Matt T Bianchi
- Neurology Department, Massachusetts General Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Balaji Goparaju
- Neurology Department, Massachusetts General Hospital, Boston, MA
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Setty AR. Underestimation of Sleep Apnea With Home Sleep Apnea Testing Compared to In-Laboratory Sleep Testing. J Clin Sleep Med 2017; 13:531-532. [PMID: 28356176 DOI: 10.5664/jcsm.6534] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/14/2017] [Indexed: 11/13/2022]
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Pulmonary hypertension and echocardiogram parameters in obstructive sleep apnea. Eur Arch Otorhinolaryngol 2017; 274:2601-2606. [DOI: 10.1007/s00405-017-4491-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
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Madsen MT, Isbrand A, Andersen UO, Andersen LJ, Taskiran M, Simonsen E, Gögenur I. The effect of MElatonin on Depressive symptoms, Anxiety, CIrcadian and Sleep disturbances in patients after acute coronary syndrome (MEDACIS): study protocol for a randomized controlled trial. Trials 2017; 18:81. [PMID: 28228148 PMCID: PMC5322602 DOI: 10.1186/s13063-017-1806-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 01/20/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Depression following acute coronary syndrome (ACS) constitutes a serious and debilitating problem. Approximately one in five patients will develop significant depression following ACS and less severe depressive symptoms are even more frequent. Furthermore, anxiety symptoms and sleep-wake disturbances are frequent. The objective of the MEDACIS trial is to investigate whether prophylactic treatment with melatonin has a preventive effect on depression, depressive and anxiety symptoms, sleep, and circadian disturbances following ACS. METHODS/DESIGN "The effect of MElatonin and Depressive symptoms, Anxiety, CIrcadian and Sleep disturbances in patients after acute coronary syndrome" trial (MEDACIS) is a multicenter, double-blinded, placebo-controlled, randomized clinical trial. A total of 240 patients with ACS and no depressive symptoms will be included in the trial for treatment with either 25 mg melatonin or placebo for a 12-week period. Development and severity of depressive symptoms will be evaluated using Major Depression Inventory every 2 weeks with the purpose of investigating the potential preventive effect of melatonin on depressive symptoms. DISCUSSION Previously, only selective serotonin reuptake inhibitors (SSRIs) have been investigated in a primary preventive setup in patients following ACS. However, SSRIs are associated with several side effects. An ideal intervention would constitute the highest degree of prevention of depressive symptoms with the lowest risk of side effects. In this regard, melatonin may have advantages due to its low toxicity as well as its proven anxiolytic and hypnotic effects. TRIAL REGISTRATION ClinicalTrials.gov, Identifier: NCT02451293 . Registered on 12 May 2015. EudraCT nr. 2015-002116-32.
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Affiliation(s)
- Michael Tvilling Madsen
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Lykkebaekvej 1, 4600 Koege, Denmark
- Department of Cardiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark
- Department of Cardiology, Holbaek Hospital, Smedelundsgade 60, 4300 Holbaek, Denmark
- Department of Cardiology, Zealand University Hospital, Roskilde, Koegevej 7-13, 4000 Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand, Faelledvej 6, Bygning 3, 4. Sal., 4200 Slagelse, Denmark
| | - Anders Isbrand
- Department of Cardiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark
| | | | - Lars Juel Andersen
- Department of Cardiology, Zealand University Hospital, Roskilde, Koegevej 7-13, 4000 Roskilde, Denmark
| | - Mustafa Taskiran
- Department of Cardiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand, Faelledvej 6, Bygning 3, 4. Sal., 4200 Slagelse, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ismail Gögenur
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Lykkebaekvej 1, 4600 Koege, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Rodrigues AP, Pinto P, Nunes B, Bárbara C. Obstructive Sleep Apnea: Epidemiology and Portuguese patients profile. REVISTA PORTUGUESA DE PNEUMOLOGIA 2017; 23:57-61. [PMID: 28254339 DOI: 10.1016/j.rppnen.2017.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 01/08/2017] [Accepted: 01/13/2017] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Obstructive Sleep Apnea (OSA) is characterized by recurrent episodes of apnea and hypopnea, secondary to collapse of the upper airways during sleep. OSA is frequently associated to cardiovascular complications. In Portugal, its magnitude is unknown. METHODS In 2014 a cross-sectional study was performed using the Portuguese General Practitioner (GP) Sentinel Network (Rede Médicos Sentinela). Participants GP reported all OSA cases diagnosed and registered in their lists of users on the 31 December 2013. Frequency of OSA has been estimated by sex and age. OSA patients were also characterized by method of diagnosis, treatment, and underlying conditions. Association between risk factors and severe OSA (odds ratio) was calculated using a logistic regression model adjusting confounding. RESULTS Prevalence of OSA on the population aged 25 years or more was 0.89% (95 CI: 0.80-1.00%); it was higher in males 1.47% (95 CI: 1.30-1.67%) and in those aged between 65 and 74 (2.35%). Most had severe OSA (48.4%). Hypertension (75.9%), obesity (74.2%) and diabetes mellitus (34.1%) were the most frequent comorbidities. Being a male (OR: 2.6; 95 CI: 1.2-5.8) and having obesity (OR: 4.0; 95 CI: 1.8-8.6) were associated with an increased risk of severe OSA. CONCLUSION Found frequency of OSA was lower than other countries estimates, which may be explained by differences on case definition but can also suggest underdiagnosis of this condition as reported by other authors.
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Affiliation(s)
- A P Rodrigues
- Departamento de Epidemiologia, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal.
| | - P Pinto
- Programa Nacional para as Doenças Respiratórias, Direção-Geral da Saúde, Serviço de Pneumologia, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - B Nunes
- Departamento de Epidemiologia, Instituto Nacional de Saúde Doutor Ricardo Jorge, Lisboa, Portugal
| | - C Bárbara
- Programa Nacional para as Doenças Respiratórias, Direção-Geral da Saúde, Serviço de Pneumologia, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Portugal
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Hilz MJ, Moeller S, Buechner S, Czarkowska H, Ayappa I, Axelrod FB, Rapoport DM. Obstructive Sleep-Disordered Breathing Is More Common than Central in Mild Familial Dysautonomia. J Clin Sleep Med 2016; 12:1607-1614. [PMID: 27655467 DOI: 10.5664/jcsm.6342] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 07/19/2016] [Indexed: 01/22/2023]
Abstract
STUDY OBJECTIVES In familial dysautonomia (FD) patients, sleep-disordered breathing (SDB) might contribute to their high risk of sleep-related sudden death. Prevalence of central versus obstructive sleep apneas is controversial but may be therapeutically relevant. We, therefore, assessed sleep structure and SDB in FD-patients with no history of SDB. METHODS 11 mildly affected FD-patients (28 ± 11 years) without clinically overt SDB and 13 controls (28 ± 10 years) underwent polysomnographic recording during one night. We assessed sleep stages, obstructive and central apneas (≥ 90% air flow reduction) and hypopneas (> 30% decrease in airflow with ≥ 4% oxygen-desaturation), and determined obstructive (oAI) and central (cAI) apnea indices and the hypopnea index (HI) as count of respective apneas/hypopneas divided by sleep time. We obtained the apnea-hypopnea index (AHI4%) from the total of apneas and hypopneas divided by sleep time. We determined differences between FD-patients and controls using the U-test and within-group differences between oAIs, cAIs, and HIs using the Friedman test and Wilcoxon test. RESULTS Sleep structure was similar in FD-patients and controls. AHI4% and HI were significantly higher in patients than controls. In patients, HIs were higher than oAIs and oAIs were higher than cAIs. In controls, there was no difference between HIs, oAIs, and cAIs. Only patients had apneas and hypopneas during slow wave sleep. CONCLUSIONS In our FD-patients, obstructive apneas were more common than central apneas. These findings may be related to FD-specific pathophysiology. The potential ramifications of SDB in FD-patients suggest the utility of polysomnography to unveil SDB and initiate treatment. COMMENTARY A commentary on this article appears in this issue on page 1583.
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Affiliation(s)
- Max J Hilz
- Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany.,Autonomic Unit, University Colloge of London, Institute of Neurology and National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Sebastian Moeller
- Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Buechner
- Department of Neurology, General Hospital of Bozen/Bolzano, Bozen/Bolzano, Italy
| | - Hanna Czarkowska
- Cushing Neuroscience Institute, NS-LIJ Health System, Great Neck, NY
| | - Indu Ayappa
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY
| | - Felicia B Axelrod
- Dysautonomia Center, New York University Langone School of Medicine, New York, NY
| | - David M Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, NY
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Lee H, Park J, Kim H, Lee KJ. New Rule-Based Algorithm for Real-Time Detecting Sleep Apnea and Hypopnea Events Using a Nasal Pressure Signal. J Med Syst 2016; 40:282. [PMID: 27787786 DOI: 10.1007/s10916-016-0637-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 10/14/2016] [Indexed: 11/28/2022]
Abstract
We developed a rule-based algorithm for automatic real-time detection of sleep apnea and hypopnea events using a nasal pressure signal. Our basic premise was that the performance of our new algorithm using the nasal pressure signal would be comparable to that using other sensors as well as manual annotation labeled by a technician on polysomnography study. We investigated fifty patients with sleep apnea-hypopnea syndrome (age: 56.8 ± 10.5 years, apnea-hypopnea index (AHI): 36.2 ± 18.1/h) during full night PSG recordings at the sleep center. The algorithm was comprised of pre-processing with a median filter, amplitude computation and apnea-hypopnea detection parts. We evaluated the performance of the algorithm a confusion matric for each event and statistical analyses for AHI. Our evaluation achieved a good performance, with a sensitivity of 86.4 %, and a positive predictive value of 84.5 % for detection of apnea and hypopnea regardless of AHI severity. Our results indicated a high correlation with the manually labeled apnea-hypopnea events during PSG, with a correlation coefficient of r = 0.94 (p < 0.0001) and a mean difference of -2.9 ± 11.6 per hour. The proposed new algorithm could provide significant clinical and computational insights to design a PSG analysis system and a continuous positive airway pressure (CPAP) device for screening sleep quality related in patients with sleep apnea-hypopnea syndrome.
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Affiliation(s)
- Hyoki Lee
- Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jonguk Park
- Department of Biomedical Engineering, Yonsei University, Wonju, Republic of Korea
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyoung-Joung Lee
- Department of Biomedical Engineering, Yonsei University, Wonju, Republic of Korea.
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Adhikary N, Shrestha SL, Sun JZ. Metabolic disturbances: role of the circadian timing system and sleep. Diabetol Int 2016; 8:14-22. [PMID: 30603302 DOI: 10.1007/s13340-016-0279-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/28/2016] [Indexed: 12/21/2022]
Abstract
The incidence of metabolic disorders such as obesity and diabetes is on the rise, and food quality is not alone to blame. Sleep disturbances, altered feeding time and circadian disruption are linked to metabolic disturbances in many clinical research studies and cross-sectional analyses. This review tried to summarize the role of the circadian timing system and sleep on energy and metabolic homeostasis. We also tried to explain the molecular and endocrine mechanisms behind circadian misalignment and sleep disorders that lead to metabolic disorders.
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Affiliation(s)
- Navin Adhikary
- 1Department of Endocrinology, Zhongnan Hospital, Wuhan University, Wuhan, 430071 China
| | - Santosh Lal Shrestha
- 2Department of Cardiology, Renmin Hospital, Wuhan University, Wuhan, 430060 China
| | - Jia Zhong Sun
- 1Department of Endocrinology, Zhongnan Hospital, Wuhan University, Wuhan, 430071 China
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Chopra A, Jung M, Kaplan RC, Appel DW, Dinces EA, Dhar S, Zee PC, Gonzalez F, Lee DJ, Ramos AR, Hoffman HJ, Redline S, Cruickshanks KJ, Shah NA. Sleep Apnea Is Associated with Hearing Impairment: The Hispanic Community Health Study/Study of Latinos. J Clin Sleep Med 2016; 12:719-26. [PMID: 26951413 DOI: 10.5664/jcsm.5804] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 01/07/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE Sleep apnea (SA) may promote hearing impairment (HI) through ischemia and inflammation of the cochlea. Our objective was to assess an independent association between SA and HI in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) participants. METHODS We used data from the HCHS/SOL, a multicenter population-based study of self- identifying Hispanic/Latinos 18- to 74-y-old adults from four US urban communities. We performed home SA testing and in-clinic audiometry testing in all participants. SA was defined as an apnea-hypopnea index (AHI) ≥ 15 events/h. HI was defined as a mean hearing threshold > 25 dB hearing level in either ear at the frequencies: 3,000 to 8,000 Hz for high-frequency HI (HF-HI) and 500 to 2,000 Hz for low-frequency HI (LF-HI). Combined-frequency HI (CF-HI) was defined as both conditions present, and Any-HI was considered as HI in either low or high frequencies. RESULTS Of 13,967 participants, 9.9% had SA and 32.3% had Any-HI. Adjusted for risk factors for HI, those with SA had a 30% higher odds of Any-HI (95% confidence interval [CI] = 8% to 57%), 26% higher odds of HF-HI (CI = 3% to 55%), 127% higher odds of LF-HI (CI = 21% to 326%), and 29% higher odds of CF-HI (CI = 0% to 65%). A dose-response association was observed between AHI severity and Any-HI (versus no SA, OR for AHI ≥ 15 and < 30 = 1.22, CI = 0.96 to 1.54, and OR for AHI ≥ 30 = 1.46, CI = 1.11 to 1.91, p = 0.002). CONCLUSION SA is associated with HF-HI and LF-HI, independent of snoring and other confounders. COMMENTARY A commentary on this article appears in this issue on page 641.
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Affiliation(s)
| | - Molly Jung
- Albert Einstein College of Medicine, Bronx, NY
| | | | | | | | | | | | | | | | | | - Howard J Hoffman
- National Institute on Deafness and Other Communication Disorders (NIDCD), National Institutes of Health (NIH), Bethesda, MD
| | | | | | - Neomi A Shah
- Icahn School of Medicine at Mount Sinai, New York, NY
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Gutierrez-Tobal GC, Alvarez D, del Campo F, Hornero R. Utility of AdaBoost to Detect Sleep Apnea-Hypopnea Syndrome From Single-Channel Airflow. IEEE Trans Biomed Eng 2016; 63:636-46. [DOI: 10.1109/tbme.2015.2467188] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Pan WY, Su MC, Wu HT, Su TJ, Lin MC, Sun CK. Multiscale entropic assessment of autonomic dysfunction in patients with obstructive sleep apnea and therapeutic impact of continuous positive airway pressure treatment. Sleep Med 2015; 20:12-7. [PMID: 27318220 DOI: 10.1016/j.sleep.2015.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 11/21/2015] [Accepted: 11/23/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Obstructive sleep apnea (OSA) is an independent risk factor for cardiovascular disease because of its associated autonomic nervous and vascular regulatory dysfunctions. We tested the hypothesis that the multiscale entropy (MSE) approach to heart rate variability analysis may be used for evaluating OSA severity through simultaneous assessment of these abnormalities. METHODS A total of 147 subjects were divided into four groups according to apnea-hypopnea index (AHI) from polysomnography (PSG): Snoring without OSA (5 > AHI, n = 31), mild (5 ≤ AHI < 15, n = 31), moderate (15 ≤ AHI < 30, n = 41), and severe (AHI ≥ 30, n = 44) OSA. Of the patients, 41 receiving continuous positive airway pressure (CPAP) treatment were included for comparison. For each subject, two segments of electrocardiographic (ECG) signals (both at stage N2) were used for R-R interval (RRI) analysis, including a 10-minute recording 10 minutes after falling asleep (ie, early phase) and another 10-minute segment at 3 hours (ie, late phase). Heart rate variability as reflected in changes in RRI between the two segments was assessed with small-scale multiscale entropy index (MEISS, sum of sample entropy from time scale from 1 to 5) and large-scale multiscale entropy index (MEILS, scale from 6 to 10). RESULTS Increase in MEILS in the late phase of sleep was noted in both the normal snoring and CPAP groups (P <0.01). Although the moderate OSA group exhibited MEISS drop in the late phase (P < 0.02), both MEISS and MEILS decreased in the late phase in the severe OSA group (P < 0.001, P < 0.02). However, no differences were noted in mild OSA subjects in both parameters. CONCLUSION The results demonstrated significant severity-dependent deterioration in autonomic and vascular regulatory function in patients with OSA as reflected in the reductions in MEISS and MEILS, respectively, and notable improvement after CPAP treatment. The MEI obtainable through PSG may indicate not only OSA severity and physiological status but also therapeutic outcome for OSA patients.
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Affiliation(s)
- Wen-Yao Pan
- Department of Electrical Engineering, National Dong Hwa University, Hualien, Taiwan
| | - Mao-Chang Su
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsien-Tsai Wu
- Department of Electrical Engineering, National Dong Hwa University, Hualien, Taiwan
| | - Te-Jen Su
- Department of Electronic Engineering, Center of Electronic Communication Techology, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan
| | - Meng-Chih Lin
- Sleep Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, I-Shou University School of Medicine for International Students, Kaohsiung, Taiwan.
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Urinary neutrophil gelatinase-associated lipocalin is associated with heavy metal exposure in welding workers. Sci Rep 2015; 5:18048. [PMID: 26673824 PMCID: PMC4682179 DOI: 10.1038/srep18048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 11/11/2015] [Indexed: 12/20/2022] Open
Abstract
Metals cause nephrotoxicity with acute and/or chronic exposure; however, few epidemiological studies have examined impacts of exposure to metal fumes on renal injury in welding workers. In total, 66 welding workers and 12 office workers were recruited from a shipyard located in southern Taiwan. Urine samples from each subject were collected at the beginning (baseline) and end of the work week (1-week exposure). Personal exposure to PM2.5 was measured. The 8-h mean PM2.5 was 50.3 μg/m3 for welding workers and 27.4 μg/m3 for office workers. iTRAQs coupled with LC-MS/MS were used to discover the pathways in response to welding PM2.5 in the urine, suggesting that extracellular matrix (ECM)-receptor interactions are a critical mechanism. ECM-receptor interaction-related biomarkers for renal injury, kidney injury molecule (KIM)-1 and neutrophil gelatinase-associated lipocalin (NGAL), were significantly elevated in welding workers post-exposure, as well as were urinary Al, Cr, Mn, Fe, Co, and Ni levels. NGAL was more significantly associated with Al (r = 0.737, p < 0.001), Cr (r = 0.705, p < 0.001), Fe (r = 0.709, p < 0.001), and Ni (r = 0.657, p < 0.001) than was KIM-1, suggesting that NGAL may be a urinary biomarker for welding PM2.5 exposure. Nephrotoxicity (e.g., renal tubular injury) may be an emerging concern in occupational health.
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El-Kholy MG, El-Shafey BI, Hantera MS, Ganna SA, El-Sorogy HA, Faisl AERF. Effect of continuous positive airway pressure on oxidative stress accompanied by obstructive sleep apnea. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2015. [DOI: 10.4103/1687-8426.158092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Álvarez D, Gutiérrez-Tobal GC, Del Campo F, Hornero R. Positive airway pressure and electrical stimulation methods for obstructive sleep apnea treatment: a patent review (2005 - 2014). Expert Opin Ther Pat 2015; 25:971-89. [PMID: 26077527 DOI: 10.1517/13543776.2015.1054094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a major health problem with significant negative effects on the health and quality of life. Continuous positive airway pressure (CPAP) is currently the primary treatment option and it is considered the most effective therapy for OSAHS. Nevertheless, comfort issues due to improper fit to patient's changing needs and breathing gas leakage limit the patient's adherence to treatment. AREAS COVERED The present patent review describes recent innovations in the treatment of OSAHS related to optimization of the positive pressure delivered to the patient, methods and systems for continuous self-adjusting pressure during inspiration and expiration phases, and techniques for electrical stimulation of nerves and muscles responsible for the airway patency. EXPERT OPINION In the last few years, CPAP-related inventions have mainly focused on obtaining an optimal self-adjusting pressure according to patient's needs. Despite intensive research carried out, treatment compliance is still a major issue. Hypoglossal electrical nerve stimulation could be an effective secondary treatment option when CPAP primary therapy fails. Several patents have been granted focused on selective stimulation techniques and parameter optimization of the stimulating pulse waveform. Nevertheless, there remain important issues to address, like effectiveness and adverse events due to improper stimulation.
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Affiliation(s)
- Daniel Álvarez
- a 1 Universidad de Valladolid, Biomedical Engineering Group, E.T.S.I. Telecomunicación , Paseo de Belén 15, 47011 Valladolid, Spain +34 983185570 ; +34 983 423667 ;
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Continuous Positive Airway Pressure Treatment Reduces Mortality in Elderly Patients with Moderate to Severe Obstructive Severe Sleep Apnea: A Cohort Study. PLoS One 2015; 10:e0127775. [PMID: 26068440 PMCID: PMC4465781 DOI: 10.1371/journal.pone.0127775] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 04/19/2015] [Indexed: 12/21/2022] Open
Abstract
Obstructive sleep apnea (OSA) is much more prevalent in older people than in middle-aged or young populations, and has been associated with cardiovascular disease. Continuous positive airway pressure (CPAP) is the first-line therapy for OSA, but its long-term clinical benefit in the elderly is unclear. Here, we carried out a prospective cohort study to explore the survival rate and incidence of cardiovascular events in elderly patients with moderate to severe OSA who did or did not receive CPAP treatment. The study included 130 patients (104 male, 26 female; mean age: 77.8 ± 6.2 years) who were followed up for a mean of 5 ± 2.54 years (range, 1–8 years). Thirty-six patients received CPAP and 88 had no CPAP. The results showed that mortality in the untreated group (21.6%) was significantly higher than in the CPAP group (5.6%). Kaplan–Meier survival analysis showed that the survival rate in the CPAP group was 94.4%, which was markedly higher than the rate of 78.4% in the untreated group. The incidence of cardiovascular events was 13.9% in the CPAP group and 55.7% in the untreated group. The present study provides evidence that CPAP can reduce mortality in older patients with moderate to severe OSA, and lead to a good long-term prognosis. The study also indicates that death in older OSA patients is associated with cardiovascular disease and diabetes.
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Briançon-Marjollet A, Weiszenstein M, Henri M, Thomas A, Godin-Ribuot D, Polak J. The impact of sleep disorders on glucose metabolism: endocrine and molecular mechanisms. Diabetol Metab Syndr 2015. [PMID: 25834642 DOI: 10.1186/s13098- 015-0018-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Modern lifestyle has profoundly modified human sleep habits. Sleep duration has shortened over recent decades from 8 to 6.5 hours resulting in chronic sleep deprivation. Additionally, irregular sleep, shift work and travelling across time zones lead to disruption of circadian rhythms and asynchrony between the master hypothalamic clock and pacemakers in peripheral tissues. Furthermore, obstructive sleep apnea syndrome (OSA), which affects 4 - 15% of the population, is not only characterized by impaired sleep architecture but also by repetitive hemoglobin desaturations during sleep. Epidemiological studies have identified impaired sleep as an independent risk factor for all cause of-, as well as for cardiovascular, mortality/morbidity. More recently, sleep abnormalities were causally linked to impairments in glucose homeostasis, metabolic syndrome and Type 2 Diabetes Mellitus (T2DM). This review summarized current knowledge on the metabolic alterations associated with the most prevalent sleep disturbances, i.e. short sleep duration, shift work and OSA. We have focused on various endocrine and molecular mechanisms underlying the associations between inadequate sleep quality, quantity and timing with impaired glucose tolerance, insulin resistance and pancreatic β-cell dysfunction. Of these mechanisms, the role of the hypothalamic-pituitary-adrenal axis, circadian pacemakers in peripheral tissues, adipose tissue metabolism, sympathetic nervous system activation, oxidative stress and whole-body inflammation are discussed. Additionally, the impact of intermittent hypoxia and sleep fragmentation (key components of OSA) on intracellular signaling and metabolism in muscle, liver, fat and pancreas are also examined. In summary, this review provides endocrine and molecular explanations for the associations between common sleep disturbances and the pathogenesis of T2DM.
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Affiliation(s)
- Anne Briançon-Marjollet
- Université Grenoble Alpes, HP2, F-38041 Grenoble, Cedex France.,INSERM U1042, F-38041 Grenoble, Cedex France
| | - Martin Weiszenstein
- Centre for Research on Diabetes, Metabolism and Nutrition, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marion Henri
- Université Grenoble Alpes, HP2, F-38041 Grenoble, Cedex France.,INSERM U1042, F-38041 Grenoble, Cedex France
| | - Amandine Thomas
- Université Grenoble Alpes, HP2, F-38041 Grenoble, Cedex France.,INSERM U1042, F-38041 Grenoble, Cedex France
| | - Diane Godin-Ribuot
- Université Grenoble Alpes, HP2, F-38041 Grenoble, Cedex France.,INSERM U1042, F-38041 Grenoble, Cedex France
| | - Jan Polak
- Centre for Research on Diabetes, Metabolism and Nutrition, Third Faculty of Medicine, Charles University, Prague, Czech Republic.,2nd Internal Medicine Department, University Hospital Kralovske Vinohrady, Prague, Czech Republic.,Sports Medicine Department, Third Faculty of Medicine, Charles University in Prague, Ruska 87, Praha 10, 100 00 Czech Republic
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Oldenburg O, Arzt M, Bitter T, Bonnemeier H, Edelmann F, Fietze I, Podszus T, Schäfer T, Schöbel C, Skobel E, Skowasch D, Penzel T, Nienaber C. Positionspapier „Schlafmedizin in der Kardiologie“. KARDIOLOGE 2015. [DOI: 10.1007/s12181-015-0654-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Multiscale Entropy Analysis of Heart Rate Variability for Assessing the Severity of Sleep Disordered Breathing. ENTROPY 2015. [DOI: 10.3390/e17010231] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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