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Nemet M, Vukoja M. Obstructive Sleep Apnea and Acute Lower Respiratory Tract Infections: A Narrative Literature Review. Antibiotics (Basel) 2024; 13:532. [PMID: 38927198 PMCID: PMC11200551 DOI: 10.3390/antibiotics13060532] [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: 05/04/2024] [Revised: 05/27/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Both obstructive sleep apnea (OSA) and acute lower respiratory tract infections (LRTIs) are important global health issues. The pathophysiological links between OSA and LRTIs include altered immune responses due to chronic intermittent hypoxia and sleep fragmentation, increased aspiration risk, and a high burden of comorbidities. In this narrative review, we evaluated the current evidence on the association between OSA and the incidence and outcomes of acute LRTIs in adults, specifically community-acquired pneumonia and viral pneumonia caused by influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Studies have demonstrated that OSA patients are more likely to develop bacterial pneumonia and exhibit a higher risk of invasive pneumococcal disease. The risk intensifies with the severity of OSA, influencing hospitalization rates and the need for intensive care. OSA is also associated with an increased risk of contracting influenza and suffering more severe disease, potentially necessitating hospitalization. Similarly, OSA contributes to increased COVID-19 disease severity, reflected by higher rates of hospitalization, longer hospital stays, and a higher incidence of acute respiratory failure. The effect of OSA on mortality rates from these infections is, however, somewhat ambiguous. Finally, we explored antibiotic therapy for OSA patients with LRTIs, addressing care settings, empirical regimens, risks, and pharmacokinetic considerations. Given the substantial burden of OSA and its significant interplay with acute LRTIs, enhanced screening, targeted vaccinations, and optimized management strategies for OSA patients should be prioritized.
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Affiliation(s)
- Marko Nemet
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia;
| | - Marija Vukoja
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia;
- The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, 21204 Novi Sad, Serbia
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Morey BN, Shi Y, Ryu S, Redline S, Kawachi I, Park HW, Lee S. Risk of sleep apnea associated with higher blood pressure among Chinese and Korean Americans. ETHNICITY & HEALTH 2024; 29:295-308. [PMID: 38303653 PMCID: PMC10987275 DOI: 10.1080/13557858.2024.2311417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE This study examines associations between sleep apnea risk and hypertension in a sample of immigrant Chinese and Korean Americans. DESIGN The dataset included Chinese and Korean patients ages 50-75 recruited from primary care physicians' offices from April 2018 to June 2020 in the Baltimore-Washington DC Metropolitan Area (n = 394). Hypertension risk was determined using a combination of blood pressure measurements, self-reported diagnosis of hypertension by a medical professional, and/or self-reported use of antihypertensive medications. Linear regression models examined the associations between sleep apnea risk and blood pressure (systolic blood pressure [SBP] and diastolic blood pressure [DBP]). Poisson regression models examined associations sleep apnea risk and hypertension. Models controlled for body mass index (BMI), demographic, and socioeconomic risk factors. We further examined models for potential effect modification by age, gender, Asian subgroup, and obesity, as well as effect modification of daytime sleepiness on the association between snoring and hypertension risk. RESULTS High risk of sleep apnea appeared to be associated positively with SBP (β = 6.77, 95% CI: 0.00-13.53), but not with DBP. The association was positive for hypertension, but it was not statistically significant (PR = 1.11, 95% CI: 0.87-1.41). We did not find effect modification of the associations between sleep apnea and hypertension risk, but we did find that daytime sleepiness moderated the effect of snoring on SBP. Snoring was associated with higher SBP, primarily in the presence of daytime sleepiness, such that predicted SBP was 133.27 mmHg (95% CI: 126.52, 140.02) for someone with both snoring and daytime sleepiness, compared to 123.37 mmHg (95% CI: 120.40, 126.34) for someone neither snoring nor daytime sleepiness. CONCLUSION Chinese and Korean immigrants living in the U.S. who are at high risk of sleep apnea have higher SBP on average, even after accounting for sociodemographic characteristics and BMI. CLINICAL TRAIL REGISTRATION : NCT03481296, date of registration: 3/29/2018.
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Affiliation(s)
- Brittany N. Morey
- University of California, Irvine, Program in Public Health, Department of Health, Society, & Behavior, Irvine, CA, U.S.A
| | - Yuxi Shi
- University of California, Irvine, School of Medicine, Department of Medicine, Irvine, CA, U.S.A
| | - Soomin Ryu
- University of Michigan School of Public Health, Department of Epidemiology, Ann Arbor, MI, U.S.A
| | - Susan Redline
- Harvard Medical School, Brigham and Women’s Hospital, Department of Medicine, and Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, U.S.A
| | - Ichiro Kawachi
- Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, MA, U.S.A
| | - Hye Won Park
- University of California, Irvine, School of Medicine, Department of Medicine, Irvine, CA, U.S.A
| | - Sunmin Lee
- University of California, Irvine, School of Medicine, Department of Medicine, Irvine, CA, U.S.A
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Luo H, Yan J, Gong R, Zhang D, Zhou X, Wang X. Identification of biomarkers and pathways for the SARS-CoV-2 infections in obstructive sleep apnea patients based on machine learning and proteomic analysis. BMC Pulm Med 2024; 24:112. [PMID: 38443855 PMCID: PMC10913609 DOI: 10.1186/s12890-024-02921-1] [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: 10/12/2023] [Accepted: 02/22/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The prevalence of obstructive sleep apnea (OSA) was found to be higher in individuals following COVID-19 infection. However, the intricate mechanisms that underscore this concomitance remain partially elucidated. The aim of this study was to delve deeper into the molecular mechanisms that underpin this comorbidity. METHODS We acquired gene expression profiles for COVID-19 (GSE157103) and OSA (GSE75097) from the Gene Expression Omnibus (GEO) database. Upon identifying shared feature genes between OSA and COVID-19 utilizing LASSO, Random forest and Support vector machines algorithms, we advanced to functional annotation, analysis of protein-protein interaction networks, module construction, and identification of pivotal genes. Furthermore, we established regulatory networks encompassing transcription factor (TF)-gene and TF-miRNA interactions, and searched for promising drug targets. Subsequently, the expression levels of pivotal genes were validated through proteomics data from COVID-19 cases. RESULTS Fourteen feature genes shared between OSA and COVID-19 were selected for further investigation. Through functional annotation, it was indicated that metabolic pathways play a role in the pathogenesis of both disorders. Subsequently, employing the cytoHubba plugin, ten hub genes were recognized, namely TP53, CCND1, MDM2, RB1, HIF1A, EP300, STAT3, CDK2, HSP90AA1, and PPARG. The finding of proteomics unveiled a substantial augmentation in the expression level of HSP90AA1 in COVID-19 patient samples, especially in severe conditions. CONCLUSIONS Our investigation illuminate a mutual pathogenic mechanism that underlies both OSA and COVID-19, which may provide novel perspectives for future investigations into the underlying mechanisms.
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Affiliation(s)
- Hong Luo
- Department of Tuberculosis and Respiratory, Wuhan Jinyintan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jisong Yan
- Department of Tuberculosis and Respiratory, Wuhan Jinyintan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Gong
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China (USTC), Hefei, Anhui, China
| | - Dingyu Zhang
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China (USTC), Hefei, Anhui, China
- Center for Translational Medicine, Wuhan Jinyintan Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei, China
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei, China
| | - Xia Zhou
- Department of Tuberculosis and Respiratory, Wuhan Jinyintan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- Hubei Clinical Research Center for Infectious Diseases, Wuhan, China.
- Wuhan Research Center for Communicable Disease Diagnosis and Treatment, Chinese Academy of Medical Sciences, Wuhan, China.
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology and Wuhan Jinyintan Hospital, Chinese Academy of Sciences, Wuhan, China.
| | - Xianguang Wang
- Department of Tuberculosis and Respiratory, Wuhan Jinyintan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- Hubei Clinical Research Center for Infectious Diseases, Wuhan, China.
- Wuhan Research Center for Communicable Disease Diagnosis and Treatment, Chinese Academy of Medical Sciences, Wuhan, China.
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology and Wuhan Jinyintan Hospital, Chinese Academy of Sciences, Wuhan, China.
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Atceken Z, Celik Y, Atasoy C, Peker Y. The Diagnostic Utility of Artificial Intelligence-Guided Computed Tomography-Based Severity Scores for Predicting Short-Term Clinical Outcomes in Adults with COVID-19 Pneumonia. J Clin Med 2023; 12:7039. [PMID: 38002652 PMCID: PMC10672493 DOI: 10.3390/jcm12227039] [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: 09/27/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Chest computed tomography (CT) imaging with the use of an artificial intelligence (AI) analysis program has been helpful for the rapid evaluation of large numbers of patients during the COVID-19 pandemic. We have previously demonstrated that adults with COVID-19 infection with high-risk obstructive sleep apnea (OSA) have poorer clinical outcomes than COVID-19 patients with low-risk OSA. In the current secondary analysis, we evaluated the association of AI-guided CT-based severity scores (SSs) with short-term outcomes in the same cohort. In total, 221 patients (mean age of 52.6 ± 15.6 years, 59% men) with eligible chest CT images from March to May 2020 were included. The AI program scanned the CT images in 3D, and the algorithm measured volumes of lobes and lungs as well as high-opacity areas, including ground glass and consolidation. An SS was defined as the ratio of the volume of high-opacity areas to that of the total lung volume. The primary outcome was the need for supplemental oxygen and hospitalization over 28 days. A receiver operating characteristic (ROC) curve analysis of the association between an SS and the need for supplemental oxygen revealed a cut-off score of 2.65 on the CT images, with a sensitivity of 81% and a specificity of 56%. In a multivariate logistic regression model, an SS > 2.65 predicted the need for supplemental oxygen, with an odds ratio (OR) of 3.98 (95% confidence interval (CI) 1.80-8.79; p < 0.001), and hospitalization, with an OR of 2.40 (95% CI 1.23-4.71; p = 0.011), adjusted for age, sex, body mass index, diabetes, hypertension, and coronary artery disease. We conclude that AI-guided CT-based SSs can be used for predicting the need for supplemental oxygen and hospitalization in patients with COVID-19 pneumonia.
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Affiliation(s)
- Zeynep Atceken
- Department of Radiology, Koc University School of Medicine, Istanbul 34010, Turkey; (Z.A.); (C.A.)
| | - Yeliz Celik
- Center for Translational Medicine (KUTTAM), Department of Pulmonary Medicine, Koc University School of Medicine, and Koc University Research, Koc University, Istanbul 34010, Turkey;
| | - Cetin Atasoy
- Department of Radiology, Koc University School of Medicine, Istanbul 34010, Turkey; (Z.A.); (C.A.)
| | - Yüksel Peker
- Center for Translational Medicine (KUTTAM), Department of Pulmonary Medicine, Koc University School of Medicine, and Koc University Research, Koc University, Istanbul 34010, Turkey;
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, 40530 Gothenburg, Sweden
- Department of Clinical Sciences, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, 22185 Lund, Sweden
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- Division of Sleep and Circadian Disorders, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA 02115, USA
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Haldar P, Prasad K, Kant S, Dwivedi SN, Vibha D, Pandit AK, Srivastava AK, Kumar A, Ikram MA, Henning T. Metabolic risk factors and psychosocial problems independently explain poor sleep quality and obstructive sleep apnea symptoms among adults in urban India. Sleep Breath 2023; 27:1541-1555. [PMID: 36280653 DOI: 10.1007/s11325-022-02725-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Abstract
STUDY OBJECTIVES To determine if metabolic risk factors are associated with poor sleep quality and obstructive sleep apnea-like symptoms (OSA symptoms) independent of psychosocial problems and demographic and lifestyle factors in older Indian adults. METHODOLOGY We analyzed baseline data from adults (≥ 50 years) from a population-based cohort, the LoCARPoN study, in India. Variables were grouped as (a) demographic and lifestyle factors such as smoking, alcohol use, and physical activity; (b) psychosocial problems including symptoms of depression, anxiety, and perceived stress; and (c) metabolic risk factors including glycated hemoglobin, high-density lipoprotein, low-density lipoprotein, total cholesterol, body mass index, and hypertension. Variables were examined as predictors of poor sleep quality and OSA symptoms. Groups of variables were added stepwise to a logistic regression. Variance explained by nested models was quantified using McFadden's pseudo R2, and change was formally tested with the log-likelihood ratio test. RESULTS Among 7505 adults, the prevalence of poor sleep quality was 16.9% (95% CI: 16.0, 17.7), and OSA symptoms were present in 7.0% (95% CI: 6.4, 7.6). Psychosocial problems had a strong independent association with both poor sleep quality (pseudo R2 increased from 0.10 to 0.15, p < 0.001) and more OSA symptoms (pseudo R2 increased from 0.08 to 0.10, p < 0.001). Metabolic risk factors had a modest independent association with sleep quality (pseudo R2 increased from 0.14 to 0.15, p < 0.01), but a strong association with OSA symptoms (pseudo R2 increased from 0.08 to 0.10, p < 0.001). CONCLUSION Psychosocial and metabolic risk factors were independently associated with sleep quality and OSA symptoms. This fact implied that OSA symptoms may affect both mental health and physical health. Our findings have public health implications because the number and proportion of the elderly in India is increasing, while the prevalence of metabolic risk factors and psychosocial problems is high already. These facts have the potential to exacerbate not only the burden of sleep disorders and OSA symptoms but also associated cardiovascular and neurologic sequelae, further stretching the Indian health-care system.
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Affiliation(s)
- Partha Haldar
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kameshwar Prasad
- Rajendra Institute of Medical Sciences, Ranchi, 834009, Jharkhand, India.
| | - Shashi Kant
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sada Nand Dwivedi
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Awadh Kishor Pandit
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Amit Kumar
- Rajendra Institute of Medical Sciences, Ranchi, 834009, Jharkhand, India
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tiemeier Henning
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Arish N, Izbicki G, Rokach A, Jarjou'i A, Kalak G, Goldberg S. Association of the risk of obstructive sleep apnoea with the severity of COVID-19. PLoS One 2023; 18:e0284063. [PMID: 37463178 DOI: 10.1371/journal.pone.0284063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 03/23/2023] [Indexed: 07/20/2023] Open
Abstract
Patients with coronavirus 2019 (COVID-19) and obstructive sleep apnoea (OSA) have a worse prognosis than COVID-19 patients without OSA. This study aimed to examine the relationship between OSA risk and the severity of COVID-19 in patients undiagnosed with OSA. Patients diagnosed with COVID-19 and hospitalized or admitted to a community hotel were recruited for the study after recovery during a clinic check-up visit 6-8 weeks after discharge. At this visit, they answered the Epworth Sleeping Scale (ESS) and Berlin questionnaire. Demographic and clinical details were collected from electronic medical records. OSA risk was observed in 37 of 119 included patients (31.1%). Patients with high OSA risk were male, significantly older, had a higher body mass index (BMI), and had higher rates of hypertension and snoring than patients with low OSA risk. Moreover, OSA risk was associated with COVID-19 severity; 48.6% of patients with high risk for OSA suffered from severe COVID-19 compared to 22% of patients with low risk for OSA (p = 0.007). The duration of hospitalization for patients with a high OSA risk was 10.97±9.43 days, while that for those with a low OSA risk was 4.71±6.86 days (p = 0.001). After adjusting for BMI, age, hypertension, and chronic disease, the odds ratio was 4.3 (95%CI, 1.2-16, p = 0.029). A high OSA risk was associated with severe COVID-19 and longer hospitalization. Thus, we recommend that the Berlin and ESS questionnaires be completed for every COVID-19-infected patient at hospitalization, especially in the presence of comorbidities.
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Affiliation(s)
- Nissim Arish
- Respiratory Research Unit, Pulmonary Institute, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gabriel Izbicki
- Respiratory Research Unit, Pulmonary Institute, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ariel Rokach
- Respiratory Research Unit, Pulmonary Institute, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amir Jarjou'i
- Respiratory Research Unit, Pulmonary Institute, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - George Kalak
- Respiratory Research Unit, Pulmonary Institute, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shmuel Goldberg
- Pediatric Unit, Pulmonary Institute, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Quan SF, Weaver MD, Czeisler MÉ, Barger LK, Booker LA, Howard ME, Jackson ML, Lane R, McDonald CF, Ridgers A, Robbins R, Varma P, Rajaratnam SM, Czeisler CA. Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among US adults. J Clin Sleep Med 2023; 19:1303-1311. [PMID: 37279079 PMCID: PMC10315594 DOI: 10.5664/jcsm.10588] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/30/2023]
Abstract
STUDY OBJECTIVES Medical comorbidities increase the risk of severe COVID-19 infection. In some studies, obstructive sleep apnea (OSA) has been identified as a comorbid condition that is associated with an increased prevalence of COVID-19 infection and hospitalization, but few have investigated this association in a general population. This study aimed to answer the following research question: In a general population, is OSA associated with increased odds of COVID-19 infection and hospitalization and are these altered with COVID-19 vaccination? METHODS This was a cross-sectional survey of a diverse sample of 15,057 US adults. RESULTS COVID-19 infection and hospitalization rates in the cohort were 38.9% and 2.9%, respectively. OSA or OSA symptoms were reported in 19.4%. In logistic regression models adjusted for demographic, socioeconomic, and comorbid medical conditions, OSA was positively associated with COVID-19 infection (adjusted odds ratio: 1.58, 95% CI: 1.39-1.79) and COVID-19 hospitalization (adjusted odds ratio: 1.55, 95% CI: 1.17-2.05). In fully adjusted models, boosted vaccination status was protective against both infection and hospitalization. Boosted vaccination status attenuated the association between OSA and COVID-19 related hospitalization but not infection. Participants with untreated or symptomatic OSA were at greater risk for COVID-19 infection; those with untreated but not symptomatic OSA were more likely to be hospitalized. CONCLUSIONS In a general population sample, OSA is associated with a greater likelihood of having had a COVID-19 infection and a COVID-19 hospitalization with the greatest impact observed among persons experiencing OSA symptoms or who were untreated for their OSA. Boosted vaccination status attenuated the association between OSA and COVID-19-related hospitalization. CITATION Quan SF, Weaver MD, Czeisler MÉ, et al. Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among U.S. adults. J Clin Sleep Med. 2023;19(7):1303-1311.
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Affiliation(s)
- Stuart F. Quan
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Matthew D. Weaver
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Mark É. Czeisler
- Francis Weld Peabody Society, Harvard Medical School, Boston, Massachusetts
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Laura K. Barger
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lauren A. Booker
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Mark E. Howard
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Melinda L. Jackson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Rashon Lane
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Christine F. McDonald
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Monash University, Melbourne Australia
| | - Anna Ridgers
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Rebecca Robbins
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Prerna Varma
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Shantha M.W. Rajaratnam
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Charles A. Czeisler
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
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Celik Y, Baygül A, Peker Y. Validation of the Modified Berlin Questionnaire for the Diagnosis of Obstructive Sleep Apnea in Patients with a History of COVID-19 Infection. J Clin Med 2023; 12:jcm12093047. [PMID: 37176488 PMCID: PMC10178945 DOI: 10.3390/jcm12093047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
(1) Background: The Berlin questionnaire (BQ) is a widely used survey to predict obstructive sleep apnea (OSA). Considering the confounding effect of obesity and hypertension on the clinical course of COVID-19, we have recently developed a modified BQ (mBQ) based on the subscales snoring intensity/frequency, witnessed apneas and morning/daytime tiredness, and demonstrated that patients with high-risk OSA had worse outcomes during the COVID-19 pandemic. In the current study, we aimed to validate the mBQ in adults with a history of COVID-19 infection. (2) Method: All cases who suffered from COVID-19 infection between 10 March and 22 June 2020, and who completed the mBQ in our first study, were invited to participate. Participants refilled the questionnaires, and an attended polysomnography (PSG) was conducted. An apnea-hypopnea index (AHI) of 15 events/h or more was considered as OSA. (3) Results: Out of the 70 participants, 27 (39%) were categorized as having a high risk of OSA based on the mBQ. According to the PSG results, 24 patients with high-risk OSA (89%) and 3 patients with low-risk OSA on the mBQ (7%) had AHI ≥ 15 events/h. The mBQ had a sensitivity of 89%, a specificity of 93%, a positive predictive value of 89%, a negative predictive value of 93%, and an accuracy of 91%. The area under the curve was 0.91 confirming a very good performance of the mBQ in screening for OSA. (4) Conclusions: The mBQ has a good level of diagnostic sensitivity, specificity, and accuracy among adults with a history of COVID-19 infection. Since the confounding effects of obesity and hypertension are eliminated, the mBQ may be used not only as a screening tool for high-risk OSA but also as a prognostic survey in clinical cohorts.
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Affiliation(s)
- Yeliz Celik
- Graduate School of Health Sciences, Koc Universitesi, 34450 Istanbul, Turkey
- Research Center for Translational Medicine (KUTTAM), Koc University School of Medicine, 34450 Istanbul, Turkey
- Irving Medical Center, Columbia Universitesi, New York, NY 10027, USA
| | - Arzu Baygül
- Graduate School of Health Sciences, Koc Universitesi, 34450 Istanbul, Turkey
- Research Center for Translational Medicine (KUTTAM), Koc University School of Medicine, 34450 Istanbul, Turkey
| | - Yüksel Peker
- Research Center for Translational Medicine (KUTTAM), Koc University School of Medicine, 34450 Istanbul, Turkey
- Department of Pulmonary Medicine, Koc University School of Medicine, 34450 Istanbul, Turkey
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41319 Gothenburg, Sweden
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA 02115, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Department of Clinical Sciences, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, 22100 Lund, Sweden
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Khosla S, Cheung J, Gurubhagavatula I. Sleep Assessment in Long COVID Clinics: A Necessary Tool for Effective Management. Neurol Clin Pract 2023; 13:e200079. [PMID: 36891281 PMCID: PMC9987203 DOI: 10.1212/cpj.0000000000200079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/11/2022] [Indexed: 01/19/2023]
Abstract
As we adapt to SARS-CoV-2, it has become apparent that the acute illness is not the only threat from this virus. Long COVID has emerged as a potentially disabling condition with multiple varied symptoms. We propose that querying patients about their sleep may allow for the assessment of a sleep-related disorder that is amenable to treatment. In addition, hypersomnolence is a prominent feature and may mimic other organic hypersomnias; therefore, inquiring about COVID-19 infection in sleepy patients is suggested.
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Affiliation(s)
- Seema Khosla
- North Dakota Center for Sleep (SK), Fargo, ND; Mayo Clinic Division of Pulmonary and Sleep Medicine (JC), Jacksonville, FL; Division of Sleep Medicine (IG), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Corporal Michael Crescenz VA Medical Center (IG), Philadelphia, PA
| | - Joseph Cheung
- North Dakota Center for Sleep (SK), Fargo, ND; Mayo Clinic Division of Pulmonary and Sleep Medicine (JC), Jacksonville, FL; Division of Sleep Medicine (IG), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Corporal Michael Crescenz VA Medical Center (IG), Philadelphia, PA
| | - Indira Gurubhagavatula
- North Dakota Center for Sleep (SK), Fargo, ND; Mayo Clinic Division of Pulmonary and Sleep Medicine (JC), Jacksonville, FL; Division of Sleep Medicine (IG), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Corporal Michael Crescenz VA Medical Center (IG), Philadelphia, PA
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10
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Morey BN, Ryu S, Shi Y, Redline S, Kawachi I, Lee S. Associations between sleep apnea risk and cardiovascular disease indicators among Chinese and Korean Americans. SLEEP EPIDEMIOLOGY 2022; 2:100037. [PMID: 36250200 PMCID: PMC9555314 DOI: 10.1016/j.sleepe.2022.100037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
STUDY OBJECTIVES While sleep apnea has been associated with cardiovascular disease (CVD) risk factors in white individuals in the U.S., these associations in Chinese and Korean Americans are less well-understood, particularly how these associations vary by age, gender, Asian origin, obesity, chronic conditions, and daytime sleepiness. METHODS We used a sample of Chinese and Korean Americans ages 50-75 (n = 394) from the Baltimore-Washington DC Metropolitan Area to examine the associations of high risk (HR) sleep apnea with diagnoseable hypercholesterolemia and diabetes, as well as the following biomarkers: total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol/HDL-C ratio, triglycerides, and glucose (non-fasting). Poisson models included demographic factors, socioeconomic status, and body mass index (BMI). We tested for potential effect modifiers. RESULTS HR-sleep apnea was associated with higher LDL-C level (β = 14.56, p < 0.05) and higher total cholesterol/HDL ratio (β = 0.64, p < 0.01). Younger respondents had higher levels of triglycerides associated with HR-sleep apnea than older respondents. For men, HR-sleep apnea was associated with higher total cholesterol, total cholesterol/HDL-C ratio, and triglycerides. Obese and overweight respondents had positive associations between HR-sleep apnea and total cholesterol, total cholesterol/HDL ratio, and triglycerides, while underweight/normal weight individuals did not. The interactions between snoring and daytime sleepiness were associated with hypercholesterolemia and diabetes. CONCLUSIONS This study demonstrates associations between sleep apnea risk and dyslipidemia among Chinese and Korean Americans. Associations were particularly pronounced among younger, male, overweight/obese, and sicker individuals. Future research should examine how to improve sleep health in Asian American populations to improve CVD risk.
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Affiliation(s)
- Brittany N. Morey
- Department of Health, Society, & Behavior, Program in Public Health, University of California Irvine, 653 E. Peltason Dr., Anteater Instruction and Research Building (AIRB) 2022, Irvine, CA 92697-3957, USA
| | - Soomin Ryu
- School of Public Policy, University of Maryland, College Park, USA
| | - Yuxi Shi
- University of California, Irvine, USA
| | - Susan Redline
- Department of Medicine, and Harvard T.H. Chan School of Public Health, Department of Epidemiology, Harvard Medical School, Brigham and Women’s Hospital, USA
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, USA
| | - Sunmin Lee
- Department of Medicine, School of Medicine, University of California, Irvine, USA
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11
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Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry. J Prosthet Dent 2022; 128:248-330. [PMID: 36096911 DOI: 10.1016/j.prosdent.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 11/23/2022]
Abstract
The Scientific Investigation Committee of the American Academy of Restorative Dentistry offers this review of the 2021 dental literature in restorative dentistry to inform busy dentists regarding noteworthy scientific and clinical progress over the past year. Each member of the committee brings discipline-specific expertise to coverage of this broad topical area. Specific subject areas addressed, in order of the appearance in this report, include COVID-19 and the dental profession (new); prosthodontics; periodontics, alveolar bone, and peri-implant tissues; implant dentistry; dental materials and therapeutics; occlusion and temporomandibular disorders; sleep-related breathing disorders; oral medicine and oral and maxillofacial surgery; and dental caries and cariology. The authors focused their efforts on reporting information likely to influence daily dental treatment decisions with an emphasis on future trends in dentistry. With the tremendous volume of dentistry and related literature being published daily, this review cannot possibly be comprehensive. Rather, its purpose is to update interested readers and provide important resource material for those interested in pursuing greater details on their own. It remains our intent to assist colleagues in negotiating the extensive volume of important information being published annually. It is our hope that readers find this work useful in successfully managing the patients and dental problems they encounter.
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12
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Pellitteri G, Surcinelli A, De Martino M, Fabris M, Janes F, Bax F, Marini A, Milanic R, Piani A, Isola M, Gigli GL, Valente M. Sleep alterations following COVID-19 are associated with both neuroinflammation and psychological disorders, although at different times. Front Neurol 2022; 13:929480. [PMID: 36062000 PMCID: PMC9428349 DOI: 10.3389/fneur.2022.929480] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionBy the end of 2019, severe acute respiratory syndrome coronavirus 2 rapidly spread all over the world impacting mental health and sleep habits. Insomnia, impaired sleep quality, and circadian rhythm alterations were all observed during the pandemic, especially among healthcare workers and in patients with acute and post-acute COVID-19. Sleep disruption may induce a pro-inflammatory state associated with an impairment of immune system function.ObjectiveWe investigated the relationship between sleep alterations, psychological disorders, and inflammatory blood biomarkers in patients with post-acute COVID-19.MethodsWe enrolled 47 subjects diagnosed with COVID-19 pneumonia at Santa Maria della Misericordia University Hospital (Udine, Italy) between March and May 2020. Selected patients were evaluated at 2 months (T1) and 10 months (T2) after discharge. Each time, we collected clinical interviews, neurological examinations, and self-administered questionnaires to assess sleep and life quality, anxiety, depression, and post-traumatic stress disorder. Blood biomarkers of endothelial activation, neuroinflammation, and inflammatory cytokines were also measured at each follow-up. Collected variables were analyzed using comparisons between groups and linear regression models.ResultsPrevalence of insomnia increased from 10.6% up to 27.3% after COVID-19. Poor sleep quality was found in 41.5% of patients at both study visits. At T1 follow-up, poor sleepers showed higher levels of neurofilament light chain, vascular cell adhesion molecule 1, and interleukin 10; no significant associations were found between sleep quality and psychological disorders. At T2 follow-up, lower sleep quality was associated with higher levels of vascular cell adhesion molecule 1 and interleukin 8, but also with higher scores for anxiety, depression, and post-traumatic stress disorder.ConclusionOur results suggest an association of poor sleep quality with both psychological disorders and neuroinflammation, although at different times, in previously hospitalized patients with moderate-to-critical COVID-19.
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Affiliation(s)
- Gaia Pellitteri
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
- *Correspondence: Gaia Pellitteri
| | - Andrea Surcinelli
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Maria De Martino
- Division of Medical Statistics, Department of Medical Area, University of Udine, Udine, Italy
| | - Martina Fabris
- Institute of Clinical Pathology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Francesco Janes
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Francesco Bax
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | | | - Romina Milanic
- Institute of Clinical Pathology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Antonella Piani
- Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Miriam Isola
- Division of Medical Statistics, Department of Medical Area, University of Udine, Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
- Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
- Department of Medical Area (DAME), University of Udine, Udine, Italy
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Mashaqi S, Kallamadi R, Matta A, Quan SF, Patel SI, Combs D, Estep L, Lee-Iannotti J, Smith C, Parthasarathy S, Gozal D. Obstructive Sleep Apnea as a Risk Factor for COVID-19 Severity-The Gut Microbiome as a Common Player Mediating Systemic Inflammation via Gut Barrier Dysfunction. Cells 2022; 11:1569. [PMID: 35563874 PMCID: PMC9101605 DOI: 10.3390/cells11091569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 02/04/2023] Open
Abstract
The novel corona virus that is now known as (SARS-CoV-2) has killed more than six million people worldwide. The disease presentation varies from mild respiratory symptoms to acute respiratory distress syndrome and ultimately death. Several risk factors have been shown to worsen the severity of COVID-19 outcomes (such as age, hypertension, diabetes mellitus, and obesity). Since many of these risk factors are known to be influenced by obstructive sleep apnea, this raises the possibility that OSA might be an independent risk factor for COVID-19 severity. A shift in the gut microbiota has been proposed to contribute to outcomes in both COVID-19 and OSA. To further evaluate the potential triangular interrelationships between these three elements, we conducted a thorough literature review attempting to elucidate these interactions. From this review, it is concluded that OSA may be a risk factor for worse COVID-19 clinical outcomes, and the shifts in gut microbiota associated with both COVID-19 and OSA may mediate processes leading to bacterial translocation via a defective gut barrier which can then foster systemic inflammation. Thus, targeting biomarkers of intestinal tight junction dysfunction in conjunction with restoring gut dysbiosis may provide novel avenues for both risk detection and adjuvant therapy.
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Affiliation(s)
- Saif Mashaqi
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ 85719, USA; (S.F.Q.); (S.I.P.); (D.C.); (L.E.); (S.P.)
| | - Rekha Kallamadi
- Department of Internal Medicine, The University of North Dakota School of Medicine, Grand Forks, ND 58203, USA; (R.K.); (A.M.)
| | - Abhishek Matta
- Department of Internal Medicine, The University of North Dakota School of Medicine, Grand Forks, ND 58203, USA; (R.K.); (A.M.)
| | - Stuart F. Quan
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ 85719, USA; (S.F.Q.); (S.I.P.); (D.C.); (L.E.); (S.P.)
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Salma I. Patel
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ 85719, USA; (S.F.Q.); (S.I.P.); (D.C.); (L.E.); (S.P.)
| | - Daniel Combs
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ 85719, USA; (S.F.Q.); (S.I.P.); (D.C.); (L.E.); (S.P.)
| | - Lauren Estep
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ 85719, USA; (S.F.Q.); (S.I.P.); (D.C.); (L.E.); (S.P.)
| | - Joyce Lee-Iannotti
- Department of Sleep Medicine, The University of Arizona College of Medicine, Phoenix, AZ 85006, USA;
| | - Charles Smith
- The Intermountain Healthcare, Merrill Gappmayer Family Medicine Center, Provo, UT 84604, USA;
| | - Sairam Parthasarathy
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, The University of Arizona College of Medicine, Tucson, AZ 85719, USA; (S.F.Q.); (S.I.P.); (D.C.); (L.E.); (S.P.)
| | - David Gozal
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO 65201, USA;
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Abstract
This chapter summarizes the known associations between COVID-19 and sleep dysfunction, including insomnia, excessive daytime sleepiness, restless legs syndrome and nightmares, and touches upon pandemic-related considerations for obstructive sleep apnea and continuous positive airway pressure treatment. Treatment strategies and management approaches are also briefly discussed.
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Affiliation(s)
- Sushanth Bhat
- Hackensack Meridian-Health JFK University Medical Center, 65 James Street, Edison, NJ, 08818, USA.
| | - Sudhansu Chokroverty
- Sleep Medicine Research, and Co-Chair Emeritus of Neurology, Hackensack Meridian-Health JFK University Medical Center, 65 James Street, Edison, NJ, 08818, USA.
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15
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Huang Y, Chen D, Fietze I, Penzel T. Obstructive Sleep Apnea with COVID-19. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1384:281-293. [PMID: 36217091 DOI: 10.1007/978-3-031-06413-5_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The novel coronavirus disease-2019 (COVID-19) and the ensuing pandemic have greatly impacted the global healthcare system due to its high infectiousness, associated high mortality, and a complete lack of immunity in the population. Globally, the COVID-19 pandemic has unleashed a health crisis that has not only seriously disrupted people's lives but also affected their normal sleep, along with physical and mental health; this situation is especially exacerbated in people suffering from pre-existing conditions, such as sleep apnea. A recent meta-analysis of 18 studies by Miller et al. (September 2020) showed that obstructive sleep apnea (OSA) is related to higher mortality and morbidity in patients with COVID-19 and is most likely independent of other risk factors. A recent meta-analysis indicated that COVID-19 patients with OSA are more severely affected than those without OSA, thereby providing further evidence that concurrent OSA may elevate the severity of COVID-19 infection, along with the risk of mortality. The COVID-19 pandemic has significantly impacted the diagnosis and therapeutic management of patients with OSA. Thus, it is necessary to identify and develop new diagnostic and therapeutic avenues in the future. In this context, the current study summarizes known associations between COVID-19 and OSA and the regular diagnostic and therapeutic strategies for OSA in the light of COVID-19 pandemic prevention and control.
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Affiliation(s)
- Ying Huang
- Charité - Universitätsmedizin Berlin, Interdisciplinary Sleep Medicine Center, Berlin, Germany.
| | - DongMing Chen
- Charité - Universtitätsmedizin Berlin, Cooperate Member of Freie Universität and Humboldt Universität, Berlin, Germany
- Department of Neurosurgery, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui Province, China
| | - Ingo Fietze
- Charité - Universitätsmedizin Berlin, Interdisciplinary Sleep Medicine Center, Berlin, Germany
| | - Thomas Penzel
- Charité - Universitätsmedizin Berlin, Interdisciplinary Sleep Medicine Center, Berlin, Germany
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Rueda-Etxebarria M, Mugueta-Aguinaga I, Rueda JR, Lascurain-Aguirrebena I. Respiratory muscle training for obstructive sleep apnoea. Hippokratia 2021. [DOI: 10.1002/14651858.cd015039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Iranzu Mugueta-Aguinaga
- Respiratory Physiotherapy Unit, Rehabilitation Service, Pneumology; Biocruces Health Research Institute, Cruces University Hospital; Barakaldo Spain
| | - José-Ramón Rueda
- Department of Preventive Medicine and Public Health; University of the Basque Country; Leioa Spain
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Diagnostic accuracy of screening questionnaires for obstructive sleep apnoea in adults in different clinical cohorts: a systematic review and meta-analysis. Sleep Breath 2021; 26:1053-1078. [PMID: 34406554 PMCID: PMC8370860 DOI: 10.1007/s11325-021-02450-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/02/2021] [Accepted: 07/20/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE The majority of individuals with clinically significant obstructive sleep apnoea (OSA) are undiagnosed and untreated. A simple screening tool may support risk stratification, identification, and appropriate management of at-risk patients. Therefore, this systematic review and meta-analysis evaluated and compared the accuracy and clinical utility of existing screening questionnaires for identifying OSA in different clinical cohorts. METHODS We conducted a systematic review and meta-analysis of observational studies assessing the diagnostic value of OSA screening questionnaires. We identified prospective studies, validated against polysomnography, and published to December 2020 from online databases. To pool the results, we used random effects bivariate binomial meta-analysis. RESULTS We included 38 studies across three clinical cohorts in the meta-analysis. In the sleep clinic cohort, the Berlin questionnaire's pooled sensitivity for apnoea-hypopnoea index (AHI) ≥ 5, ≥ 15, and ≥ 30 was 85%, 84%, and 89%, and pooled specificity was 43%, 30%, and 33%, respectively. The STOP questionnaire's pooled sensitivity for AHI ≥ 5, ≥ 15, and ≥ 30 was 90%, 90%, and 95%, and pooled specificity was 31%, 29%, and 21%. The pooled sensitivity of the STOP-Bang questionnaire for AHI ≥ 5, ≥ 15, and ≥ 30 was 92%, 95%, and 96%, and pooled specificity was 35%, 27%, and 28%. In the surgical cohort (AHI ≥ 15), the Berlin and STOP-Bang questionnaires' pooled sensitivity were 76% and 90% and pooled specificity 47% and 27%. CONCLUSION Among the identified questionnaires, the STOP-Bang questionnaire had the highest sensitivity to detect OSA but lacked specificity. Subgroup analysis considering other at-risk populations was not possible. Our observations are limited by the low certainty level in available data.
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Scrutinio D, Guida P, Aliani M, Castellana G, Guido P, Carone M. Age and comorbidities are crucial predictors of mortality in severe obstructive sleep apnoea syndrome. Eur J Intern Med 2021; 90:71-76. [PMID: 33975770 DOI: 10.1016/j.ejim.2021.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/10/2021] [Accepted: 04/15/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Obstructive sleep apnoea syndrome (OSAS) is a highly prevalent disorder. The prognostic role of comorbidity in patients with OSAS and their role for risk stratification remain poorly defined. METHODS We studied 1,592 patients with severe OSAS diagnosed by polysomnography. The primary outcome was all-cause mortality. The standardized mortality ratio (SMR) was estimated as the ratio of observed deaths to expected number of deaths in the general population. The expected numbers of deaths were derived using mortality rates from the general Apulian population. The association of comorbidities with all-cause mortality was assessed using multivariable Cox regression analysis. Finally, recursive-partitioning analysis was applied to identify the combinations of comorbidities that were most influential for mortality and to cluster the patients into risk groups according to individual comorbidities RESULTS: During 11,721 person-years of follow-up, 390 deaths (3.33 deaths/100 person-years) occurred. The median follow-up was 7 (4-10) years. The SMR was 1.47 (95% confidence intervals 1.33-1.63). Age, sex, obesity, cardiovascular diseases (CVD), moderate-to-severe chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and malignancy were independently associated with mortality risk. Recursive-partitioning analysis allowed distinguishing three clinical phenotypes differentially associated with mortality risk. The combination of CKD with CVDs or with moderate-to-severe COPD conferred the highest risk. CONCLUSIONS Severe OSAS is associated with increased risk for all-cause death. Age and comorbidity are crucial predictors of mortality in patients with severe OSAS. Clustering patients according to comorbidities allows identifying clinically meaningful phenotypes.
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Affiliation(s)
| | - Pietro Guida
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari Italy
| | - Maria Aliani
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari Italy
| | | | - Patrizia Guido
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari Italy
| | - Mauro Carone
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari Italy
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Wang H, Shao G, Rong L, Ji Y, Zhang K, Liu M, Ma L. Association between comorbid sleep apnoea-hypopnoea syndrome and prognosis of intensive care patients: a retrospective cohort study. BMJ Open 2021; 11:e048886. [PMID: 34162653 PMCID: PMC8230938 DOI: 10.1136/bmjopen-2021-048886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE In this study, we investigated the association between comorbid sleep apnoea-hypopnoea syndrome (SAHS) and the prognosis of patients in an intensive care unit (ICU) to determine whether this relationship varies between different disease subgroups. METHODS We conducted a retrospective cohort study using publicly available information from the critical care database Medical Information Mart for Intensive Care III. Adults (≥18 years of age) who attended the ICU for the first time were enrolled. Demographic information and clinical data were obtained from each patient. The primary outcome was 30-day mortality after ICU admission, and the secondary outcomes were in-hospital and ICU mortality. Multivariate logistic regression and Cox regression analyses were used to examine the associations between SAHS comorbidities and the research outcomes. Propensity score matching was used to adjust for potential confounding variables. RESULTS Of the 32 989 patients enrolled, 1918 (5.81%) were diagnosed with SAHS as a comorbid condition. Patients with SAHS had a significantly lower 30-day mortality rate compared with those without SAHS (5.27% vs 13.65%, respectively; p<0.001). The frequency of chronic obstructive pulmonary disease, cerebral disease, cardiovascular disease, hypertension, diabetes mellitus and renal failure was significantly different between the two groups. Patients with SAHS demonstrated significantly longer survival compared with patients without SAHS. Multivariate Cox proportional hazards regression identified a significant relationship between SAHS and mortality within 30 days (adjusted HR=0.610, 95% CI 0.499 to 0.747, p<0.0001). CONCLUSION SAHS as a comorbid condition decreases the risk of 30-day mortality, in-hospital mortality and ICU mortality among ICU patients.
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Affiliation(s)
- Hongxia Wang
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Guangqiang Shao
- Division of Thoracic Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, Shenzhen, People's Republic of China
| | - Lei Rong
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yang Ji
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Keke Zhang
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Min Liu
- Respiratory and Critical Care Medicine, The University of Hong Kong - Shenzhen Hospital, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ling Ma
- Otorhinolaryngology Head and Neck Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, Shenzhen, People's Republic of China
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20
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Grote L, Theorell-Haglöw J, Ulander M, Hedner J. Prolonged Effects of the COVID-19 Pandemic on Sleep Medicine Services-Longitudinal Data from the Swedish Sleep Apnea Registry. Sleep Med Clin 2021; 16:409-416. [PMID: 34325820 PMCID: PMC8258548 DOI: 10.1016/j.jsmc.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The worldwide COVID-19 pandemic has affected the operation of health care systems. The direct impact of obstructive sleep apnea (OSA) on COVID-19 infection outcome remains to be elucidated. However, the coincidence of common risk factors for OSA and severe COVID-19 suggests that patients with OSA receiving positive airway pressure therapy may have an advantage relative to those untreated when confronted with a COVID-19 infection. The ongoing COVID-19 pandemic has led to a substantial reduction of sleep medicine services, and the long-term consequences may be considerable. New strategies for the management of sleep disorders are needed to overcome the current underdiagnosis and delay of treatment.
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Affiliation(s)
- Ludger Grote
- Center for Sleep and Vigilance Disorders, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 8B, Box 421, 40530 Gothenburg, Sweden; Respiratory Department, Sleep Disorders Center, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden.
| | - Jenny Theorell-Haglöw
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset ing 40, 75185 Uppsala, Sweden; Respiratory Department, The Sleep Apnea Center, Uppsala University Hospital, 75185 Uppsala, Sweden
| | - Martin Ulander
- Department of Clinical Neurophysiology, Linköping University Hospital, 58185 Linköping, Sweden; Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 58185 Linköping, Sweden
| | - Jan Hedner
- Center for Sleep and Vigilance Disorders, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 8B, Box 421, 40530 Gothenburg, Sweden; Respiratory Department, Sleep Disorders Center, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
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Space-Time Cluster's Detection and Geographical Weighted Regression Analysis of COVID-19 Mortality on Texas Counties. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115541. [PMID: 34067291 PMCID: PMC8196888 DOI: 10.3390/ijerph18115541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/28/2021] [Accepted: 05/20/2021] [Indexed: 01/30/2023]
Abstract
As COVID-19 run rampant in high-density housing sites, it is important to use real-time data in tracking the virus mobility. Emerging cluster detection analysis is a precise way of blunting the spread of COVID-19 as quickly as possible and save lives. To track compliable mobility of COVID-19 on a spatial-temporal scale, this research appropriately analyzed the disparities between spatial-temporal clusters, expectation maximization clustering (EM), and hierarchical clustering (HC) analysis on Texas county-level. Then, based on the outcome of clustering analysis, the sensitive counties are Cottle, Stonewall, Bexar, Tarrant, Dallas, Harris, Jim hogg, and Real, corresponding to Southeast Texas analysis in Geographically Weighted Regression (GWR) modeling. The sensitive period took place in the last two quarters in 2020 and the first quarter in 2021. We explored PostSQL application to portray tracking Covid-19 trajectory. We captured 14 social, economic, and environmental impact's indices to perform principal component analysis (PCA) to reduce dimensionality and minimize multicollinearity. By using the PCA, we extracted five factors related to mortality of COVID-19, involved population and hospitalization, adult population, natural supply, economic condition, air quality or medical care. We established the GWR model to seek the sensitive factors. The result shows that adult population, economic condition, air quality, and medical care are the sensitive factors. Those factors also triggered high increase of COVID-19 mortality. This research provides geographical understanding and solution of controlling COVID-19, reference of implementing geographically targeted ways to track virus mobility, and satisfy for the need of emergency operations plan (EOP).
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22
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Chung F, Waseem R, Pham C, Penzel T, Han F, Bjorvatn B, Morin CM, Holzinger B, Espie CA, Benedict C, Cedernaes J, Saaresranta T, Wing YK, Nadorff MR, Dauvilliers Y, De Gennaro L, Plazzi G, Merikanto I, Matsui K, Leger D, Sieminski M, Mota-Rolim S, Inoue Y, Partinen M. The association between high risk of sleep apnea, comorbidities, and risk of COVID-19: a population-based international harmonized study. Sleep Breath 2021; 25:849-860. [PMID: 33907966 PMCID: PMC8079162 DOI: 10.1007/s11325-021-02373-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA) may increase the risk of severe COVID-19; however, the level of potential modulation has not yet been established. The objective of the study was to determine the association between high risk of OSA, comorbidities, and increased risk for COVID-19, hospitalization, and intensive care unit (ICU) treatment. METHODS We conducted a cross-sectional population-based web survey in adults in 14 countries/regions. The survey included sociodemographic variables and comorbidities. Participants were asked questions about COVID-19, hospitalization, and ICU treatment. Standardized questionnaire (STOP questionnaire for high risk of OSA) was included. Multivariable logistic regression was conducted adjusting for various factors. RESULTS Out of 26,539 respondents, 20,598 (35.4% male) completed the survey. Mean age and BMI of participants were 41.5 ± 16.0 years and 24.0 ± 5.0 kg/m2, respectively. The prevalence of physician-diagnosed OSA was 4.1% and high risk of OSA was 9.5%. We found that high risk of OSA (adjusted odds ratio (aOR) 1.72, 95% confidence interval (CI): 1.20, 2.47) and diabetes (aOR 2.07, 95% CI: 1.23, 3.48) were associated with reporting of a COVID-19 diagnosis. High risk for OSA (aOR 2.11, 95% CI: 1.10-4.01), being male (aOR: 2.82, 95% CI: 1.55-5.12), having diabetes (aOR: 3.93, 95% CI: 1.70-9.12), and having depression (aOR: 2.33, 95% CI: 1.15-4.77) were associated with increased risk of hospitalization or ICU treatment. CONCLUSIONS Participants at high risk of OSA had increased odds of having COVID-19 and were two times more likely to be hospitalized or treated in ICU.
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Affiliation(s)
- Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, M5T2S8, Canada. .,Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada.
| | - Rida Waseem
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, M5T2S8, Canada
| | - Chi Pham
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, M5T2S8, Canada.,Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Thomas Penzel
- Sleep Medicine Center, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - Fang Han
- Department of Respiratory Medicine, Peking University People's Hospital, Beijing, China
| | - Bjørn Bjorvatn
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
| | - Charles M Morin
- École de Psychologie, Centre d'étude des troubles du sommeil, Centre de recherche CERVO/Brain Research Center, Université Laval, Québec, Canada
| | - Brigitte Holzinger
- Institute for Dream and Consciousness Research, Medical University of Vienna, Vienna, Austria
| | - Colin A Espie
- Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Christian Benedict
- Department of Neuroscience, Sleep Science (BMC), Uppsala University, Uppsala, Sweden
| | - Jonathan Cedernaes
- Department of Neuroscience, Sleep Science (BMC), Uppsala University, Uppsala, Sweden.,Division of Endocrinology, Metabolism, and Molecular Medicine, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Tarja Saaresranta
- Division of Medicine, Department of Pulmonary Diseases, Turku University Hospital, Turku, Finland
| | - Yun Kwok Wing
- Li Chiu Kong Family Sleep Assessment Unit, Departments of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
| | - Michael R Nadorff
- Department of Psychology, Mississippi State University, Starkville, USA.,Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, USA
| | - Yves Dauvilliers
- Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, Montpellier, France
| | - Luigi De Gennaro
- Department of Psychology, Sapienza University of Rome, Rome, Italy.,IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Guiseppe Plazzi
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Ilona Merikanto
- Department of Psychology and Logopedics and SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Kentaro Matsui
- Department of Clinical Laboratory and Department of Sleep-Wake Disorders, National Center of Neurology and Psychiatry National Institute of Mental Health, Kodaira, Japan.,Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan
| | - Damien Leger
- Sleep and Vigilance Center, Hopital Hotel-Dieu de Paris, Paris, France.,Universite de Paris, VIFASOM (EA 7331 Vigilance Fatigue Sommeil et Santé Publique), Paris, France
| | - Mariusz Sieminski
- Department of Emergency Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Sergio Mota-Rolim
- Brain Institute, Onofre Lopes University Hospital, Natal, Brazil.,Physiology and Behavior Department, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Yuichi Inoue
- Department of Somnology, Tokyo Medical University, Tokyo, Japan.,Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
| | - Markku Partinen
- Helsinki Sleep Clinic, Vitalmed Research Center, and Department of Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland
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23
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Demirovic S, Lusic Kalcina L, Pavlinac Dodig I, Pecotic R, Valic M, Ivkovic N, Dogas Z. The COVID-19 Lockdown and CPAP Adherence: The More Vulnerable Ones Less Likely to Improve Adherence? Nat Sci Sleep 2021; 13:1097-1108. [PMID: 34290535 PMCID: PMC8287077 DOI: 10.2147/nss.s310257] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/05/2021] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Due to the possible interplay of factors predisposing to severe COVID-19 outcomes and negative health consequences of poorly controlled OSA, adherence to continuous positive airway pressure (CPAP) therapy among OSA patients might be crucial during COVID-19 pandemics. Lockdown-related changes in CPAP adherence were investigated in CPAP users willing to participate in this study. Pre-lockdown adherence, age, gender, comorbidities and anxiety were analyzed as predictors of COVID-19 lockdown adherence. PATIENTS AND METHODS A cross-sectional study performed at Split Sleep Medicine Center included 101 severe OSA patients (78.2% male). CPAP memory cards were assessed during 6 months of pre-lockdown and 40 days of lockdown (March/April 2020) period. A total of 81 patients in pre-lockdown met good CPAP adherence criteria (≥4 hours/night on 70% nights). RESULTS CPAP adherence improved during COVID-19 lockdown in the total sample of severe OSA patients. The percentage of adherent nights and CPAP usage hours per night increased during lockdown in good pre-lockdown CPAP adherers (p=0.011 and p=0.001, respectively), women (p=0.003 and p=0.001, respectively) and respondents younger than 58 years (p=0.007 and p<0.001, respectively). Out of 20/101 poor pre-lockdown CPAP adherers, 9 have shifted to good lockdown adherence. When comorbidities, BMI and anxiety were taken into account, older and male respondents were recognized as less likely to improve CPAP usage hours during lockdown (R2=9.4%; p=0.032). CONCLUSION The lockdown-related CPAP adherence improved in severe OSA patients, with a shift in almost half of poor pre-lockdown adherers towards good lockdown CPAP adherence. Women, younger and good pre-lockdown CPAP adherers were more adherent during lockdown. Despite being vulnerable groups for both OSA and COVID-19, no expected adherence improvements were observed in men and older patients.
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Affiliation(s)
- Sijana Demirovic
- Department of Neuroscience, University of Split School of Medicine, Split, Croatia.,Split Sleep Medicine Center, University Hospital Center Split, Split, Croatia
| | - Linda Lusic Kalcina
- Department of Neuroscience, University of Split School of Medicine, Split, Croatia.,Split Sleep Medicine Center, University Hospital Center Split, Split, Croatia
| | - Ivana Pavlinac Dodig
- Department of Neuroscience, University of Split School of Medicine, Split, Croatia.,Split Sleep Medicine Center, University Hospital Center Split, Split, Croatia
| | - Renata Pecotic
- Department of Neuroscience, University of Split School of Medicine, Split, Croatia.,Split Sleep Medicine Center, University Hospital Center Split, Split, Croatia
| | - Maja Valic
- Department of Neuroscience, University of Split School of Medicine, Split, Croatia.,Split Sleep Medicine Center, University Hospital Center Split, Split, Croatia
| | - Natalija Ivkovic
- Split Sleep Medicine Center, University Hospital Center Split, Split, Croatia
| | - Zoran Dogas
- Department of Neuroscience, University of Split School of Medicine, Split, Croatia.,Split Sleep Medicine Center, University Hospital Center Split, Split, Croatia
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