Oxytocin and women's health in midlife

Menopause marks the cessation of fertility and the transition to post-reproductive years. Nearly 1M US women experience menopause annually, but despite the significant impact it has on their physical and mental health, menopause has been insufficiently studied. Oxytocin is a neurohormone that regulates emotionality, social behaviors, and fundamental physiological systems. Localization of oxytocin receptors in the brain, reproductive tissues, bone, and heart support their role in mental health and potentially sleep, along with reproductive and cardiovascular functions. While experimental data linking oxytocin to behavior and physiology in animals are largely consistent, human data are correlative and inconclusive. As women transition into menopause, oxytocin levels decrease while their susceptibility to mood disorders, poor sleep, osteoporosis, and cardiovascular diseases increases. These concurrent changes highlight oxytocin as a potential influence on the health and mood of women along their reproductive lifespan. Here we summarize experimental rodent studies that link oxytocin to reproductive aging and metabolic health and highlight the inconclusive findings in studies of women. Most human studies relied on a single oxytocin assessment in plasma or on intranasal oxytocin administration. The pulsatile release and short half-life of plasma oxytocin limits the validity of these methods. We discuss the need for oxytocin assessments in stable bio-samples, such as urine, and to use valid assays for assessment of associations between changing oxytocin levels and well-being across the reproductive lifespan. This work has the potential to guide therapeutic strategies that will one day alleviate adverse health outcomes for many women.

Patterns of Sleep Duration and Metabolic Biomarkers Across the Menstrual Cycle

CONTEXT

Along the menstrual cycle, associations between inconsistent sleep duration and levels of metabolic biomarkers are uncertain and could involve fluctuations in estrogen concentrations.

OBJECTIVE

To examine associations between patterns of sleep duration and metabolic biomarkers across two menstrual cycles within a cohort of premenopausal women.

METHODS

The BioCycle Study was conducted in New York between 2005-2007, enrolling 259 premenopausal women over two menstrual cycles. This micro-longitudinal cohort study involved intensive data collection including daily sleep diaries and biomarker assessments of leptin, insulin, and glucose at 16 key points timed to menstrual cycle phases. We considered dynamic sleep duration, as hours slept one night or as mean hours slept during the two nights prior to each biomarker assessment. Variability in habitual sleep duration, i.e., reported daily sleep duration, summarized across both menstrual cycles. Variation in habitual sleep duration was computed using L-moments, a robust version of dispersion, skewness, and kurtosis. To examine associations between patterns of sleep duration and metabolic biomarkers, we fitted a series of linear mixed models with random intercepts and inverse probability weighting. These models were adjusted for potential demographic, lifestyle, health confounders, and menstrual cycle phase.

RESULTS

Sleep duration one night or two nights prior to clinic visits were not associated with metabolic biomarker measures we assessed. However, overall variability (dispersion) in habitual sleep duration was associated with lower mean insulin HOMA-IR levels, but not glucose. Moreover, extreme short or long bouts of sleep duration was associated with higher mean levels of leptin, insulin, and HOMA-IR.

CONCLUSIONS

These data suggest that variation in habitual sleep duration along the menstrual cycle may be associated with metabolic function.

Delayed Sleep Midpoint Across Pregnancy Is Associated with Excessive Gestational Weight Gain

Background: Changes in sleep patterns and body weight occur during pregnancy, yet it is unclear whether sleep patterns are related to gestational weight gain (GWG). This study examined the relationship between maternal sleep across pregnancy and excessive GWG. Methods: Participants from the Michigan Archive for Research on Child Health (MARCH) cohort study, who had singleton births and provided information on fall-asleep and wake-up times during early (first or second) and the third trimesters, were included (n = 372). Changes in sleep duration and sleep midpoints throughout pregnancy were calculated. Prepregnancy weight and the last maternal weight before delivery were used to calculate GWG, which was categorized into groups (inadequate, adequate, and excessive). Poisson regression models were used to examine associations between sleep changes and excessive GWG, adjusted for age, race, gestational age, prepregnancy body mass index, income, fetus gender, physical activity, added sugar, and fruit and vegetable intake. Results: Excessive GWG was observed in 46.5% of women, and was more common among those with prepregnancy obesity (p < 0.001). Women who delayed sleep midpoint by 1 hour (or more) from the early trimester assessment to the third trimester experienced higher risk of excessive GWG (Risk ratio: 1.3; 95% confidence interval: 1.1-1.7). Single time points of sleep duration and sleep midpoint or changes in sleep duration were not related to GWG. Conclusions: Delay in sleep midpoint from early-mid pregnancy to the third trimester was associated with excessive GWG. Health professionals should consider changes in sleep patterns during pregnancy to identify those prone to excessive GWG.

Does fetal size affect maternal perception of fetal movements? Evidence from an individual participant data meta-analysis

INTRODUCTION

Maternal perception of fetal movements during pregnancy are reassuring; however, the perception of a reduction in movements are concerning to women and known to be associated with increased odds of late stillbirth. Prior to full term, little evidence exists to provide guidelines on how to proceed unless there is an immediate risk to the fetus. Increased strength of movement is the most commonly reported perception of women through to full term, but perception of movement is also hypothesized to be influenced by fetal size. The study aimed to assess the pattern of maternal perception of strength and frequency of fetal movement by gestation and customized birthweight quartile in ongoing pregnancies. A further aim was to assess the association of stillbirth to perception of fetal movements stratified by customized birthweight quartile.

MATERIAL AND METHODS

This analysis was an individual participant data meta-analyses of five case-control studies investigating factors associated with stillbirth. The dataset included 851 cases of women with late stillbirth (>28 weeks' gestation) and 2257 women with ongoing pregnancies who then had a liveborn infant.

RESULTS

The frequency of prioritized fetal movement from 28 weeks' gestation showed a similar pattern for each quartile of birthweight with increased strength being the predominant perception of fetal movement through to full term. The odds of stillbirth associated with reduced fetal movements was increased in all quartiles of customized birthweight centiles but was notably greater in babies in the lowest two quartiles (Q1: adjusted OR: 9.34, 95% CI: 5.43, 16.06 and Q2: adjusted OR: 6.11, 95% CI: 3.11, 11.99). The decreased odds associated with increased strength of movement was present for all customized birthweight quartiles (adjusted OR range: 0.25-0.56).

CONCLUSIONS

Increased strength of fetal movements in late pregnancy is a positive finding irrespective of fetal size. However, reduced fetal movements are associated with stillbirth, and more so when the fetus is small.

Early-to-mid pregnancy sleep and circadian markers in relation to birth outcomes: An epigenetics pilot study

Maternal sleep and circadian health during pregnancy are emerging as important predictors of pregnancy outcomes, but examination of potential epigenetic mechanisms is rare. We investigated links between maternal leukocyte DNA methylation of circadian genes and birth outcomes within a pregnancy cohort. Women (n = 96) completed a questionnaire and provided a blood sample at least once during early-to-mid pregnancy (average gestation weeks = 14.2). Leukocyte DNA was isolated and DNA methylation (average percent of methylation) at multiple CpG sites within BMAL1, PER1, and MTNR1B genes were quantified by pyrosequencing. Birth outcomes including gestational age at delivery, birthweight, and head circumference were abstracted from medical charts. Linear regression analyses were run between each CpG site with birth outcomes, adjusting for important confounders. Sleep duration and timing were assessed as secondary exposures. Higher methylation of a CpG site in PER1 was associated with smaller log-transformed head circumference (β=-0.02 with 95% CI -0.02 to 0.01; P, trend = 0.04). Higher methylation of MTNR1B (averaged across sites) was associated with lower log-transformed birthweight (-0.08 with 95% CI -0.16 to -0.01; P, trend = 0.0495). In addition, longer sleep duration was associated with higher birthweight (0.10 with 95% CI 0.02 to 0.18 comparing > 9 h to < 8 h; P, trend = 0.04). This pilot investigation revealed that higher methylation of PER1 and MTNR1B genes, and sleep duration measured in early-to-mid pregnancy were related to birth outcomes.

Disparities in sleep-wake patterns by labor force status: Population-based findings

Sleep disturbances have been associated with unemployment, but variation in sleep-wake patterns by labor force status has rarely been examined. With a population-based sample, we investigated differences in sleep-wake patterns by labor force status (employed, unemployed, and not-in-the-labor-force) and potential disparities by sociodemographic variables. The analysis included 130,602 adults aged 25-60 y, who participated in the American Time Use Survey between 2003 and 2019. Individual sleep-wake pattern was extracted from time use logs in a strict 24-h period (04:00 h-03:59 h). Functional nonparametric regression models based on dimensionality reduction and neighborhood matching were applied to model the relationship between sleep-wake patterns and labor force status. Specifically, we predicted changes in intra-person sleep-wake patterns under hypothetical changes of labor force status from employed to unemployed or not-in-the-labor-force. We then studied moderations of this association by gender, race/ethnicity and educational attainment. In comparison to the employed state, unemployed and not-in-the-labor-force states were predicted to have later wake-times, later bedtimes, and higher tendency for taking midday naps. Changes in labor force status led to more apparent shifts in wake-times than in bedtimes. Additionally, sleep schedules of Hispanics and those with higher education level were more vulnerable to the change of labor force status from employed to unemployed.

Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology Consensus Guideline on the Screening, Diagnosis, and Treatment of Obstructive Sleep Apnea in Pregnancy

The Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology tasked an expert group to review existing evidence and to generate recommendations on the screening, diagnosis, and treatment of patients with obstructive sleep apnea during pregnancy. These recommendations are based on a systematic review of the available scientific evidence and expert opinion when scientific evidence is lacking. This guideline may not be appropriate for all clinical situations and patients, and physicians must decide whether these recommendations are appropriate for their patients on an individual basis. We recognize that not all pregnant people may identify as women. However, data on non-cisgendered pregnant patients are lacking, and many published studies use gender-binary terms; therefore, depending on the study referenced, we may refer to pregnant individuals as women. This guideline may inform the creation of clinical protocols by individual institutions that consider the unique considerations of their patient populations and the available resources.

Sleep Disparities Across Pregnancy: A Michigan Cohort Study

Introduction

Poor sleep health during pregnancy is related to adverse pregnancy outcomes. This study aims to identify sociodemographic characteristics associated with sleep health during pregnancy and to examine how they relate to changes in sleep during pregnancy.

Materials and Methods

Participants (n = 458) were from the Michigan Archive for Research on Child Health, which is a prospective pregnancy cohort. Sociodemographic characteristics and self-reported sleep timing and quality were collected in phone interviews. This longitudinal study collected sleep parameters once during the early trimesters and once during the third trimester. Fall asleep and wake-up times were used to calculate sleep duration and sleep midpoint.

Results

Compared to the third trimester, sleep duration was 12 minutes longer (p = 0.02), fall asleep time was 21 minutes earlier (p < 0.001), and the midpoint of sleep was 12 minutes earlier (p = 0.01) in early trimesters. Shorter sleep duration was noted in younger women. Sleep midpoint was later in those who were younger, overweight, or obese, racial minorities, unmarried, and with lower educational levels or socioeconomic status, and who smoked before pregnancy after adjusting for covariates. After controlling for confounders, women who were not working for pay had higher likelihood of reduced sleep duration, and women who were unmarried were more likely to have a delayed sleep midpoint in the third trimester compared to the early trimesters.

Conclusions

This study suggests that sleep parameters changed during pregnancy and sleep health differed by sociodemographic characteristics. Understanding sleep disparities could help with early detection of at-risk populations during prenatal care.

Racial/ethnic disparities in sleep-disordered breathing during pregnancy in the nuMoM2b study

OBJECTIVE

The aim of this study was to assess the prevalence and severity of sleep-disordered breathing (SDB) across racial/ethnic groups in 3702 pregnant people at 6 to 15 and 22 to 31 weeks gestational age, examine whether BMI modifies the association between race/ethnicity and SDB, and investigate whether interventions to reduce weight might reduce racial/ethnic disparities in SDB.

METHODS

Differences by race/ethnicity in SDB prevalence and severity were quantified via linear, logistic, or quasi-Poisson regression. Controlled direct effect was used to estimate whether intervening on BMI would remove/diminish differences by race/ethnicity in SDB severity.

RESULTS

This study comprised 61.2% non-Hispanic White (nHW), 11.9% non-Hispanic Black (nHB), 18.5% Hispanic, and 3.7% Asian people. SDB prevalence was higher for nHB compared with nHW pregnant people at 6 to 15 weeks (odds ratio [OR] 1.81, 95% CI [1.07, 2.97]), whereas at 21 to 32 weeks, Asian pregnant people had a higher SDB prevalence than nHW (OR 2.2, 95% CI [1.1, 4.0]). The severity of SDB differed across racial/ethnic groups in early pregnancy, with nHB pregnant people having a higher apnea-hypopnea index (AHI) (OR 1.35, 95% CI [1.07, 1.69]) compared with nHW. Having overweight/obesity was associated with a higher AHI (β = 2.36, 95% CI [1.97, 2.84]). Controlled direct effect analyses indicated that in early pregnancy, nHB and Hispanic pregnant people would have a lower AHI compared with nHW people had they had normal weight.

CONCLUSIONS

This study extends knowledge on racial/ethnic disparities in SDB to a pregnant population.

Risk factors for late preterm and term stillbirth: A secondary analysis of an individual participant data meta-analysis

OBJECTIVE

Identify independent and novel risk factors for late-preterm (28-36 weeks) and term (≥37 weeks) stillbirth and explore development of a risk-prediction model.

DESIGN

Secondary analysis of an Individual Participant Data (IPD) meta-analysis investigating modifiable stillbirth risk factors.

SETTING

An IPD database from five case-control studies in New Zealand, Australia, the UK and an international online study.

POPULATION

Women with late-stillbirth (cases, n = 851), and ongoing singleton pregnancies from 28 weeks' gestation (controls, n = 2257).

METHODS

Established and novel risk factors for late-preterm and term stillbirth underwent univariable and multivariable logistic regression modelling with multiple sensitivity analyses. Variables included maternal age, body mass index (BMI), parity, mental health, cigarette smoking, second-hand smoking, antenatal-care utilisation, and detailed fetal movement and sleep variables.

MAIN OUTCOME MEASURES

Independent risk factors with adjusted odds ratios (aOR) for late-preterm and term stillbirth.

RESULTS

After model building, 575 late-stillbirth cases and 1541 controls from three contributing case-control studies were included. Risk factor estimates from separate multivariable models of late-preterm and term stillbirth were compared. As these were similar, the final model combined all late-stillbirths. The single multivariable model confirmed established demographic risk factors, but additionally showed that fetal movement changes had both increased (decreased frequency) and reduced (hiccoughs, increasing strength, frequency or vigorous fetal movements) aOR of stillbirth. Poor antenatal-care utilisation increased risk while more-than-adequate care was protective. The area-under-the-curve was 0.84 (95% CI 0.82-0.86).

CONCLUSIONS

Similarities in risk factors for late-preterm and term stillbirth suggest the same approach for risk-assessment can be applied. Detailed fetal movement assessment and inclusion of antenatal-care utilisation could be valuable in late-stillbirth risk assessment.

Preconception sleep duration, sleep timing, and shift work in association with fecundability and live birth among women with a history of pregnancy loss

OBJECTIVE

To evaluate the associations between preconception sleep characteristics and shift work with fecundability and live birth.

DESIGN

Secondary analysis of the Effects of Aspirin in Gestation and Reproduction study, a preconception cohort.

SETTING

Four US academic medical centers.

PATIENT(S)

Women aged 18-40 with a history of 1-2 pregnancy losses who were attempting to conceive again.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURES(S)

We evaluated baseline, self-reported sleep duration, sleep midpoint, social jetlag, and shift work among 1,228 women who were observed for ≤6 cycles of pregnancy attempts to ascertain fecundability. We ascertained live birth at the end of follow up via chart abstraction. We estimated fecundability odds ratios (FORs) using discrete, Cox proportional hazards models and risk ratios (RRs) for live birth using log-Poisson models.

RESULT(S)

Sleep duration ≥9 vs. 7 to <8 hours (FOR: 0.81, 95% confidence interval [CI], 0.61; 1.08), later sleep midpoints (3rd tertile vs. 2nd tertile: FOR: 0.85; 95% CI, 0.69, 1.04) and social jetlag (continuous per hour; FOR: 0.93, 95% CI: 0.86, 1.00) were not associated with reduced fecundability. In sensitivity analyses, excluding shift workers, sleep duration ≥9 vs. 7 to <8 hours (FOR: 0.62; 95% CI, 0.42; 0.93) was associated with low fecundability. Night shift work was not associated with fecundability (vs. non-night shift work FOR: 1.17, 95% CI, 0.96; 1.42). Preconception sleep was not associated with live birth.

CONCLUSION(S)

Overall, there does not appear to be a strong association between sleep characteristics, fecundability, and live birth. Although these findings may suggest weak and imprecise associations with some sleep characteristics, our findings should be evaluated in larger cohorts of women with extremes of sleep characteristics.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT00467363.

Cell-autonomous Hedgehog signaling controls Th17 polarization and pathogenicity

Th17 cells are key drivers of autoimmune disease. However, the signaling pathways regulating Th17 polarization are poorly understood. Hedgehog signaling regulates cell fate decisions during embryogenesis and adult tissue patterning. Here we find that cell-autonomous Hedgehog signaling, independent of exogenous ligands, selectively drives the polarization of Th17 cells but not other T helper cell subsets. We show that endogenous Hedgehog ligand, Ihh, signals to activate both canonical and non-canonical Hedgehog pathways through Gli3 and AMPK. We demonstrate that Hedgehog pathway inhibition with either the clinically-approved small molecule inhibitor vismodegib or genetic ablation of Ihh in CD4+ T cells greatly diminishes disease severity in two mouse models of intestinal inflammation. We confirm that Hedgehog pathway expression is upregulated in tissue from human ulcerative colitis patients and correlates with Th17 marker expression. This work implicates Hedgehog signaling in Th17 polarization and intestinal immunopathology and indicates the potential therapeutic use of Hedgehog inhibitors in the treatment of inflammatory bowel disease.

Risk of obstructive sleep apnea after treatment of head and neck squamous cell carcinoma: a cross-sectional study

STUDY OBJECTIVES

Head and neck squamous cell carcinoma (HNSCC) or its treatment may be associated with an increased risk of obstructive sleep apnea (OSA). However, reported relationships between OSA risk factors and HNSCC are inconsistent. This study examined associations between tumor variables and risk of OSA at least one year after completion of treatment for HNSCC.

METHODS

This cross-sectional study included HNSCC patients of a large academic medical center. Inclusion criteria were age ≥18 years, cancer free for at least one year, with absence of tracheostomy or mental impairment. The STOP-BANG questionnaire, with a threshold ≥3, was used to classify HNSCC patients into elevated and low OSA risk. Tumor characteristics and treatment types were obtained from medical records. Descriptive statistics were used to compare characteristics between OSA risk groups. Unadjusted and age-adjusted logistic and linear regression models were used to explore associations between exposures and OSA risk.

RESULTS

Among 67 participants, 85% were males, mean age was 62.0 years (8.0 SD), mean body mass index was 28.7 kg/m² (4.6 SD), and mean neck circumference was 16.3 inches (1.2 SD). Three-quarters of participants received chemoradiation only. Elevated OSA risk was observed in 60% of the participants. Tumor location, tumor stage, and type of cancer treatment were not different between OSA risk groups. Hyperlipidemia was more common in the elevated OSA risk group vs. the low risk (n=16, 40% vs. n=2, 7%, p=0.004). Age-adjusted analysis showed a trend toward twofold increased odds of elevated OSA risk in patients with tumors at the base of the tongue in comparison to other locations (OR=2.3, 95% CI 0.9, 6.4). No associations between tumor stage, cancer treatment, and elevated OSA risk were observed.

CONCLUSIONS

Elevated OSA risk was common after HNSCC treatment. However, measured HNSCC characteristics generally were not different between elevated and low OSA risk groups. Given the high frequency of OSA that appears likely to exist in HNSCC patients, clinicians should inquire about OSA features in patients with a history of HNSCC.

Sleep Difficulties among Mexican Adolescents: Subjective and Objective Assessments of Sleep

OBJECTIVE/BACKGROUND

Self-reported sleep difficulties, such as insomnia symptoms, have been reported among adolescents. Yet, studies of their prevalence and correlates are scarce among Latin Americans. This study sought (1) to describe associations between sociodemographic and lifestyle factors with self-reported sleep difficulties and (2) to examine associations between self-reported sleep difficulties and actigraphy-based sleep.

PARTICIPANTS

Participants included 477 Mexican adolescents from the ELEMENT cohort.

METHODS

Over 7 days, self-reported sleep measures (hard time falling asleep, overall sleep difficulties, and specific types of sleep difficulties) were obtained from daily sleep diaries. Actigraphy-based sleep measures (duration, i.e. sleep onset to morning wake, midpoint, and fragmentation) were concurrently assessed using a wrist actigraph.

RESULTS

Mean (SD) age was 15.9 (2.2) years, and 53.5% were females. Mean (SD) sleep duration was 8.5 (1.2) h/night. Half reported a hard time falling asleep at least 3 days, and 25% had sleep difficulties at least 3 days over 7 days. The 3 types of sleep difficulties commonly reported among the entire cohort were insomnia/restlessness (29%), environmental (27%), and mental/emotional difficulties (19%). Female sex, smoking behavior, and socioeconomic indicators were among the most consistent factors associated with sleep difficulties. Subjective sleep difficulties were associated with shorter sleep duration (β = -20.8 [-35.3, -6.2] min), while subjective hard time falling asleep was associated with longer sleep duration (β = 11.3 [4.6, 27.2] min).

CONCLUSION

A high proportion of Mexican adolescents in the sample reported sleep difficulties. Findings demonstrate the importance of obtaining subjective and objective sleep measures for a more comprehensive assessment of adolescent sleep.

Sleep of infants and toddlers during 12 months of the COVID-19 pandemic in the midwestern United States

STUDY OBJECTIVES

Cultural sleep practices and COVID-19 mitigation strategies vary worldwide. The sleep of infants and toddlers during the COVID-19 pandemic in the United States (US) is understudied.

METHODS

Caregivers of children aged <3 years responded to a cross-sectional survey during 2020 (divided into quarters, with year quarter 1 largely pre-lockdown). We assessed the global effect of year quarter on parent-reported total sleep time (TST, hours) and sleep onset latency (SOL, hours) using ANOVA. We used multivariable linear regression to assess the adjusted effect of year quarter on TST, SOL and parental frustration. We used logistic regression to assess the adjusted effect of year quarter on nap consistency.

RESULTS

Of 594 children, mean age was 18.5±9.7 months; 52% were female. In the adjusted analyses, the reference categories were: quarter 1 (year quarter); ≤6 months (age category); <$25,000 (household income). TST was associated with age category (12 to ≤24 month: β=-2.86;p=0.0004, 24 to ≤36 month: β=-3.25;p<0.0001), and maternal age (β=-0.04;p=0.05). SOL was associated with year quarter (year quarter 3: β=0.16; p =0.04), age category (24 to ≤36 months: β=0.28;p<0.0001), household income ($100,000-150,000: β =-0.15;p=0.03, >$150,000: β=-0.19;p=0.01) and lack of room sharing (β=-0.09; p=0.05). Parental frustration with sleep increased with age (all p<0.05) and lack of room sharing (p=0.01). The effect of lack of room sharing on nap consistency approached significance (aOR 1.88;95%CI 0.95, 3.72).

CONCLUSIONS

Social factors such as lower household income and room sharing affected the sleep of US infants and toddlers as opposed to the COVID-19 lockdown itself.

DSM-5 insomnia disorder in pregnancy: associations with depression, suicidal ideation, and cognitive and somatic arousal, and identifying clinical cutoffs for detection

Study Objectives

The study had three primary goals. First, we estimated survey-assessed DSM-5 insomnia disorder rates in pregnancy, and described associated sociodemographics, and sleep-wake and mental health symptoms. Second, we derived cutoffs for detecting DSM-5 insomnia disorder using common self-report measures of sleep symptoms. Third, we identified clinically relevant cut-points on measures of nocturnal cognitive and somatic arousal.

Methods

Ninety-nine women (85.9% in the 2^nd trimester) completed online surveys including DSM-5 insomnia disorder criteria, the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Presleep Arousal Scale's Cognitive (PSASC) and Somatic (PSASS) factors, and Edinburgh Postnatal Depression Scale.

Results

DSM-5 insomnia disorder rate was 19.2%. Insomnia was associated with depression, suicidality, nocturnal cognitive and somatic arousal, and daytime sleepiness. An ISI scoring method that aligns with DSM-5 criteria yielded excellent metrics for detecting insomnia disorder and good sleep. Regarding quantitative cutoffs, ISI ≥ 10 and ISI ≥ 11 (but not ISI ≥ 15) were supported for detecting DSM-5 insomnia, whereas ISI ≤ 7 and ISI ≤ 9 performed well for detecting good sleep. PSQI cutoff of 5 was supported for detecting insomnia and good sleep. The optimal cutoff for nocturnal cognitive arousal was PSASC ≥ 18, whereas the optimal cutoff for somatic arousal was PSASS ≥ 13.

Conclusions

Insomnia disorder affects a large segment of pregnant women. Empirically derived cutoffs for insomnia, good sleep, cognitive arousal, and somatic arousal may inform case identification and future perinatal sleep research methodology.

Burden of sleep disturbance in non-Hispanic Black pregnant women

STUDY OBJECTIVES

Non-Hispanic Black pregnant women disproportionately experience poor perinatal outcomes compared to other racial/ethnic groups. Sleep disruption has emerged as a risk factor for adverse pregnancy outcomes but there are limited data in minority pregnant women. We examined the prevalence of habitual snoring and its timing of onset with several key sleep-wake disturbances and their associations with perinatal outcomes in a cohort of non-Hispanic Black pregnant women.

METHODS

Third trimester non-Hispanic Black pregnant women were recruited from a large, academic medical center and screened for habitual snoring - and its timing relative to pregnancy - sleep quality, symptoms of insomnia, excessive daytime sleepiness, as well as daytime function. Clinical diagnoses of hypertensive disorders of pregnancy were obtained along with delivery outcomes.

RESULTS

In 235 women the vast majority (80%) reported three or more sleep-wake disturbances, and almost half had at least five disturbances. Sixteen percent endorsed pre-pregnancy snoring and 20% pregnancy-onset snoring. Women with pregnancy-onset snoring had significantly increased odds of poor sleep quality aOR 8.2, trouble staying asleep aOR 3.6, waking up too early aOR 2.7, excessive daytime sleepiness aOR 2.3, and poor daytime function aOR 8.7 but no relationship with perinatal outcomes. In contrast, pre-pregnancy snoring was related to chronic hypertension, pre-term delivery and fetal growth restriction; aOR 2.6, aOR 2.8, and aOR 5.1 respectively.

CONCLUSIONS

Sleep-wake disturbances confer a significant burden to pregnant non-Hispanic Black women, an infrequently studied yet disproportionately affected population. Contributions of maternal sleep to racial disparities in perinatal health should be a priority for public health research.

A better understanding of the association between maternal perception of foetal movements and late stillbirth-findings from an individual participant data meta-analysis

BACKGROUND

Late stillbirth continues to affect 3-4/1000 pregnancies in high-resource settings, with even higher rates in low-resource settings. Reduced foetal movements are frequently reported by women prior to foetal death, but there remains a poor understanding of the reasons and how to deal with this symptom clinically, particularly during the preterm phase of gestation. We aimed to determine which women are at the greatest odds of stillbirth in relation to the maternal report of foetal movements in late pregnancy (≥ 28 weeks' gestation).

METHODS

This is an individual participant data meta-analysis of all identified case-control studies of late stillbirth. Studies included in the IPD were two from New Zealand, one from Australia, one from the UK and an internet-based study based out of the USA. There were a total of 851 late stillbirths, and 2257 controls with ongoing pregnancies.

RESULTS

Increasing strength of foetal movements was the most commonly reported (> 60%) pattern by women in late pregnancy, which were associated with a decreased odds of late stillbirth (adjusted odds ratio (aOR) = 0.20, 95% CI 0.15 to 0.27). Compared to no change in strength or frequency women reporting decreased frequency of movements in the last 2 weeks had increased odds of late stillbirth (aOR = 2.33, 95% CI 1.73 to 3.14). Interaction analysis showed increased strength of movements had a greater protective effect and decreased frequency of movements greater odds of late stillbirth at preterm gestations (28-36 weeks' gestation). Foetal hiccups (aOR = 0.45, 95% CI 0.36 to 0.58) and regular episodes of vigorous movement (aOR = 0.67, 95% CI 0.52 to 0.87) were associated with decreased odds of late stillbirth. A single episode of unusually vigorous movement was associated with increased odds (aOR = 2.86, 95% CI 2.01 to 4.07), which was higher in women at term.

CONCLUSIONS

Reduced foetal movements are associated with late stillbirth, with the association strongest at preterm gestations. Foetal hiccups and multiple episodes of vigorous movements are reassuring at all gestations after 28 weeks' gestation, whereas a single episode of vigorous movement is associated with stillbirth at term.

The Impact of Pet Care Needs on Medical Decision-Making among Hospitalized Patients: A Cross-Sectional Analysis of Patient Experience

Hospital-based protocols to support pet care needs for hospitalized patients may have potential to benefit patient health and wellbeing, but must be informed by experiences of hospitalized pet owners. The aim of this study was to determine the scope and need for pet care services among hospitalized patients. A panel of prior inpatients and their family members at a tertiary care center were surveyed about preferences, experiences, and need for assistance with pet care during hospitalization. Respondents (n = 113) expressed interest in a low/no-cost pet-boarding or foster program for adult patients struggling to find pet care assistance. The majority of respondents (n = 71; 63%) reported challenges securing pet care during a prior hospitalization, and/or knew someone who encountered similar challenges. Respondents also indicated that these challenges had a negative impact on health, recovery, or their own decision to receive medical care. Pet care challenges during hospitalization are likely common and have the potential to hamper medical decision-making and health outcomes of inpatients.

Impact of sleep-disordered breathing on behavior and quality of life in children aged 2 to 7 years with non-syndromic cleft lip and/or palate

INTRODUCTION

Children with cleft are at high risk for sleep-disordered breathing (SDB). However, little is known about the impact of SDB in this pediatric population. The aim of this study was to investigate whether SDB play a role in behavior and quality of life (QoL) in young children with cleft.

METHODS

Cross-sectional study of 95 children aged 2.0-7.9 years with cleft palate. Parents completed a sleep (Pediatric Sleep questionnaire), a behavior (Conners' Early Childhood scale), and a generic health-related QoL (KINDL questionnaire) assessment. Symptomatic children were referred for a polysomnography (PSG).

RESULTS

Overall, 14.7% of children (49.5% boys) screened positive for SDB and 27.4% had a PSG, which identified 84.6% with sleep apnea (apnea-hypopnea index [AHI] ≥1) and 27.2% with AHI ≥5. Positive screening for SDB was associated with elevated T-scores for anxiety and physical symptoms, significant differences in mean T-scores for inattention/hyperactivity (64.2 ± 15.7 vs. 53.9 ± 11.4, p = .02), social functioning/atypical behaviour, social functioning (60.6 ± 11.7 vs. 51.9 ± 7.3, p = .004 and 59.5 ± 10.9 vs. 51.2 ± 8.0, p = .01) and mood (57.5 ± 8.2 vs. 50.7 ± 8.2, p = .03). Lower QoL scores for emotional and family well-being were also reported in children with SDB (80.7 ± 13.4 vs. 90.0 ± 8.7, p = .01, 66.7 ± 15.8 vs. 76.9 ± 11.9, p = .04). Children with AHI ≥5 compared to those with AHI ≥1 and <5 showed significant differences in mean T-score for aggressive behaviour (65.2 ± 12.1 vs. 52.3 ± 11.3, p = .04), defiant temper (62.8 ± 9.2 vs. 51.6 ± 10.2, p = .03) and lower family QoL scores (59.4 ± 15.2 vs. 77.1 ± 9.6, p = .006).

CONCLUSIONS

In children with cleft palate the presence of SDB symptoms and moderate/severe sleep apnea was associated with behavioral (internalizing/externalizing) problems and lower family well-being.

Association between habitual snoring, middle ear disease, and speech problems in young children with non-syndromic cleft palate anomalies

The purpose of this study was to investigate the association between habitual snoring (HS), middle ear disease (MED), and speech problems in children with cleft palate. This cross-sectional study included children aged 2.0-7.9 years with non-syndromic cleft palate anomalies. Parents completed the Pediatric Sleep Questionnaire and a questionnaire about MED. Audiograms and speech assessment were also conducted. Ninety-five children were enrolled; 15.2% of families reported HS, 97.6% MED, and 17.1% speech problems. HS (37.5% vs 10.3%, P = 0.007) and early episodes of MED (92.3% vs 58.2%, P = 0.021) were more likely to be reported for children with isolated cleft palate when compared to those with cleft lip and palate. Children with cleft lip and palate had a higher frequency of MED with effusion compared to those with Robin sequence (86.4% vs 57.1%, P = 0.049). The odds ratio for HS in children with ≥1 episode of MED in the last year was 7.37 (95% confidence interval 1.55-35.15, P = 0.012). There was a trend for children with speech problems reported by parents to have HS (30.8% vs 11.5%, P= 0.076). Anatomical factors play a role in the frequency of upper airway symptoms in children with cleft palate. A recent history of at least one episode of MED was associated with an increased frequency of HS.

Healthier dietary patterns are associated with better sleep quality among midlife Mexican women

STUDY OBJECTIVES

To evaluate whether dietary patterns are associated with sleep quality in Mexican midlife women.

METHODS

The study population included 4,467 Mexican women from a longitudinal study of teachers. In 2008, a semiquantitative food frequency questionnaire was administered. Principal components analysis identified 3 dietary patterns: Fruits and Vegetables, Western (meat and processed), and Modern Mexican (tortillas and soda, low in fiber and dairy). Starting in 2012, follow-up questionnaires included the Pittsburgh Sleep Quality Index, which yields a score ranging from 0 to 21 (higher scores = worse quality). Modified Poisson regression analyses examining the association between dietary patterns (categorized into quartiles) and poor sleep quality (score > 5) were conducted, adjusting for socio-demographic and lifestyle confounders and baseline comorbid conditions.

RESULTS

Women were 41.0 ± 7.1 years at baseline, with an average follow-up of 5.5 ± 0.7 years. In fully adjusted models, women in the least-healthy quartile of the Fruits and Vegetables pattern compared with the most were 21% more likely to have poor quality sleep at follow-up (95% confidence interval 1.06, 1.42), while those in the highest quartiles of the Modern Mexican pattern were 23% more likely to have poor quality sleep compared with the lowest quartiles (95% confidence interval 1.06 to 1.43, respectively).

CONCLUSIONS

A fruit and vegetable-based dietary pattern was associated with higher sleep quality, while an unhealthier diet pattern was associated with worse sleep quality in midlife women.

Parallel Assessment Challenges in Nutritional and Sleep Epidemiology

Sleep has been consistently linked to health outcomes in clinical studies, but only in recent years has sleep become a focus in epidemiologic studies and public health. In particular, the sizable prevalence of insufficient sleep in the population warrants well-designed epidemiologic studies to examine its impact on public health. As a developing field, sleep epidemiology encounters methodological challenges similar to those faced by nutritional epidemiology research. In this article, we describe a few central challenges related to assessment of sleep duration in population-based studies in comparison with measurement challenges in nutritional epidemiology. In addition, we highlight 3 strategies applied in nutritional epidemiology to address measurement challenges and suggest ways these strategies could be implemented in large-scale sleep investigations.

The prevalence and impact of pre-existing sleep disorder diagnoses and objective sleep parameters in patients hospitalized for COVID-19

STUDY OBJECTIVES

Obstructive sleep apnea and other sleep disorders overlap with comorbidities associated with poor outcomes related to severe acute respiratory syndrome coronavirus 2 infection. However, the prevalence of obstructive sleep apnea among patients hospitalized for COVID-19 and relationship to outcomes is poorly characterized, and the relevance of other sleep disorders remains unknown. The objective of this study was to identify the prevalence of pre-existing sleep disorders and association with outcomes related to severe COVID-19 illness.

METHODS

Patients with severe acute respiratory syndrome coronavirus 2 infection admitted to the University of Michigan Hospital System were included. Electronic medical records were queried for sleep disorders diagnostic codes. Data were extracted from polysomnography and home sleep testing in a subgroup with previous diagnostic testing at our center. Logistic regression was used to examine the association of sleep disorders with mechanical ventilation requirement, treatment with vasopressors, and death and Cox proportional hazards regression for time to discharge.

RESULTS

Among n = 572 adult patients hospitalized for COVID-19, 113 (19.8%) patients had obstructive sleep apnea, 4 patients had central sleep apnea (0.7%), 5 had hypoventilation (0.9%), 63 had insomnia (11.0%), and 22 had restless legs syndrome or periodic limb movements disorder (3.9%). After adjusting for age, sex, body mass index, and race, no significant relationship was apparent between sleep disorders diagnoses or indices of sleep-disordered breathing severity and outcomes.

CONCLUSIONS

This is the first study to determine the prevalence of obstructive sleep apnea and other sleep disorders in a well-characterized cohort of patients hospitalized for COVID-19. Once hospitalized, a significant contribution of sleep disorders to outcomes was not identified. Therefore, future evaluations should focus on earlier outcomes, such as infection or clinical manifestations after exposure to severe acute respiratory syndrome coronavirus 2.

The Berlin Questionnaire in pregnancy predominantly identifies obesity

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is common in pregnant women and is a risk factor for poor perinatal outcomes. The Berlin Questionnaire (BQ) is a validated OSA screening tool that is often used in pregnancy. However, its poor performance in this population is likely attributed to the scoring paradigm that primarily identifies obesity. Moreover, the associations between the BQ and pregnancy outcomes are often those same outcomes that are obesity-related. Therefore, this study examined associations between each of the three BQ domains, independently and jointly, in relation to gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP).

METHODS

Pregnant third-trimester women were recruited from a tertiary medical center and completed the BQ, which includes three independent domains: snoring; sleepiness; and obesity/high blood pressure. Medical records were accessed for diagnoses of GDM and HDP.

RESULTS

Of the 1,588 pregnant women, 44% had a positive BQ score. Women with a positive score for domains of snoring exclusively, sleepiness exclusively, or their combination did not have an increased risk for GDM or HDP. However, women without snoring or sleepiness, but with a positive score on the BMI/BP domain had increased odds of GDM (OR 2.0, 95%CI 1.3-3.3) and HDP (OR 2.9, 95%CI 1.6-5.5). Further, any positive score in domain combinations that included BMI/BP had increased odds of GDM and HDP compared with negative scores in all domains. In addition, presence of obesity without hypertension, snoring, or sleepiness, the odds of GDM and HDP were similarly increased.

CONCLUSIONS

The poor performance of the BQ in screening for OSA risk, may be attributed to its predominant reliance on identification of obesity.

Sleep characteristics and problems of 2-year-olds with Williams syndrome: relations with language and behavior

Background

Sleep problems have been shown to have a negative impact on language development and behavior for both typically developing children and children with a range of neurodevelopmental disorders. The relation of sleep characteristics and problems to language and behavior for children with Williams syndrome (WS) is unclear. The goal of this study was to address these relations for 2-year-olds with WS. Associations of nonverbal reasoning ability, nighttime sleep duration, and excessive daytime sleepiness with language ability and behavior problems were considered.

Method

Ninety-six 2-year-olds with genetically confirmed classic-length WS deletions participated. Parents completed the Pediatric Sleep Questionnaire, which includes a Sleep-Related Breathing Disorder (SRBD) scale with a subscale measuring excessive daytime sleepiness, to assess sleep characteristics and problems. Parents also completed the Child Behavior Checklist (CBCL) and the MacArthur-Bates Communicative Development Inventory: Words and Sentences to assess behavior problems and expressive vocabulary, respectively. Children completed the Mullen Scales of Early Learning to measure nonverbal reasoning and language abilities.

Results

Parents indicated that children slept an average of 10.36 h per night (SD = 1.09, range 7.3–13.3), not differing significantly from the mean reported by Bell and Zimmerman (2010) for typically developing toddlers (p = .787). Sixteen percent of participants screened positive for SRBD and 30% for excessive daytime sleepiness. Children who screened positive for SRBD had significantly more behavior problems on all CBCL scales than children who screened negative. Children with excessive daytime sleepiness had significantly more attention/hyperactivity, stress, and externalizing problems than those who did not have daytime sleepiness. Individual differences in parent-reported nighttime sleep duration and directly measured nonverbal reasoning abilities accounted for unique variance in expressive language, receptive language, and internalizing problems. Individual differences in parent-reported daytime sleepiness accounted for unique variance in externalizing problems.

Conclusions

The relations of nighttime sleep duration, positive screens for SRBD, and excessive daytime sleepiness to language and behavior in toddlers with WS parallel prior findings for typically developing toddlers. These results highlight the importance of screening young children with WS for sleep problems. Studies investigating the efficacy of behavioral strategies for improving sleep in children with WS are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11689-020-09336-z.

Comparison of Early Oral Cancer Depth of Invasion From the American Joint Committe on Cancer 7th to 8th Edition Criteria. Does the Difference Impact the Accuracy of Clinical Decision Making?

PURPOSE

Depth of invasion (DOI) is an independent predictor of regional metastasis in oral squamous cell carcinoma. Measurement criteria for DOI were modified in the American Joint Committee on Cancer (AJCC) eighth edition. The purpose of this study was to compare DOI AJCC seventh (DOI7) and eighth (DOI8) edition criteria on frozen section accuracy for decisions regarding elective neck dissection (END) in cT1N0 oral squamous cell carcinoma.

PATIENTS AND METHODS

A blinded, retrospective, comparative study of patients who underwent ablative surgery at the University of Michigan was completed. The predictor variable was criteria for DOI measurement. The outcome variables were concordance between DOI7 and DOI8 measurements and accuracy using thresholds for END. Effect of tumor growth pattern and worst pattern of invasion, and the difference between DOI8 on frozen and permanent specimen were assessed.

RESULTS

A total of 30 specimens of T1N0 oral squamous cell carcinoma (16 tongue, 5 alveolus, 5 floor of mouth, 4 buccal mucosa) were included. DOI7 versus DOI8 on frozen and permanent specimen were significantly different (P < .05) but clinically insignificant and highly correlated (r > 0.99, P < .001). One hundred percent concordance between DOI7 and DOI8 was noted on frozen specimen in predicting the need for END when compared with permanent pathology DOI. There was no significant impact of tumor growth pattern or worst pattern of invasion on measurements and no significant difference in DOI on frozen and permanent specimen for DOI8 (P = .68). Excellent agreement between pathologists for all measurements was observed (ICC>0.99, P < 0001).

CONCLUSIONS

High concordance between DOI measurements by AJCC seventh and eighth edition criteria suggests that guidelines for DOI thresholds for END in patients with T1N0 tumors developed using the AJCC seventh edition can be safely applied using AJCC eighth edition criteria. DOI measurement by AJCC 8 criteria on frozen specimen can be used to guide decision-making regarding END, given the high correlation to AJCC 8 permanent DOI measurement.

Adolescent sleep timing and dietary patterns in relation to DNA methylation of core circadian genes: a pilot study of Mexican youth

Mistimed sleep/wake and eating patterns put shift workers at increased risk for cardiometabolic disease, and epigenetic modification of circadian genes has been proposed as a mechanism. Although not as extreme as shift workers, adolescents often have delayed sleep timing and irregular eating patterns. The aim was to assess whether sleep midpoints - median of bed and wake time - and dietary patterns in adolescents were associated with DNA methylation of circadian genes. The study population included 142 Mexican youth (average age of 14.0 (SD = 2.0) years, 49% male). Average sleep midpoint over weekdays was estimated with actigraphy. Diet was assessed with a semi-quantitative food frequency questionnaire, and three dietary patterns were derived from principal component analysis, a Plant-based & lean proteins pattern, a Meat & starchy pattern, and an Eggs, milk & refined grain pattern. DNA methylation was quantified in blood leukocytes with the Infinium MethylationEPIC BeadChip, and data from 548 CpG sites within 12 circadian genes were examined. Linear regression analyses, adjusted for sex, age, and % monocytes, showed that later sleep timing was associated with higher DNA methylation of several circadian genes, notably with RORB, PER1, CRY2, and NR1D1. Each of the dietary patterns examined was also related to circadian gene DNA methylation, but the Eggs, milk & refined grain pattern ('breakfast' pattern) had the clearest evidence of relationships with circadian genes, with inverse associations (lower DNA methylation) across all 12 genes. Findings suggest that timing-related sleep and eating behaviours among adolescents could result in epigenetic modification of clock genes.

Associations of plasma hypocretin-1 with metabolic and reproductive health: Two systematic reviews of clinical studies

The hypocretin system consists of two peptides hypocretin-1 and hypocretin-2 (HCRT1 and HCRT2). Hypocretin-containing neurons are located in the posterior and lateral hypothalamus, and have widespread projections throughout the brain and spinal cord. In addition to its presence in the cerebrospinal fluid (CSF), peripheral HCRT1 has been detected in plasma. Robust experimental evidence demonstrates functions of hypothalamic-originated HCRT1 in regulation of multiple biological systems related to sleep-wake states, energy homeostasis and endocrine function. In contrast, HCRT1 studies with human participants are limited by the necessarily invasive assessment of CSF HCRT1 to patients with underlying morbidity. Regulation by HCRT1 of energy homeostasis and reproduction in animals suggests similar regulation in humans and prompts these two systematic reviews. These reviews translate prior experimental findings from animal studies to humans and examine associations between HCRT1 and: 1) metabolic risk factors; 2) reproductive function in men, women and children. A total of 21 studies and six studies met the inclusion criteria for the two searches, respectively. Research question, study design, study population, assessments of HCRT1, reproductive, cardiometabolic data and main findings were extracted. Associations between HCRT1, metabolic and reproductive function are inconsistent. Limitations of studies and future research directions are outlined.

Sleep duration and fragmentation in relation to leukocyte DNA methylation in adolescents

STUDY OBJECTIVES

Sleep deprivation and low sleep quality are widespread among adolescents, and associate with obesity risk. Plausible mediators include diet and physical activity. Another potential interrelated pathway, as yet unexplored in adolescents, could involve epigenetic modification of metabolism genes.

METHODS

In a cohort of 351 Mexico City adolescents (47% male; mean [SD] age = 14 [2] years), 7-day actigraphy was used to assess average sleep duration, sleep fragmentation, and movement index. DNA isolated from blood leukocytes was bisulfite-converted, amplified, and pyrosequenced at four candidate regions. Linear mixed models evaluated sex-stratified associations between sleep characteristics (split into quartiles [Q]) and DNA methylation of each region, adjusted for potential confounders.

RESULTS

Mean sleep duration was 8.5 [0.8] hours for boys and 8.7 [1] hours for girls. There were sex-specific associations between sleep duration and LINE-1 (long interspersed nuclear element) methylation. Boys with longer sleep duration (Q4) had lower LINE-1 methylation than boys in the 3rd quartile reference category, while girls with both longer and shorter sleep duration had higher LINE-1 methylation compared to Q3. Longer sleep duration was associated with higher H19 methylation among girls (comparing highest to third quartile, -0.9% [-2.2, 0.5]; p, trend = 0.047). Sleep fragmentation was inversely associated with peroxisome proliferator-activated receptor alpha (PPARA) methylation among girls (comparing highest to lowest fragmentation quartile, 0.9% [0.1 to 1.8]). Girls also showed an inverse association between sleep fragmentation and hydroxysteroid (11-beta) dehydrogenase 2 (HSD11B2; Q4 to Q1, 0.6% [-1.2%, 0%]).

CONCLUSIONS

Sleep duration and fragmentation in adolescents show sex-specific associations with leukocyte DNA methylation patterns of metabolism genes.

Sleep-disordered breathing in cystic fibrosis

INTRODUCTION

Cystic fibrosis (CF) is a life-shortening, genetic disease that affects approximately 30,000 Americans. Although patients frequently report snoring, mouth breathing, and insomnia, the extent to which sleep-disordered breathing (SDB) may underlie these complaints remains unknown.

METHODS

Single-center retrospective review of polysomnography results from referred patients with and without CF individually-matched (1:2) for age, gender, race, and body mass index (BMI).

RESULTS

Mean ages were 8.0 ± 5.2 (sd) and 35.9 ± 12.9 years, among 29 children and 23 adults with CF respectively. The CF and non-CF groups were well-matched in age and BMI. Subjects with vs. without CF had three times greater odds of moderate-severe SDB (apnea-hypopnea index (AHI) ≥ 5 in children, ≥ 15 in adults) (p = 0.01). Nocturnal oxygen saturation nadir (Minimum SpO₂) was lower among CF vs. non-CF groups (p = 0.002). For every 1-unit increase in AHI, the decline in Minimum SpO₂ was larger for subjects with vs. without CF (p = 0.05). In subjects with CF, forced expiratory volume in 1 s percent predicted (FEV1 PPD) was associated with Minimum SpO₂ (Pearson r = 0.68, p < 0.0001) but not AHI (r = -0.19, p = 0.27). For every 1-unit increase in AHI, magnitude of decline in Minimum SpO₂ was larger for those with low vs. normal FEV1 PPD (p = 0.01).

CONCLUSION

Severity of SDB may be worse among referred patients with vs. without CF. The SDB may modify the relationship between CF lung disease and nocturnal hypoxemia. Markers of lung disease severity including lung function do not predict SDB severity, suggesting the need for routine polysomnography to screen for this sleep disorder.

A randomized controlled trial of digital cognitive behavioral therapy for insomnia in pregnant women

OBJECTIVE

Despite high rates of prenatal insomnia, efficacious treatment options for this population are quite limited. Early evidence from randomized controlled trials (RCTs) support the efficacy of face-to-face cognitive-behavioral therapy for insomnia (CBTI) for prenatal insomnia. Yet, as many patients are unable to access this specialist-driven care, a critical need exists to increase its accessibility. This RCT examined the efficacy internet-based digital CBTI in pregnant women with insomnia.

METHODS

Single-site RCT. A total of 91 pregnant women (29.03 ± 4.16 years) nearing/entering the third trimester who screened positive for clinical insomnia on the Insomnia Severity Index (ISI) were randomized to digital CBTI or digital sleep education control. The ISI, Pittsburgh Sleep Quality Index (PSQI), Edinburgh Postnatal Depression Scale (EPDS), and Pre-Sleep Arousal Scale's Cognitive factor (PSAS-C) served as study outcomes, which were collected before treatment and after treatment during pregnancy, then six weeks after childbirth.

RESULTS

From pre to posttreatment, CBTI patients reported reductions in ISI (-4.91 points, p < 0.001) and PSQI (-2.98 points, p < 0.001) and increases in nightly sleep duration by 32 min (p = 0.008). Sleep symptoms did not change during pregnancy in the control group. After childbirth, CBTI patients, relative to controls, slept longer by 40 min per night (p = 0.01) and reported better sleep maintenance. No pre or postnatal treatment effects on depression or cognitive arousal were observed.

CONCLUSIONS

Digital CBTI improves sleep quality and sleep duration during pregnancy and after childbirth. To better optimize outcomes, CBTI should be tailored to meet the changing needs of women as the progress through pregnancy and early parenting. NAME: Insomnia and Rumination in Late Pregnancy and the Risk for Postpartum Depression. URL: clinicaltrials.gov. Registration: NCT03596879.

Plasma DHA Is Related to Sleep Timing and Duration in a Cohort of Mexican Adolescents

BACKGROUND

Delayed sleep timing and short sleep duration represent a significant public health burden in adolescents. Whether intake of nutrients affects the pineal gland, where sleep/wake cycles are regulated, remains unclear.

OBJECTIVES

In a cross-sectional analysis, we investigated whether plasma concentrations of DHA and arachidonic acid (AA), long-chain fatty acids that can be obtained through diet, were related to sleep timing and duration in adolescents.

METHODS

The study population included 405 Mexico City adolescents (mean age ± SD = 14.2 ± 2.1 y; 48% males) who took part in a 2015-2016 follow-up visit as a part of an ongoing cohort study. Fatty acid concentrations were measured in plasma using GLC, as a percentage of total fatty acids. Sleep midpoint and duration were assessed with 7-d wrist actigraphy. We categorized DHA and AA plasma concentrations into quartiles (Q1-Q4; Q4 = highest fatty acids). We conducted cross-sectional linear regression analysis with sleep characteristics as separate outcomes and quartiles of DHA and AA as exposures, adjusting for sex, age, and BMI z-scores.

RESULTS

Mean ± SD plasma DHA (as percentage of total fatty acids) was 1.2 ± 0.4%, whereas mean ± SD plasma AA was 6.2 ± 1.5%. In adjusted analysis, higher plasma DHA was linearly associated with longer sleep duration on the weekends; to illustrate, those in Q4 compared with Q1 had 32 min longer duration (95% CI: 7, 57; P trend = 0.005). Higher DHA was also associated with earlier sleep timing during weekdays and weekends, although in a nonlinear fashion. The largest difference was a 0.75-h (45-min) later sleep midpoint in Q2 compared with Q4 (95% CI: 0.36, 1.14).

CONCLUSIONS

Plasma DHA was associated with earlier sleep timing and longer weekend sleep duration in Mexican adolescents. Whether DHA supplementation improves sleep in adolescent populations deserves consideration in randomized trials.

Key insomnia symptoms and incident pain in older adults: direct and mediated pathways through depression and anxiety

Pain is common among older adults and negatively impacts functioning. Sleep disturbances and mood disorders, specifically depression and anxiety, are closely associated with pain in older individuals, but the directionality of these associations remains unclear. In this study, we deconstruct long-term temporal effects of two key insomnia symptoms on incident pain into direct and indirect pathways, with focus on depression and anxiety symptoms, within a nationally representative sample. We utilized 2011-2013 data from the National Health and Aging Trends Study, a longitudinal survey of 2239 community-dwelling Medicare beneficiaries. Participants completed annual in-person interviews with assessments of sleep initiation and maintenance; depression, and anxiety (using the Patient Health Questionnaire-2 [PHQ-2] and the Generalized Anxiety Disorder Scale-2 [GAD-2] respectively); and bothersome pain. Causal mediation analysis was applied to examine direct effects of the two insomnia symptoms at baseline on incident pain, and their indirect effects through depression and anxiety symptoms. Almost one-third of the study participants were 69 years old or younger. A similar proportion reported bothersome pain in 2013. The two baseline insomnia symptoms predicted the development of pain. Adjusted analyses suggested that compared to older adults without the two baseline insomnia symptoms, participants with sleep initiation or maintenance difficulties had 24% (95% confidence interval [CI] 2%,51%) and 28% (95% CI 4%,55%) higher odds of incident pain, respectively. Anxiety symptoms partially mediated the relationship between the insomnia symptoms and incident pain, accounting for up to 17% of the total effect, but depressive symptoms did not. These results suggest that improved sleep or anxiety could reduce the risk for future pain.

Sleep, Diet, and Cardiometabolic Health Investigations: a Systematic Review of Analytic Strategies

PURPOSE OF REVIEW

Poor sleep is a risk factor for cardiometabolic morbidity. The relationship of sleep and cardiometabolic health could be confounded, mediated, or modified by diet, yet the incorporation of diet in sleep-cardiometabolic health studies is inconsistent. This rapid systematic literature review evaluates the conceptualization of diet as a confounder, mediator, or effect modifier within sleep-cardiometabolic health investigations, and the statistical approaches utilized.

RECENT FINDINGS

Of 4692 studies identified, 60 were retained (28 adult, 32 pediatric). Most studies included diet patterns, quality, or energy intake as confounders, while a few examined these dietary variables as mediators or effect modifiers. There was some evidence, mostly in pediatric studies, that inclusion of diet altered sleep-cardiometabolic health associations. Diet plays a diverse role within sleep-cardiometabolic health associations. Investigators should carefully consider the conceptualization of diet variables in these relationships and utilize contemporary statistical approaches when applicable.

Depression and suicidal ideation in pregnancy: exploring relationships with insomnia, short sleep, and nocturnal rumination

BACKGROUND

Sleep problems and depression are highly prevalent in pregnancy. Nocturnal rumination has been linked to insomnia and depression in non-pregnant samples, but remains poorly characterized in pregnancy. This study explored relationships of depression and suicidal ideation with insomnia, short sleep, and nocturnal rumination in mid-to-late pregnancy.

METHODS

In this study, 267 pregnant women were recruited from obstetric clinics and completed online surveys on sleep, depression, and nocturnal rumination.

RESULTS

Over half (58.4%) of the sample reported clinical insomnia on the Insomnia Severity Index, 16.1% screened positive for major depression on the Edinburgh Postnatal Depression Scale (EPDS), and 10.1% endorsed suicidal ideation. Nocturnal rumination was more robustly associated with sleep onset difficulties than with sleep maintenance issues. Depressed women were at greater odds of sleep onset insomnia (OR = 2.80), sleep maintenance insomnia (OR = 6.50), high nocturnal rumination (OR = 6.50), and negative perinatal-focused rumination (OR = 2.70). Suicidal ideation was associated with depression (OR = 3.64) and negative perinatal-focused rumination (OR = 3.50). A four-group comparison based on insomnia status and high/low rumination revealed that pregnant women with insomnia and high rumination endorsed higher rates of depression (35.6%) and suicidal ideation (17.3%) than good-sleeping women with low rumination (1.2% depressed, 4.9% suicidal). Women with insomnia alone (depression: 3.9%, suicidal: 5.9%) or high rumination alone (depression: 10.7%, suicidal: 7.1%) did not differ from good-sleeping women with low rumination.

CONCLUSIONS

High rumination and insomnia are highly common in mid-to-late pregnancy and both are associated with depression and suicidal ideation. Depression and suicidal ideation are most prevalent in pregnant women with both insomnia and high rumination. CLINICALTRIALS.

GOV IDENTIFIER

NCT03596879.

The Ghana PrenaBelt trial: a double-blind, sham-controlled, randomised clinical trial to evaluate the effect of maternal positional therapy during third-trimester sleep on birth weight

OBJECTIVE

To evaluate the effect, on birth weight and birth weight centile, of use of the PrenaBelt, a maternal positional therapy device, during sleep in the home setting throughout the third trimester of pregnancy.

DESIGN

A double-blind, sham-controlled, randomised clinical trial.

SETTING

Conducted from September 2015 to May 2016, at a single, tertiary-level centre in Accra, Ghana.

PARTICIPANTS

Two-hundred participants entered the study. One-hundred-eighty-one participants completed the study. Participants were women, 18 to 35 years of age, with low-risk, singleton, pregnancies in their third-trimester, with body mass index <35 kg/m² at the first antenatal appointment for the index pregnancy and without known foetal abnormalities, pregnancy complications or medical conditions complicating sleep.

INTERVENTIONS

Participants were randomised by computer-generated, one-to-one, simple randomisation to receive either the PrenaBelt or sham-PrenaBelt. Participants were instructed to wear their assigned device to sleep every night for the remainder of their pregnancy (approximately 12 weeks in total) and were provided a sleep diary to track their use. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants and the outcomes assessor were blinded to allocation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were birth weight and birth weight centile. Secondary outcomes included adherence to using the assigned device nightly, sleeping position, pregnancy outcomes and feedback from participants and maternity personnel.

RESULTS

One-hundred-sixty-seven participants were included in the primary analysis. The adherence to using the assigned device nightly was 56%. The mean ±SD birth weight in the PrenaBelt group (n=83) was 3191g±483 and in the sham-PrenaBelt group (n=84) was 3081g±484 (difference 110 g, 95% CI -38 to 258, p=0.14). The median (IQR) customised birth weight centile in the PrenaBelt group was 43% (18 to 67) and in the sham-PrenaBelt group was 31% (14 to 58) (difference 7%, 95% CI -2 to 17, p=0.11).

CONCLUSIONS

The PrenaBelt did not have a statistically significant effect on birth weight or birth weight centile in comparison to the sham-PrenaBelt.

TRIAL REGISTRATION NUMBER

NCT02379728.

0027 Adolescent Sleep Timing And Dietary Patterns In Relation To Dna Methylation Of Core Clock Genes

Introduction

Mistimed sleep/wake and eating patterns put adult shift workers at increased risk for chronic disease, and epigenetic modification of core clock genes has been proposed as a mechanism. Although not as extreme as shift workers, adolescents often have delayed sleep timing. Our aim was to assess whether sleep midpoints in adolescents are associated with DNA methylation of circadian genes. A secondary aim was to examine associations between dietary patterns and circadian gene methylation.

Methods

The study population included 142 Mexican youth (average age 14.0 (SD=2.0) years, 49% male) enrolled in a cohort study. Average sleep midpoint (between bed time and wake time) over 7 days was estimated with actigraphy. Diet was assessed with a semi-quantitative food frequency questionnaire, and three dietary patterns were derived from principal components analysis (a vegetable-based pattern, a meat and starch-based pattern, and a breakfast pattern). DNA methylation was quantified in blood leukocytes with the Infinium MethylatinEPIC BeadChip. We selected 166 loci (CpG sites) within CpG islands of core ‘clock’ genes known to regulate circadian rhythms (CLOCK, BMAL, PER1, PER2, PER3, CRY1, CRYI2, RORA, RORB, REV-VERBA, REV-VERBB). Linear regression was used to analyze associations between sleep midpoint or dietary patterns and logit-transformed percent methylation at the 166 CpG sites. All models were adjusted for sex and age.

Results

The average midpoint was 3:41 AM (SD=1 hr 15 min); average bed time was 11:29 PM (SD=68 min) and average wake time was 7:53 AM (SD=97 min). Sleep midpoint was positively associated with DNA methylation of CpG sites from the genes REV-VERBA and RORB at the Bonferroni-corrected significance level of p&lt;0.005. The breakfast dietary pattern (rich in eggs, milk, and bread) was inversely associated with DNA methylation at RORA (P=0.003).

Conclusion

Sleep timing and dietary habits are associated with DNA methylation of core clock genes in adolescents. Epigenetic modification of clock genes could in part underlie relationships between sleep, diet, and metabolic health among adolescents.

Support (If Any)

Dr. Jansen is supported by the NIH/NHLBI grant 5T32HL110952-05.

An Individual Participant Data Meta-analysis of Maternal Going-to-Sleep Position, Interactions with Fetal Vulnerability, and the Risk of Late Stillbirth

BACKGROUND

Maternal supine going-to-sleep position has been associated with increased risk of late stillbirth (≥ 28 weeks), but it is unknown if the risk differs between right and left side, and if some pregnancies are more vulnerable.

METHODS

Systematic searches were undertaken for an individual-level participant data (IPD) meta-analysis of case-control studies, prospective cohort studies and randomised trials undertaken up until 26 Jan, 2018, that reported data on maternal going-to-sleep position and stillbirth. Participant inclusion criteria included gestation ≥ 28 weeks', non-anomalous, singleton pregnancies. The primary outcome was stillbirth. A one-stage approach stratified by study and site was used for the meta-analysis. The interaction between supine going-to-sleep position and fetal vulnerability was assessed by bi-variable regression. The multivariable model was adjusted for a priori confounders. Registration number: PROSPERO, CRD42017047703.

FINDINGS

Six case-control studies were identified, with data obtained from five (cases, n = 851; controls, n = 2257). No data was provided by a sixth study (cases, n = 100; controls, n = 200). Supine going-to-sleep position was associated with increased odds of late stillbirth (adjusted odds ratio [aOR] 2.63, 95% CI 1.72-4.04, p < 0.0001) compared with left side. Right side had similar odds to left (aOR 1.04, 95% CI 0.83-1.31, p = 0.75). There were no significant interactions between supine going-to-sleep position and assessed indicators of fetal vulnerability, including small-for-gestational-age infants (p = 0.32), maternal obesity (p = 0.08), and smoking (p = 0.86). The population attributable risk for supine going-to-sleep position was 5.8% (3.2-9.2).

INTERPRETATION

This IPD meta-analysis confirms that supine going-to-sleep position is independently associated with late stillbirth. Going-to-sleep on left or right side appears equally safe. No significant interactions with our assessed indicators of fetal vulnerability were identified, therefore, supine going-to-sleep position can be considered a contributing factor for late stillbirth in all pregnancies. This finding could reduce late stillbirth by 5.8% if every pregnant woman ≥ 28 weeks' gestation settled to sleep on her side.

Efficacy of oral appliance therapy in patients following uvulopalatopharyngoplasty failure

Objective

Uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure performed to treat obstructive sleep apnea (OSA). This surgery, when performed alone, benefits only a minority of patients. This study was undertaken to determine the efficacy of oral appliance (OA) therapy following unsuccessful UPPP and assess for specific patient and polysomnographic characteristics that may identify those patients most likely to benefit from this combined treatment strategy.

Study Design

Retrospective of clinical outcomes in patients undergoing UPPP followed by treatment with an OA.

Methods

Polysomnographic results (baseline, status post‐UPPP, and status post‐UPPP with oral appliance use), age, gender, race, and body mass index were subjected to statistical analysis.

Results

The mean apnea hypopnea index (AHI) decreased from 23.6 at baseline to 8.6 following UPPP and oral appliance therapy. The mean O2 nadir increased from 83% at baseline to 89.9% following UPPP and treatment with an oral appliance. Fifty percent of patients (9/18) achieved an AHI <5 and were deemed “cured” of their disease. Seventy‐three percent of patients (13/18) achieved benefit with an AHI <20 and ≥50% reduction in their baseline AHI, deemed “successful therapy.” No statistically relevant demographic or polysomnographic differences were found between those who were “cured” and those with persistent disease with the exception that the O2 nadir status post UPPP was found to be lower in the “cured” group.

Conclusion

Oral appliance therapy is an effective treatment option for the majority of patients who have persistent obstructive sleep apnea following unsuccessful UPPP.

Level of Evidence

4

Modifying maternal sleep position in the third trimester of pregnancy with positional therapy: a randomised pilot trial

OBJECTIVE

To evaluate whether the percentage of time spent supine during sleep in the third trimester of pregnancy could be reduced using a positional therapy device (PrenaBelt) compared with a sham device.

DESIGN

A double-blind, randomised, sham-controlled, cross-over pilot trial.

SETTING

Conducted between March 2016 and January 2017, at a single, tertiary-level centre in Canada.

PARTICIPANTS

23 participants entered the study. 20 participants completed the study. Participants were low-risk, singleton, third-trimester pregnant women aged 18 years and older with body mass index <35 kg/m² at the first antenatal appointment for the index pregnancy and without known fetal abnormalities, pregnancy complications or medical conditions complicating sleep.

INTERVENTIONS

A two-night, polysomnography study in a sleep laboratory. Participants were randomised by computer-generated, one-to-one, simple randomisation to receive either a PrenaBelt or a sham-PrenaBelt on the first night and were crossed over to the alternate device on the second night. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants, the recruiter and personnel involved in setting up, conducting, scoring and interpreting the polysomnogram were blinded to allocation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the percentage of time spent supine during sleep. Secondary outcomes included maternal sleep architecture, respiration, self-reported sleep position and feedback.

RESULTS

The median percentage of sleep time supine was reduced from 16.4% on the sham night to 3.5% on the PrenaBelt night (pseudomedian=5.8, p=0.03). We were unable to demonstrate differences in sleep architecture or respiration. Participants underestimated the time they spent sleeping supine by 7.0%, and six (30%) participants indicated they would make changes to the PrenaBelt. There were no harms in this study.

CONCLUSIONS

This study demonstrates that the percentage of sleep time supine during late pregnancy can be significantly reduced via positional therapy.

TRIAL REGISTRATION NUMBER

NCT02377817; Results.

Modifying Maternal Sleep Position in Late Pregnancy Through Positional Therapy: A Feasibility Study

STUDY OBJECTIVES

To test whether a customized positional therapy device, PrenaBelt, would reduce time spent sleeping supine and evaluate any change in maternal or fetal parameters, in a group of healthy pregnant women in the third trimester of pregnancy.

METHODS

Participants underwent an in-home, overnight sleep study during late pregnancy (32-38 weeks). Participants were observed over 2 nights: 1 night when the PrenaBelt was not worn (nonintervention or control) and 1 night when it was (intervention). The intervention night was randomly allocated, and the study nights were consecutive. On the control night, participants were filmed using a night-capable (infrared) video camera, maternal sleep was measured by the Watch-PAT200, and the fetus was continuously monitored using the Monica AN24. On the intervention night, video, maternal, and fetal monitoring were repeated with the addition of the mother wearing the PrenaBelt.

RESULTS

A total of 25 healthy pregnant women were studied. Four had missing data for the Watch-PAT or Monica, and eight had missing or disrupted video data. Video-determined time in bed was not significantly different during intervention and control nights (P = .196, r = -.23). Median time spent supine during the intervention night was reduced from 48.3 minutes, to 28.5 minutes during the control night (P = .064, r = -.33). The difference in the proportion of time spent supine was significant (P = .039). There was no significant difference in objectively estimated sleep time (P = .651, r = -.07). Improvement was observed in both maternal and fetal parameters during the intervention night with an increase in median minimum maternal oxygen saturations (control = 91.6%, intervention = 92.4%, P = .006, r = -.42), fewer maternal oxygen desaturations (control = 7.1, intervention = 5.9, P = .095, r = -.26), and fewer fetal heart rate decelerations (control = 14.0, intervention = 10.4, P = .045, r = -.31) compared to the control night.

CONCLUSIONS

Results provide preliminary evidence that an intervention to reduce supine sleep in late pregnancy may provide maternal and fetal health benefits, with minimal effect on maternal perception of sleep quality and objectively estimated sleep time. Further research to explore relationships between objectively determined maternal sleep position, maternal respiratory indices, and fetal well-being is warranted.

Sleep disturbances and their impact in pediatric cystic fibrosis

Cystic fibrosis is a chronic, life-shortening illness that affects multiple systems and results in frequent respiratory infections, chronic cough, fat malabsorption and malnutrition. Poor sleep is often reported by patients with cystic fibrosis. Although objective data to explain these complaints have been limited, they do show poor sleep efficiency and frequent arousals. Abnormalities in gas exchange are also observed during sleep in patients with cystic fibrosis. The potential impact of these abnormalities in sleep on health and quality of life remains largely unstudied. This review summarizes what is known about sleep in children with cystic fibrosis, and implications for clinical practice. This report also highlights new evidence on the impact of sleep problems on disease-specific outcomes such as lung function, and identifies areas that need further exploration.

"They told me all mothers have worries", stillborn mother's experiences of having a 'gut instinct' that something is wrong in pregnancy: Findings from an international case-control study

OBJECTIVE

To describe and explore 'gut instinct' that something was wrong in women who identified that they experienced gut instinct during pregnancy.

METHOD

A case-control study utilising an international web-based questionnaire. Stillborn cases (n = 146) and liveborn controls (n = 234) answered the gut instinct question within 30 days of the pregnancy ending. Of those, 84 cases and 27 controls also provided qualitative comment data. Descriptive statistics were used for the question, with a fixed option and summative content analysis was used to analyse the comment data.

FINDINGS

In all, 110 (75%) of the stillborn cases answered "yes" to the gut instinct question vs only 28 (12%) of the controls who had a livebirth meaning the risk of stillbirth was 22.5 fold higher in those who experience "gut instinct" than in those who do not experience this feeling. Four themes were identified from the comment data namely: When the gut instinct occurred; How the gut instinct made the woman feel; Dreams and other related phenomena; Reassured by someone or something.

CONCLUSIONS

Women who had a stillborn baby reported a "gut instinct" that something was wrong more frequently than mothers of a live born baby. Our findings may be influenced by recall negativity bias, and a prospective study is needed to confirm or refute our findings. The possibility that "maternal intuition" exists during pregnancy and responds to changes in fetal or placental health merits further exploration.

IMPLICATIONS FOR PRACTICE

Maternity care providers should be alert to the woman when she expresses intuitive feelings, as well as asking her to report her concerns and act appropriately to assess and manage fetal wellbeing.