Knowledge of Obstructive Sleep Apnea Among the General Population in Arar, Northern Region of Saudi Arabia

BACKGROUND

Obstructive sleep apnea (OSA) can have serious health consequences if left untreated, including an increased risk of heart disease, stroke, and diabetes. Raising awareness about this condition can help reduce the stigma surrounding sleep disorders and encourage individuals to seek help if they suspect they may have OSA. It is important for the general population to be informed about this condition in order to promote better overall health and well-being.

OBJECTIVE

To assess the level of knowledge of OSA among the general population of Arar, Northern region of Saudi Arabia.

METHODOLOGY

 This study is a cross-sectional descriptive study to assess the knowledge of OSA in the general population in the northern region of Saudi Arabia. We used an online self-administered questionnaire to collect sociodemographic data and questions about the subject's awareness.

RESULTS

Four hundred thirty-nine individuals participated in this study. The majority of them 337 (76.8%) were female. About 181 (41.2%) of the studied participants were in the age category of 15-25 years and 66.3% had heard about sleep apnea. Nearly 316 (72%) reported that sleep apnea is considered dangerous. Snoring, low sleep quality, and coughing were the main symptoms of sleep apnea. Moreover, obesity, smoking, and chronic diseases were the main causes of sleep apnea, according to the participants' knowledge. About 37 (8.4%) of participants said that they were diagnosed with sleep apnea, and 30 (6.8%) of them revealed that sleep apnea affected their quality of life.

CONCLUSION

Knowledge of OSA in Saudi Arabia is considered inadequate. General population knowledge of OSA can be improved through a multi-faceted approach that involves public education campaigns, continuous medical education for healthcare professionals, and policy-level interventions.

Prevalence of Sleep Disorders Among the General Population of the Jazan Region of Southwest Saudi Arabia

BACKGROUND

Sleep disorders impose a substantial burden on the global population, leading to an array of health complications. Understanding their prevalence and associated risk factors is crucial to formulating effective interventions.

OBJECTIVE

This study aimed to determine the prevalence and associated risk factors of sleep disorders among residents of the Jazan region of Saudi Arabia.

METHODS

This cross-sectional study conducted an online survey from December 2022 to March 2023. The sample comprised 670 respondents aged 18 years and older residing in Jazan. Demographic data, lifestyle habits, sleep patterns, and sleep disorder symptoms were assessed.

RESULTS

The participants were predominantly women (62.2%), with an average age of 30.99 years and a normal body mass index. The analyses revealed that 28.8% of the respondents reported experiencing sleep disorders, and 13.4% particularly had obstructive sleep apnea. Nearly half of the participants reported having primary insomnia, excessive daytime sleepiness, and restless leg syndrome. Significant associations were found between sleep disorders and older age (p = 0.012), obesity (p = 0.043), short or thin neck (p = 0.034), smoking (p = 0.003), caffeine use (p = 0.001), existing health conditions (p = 0.001), medication use (p = 0.013), lack of daytime naps (p = 0.043), and frequent nighttime awakenings to urinate (p = 0.001). The most common self-reported reasons for nightly awakenings were urination, anxiety or stress, discomfort or noise, and health conditions.

CONCLUSIONS

The findings suggest a high prevalence of sleep disorders among adults in Jazan, Saudi Arabia. Various demographic, lifestyle, and health-related factors are linked to these disorders. Therefore, targeted sleep health education and interventions could be instrumental in tackling this significant public health issue.

Understanding the Association Between Obesity and Obstructive Sleep Apnea Syndrome: A Case-Control Study

Introduction Obstructive sleep apnea (OSA) represents a sleep-related impairment linked to upper airway function. The question of whether OSA drives obesity or if shared underlying factors contribute to both conditions remains unresolved. Hence, this present study aims to understand the interplay between obstructive sleep apnea syndrome (OSAS) and obesity through in-depth analysis of anthropometric data within control subjects and OSA patients. Methodology A case-control study was conducted, which included 40 cases and 40 matched healthy controls. Study participants with reported symptoms of snoring, daytime drowsiness, or both were included in the study. All the study participants underwent comprehensive anthropometric assessments such as height, weight, body mass index (BMI), neck circumference, waist circumference, hip circumference, waist-to-hip ratio, skin-fold thickness, and thickness measurements of biceps, triceps, suprailiac, and subscapular muscles. Results Within the OSA group, significant disparities emerged in mean age, waist circumference, waist-to-hip ratio, and diverse fat accumulations encompassing visceral, subcutaneous, trunk, and subcutaneous leg fat. Notably, skin-fold thickness at specific sites - biceps, triceps, subscapula, and suprailiac - demonstrated considerable augmentation relative to the control group. Furthermore, mean values associated with height, weight, BMI, neck circumference, fat percentage, subcutaneous arm fat, entire arm composition, and trunk skeletal muscle either equaled or exceeded those in the control group. However, statistical significance was not attained in these comparisons. Conclusion This investigation underscored a pronounced correlation between numerous endpoints characterizing OSA patients and markers of obesity. Consequently, addressing altered levels of obesity-linked anthropometric variables through pharmacological interventions might hold promise as a pivotal strategy for improving symptoms associated with OSA.

Cardiovascular capacity in adults with obstructive sleep apnoea

BACKGROUND: Obstructive sleep apnoea (OSA) patients have a decreased exercise capacity. Potential cardiovascular capacity in patients with OSA with different severity without known cardiovascular disease has not been described.OBJECTIVE: To evaluate impaired potential exercise cardiovascular capacity during cardiopulmonary exercise testing (CPET) in OSA patients and to compare cardiovascular performance reaction with different severity during graded exercise stages.DESIGN: All participants were accompanied without cardiovascular disease, especially hypertension and arrhythmia. Parameters of different stages were compared between subjects with and without OSA, and among OSA patients with varied severity.RESULTS: Despite having significantly higher peak exercise diastolic blood pressure (DBP) and ventilatory equivalent for CO2 (EQCO₂), patients with OSA had a lower peak oxygen uptake (VO₂), heart rate (HR), heart rate recovery (HRR) and respiratory reserve (BR) than normal subjects. Furthermore, significant correlations were found between VO₂, DBP, EQCO₂, HRR, BR and the apnoea-hypopnea index. In severe OSA, there was a greater difference in HR and HRR during the anaerobic threshold stages.CONCLUSIONS: OSA patients demonstrate reduced potential cardiovascular capacity, even without documented cardiovascular disease. Patients with severe OSA develop impaired exercise capacity at early stage during exercise. These data point to exaggerated haemodynamic response to graded exercise and delayed post-exercise cardiovascular response recovery in OSA patients. CPET can be a supplement for assessment of OSA severity.

Effectiveness of Continuous Positive Airway Pressure in Treating Hypertension in Obstructive Sleep Apnea: A Traditional Review

Almost one billion individuals worldwide suffer from obstructive sleep apnea (OSA). The most widely used treatment for OSA has been continuous positive airway pressure (CPAP), but its effect on blood pressure (BP) has been challenged. Our review aims to evaluate the effects of treating OSA with CPAP on BP and BP-related morbidities in adult hypertensive patients. Medical subject headings (MeSH) terminology was used to search the PubMed Central, MEDLINE, and PubMed databases for articles on the use of CPAP in OSA patients with hypertension. We selected various forms of academic writing, encompassing complete texts that were published in the English language. The study included a total of 21 papers. OSA is a serious health concern associated with a higher risk of cardiovascular disease, kidney disease, pulmonary hypertension, and aortic stiffness, which is brought on by the periodic hypoxia caused by nocturnal respiratory episodes. For individuals with moderate-to-severe OSA, CPAP therapy has been shown to have a considerable long-term benefit with a median drop of 11 mm Hg, and high adherence results in a decrease in diastolic BP. CPAP therapy directly lowers BP in OSA patients with a body mass index (BMI) of more than 30 kg/m2 and has also demonstrated improvement in early signs of atherosclerosis with lower nocturnal systolic BP levels. OSA patients with resistant hypertension also experienced lower BP after using CPAP for a year. Therefore, our findings suggest that obesity, hypersomnolence, high nocturnal BP, prolonged CPAP usage, and resistant hypertension may all have a major impact on the BP response to CPAP therapy in individuals with severe OSA.

Association between obstructive sleep apnea (OSA) and atrial fibrillation (AF): A dose-response meta-analysis

BACKGROUND

Refractory hypoxemia episodes are characteristic of obstructive sleep apnea (OSA). Patients with OSA suffer from oxidative stress in all systems. Atrial fibrillation (AF) is a type of arrhythmia that may be induced by OSA. In this study, we explored the dose-response relationship between OSA and AF. Our research provides the basis for a novel approach to AF prevention.

METHODS

We screened four databases (PubMed, Embase, the Cochrane Library, and Web of Science) for observational studies on OSA and AF. Studies were collected from database establishment to November 2020. We performed a traditional subgroup meta-analysis. Linear and spline dose-response models were applied to assess the association between the apnea-hypopnea index, an indicator of OSA severity, and the risk of AF. Review Manager version 5.3 software and Stata 16.0 were used for the analysis.

RESULTS

Sixteen observational studies were included in the study. We excluded a study from the conventional meta-analysis. In the subgroup analysis, the odds ratios for new onset AF for no obvious reason, new onset AF after surgical operations, such as coronary artery bypass grafting, and AF after ablation treatment were 1.71 (95% CI 1.37-2.13, P < .05), 2.65 (95% CI 2.32-3.01, P < .05), and 2.93 (95% CI 2.47-3.49, P < .05), respectively. Linear dose-response meta-analysis results revealed that the risk of AF increased with increasing apnea-hypopnea index value.

CONCLUSION

Through dose-response meta-analysis, we found a potential dose-response relationship between OSA severity and the risk of AF. This relationship should be considered in interventions aimed at AF prevention in the future.

The Relationship Between Obstructive Sleep Apnea (OSA) and Gastroesophageal Reflux Disease (GERD) in Inpatient Settings: A Nationwide Study

Introduction: Several studies identified a link between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA). GERD is a condition in which acid reflux from the stomach to the esophagus causes troublesome symptoms. On the other hand, OSA is defined as a sleep-related breathing disorder in which airflow significantly decreases or ceases due to upper airway obstruction, leading to arousal from sleep. OSA was found to be associated with GERD. In this study, we aim to study the characteristics and concurrent risk factors associated with GERD and OSA in a large population-based study.

Methods: Patients with the diagnosis of GERD were extracted from the National Inpatient Database (NIS) for the years 2016 to 2019. Patients' age, gender, race, and hospital information, including region and bed size, were extracted and considered as baseline characteristics. The comorbidities included are hypertension (HTN), atrial fibrillation (AFib), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pulmonary hypertension (PHTN), obesity, and smoking. Patients younger than 18 years old were excluded from this study. 

Results: Out of 22,677,620 patients with the diagnosis of GERD, 12.21% had a concurrent diagnosis of OSA (compared to 4.79% in patients without GERD, p-value <0.001). The mean age of patients with GERD and OSA was 64.47 years vs 65.42 years in patients without OSA (p-value <0.001). The GERD and OSA group had almost identical gender distribution compared to the GERD only group, as it was predominantly female patients. The white and black races were slightly more prevalent in the GERD and OSA group compared to the GERD only group. Regarding comorbidities, the prevalence of obesity was more clear in the GERD and OSA group. It was noted that the group of patients who carry a diagnosis of GERD and OSA have more prevalence of diabetes (DM), hypertension (HTN), obesity, atrial fibrillation (Afib), congestive heart failure (CHF), and pulmonary hypertension (PHTN). Patients with GERD and OSA were 21% less likely to be older than 65 years rather than younger (95% CI: 0.79-0.8, p-value <0.001), 35% less likely to be females (95% CI: 0.65-0.65, p-value <0.001), and 22% less likely to be non-white (95% CI: 0.77-0.8, p-value <0.001). Obesity was found to be the strongest association with this population, followed by PHTN, CHF, DM, HTN, Afib, and lastly smoking.

Conclusion: Patients with GERD and OSA were found more likely to be female, white, living in the southern part of the United States, obese, diabetes mellitus type 2, and being active smokers. 

Diagnosing obstructive sleep apnea in a residential treatment program for veterans with substance use disorder and PTSD

BACKGROUND

Obstructive sleep apnea (OSA) is often comorbid with both substance use disorders (SUD) and posttraumatic stress disorder (PTSD), yet frequently goes undiagnosed and untreated. We present data on the feasibility and acceptability of objective OSA diagnosis procedures, findings on OSA prevalence, and the relationship between OSA and baseline SUD/PTSD symptoms among veterans in residential treatment for comorbid PTSD/SUD.

METHODS

Participants were 47 veterans admitted to residential PTSD/SUD treatment. Participants completed questionnaires assessing PTSD and sleep symptoms, and filled out a sleep diary for seven days. Apnea-hypopnea index (AHI) was recorded using the overnight Home Sleep Apnea test (HSAT; OSA was diagnosed with AHI ≥ 5).

RESULTS

Objective OSA diagnostic testing was successfully completed in 95.7% of participants. Of the 45 veterans who went through HSAT, 46.7% had no OSA, 35.6% received a new OSA diagnosis, and 8.9% were previously diagnosed with OSA and were using positive airway pressure treatment (PAP); an additional 8.9% were previously diagnosed with OSA, reconfirmed with the HSAT, but were not using PAP. One hundred percent of respondents during follow-up deemed the testing protocol's usefulness as "Good" or "Excellent."

CONCLUSION

OSA diagnostic testing on the residential unit was feasible and acceptable by participants and was effective in diagnosing OSA. OSA testing should be considered for everyone entering a SUD and PTSD residential unit. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Polysomnographic characteristics and treatment modalities in a referred population of children with trisomy 21

BACKGROUND

Children with Trisomy 21 (T21) are at an increased risk of sleep-disordered breathing (SDB), which can impact daily functioning and cause other health complications. Accordingly, it is imperative to diagnose and treat SDB in this population. Current guidelines recommend screening polysomnogram by age 4 or sooner if clinically indicated. There are limited published studies describing characteristics of SDB in children with T21, particularly in infants and young children.

OBJECTIVE

The objective of this study is to characterize SDB and treatment modalities in infants and young children with T21.

METHODS

This is a retrospective review of a cohort of children (≤60 months of age) with T21 who completed a polysomnogram (PSG) between 2015 and 2020 at a pediatric referral center. Demographic information, relevant medical history, polysomnography parameters, and treatment details of these children were collected from EMR. Descriptive and comparative statistics were calculated for the cohort; additional subgroup analysis was completed by age 0-35 months and 36-60 months.

RESULTS

Most of the cohort met criteria for sleep apnea (84.1%), and airway surgery was the most common treatment modality (71.4%). The mean AHI was high (21.4 events/hour) with a trend towards hypoventilation (mean EtCO₂ = 55.9 mmHg; mean percentage of TST with EtCO2 > 50 mmHg 20.8%). Mean arousal index was elevated (32 events/hour). There were no significant differences in SDB by age when we compared children 0-35 months and 36-60 months.

CONCLUSIONS

This cohort of referred children with T21 showed high prevalence of SDB with a trend towards hypoventilation and disrupted sleep quality with no significant differences by age. These data highlight the importance of maintaining a high index of suspicion for SDB in young patients with T21 and obtaining PSG testing to characterize sleep and breathing.

Obstructive Sleep Apnea in Adults: What Primary Care Physicians Need to Know

Obstructive sleep apnea (OSA) remains a prominent disease state characterized as the recurrent collapse of the upper airway while sleeping and is estimated to plague 936 million adults globally. Although the initial clinical presentation of OSA appears harmless, it increases the risk of cardiovascular diseases such as heart failure, stroke, and hypertension; metabolic disorders; and an overall decrease in quality of life, in addition to increasing mortality. Current treatment of OSA includes lifestyle changes, behavioral modification, mandibular advancement devices, surgical treatment, and continuous positive airway pressure, which remains the gold standard. It is crucial to identify OSA early on and initiate treatment to mitigate the adverse health risks it imposes. This review will discuss the pathophysiology, epidemiology, management strategies, and medical treatment of OSA.

Custom-Made Dual-Functional Oral Appliance for Management of Obstructive Sleep Apneic Completely Edentulous Patient

Continuous positive airway pressure (CPAP) being a gold standard treatment to open the upper airway by application of controlled compressed air is still not a widely accepted mode of treatment among obstructive sleep apnea (OSA) individuals. To improve patency of upper airway space and reduce the risk of sleep apnoea, it is essential to provide mandibular advancement devices (MADs) that could provide non-continuous positive airway pressure (non-CPAP) for patients with OSA. Availability of prefabricated oral appliances (OAs) like MADs, tongue holding devices reduced the chair-side fabrication time but has poor adaptation, excessive salivation, and deprivation of sleep. Customized OAs can overcome these challenges, but their fabrication for an edentulous individual is challenging due to the absence of teeth and the encroachment of tongue space by the device. This clinical report gives an insight into the clinical and technical aspect of fabrication of MAD with tongue retaining space for an edentulous individual with OSA.

The Osa-Containing SWI/SNF Chromatin-Remodeling Complex Is Required in the Germline Differentiation Niche for Germline Stem Cell Progeny Differentiation

The Drosophila ovary is recognized as a powerful model to study stem cell self-renewal and differentiation. Decapentaplegic (Dpp) is secreted from the germline stem cell (GSC) niche to activate Bone Morphogenic Protein (BMP) signaling in GSCs for their self-renewal and is restricted in the differentiation niche for daughter cell differentiation. Here, we report that Switch/sucrose non-fermentable (SWI/SNF) component Osa depletion in escort cells (ECs) results in a blockage of GSC progeny differentiation. Further molecular and genetic analyses suggest that the defective germline differentiation is partially attributed to the elevated dpp transcription in ECs. Moreover, ectopic Engrailed (En) expression in osa-depleted ECs partially contributes to upregulated dpp transcription. Furthermore, we show that Osa regulates germline differentiation in a Brahma (Brm)-associated protein (BAP)-complex-dependent manner. Additionally, the loss of EC long cellular processes upon osa depletion may also partly contribute to the germline differentiation defect. Taken together, these data suggest that the epigenetic factor Osa plays an important role in controlling EC characteristics and germline lineage differentiation.

Cultivating Lifestyle Transformations in Obstructive Sleep Apnea

Today, our well-being and awareness have become markedly determined by our way of living through our everyday activities. Needless to say, daily practices specifically have a significant impact on the quality of sleep. Obstructive sleep apnea (OSA) is an exhausting sleep disorder regulating an individual's routine life. Although several therapeutic modalities are available for curing OSA, behavioral therapies are also utilized for a positive outcome. Besides, several studies are performed to prove the efficacy of lifestyle strategies to resolute OSA in adults. Reducing weight, quitting alcohol and smoking, eating a nutritional diet, and exercising are the modifications to benefit people. This review aims to expand our knowledge of the association between alterations to comportment and better treatment outcomes for sleep apnea.

Pediatric Drug-Induced Sleep Endoscopy: Technique and Scoring System

Drug-induced sleep endoscopy (DISE) is an invaluable tool for identifying sites of obstruction for patients with obstructive sleep apnea (OSA). During DISE, the patient is in a state of drug-induced sleep, and a flexible laryngoscope is passed through the nose into the upper airway. Sites of obstruction are visualized and scored to guide surgical management. Currently, there is no universally accepted method of DISE analysis and scoring. This limitation in comparability impedes large-scale analysis between clinicians, institutions, and studies. In this report, we propose a standardized method of scoring and performing DISE in children with OSA. Our DISE scoring system is internally developed, consistent through the study, and addresses all levels of potential upper airway obstruction.

Obstructive Sleep Apnea and Cardiovascular Morbidities: A Review Article

In obstructive sleep apnea (OSA), there are brief episodes of partial or total upper airway obstruction during sleep, which leads to apnea or hypopneas. Much attention is required to understand OSA's effects on the human body, owing to how common but under-diagnosed this disorder remains. Though the role of OSA in cardiovascular (CV) disease is commonly discussed, it remains unclear how it induces changes in the human body. The intermittent and recurrent hypoxia occurring at the cellular level in this condition is critical for the dramatic changes observed. Vascular endothelial cell (VEC) injury and other mechanisms seen in OSA lead to changes in the CV system. OSA can take a toll on a person's overall functioning, especially with so much importance in today's time on preventing and treating cardiac-related deaths. A total of 31 published articles were included from the PubMed database for our literature review. Most of the studies showed a strong association of OSA with hypertension, especially resistant hypertension. Findings were consistent with OSA's independent role in causing CV diseases, included heart failure, coronary artery disease (cardiac ischemia), arrhythmias, and ischemic stroke. Continuous Positive Airway Pressure (CPAP) is one of the reliable and beneficial treatments for OSA patients. OSA is a treatable and modifiable risk factor for cardiac events and related deaths. The primary purpose of our review article was to address any existing gaps between OSA and its effect on the human body with particular emphasis on cardiovascular changes.

An Uncommon Case of Partial Airway Obstruction due to Lingual Tonsillar Hypertrophy

Obstruction of the airway is a medical emergency. If it is not treated immediately, rapid and potentially life-threatening hypoxia develops. A 70-year-old woman with a history of hypertension and palatine tonsillectomy presented to our tertiary care hospital with dysphagia, odynophagia, muffled voice, and neck swelling of a one-week duration. She also complained of associated shortness of breath that began two days prior to hospital admittance. Bedside laryngoscopy revealed an enlarged base of the tongue and laryngeal edema, resulting in partial airway obstruction. A CT scan of the soft tissue of the neck revealed that lingual tonsillar hypertrophy (LTH) was the cause of the partial airway obstruction. While being closely monitored, the patient was treated with intravenous corticosteroids and antibiotics. Serial laryngoscopies were performed to track the resolution of the airway obstruction. Her hospital course remained uneventful, and the patient was discharged after four days. Though rare, LTH has a strong propensity to cause airway compromise, and it must be treated at once.

A double blind randomized placebo controlled pilot study of single-dose preoperative modafinil for functional recovery after general anesthesia in patients with obstructive sleep apnea

BACKGROUND

We theorized that modafinil, an atypical psychomotor stimulant, utilized to improve daytime somnolence in patients with obstructive sleep apnea, would improve functional recovery after general anesthesia by improving time to extubation, post-anesthesia care unit (PACU) length of stay and subjective recovery after general anesthesia.

METHODS

A double blind, randomized, placebo-controlled pilot study was performed. 102 patients with the diagnosis of obstructive sleep apnea (OSA) were randomized to receive either 200 mg of modafinil or placebo before general anesthesia. The trial was terminated for futility. The primary outcome was PACU length of stay between groups. Secondary functional metrics of improved post-anesthesia recovery were compared between groups.

RESULTS

No difference between groups was found on the primary outcome of PACU length of stay (PACULOS). Emergence from general anesthesia was not significantly different when assessed by the time period between termination of volatile anesthetic and extubation. Similarly, no difference between groups was found in intraoperative bispectral index (BIS) values, postoperative pain scores or narcotic consumption (morphine equivalent units). In the post-anesthesia care unit, respiratory rate was increased and mean arterial pressure was lower in the modafinil group.

CONCLUSIONS

Our results suggest that the use of single-dose preoperative modafinil may not improve functional recovery after general anesthesia in patients with the diagnosis of OSA. Further research is needed before use of atypical psychomotor stimulants in this surgical population.

Obstructive Sleep Apnea: From Intermittent Hypoxia to Cardiovascular Complications via Blood Platelets

Obstructive sleep apnea is a chronic condition characterized by recurrent episodes of apneas or hypopneas during sleep leading to intermittent hypoxemia and arousals. The prevalence of the sleep disordered breathing is estimated that almost 50% of men and 24% of women suffer from moderate to severe form of the disorder. Snoring, collapse of upper airways and intermittent hypoxia are main causes of smoldering systemic inflammation in patients suffering from obstructive sleep apnea. The systematic inflammation is considered one of the key mechanisms leading to significant cardiovascular complications. Blood platelets, formerly not even recognized as cells, are currently gaining attention as crucial players in the immune continuum. Platelet surface is endowed with receptors characteristic for cells classically belonging to the immune system, which enables them to recognize pathogens, immune complexes, and interact in a homo- and heterotypic aggregates. Platelets participate in the process of transcellular production of bioactive lipids by delivering both specific enzymes and substrate molecules. Despite their lack of nucleus, platelets synthetize proteins in a stimuli-dependent manner. Atherosclerosis and consequent cardiovascular complications result from disruption in homeostasis of both of the platelet roles: blood coagulation and inflammatory processes modulation. Platelet parameters, routinely evaluated as a part of complete blood count test, were proposed as markers of cardiovascular comorbidity in patients with obstructive sleep apnea. Platelets were found to be excessively activated in this group of patients, especially in obese subjects. Persistent activation results in enhanced spontaneous aggregability and change in cytokine production. Platelet-lymphocyte ratio was suggested as an independent marker for cardiovascular disease in obstructive sleep apnea syndrome and continuous positive air pressure therapy was found to have an impact on platelet parameters and phenotype. In this literature review we summarize the current knowledge on the subject of platelets involvement in obstructive sleep apnea syndrome and consider the possible pathways in which they contribute to cardiovascular comorbidity.

Use of a simple clinical tool for airway assessment to predict adverse pregnancy outcomes

OBJECTIVE

Obstructive sleep apnea (OSA) is a risk factor for adverse perinatal outcomes. We aimed to test the hypothesis that maternal Mallampati class (MC), as a marker for OSA, is associated with adverse perinatal outcomes.

STUDY DESIGN

We performed a retrospective secondary analysis of a prospective cohort of term births (≥ 37 weeks). Fetal anomalies and aneuploidy were excluded. Primary outcome was small for gestational age (SGA). Secondary outcomes included preeclampsia, neonatal cord arterial blood gas pH < 7.10 and < 7.05, base excess <  - 8 and <  - 12 mEq/L. Outcomes were compared between mothers with low MC airways and high MC airways using logistic regression.

RESULTS

A total of 1,823 women met the inclusion criteria. No significant differences were found in the risk of SGA (adjusted odds ratio [aOR] 0.9, 95% confidence interval [CI] 0.6-1.2), preeclampsia (aOR 1.2, 95% CI 0.8-1.9) or neonatal acidemia (aOR 0.8, 95% CI 0.3-2.0), between high and low MC.

CONCLUSION

High MC is not associated with adverse perinatal outcomes.

Metabolic and glycemic sequelae of sleep disturbances in children and adults

The prevalence of obesity in adults and children has increased greatly in the past three decades, as have metabolic sequelae, such as insulin resistance and type 2 diabetes mellitus (T2DM). Sleep disturbances are increasingly recognized as contributors to this widespread epidemic in adults, and data are emerging in children as well. The categories of sleep disturbances that contribute to obesity and its glycemic co-morbidities include the following: (1) alterations of sleep duration, chronic sleep restriction and excessive sleep; (2) alterations in sleep architecture; (3) sleep fragmentation; (4) circadian rhythm disorders and disruption (i.e., shift work); and (5) obstructive sleep apnea. This article reviews current evidence supporting the contributions that these sleep disorders play in the development of obesity, insulin resistance, and T2DM as well as possibly influences on glycemic control in type 1 diabetes, with a special focus on data in pediatric populations.

Consensus & evidence-based INOSA Guidelines 2014 (first edition)

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive sleep apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or co-morbidities or ≥ 15 such episodes without any sleep related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography (PSG) is the "gold standard" for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioural measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

The relationship of vertical skeletofacial morphology to oropharyngeal airway shape using cone beam computed tomography: possible implications for airway restriction

OBJECTIVE

To determine if the shape of the oropharyngeal airway is related to the vertical morphology of the skeletofacial complex, including the hyoid bone.

MATERIALS AND METHODS

Cone beam computed tomography scans from 50 pretreatment adult orthodontic records were used to obtain skeletal and airway measurements. Linear regression statistics were used to compare soft tissue variables to hard tissue predictor variables.

RESULTS

Transverse airway widening was significantly increased when the distance between the hyoid and vertebrae was reduced; when the three-dimensional (3D) facial axis angle decreased (became more vertical); when the 3D mandibular plane angle increased; when the width of the hyoid increased, or when the calculated length of the geniohyoid decreased.

CONCLUSIONS

A laterally elliptical airway-found when the face is more vertical and when the hyoid is closer to the cervical vertebrae-is hypothetically more resistant to collapse. Patients with a retrognathic, skeletal deep bite and a rounded oropharynx should be identified and corrected early to prevent potential airway problems.

Profiling microRNAs and their targets in an important fleshy fruit: tomato (Solanum lycopersicum)

Tomato (Solanum lycopersicum) is an important and the most useful plant based diet. It is widely used for its antioxidant property. Presently, only two digits, tomato microRNAs (miRNAs) are reported in miRBase: a miRNA database. This study is aimed to profile and characterize more miRNAs and their targets in tomato. A comprehensive comparative genomic approach is applied and a total of 109 new miRNAs belonging to 106 families are identified and characterized from the tomato expressed sequence tags (ESTs). All these potential miRNAs are profiled for the first time in tomato. The profiled miRNAs are also observed with stable stem-loop structures (Precursor-miRNAs), whose length ranges from 45 to 329 nucleotides (nt) with an average of 125 nt. The mature miRNAs are found in the stem of pre-miRNAs and their length ranges from 19 to 24 nt with an average of 21 nt. Furthermore, twelve miRNAs are randomly selected and experimentally validated through RT-PCR. A total of 406 putative targets are also predicted for the newly 109 tomato miRNAs. These targets are involved in structural protein, metabolism, transcription factor, growth & development, stress related, signaling pathways, storage proteins and other vital processes. Some important proteins like; 9-cisepoxycarotenoid dioxygenase (NCED), transcription factor MYB, ATP-binding cassette transporters, terpen synthase, 14-3-3 and TIR-NBS proteins are also predicted as putative targets for tomato miRNAs. These findings improve a baseline data of miRNAs and their targets in tomato. This baseline data can be utilized to fine tune this important fleshy fruit for nutritional & antioxidant properties and also under biotic & abiotic stresses.

Identification of genes underlying hypoxia tolerance in Drosophila by a P-element screen

Hypoxia occurs in physiologic conditions (e.g. high altitude) or during pathologic states (e.g. ischemia). Our research is focused on understanding the molecular mechanisms that lead to adaptation and survival or injury to hypoxic stress using Drosophila as a model system. To identify genes involved in hypoxia tolerance, we screened the P-SUP P-element insertion lines available for all the chromosomes of Drosophila. We screened for the eclosion rates of embryos developing under 5% O(2) condition and the number of adult flies surviving one week after eclosion in the same hypoxic environment. Out of 2187 lines (covering ~1870 genes) screened, 44 P-element lines representing 44 individual genes had significantly higher eclosion rates (i.e. >70%) than those of the controls (i.e. ~7-8%) under hypoxia. The molecular function of these candidate genes ranged from cell cycle regulation, DNA or protein binding, GTP binding activity, and transcriptional regulators. In addition, based on pathway analysis, we found these genes are involved in multiple pathways, such as Notch, Wnt, Jnk, and Hedgehog. Particularly, we found that 20 out of the 44 candidate genes are linked to Notch signaling pathway, strongly suggesting that this pathway is essential for hypoxia tolerance in flies. By employing the UAS/RNAi-Gal4 system, we discovered that genes such as osa (linked to Wnt and Notch pathways) and lqf (Notch regulator) play an important role in survival and development under hypoxia in Drosophila. Based on these results and our previous studies, we conclude that hypoxia tolerance is a polygenic trait including the Notch pathway.

Surgical therapy of obstructive sleep apnea: a review

Obstructive sleep apnea (OSA) is a disease characterized by intermittent and repetitive narrowing of the airway during sleep. Surgical therapies for the treatment of OSA aim to improve airway patency by addressing selected site(s) of obstruction. Because several areas may each be responsible for the narrowing, different surgical modalities have also been developed. In this review, we give an overview of surgery for each of potential obstruction site(s). As a consequence of the multi-factorial and heterogeneous etiology of OSA, surgical therapies need to be selected and performed specifically for each patient, as there is no perfect surgery that will fit all patients. As with any other treatment modalities for OSA, surgical therapies have variable efficacy, but are a very important tool on OSA management in selected patients and have been shown effectiveness in decreasing the morbidity and mortality associated with the disease.

Obstructive airway disease and obstructive sleep apnea: effect of pulmonary function

This study sought to determine whether reduced pulmonary function in obstructive airway disease (OAD) is an independent risk factor for obstructive sleep apnea (OSA). This was a prospective observational study conducted at an outpatient pulmonary clinic. Adults with a known diagnosis of COPD/asthma were enrolled as OAD group. Family members without a history of COPD/asthma who accompanied these patients to the clinic were enrolled as a control group. The Berlin Questionnaire (BQ) was used to assess OSA risk in the OAD group and controls. Forced expiratory volume in 1 second (FEV(1) % predicted) was determined from spirometry. The subjects at high risk for OSA were referred for a full overnight polysomnogram (PSG). The prevalence of patients with a high risk of OSA was 55.2% in the OAD group, which was higher than in the controls (7.5%, p < 0.0001). OAD subjects had a higher body mass index (BMI) and larger neck circumference than controls (p < 0.01). There was no difference in FEV(1) % predicted between the OAD patients at high risk and low risk of OSA. On receiver operator curve (ROC) analysis, FEV(1) % predicted was not a significant predictor of high OSA risk. Using logistic regression, FEV(1) % predicted had no association with OSA risk. There was no correlation between FEV(1) % predicted and total apnea-hypopnea index (AHI), oxygen desaturation index, % time spent below oxygen saturation 90%, and mean oxygen saturation on multiple regression analysis. OSA appears to be common in patients with COPD or asthma in an urban outpatient pulmonary clinic. However, the high prevalence of OSA in OAD patients appears to be due to obesity, and reduced pulmonary function is not an independent risk factor for OSA.

What is central sleep apnea?

Central sleep apnea (CSA) describes a group of conditions in which cessations in air flow occur without respiratory effort. In contrast, obstructive sleep apnea patients have ongoing respiratory effort during respiratory events. However, considerable overlap exists in the pathogenesis and clinical presentation of obstructive sleep apnea and CSA. A good working knowledge of the mechanisms underlying CSA is important for optimal clinical care. In general, CSA can be classified into those with excessive drive (eg, Cheyne-Stokes breathing) versus those with inadequate drive (eg, sleep hypoventilation syndrome). One critical factor contributing to the cessation of air flow during sleep is the concept of the apnea threshold, such that a P(aCO(2)) value below a certain level will lead to cessations in breathing. P(aCO(2)) can fall below the chemical apnea threshold when drive is excessive (eg, robust chemosensitivity) or when hyperventilation is occurring (eg, following arousal). Another important factor is the loss of the so-called wakefulness drive to breathe, such that some rise in P(aCO(2)) is likely to occur at the onset of sleep. A variety of factors contribute to this rise, including upper-airway collapse and diminished chemosensitivity (particularly during rapid-eye-movement sleep). In patients with low central drive, this further loss of drive at sleep onset can lead to marked hypercapnia in some cases. The treatment of CSA is also reviewed in some detail, including a role for positive airway pressure (eg, bi-level positive airway pressure in hypoventilation patients) and optimization of medical therapy (eg, in Cheyne-Stokes breathing). A paucity of research exists in this area, emphasizing the opportunities for young investigators who are interested in this field.

Empiric auto-titrating CPAP in people with suspected obstructive sleep apnea

OBJECTIVE

Efficient diagnosis and treatment of obstructive sleep apnea (OSA) can be difficult because of time delays imposed by clinic visits and serial overnight polysomnography. In some cases, it may be desirable to initiate treatment for suspected OSA prior to polysomnography. Our objective was to compare the improvement of daytime sleepiness and sleep-related quality of life of patients with high clinical likelihood of having OSA who were randomly assigned to receive empiric auto-titrating continuous positive airway pressure (CPAP) while awaiting polysomnogram versus current usual care.

METHODS

Serial patients referred for overnight polysomnography who had high clinical likelihood of having OSA were randomly assigned to usual care or immediate initiation of auto-titrating CPAP. Epworth Sleepiness Scale (ESS) scores and the Functional Outcomes of Sleep Questionnaire (FOSQ) scores were obtained at baseline, 1 month after randomization, and again after initiation of fixed CPAP in control subjects and after the sleep study in auto-CPAP patients.

RESULTS

One hundred nine patients were randomized. Baseline demographics, daytime sleepiness, and sleep-related quality of life scores were similar between groups. One-month ESS and FOSQ scores were improved in the group empirically treated with auto-titrating CPAP. ESS scores improved in the first month by a mean of -3.2 (confidence interval -1.6 to -4.8, p < 0.001) and FOSQ scores improved by a mean of 1.5, (confidence interval 0.5 to 2.7, p = 0.02), whereas scores in the usual-care group did not change (p = NS). Following therapy directed by overnight polysomnography in the control group, there were no differences in ESS or FOSQ between the groups. No adverse events were observed.

CONCLUSION

Empiric auto-CPAP resulted in symptomatic improvement of daytime sleepiness and sleep-related quality of life in a cohort of patients awaiting polysomnography who had a high pretest probability of having OSA. Additional studies are needed to evaluate the applicability of empiric treatment to other populations.

A multicenter, prospective study of a novel nasal EPAP device in the treatment of obstructive sleep apnea: efficacy and 30-day adherence

STUDY OBJECTIVES

Evaluate the efficacy of a novel device placed in the nares that imposes an expiratory resistance for the treatment of obstructive sleep apnea (OSA) and evaluate adherence to the device over a 30-day in-home trial period.

DESIGN

One diagnostic and 3 treatment polysomnograms were administered in a Latin-square design to identify the optimal expiratory resistance to be used during the 30-day in-home trial. Subjects had repeat polysomnography with the prescribed device at the end of the 30-day trial.

SETTING

Multicenter study.

PARTICIPANTS

Participants (N=34; age 27 to 67) with a baseline apnea-hypopnea index (AHI) > or =5.

MEASUREMENTS AND RESULTS

The AHI was reduced from 24.5 _ 23.6 (mean +/- SD) to an average of 13.5 +/- 18.7 (p < 0.001) across initial treatment nights. The AHI was 15.5 +/-+/- 18.9 (p = 0.001) for the prescribed device at the end of the 30-day trial. Of 24 subjects with an AHI > 10 at baseline, 13 achieved an AHI < 10 on the initial treatment nights; 10 had a similar response on the final treatment night. Percent of the night snoring decreased from 27.5 +/- 23.2 to 11.6 +/- 13.7 (p < 0.001) on initial treatment nights and 14.6 +/- 20.6 (p = 0.013) at the end of the trial; Epworth Sleepiness scores decreased from 8.7 +/- 4.0 at baseline to 6.9 +/- 4.4 (p < 0.001) at the end of the trial; the Pittsburgh Sleep Quality Index improved from 7.4 +/- 3.3 to 6.5 +/- 3.6 (p = 0.042). Mean oxygen saturation increased from 94.8 +/- 2.0 to 95.2 +/- 1.9 (p = 0.023) on initial treatment nights and 95.3 +/- 1.9 (p = 0.003) at the end of the trial. Sleep architecture was not affected. Participants reported using the device all night long for 94% of nights during the in-home trial.

CONCLUSIONS

Treatment with this novel device was well tolerated and accepted by the participants. An overall reduction in AHI was documented; however, therapeutic response was variable among the participants. Further research is required to identify the ideal candidates for this new therapeutic option in the management of OSA.

Iron stores, periodic leg movements, and sleepiness in obstructive sleep apnea

STUDY OBJECTIVES

Most clinical sleep studies are performed for suspected obstructive sleep apnea (OSA), yet one-quarter to one-half show periodic leg movements (PLMs), for reasons that remain unknown. Several other disparate sleep disorders also increase the risk for PLMs. We examined the novel hypotheses that OSA as a representative sleep disorder could promote lower body iron stores, as reflected by serum ferritin levels, and, through downstream effects on dopaminergic transmission, increase PLMs and daytime sleepiness.

METHODS

Subjects were recruited as they underwent laboratory-based polysomnography for suspected OSA. Serum ferritin levels were measured the next morning. Each subject completed an Epworth Sleepiness Scale and a brief questionnaire to assess for restless legs syndrome (RLS).

RESULTS

The frequency of apneic events showed no association with serum ferritin levels, before or after adjustment for age, sex, body mass index, and likely RLS (each p value > 0.3). Serum ferritin levels did not predict the frequency of PLMs (p = 0.7) or Epworth scores (p = 0.8). Iron deficiency as a dichotomous variable, determined by ferritin levels less than < 50 microg/L or in combination with low transferrin saturation or mean corpuscular volume, showed similar results. In exploratory analyses, contrary to expectations, lower minimum oxygen saturation and increased sleep-stage shifts predicted increased rather than decreased ferritin levels (p = 0.03 and p = 0.02, respectively).

CONCLUSIONS

Results of this study, powered to detect small to moderate effect sizes, strongly suggest that OSA does not cause lower serum ferritin levels, which, in turn, cannot explain PLMs or daytime sleepiness in these patients.

Modafinil improves functional outcomes in patients with residual excessive sleepiness associated with CPAP treatment

OBJECTIVES

The objective of this secondary analysis was to examine the effects of modafinil on the Functional Outcomes of Sleep Questionnaire (FOSQ) in patients with obstructive sleep apnea and residual excessive sleepiness with continuous positive airway pressure (CPAP) use. We also explored the association of improvement of functional status with the presenting level of subjective sleepiness.

METHODS

Data were pooled from 2 randomized placebo-controlled studies (4-week and 12-week interventions) of modafinil in patients with residual sleepiness (Epworth Sleepiness Scale score > or =10 on CPAP).

RESULTS

The analysis included 480 patients (FOSQ efficacy data n=442 patients), 292 in the modafinil group and 188 in the placebo group. The mean age (SD) of the analyzed sample was 49.7 (9.2) years; 76% were men. Following administration with modafinil, there were greater improvements from baseline in the Total score (p < 0.0001) as well as 4 of the 5 domains (p < 0.05), compared with placebo. A greater proportion of patients who received modafinil were considered responders, compared with patients who received placebo (45% vs. 25%; p < 0.001). Responder analysis based on the individual FOSQ domain items demonstrated that 18 of the 30 FOSQ items increased by at least 1 point for significantly more patients who received modafinil (p < 0.05). Improvements in functional status were not found to depend on patients' degree of subjective sleepiness at baseline.

CONCLUSION

In this secondary analysis of data from patients with OSA and excessive sleepiness despite CPAP use, modafinil was associated with improvements in patients' functional outcomes and their ability to engage in a broad array of everyday activities.

OSA: the new cardiovascular disease: part II: Overview of cardiovascular diseases associated with obstructive sleep apnea

Obstructive sleep apnea (OSA), present in 5-15% of adults, is strongly associated with the incidence and poor outcome of hypertension, coronary artery disease, arrhythmia, heart failure, and stroke. Treatment of OSA completely reverses its cardiovascular consequences. In this review, we discuss the clinical evidence for the strong association between OSA and cardiovascular disease and present an argument for approaching OSA as a cardiovascular disease. We particularly focus on the causative relationship between OSA and hypertension, and on the increasingly recognized relationship between OSA and heart failure.

The prevalence and natural history of complex sleep apnea

RATIONALE

Central sleep apnea (CSA) may occasionally occur in patients with obstructive sleep apnea during titration with a continuous positive airway pressure (CPAP) device.

OBJECTIVES

To determine the prevalence and the natural history of CPAP-emergent CSA.

METHODS

This is a retrospective study of 1286 patients with a diagnosis of OSAwho underwent titration with a positive airway device during a 1-year period. Patients were seen in consultation and underwent full-night attended polysomnography followed by full-night attended CPAP titration. Four weeks after CPAP therapy, patients returned to the clinic for follow-up, and objective adherence to CPAP was recorded. In patients who had CSA on CPAP, a second full-night attended CPAP titration was recommended.

RESULTS

Eighty-four of the 1286 patients developed a central apnea index (CAI) of 5 or greater per hour while on CPAP. The incidence of CSA varied from 3% to 10% monthly, with an overall incidence of 6.5%. Forty-two of the 84 patients returned for a second CPAP titration. In 33 patients, CSA was eliminated. In each of the remaining 9 patients, the CAI remained at 5 or greater per hour, with an average of 13 per hour. These patients characteristically had the most severe OSA, and 5 had a CAI of 5 or more per hour at baseline. Two of the 9 patients were on opioids

CONCLUSIONS

In this large retrospective study of 1286 patients with a diagnosis of OSA, 6.5% had CPAP-emergent or persistent CSA. However, CPAP-emergent CSA was generally transitory and was eliminated within 8 weeks after CPAP therapy. The prevalence of CPAP-persistent CSA was about 1.5%. Severity of OSA, a CAI of 5 or greater per hour, and use of opioids were potential risk factors.

The validity of wrist actimetry assessment of sleep with and without sleep apnea

INTRODUCTION

It is unclear whether actimetry can be reliably used to measure sleep in severe obstructive sleep apnea (OSA) patients. We compared polysomnography (PSG) with actimetric assessment of sleep on an epoch-by-epoch basis in subjects with and without OSA.

METHODS

21 subjects were recorded with simultaneous overnight standard PSG and actimetry.

RESULTS

10 subjects with apnea-hypopnea index (AHI) <10 (6.5 +/- 2.8/h) were classified as non-OSA subjects and 11 subjects with AHI >10 (42.0 +/- 27.3/h) were classified as OSA subjects. Overall sensitivity and specificity for actimetry to identify sleep was 94.6% and 40.6%, respectively, with an overall mean sleep/wake simple agreement of 84.6% and kappa of 0.38. There was no difference in agreement between non-OSA and OSA subjects (simple agreement: 83% vs. 86%, p = 0.73; kappa: 0.35 vs. 0.40, p = 0.73). The kappa agreement did not correlate with PSG arousal index (r = -0.21, p = 0.36) but declined with reduced sleep efficiency (r = 0.66, p = 0.001). There was no systematic difference (all p > 0.40) between actimetry and PSG in sleep latency, total sleep time and sleep efficiency, although correlations between the measurements using the two techniques were generally poor. However, while actimetry systematically underestimated wake after sleep onset (WASO) (35.5 +/- 18.8 vs. 59.4 +/- 35.1, p = 0.009), fragmentation index measured by actimetry only underestimated arousal index measured by PSG in OSA patients (23.9 +/- 17.8 vs. 33.1 +/- 18.5, p = 0.04).

CONCLUSIONS

Contrary to prior reports, epoch-by-epoch comparison of sleep/wake scoring showed similar fair agreement between actimetry and PSG in subjects with or without OSA. Fragmentation index by actimetry may underestimate arousals caused by respiratory events and offer misleading results in severe OSA patients.

A pilot evaluation of a nasal expiratory resistance device for the treatment of obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is a major problem in need of new treatment approaches. The present pilot study tests the hypothesis that the application of expiratory resistance via a nasal valve device would improve breathing during sleep in subjects with OSA and in primary snorers.

METHODS

Thirty men and women were recruited from the community and from the Stanford University Sleep Disorders Clinic. Twenty-four had at least mild OSA (AHI >5), and 6 were primary snorers. Subjects underwent 2 nights of polysomnographic evaluation, one with and one without a new nasal resistance device with the order of nights counterbalanced across participants. The device consisted of a small valve inserted into each nostril calibrated to provide negligible inspiratory resistance, but increased expiratory resistance with a back pressure between 60 and 90 cm H2O*sec/Liter (at 100 mL/sec flow). Standard polysomnography was conducted to compare participants' sleep both with and without the device, with the scoring conducted blind to treatment condition.

RESULTS

The apnea-hypopnea (AHI) (p < 0.001) and oxygen desaturation (O2DI) (p < 0.01) indices both significantly decreased, and the percentage of the night spent above 90% saturation (p < 0.05) significantly increased with device use. The observed amount of snoring (p < 0.001) was significantly decreased with device use, and there were no significant changes in measures of sleep architecture.

CONCLUSIONS

The results of this pilot study are suggestive of a therapeutic effect of expiratory nasal resistance for some OSA patients and indicate that this technique is worthy of further clinical study.

Adaptive pressure support servoventilation: a novel treatment for sleep apnea associated with use of opioids

RATIONALE

Opioids have become part of contemporary treatment in the management of chronic pain. However, chronic use of opioids has been associated with high prevalence of sleep apnea which could contribute to morbidity and mortality of such patients.

OBJECTIVES

The main aim of this study was to treat sleep apnea in patients on chronic opioids.

METHODS

Five consecutive patients who were referred for evaluation of obstructive sleep apnea underwent polysomnography followed by a second night therapy with continuous positive airway pressure (CPAP) device. Because CPAP proved ineffective, patients underwent a third night therapy with adaptive pressure support servoventilation.

MAIN RESULTS

The average age of the patients was 51 years. They were habitual snorers with excessive daytime sleepiness. Four suffered from chronic low back pain and one had trigeminal neuralgia. They were on opioids for 2 to 5 years before sleep apnea was diagnosed. The average apnea-hypopnea index was 70/hr. With CPAP therapy, the apnea-hypopnea index decreased to 55/hr, while the central apnea index increased from 26 to 37/hr. The patients then underwent titration with adaptive pressure support servoventilation. At final pressure, the hypopnea index was 13/hr, with central and obstructive apnea index of 0 per hour.

CONCLUSIONS

Opioids may cause severe sleep apnea syndrome. Acute treatment with CPAP eliminates obstructive apneas but increases central apneas. Adaptive pressure support servoventilation proves to be effective in the treatment of sleep related breathing disorders in patients on chronic opioids. Long-term studies on a large number of patients are necessary to determine if treatment of sleep apnea improves quality of life, decreases daytime sleepiness, and ultimately decreases the likelihood of unexpected death of patients on opioids.

Does CPAP lead to change in BMI?

STUDY OBJECTIVES

Obesity is an important risk factor for obstructive sleep apnea syndrome (OSAS), and weight loss can reduce apnea severity or even lead to resolution in some patients. Effective CPAP therapy may lead to weight loss by any of several proposed mechanisms, including, but not limited to, increased physical activity and increased responsiveness to leptin. This retrospective study sought to determine whether subjects who adhered to prescribed CPAP treatment for OSAS would lose weight, or gain less weight than control subjects who were either untreated or did not adhere to prescribed CPAP treatment.

METHODS

BMI was determined at the time of diagnosis and at followup approximately 1 year (10-14 months) later. Subjects who used CPAP > or = 4 h per night and > or = 70% of nights were considered treatment subjects. Control subjects used no treatment for OSAS or used CPAP < 4 hours per night or < 70% of nights for 1 year.

RESULTS

BMI of treatment and control subjects did not significantly differ (p = 0.3157). BMI increased with 1 year of CPAP use in women but not men (p = 0.0228) and in non-obese subjects (p = 0.0443). BMI did not significantly decrease in any group treated with CPAP.

CONCLUSIONS

CPAP was associated with weight gain in some; none lost weight. CPAP may affect weight in ways not measured here. Physicians should stress an active weight loss plan and not assume CPAP alone will lead to weight loss. A larger, prospective study may help clarify these findings.

Sleeping together: a pilot study of the effects of shared sleeping on adherence to CPAP treatment in obstructive sleep apnea

OBJECTIVES

To examine the sleep of married couples, recorded together in the laboratory before and after the husband is treated with continuous positive airway pressure (CPAP) to control his obstructive sleep apnea (OSA). The purpose was to investigate how these data relate to shared sleeping when he is on CPAP and his adherence to this treatment.

METHODS

Following a split-night diagnosis of OSA with CPAP titration, 10 married men slept for 2 additional nights with their non-apneic wife while both were recorded. The first night included a standard baseline 12-channel clinical polysomnogram without treatment. Following 2 weeks of home CPAP, the couple returned for a second polysomnography night with the husband on CPAP. Both partners completed Epworth Sleepiness Scales and Sleep Apnea Quality of Life Interviews each lab night. During the intervening 2 weeks, sleep logs were completed daily noting if CPAP was used, the presence of snoring, and where and how well they slept. Adherence data from machine downloads were obtained after an average of 4.6 months.

RESULTS

The husbands' baseline sleep differed significantly from their wives on 6 of 7 sleep variables related to OSA and on Epworth Sleepiness Scale scores. Their sleep did not differ the second night, except for his lower percentage of slow wave sleep. Adherence to CPAP was unrelated to OSA severity but positively related to the number of nights the couple slept together during the 2 weeks of home CPAP. The frequency of sleeping together was negatively related to the wives' arousal frequency on laboratory nights.

CONCLUSION

Although CPAP controls a husband's sleep-related OSA symptoms, his treatment adherence is strongly related to his wife sharing the bed. Addressing the wife's sensitivity to arousals when bed sharing may improve the husband's treatment adherence.

Sleep disorders in chronic traumatic brain injury

STUDY OBJECTIVE

To examine the spectrum of sleep disorders in patients with chronic traumatic brain injury (TBI) and determine if the severity of sleep disorder is related to severity of chronic TBI.

METHODS

Patients who underwent evaluation for sleep disorder/s following a TBI were included in this retrospective analysis. Sixty adult patients with TBI (age 20-69 yr; 38 M and 22 F), who presented with sleep-related complaints 3 months to 2 years following TBI, were studied. None had sleep complaints prior to the TBI. Orophrayngeal, chin, and TMJ examinations were considered benign. The severity of injury was assessed by the Global Assessment of Functioning (GAF) scale. Polysomnograms (PSGs) were performed on 54 patients (90%), 28 of whom underwent multiple sleep latency tests (MSLTs) because they scored >11 on the Epworth Sleepiness Scale (ESS). The Beck Depression Inventory (BDI) scale was administered if there was sleep maintenance insomnia, and the Hamilton Anxiety Scale (HAS) was administered if there was sleep onset insomnia.

RESULTS

The TBI severity was mild in 40%, moderate in 20%, and severe in 40%. The Epworth Sleepiness Scale (ESS) score was elevated (>11) in 52%. Hypersomnia was the presenting complaint in 50%, mostly due to sleep apnea, narcolepsy, and periodic limb movement disorder (PLMD). Insomnia was the presenting complaint in 25%, half with sleep maintenance insomnia and high BDI scores, and the remainder with sleep onset insomnia and high HAS scores. Parasomnia was the presenting complaint in 25%; the most frequent parasomnia was REM behavior disorder (RBD). GAF scores were significantly correlated (p < 0.05) with some of the measures of sleep disruption (stage 1, sleep efficiency, and wake during sleep), but not with others (wake before sleep, stage-shifts, PLMI, PLMA and AHI) on the PSG. Fifty-three percent (15/28) had a mean sleep onset latency <5 minutes, and 32% (9/28), also had two or more sleep onset rapid eye movement periods (SOREMPs) on the MSLT.

CONCLUSION

The results of this study demonstrate that a full spectrum of common sleep disorders occurs in patients with chronic TBI. The severity of chronic TBI as measured by GAF scores is correlated with some of the measures of sleep disruption but not others, indicating a complex and multifactorial pathogenesis.

Endothelial dysfunction in obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common disorder and is associated with adverse cardiovascular consequences, including hypertension and coronary artery disease. While the mechanisms responsible for increased risk of cardiovascular events in OSA have not yet been fully elucidated, hypoxia, inflammation, obesity, metabolic dysregulation, and sympathetic activation, may contribute to these consequences. Endothelial dysfunction may be another link between OSA and cardiovascular disease. Dysfunctional endothelium is characterized by an imbalance in production of vasoactive hormones, increased adherence of inflammatory mediators to endothelial cells and hypercoagulability, and is a known risk factor for cardiovascular events. Studies have directly measured vascular endothelial function in patients with OSA and found a muted response compared to controls. Other studies have evaluated biochemical markers of endothelial function including circulating levels of vasoactive and thrombosis mediators and provide further proof of endothelial dysfunction in this disorder. A better appreciation of the role of the dysfunctional endothelium in OSA will help shed light on the pathogenesis of cardiovascular disease in this disorder and may lead to development of novel therapies aimed at preventing untoward outcomes.

Depression and Obstructive Sleep Apnea (OSA)

For over two decades clinical studies have been conducted which suggest the existence of a relationship between depression and Obstructive Sleep Apnea (OSA). Recently, Ohayon underscored the evidence for a link between these two disorders in the general population, showing that 800 out of 100,000 individuals had both, a breathing-related sleep disorder and a major depressive disorder, with up to 20% of the subjects presenting with one of these disorders also having the other. In some populations, depending on age, gender and other demographic and health characteristics, the prevalence of both disorders may be even higher: OSA may affect more than 50% of individuals over the age of 65, and significant depressive symptoms may be present in as many as 26% of a community-dwelling population of older adults. In clinical practice, the presence of depressive symptomatology is often considered in patients with OSA, and may be accounted for and followed-up when considering treatment approaches and response to treatment. On the other hand, sleep problems and specifically OSA are rarely assessed on a regular basis in patients with a depressive disorder. However, OSA might not only be associated with a depressive syndrome, but its presence may also be responsible for failure to respond to appropriate pharmacological treatment. Furthermore, an undiagnosed OSA might be exacerbated by adjunct treatments to antidepressant medications, such as benzodiazepines. Increased awareness of the relationship between depression and OSA might significantly improve diagnostic accuracy as well as treatment outcome for both disorders. In this review, we will summarize important findings in the current literature regarding the association between depression and OSA, and the possible mechanisms by which both disorders interact. Implications for clinical practice will be discussed.

Enhancer-promoter communication mediated by Chip during Pannier-driven proneural patterning is regulated by Osa

The GATA factor Pannier activates proneural achaete/scute (ac/sc) expression during development of the sensory organs of Drosophila through enhancer binding. Chip bridges Pannier with the (Ac/Sc)-Daughterless heterodimers bound to the promoter and facilitates the enhancer-promoter communication required for proneural development. We show here that this communication is regulated by Osa, which is recruited by Pannier and Chip. Osa belongs to Brahma chromatin remodeling complexes and we show that Osa negatively regulates ac/sc. Consequently, Pannier and Chip also play an essential role during repression of proneural gene expression. Our study suggests that altering chromatin structure is essential for regulation of enhancer-promoter communication.

Osa-containing Brahma chromatin remodeling complexes are required for the repression of wingless target genes

The Wingless signaling pathway directs many developmental processes in Drosophila by regulating the expression of specific downstream target genes. We report here that the product of the trithorax group gene osa is required to repress such genes in the absence of the Wingless signal. The Wingless-regulated genes nubbin, Distal-less, and decapentaplegic and a minimal enhancer from the Ultrabithorax gene are misexpressed in osa mutants and repressed by ectopic Osa. Osa-mediated repression occurs downstream of the up-regulation of Armadillo but is sensitive both to the relative levels of activating Armadillo/Pangolin and repressing Groucho/Pangolin complexes present and to the responsiveness of the promoter to Wingless. Osa functions as a component of the Brahma chromatin-remodeling complex; other components of this complex are likewise required to repress Wingless target genes. These results suggest that altering the conformation of chromatin is an important mechanism by which Wingless signaling activates gene expression.