Genetic factors underlying insomnia and ovarian insufficiency

Premature ovarian insufficiency (POI) is characterized by a loss of regular hormone production and egg release in women below the age of 40 years, which often leads to infertility, vaginal dryness and dysfunctional sleep. Acknowledging the common co-occurrence of insomnia and POI, we tested the overlap between POI and insomnia-associated genes, which were implicated in previous large-scale populational genetics efforts. Among the 27 overlapping genes, three pathways were found as enriched: DNA replication, homologous recombination and Fanconi anemia. We then describe biological mechanisms, which link these pathways to a dysfunctional regulation and response to oxidative stress. We propose that oxidative stress may correspond to one of the convergent cellular processes between ovarian malfunction and insomnia pathogenic etiology. This overlap might also be driven by cortisol release associated with dysregulated DNA repair mechanisms. Benefiting from the enormous advances in populational genetics studies, this study provides a novel outlook on the relationship between insomnia and POI. The shared genetic factors and critical biological nodes between these two comorbidities may lead to identification of putative pharmacological and therapeutical targets, which can leverage novel approaches to treat or alleviate their symptoms.

0663 The Longterm Effect of CPAP Compared to Mandibular Advancement Device on Metabolic Profile in Mild Obstructive Sleep Apnea

Introduction

Moderate and severe Obstructive Sleep Apnea (OSA) have been independently associated to dyslipidemia with controversial results of improvement with CPAP. Less evidence exists regarding this issue in mild OSA. A current treatment for mild OSA is Mandibular Advancement Device (MAD), however its effectiveness on metabolic profile needs to be compared to CPAP.Our aim was to compare MAD with CPAP and no treatment on metabolic profile during one year in mild OSA.

Methods

Cross sectional analyses included 79 mild OSA patients randomized in CPAP group (n: 31), MAD group (n. 25) and Control group (n: 23). Metabolic profile was investigated before and after 6 and months.

Results

Mean age: 47± 9 years, BMI: 28±3.7 kg/m AHI: 9.5±2.9/h. There were no differences in anthropometric data, total cholesterol (TCT) HDL-C, LDL-C, Triglycerides (TC) and glycated Hemoglobin (Hb1c) among groups. MAD and CPAP reduced AHI at 6 and 12 months (9.3 ± 5.2 to 4.2 ± 9.1 to 3.8 ± 12.6 / 10.0 ± 4.6 to 1.2 ± 9.9 to 1.7 ± 14.2, p: 0.01 respectively). BMI did not change in groups at 6 and 12 months. MAD adherence was higher than CPAP at 6 months (5.8 ± 2.8 hs/day vs 3.8 ± 3.0 hs/day; p: 0.01) and 12 months 5.7 ± 2.7 hs/day vs 3.8 ± 3.4 hs/day; p: 0.01). Despite of lower adherence than MAD, CPAP was effective in reduce TCT and LDL- CT at 6 and 12 months (Intention to treat analyses TCT: 189.3±51.4 mg/dl to 186.1±51.4 mg/dl to 174.6±51 mg/dl; p: 0.03 / 112.8±48.7 mg/dl to 110.5±48.7 mg/dl to 95.8±48.7mg/dl; p: 0.03 respectively), however HDL-C, TG and Hbc didn′t change.

Conclusion

Long term CPAP treatment was effective in reducing cholesterol in mild OSA.

Support

Associação Fundo Incentivo à Psicobiologia (AFIP)

CAPES

0270 Somnolence Profiles in Mice Submitted to Acute and Chronic Sleep Deprivation

Introduction

Sleepiness is a behavioral marker of homeostatic sleep regulation and is related to several negative outcomes with interindividual variation, which may amount to central sleep mechanisms. However, there is a lack of evidence linking progressive sleep need and sleepiness with factors of individual variability, which could be tested by acute and chronic sleep deprivation. Thus, the study objective was to investigate the development of sleepiness in sleep deprived mice.

Methods

C57BL/6J male mice (n=340) were distributed in 5 sleep deprivation groups, 5 sleep rebound groups and 10 control groups. Animals underwent acute total sleep deprivation for 3, 6, 9 or 12 hours or chronic sleep deprivation for 6 hours for 5 consecutive days. Sleep rebound groups had the opportunity to sleep for 1, 2, 3, 4 hours after acute sleep deprivation or 24 hours after chronic sleep deprivation. During the protocol, sleep attempts were counted as a sleepiness index. After euthanasia, blood was collected for corticosterone assessment.

Results

Using the average group sleep attempts, it was possible to differentiate between sleepy (mean>group average) and resistant to sleepiness animals (mean<group average). Frequency of resistant mice was 65%, 56%, 56% and 53% for 3, 6, 9 and 12 hours of acute sleep deprivation, respectively, and 74% in chronic sleep deprivation. 52% of the sleepiness variance might be explained by individual variation during chronic sleep deprivation and 68% of sleepiness variance during acute sleep deprivation was attributed to extended wakefulness. A normal corticosterone zenith was observed at the start of the dark phase, independent of sleep deprivation.

Conclusion

Different degrees of sleepiness in sleep deprived mice were verified. Sleep deprivation per se was the main factor explaining sleepiness during acute sleep deprivation whereas in chronic deprivation individual variation was more relevant.

Support

This work was financially supported by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) (#2017/18455-5), Coordenação de Aperfeiçoamento de Pessoal Nível Superior (CAPES) - grant code 001, ConselhoNacional de Desenvolvimento Científico e Tecnológico (CNPq) (#169040/2017–8)and Associação Fundo de Incentivo à Pesquisa (AFIP).

0563 Inspiratory Flow Limitation in Non OSA Individuals: Risk Factors and Clinical Complaints After 8 Years of Follow in a General Population

Introduction

Inspiratory flow limitation (IFL) indicated by the flattening of inspiratory curve, is a respiratory pattern in polysomnography (PSG) suggested as a parameter used to identify individuals with sleep breathing disorder. The cutoff value is still not well defined. The purpose of this study was to evaluate the frequency and clinical impact of IFL after 8-year follow up ingeneral population.

Methods

MethodsBaseline sample was derived from a prospective population-based study (Epidemiologic Sleep Study, EPISONO). A total of 1,042 subjects completed the study assessments in 2007 and 712 from these participants were reassessed in 2016.Full night PSG at baseline and follow-up was performed and clinical outcomes were analyzed. IFL was manually scored and TST spent in IFL during sleep was calculated.

Results

In 2007 and 2016, IFL in non OSA individuals′ mean value was 10.1% and 17.7 % of TST and 95th percentile was 37.8 % and 49.9 % respectively. OSA patients had higher BMI than nonOSA in 2007 (p = 0.01), however, BMI and age were not risk factors to develop OSA or to increase IFL after 8 years. Individuals with IFL that became OSA after 8 years had a higher BMI, regardless of time, than those that did not develop OSA. Individuals who presented <15% of TST with IFL in 2007 and changed to ≥15% in 2016demonstrated significantly worse Beck depression score compared to group that maintained IFL < 5%. Individuals with ≥ 15% of TST with IFL in 2007 and in 2016 also increased depression severity score and Whoqol social relationship and environment domainscompared to the group with <15%.

Conclusion

Non OSA individuals presented 10.1% in 2007 and 17.7% in 2016 of TST in IFL. After 8 years, individuals with ≥15% of IFL presented worsening of depression severity and sleep quality.

Support

The authors would like to thank for the support by grants from Associação Fundo de Incentivo a Pesquisa (AFIP), Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

0577 Cluster Analysis for the Association Between Obstructive Sleep Apnea Phenotypes: A Population-Based Longitudinal Study

Introduction

The identification of subgroups of obstructive sleep apnea (OSA) is critical to understand disease causality and ultimately develop optimal care strategies customized for each subgroup. In this sense, we aimed to perform a cluster analysis to identify subgroups of individuals with OSA based on clinical parameters. Furthermore, we aimed to analyze whether subgroups remain after 8 years.

Methods

We used data derived from the Sao Paulo Epidemiologic Sleep Study (EPISONO) cohort, which was followed over 8 years. All individuals underwent polysomnography, answered questionnaires and had their blood collected for biochemical exams. OSA was defined according to an AHI equal or greater than 15 events per hour. Cluster analysis was performed using latent class analysis (LCA).

Results

Of the 1,042 individuals in the EPISONO baseline cohort, 68.3% accepted to participate in the follow-up study (n=712). We were able to replicate the OSA 3-cluster solution observed in previous studies: disturbed sleep, minimally symptomatic and excessively sleepy in both baseline (35.5%, 45.4% and 19.1%, respectively) and follow-up studies (41.9%, 43.4% and 14.8%, respectively). 44.8% of the participants migrated clusters between the two evaluations and the factor associated with this was a greater delta-AHI (B=-0.033, df=1, p=0.003). The optimal cluster solution for our sample based on Bayesian information criterion (BIC) was 2 clusters for baseline (disturbed sleep and excessively sleepy) and 3 clusters for follow-up (disturbed sleep, minimally symptomatic and excessively sleepy).

Conclusion

The results found replicate and confirm previously identified clinical clusters in OSA even in a longitudinal analysis.

Support

This work was supported by grants from AFIP, FAPESP and CAPES.

0493 Use of Sleep Aid Medication is Associated with Memory Deficits: A Population-Based Study

Introduction

Use of medications to treat sleep complaints is a common practice that may incur in cognitive deficits. Evidence, beyond the well-described effects of benzodiazepines on cognition, still needs expansion. This study assessed the use of sleep aid medications of different classes and associated factors on prospective and retrospective memory in a representative populational sample from São Paulo.

Methods

Volunteers in the EPISONO study underwent evaluation through questionnaires and a complete polysomnography exam. A subsample of 500 volunteers (Mean Age=42.9 years; 307 women) was included. Users (N=250) and non-users (N=250; randomly selected among the non-using volunteers) of sleep medication were evaluated regarding scores in 8 subscales and the overall score of the Prospective and Retrospective Memory Questionnaire (PRMQ). Afterwards, users of classes of medications were compared. Covariates, including scores in psychiatric evaluation scales and polysomnographic findings, were added in both segments to identify the factors with highest interference in the results obtained.

Results

Medication users consistently performed worse in prospective memory and short-term internal-cued retrospective memory even when covariates were added. Scores in Beck Anxiety and Depression Inventories, Insomnia Severity Index and variables related to wakefulness and sleep architecture were the covariates with the highest interference in the results. When comparing types of medication, few differences were seen, suggesting that for such analysis, a sample with higher power would be appropriate.

Conclusion

Users of sleep medication presented impairment in prospective memory. Factors such as sleep architecture and continuity, as well as insomnia, anxiety and depression symptoms must be considered when evaluating cognitive deficits and pharmacological treatment in patients with sleep complaints, as they may participate in this relationship. Future studies are necessary to characterize the impact of different medication classes on prospective and retrospective memory.

Support

Our studies are supported by Associação Fundo de Incentivo à Pesquisa (AFIP) and Conselho Nacional de Desenvolvimento Científico Tecnológico (CNPq - Grant #133397/2017-3); S.T. and M.L.A. received CNPq fellowships.

0828 Descriptive Model of Sleep Quality in the Older Adults

Introduction

Poor sleep quality is a health condition that impacts the quality of life of the older population. In the literature, there are questions about which objective sleep parameters should be considered to describe precisely the definition of sleep quality. There is ongoing debate with this term usually being used in relation to subjective sleep perception. This study aimed to investigate which objective and subjective sleep parameters contribute to a measurement of sleep quality in older adults.

Methods

A cross-sectional study using a representative sample of adults from the city of São Paulo, Brazil was performed. We used a dataset from the 2015 Epidemiological Study of Sleep from the City of São Paulo (EPISONO), including only individuals aged 60 years or more. We used exploratory factor analysis and structural equation modelling to identify relevant variables to a descriptive model of sleep quality.

Results

A total of 152 older adults were included. The final model consists of two factors, objective sleep quality which comprises sleep efficiency, total sleep time and sleep latency, and poor sleep perception, constituted by scores in the Pittsburgh Sleep Quality Index and Insomnia Severity Index.

Conclusion

The results suggested that sleep quality had both an objective (sleep efficiency, total sleep time, latency of sleep onset) and subjective dimensions (subjective questionnaires). These results may be useful in the clinical scenario, serving as leads for a better understanding of the sleep quality in aging patients. Future studies may also benefit from this descriptive model to further researches other associations, such as sleep and pain in this population.

Support

The study was supported by Associação Fundo de Incentivo à Pesquisa (AFIP) and Coordenação de Aperfeiçoamento de Nível Superior (CAPES). ST and MLA received support from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

0272 Effects of Gestational Sleep Restriction on Maternal Behavior in Rodents: A Systematic Review and Meta-Analysis

Introduction

Sleep restriction during pregnancy is related with postpartum depression in clinical settings. Preclinical studies have been conducted in rodent models of maternal behavior, intending to evaluate the mechanisms behind this relationship, but have raised inconsistent data so far. Our aims were to perform a preclinical meta-analysis, evaluating the actual effects or prenatal sleep restriction on maternal behavior in rodents.

Methods

A bibliographic search was conducted in Pubmed, Scopus, Web of Science, Psychinfo and Lilacs. Search strategy encompassed three domains: sleep restriction during pregnancy (as intervention), maternal behavior (as outcome) and experimentation animals (as population). Studies were first selected based on titles and abstracts, followed by full text analysis and data extraction. Individual effect size for each articles was calculated using standardized mean difference and meta-analysis was conducted using a DerSimonian and Laird random effects model.

Results

144 articles were included in our initial data screening. Sample was reduced to six records after screening. A meta-analysis was performed, including data from two maternal behavior tests (pup retrieval test and ethogram-based analyses). A total of 115 animals were included. Meta-analysis showed that sleep restriction during pregnancy have no significant effects on maternal behavior.

Conclusion

Clinical studies and meta-analysis have shown that sleep restriction and disorders during pregnancy increase risk for postpartum depression. However, preclinical studies fail to corroborate these results, as sleep restriction during pregnancy does not reduce maternal behavior in rodents. The presence of negative effects in women and the maintenance of normal maternal behavior levels in rodents under comparable intervention demonstrate that other factors might mediate this relationship (among which, sociocultural factors might play a role). The maintenance of maternal behavior seems to be an adaptive behavior, assuring the suitability and survival of the litter, even in face of environmental stresses.

Support

AFIP, FAVC, CNPq, FAPESP

0830 Hormonal Contraceptive Use and Sleep: A Systematic Review and Meta-Analysis

Introduction

The effects of hormonal contraceptives on sleep has been matter of debate in current literature. While some articles observed a sleep promoting effect and reduced sleep disordered breathing, others have failed to detect any result or even detected a worse sleep pattern in women using hormonal contraception. As the literature has been growing on this field, a systematic review is necessary to gather and compare all the studies in a comprehensive way.

Methods

A bibliographic search was conducted in Pubmed, Scopus and Web of Science. Studies were selected first based on titles and abstracts, followed by full text analysis and data extraction. Only original studies evaluating women using hormonal contraception were considered eligible. Both objective and subjective sleep-related outcomes were extracted for analyzes. Individual effect size for each articles was calculated using regular or standardized mean differences and meta-analyses were conducted using a DerSimonian and Laird random effects model.

Results

After the bibliographic search, 1787 non-duplicated articles were included in our initial data screening. Articles sample was reduced to 114 records after abstract screening and to ten studies after full text analyses. The following sleep outcomes were eligible for meta-analysis: Pittsburgh Sleep Quality Index (PSQI - 3 studies), total time in bed (4), subjective total sleep time (4), objective total sleep time (3), sleep latency (6), sleep efficiency (6). None of them resulted in statistically significant effects of contraceptive use and the effect size ± 95% interval of confidence overlapped the zero value.

Conclusion

Hormonal contraceptives is not associated to any alteration in sleep patterns in women. This conclusion should be restricted to a general framework, since our sample does not allowed stratified analyses. Future studies should consider the effect of specific hormonal composition (ex.: combined vs. progestogen-only contraceptives) and administration route (contraceptive pills vs. levonorgestrel intrauterine device).

Support

AFIP, CAPES, CNPq

0831 Hot Flashes and Insomnia Throughout the Life Span of Women from the Episono Cohort

Introduction

Hormonal changes may trigger sleep disturbances in women. Insomnia affects one in every three-to-four of them, most likely during pre to post menopause, and especially in association with hot flashes. Thus, the present study aimed to investigate the occurrence of hot flashes among women with and without insomnia and on different reproductive stages.

Methods

Sampling procedure was a three-stage clustering of the population of Sao Paulo, Brazil according to gender, age (20-80 years), and socio-economic status. A total of 574 women were interviewed, underwent polysomnographic recording (PSG), and had fasting-blood samples collected. Hormone levels and a gynecological questionnaire were used to classify reproductive stages. Premenopausal women were classified either in the follicular, luteal, or periovulatory stage or as anovulatory or under hormonal contraceptives; whereas those menopausal were classified in perimenopause or in early or late stages. Individuals reporting frequent and persistent insomnia symptoms accompanied by relevant daytime impairment were classified with insomnia syndrome. Objective insomnia was defined by increased sleep onset latency and/or awake after sleep onset, decreasing sleep duration.

Results

The final sample included 550 women, representing 53% of the EPISONO cohort (n=1,042). Hot flashes were reported by 9% of the premenopausal women (n=339) and by 42% of the menopausal. Complaints were more frequent among women in perimenopause (67%) and those in use of hormonal therapy (60%), and it tended to decrease in later stages (33%); whereas before menopause, hot flashes were especially reported by anovulatory women (26%), while significantly less by those using contraceptives (6%). Hot flashes were associated with a 2-fold increase in insomnia symptoms and while it predicted objective sleep alterations among premenopausal women, they did not after menopause, when alterations in sleep were better explained by an effect of aging.

Conclusion

Our current findings suggest that hot flashes are associated with irregular menstrual cycles among premenopausal women, and particularly with early stages of menopause, predicting both subjective and objective sleep alterations.

Support

This research was supported by fellowships from Associação Fundo de Incentivo à Pesquisa (AFIP) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Finance Code 001.

0002 Decreased Concentration of Klotho and Increased Concentration of FGF-23 in the Cerebrospinal Fluid of Patients with Narcolepsy

Introduction

Narcolepsy is a disorder characterized by hypersomnolence, cataplexy, sleep paralysis, hallucinations and sleep fragmentation. Patients with type 1 narcolepsy have cataplexy and/or hypocretin-1 deficiency. Klotho is a protein expressed by kidneys and choroid plexus, with anti-aging properties. Fibroblast growth factor 23 (FGF-23) is a hormone secreted by osteocytes with actions on mineral metabolism. The purpose of study was to explore the status of concentration of klotho and FGF23 in the cerebrospinal fluids (CSF) of patients with narcolepsy.

Methods

59 patients with narcolepsy and 17 individuals were enrolled. We used a radioimmunoassay technique, human klotho enzyme-linked immunosorbent assay (ELISA), human intact FGF23 ELISA and spectrophotometry to measure hypocretin-1, klotho, FGF-23 and phosphorus, respectively. T-Student Test was used to compare klotho and phosphate concentrations and Mann-Whitney U Test was used to compare FGF-23 levels between groups. ANOVA Test was used to compare klotho and phosphate CSF concentrations among narcolepsy patients with CSF hypocretin-1 <110pg/ml (HCRT-) and narcolepsy patients with CSF hypocretin-1 >110pg/ml (HCRT+) versus control subjects.

Results

Klotho and phosphorus CSF levels were lower in narcoleptic patients than in control (908.18 ± 405.51 versus 1265.78 ± 523.26 pg/ml; p=0.004 and 1.34 ± 0.25 versus 1.58 ± 0.23 mg/dl; p= 0.001, respectively). We found higher median FGF-23 levels in narcoleptic patients (5.51 versus 4.00 RU/ml; p= 0.001). Klotho and phosphorus CSF levels were lower in both HCRT-/HCRT+ than controls (892.63 ± 388.34/ 925.95 ± 430.76 versus 1265.78 ± 523.26 pg/ml; p=0.014 and 1.35 ± 0.28/ 1.33 ± 0.22 versus 1.58 ± 0.23 mg/dl; p= 0.004). Moreover, we found higher median FGF-23 levels in both HCRT-/HCRT+ groups versus controls (5.51/ 6.02 versus 4.00 RU/ml in controls), p= 0.009.

Conclusion

Patients with narcolepsy have decreased CSF concentration of klotho and increased CSF levels of FGF-23. These findings may play a role in understanding the pathogenesis of narcolepsy.

Support

 

0832 Physical Exercise Improves Sleep and Muscle Function in Sarcopenic Patients: A Randomized Controlled Trial

Introduction

Sarcopenia is a multifactorial condition that, like sleep debt, affects the elderly and is related to metabolic, endocrine, inflammatory alterations and risk to mortality. Resistance training (RT), in turn, can improve both factors. Aim: investigate the effects of 12-week RT on sleep and muscle function in the sarcopenic elderly.

Methods

28 sarcopenic elderly were equally distributed in 2 groups at random: CTL: who participated in weekly lifestyle change lectures or; RT: who did the progressive load RT. Sleep was assessed by polysomnography, actigraphy and questionnaires. Isokinetic and isometric of peak torque (PT) of skeletal muscle, anabolic and catabolic hormones, pro and anti-inflammatory cytokines concentrations were also evaluated. For intention to treat analysis (Δ) the generalized linear/non-linear for absolute variables or Wilcoxon rank-sum (Mann-Whitney) test. Data are expressed as mean±standard deviation or median, minimum and maximum values and difference witch p<0.05.

Results

The RT reduced the time to sleep onset (16.09±15.21) compared to CTL (29.98±22.57) group after the intervention. The Δ shows that RT had more N3 sleep (median:0.90, min:-13.40, max: 25.00) than CTL (median:-3.35, min:-15.20, max:19.10). The RT increases TTS (median:57.55, min:-204.75, max:220.91 vs median:-9.63, min:-120.98, max:185.57) and improved self-reported sleep quality (median: -1.50, min: -9.00, max: 4.00 vs median: 0.50, min: -3.00, max: 6.00) and sleep efficiency (median: 9.50, min: -15.00, max: 34.00 vs 0.00, min: -28.00, max: 18.00). For all muscle function parameters (extension and flexion knee in isokinetic or isometric PT) RT had higher values compared to CTL group after 12 weeks of intervention (p<0.05). IL-1ra concentrations were higher in RT (median: 0.04, min: -0.02, max: 0.36) vs CTL (median:-0.01, min:-0.12, max:0.07).

Conclusion

Progressive load resistance training improves sleep parameters associated to muscle recovery in elderly people with sarcopenia, along with positive changes in physical performance.

Support

Associação Fundo de Incentivo à Pesquisa (AFIP), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP).

0635 Effects of Donepezil in Patients with Residual Excessive Sleepiness of Obstructive Sleep Apnea: A Double Blind; Randomized Placebo; Controlled Study

Introduction

Residual excessive sleepiness (RES) is presented by 6% of obstructive sleep apnea patients despite effective CPAP therapy. Few interventions have been tested for this condition and are focused on daytime stimulants. Recently, cholinergic activity decline was suggested as a potential mechanism in the pathophysiology of RES. This study aimed to investigate the effects of donepezil, an anticholinesterase inhibitor, in patients with RES.

Methods

This double-blind, randomized, placebo-controlled crossover study included participants with RES (35-65 years). Neuropsychiatric disorders, alcoholism, smoking, shiftwork, psychoactive drugs, other sleep disorders were exclusion criteria. Participants were assigned to one intervention arm (donepezil 5 mg for 15 days followed by donepezil 10mg for 15 days or placebo in the morning). After a 20-day wash-out, the same procedure was repeated following the crossover design. Somnolence measured by the Epworth sleepiness scale (ESS) and Maintenance of Wakefulness Test (MWT) were the primary endpoints. PSG, cognitive (trail test, continuous performance test) and Beck’s depression scale parameters were secondary endpoints. General Linear Models for repeated measures compared interventions responses. Cohen’s d measured effect sizes. Adverse events (AEs) were assessed by questionnaire.

Results

The study enrolled eight individuals. ESS was lower in the donepezil arm than in the placebo arm (8.9±4.4 vs 15.7±4.1, p<0.05). Effect size for ESS was high (d 1.61). Other endpoints were not different among study arms. Randomization order didn’t affect the results. No AEs were reported.

Conclusion

Donepezil improved subjective sleepiness in individuals with RES. To our knowledge, this is the first study to report the effects of a cholinergic intervention in patients with RES. Effect size was high for self-reported sleepiness, which may impact on quality of life and risk of disability in people with RES. Agents acting on the cholinergic system are potential targets for treating RES.

Support

Acknowledgements Brazilian National Council for Scientific and Technological Development (CNPq) This study is supported by AFIP (Associacao Fundo Incentivo a Pesquisa).

1126 Relationship Between Headache and Sleep: A Longitudinal Study from the Population of Sao Paulo City (Brazil)

Introduction

The complaint of nocturnal awakening with headache (NAH), was prevalent (8.4%) in the São Paulo population and was associated with sleep disturbances, as demonstrated in a study conducted in 2007 (EPISONO). Indeed, this relationship between sleep and headache is well documented in the literature. Objective: To assess the incidence and evolution of NAH and to associate sleep-related variables in an eight-year prospective study.

Methods

From 1042 volunteers enrolled in the baseline, 712 agreed to participate in the follow-up. Questionnaires and scales were applied and polysomnography and actigraphy performed. The complaint of NAH was analyzed according to a frequency questionnaire and separated into frequent or occasional.

Results

At follow-up, 110 volunteers reported NAH, of which 82 were the same as those from the baseline, but only 38 had frequent complaints. Comparing with volunteers whose headache has become occasional, we have as a difference the insomnia severity index which is significantly higher in the group with frequent NAH (8.40 ± 5.10 vs 11.20±6.40 p:0.03) and worse sleep quality as measured by the Pittsburgh questionnaire (7.25±3.60 vs 10.25±4.60 p:0.002). In addition, these volunteers had higher anxiety (10.40±9.30 vs 12.00± 10:00 p: 0.008) and depression (10.60±9.90 vs 12:00±9.90 p:0.005) from Beck’s questionnaires and greater fatigue (4.85±3.10 vs 9.75±5.55 p:0.001). The associations of NAH with insomnia, nightmares, and bruxism observed in the baseline continued, but no difference was observed between those who had frequent or occasional complaints at follow-up.

Conclusion

Our study showed that NAH was highly prevalent in the Sao Paulo population in both the baseline and follow-up studies, but this frequency had a reduction in follow-up. Volunteers who persisted with the frequent complaint showed greater severity of insomnia, higher anxiety and depression and greater fatigue.

Support

Associação Fundo de Incentivo à Pesquisa (AFIP) and São Paulo Research Foundation (FAPESP)

0498 Effect of Lavender Essential Oil on Sleep in Postmenopausal Women with Insomnia: Double-Blind Randomized Controlled Trial

Introduction

Sleep is essential for women’s health and its deprivation leads to serious physiological consequences. In addition, insomnia is a common complaint in postmenopausal women. Thus, the present study aimed to evaluate the effect of Lavandula angustifolia essential oil inhalation on sleep and menopausal symptoms in postmenopausal women with insomnia.

Methods

Experimental, double-blind, randomized controlled trial composed by 33 women (48 - 65 years) with clinical diagnosis of insomnia divided in two groups that inhaled different oils before sleep during 29 days: Placebo Group - PG (sunflower oil) and Aroma Group - AG (Lavandula angustifolia essential oil). Both groups received sleep hygiene guidelines and were followed weekly. To assess the effect of the intervention on menopausal symptoms the Menopause Rating Scale (MRS) and the Hospital Anxiety and Depression Scale (HADS) were used and for sleep evaluation the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI) were used. Additionally, polysomnography were used to assess sleep pattern. All outcomes were evaluated before and after intervention. Statistical analysis was performed using SPSS 22 through Generalized Estimed Equations test with significance set at p≤ 0.05.

Results

Comparing the pre and post-intervention periods, AG participants had a significant decrease in sleep onset latency, depression level, hot flashes, menopausal symptoms and a significant increase in sleep quality. Polysomnography data showed increased sleep efficiency and decreased wakefulness after sleep onset on AG participants. After the intervention, all volunteers presented improvement in all outcomes of sleep and menopausal symptoms measured by questionnaires.

Conclusion

The intervention was effective in improving the sleep pattern of AG participants, but was not significant when compared to PG participants. In addition, sleep hygiene instructions were essential to improve the sleep pattern of all volunteers. Therefore, inhalation of lavender essential oil is a safe, low-cost practice that should be considered as a complementary option to conventional treatments, whether medical, psychological or other integrative and complementary practices.

Support

This research was supported by fellowships from Associação Fundo de Incentivo à Pesquisa (AFIP), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Finance Code 001 and Conselho Nacional de Pesquisa (CNPq).

0022 Klotho Genetic Variants Mediate the Association Between Obstructive Sleep Apnea and Short Telomere Length

Introduction

The core features of obstructive sleep apnea (OSA) can potentially contribute to the acceleration of telomere shortening mechanisms. Among these factors, klotho reduction can contribute since it is associated with accelerated systemic inflammation and oxidative stress and has recently been associated with OSA. Also, decreased levels of klotho are implicated in the regulation of telomerase activity. Therefore, we aimed to evaluate the effect of common genetic variants (SNPs) on KLOTHO gene on the association between OSA and short telomere length.

Methods

As part of the Sao Paulo Epidemiologic Sleep Study cohort, 1,042 individuals answered questionnaires, underwent polysomnography and had blood collected for DNA extraction. OSA was defined according to AHI equal or greater than 15 events per hour. Leukocyte telomere length (LTL) was measured through qPCR and SNPs were genotyped by microarray.

Results

LTL was significantly shorter in OSA compared to controls in a severity-dependent manner (B=0.055, CI=0.007–0.102, p=0.02). Among the 43 SNPs analyzed, we observed that 4 SNPs (rs525014, rs7982726, rs685417 and rs9563124) significantly mediated the association between OSA and short LTL (B=0.046, df=1, p=0.005; B=0.044, df=1, p=0.007; B=0.045, df=1, p=0.006; B=0.044, df=1, p=0.007; respectively). Furthermore, this association was under an additive model since having one or two alleles of the alternative variants were significantly associated with shorter LTL.

Conclusion

We could conclude that klotho opens a new venue in OSA research and would be applicable to prevent the consequences of short telomeres in individuals with OSA.

Support

This work was supported by grants from AFIP, FAPESP and CAPES.

0639 Long Term Oral Appliance Therapy Decreases Stress Symptoms In Upper Airway Resistance Syndrome Patients

Introduction

Upper Airway Resistance Syndrome (UARS) is suspected in individuals with excessive daytime sleepiness, fatigue and sleep fragmentation due to increased respiratory effort. UARS can negatively impact daytime function and decrease quality of life. Cognitive impairment in UARS patients has not been well stablished yet. The objective of the study was to evaluate the long-term effects of a mandibular advancement device (MAD) on cognitive function in patients with UARS compared with placebo.

Methods

This study was a randomized placebo-controlled clinical trial. Thirty UARS patients were randomized in two groups: placebo and MAD groups. UARS criteria were the presence of sleepiness (Epworth Sleepiness Scale ≥ 10) and/or fatigue (Modified Fatigue Impact Scale ≥ 38) associated with an apnea/hypopnea index (AHI) ≤ 5 and a respiratory disturbance index (RDI) > 5 events/hour of sleep, and/or flow limitation in more than 30% of total sleep time. All patients completed the Rey Auditory-Verbal Learning Test (RAVLT), the Logical Memory Test, the Stroop Color Test, the Trail Making Test, the Digit Symbol Substitution Test and Inventory of Stress Symptoms (Lipp test). Cognition protocol was defined based on most used neuropsychological tests in the literature. Evaluations were performed before and after 1.5 years of treatment.

Results

There was no statistically significant difference in RAVLT, Logical Memory Test, Stroop Color Test, Trail Making Test, Digit Symbol Substitution Test before and after 1.5 year of treatment in both groups. The Lipp test score decreased at alarm phase (p = 0.05) and at resistance phase (p = 0.01) after 1.5 year of MAD treatment compared to placebo.

Conclusion

Mandibular advancement device was effective in decreasing stress symptoms in alarm and resistance phases of Lipp test in UARS patients after 1.5-years of MAD treatment.

Support

The authors would like to thank for the support by grants from Associação Fundo de Incentivo a Pesquisa (AFIP), Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

1079 Is PTSD In Young Women Associated With Rem Sleep Abnormalities?

Introduction

The increase in violence against young women has a high impact on the prevalence of Posttraumatic stress disorder (PTSD). The lifetime prevalence of PTSD is twice as high in women. However, most studies assessing sleep disturbances in PTSD were conducted predominantly in male samples and combat veterans. Objective: To analyze the sleep of young women with and without PTSD. Hypothesis: Women with PTSD have worse sleep quality, higher arousability, and higher muscle activity during REM sleep.

Methods

Case-controlled study with young women. Seventy-four women who suffered sexual assault and developed PTSD (DSM-5); and 64 women from the community without PTSD. Women were recruited from the PTSD outpatient clinic (Universidade Federal de São Paulo, Brazil).Clinician-Administered Posttraumatic Stress Scale (CAPS 5), Beck Depression and Anxiety Inventories (BDI) (BAI), full in-lab Polysomnography (PSG), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Índex (PSQI), Fatigue Impact Scale (FIS), and Insomnia Severity Índex (ISI) were applied to all participants. Analysis of variance, regression models, and general linear modeling were used.

Results

Patients mean age was 28 vs 24 for the control group (p=0.004). CAPS mean score in PTSD-group was 42.5±9.1. BDI, BAI, FIS, PSQI, ISI scores were worse in PTSD-group (p<0.05, all). Pittsburgh Sleep Quality Index (PSQI) score was significantly associated with CAPS 5 independently of depression, fatigue, and sleep fragmentation.

The PTSD women had lower total sleep time (p= 0.01) and lower REM sleep percentage (p=0.04). However, the control group had higher arousal index (p=.0.01) and had higher muscle activity during REM sleep (p=0.03) than PTSD.

Conclusion

Women with PTSD had significantly worse score in PSQI, FIS, and ISI. PSQI score was associated with PTSD severity. However, when PSG results are concerned, we found higher sleep fragmentation in the control group. We speculate that women with PTSD may have felt safer and taken care of in the lab, which might explain the difference between objective and subjective measures of sleep quality in PTSD.

Support

Acknowledgments: FAPESP: Fundação de Apoio à pesquisa de São Paulo, AFIP: Associação Incentivo a Pesquisa

0881 Clinical Evaluation of Adeno-Tonsillar Hyperplasia in Non-Syndromic Children and Adolescents During Growth Hormone Treatment

Introduction

Recombinant human Growth Hormone (rhGH) is an important pharmacological agent for linear growth stimulation and body composition in children with growth hormone deficiency (GHD). However, reports indicate that treatment with rhGH can be associated with adeno-tonsillar hyperplasia. This condition can lead to occurrence of obstructive sleep apnea (OSA) and worsening of sleep and life quality. Nonetheless, studies assessing this outcome in non-syndromic children are scarce.

Methods

We evaluated the difference in size of pharyngeal and palatine tonsils in patients aged between 5 and 17 being treated with recombinant human Growth Hormone (rhGH). We conducted a prospective longitudinal observational study. Twelve patients in treatment with rhGH were evaluated by otorhinolaryngological physical examination, nasofibrolaryngoscopy and obstructive sleep apnea (OSA)-18 questionnaire in two different time-points: when selected (T0) and after 6 months (T1).

Results

No significant associations were found regarding palatine and pharyngeal tonsil size with rhGH treatment. In relation to OSA 18 questionnaires, there was no statistically significant result in the absence of covariables for the general score as well as for the five domains that it comprises. When covariables were included in the analyses, controlled by the patients age, we observed statistically significant increases in the general score and in the domains relating to sleep disorders, emotional suffering, diurnal problems and the caretaker′s concerns.

Conclusion

In the present study, pharyngeal or palatine tonsils hyperplasia were infrequent during treatment with rhGH in the non-syndromic children and adolescents. However, the impact on sleep and quality of life that may arise warrant careful monitoring during therapy.

Support

Associação Fundo de Incentivo à Pesquisa (AFIP).

Sleep disturbance and atopic dermatitis: A bidirectional relationship?

Atopic dermatitis (AD) is one of the most common pediatric dermatologic disorders and is associated with an increased risk of recurrent bacterial and viral cutaneous infections, such as impetigo, the most common bacterial infection in children. AD may impair patient quality of life in a number of ways, one of which is its impact on sleep. The way that the condition affects sleep has not yet been fully elucidated; it is clear that the symptoms of the disease such as pruritus and scratching can affect sleep but other factors, such as changes in the immunological system related to the disease can also have an effect. We argue that this relationship may be bi-directional, with changes to the skin barrier (barrier dysfunction, alterations in its microbiome and oxidative stress) and immunological function caused by the condition impairing sleep and leading to imbalanced inflammatory pathways that exacerbate AD and other associated conditions such as impetigo. We highlight the need for further studies to investigate this correlation between AD and sleep to make the role of this relationship clearer.