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King TFJ, Mok Y, Dacay LM, Wong HS, Hsu PP, Tan A, Wong KM, Saffari SE, Lenders JWM, Puar TH. Plasma Metanephrines Yield Fewer False-Positive Results Than Urine Metanephrines in Patients With Obstructive Sleep Apnea. J Clin Endocrinol Metab 2024; 109:844-851. [PMID: 37721483 DOI: 10.1210/clinem/dgad553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/08/2023] [Accepted: 09/16/2023] [Indexed: 09/19/2023]
Abstract
CONTEXT Obstructive sleep apnea (OSA) is associated with increased nocturnal sympathetic activity. In OSA patients, elevations in metanephrines may lead to false-positive tests when evaluating for pheochromocytoma or paraganglioma (PPGL). OBJECTIVE To evaluate whether morning plasma metanephrines would lead to fewer false-positive results than 24-hour urinary metanephrines in OSA patients. METHODS Patients undergoing polysomnography for suspected OSA were recruited. Plasma free and 24-hour urinary metanephrines were measured by HPLC-MS/MS. Patients with elevated levels had repeat measurements, abdominal imaging, and follow-up to diagnose or exclude a PPGL. RESULTS Seventy-six patients completed polysomnography and biochemical testing; 68 (89.5%) patients had OSA, of whom 19 (27.9%) had elevated plasma and/or urinary metanephrines. On follow-up, one patient had a bladder paraganglioma, while PPGL was excluded in the remaining patients. OSA patients had more false-positive urinary metanephrines (17 of 67, 25.4%) than plasma metanephrines (2 of 67, 3.0%), P < .01, and this was more common in severe OSA (13 of 34, 38.2%), compared to moderate/mild OSA (4 of 33, 12.1%), P < .01. Both plasma and urinary metanephrines decreased after treatment with continuous positive airway pressure. On multivariable analysis, severe OSA, obesity, and family history of hypertension were positive predictors for false-positive urinary metanephrines in patients with suspected OSA. CONCLUSION In OSA patients, plasma metanephrines are less likely to yield false-positive results for the diagnosis of PPGL than 24-hour urinary metanephrines. In patients with suspected OSA, obesity, or a family history of hypertension, plasma metanephrines may be the preferred first-line test to avoid unnecessary anxiety or follow-up.
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Affiliation(s)
- Thomas F J King
- Department of Endocrinology, Changi General Hospital, Singapore 529889, Singapore
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore 169547, Singapore
| | - Yingjuan Mok
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore 529889, Singapore
- Department of Sleep Medicine, Surgery and Science, Changi General Hospital, Singapore 529889, Singapore
| | - Lily Mae Dacay
- Department of Endocrinology, Changi General Hospital, Singapore 529889, Singapore
| | - Hang Siang Wong
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore 529889, Singapore
- Department of Sleep Medicine, Surgery and Science, Changi General Hospital, Singapore 529889, Singapore
| | - Pon Poh Hsu
- Department of Otorhinolaryngology, Changi General Hospital, Singapore 529889, Singapore
| | - Alvin Tan
- Department of Otorhinolaryngology, Changi General Hospital, Singapore 529889, Singapore
| | - Kang Min Wong
- Department of Radiology, Changi General Hospital, Singapore 529889, Singapore
| | - Seyed Ehsan Saffari
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore 169547, Singapore
- Department of Neurology, National Neuroscience Institute, Singapore 308433, Singapore
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Troy H Puar
- Department of Endocrinology, Changi General Hospital, Singapore 529889, Singapore
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore 169547, Singapore
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Monegro A, Gawri K. Heart rate variability in children with sleep disordered breathing. PROGRESS IN PEDIATRIC CARDIOLOGY 2023. [DOI: 10.1016/j.ppedcard.2023.101620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Chen M, Wang B, Huang J, Zhao J, Chen J, Chen G. The role of platelet-related parameters for the prediction of NAFLD in OSAHS patients. BMC Pulm Med 2022; 22:487. [PMID: 36566219 DOI: 10.1186/s12890-022-02291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022] Open
Abstract
PURPOSE As the detection of non-alcoholic fatty liver disease (NAFLD) is imperative for the prevention of its complications, we aimed to explore the predictive value of platelet to lymphocyte count ratio (PLR) and white blood cell count to mean platelet volume ratio (WBC/MPV) in relation to the occurrence of NAFLD among patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). METHODS This was a cross-sectional study consisting of 351 patients with OSAHS (279 with and 72 without NAFLD). The logistic regression analysis was performed to estimate associations between PLR, WBC/MPV, and NAFLD. Finally, the receiver operating characteristic curve (ROC curve) was used to analyze the efficacy of PLR and WBC/MPV in NAFLD prediction. RESULTS Compared to the OSAHS-only group, there was a rising trend in AHI and TS90% in the OSAHS + NAFLD group. And the logistic regression analysis identified average oxygen saturation (MaSO2), WBC/MPV and PLR as predicted factors (odds ratio [OR] = 1.134, P = 0.031; OR = 7.559, P = 0.018, OR = 0.980, P < 0.001, respectively) for NAFLD in OSAHS patients. Moreover, compared with WBC/MPV, PLR, FLI, and APRI, a combination of WBC/MPV and PLR presented the largest AUC for the detection of NAFLD in BMI < 28 kg/m2 (0.753, 95% CI 0.684-0.822), and in age ≥ 60 years subgroup (0.786, 95% CI 0.692-0.880) in ROC analysis. Meanwhile, a combination of WBC/MPV and PLR presented the second largest AUC for the detection of NAFLD in all subjects (0.743, 95% CI 0.708-0.831), as well as in the age < 60 years subgroup (0.729, 95% CI 0.652-0.806), only ranked after FLI, suggesting the combination of WBC/MPV and PLR has a good predictive value for NAFLD in OSAHS patients. CONCLUSION We confirmed that the levels of WBC/MPV, PLR, and MaSO2 were closely related to the occurrence of NAFLD among OSAHS patients. Furthermore, our results highlighted the clinical combination of WBC/MPV and PLR levels could act as a simple and effective biomarker for screening NAFLD in patients with OSAHS.
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Affiliation(s)
- Menglan Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Institute of Respiratory Disease, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Department of Respiratory and Critical Care Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian Province, People's Republic of China
| | - Biying Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Institute of Respiratory Disease, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Department of Respiratory and Critical Care Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian Province, People's Republic of China
| | - Jiefeng Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Institute of Respiratory Disease, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Department of Respiratory and Critical Care Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian Province, People's Republic of China
| | - Jianming Zhao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Institute of Respiratory Disease, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Department of Respiratory and Critical Care Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian Province, People's Republic of China
| | - Jia Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Fujian Provincial Sleep-Disordered Breathing Clinic Center, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Institute of Respiratory Disease, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China.,Department of Respiratory and Critical Care Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian Province, People's Republic of China
| | - Gongping Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China. .,Fujian Provincial Sleep-Disordered Breathing Clinic Center, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China. .,Institute of Respiratory Disease, Fujian Medical University, No. 20, Chazhong Road, Taijiang District, Fuzhou, 350005, Fujian Province, People's Republic of China. .,Department of Respiratory and Critical Care Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, Fujian Province, People's Republic of China.
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Level of urinary catecholamine in children with Sleep Disordered Breathing: A systematic review and meta-analysis. Sleep Med 2022; 100:565-572. [PMID: 36327585 DOI: 10.1016/j.sleep.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the levels of different urinary catecholamines amongst paediatric patients with and without sleep-disordered breathing (SDB). METHODS Literature searches were conducted on PubMed and EMBASE until 25/06/2022. Inclusion criteria were original human studies, English language, paediatric subjects diagnosed with SDB/obstructive sleep apnoea (OSA). The quality of studies was assessed by the Newcastle-Ottawa Quality Assessment (NOSGEN). The registered number of this study on the International Prospective Register of Systematic Reviews (PROSPERO) is CRD42022332939. The main outcome measured was standardised mean difference (SMD) of urinary catecholamine between subjects with and without SDB, between those with and without OSA, and also between subjects with mild OSA and those with moderate/ severe OSA. Sensitivity analyses were performed to avoid bias. RESULTS 9 studies (8 cross-sectional and 1 cohort study) with a total of 838 subjects, were included in the quantitative analysis. Urine level of noradrenaline was higher in patients with SDB, which included primary snoring (PS), when compared to controls: SMD = 0.86 (95%CI=0.32-1.41; I2=85%, P=0.002). The levels of urinary noradrenaline and adrenaline were higher in children with OSA when compared to controls: SMD = 1.45 (95%CI=0.91-2.00; I2=75%, P < 0.001); SMD = 1.84 (0.00-3.67; I2=97%, P=0.05). Urine level of noradrenaline was higher in subjects with moderate/severe OSA compared to the mild OSA: SMD = 0.55 (95%CI=0.10-1.00; I2=0%, P=0.02). Urinary dopamine was not associated with SDB regardless of severity. CONCLUSIONS Urinary noradrenaline was higher in all patients with SDB. Subjects with OSA, a more severe form of SDB, had higher urine levels of noradrenaline and adrenaline. Hence, noradrenaline and adrenaline may be markers of sympathetic overtone in patients with SDB and could potentially act as surrogate markers for SDB complications. Further studies are needed to assess this association.
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Sica E, De Bernardi F, Nosetti L, Martini S, Cosentino M, Castelnuovo P, Marino F. Catecholamines and children obstructive sleep apnea: a systematic review. Sleep Med 2021; 87:227-232. [PMID: 34638100 DOI: 10.1016/j.sleep.2021.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder in children and is characterized by recurrent total or partial upper airway collapse episodes during sleep. OSA is associated with cardiovascular, metabolic and neurobehavioural complications related to sympathetic nervous system (SNS) activation. A key role in originating these complications and in underlying pathophysiologic mechanisms can be attributed to altered catecholamines (CAs) metabolism. METHODS A systematic review was performed according to the PRISMA Statement guidelines for research studies correlating OSA in children with catecholamines. RESULTS Only 13 studies out of 151 reports were included in the review. Most studies (9 out of 13) showed increased secretion for some catecholamines in patients with a sleep-related breathing disorder or OSA compared to a control group or post treatment control group. CONCLUSION OSA can activate the sympathetic nervous system (SNS) and increase catecholamines (CAs) production, perhaps contributing to increased morbidity. However, underlying pathophysiologic mechanisms remain still unclear.
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Affiliation(s)
- Eleonora Sica
- PhD Course in Clinical and Experimental Medicine and Medical Humanities, University of Insubria, Varese, Italy; Department of Otorhinolaryngology, University of Insubria, Varese, Italy.
| | | | - Luana Nosetti
- Department of Paediatrics, University of Insubria, Varese, Italy
| | - Stefano Martini
- Center for Research in Medical Pharmacology, University of Insubria, Varese, Italy
| | - Marco Cosentino
- Center for Research in Medical Pharmacology, University of Insubria, Varese, Italy
| | - Paolo Castelnuovo
- Department of Otorhinolaryngology, University of Insubria, Varese, Italy
| | - Franca Marino
- Center for Research in Medical Pharmacology, University of Insubria, Varese, Italy
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Malakasioti G, Alexopoulos EI, Batziou N, Velentza L, Mylona AM, Lachanas V, Skoulakis C, Gourgoulianis K, Kaditis AG. Frequency of moderate-to-severe obstructive sleep apnea syndrome among children with snoring and blood pressure in the hypertensive range. Pediatr Nephrol 2020; 35:1491-1498. [PMID: 32232636 DOI: 10.1007/s00467-020-04544-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/23/2020] [Accepted: 03/18/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND It is recommended that children with hypertension and loud snoring should be referred for polysomnography. We aimed to compare the frequency of moderate-to-severe obstructive sleep apnea syndrome (OSAS) among snorers with and without hypertension. Thus, it was hypothesized that systolic or diastolic hypertension among children with snoring is a risk factor for moderate-to-severe OSAS. METHODS Data of children with snoring and adenotonsillar hypertrophy and/or obesity referred for polysomnography were retrospectively analyzed. Blood pressure (BP) was measured three times in the morning after polysomnography and percentiles were calculated for the average of the second and third measurement. Association of systolic or diastolic hypertension with moderate-to severe OSAS (apnea-hypopnea index-AHI > 5 episodes/h) adjusted for age and obesity was assessed by logistic regression. RESULTS Data of 646 children with snoring (median age, 6.5 years; 3-14.9 years; 25.7% obese) were analyzed. Prevalence of systolic or diastolic hypertension was 14.1% and 16.1%, respectively and frequency of AHI > 5 episodes/h was 18.3%. Systolic hypertension was a significant predictor of moderate-to-severe OSAS (OR 1.87; 95% CI 1.10 to 3.17; P = 0.02) after adjustment for age and obesity, but diastolic hypertension was not (OR, 0.96; 0.55 to 1.67; P > 0.05). Odds of AHI > 5 episodes/h prior to considering systolic hypertension was 0.25 and after considering its presence, increased to 0.46 (Bayes' theorem), or for every three children with systolic hypertension and snoring tested, one had AHI > 5 episodes/h. CONCLUSIONS In the context of systolic hypertension and snoring, referral for polysomnography to rule out moderate-to-severe OSAS is a clinically productive practice.
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Affiliation(s)
- Georgia Malakasioti
- Department of Pediatric Nephrology, "P. & A. Kyriakou" Children's Hospital, Thivon and Levadias St, 115 27, Athens, Greece.
| | | | - Nikoleta Batziou
- Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Lilly Velentza
- Sleep Disorders Laboratory, Larissa University Hospital, Larissa, Greece
| | - Anna-Maria Mylona
- Sleep Disorders Laboratory, Larissa University Hospital, Larissa, Greece
| | - Vasilios Lachanas
- Department of Otorhinolaryngology, Larissa University Hospital, Larissa, Greece
| | | | | | - Athanasios G Kaditis
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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Lorenzoni G, Azzolina D, Sethi G, Manchanda S, Gregori D, Gulati A, Baldi I. Identifying Pathways Mediating Obstructive Sleep Apnea and Obesity in Indian Children. Indian J Pediatr 2019; 86:15-19. [PMID: 30661192 DOI: 10.1007/s12098-018-2828-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/27/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Overweight and obesity in children is associated with several metabolic and cardiovascular impairments, including obstructive sleep apnea (OSA). However, the causal pathway from OSA to obesity is not fully known yet. The aim of this study was to explore the association between OSA and obesity-related metabolic outcomes in obese Indian children. METHODS An observational, cross-sectional study was conducted. Obese children referred to the Otorhinolaryngology Department at the Maulana Azad Medical College (New Delhi, India) for suspicion of OSA were consecutively enrolled. OSA was diagnosed by polysomnographic parameters. Homeostasis model assessment (HOMA) was calculated to measure insulin sensitivity and HOMA > 4.39 was considered as a threshold for insulin resistance. The association between various polysomnographic measures and HOMA, adiponectin and various urinary catecholamines was assessed. RESULTS Complete polysomnographic parameters were available for 45 children; of these 29 were found to suffer from OSA. OSA children had significantly higher glucose concentrations compared to non-OSA ones (p value = 0.012) but no differences were found in insulin resistance and urinary catecholamines levels. Older age was significantly associated to lower levels of catecholamines. No significant associations were found between polysomnographic parameters and both HOMA and adiponectin. Only age was found to be significantly associated with HOMA (p = 0.03) and adiponectin (p = 0.01). CONCLUSIONS A better understanding of the role played by OSA on obese children's metabolic functions is crucial to implement specific prevention strategies to reduce the public health burden of non-communicable diseases.
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Affiliation(s)
- Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gulshan Sethi
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | - Sanjay Manchanda
- Department of Sleep Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Achal Gulati
- Department of Otorhinolaryngology and Head and Neck Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - Ileana Baldi
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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Hirsch D, Evans CA, Wong M, Machaalani R, Waters KA. Biochemical markers of cardiac dysfunction in children with obstructive sleep apnoea (OSA). Sleep Breath 2018; 23:95-101. [DOI: 10.1007/s11325-018-1666-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 12/13/2022]
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DelRosso LM, King J, Ferri R. Systolic Blood Pressure Elevation in Children with Obstructive Sleep Apnea Is Improved with Positive Airway Pressure Use. J Pediatr 2018; 195:102-107.e1. [PMID: 29277419 DOI: 10.1016/j.jpeds.2017.11.043] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/24/2017] [Accepted: 11/17/2017] [Indexed: 01/29/2023]
Abstract
INTRODUCTION To evaluate the effect of continuous positive airway pressure (CPAP) treatment on blood pressure (BP) in children with obstructive sleep apnea (OSA). STUDY DESIGN Retrospective chart review of children aged 7-17 referred to Benioff Children's Hospital Oakland for the evaluation of snoring. Data collected included age, body mass index (BMI), BP, heart rate, apnea-hypopnea index, and oxygen saturation nadir. Children were divided into 3 groups: snorers, untreated OSA, and OSA treated with CPAP. Seventy-five children were identified, 25 in each group. RESULTS There was no difference in age or apnea-hypopnea index among the groups. The CPAP group had higher BMI than the snorers and untreated OSA groups. Systolic BP was higher in the 2 OSA groups compared with the snorers. After CPAP treatment, systolic BP decreased. The BP decrease was significantly greater in patients with higher BMI at baseline. There was no significant change in diastolic BP in the 3 groups. CONCLUSION Children with OSA have higher systolic BP than habitual snorers. Treatment with CPAP in children with OSA for 6 months reduced their systolic BP despite a small increase in their BMI.
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Affiliation(s)
- Lourdes M DelRosso
- Pediatric Pulmonary, UCSF Benioff Children's Hospital Oakland (BCHO), Oakland, CA; Children's Hospital Oakland Research Institute, Oakland, CA.
| | - Janet King
- Children's Hospital Oakland Research Institute, Oakland, CA
| | - Raffaele Ferri
- Sleep Research Center, Oasi Research Institute IRCCS, Troina, Italy
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The impact of sleep disordered breathing on cardiovascular health in overweight children. Sleep Med 2018; 41:58-68. [DOI: 10.1016/j.sleep.2017.09.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 12/21/2022]
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Yiallourou SR, Wallace EM, Whatley C, Odoi A, Hollis S, Weichard AJ, Muthusamy JS, Varma S, Cameron J, Narayan O, Horne RSC. Sleep: A Window Into Autonomic Control in Children Born Preterm and Growth Restricted. Sleep 2017; 40:3737644. [PMID: 28419371 DOI: 10.1093/sleep/zsx048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 11/14/2022] Open
Abstract
Study Objectives Preterm birth and fetal growth restriction (FGR) are both associated with risk of hypertension in adulthood. Mechanisms leading to this pathology are unclear. In children aged 5-12 years, who were born preterm and FGR, we used sleep as a tool to assess autonomic control with assessment of cardiovascular structure and function. Methods Eighteen children born preterm and FGR, 15 children born preterm with appropriate birth weights for gestational age (AGA), and 20 AGA term-born children were studied. Children underwent overnight polysomnography with the addition of continuous noninvasive blood pressure (Finometer™). Spectral measures of heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity were assessed and overnight urinary catecholamine levels measured. Echocardiographic studies (Vivid7, GE Healthcare) were performed and vascular compliance assessed (Miller Instruments™). Statistical comparisons were adjusted for age and body size. Results Compared to term children, preterm AGA children had increased high frequency HRV (p < .05) and BPV (p < .05) during sleep, reflecting increased parasympathetic activation and blood pressure changes related to respiration. Preterm FGR children had smaller left ventricular lengths, ascending aorta, and left ventricular outflow tract diameter (p < .05 for all) and vascular compliance was positively correlated with gestational age (r2 = 0.93, p < .05). Conclusions FGR combined with preterm birth did not alter autonomic control but altered heart structure in children. In contrast, preterm birth alone altered autonomic control but had no change in heart structure. These changes in children born preterm and FGR may contribute, in part, to increased risk of cardiovascular disease later in life but by different mechanisms.
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Affiliation(s)
- Stephanie R Yiallourou
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
| | - Euan M Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Christie Whatley
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Melbourne, Australia
| | - Alexsandria Odoi
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Samantha Hollis
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Aidan J Weichard
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | | | - Suraj Varma
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Melbourne, Australia
| | - James Cameron
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Melbourne, Australia
| | - Om Narayan
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Melbourne, Australia
| | - Rosemary S C Horne
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
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Bholah R, Bunchman TE. Review of Pediatric Pheochromocytoma and Paraganglioma. Front Pediatr 2017; 5:155. [PMID: 28752085 PMCID: PMC5508015 DOI: 10.3389/fped.2017.00155] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/26/2017] [Indexed: 01/01/2023] Open
Abstract
Pheochromocytoma (PCC) and paraganglioma (PGL) are rare chromaffin cell tumors which secrete catecholamines and form part of the family of neuroendocrine tumors. Although a rare cause of secondary hypertension in pediatrics, the presentation of hypertension in these patients is characteristic, and treatment is definitive. The gold standard for diagnosis is via measurement of plasma free metanephrines, with imaging studies performed for localization, identification of metastatic lesions and for surgical resection. Preoperative therapy with alpha-blocking agents, beta blockers, and potentially tyrosine hydroxylase inhibitors aid in a safe pre-, intra- and postoperative course. PCC and PGL are inherited in as much as 80% of pediatric cases, and all patients with mutations should be followed closely given the risk of recurrence and malignancy. While the presentation of chromaffin cell tumors has been well described with multiple endocrine neoplasia, NF1, and Von Hippel-Lindau syndromes, the identification of new gene mutations leading to chromaffin cell tumors at a young age is changing the landscape of how clinicians approach such cases. The paraganglioma-pheochromocytoma syndromes (SDHx) comprise familial gene mutations, of which the SDHB gene mutation carries a high rate of malignancy. Since the inheritance rate of such tumors is higher than previously described, genetic screening is recommended in all patients, and lifelong follow-up for recurrent tumors is a must. A multidisciplinary team approach allows for optimal health-care delivery in such children. This review serves to provide an overview of pediatric PCC and PGL, including updates on the preferred methods of imaging, guidelines on gene testing as well as management of hypertension in such patients.
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Affiliation(s)
- Reshma Bholah
- Pediatric Nephrology, Virginia Commonwealth University, Richmond, VA, United States
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Tan HL, Alonso Alvarez ML, Tsaoussoglou M, Weber S, Kaditis AG. When and why to treat the child who snores? Pediatr Pulmonol 2017; 52:399-412. [PMID: 28029756 DOI: 10.1002/ppul.23658] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/25/2016] [Accepted: 11/30/2016] [Indexed: 12/31/2022]
Abstract
Obstructive sleep-disordered breathing (SDB) can result in cardiovascular and neurocognitive morbidity as well as adversely affect behavior, growth, quality of life, and nocturnal continence. This article summarizes the latest evidence regarding the morbidity related to obstructive SDB, commenting on the impact of severity of obstruction, that is, the difference in effects seen of moderate to severe obstructive sleep apnea syndrome (OSAS) compared to those of mild OSAS or primary snoring. The impact of therapy is discussed, focusing on which children are likely to benefit from treatment interventions; namely those with moderate or severe OSAS irrespective of the presence of morbidity, children with mild OSAS with associated morbidity or predictors of SDB persistence such as obesity, and children with complex conditions accompanied by upper airway obstruction like craniosynostosis and Prader-Willi syndrome. The co-existing conditions which may improve when treatment for obstructive SDB is offered are reviewed, while the clinical parameters associated with spontaneous improvement or resolution of obstructive SDB are discussed. The intention being to enable clinicians to make informed decisions on who should be treated, when and why. Pediatr Pulmonol. 2017;52:399-412. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Hui-Leng Tan
- Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, Sydney St., London SW3 6NP, United Kingdom
| | - Maria Luz Alonso Alvarez
- Multidisciplinary Sleep Unit, Pulmonology, University Hospital of Burgos and CIBER of Respiratory Diseases (CIBERES), Burgos Foundation for Health Research, Burgos, Spain
| | - Marina Tsaoussoglou
- Pediatric Pulmonology Unit, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
| | - Silke Weber
- Department of Ophthalmology, Otolaryngology and Head and Neck Surgery, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, São Paulo, Brazil
| | - Athanasios G Kaditis
- Pediatric Pulmonology Unit, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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Kontos A, van den Heuvel C, Pamula Y, Martin J, Lushington K, Baumert M, Willoughby S, Gent R, Couper J, Kennedy D. Delayed brachial artery dilation response and increased resting blood flow velocity in young children with mild sleep-disordered breathing. Sleep Med 2015; 16:1451-6. [DOI: 10.1016/j.sleep.2015.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/04/2015] [Accepted: 08/07/2015] [Indexed: 11/30/2022]
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Walter LM, Biggs SN, Nisbet LC, Weichard AJ, Hollis SL, Davey MJ, Anderson V, Nixon GM, Horne RSC. Improved long-term autonomic function following resolution of sleep-disordered breathing in preschool-aged children. Sleep Breath 2015; 20:309-19. [DOI: 10.1007/s11325-015-1268-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/22/2015] [Accepted: 09/21/2015] [Indexed: 12/13/2022]
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De Luca Canto G, Pachêco-Pereira C, Aydinoz S, Major PW, Flores-Mir C, Gozal D. Diagnostic capability of biological markers in assessment of obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med 2015; 11:27-36. [PMID: 25325575 DOI: 10.5664/jcsm.4358] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/11/2014] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The purpose of this systematic review is to evaluate the diagnostic value of biological markers (exhaled breath condensate, blood, salivary and urinary) in the diagnosis of OSA in comparison to the gold standard of nocturnal PSG. METHODS Studies that differentiated OSA from controls based on PSG results, without age restriction, were eligible for inclusion. The sample of selected studies could include studies in obese patients and with known cardiac disease. A detailed individual search strategy for each of the following bibliographic databases was developed: Cochrane, EMBASE, MEDLINE, PubMed, and LILACS. The references cited in these articles were also crosschecked and a partial grey literature search was undertaken using Google Scholar. The methodology of selected studies was evaluated using the 14-item Quality Assessment Tool for Diagnostic Accuracy Studies. RESULTS After a two-step selection process, nine articles were identified and subjected to qualitative and quantitative analyses. Among them, only one study conducted in children and one in adults found biomarkers that exhibit sufficiently satisfactory diagnostic accuracy that enables application as a diagnostic method for OSA. CONCLUSION Kallikrein-1, uromodulin, urocotin-3, and orosomucoid-1 when combined have enough accuracy to be an OSA diagnostic test in children. IL-6 and IL-10 plasma levels have potential to be good biomarkers in identifying or excluding the presence of OSA in adults.
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Affiliation(s)
- Graziela De Luca Canto
- Department of Dentistry, Federal University of Santa Catarina, Florianopolis, SC, Brazil.,School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Canada
| | | | - Secil Aydinoz
- GATA Haydarpasa Teaching Hospital, Istanbul, Turkey.,Department of Pediatrics, University of Chicago, Chicago, IL
| | - Paul W Major
- School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Canada
| | - Carlos Flores-Mir
- School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Canada
| | - David Gozal
- Department of Pediatrics, University of Chicago, Chicago, IL
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Canto GDL, Pachêco-Pereira C, Aydinoz S, Major PW, Flores-Mir C, Gozal D. Biomarkers associated with obstructive sleep apnea: A scoping review. Sleep Med Rev 2014; 23:28-45. [PMID: 25645128 DOI: 10.1016/j.smrv.2014.11.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 11/12/2014] [Accepted: 11/12/2014] [Indexed: 12/31/2022]
Abstract
The overall validity of biomarkers in the diagnosis of obstructive sleep apnea (OSA) remains unclear. We conducted a scoping review to provide assessments of biomarkers characteristics in the context of obstructive sleep apnea (OSA) and to identify gaps in the literature. A scoping review of studies in humans without age restriction that evaluated the potential diagnostic value of biological markers (blood, exhaled breath condensate, salivary, and urinary) in the OSA diagnosis was undertaken. Retained articles were those focused on the identification of biomarkers in subjects with OSA, the latter being confirmed with a full overnight or home-based polysomnography (PSG). Search strategies for six different databases were developed. The methodology of selected studies was classified using an adaptation of the evidence quality criteria from the American Academy of Pediatrics. Additionally the biomarkers were classified according to their potential clinical application. We identified 572 relevant studies, of which 117 met the inclusion criteria. Eighty-two studies were conducted in adults, 34 studies involved children, and one study had a sample composed of both adults and children. Most of the studies evaluated blood biomarkers. Potential diagnostic biomarkers were found in nine pediatric studies and in 58 adults studies. Only nine studies reported sensitivity and specificity, which varied substantially from 43% to 100%, and from 45% to 100%, respectively. Studies in adults have focused on the investigation of IL-6, TNF-α and hsCRP. There was no specific biomarker that was tested by a majority of authors in pediatric studies, and combinatorial urine biomarker approaches have shown preliminary promising results. In adults IL-6 and IL-10 seem to have a favorable potential to become a good biomarker to identify OSA.
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Affiliation(s)
- Graziela De Luca Canto
- Department of Dentistry, Federal University of Santa Catarina, Florianopolis, SC, Brazil; School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Canada
| | | | - Secil Aydinoz
- GATA Haydarpasa Teaching Hospital, Istanbul, Turkey; Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, USA
| | - Paul W Major
- School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Canada
| | - Carlos Flores-Mir
- School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Canada
| | - David Gozal
- Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, USA; Comer Children's Hospital, USA.
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Poincaré plot width, morning urine norepinephrine levels, and autonomic imbalance in children with obstructive sleep apnea. Pediatr Neurol 2014; 51:246-51. [PMID: 25079573 DOI: 10.1016/j.pediatrneurol.2014.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/02/2014] [Accepted: 05/04/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) in childhood is accompanied by sympathetic overflow unopposed by the parasympathetic tone. Complex methods like power spectral analysis of heart rate variability have been applied to study this imbalance. In this report, width of Poincaré scattergram of the R-R interval (parasympathetic tone) and morning urine norepinephrine concentration (sympathetic activity) were used to assess autonomic imbalance. METHODS Poincaré plot was obtained from the electrocardiographic channel of nocturnal polysomnography and its width was measured, and norepinephrine-to-creatinine concentration ratio was calculated in morning urine specimen. RESULTS Twenty children with obstructive sleep apnea and moderate-to-severe nocturnal hypoxemia (oxygen saturation of hemoglobin [SpO(2)] nadir <90%), 24 subjects with mild hypoxemia (SpO(2) nadir ≥90%), and 11 control subjects were recruited. Children with obstructive sleep apnea and moderate-to-severe hypoxemia had significantly narrower Poincaré plot width (318.7 ± 139.3 ms) and higher ln-transformed urine norepinephrine-to-creatinine ratio (4.5 ± 0.6) than control subjects (484.2 ± 104.4 ms and 3.8 ± 0.4, respectively; P < 0.05). Ln-transformed urine norepinephrine levels were inversely related to Poincaré plot width (P = 0.02). CONCLUSIONS Subjects with obstructive sleep apnea and moderate-to-severe nocturnal hypoxemia have enhanced sympathetic activity and reduced parasympathetic drive. Poincaré plot width and urine norepinephrine levels are simple measures of autonomic imbalance in pediatric obstructive sleep apnea.
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Evans CA, Selvadurai H, Baur LA, Waters KA. Effects of obstructive sleep apnea and obesity on exercise function in children. Sleep 2014; 37:1103-10. [PMID: 24882905 DOI: 10.5665/sleep.3770] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
STUDY OBJECTIVES Evaluate the relative contributions of weight status and obstructive sleep apnea (OSA) to cardiopulmonary exercise responses in children. DESIGN Prospective, cross-sectional study. Participants underwent anthropometric measurements, overnight polysomnography, spirometry, cardiopulmonary exercise function testing on a cycle ergometer, and cardiac doppler imaging. OSA was defined as ≥ 1 obstructive apnea or hypopnea per hour of sleep (OAHI). The effect of OSA on exercise function was evaluated after the parameters were corrected for body mass index (BMI) z-scores. Similarly, the effect of obesity on exercise function was examined when the variables were adjusted for OAHI. SETTING Tertiary pediatric hospital. PARTICIPANTS Healthy weight and obese children, aged 7-12 y. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Seventy-one children were studied. In comparison with weight-matched children without OSA, children with OSA had a lower cardiac output, stroke volume index, heart rate, and oxygen consumption (VO2 peak) at peak exercise capacity. After adjusting for BMI z-score, children with OSA had 1.5 L/min (95% confidence interval -2.3 to -0.6 L/min; P = 0.001) lower cardiac output at peak exercise capacity, but minute ventilation and ventilatory responses to exercise were not affected. Obesity was only associated with physical deconditioning. Cardiac dysfunction was associated with the frequency of respiratory-related arousals, the severity of hypoxia, and heart rate during sleep. CONCLUSIONS Children with OSA are exercise limited due to a reduced cardiac output and VO2 peak at peak exercise capacity, independent of their weight status. Comorbid OSA can further decrease exercise performance in obese children.
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Affiliation(s)
- Carla A Evans
- The Children's Hospital at Westmead Clinical School, Discipline of Paediatrics & Child Health, Faculty of Medicine, The University of Sydney NSW Australia
| | - Hiran Selvadurai
- The Children's Hospital at Westmead Clinical School, Discipline of Paediatrics & Child Health, Faculty of Medicine, The University of Sydney NSW Australia ; The Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead NSW Australia
| | - Louise A Baur
- The Children's Hospital at Westmead Clinical School, Discipline of Paediatrics & Child Health, Faculty of Medicine, The University of Sydney NSW Australia ; Weight Management Service, The Children's Hospital at Westmead, Westmead NSW Australia
| | - Karen A Waters
- The Children's Hospital at Westmead Clinical School, Discipline of Paediatrics & Child Health, Faculty of Medicine, The University of Sydney NSW Australia ; The Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead NSW Australia
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Tan HL, Kheirandish-Gozal L, Gozal D. The promise of translational and personalised approaches for paediatric obstructive sleep apnoea: an 'Omics' perspective. Thorax 2014; 69:474-80. [PMID: 24550060 DOI: 10.1136/thoraxjnl-2013-204640] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Obstructive sleep apnoea (OSA) can result in significant morbidities including the cardiovascular, metabolic and neurocognitive systems. These effects are purportedly mediated via activation of inflammatory cascades and the induction of oxidative stress, ultimately resulting in cellular injury and dysfunction. While great advances have been made in sleep medicine research in the past decades, there are still wide gaps in our knowledge concerning the exact underlying pathophysiological mechanisms of OSA and consequences. Without resolving these issues, the reasons why patients with a similar severity of OSA can have markedly different clinical presentation and end-organ morbidity, that is, phenotype, will continue to remain elusive. This review aims to highlight the recent exciting discoveries in genotype-phenotype interactions, epigenetics, genomics and proteomics related to OSA. Just as PCR revolutionised the field of genetics, the potential power of 'Omics' promises to transform the field of sleep medicine, and provide critical insights into the downstream pathological cascades inherent to OSA, thereby enabling personalised diagnosis and management for this highly prevalent sleep disorder.
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Affiliation(s)
- Hui-Leng Tan
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, , London, UK
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22
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Long-term changes in heart rate variability in elementary school–aged children with sleep-disordered breathing. Sleep Med 2014; 15:76-82. [DOI: 10.1016/j.sleep.2013.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/21/2013] [Accepted: 06/24/2013] [Indexed: 11/20/2022]
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Nisbet LC, Yiallourou SR, Nixon GM, Biggs SN, Davey MJ, Trinder J, Walter LM, Horne RSC. Nocturnal autonomic function in preschool children with sleep-disordered breathing. Sleep Med 2013; 14:1310-6. [PMID: 24091143 DOI: 10.1016/j.sleep.2013.07.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 06/21/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with autonomic dysfunction in adults and school-aged children; however, this association has not been investigated in preschool children. We aimed to analyze heart rate variability (HRV) and catecholamine levels in preschool children with OSA. METHODS One hundred and forty-two snoring children aged 3-5years and 38 nonsnoring control group children underwent overnight polysomnography (PSG). Nocturnal urinary catecholamines were measured in 120 children. Children were grouped according to their obstructive apnea-hypopnea index (OAHI) (control [no snoring], OAHI⩽1event/h; primary snoring, OAHI⩽1event/h; mild OSA OAHI>1⩽5events/h; moderate to severe [MS] OSA, OAHI>5events/h). The HRV parameters for each child were averaged during rapid eye movement (REM) and non-REM (NREM) sleep. RESULTS During stable sleep, low-frequency (LF) HRV was similar between groups. High-frequency (HF) HRV was higher in the MS OSA group compared with the control group during all sleep stages (NREM sleep stages 1 and 2 [NREM1/2], 4234±523ms(2) vs 2604±457ms(2); NREM sleep stages 3 and 4 [NREM3/4], 4152±741ms(2) vs 3035±647ms(2); REM, 1836±255ms(2) vs 1456±292ms(2); P<.01 for all). The LF/HF ratio was lower in the MS OSA group compared with the control group (NREM1/2, 0.4±0.06 vs 0.7±0.05; NREM3/4, 0.3±0.06 vs 0.4±0.05; REM, 0.8±0.1 vs 1.3±0.1; P<.01 for all). Catecholamine levels were not different between groups. CONCLUSIONS In preschool children, OSA is associated with altered HRV, largely due to the HF fluctuations in heart rate (HR) which occur during respiratory events and are still evident during stable sleep. The preschool age may represent a window of opportunity for treatment of OSA before the onset of the severe autonomic dysfunction associated with OSA in adults and older children.
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Affiliation(s)
- Lauren C Nisbet
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Australia
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Kheirandish-Gozal L, McManus CJT, Kellermann GH, Samiei A, Gozal D. Urinary neurotransmitters are selectively altered in children with obstructive sleep apnea and predict cognitive morbidity. Chest 2013; 143:1576-1583. [PMID: 23306904 DOI: 10.1378/chest.12-2606] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Pediatric obstructive sleep apnea (OSA) is associated with cognitive dysfunction, suggesting altered neurotransmitter function. We explored overnight changes in neurotransmitters in the urine of children with and without OSA. METHODS Urine samples were collected from children with OSA and from control subjects before and after sleep studies. A neurocognitive battery assessing general cognitive ability (GCA) was administered to a subset of children with OSA. Samples were subjected to multiple enzyme-linked immunosorbent assays for 12 neurotransmitters, and adjusted for creatinine concentrations. RESULTS The study comprised 50 children with OSA and 20 control subjects. Of the children with OSA, 20 had normal GCA score (mean ± SD) (101.2 ± 14.5) and 16 had a reduced GCA score (87.3 ± 13.9; P < .001). Overnight increases in epinephrine, norepinephrine, and γ-aminobutyric acid (GABA) levels emerged in children with OSA; taurine levels decreased. Using combinatorial approaches and cutoff values for overnight changes of these four neurotransmitters enabled prediction of OSA (area under the curve [AUC]: 0.923; P < .0001). Furthermore, GABA and taurine alterations, as well as overnight reductions in phenylethylamine, were more prominent in children with OSA and low GCA than in children with OSA and normal GCA (P < .001), and they reliably discriminated GCA status (AUC: 0.977; P < .0001). CONCLUSIONS Pediatric OSA is associated with overnight increases in urinary concentrations of catecholamines indicative of heightened sympathetic outflow. Increases in GABA levels and decreases in taurine levels could underlie mechanisms of neuronal excitotoxicity and dysfunction. Combinatorial approaches using defined cutoffs in overnight changes in concentrations of selected neurotransmitters in urine may not only predict OSA but also the presence of cognitive deficits. Larger cohort studies appear warranted to confirm these findings.
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Affiliation(s)
- Leila Kheirandish-Gozal
- Department of Pediatrics, Pritzker School of Medicine, The University of Chicago, Chicago, IL
| | | | | | - Arash Samiei
- Department of Pediatrics, Pritzker School of Medicine, The University of Chicago, Chicago, IL
| | - David Gozal
- Department of Pediatrics, Pritzker School of Medicine, The University of Chicago, Chicago, IL.
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Nisbet LC, Yiallourou SR, Nixon GM, Biggs SN, Davey MJ, Trinder J, Walter LM, Horne RSC. Characterization of the acute pulse transit time response to obstructive apneas and hypopneas in preschool children with sleep-disordered breathing. Sleep Med 2013; 14:1123-31. [PMID: 24047534 DOI: 10.1016/j.sleep.2013.06.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 06/24/2013] [Accepted: 06/27/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Surges in heart rate (HR) and blood pressure (BP) at apnea termination contribute to the hypertension seen in obstructive sleep apnea (OSA). Because childhood OSA prevalence peaks in the preschool years, we aimed to characterize the cardiovascular response to obstructive events in preschool-aged children. METHODS Clinically referred children aged 3-5 years were grouped by obstructive apnea-hypopnea index (OAHI) into the following: primary snoring (PS) (OAHI≤1 event/h [n=21]), mild OSA (OAHI>1-≤5 [n=32]), and moderate to severe (MS) OSA (OAHI>5 [n=28]). Beat-to-beat pulse transit time (PTT), an inverse continuous indicator of BP changes, and HR were averaged during the two halves (early and late) and during the peak after (post) each obstructive event and were expressed as percentage change from late- to post-event. RESULTS We analyzed 422 events consisting of 55 apneas and 367 hypopneas. A significant post-event increase in HR and fall in PTT occurred in all severity groups (P<.05 for all). A greater response was associated with OSA, nonrapid eye movement sleep (NREM), cortical arousal, hypopneas, and oxygen desaturation (P<.05 for all). CONCLUSIONS Obstructive events elicit acute cardiovascular changes in preschool children. Such circulatory perturbations have been implicated in the development of hypertension, and our findings complement previous studies to suggest a cumulative impact of snoring on the cardiovascular system from childhood into adulthood.
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Affiliation(s)
- Lauren C Nisbet
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Victoria, Australia
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Nisbet LC, Yiallourou SR, Walter LM, Horne RSC. Blood pressure regulation, autonomic control and sleep disordered breathing in children. Sleep Med Rev 2013; 18:179-89. [PMID: 23850404 DOI: 10.1016/j.smrv.2013.04.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 04/10/2013] [Accepted: 04/29/2013] [Indexed: 02/07/2023]
Abstract
Sleep disordered breathing (SDB) ranges in severity from primary snoring (PS) to obstructive sleep apnoea (OSA). In adults, SDB is associated with adverse cardiovascular consequences which are mediated, in part, by autonomic dysfunction. Although SDB is common in children, fewer paediatric studies have investigated these cardiovascular effects. Initial research focused on those with OSA, indeed children with PS were occasionally utilised as the comparison control group. However, it is essential to understand the ramifications of this disorder in all its severities, as currently the milder forms of SDB are often untreated. Methodologies used to assess autonomic function in children with SDB include blood pressure (BP), BP variability, baroreflex sensitivity, heart rate variability, peripheral arterial tonometry and catecholamine assays. The aim of this review was to summarise the findings of paediatric studies to date and explore the relationship between autonomic dysfunction and SDB in children, paying particular attention to the roles of disease severity and/or age. This review found evidence of autonomic dysfunction in children with SDB during both wakefulness and sleep. BP dysregulation, elevated generalised sympathetic activity and impairment of autonomic reflexes occur in school-aged children and adolescents with SDB. The adverse effects of SDB seem somewhat less in young children, although more studies are needed. There is mounting evidence that the cardiovascular and autonomic consequences of SDB are not limited to those with OSA, but are also evident in children with PS. The severity of disease and age of onset of autonomic consequences may be important guides for the treatment of SDB.
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Affiliation(s)
- Lauren C Nisbet
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Australia
| | - Stephanie R Yiallourou
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Australia
| | - Lisa M Walter
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Australia
| | - Rosemary S C Horne
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Australia.
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27
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Vlahandonis A, Walter LM, Horne RS. Does treatment of SDB in children improve cardiovascular outcome? Sleep Med Rev 2013; 17:75-85. [DOI: 10.1016/j.smrv.2012.04.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 04/20/2012] [Accepted: 04/20/2012] [Indexed: 02/01/2023]
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28
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Varlami V, Malakasioti G, Alexopoulos EI, Theologi V, Theophanous E, Liakos N, Daskalopoulou E, Gourgoulianis K, Kaditis AG. Low-grade albuminuria in children with obstructive sleep apnea. J Sleep Res 2012; 22:289-94. [DOI: 10.1111/jsr.12021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 10/08/2012] [Indexed: 12/01/2022]
Affiliation(s)
- Vasiliki Varlami
- Sleep Disorders Laboratory; University of Thessaly School of Medicine and Larissa University Hospital; Larissa Greece
| | - Georgia Malakasioti
- Sleep Disorders Laboratory; University of Thessaly School of Medicine and Larissa University Hospital; Larissa Greece
| | - Emmanouel I. Alexopoulos
- Sleep Disorders Laboratory; University of Thessaly School of Medicine and Larissa University Hospital; Larissa Greece
| | - Vasiliki Theologi
- Sleep Disorders Laboratory; University of Thessaly School of Medicine and Larissa University Hospital; Larissa Greece
| | - Eleni Theophanous
- Sleep Disorders Laboratory; University of Thessaly School of Medicine and Larissa University Hospital; Larissa Greece
| | - Nikolaos Liakos
- Department of Biochemistry; Larissa University Hospital; Larissa Greece
| | - Euphemia Daskalopoulou
- Department of Internal Medicine; Sleep Laboratory; St Paul General Hospital; Thessaloniki Greece
| | - Konstantinos Gourgoulianis
- Sleep Disorders Laboratory; University of Thessaly School of Medicine and Larissa University Hospital; Larissa Greece
| | - Athanasios G. Kaditis
- Pediatric Pulmonology Unit and Sleep Disorders Laboratory; University of Athens School of Medicine and Aghia Sophia Children's Hospital; Athens Greece
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Gozal D, Hakim F, Kheirandish-Gozal L. Chemoreceptors, baroreceptors, and autonomic deregulation in children with obstructive sleep apnea. Respir Physiol Neurobiol 2012; 185:177-85. [PMID: 22954503 DOI: 10.1016/j.resp.2012.08.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 08/21/2012] [Accepted: 08/23/2012] [Indexed: 11/17/2022]
Abstract
Obstructive sleep apnea (OSA) is highly prevalent sleep disorder of breathing in both adults and children that is fraught with substantial cardiovascular morbidities, the latter being attributable to a complex interplay between intermittent hypoxia (IH), episodic hypercapnia, recurrent large intra-thoracic pressure swings, and sleep disruption. Alterations in autonomic nervous system function could underlie the perturbations in cardiovascular, neurocognitive, immune, endocrine and metabolic functions that affect many of the patients suffering from OSA. Although these issues have received substantial attention in adults, the same has thus far failed to occur in children, creating a quasi misperception that children are protected. Here, we provide a critical overview of the evidence supporting the presence of autonomic nervous system (ANS) perturbations in children with OSA, draw some parallel assessments to known mechanisms in rodents and adult humans, particularly, peripheral and central chemoreceptor and baroreceptor pathways, and suggest future research directions.
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Affiliation(s)
- David Gozal
- Department of Pediatrics, Comer Children's Hospital, The University of Chicago, Chicago, IL, USA.
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Kaditis A, Kheirandish-Gozal L, Gozal D. Algorithm for the diagnosis and treatment of pediatric OSA: A proposal of two pediatric sleep centers. Sleep Med 2012; 13:217-27. [DOI: 10.1016/j.sleep.2011.09.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Revised: 09/04/2011] [Accepted: 09/07/2011] [Indexed: 01/28/2023]
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Hakim F, Gozal D, Kheirandish-Gozal L. Sympathetic and catecholaminergic alterations in sleep apnea with particular emphasis on children. Front Neurol 2012; 3:7. [PMID: 22319509 PMCID: PMC3268184 DOI: 10.3389/fneur.2012.00007] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 01/10/2012] [Indexed: 01/04/2023] Open
Abstract
Sleep is involved in the regulation of major organ functions in the human body, and disruption of sleep potentially can elicit organ dysfunction. Obstructive sleep apnea (OSA) is the most prevalent sleep disorder of breathing in adults and children, and its manifestations reflect the interactions between intermittent hypoxia, intermittent hypercapnia, increased intra-thoracic pressure swings, and sleep fragmentation, as elicited by the episodic changes in upper airway resistance during sleep. The sympathetic nervous system is an important modulator of the cardiovascular, immune, endocrine and metabolic systems, and alterations in autonomic activity may lead to metabolic imbalance and organ dysfunction. Here we review how OSA and its constitutive components can lead to perturbation of the autonomic nervous system in general, and to altered regulation of catecholamines, both of which then playing an important role in some of the mechanisms underlying OSA-induced morbidities.
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Affiliation(s)
- Fahed Hakim
- Department of Pediatrics, Comer Children's Hospital, The University of Chicago Chicago, IL, USA
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Abstract
The clinical syndrome of obstructive sleep apnea (OSAS) in children is a distinct, yet somewhat overlapping disorder with the condition that occurs in adults, such that the clinical manifestations, polysomnographic findings, diagnostic criteria and treatment approaches need to be considered in an age-specific manner. Childhood OSAS has now become widely recognized as a frequent disorder and as a major public health problem. Pediatric OSAS, particularly when obesity is concurrently present, is associated with substantial end-organ morbidities and increased healthcare utilization. Although adenotonsillectomy (T&A) remains the first line of treatment, evidence in recent years suggests that the outcomes of this surgical procedure may not be as favorable as expected, such that post-T&A polysomnographic evaluation may be needed, especially in high-risk patient groups. In addition, incorporation of nonsurgical approaches for milder forms of the disorder and for residual OSAS after T&A is now being investigated.
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Affiliation(s)
- Riva Tauman
- Sleep Disorders Center, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv 64239, Israel.
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Effects of adenotonsillectomy on R–R interval and brain natriuretic peptide levels in children with sleep apnea: A preliminary report. Sleep Med 2011; 12:646-51. [DOI: 10.1016/j.sleep.2011.01.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 01/04/2011] [Accepted: 01/09/2011] [Indexed: 11/22/2022]
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Affiliation(s)
- Rakesh Bhattacharjee
- Sections of Pediatric Sleep Medicine and Pediatric Pulmonology, Department of Pediatrics, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - David Gozal
- Sections of Pediatric Sleep Medicine and Pediatric Pulmonology, Department of Pediatrics, Pritzker School of Medicine, University of Chicago, Chicago, IL.
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O’Driscoll DM, Horne RS, Davey MJ, Hope SA, Anderson V, Trinder J, Walker AM, Nixon GM. Increased sympathetic activity in children with obstructive sleep apnea: Cardiovascular implications. Sleep Med 2011; 12:483-8. [DOI: 10.1016/j.sleep.2010.09.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 09/06/2010] [Accepted: 09/13/2010] [Indexed: 10/18/2022]
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Bhattacharjee R, Gozal D. Metabolic disease in sleep disordered breathing: puberty! puberty! Sleep 2010; 33:1133-4. [PMID: 20857857 DOI: 10.1093/sleep/33.9.1133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Rakesh Bhattacharjee
- Division of Sleep and Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Kaditis A. From obstructive sleep apnea in childhood to cardiovascular disease in adulthood: what is the evidence? Sleep 2010; 33:1279-80. [PMID: 21061848 DOI: 10.1093/sleep/33.10.1279] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Athanasios Kaditis
- Pediatric Pulmonology and Sleep Disorders Laboratory, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece.
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Sans Capdevila Ó, Wienberg P, Haag O, Cols M. Comorbilidades de los trastornos respiratorios del sueño en los niños. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2010; 61 Suppl 1:26-32. [DOI: 10.1016/s0001-6519(10)71242-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Gozal D, Kheirandish-Gozal L, Bhattacharjee R, Spruyt K. Neurocognitive and endothelial dysfunction in children with obstructive sleep apnea. Pediatrics 2010; 126:e1161-7. [PMID: 20956420 DOI: 10.1542/peds.2010-0688] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Pediatric obstructive sleep apnea syndrome (OSAS) is associated with neurocognitive and endothelial dysfunction. However, it is unclear whether these 2 frequent morbidities of OSAS in children represent similar or different underlying pathophysiological processes, because they have never been concurrently assessed in children. METHODS Consecutive children (ages 5-8 years) with polysomnographically based OSAS underwent cognitive battery evaluation (Differential Ability Scales and the NeuroPsychological Assessment Battery) and cuff-occlusion hyperemic tests for assessment of endothelial function. The presence of neurocognitive deficits (NC(+)) was defined on the basis of the presence of ≥ 2 abnormal cognitive test results. Endothelial dysfunction (ED(+)) was defined as a time to maximal postocclusive hyperemic response of ≥ 45 seconds (T(max)). RESULTS Twenty-one control children and 87 children with OSAS completed both cognitive and endothelial tests. Of these children, 48 were NC(+) and 50 had a T(max) of ≥ 45 seconds, and at least 80% of these children were in both groups. Conversely, among children in whom there was no presence of neurocognitive deficits (NC(-)), only 25.6% were ED(+), whereas among those without endothelial dysfunction (ED(-)) only 21.6% were NC(+). Furthermore, approximately one-third of the children with OSAS was NC(-) and ED(-). Thus, findings on hyperemic vascular responses were highly predictive of neurocognitive status. CONCLUSIONS Endothelial dysfunction and neurocognitive deficits are more likely to coexist than otherwise predicted from the frequency of each of these morbidities alone in pediatric OSAS. Thus, both of these morbid consequences may share similar pathogenetic mechanisms. Furthermore, a simple test such as the postocclusive hyperemic vascular response may help detect at-risk patients for neuropsychological deficits.
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Affiliation(s)
- David Gozal
- Department of Pediatrics, University of Chicago, 5721 S Maryland Ave, MC 8000, Suite K-160, Chicago, IL 60637, USA.
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40
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Kaditis AG, Alexopoulos EI, Evangelopoulos K, Kostadima E, Varlami V, Boultadakis E, Liakos N, Zakynthinos E, Zintzaras E, Gourgoulianis K. Correlation of urinary excretion of sodium with severity of sleep-disordered breathing in children: a preliminary study. Pediatr Pulmonol 2010; 45:999-1004. [PMID: 20648668 DOI: 10.1002/ppul.21285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nocturnal urinary sodium excretion is related to blood pressure (BP) levels. Elevated BP and increased nocturnal natriuresis have been demonstrated in adults with sleep apnea. Although evidence indicates increased BP in children with obstructive sleep-disordered breathing (SDB), it is unknown whether these children have also enhanced urinary sodium excretion. OBJECTIVE To evaluate the effects of SDB and morning BP on urinary sodium excretion. METHODS Consecutive children with snoring (n = 95) underwent polysomnography and morning BP measurement. Fractional excretion of sodium (FE(Na)) was the primary outcome measure and was calculated using sodium and creatinine concentrations in early morning serum and urine specimens. RESULTS Subjects with moderate-to-severe SDB had similar log-transformed FE(Na) to that of children with mild SDB and higher than children with primary snoring: -0.13 ± 0.53 versus -0.28 ± 0.41 versus -0.61 ± 0.65 (P = 0.657 and P = 0.003). Obstructive apnea-hypopnea index was significantly related to FE(Na) after adjustment for age, gender and body mass index z-score (P = 0.002). Children with moderate-to-severe SDB had similar systolic BP z-scores to those of subjects with mild SDB and higher than participants with primary snoring: 0.7 ± 1.2 versus 0.1 ± 1.0 versus -0.02 ± 1.0 (P = 0.074 and P = 0.046). In addition, participants with diastolic BP z-scores in the upper quartile of measured values had higher FE(Na) than subjects with z-scores in the lower quartiles: -0.08 ± 0.39 versus -0.41 ± 0.57 (P = 0.007). CONCLUSIONS Morning natriuresis is related to severity of SDB in children and this association may be mediated in part by elevated BP.
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Affiliation(s)
- Athanasios G Kaditis
- Sleep Disorders Laboratory, University of Thessaly School of Medicine, Larissa, Greece.
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Montesano M, Miano S, Paolino MC, Massolo AC, Ianniello F, Forlani M, Villa MP. Autonomic cardiovascular tests in children with obstructive sleep apnea syndrome. Sleep 2010; 33:1349-55. [PMID: 21061857 PMCID: PMC2941421 DOI: 10.1093/sleep/33.10.1349] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVES The aim of our study was to investigate cardiovascular autonomic activity during wakefulness, using cardiovascular tests, in a population of children with OSAS. DESIGN Prospective study. SETTING Sleep unit of an academic center. PARTICIPANTS We included 25 children (mean age 10.2 +/- 2.3 years) undergoing a diagnostic assessment for OSAS, and 25 age-matched healthy control subjects. All subjects underwent an overnight polysomnography and autonomic cardiovascular tests using parts of the Ewing test battery, which is a physiological test used for the assessment of autonomic function (head-up tilt test, Valsalva maneuver, deep breathing test). MEASUREMENTS AND RESULTS Eighteen of 25 children with OSAS (11 males, mean age 9.4 +/- 1.7 years) concluded the study. OSAS patients had higher systolic blood pressure, diastolic blood pressure, baseline heart rate, the 30:15 index (which represents the RR interval at the 15th and 30th beats during the head up tilt test), and delta diastolic and systolic blood pressure during the head-up tilt test, while the heart rate variability during the deep breathing test was lower, compared with controls. A positive correlation between systolic and diastolic blood pressure and the apnea-hypopnea index (AHI), and negative between AHI and both the 30:15 index and Valsalva ratio, were found. Stepwise linear regression analysis detected a negative correlation between AHI and the 30:15 index and Valsalva ratio, a positive correlation between overnight mean oxygen saturation and delta heart rate, and between AHI and delta systolic blood pressure. CONCLUSIONS Our data point to an increase in basal sympathetic activity during wakefulness and to an impaired reaction to several physiological stimuli, which is dependent on the severity of OSAS.
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Affiliation(s)
- Marilisa Montesano
- Pediatric Department, “La Sapienza” University, II Faculty, Medicine, Rome, Italy
| | - Silvia Miano
- Pediatric Department, “La Sapienza” University, II Faculty, Medicine, Rome, Italy
| | - Maria Chiara Paolino
- Pediatric Department, “La Sapienza” University, II Faculty, Medicine, Rome, Italy
| | - Anna Claudia Massolo
- Pediatric Department, “La Sapienza” University, II Faculty, Medicine, Rome, Italy
| | - Filomena Ianniello
- Pediatric Department, “La Sapienza” University, II Faculty, Medicine, Rome, Italy
| | - Martina Forlani
- Pediatric Department, “La Sapienza” University, II Faculty, Medicine, Rome, Italy
| | - Maria Pia Villa
- Pediatric Department, “La Sapienza” University, II Faculty, Medicine, Rome, Italy
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Alexopoulos EI, Gletsou E, Kostadima E, Kaditis D, Zakynthinos E, Gourgoulianis K, Kaditis A. Effects of obstructive sleep apnea severity on serum lipid levels in Greek children with snoring. Sleep Breath 2010; 15:625-31. [PMID: 21063795 DOI: 10.1007/s11325-010-0410-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 08/24/2010] [Indexed: 01/19/2023]
Abstract
BACKGROUND Although obstructive sleep apnea (OSA) is related to dyslipidemia in adults, limited data are available regarding its effects on serum lipids during childhood. Aim of this study was to assess the potential relationships between severity of OSA and cholesterol or triglyceride levels in a cohort of Greek children. METHODS Data from children with snoring who underwent polysomnography and complete serum lipids measurements during a specified study period were analyzed retrospectively. RESULTS Overall, obese children (n = 261) had lower HDL cholesterol levels than non-obese subjects (n = 113) (49.6 ± 10.5 vs. 53.9 ± 11.4 mg/dL; p = 0.001) and higher triglyceride concentrations (69.8 ± 32.2 vs. 63.2 ± 27 mg/dL; p = 0.041). Non-obese subjects with moderate-to-severe OSA did not differ in triglycerides, total, and LDL cholesterol concentrations but had lower HDL cholesterol, when compared to non-obese children with primary snoring/mild OSA (50.4 ± 13.1 vs. 54.9 ± 10.7 mg/dL; p = 0.008). The risk for having low HDL cholesterol (≤40 mg/dL) was threefold higher in non-obese subjects with moderate-to-severe OSA than in those with primary snoring/mild OSA, even after adjustment for age and gender [OR = 3.44 (95% CI 1.44 to 8.24; p = 0.006)]. Concentrations of serum lipids in obese children were not associated with severity of OSA. HDL cholesterol was 48.5 ± 8.7 mg/dL in subjects with moderate-to-severe OSA and 50.0 ± 11.1 mg/dL in children with primary snoring/mild OSA (p = 0.519). CONCLUSIONS HDL cholesterol levels are inversely related to severity of OSA in non-obese children with snoring.
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Kelly A, Dougherty S, Cucchiara A, Marcus CL, Brooks LJ. Catecholamines, adiponectin, and insulin resistance as measured by HOMA in children with obstructive sleep apnea. Sleep 2010; 33:1185-91. [PMID: 20857865 PMCID: PMC2938859 DOI: 10.1093/sleep/33.9.1185] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) has been implicated in the pathophysiology of metabolic syndrome. Its contribution to insulin resistance is complicated by obesity and puberty. We hypothesized that OSA is associated with worse insulin resistance and lower adiponectin after adjustment for obesity and puberty and that catecholamines might mediate these changes. METHODS Normal controls and children with suspected OSA were recruited and categorized as pubertal or prepubertal. Overnight polysomnography (PSG) was performed. Subjects were categorized as OSA for total apnea hypopnea index (Total-AHI) > or = 1.5 events/h. Fasting blood glucose, insulin, adiponectin, and 24-hour urinary catecholamines were obtained. Homeostatic model assessment of insulin resistance (HOMA) was calculated. The independent effects of OSA upon HOMA, adiponectin, and urinary catecholamines following adjustment for body mass index (BMI) were determined. RESULTS (median; min, max): Subjects (n = 98, 42F; 11 +/- 4 years, 37 prepubertal) were generally overweight (BMI-Z = 2.1; -3, 4.1) and had wide-ranging insulin sensitivities (HOMA = 2.7; 0.5, 27) and PSG parameters (Total-AHI = 1.6; 0, 185). The risks of elevated insulin (P = 0.04) and HOMA (P = 0.05) were higher in OSA vs non OSA obese pubertal children. Polysomnographic markers of OSA, including Total-AHI (P = 0.001, R2 = 0.32), were negatively associated with adiponectin in pubertal children. Total-AHI and oxygen desaturation were associated with higher urinary normetanephrine and norepinephrine. CONCLUSIONS In obese pubertal children, OSA was associated with worse insulin resistance. Worsening OSA was associated with lower adiponectin and increasing urinary catecholamines. Whether OSA directly lowers adiponectin and aggravates a predisposition to insulin resistance is unknown, but these preliminary findings highlight the importance of further studying pediatric OSA.
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Affiliation(s)
- Andrea Kelly
- Division Endocrinology/Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.
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44
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Gozal D, Kheirandish-Gozal L. New approaches to the diagnosis of sleep-disordered breathing in children. Sleep Med 2010; 11:708-13. [DOI: 10.1016/j.sleep.2009.12.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 12/21/2009] [Accepted: 12/22/2009] [Indexed: 11/26/2022]
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45
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Autonomic alterations and endothelial dysfunction in pediatric obstructive sleep apnea. Sleep Med 2010; 11:714-20. [DOI: 10.1016/j.sleep.2009.12.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 12/06/2009] [Accepted: 12/12/2009] [Indexed: 11/21/2022]
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47
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Kaditis AG, Alexopoulos EI, Dalapascha M, Papageorgiou K, Kostadima E, Kaditis DG, Gourgoulianis K, Zakynthinos E. Cardiac systolic function in Greek children with obstructive sleep-disordered breathing. Sleep Med 2010; 11:406-12. [DOI: 10.1016/j.sleep.2009.05.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Revised: 04/18/2009] [Accepted: 05/11/2009] [Indexed: 10/19/2022]
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Kaditis A, Gozal D, Snow AB, Kheirandish-Gozal L, Alexopoulos E, Varlami V, Papathanasiou AA, Capdevila OS, Bhattacharjee R, Kim J, Gourgoulianis K, Zintzaras E. Uric acid excretion in North American and Southeast European children with obstructive sleep apnea. Sleep Med 2010; 11:489-93. [PMID: 20181522 DOI: 10.1016/j.sleep.2009.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Revised: 06/18/2009] [Accepted: 06/25/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Responses to nocturnal hypoxemia accompanying sleep-disordered breathing (SDB) may vary in different populations. Aims of this study were to (1) assess whether severity of SDB is related to uric acid excretion in North American and Southeast European children and (2) evaluate the interaction between nocturnal hypoxemia and country of children's origin in uric acid excretion. METHODS Consecutive US and Greek children with snoring who were referred for polysomnography were recruited. Uric acid excretion expressed as uric acid-to-creatinine concentrations ratio in a morning urine specimen was the primary outcome measure. RESULTS One hundred and twenty-six US children (6.8+/-0.7years old) and 123 Greek children (6.4+/-2.5years old) were recruited. Forty-three US and 53 Greek participants had moderate-to-severe nocturnal hypoxemia (SpO(2) nadir <90%). Obstructive apnea-hypopnea index and SpO(2) nadir were related to uric acid excretion in Greek (but not US) children after adjustment by age, gender and body mass index z-score (p<0.05). There was a significant interaction between severity of hypoxemia and country of children's origin in uric acid excretion after adjustment by age, gender and body mass index z-score (p=0.036). Greek children with moderate-to-severe hypoxemia had higher uric acid excretion (0.85+/-0.35) than those with mild/no hypoxemia (0.69+/-0.25) (p=0.005). US children with moderate-to-severe hypoxemia (0.41+/-0.20) did not differ in uric acid excretion from those with mild/no hypoxemia (0.42+/-0.22) (p=0.823). CONCLUSIONS Uric acid excretion differs in children with SDB and different ethnic backgrounds or environmental exposures.
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Affiliation(s)
- Athanasios Kaditis
- Sleep Disorders Laboratory, University of Thessaly School of Medicine, Larissa, Greece.
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49
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O'Driscoll DM, Foster AM, Ng ML, Yang JSC, Bashir F, Nixon GM, Davey MJ, Anderson V, Walker AM, Trinder J, Horne RSC. Acute cardiovascular changes with obstructive events in children with sleep disordered breathing. Sleep 2009; 32:1265-71. [PMID: 19848356 PMCID: PMC2753805 DOI: 10.1093/sleep/32.10.1265] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVES Obstructive apneas in adults are associated with acute changes in blood pressure (BP) and heart rate (HR) that may contribute to poor cardiovascular outcome. Children with sleep disordered breathing (SDB) are similarly at risk for cardiovascular complications. We aimed to test the hypothesis that BP and HR are augmented during obstructive events in children equivalent to levels reported in adults. DESIGN Beat-by-beat mean arterial pressure (MAP) and HR were analyzed over the course of obstructive events (pre, early, late, and post-event) during NREM and REM sleep and compared using 2-way ANOVA with post hoc analyses. SETTING Pediatric sleep laboratory. PATIENTS OR PARTICIPANTS 30 children (15M/15F) aged 7-12 y referred for investigation of SDB INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS All children underwent overnight polysomnography with continuous BP recording. MAP and HR increased significantly from late to post event in both sleep states (mean +/- SEM, NREM: MAP, 74 +/- 3 to 93 +/- 3 mm Hg; HR, 76 +/- 2 to 97 +/- 2 bpm. REM: MAP, 76 +/- 3 to 89 +/- 3 mm Hg; HR, 76 +/- 2 to 91 +/- 2 bpm. P < 0.05 for all). NREM sleep state and arousal from sleep were significant independent predictors of the magnitude of cardiovascular change from late to post event (P < 0.05 for all). CONCLUSIONS Children with SDB experience significant changes in HR and BP during obstructive events with magnitudes that are similar to levels reported in adults. These changes are more pronounced during NREM sleep and with arousal. These acute cardiovascular changes may have important implications for poor cardiovascular outcome in children with OSA as repetitive cardiovascular perturbations may contribute to the development of hypertension.
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Affiliation(s)
- Denise M O'Driscoll
- Ritchie Centre for Baby Health Research, Monash Institute of Medical Research, Monash University, Victoria, Australia.
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50
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Snow AB, Khalyfa A, Serpero LD, Capdevila OS, Kim J, Buazza MO, Gozal D. Catecholamine alterations in pediatric obstructive sleep apnea: effect of obesity. Pediatr Pulmonol 2009; 44:559-67. [PMID: 19431192 DOI: 10.1002/ppul.21015] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) elicits increased sympathetic activity in adults and increased urinary catecholamines. Moreover, urinary catecholamine excretion is altered in obese patients. We hypothesized that morning urine catecholamine levels would be correlated with the severity of obstructive sleep apnea and degree of obesity in children. METHODS Children referred to the pediatric sleep center for habitual snoring underwent overnight polysomnography, and the first morning voided urine sample was collected. Urinary concentrations of norepinephrine, epinephrine and dopamine were measured and corrected for creatinine levels. In a subset of children, blood samples were drawn and gene expression of catecholamine-relevant genes analyzed by quantitative real-time PCR. RESULTS One hundred fifty-nine children were recruited and completed the protocol. Children with OSA had significantly higher urinary norepinephrine and epinephrine levels, but not dopamine, compared to habitual snorers (norepinephrine: 40.1 +/- 24.7 ng/mg creatinine vs. 31.6 +/- 16.2 ng/mg creatinine, P < 0.01; epinephrine: 6.4 +/- 10.5 ng/mg vs. 4.5 +/- 0.5 ng/mg, P < 0.01). There was a positive correlation between norepinephrine and epinephrine values and polysomnographic indices, but no effect of obesity on catecholamine levels. In addition, expression of several of the major genes involved in synthesis and transport of catecholamines, as well as in selected receptors were compatible with increased bioavailability of catecholamines. CONCLUSIONS In children with OSA, morning urinary norepinephrine and epinephrine levels are significantly higher than those without OSA, and correlate with the severity of the disease. Gene expression patterns are in agreement with such findings. Urine catecholamine levels do not appear to be influenced by the presence of obesity. Thus, altered sympathetic activity in OSA patients appears to occur independently of the presence of obesity.
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Affiliation(s)
- Ayelet B Snow
- Division of Pediatric Sleep Medicine and Kosair Children's Hospital Research Institute, Department of Pediatrics, University of Louisville, Louisville, KY 40202, USA
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