The association between high risk of sleep apnea, comorbidities, and risk of COVID-19: a population-based international harmonized study

Effects of Obstructive Sleep Apnea on Airway Immunity and Susceptibility to Respiratory Infections

Obstructive sleep apnea is a prevalent sleep disorder characterized by recurrent episodes of partial or complete upper airway collapse during sleep, leading to disrupted breathing patterns and intermittent hypoxia. OSA results in systemic inflammation but also directly affects the upper and lower airways leading to upregulation of inflammatory pathways and alterations of the local microbiome. These changes result in increased susceptibility to respiratory infections such as influenza, COVID-19, and bacterial pneumonia. This relationship is more complex and bidirectional in individuals with chronic lung disease such as chronic obstructive lung disease, interstitial lung disease and bronchiectasis.

Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 Infection

BACKGROUND

Obstructive sleep apnea is associated with COVID-19 infection. Less clear is whether obstructive sleep apnea is a risk factor for the development of post-acute sequelae of SARS-CoV-2 infection (PASC).

STUDY DESIGN

Cross-sectional survey of a general population of 24,803 US adults to determine the association of obstructive sleep apnea with PASC.

RESULTS

COVID-19 infection occurred in 10,324 (41.6%) participants. Prevalence of persistent (>3 months post infection) putative PASC-related physical and mental health symptoms ranged from 6.5% (peripheral edema) to 19.6% (nervous/anxious). In logistic regression models, obstructive sleep apnea was associated with all putative PASC-related symptoms with the highest adjusted odds ratios being fever (2.053) and nervous/anxious (1.939). In 4 logistic regression models of overall PASC derived from elastic net regression, obstructive sleep apnea was associated with PASC (range of adjusted odds ratios: 1.934-2.071); this association was mitigated in those with treated obstructive sleep apnea. In the best fitting overall model requiring ≥3 symptoms, PASC prevalence was 21.9%.

CONCLUSION

In a general population sample, obstructive sleep apnea is associated with the development of PASC-related symptoms and a global definition of PASC. Treated obstructive sleep apnea mitigates the latter risk. The presence of 3 or more PASC symptoms may be useful in identifying cases and for future research.

Association between risk of obstructive sleep apnea severity and risk of severe COVID-19 symptoms: insights from salivary and serum cytokines

Objectives

Obstructive sleep apnea (OSA) can adversely affect the immune response through clinical factors such as hypoxia, inflammation, and sleep disturbance. Since SARS-CoV-2 heavily relies on local and systemic host immune responses, this study aims to examine the links between the severity of OSA risk, cytokine levels, and the severity of symptoms associated with SARS-CoV-2 infection.

Methods

Saliva and blood samples from 50 COVID-19 patients and 30 non-infected hospital staff members were collected. Using Luminex multiplex analysis, 65 blood and salivary cytokines were examined from the collected samples. Ordinal logistic regression analysis was utilized to examine the association between the self-reported risk of OSA, assessed through the STOP-Bang questionnaire, and the likelihood of experiencing severe symptoms of COVID-19. Mann-Whitney test was then performed to compare the cytokine levels between individuals with moderate to severe risk of OSA to those with a mild risk of OSA.

Results

Ordinal logistic regression analysis revealed that individuals with a moderate to severe risk of OSA were 7.60 times more likely to experience more severe symptoms of COVID-19 compared to those with a mild risk of OSA (OR = 7.60, 95%CI: 3.03, 19.06, p < 0.001). Moreover, among COVID-19-positive patients with a moderate to severe risk of OSA, there was a statistically significant negative correlation with serum IL-6 (p < 0.05), Eotaxin (CCL11) (p = 0.04), and salivary MIP-3α/CCL20 (p = 0.04). In contrast, individuals without COVID-19 who had a moderate to severe risk of OSA exhibited a significant positive correlation with serum IL-6 (p = 0.04).

Conclusion

Individuals with moderate to severe risk of OSA were more likely to experience severe COVID-19 symptoms than those with mild risk for OSA. Additional analysis from the present studies revealed distinct patterns of oral and systemic immune responses between individuals with mild and moderate to severe risk of OSA. Findings from the present study underscores the importance of early detection and management of OSA to improve clinical outcomes, particularly when faced with the subsequent superimposed infection such as COVID-19.

Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 infection (PASC)

Background

Obstructive sleep apnea (OSA) is associated with COVID-19 infection. Fewer investigations have assessed OSA as a possible risk for the development of Post-Acute Sequelae of SARS-CoV-2 infection (PASC).

Research Question

In a general population, is OSA associated with increased odds of PASC-related symptoms and with an overall definition of PASC?

Study Design

Cross-sectional survey of a general population of 24,803 U.S. adults.

Results

COVID-19 infection occurred in 10,324 (41.6%) participants. Prevalence rates for a wide variety of persistent (> 3 months post infection) putative PASC-related physical and mental health symptoms ranged from 6.5% (peripheral edema) to 19.6% (nervous/anxious). In logistic regression models adjusted for demographic, anthropometric, comorbid medical and socioeconomic factors, OSA was associated with all putative PASC-related symptoms with the highest adjusted odds ratios (aOR) being fever (2.053) and nervous/anxious (1.939) respectively. Elastic net regression identified the 13 of 37 symptoms most strongly associated with COVID-19 infection. Four definitions of PASC were developed using these symptoms either weighted equally or proportionally by their regression coefficients. In all 4 logistic regression models using these definitions, OSA was associated with PASC (range of aORs: 1.934-2.071); this association was mitigated in those with treated OSA. In the best fitting overall model requiring ≥3 symptoms, PASC prevalence was 21.9%.

Conclusion

In a general population sample, OSA is associated with the development of PASC-related symptoms and a global definition of PASC. A PASC definition requiring the presence of 3 or more symptoms may be useful in identifying cases and for future research.

COVID-19 breakthrough infections and sleep disorders: A population-based propensity matched analysis

Objectives

Examine risks for breakthrough COVID-19 infections in vaccinated patients with selected sleep disorders.

Methods

Real-time search and analysis using the TriNetX platform to evaluate risk of COVID-19 breakthrough infections (BTI) for patients having ICD-10 diagnoses relating to insomnia, circadian rhythm disorders, and inadequate sleep. The sleep disorder and control cohorts underwent propensity matching including factors for age, gender, race, ethnicity, and multiple co-morbid conditions.

Results

Of 24,720 patients identified as having a sleep disturbance relating to insomnia, circadian rhythm disorder, or inadequate sleep, 815 (3.2 %) were found to have a developed a BTI. There was a significant increased risk of BTI noted between the sleep disorder and control cohorts (adjusted odds ratio (aOR) of 1.40, 95 % confidence interval (CI) of 1.23-1.58). Subgroup analysis showed an elevated risk for BTI receiving two doses (aOR 1.53, 95 % CI 1.24-1.89) versus three doses (aOR 1.45, 95 % CI 1.24-1.69). Patients with the sleep disturbance were not found to be at an increased risk of hospitalization, intubation, death, or composite outcome of death and intubation.

Conclusion

The presence of having a diagnosis of insomnia, circadian rhythm disorder, or inadequate sleep was associated with increased risk of COVID-19 breakthrough infection.

Obstructive sleep apnea: a major risk factor for COVID-19 encephalopathy?

BACKGROUND

This study evaluates the impact of high risk of obstructive sleep apnea (OSA) on coronavirus disease 2019 (COVID-19) acute encephalopathy (AE).

METHODS

Between 3/1/2020 and 11/1/2021, 97 consecutive patients were evaluated at the Geneva University Hospitals with a neurological diagnosis of COVID-19 AE. They were divided in two groups depending on the presence or absence of high risk for OSA based on the modified NOSAS score (mNOSAS, respectively ≥ 8 and < 8). We compared patients' characteristics (clinical, biological, brain MRI, EEG, pulmonary CT). The severity of COVID-19 AE relied on the RASS and CAM scores.

RESULTS

Most COVID-19 AE patients presented with a high mNOSAS, suggesting high risk of OSA (> 80%). Patients with a high mNOSAS had a more severe form of COVID-19 AE (84.8% versus 27.8%), longer mean duration of COVID-19 AE (27.9 versus 16.9 days), higher mRS at discharge (≥ 3 in 58.2% versus 16.7%), and increased prevalence of brain vessels enhancement (98.1% versus 20.0%). High risk of OSA was associated with a 14 fold increased risk of developing a severe COVID-19 AE (OR = 14.52).

DISCUSSION

These observations suggest an association between high risk of OSA and COVID-19 AE severity. High risk of OSA could be a predisposing factor leading to severe COVID-19 AE and consecutive long-term sequalae.

Association of clinically significant obstructive sleep apnoea with risks of contracting COVID-19 and serious COVID-19 complications: a retrospective population-based study of health administrative data

RATIONALE/OBJECTIVES

Despite plausible pathophysiological mechanisms, more research is needed to confirm the relationship between obstructive sleep apnoea (OSA) and the risk of COVID-19 infection or COVID-19-related serious complications.

METHODS

We conducted a retrospective population-based cohort study using provincial health administrative data (Ontario, Canada). Adults with physician-diagnosed OSA who received positive airway pressure therapy in the 5 years prepandemic (OSA group) were propensity score matched by baseline characteristics to individuals in the general population at low risk of OSA (non-OSA group) using inverse probability of treatment weighting. Weighted HRs of (1) a positive COVID-19 test and (2) COVID-19-related emergency department (ED) visits, hospitalisations, intensive care unit (ICU) admissions and mortality, within 12 months of pandemic onset, were compared between groups. We also evaluated the impact of comorbid cardiometabolic or chronic airways disease.

RESULTS

We identified and matched 324 029 individuals in the OSA group to 4 588 200 individuals in the non-OSA group. Compared with the non-OSA group, those in the OSA group were at a greater hazard of testing positive for COVID-19 (HR=1.17, 95% CI 1.13 to 1.21), having a COVID-19-related ED visit (HR=1.62, 95% CI 1.51 to 1.73), hospitalisation (HR=1.50, 95% CI 1.37 to 1.65) or ICU admission (HR=1.53, 95% CI 1.27 to 1.84). COVID-19-related 30-day mortality was not different (HR=0.98, 95% CI 0.82 to 1.16).We found that for the OSA group, comorbid airways disease but not cardiometabolic conditions increased the hazards of COVID-19-related outcomes, including mortality.

CONCLUSION

In this large population-based study, we demonstrated that a recent diagnosis of OSA requiring treatment was associated with an increased hazard of testing positive for COVID-19 and serious COVID-19-related complications, particularly in those with co-existing chronic airways disease.

Impact of the early months of the COVID-19 pandemic on the sleep patterns of a Brazilian population sample

Humanitarian and health crisis have drastic effects on the physical and mental well-being of people. The COVID-19 pandemic forced many countries to impose containment measures on its population to halt the spread of the new coronavirus (SARS-CoV-2). This aim of this study was to explore self-reported sleep quality and insomnia symptoms in a sample of the Brazilian population before and during the COVID-19 quarantine period. Our data was collected through online questionnaires, including the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, and the Sleep Hygiene Index. The final sample comprised 1,109 volunteers. Generalized estimating equations (GEE) revealed that during the initial months of the COVID-19 pandemic, alterations in self-reported sleep parameters were observed in the participants. Sleep efficiency and sleep duration increased, but there was a worsening in sleep quality and an increase in symptoms related to insomnia.

Association of the risk of obstructive sleep apnoea with the severity of COVID-19

Patients with coronavirus 2019 (COVID-19) and obstructive sleep apnoea (OSA) have a worse prognosis than COVID-19 patients without OSA. This study aimed to examine the relationship between OSA risk and the severity of COVID-19 in patients undiagnosed with OSA. Patients diagnosed with COVID-19 and hospitalized or admitted to a community hotel were recruited for the study after recovery during a clinic check-up visit 6-8 weeks after discharge. At this visit, they answered the Epworth Sleeping Scale (ESS) and Berlin questionnaire. Demographic and clinical details were collected from electronic medical records. OSA risk was observed in 37 of 119 included patients (31.1%). Patients with high OSA risk were male, significantly older, had a higher body mass index (BMI), and had higher rates of hypertension and snoring than patients with low OSA risk. Moreover, OSA risk was associated with COVID-19 severity; 48.6% of patients with high risk for OSA suffered from severe COVID-19 compared to 22% of patients with low risk for OSA (p = 0.007). The duration of hospitalization for patients with a high OSA risk was 10.97±9.43 days, while that for those with a low OSA risk was 4.71±6.86 days (p = 0.001). After adjusting for BMI, age, hypertension, and chronic disease, the odds ratio was 4.3 (95%CI, 1.2-16, p = 0.029). A high OSA risk was associated with severe COVID-19 and longer hospitalization. Thus, we recommend that the Berlin and ESS questionnaires be completed for every COVID-19-infected patient at hospitalization, especially in the presence of comorbidities.

Association of Chronotype and Shiftwork with COVID-19 Infection

Objective

This study assesses whether chronotype is related to COVID-19 infection and whether there is an interaction with shift work.

Methods

Cross-sectional survey of 19,821 U.S. adults.

Results

COVID-19 infection occurred in 40% of participants, 32.6% morning and 17.2% evening chronotypes. After adjusting for demographic and socioeconomic factors, shift work, sleep duration and comorbidities, morning chronotype was associated with a higher (aOR: 1.15, 95% CI 1.10-1.21) and evening chronotype with a lower (aOR: 0.82, 95% CI: 0.78-0.87) prevalence of COVID-19 infection in comparison to an intermediate chronotype. Working exclusively night shifts was not associated with higher prevalence of COVID-19. Morning chronotype and working some evening shifts was associated with the highest prevalence of previous COVID-19 infection (aOR: 1.87, 95% CI: 1.28-2.74).

Conclusion

Morning chronotype and working a mixture of shifts increase risk of COVID-19 infection.

Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among US adults

STUDY OBJECTIVES

Medical comorbidities increase the risk of severe COVID-19 infection. In some studies, obstructive sleep apnea (OSA) has been identified as a comorbid condition that is associated with an increased prevalence of COVID-19 infection and hospitalization, but few have investigated this association in a general population. This study aimed to answer the following research question: In a general population, is OSA associated with increased odds of COVID-19 infection and hospitalization and are these altered with COVID-19 vaccination?

METHODS

This was a cross-sectional survey of a diverse sample of 15,057 US adults.

RESULTS

COVID-19 infection and hospitalization rates in the cohort were 38.9% and 2.9%, respectively. OSA or OSA symptoms were reported in 19.4%. In logistic regression models adjusted for demographic, socioeconomic, and comorbid medical conditions, OSA was positively associated with COVID-19 infection (adjusted odds ratio: 1.58, 95% CI: 1.39-1.79) and COVID-19 hospitalization (adjusted odds ratio: 1.55, 95% CI: 1.17-2.05). In fully adjusted models, boosted vaccination status was protective against both infection and hospitalization. Boosted vaccination status attenuated the association between OSA and COVID-19 related hospitalization but not infection. Participants with untreated or symptomatic OSA were at greater risk for COVID-19 infection; those with untreated but not symptomatic OSA were more likely to be hospitalized.

CONCLUSIONS

In a general population sample, OSA is associated with a greater likelihood of having had a COVID-19 infection and a COVID-19 hospitalization with the greatest impact observed among persons experiencing OSA symptoms or who were untreated for their OSA. Boosted vaccination status attenuated the association between OSA and COVID-19-related hospitalization.

CITATION

Quan SF, Weaver MD, Czeisler MÉ, et al. Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among U.S. adults. J Clin Sleep Med. 2023;19(7):1303-1311.

Association between hypersomnolence and the COVID-19 pandemic: The International COVID-19 Sleep Study (ICOSS)

BACKGROUND

The COVID-19 pandemic and related restriction measures have affected our daily life, sleep, and circadian rhythms worldwide. Their effects on hypersomnolence and fatigue remain unclear.

METHODS

The International COVID-19 Sleep Study questionnaire which included items on hypersomnolence such as excessive daytime sleepiness (EDS), and excessive quantity of sleep (EQS), as well as sociodemographic factors, sleep patterns, psychological symptoms, and quality of life was distributed in 15 countries across the world from May to September in 2020.

RESULTS

Altogether responses from 18,785 survey participants (65% women, median age 39 years) were available for analysis. Only 2.8% reported having had COVID-19. Compared to before the pandemic, the prevalence of EDS, EQS, and fatigue increased from 17.9% to 25.5%, 1.6%-4.9%, and 19.4%-28.3% amid the pandemic, respectively. In univariate logistic regression models, reports of having a COVID-19 were associated with EQS (OR 5.3; 95%-CI 3.6-8.0), EDS (2.6; 2.0-3.4), and fatigue (2.8; 2.1-3.6). In adjusted multivariate logistic regression, sleep duration shorter than desired (3.9; 3.2-4.7), depressive symptoms (3.1; 2.7-3.5), use of hypnotics (2.3; 1.9-2.8), and having reported COVID-19 (1.9; 1.3-2.6) remained strong predictors of EDS. Similar associations emerged for fatigue. In the multivariate model, depressive symptoms (4.1; 3.6-4.6) and reports of having COVID-19 (2.0; 1.4-2.8) remained associated with EQS.

CONCLUSIONS

A large increase in EDS, EQS, and fatigue occurred due to the COVID-19 pandemic, and especially in self-reported cases of COVID-19. These findings warrant a thorough understanding of their pathophysiology to target prevention and treatment strategies for long COVID condition.

Adherence to CPAP in summer to autumn predicts self-reported common cold symptoms in patients with obstructive sleep apnea in winter: A prospective observational study

OBJECTIVE

We conducted a prospective observational study to determine the relationship between adherence to continuous positive airway pressure (CPAP) and susceptibility to the common cold in moderate-to-severe obstructive sleep apnea (OSA) patients.

METHODS

We prospectively investigated the number of days with common cold symptoms from November 2019 to February 2020. The rate of CPAP use for 4 h/night in the preceding four months (July to October 2019) was used as a measure of CPAP adherence. Multiple generalized linear models were used to evaluate the association to days of common cold symptoms after controlling for demographic variables, habitual short sleep duration, and insomnia severity.

RESULTS

We included 123 outpatients (median age 63 years) with moderate-to-severe OSA treated with CPAP. In the multivariate generalized linear model, better CPAP adherence was independently significantly associated with days with fewer common cold symptoms (β = -0.248, P = 0.031); meanwhile, the severity of insomnia and habitual short sleep duration was not significantly associated with it. Subgroup analyses revealed that the association between CPAP adherence and days with common cold symptoms was also significant in young to middle-aged (<65 years) participants (β = -0.407, P = 0.005). In contrast, the association was negligible in older (≥65 years) participants.

CONCLUSIONS

CPAP adherence may be protective against viral infections in patients with moderate-to-severe OSA. This effect appears to be more pronounced in young to middle-aged patients with OSA.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Influences of sleep and lifestyle factors on the risk for covid-19 infections, from internet survey of 10,000 Japanese business workers

We conducted an internet survey to assess sociodemographic variables, lifestyle factors, sleep problems, and comorbidities for sleep apnea syndrome (SAS) in COVID-19 and influenza (FLU) infections. Data from 10,323 workers (50.0% male) were analyzed. COVID-19 was diagnosed in 144 subjects (COVID-19+), and 8,693 were classified as not suspected to be infected (COVID-19-). SAS had been diagnosed in 35.4% of the COVID-19+ subjects, but only 231 (2.7%) of the 8,693 COVID-19- subjects. COVID-19+ subjects were more susceptible to FLU (35.4%) compared to COVID-19- subjects (3.0%). A multivariate analysis revealed that higher risks of COVID-19+ were linked to the following factors: going out without a face mask (OR 7.05, 95% CI 4.53-11.00), FLU+ (OR 6.33, 95% CI 3.80-10.54), excessive exercise before going to sleep (OR 2.10, 95% CI 1.63-2.70), SAS+ (OR 5.08, 95% CI 2.88-8.94), younger age (OR 1.05, 95% CI 1.03-1.07), falling sleep while sitting or talking with someone (OR 3.70, 95% CI 2.30-5.95), and use of hypnotics (OR 2.28, 95% CI 1.20-4.30). Since sleep impairment played a relatively small role in COVID-19+/SAS- subjects, we assume that SAS itself was a more significant risk factor for COVID-19 infection rather than sleep impairment. A better understanding of the mechanisms that result in increased susceptibility to COVID-19 in SAS is vital for helping prevent COVID-19.

Analysis of the correlations between insomnia and mental health during the COVID-19 pandemic in Germany

Objective

This study evaluates correlations between insomnia and mental health during the COVID-19 pandemic in Germany.

Methods

The internet-based International COVID-19 Sleep Study (ICOSS) questionnaire including sociodemographic questions as well as sleep- and emotion-related scales was distributed in Germany during the COVID-19 pandemic from May 1 to September 30, 2020. Insomnia and mental state were assessed using the Insomnia Severity Index (ISI), Patient Health Questionnaire (PHQ), Generalized Anxiety Disorder (GAD-2), and visual analogue scale. Qualitative analyses of demographic characteristics were performed and correlation analyses of the variables calculated.

Results

A total of 1103 individuals participated and 858 valid questionnaires (70.61% females) were obtained. Mean age and body mass index were 41.97 ± 12.9 years and 26 ± 5.9 kg/m², respectively. Most participants were married (n = 486, 56.6%), living in the city (n = 646, 75.3%), and white (n = 442, 51.5%). The prevalence of insomnia, anxiety, and depression was 19.5% (ISI > 7), 6.6% (GAD-2 > 3), and 4.8% (PHQ-2 > 3), respectively. Compared to the insomnia group, the mean and median ISI, PHQ‑4, PHQ‑2, and GAD‑2 scores of the non-insomnia group were lower, while their mean and median quality of life and quality of health scores were significantly higher (P < 0.05). Pearson correlation analysis showed a positive correlation between the ISI and PHQ‑2 (r = 0.521, P < 0.001), GAD‑2 (r = 0.483, P < 0.001), and PHQ‑4 scores (r = 0.562, P < 0.001); however, the ISI score negatively correlated with the quality of life (r = −0.490, P < 0.001) and quality of health scores (r = −0.437, P < 0.001).

Conclusion

Insomnia, anxiety, and depression were very prevalent during the pandemic. Anxiety and depression were more severe in the insomnia than in the non-insomnia group, and insomnia and mental health are closely related.

Sleep quality and mental health during the COVID-19 pandemic in patients with severe obstructive sleep apnea

Background

The first wave of the COVID-19 pandemic has produced remarkable effects on the sleep quality and mental status of the general population and more dramatic effects on patients with chronic illness. Patients with obstructive sleep apnea (OSA), already suffering from disordered sleep, might be more susceptible to the effect of the pandemic on their sleep quality and mental health. We therefore performed a case–control study to compare sleep quality, depression and anxiety symptoms reported by patients with severe OSA and age-matched healthy subjects during the first wave of the COVID-19. In June–July 2020 we enrolled a total of 222 patients with severe OSA, all treated with continuous positive airway pressure, and 164 healthy controls. Self-reported sleep quality was assessed using the Pittsburg Sleep Quality Index (PSQI). Symptoms of depression were assessed using the Patient Health Questionnaire module 9 (PHQ-9), while the specific “Coronavirus Anxiety Scale” (CAS) evaluated the level of anxiety.

Results

Patients with OSA (61% males, 65 ± 9.6 years old, BMI 30.5 ± 3.6) and healthy controls had similar characteristics except for BMI slightly lower in controls. The perceived quality of sleep, referred to the pre-pandemic period, was significantly worse in patients with OSA than in controls. During the pandemic the rate of reported sleep disturbance increased from 54 to 66% in patients with OSA and from 29 to 40% in controls. A high percentage of patients and controls reported symptoms of depression (61% OSA and 65% controls), whereas lower levels of anxiety, similar in the two groups, were observed. In patients with OSA the PSQI score significantly positively correlated with the PHQ-9 score (r² = 0.81) and the CAS score (r² = 0.65).

Conclusion

The rate of reported sleep disturbance in patients with OSA during the first wave of the COVID-19 pandemic is one of the highest evidenced in literature so far. As for the general population, in these patients there is a strict link between the perceived sleep quality and the psychological distress caused by the pandemic. A further deterioration of sleep quality is a fearsome event in the life of these patients who face life-long sleep problems.

Bidirektionale Aspekte von SARS-CoV-2 und Schlafstörungen

Im vorliegenden Überblick wird der Zusammenhang zwischen der Schlaflänge, der Schlafqualität, dem Immunsystem und einer SARS-CoV-2-Infektion aufgezeigt. Kurzer und/oder schlechter Schlaf kann einen Einfluss auf das Entstehen einer Infektion sowie deren Verlauf haben. Ebenso können eine SARS-CoV-2-Infektion sowie die pandemiebedingten Umstände den Schlaf negativ beeinflussen. Dabei nimmt insbesondere die Schlafqualität ab. Die Pandemie hat somit das Potenzial, Schlafstörungen auszulösen, zu verstärken und/oder aufrechtzuerhalten. Diese Befunde haben insofern Relevanz, als nur ein ausreichender und erholsamer Schlaf das Immunsystem stärkt und protektiv bezüglich einer Infektion und ihres Verlaufs wirken kann. Die Pandemie stellt somit eine weitere Herausforderung für die Schlafmedizin dar und bietet gleichzeitig die Chance, die Bedeutung des Schlafs für die Gesundheit und den Krankheitsverlauf zu vermitteln.

Sleepless in Solitude-Insomnia Symptoms Severity and Psychopathological Symptoms among University Students during the COVID-19 Pandemic in Poland

Since 25 March 2020, all schools, colleges, and universities in Poland have indefinitely closed and, where possible, have activated distance learning because of the COVID-19 pandemic. Considering that the undergraduate years are usually characterized by a high prevalence of emotional disorders and sleep problems, it can be expected that the current situation may have a remarkable impact on the student population. This study aimed to investigate the occurrence of sleep problems among Polish university students as well as the relationship of insomnia symptoms severity with psychopathological symptoms, posttraumatic stress disorder (PTSD) symptoms, and behavioral factors, such as substance use, changes in the amount of sleep, and the level of physical activity during the COVID-19 pandemic. Data were collected from 1111 Polish university students via an online survey conducted between IV and VI 2020. The survey included demographic variables, the level of psychopathological symptoms (General Health Questionnaire, GHQ-28), insomnia (Insomnia Severity Index, ISI), and symptoms of posttraumatic stress (Impact of Events Scale-Revised, IES-R). The results showed that over half of the studied group of students had some form of sleep disturbances during the period of data collection, with moderate-to-severe insomnia symptoms noted in 21.6%. At the same time, the majority of the sample declared they slept more during the pandemic. A significant positive correlation was observed between the severity of insomnia symptoms and PTSD symptoms, as well as GHQ scores, increased substance use, and decreased physical activity. An additional association between the presence of dreams related to the event and insomnia symptoms as well as GHQ scores has been found. The results suggest that sleep problems may be prevalent among university students during the pandemic. Moreover, although the symptoms of insomnia, as well as the severity of sleep disturbance, significantly correlated with all the investigated variables, the direction of those associations remains to be established.

Impact of Metabolic Risk Factors on COVID-19 Clinical Outcomes: An Extensive Review

BACKGROUND

Cardiovascular (CV) risk factors, particularly cardiometabolic, seem to be associated with heightened severity and increased morbimortality in patients infected with the novel Coronavirus disease-2019 (COVID-19).

METHODS

A thorough scoping review was conducted to elucidate and summarize the latest evidence for the effects of adverse cardiac metabolic profiles on the severity, morbidity, and prognosis of COVID-19 infection.

RESULTS

The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is complex, being characterized by viral-induced immune dysregulation and hypercytokinemia, particularly in patients with critical disease, evolving with profound endothelial dysfunction, systemic inflammation, and prothrombotic state. Moreover, cardiovascular comorbidities such as diabetes are the most prevalent amongst individuals requiring hospitalization, raising concerns towards the clinical evolution and prognosis of these patients. The chronic proinflammatory state observed in patients with cardiovascular risk factors may contribute to the immune dysregulation mediated by SARS-CoV-2, favoring more adverse clinical outcomes and increased severity. Cardiometabolism is defined as a combination of interrelated risk factors and metabolic dysfunctions such as dyslipidemia, insulin resistance, impaired glucose tolerance, and central adiposity, which increase the likelihood of vascular events, being imperative to specifically analyze its clinical association with COVID-19 outcomes.

CONCLUSION

DM and obesity appears to be important risk factors for severe COVID-19. The chronic proinflammatory state observed in patients with excess visceral adipose tissue (VAT) possibly augments COVID-19 immune hyperactivity leading to more adverse clinical outcomes in these patients.

Obstructive Sleep Apnea with COVID-19

The novel coronavirus disease-2019 (COVID-19) and the ensuing pandemic have greatly impacted the global healthcare system due to its high infectiousness, associated high mortality, and a complete lack of immunity in the population. Globally, the COVID-19 pandemic has unleashed a health crisis that has not only seriously disrupted people's lives but also affected their normal sleep, along with physical and mental health; this situation is especially exacerbated in people suffering from pre-existing conditions, such as sleep apnea. A recent meta-analysis of 18 studies by Miller et al. (September 2020) showed that obstructive sleep apnea (OSA) is related to higher mortality and morbidity in patients with COVID-19 and is most likely independent of other risk factors. A recent meta-analysis indicated that COVID-19 patients with OSA are more severely affected than those without OSA, thereby providing further evidence that concurrent OSA may elevate the severity of COVID-19 infection, along with the risk of mortality. The COVID-19 pandemic has significantly impacted the diagnosis and therapeutic management of patients with OSA. Thus, it is necessary to identify and develop new diagnostic and therapeutic avenues in the future. In this context, the current study summarizes known associations between COVID-19 and OSA and the regular diagnostic and therapeutic strategies for OSA in the light of COVID-19 pandemic prevention and control.

Has the COVID-19 Pandemic Traumatized Us Collectively? The Impact of the COVID-19 Pandemic on Mental Health and Sleep Factors via Traumatization: A Multinational Survey

PURPOSE

The COVID-19 pandemic affects mental health and sleep, resulting in frequent nightmares. Therefore, identifying factors associated with nightmare frequency is important, as it can indicate mental health issues. The study aimed to investigate increases in nightmare frequency comparing the pre-pandemic and pandemic period, and identify its risk factors. Further, the mediating role of post-traumatic stress disorder symptoms between the pandemic and nightmares is explored.

PATIENTS AND METHODS

For this cross-sectional survey data were obtained via self-rating online survey (ICOSS: details in Partinen et al, 2021), which was open to anyone older than 18 years. The final volunteer sample consisted of 15,292 participants, divided according to their nightmare frequency (high: ≥1-2 nights/week; low: <1-2 nights/week). A total of 9100 participants were excluded if answers on variables of interest were missing or receiving rewards for participation. Chi-square tests identified changes of nightmare frequency. Predictors of high nightmare frequency were assessed using logistic regression and presented as Odds Ratios. Post-hoc mediation models were used to investigate the role of post-traumatic stress symptoms (PTSS).

RESULTS

The mean age was 41.63 (SD=16.55) with 64.05% females. High nightmare frequency increased significantly from 13.24% to 22.35% during the pandemic. Factors associated with it included self-reported PTSS (OR=2.11), other mental disorders and various sleep disorders or problems. Financial burden due to the pandemic, confinement, having had COVID-19, and work situation during the pandemic were associated with nightmare frequency, those relations were partly mediated through PTSS.

CONCLUSION

Our results display the pandemic influence on nightmare frequency, which in turn connects to multiple mental health and sleep factors. These relations were partly mediated through PTSS. The COVID-19 pandemic appears to have caused traumatization of a substantial proportion of society. Health care workers should consider nightmares in their screening routines, as it might indicate PTSS and/or other mental and sleep disorders.

Prevalence and Characteristics of Sleep Apnea in Intensive Care Unit Survivors After SARS-CoV-2 Pneumonia

BACKGROUND

Sleep apnea (SA) was reported as possibly exacerbating symptoms of COVID-19, a disease induced by SARS-CoV-2 virus. The same comorbidities are common with both pathologies. This study aimed to estimate the prevalence, characteristics of SA and variation in AHI three months after severe COVID-19 requiring intensive care unit (ICU) admission.

METHODS

A prospective cohort of patients admitted to ICU for severe COVID-19 underwent an overnight home polygraphy 3 months after onset of symptoms, as part of a comprehensive follow-up program (pulmonary function tests, 6-minute walk tests and chest CT-scan). Patients with an apnea hypopnea index (AHI) ≥5 were considered as having SA. We performed a comparative descriptive analysis of 2 subgroups according to the existence, severity of SA and indication for effective SA treatment: patients with absent or mild SA (AHI <15) vs patients with moderate to severe SA (AHI ≥15).

RESULTS

Among 68 patients included, 62 (91%) had known comorbidities (34 hypertension, 21 obesity, 20 dyslipidemia, 16 type 2 diabetes). It has been observed a preexisting SA for 13 patients (19.1%). At 3 months, 62 patients (91%) had SA with 85.5% of obstructive events. Twenty-four patients had no or a mild SA (AHI <15) and 44 had moderate to severe SA (AHI ≥15). Ischemic heart disease exclusively affected the moderate to severe SA group. Except for thoracic CT-scan which revealed less honeycomb lesions, COVID-19 symptoms were more severe in the group with moderate to severe SA, requiring a longer curarization, more prone position sessions and more frequent tracheotomy.

CONCLUSION

SA involved 91% of patients in our population at 3 months of severe COVID-19 and was mainly obstructive type. Although SA might be a risk factor as well as consequences of ICU care in severe COVID-19 infection, our results underline the importance of sleep explorations after an ICU stay for this disease.

Disturbances in sleep, circadian rhythms and daytime functioning in relation to coronavirus infection and Long-COVID - A multinational ICOSS study

This protocol paper describes the second survey produced by the International Covid Sleep Study (ICOSS) group with the aim to examine the associations between SARS-CoV-2 infection and sleep, sleepiness, and circadian problems as potential predisposing factors for more severe COVID-19 disease profile and for development of Long-COVID in the general population. The survey consists of 47 questions on sleep, daytime sleepiness, circadian rhythm, health, mental wellbeing, life habits, and socioeconomic situation before and during the pandemic, and conditional questions to those reporting having had coronavirus infection, being vaccinated, or suffering from particular sleep symptoms or sleep disorders. Surveys will be administered online between May and November 2021 in Austria, Brazil, Bulgaria, Canada, China, Croatia, Finland, France, Germany, Israel, Italy, Japan, Norway, Portugal, Sweden and USA. Data collected by the survey will give valuable information on the open questions regarding COVID-19 disease risk factors, symptomatology and evolution of Long-COVID, and on other long-term consequences related to the pandemic.

Obstructive sleep apnea is an independent risk factor for severe COVID-19: a population-based study

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been proposed as a risk factor for severe COVID-19. Confounding is an important consideration as OSA is associated with several known risk factors for severe COVID-19. Our aim was to assess the association of OSA with hospitalization due to COVID-19 using a population-based cohort with detailed information on OSA and comorbidities.

METHODS

Included were all community-dwelling Icelandic citizens 18 years of age and older diagnosed with SARS-CoV-2 infection in 2020. Data on demographics, comorbidities, and outcomes of COVID-19 was obtained from centralized national registries. Diagnosis of OSA was retrieved from the centralized Sleep Department Registry at Landspitali-The National University Hospital. Severe COVID-19 was defined as the composite outcome of hospitalization and death. The associations between OSA and the outcome were expressed as odds ratios (OR) with 95% confidence intervals (95% CI), calculated using logistic regression models and inverse probability weighting.

RESULTS

A total of 4,756 individuals diagnosed with SARS-CoV-2 infection in Iceland were included in the study (1.3% of the Icelandic population), of whom 185 had a diagnosis of OSA. In total, 238 were hospitalized or died, 38 of whom had OSA. Adjusted for age, sex, and BMI, OSA was associated with poor outcome (OR 2.2, 95% CI 1.4 -3.5). This association was slightly attenuated (OR 2.0, 95% CI 2.0, 1.2-3.2) when adjusted for demographic characteristics and various comorbidities.

CONCLUSIONS

OSA was associated with twofold increase in risk of severe COVID-19, and the association was not explained by obesity or other comorbidities.

Sleep medicine and coronavirus disease 2019

PURPOSE OF REVIEW

To evaluate the impact of the COVID-19 pandemic on the care of people with sleep disorders, to explore relationships between OSA and COVID-19, and to describe current knowledge of the effect of the pandemic on sleep globally.

RECENT FINDINGS

COVID-19 has led to significant changes in the practice of sleep medicine, including the care of patients with OSA. An OSA diagnosis may portend a worse prognosis with COVID-19, whilst prior COVID-19 may have an impact on sleep breathing.

SUMMARY

The pandemic has caused marked difficulties with access to diagnostic sleep studies and reduced capacity for CPAP initiation. Conversely, adherence to CPAP therapy may have improved, and use of remote consultations and telemonitoring has increased. An OSA diagnosis may be associated with increased risk of severe COVID-19, although any apparent relationship may be attributable to confounding factors, such as obesity and metabolic disease. Small studies have reported some increase in CPAP requirements in OSA patients following COVID-19 infection. More generally, the pandemic has been associated with a deterioration in subjective sleep quality across the population; much of this appears because of increased anxiety and stress. Finally, studies assessing putative links between COVID-19 and REM sleep issues are ongoing.

Mental and neurological disorders and risk of COVID-19 susceptibility, illness severity and mortality: A systematic review, meta-analysis and call for action

BACKGROUND

Coronavirus disease 2019 (COVID-19) has evolved into a worldwide pandemic, and has been found to be closely associated with mental and neurological disorders. We aimed to comprehensively quantify the association between mental and neurological disorders, both pre-existing and subsequent, and the risk of susceptibility, severity and mortality of COVID-19.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Web of Science, Embase, PsycINFO, and Cochrane library databases for studies published from the inception up to January 16, 2021 and updated at July 7, 2021. Observational studies including cohort and case-control, cross-sectional studies and case series that reported risk estimates of the association between mental or neurological disorders and COVID-19 susceptibility, illness severity and mortality were included. Two researchers independently extracted data and conducted the quality assessment. Based on I2 heterogeneity, we used a random effects model to calculate pooled odds ratios (OR) and 95% confidence intervals (95% CI). Subgroup analyses and meta-regression analysis were also performed. This study was registered on PROSPERO (registration number: CRD 42021230832).

FINDING

A total of 149 studies (227,351,954 participants, 89,235,737 COVID-19 patients) were included in this analysis, in which 27 reported morbidity (132,727,798), 56 reported illness severity (83,097,968) and 115 reported mortality (88,878,662). Overall, mental and neurological disorders were associated with a significant high risk of infection (pre-existing mental: OR 1·67, 95% CI 1·12-2·49; and pre-existing neurological: 2·05, 1·58-2·67), illness severity (mental: pre-existing, 1·40, 1·25-1·57; sequelae, 4·85, 2·53-9·32; neurological: pre-existing, 1·43, 1·09-1·88; sequelae, 2·17, 1·45-3·24), and mortality (mental: pre-existing, 1·47, 1·26-1·72; neurological: pre-existing, 2·08, 1·61-2·69; sequelae, 2·03, 1·66-2·49) from COVID-19. Subgroup analysis revealed that association with illness severity was stronger among younger COVID-19 patients, and those with subsequent mental disorders, living in low- and middle-income regions. Younger patients with mental and neurological disorders were associated with higher mortality than elders. For type-specific mental disorders, susceptibility to contracting COVID-19 was associated with pre-existing mood disorders, anxiety, and attention-deficit hyperactivity disorder (ADHD); illness severity was associated with both pre-existing and subsequent mood disorders as well as sleep disturbance; and mortality was associated with pre-existing schizophrenia. For neurological disorders, susceptibility was associated with pre-existing dementia; both severity and mortality were associated with subsequent delirium and altered mental status; besides, mortality was associated with pre-existing and subsequent dementia and multiple specific neurological diseases. Heterogeneities were substantial across studies in most analysis.

INTERPRETATION

The findings show an important role of mental and neurological disorders in the context of COVID-19 and provide clues and directions for identifying and protecting vulnerable populations in the pandemic. Early detection and intervention for neurological and mental disorders are urgently needed to control morbidity and mortality induced by the COVID-19 pandemic. However, there was substantial heterogeneity among the included studies, and the results should be interpreted with caution. More studies are needed to explore long-term mental and neurological sequela, as well as the underlying brain mechanisms for the sake of elucidating the causal pathways for these associations.

FUNDING

This study is supported by grants from the National Key Research and Development Program of China, the National Natural Science Foundation of China, Special Research Fund of PKUHSC for Prevention and Control of COVID-19, and the Fundamental Research Funds for the Central Universities.