Sleep Apnea and Skin

Does Obstructive Sleep Apnoea Syndrome Influence the Development and Treatment of Diabetic Foot? A Brief Narrative Review

Both obstructive sleep apnoea syndrome (OSAS) and diabetes mellitus (DM) are common conditions that often coexist and share many similar risk factors. Diabetic foot is a common complication of DM, which may lead to lower-limb amputation. OSAS is considered a risk factor for type 2 DM (T2DM). There is also evidence that OSAS may be linked with the development, as well as the healing of diabetic foot. Multiple mechanisms triggered by sleep fragmentation and intermittent hypoxaemia in OSAS could contribute to the development of diabetic foot ulcers (DFUs). More interestingly, emerging evidence implies a favourable impact of continuous positive airway pressure (CPAP) treatment on DFU healing. Healing DFUs and minimising recurrence rates remains a challenge for health care professionals. In this context, management of OSAS might prove a useful therapeutic adjunct for DFUS. However, data is still limited and randomised controlled trials are needed to further explore this interesting potential.

Adenotonsillectomy and Health Care Utilization in Children With Snoring and Mild Sleep Apnea: A Randomized Clinical Trial

Importance

The literature indicates that health care utilization (HCU) of children with untreated moderate-to-severe obstructive sleep apnea is greater than that of matched controls before diagnosis, and treatment is associated with a decline in HCU not observed in those who remain untreated. Research on this topic has been limited to retrospective analyses and observational cohort studies; little is known about HCU among the many children with snoring and mild sleep-disordered breathing (SDB).

Objective

To determine whether adenotonsillectomy in comparison with watchful waiting with supportive care is associated with fewer health care encounters and prescriptions.

Design, Setting, and Participants

This randomized clinical trial, Pediatric Adenotonsillectomy Trial for Snoring (PATS), was a 12-month, parallel-arm trial conducted from 2016 to 2022 in tertiary care centers in the United States. Participants were recruited from otolaryngology, sleep, pulmonary, or general pediatric clinics; aged 3 to 13 years; diagnosed with mild SDB; had a tonsillar hypertrophy grade of 2 or more; and had a body mass index z score less than 3. Children referred from a clinician outside of the local electronic medical record system were excluded. Data analysis was conducted from June 2022 to April 2024.

Intervention

Early adenotonsillectomy.

Main Outcomes and Measures

Evaluation of HCU was a prespecified secondary aim of PATS. Total encounters and total prescriptions over the 12 months after randomization were analyzed.

Results

Among 459 children who were randomized, the analytic sample included 381 children, after excluding those referred from outside the local electronic medical record system. The median (IQR) age was 6 (4-8) years; 192 participants (50%) were female and 189 (50%) male. Adenotonsillectomy was associated with a 32% reduction in total health care encounters (mean difference, -1.25 per participant per year; 95% CI, -1.96 to -0.53) and a 48% reduction in prescriptions (mean difference, -2.53 per participant per year; 95% CI, -4.12 to -0.94). The difference in encounters was primarily driven by fewer office visits and outpatient procedures rather than by reduced hospitalizations or urgent care visits.

Conclusions and Relevance

This study found that adenotonsillectomy was associated with reduced all-cause HCU in children with mild SDB, supporting early intervention for children with mild SDB. Future research focused on the cost effectiveness of adenotonsillectomy for pediatric SDB is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT02562040.

Persistent sleep apnea after adenotonsillectomy in pediatric patients with head and neck burns

BACKGROUND

To determine if face, head, or neck burns increases risk of persistent sleep disordered breathing (SDB) or obstructive sleep apnea (OSA) after adenotonsillectomy.

METHODS

The TriNetX database was used to gather data for patients who had face, head, or neck burn including mouth and pharynx and history of sleep study with adenotonsillectomy. A comparison of persistent SDB or OSA was done between cohort 1, a group with sleep study and adenotonsillectomy after burn injury, and cohort 2, a group with treatment before a burn. Risk of persistence was evaluated as relative risk (RR) with 95 % confidence interval (CI).

RESULTS

Eighty-three pediatric patients were included. Fifty-one patients were in cohort 1, and 32 in cohort 2. Forty-three patients in cohort 1 had persistent SDB or OSA as compared to 11 in cohort 2, which was statistically significant (RR: 2.45; 95 % CI: 1.50-4.02; p-value <0.0001). After propensity score matching, both groups had 23 patients, and 19 had persistent SDB or OSA in cohort 2, while cohort 1 had 10 patients. The difference in persistence was significant (RR 1.9; 95 % CI: 1.15-3.14; p-value equals 0.006).

CONCLUSIONS

Pediatric patients with a face, head, or neck burn had a higher rate of persistent SDB or OSA after adenotonsillectomy compared to patients who had surgery prior to thermal injury.

Hesperetin activates CISD2 to attenuate senescence in human keratinocytes from an older person and rejuvenates naturally aged skin in mice

BACKGROUND

CDGSH iron-sulfur domain-containing protein 2 (CISD2), a pro-longevity gene, mediates healthspan in mammals. CISD2 is down-regulated during aging. Furthermore, a persistently high level of CISD2 promotes longevity and ameliorates an age-related skin phenotype in transgenic mice. Here we translate the genetic evidence into a pharmaceutical application using a potent CISD2 activator, hesperetin, which enhances CISD2 expression in HEK001 human keratinocytes from an older person. We also treated naturally aged mice in order to study the activator's anti-aging efficacy.

METHODS

We studied the biological effects of hesperetin on aging skin using, firstly, a cell-based platform, namely a HEK001 human keratinocyte cell line established from an older person. Secondly, we used a mouse model, namely old mice at 21-month old. In the latter case, we investigate the anti-aging efficacy of hesperetin on ultraviolet B (UVB)-induced photoaging and naturally aged skin. Furthermore, to identify the underlying mechanisms and potential biological pathways involved in this process we carried out transcriptomic analysis. Finally, CISD2 knockdown HEK001 keratinocytes and Cisd2 knockout mice were used to study the Cisd2-dependent effects of hesperetin on skin aging.

RESULTS

Four findings are pinpointed. Firstly, in human skin, CISD2 is mainly expressed in proliferating keratinocytes from the epidermal basal layer and, furthermore, CISD2 is down-regulated in the sun-exposed epidermis. Secondly, in HEK001 human keratinocytes from an older person, hesperetin enhances mitochondrial function and protects against reactive oxygen species-induced oxidative stress via increased CISD2 expression; this enhancement is CISD2-dependent. Additionally, hesperetin alleviates UVB-induced damage and suppresses matrix metalloproteinase-1 expression, the latter being a major indicator of UVB-induced damage in keratinocytes. Thirdly, transcriptomic analysis revealed that hesperetin modulates a panel of differentially expressed genes that are associated with mitochondrial function, redox homeostasis, keratinocyte function, and inflammation in order to attenuate senescence. Intriguingly, hesperetin activates two known longevity-associated regulators, namely FOXO3a and FOXM1, in order to suppress the senescence-associated secretory phenotype. Finally, in mouse skin, hesperetin enhances CISD2 expression to ameliorate UVB-induced photoaging and this occurs via a mechanism involving CISD2. Most strikingly, late-life treatment with hesperetin started at 21-month old and lasting for 5 months, is able to retard skin aging and rejuvenate naturally aged skin in mice.

CONCLUSIONS

Our results reveal that a pharmacological elevation of CISD2 expression at a late-life stage using hesperetin treatment is a feasible approach to effectively mitigating both intrinsic and extrinsic skin aging and that hesperetin could act as a functional food or as a skincare product for fighting skin aging.

Circadian Biology in Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a complex process that can lead to the dysregulation of the molecular clock, as well as 24 h rhythms of sleep and wake, blood pressure, and other associated biological processes. Previous work has demonstrated crosstalk between the circadian clock and hypoxia-responsive pathways. However, even in the absence of OSA, disrupted clocks can exacerbate OSA-associated outcomes (e.g., cardiovascular or cognitive outcomes). As we expand our understanding of circadian biology in the setting of OSA, this information could play a significant role in the diagnosis and treatment of OSA. Here, we summarize the pre-existing knowledge of circadian biology in patients with OSA and examine the utility of circadian biomarkers as alternative clinical tools.

Sleep Disturbance in School-Aged Children with Atopic Dermatitis: Prevalence and Severity in a Cross-Sectional Sample

BACKGROUND

Atopic dermatitis (AD) causes sleep disturbance but the epidemiology is not known.

OBJECTIVE

To estimate the US prevalence of sleep disturbance and its impact on psychological and neurocognitive function.

METHODS

We conducted a cross-sectional survey of 180 parent-child dyads with AD using stratified sampling based on disease severity (Patient Oriented Eczema Measure: mild [n = 30), moderate (n = 75) or severe (n = 75]), age, and race (White or Black or African American or other). Symptoms of sleep and psychologic health were assessed using the Patient-Reported Outcome Measurement Information System. To estimate the prevalence of sleep disturbance, we calculated weights using poststratification adjustment making marginal frequencies of AD severity, race, and age similar to marginal frequencies in the 2007 National Survey of Children's Health. Unweighted regression models examined associations with sleep disturbance.

RESULTS

In children age 5 to 17 years with AD, we estimated that sleep disturbance occurred in 66.9% (95% confidence interval, 53.3% to 80.5%; 3,116,305 children). The odds of severe sleep disturbance (worse than 95% of US children) were highest in moderate to severe versus mild AD (2.03 [1.00-4.10]; P = .0495; compared with 8.68 [1.82-41.49]; P = .0068). Predictors of parent proxy-reported sleep disturbance were itch intensity (adjusted β [95% confidence interval] 1.33 [0.62-2.04]) and low income (<$50,000: 6.64 [2.05-11.23]; and $50,000 to less than 100,000: 4.75 [0.35-9.14]). Controlling for disease severity, itch intensity, and significant sociodemographics-parent-proxy, reported sleep disturbance was associated with increased severity of sleep-related impairment, depression, fatigue, and anxiety, in addition to worse inattention and impulsivity. In fully adjusted models, children who self-reported sleep disturbance (T-score ≥60) had increased odds of sleep-related impairment (1.20 [1.11-1.29]), depression (1.13 [1.03, 1.24]), fatigue (1.28 [1.06-1.54]), and anxiety (1.16 [1.02-1.31]).

CONCLUSIONS

Sleep disturbance is a common symptom of AD. It affects about 3 million US children and is associated with neuropsychiatric impairment, including depression, anxiety, and inattention. Clinicians should screen for these symptoms in school-aged children, particularly those with moderate to severe AD.