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Donovan LM, Hoyos CM, Kimoff RJ, Morrell MJ, Bosch NA, Chooljian DM, McEvoy RD, Sawyer AM, Wagner TH, Al-Lamee RR, Bishop D, Carno MA, Epstein M, Hanson M, Ip MSM, Létourneau M, Pamidi S, Patel SR, Pépin JL, Punjabi NM, Redline S, Thornton JD, Patil SP. Strategies to Assess the Effect of Continuous Positive Airway Pressure on Long-Term Clinically Important Outcomes among Patients with Symptomatic Obstructive Sleep Apnea: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:931-943. [PMID: 37387624 DOI: 10.1513/annalsats.202303-258st] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnea (OSA). Although CPAP improves symptoms (e.g., daytime sleepiness), there is a lack of high-quality evidence that CPAP prevents many long-term outcomes, including cognitive impairment, myocardial infarction, and stroke. Observational studies suggest that patients with symptoms may be particularly likely to experience these preventive benefits with CPAP, but ethical and practical concerns limited the participation of such patients in prior long-term randomized trials. As a result, there is uncertainty about the full benefits of CPAP, and resolving this uncertainty is a key priority for the field. This workshop assembled clinicians, researchers, ethicists, and patients to identify strategies to understand the causal effects of CPAP on long-term clinically important outcomes among patients with symptomatic OSA. Quasi-experimental designs can provide valuable information and are less time and resource intensive than trials. Under specific conditions and assumptions, quasi-experimental studies may be able to provide causal estimates of CPAP's effectiveness from generalizable observational cohorts. However, randomized trials represent the most reliable approach to understanding the causal effects of CPAP among patients with symptoms. Randomized trials of CPAP can ethically include patients with symptomatic OSA, as long as there is outcome-specific equipoise, adequate informed consent, and a plan to maximize safety while minimizing harm (e.g., monitoring for pathologic sleepiness). Furthermore, multiple strategies exist to ensure the generalizability and practicality of future randomized trials of CPAP. These strategies include reducing the burden of trial procedures, improving patient-centeredness, and engaging historically excluded and underserved populations.
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Hoff E, Zou D, Grote L, Stenlöf K, Hedner J. The placebo effect in pharmacological treatment of obstructive sleep apnea, a systematic review and meta-analysis. Sleep Med 2023; 106:1-7. [PMID: 37023489 DOI: 10.1016/j.sleep.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE New drug treatments are under development in obstructive sleep apnea (OSA). The placebo effect is well recognized in various conditions, but its relevance in OSA is debated. In the current study we determined the influence of a placebo effect in studies of drug therapy in OSA. METHODS A systematic review and meta-analysis (PROSPERO CRD42021229410) with searches in MEDLINE, Scopus, Web of Science and Cochrane CENTRAL from inception to 2021-01-19. Inclusion criteria were (i) RCTs of adults with OSA, (ii) drug intervention with placebo baseline and follow-up sleep study (iii) outcomes: apnea hypopnea index (AHI), mean oxygen saturation (mSaO2), oxygen desaturation index (ODI) and/or Epworth Sleepiness Scale (ESS). Risk-of-bias was assessed with Cochrane RoB 2. RESULTS 7436 articles were identified and 29 studies included (n = 413). Studies were generally small (median n = 14), with 78% men, baseline AHI range 9-74 events/h and treatment duration range 1-120 days. Meta-analyses were conducted for main outcomes. Mean change of the primary outcome, AHI, was -0.84 (95% CI -2.98 to 1.30); mSaO2 and ODI estimations were also non-significant. ESS showed a trend towards a reduction of -1 unit. Subgroup analysis did not show significant differences. Risk-of-bias assessment indicated mostly low risk but studies were small with wide confidence intervals. CONCLUSIONS In this meta-analysis we did not identify systematic placebo effects on the AHI, ODI or mSaO2 while ESS score showed a trend for a small reduction. These results have an impact on the design and interpretation of drug trials in OSA.
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Affiliation(s)
- Erik Hoff
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Södra Älvsborgs Hospital, Department of Infectious Diseases, Borås, Sweden.
| | - Ding Zou
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Ludger Grote
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Centre for Sleep Medicine, Department of Pulmonary Medicine, Gothenburg, Sweden.
| | - Kaj Stenlöf
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Jan Hedner
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Centre for Sleep Medicine, Department of Pulmonary Medicine, Gothenburg, Sweden.
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Lv R, Liu X, Zhang Y, Dong N, Wang X, He Y, Yue H, Yin Q. Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome. Signal Transduct Target Ther 2023; 8:218. [PMID: 37230968 DOI: 10.1038/s41392-023-01496-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.
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Affiliation(s)
- Renjun Lv
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xueying Liu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Yue Zhang
- Department of Geriatrics, the 2nd Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Na Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xiao Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yao He
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Hongmei Yue
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
| | - Qingqing Yin
- Department of Geriatric Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
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4
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Huang L, Li H, Shu Y, Li K, Xie W, Zeng Y, Long T, Zeng L, Liu X, Peng D. Changes in Functional Connectivity of Hippocampal Subregions in Patients with Obstructive Sleep Apnea after Six Months of Continuous Positive Airway Pressure Treatment. Brain Sci 2023; 13:brainsci13050838. [PMID: 37239310 DOI: 10.3390/brainsci13050838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Previous studies have shown that the structural and functional impairments of hippocampal subregions in patients with obstructive sleep apnea (OSA) are related to cognitive impairment. Continuous positive airway pressure (CPAP) treatment can improve the clinical symptoms of OSA. Therefore, this study aimed to investigate functional connectivity (FC) changes in hippocampal subregions of patients with OSA after six months of CPAP treatment (post-CPAP) and its relationship with neurocognitive function. We collected and analyzed baseline (pre-CPAP) and post-CPAP data from 20 patients with OSA, including sleep monitoring, clinical evaluation, and resting-state functional magnetic resonance imaging. The results showed that compared with pre-CPAP OSA patients, the FC between the right anterior hippocampal gyrus and multiple brain regions, and between the left anterior hippocampal gyrus and posterior central gyrus were reduced in post-CPAP OSA patients. By contrast, the FC between the left middle hippocampus and the left precentral gyrus was increased. The changes in FC in these brain regions were closely related to cognitive dysfunction. Therefore, our findings suggest that CPAP treatment can effectively change the FC patterns of hippocampal subregions in patients with OSA, facilitating a better understanding of the neural mechanisms of cognitive function improvement, and emphasizing the importance of early diagnosis and timely treatment of OSA.
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Affiliation(s)
- Ling Huang
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Haijun Li
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
- PET Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Yongqiang Shu
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Kunyao Li
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Wei Xie
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Yaping Zeng
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Ting Long
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Li Zeng
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Xiang Liu
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Dechang Peng
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
- PET Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
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5
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Placebo response in objective and subjective measures of hypersomnia in randomized clinical trials on obstructive sleep apnea. A systematic review and meta-analysis. Sleep Med Rev 2023; 67:101720. [PMID: 36495752 DOI: 10.1016/j.smrv.2022.101720] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
Sleepiness is one of the outcomes most used in randomized clinical trials (RCT) on the effect of treatments for obstructive sleep apnea (OSA). Furthermore, it is known that there is a placebo effect, especially in subjective measures. Therefore, given that sleepiness is a subjective measure, the objective of this systematic review with meta-analysis and three-level meta-regression was to assess the response to different placebos (pills and sham-CPAP) used in RCTs in OSA, both on subjective (Epworth Sleepiness Scale [ESS]) and objective (Multiple Sleep Latency Test [MSLT], Maintenance Wake Test [MWT], the Osler test and the Psychomotor Vigilance Task [PVT]). We observed a statistically significant placebo effect in both subjective and objective measures of hypersomnia, and in both sham-CPAP and pills. This placebo effect was greater, even clinically significant, in subjective measures (ESS: -2.84 points) and in those RCTs that used pills as a placebo. In the meta-regression, only a higher baseline value of the ESS and Osler test was related to the placebo effect.
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Zhao YY, Wang R, Gleason KJ, Lewis EF, Quan SF, Toth CM, Song Y, Morrical M, Rueschman M, Mittleman MA, Redline S. Effect of continuous positive airway pressure treatment on ambulatory blood pressures in high-risk sleep apnea patients: a randomized controlled trial. J Clin Sleep Med 2022; 18:1899-1907. [PMID: 35459446 PMCID: PMC9340589 DOI: 10.5664/jcsm.10012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The long-term effect of continuous positive airway pressure (CPAP) on 24-hour blood pressure (BP) in high-risk patients with obstructive sleep apnea (OSA) is uncertain. We aimed to determine the effect of CPAP treatment on ambulatory BP in individuals with moderate or severe OSA and cardiovascular disease (CVD) or multiple CVD risk factors without severe sleepiness. METHODS In this randomized, controlled, parallel group study, 169 participants were randomly assigned to CPAP treatment or the control group. The primary outcome was the change in mean 24-hour systolic BP between groups from baseline to the average of 6 and 12 month measurements using mixed effect linear regression models. RESULTS The 24-hour systolic BP did not significantly differ by group, although there was a trend of decrease in the CPAP group (treatment effect -2.7 mm Hg [95% confidence interval -5.9 to 0.6]; P=0.105) compared with control. CPAP had the greatest effect on nighttime systolic BP (treatment effect -5.9 mm Hg [95% confidence interval -9.9 to -1.9]; P=0.004). Similar improvements in other nocturnal BP indices were observed. CONCLUSIONS In high risk patients with moderate-severe OSA without severe sleepiness, CPAP resulted in modest BP improvements over 6 to 12 months of follow-up, with possibly larger effects for nocturnal BP. Use of office blood pressure may under-estimate the effect of CPAP on BP profile in patients with OSA. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Sleep Apnea Intervention for Cardiovascular Disease Reduction; Identifier: NCT01261390; URL: https://clinicaltrials.gov/ct2/show/NCT01261390.
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Affiliation(s)
- Ying Y Zhao
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Medicine, Joseph Brant Hospital, Burlington, Ontario, Canada
| | - Rui Wang
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Kevin J Gleason
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Stuart F Quan
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Claudia M Toth
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Yue Song
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Michael Morrical
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Michael Rueschman
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Murray A Mittleman
- Harvard Medical School, Boston, MA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan Redline
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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7
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Labarca G, Schmidt A, Dreyse J, Jorquera J, Barbe F. Telemedicine interventions for CPAP adherence in obstructive sleep apnea patients: Systematic review and meta-analysis. Sleep Med Rev 2021; 60:101543. [PMID: 34537668 DOI: 10.1016/j.smrv.2021.101543] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/07/2021] [Accepted: 08/23/2021] [Indexed: 12/11/2022]
Abstract
Continuous positive airway pressure (CPAP) is the preferred therapy in patients with obstructive sleep apnea (OSA). However, data suggests treatment adherence is low. In recent years, telemedicine-based intervention (TM) has been evaluated to increase adherence. In this systematic review and meta-analysis of randomized controlled trials (RCTs), we evaluated the efficacy of TM on CPAP adherence in patients with OSA. Two independent reviewers explored five databases; the risk of bias (RoB) was evaluated using the Cochrane tool. Outcomes were defined as the mean difference (MD) in CPAP use per night and the proportion of patients with increased CPAP adherence of ≥4 h/night. The meta-analysis was conducted following the DerSimonian-Laird method, and the certainty of the evidence was rated according to GRADE. We included 16 RCTs including 3039 participants. The RoB was low in 12/16 studies. TM was associated with an increase in CPAP adherence of 29.2 min/night, I2 =75% (p < 0.01), and CPAP adherence ≧4 h/night, RR: 1.09 (1.02-1.17), I2 =22%. Subgroup analyses reported better results between three and 6 months, in the sleepy subgroup. Finally, based on the results obtained in this systematic review, there is favorable evidence regarding the treatment with TM in patients with OSA using CPAP. REVIEW REGISTRATION NUMBER: CRD42020165367.
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Affiliation(s)
- Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, University of Concepcion, Concepcion, Chile.
| | - Alexia Schmidt
- Faculty of Medicine, University of Concepcion, Concepcion, Chile
| | - Jorge Dreyse
- Centro de Enfermedades Respiratorias y Grupo de Estudio Trastornos Respiratorios Del Sueño (GETRS) Clínica Las Condes, Santiago, Chile
| | - Jorge Jorquera
- Centro de Enfermedades Respiratorias y Grupo de Estudio Trastornos Respiratorios Del Sueño (GETRS) Clínica Las Condes, Santiago, Chile
| | - Ferran Barbe
- Respiratory Department. Hospital Univ Arnau de Vilanova, IRBLleida. and CIBERES, Madrid, Spain
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Hincker A, Nadler J, Karan S, Carter E, Porat S, Warner B, Ju YES, Ben Abdallah A, Wilson E, Lockhart EM, Ginosar Y. Sleep Apnea and Fetal Growth Restriction (SAFER) study: protocol for a pragmatic randomised clinical trial of positive airway pressure as an antenatal therapy for fetal growth restriction in maternal obstructive sleep apnoea. BMJ Open 2021; 11:e049120. [PMID: 34187829 PMCID: PMC8245445 DOI: 10.1136/bmjopen-2021-049120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Fetal growth restriction (FGR) is a major contributor to fetal and neonatal morbidity and mortality with intrauterine, neonatal and lifelong complications. This study explores maternal obstructive sleep apnoea (OSA) as a potentially modifiable risk factor for FGR. We hypothesise that, in pregnancies complicated by FGR, treating mothers who have OSA using positive airway pressure (PAP) will improve birth weight and neonatal outcomes. METHODS AND ANALYSIS The Sleep Apnea and Fetal Growth Restriction study is a prospective, block-randomised, single-blinded, multicentre, pragmatic controlled trial. We enrol pregnant women aged 18-50, between 22 and 31 weeks of gestation, with established FGR based on second trimester ultrasound, who do not have other prespecified known causes of FGR (such as congenital anomalies or intrauterine infection). In stage 1, participants are screened by questionnaire for OSA risk. If OSA risk is identified, participants proceed to stage 2, where they undergo home sleep apnoea testing. Participants are determined to have OSA if they have an apnoea-hypopnoea index (AHI) ≥5 (if the oxygen desaturation index (ODI) is also ≥5) or if they have an AHI ≥10 (even if the ODI is <5). These participants proceed to stage 3, where they are randomised to nightly treatment with PAP or no PAP (standard care control), which is maintained until delivery. The primary outcome is unadjusted birth weight; secondary outcomes include fetal growth velocity on ultrasound, enrolment-to-delivery interval, gestational age at delivery, birth weight corrected for gestational age, stillbirth, Apgar score, rate of admission to higher levels of care (neonatal intensive care unit or special care nursery) and length of neonatal stay. These outcomes are compared between PAP and control using intention-to-treat analysis. ETHICS AND DISSEMINATION This study has been approved by the Institutional Review Boards at Washington University in St Louis, Missouri; Hadassah Hebrew University Medical Center, Jerusalem; and the University of Rochester, New York. Recruitment began in Washington University in November 2019 but stopped from March to November 2020 due to COVID-19. Recruitment began in Hadassah Hebrew University in March 2021, and in the University of Rochester in May 2021. Dissemination plans include presentations at scientific conferences and scientific publications. TRIAL REGISTRATION NUMBER NCT04084990.
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Affiliation(s)
- Alex Hincker
- Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Jacob Nadler
- Anesthesiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Suzanne Karan
- Anesthesiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Ebony Carter
- Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Shay Porat
- Obstetrics and Gynecology, Hadassah University Hospital, and the Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Barbara Warner
- Neonatology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Yo-El S Ju
- Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Arbi Ben Abdallah
- Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Elizabeth Wilson
- Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Ellen M Lockhart
- Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Yehuda Ginosar
- Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Anesthesiology, Critical Care and Pain Medicine, and the Wohl Institute of Translational Medicine, Hadassah University Hospital and the Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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9
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Lui MMS, Tse HF, Lam DCL, Lau KK, Chan CWS, Ip MSM. Continuous positive airway pressure improves blood pressure and serum cardiovascular biomarkers in obstructive sleep apnoea and hypertension. Eur Respir J 2021; 58:13993003.03687-2020. [PMID: 33795324 DOI: 10.1183/13993003.03687-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/23/2021] [Indexed: 11/05/2022]
Abstract
RATIONALE The impact of treatment for obstructive sleep apnoea (OSA) on reduction of cardiovascular risk is unclear. This study aimed to examine the effect of continuous positive airway pressure (CPAP) on ambulatory blood pressure (BP) and subclinical myocardial injury in subjects with OSA and hypertension. METHODS Subjects with hypertension requiring at least three anti-hypertensive medications and moderate-severe OSA were enrolled. Eligible subjects were randomized (1:1) to receive either CPAP treatment or control (no CPAP) for eight weeks. Changes in ambulatory BP and serum biomarkers were compared. Stratified analysis according to circadian BP pattern was performed. MAIN RESULTS Ninety two subjects (75% men; age, 51±8 years; apnoea-hypopnoea index 40±8 events·h-1, taking average of 3.4 anti-hypertensive drugs [range 3-6]) were randomised. The group on CPAP treatment, compared to the control group, demonstrated significant reduction in 24-h systolic BP (-4.4 mmHg, 95% CI -8.7 to -0.1, p=0.046), 24-h diastolic BP (-2.9 mmHg, 95% CI -5.5 to -0.2, p=0.032), daytime systolic BP (-5.4 mmHg, -9.7 to -1.0, p=0.016) and daytime diastolic BP (-3.4 mmHg, 95% CI -6.1 to -0.8, p=0.012). CPAP treatment was associated with significant BP lowering only in non-dippers, but not in dippers. Serum troponin I (mean difference -1.74 pg·mL-1, 95% CI -2.97 to -0.5, p=0.006) and brain natriuretic peptide (-9.1 pg·mL-1, 95% CI -17.6 to -0.6, p=0.036) were significantly reduced in CPAP compared to control group. CONCLUSION In a cohort with OSA and multiple cardiovascular risk factors including difficult-to-control hypertension, short-term CPAP treatment improved ambulatory BP and alleviated subclinical myocardial injury and strain.
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Affiliation(s)
- Macy Mei-Sze Lui
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - David Chi-Leung Lam
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Kui-Kai Lau
- Division of Neurology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Carmen Wing-Sze Chan
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Mary Sau-Man Ip
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
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10
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Where to Next for Optimizing Adherence in Large-Scale Trials of Continuous Positive Airway Pressure? Sleep Med Clin 2020; 16:125-144. [PMID: 33485525 DOI: 10.1016/j.jsmc.2020.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Large-scale randomized trials of positive airway pressure (PAP) efficacy have been largely negative but PAP adherence was notably suboptimal across the trials. To address this limitation, evidence-based PAP adherence protocols embedded within the larger trial protocol are recommended. The complexity of such protocols depends on adequacy of resources, including funding and inclusion of behavioral scientist experts on the scientific team, and trial-specific considerations (eg, target population) and methods. Recommendations for optimizing PAP adherence in large-scale trials are set forth that address rigor and reproducibility.
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11
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Zeng S, Li F, Wang R, Li F. Propensity score weighting for covariate adjustment in randomized clinical trials. Stat Med 2020; 40:842-858. [PMID: 33174296 DOI: 10.1002/sim.8805] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/11/2020] [Accepted: 10/23/2020] [Indexed: 01/15/2023]
Abstract
Chance imbalance in baseline characteristics is common in randomized clinical trials. Regression adjustment such as the analysis of covariance (ANCOVA) is often used to account for imbalance and increase precision of the treatment effect estimate. An objective alternative is through inverse probability weighting (IPW) of the propensity scores. Although IPW and ANCOVA are asymptotically equivalent, the former may demonstrate inferior performance in finite samples. In this article, we point out that IPW is a special case of the general class of balancing weights, and advocate to use overlap weighting (OW) for covariate adjustment. The OW method has a unique advantage of completely removing chance imbalance when the propensity score is estimated by logistic regression. We show that the OW estimator attains the same semiparametric variance lower bound as the most efficient ANCOVA estimator and the IPW estimator for a continuous outcome, and derive closed-form variance estimators for OW when estimating additive and ratio estimands. Through extensive simulations, we demonstrate OW consistently outperforms IPW in finite samples and improves the efficiency over ANCOVA and augmented IPW when the degree of treatment effect heterogeneity is moderate or when the outcome model is incorrectly specified. We apply the proposed OW estimator to the Best Apnea Interventions for Research (BestAIR) randomized trial to evaluate the effect of continuous positive airway pressure on patient health outcomes. All the discussed propensity score weighting methods are implemented in the R package PSweight.
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Affiliation(s)
- Shuxi Zeng
- Department of Statistical Science, Duke University, Durham, North Carolina, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA.,Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Fan Li
- Department of Statistical Science, Duke University, Durham, North Carolina, USA
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Labarca G, Dreyse J, Drake L, Jorquera J, Barbe F. Efficacy of continuous positive airway pressure (CPAP) in the prevention of cardiovascular events in patients with obstructive sleep apnea: Systematic review and meta-analysis. Sleep Med Rev 2020; 52:101312. [DOI: 10.1016/j.smrv.2020.101312] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/17/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022]
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13
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Sundar KM, Willis AM, Smith S, Hu N, Kitt JP, Birring SS. A Randomized, Controlled, Pilot Study of CPAP for Patients with Chronic Cough and Obstructive Sleep Apnea. Lung 2020; 198:449-457. [PMID: 32356074 DOI: 10.1007/s00408-020-00354-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/06/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND An association between chronic cough and obstructive sleep apnea (OSA) has been reported in prior studies with resolution or improvement in cough after continuous positive airway pressure (CPAP) therapy. Controlled studies of the benefit of CPAP on cough-quality of life measures have not been conducted. RESEARCH QUESTION Does CPAP therapy for OSA improve cough in patients with chronic unexplained cough? STUDY DESIGN AND METHODS Patients with unexplained chronic cough (> 2 months duration of cough) and OSA were randomized to receive either CPAP or sham CPAP therapy for 6 weeks. The primary end point was the change in health status assessed with the Leicester Cough Questionnaire (LCQ) in patients treated with CPAP vs. sham CPAP. Secondary end points were changes in exhaled breath condensate markers of airway inflammation (interleukin-6, nitrite/nitrates, hydrogen peroxide and 8-isoprostanes). RESULTS A total of 22 patients with chronic unexplained cough and OSA were randomized of whom18 completed 6 weeks of treatments with either CPAP or sham CPAP. The CPAP vs. sham CPAP-treated group were comparable in terms of sex distribution, body mass index, and OSA severity. Following CPAP therapy, there was a significantly greater improvement in total LCQ scores as compared to those treated with sham therapy (ANCOVA p value 0.016). No significant differences were noted in the exhaled breath condensate marker changes between CPAP-treated vs. sham CPAP-treated groups. CONCLUSION Treatment of comorbid OSA in patients with chronic cough improved cough quality of life measures following treatment of OSA with CPAP in this pilot study. Larger studies to understand this association and unravel mechanisms of CPAP benefit in chronic cough need to be undertaken. Clinical Trial Registration NCT03172130.
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Affiliation(s)
- Krishna M Sundar
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA. .,Sleep-Wake Center, University of Utah, Salt Lake City, Utah, USA. .,Division of Pulmonary Medicine, University of Utah, 26 N 1900E, Salt Lake City, UT, 84112, USA.
| | - Alika M Willis
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Sarah Smith
- Sleep-Wake Center, University of Utah, Salt Lake City, Utah, USA
| | - Nan Hu
- Family & Preventive Medicine, University of Utah, Salt Lake City, Utah, USA.,Department of Biostatistics, Robert Stempel College of Public Health and Social Work and Division of Public Health, Florida International University, Miami, FL, USA
| | - Jay P Kitt
- Department of Biomedical Informatics and Department of Chemistry, University of Utah, Salt Lake City, Utah, USA
| | - Surinder S Birring
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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Cardiovascular Benefits of Continuous Positive Airway Pressure: The Quest Continues…. Ann Am Thorac Soc 2020; 17:427-428. [PMID: 32233859 DOI: 10.1513/annalsats.202001-026ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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