Daytime sleepiness, snoring and gastro-oesophageal reflux amongst young adults in three European countries

Emergence of different dimensions of sleepiness in a general population sample: An EPISONO study

INTRODUCTION

Recent evidence supports the idea that sleepiness has several dimensions, comprising psychophysiological phenomena, such as sleep propensity and sleepiness perception. The Epworth Sleepiness Scale (ESS) is among one of the most used sleepiness assessment tools, but recent data suggest that it might not detect problematic impairments in sleep health. More research is warranted investigating sleepiness dimensions with large sample sizes, using both objective and subjective methods of analyzing sleep.

METHODS

We used data from the Epidemiological Sleep Study (EPISONO), a major study carried out in Brazil using a representative sample of 1042 participants of the general population of Sao Paulo city, who completed questionnaires and underwent type I polysomnography. Sleepiness was measured by the ESS (sleep propensity) and the UNIFESP Sleep Questionnaire, which asked about the frequency of feeling sleepy during the day (sleepiness perception). The participants were distributed into 4 groups in respect of excessive daytime sleepiness (EDS) according to the following criteria: 1) having an ESS score >10 (ESS group). 2) feeling sleepy ≥3 times per week (Frequent EDS group). 3) the combined criteria (Combined EDS group). 4) having no evidence of EDS (no EDS group). The UNIFESP Sleep Questionnaire was used to obtain self-reported sleep duration, sleep debt, and sleep duration variability. Participants also completed the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, and a pre-polysomnography sleep questionnaire.

RESULTS

After removing participants with missing data, there were 620 participants with no EDS, 255 individuals in the ESS group, 68 in the Frequent EDS group, and 73 in the Combined EDS group. Compared to the no EDS group, the ESS and Combined EDS groups had significantly increased sleep efficiency, diminished sleep latency, wake after sleep onset, and self-reported weekly sleep duration. The Frequent and Combined EDS groups had significantly higher scores in the Insomnia Severity Index and Pittsburgh Sleep Quality Index. All EDS groups had an increased likelihood of nonrestorative sleep. EDS frequency and the ESS scores were significantly correlated.

CONCLUSIONS

Participants with a high sleep propensity had a profile suggesting prior sleep deprivation, while high sleepiness perception was associated with impaired sleep quality. These findings indicated that, in the general population, these instruments evaluated separate sleepiness dimensions with different associations, highlighting that screening using a combination of instruments might be more effective in detecting impairments in sleep health.

Different components of excessive daytime sleepiness and the change with positive airway pressure treatment in patients with obstructive sleep apnea: Results from the Icelandic Sleep Apnea Cohort (ISAC)

Excessive daytime sleepiness includes both an inability to stay awake during the day and a general feeling of sleepiness. We describe different dimensions of daytime sleepiness in adults with moderate-severe obstructive sleep apnea (OSA) before and after 2 years of positive airway pressure (PAP) treatment. Using the Epworth Sleepiness Scale (score >10 defined as "risk of dozing") and Basic Nordic Sleep Questionnaire (feeling sleepy ≥3 times/week defined as "feeling sleepy"), participants were categorised into sleepiness phenotypes labelled non-sleepy, risk of dozing only, feeling sleepy only, or both symptoms. Participants repeated baseline assessments and PAP adherence was evaluated after 2 years. PAP-adherent subjects with sleepiness symptoms at both baseline and follow-up were considered persistently sleepy. Of the 810 participants, 722 (89%) returned for follow-up. At baseline, 17.7% were non-sleepy, 7.7% were at risk of dozing only, 24.7% were feeling sleepy only, and 49.9% had both symptoms. PAP adherence did not differ by baseline sleepiness phenotype. Patients with risk of dozing demonstrated greater PAP benefits for sleepiness symptoms than non-sleepy and feeling sleepy only phenotypes. Using these phenotypes, 42.3% of PAP users had persistent sleepiness; they had less severe OSA (p < 0.001), more persistent OSA symptoms and more often had symptoms of insomnia than patients in whom sleepiness resolved. Our present results, therefore, suggest that measuring the risk of dozing and the feeling of sleepiness reflect different sleepiness components and may respond differently to PAP. Patients feeling sleepy without risk of dozing may need more thorough evaluation for factors contributing to sleepiness before initiating treatment.

Snoring and environmental exposure: results from the Swedish GA2LEN study

OBJECTIVE

Habitual snoring is associated with fatigue, headaches and low work performance. This cross-sectional study aimed to investigate if snoring is affected by environmental factors such as home dampness and exposure to air pollution.

SETTING

General population sample from four Swedish cities.

PARTICIPANTS

25 848 participants from the Swedish part of the epidemiological Global Asthma and Allergy and European network of excellence study carried out in 2008. The participants completed a postal questionnaire on snoring and, indoor and outdoor environmental exposure as well as potential confounders including smoking, weight, height and educational level.

RESULTS

Of the participants, 4211 (16.3%) were habitual snorers. Habitual snorers reported water damage (8.3% vs 7.0% p<0.0001), floor dampness (4.6% vs 3.8% % p<0.0001) and visible mould (5.2% vs 3.8% p<0.0001) in their homes more often than non-snorers. Habitual snorers stated being annoyed by air pollution more often than non-snorers with habitual snorers reporting being irritated with the air in their residential area to a higher extent (sometimes 16.2% vs 13.9%, and daily 4.6% vs 3.1%) as well as annoyance from traffic fumes (somewhat 19% vs 18.5% and very 5% vs 3.6%) (p<0.0001). These results remained significant after adjustment for age, body mass index, smoking history and educational level.

CONCLUSION

Snoring is more prevalent in subjects reporting home dampness and air pollution. These association should be confirmed in further research using objective measurements and a longitudinal approach.

Chronic Severe Sleep Problems among Non-Nordic Immigrants. Data from a Population Postal Survey in Mid-Sweden

Sweden has a large population of both recent and established immigrants with high prevalence of risk factors for ill health. Here, we aimed to explore the prevalence of chronic severe sleep problems (CSSP) among non-Nordic-born persons, and to evaluate the risk for CSSP when fully adjusted for covariates. Our additional hypothesis was that lengthier time since immigration would reduce the risk for CSSP. We used data from a large-population postal survey covering life and health issues among inhabitants in mid-Sweden. Relationship between different countries of birth and CSSP was assessed in logistic analyses for more severe and longstanding pain, sex, employment, mental disability, gastrointestinal problems, and length of stay (short, middle time, and up to ten years of stay). Persons of non-Nordic birth reported significantly more often CSSP, regardless of short or long-term stay. Our findings indicate that non-Nordic birth, regardless of residence time and covariates, was an independent and significant predictor for CSSP. The findings may contribute to increasing awareness in healthcare personnel to recognize chronic sleep problems among immigrant patients. Thus, our study might contribute to developing strategies to enhance health for minorities.

Association between Co-Morbidities and the Prevalence of Excessive Daytime Sleepiness over a Four-Year Period

Excessive daytime sleepiness (EDS) is a common problem in general the Canadian population. It can effect day-to-day activities and is also associated with several health issues. This study aimed to investigate the association between co-morbidities and the prevalence of EDS over a four-year period in adults living in two First Nation communities. Data collected during the First Nations Lung Health Project (FNLHP) conducted in two Cree First Nation communities in Saskatchewan in 2012–2013 (Cycle 1) and 2016 (Cycle 2) were used for this analysis. There were 859 participants aged 18 years and older at baseline (Cycle 1) and 821 participants aged 18 years and older at follow-up (Cycle 2) who completed the interviewer-administered questionnaire. An Epworth Sleepiness Scale (ESS) score > 10 was considered to be abnormal and identified as a case of EDS at both time points. A multilevel logistic regression model using a generalized estimating equations approach was used to analyze the data. The prevalence of EDS at baseline (Cycle 1) was 11.2% (91/815) and 10.0% (80/803) at follow-up (Cycle 2). Based on the predicted model, longitudinal change in the prevalence of EDS was −0.11% for 358 individuals who participated in both cycles. There were 49% males at baseline and 48% males at follow-up. Multivariate regression model results revealed that crowding, shortness of breath, loud snoring, chronic lung disease, depression and gastric reflux were the main significant predictors of EDS. In addition, the interaction between sex and age was significant. Some of the co-morbid conditions were associated with EDS. Therefore, managing such conditions requires considerations in strategies to decrease the prevalence of daytime sleepiness.

Excessive daytime sleepiness and its predictors among medical and health science students of University of Gondar, Northwest Ethiopia: institution-based cross-sectional study

Background

Excessive daytime sleepiness (EDS) is a condition of sleepiness when a person would not be expected to sleep. University students are prone to EDS due to the competitive learning environment and fragmented night sleep. No study was conducted in Ethiopia on EDS. Therefore, this study aimed to determine EDS and its predictors among University of Gondar (UoG) Medical and Health Science students.

Methods

Institution-based cross-sectional study was carried out on 383 Medical and Health Science students of UoG who were recruited using a computer-generated simple random sampling technique. We used a validated Epworth daytime sleepiness tool to collect data. Epi-Info™ 7 and Stata 14 were used for data entry and analysis, respectively. Bivariable and multivariable binary logistic regression analyses were performed to find out predictors. Odds ratio with 95% uncertainty interval were computed. In the final model, a variable with a p < 0.05 was declared as a predictor of EDS.

Results

Three hundred and eighty-three students completed the questionnaire. Males were 69.97% and the mean age of participants was 20.79 (±1.83) years. In the current study, the prevalence of EDS was 31.07% (95% UI: 26.62–35.91). The odds of getting EDS was 1.83 (AOR = 1.83, 95% UI: 1.14–2.96) and 1.84 (AOR = 1.84, 95% UI: 1.13–3.00) higher among students who reported night sleep behaviour disorders and depression, respectively.

Conclusion

This study revealed that EDS is high and predicted by depression and night sleep behaviour disorders. These findings suggest the need to set preventive strategies such as counselling of students to reduce depression and night sleep behaviour disorders. Further studies particularly qualitative studies are required to find out more factors affecting EDS.

Impacts of Sleep Duration and Snoring on The Risk of Esophageal Squamous Cell Carcinoma

Background Sleep duration and snoring are correlated with tumorigenesis while their associations with esophageal squamous cell carcinoma (ESCC) are unclear. The purpose of this study is to investigate the impacts of night sleep duration and snoring on ESCC risk.

Methods This study included a total of 527 esophageal squamous cell carcinoma patients and 505 gender- and age- matched healthy controls from five hospitals in China. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by conditional logistic regression models.

Results Subjects with sleep duration <7 h (adjusted OR 3.18, 95%CI 1.55-6.53) and regular snoring (adjusted OR 2.56, 95%CI 1.82-3.59) were exposed to high esophageal squamous cell carcinoma risk. After the multivariate models adjusted for body mass index (BMI), the results changed slightly. In the stratified analysis regarding gender, the similar trends occurred in both men and women, and BMI ≥25.0 kg/m² (adjusted OR 0.68, 95%CI 0.48-0.96) was associated with decreased esophageal squamous cell carcinoma risk in men. Additionally, the esophageal squamous cell carcinoma risk attributable to sleep duration <7 h and regular snoring could be completely or partially diminished in subjects with BMI ≥25.0 kg/m².

Conclusion In both genders, short sleep duration (<7h) and regular snoring were significantly related to increased risk of esophageal squamous cell carcinoma independently.

Definition of excessive daytime sleepiness in the general population: Feeling sleepy relates better to sleep-related symptoms and quality of life than the Epworth Sleepiness Scale score. Results from an epidemiological study

Many different subjective tools are being used to measure excessive daytime sleepiness (EDS) but the most widely used is the Epworth Sleepiness Scale (ESS). However, it is unclear if using the ESS is adequate on its own when assessing EDS. The aim of this study was to estimate the characteristics and prevalence of EDS using the ESS and the Basic Nordic Sleep Questionnaire (BNSQ) in general population samples. Participants aged 40 years and older answered questions about sleepiness, health, sleep-related symptoms and quality of life. Two groups were defined as suffering from EDS: those who scored >10 on the ESS (with increased risk of dozing off) and those reporting feeling sleepy during the day ≥3 times per week on the BNSQ. In total, 1,338 subjects (53% male, 74.1% response rate) participated, 13.1% reported an increased risk of dozing off, 23.2% reported feeling sleepy and 6.4% reported both. The prevalence of restless leg syndrome, nocturnal gastroesophageal reflux, difficulties initiating and maintaining sleep and nocturnal sweating was higher among subjects reporting feeling sleepy compared to non-sleepy subjects. Also, subjects reporting feeling sleepy had poorer quality of life and reported more often feeling unrested during the day than non-sleepy subjects. However, subjects reporting increased risk of dozing off (ESS > 10) without feeling sleepy had a similar symptom profile as the non-sleepy subjects. Therefore, reporting only risk of dozing off without feeling sleepy may not reflect problematic sleepiness and more instruments in addition to ESS are needed when evaluating daytime sleepiness.

Excessive daytime sleepiness in asthma: What are the risk factors?

OBJECTIVE

Previous studies have found that excessive daytime sleepiness (EDS) is a more common problem in asthmatic subjects than in the general population. The aim of this study was to investigate whether the prevalence of EDS is increased in asthmatic subjects and, if so, to analyse the occurrence of potential risk factors for EDS in asthmatics.

METHODS

Cross-sectional epidemiological study. In 2008, a postal questionnaire was sent out to a random sample of 45,000 individuals aged 16-75 years in four Swedish cities.

RESULTS

Of the 25,160 persons who participated, 7.3% were defined as having asthma. The prevalence of EDS was significantly higher in asthmatic subjects (42.1% vs. 28.5%, p < 0.001) compared with non-asthmatic subjects. Asthma was an independent risk factor for EDS (adjusted OR 1.29) and the risk of having EDS increased with asthma severity. Risk factors for EDS in subjects with asthma included insomnia (OR, 3.87; 95% CI, 3.10-4.84); chronic rhinosinusitis (OR, 2.00; 95% CI, 1.53-2.62); current smoking (OR, 1.60; 95% CI, 1.15-2.22) and obesity (OR, 1.53; 95% CI, 1.09-2.13).

CONCLUSIONS

EDS is a common problem among subjects with asthma. Asthma is an independent risk factor for having EDS. Furthermore, subjects with asthma often have other risk factors for EDS, many of them potentially modifiable.

Treatment of Snoring with a Nasopharyngeal Airway Tube

Objective. To study the feasibility of a standard nasopharyngeal airway tube (NPAT) as treatment for snoring. Methods. An obese 35-year-old man, who is a chronic, heroic snorer, used NPATs while (1) the patient's bedpartner scored the snoring and (2) the patient recorded himself with the smartphone snoring app “Quit Snoring.” Baseline snoring was 8–10/10 (10 = snoring that could be heard through a closed door and interrupted the bedpartner's sleep to the point where they would sometimes have to sleep separately) and 60–200 snores/hr. Several standard NPATs were tested, consisting of soft polyvinyl chloride material raging between 24- and 36-French (Fr) tubes. Results. The 24 Fr tube did not abate snoring. The 26 Fr tube was able to abate the snoring sound most of the night (smartphone app: 11.4 snores/hr, bedpartner VAS = 2/10). The 28 and 30 Fr tubes abated the snoring sound the entire time worn (smartphone app: 0 snores, bedpartner VAS 0/10) but could not be tolerated more than 2.5 hours. The tube of 36 Fr size could not be inserted, despite several attempts bilaterally. Conclusion. Appropriately sized nasopharyngeal airway tubes may abate the snoring sound; however, as in this patient, they may be too painful and intolerable for daily use.

Meta-analysis of the effect of proton pump inhibitors on obstructive sleep apnea symptoms and indices in patients with gastroesophageal reflux disease

This study was designed to assess evidence for an association between the treatment of gastroesophageal reflux disease (GERD) with proton pump inhibitors (PPIs) and improvement in obstructive sleep apnea (OSA). We conducted a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies to evaluate the treatment effect of PPIs on OSA symptoms and indices in patients with GERD. EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were reviewed up to October 2014. From 238 articles, two randomized trials and four prospective cohort studies were selected. In four cohort studies there were no differences in the apnea-hypopnea indices before and after treatment with PPIs (standard mean difference, 0.21; 95% confidence interval, -0.11 to 0.54). There was moderate heterogeneity among these studies. Two cohort studies revealed significantly decreased apnea indices after treatment (percent change, 31% and 35%), but one showed no significant difference. A significant improvement in the Epworth Sleepiness Scale was observed in three cohort studies and one trial. The frequency of apnea attacks recorded in diaries was decreased by 73% in one trial. In conclusion, available studies do not provide enough evidence to make firm conclusions about the effects of PPI treatment on OSA symptoms and indices in patients with concomitant GERD. Controlled clinical trials with larger sample sizes are needed to evaluate these associations. We recommend PPIs in OSA patients with concomitant GERD to treat reflux symptoms. This treatment may improve the quality of sleep without any effect on apnea-hypopnea indices.

Predictors for Development of Excessive Daytime Sleepiness in Women: A Population-Based 10-Year Follow-Up

STUDY OBJECTIVES

To analyze predictors of excessive daytime sleepiness (EDS) and to analyze how changes within risk factors over time predict incident EDS in women.

DESIGN

Population-based prospective study.

SETTING

General population of the City of Uppsala, Sweden.

PARTICIPANTS

From a random, general population sample of 7,051 women from the Sleep and HEalth in women ("SHE") cohort, 4,322 women without EDS at baseline were followed up after 10 y.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

At baseline and follow-up, women answered a questionnaire on sleeping habits, somatic disease, obesity, insomnia, anxiety and depression, lifestyle, and social factors. The risk of incident EDS was analyzed from changes over time in risk factors using logistic regression modeling. Of the women, EDS developed in 7.9%. Incident: insomnia (adjusted odds ratio = 5.01; 95% confidence interval 3.63-6.92), anxiety and/or depression (3.34; 2.22-5.02), somatic disease (1.73; 1.17-2.55), obesity (1.91; 1.14-2.57), snoring (1.91; 1.17-3.10) and smoking (4.31; 1.95-9.54) were all independent risk factors for the development of EDS. In addition, persistent: insomnia (4.44; 2.97-6.65) and anxiety and/or depression (4.91; 3.17-7.62) increased the risk of developing EDS. Apart from incident: snoring and obesity, similar results were obtained when only including women without somatic disease in the analyses.

CONCLUSION

Insomnia, anxiety and/or depression, and smoking were the most important factors for predicting incident excessive daytime sleepiness (EDS) and, in addition, somatic disease, obesity, and snoring predicted EDS. It is important not only to treat these conditions but also to inform women of the importance of a healthy lifestyle in order to prevent and reduce EDS in women.

Atypical symptoms and health-related quality of life of patients with asymptomatic reflux esophagitis

BACKGROUND AND AIM

Asymptomatic reflux esophagitis (RE) is simply regarded as RE without the typical reflux symptoms, but it is unknown whether patients with asymptomatic RE have atypical symptoms. The aim of this study was to examine the clinical characteristics and health-related quality of life (HRQOL) of patients with asymptomatic RE.

PATIENTS AND METHODS

Consecutive patients with RE were enrolled during January 2010 to August 2012, and of them, 41 who had taken acid-suppressing drugs were excluded, leaving 280 patients as the study group. The patients' symptoms were evaluated using a self-completed questionnaire (modified Frequency Scale for the Symptoms of gastroesophageal reflux disease [FSSG]), as well as an HRQOL questionnaire (SF-8). We defined the typical symptoms of RE as heartburn and regurgitation. Asymptomatic RE was defined if the total symptom score was 0 or the minimum (1 point) for typical reflux symptoms in the modified FSSG.

RESULTS

Of the 280 RE patients, 71.8% (n = 201) were symptomatic and 28.2% (n = 79) were asymptomatic. The atypical symptom scores were significantly lower in asymptomatic RE (2.2 ± 2.2) than in symptomatic RE patients (6.9 ± 5.2) (P < 0.0001), and the HRQOL scores were significantly higher in asymptomatic RE than in symptomatic RE (P < 0.0001). Sleep was significantly less disturbed and chronic cough less frequent in asymptomatic RE than in symptomatic RE.

CONCLUSION

Frequency and severity of atypical symptoms in patients with asymptomatic RE were significantly less than in patients with symptomatic RE, and the HRQOL score was significantly higher in those patients. These observations suggest a specific patient cohort that is truly unlikely to manifest symptoms.

Naps are associated more commonly with gastroesophageal reflux, compared with nocturnal sleep

BACKGROUND & AIMS

Acid reflux during nighttime sleep has been associated with more severe gastroesophageal reflux disease (GERD). Napping is common, especially after lunch time, in many cultures. We aimed to compare reflux characteristics between nighttime sleep and naps in patients with GERD.

METHODS

We performed a study of 15 patients (mean age, 58.5 ± 18.4 y; 10 men) with heartburn and/or regurgitation at least 3 times/week for the past 3 months, who experienced a nap in addition to regular nighttime sleep. All were evaluated using the demographics and GERD Symptoms Checklist questionnaires. Patients underwent pH testing concomitantly with actigraphy when they were not receiving antireflux treatment; only patients with abnormal results from pH tests were included in the study. Raw data from actigraphy analyses were superimposed over those collected from pH monitoring, matched by time. Integrative software was used to determine recumbent-awake, recumbent-asleep, and naps alongside pH monitoring data.

RESULTS

The mean duration of nocturnal sleep time and nap time were 446.0 ± 100.7 minutes and 61.9 ± 51.8 minutes, respectively. The mean number of reflux events per hour was significantly greater during nap than nocturnal sleep time (40.1 ± 69.9/h vs 3.5 ± 4.2/h; P < .05). The mean duration of reflux events was longer during nap than nocturnal sleep time (1.9 ± 2.8 min vs 1.5 ± 2.7 min). The percentage of time spent at a pH less than 4 was significantly greater during naptime than nocturnal sleep time (36.2% ± 38.8% vs 8.9% ± 11.6%; P < .05). Arousals from naps were rare, compared with nocturnal sleep (mean, 0.7 ± 1.1 vs 4.2 ± 2.9; P < .05). Patients also experienced more acid reflux associated with symptoms during nap than nocturnal sleep (mean, 8.08% vs 0.45%; P < .05).

CONCLUSIONS

We associated naps with significantly greater numbers of, and duration of, esophageal acid exposure and symptoms, compared with nocturnal sleep. Naps therefore might have important effects on disease severity.

Esophageal Reflux Disease Proton Pump Inhibitor Therapy Impact on Sleep Disturbance

Objective. To perform a systematic literature review that evaluates the impact of proton pump inhibitor treatment of gastroesophageal reflux disease on sleep disturbance–related outcomes.

Data Sources. PubMed, Web of Science, and Cochrane databases were searched from 1989 (when omeprazole became available) to present; additional references gleaned from citations.

Review Methods. The search strategy identified all randomized placebo-controlled clinical trials published in English; both proton pump inhibitor use and outcome measures of sleep disturbance were reported for esophageal reflux disease patients. Using a preestablished systematic review protocol and data extraction format, 4 coauthors independently reviewed all articles.

Results. The original search identified 20 articles; 9 were not directly relevant, and 3 were not placebo controlled. Sample sizes varied from 15 to 642; mean age was 47.4 ± 4.56 years; mean body mass index was 29.4 ± 2.9; the proportion of women varied widely across studies. Esomeprazole was studied most frequently. More than 50% of publications permitted rescue antacids. Two studies reported polysomnography outcomes, without statistically significant improvement. All studies reported non-polysomnography outcomes; 7 identified statistically significant improvements demonstrating drug treatment superiority over placebo.

Conclusion. The existing evidence supports the use of proton pump inhibitors as a treatment for esophageal reflux disease to improve quality-of-life sleep disturbance–related outcomes. Given the wide variability in proton pump inhibitor treatments and sleep disturbance–related outcomes reported, however, study-specific results cannot be directly compared or aggregated. This conclusion appears robust not only for 7 of 8 studies included but also for the 3 highest quality studies.

Analysis of 24-hour esophageal pH monitoring: the effect of state of consciousness

This review addresses current advances in the diagnosis of sleep-related gastroesophageal reflux using ambulatory esophageal pH monitoring and laboratory monitoring, which includes polygraphic assessment of the state of consciousness. This 24-hour pH monitoring uses a new strategy of interpretation that characterizes acidic reflux events and specifically assesses the patient's position and state of consciousness. Thus, the recognition of reflux events during waking and sleep will add to the overall assessment of gastroesophageal reflux and its severity and clinical relevance. The pH testing, together with overnight polysomnography, offers an opportunity to link nighttime reflux with disease severity. The application of multichannel impedance with pH monitoring allows detection of acidic and nonacidic reflux events during sleep and also helps to elucidate the physiologic response of the esophagus to these events during sleep. The significance of these findings will increase our knowledge of esophageal physiology and the pathologic mechanisms underlying gastroesophageal reflux disease.

Occurrence of nighttime gastroesophageal reflux in disturbed and normal sleepers

BACKGROUND & AIMS

It is not uncommon in a sleep laboratory to encounter individuals who have complaints of disturbed sleep, but who do not meet the criteria for a sleep disorder when evaluated by polysomnography. Because gastroesophageal reflux is known to occur in many individuals without their awareness, it is possible that some of these individuals might be suffering from reflux that is disturbing their sleep.

METHODS

Eighty-one individuals with complaints of disturbed or unrefreshing sleep, but no complaints of heartburn, were recruited. A comparison group of 39 individuals with neither sleep nor heartburn complaints also was studied. Both groups were studied on 2 separate occasions by simultaneous polysomnography and pH monitoring to detect the presence of nighttime gastroesophageal reflux and to determine sleep outcomes.

RESULTS

In the disturbed-sleep group 27% of subjects had at least one reflux event compared with 33% in the normals. In the subjects who experienced reflux, the disturbed-sleep group had a significantly greater percentage of acid exposure time compared with the normals (9.5% vs 1.6%; P < .05). Participants in the disturbed-sleep group also had a longer sleep-onset latency (P < .05) and less total sleep time (P < .05) compared with the normal sleepers.

CONCLUSIONS

Among individuals with complaints of disturbed sleep, there was a subset of individuals who had significant gastroesophageal reflux. We speculate that sleep-related gastroesophageal reflux may play a role in producing disturbed sleep in individuals without heartburn and otherwise unexplained sleep disturbance.

From wakefulness to excessive sleepiness: what we know and still need to know

The epidemiological study of hypersomnia symptoms is still in its infancy; most epidemiological surveys on this topic were published in the last decade. More than two dozen representative community studies can be found. These studies assessed two aspects of hypersomnia: excessive quantity of sleep and sleep propensity during wakefulness excessive daytime sleepiness. The prevalence of excessive quantity of sleep when referring to the subjective evaluation of sleep duration is around 4% of the population. Excessive daytime sleepiness has been mostly investigated in terms of frequency or severity; duration of the symptom has rarely been investigated. Excessive daytime sleepiness occurring at least 3 days per week has been reported in between 4% and 20.6% of the population, while severe excessive daytime sleepiness was reported at 5%. In most studies, men and women are equally affected. In the International Classification of Sleep Disorders, hypersomnia symptoms are the essential feature of three disorders: insufficient sleep syndrome, hypersomnia (idiopathic, recurrent or posttraumatic) and narcolepsy. Insufficient sleep syndrome and hypersomnia diagnoses are poorly documented. The co-occurrence of insufficient sleep and excessive daytime sleepiness has been explored in some studies and prevalence has been found in around 8% of the general population. However, these subjects often have other conditions such as insomnia, depression or sleep apnea. Therefore, the prevalence of insufficient sleep syndrome is more likely to be between 1% and 4% of the population. Idiopathic hypersomnia would be rare in the general population with prevalence, around 0.3%. Narcolepsy has been more extensively studied, with a prevalence around 0.045% in the general population. Genetic epidemiological studies of narcolepsy have shown that between 1.5% and 20.8% of narcoleptic individuals have at least one family member with the disease. The large variation is mostly due to the method used to collect the information on the family members; systematic investigation of all family members provided higher results. There is still a lot to be done in the epidemiological field of hypersomnia. Inconsistencies in its definition and measurement limit the generalization of the results. The use of a single question fails to capture the complexity of the symptom. The natural evolution of hypersomnia remains to be documented.

Randomized placebo-controlled trial of pantoprazole for daytime sleepiness in GERD and obstructive sleep disordered breathing

OBJECTIVE: To determine the efficacy of pantoprazole therapy for daytime somnolence, psychomotor vigilance, and quality of life in patients with mild-moderate obstructive sleep disordered breathing (OSDB) and gastroesophageal reflux disease (GERD).

STUDY DESIGN: Randomized, double-blind, placebo-controlled crossover trial.

METHODS: Sixty patients with daytime sleepiness, mildmoderate OSDB and GERD were randomly assigned a 2-week treatment with pantoprazole 40 mg or placebo followed by a 2-week washout period and crossover respectively to 2-week treatment with placebo or pantoprazole. Outcomes included Epworth Sleepiness Score (ESS), sleep-related quality-of-life (FOSQ), and reaction time.

RESULTS: With pantoprazole, patients reported statistically significantly greater improvement of overall reflux symptoms ( P = 0.0003) and in ESS ( P = 0.04). A significant improvement was noted in FOSQ for both treatments with a trend toward greater improvement with pantoprazole ( P = 0.058). No improvement in reaction times was observed.

CONCLUSION: Patients with coexistent GERD and OSDB noted significant improvement in daytime sleepiness after treatment with pantoprazole over placebo likely related to a reduction in nocturnal reflux-related arousals.

Risk factors and correlates of snoring and observed apnea

BACKGROUND AND PURPOSE

Risk factors and correlates of snoring and observed apnea in the population are not well known. This study aimed to assess risk factors and correlates of snoring and observed apnea.

METHODS

Parents and grandparents of students from 20 randomly selected primary schools in urban and rural areas of Kirikkale, Turkey were asked about respiratory diseases, psychological distress and sleep-related disorders, using the Respiratory Questionnaire, Hospital Anxiety and Depression (HAD) scale and Sleep Questionnaire, respectively, which were returned by their children.

RESULTS

Out of 13,225 parents and grandparents of primary school students 12,270 returned the questionnaires, for an overall response rate of 92.7%. Snoring and the observed apnea were more prevalent among subjects from rural than those from urban areas (52.6% vs. 46.6%, odds ratio (OR): 1.2, p<0.001 and 16.2% vs. 10.1%, OR: 1.7, p<0.001, respectively). Exposure to biomass smoke and smoking were associated with an increased risk of snoring and observed apnea, after adjusting for gender, age, body mass index, income and education in the multivariate linear model. In all subjects, increases in performance ability, daytime sleepiness, psychological distress and dyspnea scores observed in categories indicating increases in snoring intensity and observed apnea frequency constituted a trend but did always not reach statistical significance. Lastly, prevalence of traffic accidents, falling asleep at the wheel and morning headaches increased with the increments of snoring intensity and apnea frequency.

CONCLUSIONS

Exposure to biomass smoke in rural areas may account for the higher prevalence of snoring and observed apnea. Snoring intensity and observed apnea frequency may increase prevalence of traffic accidents along with many unfavorable symptoms.

Sleep symptoms and gastroesophageal reflux

BACKGROUND

This study was to determine whether patients with significant nighttime heartburn had more disturbed sleep and more gastroesophageal acid reflux than those without significant nighttime heartburn.

METHODS

Thirty-three reflux patients were stratified into 2 groups (nighttime heartburn, without nighttime heartburn). All patients completed questionnaires assessing daytime and nighttime heartburn and subjective sleep by Pittsburgh Sleep Quality Index. All participants underwent 24-hour esophageal pH monitoring and an overnight polysomnographic study.

RESULTS

The number of reflux events longer than 5 minutes was significantly greater in patients with nighttime heartburn than in those without nighttime heartburn for the total (P=0.004) and upright (P=0.01) position periods. Acid contact time was significantly greater in patients with nighttime heartburn during the upright (P=0.003) period and during the total (P=0.001) period. Patients with nighttime heartburn reported significantly greater subjective sleep impairment (8.1+/-0.7) than those without nighttime heartburn (6.1+/-0.4; P=0.02), but no difference could be observed in any objective sleep parameter by an overnight polysomnographic study between the groups.

CONCLUSIONS

Patients with significant nighttime heartburn seem to have more acid reflux compared with those without nighttime heartburn. Nighttime heartburn together with sleep complaints is associated with excessive gastroesophageal reflux.

Sonolência excessiva diurna na população geral de um município brasileiro

OBJETIVO: Buscou-se avaliar a prevalência da sonolência excessiva diurna (SED) na população geral de um município brasileiro. MÉTODO: Foram feitas 198 entrevistas domiciliares entre os adultos, em amostra representativa da população geral de Ribeirão do Largo, BA. A amostragem foi aleatória simples. Tinham SED as pessoas com 11 ou mais pontos na Escala de Sonolência de Epworth (ESE). Usaram-se os testes de qui-quadrado, Fisher e ANOVA; nível de significância 5%. RESULTADOS: Tinham SED 21,5% da população (DP = 2,9%; IC 15,8% a 27,2%); não houve associação significativa entre SED e idade (p = 0,924), nem IMC (p = 0,197), sexo (p = 0,095), instrução (p = 0,700), estado civil (p = 0,414) e uso de hipnóticos (p = 0,176). Houve associação com o despertar precoce (p = 0,046). CONCLUSÃO: Foi alta a prevalência de SED na população estudada.

The effect of 1 week of continuous positive airway pressure treatment in obstructive sleep apnea patients with concomitant gastroesophageal reflux

STUDY OBJECTIVES

Patients with obstructive sleep apnea (OSA) have a very high incidence of gastroesophageal reflux (GER). Previous studies have shown that the use of continuous positive airway pressure (CPAP) reduces the frequency of reflux events, but these studies only assessed the effect of a single night of treatment. The aim of this study was to assess the effect of 1 week of CPAP treatment on reflux in patients with OSA and GER.

DESIGN

Sixteen patients with OSA and GER were recruited. Polysomnography followed by 24-h, continuous esophageal pH monitoring were performed at baseline. Patients with an apnea-hypopnea index (AHI) > 20/h and 24-h acid contact time (ACT) of at least 6% were included. As part of the polysomnography-qualifying evaluation, all patients underwent CPAP titration to reduce the AHI to < 10/h. Patients were then sent home receiving nasal CPAP for 1 week; after 1 week, esophageal pH monitoring was repeated while receiving CPAP.

MEASUREMENTS AND RESULTS

The AHI fell from 63.3 +/- 38.5 to 3.2 +/- 2.2/h (mean +/- SD) [p < 0.001]. Total ACT fell from 13.9 +/- 11.6 to 5.6 +/- 2.7% (p < 0.001). The upright ACT was reduced from 12.4 +/- 6.8 to 6.8 +/- 3.8% (p = 0.01), and the supine (during the sleeping interval) ACT was reduced from 16.3 +/- 18.8 to 3.8 +/- 7.6% (p < 0.01). Eighty-one percent of the patients had a reduction in supine ACT to within the normal range (< 4%).

CONCLUSIONS

In OSA patients with significant heartburn complaints, CPAP would appear to be an efficacious approach to the treatment of both disorders.

Correlates of daytime sleepiness in patients with asthma

BACKGROUND AND PURPOSE

Patients with asthma often complain of daytime sleepiness, which is usually attributed to a direct effect of asthma on nocturnal sleep quality. We investigated this and other potential explanations for daytime sleepiness among asthmatics.

PATIENTS AND METHODS

One hundred fifteen adult asthmatics were assessed for perceived daytime sleepiness (one question item), subjective sleepiness (Epworth Sleepiness Scale score, ESS), obstructive sleep apnea risk (Sleep Apnea scale score within Sleep Disorders Questionnaire, SA-SDQ), asthma severity step, relevant comorbid conditions, and current asthma medications.

RESULTS

Among all subjects, 55% perceived excessive daytime sleepiness and 47% had ESS>10. Most subjects reported snoring (n=99, or 86%) and many snored habitually (n=44, 38%). The ESS correlated with SA-SDQ (P<0.0001), male gender (P=0.01), and asthma severity step (P=0.04). In a multiple regression model, the ESS was independently associated with SA-SDQ (P=0.0003) and male gender (P=0.02), but not with asthma severity step (P=0.51). There were no correlations between ESS and age, body mass index (BMI), forced expiratory volume in one second as percent of predicted value (FEV(1)%), comorbidities, or medication used to treat asthma.

CONCLUSIONS

Sleepiness is common in asthmatics and may reflect occult obstructive sleep apnea more often than effects of asthma itself, other comorbid conditions, or asthma medications.

Lipid-laden alveolar macrophage index in sputum is not useful in the differential diagnosis of pulmonary symptoms secondary to gastroesophageal reflux

BACKGROUND

Gastroesophageal reflux (GER) is frequently associated with pulmonary diseases. Esophageal acid-induced bronchoconstriction and recurrent microaspirations of gastric content are the proposed mechanisms. At present there is not a sensitive test available to prove a causal relationship between pulmonary symptoms and GER. In this study we aimed to investigate the value of a marker of aspiration: lipid-laden alveolar macrophage index (LLAM) in induced sputum, in the diagnosis of pulmonary symptoms highly suspected to be due to GER.

METHODS

Twenty-two patients with the endoscopic diagnosis of erosive esophagitis who had various pulmonary symptoms that could not be attributed to any apparent etiology constituted the study group. Fifteen healthy volunteers with no prior diagnosis of gastroesophageal and lung disease constituted the control group. Subjects were questioned for pulmonary and abdominal symptoms and underwent physical examination, chest radiography, pulmonary function tests, and sputum induction. Prepared cytospins were stained with oil red-O to detect cytoplasmic lipid droplets and LLAM index was calculated.

RESULTS

There was no statistically significant difference between the LLAM indexes of the study (1.9 +/- 3.3) and control group (4.2 +/- 4.5). LLAM index had a significant positive correlation with the duration of reflux symptoms (p=0.01, r=0.5).

CONCLUSIONS

LLAM index is not found to be a valuable method in the differential diagnosis of pulmonary symptoms suspected to be due to GER.

Insomnia is more common among subjects living in damp buildings

BACKGROUND

Insomnia is a condition with a high prevalence and a great impact on quality of life. Little is known about the relation between and sleep disturbances and the home environment.

AIM

To analyse the association between insomnia and building dampness.

METHODS

In a cross-sectional, multicentre, population study, 16 190 subjects (mean age 40 years, 53% women) were studied from Reykjavik in Iceland, Bergen in Norway, Umeå, Uppsala, and Göteborg in Sweden, Aarhus in Denmark, and Tartu in Estonia. Symptoms related to insomnia were assessed by questionnaire.

RESULTS

Subjects living in houses with reported signs of building dampness (n = 2873) had a higher prevalence of insomnia (29.4 v 23.6%; crude odds ratio 1.35, 95% CI 1.23 to 1.48). The association between insomnia and different indicators of building dampness was strongest for floor dampness: "bubbles or discoloration on plastic floor covering or discoloration of parquet floor" (crude odds ratio 1.96, 95% CI 1.66 to 2.32). The associations remained significant after adjusting for possible confounders such as sex, age, smoking history, housing, body mass index, and respiratory diseases. There was no significant difference between the centres in the association between insomnia and building dampness.

CONCLUSION

Insomnia is more common in subjects living in damp buildings. This indicates that avoiding dampness in building constructions and improving ventilation in homes may possibly have a positive effect on the quality of sleep.

The effect of acid suppression on sleep patterns and sleep-related gastro-oesophageal reflux

BACKGROUND

Several studies have demonstrated that night-time gastro-oesophageal reflux affects sleep quality, and thereby impairs daytime functioning.

AIM

To determine whether treatment with a proton-pump inhibitor (rabeprazole) would improve both objective and subjective measures of sleep.

METHODS

Individuals with complaints of significant gastro-oesophageal reflux disease were studied by polysomnography and 24-h pH monitoring on two separate nights. On one occasion, participants received 20 mg rabeprazole b.d., and on another they received placebo. Both study conditions were preceded by a week of treatment with either rabeprazole or placebo. The order of treatments was randomized.

RESULTS

Rabeprazole significantly reduced overall acid reflux, but it did not significantly reduce night-time acid contact. Rabeprazole treatment significantly improved subjective indices of sleep quality. There were no significant differences on objective measures of sleep between placebo and rabeprazole treatment.

CONCLUSIONS

Consistent with other studies of pharmacological treatments for gastro-oesophageal reflux, subjective measures of sleep improved with heartburn medication but objective measures were not affected.

Review article: impact of night-time reflux on lifestyle - unrecognized issues in reflux disease

Gastro-oesophageal reflux disease (GERD), manifesting with symptoms including heartburn and regurgitation, affects people during both daytime and nocturnal hours. Night-time GERD has been reported to have a greater impact on a patient's life than daytime GERD due to prolonged oesophageal acid exposure time per reflux episode. To further understand this issue, it is important to implement quality of life (QOL) measures. QOL studies are becoming increasingly important to physicians in making clinical decisions, and generic and disease-specific health-related QOL (HRQL) tools have been developed to measure a wide variety of topics. There are currently no universally accepted guidelines on how to best measure HRQL in GERD patients. It is important to note that these surveys may not yield accurate results because many GERD sufferers may feel that their symptoms are not serious enough to seek treatment. Some surveys include the GERD-HRQL assessment, the Short Form Health Survey (SF-36), and the Gallup survey. When compared with daytime GERD patients, night-time GERD patients may suffer from sleep deprivation, which in turn leads to physical and emotional problems and a poor overall QOL. Studies indicate that the prevalence and impact of night-time heartburn have been underestimated and that adequate treatment of symptoms is often not achieved. In addition, GERD greatly affects work productivity and leads to a significant economic burden on society. Although limited studies are available on the impact of pharmacological treatment on GERD QOL, recent findings indicate that proton pump inhibitors are more effective than H(2)-receptor antagonists for the improvement of overall QOL.

Symptomatic gastro-oesophageal reflux, arousals and sleep quality in patients undergoing polysomnography for possible obstructive sleep apnoea

INTRODUCTION

Nocturnal acid reflux is common and could disturb sleep by causing arousals that fragment sleep.

AIM

To determine the prevalence of gastro-oesophageal reflux symptoms and their association with arousals, stages of sleep and quality of life in patients undergoing evaluation for excessive daytime sleepiness and obstructive sleep apnoea.

METHODS

Ninety-four consecutive patients with excessive daytime sleepiness were prospectively studied. Patients completed the gastrointestinal symptom rating scale, a validated symptom questionnaire for reflux disease and a disease-specific quality of life questionnaire, the sleep apnoea quality of life index and then underwent overnight polysomnography, which was read in a blinded manner.

RESULTS

There were 40 males and 54 females with a mean age of 47 +/- 13 years. Reflux symptoms were present in 63 of the 94 (67%) patients. Patients with reflux symptoms had significantly more arousals from sleep 43 +/- 70/h than those without (20 +/- 24/h; P = 0.03). The sleep duration during the second stage of sleep was shorter (44 +/- 21%) for those with reflux symptoms than those without (52 +/- 12%; P = 0.03). Patients with reflux spent significantly shorter periods in stage II sleep (44 +/- 21%) than those without (52 +/- 12%; P = 0.03). The sleep-related quality of life score in patients with gastro-oesophageal reflux (3.1 +/- 1.1) was significantly lower than in patients without reflux (3.7 +/- 1.0; P = 0.02). Regression analysis demonstrated a significant inverse correlation between quality of life and reflux symptom score (P =0.002) and total spontaneous arousals (P = 0.04).

CONCLUSIONS

Gastro-oesophageal reflux is common in patients with sleep disorders, is associated with increased arousal, decreased durations spent in the deeper stages of sleep and poorer sleep-related quality of life.

Pantoprazole for Sleepiness Associated with Acid Reflux and Obstructive Sleep Disordered Breathing

OBJECTIVE

To determine the effectiveness of Pantoprazole (Wyeth Pharmaceuticals Inc., Philadelphia, PA) therapy for daytime sleepiness in patients with symptoms of acid reflux and obstructive sleep-disordered breathing (OSDB).

STUDY DESIGN

Prospective interventional cohort study.

METHODS

Twenty-seven adult subjects (67% men) with symptoms of acid reflux disease and mild to moderate OSDB were included in a 3-month study of proton pump inhibitor therapy (Pantoprazole 40 mg once daily). Primary outcomes included changes in daytime sleepiness, reflux symptoms, and bed partner assessment of snoring. Secondary outcomes included changes in snoring quantification, apnea, and apnea-hypopnea indices (AHI) with SNAP Laboratories (Glenview, IL) home sleep study and self-reported global symptom improvement.

RESULTS

At baseline, patients were typically middle-aged, obese men with mild to moderate sleep apnea (mean AHI = 15) with excessive daytime somnolence (mean Epworth Sleepiness Score = 13). After 3-month treatment with Pantoprazole, a statistically significant improvement was noted for daytime sleepiness (P = .002) and total reflux symptoms (P = .0006). Subjects also reported a significant reduction in reflux awakening them from sleep (P < .0001). Bed-partner assessment of snoring significantly improved (P = .03); however, no significant improvements were noted in snoring quantification, apnea, or AHI. When compared with a disease-severity matched historic placebo-control group, this cohort demonstrated a significantly greater reduction in daytime sleepiness (P = .04).

CONCLUSIONS

This cohort of subjects had significant improvements in daytime sleepiness and reflux symptoms, including reflux awakening from sleep, with Pantoprazole therapy. Further controlled studies are indicated to confirm these results. Improvement in daytime somnolence likely resulted from a reduction in reflux-related arousals because no improvements occurred in OSDB.

The influence of active and passive smoking on habitual snoring

The impact of active smoking, passive smoking, and obesity on habitual snoring in the population is mainly unknown. We aimed to study the relationship of habitual snoring with active and passive tobacco smoking in a population-based sample. A total of 15,555 of 21,802 (71%) randomly selected men and women aged 25-54 years from Iceland, Estonia, Denmark, Norway, and Sweden answered a postal questionnaire. Habitual snoring, defined as loud and disturbing snoring at least 3 nights a week, was more prevalent among current smokers (24.0%, p < 0.0001) and ex-smokers (20.3%, p < 0.0001) than in never-smokers (13.7%). Snoring was also more prevalent in never-smokers exposed to passive smoking at home on a daily basis than in never-smokers without this exposure (19.8% vs. 13.3%, p < 0.0001). The frequency of habitual snoring increased with the amount of tobacco smoked. Active smoking and passive smoking were related to snoring, independent of obesity, sex, center, and age. Ever smoking accounted for 17.1% of the attributable risk of habitual snoring, obesity (body mass index > or = 30 kg/m(2)) for 4.3%, and passive smoking for 2.2%. Smoking, both current and ex-smoking, is a major contributor to habitual snoring in the general population. Passive smoking is a previously unrecognized risk factor for snoring among adults.

Severity of gastroesophageal reflux disease influences daytime somnolence: A clinical study of 134 patients underwent upper panendoscopy

AIM: To asses the relationship between severity of gastroesophageal refluxe disease and Epworth sleepiness scale as an indicator of daytime somnolence.

METHODS: One hundred and thirty-four patients underwent an upper panendoscopy as indicated by the typical reflux symptoms and were also investigated with regard to somnolence. Sleepiness was evaluated by Epworth Sleepiness Scale, which was compared to the severity of endoscopic findings (Savary-Miller/modified by Siewert). Patients with psychiatric disorders or being on sedato-hypnotics as well as shift workers were excluded from the study. The relationship between the severity of the reflux disease and daytime somnolence was analyzed with the help of multivariate regression analysis.

RESULTS: A positive tendency was found between the severity of the reflux disease and the corresponding Epworth Sleepiness Scale. In the case of the more severe type-Savary-Miller III-at least a mild hypersomnia was found. For this group daytime somnolence was significantly higher than in the case of the non-erosive type of Gastroesophageal Reflux Disease representing the mildest stage of reflux disease.

CONCLUSION: The severity of Gastroesophageal Reflux Disease influences daytime somnolence.

Prevalence of excessive daytime sleepiness and associated factors in a Brazilian community: the Bambuı́ study

BACKGROUND AND PURPOSE

Population-based studies of excessive daytime sleepiness (EDS) among adults residing in communities in developing countries are scarce. The objectives of the present study were to determine the prevalence of EDS in a Brazilian town with 15,000 inhabitants (Bambuí, MG), and the socio-demographic characteristics associated with it.

PATIENTS AND METHODS

In this study, 87.3% of 1221 randomly selected individuals aged 18+ participated. EDS was defined as the presence of sleepiness during the previous month, occurring three or more times per week, with consequent impairment of daily activities.

RESULTS

EDS was reported by 16.8% of the participants. There was no association with age groups (P=0.978). Higher prevalence of EDS was seen for women than for men in the following age groups: 18-29, 45-59 and 60+. After adjustment for gender, only family income was associated with EDS. Complaints of insomnia and the use of medicine to improve sleep during the previous month were more frequent among individuals with EDS than among those without it. Among those with EDS, 46.3% had been symptomatic for more than 1 year; 25 (2.34%) reported use of medication at some time in their lives to improve EDS.

CONCLUSION

Social differences (represented by a lower family income) were an observed factor in the distribution of EDS, as were gender and insomnia. The high prevalence of EDS indicates that it is an important health problem, even in a small community of a developing country.

Nighttime heartburn is an under-appreciated clinical problem that impacts sleep and daytime function: the results of a Gallup survey conducted on behalf of the American Gastroenterological Association

OBJECTIVE

Although a large body of information exists about the prevalence of gastroesophageal reflux disease (GERD) in general, available data specifically addressing nocturnal reflux are limited. Because nocturnal acid reflux is reported to be associated with more severe injuries such as esophagitis and stricture, as well as adenocarcinoma of the esophagus, a better understanding of the prevalence and impact of nighttime heartburn as a sign of nocturnal acid reflux events can have significant potential management implications. The aims of this study were to determine the prevalence of nighttime heartburn and reflux-attributed supraesophageal symptoms among patients with GERD; and the impact of nighttime heartburn on sleep and several activities of daily living that could affect quality of life.

METHODS

A nationwide telephone survey of 1000 adults experiencing heartburn at least once a week was conducted by the Gallup Organization on behalf of the American Gastroenterological Association.

RESULTS

Altogether, 79% of respondents reported experiencing heartburn at night. Among those, 75% reported that symptoms affected their sleep, 63% believed that heartburn negatively affected their ability to sleep well, and 40% believed that nocturnal heartburn impaired their ability to function the following day. Of the 791 respondents with nighttime heartburn, 71% reported taking over-the-counter medicine for it, but only 29% of these rated this approach extremely effective. Forty-one percent reported trying prescription medicines, and 49% of these rated this approach extremely effective.

CONCLUSIONS

Nighttime heartburn occurs in a large majority of adults with GERD, resulting in sleeping difficulties and impaired next-day function. The expected result from implemented therapy for heartburn is not achieved by a sizable percentage of patients.

Excessive daytime sleepiness in Campo Grande general population, Brazil

The prevalence of excessive daytime sleepiness (EDS) in general population was determined by means of 408 home interviews of adults, in a representative sample of Campo Grande city, Brazil. The random sample was stratified by sex, age and economic social status. EDS was considered in those with indexes 11 or more in the Epworth Sleepiness Scale. Statistics used chi-square, Fisher and Pearson tests; and inferences based on binomial distribution parameters; the significance level was 5% and confidence interval (CI) was 95%. The prevalence of EDS was 18.9% of the general population ( SD=1.9%; CI 15.1% to 22.7%). No significant association was found between EDS and the use of hypnotics, nor with insomnia, body mass index, sex, age, years of schooling, economic social status, marital status, occupation and the use of alternative means to improve sleep. When the sample was separated according to sex, only the male group showed significant association between EDS and actual insomnia (p=0.005).

Who are the "occasional" snorers?

STUDY OBJECTIVES

To assess the prevalence of occasional snoring in a group of middle-aged men, and to compare anthropometric variables and prevalence of sleep-related symptoms of subjects who occasionally snore with those of other snoring categories.

DESIGN

A field survey of a sample of middle-aged men in France.

PARTICIPANTS

Male employees of a local university and subjects from the community attending a preventive medicine center. Participation rate was 93.5%.

MEASUREMENTS

Anthropometric variables were recorded in 499 subjects aged 23 to 66 years (mean, 44.3 years). The subjects completed a standard sleep questionnaire and were classified according to the snoring frequency as never, rarely, sometimes, occasional, several nights per week, and every night. The subjects who snore occasionally represented 8.6% of the total.

RESULTS

The anthropometric data of subjects who snore occasionally were similar to those of subjects who habitually snore. When compared with subjects who do not snore, older age and a larger neck girth were significant. Subjects who snore occasionally were also significantly more often subjects who snore loudly, and tended more frequently to have breathing stops during sleep.

CONCLUSIONS

Our epidemiologic study shows that approximately 9% of a sample of middle-aged men snore occasionally. Subjects who snore occasionally have anthropometric characteristics close to those of subjects who snore habitually. The prevalence of the main sleep-related symptoms is between that of subjects who do not snore and of subjects who snore habitually. In an epidemiologic setting, inclusion of subjects who snore occasionally as subjects who do not snore or subjects who snore habitually will lead to bias. The present results suggest they should be identified and considered as a separate category.

Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder

STUDY OBJECTIVES

A link between gastroesophageal reflux (GER) and obstructive sleep apnea (OSA) has been suggested; however, the prevalence and frequency of symptomatic GER and the influence of OSA severity on GER are not known.

DESIGN AND PATIENTS

Two hundred seventy-one subjects referred for overnight sleep studies were investigated for subjects with a breathing sleep disorder, occurrence of symptomatic GER, potential risk factors for both conditions, and comorbidity using a validated questionnaire.

RESULTS

Overall, 160 of the 228 respondents (73%; 135 subjects with OSA and 93 subjects who snore) reported GER-related symptoms, with heartburn and/or acid regurgitation being the leading symptoms. No evidence of a difference in the occurrence of symptomatic GER between subjects who snore and subjects with OSA was observed (odds ratio [OR], 1.21; 95% confidence interval [CI], 0.7 to 2.1). Furthermore, the occurrence of reflux symptoms was not influenced by the severity of OSA (OR per 10 4% arterial oxygen saturation [SaO(2)] dips per hour, 0.98; 95% CI, 0.8 to 1.1). Self-reported comorbidity was higher in subjects with OSA compared with subjects who snore (p = 0.02), but none of the potential risks produced an association with the presence of reflux symptoms in this sample of patients with a breathing sleep disorder.

CONCLUSION

We conclude that symptomatic GER is common in subjects with a breathing sleep disorder, but there was no difference between those with OSA and subjects who snore.

Association of body mass index with respiratory symptoms and atopy: results from the European Community Respiratory Health Survey

BACKGROUND

There are several reports showing that obese adults report more respiratory symptoms suggestive of asthma than those who are not obese.

OBJECTIVE

To determine the association of body mass index with respiratory symptoms and atopy in young adults

METHOD

Information collected from 15,454 participants in the European Community Respiratory Health Survey, a multicentre cross-sectional survey of young adults, was analysed to determine the association of body mass index with respiratory symptoms and atopy.

RESULTS

Men and women with a body mass index of greater than 30 were at an increased risk of wheeze with shortness of breath compared with those with a body mass of 20-24.99 (OR in men 1.85, 95% confidence interval 1.41-2.42; OR in women 2.03, 95% confidence interval 1.59-2.58). Similar associations were observed for other symptoms suggestive of asthma. Body mass index was not associated with 'hayfever or nasal allergies', specific IgE to house dust mite, grass or cat or with total IgE in men or women.

CONCLUSION

Reported associations of body mass index with symptoms suggestive of asthma are unlikely to be explained by a higher risk of atopy in the obese. Alternative explanations must be sought.

Nocturnal worsening of asthma and sleep-disordered breathing

Asthma has a tendency, to destabilize and get worse at night, probably due to a nocturnal increase in airiway inflammation and bronchial responsiveness. Nocturnal airway narrowing in asthma is often associated with sleep disorders, such as episodes of nocturnal and early morning awakening, difficulty in maintaining sleep, and day time sleepiness. On the other hand, an association has been documented between nocturnal sleep-disordered breathing and asthma. This review highlights the causes of nocturnal worsening of asthma and examines the evidence pointing toward a causal relationship between nocturnal asthma and sleep-disordered breathing.

Respiratory symptoms and nocturnal gastroesophageal reflux: a population-based study of young adults in three European countries

STUDY OBJECTIVE

To estimate the possible association between reported symptoms of gastroesophageal reflux (GER) after bedtime, sleep-disordered breathing, respiratory symptoms, and asthma.

DESIGN

Cross-sectional international population survey.

PARTICIPANTS

Participants consisted of 2,661 subjects (age range, 20 to 48 years) from three countries (Iceland, Belgium, and Sweden), of whom 2,202 were randomly selected from the general population and 459 were added because of reported asthma.

MEASUREMENTS

The investigation included a structured interview, spirometry, methacholine challenge, peak flow diary, skin-prick tests, and a questionnaire on sleep disturbances.

RESULTS

In the random population sample, 101 subjects (4.6%) reported GER, which was defined as the occurrence of heartburn or belching after going to bed at least once per week. Subjects with nocturnal GER more often were overweight and had symptoms of sleep-disordered breathing than participants not reporting GER. Participants with GER were more likely to report wheezing (adjusted odds ratio [OR], 2.5), breathlessness at rest (adjusted OR, 2.8), and nocturnal breathlessness (adjusted OR, 2.9), and they had increased peak flow variability compared to the subjects without GER. Physician-diagnosed current asthma was reported by 9% of subjects with GER compared to 4% of those not reporting GER (p < 0.05). Subjects with the combination of asthma and GER had a higher prevalence of nocturnal cough, morning phlegm, sleep-related symptoms, and higher peak flow variability than subjects with asthma alone.

CONCLUSION

The occurrence of GER after bedtime is strongly associated with both asthma and respiratory symptoms, as well as symptoms of obstructive sleep apnea syndrome. The partial narrowing or occlusion of the upper airway during sleep, followed by an increase in intrathoracic pressure, might predispose the patient to nocturnal GER and, consequently, to respiratory symptoms.