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Narwade G, Madan M, Kumar R, Ish P, Mahendran AJ, Kaushik R, Gupta N. Clinical characteristics of non-sleepy obstructive sleep apnea patients: a study in a tertiary care sleep clinic in India. Monaldi Arch Chest Dis 2024. [PMID: 38738280 DOI: 10.4081/monaldi.2024.3031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024] Open
Abstract
Obstructive sleep apnea (OSA) encompasses a diverse population, manifesting with or without symptoms of excessive daytime sleepiness. There is contention surrounding the significance of non-sleepy OSA within clinical contexts and whether routine treatment is warranted. This study aims to evaluate epidemiological and clinical distinctions between sleepy and non-sleepy OSA patients. A retrospective analysis was conducted on consecutive patients undergoing polysomnography for OSA assessment at tertiary care hospitals between 2018 and 2023. For 176 of 250 patients, complete polysomnography records with OSA diagnoses were available. Non-sleepy OSA was defined when a patient had an Epworth sleepiness scale score <10 and polysomnography demonstrated an apnea hypopnea index ≥5/hour. Non-sleepy OSA patients were matched with sleepy OSA patients in terms of age and gender distribution (mean age 51.24±13.25 years versus 50.9±10.87 years, male 70.4% versus 73.3%). The sensitivity of STOP-BANG≥3 for the non-sleepy OSA group was 87.7%, 89.3%, and 95.2% for any OSA severity, moderate to severe OSA, and severe OSA, respectively, while the corresponding sensitivity for the sleepy OSA group was 96.5%, 98.6%, and 100% for any OSA severity, moderate to severe OSA, and severe OSA, respectively. A novel symptom scoring tool, HASSUN (hypertension, nocturnal apneas, snoring, sleep disturbance, unrefreshing sleep, and nocturia), demonstrated a sensitivity of over 90% for all severity categories of OSA in both non-sleepy and sleepy OSA groups. The prevalence of cardiovascular and metabolic comorbidities did not significantly differ between non-sleepy and sleepy OSA patients. The physiological parameters, including forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC ratio, arterial partial pressure of oxygen, and bicarbonate at baseline, were comparable between the two groups. To conclude, non-sleepy OSA patients are less obese, exhibit fewer symptoms, and have less severe OSA in comparison to sleepy OSA. Non-sleepy OSA patients display a similar likelihood of cardiovascular and metabolic comorbidities compared to sleepy OSA patients. Further investigations are warranted to elucidate the mechanisms underlying cardiovascular metabolic comorbidities in non-sleepy OSA patients. The proposed HASSUN scoring tool for non-sleepy OSA screening necessitates validation in future studies.
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Affiliation(s)
- Ganesh Narwade
- Department of Pulmonary Medicine, Critical Care and Sleep, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - Manu Madan
- Department of Pulmonary Medicine, Critical Care and Sleep, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - Rohit Kumar
- Department of Pulmonary Medicine, Critical Care and Sleep, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - Pranav Ish
- Department of Pulmonary Medicine, Critical Care and Sleep, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - A J Mahendran
- Department of Pulmonary Medicine, Critical Care and Sleep, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - Rajnish Kaushik
- Department of Pulmonary Medicine, Critical Care and Sleep, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
| | - Nitesh Gupta
- Department of Pulmonary Medicine, Critical Care and Sleep, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
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Thorarinsdottir EH, Pack AI, Gislason T, Kuna ST, Penzel T, Yun Li Q, Cistulli PA, Magalang UJ, McArdle N, Singh B, Janson C, Aspelund T, Younes M, de Chazal P, Tufik S, Keenan BT. Polysomnographic characteristics of excessive daytime sleepiness phenotypes in obstructive sleep apnea: results from the international sleep apnea global interdisciplinary consortium. Sleep 2024; 47:zsae035. [PMID: 38315511 DOI: 10.1093/sleep/zsae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 01/08/2024] [Indexed: 02/07/2024] Open
Abstract
STUDY OBJECTIVES Excessive daytime sleepiness (EDS) is a major symptom of obstructive sleep apnea (OSA). Traditional polysomnographic (PSG) measures only partially explain EDS in OSA. This study analyzed traditional and novel PSG characteristics of two different measures of EDS among patients with OSA. METHODS Sleepiness was assessed using the Epworth Sleepiness Scale (>10 points defined as "risk of dozing") and a measure of general sleepiness (feeling sleepy ≥ 3 times/week defined as "feeling sleepy"). Four sleepiness phenotypes were identified: "non-sleepy," "risk of dozing only," "feeling sleepy only," and "both at risk of dozing and feeling sleepy." RESULTS Altogether, 2083 patients with OSA (69% male) with an apnea-hypopnea index (AHI) ≥ 5 events/hour were studied; 46% were "non-sleepy," 26% at "risk of dozing only," 7% were "feeling sleepy only," and 21% reported both. The two phenotypes at "risk of dozing" had higher AHI, more severe hypoxemia (as measured by oxygen desaturation index, minimum and average oxygen saturation [SpO2], time spent < 90% SpO2, and hypoxic impacts) and they spent less time awake, had shorter sleep latency, and higher heart rate response to arousals than "non-sleepy" and "feeling sleepy only" phenotypes. While statistically significant, effect sizes were small. Sleep stages, frequency of arousals, wake after sleep onset and limb movement did not differ between sleepiness phenotypes after adjusting for confounders. CONCLUSIONS In a large international group of patients with OSA, PSG characteristics were weakly associated with EDS. The physiological measures differed among individuals characterized as "risk of dozing" or "non-sleepy," while "feeling sleepy only" did not differ from "non-sleepy" individuals.
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Affiliation(s)
- Elin H Thorarinsdottir
- Primary Health Care of the Capital Area, Department of Family Medicine, Reykjavik, Iceland
- Faculty of Medicine, Department of Medicine, University of Iceland, Reykjavik, Iceland
| | - Allan I Pack
- Division of Sleep Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thorarinn Gislason
- Faculty of Medicine, Department of Medicine, University of Iceland, Reykjavik, Iceland
- Sleep Department, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Samuel T Kuna
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Thomas Penzel
- Interdisciplinary Center of Sleep Medicine, Charité University Hospital, Berlin, Germany
| | - Qing Yun Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peter A Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Australia
| | - Ulysses J Magalang
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Nigel McArdle
- Western Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Bhajan Singh
- Western Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Thor Aspelund
- Faculty of Medicine, Department of Medicine, University of Iceland, Reykjavik, Iceland
- Icelandic Heart Association, Kopavogur, Iceland
| | - Magdy Younes
- Sleep disorders center, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Philip de Chazal
- Charles Perkins Centre, Faculty of Engineering, University of Sydney, Sydney, Australia
| | - Sergio Tufik
- Department of Psychobiology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Brendan T Keenan
- Division of Sleep Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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3
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Hyung PG, Kyung KT, Kweon KS, Woo YB, Hoon LS, Lok JC, Young WJ. The relationship between sleep quality, daytime sleepiness, and rapid eye movement obstructive sleep apnea (REM-OSA). Sleep Breath 2022; 27:737-743. [DOI: 10.1007/s11325-022-02645-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 04/08/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
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Qin H, Steenbergen N, Glos M, Wessel N, Kraemer JF, Vaquerizo-Villar F, Penzel T. The Different Facets of Heart Rate Variability in Obstructive Sleep Apnea. Front Psychiatry 2021; 12:642333. [PMID: 34366907 PMCID: PMC8339263 DOI: 10.3389/fpsyt.2021.642333] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/14/2021] [Indexed: 12/15/2022] Open
Abstract
Obstructive sleep apnea (OSA), a heterogeneous and multifactorial sleep related breathing disorder with high prevalence, is a recognized risk factor for cardiovascular morbidity and mortality. Autonomic dysfunction leads to adverse cardiovascular outcomes in diverse pathways. Heart rate is a complex physiological process involving neurovisceral networks and relative regulatory mechanisms such as thermoregulation, renin-angiotensin-aldosterone mechanisms, and metabolic mechanisms. Heart rate variability (HRV) is considered as a reliable and non-invasive measure of autonomic modulation response and adaptation to endogenous and exogenous stimuli. HRV measures may add a new dimension to help understand the interplay between cardiac and nervous system involvement in OSA. The aim of this review is to introduce the various applications of HRV in different aspects of OSA to examine the impaired neuro-cardiac modulation. More specifically, the topics covered include: HRV time windows, sleep staging, arousal, sleepiness, hypoxia, mental illness, and mortality and morbidity. All of these aspects show pathways in the clinical implementation of HRV to screen, diagnose, classify, and predict patients as a reasonable and more convenient alternative to current measures.
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Affiliation(s)
- Hua Qin
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Martin Glos
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Niels Wessel
- Department of Physics, Humboldt Universität zu Berlin, Berlin, Germany
| | - Jan F. Kraemer
- Department of Physics, Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando Vaquerizo-Villar
- Biomedical Engineering Group, Universidad de Valladolid, Valladolid, Spain
- Centro de Investigación Biomédica en Red-Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
| | - Thomas Penzel
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Saratov State University, Russian Federation, Saratov, Russia
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Malhotra A, Ayappa I, Ayas N, Collop N, Kirsch D, Mcardle N, Mehra R, Pack AI, Punjabi N, White DP, Gottlieb DJ. Metrics of sleep apnea severity: beyond the apnea-hypopnea index. Sleep 2021; 44:zsab030. [PMID: 33693939 PMCID: PMC8271129 DOI: 10.1093/sleep/zsab030] [Citation(s) in RCA: 155] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/31/2021] [Indexed: 12/13/2022] Open
Abstract
Obstructive sleep apnea (OSA) is thought to affect almost 1 billion people worldwide. OSA has well established cardiovascular and neurocognitive sequelae, although the optimal metric to assess its severity and/or potential response to therapy remains unclear. The apnea-hypopnea index (AHI) is well established; thus, we review its history and predictive value in various different clinical contexts. Although the AHI is often criticized for its limitations, it remains the best studied metric of OSA severity, albeit imperfect. We further review the potential value of alternative metrics including hypoxic burden, arousal intensity, odds ratio product, and cardiopulmonary coupling. We conclude with possible future directions to capture clinically meaningful OSA endophenotypes including the use of genetics, blood biomarkers, machine/deep learning and wearable technologies. Further research in OSA should be directed towards providing diagnostic and prognostic information to make the OSA diagnosis more accessible and to improving prognostic information regarding OSA consequences, in order to guide patient care and to help in the design of future clinical trials.
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Affiliation(s)
- Atul Malhotra
- Department of Medicine, University of California San Diego, La Jolla, CA
| | - Indu Ayappa
- Department of Medicine, Mt. Sinai, New York, NY
| | - Najib Ayas
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nancy Collop
- Department of Medicine, Emory University, Atlanta, GA
| | - Douglas Kirsch
- Department of Medicine, Atrium Health Sleep Medicine, Atrium Health, Charlotte, NC
| | - Nigel Mcardle
- Department of Medicine, The University of Western Australia, Perth, Australia
| | - Reena Mehra
- Department of Medicine, Cleveland Clinic, Cleveland, OH
| | - Allan I Pack
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
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6
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Meira E Cruz M, Kryger MH, Morin CM, Palombini L, Salles C, Gozal D. Comorbid Insomnia and Sleep Apnea: mechanisms and implications of an underrecognized and misinterpreted sleep disorder. Sleep Med 2021; 84:283-288. [PMID: 34214960 DOI: 10.1016/j.sleep.2021.05.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/29/2021] [Accepted: 05/31/2021] [Indexed: 11/24/2022]
Abstract
Sleep-disordered breathing (SDB) and insomnia have long been recognized as important sleep disrupters often associated with increased morbidity and mortality. Although they are often seen as divergent conditions, mainly because their cardinal symptoms (excessive daytime sleepiness, and sleep loss) differ, these two sleep disorders present with many common symptoms, which may hinder diagnosis and treatment. In addition to possible bidirectional pathways between SDB and insomnia, other factors such as circadian timing may play a role. In this paper, we review the mechanisms, differential clinical aspects, and implications of Comorbid Insomnia and Sleep Apnea, sometimes termed COMISA.
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Affiliation(s)
- Miguel Meira E Cruz
- Sleep Unit, Centro Cardiovascular da Universidade de Lisboa, Lisbon School of Medicine, Lisbon, Portugal; International Center on Clinical Sleep Medicine and Research, Bahiana School of Medicine and Public Health, Salvador, Brazil; Neuroimmune Pain Interface Lab, Faculdade São Leopoldo Mandic, Campinas, Brazil.
| | - Meir H Kryger
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | - Cristina Salles
- International Center on Clinical Sleep Medicine and Research, Bahiana School of Medicine and Public Health, Salvador, Brazil
| | - David Gozal
- Department of Child Health, University of Missouri, MO, USA
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7
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Evangelista E, Rassu AL, Barateau L, Lopez R, Chenini S, Jaussent I, Dauvilliers Y. Characteristics associated with hypersomnia and excessive daytime sleepiness identified by extended polysomnography recording. Sleep 2021; 44:6010320. [PMID: 33249509 DOI: 10.1093/sleep/zsaa264] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/19/2020] [Indexed: 12/20/2022] Open
Abstract
STUDY OBJECTIVES Hypersomnolence, defined by excessive daytime sleepiness (EDS) or excessive quantity of sleep (EQS), has been associated with increased morbidity. The aim of this study was to determine the clinical and polysomnographic characteristics associated with EQS and EDS assessed objectively during extended polysomnography recording. METHODS A total of 266 drug-free subjects (201 women; mean age: 26.5 years [16.08; 60.87]) underwent 32-h bed-rest polysomnography recording preceded by polysomnography and modified multiple sleep latency test (mMSLT). Participants were categorized according to their total sleep time (bed-rest TST ≥19 h, hypersomnia), objective EDS (mean sleep latency on MSLT ≤8 min), and self-reported EDS (Epworth sleepiness scale score >10) and EQS (≥9 h/24 h per week). RESULTS Subjects with hypersomnia were often younger, with normal sleep architecture, high nighttime sleep efficiency, and severe objective EDS. No association with sex, body mass index, Epworth sleepiness scale, EQS, and depressive symptoms was detected. Subjects with objective EDS had less EQS, higher sleep efficiency, and increased hypersomnia. Discrepancies were observed between objective and self-reported measures of sleep duration and EDS. Finally, 71 subjects were identified who had objective hypersomnia and/or EDS, no medical and psychiatric conditions and normal polysomnography parameters, and therefore met the stringent criteria of idiopathic hypersomnia, an orphan disorder. CONCLUSIONS Sleep duration and EDS should be quantified using self-reported and objective measures in a controlled procedure to differentiate long sleepers, patients with hypersomnia, and patients with idiopathic hypersomnia. This will help to better understand their biology, to identify specific biomarkers, and to assess related health outcomes.
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Affiliation(s)
- Elisa Evangelista
- Sleep Disorder Unit, Narcolepsy and Hypersomnia National Reference Center, Neurology Department, Gui-de-Chauliac Hospital, University Montpellier, France.,Institute for Neurosciences of Montpellier INM, University Montpellier, INSERM, Montpellier, France
| | - Anna Laura Rassu
- Sleep Disorder Unit, Narcolepsy and Hypersomnia National Reference Center, Neurology Department, Gui-de-Chauliac Hospital, University Montpellier, France
| | - Lucie Barateau
- Sleep Disorder Unit, Narcolepsy and Hypersomnia National Reference Center, Neurology Department, Gui-de-Chauliac Hospital, University Montpellier, France.,Institute for Neurosciences of Montpellier INM, University Montpellier, INSERM, Montpellier, France
| | - Régis Lopez
- Sleep Disorder Unit, Narcolepsy and Hypersomnia National Reference Center, Neurology Department, Gui-de-Chauliac Hospital, University Montpellier, France.,Institute for Neurosciences of Montpellier INM, University Montpellier, INSERM, Montpellier, France
| | - Sofiène Chenini
- Sleep Disorder Unit, Narcolepsy and Hypersomnia National Reference Center, Neurology Department, Gui-de-Chauliac Hospital, University Montpellier, France
| | - Isabelle Jaussent
- Institute for Neurosciences of Montpellier INM, University Montpellier, INSERM, Montpellier, France
| | - Yves Dauvilliers
- Sleep Disorder Unit, Narcolepsy and Hypersomnia National Reference Center, Neurology Department, Gui-de-Chauliac Hospital, University Montpellier, France.,Institute for Neurosciences of Montpellier INM, University Montpellier, INSERM, Montpellier, France
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8
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Cordone S, Scarpelli S, Alfonsi V, De Gennaro L, Gorgoni M. Sleep-Based Interventions in Alzheimer's Disease: Promising Approaches from Prevention to Treatment along the Disease Trajectory. Pharmaceuticals (Basel) 2021; 14:ph14040383. [PMID: 33921870 PMCID: PMC8073746 DOI: 10.3390/ph14040383] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/10/2021] [Accepted: 04/16/2021] [Indexed: 02/07/2023] Open
Abstract
The multifactorial nature of Alzheimer’s disease (AD) has led scientific researchers to focus on the modifiable and treatable risk factors of AD. Sleep fits into this context, given the bidirectional relationship with AD confirmed by several studies over the last years. Sleep disorders appear at an early stage of AD and continue throughout the entire course of the pathology. Specifically, sleep abnormalities, such as more fragmented sleep, increase in time of awakenings, worsening of sleep quality and primary sleep disorders raise with the severity and progression of AD. Intervening on sleep, therefore, means acting both with prevention strategies in the pre-clinical phase and with treatments during the course of the disease. This review explores sleep disturbances in the different stages of AD, starting from the pre-clinical stage. Particular attention is given to the empirical evidence investigating obstructive sleep apnea (OSA) disorder and the mechanisms overlapping and sharing with AD. Next, we discuss sleep-based intervention strategies in the healthy elderly population, mild cognitive impairment (MCI) and AD patients. We mention interventions related to behavioral strategies, combination therapies, and bright light therapy, leaving extensive space for new and raising evidence on continuous positive air pressure (CPAP) treatment effectiveness. Finally, we clarify the role of NREM sleep across the AD trajectory and consider the most recent studies based on the promising results of NREM sleep enhancement, which use innovative experimental designs and techniques.
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Affiliation(s)
- Susanna Cordone
- UniCamillus, Saint Camillus International University of Health Sciences, 00131 Rome, Italy;
| | - Serena Scarpelli
- Department of Psychology, University of Rome “Sapienza”, 00185 Rome, Italy; (S.S.); (M.G.)
| | | | - Luigi De Gennaro
- Department of Psychology, University of Rome “Sapienza”, 00185 Rome, Italy; (S.S.); (M.G.)
- IRCCS Fondazione Santa Lucia, 00179 Rome, Italy;
- Correspondence:
| | - Maurizio Gorgoni
- Department of Psychology, University of Rome “Sapienza”, 00185 Rome, Italy; (S.S.); (M.G.)
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9
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Fanfulla F, Pinna GD, Marrone O, D’Artavilla Lupo N, Arcovio S, Bonsignore MR, Morrone E. Determinants of Sleepiness at Wheel and Missing Accidents in Patients With Obstructive Sleep Apnea. Front Neurosci 2021; 15:656203. [PMID: 33927591 PMCID: PMC8076750 DOI: 10.3389/fnins.2021.656203] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES Motor-vehicle crashes are frequent in untreated OSA patients but there is still uncertainty on prevalence as well as physiological or clinical determinants of sleepiness at the wheel (SW) in OSA patients. We assessed determinants of SW or sleepiness related near-miss car accident (NMA) in a group of non-professional drivers with OSA. METHODS A 237 consecutive, treatment-naïve PSG-diagnosed OSA patients (161 males, 53.1 ± 12.6 years) were enrolled. Self-reported SW was assessed by positive answer to the question, "Have you had episodes of falling asleep while driving or episodes of drowsiness at wheel that could interfere with your driving skill in the last year?" Occurrence of NMA in the last 3 years was also individually recorded. Habitual self-reported average sleep time was collected. RESULTS SW was found in 41.3% of patients but one-quarter of patients with SW did not report excessive daytime sleepiness. Predictors of SW were the following subjective factors: Epworth sleepiness scale score (ESS-OR 1.26; IC 1.1-1.4; p < 0.0001), depressive symptoms (BDI-OR 1.2; IC 1.06-1.18; p < 0.0001) and level of risk exposure (annual mileage-OR 1.9; IC 1.15-3.1; p = 0.007). NMAs were reported by 9.7% of patients, but more frequently by SW+ than SW- (22.4% vs. 0.7%; χ2 31, p < 0.0001). The occurrence of NMAs was significantly associated to ESS, BDI, habitual sleep duration and ODI (R 2 = 0.41). CONCLUSION SW is not predicted by severity of OSA. Evaluation of risk exposure, assessment of depressive symptoms, and reported NMA should be included in the clinical evaluation, particularly in patients with reduced habitual sleep time and severe nocturnal hypoxia.
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Affiliation(s)
- Francesco Fanfulla
- Sleep and Respiratory Function Unit of the Pavia and Montescano Institutes, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Gian Domenico Pinna
- Department of Biomedical Engineering of the Montescano Institute, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Oreste Marrone
- Istituto per la Ricerca e l’Innovazione Biomedica (IRIB), National Research Council (CNR), Palermo, Italy
| | - Nadia D’Artavilla Lupo
- Sleep and Respiratory Function Unit of the Pavia and Montescano Institutes, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Simona Arcovio
- Sleep and Respiratory Function Unit of the Pavia and Montescano Institutes, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Maria R. Bonsignore
- Division of Respiratory Medicine, Dipartimento di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), University of Palermo, Palermo, Italy
| | - Elisa Morrone
- Sleep and Respiratory Function Unit of the Pavia and Montescano Institutes, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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10
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Punjabi NM, Lim D. Pro - Sleep fragmentation causes hypersomnolence in sleep apnea: The convergence of rationalism and empiricism. Sleep Med Rev 2020; 55:101397. [PMID: 33271460 DOI: 10.1016/j.smrv.2020.101397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Naresh M Punjabi
- Department of Medicine University of Miami, Miller School of Medicine, United States.
| | - Diane Lim
- Department of Medicine University of Miami, Miller School of Medicine, United States
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11
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Kasai T, Taranto Montemurro L, Yumino D, Wang H, Floras JS, Newton GE, Mak S, Ruttanaumpawan P, Parker JD, Bradley TD. Inverse relationship of subjective daytime sleepiness to mortality in heart failure patients with sleep apnoea. ESC Heart Fail 2020; 7:2448-2454. [PMID: 32608195 PMCID: PMC7524079 DOI: 10.1002/ehf2.12808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/20/2020] [Accepted: 05/14/2020] [Indexed: 12/27/2022] Open
Abstract
Aims Patients with sleep apnoea (SA) and heart failure (HF) are less sleepy than SA patients without HF. HF and SA both increase sympathetic nervous system activity (SNA). SNA can augment alertness. We previously showed that in HF patients, the degree of daytime sleepiness was not related to the severity of SA but was inversely related to SNA. Elevated SNA is associated with increased mortality in HF. Therefore, we hypothesized that in HF patients with SA, the degree of daytime sleepiness will be inversely related to mortality. Methods and results In a prospective cohort study, 218 consecutive patients with systolic HF had overnight polysomnography. Among them, 80 subjects with SA (apnoea–hypopnoea index ≥15) were followed for a mean of 28 months to determine all‐cause mortality rate. Subjective daytime sleepiness was assessed by the Epworth Sleepiness Scale (ESS). During follow‐up, 20 patients died. The 5 year death rate in patients with ESS less than 6 (i.e. less sleepy) was significantly higher than in patients with an ESS at or above the median of 6 (i.e. sleepier) [21.3 deaths/100 patient‐years vs. 6.2 deaths/100 patient‐years, unadjusted hazard ratio (HR) 2.94, 95% confidence interval (CI) 1.20 to 7.20, P = 0.018]. After adjusting for confounding factors that included sex, history of hypertension, and mean arterial oxyhaemoglobin saturation, compared with the sleepier patients, less sleepy patients had greater risk of mortality (HR 2.56, 95% CI 1.01 to 6.47, P = 0.047). As a continuous variable, ESS scores were inversely related to mortality risk (HR 0.86, 95% CI 0.75 to 0.98, P = 0.022). Conclusions In patients with HF and SA, the degree of subjective daytime sleepiness is inversely related to the mortality risk, suggesting that among HF patients with SA, those with the least daytime sleepiness are at greater risk of death. They may therefore have greater potential for mortality benefit from therapy of SA than those with greater daytime sleepiness.
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Affiliation(s)
- Takatoshi Kasai
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Luigi Taranto Montemurro
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| | - Dai Yumino
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| | - Hanqiao Wang
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| | - John S Floras
- Department of Medicine of the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Toronto General Hospital of the University Health Network, 9N-943, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Gary E Newton
- Department of Medicine of the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Susanna Mak
- Department of Medicine of the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pimon Ruttanaumpawan
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| | - John D Parker
- Department of Medicine of the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Toronto General Hospital of the University Health Network, 9N-943, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - T Douglas Bradley
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Toronto General Hospital of the University Health Network, 9N-943, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
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12
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Angelelli P, Macchitella L, Toraldo DM, Abbate E, Marinelli CV, Arigliani M, De Benedetto M. The Neuropsychological Profile of Attention Deficits of Patients with Obstructive Sleep Apnea: An Update on the Daytime Attentional Impairment. Brain Sci 2020; 10:brainsci10060325. [PMID: 32471112 PMCID: PMC7349097 DOI: 10.3390/brainsci10060325] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/20/2020] [Accepted: 05/22/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction: Patients with obstructive sleep apnea (OSA) suffer from several neurocognitive disturbances. One of the neuropsychological processes most investigated in OSA patients is attention, but the results have been controversial. Here, we update the attention profile of OSA patients with the final aim to improve attention assessment, with a possible impact on clinical and medical-legal practices, in terms of which attention subdomains and parameters need consideration and which one is a high-risk OSA phenotype for attention dysfunctions. Method: For this purpose, we assessed 32 previously untreated OSA patients (26 men and 6 women) under 65 years of age (mean age 53.2 ± 7.3; mean education level 10.4 ± 3.4 years) suffering from moderate to severe sleep apnea and hypopnea (mean apnea-hypopnea index (AHI) 45.3 ± 22.9, range 16.1–69.6). A control group of 34 healthy participants matched with OSA patients for age, education level, and general cognitive functioning were also enrolled. The OSA patients and healthy participants were tested through an extensive computerized battery (Test of Attentional Performance, TAP) that evaluated intensive (i.e., alertness and vigilance) and selective (i.e., divided and selective) dimensions of attention and returned different outcome parameters (i.e., reaction time, stability of performance, and various types of errors). Data analysis: The data were analyzed by ANCOVA which compared the speed and accuracy performance of the OSA and control participants (cognitive reserve was treated as a covariate). The possible mechanisms underlying attention deficits in OSA patients were examined through correlation analysis among AHI, oxygenation parameters, sleepiness scores, and TAP outcomes and by comparing the following three phenotypes of patients: severe OSA and severe nocturnal desaturators (AHI++D+), severe OSA nondesaturators (AHI++D−), and moderate OSA nondesaturators (AHI+D−). Results: The results suggest that the OSA patients manifest deficits in both intensive and selective attention processes and that reaction time (RT) alone is ineffective for detecting and characterizing their problems, for which error analysis and stability of performance also have to be considered. Patients with severe OSA and severe hypoxemia underperformed on alertness and vigilance attention subtests. Conclusions: The data suggest the importance of evaluating attention deficits among OSA patients through several parameters (including performance instability). Moreover, the data suggest a multifaceted mechanism underlying attention dysfunction in OSA patients.
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Affiliation(s)
- Paola Angelelli
- Lab of Applied Psychology and Intervention, Department of History, Society and Human Studies, University of Salento, 73100 Lecce, Italy; (L.M.); (E.A.); (C.V.M.)
- Correspondence:
| | - Luigi Macchitella
- Lab of Applied Psychology and Intervention, Department of History, Society and Human Studies, University of Salento, 73100 Lecce, Italy; (L.M.); (E.A.); (C.V.M.)
| | | | - Elena Abbate
- Lab of Applied Psychology and Intervention, Department of History, Society and Human Studies, University of Salento, 73100 Lecce, Italy; (L.M.); (E.A.); (C.V.M.)
| | - Chiara Valeria Marinelli
- Lab of Applied Psychology and Intervention, Department of History, Society and Human Studies, University of Salento, 73100 Lecce, Italy; (L.M.); (E.A.); (C.V.M.)
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13
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Berger M, Hirotsu C, Haba-Rubio J, Betta M, Bernardi G, Siclari F, Waeber G, Vollenweider P, Marques-Vidal P, Heinzer R. Risk factors of excessive daytime sleepiness in a prospective population-based cohort. J Sleep Res 2020; 30:e13069. [PMID: 32412149 DOI: 10.1111/jsr.13069] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 01/01/2023]
Abstract
Although excessive daytime sleepiness is commonly evaluated in clinical and research settings using the Epworth Sleepiness Scale, few studies have assessed the factors associated with its incidence in the general population. We prospectively investigated the predictors of incident and persistent excessive daytime sleepiness in 2,751 subjects (46.1% men, mean age 56.0 ± 9.8 years) from the CoLaus-PsyCoLaus population-based cohort (Lausanne, Switzerland) over 5 years. Participants completed the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index, and underwent a full clinical evaluation at baseline and 5 years afterwards. Ambulatory polysomnography was performed at baseline in a sub-sample of 1,404 subjects. Among the 2,438 subjects without excessive daytime sleepiness (Epworth Sleepiness Scale ≤ 10) at baseline, the 5-year incidence of excessive daytime sleepiness was 5.1% (n = 124). Multivariate logistic regression revealed that male sex, depressive symptoms, reported poor sleep quality and moderate to severe obstructive sleep apnea were independent predictors of incident excessive daytime sleepiness, while older age, moderate coffee consumption, periodic leg movement during sleep and hypertension were independent protective factors. Stratified analysis according to sex and age showed some distinctive associations. Among the 313 patients with excessive daytime sleepiness at baseline, 137 (43.8%) had persistent excessive daytime sleepiness 5 years later. Our findings provide new insights into the predictors of incident excessive daytime sleepiness, but interventional studies are needed to understand the impact of treating these risk factors on the incidence of excessive daytime sleepiness.
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Affiliation(s)
- Mathieu Berger
- Center for Investigation and Research in Sleep (CIRS), Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Camila Hirotsu
- Center for Investigation and Research in Sleep (CIRS), Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Jose Haba-Rubio
- Center for Investigation and Research in Sleep (CIRS), Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Monica Betta
- IMT School for Advanced Studies Lucca, Lucca, Italy
| | | | - Francesca Siclari
- Center for Investigation and Research in Sleep (CIRS), Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Gerard Waeber
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Peter Vollenweider
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Pedro Marques-Vidal
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Raphael Heinzer
- Center for Investigation and Research in Sleep (CIRS), Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
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14
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Carvalho DZ, St Louis EK, Knopman DS, Boeve BF, Lowe VJ, Roberts RO, Mielke MM, Przybelski SA, Machulda MM, Petersen RC, Jack CR, Vemuri P. Association of Excessive Daytime Sleepiness With Longitudinal β-Amyloid Accumulation in Elderly Persons Without Dementia. JAMA Neurol 2019. [PMID: 29532057 DOI: 10.1001/jamaneurol.2018.0049] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Aging is associated with excessive daytime sleepiness (EDS), which has been linked to cognitive decline in the elderly. However, whether EDS is associated with the pathologic processes of Alzheimer disease remains unclear. Objective To investigate whether EDS at baseline is associated with a longitudinal increase in regional β-amyloid (Aβ) accumulation in a cohort of elderly individuals without dementia. Design, Setting, and Participants This prospective analysis included participants enrolled in the Mayo Clinic Study of Aging, a longitudinal population-based study in Olmsted County, Minnesota. Of 2900 participants, 2172 (74.9%) agreed to undergo carbon 11-labeled Pittsburgh compound B positron emission tomography (PiB-PET). We included 283 participants 70 years or older without dementia who completed surveys assessing sleepiness at baseline and had at least 2 consecutive PiB-PET scans from January 1, 2009, through July 31, 2016, after excluding 45 (13.7%) who had a comorbid neurologic disorder. Main Outcomes and Measures Excessive daytime sleepiness was defined as an Epworth Sleepiness Scale score of at least 10. The difference in Aβ levels between the 2 consecutive scans (ΔPiB) in Aβ-susceptible regions (prefrontal, anterior cingulate, posterior cingulate-precuneus, and parietal) was determined. Multiple linear regression models were fit to explore associations between baseline EDS and ΔPiB while adjusting for baseline age, sex, presence of the apolipoprotein E ε4 allele, educational level, baseline PiB uptake, global PiB positivity (standardized uptake value ratio ≥1.4), physical activity, cardiovascular comorbidities (obesity, hypertension, hyperlipidemia, and diabetes), reduced sleep duration, respiratory symptoms during sleep, depression, and interval between scans. Results Of the initial 283 participants, mean (SD) age was 77.1 (4.8) years; 204 (72.1%) were men and 79 (27.9%) were women. Sixty-three participants (22.3%) had EDS. Baseline EDS was significantly associated with increased regional Aβ accumulation in the anterior cingulate (B coefficient = 0.031; 95% CI, 0.001-0.061; P = .04), posterior cingulate-precuneus (B coefficient = 0.038; 95% CI, 0.006-0.069; P = .02), and parietal (B coefficient = 0.033; 95% CI, 0.001-0.065; P = .04) regions. Association of EDS with longitudinal Aβ accumulation was stronger in participants with baseline global PiB positivity in the anterior cingulate (B coefficient = 0.065; 95% CI, 0.010-0.118; P = .02) and cingulate-precuneus (B coefficient = 0.068; 95% CI, 0.009-0.126; P = .02) regions. Conclusions and Relevance Baseline EDS was associated with increased longitudinal Aβ accumulation in elderly persons without dementia, suggesting that those with EDS may be more vulnerable to pathologic changes associated with Alzheimer disease. Further work is needed to elucidate whether EDS is a clinical marker of greater sleep instability, synaptic or network overload, or neurodegeneration of wakefulness-promoting centers. Early identification of patients with EDS and treatment of underlying sleep disorders could reduce Aβ accumulation in this vulnerable group.
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Affiliation(s)
| | | | | | | | - Val J Lowe
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Rosebud O Roberts
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Michelle M Mielke
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Scott A Przybelski
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
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15
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Excessive daytime sleepiness in obstructive sleep apnea: implications for driving licenses. Sleep Breath 2019; 24:37-47. [PMID: 31342234 DOI: 10.1007/s11325-019-01903-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/14/2019] [Accepted: 07/16/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Excessive daytime sleepiness (EDS) while driving is a major international public health issue resulting in a more than doubled risk of motor vehicle accidents (MVAs). Obstructive sleep apnea (OSA) is the most frequent medical cause of EDS. Therefore, the European Union Directive 2014/85/EU determined that "untreated moderate to severe OSA coincident with EDS constitutes a medical disorder leading to unfitness to drive." The paper aims are to provide a brief review of sleepiness and its implications for driving safety, as well as to describe the subjective and objective methods to accurately evaluate EDS in order to assess fitness to drive in patients with OSA. METHODS We examined databases including PubMed, Medline, and EMBASE using the search terms "sleepiness at the wheel, excessive daytime sleepiness, sleepiness measure, sleep-wake cycle, obstructive sleep apnea, driving license, fitness to drive." RESULTS Significant interindividual variability in EDS exists in patients with comparable severity of OSA. Objective methods of measuring EDS are too expensive and time consuming to be suitable for the certification of driving licenses. The reliability of subjective methods depends upon the clinical setting and subjective tools assess only limited aspects of EDS. Objective measures, such as biochemical biomarkers, must, therefore, support subjective methods. CONCLUSIONS Extensive data have supported different subjective and objective methods for the appraisal of EDS in patients with OSA depending upon the clinical and experimental setting. Challenges remain to determine an appropriate tool for the evaluation of fitness to drive.
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16
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Clinical Features and Contributing Factors of Excessive Daytime Sleepiness in Chinese Obstructive Sleep Apnea Patients: The Role of Comorbid Symptoms and Polysomnographic Variables. Can Respir J 2019; 2019:5476372. [PMID: 31360269 PMCID: PMC6652063 DOI: 10.1155/2019/5476372] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/29/2019] [Accepted: 05/13/2019] [Indexed: 01/31/2023] Open
Abstract
Background The occurrence and severity of excessive daytime sleepiness (EDS) vary considerably among obstructive sleep apnea (OSA) patients. This study was designed to investigate the characteristics of EDS and identify its contributing factors in OSA patients. Methods This was a cross-sectional study from a tertiary medical center in China. A total of 874 consecutive patients with newly diagnosed OSA were included. Subjective daytime sleepiness was assessed with the Epworth Sleepiness Scale (ESS). The subjects were assigned to the non-EDS group (582 patients), mild to moderate EDS group (227 patients), and severe EDS group (65 patients) according to the ESS scores. The clinical features and polysomnographic parameters were acquired and analyzed to identify the differences between groups and the determinants of EDS. Results The age of patients with severe EDS (49.5 ± 11.3) was slightly greater than that of patients with mild to moderate EDS (44.5 ± 10.2) (p < 0.05) and non-EDS patients (45.2 ± 12.0) (p < 0.05). Body mass index (BMI) was highest in the severe EDS group (29.1 ± 3.6 kg/m2) (p < 0.0001), intermediate in the mild to moderate EDS group (27.9 ± 3.3 kg/m2), and lower in the non-EDS group (26.8 ± 3.3 kg/m2). Logistic regression analysis showed waist circumference, memory loss, work/commute disturbances, and sleep efficiency were independently associated with mild to moderate EDS, and the microarousal index, apnea-hypopnea index (AHI), and saturation impair time below 90% were independent contributing factors of mild to moderate EDS. Meanwhile, age, neck circumference, gasping/choking, memory loss, work/commute disturbances, and sleep latency were independently associated with severe EDS, and the AHI and mean SpO2 were independent contributing factors of severe EDS. Conclusions OSA patients with various severities of EDS are more obese and have more comorbid symptoms compared to patients without EDS. Sleep fragmentation, respiratory events, and nocturnal hypoxia may be predictors of EDS. Comprehensive consideration of demographic, clinical, and polysomnographic factors is required when evaluating OSA patients.
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17
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Mullane S, Loke W. Influence of short-term side effects on oral sleep appliance compliance among CPAP-intolerant patients: An objective monitoring of compliance. J Oral Rehabil 2019; 46:715-722. [PMID: 30989665 DOI: 10.1111/joor.12802] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 04/05/2019] [Accepted: 04/10/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the predictive value of side effects on usage times during the initial titration phase of oral appliance therapy for sleep apnoea. The secondary objective was to assess the correlation between subjective and objective usage times. METHODS A total of 21 subjects diagnosed with sleep apnoea and a history of non-compliance with CPAP therapy were enrolled in the 4-week clinical study. Objective compliance was assessed through an intra-oral compliance monitor embedded in a Thornton Adjustable Positioner. Subjective compliance was evaluated through self-reporting and questionnaire for side effects. RESULTS Excess salivation, xerostomia and tooth discomfort were the most common side effects (61%-67%). Noises (OR = 10, 95% CI = 0.85-117.02, P = 0.067), jaw discomfort (OR = 15, 95% CI = 1.21-185.20, P = 0.035) and gum discomfort (OR = 8.86, 95% CI = 1.0-∞, P = 0.038) were highly predictive of non-compliance. Subjects with either "none" or "mild" side effects recorded a mean oral appliance usage time ≥5.5 hours/night, while subjects reporting "severe" side effects recorded a mean usage time ≤4 hours/night. The mean usage time was 5.49 hours/night, with nightly compliance (defined as >4 hours per night for 70% the nights per week) at 33%. Nonetheless, compliance increased from 26%-50% from week 1 to week 4. The subjective and objective usage times were highly correlated (r = 0.81). CONCLUSIONS There was a high correlation between subjective and objective compliance reporting data. Moderate/severe side effects had the greatest effect on compliance.
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Affiliation(s)
- Shane Mullane
- Private Practice, Prosthodontics, Newcastle West, Co., Limerick, Ireland
| | - Weiqiang Loke
- Department of Restorative Dentistry, Faculty of Dentistry, National University of Singapore, Singapore City, Singapore
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18
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Taranto Montemurro L. The enigma of severe obstructive sleep apnea without sleepiness. J Clin Hypertens (Greenwich) 2019; 21:397-398. [PMID: 30724468 DOI: 10.1111/jch.13480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Luigi Taranto Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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19
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Noda A, Yasuma F, Miyata S, Iwamoto K, Yasuda Y, Ozaki N. Sleep Fragmentation and Risk of Automobile Accidents in Patients with Obstructive Sleep Apnea—Sleep Fragmentation and Automobile Accidents in OSA. Health (London) 2019. [DOI: 10.4236/health.2019.112015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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20
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Garbarino S, Scoditti E, Lanteri P, Conte L, Magnavita N, Toraldo DM. Obstructive Sleep Apnea With or Without Excessive Daytime Sleepiness: Clinical and Experimental Data-Driven Phenotyping. Front Neurol 2018; 9:505. [PMID: 29997573 PMCID: PMC6030350 DOI: 10.3389/fneur.2018.00505] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction: Obstructive sleep apnea (OSA) is a serious and prevalent medical condition with major consequences for health and safety. Excessive daytime sleepiness (EDS) is a common-but not universal-accompanying symptom. The purpose of this literature analysis is to understand whether the presence/absence of EDS is associated with different physiopathologic, prognostic, and therapeutic outcomes in OSA patients. Methods: Articles in English published in PubMed, Medline, and EMBASE between January 2000 and June 2017, focusing on no-EDS OSA patients, were critically reviewed. Results: A relevant percentage of OSA patients do not complain of EDS. EDS is a significant and independent predictor of incident cardiovascular disease (CVD) and is associated with all-cause mortality and an increased risk of metabolic syndrome and diabetes. Male gender, younger age, high body mass index, are predictors of EDS. The positive effects of nasal continuous positive airway pressure (CPAP) therapy on blood pressure, insulin resistance, fatal and non-fatal CVD, and endothelial dysfunction risk factors have been demonstrated in EDS-OSA patients, but results are inconsistent in no-EDS patients. The most sustainable cause of EDS is nocturnal hypoxemia and alterations of sleep architecture, including sleep fragmentation. These changes are less evident in no-EDS patients that seem less susceptible to the cortical effects of apneas. Conclusions: There is no consensus if we should consider OSA as a single disease with different phenotypes with or without EDS, or if there are different diseases with different genetic/epigenetic determinants, pathogenic mechanisms, prognosis, and treatment.The small number of studies focused on this issue indicates the need for further research in this area. Clinicians must carefully assess the presence or absence of EDS and decide accordingly the treatment. This approach could improve combination therapy targeted to a patient's specific pathology to enhance both efficacy and long-term adherence to OSA treatment and significantly reduce the social, economic, and health negative impact of OSA.
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Affiliation(s)
- Sergio Garbarino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal/Child Sciences, University of Genoa, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Egeria Scoditti
- Institute of Clinical Physiology, National Research Council (CNR), Lecce, Italy
| | - Paola Lanteri
- Department of Neurological Science, G. Gaslini Institute, Genoa, Italy
| | - Luana Conte
- Interdisciplinary Laboratory of Applied Research in Medicine (DReAM), "V Fazzi" University Hospital, ASL Lecce, Lecce, Italy.,Department of Biological and Environmental Sciences and Technologies, University of Salento, Lecce, Italy
| | - Nicola Magnavita
- Institute of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico M Toraldo
- Rehabilitation Department, Cardio-Respiratory Care Unit, "V Fazzi" Hospital, ASL Lecce, Lecce, Italy
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21
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Prasad B, Steffen AD, Van Dongen HPA, Pack FM, Strakovsky I, Staley B, Dinges DF, Maislin G, Pack AI, Weaver TE. Determinants of sleepiness in obstructive sleep apnea. Sleep 2018; 41:4850639. [PMID: 29444292 DOI: 10.1093/sleep/zsx199] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 09/18/2017] [Indexed: 01/15/2023] Open
Abstract
STUDY OBJECTIVES Significant interindividual variability in sleepiness is observed in clinical populations with obstructive sleep apnea (OSA). This phenomenon is only partially explained by the apnea-hypopnea index (AHI). Understanding factors that lead to sleepiness is critical to effective management of patients with OSA. We examined demographic and other factors associated with sleepiness in OSA. METHODS Prospective study of 283 patients with newly diagnosed OSA by polysomnography (AHI ≥ 5 per hour). Subjective sleepiness (Epworth Sleep Scale [ESS] ≥ 11) and objective sleepiness (psychomotor vigilance task [PVT] mean lapse ≥ 2) were assessed. RESULTS Participants were classified into four groups (1: sleepy by ESS and PVT, 2: sleepy by PVT only, 3: sleepy by ESS only, and 4: nonsleepy reference group) and compared by generalized logit model. Shorter daily sleep duration by actigraphy and less morningness were associated with higher risk of sleepiness (Odds ratio [OR] = 0.52, 95% confidence interval [CI] 0.33-0.82 and OR = 0.89, CI 0.80-0.98, respectively). African-American race was associated with sleepiness (group 1, OR = 8.8, CI 2.8-27.3; group 2, OR = 16.6, CI 3.3-83.6; and group 3, OR = 3.3, CI 1.0-10.1). IL-6 level was higher in groups 1 and 3 (OR = 1.9, CI 1.0-3.4 and OR 2.0, CI 1.1-3.7, respectively). CONCLUSIONS African-American race, short sleep duration, chronotype, and increased proinflammatory cytokine IL-6 level were associated with sleepiness in OSA. These findings will inform future investigations determining mechanisms of sleepiness in OSA.
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Affiliation(s)
- Bharati Prasad
- Department of Medicine, Pulmonary, Critical Care, Sleep and Allergy, College of Medicine, University of Illinois at Chicago, Chicago, IL.,Jesse Brown VA Medical Center, Chicago, IL.,Center for Narcolepsy, Sleep and Health Research, College of Nursing, University of Illinois at Chicago, Chicago, IL
| | - Alana D Steffen
- Center for Narcolepsy, Sleep and Health Research, College of Nursing, University of Illinois at Chicago, Chicago, IL.,Department of Health System Science, College of Nursing, University of Illinois at Chicago, Chicago, IL
| | - Hans P A Van Dongen
- Sleep and Performance Research Center, Washington State University, Spokane, WA
| | - Francis M Pack
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Inna Strakovsky
- Office of Clinical Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bethany Staley
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David F Dinges
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Psychiatry, Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Greg Maislin
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Allan I Pack
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Terri E Weaver
- Center for Narcolepsy, Sleep and Health Research, College of Nursing, University of Illinois at Chicago, Chicago, IL.,Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL
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22
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Ramsay M. Patient ventilator asynchrony and sleep disruption during non-invasive ventilation. J Thorac Dis 2018; 10:S80-S85. [PMID: 29445531 DOI: 10.21037/jtd.2017.11.31] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patient-ventilator asynchrony (PVA) are a common phenomenon affecting all patients receiving long-term domiciliary ventilation. The interruption of synchrony between the patient and the ventilator has been reported to be a possible cause of nocturnal sleep disruption leaking to arousals, awakenings and reduced periods of stage 3 and REM sleep overnight. The cause of PVA is multi-factorial driven frequently by leak at the interface, changing respiratory breathing patterns and changes in sleep stages. It currently remains unclear as to whether the PVA is the cause of sleep fragmentation or if PVA is purely a marker of unsuccessful ventilatory control, patient discomfort and underlying sleep disruption.
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23
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The influence of sleep disordered breathing in REM sleep behavior disorder. Sleep Med 2017; 37:210-215. [PMID: 28673760 DOI: 10.1016/j.sleep.2017.05.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/17/2017] [Accepted: 05/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES/BACKGROUND Because both REM sleep behavior disorder (RBD) and Obstructive Sleep Apnea (OSA) can present with similar symptoms, it is important to understand the influence of OSA in the clinical manifestations of RBD and whether RBD modulates OSA severity. Our objectives were to compare: 1. the intensity of non-motor symptoms between RBD patients with (RBD-OSA) and without OSA (RBD-non-OSA), and 2. polysomnographic features between RBD-OSA and OSA without RBD (OSA-non-RBD) patients. METHODS 32 RBD cases were divided in two groups according to the presence of moderate to severe OSA [Apnea Hypopnea Index (AIH) > 14] (RBD-OSA vs. RBD-non-OSA). Non-motor symptoms were assessed with Montreal Cognitive Assessment Scale, SCOPA-Sleep and the Non-Motor Symptom Scale (NMSS) for Parkinson's disease. RBD-OSA patients were compared to 20 OSA-non-RBD patients matched for age, AHI and gender. RESULTS Compared to RBD-non-OSA (n = 22) patients, RBD-OSA patients (n = 10) showed significantly higher scores in SCOPA-Sleep Daytime and NMSS Attention/Memory, Gastrointestinal and Urinary domains, as well as higher sleep fragmentation, more oxygen desaturation and higher AIH in NREM sleep. RBD-OSA patients presented with less O2 desaturation, snoring, and BMI when compared to OSA-non-RBD patients. DISCUSSION Our data suggests that OSA contributes to hypersomnolence, gastro-intestinal, memory, and urinary complaints in RBD patients. RBD patients seem to have a milder OSA phenotype (possible reflecting a protective role conferred by the maintenance of muscle tone during REM sleep) and to be less prone to obesity and snoring than non-RBD patients.
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Mccarthy A, Loomis S, Eastwood B, Wafford KA, Winsky-Sommerer R, Gilmour G. Modelling maintenance of wakefulness in rats: comparing potential non-invasive sleep-restriction methods and their effects on sleep and attentional performance. J Sleep Res 2016; 26:179-187. [DOI: 10.1111/jsr.12464] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 08/30/2016] [Indexed: 11/30/2022]
Affiliation(s)
| | - Sally Loomis
- Eli Lilly & Co. Ltd; Erl Wood Manor; Windlesham Surrey UK
| | - Brian Eastwood
- Eli Lilly & Co. Ltd; Erl Wood Manor; Windlesham Surrey UK
| | | | - Raphaëlle Winsky-Sommerer
- Surrey Sleep Research Centre; Faculty of Health and Medical Sciences; University of Surrey; Guildford Surrey UK
| | - Gary Gilmour
- Eli Lilly & Co. Ltd; Erl Wood Manor; Windlesham Surrey UK
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Kim CS, Kim DS. The Association between Excessive Daytime Sleepiness and Blood Pressure in Patients with Obstructive Sleep Apnea-Hypopnea Syndrome. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2016. [DOI: 10.15324/kjcls.2016.48.3.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Cheon-Sik Kim
- Departments of Neurology, Asan Medical Center, Seoul 05505, Korea
| | - Dae-Sik Kim
- Department of Clinical Laboratory Science, Dongnam University, Suwon 16328, Korea
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Somatic arousal and sleepiness/fatigue among patients with sleep-disordered breathing. Sleep Breath 2016; 20:749-58. [PMID: 26739833 DOI: 10.1007/s11325-015-1294-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/02/2015] [Accepted: 12/08/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES In a large clinical sample, we tested the hypothesis that levels of sleepiness and fatigue among upper airway resistance syndrome (UARS) patients are correlated with levels of somatic arousal (SA; reflecting the sympathetic nervous system component of the stress response). We also tested the correlations of post-treatment change in these three parameters, and we extended the investigation to obstructive sleep apnea/hypopnea (OSA/H) patients. METHODS From 5 years of patient data, we obtained scores on the body sensation questionnaire (BSQ), measuring the level of SA, the fatigue severity scale (FSS), and Epworth sleepiness scale (ESS) for 152 consecutive UARS patients and 150 consecutive OSA/H patients. For each group, we correlated the FSS and ESS scores with the BSQ scores. Among the 45 UARS patients and 49 OSA/H patients treated with nasal CPAP who provided post-treatment data, we correlated change in FSS and ESS scores with change in BSQ scores. RESULTS Scores on the BSQ, FSS, and ESS for UARS patients and OSA/H patients were comparable. In both UARS and OSA/H patients, both the FSS and ESS scores were positively correlated with the BSQ score. Nasal CPAP use decreased all three questionnaire scores in both patient groups. In the pooled data, changes in FSS were significantly correlated with changes in BSQ. CONCLUSIONS Our findings confirm our preliminary observations that sleepiness and fatigue among UARS patients are correlated with their level of SA and suggest that the same is true for OSA/H patients. The decrease of SA following treatment suggests that SDB is a cause of SA among patients with UARS and OSA/H.
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El-Sheikh M, Buckhalt JA. Ii. Moving sleep and child development research forward: priorities and recommendations from the srcd-sponsored forum on sleep and child development. Monogr Soc Res Child Dev 2015; 80:15-32. [PMID: 25704733 DOI: 10.1111/mono.12142] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Prevalent in typically developing children, insufficient or poor-quality sleep are matters of public health concern. Programmatic studies of the predictors and sequelae of sleep are increasing rapidly and yielding novel research paradigms that explicate connections between sleep, family processes, and child development within the sociocultural milieu. In an SRCD-sponsored Forum, established researchers and junior scholars from disparate areas of inquiry (e.g., Pediatrics; Public Health; Psychology; Anthropology) convened. An overarching goal of the Forum was to promote dialogue and collaborations, identify pivotal areas in the study of typically developing children's sleep, and integrate knowledge of sleep and child development across disciplines toward making conceptual advances about the ways that sleep and waking behaviors are intertwined. In addition to conceptual advances, a second goal focused on the need for methodological advances, including contemporary approaches and tools in the measures and analyses of sleep to help accelerate the pace and enhance the quality of research in this interdisciplinary field.
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Affiliation(s)
- Mona El-Sheikh
- Department of Human Development and Family Studies, Auburn University
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Obstructive Sleep Apnea, Hypertension, and Their Additive Effects on Atherosclerosis. Biochem Res Int 2015; 2015:984193. [PMID: 26697221 PMCID: PMC4678058 DOI: 10.1155/2015/984193] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 09/29/2015] [Indexed: 01/30/2023] Open
Abstract
Background and Aims. It is widely accepted that obstructive sleep apnea (OSA) is independently associated with atherosclerosis. Similar to OSA, hypertension (HTN) is a condition associated with atherosclerosis. However, to date, the impact of the simultaneous presence of OSA and HTN on the risk of atherosclerosis has not been extensively studied. The aim of this study was to evaluate the consequences of the coexistence of OSA and HTN on carotid intima-media thickness (IMT) and on inflammatory markers of atherosclerosis (such as interleukin- [IL-] 6 and pentraxin- [PTX-] 3). Methods. The study design allowed us to define 4 groups: (1) controls (n = 30); (2) OSA patients without HTN (n = 30); (3) HTN patients without OSA (n = 30); (4) patients with OSA and HTN (n = 30). In the morning after portable monitoring (between 7 am and 8 am), blood samples were collected, and carotid IMT was measured. Results. Carotid IMT, IL-6, and PTX-3 in OSA normotensive patients and in non-OSA HTN subjects were significantly higher compared to control subjects; in addition, in OSA hypertensive patients they were significantly increased compared to OSA normotensive, non-OSA HTN, or control subjects. Conclusions. OSA and HTN have an additive role in the progression of carotid atherosclerosis and in blood levels of inflammatory markers for atherosclerosis, such as interleukin-6 and pentraxin-3.
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Slow wave sleep in the chronically fatigued: Power spectra distribution patterns in chronic fatigue syndrome and primary insomnia. Clin Neurophysiol 2015; 126:1926-33. [DOI: 10.1016/j.clinph.2014.12.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 10/31/2014] [Accepted: 12/31/2014] [Indexed: 12/24/2022]
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Schwartz NG, Rattner A, Schwartz AR, Mokhlesi B, Gilman RH, Bernabe-Ortiz A, Miranda JJ, Checkley W. Sleep Disordered Breathing in Four Resource-Limited Settings in Peru: Prevalence, Risk Factors, and Association with Chronic Diseases. Sleep 2015; 38:1451-9. [PMID: 25845694 DOI: 10.5665/sleep.4988] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 03/07/2015] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Sleep disordered breathing (SDB) is a highly prevalent condition in high-income countries, with major consequences for cardiopulmonary health, public safety, healthcare utilization, and mortality. However, its prevalence and effect in low- and middle-income countries are less well known. We sought to determine the prevalence, risk factors, and comorbidities of SDB symptoms in four resource-limited settings. DESIGN Cross-sectional analysis of the CRONICAS Cohort, a population-based age- and sex-stratified sample. SETTING Four resource-limited settings in Peru varying in altitude, urbanization, and air pollution. PARTICIPANTS There were 2,682 adults aged 35 to 92 y. MEASUREMENTS AND RESULTS Self-reported SDB symptoms (habitual snoring, observed apneas, Epworth Sleepiness Scale), sociodemographics, medical history, anthropometrics, spirometry, blood biomarkers were reported. We found a high prevalence of habitual snoring (30.2%, 95% confidence interval [CI] 28.5-32.0%), observed apneas (20.9%, 95% CI 19.4-22.5%) and excessive daytime sleepiness (18.6%, 95% CI 17.1-20.1%). SDB symptoms varied across sites; prevalence and adjusted odds for habitual snoring were greatest at sea level, whereas those for observed apneas were greatest at high altitude. In multivariable analysis, habitual snoring was associated with older age, male sex, body mass index (BMI), and higher socioeconomic status; observed apneas were associated with BMI; and excessive daytime sleepiness was associated with older age, female sex, and medium socioeconomic status. Adjusted odds of cardiovascular disease, depression, and hypertension and total chronic disease burden increased progressively with the number of SDB symptoms. A threefold increase in the odds of having an additional chronic comorbid disease (adjusted odds ratio 3.57, 95% CI 2.18-5.84) was observed in those with all three versus no SDB symptoms. CONCLUSIONS Sleep disordered breathing symptoms were highly prevalent, varied widely across four resource-limited settings in Peru, and exhibited strong independent associations with chronic diseases.
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Affiliation(s)
- Noah G Schwartz
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD.,Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Adi Rattner
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Alan R Schwartz
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Babak Mokhlesi
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Robert H Gilman
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Antonio Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Departamento de Medicina, Escuela de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD.,Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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Conde SV, Sacramento JF, Guarino MP, Gonzalez C, Obeso A, Diogo LN, Monteiro EC, Ribeiro MJ. Carotid body, insulin, and metabolic diseases: unraveling the links. Front Physiol 2014; 5:418. [PMID: 25400585 PMCID: PMC4212612 DOI: 10.3389/fphys.2014.00418] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 10/10/2014] [Indexed: 11/13/2022] Open
Abstract
The carotid bodies (CB) are peripheral chemoreceptors that sense changes in arterial blood O2, CO2, and pH levels. Hypoxia, hypercapnia, and acidosis activate the CB, which respond by increasing the action potential frequency in their sensory nerve, the carotid sinus nerve (CSN). CSN activity is integrated in the brain stem to induce a panoply of cardiorespiratory reflexes aimed, primarily, to normalize the altered blood gases, via hyperventilation, and to regulate blood pressure and cardiac performance, via sympathetic nervous system (SNS) activation. Besides its role in the cardiorespiratory control the CB has been proposed as a metabolic sensor implicated in the control of energy homeostasis and, more recently, in the regulation of whole body insulin sensitivity. Hypercaloric diets cause CB overactivation in rats, which seems to be at the origin of the development of insulin resistance and hypertension, core features of metabolic syndrome and type 2 diabetes. Consistent with this notion, CB sensory denervation prevents metabolic and hemodynamic alterations in hypercaloric feed animal. Obstructive sleep apnea (OSA) is another chronic disorder characterized by increased CB activity and intimately related with several metabolic and cardiovascular abnormalities. In this manuscript we review in a concise manner the putative pathways linking CB chemoreceptors deregulation with the pathogenesis of insulin resistance and arterial hypertension. Also, the link between chronic intermittent hypoxia (CIH) and insulin resistance is discussed. Then, a final section is devoted to debate strategies to reduce CB activity and its use for prevention and therapeutics of metabolic diseases with an emphasis on new exciting research in the modulation of bioelectronic signals, likely to be central in the future.
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Affiliation(s)
- Sílvia V Conde
- CEDOC, Centro Estudos Doenças Crónicas, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa Lisboa, Portugal
| | - Joana F Sacramento
- CEDOC, Centro Estudos Doenças Crónicas, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa Lisboa, Portugal
| | - Maria P Guarino
- CEDOC, Centro Estudos Doenças Crónicas, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa Lisboa, Portugal ; Health Research Unit - UIS, School of Health Sciences, Polytechnic Institute of Leiria Leiria, Portugal
| | - Constancio Gonzalez
- Departamento de Bioquímica y Biología Molecular y Fisiología, Facultad de Medicina, Instituto de Biología y Genética Molecular, Consejo Superior de Investigaciones Científicas, Ciber de Enfermedades Respiratorias, CIBERES, Instituto de Salud Carlos III, Universidad de Valladolid Valladolid, España
| | - Ana Obeso
- Departamento de Bioquímica y Biología Molecular y Fisiología, Facultad de Medicina, Instituto de Biología y Genética Molecular, Consejo Superior de Investigaciones Científicas, Ciber de Enfermedades Respiratorias, CIBERES, Instituto de Salud Carlos III, Universidad de Valladolid Valladolid, España
| | - Lucilia N Diogo
- CEDOC, Centro Estudos Doenças Crónicas, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa Lisboa, Portugal
| | - Emilia C Monteiro
- CEDOC, Centro Estudos Doenças Crónicas, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa Lisboa, Portugal
| | - Maria J Ribeiro
- CEDOC, Centro Estudos Doenças Crónicas, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa Lisboa, Portugal
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Importance of yawning in the evaluation of excessive daytime sleepiness: a prospective clinical study. Eur Arch Otorhinolaryngol 2014; 272:3611-5. [PMID: 25261103 DOI: 10.1007/s00405-014-3302-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
As a dark and not fully understood side of human nature, yawning is believed to be a signs of various physiological or pathological behaviors of human. In this study, we aimed to investigate the importance of yawning in the evaluation of sleepiness. One hundred and twenty-nine snorers who were suspected to have obstructive sleep apnea syndrome underwent polysomnography and were asked to fill the Epworth sleepiness scale. The number of yawnings of patients was counted during the day following polysomnography. Patients were stratified into two groups: those have apnea hypopnea index <5 (n = 43, group 1) and those have apnea hypopnea index >30 (n = 86, group 2). Mean duration of sleep phases, oxygen saturations, sleep efficacies, yawning frequencies and Epworth scores of the groups were compared. Correlations of yawning frequency with Epworth scores, duration of sleep phases and mean oxygen saturations were investigated. Sleep efficacies were similar between the groups (p > 0.05). Yawning frequencies in group 1 and group 2 were 43.48 and 75.76 (mean rank), respectively (p < 0.01). Mean N1, N2, N3 phase durations and oxygen saturations were significantly lower in group 2 (p < 0.01). While there was a negative correlation between yawning frequency and duration of the non-REM phases and mean oxygen saturation (r = -0.53 and r = -0.31, respectively, p < 0.05), yawning frequency was positively correlated with Epworth scores (r = 0.46, p < 0.05). In addition to the shortened phases of sleep, increased Epworth score and decreased oxygen saturation, increased yawning frequency may indicate sleep deprivation.
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Patil SP, Brown TT, Jacobson LP, Margolick JB, Laffan A, Johnson-Hill L, Godfrey R, Johnson J, Reynolds S, Schwartz AR, Smith PL. Sleep disordered breathing, fatigue, and sleepiness in HIV-infected and -uninfected men. PLoS One 2014; 9:e99258. [PMID: 24991815 PMCID: PMC4084642 DOI: 10.1371/journal.pone.0099258] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 05/12/2014] [Indexed: 12/18/2022] Open
Abstract
Study Objectives We investigated the association of HIV infection and highly active antiretroviral therapy (HAART) with sleep disordered breathing (SDB), fatigue, and sleepiness. Methods HIV-uninfected men (HIV−; n = 60), HIV-infected men using HAART (HIV+/HAART+; n = 58), and HIV-infected men not using HAART (HIV+/HAART−; n = 41) recruited from two sites of the Multicenter AIDS cohort study (MACS) underwent a nocturnal sleep study, anthropometric assessment, and questionnaires for fatigue and the Epworth Sleepiness Scale. The prevalence of SDB in HIV- men was compared to that in men matched from the Sleep Heart Health Study (SHHS). Results The prevalence of SDB was unexpectedly high in all groups: 86.7% for HIV−, 70.7% for HIV+/HAART+, and 73.2% for HIV+/HAART−, despite lower body-mass indices (BMI) in HIV+ groups. The higher prevalence in the HIV− men was significant in univariate analyses but not after adjustment for BMI and other variables. SDB was significantly more common in HIV− men in this study than those in SHHS, and was common in participants with BMIs <25 kg/m2. HIV+ men reported fatigue more frequently than HIV− men (25.5% vs. 6.7%; p = 0.003), but self-reported sleepiness did not differ among the three groups. Sleepiness, but not fatigue, was significantly associated with SDB. Conclusions SDB was highly prevalent in HIV− and HIV+ men, despite a normal or slightly elevated BMI. The high rate of SDB in men who have sex with men deserves further investigation. Sleepiness, but not fatigue, was related to the presence of SDB. Clinicians caring for HIV-infected patients should distinguish between fatigue and sleepiness when considering those at risk for SDB, especially in non-obese men.
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Affiliation(s)
- Susheel P. Patil
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | - Todd T. Brown
- Division of Endocrinology and Metabolism, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Lisa P. Jacobson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Joseph B. Margolick
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Alison Laffan
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Lisette Johnson-Hill
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Rebecca Godfrey
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jacquett Johnson
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Sandra Reynolds
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Alan R. Schwartz
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Philip L. Smith
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
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Neu D, Mairesse O, Verbanck P, Linkowski P, Le Bon O. Non-REM sleep EEG power distribution in fatigue and sleepiness. J Psychosom Res 2014; 76:286-91. [PMID: 24630178 DOI: 10.1016/j.jpsychores.2014.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 01/13/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this study is to contribute to the sleep-related differentiation between daytime fatigue and sleepiness. METHODS 135 subjects presenting with sleep apnea-hypopnea syndrome (SAHS, n=58) or chronic fatigue syndrome (CFS, n=52) with respective sleepiness or fatigue complaints and a control group (n=25) underwent polysomnography and psychometric assessments for fatigue, sleepiness, affective symptoms and perceived sleep quality. Sleep EEG spectral analysis for ultra slow, delta, theta, alpha, sigma and beta power bands was performed on frontal, central and occipital derivations. RESULTS Patient groups presented with impaired subjective sleep quality and higher affective symptom intensity. CFS patients presented with highest fatigue and SAHS patients with highest sleepiness levels. All groups showed similar total sleep time. Subject groups mainly differed in sleep efficiency, wake after sleep onset, duration of light sleep (N1, N2) and slow wave sleep, as well as in sleep fragmentation and respiratory disturbance. Relative non-REM sleep power spectra distributions suggest a pattern of power exchange in higher frequency bands at the expense of central ultra slow power in CFS patients during all non-REM stages. In SAHS patients, however, we found an opposite pattern at occipital sites during N1 and N2. CONCLUSIONS Slow wave activity presents as a crossroad of fatigue and sleepiness with, however, different spectral power band distributions during non-REM sleep. The homeostatic function of sleep might be compromised in CFS patients and could explain why, in contrast to sleepiness, fatigue does not resolve with sleep in these patients. The present findings thus contribute to the differentiation of both phenomena.
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Affiliation(s)
- Daniel Neu
- Brugmann University Hospital, Sleep Laboratory & Unit for Chronobiology U78, Free University of Brussels (U.L.B/V.U.B.), Brussels, Belgium; UNI, ULB Neurosciences Institute, Faculty of Medicine, Laboratory for Medical Psychology ULB312, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium.
| | - Olivier Mairesse
- Brugmann University Hospital, Sleep Laboratory & Unit for Chronobiology U78, Free University of Brussels (U.L.B/V.U.B.), Brussels, Belgium; UNI, ULB Neurosciences Institute, Faculty of Medicine, Laboratory for Medical Psychology ULB312, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium; Department of Experimental and Applied Psychology (EXTO), Vrije Universiteit Brussel (V.U.B.), Brussels, Belgium.
| | - Paul Verbanck
- Brugmann University Hospital, Sleep Laboratory & Unit for Chronobiology U78, Free University of Brussels (U.L.B/V.U.B.), Brussels, Belgium; UNI, ULB Neurosciences Institute, Faculty of Medicine, Laboratory for Medical Psychology ULB312, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium.
| | - Paul Linkowski
- University Clinics of Brussels, Erasme Hospital, Sleep Laboratory, Department of Psychiatry, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium.
| | - Olivier Le Bon
- UNI, ULB Neurosciences Institute, Faculty of Medicine, Laboratory for Medical Psychology ULB312, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium; Tivoli University Hospital, Department of Psychiatry, U.L.B., La Louvière, Belgium.
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Correlation between inflammatory markers of atherosclerosis and carotid intima-media thickness in Obstructive Sleep Apnea. Molecules 2014; 19:1651-62. [PMID: 24481114 PMCID: PMC6271201 DOI: 10.3390/molecules19021651] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 12/30/2022] Open
Abstract
Obstructive Sleep Apnea (OSA) is a sleep-related breathing disorder associated with the development of cardiovascular diseases and atherosclerosis. Systemic inflammation plays an important role in the development of cardiovascular complications in OSA patients. The aim of the study was to evaluate the relationship between carotid intima-media thickness (cIMT) and inflammatory markers plasma levels in OSA patients. We enrolled 80 OSA patients and 40 controls matched for age and body mass index (BMI). The presence and severity of sleep apnea was determined by in-laboratory portable monitoring (PM). Demographic data, blood pressure, heart rate, and cIMT were measured. High-sensitive C-Reactive Protein (hsCRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α and pentraxin (PTX)-3 serum concentrations were detected. cIMT was higher in OSA patients than controls (0.89 ± 0.13 mm vs. 0.65 ± 0.1 mm, p < 0.01). Moderate-severe OSA patients (0.95 ± 0.09 mm) had significantly increased cIMT than mild OSA (0.76 ± 0.1 mm; p < 0.01) and control (0.65 ± 0.1 mm; p < 0.01). hsCRP, IL-6, TNF-α, and PTX-3 in patients with OSA (1.67 ± 0.66 mg/L, 2.86 ± 1.39 pg/mL, 20.09 ± 5.39 pg/mL, 2.1 ± 0.59 ng/mL, respectively) were significantly higher than in controls (1.08 ± 0.53 mg/L, p < 0.01; 1.5 ± 0.67 pg/mL, p < 0.01; 12.53 ± 3.48 pg/mL, p < 0.01; 1.45 ± 0.41 ng/mL, p < 0.01, respectively). Carotid IMT was significantly correlated to CRP (r = 0.44; p < 0.01), IL-6 (r = 0.42; p < 0.01), TNF-α (r = 0.53; p < 0.01), and PTX-3 (r = 0.49; p < 0.01). OSA patients showed increased cIMT, CRP, IL-6, TNF-α, and PTX-3 levels. Inflammatory markers levels are correlated to cIMT in OSA patients.
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Wang Q, Zhang C, Jia P, Zhang J, Feng L, Wei S, Luo Y, Su L, Zhao C, Dong H, Ma J, Wang G. The association between the phenotype of excessive daytime sleepiness and blood pressure in patients with obstructive sleep apnea-hypopnea syndrome. Int J Med Sci 2014; 11:713-20. [PMID: 24843321 PMCID: PMC4025171 DOI: 10.7150/ijms.7487] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 03/08/2014] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Investigate the clinical features and the blood pressure (BP) pattern of the phenotype of excessive daytime sleepiness (EDS) in OSAHS. METHODS A total of 508 Chinese adults with suspected OSAHS were referred to our sleep laboratory from October 2009 to May 2012. On the same night of polysomnography (PSG), the levels of blood pressure were measured before sleeping (bedtime BP) and immediately after waking up in the next morning (morning BP). EDS was recognized as Epworth Sleepiness Scale (ESS)≥9. Subjects were classified into four groups based on the apnea-hypopnea index (AHI) from PSG as follows: control (simple snoring) group (control, n=104) with AHI<5; mild group (mild, n=89) with AHI≥5 and <15; moderate group (moderate, n=70) with AHI≥15 and<30; and severe group (severe, n=245) with AHI ≥30. The differences and correlations between BP and PSG parameters in EDS and non-EDS group of OSAHS patients were analyzed. RESULTS In all subjects, ESS was positively correlated with morning diastolic blood pressure (DBP), Mean arterial pressure (MAP) and bedtime DBP (r=0.144, 0.102 and 0.114, respectively, each P value<0.05). In OSAHS patients, ESS was only positively correlated with morning DBP (r=0.137, P<0.05). OSAHS patients with EDS phenotype were younger and were more likely to have the symptom of waking up feeling tired (36.1% vs. 23.2%, p=0.023), who had lower MSaO2, longer SIT90 (the ratio of time of SpO2 below 90% in total sleep time) and higher DBP (bedtime as well as morning). In patients with AHI≥15, ESS was correlated positively with both bedtime and morning DBP after controlling the confounding effects of age, sex, BMI, AHI and nadir nocturnal oxygen saturation( r=0.126,0.143, respectively, both P values<0.05). And in OSAHS patients of EDS phenotype, the bedtime DBP, bedtime MAP, morning DBP, and morning MAP were 3~5 mm Hg higher than that in patients of non-EDS phenotype(P<0.05). In the moderate and severe OSAHS group, patients with EDS phenotype were younger and had a lower mean blood oxygen saturation (MSaO2), longer time of SpO2 below 90% and higher SIT90 than patients with non-EDS phenotype (P<0.05). In hypertensive OSAHS patients, patients with EDS were also younger and had higher micro-arousal index (MiI), as well as higher morning DBP, morning MAP and bedtime DBP than that in non-EDS group (P<0.05). CONCLUSIONS EDS in OSAHS patients is a special phenotype, which was characterized by younger age, higher DBP and more severe hypoxic load. This feature is mainly manifested in moderate and severe OSAHS patients. It is very important to identify the phenotype of EDS in patients with OSAHS, who may meet more benefits from effective treatment of OSAHS by correcting the intermittent nocturnal hypoxia and sleep fragmentation.
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Affiliation(s)
- Qimin Wang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Cheng Zhang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Peng Jia
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Liping Feng
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Shumin Wei
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Yiping Luo
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Li Su
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Can Zhao
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Hui Dong
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Jing Ma
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Guangfa Wang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
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Gerbino G, Bianchi FA, Verzé L, Ramieri G. Soft tissue changes after maxillo-mandibular advancement in OSAS patients: A three-dimensional study. J Craniomaxillofac Surg 2014; 42:66-72. [DOI: 10.1016/j.jcms.2013.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 02/19/2013] [Accepted: 02/19/2013] [Indexed: 11/25/2022] Open
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Langrock R, Swihart BJ, Caffo BS, Punjabi NM, Crainiceanu CM. Combining hidden Markov models for comparing the dynamics of multiple sleep electroencephalograms. Stat Med 2013; 32:3342-56. [PMID: 23348835 PMCID: PMC3753805 DOI: 10.1002/sim.5747] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 01/04/2013] [Indexed: 11/11/2022]
Abstract
In this manuscript, we consider methods for the analysis of populations of electroencephalogram signals during sleep for the study of sleep disorders using hidden Markov models (HMMs). Notably, we propose an easily implemented method for simultaneously modeling multiple time series that involve large amounts of data. We apply these methods to study sleep-disordered breathing (SDB) in the Sleep Heart Health Study (SHHS), a landmark study of SDB and cardiovascular consequences. We use the entire, longitudinally collected, SHHS cohort to develop HMM population parameters, which we then apply to obtain subject-specific Markovian predictions. From these predictions, we create several indices of interest, such as transition frequencies between latent states. Our HMM analysis of electroencephalogram signals uncovers interesting findings regarding differences in brain activity during sleep between those with and without SDB. These findings include stability of the percent time spent in HMM latent states across matched diseased and non-diseased groups and differences in the rate of transitioning.
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Affiliation(s)
- Roland Langrock
- School of Mathematics and Statistics, University of St Andrews, The Observatory, Buchanan Gardens, St Andrews, Fife, KY16 PLZ, Scotland, UK.
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Khan NNS, Badr MS. Deep venous thrombosis attributed to sleep apnea. Am J Med 2013; 126:e21. [PMID: 23885685 DOI: 10.1016/j.amjmed.2013.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 01/15/2013] [Accepted: 01/15/2013] [Indexed: 10/26/2022]
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Otuyama LJ, Rizzi CF, Piovezan RD, Werli KS, Brasil EL, Sukys-Claudino L, Tufik S, Poyares D. The cholinergic system may play a role in the pathophysiology of residual excessive sleepiness in patients with obstructive sleep apnea. Med Hypotheses 2013; 81:509-11. [PMID: 23891038 DOI: 10.1016/j.mehy.2013.06.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 06/30/2013] [Indexed: 11/15/2022]
Abstract
Obstructive sleep apnea (OSA) is a prevalent condition characterized by momentary cessations in breathing during sleep due to intermittent obstruction of the upper airway. OSA has been frequently associated with a number of medical comorbidities. CPAP (continuous positive airway pressure) is the gold standard treatment and is known to improve OSA symptoms, including excessive sleepiness. However, 12-14% of CPAP-treated patients continue to complain of sleepiness despite normalization of ventilation during sleep, and 6% after exclusion of other causes of EDS. This is of great concern because EDS is strongly associated with systemic health disorders, lower work performance, and a high risk of accidents. We hypothesized that decreased central cholinergic activity plays a role in the pathophysiology of residual excessive sleepiness in patients with OSA treated with CPAP. Acetylcholine (Ach) plays a large role in wakefulness physiology, and its levels are reduced in sleepiness. Herein, we discuss the potential role of the cholinergic system in this new clinical condition.
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Affiliation(s)
- Leonardo J Otuyama
- Sleep Medicine and Biology Discipline, Psychobiology Department, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 925. Vila Clementino, Sao Paulo, SP 04024-002, Brazil.
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Characteristics of obstructive sleep apnea in patients with Parkinson's disease. J Neurol Sci 2013; 327:22-4. [DOI: 10.1016/j.jns.2013.01.036] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 01/25/2013] [Accepted: 01/29/2013] [Indexed: 11/19/2022]
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Taranto Montemurro L, Floras JS, Millar PJ, Kasai T, Gabriel JM, Spaak J, Coelho FMS, Bradley TD. Inverse relationship of subjective daytime sleepiness to sympathetic activity in patients with heart failure and obstructive sleep apnea. Chest 2012; 142:1222-1228. [PMID: 23303285 DOI: 10.1378/chest.11-2963] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Patients with heart failure (HF) and obstructive sleep apnea (OSA) are less sleepy than patients with OSA but without HF. Furthermore, unlike the non-HF population, in the HF population, the degree of daytime sleepiness is not related to the apnea-hypopnea index (AHI). The sympathetic nervous system plays a critical role in alertness. HF and OSA both increase sympathetic nervous system activity (SNA) during wakefulness. We hypothesized that in patients with HF and OSA, the degree of subjective daytime sleepiness would be inversely related to SNA. METHODS Daytime muscle SNA (MSNA) was recorded in patients with HF and OSA. Subjective daytime sleepiness was assessed by the Epworth Sleepiness Scale (ESS). RESULTS We studied 27 patients with HF and OSA and divided them into two groups based on the median ESS score: a less sleepy group, with an ESS score < 6 (n = 13), and a sleepier group, with an ESS score ≥ 6 (n = 14). The less sleepy group had higher MSNA than did the sleepier group (82.5 ± 9.9 bursts/100 cardiac cycles vs 69.3 ± 18.6 bursts/100 cardiac cycles; P = .037) and a longer sleep-onset latency (33 ± 29 min vs 14 ± 13 min; P = .039). The ESS score was inversely related to MSNA (r = -0.63; P < .001) but not to the AHI, arousal index, or indices of oxygen desaturation. CONCLUSIONS In patients with HF and OSA, the degree of subjective daytime sleepiness is inversely related to MSNA. This relationship is likely mediated via central adrenergic alerting mechanisms. These findings help to explain the previously reported lack of daytime hypersomnolence in patients with HF and OSA.
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Affiliation(s)
| | - John S Floras
- Department of Medicine of the University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Philip J Millar
- Department of Medicine of the University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Takatoshi Kasai
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Joseph M Gabriel
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Jonas Spaak
- Department of Medicine of the University Health Network and Mount Sinai Hospital, Toronto, ON, Canada; Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Danderyd, Sweden
| | | | - T Douglas Bradley
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, Toronto, ON, Canada; Department of Medicine of the University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
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Mavanji V, Billington CJ, Kotz CM, Teske JA. Sleep and obesity: a focus on animal models. Neurosci Biobehav Rev 2012; 36:1015-29. [PMID: 22266350 DOI: 10.1016/j.neubiorev.2012.01.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 11/25/2011] [Accepted: 01/07/2012] [Indexed: 12/19/2022]
Abstract
The rapid rise in obesity prevalence in the modern world parallels a significant reduction in restorative sleep (Agras et al., 2004; Dixon et al., 2007, 2001; Gangwisch and Heymsfield, 2004; Gupta et al., 2002; Sekine et al., 2002; Vioque et al., 2000; Wolk et al., 2003). Reduced sleep time and quality increases the risk for obesity, but the underlying mechanisms remain unclear (Gangwisch et al., 2005; Hicks et al., 1986; Imaki et al., 2002; Jennings et al., 2007; Moreno et al., 2006). A majority of the theories linking human sleep disturbances and obesity rely on self-reported sleep. However, studies with objective measurements of sleep/wake parameters suggest a U-shaped relationship between sleep and obesity. Studies in animal models are needed to improve our understanding of the association between sleep disturbances and obesity. Genetic and experimenter-induced models mimicking characteristics of human obesity are now available and these animal models will be useful in understanding whether sleep disturbances determine propensity for obesity, or result from obesity. These models exhibit weight gain profiles consistently different from control animals. Thus a careful evaluation of animal models will provide insight into the relationship between sleep disturbances and obesity in humans. In this review we first briefly consider the fundamentals of sleep and key sleep disturbances, such as sleep fragmentation and excessive daytime sleepiness (EDS), observed in obese individuals. Then we consider sleep deprivation studies and the role of circadian alterations in obesity. We describe sleep/wake changes in various rodent models of obesity and obesity resistance. Finally, we discuss possible mechanisms linking sleep disturbances with obesity.
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Affiliation(s)
- Vijayakumar Mavanji
- Minnesota Obesity Prevention Training Program, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
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Moon HJ, Kang B, Nam H. Polysomnographic Parameters Related to Daytime Sleepiness in Obstructive Sleep Apnea Syndrome: A Preliminary Study. SLEEP MEDICINE RESEARCH 2011. [DOI: 10.17241/smr.2011.2.3.96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Schwartz AR, Barnes M, Hillman D, Malhotra A, Kezirian E, Smith PL, Hoegh T, Parrish D, Eastwood PR. Acute upper airway responses to hypoglossal nerve stimulation during sleep in obstructive sleep apnea. Am J Respir Crit Care Med 2011; 185:420-6. [PMID: 22135343 DOI: 10.1164/rccm.201109-1614oc] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Hypoglossal nerve stimulation (HGNS) recruits lingual muscles, reduces pharyngeal collapsibility, and treats sleep apnea. OBJECTIVES We hypothesized that graded increases in HGNS relieve pharyngeal obstruction progressively during sleep. METHODS Responses were examined in 30 patients with sleep apnea who were implanted with an HGNS system. Current (milliampere) was increased stepwise during non-REM sleep. Frequency and pulse width were fixed. At each current level, stimulation was applied on alternating breaths, and responses in maximal inspiratory airflow (V(I)max) and inspiratory airflow limitation (IFL) were assessed. Pharyngeal responses to HGNS were characterized by the current levels at which V(I)max first increased and peaked (flow capture and peak flow thresholds), and by the V(I)max increase from flow capture to peak (ΔV(I)max). MEASUREMENTS AND MAIN RESULTS HGNS produced linear increases in V(I)max from unstimulated levels at flow capture to peak flow thresholds (215 ± 21 to 509 ± 37 ml/s; mean ± SE; P < 0.001) with increasing current from 1.05 ± 0.09 to 1.46 ± 0.11 mA. V(I)max increased in all patients and IFL was abolished in 57% of patients (non-IFL subgroup). In the non-IFL compared with IFL subgroup, the flow response slope was greater (1241 ± 199 vs. 674 ± 166 ml/s/mA; P < 0.05) and the stimulation amplitude at peak flow was lower (1.23 ± 0.10 vs. 1.80 ± 0.20 mA; P < 0.05) without differences in peak flow. CONCLUSIONS HGNS produced marked dose-related increases in airflow without arousing patients from sleep. Increases in airflow were of sufficient magnitude to eliminate IFL in most patients and IFL and non-IFL subgroups achieved normal or near-normal levels of flow, suggesting potential HGNS efficacy across a broad range of sleep apnea severity.
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Aurora RN, Caffo B, Crainiceanu C, Punjabi NM. Correlating subjective and objective sleepiness: revisiting the association using survival analysis. Sleep 2011; 34:1707-14. [PMID: 22131609 PMCID: PMC3208849 DOI: 10.5665/sleep.1442] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES The Epworth Sleepiness Scale (ESS) and multiple sleep latency test (MSLT) are the most commonly used measures of subjective and objective sleepiness, respectively. The strength of the association between these measures as well as the optimal ESS threshold that indicates objective sleepiness remains a topic of significant interest in the clinical and research arenas. The current investigation sought to: (a) examine the association between the ESS and the average sleep latency from the MSLT using the techniques of survival analysis; (b) determine whether specific patient factors influence the association; (c) examine the utility of each ESS question; and (d) identify the optimal ESS threshold that indicates objective sleepiness. DESIGN Cross-sectional study. PATIENTS AND SETTINGS Patients (N = 675) referred for polysomnography and MSLT. MEASUREMENTS AND RESULTS Using techniques of survival analysis, a significant association was noted between the ESS score and the average sleep latency. The adjusted hazard ratios for sleep onset during the MSLT for the ESS quartiles were 1.00 (ESS < 9), 1.32 (ESS: 10-13), 1.85 (ESS: 14-17), and 2.53 (ESS ≥ 18), respectively. The association was independent of several patient factors and was distinct for the 4 naps. Furthermore, most of the ESS questions were individually predictive of the average sleep latency except the tendency to doze off when lying down to rest in the afternoon, which was only predictive in patients with less than a college education. Finally, an ESS score ≥ 13 optimally predicted an average sleep latency < 8 minutes. CONCLUSIONS In contrast to previous reports, the association between the ESS and the average sleep latency is clearly apparent when the data are analyzed by survival analysis, and most of the ESS questions are predictive of objective sleepiness. An ESS score ≥ 13 most effectively predicts objective sleepiness, which is higher than what has typically been used in clinical practice. Given the ease of administering the ESS, it represents a relatively simple and cost-effective method for identifying individuals at risk for daytime sleepiness.
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Affiliation(s)
- R. Nisha Aurora
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian Caffo
- Departments of Biostatistics and Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Ciprian Crainiceanu
- Departments of Biostatistics and Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Naresh M. Punjabi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
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Bianchi MT, Eiseman NA, Cash SS, Mietus J, Peng CK, Thomas RJ. Probabilistic sleep architecture models in patients with and without sleep apnea. J Sleep Res 2011; 21:330-41. [PMID: 21955148 DOI: 10.1111/j.1365-2869.2011.00937.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sleep fragmentation of any cause is disruptive to the rejuvenating value of sleep. However, methods to quantify sleep architecture remain limited. We have previously shown that human sleep-wake stage distributions exhibit multi-exponential dynamics, which are fragmented by obstructive sleep apnea (OSA), suggesting that Markov models may be a useful method to quantify architecture in health and disease. Sleep stage data were obtained from two subsets of the Sleep Heart Health Study database: control subjects with no medications, no OSA, no medical co-morbidities and no sleepiness (n = 374); and subjects with severe OSA (n = 338). Sleep architecture was simplified into three stages: wake after sleep onset (WASO); non-rapid eye movement (NREM) sleep; and rapid eye movement (REM) sleep. The connectivity and transition rates among eight 'generator' states of a first-order continuous-time Markov model were inferred from the observed ('phenotypic') distributions: three exponentials each of NREM sleep and WASO; and two exponentials of REM sleep. Ultradian REM cycling was accomplished by imposing time-variation to REM state entry rates. Fragmentation in subjects with severe OSA involved faster transition probabilities as well as additional state transition paths within the model. The Markov models exhibit two important features of human sleep architecture: multi-exponential stage dynamics (accounting for observed bout distributions); and probabilistic transitions (an inherent source of variability). In addition, the model quantifies the fragmentation associated with severe OSA. Markov sleep models may prove important for quantifying sleep disruption to provide objective metrics to correlate with endpoints ranging from sleepiness to cardiovascular morbidity.
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Affiliation(s)
- Matt T Bianchi
- Neurology Department, Massachusetts General Hospital, Boston, MA 02114, USA.
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Kirkness JP, Peterson LA, Squier SB, McGinley BM, Schneider H, Meyer A, Schwartz AR, Smith PL, Patil SP. Performance characteristics of upper airway critical collapsing pressure measurements during sleep. Sleep 2011; 34:459-67. [PMID: 21461324 DOI: 10.1093/sleep/34.4.459] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The critical pressure (P(CRIT)), a measurement of upper airway collapsibility, is a determinant of the severity of upper airway obstruction during sleep. We examined the performance characteristics of the passive and active P(CRIT) by examining both within-night and between-night variability in the measurements. METHODS We studied 54 sleep apnea patients (39 men, 15 women) and 34 normal subjects (20 men, 14 women) on either 1 or 2 nights during sleep. The P(CRIT) was measured during relative hypotonia ("passive" state) or during periods of sustained upper airway obstruction used to recruit upper airway neuromuscular responses ("active" state) within- and between-nights. In a subgroup of 10 normal subjects, we performed repeated measurements during hypnotic-induced sleep. Bland-Altman analyses were used to determine the within-night and between-night reliability of the P(CRIT) measurements. RESULTS There were no significant within-night or between-night differences for the mean passive P(CRIT). The active P(CRIT) was ∼1 cm H(2)O more collapsible on the second night than on the first night. The limits of agreement, which bound the passive and active P(CRIT), was ∼ ± 3 cm H(2)O and was reduced to ∼ ± 1 cm H(2)O for the passive P(CRIT) with hypnotic-induced sleep. CONCLUSION Passive and active P(CRIT) measurements are reasonably reliable within and between nights. An approximately 3 cm H(2)O change in passive or active P(CRIT) appears to represent the minimally significant change in P(CRIT) necessary to assess the effect of an intervention (e.g., positional therapy, surgical interventions, oral appliance effects, and pharmacotherapy) on upper airway mechanical loads or neuromuscular responses.
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Affiliation(s)
- Jason P Kirkness
- Johns Hopkins Sleep Disorders Center, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA.
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[Which pretherapeutic evaluation of a newly diagnosed patient with obstructive sleep apnea syndrome?]. Rev Mal Respir 2010; 27 Suppl 3:S124-36. [PMID: 21129621 DOI: 10.1016/s0761-8425(10)70018-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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