EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

The efficacy and safety of Bazi Bushen Capsule in treating premature aging: A randomized, double blind, multicenter, placebo-controlled clinical trial

PURPOSE

It is unclear whether traditional Chinese patent medicines can resist premature aging. This prospective study investigated the effects of Bazi Bushen Capsule (BZBS) which is a traditional Chinese patent medicine for tonifying the kidney essence on premature senility symptoms and quality of life, telomerase activity and telomere length.

STUDY DESIGN AND METHODS

It was a parallel, multicenter, double-blind, randomized, and placebo-controlled trial. Subjects (n = 530) aged 30-78 years were randomized to receive BZBS or placebo capsules 12 weeks. The primary outcome was the clinical feature of change in kidney deficiency for aging evaluation scale (CFCKD-AES) and tilburg frailty indicator (TFI). The secondary outcomes were SF-36, serum sex hormone level, five times sit-to-stand time (FTSST), 6MWT, motor function test-grip strength, balance test, walking speed, muscle mass measurement, telomerase and telomere length.

RESULTS

After 12 weeks of treatment, the CFCKD-AES and TFI scores in the BZBS group decreased by 13.79 and 1.50 respectively (6.42 and 0.58 in the placebo group, respectively); The SF-36 in the BZBS group increased by 98.38 (23.79 in the placebo group). The FTSST, motor function test grip strength, balance test, walking speed, and muscle mass in the elderly subgroup were all improved in the BZBS group. The telomerase content in the BZBS group increased by 150.04 ng/ml compared to the placebo group. The fever led one patient in the placebo group to discontinue the trial. One patient in the placebo group withdrew from the trial due to pregnancy. None of the serious AEs led to treatment discontinuation, and 3 AEs (1.14%) were assessed as related to BZBS by the primary investigator.

CONCLUSIONS

BZBS can improve premature aging symptoms, frailty scores, and quality of life, as well as improve FTSST, motor function: grip strength, balance test, walking speed, and muscle mass in elderly subgroups of patients, and enhance telomerase activity, but it is not significantly associated with increasing telomere length which is important for healthy aging.

TRIAL REGISTRY

https://www.chictr.org.cn/showproj.html?proj=166181.

Sleep disruption and premolar absence, NHANES, 2017-2020: A cross-sectional study

OBJECTIVE

Orthodontic treatment often involves four first premolar extractions. There is concern that the retraction of the anterior teeth due to extraction of first premolars may constrict tongue space and will reduce oral cavity and oropharynx space. Constricted airways are often associated with sleep disordered breathing (SDB) and sleep disruption. The aim of this study was to determine if there is an association of SDB factors with the absence of first premolars.

METHODS

A cross-sectional study was conducted using National Health and Nutrition Examination Survey (NHANES) 2017-March 2020 data on participants, aged 18-65 years (n = 4742). Variables of interest included self-reports of SDB (symptoms of disrupted sleep such as snoring, snorting, daytime sleepiness, and inappropriate number of hours of sleep). Data for the presence/absence of first premolars were gathered from the oral examination section of NHANES. An assumption was made that absence of four first premolars in dentate participants indicated extractions for orthodontic treatment. Data analyses were conducted with Rao Scott chi squared test.

RESULTS

There were no significant associations of SDB and symptoms of disrupted sleep associated with the absence of four first premolars in dentate participants.

CONCLUSION

Concerns of the impact of first premolar extractions on SDB were not supported with this study.

Impact of Comorbid Sleep-Disordered Breathing and Atrial Fibrillation on the Long-Term Outcome After Ischemic Stroke

BACKGROUND

Sleep-disordered breathing (SDB) and atrial fibrillation (AF) are highly prevalent in patients with stroke and are recognized as independent risk factors for stroke. Little is known about the impact of comorbid SDB and AF on long-term outcomes after stroke.

METHODS

In this prospective cohort study, 353 patients with acute ischemic stroke or transient ischemic attacks were analyzed. Patients were screened for SDB by respiratory polygraphy during acute hospitalization. Screening for AF was performed using a 7-day ECG up to 3× in the first 6 months. Follow-up visits were scheduled at 1, 3, 12, 24, and 36 months poststroke. Cox regression models adjusted for various factors (age, sex, body mass index, hypertension, diabetes, dyslipidemia, and heart failure) were used to assess the impact of comorbid SDB and AF on subsequent death or cerebro-cardiovascular events.

RESULTS

Among 353 patients (299 ischemic stroke and 54 transient ischemic attacks), median age, 67 (interquartile range, 57-74) years with 63% males. Moderate-to-severe SDB (apnea-hypopnea index score, ≥15/h) was present in 118 (33.4%) patients. Among the 56 (15.9%) patients with AF, 28 had comorbid moderate-to-severe SDB and AF. Over 36 months, there were 12 deaths and 67 recurrent cerebro-cardiovascular events. Patients with comorbid moderate-to-severe SDB and AF had a higher risk of subsequent death or cerebro-cardiovascular events compared with those with only moderate-to-severe SDB without AF (hazard ratio, 2.49 [95% CI, 1.18-5.24]) and to those without moderate-to-severe SDB or AF (hazard ratio, 2.25 [95% CI, 1.12-4.50]). However, no significant difference was found between the comorbid moderate-to-severe SDB and AF group and the group with only AF without moderate-to-severe SDB (hazard ratio, 1.64 [95% CI, 0.62-4.36]).

CONCLUSIONS

Comorbid moderate-to-severe SDB and AF significantly increase the risk of long-term mortality or recurrent cerebro-cardiovascular events after acute ischemic stroke. Considering both conditions as cumulative and modifiable cerebro-cardiovascular risk factors is of interest for the management of acute stroke.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02559739.

Functional recovery after ischemic stroke: Impact of different sleep health parameters

Sleep disturbances after ischaemic stroke include alterations of sleep architecture, obstructive sleep apnea, restless legs syndrome, daytime sleepiness and insomnia. Our aim was to explore their impacts on functional outcomes at month 3 after stroke, and to assess the benefit of continuous positive airway pressure in patients with severe obstructive sleep apnea. Ninety patients with supra-tentorial ischaemic stroke underwent clinical screening for sleep disorders and polysomnography at day 15 ± 4 after stroke in a multisite study. Patients with severe obstructive apnea (apnea-hypopnea index ≥ 30 per hr) were randomized into two groups: continuous positive airway pressure-treated and sham (1:1 ratio). Functional independence was assessed with the Barthel Index at month 3 after stroke in function of apnea-hypopnea index severity and treatment group. Secondary objectives were disability (modified Rankin score) and National Institute of Health Stroke Scale according to apnea-hypopnea index. Sixty-one patients (71.8 years, 42.6% men) completed the study: 51 (83.6%) had obstructive apnea (21.3% severe apnea), 10 (16.7%) daytime sleepiness, 13 (24.1%) insomnia, 3 (5.7%) depression, and 20 (34.5%) restless legs syndrome. Barthel Index, modified Rankin score and Stroke Scale were similar at baseline and 3 months post-stroke in the different obstructive sleep apnea groups. Changes at 3 months in those three scores were similar in continuous positive airway pressure versus sham-continuous positive airway pressure patients. In patients with worse clinical outcomes at month 3, mean nocturnal oxygen saturation was lower whereas there was no association with apnea-hypopnea index. Poorer outcomes at 3 months were also associated with insomnia, restless legs syndrome, depressive symptoms, and decreased total sleep time and rapid eye movement sleep.

Consensus Statements among European Sleep Surgery Experts on Snoring and Obstructive Sleep Apnea: Part 1 Definitions and Diagnosis

Seeking consensus on definitions and diagnosis of snoring and obstructive sleep apnea (OSA) among sleep surgeons is important, particularly in this relatively new field with variability in knowledge and practices. A set of statements was developed based on the literature and circulated among eight panel members of European experts, utilizing the Delphi method. Responses in agreement and disagreement on each statement and the comments were used to assess the level of consensus and develop a revised version. The new version with the level of consensus and anonymized comments was sent to each panel member as the second round. This was repeated a total of five rounds. The total number of statements included in the initial set was 112. In the first round, of all eight panelists, the percentage of questions that had consensus among the eight, seven, and six panelists were 45%, 4.5%, and 7.1%, respectively. In the final set of statements consisting of 99, the percentage of questions that had consensus among the 8, 7, and 6 panelists went up to 66.7%, 24.2%, and 6.1%, respectively. Delphi's method demonstrated an efficient method of interaction among experts and the establishment of consensus on a specific set of statements.

Fractional exhaled nitric oxide-a possible biomarker for risk of obstructive sleep apnea in snorers

STUDY OBJECTIVES

Airway inflammation in patients with obstructive sleep apnea (OSA) has been described and can be assessed by measuring the biomarker fractional exhaled nitric oxide (FeNO). In this pilot study, we investigated FeNO measurements in identification of OSA among persons with snoring.

METHODS

In this study we aimed to investigate (1) if FeNO could be used in screening for OSA, (2) if daytime sleepiness correlated to FeNO levels, and (3) whether asthma affected FeNO levels. Persons with snoring were prospectively included in three primary care ear, nose, and throat clinics. Patients underwent spirometry, FeNO tests, and partial polygraphy. They filled out questionnaires on sinonasal and asthma symptoms, daytime sleepiness, and quality of life. Current smokers, patients with upper airway inflammatory conditions, and patients treated with steroids were excluded.

RESULTS

Forty-nine individuals were included. Median apnea-hypopnea index was 11.4, mean age was 50.9 years, and 29% were females. OSA was diagnosed in 73% of the patients of whom 53% had moderate-severe disease. Patients with moderate-severe OSA had significantly higher FeNO counts than patients with no or mild OSA (P = .024). Patients younger than 50 years with a FeNO below 15 had the lowest prevalence of moderate-severe OSA. No correlation was found between FeNO measurements and daytime sleepiness, and asthma did not affect FeNO levels.

CONCLUSIONS

We found a low prevalence of moderate-severe OSA in persons with snoring when FeNO and age were low. This might be considered in a future screening model, though further studies testing the FeNO cutoff level and the diagnostic accuracy are warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: NO Measurements in Screening for Asthma and OSA, in Patients With Severe Snoring; URL: https://clinicaltrials.gov/study/NCT03964324; Identifier: NCT03964324.

CITATION

Kiaer E, Ravn A, Jennum P, et al. Fractional exhaled nitric oxide-a possible biomarker for risk of obstructive sleep apnea in snorers. J Clin Sleep Med. 2024;20(1):85-92.

Blood pressure variability, nocturnal heart rate variability and endothelial function predict recurrent cerebro-cardiovascular events following ischemic stroke

Introduction

Cardiovascular parameters characterizing blood pressure (BP), heart rate (HR), endothelial function and arterial stiffness predict cerebro-cardiovascular events (CCVE) in the general population. Considering the paucity of data in stroke patients, we assessed these parameters as potential predictors of recurrent CCVE at acute stroke stroke.

Patients and methods

This is a secondary outcome analysis of a prospective observational longitudinal Sleep Deficiency & Stroke Outcome Study (ClinicalTrials.gov Identifier: NCT02559739). The study consecutively recruited acute ischemic stroke patients. Cardiovascular parameters (blood pressure variability [BPV], heart rate variability [HRV], endothelial function, and arterial stiffness) were assessed within the first week post-stroke. Future CCVE were recorded over a 3-year follow-up. Multivariate Cox regression analysis was used to investigate the prognostic value of 48 cardiovascular parameters regarding CCVE risk.

Results

Out of 447 recruited patients, 359 were included in this analysis. 20% of patients developed a future CCVE. A high variability of systolic BP (n = 333) and nocturnal HR (non-linear parameters; n = 187) at acute stroke predicted CCVE risk after adjustment for demographic parameters, cardiovascular risk factors and mean BP or HR, respectively. Endothelial dysfunction (n = 105) at acute stroke predicted CCVE risk after adjustment for age and sex, but not after adjustment for cardiovascular risk factors. Diurnal HR and arterial stiffness at acute stroke were not associated with CCVE risk.

Conclusion

High blood pressure variability, high nocturnal HRV and endothelial function contribute to the risk for future CCVE after stroke.

A clinical review of obstructive sleep apnea

ABSTRACT

Symptoms of obstructive sleep apnea (OSA) often are overlooked or misinterpreted, but without treatment, patients are at increased risk for potentially life-threatening conditions including stroke and heart failure. Clinician awareness of the risk factors for and treatment of OSA can prevent the development or progression of these complications in patients.

Factors influencing recurrence after an ischemic stroke vary by sex

OBJECTIVES

To determine the factors that affect recurrent stroke after acute ischemic stroke, specifically between male and female groups.

METHODS

We examined relative factors associated with recurrent stroke in Chinese patients with first-ever ischemic stroke. LASSO (least absolute shrinkage and selection operator) Cox regression were used to determine the predictors of recurrent stroke in the male and female groups. Next, We used Kaplan-Meier survival curves and interactions among these predictors to assess the association between relapse-related factors and recurrent stroke.

RESULTS

During one year of follow-up, we documented 42 incidents of recurrent stroke in males and 15 in females. There was no significant difference in the overall recurrence rate between men and women. We finally identified three variables in males and one variable in females associated considerably with recurrent stroke by LASSO Cox regression. In females, good sleep appeared to be the most significant protective factor against recurrent stroke(hazard ratio [HR], 0.21; 95% CI, 0.08-0.57). In the male group, we found two risk factors: atherosclerotic burden (HR, 2.42; 95% CI, 1.30-4.51) and coronary heart disease (HR, 2.98; 95% CI, 1.16-7.66); and one protective factor: domestic/physical activities (HR, 0.45; 95% CI, 0.24-0.83). We also found an interaction between good sleep and domestic/physical activities in males (Pinteraction = 0.016).

DISCUSSION

Our data indicate that the factors for recurrent stroke may differ by sex. Engaging in domestic/physical activities may substantially lower recurrent strokes in Chinese adult males. And good sleep in females appears to be more important in preventing stroke recurrence.

Sleep-Disordered Breathing and Prognosis after Ischemic Stroke: It Is Not Apnea-Hypopnea Index That Matters

BACKGROUND

Sleep-disordered breathing (SDB) is highly prevalent after stroke and is considered to be a risk factor for poor post-stroke outcomes. The aim of this observational study was to evaluate the effect of nocturnal respiratory-related indices based on nocturnal respiratory polygraphy on clinical outcomes (including mortality and non-fatal events) in patients with ischemic stroke.

METHODS

A total of 328 consecutive patients (181 (55%) males, mean age 65.8 ± 11.2 years old) with confirmed ischemic stroke admitted to a stroke unit within 24 h after stroke onset were included in the analysis. All patients underwent standard diagnostic and treatment procedures, and sleep polygraphy was performed within the clinical routine in the first 72 h after admission. The long-term outcomes were assessed by cumulative endpoint (death of any cause, new non-fatal myocardial infarction, new non-fatal stroke/transient ischemic attack, emergency revascularization, emergency hospitalization due to the worsening of cardiovascular disease). A Cox-regression analysis was applied to evaluate the effects of nocturnal respiratory indices on survival.

RESULTS

The mean follow-up period comprised 12 months (maximal-48 months). Patients with unfavourable outcomes demonstrated a higher obstructive apnea-hypopnea index, a higher hypoxemia burden assessed as a percent of the time with SpO₂ < 90%, a higher average desaturation drop, and a higher respiratory rate at night. Survival time was significantly lower (30.6 (26.5; 34.7) versus 37.9 (34.2; 41.6) months (Log Rank 6.857, p = 0.009)) in patients with higher hypoxemia burden (SpO₂ < 90% during ≥2.1% versus <2.1% of total analyzed time). However, survival time did not differ depending on the SDB presence assessed by AHI thresholds (either ≥5 or ≥15/h). The multivariable Cox proportional hazards regression (backward stepwise analysis) model demonstrated that the parameters of hypoxemia burden were significantly associated with survival time, independent of age, stroke severity, stroke-related medical interventions, comorbidities, and laboratory tests.

CONCLUSION

Our study demonstrates that the indices of hypoxemia burden have additional independent predictive value for long-term outcomes (mortality and non-fatal cardiovascular events) after ischemic stroke.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Circadian Factors in Stroke: A Clinician's Perspective

Stroke remains one of the leading causes of mortality and long-term and permanent disability worldwide despite technological innovations and developments in pharmacotherapy. In the last few decades, the growing data have evidenced the role of the circadian system in brain vulnerability to damage, the development and evolution of stroke, and short-term and long-term recovery. On the other hand, the stroke itself can affect the circadian system via direct injury of specific brain structures involved in circadian regulation (i.e., hypothalamus, retinohypothalamic tracts, etc.) and impairment of endogenous regulatory mechanisms, metabolic derangement, and a neurogenic inflammatory response in acute stroke. Moreover, the disruption of circadian rhythms can occur or exacerbate as a result of exogenous factors related to hospitalization itself, the conditions in the intensive care unit and the ward (light, noise, etc.), medication (sedatives and hypnotics), and loss of external factors entraining the circadian rhythms. In the acute phase of stroke, patients demonstrate abnormal circadian variations in circadian biomarkers (melatonin, cortisol), core body temperature, and rest-activity patterns. The approaches aimed at the restoration of disrupted circadian patterns include pharmacological (melatonin supplementation) and non-medication (bright light therapy, shifting feeding schedules, etc.) interventions; however, their effects on short- and long-term recovery after stroke are not well understood.

Obstructive Sleep Apnea - Influence on the Cardiovascular System and Cognition

Kardiovaskuläre und kognitive Erkrankungen sind ebenso wie die obstruktive Schlafapnoe sehr häufige Krankheiten mit einer erheblichen Beeinträchtigung der Lebensqualität und einer deutlichen sozioökonomischen Bedeutung. Die Auswirkungen einer unbehandelten obstruktiven Schlafapnoe (OSA) auf das kardiovaskuläre und kognitive Erkrankungsrisiko und die Therapieeffekte einer OSA sind für die meisten kardiovaskulären und kognitiven Folgeerkrankungen wissenschaftlich nachgewiesen. Für die klinische Praxis besteht ein deutlicher Bedarf nach mehr Interdisziplinarität. Aus schlafmedizinischer Sicht müssen bei der Therapieindikation das individuelle kardiovaskuläre und kognitive Risiko berücksichtigt und kognitive Erkrankungen bei der Beurteilung der Therapieintoleranz und residuellen Symptomatik beachtet werden. Aus internistischer Sicht sollte bei Patienten mit schlecht einstellbarem Hypertonus, Vorhofflimmern, koronarer Herzkrankheit und Schlaganfall die Abklärung einer OSA in die Diagnostik integriert werden. Bei Patienten mit milder kognitiver Beeinträchtigung, Alzheimer-Krankheit und Depression können sich die typischen Symptome wie Fatigue, Tagesmüdigkeit und Reduktion der kognitiven Leistungen mit OSA-Symptomen überschneiden. Die Diagnostik einer OSA sollte in die Abklärung dieser Krankheitsbilder integriert werden, da eine Therapie der OSA die kognitiven Beeinträchtigungen reduzieren und die Lebensqualität verbessern kann.

National Knowledge-Driven Management of Obstructive Sleep Apnea-The Swedish Approach

INTRODUCTION

This paper describes the development of "Swedish Guidelines for OSA treatment" and the underlying managed care process. The Apnea Hypopnea Index (AHI) is traditionally used as a single parameter for obstructive sleep apnea (OSA) severity classification, although poorly associated with symptomatology and outcome. We instead implement a novel matrix for shared treatment decisions based on available evidence.

METHODS

A national expert group including medical and dental specialists, nurses, and patient representatives developed the knowledge-driven management model. A Delphi round was performed amongst experts from all Swedish regions (N = 24). Evidence reflecting treatment effects was extracted from systematic reviews, meta-analyses, and randomized clinical trials.

RESULTS

The treatment decision in the process includes a matrix with five categories from a "very weak"" to "very strong" indication to treat, and it includes factors with potential influence on outcome, including (A) OSA-related symptoms, (B) cardiometabolic comorbidities, (C) frequency of respiratory events, and (D) age. OSA-related symptoms indicate a strong incitement to treat, whereas the absence of symptoms, age above 65 years, and no or well-controlled comorbidities indicate a weak treatment indication, irrespective of AHI.

CONCLUSIONS

The novel treatment matrix is based on the effects of treatments rather than the actual frequency of respiratory events during sleep. A nationwide implementation of this matrix is ongoing, and the outcome is monitored in a prospective evaluation by means of the Swedish Sleep Apnea Registry (SESAR).

Clinical significance of obstructive sleep apnea in patients with acute coronary syndrome with or without prior stroke: a prospective cohort study

BACKGROUND AND OBJECTIVE

Whether obstructive sleep apnea (OSA) is associated with worse prognosis in patients with acute coronary syndrome (ACS) with or without prior stroke remains unclear. We investigated the association of OSA with cardiovascular events in ACS patients with or without prior stroke.

METHODS

Between June 2015 and January 2020, we prospectively recruited eligible ACS patients who underwent cardiorespiratory polygraphy during hospitalization. We defined OSA as an apnea hypopnea index (AHI) ≥ 15 events/hour. The primary composite end point was major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization, or hospitalization for unstable angina or heart failure.

RESULTS

Among 1927 patients enrolled, 207 patients had prior stroke (10.7%) and 1014 had OSA (52.6%). After a mean follow-up of 2.9 years, patients with stroke had significantly higher risk of MACCEs than those without stroke (hazard ratio [HR]:1.49; 95% confidence interval [CI]: 1.12-1.98, P = 0.007). The multivariate analysis showed that patients with OSA had 2.0 times the risk of MACCEs in prior stroke group (41 events [33.9%] vs 18 events [20.9%]; HR:2.04, 95% CI:1.13-3.69, P = 0.018), but not in non-prior stroke group (186 events [20.8%] vs 144 events [17.4]; HR:1.21, 95% CI 0.96-1.52, P = 0.10). No significant interaction was noted between prior stroke and OSA for MACCE (interaction P = 0.17).

CONCLUSIONS

Among ACS patients, the presence of OSA was associated with an increased risk of cardiovascular events in patients with prior stroke. Further trials exploring the efficacy of OSA treatment in high-risk patients with ACS and prior stroke are warranted. Trial registration Clinicaltrials.gov identifier NCT03362385.

Retinal vascular fractal dimension measurements in patients with obstructive sleep apnea syndrome: a retrospective case-control study

STUDY OBJECTIVES

We performed a case-control study to investigate the correlation between the apnea-hypopnea index (AHI) and the retinal vascular fractal dimension (FD).

METHODS

We selected 527 individuals who underwent polysomnography during health checkups at the Huadong Sanatorium from January to December 2021 as the study population, of whom 468 were included and 59 were excluded. All participants underwent a detailed health examination, including medical history assessment, physical examination, assessment of lifestyle factors, fundus photography, and laboratory examinations. The retinal vasculature was quantitatively assessed using Singapore I Vessel Assessment (SIVA) software. The relationship between the AHI and the retinal vessel quantitative was examined by multiple linear regression analyses and restricted cubic spline.

RESULTS

Among the 468 studied individuals, the average age was 51.51 (43-58) years, with 369 (78.85%) men and 99 (21.15%) women. According to the AHI indicator, 355 individuals were diagnosed with obstructive sleep apnea (OSA) syndrome, with an average AHI of 17.00 (9.200-30.130) events/h; 113 individuals were classified as controls, with an average AHI of 2.13 (0.88-3.63) events/h. In multiple linear regression, following varying degrees of adjustment for confounding factors, FD was reduced by 0.013 (P = .012; 95% confidence interval [CI]: -0.024 to -0.003), FD arteriole (FDa) was reduced by 0.013 (P = .019; 95% CI: -0.024 to -0.002), and FD venule (FDv) was reduced by 0.014 (P = .08; 95% CI: -0.024 to -0.004) in the high-AHI group compared with the low-AHI group. All tests for trend P values were < .05. The restricted cubic spline in the overall OSA population and the individuals without diabetes revealed a U-shaped pattern of decreasing, then increasing, FD, FDa, and FDv with a rising AHI. In the OSA individual with diabetes, FD, FDa, and FDv gradually decreased with increasing AHI.

CONCLUSIONS

The FD is associated with AHI in OSA individuals. The link between AHI and FD varied for OSA individuals with and without diabetes.

CITATION

Wang J, Chen T, Qi X, Li Y, Yang X, Meng X. Retinal vascular fractal dimension measurements in patients with obstructive sleep apnea syndrome: a retrospective case-control study. J Clin Sleep Med. 2023;19(3):479-490.

[Insomnia in neurological patients with disabilities]

Sleep is the most important factor reflecting the level of psychophysical well-being of a person and influencing him/her to the same extent. The greater susceptibility to sleep disturbances in patients with disabilities is associated with numerous factors. In the existing literature, there are few studies of insomnia in people with neurological disabilities. This article presents a current view on sleep disorders in disabled people and methods for their treatment.

Legal action for access to resources inefficiently made available in health care systems in Brazil: a case study on obstructive sleep apnea

OBJECTIVE

Obstructive sleep apnea (OSA) is a highly prevalent chronic disease, associated with morbidity and mortality. Although effective treatment for OSA is commercially available, their provision is not guaranteed by lines of care throughout Brazil, making legal action necessary. This study aimed at presenting data related to the volume of legal proceedings regarding the access to diagnosis and treatment of OSA in Brazil.

METHODS

This was a descriptive study of national scope, evaluating the period between January of 2016 and December of 2020. The number of lawsuits was analyzed according to the object of the demand (diagnosis or treatment). Projections of total expenses were carried out according to the number of lawsuits.

RESULTS

We identified 1,462 legal proceedings (17.6% and 82.4% related to diagnosis and treatment, respectively). The projection of expenditure for OSA diagnosis in the public and private spheres were R$575,227 and R$188,002, respectively. The projection of expenditure for OSA treatment in the public and private spheres were R$2,656,696 and R$253,050, respectively. There was a reduction in the number of lawsuits between 2017 and 2019.

CONCLUSIONS

Legal action as a strategy for accessing diagnostic and therapeutic resources related to OSA is a recurrent practice, resulting in inefficiency and inequity. The reduction in the number of lawsuits between 2017 and 2019 might be explained by the expansion of local health care policies or by barriers in the journey of patients with OSA, such as difficulties in being referred to specialized health care and low availability of diagnostic resources.

Effects of severe obstructive sleep apnea on functional prognosis in the acute phase of ischemic stroke and quantitative electroencephalographic markers

OBJECTIVE

To investigate the effect of severe obstructive sleep apnea (OSA) on functional prognosis in the acute phase and quantitative electroencephalography (EEG) markers during sleep in ischemic stroke patients.

METHODS

This study included 125 mild-to-moderate acute ischemic stroke patients with OSA who underwent polysomnography (PSG) within one week of stroke onset between January 2015 and June 2020. Patients were grouped according to their apnea-hypopnea index (</≥ 30/h). Poor functional prognosis was defined as modified Rankin Scale score ≥3. The EEG recorded by PSG was extracted during different sleep stages for power spectrum analysis. The delta/alpha power ratio (DAR), (delta + theta)/(alpha + beta) ratio (the slowing ratio, TSR), and the relative power (RP) of each frequency band were calculated. Differences in clinical, PSG, and quantitative EEG characteristics were compared between the groups. Additionally, we explored predictors of poor functional prognosis.

RESULTS

Patients with severe OSA had a higher proportion of hypertension, lower relative power of high-frequency bands, and higher delta RP, TSR, and DAR (p < 0.05). Severe OSA was associated with a 3.6-fold increase in risk of poor prognosis (p < 0.05). Increased delta RP and TSR, as well as decreased alpha, beta, and sigma RP, may be independent predictors of a poor functional prognosis.

CONCLUSIONS

Severe OSA is an independent risk factor for a poor functional prognosis in patients with acute ischemic stroke, and quantitative EEG during sleep showed a significant slow wave enhancement, suggesting more severe brain dysfunction. The treatment of severe OSA may improve functional prognosis.

ERS technical standards for using type III devices (limited channel studies) in the diagnosis of sleep disordered breathing in adults and children

For more than three decades, type III devices have been used in the diagnosis of sleep disordered breathing in supervised as well as unsupervised settings. They have satisfactory positive and negative predictive values for detecting obstructive and central sleep apnoea in populations with moderately high pre-test probability of symptoms associated with these events. However, standardisation of commercially available type III devices has never been undertaken and the technical specifications can vary widely. None have been subjected to the same rigorous processes as most other diagnostic modalities in the medical field. Although type III devices do not include acquisition of electroencephalographic signals overnight, the minimum number of physical sensors required to allow for respiratory event scoring using standards outlined by the American Academy of Sleep Medicine remains debatable. This technical standard summarises data on type III studies published since 2007 from multiple perspectives in both adult and paediatric sleep practice. Most importantly, it aims to provide a framework for considering current type III device limitations in the diagnosis of sleep disordered breathing while raising research- and practice-related questions aimed at improving our use of these devices in the present and future.

Causal Relations Between Obstructive Sleep Apnea and Stroke: A Mendelian Randomization Study

Background

Previous studies of obstructive sleep apnea (OSA) in relation to stroke have been noted. However, the exact causality remains to be clearly defined. We aimed to adopt a two-sample Mendelian randomization study to investigate the causal effects of OSA on stroke and its subtypes.

Methods

A two-sample Mendelian randomization (MR) analysis was conducted to evaluate the causal effect of OSA on stroke and its subtypes, including, based on publicly genome-wide association studies (GWAS) databases. The inverse variance weighted (IVW) method was used as the main analysis. MR-Egger regression, weighted mode, weighted median, and MR pleiotropy residual sum and outlier (MR-PRESSO) were performed methods and were adopted as supplementary analysis to ensure the robustness of the results.

Results

Genetically predicted OSA was not related to the risk of stroke (odds ratio (OR), 0.99, 95% CI, 0.81-1.21, p = 0.909), and its subtypes, ischemic stroke (IS) (OR, 1.01, 95% CI, 0.82-1.23, p = 0.927), large vessel stroke (LVS) (OR, 1.05, 95% CI, 0.73-1.51, p = 0.795), cardioembolic stroke (CES) (OR, 1.03, 95% CI, 0.74-1.43, p = 0.855), small vessel stroke (SVS) (OR, 1.13, 95% CI, 0.88-1.46, p = 0.329), lacunar stroke (LS) (OR, 1.07, 95% CI, 0.74-1.56, p = 0.721) as well as intracerebral hemorrhage (ICH) (OR, 0.37, 95% CI = 0.09, 1.48, p = 0.160) (Wald ratio method). Other supplementary MR methods also confirmed similar results.

Conclusion

There may be no direct causal relationship between OSA and stroke or its subtypes.

Chronic insomnia disorder as risk factor for stroke: a systematic review

BACKGROUND

Stroke is one of the main causes of mortality worldwide. Nonetheless, there are still risk factors that have not been fully elucidated, such as chronic insomnia disorder.

OBJECTIVE

To evaluate the association between chronic insomnia disorder and the risk of stroke in adults, through a systematic review.

METHODS

Multiple studies available in the Embase, Lilacs, and Medline platforms were evaluated in English, Spanish, French, and Portuguese. The selection of papers was restricted to those that had investigated the association between chronic insomnia disorder and stroke in adults, regardless of gender or nationality, without a previous history of stroke. The data was extracted with the Cochrane Effective Practice and Organization of Care (EPOC) form. The risk of bias was evaluated by the EPOC Risk of bias tool.

RESULTS

A total of 138 articles were identified. After a detailed evaluation with the eligibility criteria, four articles were included in the present systematic review. Three of them recognized the association between chronic insomnia disorder and stroke. The comparative analysis was limited, since the studies used distinct insomnia classifications. Regarding the risk of bias, the analysis displayed an important risk in the selection and allocation of participants, besides the use of own insomnia diagnosis criteria, disrespecting chronology and factors indicated by already established classifications.

CONCLUSIONS

There is not enough data to determine that chronic insomnia disorder is a risk factor for stroke. The present study points out the existence of a possible relationship between insomnia disorder and stroke, suggesting that further studies adopt standardized criteria and instruments.

Sleep patterns correlates with the efficacy of tDCS on post-stroke patients with prolonged disorders of consciousness

BACKGROUND

The subclassification of prolonged disorders of consciousness (DoC) based on sleep patterns is important for the evaluation and treatment of the disease. This study evaluates the correlation between polysomnographic patterns and the efficacy of transcranial direct current stimulation (tDCS) in patients with prolonged DoC due to stroke.

METHODS

In total, 33 patients in the vegetative state (VS) with sleep cycles or without sleep cycles were randomly assigned to either active or sham tDCS groups. Polysomnography was used to monitor sleep changes before and after intervention. Additionally, clinical scale scores and electroencephalogram (EEG) analysis were performed before and after intervention to evaluate the efficacy of tDCS on the patients subclassified according to their sleep patterns.

RESULTS

The results suggest that tDCS improved the sleep structure, significantly prolonged total sleep time (TST) (95%CI: 14.387-283.527, P = 0.013) and NREM sleep stage 2 (95%CI: 3.157-246.165, P = 0.040) of the VS patients with sleep cycles. It also significantly enhanced brain function of patients with sleep cycles, which were reflected by the increased clinical scores (95%CI: 0.340-3.440, P < 0.001), the EEG powers and functional connectivity in the brain and the 6-month prognosis. Moreover, the changes in NREM sleep stage 2 had a significant positive correlation with each index of the β band.

CONCLUSION

This study reveals the importance of sleep patterns in the prognosis and treatment of prolonged DoC and provides new evidence for the efficacy of tDCS in post-stroke patients with VS patients subclassified by sleep pattern. Trial registration URL: https://www.

CLINICALTRIALS

gov . Unique identifier: NCT03809936. Registered 18 January 2019.

Repetitive transcranial magnetic stimulation (rTMS) for post-stroke sleep disorders: a systematic review of randomized controlled trials

OBJECTIVE

Survivors of stroke often experience post-stroke sleep disorders (PSSDs), but pharmacotherapy risks adverse side effects. Transcranial magnetic stimulation (TMS) is potentially a nonpharmacotherapeutic option. This meta-analysis investigated the effects of rTMS to treat PSSD.

METHODS

Databases were searched for randomized controlled trials (RCTs) of rTMS to treat PSSD, conducted in accordance with the PRISMA 2020 guidelines. Risk-of-bias assessments were performed using the Cochrane risk-of-bias tool. A meta-analysis of the following indexes was performed using RevMan 5.4 software: Pittsburgh sleep quality index; effective rate of sleep improvement; Hamilton Anxiety Rating Scale (for mood); and National Institute of Health Stroke Scale (NIHSS, stroke severity). Mean differences (MDs) and confidence intervals (CIs) were calculated.

RESULTS

The meta-analysis included 17 RCTs, with 1411 patients overall. The indexes indicated that rTMS could improve the sleep quality, mood, and stroke severity of patients with PSSD: Pittsburgh sleep quality index (12 studies; MD =  - 2.51, 95% CI [- 3.24, - 1.79], P < 0.00001); effective rate of sleep improvement (7 studies; MD = 4.03, 95% CI [2.43, 6.68], P < 0.0001); Hamilton Anxiety Rating Scale (2 studies; MD =  - 4.05, 95% CI [- 4.77, - 3.32], P < 0.00001); and NIHSS (2 studies; MD = -2.71, 95% CI [- 3.36, - 2.06], P < 0.00001).

CONCLUSION

The results suggest that rTMS may have positive effects on the sleep quality, mood, and stroke severity of patients with PSSD.

Validation Study of the Richards-Campbell Sleep Questionnaire in Patients with Acute Stroke

Sleep disorders are frequent in acute stroke. The Richards-Campbell Sleep Questionnaire (RCSQ) is a validated scale for the sleep assessment in intensive care unit. The aim of the present study is to validate RCSQ for use in patients with acute stroke. We performed a validation study by comparing the RCSQ with polysomnography (PSG), the standardized measure of sleep. Inclusion criteria were age ≥ 18 years and a radiologically confirmed diagnosis of stroke. Exclusion criteria were global aphasia, extreme severity of clinical conditions and inability to attend PSG. All patients underwent PSG in a stroke unit, the day after a subjective sleep assessment by means of the RCSQ. The RCSQ was compared with PSG parameters to assess the degree of concordance of the two measures. The cohort consisted of 36 patients. Mean RCSQ score was 61.5 ± 24.8. The total score of the RCSQ showed a good degree of concordance with the sleep efficiency index of PSG. Accuracy of the RCSQ was 70%, sensitivity 71% and specificity 68%. The RCSQ is a good tool for screening the sleep quality in the setting of a stroke unit. Therefore, it could be useful to select the patients who might beneficiate from an instrumental sleep evaluation.

Restless legs syndrome due to brainstem stroke: A systematic review

Restless Legs Syndrome (RLS) is a sleep-related movement disorder, which can also result from brainstem pathology. A systematic review of articles published in the electronic databases PubMed and Web of Science was conducted to summarize the existent literature on RLS associated with a brainstem stroke. We identified eight articles including 19 subjects with RLS due to brainstem ischemic lesion. The symptoms occurred simultaneously with the infarction (66.7%) or few days after (33.3%). The most common location of infarction was pons and less commonly medulla. In most cases (68.4%), symptoms were unilateral. In the majority of those cases (92.3%), the contralateral limb was affected due to a lateral pons infarction. RLS symptoms after infarction improved or resolved in almost 90% of cases within a few days up to 3 months. In almost all patients who received dopaminergic treatment (11 out of 13, 91.7%), the symptoms improved significantly or resolved completely. Screening for RLS has to be considered in patients suffering a brainstem stroke, particularly anteromedial pontine infarction. The appearance of acute unilateral RLS symptoms, usually in association with other sensorimotor deficits, should prompt the clinician to consider a vascular event in the brainstem. RLS in these cases seem to have a favorable outcome and respond well to dopaminergic treatment.

Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I

The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.

Current and Novel Treatment Options for OSA

Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy.

The analysis of individual pathophysiological composition opens new directions towards personalised treatment of OSA, focusing not only on pharyngeal dilation, but also on technical or pharmaceutical interventions on muscle function or breathing regulationhttps://bit.ly/3sayhkd

The European Sleep Research Society – past, present and future

It is 50 years ago, in 1972, that the founding conference of the European Sleep Research Society (ESRS) was organised in Basel. Since then the Society has had 13 presidents and a multitude of board members and has organised, among other things, another 24 congresses. At this 50th anniversary, as the 26th ESRS congress is approaching, we have summarised the history of the ESRS. In this review, we provide a background to show why the foundation of a European society was a logical step, and show how, in the course of the past 50 years, the Society changed and grew. We give special attention to some developments that occurred over the years and discuss where the ESRS stands now, and how we foresee its future.

The interaction among OSA, CPAP, and medications in patients with comorbid OSA and cardiovascular/cerebrovascular disease: a randomized controlled trial

Background

Most patients with comorbid sleep apnea (OSA), cardiovascular (CV) disease, and/or cerebrovascular (CeV) disease simultaneously take medications. Whether OSA and continuous positive airway pressure (CPAP) interact with CV/CeV medications remains unknown. This study aimed to determine the interaction among OSA, CPAP, and CV/CeV medications; the effects of medications on major adverse cardiac and cerebrovascular events, and survival in patients with comorbid OSA and CV/CeV.

Methods

This was a post hoc analysis of the data from one center of the Sleep Apnea Cardiovascular Endpoints Study. Participants (aged 45–75 years) with comorbid OSA and CV/CeV were randomized to receive usual care with or without CPAP from December 2008 to November 2013. The primary endpoint was death and the secondary endpoint was a composite of death, myocardial infarction, stroke, hospitalization for unstable angina, heart failure, and transient ischemic attack.

Results

In total, 131 patients were analyzed. Sixty-three were in the CPAP group and 68 were in the usual care group, 41 had good adherence to CPAP (65.1%), and the median follow-up time was 43.0 (35.0, 54.0) months. In Cox regression analysis, ACE inhibitors and nitrates were independent factors for decreased survival in patients with comorbid OSA and CV/CeV (chi-square = 22.932, P = 0.003; ACE inhibitors: OR 7.241, P = 0.048, 95% CI 1.016–51.628; nitrates: OR 18.012, P = 0.011, 95% CI 1.923–168.750). ACE inhibitors increased mortality and secondary endpoints in the CPAP group (chi-square = 4.134, P = 0.042) but not in patients with good CPAP adherence. Clopidogrel and nitrates decreased survival in usual care group (clopidogrel: chi-square = 5.312, P = 0.021; nitrates: chi-square = 6.417, P = 0.011), but not in CPAP group.

Conclusions

OSA may predispose patients with CV/CeV and CV/CeV medications to a negative effect. CPAP treatment may neutralize the negative effects of OSA by relieving chronic intermittent hypoxia.

Trial registration ClinicalTrials.gov (NCT00738179, first registration date: 20/08/2008).

Usefulness of self-administered questionnaires in screening for direct referral for polysomnography without sleep physician review

STUDY OBJECTIVES

To evaluate self-administered screening questionnaires (Epworth, Berlin, OSA50 and STOP-Bang questionnaires) in patients considered for polysomnography for probable OSA suitable for direct polysomnography without sleep specialist review and to evaluate the usefulness of combining questionnaires in this population.

METHODS

Retrospective review of tertiary sleep center referrals (November 2017 to April 2020) where ≥ 3 screening questionnaires were completed, and type 1 polysomnography was performed. Sensitivity, specificity, positive and negative predictive values, and Likelihood ratios to detect AHI ≥15 or ≥30 were calculated for each questionnaire (with or without ESS ≥ 8) or any positive questionnaire with ESS ≥ 8.

RESULTS

2,152 patients were included. The questionnaires were completed in the majority (Epworth 96%, Berlin 77%, OSA50 84% and STOP-Bang 90%) of referrals. Berlin was most sensitive (82.5% and 85% to detect AHI ≥ 15 and ≥ 30 respectively) but least specific (23% both thresholds). STOP-Bang was least sensitive (66% and 42% respectively) but most specific (68% and 60% respectively). Sensitivity declined if combined with ESS ≥ 8. Combining any questionnaire with ESS ≥ 8 returned intermediate sensitivity of 61% and 73% and specificity of 49% and 47% for AHI ≥ 15 and ≥ 30 respectively. STOP-Bang alone was predictive of OSA on multivariate analysis but was only associated with a clinically insignificant positive Likelihood Ratio. However, STOP-Bang is associated with unacceptable false positive and negative rates which did not support its use.

CONCLUSIONS

Self-administered questionnaires are inadequate in patients under consideration for polysomnography and should not be used as clinical support for suitability of direct polysomnography without sleep specialist review. Combining questionnaires causes deteriorated performance.

Obstructive sleep apnea and stroke: The mechanisms, the randomized trials, and the road ahead

When considered separately from cardiovascular disease, stroke is the third leading cause of death in the U.S. and is the leading cause of long-term disability in adults. New approaches that can be offered to the majority of ischemic stroke patients, can be continued throughout post-stroke care, can limit stroke severity, and can complement or even enhance rehabilitation, would transform ischemic stroke recovery. The treatment of obstructive sleep apnea (OSA) in patients with acute ischemic stroke may represent one such approach. This manuscript reviews the epidemiologic studies of the bidirectional association between OSA and stroke, and the mechanisms and molecular signatures of OSA leading to transient ischemic attack and stroke as well as the randomized controlled trials and observational cohort studies examining continuous positive airway treatment efficacy on the impact of stroke outcomes. Finally, the insights these studies provide on future research are also discussed.

Sleep-disordered breathing and ventilatory chemosensitivity in first ischaemic stroke patients: a prospective cohort study

RATIONALE

Sleep-disordered breathing (SDB) is highly prevalent after stroke. The clinical and ventilatory chemosensitivity characteristics of SDB, namely obstructive, central and coexisting obstructive and central sleep apnoea (coexisting sleep apnoea) following stroke are poorly described.

OBJECTIVE

To determine the respective clinical and ventilatory chemosensitivity characteristics of SDB at least 3 months after a first ischaemic stroke.

METHODS

Cross-sectional analysis of a prospective, monocentric cohort conducted in a university hospital. 380 consecutive stroke or transient ischaemic attack patients were screened between December 2016 and December 2019.

MEASUREMENTS AND MAIN RESULTS

Full-night polysomnography, and hypercapnic ventilatory response were performed at a median (Q1; Q3) time from stroke onset of 134.5 (97.0; 227.3) days. 185 first-time stroke patients were included in the analysis. 94 (50.8%) patients presented no or mild SDB (Apnoea-Hypopnoea Index <15 events/hour of sleep) and 91 (49.2%) moderate to severe SDB, of which 52 (57.1%) presented obstructive sleep apnoea and 39 (42.9%) coexisting or central sleep apnoea. Obstructive sleep apnoea patients significantly differed regarding their clinical presentation from patients with no or mild SDB, whereas there was no difference with coexisting and central sleep apnoea patients. The latter presented a higher frequency of cerebellar lesions along with a heightened hypercapnic ventilatory response compared with no or mild SDB patients.

CONCLUSION

SDB in first-time stroke patients differ in their presentation by their respective clinical traits and ventilatory chemosensitivity characteristics. The heightened hypercapnic ventilatory response in coexisting and central sleep apnoea stroke patients may orientate them to specific ventilatory support.

Getting More from the Sleep Recording

Sleep studies have typically followed criteria established many decades ago, but emerging technologies allow signal analyses that go far beyond the scoring rules for manual analysis of sleep recordings. These technologies may apply to the analysis of signals obtained in standard polysomnography in addition to novel signals more recently developed that provide both direct and indirect measures of sleep and breathing in the ambulatory setting. Automated analysis of signals such as electroencephalogram and oxygen saturation, in addition to heart rate and rhythm, provides a wealth of additional information on sleep and breathing disturbances and their potential for comorbidity.

Acupuncture Reduced the Risk for Insomnia in Stroke Patients: A Propensity-Score Matched Cohort Study

Background: Post-stroke insomnia (PSI) affects the quality of life for stroke patients, reduces the likelihood of successful rehabilitation, and produces additional complications following stroke. Previous reports have provided some information regarding PSI risk factors, but little is known concerning protective factors for PSI. This study analyzed the relationship between acupuncture and insomnia in stroke patients and explored the use of acupuncture as a preventive treatment.

Methods: Patients diagnosed with stroke from 2010 to 2019 were identified in the case database of the First Affiliated Hospital of Guangzhou University of Chinese These patients followed until 2020, and numerous factors were examined, including gender, age, stroke type, stroke location, and baseline comorbidities. A 1:1 propensity score was used to match an equal number of patients receiving acupuncture with stroke patients who did not receive acupuncture (N = 1,680 for each group). The purpose of the study was to compare the incidence of insomnia in these two stroke cohorts. We used the Cox regression model and Kaplan-Meier method to estimate the risk of insomnia as the outcome event.

Results: Compared with the non-acupuncture cohort in general, stroke patients who received acupuncture treatment exhibited a lower risk of insomnia after adjusting for age, gender, stroke type, stroke location, and comorbidities (adjusted hazard ratio HR = 0.27, 95% confidential interval = 0.23 to 0.32). Acupuncture also reduced the risk of PSI for both genders. The respective risks were HR = 0.28 (adjusted) for males and HR = 0.26 (adjusted) for females. Acupuncture also lowered the risk for PSI for different age groups. The risks were HR = 0.22 (adjusted) for individuals 18 to 39 years of age, HR = 0.31 (adjusted) for individuals 40 to 59 years of age, HR = 0.28 (adjusted) for those 60 to 79 years of age, and HR = 0.18 (adjusted) for individuals 80 years of age and older. Concerning the stroke type, regardless of whether the stroke was ischemic, hemorrhagic, or a combination of the two stroke types, patients who received acupuncture exhibited lower risk (adjusted HR = 0.28, 0.17, and 0.49, respectively). Concerning stroke location, except for the cerebral hemispheres (adjusted HR = 1.10, 95% confidential interval = 0.12 to 1.01), the risk of PSI after receiving acupuncture was lower for the frontal lobe (adjusted HR = 0.42), the basal ganglia (adjusted HR = 0.22), the radiation crown (adjusted HR = 0.42), the diencephalon (adjusted HR = 0.20), or multiple partial strokes (adjusted HR = 0.26), the risk of PSI after receiving acupuncture was lower. For all baseline complications, acupuncture reduced the risk of insomnia. The cumulative incidence of insomnia in the acupuncture cohort was significantly lower than the non-acupuncture cohort (log-rank test, P = 0.000).

Limitations: First, our research only included patients from a single center. Second, we did not classify the post-stroke insomnia severity. Second, the information was extracted manually. Overall, the sample size was small, and we needed to increase the sample size to strengthen the conclusions.

Conclusion: Acupuncture treatment reduced the risk of insomnia in stroke patients. Future research be conducted with increased sample sizes and further elaboration on the specific acupuncture protocols that were used.

Sleep in Neurologic Disorders

Sleep is a complex brain state with fundamental relevance for cognitive functions, synaptic plasticity, brain resilience, and autonomic balance. Sleep pathologies may interfere with cerebral circuit organization, leading to negative consequences and favoring the development of neurologic disorders. Conversely, the latter can interfere with sleep functions. Accordingly, assessment of sleep quality is always recommended in the diagnosis of patients with neurologic disorders and during neurorehabilitation programs. This review investigates the complex interplay between sleep and brain pathologies, focusing on diseases in which the association with sleep disturbances is commonly overlooked and whereby major benefits may derive from their proper management.

Insomnia disorder: clinical and research challenges for the 21st century

BACKGROUND AND PURPOSE

Insomnia is a common and debilitating disorder that is frequently associated with important consequences for physical health and well-being.

METHODS

An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field of insomnia and identified future priorities.

RESULTS

The association of trajectories of insomnia with subsequent quality of life, health and mortality should be investigated in large populations. Prospective health economics studies by separating the costs driven specifically by insomnia and costs attributable to its long-term effects are needed. Ignoring the heterogeneity of insomnia patients leads to inadequate diagnosis and inefficient treatment. Individualized interventions should be promoted. More data are needed on both the impact of sleep on overnight effects, such as emotion regulation, and the potential compensatory effort to counteract diurnal impairments. Another gap is the definition of neurocognitive deficits in insomnia patients compared to normal subjects after chronic sleep loss. There are also a number of key gaps related to insomnia treatment. Expert guidelines indicate cognitive-behavioural therapy for insomnia as first-line treatment. They neglect, however, the reality of major healthcare providers. The role of combined therapy, cognitive-behavioural therapy for insomnia plus pharmacological treatment, should be evaluated more extensively.

CONCLUSION

Whilst insomnia disorder might affect large proportions of the population, there are a number of significant gaps in the epidemiological/clinical/research studies carried out to date. In particular, the identification of different insomnia phenotypes could allow more cost-effective and efficient therapies.

Obstructive sleep apnea in Norwegian adults with achondroplasia: a population-based study

Background

Previous studies have found a high prevalence of obstructive sleep apnea (OSA) in children with achondroplasia, but clinical studies on this complication in adults with achondroplasia are lacking.

Objectives

This population-based, cross-sectional study investigated the prevalence, severity, and predictive factors of OSA in Norwegian adults with achondroplasia.

Methods

We collected clinical data on 49 participants. Participants without a preexisting diagnosis of OSA had an overnight sleep registration. OSA was defined as an apnea–hypopnea index (AHI) ≥ 5 plus characteristic clinical symptoms, or AHI ≥ 15. We used the Berlin Questionnaire to assess clinical symptoms of OSA.

Results

OSA was found in 59% (29/49) of the participants (95% confidence interval 44 to 73%), of whom 59% (17/29) had moderate to severe OSA (AHI ≥ 15), and 48% (14/29) were previously undiagnosed. Variables predictive of OSA were: excessive daytime sleepiness; unrested sleep; loud snoring; observed nocturnal breathing stops; hypertension; age > 40 years; and BMI > 30 kg/m².

Conclusion

OSA was highly prevalent in Norwegian adults with achondroplasia, which we believe is representative of this population worldwide. Follow-up of adults with achondroplasia should include assessment of symptoms and signs of OSA, with a low threshold for conducting an overnight sleep registration if findings suggestive of OSA are present.

Sleep Disorders in Stroke: An Update on Management

Stroke is a leading cause of disability and mortality all over the world. Due to an aging population, the incidence of stroke is rising significantly, which has led to devastating consequences for patients. In addition to traditional risk factors such as age, hypertension, hyperlipidemia, diabetes and atrial fibrillation, sleep disorders, as independent modifiable risk factors for stroke, have been highlighted increasingly. In this review, we provide an overview of common types of current sleep disturbances in cerebrovascular diseases, including insomnia, hypersomnia, breathing-related sleep disorders, and parasomnias. Moreover, evidence-based clinical therapeutic strategies and pitfalls of specific sleep disorders after stroke are discussed. We also review the neurobiological mechanisms of these treatments as well as their effects on stroke. Since depression after stroke is so prevalent and closely related to sleep disorders, treatments of post-stroke depression are also briefly mentioned in this review article.

Trazodone improves obstructive sleep apnea after ischemic stroke: a randomized, double-blind, placebo-controlled, crossover pilot study

BACKGROUND

Low arousal threshold plays a part in the pathogenesis of obstructive sleep apnea (OSA) and may be improved by sedatives. Sedative antidepressants are frequently prescribed for stroke patients due to their high prevalence of insomnia and depression. However, the effect of sedative antidepressants on the severity of OSA in stroke patients has not been studied well.

METHODS

In a double-blinded randomized crossover pilot study, 22 post-acute ischemic stroke patients (mean age, 61.7 ± 10.6 y) with OSA received 100 mg of trazodone or a placebo just before polysomnography, with approximately 1 week between measures. The study also measured baseline heart rate variability and 24-h ambulatory blood pressure.

RESULTS

Administration of trazodone significantly increased the percentage time of slow-wave sleep (31.5 ± 13.2 vs. 18.4 ± 8.7%; P < 0.001) and improved almost all the parameters of OSA severity, including the apnea-hypopnea index (AHI, 25.4 ± 15.4 vs. 39.1 ± 18.4 events/h; P < 0.001), the respiratory arousal index (9.8 (5.8-11.95) vs. 14.1 (11.3-18.7) events/h; P < 0.001), and the minimum oxygen saturation (80.2 ± 9.1 vs. 77.1 ± 9.6%; P = 0.016). Responders to therapy (AHI reduced by > 50%; n = 7/22) had predominant OSA during rapid-eye-movement sleep and decreased sympathetic tone, as reflected in significantly lower mean blood pressure, diastolic blood pressure, and normalized low-frequency power.

CONCLUSIONS

Obstructive sleep apnea with comorbid ischemic stroke may be a distinctive phenotype which responds quite well to trazodone, decreasing OSA severity without increasing nocturnal hypoxia.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04162743, 2019/11/10.

Recognizable Clinical Subtypes of Obstructive Sleep Apnea After Ischemic Stroke: A Cluster Analysis

BACKGROUND AND PURPOSE

Obstructive sleep apnea (OSA) increases risk of stroke recurrence and mortality in ischemic stroke patients. However, equivocal treatment effects warrant further categorization of post-stroke OSA for risk stratification and individualized treatment planning.

METHODS

The study recruited 232 ischemic stroke patients with moderate-to-severe OSA admitted for inpatient rehabilitation consecutively. Latent class analysis was performed based on sex, age, smoking, daytime sleepiness, depression, obesity, sedative use, atrial fibrillation, diabetes, dyslipidemia, hypertension, recurrent stroke and dysphagia. The augmentation index, a marker of arterial stiffness, was measured by applanation tonometry.

RESULTS

A three-cluster model provided the best fit. Cluster 1 (n=84, 36.2%) was older in age, predominantly female, with the highest hypopnea index and prevalence of atrial fibrillation. Moreover, patients in Cluster 1 had significantly higher augmentation index than those in Cluster 2. Cluster 2 patients (N=80, 34.5%) were of older age, predominantly male, with the highest prevalence of depression, the lowest prevalence of hypertension and had the most normal body mass index (BMI). Additionally, Cluster 2 had less nocturnal hypoxia as compared to Cluster 3. Cluster 3 (n=68, 29.3%) was the youngest in age, predominantly male, with the highest BMI, cumulative risk score, and prevalence of dyslipidemia of the three clusters.

CONCLUSION

Post-stroke OSA can be categorized into three clinical phenotypes. Patients in Clusters 1 and 3 both had elevated cardiovascular risk and treatment can be based on their distinct characteristics. Patients in Cluster 2 had relatively lower risk of cardiovascular events and the benefits of OSA treatment requires further study.

Technologic advances in the assessment and management of obstructive sleep apnoea beyond the apnoea-hypopnoea index: a narrative review

Obstructive sleep apnoea (OSA) is a growing and serious worldwide health problem with significant health and socioeconomic consequences. Current diagnostic testing strategies are limited by cost, access to resources and over reliance on one measure, namely the apnoea-hypopnoea frequency per hour (AHI). Recent evidence supports moving away from the AHI as the principle measure of OSA severity towards a more personalised approach to OSA diagnosis and treatment that includes phenotypic and biological traits. Novel advances in technology include the use of signals such as heart rate variability (HRV), oximetry and peripheral arterial tonometry (PAT) as alternative or additional measures. Ubiquitous use of smartphones and developments in wearable technology have also led to increased availability of applications and devices to facilitate home screening of at-risk populations, although current evidence indicates relatively poor accuracy in comparison with the traditional gold standard polysomnography (PSG). In this review, we evaluate the current strategies for diagnosing OSA in the context of their limitations, potential physiological targets as alternatives to AHI and the role of novel technology in OSA. We also evaluate the current evidence for using newer technologies in OSA diagnosis, the physiological targets such as smartphone applications and wearable technology. Future developments in OSA diagnosis and assessment will likely focus increasingly on systemic effects of sleep disordered breathing (SDB) such as changes in nocturnal oxygen and blood pressure (BP); and may also include other factors such as circulating biomarkers. These developments will likely require a re-evaluation of the diagnostic and grading criteria for clinically significant OSA.

SAS CARE 2 - a randomized study of CPAP in patients with obstructive sleep disordered breathing following ischemic stroke or transient ischemic attack

Objective/background

The benefit of Continuous Positive Airway Pressure (CPAP) treatment following ischemic stroke in patients with obstructive sleep-disordered breathing (SDB) is unclear. We set out to investigate this open question in a randomized controlled trial as part of the SAS-CARE study.

Patients/methods.

Non-sleepy patients (ESS < 10) with ischemic stroke or transient ischemic attack (TIA) and obstructive SDB (AHI ≥ 20) 3 months post-stroke were randomized 1:1 to CPAP treatment (CPAP+) or standard care. Primary outcome was the occurrence of vascular events (TIA/stroke, myocardial infarction/revascularization, hospitalization for heart failure or unstable angina) or death within 24 months post-stroke. Secondary outcomes included Modified Rankin Scale (mRS) and Barthel Index.

Results

Among 238 SAS-CARE patients 41 (17%) non-sleepy obstructive SDB patients were randomized to CPAP (n = 19) or standard care (n = 22). Most patients (80%) had stroke and were males (78%), mean age was 64 ± 7 years and mean NIHSS score 0.6 ± 1.0 (range: 0–5). The primary endpoint was met by one patient in the standard care arm (a new stroke). In an intent-to treat analysis disregarding adherence, this corresponds to an absolute risk difference of 4.5% or an NNT = 22. mRS and Barthel Index were stable and similar between arms. CPAP adherence was sufficient in 60% of evaluable patients at month 24.

Conclusion

No benefit of CPAP started three months post-stroke was found in terms of new cardio- and cerebrovascular events over 2 years. This may be related to the small size of this study, the mild stoke severity, the exclusion of sleepy patients, the delayed start of treatment, and the overall low event rate.

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No benefit of CPAP started 3 months post-stroke was found.

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A sufficient CPAP compliance was observed over 2 years in 60% of patients.

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Studies of CPAP in mild stroke need to be large and include long-term outcomes.