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Powlson AS, Annamalai AK, Moir S, Webb AJ, Bala L, Graggaber J, Kandasamy N, Koulouri O, Halsall DJ, Shneerson JM, Gurnell M. High prevalence of severe sleep cycle disruption in de novo acromegaly and underdiagnosis by common clinical screening tools: A prospective, observational, cross-sectional study. Clin Endocrinol (Oxf) 2024; 100:251-259. [PMID: 38127470 DOI: 10.1111/cen.14994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
CONTEXT Although sleep disordered breathing (SDB) is well-recognised in acromegaly, most studies have reported heterogeneous, often heavily treated, groups and few have performed detailed sleep phenotyping at presentation. OBJECTIVE To study SDB using the gold standard of polysomnography, in the largest group of newly-diagnosed, treatment-naïve patients with acromegaly. SETTING AND PATIENTS 40 patients [22 males, 18 females; mean age 54 years (range 23-78)], were studied to: (i) establish the prevalence and severity of SDB (ii) assess the reliability of commonly employed screening tools [Epworth Sleepiness Scale (ESS) and overnight oxygen desaturation index (DI)] to detect SDB (iii) determine the extent to which sleep architecture is disrupted. RESULTS Obstructive sleep apnoea (OSA), defined by the apnoea-hypopnoea index (AHI), was present in 79% of subjects (mild, n = 12; moderate, n = 5; severe, n = 14). However, in these individuals with OSA by AHI criteria, ESS (positive in 35% [n = 11]) and DI (positive in 71%: mild, n = 11; moderate, n = 6; severe, n = 5) markedly underestimated its prevalence/extent. Seventy-eight percent of patients exhibited increased arousal, with marked disruption of the sleep cycle, despite most (82%) having normal total time asleep. Fourteen patients spent longer in stage 1 sleep. Deeper sleep stages were severely attenuated in many subjects (reduced stage 2, n = 18; reduced slow wave sleep, n = 24; reduced rapid eye movement sleep, n = 32). CONCLUSION Our study provides strong support for clinical guidelines that recommend screening for sleep apnoea syndrome in patients with newly-diagnosed acromegaly. Importantly, however, it highlights shortcomings in commonly recommended screening tools (questionnaires, desaturation index) and demonstrates the added value of polysomnography to allow timely detection of obstructive sleep apnoea and associated sleep cycle disruption.
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Affiliation(s)
- Andrew S Powlson
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Anand K Annamalai
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Samantha Moir
- The Respiratory Support & Sleep Centre, Royal Papworth Hospital, Cambridge, UK
| | - Alison J Webb
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Laksha Bala
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Johann Graggaber
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Narayanan Kandasamy
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Olympia Koulouri
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - David J Halsall
- Clinical Biochemistry, Cambridge University Hospitals, Cambridge, UK
| | - John M Shneerson
- The Respiratory Support & Sleep Centre, Royal Papworth Hospital, Cambridge, UK
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
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Muscogiuri G, Zanata I, Barrea L, Cozzolino A, Filice E, Messina E, Colao A, Faggiano A. A practical nutritional guideline to manage neuroendocrine neoplasms through chronotype and sleep. Crit Rev Food Sci Nutr 2022; 63:7546-7563. [PMID: 35285728 DOI: 10.1080/10408398.2022.2047882] [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] [Indexed: 11/03/2022]
Abstract
Chronotype is the attitude of subjects to carry out their daily activities mainly in the morning ("lark") or in the evening ("owl"). The intermediate chronotype is located between these two categories. It has been demonstrated that chronotype can influence the incidence, course and response to treatments of tumors. In particular patients diagnosed with gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) and evening chronotype are characterized by unhealthy lifestyle, obesity, metabolic syndrome, a worsen cardiometabolic profile, a poor prognosis with a progressive disease and the development of metastasis. In addition, evening chronotype has been associated with sleep disturbances, which in turn have been related to tumor development and progression of tumors. There is a strict connection between sleep disturbances and NENs because of the hyperactivation of proangiogenic factors that caused aberrant neoangiogenesis. A nutritional tailored approach could represent a tool to align subjects with evening chronotype to physiological biological rhythms based on the properties of some macro and micronutrients of being substrate for melatonin synthesis. Thus, we aimed to provide an overview on the association of chronotype categories and sleep disturbances with NENs and to provide nutritional advices to manage subjects with NENs and these disturbances of circadian rhythm.
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Affiliation(s)
- Giovanna Muscogiuri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Centro Italiano per la cura e il Benessere del paziente con Obesità (C.I.B.O), Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Cattedra Unesco "Educazione alla salute e allo sviluppo sostenibile,", Università Federico II di Napoli, Naples, Italy
| | - Isabella Zanata
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Luigi Barrea
- Centro Italiano per la cura e il Benessere del paziente con Obesità (C.I.B.O), Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Scienze Umanistiche, Università Telematica Pegaso, Naples, Italy
| | - Alessia Cozzolino
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emanuele Filice
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Erika Messina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Centro Italiano per la cura e il Benessere del paziente con Obesità (C.I.B.O), Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Cattedra Unesco "Educazione alla salute e allo sviluppo sostenibile,", Università Federico II di Napoli, Naples, Italy
| | - Antongiulio Faggiano
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Parolin M, Dassie F, Alessio L, Wennberg A, Rossato M, Vettor R, Maffei P, Pagano C. Obstructive Sleep Apnea in Acromegaly and the Effect of Treatment: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2020; 105:5624994. [PMID: 31722411 DOI: 10.1210/clinem/dgz116] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/11/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway collapse requiring nocturnal ventilatory assistance. Multiple studies have investigated the relationship between acromegaly and OSA, reporting discordant results. AIM To conduct a meta-analysis on the risk for OSA in acromegaly, and in particular to assess the role of disease activity and the effect of treatments. METHODS AND STUDY SELECTION A search through literature databases retrieved 21 articles for a total of 24 studies (n = 734). Selected outcomes were OSA prevalence and apnea-hypopnea index (AHI) in studies comparing acromegalic patients with active (ACT) vs inactive (INACT) disease and pretreatment and posttreatment measures. Factors used for moderator and meta-regression analysis included the percentage of patients with severe OSA, patient sex, age, body mass index, levels of insulin-like growth factor 1, disease duration and follow-up, and therapy. RESULTS OSA prevalence was similar in patients with acromegaly who had ACT and INACT disease (ES = -0.16; 95% CI, -0.47 to 0.15; number of studies [k] = 10; P = 0.32). In addition, AHI was similar in ACT and INACT acromegaly patients (ES = -0.03; 95% CI, -0.49 to 0.43; k = 6; P = 0.89). When AHI was compared before and after treatment in patients with acromegaly (median follow-up of 6 months), a significant improvement was observed after treatment (ES = -0.36; 95% CI, -0.49 to -0.23; k = 10; P < 0.0001). In moderator analysis, the percentage of patients with severe OSA in the populations significantly influenced the difference in OSA prevalence (P = 0.038) and AHI (P = 0.04) in ACT vs INACT patients. CONCLUSION Prevalence of OSA and AHI is similar in ACT and INACT patients in cross-sectional studies. However, when AHI was measured longitudinally before and after treatment, a significant improvement was observed after treatment.
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Affiliation(s)
- Matteo Parolin
- Department of Medicine, University of Padua, via Giustiniani 2, Padova, Italy
| | - Francesca Dassie
- Department of Medicine, University of Padua, via Giustiniani 2, Padova, Italy
| | - Luigi Alessio
- Department of Neurosciences, University of Padua, via Giustiniani 2, Padova, Italy
| | - Alexandra Wennberg
- Department of Neurosciences, University of Padua, via Giustiniani 2, Padova, Italy
| | - Marco Rossato
- Department of Medicine, University of Padua, via Giustiniani 2, Padova, Italy
| | - Roberto Vettor
- Department of Medicine, University of Padua, via Giustiniani 2, Padova, Italy
| | - Pietro Maffei
- Department of Medicine, University of Padua, via Giustiniani 2, Padova, Italy
| | - Claudio Pagano
- Department of Medicine, University of Padua, via Giustiniani 2, Padova, Italy
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Abstract
In acromegaly, growth hormone (GH) and insulin-like growth factor-1 (IGF-1) excess results in a specific cardiomyopathy characterized by concentric cardiac hypertrophy primarily associated with diastolic dysfunction that can lead to impaired systolic function and eventually heart failure. This review of the literature evaluates the effect of therapeutic intervention on cardiac parameters. Clinical studies investigating the impact of treatments for acromegaly on cardiac function published between January 1980 and January 2009 were identified through electronic searches of Medline. Suppression of GH and IGF-1 following surgery or medical treatment with somatostatin analogue therapy is effective in decreasing left ventricular (LV) hypertrophy, with subsequent improvement in cardiac function. First-line treatment with somatostatin analogues resulted in improved cardiac outcome compared with first-line surgery, possibly due to somatostatin analogues acting directly through somatostatin receptors on cardiac cells. Additional cardiac improvement has been reported when somatostatin analogue treatment was combined with surgery. In patients where complete biochemical control was not achieved, an improved cardiac performance following treatment with somatostatin analogues has been reported. Treatment with pegvisomant has been demonstrated to reduce LV hypertrophy and improve diastolic and systolic performance. In contrast, reports have suggested that treatment with the dopamine agonist cabergoline increased the incidence of valvular heart disease. Although surgery and somatostatin analogues are effective in improving cardiomyopathy, a greater beneficial effect is observed with somatostatin analogue treatment. Selected patients with acromegaly should consider first-line therapy or pre-treatment with somatostatin analogues prior to surgery to achieve biochemical control and improve cardiac dysfunction.
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Affiliation(s)
- Annamaria Colao
- Department of Molecular and Clinical Endocrinology and Oncology, Section of Endocrinology, Federico II University of Naples, Naples, Italy.
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Kashine S, Kishida K, Funahashi T, Shimomura I. Characteristics of sleep-disordered breathing in Japanese patients with acromegaly. Endocr J 2012; 59:31-8. [PMID: 21996595 DOI: 10.1507/endocrj.ej11-0171] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sleep-disordered breathing (SDB), especially sleep apnea-hypopnea syndrome (SAS), is often observed in patients with active acromegaly. This complication is a risk factor for cardiovascular disease and associated with increased morbidity and mortality in acromegaly. However there is little information on SDB in Japanese patients with acromegaly. We investigated the prevalence of SDB and association between the severity of SDB and various features and biomarkers in Japanese patients with acromegaly. Twenty-four Japanese patients with active acromegaly underwent overnight cardiorespiratory monitoring, hormonal assays and cephalometric measurements on X-ray. A high prevalence of SDB was detected in acromegaly (87.5%). Log apnea-hypopnea index (AHI) correlated positively with soft palate length / body height (X-ray) (r=0.44, p=0.043), but not with log growth hormone levels and insulin-like growth factor type-1 standard deviation scores, size of pituitary adenoma, disease duration, body mass index, waist circumference, estimated visceral fat area, heel pad thickness / height, tongue thickness/ height, or oropharyngeal dimension/ height. In conclusion, our study demonstrated a high prevalence of SDB in Japanese patients with acromegaly, and its severity correlated with soft palate length. Based on the high incidence of SDB identified in the present study, we recommend that all patients with acromegaly are routinely screened for SDB for early diagnosis and treatment.
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Affiliation(s)
- Susumu Kashine
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
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Davì MV, Giustina A. Sleep apnea in acromegaly: a review on prevalence, pathogenetic aspects and treatment. Expert Rev Endocrinol Metab 2012; 7:55-62. [PMID: 30736111 DOI: 10.1586/eem.11.82] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Sleep apnea syndrome is a common complication of acromegaly with a negative impact on quality of life and survival. Obstructive sleep apnea is the prevailing form and is characterized by recurrent episodes of apnea and hypopnea owing to the total or partial collapse of the upper airways during sleep. The craniofacial deformations and the hypertrophy of upper airway soft tissue are responsible for its occurrence. Successful treatment of acromegaly can improve the severity of this complication, but can only seldom reverse it, particularly after a long time of active acromegaly. Thus, it is advisable to evaluate patients for sleep apnea syndrome at diagnosis and during treatment, and also when acromegaly is biochemically controlled. In selected cases, continuous positive airway pressure should be implemented to improve patient outcome.
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Affiliation(s)
- Maria Vittoria Davì
- a Clinic of Internal Medicine D, Department of Medicine, University of Verona, Italy
| | - Andrea Giustina
- b Department of Medical and Surgical Sciences, University of Brescia, Italy Endocrine Service, Montichiari Hospital, Via Ciotti 154, 25018 Montichiari, Brescia, Italy.
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De Menis E, Giustina A, Colao A, Degli Uberti E, Ghigo E, Minuto F, Bogazzi F, Drigo R, Cattaneo A, Aimaretti G. Assessment of the awareness and management of sleep apnea syndrome in acromegaly. The COM.E.TA (Comorbidities Evaluation and Treatment in Acromegaly) Italian Study Group. J Endocrinol Invest 2011; 34:60-4. [PMID: 21406941 DOI: 10.1007/bf03346696] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In 2007 the Italian COM.E.T.A. (COMorbidities Evaluation and Treatment in Acromegaly) study group started to assess the application in a clinical setting of the Versailles criteria for management of acromegaly complications by a first questionnaire focusing on cardiovascular co-morbidities. A further questionnaire on sleep apnea syndrome (SAS) was delivered by the COM.E.T.A. study group to 107 endocrine centers in Italy. The results of our survey suggest that SAS is a well-known comorbidity even if its estimated prevalence is lower than in the literature. Polysomnography is the preferred tool for diagnosis. Control of SAS is considered relevant both for quality of life and co-morbidities. Continuous positive airway pressure is the cornerstone of therapy, but patients' acceptance may be critical. Control of GH/IGF-I secretion is important to improve SAS. Management of SAS requires cooperation between specialists.
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Affiliation(s)
- E De Menis
- Department of Internal Medicine, General Hospital, v. Monte Grappa 30, 31044 Montebelluna, Italy.
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Netzer N, Eliasson AH, Netzer C, Kristo DA. Overnight pulse oximetry for sleep-disordered breathing in adults: a review. Chest 2001; 120:625-33. [PMID: 11502669 DOI: 10.1378/chest.120.2.625] [Citation(s) in RCA: 239] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pulse oximetry is a well-established tool routinely used in many settings of modern medicine to determine a patient's arterial oxygen saturation and heart rate. The decreasing size of pulse oximeters over recent years has broadened their spectrum of use. For diagnosis and treatment of sleep-disordered breathing, overnight pulse oximetry helps determine the severity of disease and is used as an economical means to detect sleep apnea. In this article, we outline the clinical utility and economical benefit of overnight pulse oximetry in sleep and breathing disorders in adults and highlight the controversies regarding its limitations as presented in published studies.
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Affiliation(s)
- N Netzer
- Pulmonary and Critical Care Medicine Service, Department of Medicine, Walter Reed Army Medical Center, Washington DC 20307, USA
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