Screening Questionnaires for Obstructive Sleep Apnea: An Updated Systematic Review

A Study of Volatile Organic Compounds in Patients with Obstructive Sleep Apnea

Background: Obstructive Sleep Apnea (OSA) is a prevalent sleep disorder characterized by intermittent upper airway obstruction, leading to significant health consequences. Traditional diagnostic methods, such as polysomnography, are time-consuming and resource-intensive. Objectives: This study explores the potential of proton-transfer-reaction mass spectrometry (PTR-MS) in identifying volatile organic compound (VOC) biomarkers for the non-invasive detection of OSA. Methods: Breath samples from 89 participants, including 49 OSA patients and 40 controls, were analyzed using PTR-MS. Significance analysis was performed between OSA patients and controls to identify potential biomarkers for OSA. To as-sess the differences in VOC concentrations between OSA patients and control subjects, the Wilcoxon rank-sum test was employed. partial least squares discriminant analysis (PLS-DA) analysis and heatmap plot was conducted to visualize the differentiation between OSA patients and control subjects based on their VOC profiles.In order to further investigate the correlation between identified biomarkers and the severity of OSA measured by Apnea-Hypopnea Index (AHI), regression analysis was conducted between biomarkers and AHI Index. Results: The results identified specific VOCs, including m045 (acetaldehyde), m095.950, and m097.071, which showed significant differences between OSA patients and controls. Advanced statistical analyses, including PLS-DA and correlation mapping, highlighted the robustness of these biomarkers, with m045 (acetaldehyde) specifically emerging as a potential biomarker associated with the AHI Index. Conclusions: This study underscores the potential of VOCs as biomarkers for identifying patients with severe AHI levels. The analysis of VOCs using PTR-MS presents a rapid, non-invasive, and cost-effective method that could be seamlessly integrated into clinical practice, allowing clinicians to better stratify patients based on their need for polysomnography and prioritize those requiring earlier testing. Future studies are necessary to validate these findings in larger cohorts and to explore the integration of PTR-MS with other diagnostic modalities for improved accuracy and clinical utility.

Tongue Ultrasonography in the Screening of Severe Obstructive Sleep Apnea Syndrome-Promising Potential for Overloaded Sleep Centers

Obstructive sleep apnea syndrome (OSAS) is a frequently underdiagnosed sleep disorder marked by recurrent episodes of apnea and/or hypopnea during sleep, primarily resulting from the partial or complete collapse of the upper airway. OSAS significantly affects patients' health and quality of life. Additionally, it is a recognized risk factor for inducing microsleep episodes during daily activities, particularly in occupations such as professional driving, where sustained attention is critical. The aim of our study was to identify an effective screening test for use in outpatient settings, capable of distinguishing patients with a severe form of OSAS. Patients who test positive with this screening tool would subsequently be prioritized for polysomnographic evaluation in a sleep laboratory. A total of 64 patients who underwent polysomnography (PSG) or polygraphy (PG) examination at our clinic were subsequently examined by USG of the tongue with measurements of tongue base thickness (TBT) and the distance between lingual arteries (DLA) during wakefulness and in a relaxed tongue position. The measurements of TBT and DLA were subsequently correlated with the apnea-hypopnea index (AHI) obtained from PSG or PG. In our cohort of patients diagnosed with severe OSAS, a TBT threshold of ≥65 mm served as an effective cutoff value. A TBT value of ≥65 mm reached an AUC value of 78.1%, sensitivity of 74.4%, specificity of 61.9%, positive predictive value of 80%, negative predictive value of 54.2% and overall accuracy of 70.3%. A DLA value of ≥30 mm in our sample of patients with severe OSAS showed an AUC of 76.5%, sensitivity of 69.8%, specificity of 71.1%, positive predictive value of 83.3%, negative predictive value of 53.6%, and overall accuracy of 70.3%. Tongue USG markers, particularly TBT and DLA measurements during wakefulness and in a relaxed tongue position, show potential as effective screening tools for identifying severe OSAS in European populations. These markers demonstrate improved accuracy over traditional screening questionnaires by reducing the likelihood of false-negative results. Patients with a positive screening should preferably be referred for polysomnography. In this way, patients with a serious illness could receive adequate therapy sooner.

Screening for moderate to severe obstructive sleep apnea by using heart rate variability features based on random forest algorithm

PURPOSE

More than 80% of patients with moderate to severe obstructive sleep apnea (OSA) are still not diagnosed timely. The prediction model based on random forest (RF) algorithm was established by using heart rate variability (HRV), clinical and demographic features so as to screen for the patients with high risk of moderate and severe obstructive sleep apnea.

METHODS

The sleep monitoring data of 798 patients were randomly divided into training set (n = 558) and test set (n = 240) in 7:3 proportion. Grid search was applied to determine the best parameters of the RF model. 10-fold cross validation was utilized to evaluate the predictive performance of the RF model, which was then compared to the performance of the Logistic regression model.

RESULTS

Among the 798 patients, 638 were males and 160 were females, with the average age of 43.51 years old and the mean body mass index (BMI) of 25.92 kg/m2. The sensitivity, specificity, accuracy, F1 score and the area under receiver operating characteristic curve for RF model and Logistic regression model were 94.68% vs. 73.94%; 73.08% vs. 86.54%; 90.00% vs. 76.67%; 0.94 vs. 0.83 and 0.83 vs. 0.80 respectively.

CONCLUSIONS

The RF prediction model can effectively distinguish patients with moderate to severe OSA, which is expected to carry out in a large-scale population in order to screening for high-risk patients, and helps to evaluate the effect of OSA treatment continuously.

Effects of zinc supplementation on sleep quality in humans: A systematic review of randomized controlled trials

Background and Aims

Alternative therapies, such as zinc supplementation, have been explored as potential interventions for sleep disorders. However, the efficacy of zinc supplementation in improving sleep quality remains uncertain. This systematic review aims to examine the impacts of zinc supplementation on sleep quality in humans.

Methods

The Web of Science, Medline, Scopus, and Google Scholar databases were comprehensively searched to find studies investigating the effect of zinc supplementation on sleep quality. After identifying relevant studies by screening, relevant data were extracted from them. The quality assessment was conducted using the Cochrane quality assessment tool.

Results

This systematic review included eight studies. The interventions ranged from 4 to 48 weeks, with a daily dose of zinc supplementation varying between 10 and 73.3 mg. The majority of the evidence examined in this review pointed to the significant improvement effect of zinc supplementation on sleep quality in adults compared to the control groups. Furthermore, zinc supplementation did not have a significant effect on sleep disorders. However, there was no consensus about these findings. Also, the effect of supplementation on sleep duration in nonadults was contradictory.

Conclusions

This systematic review suggests that zinc supplementation may lead to improvements in sleep quality. However, more research, primarily clinical trials, is needed to clarify the beneficial effects of zinc supplementation on sleep quality with consideration of dietary zinc intake and the Recommended Dietary Allowances of zinc (RDA) in the different populations. It is also recommended to investigate the effect of zinc supplementation on sleep quality in people with zinc deficiency in future studies.

Promoting identification of obstructive sleep apnea among patients with psychiatric conditions

ABSTRACT

Obstructive sleep apnea (OSA) is prevalent but remains underdiagnosed and undertreated. Recognizing OSA in patients with psychiatric disorders can be challenging due to the conditions' overlapping symptoms. To aid primary care NPs in identifying OSA among patients with psychiatric disorders, this article examines overlapping symptoms and outlines diagnostic reasoning. It also provides an overview of the anatomy and neurotransmitters involved in OSA, as well as OSA-specific screening tools and risk stratification, to promote the condition's identification among this population.

Screening Tools for Obstructive Sleep Apnea in Pregnant Women: An Extended and Updated Systematic Review and Meta-analysis

The prevalence of obstructive sleep apnea syndrome (OSA) increases in women during pregnancy and negatively affects maternal and fetal outcomes. The updated systematic review and meta-analysis aimed to evaluate the validity of the Berlin, STOP-Bang, and Epworth sleepiness scale (ESS) questionnaires in detecting OSA in pregnant women. PubMed, Embase, and Web of Science were searched systematically up to March 2022. After eligible studies inclusion, two independent reviewers extracted demographic and clinical data. Bivariate random effects models were used to estimate the pooled accuracy measures including sensitivity and specificity, positive (PPV) and negative predictive values (NPVs), diagnostic odds ratio (DOR), and receiver operating characteristic curve (ROC) curve. We included 8 studies including 710 pregnant women with suspected OSA. The performance values of Berlin, STOP-Bang, and ESS questionnaires were as follows: the pooled sensitivity were 61% (95% confidence interval (CI): 40%-80%), 59% (95% CI: 49%-69%), and 29%, (95% CI: 10%-60%); pooled specificity were 61% (95% CI: 42%-78%), 80% (95% CI: 55%-93%), and 80% (95% CI: 50%-94%); pooled PPVs were 60% (95% CI: 0.49-0.72), 73% (95% CI: 61%-85%), and 59% (95% CI: 31%-87%); pooled NPVs were 60% (95% CI: 0.49-0.71), 65% (95% CI: 54%-76%), and 53% (95% CI: 41%-64%); and pooled DORs were 3 (95% CI: 1-5), 6 (95% CI: 2-19), and 2 (95% CI: 1-3), respectively. It seems that the Berlin, STOP-Bang, and ESS questionnaires had poor to moderate sensitivity and specificity in pregnancy, with the ESS showing the worst characteristics. Further studies are required to evaluate the performance of alternative screening methods for OSA in pregnancy.

Screening for treatment-required sleep apnoea in patients with spinal cord injury within one year after injury in a rehabilitation setting

PURPOSE

The current study aims to assess the efficacy of the Stop-Bang Questionnaire (SBQ) in screening treatment-required sleep apnoea following Spinal Cord Injury (SCI). Additionally, we explore the performance of combined questionnaires and pulse oximetry to determine the most cost-effective method.

METHODS

The study employs a cross-sectional observational design. All patients admitted to in-hospital rehabilitation at the Spinal Cord Injury Centre of Western Denmark from September 2022 to February 2023 were continuously enrolled. Participating patients underwent SBQ screening, a standard sleep questionnaire, and cardiorespiratory monitoring, followed by an individual consultation with a physician.

RESULTS

During the study period, 35 SCI patients were admitted, with 24 providing informed consent. Among the 24 included patients, there was a 75% prevalence of mild to severe sleep apnoea, and 46% had treatment-required sleep apnoea. The SBQ missed only one patient with treatment-required sleep apnoea but misclassified eight patients. Combining SBQ with the pulse oximetry demonstrated the best performance in identifying patients with sleep apnoea.

CONCLUSION

The study indicates that SBQ alone is insufficient for screening treatment-required sleep apnoea. Exploratory analysis suggests that combining SBQ with a simple pulse oximetry measurement might enhance accuracy.

Periodontal effects of two Somnodent oral devices for the treatment of OSA: A finite element study

OBJECTIVE

The study aims to evaluate the stresses and the deformations generated at the periodontal level by two mandibular advancement devices (MADs) using finite element analysis.

METHODS

A three-dimensional digital model of the skull of a 29-year-old patient was created using a CBCT. The 3D models of two MADs (Somnodent FlexTM and Somnodent AvantTM) were reconstructed from scanning prototypes based on the patient's anatomy. The overall geometry was imported into software for the finite element study. A force of 11.18 N representing an advancement of 9.5 mm was applied to the devices. A finite element analysis wfas subsequently performed.

RESULTS

Somnodent FlexTM generates a peak of 3.27 kPa on periodontal ligaments and 287 kPa on teeth. For Somnodent AvantTM the maximum stress is 4.53 kPa on periodontal ligaments and 467 kPa on teeth.

CONCLUSION

Different activation mechanisms of the devices generate stresses of different entities.

Sleep Apnea and Atrial Fibrillation: Clinical Features and Screening Diagnostic Options

INTRODUCTION

Obstructive sleep apnea (OSA) is associated with an increased risk of hypertension, coronary artery disease, heart failure (HF), and atrial fibrillation (AF).

MATERIALS AND METHODS

A total of 179 patients aged 34-81 years were included in the study. The median age was 63 years (interquartile range: 56-69 years). Of these patients, 105 (58.7%) were men, and 74 (41.3%) were women; there were cases of paroxysmal (n = 99), persistent (n = 64), and permanent AF (n = 16). All patients underwent investigations including respiratory sleep monitoring, echocardiography, and 24 h Holter electrocardiography monitoring. Statistical analyses were performed using IBM SPSS Statistics 26.0.

RESULTS

OSA was detected in 131 (73.2%) patients. In patients with OSA, paroxysmal AF was commonest (n = 65), followed by persistent AF (n = 51) and permanent AF (n = 15). The patients with sleep apnea had increased body mass index (33.6 kg/m2; p = 0.02), waist circumference (114 cm; p < 0.001), and neck circumference (42 cm; p < 0.001) values. HF (OR 2.9; 95% CI: 1.4-5.9; p = 0.004) and type 2 diabetes (OR 3.6; 95% CI: 1.5-8.3; p = 0.001) were more common in patients with AF and OSA. The STOP-BANG scale (AUC = 0.706 ± 0.044; 95% CI: 0.619-0.792; p < 0.001) and the Berlin questionnaire (AUC = 0.699 ± 0.044; 95% CI: 0.614-0.785) had a higher predictive ability for identifying sleep apnea.

CONCLUSIONS

Patients with AF demonstrate a high prevalence of OSA and an increased association with cardiovascular comorbidities. The STOP-BANG scale and the Berlin questionnaire can be used to screen for OSA in patients with AF.

Obstructive sleep apnea syndrome: A frequent and difficult-to-detect complication of radiotherapy for oropharyngeal cancers

This pilot study reveals a higher prevalence of obstructive sleep apnea syndrome (OSAS) in patients treated for oropharyngeal squamous cell carcinoma with radiotherapy compared to the general population. OSAS indicators such as the Epworth Sleepiness Scale seem insufficient in the diagnostic approach to OSAS in this population and systematic screenings should be considered.

A New Screening Tool (BAMSA) for Sleep Apnea in Male Professional Truck Drivers

Obstructive sleep apnea (OSA) is common in professional truck drivers. It is important that OSA is recognized since undiagnosed and/or untreated sleep apnea is a risk factor for sleepiness-related traffic accidents. In this study, we developed a new simple tool to screen for obstructive sleep apnea (OSA) in this population. Altogether, 2066 professional truck drivers received a structured questionnaire. A total of 175 drivers had a clinical examination and were invited to participate in sleep laboratory studies, including cardiorespiratory polygraphy. We studied associations of different risk factors with the presence of sleep apnea. We established a new simple screening tool for obstructive sleep apnea (OSA) that was compared to other existing screening tools. A total of 1095 drivers completed the questionnaire. Successful cardiorespiratory polygraphy was obtained for 172 drivers. Full data were available for 160 male drivers included in the analyses. The following five risk factors for sleep apnea formed the BAMSA score (0 to 5): BMI > 30 kgm-2, age > 50 years, male gender, snoring at least one night per week, and the presence of apnea at least sometimes. BAMSA showed a sensitivity of 85.7% and a specificity of 78.8% in detecting AHI ≥ 15 when using a cut-off point of 4, and the ROC area was 0.823. BAMSA is a sensitive and easy-to-use tool in predicting obstructive sleep apnea in male professional drivers.

Correlation of morning dry mouth with clinical features of OSA in a community population: a cross-sectional study

OBJECTIVES

Morning dry mouth, commonly seen in Obstructive Sleep Apnea (OSA) patients, is absent in current OSA screening tools. This study evaluated the link between morning dry mouth and OSA's clinical symptoms and complications, aiming to determine its viability as a screening indicator.

METHODS

This research analyses baseline data from a prospective cohort study (the PIFCOPD study). Demographic information, medical history, and the presence of morning dry mouth symptoms were collected. The STOP-Bang questionnaire was performed for OSA screening. Logistic regression analyses were employed to establish the correlations between morning dry mouth and the clinical symptoms and comorbidities of OSA.

RESULT

1291 participants (62.1±7.5 years; 501 males, 790 females) were included, of which 416 reported morning dry mouth (32.2%). 42.6% in the high-risk OSA group and 22.1% in the low-risk group reported morning dry mouth. Individuals with morning dry mouth also showed higher STOP-Bang scores (3.3±1.6 vs. 2.3±1.4, P<0.01). Significant associations were found between morning dry mouth and loud snoring, observed sleep apnea, daytime fatigue, and hyperlipidemia (P<0.01), but not with alcohol consumption, tea consumption, diabetes, or hypertension.

CONCLUSION

Morning dry mouth is associated with increased OSA risk and its clinical signs, suggesting its potential as an OSA screening symptom.

CLINICAL TRIAL REGISTRATION

This study has been registered at www.ClinicalTrials.gov (registration identifier: NCT03532893) on 21 May 2018.

Risk of obstructive sleep apnea among health workers: results of a screening in a large Italian University Hospital

PURPOSE

Obstructive sleep apnea (OSA) is a common respiratory sleep disorder, related to increased mortality, poor quality of life, and higher risk of work accidents and injuries. Studies on the risk of OSA (rOSA) among health workers (HW) are scant. The aims of this study were to investigate this issue in a large University Hospital and to assess the effectiveness of a screening program.

METHODS

The STOP-BANG questionnaire (SBQ) was sent via e-mail to the 5031 HW employed at the University Hospital of Verona. HW who completed the SBQ were classified at low, moderate, and high rOSA. HW at high rOSA were invited to undergo nocturnal polygraphy. The determinants of rOSA were studied by non-parametric Kruskal-Wallis test, Pearson's chi-squared, and multinomial logistic model.

RESULTS

Of 5031 HW, 1564 (31.1%) completed the online questionnaire. Responders with low, moderate, and high rOSA were 72.7%, 13.7%, and 13.6%. Male gender, older age, and higher body mass index (BMI) were significant predictors of high rOSA, as expected. Physicians had the lowest probability of being in the high-risk category. Polygraphy was performed in 64 subjects. The positive predictive value of the self-administered SBQ was 68.8% (95%C.I. 55.9-79.8%) but raised to 96.9% (95%C.I. 89.2-99.6%) when re-administered by medical staff.

CONCLUSION

SBQ showed its effectiveness as a screening tool in detecting undiagnosed OSA in HW. Systematic screening for OSA in work settings could allow early diagnosis and treatment, reducing short- and long-term health effects of OSA.

The predictive values of BOAH and No-apnea score for screening obstructive sleep apnea in rotating shift worker drivers

Objective

To evaluate the BOAH (Body mass index, Observed apnea, Age, and Hypertension) and No-apnea score's diagnostic values for detecting obstructive sleep apnea (OSA) risk in shift workers.

Methods

Cross-sectional study with male rotating shift workers and drivers of heavy off-road machinery. The BOAH score is based on body mass index, witnessed apneas during sleep, age, and hypertension. The No-apnea score is based on neck circumference and age. Based on the apnea-hypopnea index (AHI), the severity of OSA was categorized as least mild OSA (AHI ≥5/h), moderate to severe OSA (AHI ≥15/h), and severe OSA (AHI ≥30/h). Sensitivity, specificity, positive predictive value, negative predictive value, and areas under the curve (AUC) were calculated.

Results

Among 119 workers evaluated, 84.0% had AHI ≥5, 46.2% had AHI ≥15, and 14.3% had AHI ≥30. BOAH score with 2 points for AHI ≥5, the AUC was 0.679, and sensitivity and specificity were 41.0% and 94.7%, respectively. No-apnea score with 3 points AHI ≥5, the AUC was 0.692, and sensitivity and specificity were 70.0% and 68.4%, respectively. Furthermore, using at least one of the positive scores, the AUC was higher when compared to the single tests for AHI ≥5 (AUC = 0.727). And when both scores were positive, the AUC was higher for AHI ≥30 (AUC = 0.706).

Conclusion

In rotating shift workers and drivers of heavy off-road machinery, BOAH, and No-apnea scores can be helpful tools in identifying individuals at risk for sleep apnea. In addition, matching the scores may increase the prediction of OSA.

Effect of Prosthetic Rehabilitation on Airway Space in Edentulous Patients with Obstructive Sleep Apnea- a Preliminary Observational Study

Statement of the Problem

The common causes of obstructive sleep apnea (OSA) are identified as anatomic and/or functional abnormality in the oral cavity, oropharynx, velopharynx, and hypopharynx leading to compromised airway space and increased collapsibility.

Purpose

This study was conducted to evaluate the effect of implant-supported mandibular complete denture in improving the airway space among completely edentulous patients with OSA and compare it with conventional complete denture.

Materials and Method

In this observational study, completely edentulous individuals were screened with snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and gender (STOP-Bang) questionnaire to evaluate the incidence of OSA. Ten mild-moderate patients were included as study participants. Lateral cephalograms (L1) made at the edentulous state was considered baseline. They were rehabilitated with complete denture prosthesis. One week after denture insertion, two implants were placed in the edentulous mandibular arch. Delayed loading protocol was followed. Lateral cephalogram (L2) was made 6 months after complete denture insertion and 6 months after implant-supported prosthesis (L3). Cephalometric tracings were used to evaluate change in upper airway space (UAS), middle airway space (MAS), and lower airway space (LAS). Repeated measures ANOVA was used to evaluate statistical significance in the airway measurements made at the three intervals. Post hoc Tukey HSD and Bonferroni test were used to assess if the differences obtained were truly significant.

Results

Statistical analysis revealed significant differences in UAS, MAS and LAS between L1, L2 and L3 (p< 0.05). Post hoc Tukey HSD indicated that UAS increased significantly at all three intervals followed by LAS and MAS respectively (α=.05). Post hoc Bon-ferroni test indicated that implant-supported mandibular complete dentures had a significant improvement in airway space when compared to conventional complete dentures (α=.05).

Conclusion

Implant-supported mandibular complete denture could be effective in edentulous patients with mild-moderate OSA.

Evaluation of upper airway characteristics in patients with and without sleep apnea using cone-beam computed tomography and computational fluid dynamics

OBJECTIVE

To determine if upper airway characteristics and airway pressure change significantly between low risk, healthy non-OSA subjects, and OSA subjects during respiration using cone-beam computed tomography (CBCT) imaging and steady-state k-ω model computational fluid dynamics (CFD) fluid flow simulations, respectively.

MATERIALS AND METHODS

CBCT scans were collected at both end-inhalation and end-exhalation for 16 low-risk non-OSA subjects and compared to existing CBCT data from 7 OSA subjects. The CBCT images were imported into Dolphin Imaging and the upper airway was segmented into stereolithography (STL) files for area and volumetric measurements. Subject models that met pre-processing criteria underwent CFD simulations using ANSYS Fluent Meshing (Canonsburg, PA) in which unstructured mesh models were generated to solve the standard dual equation turbulence model (k-ω). Objective and supplemental descriptive measures were obtained and statistical analyses were performed with both parametric and non-parametric tests to evaluate statistical significance at P < .05.

RESULTS

Regarding area and volumetric assessments, there were statistically significant mean differences in Total Volume and Minimum CSA between non-OSA and OSA groups at inhalation and exhalation (P = .002, .003, .004, and .007), respectively. There were also statistically significant mean differences in volume and min CSA between the inhalation and exhalation for the non-OSA group (P < .001 and .002), respectively.

CONCLUSION

While analysis of the CFD simulation was limited by the collected data available, a finding consistent with published literature was that the OSA subject group simulation models depicted the point of lowest pressure coinciding with the area of maximum constriction.

Recurrent Cough in the Elderly: A Forgotten Entity

INTRODUCTION

Recurrent cough is little researched in adults. We investigated the prevalence, risk factors, and consequences of recurrent cough, and compared the results to those of isolated chronic cough.

METHODS

Cross-sectional email survey in an elderly community-based population. Recurrent cough was defined as ≥ 3 cough episodes within one year (each lasting ≥ 1 week) and no current chronic cough. Isolated chronic cough was defined as current cough lasting ≥ 8 weeks and no recurrent cough.

RESULTS

The prevalence of recurrent cough was 3.8% among all respondents (n = 5983). Recurrent cough was associated with asthma (aOR 3.32 (95% CI 2.13-5.18)), chronic rhinosinusitis (2.91 (1.89-4.46)), family history of chronic cough (2.59 (1.88-3.56)), analgesic intolerance (2.13 (1.27-3.57)), male gender (1.92 (1.39-2.66)), gastro-esophageal reflux disease (1.73 (1.21-2.47)), obstructive sleep apnoea (1.69 (1.23-2.32)), symptom sum (1.12 per symptom (1.03-1.22)), and younger age (0.96 per year (0.93-1.00)). Isolated chronic cough was associated with chronic rhinosinusitis (3.45 (2.39-4.97)), asthma (2.17 (1.38-3.41), gastro-esophageal reflux disease (1.80 (1.32-2.47)), family history of chronic cough (1.80 (1.35-2.41)), obstructive sleep apnoea (1.49 (1.12-2.00)), symptom sum (1.18 per symptom (1.10-1.27)), and body mass index (0.96 per unit (0.93-1.00)). Among subjects with recurrent and isolated chronic cough, the prevalence of depressive symptoms were 7.7% and 4.2%, p = 0.11, the Leicester Cough Questionnaire total scores 15.2 (14.6-15.8) and 16.3 (16.0-16.6), P = 0.001, and the mean number of yearly cough-related doctor`s visits 0.58 (0.45-0.71) and 0.36 (0.19-0.53), P = 0.007, respectively.

CONCLUSION

The risk factors and consequences of recurrent and isolated chronic cough were comparable. Recurrent cough seems beneficial to address in cough evaluation.

The Prevalence of Obstructive Sleep Apnea and Associated Symptoms among Patients with Sickle Cell Disease: A Systematic Review and Meta-analysis

Previous studies have shown that patients with sickle cell disease (SCD) are at high risk for obstructive sleep apnea (OSA). In the current study, we aimed to systematically review the literature to address the prevalence of OSA and associated symptoms among patients with SCD. Electronic databases, including Web of Science, Scopus, PubMed, Google Scholar, and Embase were systematically searched to identify the relevant original articles on patients with SCD. Newcastle Ottawa scale was used for quality assessment. Data were pooled by using random effects models. Subgroup analyses were performed by age groups. Thirty-nine studies containing details of 299,358 patients with SCD were included. The pooled results showed that more than half of these patients had OSA with different severities. The prevalence rates of OSA among children with apnea hypopnea index (AHI) cutoffs of above 1, 1.5, and 5 were 51% (95% confidence interval (CI) 36-67%), 29% (95% CI 19-40%), and 18% (95% CI 14-23%), respectively. The prevalence of OSA among adults with AHI cutoff of 5 was 43% (95% CI 21-64%). The pooled rates of snoring, nocturnal enuresis, nocturnal desaturation, and daytime sleepiness were 55% (95% CI 42-69%), 37% (95% CI 33-41%), 49% (95% CI 26-72%), and 21% (95% CI 12-30%), respectively. Given the high prevalence of OSA in patients with SCD, probable greater burden of SCD complications, and irreversible consequences of OSA, screening for OSA symptoms and signs seems useful in these patients. By screening and identifying this heterogeneous disorder earlier, available treatment modalities can be individualized for each patient.

Association of dual use of cigarettes with obstructive sleep apnea assessed by the STOP-Bang score

INTRODUCTION

Although previous studies have addressed the association between smoking and obstructive sleep apnea (OSA), there are few studies on the association between electronic cigarette use and OSA. Thus, we aimed to evaluate the association between the dual use of electronic and conventional cigarettes and OSA.

METHODS

Data from 7350 participants of the 2019-2021 Korean National Health and Nutrition Examination Survey were analyzed in this population-based study. The STOP-Bang score was calculated using eight items: snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and sex. The main independent variable was smoking behavior. A multiple logistic regression analysis was performed. Subgroup analysis was conducted to analyze the association between smoking behavior in detail and OSA, and stratified analyses were additionally performed.

RESULTS

Of the 7350 participants, 417 (5.7%) had a high risk of OSA, according to the STOP-Bang score. Compared to the non-smoker group, the dual user group had a 2.46-fold increase in the odds of OSA (adjusted odds ratio, AOR = 2.45; 95% CI: 1.04-5.79). Current non-smokers who were dual users in the past had increased odds of having OSA (AOR=3.61; 95% CI: 1.32-9.92). In the stratified analyses, dual cigarette use was significantly associated with OSA in females and those with a low physical activity level.

CONCLUSIONS

Dual users and cigarette-only users had an increased probability of developing OSA. Even if they are not currently smoking or vaping, individuals who were dual users in the past were associated with a higher risk of OSA. The association between dual cigarette use and OSA was more pronounced in females and those with a low physical activity level. While intervening for obstructive sleep apnea or investigating risk factors, new smoking methods such as vaping and dual use should be considered along with conventional smoking.

Validity and reliability of the Berlin questionnaire for the detection of moderate or severe obstructive sleep apnea in patients aged 40 years or older detected from primary care

Background

The obstructive sleep apnea syndrome (OSA) is a highly prevalent condition. In Spain and other countries, only 5%-9% of patients with OSA have been diagnosed and treated. The lack of accessibility to diagnosis is considered the main cause of this situation through easy-to-use screening instruments, it is necessary to check their validity and reliability in the context where they are to be used.

Objective

To validate the Spanish translation of the Berlin questionnaire for screening for moderate or severe OSA in patients aged 40 years or more detected in primary care.

Methods

A descriptive observational study, with a first qualitative phase of transcultural adaptation to Spanish using the translation-back-translation method. Setting: primary care level of the Spanish National Health System. A total of 255 patients recruited from 7 healthcare centers completed the study. The Berlin questionnaire was administered to the recruited patients, and subsequently, a respiratory polygraphy was performed to confirm the diagnosis of OSA. The concurrent criterion validity of the questionnaire and its reliability in terms of internal consistency and reproducibility (intra-observer agreement) were analyzed.

Results

The patients' mean age was 54.76 years (SD: 6.57; 95% CI: 53.53-54.99), and 54.12% were men (95% CI: 47.96-60.27). We found that 61.57% (95% CI: 55.57-67.57) presented OSA (apnea-hypopnea index-AHI >5), and 45.5% (95% CI: 17.05-57.92) presented moderate or severe (AHI >15) OSA. The Berlin questionnaire, with a cut-off point of 4.5, showed a sensitivity of 76.77% (95% CI: 67.94-85.59), a specificity of 74.49% (95% CI: 65.35-83.63), a positive predictive value of 75.25% (95% CI: 66.34-84.16), a negative predictive value of 76.04% (95% CI: 66.98-85.10), and an area under the curve of 0.786 (95% CI: 0.721-0.851). Cronbach's alpha coefficient was 0.730 (95% CI: 0.668-0.784), and the Kappa index was 0.739 (95% CI, 0.384-1.000).

Conclusion

The Spanish adaptation of the Berlin questionnaire has good validity and reliability as a test for the diagnostic screening of moderate or severe OSA in patients aged 40 years or older. The findings of our study confirm that primary care physicians should use such screening tools to predict OSA.

Modified STOP-bang questionnaire incorporating morning dry mouth and BMI adjustment in China: a retrospective study of 590 patients

BACKGROUND

Morning dry mouth (MDM) is a common symptom of Obstructive Sleep Apnea (OSA) yet current OSA screening tools overlook it.

OBJECTIVE

To enhance the specificity of the Stop-Bang questionnaire (SBQ) by adding an MDM symptom.

METHOD

A retrospective analysis on 590 patients from Peking University First Hospital (2013-2018) suspected of OSA was conducted. They underwent polysomnography. The research incorporated the MDM symptom into SBQ and adjusted the body mass index (BMI) threshold to 28 kg/m2. Predictive parameters were then calculated.

RESULTS

83.1% patients were diagnosed with OSA, with 61.4% reporting MDM. Multivariate regression confirmed MDM significantly influenced Apnea-Hypopnea Index (AHI). Adjusted SBQ with MDM showed a slight decrease in sensitivity but improved specificity, especially when using a BMI threshold of > 28 kg/m2. For AHI ≥ 5 events/h and AHI ≥ 15 events/h, adjusted SBQ with MDM (BMI >28 kg/m2) obtained the highest Youden index.

CONCLUSION

Incorporating the MDM symptom into SBQ and adjusting the BMI threshold enhances the diagnostic specificity for OSA.

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.

Validation of the Modified Berlin Questionnaire for the Diagnosis of Obstructive Sleep Apnea in Patients with a History of COVID-19 Infection

(1) Background: The Berlin questionnaire (BQ) is a widely used survey to predict obstructive sleep apnea (OSA). Considering the confounding effect of obesity and hypertension on the clinical course of COVID-19, we have recently developed a modified BQ (mBQ) based on the subscales snoring intensity/frequency, witnessed apneas and morning/daytime tiredness, and demonstrated that patients with high-risk OSA had worse outcomes during the COVID-19 pandemic. In the current study, we aimed to validate the mBQ in adults with a history of COVID-19 infection. (2) Method: All cases who suffered from COVID-19 infection between 10 March and 22 June 2020, and who completed the mBQ in our first study, were invited to participate. Participants refilled the questionnaires, and an attended polysomnography (PSG) was conducted. An apnea-hypopnea index (AHI) of 15 events/h or more was considered as OSA. (3) Results: Out of the 70 participants, 27 (39%) were categorized as having a high risk of OSA based on the mBQ. According to the PSG results, 24 patients with high-risk OSA (89%) and 3 patients with low-risk OSA on the mBQ (7%) had AHI ≥ 15 events/h. The mBQ had a sensitivity of 89%, a specificity of 93%, a positive predictive value of 89%, a negative predictive value of 93%, and an accuracy of 91%. The area under the curve was 0.91 confirming a very good performance of the mBQ in screening for OSA. (4) Conclusions: The mBQ has a good level of diagnostic sensitivity, specificity, and accuracy among adults with a history of COVID-19 infection. Since the confounding effects of obesity and hypertension are eliminated, the mBQ may be used not only as a screening tool for high-risk OSA but also as a prognostic survey in clinical cohorts.

Impact of Complete Denture and Mandibular Advancement Device in the Management of Completely Edentulous Obstructive Sleep Apneic Individuals: A Systematic Review with Meta-Analysis

Statement of the Problem

Obstructive sleep apnea (OSA) is an underdiagnosed and potentially serious disorder that is accentuated by edentulism. The overclosure of the mandible and a potential upper airway collapse during sleep creates challenges in treating edentulous sleep apneic patients.

Purpose

To evaluate complete dentures and mandibular advancement devices as potential oral appliances in the management of sleep apnea in completely edentulous patients.

Materials and Method

The study design was a systematic review with meta-analysis. The search criteria complied with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and the keywords in population, intervention, control, and outcomes (PICO) format was systematically searched for relevant research articles published till August 2021 in an electronic database (PubMed, Cochrane, Science Direct, Ovid). Randomized controlled trials and cohort studies were included that compared the effectiveness of oral appliances on apnea-hypopnea index (AHI), airway space, and quality of sleep in edentulous sleep apneic patients.

Results

1785 articles were derived from the initial search and based on inclusion criteria, 10 articles were systematically filtered for qualitative analysis and assessed for risk of bias using the Cochrane risk of bias tool and ROBINS-I tool. Out of the 10 articles, 5 articles were taken for quantitative analysis. The use of a mandibular advancement device (MAD) showed a decrease in AHI score, but the available data was heterogeneous to conduct a meta-analysis. The mean difference of AHI for the random effect model between the non-complete denture and complete denture wearers at sleep was -0.49[95% CI (-1.47,0.48)] events per hour, but the change was non-significant (p>.05).

Conclusion

The complete dentures as an oral appliance had reduced apneic episodes in completely edentulous sleep apneic patients, but the effectiveness cannot be solely attributed to the prosthesis in the treatment of OSA. MAD showed greater improvement in reducing AHI, however, the level of evidence was inadequate to provide a conclusive statement.

Healthcare-Seeking Behaviour Due to Cough in Finnish Elderly: Too Much and Too Little

INTRODUCTION

Cough-related healthcare-seeking has not been studied specifically in the elderly, although chronic cough is most prevalent among them. We studied the frequencies and predictors of any (≥ 1) and repeated (≥ 3) doctor's visits due to any cough episode during the past year, and due to the current cough episode.

METHODS

This was a cross-sectional email survey among a Finnish community-based elderly population. Participants with current cough and age ≥ 64 years were included in the analyses (n = 1109).

RESULTS

The proportions of participants with ≥ 1 and ≥ 3 cough-related doctor's visits during the past year were 25.9% and 7.1%, respectively. Repeated visitors accounted for 55.9% of the visits during the past year. These visits first increased with cough duration but decreased after 5 years. In the multivariate analysis, bronchiectasis [aOR 3.22 (CI95% 1.08-9.58)], asthma [2.62 (1.56-4.40)], chronic sputum production [1.61 (0.94-2.76)], low self-assessed health status [1.40 (1.04-1.88)] and Leicester Cough Questionnaire total score [1.34 per tertile (1.10-1.62)] predicted repeated cough-related doctor's visits during the past year. The proportions of ≥ 1 and ≥ 3 doctor's visits due to current cough were 31.8% and 15.5%, respectively. Among participants with current chronic cough, 60.1% had not visited a doctor.

CONCLUSION

A minority of participants accounted for most of the cough-related doctor's visits during the past year, whereas most participants with chronic cough had never sought medical help for it. The heavy healthcare users were not those with the longest cough episodes. Repeated visitors due to cough were characterised by chronic phlegmy respiratory conditions, and quality-of-life impairment.

Machine learning approaches for predicting sleep arousal response based on heart rate variability, oxygen saturation, and body profiles

Objective

Obstructive sleep apnea is a global health concern, and several tools have been developed to screen its severity. However, most tools focus on respiratory events instead of sleep arousal, which can also affect sleep efficiency. This study employed easy-to-measure parameters-namely heart rate variability, oxygen saturation, and body profiles-to predict arousal occurrence.

Methods

Body profiles and polysomnography recordings were collected from 659 patients. Continuous heart rate variability and oximetry measurements were performed and then labeled based on the presence of sleep arousal. The dataset, comprising five body profiles, mean heart rate, six heart rate variability, and five oximetry variables, was then split into 80% training/validation and 20% testing datasets. Eight machine learning approaches were employed. The model with the highest accuracy, area under the receiver operating characteristic curve, and area under the precision recall curve values in the training/validation dataset was applied to the testing dataset and to determine feature importance.

Results

InceptionTime, which exhibited superior performance in predicting sleep arousal in the training dataset, was used to classify the testing dataset and explore feature importance. In the testing dataset, InceptionTime achieved an accuracy of 76.21%, an area under the receiver operating characteristic curve of 84.33%, and an area under the precision recall curve of 86.28%. The standard deviations of time intervals between successive normal heartbeats and the square roots of the means of the squares of successive differences between normal heartbeats were predominant predictors of arousal occurrence.

Conclusions

The established models can be considered for screening sleep arousal occurrence or integrated in wearable devices for home-based sleep examination.

Comorbidities associated with high-risk obstructive sleep apnea based on the STOP-BANG questionnaire: a nationwide population-based study

BACKGROUND/AIMS

We investigated the prevalence, associated factors, and comorbidities of high-risk obstructive sleep apnea (OSA) as determined by the STOP-BANG questionnaire in a Korean adult population.

METHODS

Data were obtained from 7,650 adults (aged ≥ 40 years) who participated in the Korea National Health and Nutrition Examination Survey (2019-2020). Multiple logistic regression analyses were used to evaluate the association of socioeconomic status, lifestyle related factors, and comorbidities with high-risk OSA (STOP-BANG score, 5-8).

RESULTS

The prevalence of high-risk OSA according to the STOP-BANG questionnaire was 12.0 %. Older age, male, current smoking, heavy alcohol consumption, and more comorbidities were associated with higher STOP-BANG scores. In multivariable adjusted analysis, diabetes mellitus (DM) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.25 to 1.97), hypertension (OR, 4.81; 95% CI, 3.88 to 5.97), and obesity (OR, 2.02; 95% CI, 1.60 to 2.56) were associated with high risk of OSA, and when hypertension, DM, and obesity were combined, the risk increased synergistically (OR, 3.88; 95% CI, 2.94 to 5.11).

CONCLUSION

According to the STOP-BANG questionnaire, the high risk of OSA was more common in males, and was associated with chronic metabolic disease, particularly in those with DM, hypertension, and obesity combined. Active OSA screening, prevention, and management may be beneficial to improving health outcomes related to OSA in these populations.

The Overlap Syndrome of Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease: A Systematic Review

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are common diseases that strongly impact the quality and length of life. Their coexistence is determined by overlap syndrome (OS). This systematic review aims to define the significance of these comorbidities according to the current state of knowledge. For this systematic review, we searched PubMed, Scopus, and Cochrane for studies published between 2018 and 26 October 2022, to find original, observational, human studies published in English, where the diagnosis of COPD was according to the Global Initiative for Obstructive Lung Disease guidelines and the diagnosis of OSA was based on polysomnography. The quality of studies was assessed using the Newcastle-Ottawa quality assessment tool for cohort and case-control studies, as well as its modification for cross-sectional studies. Of the 1548 records identified, 38 were eligible and included in this systematic review. The included studies covered a total population of 27,064 participants. This paper summarizes the most important, up-to-date information regarding OS, including the prevalence, meaning of age/gender/body mass index, polysomnography findings, pulmonary function, comorbidities, predicting OSA among COPD patients, and treatment of this syndrome.

Impact of a Weight-Loss Rehabilitation Program on Sleep Apnea Risk and Subjective Sleepiness in Patients with Overweight/Obesity: The DietSleep Study

Obstructive sleep apnea (OSA) is one of the most frequent chronic diseases, and comorbid obesity occurs in more than 60% of cases. Variations in body weight influence both OSA severity and OSA-related symptoms. We prospectively assessed the impact of a weight-loss program using the Berlin score to reflect OSA risk, and we also used the Epworth Sleepiness Scale (ESS) to assess daytime sleepiness. DietSleep was a prospective multicentric cohort study investigating OSA risk and daytime sleepiness before and after weight-loss intervention. One hundred and twenty-seven patients were included (initial OSA risk 36%), most of whom were women (85.8%) with a median body mass index (BMI) of 29.7 kg/m2, and the interquartile range was (27.6; 34). The diet-based weight-loss program induced a median decrease in BMI of 3.7 kg/m2 (−5; −2.9) (body weight~12.1% (−16.0; −8.8)) over a period of 171 days (114; 269). Changes in anthropometric values were similar regarding OSA risk after adjusting for initial values. Berlin scores significantly improved from 3 (1; 5) to 1 (0; 2), p < 0.01; the proportion of patients with a Berlin score ≥2 decreased from 36% to 7% after the intervention. The proportion of patients with ESS ≥11 decreased from 13% to 2%. These results confirm that a weight-loss program produces clinically relevant weight loss and a significant improvement in both OSA and subjective daytime sleepiness.

Screening for Obstructive Sleep Apnea Risk by Using Machine Learning Approaches and Anthropometric Features

Obstructive sleep apnea (OSA) is a global health concern and is typically diagnosed using in-laboratory polysomnography (PSG). However, PSG is highly time-consuming and labor-intensive. We, therefore, developed machine learning models based on easily accessed anthropometric features to screen for the risk of moderate to severe and severe OSA. We enrolled 3503 patients from Taiwan and determined their PSG parameters and anthropometric features. Subsequently, we compared the mean values among patients with different OSA severity and considered correlations among all participants. We developed models based on the following machine learning approaches: logistic regression, k-nearest neighbors, naïve Bayes, random forest (RF), support vector machine, and XGBoost. Collected data were first independently split into two data sets (training and validation: 80%; testing: 20%). Thereafter, we adopted the model with the highest accuracy in the training and validation stage to predict the testing set. We explored the importance of each feature in the OSA risk screening by calculating the Shapley values of each input variable. The RF model achieved the highest accuracy for moderate to severe (84.74%) and severe (72.61%) OSA. The level of visceral fat was found to be a predominant feature in the risk screening models of OSA with the aforementioned levels of severity. Our machine learning models can be employed to screen for OSA risk in the populations in Taiwan and in those with similar craniofacial structures.

Automatic diagnosis of sleep apnea from biomedical signals using artificial intelligence techniques: Methods, challenges, and future works

Apnea is a sleep disorder that stops or reduces airflow for a short time during sleep. Sleep apnea may last for a few seconds and happen for many while sleeping. This reduction in breathing is associated with loud snoring, which may awaken the person with a feeling of suffocation. So far, a variety of methods have been introduced by researchers to diagnose sleep apnea, among which the polysomnography (PSG) method is known to be the best. Analysis of PSG signals is very complicated. Many studies have been conducted on the automatic diagnosis of sleep apnea from biological signals using artificial intelligence (AI), including machine learning (ML) and deep learning (DL) methods. This research reviews and investigates the studies on the diagnosis of sleep apnea using AI methods. First, computer aided diagnosis system (CADS) for sleep apnea using ML and DL techniques along with its parts including dataset, preprocessing, and ML and DL methods are introduced. This research also summarizes the important specifications of the studies on the diagnosis of sleep apnea using ML and DL methods in a table. In the following, a comprehensive discussion is made on the studies carried out in this field. The challenges in the diagnosis of sleep apnea using AI methods are of paramount importance for researchers. Accordingly, these obstacles are elaborately addressed. In another section, the most important future works for studies on sleep apnea detection from PSG signals and AI techniques are presented. Ultimately, the essential findings of this study are provided in the conclusion section.

This article is categorized under:

The relationship between obstructive sleep apnoea and erectile dysfunction: An underdiagnosed link? A prospective cross-sectional study

This cross‐sectional study aimed to investigate the prevalence and clinical characteristics of erectile dysfunction in patients with obstructive sleep apnoea. We enrolled 133 male patients with suspected obstructive sleep apnoea. Ear, nose and throat evaluation, laboratory tests, body mass index, Epworth sleepiness scale, 5‐international index of erectile function, overnight ambulatory polygraphy and drug‐induced sleep endoscopy patterns were assessed. Eighty patients reported obstructive sleep apnoea. 60% (n = 48) reported erectile dysfunction. Statistically significant correlations were found between 5‐International Index of Erectile Function and age, hypertension, diabetes, Epworth sleepiness scale, apnoea‐hypopnea index score, O₂ saturation‐nadir, and oxygen desaturation index. Age, diabetes and O₂ saturation‐nadir were independent predictors of erectile function. Epworth sleepiness scale, apnoea‐hypopnea index score, O₂ saturation‐nadir, oxygen desaturation index and albumin were higher compared to patients without erectile dysfunction. No statistically significant differences were reported for drug‐induced sleep endoscopy patterns and erectile dysfunction. Patients with obstructive sleep apnoea were at significant risk of having erectile dysfunction. Males with obstructive sleep apnoea should be investigated for erectile dysfunction.

Guidelines in Practice: Moderate Sedation and Analgesia

Moderate sedation and analgesia (MSA) can help patients experience less anxiety and discomfort, tolerate procedures that do not require general anesthesia, and maintain the ability to respond to verbal commands. Nurses administer MSA in a variety of clinical areas, and facility leaders may have difficulty creating a single standard of care for this task. Completion of a presedation assessment that includes the patient in the decision-making process is an important aspect of care. When administering MSA, nurses should have immediate unrestricted patient access and no competing responsibilities that could distract them from monitoring and assessing the patient. Nurses should complete education and competency verification activities before administering MSA. AORN recently revised the "Guideline for care of the patient receiving moderate sedation/analgesia," and this article addresses the standard of care, the presedation assessment, patient monitoring, and competency; it also includes scenarios describing specific concerns in two patient care areas.

Obstructive Sleep Apnoea Syndrome Screening Through Wrist-Worn Smartbands: A Machine-Learning Approach

Purpose

A large portion of the adult population is thought to suffer from obstructive sleep apnoea syndrome (OSAS), a sleep-related breathing disorder associated with increased morbidity and mortality. International guidelines include the polysomnography and the cardiorespiratory monitoring (CRM) as diagnostic tools for OSAS, but they are unfit for a large-scale screening, given their invasiveness, high cost and lengthy process of scoring. Current screening methods are based on self-reported questionnaires that suffer from lack of objectivity. On the contrary, commercial smartbands are wearable devices capable of collecting accelerometric and photoplethysmographic data in a user-friendly and objective way. We questioned whether machine-learning (ML) classifiers trained on data collected through these wearable devices would help predict OSAS severity.

Patients and Methods

Each of the patients (n = 78, mean age ± SD: 57.2 ± 12.9 years; 30 females) underwent CRM and concurrently wore a commercial wrist smartband. CRM's traces were scored, and OSAS severity was reported as apnoea hypopnoea index (AHI). We trained three pairs of classifiers to make the following prediction: AHI <5 vs AHI ≥5, AHI <15 vs AHI ≥15, and AHI <30 vs AHI ≥30.

Results

According to the Matthews correlation coefficient (MCC), the proposed algorithms reached an overall good correlation with the ground truth (CRM) for AHI <5 vs AHI ≥5 (MCC: 0.4) and AHI <30 vs AHI ≥30 (MCC: 0.3) classifications. AHI <5 vs AHI ≥5 and AHI <30 vs AHI ≥30 classifiers' sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and diagnostic odds ratio (DOR) are comparable with the STOP-Bang questionnaire, an established OSAS screening tool.

Conclusion

Machine learning algorithms showed an overall good performance. Unlike questionnaires, these are based on objectively collected data. Furthermore, these commercial devices are widely distributed in the general population. The aforementioned advantages of machine-learning algorithms applied to smartbands' data over questionnaires lead to the conclusion that they could serve a population-scale screening for OSAS.

Cough in the Elderly During the COVID-19 Pandemic

INTRODUCTION

The prevalence of chronic cough increases with age. However, data on the prevalence and background disorders of cough subtypes in the elderly are scarce. The objective of this study was to identify the point prevalence and risk factors of acute, subacute, and chronic cough in an elderly community-based population.

METHODS

This was a cross-sectional email survey amongst 26,205 members of the Finnish Pensioners' Federation during the COVID-19 pandemic in spring 2021.

RESULTS

The response rate was 23.6% (6189). 5983 subjects aged at least 64 years were included in the analyses (mean 72.6 years, 66.3% female). The point prevalence of daily acute, subacute, and chronic cough were 1.4%, 0.7%, and 9.6%, respectively. Only 0.4% of the subjects had a COVID-19 infection. In the multivariate analyses, chronic rhinosinusitis, and obstructive sleep apnoea were common risk factors for all cough subtypes. Chronic cough had several risk factors; Bronchiectasis (OR 5.79 (CI95% 2.70-12.41)), current asthma (2.67 (2.02-3.54)), chronic rhinosinusitis (2.51 (1.94-3.24)), somatic symptom score (1.13 per symptom (1.07-1.19)), family history of chronic cough (1.88 (1.54-2.30)), gastro-oesophageal reflux disease (1.86 (1.50-2.32)), advanced age (1.20 per decade (1.02-1.40)), chronic obstructive pulmonary disease (1.74 (0.99-3.05)), dog ownership (1.42 (1.07-1.89)), and obstructive sleep apnoea (1.41 (1.16-1.73)).

CONCLUSION

Acute and subacute cough, as well as previous COVID-19 infection, were uncommon in this Finnish elderly population. The prevalence of chronic cough was higher than that previously found in younger adults. Chronic cough is a multifactorial disorder in the elderly.

Results of a 1-Year Follow-Up Sleep Apnea Screening and Referral Initiative During Routine Yearly Examination of Environmental Inspection Workers

BACKGROUND

There are strong links between obstructive sleep apnea (OSA), chronic disease, mental health, job performance, and motor vehicle accidents. Corporate wellness clinics and health monitoring programs present ideal settings to educate and screen employees for OSA.

METHODS

In January 2020, the Stop-Bang Sleep Apnea Questionnaire was added to the yearly health monitoring program of 571 State of Texas air, water, and hazardous waste workers as part of routine care. Medium- and high-risk (HR) scoring employees were counseled to seek follow-up care from a primary-care provider (PCP). The January 2021 exams provided an opportunity to determine the success of counseling efforts.

FINDINGS

Of the 479 returning employees in 2021, 24 (49%) of HR and 17 (21.8%) of intermediate risk (IR) had discussed OSA with a PCP. Seven (14.3%) HR and 1 (<1%) IR employee underwent a sleep study and 4 (8.2%) were prescribed continuous positive airway pressure (CPAP).

CONCLUSIONS/APPLICATION TO PRACTICE

Screening for OSA at the workplace was inexpensive and, when diagnosed and treated, can mitigate associated chronic disease, improve worker productivity, and reduce associated accidents and injuries. The described OSA screening delivered value to the employer and employees. The screening was performed at a very low cost, involved little time on the part of the nurse practitioner and employees, brought signs and symptoms of OSA to the consciousness level of 571 employees, encouraged at-risk participants to discuss OSA with a PCP and led to 4 (8.2%) being prescribed CPAP.

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.

Development, testing, and feasibility of a customized mobile application for obstructive sleep apnea (OSA) risk assessment: A hospital-based pilot study

Introduction

Obstructive Sleep Apnea (OSA), the most prevalent form of sleep-related breathing disorder has practical and financial limitations in diagnosis by polysomnography, hence OSA risk-assessment can identify OSA-related symptoms early.

Objectives

To develop a mobile application for OSA-risk assessment and tests its validity, feasibility, and application in a hospital-based pilot sample.

Study design and methods

The study comprised of two parts.

Part i

Development of a mobile application "OSA-Risk Assessment Tool" using automated questionnaires.

Part ii

A pilot study to screen OSA-risk in 200 patients (100 adults,100 children) from the orthodontic OPD of a Govt. Dental Hospital, using the mobile application. Internal validation by manual and mobile-based methods was done on 30 random patients. Non-parametric tests assessed the statistical differences between OSA-risk and nonOSA-risk variables.

Results

The prevalence of OSA-risk was 21.4% in adults and 8% in children. In adults, OSA-risk showed significantly greater neck circumference (p = 0.0001), waist circumference(p = 0.001), body mass index(p = 0.008), daytime sleepiness, headache, and mouth breathing(p = 0.0001). In children, OSA-risk is associated with a dry mouth on awakening, daytime sleepiness, and mouth breathing, and nocturnal enuresis. The low OSA-risk patients were suggested standardized preventive management counseling and orthodontic interventions while medium to high-risk underwent sleep-specialist referrals.

Conclusions

This study supports the feasibility and usability of the mobile application "OSA-risk assessment tool" in a hospital setup. This cost-effective tool can be advocated for self-evaluation, early detection, and awareness in pandemic times. The future upgraded versions may include preventive modules and real-time coordination with the nearest sleep clinics and specialists.

Current and future strategies for diagnostic and management of obstructive sleep apnea

INTRODUCTION

Obstructive sleep apnea (OSA) is a common sleep disorder with multiple comorbidities including hypertension, diabetes, and cardiovascular disorders. Detected based on an overnight sleep study is called polysomnography (PSG); OSA still remains undiagnosed in majority of the population mainly attributed to lack of awareness. To overcome the limitations posed by PSG such as patient discomfort and overnight hospitalization, newer technologies are being explored. In addition, challenges associated with current management of OSA using continuous positive airway pressure (CPAP), etc. presents several pitfalls.

AREAS COVERED

Conventional and modern detection/management techniques including PSG, CPAP, smart wearable/pillows, bio-motion sensors, etc., have both pros and cons. To fulfill the limitations in OSA diagnostics, there is an imperative need for new technology for screening of symptomatic and more importantly asymptomatic OSA patients to reduce the risk of several associated life-threatening comorbidities. In this line, molecular marker-based diagnostics have shown great promises.

EXPERT OPINION

A detailed overview is presented on the OSA management and diagnostic approaches and recent advances in the molecular screening methods. The potentials of biomarker-based detection and its limitations are also portrayed and a comparison between the standard, current modern approaches, and promising futuristic technologies for OSA diagnostics and management is set forth.ABBREVIATIONS AHI: Apnea hypopnea index; AI: artificial intelligence; CAM: Cell adhesion molecules; CPAP: Continuous Positive Airway Pressure; COVID-19: Coronavirus Disease 2019; CVD: Cardiovascular disease; ELISA: Enzyme linked immunosorbent assay; HSAT: Home sleep apnea testing; IR-UWB: Impulse radio-ultra wideband; MMA: maxillomandibular advancement; PSG: Polysomnography; OSA: Obstructive sleep apnea; SOD: Superoxide dismutase; QD: Quantum dot.

Referral rate for obstructive sleep apnea in a pre-doctoral dental clinic using the STOP-Bang Questionnaire

OBJECTIVES

Obstructive sleep apnea (OSA) is a common condition that can result in significant illness when untreated. Only 10%-20% of individuals with OSA are believed to be properly diagnosed. Consequently, dentists are encouraged to identify patients at high risk for OSA. The aim of this study was to determine whether patients in a dental school student clinic were referred for evaluation of OSA when appropriate.

MATERIALS AND METHODS

All patients 18 or older admitted to the College of Dentistry between July 2017 and March 2020 completed a medical history form. Data were extracted from their responses to determine a STOP-Bang score, as well as data regarding a previous diagnosis of OSA and a list of referrals. Students are expected to refer patients appropriately where there are indications of a high risk of undiagnosed disease. In the case of a sleep apnea evaluation, this would include any patient whose STOP-Bang score was 5 or greater, per the lecture on sleep disorders. For patients identified as high risk, notes and referral forms were reviewed to determine if the appropriate referral occurred.

RESULTS

Of the 21,312 new patients, 1098 (5.2%) were identified as high-risk for OSA. Of those, 398 (36%) had not been previously diagnosed with OSA. None of these 398 patients received a referral for further evaluation of OSA.

CONCLUSION

The rate of referral for further evaluation for patients deemed at high risk for OSA was inadequate. Continued education and changes to the electronic health record are needed to ensure those at high-risk for OSA are appropriately managed.

The Association Between Obstructive Sleep Apnea and Cotton-Wool Spots in Nonproliferative Diabetic Retinopathy

Purpose:

This work reports the association of obstructive sleep apnea (OSA) and cotton-wool spots (CWS) seen in patients with nonproliferative diabetic retinopathy (DR).

Methods:

A random sample of patients diagnosed with DR between January 1, 2015 and December 31, 2018, were selected from medical-billing codes. Dilated funduscopic examination findings and medical history were analyzed by reviewing medical records.

Results:

CWS were present in 12 of 118 patients without OSA, compared with 11 of 32 patients with OSA (10.2% vs 34.4%, respectively; P = .002). OSA was more common in men (68.8%, P = .03) and associated with a higher body mass index (30.0 ± 5.0 without OSA vs 33.6 ± 5.5 with OSA, P < .001). When comparing those with and without OSA, there was no association with age; glycated hemoglobin A1c; stage of DR; insulin dependence; presence of diabetic macular edema; smoking status; or a history of hypertension, hyperlipidemia, cardiovascular disease, or other breathing disorder.

Conclusions:

The presence of OSA is associated with CWS in patients with DR, as well as male sex and a higher body mass index. Further research is needed to determine the ophthalmologist’s role in the timely referral of patients with CWS for OSA evaluation.

A Fuzzy Neural Network Model for Rapid Prediction of Optimal Positive Airway Pressures in OSAS Patients

Manual titration of positive airway pressure (PAP) is a gold standard to provide an optimal pressure for the treatment of obstructive sleep apnea-hypopnea syndrome (OSAS). Since manual titration studies were costly and time-consuming, many statistical models for predicting effective PAPs were reported. However, the prediction accuracies of the models associated with nocturnal parameters still remain low. This study proposes a fuzzy neural prediction network (FNPN) with input candidate variables, selected among easily available measurements (e.g., body mass index (BMI), waist circumstance (WC), and body composition) and OSAS related questionnaires, to rapidly predict an optimal PAP. The FNPN comprises fuzzy rules and is characterized with the ability of automatic rule growing and pruning from training data. A total of 147 participants from April 2018 to April 2019 were enrolled in Taichung Veterans General Hospital, Taiwan. After two selection processes for feature extraction, WC and BMI were the significant variables for entering the FNPN to predict optimal PAP. Experimental results showed that the average successful prediction rate of the proposed method was 71.8%. This study also found that Epworth sleepiness scales (ESS) and body composition, such as visceral fat area and percent body fat, were excluded in the final prediction model. Compared with existing models, the proposed prediction approach provided a rapid prediction of optimal PAP with higher accuracy.

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Predicting perinatal outcomes with an obstructive sleep apnea screening tool

The objective was to determine if a screening tool for obstructive sleep apnea could be used to predict adverse perinatal outcomes. This was a prospective observational study of patients receiving prenatal care and universally screened for obstructive sleep apnea with the STOP Questionnaire (four questions related to Snoring, Tiredness during daytime, Observed apnea, and high blood Pressure). Confounding variables were included in a backwards logistic regression model to predict adverse perinatal outcomes. The study population of 442 women had positive STOP screens (64; 14.5%) associated with preterm delivery and neonatal intensive care unit admissions. For preterm delivery, history of preterm delivery was the strongest predictor with odds ratios of 4.2 (95% confidence interval 2.0-8.8; p < 0.001), followed by STOP, odds ratios 2.8 (95% confidence interval 1.4-5.8; p = 0.004) and nulliparity, odds ratios 2.3 (95% confidence interval 1.2-4.4; p = 0.013). A positive STOP was the only significant predictor for neonatal intensive care unit admissions, odds ratios 2.5 (95% confidence interval 1.1-5.7; p = 0.036). STOP screening test performance indicated low sensitivity but high specificity: preterm delivery (28.3%, 87.4%), neonatal intensive care unit admissions (27.3%, 86.6%), low birth weight (25.0%, 86.9%), and preeclampsia (16.7%, 85.6%). As a stand-alone tool, the STOP Questionnaire has limited performance, but could be explored in combination with other factors that might increase sensitivity to predict preterm delivery and neonatal intensive care unit admission.