Differences and associations between nocturnal voiding/nocturia and sleep disorders

Respiratory-related leg movements (RRLMs) may contribute to the cardiovascular risk associated with obstructive sleep apnea (OSA). Selective serotonin reuptake inhibitors (SSRIs), but not bupropion, increase periodic leg movements in sleep. This study examines whether patients with OSA using SSRIs have more RRLMs than those taking bupropion or no antidepressant. Patients with an apnea-hypopnea index (AHI) of at least 10 events/h during a full-night diagnostic study or split-night study, who were taking bupropion (n = 32), an SSRI (n = 31), or no antidepressant (n = 31), were selected from a database of prestudy questionnaires. RRLMs were scored according to World Association of Sleep Medicine 2016 standards. Patients using SSRIs had significantly greater overall RRLM% (defined as the percentage of respiratory events associated with a leg movement, including apneas, hypopneas, and respiratory effort-related arousals), RRLM index, and periodic limb movement index relative to patients using bupropion and control patients. The difference between the RRLM% in the SSRI and bupropion groups was limited to patients undergoing split-night studies, and that of the SSRI and control groups was limited to patients undergoing full-night diagnostic studies. The greater number of RRLMs and PLMs in the SSRI group may contribute to treatment-emergent insomnia often seen with SSRI use. Fragmented sleep and elevated autonomic nervous system activation associated with increased RRLMs in patients with OSA taking SSRIs might also limit the tolerability of antidepressant treatment, as well as increase the risk for cardiovascular disease.

Obstructive sleep apnea syndrome (OSAS) is associated with impairment of cognitive function, and improvement is often noted with treatment. Golf is a sport that requires a range of cognitive skills. We evaluated the impact of nasal positive airway pressure (PAP) therapy on the handicap index (HI) of golfers with OSAS. Golfers underwent a nocturnal polysomnogram (NPSG) to determine whether they had significant OSAS (respiratory disturbance index > 15). Twelve subjects with a positive NPSG were treated with PAP. HI, an Epworth Sleepiness Scale (ESS), and sleep questionnaire (SQ) were submitted upon study entry. After 20 rounds of golf on PAP treatment, the HI was recalculated, and the questionnaires were repeated. A matched control group composed of non-OSAS subjects was studied to assess the impact of the study construct on HI, ESS, and SQ. Statistical comparisons between pre- and post-PAP treatment were calculated. The control subjects demonstrated no significant change in HI, ESS, or SQ during this study, while the OSAS group demonstrated a significant drop in average HI (11.3%, p = 0.01), ESS, (p = 0.01), and SQ (p = 0.003). Among the more skilled golfers (defined as HI ≤ 12), the average HI dropped by an even greater degree (31.5%). Average utilization of PAP was 91.4% based on data card reporting. Treatment of OSAS with PAP enhanced performance in golfers with this condition. Treatment adherence was unusually high in this study. Non-medical performance improvement may be a strong motivator for selected subjects with OSAS to seek treatment and maximize adherence.

Pediatric restless legs syndrome and periodic limb movement disorder: Parent–child pairs

Objective To evaluate serum soluble lectin-like oxidized low density lipoprotein receptor -1 (sLOX-1) level in patients with obstructive sleep apnea syndrome (OSAS) and effect of continuous positive airway pressure (CPAP) on serum sLOX-1 level in patients with OSAS. Methods Twenty cases of moderate and severe OSAS patients were selected as the OSAS group by means of polysomnography (PSG), and 15 healthy cases were enrolled as the control group. The serum sLOX-1 levels were measured in the OSAS group and the control group. After treatment with CPAP in the OSAS group, the serum sLOX-1 level was measured again. Results Before treatment, the serum sLOX-1 level was (105.26±37.47) pg/ml in the OSAS group, in which the serum sLOX-1 level was significantly higher than that in the control group [(99.98±18.78) pg/ml] (P < 0.05). After 1 week CPAP treatment in the OSAS group, the serum sLOX-1 level dropped to (93.34±21.24) pg/ml. Comparing the levels between before and after treatment, the difference was statistically significant (P < 0.05). Before treatment in the OSAS group, the serum sLOX-1 level was positively correlated with apnea hyponea index (AHI) (r = 0.416, P < 0.05). Conclusion The level of serum sLOX-1 increases in patients with OSAS. CPAP can effectively reduce the level of serum sLOX-1 in patients with OSAS. Key words: Obstructive sleep apnea syndrome; Continuous positive airway pressure; Soluble lectin-like oxidized low-density lipoprotein receptor-1

Objective To investigate the interaction between Glut4 and IL-1β gene polymorphisms and risk factors of obstructive sleep apnea syndrome (OSAS) in development of OSAS by using multifactorial dimension reduction (MDR) . Methods From January to December in 2010, consecutive patients hospitalized in the Hypertension Department of Xinjiang Autonomous Region People's Hospital were included in this study. Night-time polysomnography and biochemical indicators were measured in 606 hypertensive patients suspected to have OSAS (including 447 cases of confirmed OSAS) . Taqman-PCR was used to genotype the taq-SNPs of Glut4 (rs5417, rs5415, rs5435) and IL-1β (rs1143627, rs1143634, rs1143633) . The interactions between glut4 and IL-1β SNP locus polymorphisms and risk factors of OSAS (such as obesity) were analyzed. Results There was no significant difference in population distribution and model construction for Glut4 rs5417 and IL-1 rs1143633 genotypes between OSAS and control groups. The frequency of CC genotype at Glut4 rs5417 locus was significantly higher in the OSAS group than that in the control group (63.3% vs 27.7%, P<0.05) . After adjustment of sex, age, triglyceride, cholesterol, blood glucose, body mass index and other risk factors, Logistic regression analysis showed that the synergistic effect of the Glut4 Rs5417 and IL-1β rs1143633 significantly increased the risk for obstructive sleep apnea in the Han population [OR (95%CI) : 0.5 (0.3, 0.9) ] (P=0.012) . In the overweight and obese patients, GST4 rs5417 (CC) genotype and IL-1β rs1143633 (CT) genotype increased the risk for OSAS [OR (95%CI) : 4.9 (2.8, 8.5) , P<0.05; OR (95%CI) 4.4 (2.3, 8.6) , P<0.05 respectively]. The optimal model of MDR data showed a strong synergy between the Glut4 rs5417 and IL-1β rs1143633, with the test accuracy being 57. 0, and a good consistency in cross-test (8/10) (P=0.004) . Conclusion During the development and progression of OSAS, synergistic interactions between the Glut4 rs5417 and IL-1β rs1143633 may increase the risk of OSAS. Overweight and obese patients who carry rs5417 (CC) and/or rs1143633 (CT) may have synergistically increased risk for OSAS. Key words: Sleep apnea, obstructive; Multifactorial dimension reduction; Glut4; IL-1β; Interaction

It is claimed that gastroesophageal reflux disease (GERD) increases in patients with obstructive sleep apnea syndrome (OSAS). We aimed to evaluate the prevalence of GERD in patients with OSAS and primary snoring and identify OSAS-related risk factors associated with GERD. In this prospective, cross-sectional, multicenter study, in total 1,104 patients were recruited for polysomnography: 147 subjects were in non-OSAS (primary snoring) and 957 patients were in OSAS group. All patients completed a validated GERD questionnaire. Demographic, anthropometric characteristics, and medical history were recorded. The prevalence of GERD was similar in OSAS (38.9%) and non-OSAS (32.0%) groups (p = 0.064). There was no difference in terms of major gastroesophageal reflux (GER) symptoms (heartburn/acid regurgitation) between non-OSAS and mild, moderate, and severe OSAS groups. The prevalence of GERD was increased in female OSAS patients (46.6%) compared to males (35.7%) (p = 0.002). In OSAS patients with GERD, body mass index was greater (34.0 ± 7.0 vs. 33.1 ± 6.8, p = 0.049), waist (115.5 ± 13.9 vs. 113.1 ± 13.4, p = 0.007) and hip (117.9 ± 13.7 vs. 114.2 ± 12.8, p < 0.0001) circumferences were larger, and Epworth sleepiness scores were higher (10.3 ± 6.0 vs. 8.8 ± 5.6, p < 0.0001) than OSAS patients without GERD. Multivariate analysis showed that GERD was significantly associated with female gender, hip circumference, and daytime sleepiness. In this large cohort, the prevalence of GERD was significantly increased in those with primary snoring and OSAS compared to the general population, but severity of OSAS did not influence GERD prevalence. The present results suggest that OSAS was not likely a causative factor but female gender, obesity, and sleepiness were related with prevalence of GERD in OSAS patients.

Sleep Related Problems and Urological Symptoms: Testing the Hypothesis of Bidirectionality in a Longitudinal, Population Based Study

Postoperative Complications in Patients With Obstructive Sleep Apnea Syndrome Undergoing Hip or Knee Replacement: A Case-Control Study

Objective To observe the changes of the area and part of infarction in patients with cerebral infarction complicating by obstructive sleep apnea syndrome (OSAS), and investigate their relationship with OSAS. Methods 200 stroke patients were recruited out of department of neurology of our hospital from July 2015 to April 2017, all patients were monitored with polysomnography for 6 hours to 3 weeks. All patients were divided into stroke group (n=89) and stroke with OSAS group (n=111) according to the apnea hypopnea index (AHI), or anterior-circulation infarction group (n=146) and posterior-circulation infarction group (n=54), or large area infarction group (infarction area ≥5 cm, n=47) and non-large area infarction group (infarction area <5 cm, n=153). The general condition, the part of infarction, the area of infarction, NIHSS score, sleep parameters of all patients were recorded. Statistical tests were implemented with IBM SPSS22.0. Results There were 63 patients with anterior-circulation infarction (70.8%) in stroke group; there were 40 patients with anterior-circulation infarction (80.0%) in stroke with mild OSAS group; there were 25 patients with anterior-circulation infarction (75.8%) in stroke with moderate OSAS group; there were 18 patients with anterior-circulation infarction (64.3%) in stroke with severe OSAS group; there was no statistically significant difference in the ratio of anterior-circulation infarction among the four groups (P>0.05). There were 20 patients with cerebral infarction (22.5%) and 27 patients with cerebral infarction complicating by OSAS (24.3%) in large area infarction group; there were 69 patients with cerebral infarction (77.5%) and 84 patients with cerebral infarction complicating by OSAS (75.7%) in non-large area infarction group; there was no statistically significant difference (P>0.05). Conclusion The area and part of cerebral infarction may not be related to the severity of OSAS. Key words: Cerebral infarction; Obstructive sleep apnea syndrome; Anterior circulation; Posterior circulation

Persons with epilepsy (PWE) frequently contend with disrupted sleep related to multiple seizure related as well as other factors like medications and comorbidities. Such disturbances often lead to fragmented sleep, which can adversely affect quality of life and compromise seizure management. Previous Although previous research has addressed conditions like sleep apnea and insomnia among PWE, less attention has been paid to periodic limb movements (PLMs), a requirement for diagnosis of the periodic limb movement disorder and also commonly observed in restless legs syndrome (RLS) as well as other conditions. This study aims to determine the prevalence and specific features of PLMs in PWE and to explore how these movements correlate with objective sleep measurements. This investigation employed a retrospective chart review of consecutive adult patients diagnosed with epilepsy who underwent polysomnography at a tertiary-care sleep laboratory over a ten-year span. The control group consisted of individuals evaluated for possible obstructive sleep apnea, who were matched to cases based on age, sex, and the severity of sleep apnea. Patient records were initially identified using keywords related to "epilepsy" or "seizures." Epilepsy diagnosis was confirmed through detailed chart review, which also yielded clinical details likety duration of epilepsy, seizure classification, and antiseizure medication usage. Sleep parameters such as sleep efficiency, spontaneous arousal index, periodic limb movement index, periodic limb movement with arousal index, and apnea-hypopnea index were extracted from archived polysomnography reports. The subsequent analysis was carried out using descriptive statistical methods using RStudio version 4.4.1. A total of 152 relevant patient records were found in the database. Of these, 61 patients with epilepsy (mean age 41.4 ± 17.2 years, including 31 females) met the inclusion criteria and were matched with 61 patients suspected for OSA. Within the epilepsy cohort, 43 patients experienced focal-onset epilepsy while 16 had generalized epilepsy. 25 patients were prescribed two or more antiseizure medications, and 12 were categorized as medically refractory. PLMs were detected in 23 % of patients with epilepsy compared to 26 % in the control group, with mean PLMI values of 6.1 ± 16.8 and 8.8 ± 20.7, respectively. The PLMAI was also similar between the two groups (0.5 ± 1.0 vs. 1.1 ± 2.4). Other sleep parameters, including the mean AHI (16.0 ± 20.0 in the epilepsy group vs. 19.7 ± 19.4 in the control group), did not exhibit significant differences between groups. Within the epilepsy cohort, the only factor linked to the presence of periodic limb movements was older age, with no observed association with seizure type, number of antiseizure medications, or seizure control. PLMs are a frequently observed phenomenon in polysomnographic studies of PWE and are predominantly related to advancing age. Given the comparable indices of periodic limb movements in both the epilepsy group and an age- and sex-matched cohort with obstructive sleep apnea, the findings suggest that obstructive sleep apnea might be a major contributor to the periodic limb movements seen among PWE.

Spectral analysis of sleep EEG in patients with restless legs syndrome

Short-term blood pressure (BP) variability is an important cardiovascular risk factor. Whether patients with obstructive sleep apnea syndrome (OSAS) indeed display increased short-term BP variability and, if so, what is its underlying mechanism remain unclear. We compared the short-term BP variability between hypertensive patients with OSAS (OSAS group; n= 212) and those without OSAS (control group; n = 82) by examining data of 24-h ambulatory BP monitoring (ABPM) and investigated the effects of continuous positive airway pressure (CPAP) therapy on short-term BP variability in 37 hypertensive patients with OSAS. Short-term BP variability was calculated with the average real variability (ARV) of awake and sleep BP. ARVs of sleep systolic BP (SBP) and diastolic BP (DBP) were significantly higher in the OSAS group than in the control group. There was no significant difference in ARVs of awake SBP and DBP between the two groups. In the OSAS group, multiple regression analyses revealed that the body mass index (BMI) was an independent determinant for ARV of sleep DBP and that the lowest SpO2 was an independent determinant for ARVs of sleep SBP and sleep DBP. CPAP therapy decreased ARVs of sleep SBP and DBP. These results suggested that higher short-term BP variability during sleep is a characteristic feature of hypertensive patients with OSAS and that obesity and hypoxemia play essential roles in increasing short-term BP variability during sleep. CPAP therapy may improve exaggerated short-term BP variability during sleep in patients with OSAS.

In his famous monograph “An Essay in Shaking Palsy,” James Parkinson provided astute descriptions of impaired sleep in his case series of patients with Parkinson's disease (PD) two centuries ago. It is only three decades ago that sleep dysfunction started to attract attention of medical and scientific communities involved in the clinical care and research of PD. Tremendous advancements in our understanding of impaired sleep and alertness associated with PD have developed since then. Sleep problems are one of the major, challenging issues in patients with PD, affecting a significant number of patients. The etiology of sleep problems is multifactorial, including disease-related nocturnal symptoms, medication adverse effects, and primary sleep disorders including restless legs syndrome, rapid eye movement sleep behavior disorder, and sleep apnea syndrome. These causes of impaired sleep-wake cycles in the PD population often coexist or even overlap, rendering the management of sleep problems in PD patients difficult. Also, excessive daytime sleepiness is observed in a significant number of patients. In PD patients, therefore, appropriate assessment of disease-related nocturnal disturbances and primary sleep disorders is imperative. This special issue addresses unmet need for understanding PD-related sleep problems. PD sleep scale 2 (PDSS-2) is a recently developed tool for screening and managing sleep disturbance in PD patients, consisting of 15 items which are clinically relevant to nocturnal problems including nonmotor and motor problems in PD [1]. The original PDSS-2 (German and English) has been translated into several languages, including Japanese [2] and Italian [3]. The PDSS-2 has been used to observe treatment response. In a double-blind, placebo-controlled trial, including 287 PD patients, mean PDSS-2 total score decreased by −5.9 points with rotigotine and by −1.9 points with placebo [4]. In this special issue, K. Horvath et al. estimated the threshold representing minimal clinically important difference of the PDSS-2 total score: the study results showed −3.44 points for detecting improvement or the threshold of 2.07 points for observing worsening. This finding is important when planning studies using the PDSS-2 as outcome measures. Full-night polysomnography (PSG) is a gold standard for diagnosing sleep apnea syndrome; however, applying PSG is often difficult in patients with PD, who have severe parkinsonism or psychiatric comorbidity. P. Gros et al. evaluated the usefulness of unattended portable monitoring (PM) for diagnosis of obstructive sleep apnea (OSA) in patients with PD. Although discrepancy between portable monitoring and PSG was greater in PD patients with more motor dysfunction, the authors confirmed the usefulness of portable monitoring in diagnosing moderate to severe OSA in PD patients. These results provide the rationale for the use of portable sleep monitoring in PD and are very relevant for circumstances where a complete PSG in a sleep laboratory is not available and/or feasible. M. Kaminska et al. performed a review on the relationship between OSA and PD. Although the clinical significance of OSA in PD has been controversial [5, 6], the authors suggest the possibility that treatment of OSA could delay cognitive decline or motor dysfunction in patients with PD. This area of research is of high significance as it is important to assess the prevalence of OSA and the impact of its treatment in the PD population. D. Martinez-Ramirez et al. correlated PSG findings and sleep disorders with clinical characteristics in PD patients and found that sleep disorders and sleep architecture were poorly predictable by clinical characteristic of PD patients. This comprehensive study demonstrates the complexity of sleep dysfunction associated with PD and its complex associations with metrics of PD. In a fine and thoughtful study K. Suzuki et al. provided an interesting insight into the complex relationship between PD and restless legs syndrome (RLS) and leg motor restlessness (LMR). A significant relationship between RLS and PD is suggested by observing a favorable response to dopaminergic treatment in both disorders. However, RLS prevalence in PD patients varies according to different studies. Recently, LMR, characterized by an urge to move the legs that does not fulfill the diagnostic criteria for RLS, has been reported more frequently in patients untreated with PD than healthy controls. This review article may provide a new insight into the relationship between RLS, LMR, and PD. Finally, the complex and still only partially understood interaction of impulse control disorders in PD and sleep is discussed in a review from the clinic of one of the guest editors. In summary, sleep problems are common but underreported by PD patients and underdiagnosed by health professionals. Further understanding of mechanisms that underlie impaired sleep and alertness in PD will allow for development of much needed treatment approaches for this nonmotor manifestation of PD. Koichi Hirata Birgit Hogl Eng King Tan Aleksandar Videnovic

Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients

Restless legs syndrome (RLS), also referred to as a Willis-Ekbom disease (WED), is a neurological illness that equally affects women and men1. RLS is a set of sensory and motor symptoms that are triggered by rest (e.g. lying down or sitting), either when one is trying to go to sleep or during periods of peaceful wakefulness. The symptoms worsen in the evening and early hours of the night during the day or night cycle. RLS is still diagnosed clinically using subjective complaints. Thus, the subsequent four symptoms were created and determined as minimum criteria for RLS diagnosis by the IRLSSG2,3. In the general community, RLS affects 5% to 15% of people, yet it is commonly misdiagnosed and untreated. It is more common in women and rises with age. RLS may be primary (idiopathic) or secondary, and it may be linked to illnesses including end-stage renal disease, pregnancy, or iron-deficiency anemia1,4. Sleep initiation and maintenance were found to be severely impacted by unpleasant sensations in individuals with RLS5. Sleep disturbance is caused by PLMS, which can be found in eighty to ninety percent of RLS patients. A series of flexion movement at the ankle, knee, and hip is distinguished of PLMS (PLMS, periodic leg movements of Sleep) which are repetitive leg jerks. They happen while sleeping, especially in the first and second NREM phases, as well as while relaxing awake (PLMW, periodic leg movements during awake). PLMS has been related with cortical arousal and awaking, insomnia, and excessive drowsiness during day6. The prolonged recurrence of these symptoms severely reduced the sleep quality of people with RLS, perhaps leading to the onset of anxiety and depression7. Improper sleep cycles among RLS sufferers could affect their health, productivity, and social activities5. However irregular sleep patterns and sensory issues during the day may have an impact on ADLs, QoL and even cause cognitive impairment. RLS has been responsible for daytime exhaustion, excessive sleepiness, increased physical and mental health issues, and symptoms of anxiety and sadness6. DOI: https://doi.org/10.52783/jchr.v15.i6.10944