Anne-Laure Borel

Hypertension and sleep: overview of a tight relationship.

Autonomic cardiovascular control changes across sleep stages. Thus, blood pressure (BP), heart rate and peripheral vascular resistance progressively decrease in non-rapid eye movement sleep. Any deterioration in sleep quality or quantity may be associated with an increase in nocturnal BP which could participate in the development or poor control of hypertension. In the present report, sleep problems/disorders, which impact either the quality or quantity of sleep, are reviewed for their interaction with BP regulation and their potential association with prevalent or incident hypertension. Obstructive sleep apnea syndrome, sleep duration/deprivation, insomnia, restless legs syndrome and narcolepsy are successively reviewed. Obstructive sleep apnea is clearly associated with the development of hypertension that is only slightly reduced by continuous positive airway pressure treatment. Shorter and longer sleep durations are associated with prevalent or incident hypertension but age, gender, environmental exposures and ethnic differences are clear confounders. Insomnia with objective short sleep duration, restless legs syndrome and narcolepsy may impact BP control, needing additional studies to establish their impact in the development of permanent hypertension. Addressing sleep disorders or sleep habits seems a relevant issue when considering the risk of developing hypertension or the control of pre-existent hypertension. Combined sleep problems may have potential synergistic deleterious effects.

High prevalence of obstructive sleep apnoea syndrome in a Type 1 diabetic adult population: a pilot study

Owing tochronichyperglycaemiaandcardiovascularautonomic neuropathy, Type 1 diabetes patients exhibit increased cardiovascular risk [1]. Both glycaemic control and cardiovascular risk are also associated with obstructive sleep apnoea syndrome [2]. Assessing the association systematically and treating both conditions may play a part in improving the prognosis of Type 1 diabetic patients. Forty Type 1 diabetic adults were consecutively recruited during their regular follow-up in a tertiary centre outpatients clinic. Patients were asked to participate in a screening oximetric procedure, in order to detect sleep breathing disorders. Three of the patients had already been investigated for sleep disorders, with two being treated for obstructive sleep apnoea syndrome and one having no sleep disorder. The 37 remaining subjects completed an Epworth sleepiness scale, a questionnaire addressing sleep problems, and spent a night at home with an oximetric recording. Polysomnography was routinely proposed to subjects with borderline or pathological oximetry and proposed at random to 1 ⁄ 10 patients with normal oximetry. Oximetry was classified as normal in the absence of oxygen saturation (SaO2) fluctuations, as pathological when repetitive desaturation–reoxygenation sequences occurred and as borderline when SaO2 fluctuations were limited in amplitude or appeared during limited periods of time. A variability index of SaO2 objectively quantified these SaO2 fluctuations with a previously demonstrated high negative predictive value in detecting obstructive sleep apnoea syndrome [3]. Obstructive sleep apnoea syndrome was defined by an apnoea + hypopnoea index > 15 ⁄ h during polysomnography. Among the 37 oximetric recordings, 13 were normal, nine were borderline and 15 were pathological. Polysomnography was offered to 25 patients, accepted by 18 and sleep apnoea was demonstrated in 14 patients (0 ⁄ 1, 2 ⁄ 4 and 12 ⁄ 13 in

Sleep habits and diabetes

Sleep duration has been constantly decreasing over the past 50 years. Short sleep duration, sleep quality and, recently, long sleep duration have all been linked to poor health outcomes, increasing the risk of developing metabolic diseases and cardiovascular events. Beyond the duration of sleep, the timing of sleep may also have consequences. Having a tendency to go early to bed (early chronotype) compared with the habit of going to bed later (late chronotype) can interfere considerably with social schedules (school, work). Eventually, a misalignment arises in sleep timing between work days and free days that has been described as social jet lag. The present review looks at how different sleep habits can interfere with diabetes, excluding sleep breathing disorders, and successively looks at the effects of sleep duration, chronotype and social jet lag on the risk of developing diabetes as well as on the metabolic control of both type 1 and type 2 diabetes. Finally, this review addresses the current state of knowledge of physiological mechanisms that could be linking sleep habits and metabolic health.

Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study

PurposeFew data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48xa0h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock.MethodsIn the prospective OutcomeRea database, we identified adults with IMV >72xa0h and shock (arterial systolic pressure <90xa0mmHg) within 48xa0h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics.ResultsWe included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95xa0% confidence interval (CI) 0.81–0.98, Pxa0=xa00.01] and day-7 mortality (HR 0.76, CI 0.66–0.87, Pxa0<xa00.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89–1.12, Pxa0=xa00.98). Early nutrition increased VAP risk over the 28xa0days (HR 1.08, CI 1.00–1.17, Pxa0=xa00.046) and until dayxa07 (HR 7.17, CI 6.27–8.19, Pxa0<xa00.001) but decreased VAP risk from daysxa07 to 28 (HR 0.85, CI 0.78–0.92, Pxa0<xa00.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00–1.22, Pxa0=xa00.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20xa0kcal/kg/day.ConclusionIn mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.

Glucose tolerance and cardiovascular risk biomarkers in non-diabetic non-obese obstructive sleep apnea patients: Effects of long-term continuous positive airway pressure

BACKGROUNDnInsulin resistance, glucose dyshomeostasis and oxidative stress are associated to the cardiovascular consequences of obstructive sleep apnea (OSA). The effects of a long-term continuous positive airway pressure (LT-CPAP) treatment on such mechanisms still remain conflicting.nnnOBJECTIVEnTo investigate the effect of LT-CPAP on glucose tolerance, insulin sensitivity, oxidative stress and cardiovascular biomarkers in non-obese non-diabetic OSA patients.nnnPATIENTS & METHODSnTwenty-eight apneic, otherwise healthy, men suffering from OSA (mean age = 48.9 ± 9.4 years; apnea-hypopnea index = 41.1 ± 16.1 events/h; BMI = 26.6 ± 2.8 kg/m(2); fasting glucose = 4.98 ± 0.37 mmol/L) were evaluated before and after LT-CPAP by an oral glucose tolerance test (OGTT), measuring plasma glucose, insulin and proinsulin. Glycated hemoglobin, homeostasis model assessment resistance insulin, blood lipids, oxidative stress, homocysteine and NT-pro-brain natriuretic peptide (NT-proBNP) were also measured.nnnRESULTSnLT-CPAP treatment lasted 13.9 ± 6.5 months. At baseline, the time spent at SaO2<90%, minimal and mean SaO2 were associated with insulin area under the curve during OGTT (r = 0.448, P = 0.011; r = -0.382; P = 0.047 and r = -0.424; P = 0.028, respectively) and most other glucose/insulin homeostasis biomarkers, as well as with homocysteine (r = 0.531, P = 0.006; r = -0.487; P = 0.011 and r = -0.409; P = 0.034, respectively). LT-CPAP had no effect on all the OGTT-related measurements, but increased plasma total antioxidant status (+7.74%; P = 0.035) in a duration-dependent manner (r = 0.607; P < 0.001), and decreased both homocysteine (-15.2%; P = 0.002) and NT-proBNP levels (-39.3%; P = 0.002).nnnCONCLUSIONSnIn non-obese non-diabetic OSA patients, nocturnal oxygen desaturation is strongly associated to insulin resistance. LT-CPAP does not improve glucose homeostasis nor insulin sensitivity but has a favorable effect on antioxidant capacity and cardiovascular risk biomarkers.

Treatment Discontinuation Following Bariatric Surgery in Obstructive Sleep Apnea: a Controlled Cohort Study.

BackgroundUncontrolled studies looking at the discontinuation of obstructive sleep apnea (OSA) treatment after bariatric surgery (BS) have suggested that surgery improves OSA. However, this discontinuation of OSA treatment by BS patients has never been compared to a matched population without BS. The objectives of this study are to evaluate whether BS increases OSA treatment discontinuation compared to that in matched patients without BS and to identify predictive factors of OSA treatment discontinuation in BS patients. The study took place in an ambulatory, tertiary hospital.MethodsWe included 61 OSA patients who underwent BS in a retrospective controlled cohort study. The computerized matching procedure included age, sex, body mass index, year of starting OSA treatment, treatment type, and duration selected 59 controls matched to 28 patients with BS. The main outcome was OSA treatment discontinuation within 2xa0years after BS.ResultsPatients with BS stopped OSA treatment more often than controls, usually between 6xa0months and 1xa0year after BS: hazards ratio (HR (95xa0%, CI)) 15.93 (3.29, 77.00). Before 6xa0months or beyond 1xa0year after BS, treatment discontinuation was not different between BS patients and controls. In univariate analyses, female gender, absence of co-morbidities, greater weight loss, and lower baseline OSA severity were associated with stopping OSA treatment after BS. No factor remained independently associated in multivariate analysis.ConclusionsApneic patients having BS stop OSA treatment more than matched controls. Treatment discontinuation may be attributed to recovery or to abandonment. The effect of BS on OSA may have been overestimated in uncontrolled BS studies that ignored basal OSA treatment discontinuation in routine clinical practice.

Safety of Mini/One Anastomosis Gastric Bypass (MGB/OAGB)—Reply to Musella et al

Dear Editor, We read with great interest the article from Musella et al. BComplications Following the Mini/One Anastomosis Gastric Bypass (MGB/OAGB): a Multi-institutional Survey on 2678 Patients with a Mid-term (5 Years) Follow-up^ published in Obesity Surgery [1]. Musella et al. aimed to determine the complication rate of MGB/OAGB in comparison with other surgical techniques. In our opinion, their article did not reach this goal. This retrospective, observational, and uncontrolled study described postoperative complications during the first 5 years of follow-up after the surgery. Authors concluded that MGB/ OAGB « seems to compare very favourably, in terms of complication rate » to other techniques. We have different concerns regarding this affirmation. The follow-up rate in this study is low, 84.1% at 1 year and only 62.6% at 5 years. The loss of follow-up in the field of bariatric surgery has been already highlighted in a systematic review suggesting that most studies are unable to affirm the safety of this treatment [2]. We believe that the low rate of follow-up in the article fromMusella et al. could be associated with an underreporting of bariatric surgery complications, especially with regard to malnutrition: nutritional complications are more frequent without postoperative nutritional monitoring. Moreover, patients, who experiment nutritional complications secondary to bariatric surgery, usually look for help in a different hospital than where the surgery was performed. We reported two case series of nutritional complications after bariatric surgery in which 5/6 and 11/12 patients, respectively, changed of hospital for the management of nutritional postoperative complications [3, 4]. Of note, in these two case series, 4/6 and 7/12 patients developed malnutrition after MGB/OAGB. Musella et al. discussed their results and the risk of late complications associated with MGB/OAGB by comparing the complication rate in this retrospective uncontrolled study to the complication rate of sleeve gastrectomy and Roux-en-Y gastric bypass found in different studies with different follow-ups. These indirect comparisons do not allow conclusions to be drawn. We and others have tried to alert the bariatric surgery community on the nutritional risk associated with this surgery [3, 5]. Our impression is that the need to reverse MBG/ OAGB because of severe malnutrition becomes more frequent in routine clinical practice [6, 7]. Accurate comparison of MBG/OAGB to Roux-en-Y gastric bypass complications’ rate will be possible, when the 2-year follow-up randomised clinical trial YOMEGA will be published (Clinical trial NCT02139813). In light of these observations and previous alerts regarding the risk of malnutrition associated with MBG/OAGB, we believe that MGB/OAGB technique should be limited as long as its safety has not been properly demonstrated.

Drugs influencing acid base balance and bicarbonate concentration readings

ABSTRACT Serum bicarbonate dosage is sensitive to pharmacological interferences. However, elevated bicarbonate concentration reflects chronic hypoventilation and has been proposed as a simple marker for screening patients with Obesity Hypoventilation Syndrome (OHS), a currently underdiagnosed multimorbid and high mortality disease. We provide a practical overview of the different drugs acting on the acid-base equilibrium to aid clinicians to interpret bicarbonate concentration readings. Little is known about the chronic impact of the usual doses of these drugs on serum bicarbonate concentration and further studies are needed. It is essential to take into account drugs that could interfere with this parameter to avoid misinterpretation of serum bicarbonate levels.

O77 Effets des habitudes de sommeil sur le contrôle glycémique du diabète de type 1: rôle du « décalage horaire lié aux contraintes sociales »

Introduction La qualite comme la quantite de sommeil de sommeil influencent la resistance a linsuline. Les habitudes de sommeil sont susceptibles dinfluencer le controle glycemique des sujets diabetiques de type 2 mais aussi de type 1. Objectif Evaluer limpact de differentes caracteristiques des habitudes de sommeil sur lequilibre glycemique de patients diabetiques de type 1. Patients et methodes 80 patients diabetiques de type 1 adultes ont ete inclus. Leur duree de sommeil, chronotype matinal ou vesperal, decalage horaire lie aux contraintes sociales (social jetlag) ont ete objectivement mesures par montre actimetrique. Les caracteristiques socio-economiques, lhistoire medicale et les troubles respiratoires du sommeil (evalues par oxymetrie) ont ete etudies comme potentiels facteurs confondants. Les patients ont complete un rappel alimentaire des 24 heures. Resultats Les patients etaient âges de 41 ans [IQR 27-51], 46 % etaient des femmes, lindice de masse corporel etait de 24,4 kg/m² (3,8). Lanciennete du diabete etait en moyenne de 165 mois [IQR 11-294]. Lhemoglobine glyquee moyenne etait de 8,3 % (1,5). Les differentes caracteristiques du sommeil, du traitement du diabete, socio-economiques et alimentaires ont ete testees en analyses univariees pour leur association avec lhemoglobine glyquee. Les variables montrant une valeur de p p p =0,023), la consommation de cafe ( p =0,015), la consommation dun encas le soir (0,003) et le tabagisme ( p =0,006) etaient independamment associes a lhemoglobine glyquee (R 2 =44 %). Conclusion Le social jetlag, definissant un decalage horaire du sommeil entre les jours travailles et les jours libres de faible amplitude mais recurrent, est une habitude de sommeil qui sinstalle largement dans nos societes. Il apparait comme une caracteristique des habitudes de sommeil determinante pour lequilibre glycemique du diabete de type 1. Declaration d’interet Les auteurs declarent ne pas avoir dinteret direct ou indirect (financier ou en nature) avec un organisme prive, industriel ou commercial en relation avec le sujet presente.

PO16 Le syndrome d’apnée du sommeil est hautement prévalent chez les patients diabétiques de type 1

Introduction Le syndrome d’apnees du sommeil augmente le risque cardio-vasculaire. Sa prevalence est elevee parmi les sujets obeses ou diabetiques de type 2. La prevalence du syndrome d’apnee du sommeil dans le diabete de type 1 n’a jamais ete etablie a ce jour. Patients et Methodes Determiner la prevalence du syndrome d’apnees apnee du sommeil parmi une population de sujets diabetiques de type 1 et les facteurs predictifs de l’association. Patients et methodes : 40 sujets diabetiques de type 1 ont ete consecutivement inclus pour un depistage des troubles respiratoires du sommeil par oxymetrie nocturne. Selon le resultat de l’oxymetrie (normale, douteuse ou anormale), tous les patients qui presentaient une oxymetrie douteuse ou anormale et un sujet sur dix qui presentait une oxymetrie normale se sont vus proposer une polysomnographie de confirmation. Resultats : Parmi les 40 sujets depistes (âge 43 ± 13 ans, Index de masse corporelle 24,7 ± 3,0 kg/m 2 , anciennete du diabete 23 ± 14 ans, HbA1c 7,8 ± 0,9 %), 40 % presentaient un syndrome d’apnee du sommeil (SAS) prouve par polysomnographie (index apnees + hypopnees > 15/h). Les sujets qui presentaient une oxymetrie anormale etaient plus âges, avaient plus longue evolution de la maladie diabetique et etaient plus frequemment affectes de retinopathie et de complications macrovasculaires. L’âge des sujets etait positivement correle a la variabilite de la saturation en oxygene (une plus grande variabilite refletant une plus grande severite de l’apnee du sommeil) (R = 0,61, p Conclusion : Nous avons retrouve une prevalence de 40% pour le syndrome d’apnee du sommeil parmi les sujets diabetiques de type 1. Le depistage du syndrome d’apnees du sommeil apparait donc comme un enjeu important de la prise en charge du diabete de type 1 car son traitement pourrait participer a la reduction de la morbidite cardiovasculaire associee au diabete de type 1.