Arn H. Eliasson

Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis.

OBJECTIVE Limited evidence suggests bariatric surgery can result in high cure rates for obstructive sleep apnea (OSA) in the morbidly obese. We performed a systematic review and meta-analysis to identify the effects of surgical weight loss on the apnea-hypopnea index. METHODS Relevant studies were identified by computerized searches of MEDLINE and EMBASE (from inception to March 17, 2008), and review of bibliographies of selected articles. Included studies reported results of polysomnographies performed before and at least 3 months after bariatric surgery. Data abstracted from each article included patient characteristics, sample size who underwent both preoperative and postoperative polysomnograms, types of bariatric surgery performed, results of preoperative and postoperative measures of OSA and body mass index, publication year, country of origin, trial perspective (prospective vs retrospective), and study quality. RESULTS Twelve studies representing 342 patients were identified. The pooled mean body mass index was reduced by 17.9 kg/m(2) (95% confidence interval [CI], 16.5-19.3) from 55.3 kg/m(2) (95% CI, 53.5-57.1) to 37.7 kg/m(2) (95% CI, 36.6-38.9). The random-effects pooled baseline apnea hypopnea index of 54.7 events/hour (95% CI, 49.0-60.3) was reduced by 38.2 events/hour (95% CI, 31.9-44.4) to a final value of 15.8 events/hour (95% CI, 12.6-19.0). CONCLUSION Bariatric surgery significantly reduces the apnea hypopnea index. However, the mean apnea hypopnea index after surgical weight loss was consistent with moderately severe OSA. Our data suggest that patients undergoing bariatric surgery should not expect a cure of OSA after surgical weight loss. These patients will likely need continued treatment for OSA to minimize its complications.

Association of Sleep and Academic Performance

Poor school performance by adolescent students has been attributed in part to insufficient sleep. It is recognized that a number of factors lead to diminished total sleep time and chief among these are early school start times and sleep phase delay in adolescence. Political initiatives are gaining momentum across the United States to require later school start times with the intent of increasing total sleep time and consequently improving school performance. Later school start times come with significant costs and impact other activities of families and communities. The decision to implement later school start times cannot be made lightly and deserves support of well-performed research on the impact of these changes. A study evaluating the association of academic performance and total sleep time was performed in middle school and high school students in a suburban Maryland school system. Preliminary results of this study show no correlation of total sleep time with academic performance. Before mandating costly changes in school schedules, it would be useful to perform further research to determine the effects of increasing sleep time on the behaviors of adolescent students.

Chest Wall Implantation of Lung Cancer After Thin-Needle Aspiration Biopsy

Percutaneous aspirational biopsy of intrathoracic lesions has become a popular technique. One of the rarest complications is that of implantation of malignant cells within the needle tract and subsequent development of a chest wall mass. A case of chest wall implantation of adenocarcinoma of the lung after thin-needle biopsy is reported. The lesion was successfully treated with radical full-thickness excision of the chest wall and immediate reconstruction with a large rectus abdominis musculocutaneous flap.

Early to bed, early to rise! Sleep habits and academic performance in college students.

PurposePrior studies have placed emphasis on the need for adequate total sleep time for student performance. We sought to investigate the relative importance of total sleep time compared to the timing of sleep and wakefulness for academic performance.MethodsWe performed a questionnaire-based survey of college students in October 2007. The questionnaire gathered detailed information on sleep habits including naps, reasons for missing sleep, academic performance, study habits, time spent working outside of school, and stimulant use.ResultsCompared to those with the lowest academic performance, students with the highest performance had significantly earlier bedtimes (p = 0.05) and wake times (p = 0.008). Napping tended to be more common among high performers (p = 0.07). Of importance, there were no significant differences in total sleep time with or without naps, weekend sleep habits, study time, gender, race, reasons for staying up at night, nor in use of caffeinated beverages, over-the-counter stimulant pills, or use of prescription stimulants.ConclusionsTiming of sleep and wakefulness correlated more closely with academic performance than total sleep time and other relevant factors. These findings have important implications for programs intended to improve academic performance by targeting sleep habits of students.

Women with Sleep Apnea Have Lower Levels of Sex Hormones

Background: Low levels of sex hormones, especially progesterone, are suspected as a risk factor for sleep-disordered breathing (SDB). Objective: To test the hypothesis that serum levels of progesterone, estradiol, and 17-OH progesterone are lower in those women with clinically significant SDB. Design: Clinical cohort of convenience. Setting: University Hospital Sleep Laboratory. Methods: We investigated sleep and breathing parameters and serum levels of sex hormones in 53 consecutive women (ages 24 to 72 years) being evaluated for symptoms of daytime sleepiness. Analysis of hormonal status by specific radioimmunoassays and fluorescence immunoassays was done from blood samples taken after an overnight polysomnography. Results: Across the cohort, taking account of age and cycle time or postmenopausal status, those with an apnea-hypopnea index (AHI) greater than 10/hrs of sleep had significantly lower levels of 17-OH progesterone, progesterone, and estradiol than those with an AHI less than 10. Conclusion: We conclude that reductions in female sex hormones are associated with an increased probability of SDB in women with daytime sleepiness.

Pneumatic Compression Devices Are an Effective Therapy for Restless Legs Syndrome: A Prospective, Randomized, Double-Blinded, Sham-Controlled Trial

BACKGROUND Pharmacotherapy for restless legs syndrome (RLS) may be ineffective or complicated by side effects. Uncontrolled series using pneumatic compression devices (PCDs) have been shown to reduce symptoms of RLS. We sought to assess the efficacy of PCDs as a nonpharmacologic treatment for RLS. METHODS We performed a prospective, randomized, double-blinded, sham-controlled trial of individuals with RLS. Subjects wore a therapeutic or sham device prior to the usual onset of symptoms for a minimum of 1 h daily. Measures of severity of illness, quality of life, daytime sleepiness, and fatigue were compared at baseline and after 1 month of therapy. RESULTS Thirty-five subjects were enrolled. Groups were similar at baseline. Therapeutic PCDs significantly improved all measured variables more than shams. Restless Legs Severity Score improved from 14.1 +/- 3.9 to 8.4 +/- 3.4 (p = 0.006) and Johns Hopkins Restless Legs Scale improved from 2.2 +/- 0.5 to 1.2 +/- 0.7 (p = 0.01). All quality of life domains improved more with therapeutic than sham devices (social function 14% vs 1%, respectively; p = 0.03; daytime function 21% vs 6%, respectively, p = 0.02; sleep quality 16% vs 8%, respectively, p = 0.05; emotional well-being 17% vs 10%, respectively, p = 0.15). Both Epworth sleepiness scale (6.5 +/- 4.0 vs 11.3 +/- 3.9, respectively, p = 0.04) and fatigue (4.1 +/- 2.1 vs 6.9 +/- 2.0, respectively, p = 0.01) improved more with therapeutic devices than sham devices. Complete relief occurred in one third of subjects using therapeutic and in no subjects using sham devices. CONCLUSION PCDs resulted in clinically significant improvements in symptoms of RLS in comparison to the use of sham devices and may be an effective adjunctive or alternative therapy for RLS. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT00479531.

Comparison of Adjustable and Fixed Oral Appliances for the Treatment of Obstructive Sleep Apnea

STUDY OBJECTIVES To compare the efficacy of adjustable and fixed oral appliances for the treatment of OSA. METHODS Retrospective review of consecutive patients with OSA treated with either adjustable or fixed oral appliances. Polysomnography was conducted before and during therapy. Effective treatment was defined as an apnea-hypopnea index (AHI) < 5 events/h or < 10 events/h with resolution of sleepiness (Epworth < 10). We compared efficacy rates between fixed and adjustable appliances and sought to identify factors associated with greater success. RESULTS We included 805 patients, 602 (74.8%) treated with an adjustable and 203 (25.2%) a fixed oral appliances. Among the cohort, 86.4% were men; mean age was 41.3 ± 9.2 years. Mean AHI was 30.7 ± 25.6, with 34.1% having mild (AHI 5-14.9), 29.2% moderate (AHI 15-29.9), and 36.8% severe (AHI ≥ 30) OSA. Successful therapy was significantly more common with adjustable appliances. Obstructive events were reduced to < 5/h in 56.8% with adjustable compared to 47.0% with fixed appliances (p = 0.02). Similarly, a reduction of events to < 10 with resolution of sleepiness occurred in 66.4% with adjustable appliances versus 44.9% with fixed appliances (p < 0.001). For both devices, success was more common in younger patients, with lower BMI and less severe disease. CONCLUSIONS Adjustable devices produced greater reductions in obstructive events and were more likely to provide successful therapy, especially in moderate-severe OSA. Fixed appliances were effective in mild disease, but were less successful in those with higher AHIs. Given these findings, the baseline AHI should be considered when selecting the type of oral appliance.

Perceived stress correlates with disturbed sleep: a link connecting stress and cardiovascular disease.

The association between stress and cardiovascular disease (CVD) risk is becoming established. A mechanistic link clarifying the intermediate steps between the experience of stress and the development of CVD would support this association. We sought to examine the role of perceived stress as a factor associated with disturbed sleep with the goal of providing an explanation for the stress–CVD connection. We performed a cross-sectional analysis of data recorded by subjects at entry to our CVD prevention program. Data collection included questionnaire surveys, anthropometrics, and a CVD-relevant laboratory panel. Of 350 consecutively enrolled subjects (mean age 54.4 ± 12.4 [SD] years, 138 men, 39%), 165 (47%) scored above the mean for stress measures. These high-stress subjects displayed an increased cardiovascular risk profile including elevated body mass index (mean ± SD 31.1 ± 5.9 vs. 29.0 ± 5.9, rs = 0.175), increased waist circumference (102 ± 17 cm vs. 98 ± 14, rs = 0.135), and elevated high-sensitivity serum C-reactive protein (0.384 mg/dl vs. 0.356, rs = 0.109). High-stress subjects also demonstrated greater daytime sleepiness (Epworth Sleepiness Scale: 10.4 ± 5.0 vs. 7.8 ± 4.8, rs < 0.316), greater fatigue (fatigue scale: 5.4 ± 2.2 vs. 3.4 ± 2.4, rs = 0.484), poorer sleep quality (Pittsburgh Sleep Quality Index: 8.5 ± 4.4 vs. 5.9 ± 4.0, rs = 0.416), and shorter sleep duration (20 min less/24 h, rs = negative 0.177) with a higher risk for sleep apnea (60% at high risk vs. 40%, p = 0.003) than low-stress subjects. High stress was associated with significant disturbances in sleep duration and sleep quality. Stress levels also correlated with daytime consequences of disturbed sleep. The stress–sleep connection may be an important mechanistic mediator of the association between stress and CVD.

Original ResearchSleep MedicinePneumatic Compression Devices Are an Effective Therapy for Restless Legs Syndrome: A Prospective, Randomized, Double-Blinded, Sham-Controlled Trial

BACKGROUND Pharmacotherapy for restless legs syndrome (RLS) may be ineffective or complicated by side effects. Uncontrolled series using pneumatic compression devices (PCDs) have been shown to reduce symptoms of RLS. We sought to assess the efficacy of PCDs as a nonpharmacologic treatment for RLS. METHODS We performed a prospective, randomized, double-blinded, sham-controlled trial of individuals with RLS. Subjects wore a therapeutic or sham device prior to the usual onset of symptoms for a minimum of 1 h daily. Measures of severity of illness, quality of life, daytime sleepiness, and fatigue were compared at baseline and after 1 month of therapy. RESULTS Thirty-five subjects were enrolled. Groups were similar at baseline. Therapeutic PCDs significantly improved all measured variables more than shams. Restless Legs Severity Score improved from 14.1 +/- 3.9 to 8.4 +/- 3.4 (p = 0.006) and Johns Hopkins Restless Legs Scale improved from 2.2 +/- 0.5 to 1.2 +/- 0.7 (p = 0.01). All quality of life domains improved more with therapeutic than sham devices (social function 14% vs 1%, respectively; p = 0.03; daytime function 21% vs 6%, respectively, p = 0.02; sleep quality 16% vs 8%, respectively, p = 0.05; emotional well-being 17% vs 10%, respectively, p = 0.15). Both Epworth sleepiness scale (6.5 +/- 4.0 vs 11.3 +/- 3.9, respectively, p = 0.04) and fatigue (4.1 +/- 2.1 vs 6.9 +/- 2.0, respectively, p = 0.01) improved more with therapeutic devices than sham devices. Complete relief occurred in one third of subjects using therapeutic and in no subjects using sham devices. CONCLUSION PCDs resulted in clinically significant improvements in symptoms of RLS in comparison to the use of sham devices and may be an effective adjunctive or alternative therapy for RLS. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT00479531.

Sedative Use During Continuous Positive Airway Pressure Titration Improves Subsequent Compliance A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND The initial experience with continuous positive airway pressure (CPAP) may predict subsequent compliance. In a retrospective study, we found that premedication with nonbenzodiazepine sedative-hypnotic agents during CPAP titration polysomnography independently predicted short-term compliance. To validate these findings, we conducted a prospective clinical trial to assess whether premedication with eszopiclone prior to CPAP titration would improve short-term CPAP compliance. METHODS Subjects in this randomized, double-blind, placebo-controlled trial received 3 mg of eszopiclone or matching placebo prior to undergoing CPAP titration polysomnography. We compared the quality of CPAP titrations and objective measures of compliance during the first 4 to 6 weeks of therapy between the two groups. RESULTS We enrolled 117 subjects, and 98 subjects completed the protocol (eszopiclone, 50 subjects; placebo, 48 subjects). Other than there being more women in the eszopiclone group, the groups were similar at baseline. Compared with placebo, premedication with eszopiclone significantly improved mean (+/- SD) sleep efficiency (87.8 +/- 5.8% vs 80.1 +/- 10.5%, respectively; p = 0.002) and mean total sleep time (350.9 +/- 33.6 min vs 319.7 +/- 48.7 min, respectively; p = 0.007). A trend toward improved sleep latency (19.4 +/- 16.1 min vs 31.8 +/- 30.4 min, respectively; p = 0.08) and the number of residual obstructive events observed at the final CPAP pressure (6.4 +/- 7 events/h vs 12.8 +/- 14.6 events/h, respectively; p = 0.08) during polysomnography was found. Eszopiclone significantly improved CPAP compliance. Among subjects premedicated with eszopiclone, CPAP was used on a higher percentage of nights (75.9 +/- 20.0% vs 60.1 +/- 24.3%, respectively; p = 0.005) and for more hours per night (4.8 +/- 1.5 h vs 3.9 +/- 1.8 h, respectively; p = 0.03). CONCLUSIONS Premedication with eszopiclone on the night of CPAP titration improved the quality of CPAP titration and led to significantly greater short-term compliance. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00507117.