Harneet K. Walia

Sleep disturbances in cancer patients: Underrecognized and undertreated

Sleep-related complaints are extremely common in patients with cancer but often are not recognized, and even if they are, they are seldom treated. Recognizing insomnia in cancer patients is imperative, as appropriate treatment can improve quality of life. In cancer patients, sleep disturbances are a treatable problem that profoundly affect all aspects of quality of life.

Longitudinal Effect of CPAP on BP in Resistant and Nonresistant Hypertension in a Large Clinic-Based Cohort

BACKGROUND Clinic-based effectiveness studies of sleep-disordered breathing (SDB) treatment in reducing BP in resistant hypertension (RHTN) vs non-RHTN are sparse. We hypothesize that CPAP use in SDB reduces BP significantly in RHTN and non-RHTN in a large clinic-based cohort. METHODS Electronic medical records were reviewed in patients with SDB and comorbid RHTN and non-RHTN for CPAP therapy initiation (baseline) and subsequent visits. We estimated generalizable BP changes from multivariable mixed-effects linear models for systolic BP (SBP), diastolic BP, and mean arterial pressure, adjusting for RHTN status, age, sex, race, BMI, cardiac history, and diabetes and repeated measure correlation. RESULTS Of 894 patients, 130 (15%) had RHTN at baseline (age, 58 ± 12 years; 52% men; BMI, 36 ± 9 kg/m(2)). Patients with RHTN had significantly higher BP overall (P < .001), most notably for SBP (6.9 mm Hg; 95% CI, 3.84, 9.94). In the year following CPAP initiation, improvements in BP indexes did not generally differ based on RHTN status in which RHTN status was a fixed effect. However, there was a significant decrease in SBP (3.08 mm Hg; 95% CI, 1.79, 4.37), diastolic BP (2.28; 95% CI, 1.56, 3.00), and mean arterial pressure (2.54 mm Hg; 95% CI, 1.73, 3.36) in both groups. CONCLUSIONS In this clinic-based effectiveness study involving patients closely followed for BP control, a significant reduction of BP measures (strongest for SBP) was observed in response to CPAP which was similar in RHTN and non-RHTN groups thus informing expected clinical CPAP treatment response.

Positive Airway Pressure-Induced Conversion of Atrial Fibrillation to Normal Sinus Rhythm in Severe Obstructive Sleep Apnea.

ABSTRACT Accumulating data implicate obstructive sleep apnea (OSA) as a predisposing factor to the development of atrial fibrillation (AF), the latter representing the most common sustained cardiac arrhythmia. The postulated mechanisms leading to atrial arrhythmogenesis in OSA include alterations in intrathoracic pressures, intermittent hypoxemia, and autonomic nervous system fluctuations. Although these OSA-related pathophysiologic pathways may result in atrial structural and electrical remodeling, thereby predisposing to AF, there are data to suggest that the immediate influences of respiratory events may trigger arrhythmic events. This case demonstrates an immediate reversal of AF to normal sinus rhythm with optimal continuous positive airway pressure (CPAP) therapy in the background of severe OSA. These findings of immediate benefit of reversal of OSA pathophysiology on cardiac arrhythmia suggest OSA may have acute influences on cardiac electrophysiology.

Impact of Sleep-Disordered Breathing Treatment on Quality of Life Measures in a Large Clinic-Based Cohort

STUDY OBJECTIVES This study aims to report the effect of positive airway pressure (PAP) therapy on quality of life (QoL) measures in the clinical sleep-disordered breathing (SDB) population. METHODS We examined general QoL measures assessed by European Quality of Life-5D (EQ-5D) and sleep-specific QoL by examining Functional Outcomes of Sleep Questionnaire (FOSQ) scores before and after PAP therapy retrospectively in a clinical SDB population using paired and two-sample t tests. Age and socioeconomic status (SES) effect modification on pre-PAP QoL measures were investigated utilizing the interaction terms. RESULTS A total of 2,027 patients with SDB initiated PAP therapy between January 1, 2010 and December 31, 2014. The mean age of the cohort was 56.2 years (standard deviation = 13.2), with 45.8% female and 76.9% Caucasians. EQ-5D change after exclusion of those with normal QoL was 0.042 (0.152) in all patients, 0.051 (0.150) in patients who were PAP adherent by self-report, and 0.050 (0.132) in patients who were objectively PAP adherent (n = 704 of 1,011 with available objective adherence data, 69.6%). Change in FOSQ after excluding those with normal FOSQ was 1.9 (2.9) in all patients, 2.2 (2.9) in patients who were PAP adherent by self-report, and 2.3 (2.9) in patients who were objectively PAP adherent. Those with (1) worse QoL at baseline and younger age and (2) worse QoL at baseline and residing in lower SES strata had worse outcomes after PAP therapy (P < .05). CONCLUSIONS We found consistent improvement in global and sleep-specific QoL measures after PAP therapy, hence providing evidence of PAP benefit in the clinical population and rationale for targeted efforts to optimize QoL in younger and lower SES subgroups.

Clarifying the role of hypoxia in obstructive sleep apnea as a potential promulgator of atrial fibrillation in ischemic stroke

Journal of Clinical Sleep Medicine, Vol. 13, No. 5, 2017 The burden of ischemic stroke in terms of incidence, mortality and disability-adjusted life-years has increased over the last several decades.1 Approximately 800,000 new or recurrent strokes are diagnosed every year in the United States alone.2 Atrial fibrillation (AF), an established risk factor for ischemic stroke, is recognized as the most prevalent of cardiac arrhythmias, affecting approximately 34 million persons globally3 and associated with increased cardiovascular-specific and all-cause mortality.4 Obstructive sleep apnea (OSA) shares an intricate relationship with AF and ischemic stroke.5 Epidemiologic and clinic-based data suggest OSA serves as a risk factor for the development of both AF6 and stroke.7 Although OSA has direct effects on stroke risk, OSA also likely operates via indirect pathways to contribute to development of stroke (eg, via increased atrial arrhythmogenesis).3 The interrelationships of OSA, AF, and stroke are likely mediated by OSA-related pathophysiological perturbations including intermittent hypoxemia, oxidative stress, autonomic nervous system dysregulation, augmented systemic inflammation, intrathoracic pressure swings, and increased levels of prothrombotic markers.8 OSA has been recognized as a risk factor for secondary prevention in ischemic stroke according to American Heart Association/American Stroke Association guidelines.9 Nearly one-fourth of strokes occurring in the United States are recurrent events. Therefore, determining the cause of stroke is a key element in developing specific management strategies to reduce a patient’s risk of subsequent events. Identifying specific aspects of OSA pathophysiology contributing to AF in ischemic stroke patients provides an opportunity to implement more efficient risk stratification strategies to stroke management. In the current issue of Journal of Clinical Sleep Medicine, Chen and colleagues aimed to elucidate the association of OSA and AF in patients with ischemic stroke.10 They conducted a cross-sectional examination of 158 patients (111 men) with ischemic stroke (occurring more than 1 week prior and within 1 year) admitted for neurorehabilitation. Patients were grouped into categories of paroxysmal AF identified prior to stroke (n = 26) and non-AF, and underwent in-laboratory polysomnography. The median scores of mean desaturation tended to be higher in the AF group compared to the non-AF group (6.7% versus 5.6%). Although in unadjusted analyses no significant association was COMMENTARY

Overview of Common Sleep Disorders and Intersection with Dermatologic Conditions

Sleep disorders are very common, often under-recognized and therefore undertreated, are associated with a myriad of medical conditions and could lead to significant impairment of quality of life. This review provides an up-to-date synopsis of common sleep disorders encompassing insufficient sleep syndrome, insomnia, circadian rhythm disorders and obstructive sleep apnea with a brief overview of epidemiology, screening, diagnostic testing and treatment. We also emphasize the emerging area of the intersection of sleep disorders and dermatologic conditions and present compelling data regarding underlying mechanisms including sleep dysfunction in relation to disorders of skin inflammation, aging and skin cancer.