Safal Shetty

Sleep Duration and Diabetes Risk: Population Trends and Potential Mechanisms

Sleep is important for regulating many physiologic functions that relate to metabolism. Because of this, there is substantial evidence to suggest that sleep habits and sleep disorders are related to diabetes risk. In specific, insufficient sleep duration and/or sleep restriction in the laboratory, poor sleep quality, and sleep disorders such as insomnia and sleep apnea have all been associated with diabetes risk. This research spans epidemiologic and laboratory studies. Both physiologic mechanisms such as insulin resistance, decreased leptin, and increased ghrelin and inflammation and behavioral mechanisms such as increased food intake, impaired decision-making, and increased likelihood of other behavioral risk factors such as smoking, sedentary behavior, and alcohol use predispose to both diabetes and obesity, which itself is an important diabetes risk factor. This review describes the evidence linking sleep and diabetes risk at the population and laboratory levels.

Sleep: important considerations for the prevention of cardiovascular disease.

Purpose of review Sleep plays many roles in maintenance of cardiovascular health. This review summarizes the literature across several areas of sleep and sleep disorders in relation to cardiometabolic disease risk factors. Recent findings Insufficient sleep duration is prevalent in the population and is associated with weight gain and obesity, inflammation, cardiovascular disease, diabetes, and mortality. Insomnia is also highly present and represents an important risk factor for cardiovascular disease, especially when accompanied by short sleep duration. Sleep apnea is a well-characterized risk factor for cardiometabolic disease and cardiovascular mortality. Other issues are relevant as well. For example, sleep disorders in pediatric populations may convey cardiovascular risks. Also, sleep may play an important role in cardiovascular health disparities. Summary Sleep and sleep disorders are implicated in cardiometabolic disease risk. This review addresses these and other issues, concluding with recommendations for research and clinical practice.

Obesity hypoventilation syndrome

Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness. The disorder involves a complex interaction between impaired respiratory mechanics, ventilatory drive, and sleep-disordered breathing. Early diagnosis and treatment is important because delay in treatment is associated with significant mortality and morbidity. Available treatment options include noninvasive positive airway pressure (PAP) therapies and weight loss. There is limited long-term data regarding the effectiveness of such therapies. This review outlines the current concepts of clinical presentation and diagnostic and management strategies to help identify and treat patients with obesity hypoventilation syndromes.

Insomnia, Health-Related Quality of Life and Health Outcomes in Children: A Seven Year Longitudinal Cohort

Insomnia is common in children, and is associated with decreased school performance and increased psychopathology. Although adult insomnia is linked to worsened health-related quality of life (HRQOL), there is insufficient data evaluating insomnia and HRQOL in children. We examined the HRQOL and health associations of insomnia in a longitudinal cohort of 194 children (96 girls, age at study start 8.7 ± 1.6 years, age at data analysis 15.0 ± 1.8 years) over 7 years. International Classification of Sleep Disorders, second edition (ICSD2) derived insomnia was seen intermittently in 27% of children, and was persistent in 4%. Children reporting ICSD2-derived insomnia had lower HRQOL. Additionally, the presence of insomnia was associated with an increased risk of reporting a new medical condition (intermittent insomnia odds ratio 5.9 [95% CI 1.3–26.7, p = 0.04], persistent insomnia odds ratio 8 [95% CI 2.3–27.7, p = 0.001]). Persistent ICSD2-derived insomnia was associated with an increased risk of reporting a new medication (odds ratio 4.9 (95% CI 1.0–23.6), p = 0.049), and reporting a new psychiatric medication (odds ratio 13.7, 95% CI: 2.6–73.5, p = 0.002). These associations were present even after adjusting for socioeconomic factors and the presence of obstructive sleep apnea. Insomnia in children is associated with worsened HRQOL and health outcomes.

Unanticipated Nocturnal Oxygen Requirement during Positive Pressure Therapy for Sleep Apnea and Medical Comorbidities

STUDY OBJECTIVES Home-based management of sleep-disordered breathing (SDB) generally excludes patients with significant medical comorbidities, but such an approach lacks scientific evidence. The current study examined whether significant medical comorbidities are associated with persistent hypoxia that requires unanticipated nocturnal O2 supplementation to positive airway pressure (PAP) therapy. Conceivably, in such patients, home-based management of SDB may not detect or therefore adequately treat persistent hypoxia. METHODS In this retrospective study of 200 patients undergoing laboratory-based polysomnography, we ascertained significant medical comorbidities (chronic obstructive pulmonary disease, congestive heart failure, and morbid obesity) and their association with the need for unanticipated O2 supplementation to PAP therapy. Postural oxygen (SpO2) desaturations between upright and reclining positions were determined during calm wakefulness. RESULTS Postural change in SpO2 during calm wakefulness was greater in patients who eventually needed nocturnal O2 supplementation to PAP therapy than those needing PAP therapy alone (p < 0.0001). The presence of chronic obstructive pulmonary disease (odds ratio [OR] 6.0; 95% confidence interval [CI]; 2.1, 17.5; p = 0.001), morbid obesity (OR 3.6; 95% CI 1.9, 7.0; p < 0.0001), and age older than 50 y (OR 2.8; 95% CI 1.3, 5.9; p = 0.007) but not heart failure were associated with unanticipated need for nocturnal O2 supplementation. A clinical prediction rule of less than two determinants (age older than 50 y, morbid obesity, chronic obstructive pulmonary disease, and postural SpO2 desaturation greater than 5%) had excellent negative predictive value (0.92; 95% CI 0.85, 0.96) and likelihood ratio of negative test (0.08; 95% CI 0.04, 0.16). CONCLUSIONS Medical comorbidities can predict persistent hypoxia that requires unanticipated O2 supplementation to PAP therapy. Such findings justify the use of medical comorbidities to exclude home management of SDB. COMMENTARY A commentary on this article appears in this issue on page 7.

‘Loud Continuous Murmur’ After Aortic Surgery: A Clue to an Aortic Root to Right Ventricular Outflow Tract Fistula

A 23-year-old man with a history significant for systemic lupus erythematosus and end-stage renal disease was admitted with chest pain and worsening shortness of breath. He had a past history of aortic valve endocarditis needing tissue aortic valve replacement. A few weeks later he was readmitted with prosthetic aortic valve endocarditis from coagulase negative staphylococcal bacteremia, further complicated by an aortic root abscess. He underwent redo aortic valve replacement with a mechanical aortic valve and repair of the aortic root abscess. He was febrile, with a blood pressure of 165/83 mm Hg and a heart rate of 75 beats per minute. Pertinent physical examination findings included a collapsing pulse and a continuous machinery murmur. Laboratory evaluation was notable for anemia with hemoglobin of 8.5 g/dL, an elevated white blood cell count, and creatinine at 4.9 mg/dL. International normalized ratio was 1.7. Chest X-ray was suggestive of a moderate-size right pleural effusion. In the presence of a continuous murmur and previous history of prosthetic valve endocarditis, a transthoracic echocardiogram was performed. The findings were concerning for prosthetic valve endocarditis with an aortic root abscess, and a fistulous connection between the aortic root and the right ventricular outflow tract. A real-time 3-dimensional transesophageal echocardiogram (RT-3DTEE) confirmed an aortic root to right ventricular outflow tract fistula (Figure A). There was also a dehiscence of the prosthetic aortic valve well visualized on RT-3DTEE (Figure B) with significant aortic regurgitation (Figure C). The patient underwent redo median sternotomy, removal of the mechanical aortic valve, replacement with an aortic valve/homograft (23 mm; CryoLife, Kennesaw, Ga), and repair of aortic

Mend the Mind and Mind the “MCC”

1001 Editorial—Parthasarathy et al. The World Health Organization (WHO) has stated that mental illnesses are the leading causes of disability worldwide and account for 37% of healthy years lost from non-communicable diseases.1 Non-communicable diseases—such as cardiovascular disease, chronic respiratory disease, cancer, diabetes, and mental health conditions—are estimated to result in

A meta-analysis of sleep-promoting interventions during critical illness.

47 trillion loss, which, in turn, accounts for 75% of the global Gross Domestic Product [GDP]).2 Depression alone is expected to be responsible for one-third of health years lost to disability from mental illness.1,2 Mental illnesses such as depression and physical ailments such as ischemic heart disease are examples of 17 chronic conditions that coexist in at least one in four Americans and such co-location is termed multiple (two or more) concurrent chronic conditions (MCC).3 MCC accounts for approximately 66% of total health care expenditures in the U.S. that is spent on 27% of Americans.3 Importantly, combinations of MCC, such as co-occurrence of coronary artery disease and depression may have synergistic interactions and lead to worse health outcomes of individuals with such serious mental illnesses due to poor attention to treatment adherence and disease understanding.4 It naturally follows that the participants of the Grand Challenges in Global Mental health identified the need for integrating the treatment of mental disorders with chronic disease care and suggested redesign of healthcare systems.5 In this issue of SLEEP, Jae-Min Kim and colleagues6 report having successfully integrated treatment of a mental health condition (i.e., depression) in patients with a common medical condition (i.e., acute coronary syndrome), and demonstrated both the high prevalence of depression in patients with acute coronary syndrome and that sleep outcomes can be improved through treatment of depression. They should not only be commended for an arduous and well done study in such a challenging population, but also for setting the stage for coordinated care across mental and physical health domains. In this study of Kim et al., both sleep and depression were evaluated within two weeks of the acute coronary syndrome episode, which is much earlier than that in other similar studies of sleep and depression in patients with ischemic EDITORIAL