Accessibility to manage the obstructive sleep apnea within the Brazilian Unified Health System

Abstract Objective To measure the average time for the diagnosis and for the therapeutic prescription of Continuous Positive Airway Pressure (CPAP) at a hospital in Botucatu Medical School - State University São Paulo, UNESP. Method A retrospective observational study was carried out by collecting data from the electronic medical records of patients over 18-years of age, who had a diagnostic polysomnography testing scheduled between January and December 2017. Result Of the 347 patients eligible for the study, 94 (27.1%) missed follow-up and 103 (29.7%) had a referral for CPAP use. Until February 2021, only 37 (35.9%) of these patients had already acquired and were using the device, the remaining 66 (64.1%) were waiting or gave up the therapy. The mean value of the waiting time interval between the referral of the diagnostic test and its performance was equivalent to 197 days (6.5 months). The mean time between diagnostic polysomnography and CPAP prescription was 440-days (14.5-months), with a total mean time of 624 days (21-months). Conclusion As in other services, the diagnostic-therapeutic flow proved to be highly inefficient, with a long waiting period, difficult access to treatment and a high dropout rate. These findings highlight the need to establish new patient-centered strategies with measures that speed up the flow and facilitate access to CPAP, in order to reduce the morbidity and mortality associated with this condition. Level of evidence Level 3 - Non-randomized controlled cohort/follow-up study Recommendation B.

Pharmacological treatment for obstructive sleep apnea: A systematic review and meta-analysis

Abstract Objective Summarize the evidence on drug therapies for obstructive sleep apnea. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, Embase, Scopus, Web of Science, SciELO, LILACS, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched on February 17th, 2023. A search strategy retrieved randomized clinical trials comparing the Apnea-Hypopnea Index (AHI) in pharmacotherapies. Studies were selected and data was extracted by two authors independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. RevMan 5.4. was used for data synthesis. Results 4930 articles were obtained, 68 met inclusion criteria, and 29 studies (involving 11 drugs) were combined in a meta-analysis. Atomoxetine plus oxybutynin vs placebo in AHI mean difference of -7.71 (-10.59, -4.83) [Fixed, 95 % CI, I2 = 50 %, overall effect: Z = 5.25, p < 0.001]. Donepezil vs placebo in AHI mean difference of -8.56 (-15.78, -1.33) [Fixed, 95 % CI, I2 = 21 %, overall effect: Z = 2.32, p = 0.02]. Sodium oxybate vs placebo in AHI mean difference of -5.50 (-9.28, -1.73) [Fixed, 95 % CI, I2 = 32 %, overall effect: Z = 2.86, p = 0.004]. Trazodone vs placebo in AHI mean difference of -12.75 (-21.30, -4.19) [Fixed, 95 % CI, I2 = 0 %, overall effect: Z = 2.92, p = 0.003]. Conclusion The combination of noradrenergic and antimuscarinic drugs shows promising results. Identifying endotypes may be the key to future drug therapies for obstructive sleep apnea. Moreover, studies with longer follow-up assessing the safety and sustained effects of these treatments are needed. PROSPERO registration number CRD42022362639.

Aspects clinico-neurophysiologiques des troubles du sommeil dans une population d'adultes jeunes entre 18-35 ans / Clinical-neurophysiological aspects of sleep disorders in a population of young adults aged 18-35 years

Contexte et objectifs : L'accès aux tests neurophysiologiques pour le diagnostic des Troubles du Sommeil (TS) est très limité dans les pays d'Afrique subsaharienne. La présente étude avait pour objectif de déterminer les caractéristiques épidémiologiques, cliniques et neurophysiologiques des (TS) dans un groupe de jeunes adultes. Méthodes : Il s'est agi d'une étude descriptive d'une série de cas, réalisée au centre de Médecine du sommeil et des maladies respiratoires de l'hôpital de la Croix-Rousse de Lyon du 1er janvier au 31 mars 2019. Les patients hospitalisés pendant cette période pour l'exploration d'un (TS) ont été sélectionnés. Etaient éligibles ceux dont l'âge était compris entre 18 et 35 ans, des deux sexes, ayant renseigné un questionnaire et ayant bénéficié au minimum d'une polysomnographie (PSG). Résultats : Quatre-vingt-onze patients étaient examinés. Les femmes étaient les plus affectées (59,3 %). Leur âge moyen était de 26,6 ± 5 ans. La PSG a incriminé le Syndrome d'Apnée Hypopnée Obstructive du sommeil (SAHOS) comme étiologie principale (66 %). Pour les patients sans SAHOS, 38,7 % avaient une PSG normale et la PSG avec d'autres tests de sommeil ont objectivé, pour le reste (61,3 %), d'autres types de (TS). La dépression (50,7 %) et la fatigue chronique (84,6 %) étaient très fréquentes. L'indice d'efficacité du sommeil était faible pour 70 % des patients avec SAHOS. Il y avait un déséquilibre de la durée des stades du sommeil, augmentée pour le sommeil lent léger et diminuée pour le sommeil lent profond dans la population avec SAHOS, tandis que la durée du sommeil paradoxal chez ceux sans SAHOS était augmentée. Conclusion Le SAHOS est fréquent dans cette formation hospitalière, avec des répercussions significatives à type de dépression et de fatigue chronique. Il est important que des mesures rendant accessible l'usage des tests d'exploration du sommeil particulièrement en Afrique au sud du Sahara, soient mises en place pour diagnostiquer ces troubles

Context and objective. Access to neurophysiological tests for diagnostic of sleep disorders (SD) is very limited in Sub-Saharan Africa countries. The objective was to determine the epidemiological, clinical and neurophysiological characteristics of SD in a young adult group. Methods. This was a descriptive serial cases study carried out at the Sleep Medicine and Respiratory Diseases Center of the CroixRousse hospital of Lyon between January 1st and March 31th, 2019. Patients hospitalized during this period with tests for SD were selected. Eligible were those aged between 18 and 35 years, both sexes, who completed a questionnaire and who received at least a polysomnography (PSG). Results. Ninety-one patients were involved. Women remained the most affected (59.3%). Mean age was 26.6±5 years. PSG incriminated obstructive sleep apnea (OSA) syndrome as the primary etiology (66%). For patients without OSA, 38.7% had normal PSG. For the remaining 61.3% of patients, other types of SD were found using PSG with various sleep tests. Depression (50.7%) was an important comorbidity, and chronic fatigue (84.6%) was the most frequent complaint. Sleep efficiency index was low for 70% of sleep apnea patients. There was an imbalance in the duration of sleep stages, with an increase in light slow-wave sleep in the OSA population and a decrease in their deep slow-wave sleep, while REM sleep duration in patients without OSA was increased. Conclusion: OSA was the primary etiology in our study, with significant repercussions like depression and chronic fatigue. Public health measures such as increasing access to the use of sleep exploration tests, especially in subSaharan Africa, should be put in place for the diagnosis of these sleep disorders and their consequences

Alertamientos y movimientos periódicos de las piernas durante las etapas de sueño y deterioro cognitivo leve en adultos mayores. Estudio preliminar / Arousals and periodic leg movements during sleep stages and mild cognitive impairment in older adults: a preliminary study

RESUMEN La fragmentación del sueño puede asociarse con distintas enfermedades, entre ellas, la demencia. En este sentido, la fragmentación de sueño, indicada por el índice de alertamientos y/o movimientos periódicos de las piernas (MPP), podría ser un marcador temprano de deterioro cognitivo leve (DCL), un síndrome precursor de la demencia. El objetivo del presente estudio fue medir el índice de prevalencia de los alertamientos y de los MPP durante el sueño en un grupo control y un grupo con DCL, así como determinar si hay diferencia entre los grupos en ambos índices y establecer si existe una correlación entre los dos fenómenos. En 9 participantes (3 mujeres controles y 3 mujeres con DCL; y 3 hombres con DCL) (edad: 69.1 ± 5; años de educación: 8 ± 2) se registró una noche de polisomnografía. Se obtuvieron los índices por hora de alertamientos y para cada etapa de sueño, así como los MPP globales y por hora; además se realizaron análisis entre y dentro de cada grupo. Se encontró una correlación positiva y un mayor número de MPP que de alertamientos durante toda la noche en los participantes con DCL. Conocer la prevalencia y asociación de ambos fenómenos contribuye en la formulación de una evaluación más cuidadosa y profunda de los adultos mayores en riesgo de desarrollar DCL y/o demencia.

ABSTRACT Sleep fragmentation may be associated with several diseases, including dementia. In this sense, sleep fragmentation, indicated by the rates of arousals and/or periodic leg movements (PLM), could be an early marker of Mild Cognitive Impairment (MCI), a syndromic stage prior to dementia. Therefore, the objective of this study was to compare the index of PLM with that of arousals and correlate both indexes in people with MCI and without MCI during all sleep stages. In 9 participants (3 control women and 3 women with MCI; and 3 men with MCI) (ages: 69.1 ± 5; years of education: 8 ± 2), one night of polysomnography was performed. Hourly rates of arousals and PLM were scored from each sleep stage. Analyses were performed within and between PLM and arousals for each group. Significant differences and a positive correlation were found between the arousal and the PLM rates for the group with MCI during the whole night. Knowledge of the prevalence and the association of both phenomena may contribute to a more careful and thorough evaluation of older adults at risk of developing MCI and/or dementia.

REM sleep behavior disorder: update on diagnosis and management / Transtorno comportamental do sono REM: atualização no diagnóstico e manejo

Abstract REM sleep behavior disorder (RBD) is characterized by a loss of atonia of skeletal muscles during REM sleep, associated with acting out behaviors during dreams. Knowledge of this pathology is important to predict neurodegenerative diseases since there is a strong association of RBD with diseases caused by the deposition of alpha-synuclein in neurons (synucleinopathies), such as Parkinson's disease (PD), multiple system atrophy (MSA), and dementia with Lewy bodies (DLB). Proper diagnosis of this condition will enable the use of future neuroprotective strategies before motor and cognitive symptoms. Diagnostic assessment should begin with a detailed clinical history with the patient and bed partner or roommate and the examination of any recorded home videos. Polysomnography (PSG) is necessary to verify the loss of sleep atonia and, when documented, the behaviors during sleep. Technical recommendations for PSG acquisition and analysis are defined in the AASM Manual for the scoring of sleep and associated events, and the PSG report should describe the percentage of REM sleep epochs that meet the criteria for RWA (REM without atonia) to better distinguish patients with and without RBD. Additionally, PSG helps rule out conditions that may mimic RBD, such as obstructive sleep apnea, non-REM sleep parasomnias, nocturnal epileptic seizures, periodic limb movements, and psychiatric disorders. Treatment of RBD involves guidance on protecting the environment and avoiding injuries to the patient and bed partner/roommate. Use of medications are also reviewed in the article. The development of neuroprotective medications will be crucial for future RBD therapy.

Resumo O transtorno comportamental do sono REM (TCSREM) é caracterizado por uma perda de atonia dos músculos esqueléticos durante o sono REM, associada a comportamentos de atuação durante os sonhos. O conhecimento desse transtorno é importante como preditor de doenças neurodegenerativas, uma vez que existe uma forte associação de TCSREM com doenças causadas pela deposição de alfa-sinucleína nos neurônios, como a doença de Parkinson (DP), atrofia de múltiplos sistemas (MSA) e demência com corpos de Lewy (DLB). O diagnóstico adequado dessa condição permitirá o uso de futuras estratégias neuroprotetoras antes do aparecimento dos sintomas motores e cognitivos. A avaliação diagnóstica deve começar com uma história clínica detalhada com o paciente e acompanhante, além de exame de vídeos. A polissonografia (PSG) é necessária para verificar a perda da atonia do sono e, quando documentados, os comportamentos durante o sono. As recomendações técnicas para aquisição e análise de PSG são definidas no Manual da AASM (Scoring of sleep and associated events) e o relatório de PSG deve descrever a porcentagem de períodos de sono REM que atendem aos critérios para REM sem atonia. Além disso, a PSG ajuda a descartar condições que podem mimetizar o TCSREM, como apneia obstrutiva do sono, parassonias do sono não REM, crises epilépticas noturnas, movimentos periódicos dos membros e transtornos psiquiátricos. O tratamento do TCSREM envolve orientações sobre adaptações do ambiente para evitar lesões ao paciente e ao colega de quarto. Medicamentos utilizados são revistos no artigo, assim como o crucial desenvolvimento de medicamentos neuroprotetores.

Obstructive Sleep Apnea and Hearing Loss: Is There Any Correlation?

Abstract Introduction Obstructive sleep apnea (OSA) is a breathing disorder related to sleep that has a negative effect on the behavior and health of people around the globe. Chronic hypoxemia and variations in the concentration of oxygen in the blood noticed in OSA individuals may have adverse effects on the process of auditory transduction and transmission. Objective To assess the effect of OSA on hearing and to find out the parameters that have more influence on hearing recorded during polysomnography of patients with OSA. Methods The present is a hospital-based, observational, analytical, cross-sectional study conducted over a period of one year. After application of the exclusion criteria, the patients were then submitted to the application of the Berlin questionnaire, as well as polysomnography, impedance, and pure tone audiometry (PTA). Results A total of 58 individuals were studied. Age, gender, and height were comparable among cases and controls, while weight, body mass index (BMI), and neck circumference were significantly higher in cases in comparison to controls. The mean PTA was significantly higher at 10 kHz or higher frequencies in cases in comparison to controls. Conclusion We observed that there is evidence that the auditory mechanism is affected in OSA patients. We recommend early auditory screening of OSA patients for timely diagnosis and to raise awareness about its prevention.

Enfermedad de Pompe y compromiso respiratorio

Introducción: El compromiso respiratorio en la enfermedad de Pompe es una de sus manifestaciones más frecuentes, tiene un impacto negativo en la calidad de vida y facilita la aparición de múltiples complicaciones. Se puede presentar como parte evolutiva de la enfermedad o incluso ser el síntoma inicial de la patología. Contenidos: La presentación clínica del compromiso respiratorio en la enfermedad de Pompe se caracteriza por disnea, ortopnea, cefalea y tos, y sus cambios paraclínicos incluyen hipercapnia, policitemia, elevación del índice de apnea/hipopnea, así como disminución de la capacidad vital y de las presiones inspiratoria y espiratorias máximas. El compromiso respiratorio es causado principalmente por disfunción muscular (especialmente el diafragma) y alteración de la regulación del sistema nervioso central. Conclusiones: Es fundamental la valoración acuciosa inicial de los patrones respiratorios y por supuesto su seguimiento, el cual dependerá del tipo de progresión de la disfunción respiratoria (rápida o lenta) o del requerimiento específico para cada paciente (ventilación no invasiva o invasiva).

Introduction: Respiratory compromise in Pompe disease is one of the most frequent manifestations, which has a negative impact on quality of life and leads to multiple complications. This can occur as an evolutionary part of the disease, or even be the initial symptom of the pathology. Contents: Its clinical presentation is characterized by dyspnea, orthopnea, headache, and cough, and its paraclinical changes include hypercapnia, polycythemia, elevated apnea/hypopnea index, decreased vital capacity, and decreased maximum inspiratory and expiratory pressures. Respiratory compromise is caused mainly by muscular dysfunction (especially the diaphragm) and alteration of regulation of the central nervous system. Conclusions: An initial careful assessment of respiratory patterns is essential, and of course their follow-up, that will depend of the type of progression of respiratory dysfunction (rapid or slow) or the specific requirement for each patient (non-invasive or invasive ventilation).

Características clínicas y demográficas de los pacientes con apnea obstructiva de sueño manejados quirúrgicamente en el servicio de otorrinolaringología del Hospital Militar Central entre los años 2016-2020 / Clinical and demographic characteristics of patients with obstructive sleep apnea surgically managed in the otorhinolaryngology service of the Central Military Hospital of Bogota between 2016-2020

Introducción: la apnea obstructiva del sueño (AOS) conlleva un alto riesgo cardiovascular, metabólico y neurológico. Los dispositivos de presión positiva continua (CPAP) o dispositivos de avance mandibular (DAM) pueden ferulizar la vía aérea superior (VAS) y mejorar la obstrucción; sin embargo, la adherencia es muy baja. Se ha demostrado que los procedimientos quirúrgicos de la VAS pueden llevar a una reducción significativa en la frecuencia de apneas e hipopneas. El objetivo del estudio fue describir las características clínicas y demográficas y los cambios en la somnolencia diurna excesiva, en el índice de apnea e hipopnea (IAH) y en la saturación de oxígeno (SpO2 ) de los pacientes con AOS manejados quirúrgicamente en el Servicio de Otorrinolaringología entre los años 2016 a 2020. Materiales y métodos: Se realizó un estudio observacional descriptivo tipo serie de casos. Resultados: se incluyeron nueve pacientes que cumplían los criterios de inclusión, el 77,8 % presentaban sobrepeso u obesidad. Se disminuyó la puntuación de la Epworth Sleepiness Scale (ESS) en el 100 % de los pacientes pre y posquirúrgicos. Adicionalmente, la polisomnografía (PSG) pre y posoperatoria mostró un aumento en la eficiencia de sueño con la mejoría de parámetros de oxigenación. Se encontró una disminución en el IAH en el 88,8 % de los pacientes. Conclusión: los hallazgos en este estudio sugieren que la cirugía de VAS es segura para realizar en pacientes con AOS. No todos los pacientes son candidatos a manejo quirúrgico y es importante una selección adecuada para disminuir las complicaciones.

Introduction: Obstructive sleep apnea (OSA) is a pathology that leads to a high risk of developing cardiovascular, metabolic, and neurological diseases. Positive airway pressure (CPAP) or mandibular advancement devices (MAD) can open superior airway (SAW) improve the obstruction, however, adherence is too low. It has already been shown that surgical SAW procedures, compared with medical management, can lead to a significant reduction in the frequency of apneas and hypopneas. The aim of this study was to describe the clinical and demographic characteristics, changes in excessive daytime sleepiness using Epworth Sleepiness Scale (ESS), apnea-hipopnea index (AHI) and SpO2 in patients with OSA managed surgically. Methods: A descriptive observational case series type study was carried out. Results: Nine patients were included, 77.8% were overweight or obese. A decrease in the ESS was found in 100% of the patients when pre- and post-operative scores were compared. Additionally, pre and postoperative polysomnography (PSG) showed an increase in sleep efficiency with improvement in oxygenation parameters such as mean saturation and minimum saturation. Regarding respiratory events, we found a decrease in AHI in 88.8% of patients. Conclusion: The findings in this study suggest that SAW surgery is safe to perform in patients with OSA. However, it is necessary to keep in mind that not all patients are candidates for surgical management and that adequate patient selection is important to reduce procedural complications.

Sleep assessment in adults with Down syndrome: correlation between functionality and polysomnographic findings / Avaliação do sono de adultos com síndrome de Down: correlações entre funcionalidade e achados polissonográficos

Abstract Background Sleep disorders have a negative impact on health, being associated with neurocognitive problems, cardiovascular diseases and obesity, influencing children's development and learning. Objective To assess the sleep pattern of people with Down syndrome (DS) and correlate changes with functionality and behavior. Methods A cross-sectional study was conducted to evaluate the sleep pattern in adults with DS > 18 years old. Twenty-two participants were assessed using the Pittsburgh Sleep Quality Index, the Functional Independence Measure and the Strengths and Difficulties Questionnaire, and the 11 who presented indications of disorders by the screening questionnaires were referred to polysomnography. Statistical tests were performed using a significance level of 5%, including sample normality tests and correlation tests (sleep and functionality). Results Impairment in sleep architecture was found due to an increase in the rate of awakenings in 100% of the participants, a decrease in the number of slow waves, and a high prevalence of sleep disordered breathing (SDB), with higher averages in the Apnea and Hypopnea Index (AHI) in the group. There was a negative correlation between sleep quality and global functionality (p= 0.011) and the motor (p= 0.074), cognitive (p= 0.010), and personal care (p= 0.072) dimensions in the group. Global and hyperactivity behavior changes were related to worse sleep quality (p= 0.072; p= 0.015, respectively). Conclusion There is an impairment in the sleep quality of adults with DS, with an increase in the rate of awakenings, a decrease in the number of slow waves, and a high prevalence of SDB affecting this population in the functional and behavioral aspects.

Resumo Antecedentes Os distúrbios de sono têm impacto negativo na saúde, estando associados a problemas neurocognitivos, doenças cardiovasculares e obesidade, influenciando no desenvolvimento e aprendizado. Objetivo Avaliar o padrão de sono de pessoas com síndrome de Down (SD) e correlacionar as alterações com a funcionalidade e comportamento. Métodos Foi realizado um estudo transversal para avaliação do padrão de sono em adultos com SD > 18 anos. Foram avaliados 22 participantes, através do Índice de Qualidade do Sono de Pittsburgh, da Medida de Independência Funcional e do Questionaário de Capacidades e Dificuldades. Os 11 participantes que apresentaram indicativos de presença de distúrbios pelos questionários de triagem foram indicados a polissonografia. Os testes estatísticos foram realizados com nível de significância de 5%, incluindo testes de normalidade e testes de correlação (sono e funcionalidade). Resultados Foi encontrado prejuízo na arquitetura de sono pelo aumento do índice de despertares em 100% dos participantes, diminuição na quantidade de ondas lentas, e alta prevalência de distúrbio respiratório do sono (DRS), com maiores médias nos Índices de Apneia e Hipopneia (IAH). Houve correlação negativa entre a qualidade de sono e a funcionalidade global (p= 0,011), e as dimensões motora (p= 0,074), cognitiva (p= 0,010) e cuidados pessoais (p= 0,072). As alterações de comportamento global e comportamentos de hiperatividade foram relacionados à pior qualidade do sono (p= 0,072; p= 0,015, respectivamente). Conclusão Existe prejuízo na qualidade de sono de adultos com SD, com aumento de índice de despertares, diminuição na quantidade de ondas lentas, e alta prevalência de DRS, afetando essa população nos aspectos funcionais e comportamentais.

Is maxillomandibular advancement an effective treatment for obstructive sleep apnea? Systematic literature review and meta-analysis

Abstract Objectives To evaluate the effectiveness of maxillomandibular advancement surgery in the treatment of Obstructive Sleep Apnea by comparing the pre- and postoperative Apnea and Hypopnea Index, in addition to classifying the degree of evidence and risk of intervention bias. Methods A systematic review of the literature was carried out in the PUBMED, LILACS, EMBASE, SCOPUS, WEB OF SCIENCE and COCHRANE platforms, including cohort studies with polysomnographic follow-up, without other associated pharyngeal or nasal surgical procedures. The risk of study bias was assessed using the Modified Delphi technique. Pre- and postoperative Apnea and Hypopnea Index data were plotted for meta-analysis, and the quality of evidence was assessed using the GRADE system. Results Of 1882 references, 32 articles were selected for full-text reading, of which four studies were included, totaling 83 adults with obstructive sleep apnea who underwent maxillomandibular advancement. The meta-analysis was in favor of the intervention (DM = −33.36, 95% CI −41.43 to −25.29, p< 0.00001), with a mean percentage reduction in the Apnea and Hypopnea Index of 79.5% after surgery, even though the level of evidence was classified as very low quality by the GRADE system. Conclusion The meta-analysis was in favor of the intervention, characterizing maxillomandibular advancement surgery as an effective treatment for obstructive sleep apnea in adults.

Effects of low-frequency repetitive transcranial magnetic stimulation combined with music biofeedback on insomnia / 中国基层医药

Objective:To investigate the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with music biofeedback on insomnia.Methods:Sixty patients with insomnia who received treatment in Outpatient Department of Seventh People's Hospital of Dongyang from January to August 2021 were included in this study. They were randomly divided into an observation group ( n = 30) and a control group ( n = 30) using the random number table. The control group was given music biofeedback therapy and conventional drug treatment, and the observation group was treated with rTMS based on music biofeedback therapy. The changes in polysomnography sleep structure and Pittsburgh Sleep Quality Index score after 1 month of treatment relative to before treatment were determined in each group. Results:After 1 month of treatment, the total sleep time, sleep efficiency, rapid eye movement (REM) sleep, non-REM sleep phase II (N2%) and non-REM sleep phase III (N3%) in the observation group were (419.87 ± 42.63) minutes, (83.69 ± 13.39)%, (25.27 ± 3.26)%, (53.75 ± 11.36)% and (16.27 ± 2.25)%, respectively, and they were (388.74 ± 40.39) minutes, (76.38 ± 13.17)%, (23.16 ± 2.68)%, (51.62 ± 12.27)%, and (14.36 ± 2.21)%, respectively. There were significant differences in these indices between the two groups ( t = -2.90, -2.13, -2.22, -2.26, -3.31, P = 0.005, 0.037, 0.030, 0.027, 0.002). The sleep latency, actual wake time, numbet of awakenings, non-REM sleep phase I (N1%), and total score of Pittsburgh Sleep Quality Index in the observation group were (24.16 ± 7.82) minutes, (23.18 ± 6.95) minutes, (1.76 ± 0.28) times, (9.74 ± 2.12)%, (9.17 ± 1.56) minutes, respectively. They were (28.35 ± 7.74) minutes, (28.36 ± 7.21) minutes, (2.25 ± 0.79) times, (11.12 ± 1.17)%, and (10.26 ± 1.42) minutes, respectively in the control group. There were significant differences in these indices between the two groups ( t = 2.09, 2.83, 3.20, 3.12, 2.83, P = 0.041, 0.006, 0.002, 0.003, 0.038). Conclusion:rTMS combined with music biofeedback for the treatment of insomnia can effectively improve sleep quality in patients with insomnia.

Bushen Anshen acupuncture for perimenopausal insomnia of kidney-yin deficiency: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the clinical efficacy of Bushen Anshen acupuncture (acupuncture for tonifying kidney and calming spirit ) in treating perimenopausal insomnia (PMI) of kidney-yin deficiency.@*METHODS@#A total of 72 patients with PMI of kidney-yin deficiency were randomized into an observation group (36 cases, 1 case dropped off) and a control group (36 cases, 1 case dropped off). Acupuncture was applied at Baihui (GV 20) and bilateral Shenshu (BL 23), Taixi (KI 3), Anmian (Extra) in the observation group, while sham acupuncture of shallow needling at non-acupoints was applied in the control group. The treatment was required once every other day, 3 times a week for 10 times in the two groups. Before and after treatment, Pittsburgh sleep quality index (PSQI) was used to evaluate the subjective sleep quality, and polysomnography (PSG) was used to monitor the objective sleep quality in the two groups.@*RESULTS@#After treatment, the scores of sleep quality, sleep latency, sleep duration, sleep efficiency, hypnotic, daytime dysfunction and total score of PSQI were decreased compared with those before treatment in the observation group (P<0.01), the scores of sleep duration, sleep efficiency and total score of PSQI were decreased compared with those before treatment in the control group (P<0.05); the scores of sleep quality, sleep latency, sleep efficiency, hypnotic and total score of PSQI in the observation group were lower than those in the control group (P<0.05). After treatment, the sleep time was prolonged, the sleep efficiency was improved, the sleep latency and the awake time after falling asleep were shortened, the arousal awake index was reduced (P<0.01) when PSG indexes were monitored, and the percentage of non-rapid eye movement sleep period 1 (N1%) was decreased while the percentage of non-rapid eye movement sleep period 3 (N3%) was increased (P<0.05) compared with those before treatment in the observation group; there was no statistical difference in the PSG indexes compared with those before treatment in the control group (P>0.05). After treatment, compared with the control group, the sleep time was prolonged, the sleep efficiency was improved, the sleep latency and the awake time after falling asleep were shortened, the arousal awake index and N1% were decreased in the observation group (P<0.01).@*CONCLUSION@#Bushen Anshen acupuncture can effectively improve the subjective and objective sleep quality in PMI patients of kidney-yin deficiency.

Study on the method of polysomnography sleep stage staging based on attention mechanism and bidirectional gate recurrent unit / 生物医学工程学杂志

Polysomnography (PSG) monitoring is an important method for clinical diagnosis of diseases such as insomnia, apnea and so on. In order to solve the problem of time-consuming and energy-consuming sleep stage staging of sleep disorder patients using manual frame-by-frame visual judgment PSG, this study proposed a deep learning algorithm model combining convolutional neural networks (CNN) and bidirectional gate recurrent neural networks (Bi GRU). A dynamic sparse self-attention mechanism was designed to solve the problem that gated recurrent neural networks (GRU) is difficult to obtain accurate vector representation of long-distance information. This study collected 143 overnight PSG data of patients from Shanghai Mental Health Center with sleep disorders, which were combined with 153 overnight PSG data of patients from the open-source dataset, and selected 9 electrophysiological channel signals including 6 electroencephalogram (EEG) signal channels, 2 electrooculogram (EOG) signal channels and a single mandibular electromyogram (EMG) signal channel. These data were used for model training, testing and evaluation. After cross validation, the accuracy was (84.0±2.0)%, and Cohen's kappa value was 0.77±0.50. It showed better performance than the Cohen's kappa value of physician score of 0.75±0.11. The experimental results show that the algorithm model in this paper has a high staging effect in different populations and is widely applicable. It is of great significance to assist clinicians in rapid and large-scale PSG sleep automatic staging.

Analysis of continuous polysomnography in children with recurrent vertigo / 临床耳鼻咽喉头颈外科杂志

Objective:To explore the relationship between sleep status and the disease in children with recurrent vertigo（RVC） by analyzing the objective sleep condition of children with recurrent vertigo. Methods:According to the diagnostic criteria of RVC, 50 children with RVC and 20 normal controls without RVC were selected. According to the vertigo questionnaire score, the RVC group was divided into mild, moderate and severe groups according to severity. Continuous polysomnography（PSG） was performed for all participants, and SPSS 25.0 statistical software was used to analyze the monitoring results. Results:①There were significant differences in sleep time of each period, total sleep time and sleep efficiency between RVC group and control group（P<0.05）, but there was no significant difference in sleep latency（P>0.05）. The specific manifestations were that the proportion of sleep time in N1 and N2 phases increased, the proportion of sleep time in N3 and REM phases decreased, the total sleep time and sleep efficiency decreased in RVC group. ②The abnormal rate of sleep apnea hypopnea index, that is, the proportion of AHI≥5 times/h and the abnormal rate of lowest blood oxygen saturation in RVC group were higher than those in normal control group. There was significant difference between the two groups（P<0.05）. ③There were significant differences in the proportion of AHI≥5 times/h and lowest SpO2 among mild group, moderate group and severe group（P<0.05）. ④There was no significant correlation between the degree of vertigo and the abnormal rate of AHI in children with RVC, but there was a negative correlation between the degree of vertigo and the abnormal rate of lowest SpO2 in children with RVC. Conclusion:Children with RVC are often accompanied by sleep disorders, clinicians should pay attention to both the symptoms of vertigo and sleep condition in children. Polysomnography is non-invasive and operable, providing a new idea to the auxiliary examination of RVC in children. It is of certain clinical significance for the comprehensive treatment of children with RVC to actively improve vertigo symptoms and pay attention to improving sleep quality.

Legal action for access to resources inefficiently made available in health care systems in Brazil: a case study on obstructive sleep apnea / Judicialização para acesso a recursos disponibilizados de forma ineficiente nos sistemas de saúde do Brasil: estudo de caso sobre apneia obstrutiva do sono

ABSTRACT Objective: Obstructive sleep apnea (OSA) is a highly prevalent chronic disease, associated with morbidity and mortality. Although effective treatment for OSA is commercially available, their provision is not guaranteed by lines of care throughout Brazil, making legal action necessary. This study aimed at presenting data related to the volume of legal proceedings regarding the access to diagnosis and treatment of OSA in Brazil. Methods: This was a descriptive study of national scope, evaluating the period between January of 2016 and December of 2020. The number of lawsuits was analyzed according to the object of the demand (diagnosis or treatment). Projections of total expenses were carried out according to the number of lawsuits. Results: We identified 1,462 legal proceedings (17.6% and 82.4% related to diagnosis and treatment, respectively). The projection of expenditure for OSA diagnosis in the public and private spheres were R$575,227 and R$188,002, respectively. The projection of expenditure for OSA treatment in the public and private spheres were R$2,656,696 and R$253,050, respectively. There was a reduction in the number of lawsuits between 2017 and 2019. Conclusions: Legal action as a strategy for accessing diagnostic and therapeutic resources related to OSA is a recurrent practice, resulting in inefficiency and inequity. The reduction in the number of lawsuits between 2017 and 2019 might be explained by the expansion of local health care policies or by barriers in the journey of patients with OSA, such as difficulties in being referred to specialized health care and low availability of diagnostic resources.

RESUMO Objetivo: A apneia obstrutiva do sono (AOS) é uma doença crônica altamente prevalente, associada a morbidade e mortalidade. Embora tratamentos efetivos para a AOS estejam disponíveis comercialmente, seu fornecimento não é garantido pelos fluxos de atendimento em todo o Brasil, tornando necessária a judicialização. Este estudo teve como objetivo apresentar dados referentes ao volume de processos judiciais relacionados ao acesso ao diagnóstico e tratamento da AOS no Brasil. Métodos: Estudo descritivo de abrangência nacional, avaliando o período entre janeiro de 2016 e dezembro de 2020. O número de demandas judiciais foi analisado de acordo com o objeto da demanda (diagnóstico ou tratamento). As projeções das despesas totais foram realizadas de acordo com o número de demandas judiciais. Resultados: Foram identificados 1.462 processos judiciais (17,6% e 82,4% referentes a diagnóstico e tratamento, respectivamente). A projeção dos gastos com o diagnóstico da AOS nas esferas pública e privada foi de R$ 575.227 e R$ 188.002, respectivamente. A projeção dos gastos com o tratamento da AOS nas esferas pública e privada foi de R$ 2.656.696 e R$ 253.050, respectivamente. Houve redução do número de demandas judiciais entre 2017 e 2019. Conclusões: A judicialização como estratégia de acesso a recursos diagnósticos e terapêuticos relacionados à AOS é uma prática recorrente, resultando em ineficiência e iniquidade. A redução do número de demandas judiciais entre 2017 e 2019 pode ser explicada pela expansão das políticas locais de saúde ou por barreiras na jornada dos pacientes com AOS, como dificuldades de encaminhamento para atendimento especializado e a baixa disponibilidade de recursos diagnósticos.

Obstructive sleep apnea screening in different age groups: performance of the Berlin, STOP-Bang questionnaires and Epworth Sleepiness Scale

Abstract Objective To evaluate the performance of the Berlin Questionnaire, the STOP-Bang Questionnaire, and the Epworth Sleepiness Scale in screening for the disease in adults of different age groups by comparing them with polysomnography. Methods Cross-sectional study with prospective patient allocation, in which individuals underwent a medical interview, completion of the three screening instruments, and polysomnography. Individuals were categorized into three age groups: 18-39, 40-59, and ≥60 years. The results of the screening instruments were compared to the diagnostic criteria of the International Classification of Sleep Disorders—third edition. Performance was assessed using 2 × 2 contingency tables, estimating sensitivity, specificity, predictive value, likelihood ratio, and accuracy. Receiver Operating Characteristic curves were also constructed and the area under the curve was estimated for each instrument by age group. Results We obtained a sample with 321 individuals suitable for analysis. The mean age was 50 years, with a predominance of females (56%). The prevalence of the disease in the overall sample was 79%, more prevalent in males in any age group and more frequent in the middle age group. The analyzes revealed that STOP-Bang performed better, both for the overall sample and for all age groups, followed by Berlin Questionnaire and Epworth Sleepiness Scale. Conclusion In an outpatient setting with individuals with characteristics similar to those in this study, it seems sensible to choose the STOP-Bang as a screening tool for the disease, regardless of age group. Level of evidence according the guide for authors: level 2.

A Comparison and Validation of Predicted Continuous Positive Airway Pressure Formulas vs Autotitration

Background: Continuous positive airway pressure (CPAP) is the treatment of obstructive sleep apnea (OSA). The CPAP pressure is generally estimated by manual titration or an auto-CPAP device. An alternative method involves the use of the predictive equation. There is limited study available for the Indian population. Objectives: To compare CPAP pressure obtained by mathematical formulas with auto-CPAP titration and formulation, a preliminary predictive equation from derived data to be validated with titrated CPAP. Methods and materials: A retrospective observational study was performed in 130 patients in Department of Pulmonary Medicine of our institute from April 2019 to July 2021. Detailed history, anthropometric parameters, whole-night level-II polysomnography (PSG), and CPAP titration were performed. Stepwise linear regression was applied to establish predictive equation. This equation results were compared with available other equations and autotitrated readings. Results: The mean (SD) of age, BMI, neck girth, Epworth score, lowest SPO2 (%), and AHI was 56.72 (11.31), 33.87 (6.43), 39.7 (4.46), 17.75 (3.18), 84.65 (8.44), and 48.75 (21.09), respectively, with male杅emale ratio of 3:2. Mild, moderate, and severe OSA were 7 (5.4%), 18 (13.8%), and 105 (80.8%), respectively. Continuous positive airway pressure obtained from equations was in the range of 7.40�.95 cm H2O. Obtained readings by equations showed a comparable correlation with CPAP-titrated results (p <0.001). Conclusion: The optimum titration pressure correlates with pressure derived from the predictive equation that is predicted average therapeutic CPAP pressure = 3.98 + 0.065 (ODI) + (AHI) + 0.018 (nadir SPO2) - 0.013 (NC).

Obstructive Sleep Apnea and Sleep Quality in Women with Polycystic Ovary Syndrome: A Cross-sectional Study

Background: Polycystic ovary syndrome (PCOS) is a common disorder in women of reproductive age. Although PCOS patients have a high prevalence of obstructive sleep apnea (OSA), there is limited data on sleep quality and abnormalities in sleep architecture among this patient population. We conducted a study to assess the frequency of OSA and poor sleep quality in women with PCOS and to assess any association between these sleep disorders and metabolic abnormalities. Materials and methods: An observational study of adults with PCOS (by revised Rotterdam criteria) from May 2015 to June 2017 was conducted. Patients with thyroid disorders, pre-existing depression, current pregnancy, and recent drug use (benzodiazepines, antidiabetics, antiepileptics, steroids, and androgens) were excluded. The evaluations included the following: overnight polysomnography (PSG), lipid profile, testosterone, fasting insulin, fasting glucose levels, free androgen index (FAI), and homeostatic model assessment for insulin resistance (HOMA-IR); sleep quality [Pittsburgh Sleep Quality Index (PSQI), Jenkins Sleep Scale (JSS)], daytime sleepiness and possible depression were assessed by standard questionnaires. Descriptive statistics, t-test/Mann朩hitney test, Chi-squared test/Fischer's test were used as appropriate; p <0.05 was considered statistically significant. Results: A total of 65 patients, mean age 24.3 � 4.0 years; mean body mass index (BMI) 26.4 � 5.3 kg/m2 were included. Frequencies of sleep disorders were evaluated as follows: Obstructive sleep apnea 10.9% (7/64) [95% confidence interval (CI): 5.4�.9%], poor sleep quality 35.0% (21/60) (95% CI: 24.2�.6%) by JSS, 54.2% (32/59) (95% CI: 41.6�.3%) by PSQI. The PSG indicators of sleep quality were abnormal in arousal index, 96.8% (62); %wake time, 62.5% (40); sleep latency, 40.6% (26); and sleep efficiency, 12.5% (8). Anthropometric indicators of obesity were higher in OSA vs non-OSA patients (p <0.05). The OSA patients had lower total sleep time and %N2 stage, and higher desaturation index than non-OSA patients. When patients with good and poor sleep quality were compared, poor sleepers (by JSS and PSQI) had higher depression scores; poor sleepers by JSS had a lower waist杊ip ratio (p <0.05). Daytime sleepiness scores were similar in OSA and non-OSA patients, and in good and poor sleepers. Conclusion: Sleep disorders, particularly poor sleep quality, are frequent in women with PCOS. Patients should be screened for these disorders using specific questionnaires. Further research into the metabolic consequences of these sleep disorders is mandated.

A study on the effect of mobile phone use on sleep

Background & objectives: Several studies have been conducted globally to assess the impact of usage of mobile phones on quality and duration of sleep as also on day time sleepiness. The objective of the present study was to assess the effect of mobile phone usage on the quality and composition of sleep in a sample from Indian population. Methods: The study was conducted at two tertiary care hospitals in north India from July 2014 to September 2019. A total of 566 participants were recruited in this study from both the centres. Sleep quality was assessed with the help of the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Subsequently, actigraphy was done in 96 participants and polysomnography in 95 participants. Results: Of the 566 participants, 128 (22.61%) had PSQI ?5, reflecting poor sleep quality. A higher use of mobile phone was significantly associated with a poor sleep quality as a component of PSQI questionnaire (P=0.01) and higher overall PSQI score (P=0.01). The latency from sleep onset to N2 and N3 sleep stages was significantly shorter in participants having a higher mobile phone usage as compared to those with a lower usage [Median (range): 13.5 min (1.5-109) vs. 6.5 min (0-89); P=0.02] and [Median (range): 49 min (8.5-220.5) vs. 28.75 min (0-141); P=0.03], respectively. Interpretation & conclusions: This study focused on the maladaptive changes brought on by mobile phone usage on sleep. More studies with larger sample sizes need to be done that may serve to confirm the hypothesis generating findings of our study

Craniofacial morphology in patients with obstructive sleep apnea: cephalometric evaluation / Morfologia craniofacial em pacientes com apneia obstrutiva do sono: avaliação cefalométrica

Abstract Introduction: Obstructive sleep apnea is characterized by a reduced airflow through the upper airways during sleep. Two forms of obstructive sleep apnea are described: the central form and the obstructive form. The obstructive form is related to many factors, such as the craniofacial morphology. Objective: To evaluate the correlation between the morphology of the cranial base, of the mandible and the maxilla, and obstructive sleep apnea severity. Methods: Eighty-four patients, mean age of 50.4 years old; 73 males and 11 females with obstructive sleep apnea were enrolled in the present study. Patients with high body mass index and comorbidities were excluded. Lateral cephalograms and polysomnography were collected for each patient to evaluate the correlation between craniofacial morphology and obstructive sleep apnea severity. A Spearman's rho correlation test between cephalometric measurements and obstructive sleep apnea indexes was computed. Statistical significance was set at p < 0.05. Results: Patients with a severe obstructive sleep apnea presented a reduction of sagittal growth of both effective mandibular length and cranio-basal length. The mandibular length was the only variable with a statistical correlation with apnea-hypopnea index. Vertical dimension showed a weak correlation with the severity of obstructive sleep apnea. No correlation with maxillary sagittal dimension was shown. Conclusion: Obstructive sleep apnea severity may be correlated to mandibular and cranial base growth. Facial vertical dimension had no correlation with obstructive sleep apnea severity.

Resumo Introdução: A apneia obstrutiva do sono é caracterizada por um fluxo de ar reduzido nas vias aéreas superiores durante o sono. Duas formas de apneia são descritas: a forma central e a forma obstrutiva. A forma obstrutiva tem sido relacionada a vários fatores, como a morfologia craniofacial. Objetivo: Avaliar a correlação entre a morfologia da base do crânio, da mandíbula e da maxila e a gravidade da apneia obstrutiva do sono. Método: Foram incluídos no presente estudo 84 pacientes com apneia obstrutiva do sono, com média de 50,4 anos; 73 homens e 11 mulheres. Pacientes com alto índice de massa corpórea e comorbidades foram excluídos. Foram coletados cefalogramas laterais e polissonografia para cada paciente para avaliar a correlação entre a morfologia craniofacial e a gravidade da apneia. Foi computado o coeficiente de correlação de postos de Spearman (rho) entre medidas cefalométricas e índices de apneia obstrutiva do sono. A significância estatística foi estabelecida em p < 0,05. Resultados: Pacientes com apneia obstrutiva do sono grave apresentaram redução do crescimento sagital do comprimento mandibular efetivo e do comprimento crânio-basal. O comprimento mandibular foi a única variável que apresentou correlação estatística com o índice de apneia-hipopneia. A dimensão vertical mostrou uma fraca correlação com a gravidade da apneia. Não foi demonstrada correlação com a dimensão maxilar sagital. Conclusão: A gravidade da apneia obstrutiva do sono pode estar correlacionada ao crescimento da base mandibular e craniana. A dimensão facial vertical não apresentou correlação com a gravidade da apneia.