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Objective: This case-control study sought to assess comorbid medical disorders in patients with narcolepsy type-1 (NT-1) and type-2 (NT-2). Material and Methods: he study comprised 80 consecutive Arab (Saudi) patients with narcolepsy (NT-1=56 and NT-2=24) and a control group of 211 adults matched for age, sex, and body mass index (BMI). Data were collected from cases and controls based on a predesigned questionnaire that was formulated based on previous studies to evaluate the chosen medical comorbidities. Results: Narcolepsy patients had a higher prevalence of hypothyroidism and hyperlipidemia and a higher prevalence of high-risk for OSA than controls. Hyperlipidemia was more common in cases than controls, 8 (10%) vs. 3 (1.4%), p=0.002. After adjusting for age, sex, and BMI, the odds-ratios for hypothyroidism and high risk for OSA in the NT-1 group was 5.49 (95% CI, [0.8 - 38.6]) and 69.99 ((95%CI [20.6 -237.4]), respectively, and in the NT-2 group, 12.5, 95%CI [1.6-97.7], and 33.3, 95%CI [8.2-135.7], respectively. Conclusion: Arab (Saudi) narcolepsy patients had a higher association with hypothyroidism, hyperlipidemia, and a higher risk of OSA than controls.

A limited number of papers have addressed the association between non-dipping-blood pressure (BP) obstructive sleep apnea (OSA), and no study has assessed BP-dipping during rapid eye movement (REM) and non-REM sleep in OSA patients. This study sought to noninvasively assess BP-dipping during REM and non-REM (NREM)-sleep using a beat-by-beat measurement method (pulse-transit-time (PTT)). Thirty consecutive OSA patients (men = 50%) who had not been treated for OSA before and who had > 20-min of REM-sleep were included. During sleep, BP was indirectly determined via PTT. Patients were divided into dippers and non-dippers based on the average systolic-BP during REM and NREM-sleep. The studied group had a a median age of 50 (42–58.5) years and a body mass index of 33.8 (27.6–37.5) kg/m2. The median AHI of the study group was 32.6 (20.1–58.1) events/h (range: 7–124), and 89% of them had moderate-to-severe OSA. The prevalence of non-dippers during REM-sleep was 93.3%, and during NREM-sleep was 80%. During NREM sleep, non-dippers had a higher waist circumference and waist-hip-ratio, higher severity of OSA, longer-time spent with oxygen saturation p-value = 0.03). This short report demonstrated that BP-dipping occurs during REM and NREM-sleep in patients with moderate-to-severe OSA. There was a trend of more severe OSA among the non-dippers during NREM-sleep, and severe OSA was independently correlated with BP non-dipping during NREM sleep.

Aljohara S Almeneessier,1,2 Salih Aleissi,1 Awad H Olaish,1 Ahmed S BaHammam1 1The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Ahmed S BaHammamMedicine, University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Box 225503, Riyadh 11324, Saudi ArabiaTel +966-11-467-9495Fax +966-11-467-9179Email ashammam2@gmail.comPurpose: Long-term studies assessing positive airway pressure (PAP) therapy adherence in patients with obesity hypoventilation (OHS) are limited. The aim of this study was to assess PAP therapy adherence in Arab (Saudi) patients with OHS and an apnea-hypopnea index (AHI) > 30/h.Methods: A prospective cohort study of consecutive adult patients diagnosed with OHS between March 2010 and September 2019 was conducted. During the therapeutic sleep study, all OHS patients were started on continuous PAP (CPAP). Patients who failed to maintain oxygen saturation ≥ 88% despite the elimination of obstructive respiratory events were shifted to bi-level PAP (BPAP). Objective assessment of adherence was performed at 1, 6, and 12 months after initiating PAP therapy. We adopted the American-Thoracic-Society criteria for PAP adherence.Results: The study included 101 patients (women = 65 patients) with OHS, an AHI ≥ 30/h, and a mean age of 54.9 ± 12.7 years. Successful titration on CPAP was achieved in 64.4% of the patients and BPAP was required for 35.6% of the patients who failed CPAP titration. At the end of the study, 43.6% of the patients used PAP therapy in an acceptable manner. Adherence after 1 and 6 months was the only independent predictors of adherence at 12 months.Conclusion: PAP adherence among Saudi patients with OHS and severe obstructive sleep apnea was relatively low. Almost two-thirds of patients tolerated CPAP titration with the elimination of respiratory events and desaturation. Early adherence to PAP therapy was the only predictor of PAP therapy adherence at the end of the study.Keywords: CPAP, bi-level positive airway pressure, compliance, obstructive sleep apnea, desaturation, titration

Purpose The study sought to assess demographics, clinical features, comorbidities, and polysomnographic features of a large cohort of clinic-based patients with rapid eye movement-predominant obstructive sleep apnea (REM-predominant-OSA) in both genders, while assessing the relationship between REM-predominant OSA in one hand and menopausal status and age on the other. Methods This prospective observational study was conducted between January 2003 and December 2017. REM-predominant OSA diagnostic criteria included an AHI of ≥5/h, with REM-AHI/non-REM-AHI of >2, a non-REM-AHI of 5 events/h and did not meet the criteria for REM-predominant OSA were included in the non-stage-specific OSA group (NSS). Results The study consisted of 1346 men and 823 women (total=2169). REM-predominant OSA was diagnosed in 17% (n=369). The prevalence of REM-predominant OSA in women was 25% compared with 12% in men. Several independent associations of REM-predominant OSA were identified in the whole group, including age (OR: 0.97 [0.95-0.98], p 0.01), REM sleep duration (min) (OR: 1.02 [1.02-1.03], < 0.01), and time with SpO2

Purpose Data on hypothyroidism in patients with obesity hypoventilation syndrome (OHS) are scarce. This study assessed the prevalence of hypothyroidism among a large group of patients with OHS. Patients and Methods This was a prospective observational study of 308 consecutive patients with OHS seen between January 2002 and December 2018. Serum thyroid-stimulating hormone (TSH) and free-thyroxine (FT4) levels were measured in all patients. The OHS patients were compared with 445 patients with obstructive sleep apnoea (OSA) matched for age, sex, and body mass index (BMI). Results The OHS patients had a mean age of 55.1 ± 13.8 years and a BMI of 43.9 ± 14.8 kg/m2; apnoea hypopnea index was ≥30 events/hr in 222 (72%). Clinical hypothyroidism was diagnosed in 58 (18.8%) of the OHS patients; only two cases (0.6%) were diagnosed in the sleep disorders clinic (newly diagnosed cases). Subclinical hypothyroidism was diagnosed in 19 (6.2%) of the OHS patients based on elevated TSH and normal FT4 levels; all cases were newly diagnosed. A logistic regression model identified female sex as the only predictor of clinical hypothyroidism in OHS patients (odds ratio: 2.801 [1.386-5.662], p = 0.004). There was no significant difference in clinical hypothyroidism prevalence between the OHS and OSA patients; however, subclinical hypothyroidism was more common in OHS than in OSA patients (6.2% vs 2.9%, respectively, p = 0.03). Conclusion Clinical hypothyroidism was prevalent among patients with OHS; however, newly diagnosed cases of clinical hypothyroidism were relatively low. Female sex was the only predictor of clinical hypothyroidism.

Background: The association between restless leg syndrome (RLS) and inflammatory bowel disease (IBD) has often been an under-investigated and clinically misdiagnosed entity. An emphasis should be made on the severity and associated factors, as the prevalence of both entities is on the rise globally. In this study we aimed to investigate the prevalence, severity and associated risk factors of RLS in patients with IBD. Methods: A multi-center, prospective cross-sectional study was conducted with age and gender matched controls in the ratio of 1:3. Cases of IBD were confirmed according to European Crohns and Colitis Organization guidelines. The study recruited 377 cases and 1131 age and gender-matched controls. RLS severity and prevalence was determined using a validated International Restless Legs Syndrome Study Group questionnaire. The anthropometric and blood biochemical measurements were retrieved from the patient's medical records. Associated factors were analyzed by regression analysis. Results: The prevalence of RLS in patients with IBD and non-IBD control groups was 21.5% and 9.7%, respectively (P = 0.001). The severity index of RLS symptoms in all the three categories of mild, moderate and severe RLS was higher in the IBD group (P = 0.001). Obesity (BMI >30 Kg/m2) was more prevalent in patients with IBD with RLS than without RLS (21.9%: 10.3%, P = 0.009). Ages between 46 and 59 years (OR = 18.7 [2.6–29.4], P = 0.008), obesity (OR = 22 [2.6–29.4], P = 0.005), higher TSH levels (OR = 1.7 [1.0–3.0], P = 0.033), and lower hemoglobin levels (P = 0.028) showed a greater risk associated with RLS. Conclusion: Prevalence and severity of RLS was higher in patients with IBD. The risk factors for RLS in IBD include increasing age, obesity, higher TSH, and lower hemoglobin.

Rapid eye movement-predominant obstructive sleep apnea has been shown to be independently associated with hypertension. This study aimed to non-invasively measure blood pressure during the rapid eye movement (REM) and non-rapid eye movement (NREM) obstructive events and the post-obstructive event period. Thirty-two consecutive continuous positive airway pressure-naïve obstructive sleep apnea patients (men, 50%) aged 50.2 ± 12 years underwent overnight polysomnography. Blood pressure was assessed indirectly using a validated method based on the pulse transit time and pulse wave velocity during the NREM and REM obstructive events (both apneas and hypopneas) and the post-obstructive event period. Among the recruited patients, 10 (31.3%) had hypertension. Mean apnea-hypopnea index was 40.1 ± 27.6 events/hr. Apnea-hypopnea indexes were 38.3 ± 30.6 and 51.9 ± 28.3 events/hr for NREM and REM sleep, respectively. No differences were detected in obstructive respiratory event duration or degree of desaturation between REM and NREM sleep. Additionally, no difference in blood pressure (systolic and diastolic) was detected between REM and NREM sleep during obstructive events and post-obstructive event period. Simple linear regression identified history of hypertension as a predictor of increased systolic blood pressure during obstructive events and post-obstructive event period in both rapid eye movement and non-rapid eye movement sleep. Oxygen desaturation index was also a predictor of increased systolic blood pressure during obstructive events and post-obstructive event period in REM sleep. When obstructive event duration and the degree of desaturation were comparable, no difference in blood pressure was found between REM and NREM sleep during obstructive events and post-obstructive event period.

This case-control study assessed the prevalence of psychiatric disorders in Arab (Saudi) patients with narcolepsy using a structured clinical interview. The study included 74 adult patients with narcolepsy and 265 controls matched for age and sex. Narcolepsy diagnosis was made according to the International Classification of Sleep Disorders-Third Edition. Psychiatric disorders were diagnosed via using a validated Arabic version of the Mini International Neuropsychiatric Interview DSM-IV (MINI version 6). A multivariate logistic regression model was used to assess the potential influence of narcolepsy on the comorbidity of psychiatric disorders. The mean age of the patients was 29.4 ± 10.2 years, and males accounted for 81% of the study sample. Forty-four patients (60%) were diagnosed with narcolepsy type-1 (NT1) and 30 (40%) with narcolepsy type-2 (NT2). Psychiatric disorders were diagnosed in 45% of patients with narcolepsy compared with 15% of the controls (p

We hypothesized that diurnal intermittent fasting would not increase slow frequency EEG waves, which reflect increased sleepiness. Therefore, this study aimed at performing a quantitative EEG analysis of young healthy volunteers with and without diurnal intermittent fasting while controlling for potential confounders.Eight young healthy volunteers (mean age: 24.4 ± 3.7 years) reported to the laboratory during the following five occasions: (1) adaptation, (2) 4 weeks before Ramadan while performing diurnal intermittent fasting (fasting from dawn to sunset) for 1 week (fasting outside Ramadan), (3) 1 week before Ramadan (nonfasting baseline), (4) during the second week of Ramadan while fasting (Ramadan), and (5) 2 weeks after Ramadan (recovery). Frontal, central, and occipital EEG signals were monitored four times (09:15, 11:15, 13:15, and 15:15 for 15 minutes each time) while the participants were awake to assess EEG spectral power of the delta, theta, alpha, and beta frequency bands.During wakefulness, no difference in EEG slowing was observed between nonfasting baseline and fasting during and outside Ramadan. There were no differences in the mean absolute power of each band in any studied brain region in any of the four study periods. Moreover, there was no difference in EEG absolute powers in the delta, theta, alpha, and beta frequency bands for any individual brain region during the four study periods.Spectral analysis of EEG power indicates that diurnal intermittent fasting does not increase sleepiness. Future larger studies are needed to confirm the current findings.

Background: Autoimmunity has been proposed as a cause of narcolepsy. A few studies have assessed comorbid autoimmune diseases in patients with narcolepsy, with conflicting results; however, no study has assessed autoimmune diseases in Arab narcolepsy patients. This study aimed to assess the coexistence of immune-mediated conditions such as allergies, autoimmune diseases, and autoinflammatory diseases in patients with narcolepsy type 1 (with cataplexy) (NT1) and narcolepsy type 2 (without cataplexy) (NT2). Methods: Personal and family history of autoimmune/autoinflammatory and allergic disorders was collected using a questionnaire in 80 consecutive Saudi patients with narcolepsy (46 NT1 and 24 NT2), who were diagnosed according to the International Classification of Sleep Disorders, Third Edition. The control group comprised 222 adults from the general population. Results: Comorbid autoimmune/autoinflammatory diseases were reported by 21.4% of the NT1 patients, and 12.2% of the controls, with no significant difference between cases and controls in a model adjusted for confounding covariates. However, allergic disorders were significantly more prevalent among NT1 patients. Both comorbid autoimmune/autoinflammatory and allergic disorders were significantly more prevalent among NT2 patients compared to controls. No differences in demographic and clinical characteristics were detected between narcolepsy patients with and without autoimmune/autoinflammatory diseases. Conclusion: NT1 is not associated with increased comorbid autoimmune diseases in the studied sample of Saudi patients. However, autoimmune diseases are associated with NT2, and allergic disorders are associated with both NT1 and NT2. These findings suggest the existence of dysregulation in the immune system of narcolepsy patients that requires further research.

This case-control study sought to assess comorbid medical disorders in patients with narcolepsy type-1 (NT-1) and type-2 (NT-2).The study comprised 80 consecutive Arab (Saudi) patients with narcolepsy (NT-1=56 and NT-2=24) and a control group of 211 adults matched for age, sex, and body mass index (BMI). Data were collected from cases and controls based on a predesigned questionnaire that was formulated based on previous studies to evaluate the chosen medical comorbidities.Narcolepsy patients had a higher prevalence of hypothyroidism and hyperlipidemia and a higher prevalence of high-risk for OSA than controls. Hyperlipidemia was more common in cases than controls, 8 (10%) vs. 3 (1.4%), p=0.002. After adjusting for age, sex, and BMI, the odds-ratios for hypothyroidism and high risk for OSA in the NT-1 group was 5.49 (95% CI, [0.8 - 38.6]) and 69.99 ((95%CI [20.6 -237.4]), respectively, and in the NT-2 group, 12.5, 95%CI [1.6-97.7], and 33.3, 95%CI [8.2-135.7], respectively.Arab (Saudi) narcolepsy patients had a higher association with hypothyroidism, hyperlipidemia, and a higher risk of OSA than controls.

Purpose The study sought to assess demographics, clinical features, comorbidities, and polysomnographic features of a large cohort of clinic-based patients with rapid eye movement-predominant obstructive sleep apnea (REM-predominant-OSA) in both genders, while assessing the relationship between REM-predominant OSA in one hand and menopausal status and age on the other. Methods This prospective observational study was conducted between January 2003 and December 2017. REM-predominant OSA diagnostic criteria included an AHI of ≥5/h, with REM-AHI/non-REM-AHI of >2, a non-REM-AHI of 5 events/h and did not meet the criteria for REM-predominant OSA were included in the non-stage-specific OSA group (NSS). Results The study consisted of 1346 men and 823 women (total=2169). REM-predominant OSA was diagnosed in 17% (n=369). The prevalence of REM-predominant OSA in women was 25% compared with 12% in men. Several independent associations of REM-predominant OSA were identified in the whole group, including age (OR: 0.97 [0.95–0.98], p0.01), REM sleep duration (min) (OR: 1.02 [1.02–1.03], < 0.01), and time with SpO2

BACKGROUND: Many individuals complain of disturbed sleep during the wintertime when their air conditioner (AC) is off. Therefore, we conducted this study to objectively assess the impact of AC sound on sleep latency, sleep duration, and sleep efficiency. METHODS: An experimental study was conducted on 48 healthy young adults, in their homes, to assess the effect of a standardized AC white noise, on sleep latency, duration, and efficiency, while simultaneously monitoring light intensity and room temperature. The study was conducted during the winter months. Sleep quality was objectively assessed using sleep actigraphy. Participants were monitored for two nights, during which two different, randomized sets of conditions were used: During one of the nights, the adults were exposed to 43 dB AC white noise; during the other night, adults were not exposed to the AC white noise. RESULTS: Actigraphy results showed that the mean sleep duration during the AC sound nights (ASNs) was 466.8 ± 60.8 min, compared to 478.8 ± 55.4 min during the non-AC sound nights (NASNs) (P = 0.6). Sleep-onset latency was 10.8 ± 15.2 min and 15.1 ± 18.2 min during the ASNs and the NASNs, respectively (P = 0.8). Moreover, there was no difference in sleep efficiency, 81% ± 7.8% vs. 78.8% ± 15.4% in the ASNs and NASNs, respectively (P = 0.9). CONCLUSION: AC sound had no significant positive effect on sleep duration, latency, and efficiency.

BACKGROUND: Food restriction has been demonstrated to increase the alertness in different species and to increase the levels of the wake-promoting neurotransmitter orexin. We hypothesized that diurnal intermittent fasting (DIF) increases orexin-A levels during fasting. Therefore, we conducted this study to assess the effects of DIF, during the month of Ramadan, on orexin, while controlling for lifestyle changes that may accompany Ramadan such as sleep duration, bedtime and wake time, energy expenditure, light exposure, and food. METHODS: Eight young healthy volunteers (mean age, 25.4 ± 3.5 years) reported to the laboratory on three occasions: (1) 4 weeks before Ramadan while performing DIF for 1 week outside the month of Ramadan (fasting outside Ramadan); (2) 1 week before Ramadan (nonfasting baseline) (BL); and (3) during the 2nd week of Ramadan while performing DIF (Ramadan). Plasma levels of orexin-A were measured using an enzyme immunoassay five times at 22:00, 02:00, 04:00, 06:00, and 11:00. Caloric intake, light exposure, and sleep schedule were maintained during the participants’ stays in the laboratory in the three study periods. RESULTS: Orexin-A levels increased in the daytime during fasting and decreased at night compared to BL. The differences in orexin-A levels between DIF and BL were significant at 06:00, 11:00, 22:00, and 02:00. CONCLUSIONS: DIF increases orexin-A levels in the plasma during fasting hours. This finding supports findings from animal studies showing that fasting increases alertness.

No studies have assessed the prevalence of fatigue, depression, sleepiness, and the risk of obstructive sleep apnea (OSA) among commercial airlines pilots in the Gulf Cooperation Council (GCC). This was a quantitative cross­sectional study conducted among pilots who were on active duty and had flown during the past 6 months for one of three commercial airline companies. We included participants with age between 20 and 65 years. Data were collected using a predesigned electronic questionnaire composed of questions related to demographic information in addition to the Fatigue Severity Scale (FSS), the Berlin Questionnaire, the Epworth Sleepiness Scale (ESS), and the Hospital Anxiety and Depression Scale (HADS). The study included 328 pilots with a mean age ± standard deviation of 41.4 ± 9.7 years. Overall, 224 (68.3%) pilots had an FSS score ≥ 36 indicating severe fatigue and 221 (67.4%) reported making mistakes in the cockpit because of fatigue. One hundred and twelve (34.1%) pilots had an ESS score ≥ 10 indicating excessive daytime sleepiness and 148 (45.1%) reported falling asleep at the controls at least once without previously agreeing with their colleagues. One hundred and thirteen (34.5%) pilots had an abnormal HADS depression score (≥ 8), and 96 (29.3%) pilots were at high risk for OSA requiring further assessment. Fatigue, sleepiness, risk of OSA, and depression are prevalent among GCC commercial airline pilots. Regular assessment by aviation authorities is needed to detect and treat these medical problems.

Objectives: To assess primary care physicians’ (PCPs) knowledge and attitudes toward sleep disorders. Methods : In this cross-sectional quantitative study, we surveyed 88 primary care centers under the Ministry of Health during 2015 in Riyadh, Saudi Arabia, using a combination of pre-designed validated questionnaires. Knowledge was assessed using the Assessment of Sleep Knowledge in Medical Education (ASKME) questionnaire, and attitude was assessed using a pre-designed survey. For numerical variables, t-test was used, and for categorical variables, Chi-square test was used. Results : Data from 223 PCPs (males 50.2%) were analyzed. Among the participants, 44 (19.9%) did not know that sleep medicine is a distinct medical specialty, and 24 (10.9%) felt that sleep disorders are uncommon medical problems based on their daily practice. Only 87 (39%) of physicians stated that they referred patients with sleep disorders to specialized medical centers for further management. The mean score of the ASKME questionnaire was 14.4 ± 4 out of 30 (48%). The majority of physicians (78.5%) obtained a score between 11 and 20. Score results were not related to gender or years of practice. Conclusion : Primary care physicians’ have a low level of awareness and poor knowledge of sleep medicine and sleep disorders. Saudi Med J 2017; Vol. 38 (5): 553-559 doi: 10.15537/smj.2017.5.17936 How to cite this article: Saleem AH, Al Rashed FA, Alkharboush GA, Almazyed OM, Olaish AH, Almeneessier AS, BaHammam AS. Primary care physicians' knowledge of sleep medicine and barriers to transfer of patients with sleep disorders. A cross-sectional study. Saudi Med J . 2017 May;38(5):553-559. doi: 10.15537/smj.2017.5.17936.

Objectives: Motor vehicle collisions (MVCs) are a significant health burden in Saudi Arabia. The literature has consistently indicated that chronic medical conditions, such as diabetes, heart disease, stroke, obstructive sleep apnea, and neurodevelopmental disorders, increase the risk of MVCs. Therefore, assessment of driver fitness by primary care physicians (PCPs) remains a major health intervention that might reduce MVCs. We studied the practices of PCPs in assessing medical fitness to drive in at-risk patients. Methods: We conducted a cross-sectional study of all 88 government-funded primary care centers in the city of Riyadh, Saudi Arabia. We administered a self-reported questionnaire to PCPs that inquired about their driving risk assessment for specific medical conditions. Results: Among all PCPs and centers, 189 PCPs (63%) from 74 centers (84%) participated in our survey. The mean age of the PCPs was 40 ± 10 years, and 108 (57%) were men. The average clinical experience of the group was 13 ± 9 years. Fewer than half of PCPs considered diabetes mellitus (45%) and obstructive sleep apnea (46%) as potential risks for MVCs. Approximately 45% of PCPs did not notify any authority or relatives of potential driving issues that they noticed in their patients. Only 15% of the participants believed that PCPs were responsible for alerting authorities about their fitness to drive. Conclusions: PCPs did not adequately assess their patients' driving history and eligibility. Efforts are needed to improve awareness among PCPs regarding the effects of chronic medical conditions on driving.

BACKGROUND: This case-control study aimed to assess the prevalence of symptoms and risk of obstructive sleep apnea (OSA) among Saudi pregnant women. METHODS: The study included consecutive Saudi pregnant women attending the antenatal service between July 2015 and December 2016. Pregnant women were compared with an age-matched group of nonpregnant women. OSA symptoms and risk were assessed using a validated Arabic version of the Berlin questionnaire (BQ). RESULTS: The study included 742 pregnant women and 742 age-matched nonpregnant women. At the time of the survey, 8.2% were in the first trimester; 33.4% in the second trimester; and 58.4%in third trimester. Snoring was reported by 14% of pregnant women, and 5% reported breathing pauses during sleep. Based on the BQ stratification for risk of OSA, 19.3% of pregnant women and 16.6% of the control group were at high risk for OSA. A comparison between the high OSA-risk and low OSA-risk pregnant women revealed that the pregnant women in high risk group were older (30.9 ± 5.9 years vs. 29 ± 5.4 years, P = 0.001), had a higher body mass index (BMI) (34.3 ± 5.2 kg/m2 vs. 28.7 ± 5.8 kg/m2, P < 0.001), and higher parity (1.9 ± 2 vs. 1.5 ± 1.7, P = 0.020). A multivariate logistic regression analysis revealed the following independent variables, BMI (odds ratio [OR] 1.173 [95% confidence interval [CI] 1.129–1.219],P < 0.001), pregnancy-induced hypertension (OR 7.85 [95% CI 1.691–36.447], P = 0.013), and the presence of restless legs syndrome (OR 2.209 [95% CI 1.332–3.279],P < 0.001). CONCLUSIONS: OSA symptoms and risk were relatively common among Saudi pregnant women. Increasing the awareness among physicians about this association is essential to improve early detection of the disorder.

The effects of caffeine on drowsiness and reaction time in patients with narcolepsy are unclear. We aimed to assess the effects of caffeine as add-on therapy in narcolepsy patients. A randomized, double-blind, placebo-control clinical pilot trial was conducted with a parallel, two-arm trial allocation ratio of 1:1. Participants attended two study visits 7 days apart. The drug was administered orally in a single opaque capsule containing 200 mg caffeine/placebo daily in the morning for 1 week. Sleepiness was assessed objectively using infrared reflectance oculography to measure the percentage of long eye closure (LEC%) and subjectively using two sleepiness scales, the Stanford Sleepiness Scale (SSS) and Karolinska Sleepiness Scale (KSS). Parameters were measured at baseline (BL) prior to taking the drug, after taking the first dose (FD), and after 1 week (WD) of daily caffeine. Sixteen participants with narcolepsy were included. No significant differences between groups in baseline measurements were observed. LEC% was significantly decreased after the FD and WD compared with baseline levels (BL 1.4 ± 2.1 vs. FD 0.06 ± 0.0.6 and WD 0.03 ± 0.04). Significant improvements in alertness were observed using the KSS when comparing BL with FD and WD (6.3 ± 1.6, 4.9 ± 1.7, and 4.7 ± 1.7, respectively; p = 0.01). No changes in reaction time or SSS scores were noted. Our findings suggest that a small dose of caffeine has positive effects on alertness in patients with narcolepsy. However, larger trials are required to confirm these findings. ClinicalTrial.gov NCT02832336

This study assessed the prevalence of restless legs syndrome (RLS) and its correlates and severity among non-pregnant Saudi women of childbearing age. Consecutive non-pregnant female visitors (age 15–44 years) of the primary care centers of the female University campus at King Saud University (n = 1,136) were interviewed face-to-face to determine the presence and severity of RLS using the International Restless Legs Syndrome (IRLS) Study Group criteria and IRLS severity scale. A total of 271 participants (24%) were diagnosed with RLS. Of these cases, severe/very severe RLS was diagnosed in 13% and mild/moderate in 87%. None of these participants had been diagnosed or treated for RLS before. Subjects with RLS were older, had a higher body mass index, and a higher prevalence of vitamin D deficiency and diabetes mellitus than those without RLS. Multivariate binary logistic regression analysis identified the following independent predictors of RLS: age (OR 1.03 [1.009–1.051], p = 0.004), vitamin D deficiency (OR 2.147 [1.612–2.86], p

Objective: Truck drivers represent a group at a particularly higher risk of motor vehicle accidents (MVAs). Sleepy driving and obstructive sleep apnea (OSA) among truck drivers are major risk factors for MVAs. No study has assessed the prevalence of sleepy driving and risk of OSA among truck drivers in Saudi Arabia. Therefore, this study aimed to assess sleepy driving and risk of OSA among these truck drivers. Methods: This study included 338 male truck drivers working in Saudi Arabia. A validated questionnaire regarding sleepy driving and OSA was used. The questionnaire included sociodemographic assessment, the Epworth Sleepiness Scale (ESS), the Berlin Questionnaire (BQ), and driving-related items. Results: The drivers had a mean age of 42.9 ± 9.7 years. The majority (94.7%) drove more than 5 h a day. A history of MVAs during the last 6 months was reported by 6.5%. Approximately 95% of the participants reported that they had accidentally fallen asleep at least once while driving over the past 6 months, and 49.7% stated that this had happened more than 5 times during the last 6 months. Based on the BQ score, a high risk of OSA was detected in 29% of the drivers. “Not getting good-quality sleep” (odds ratio [OR] = 2.89; 95% confidence interval [CI], 1.08–7.75; P = .014) and driving experience from 6 to 10 years (OR = 3.37; 95% CI, 1.28–8.91; P = .034) were the only independent predictors of MVAs in the past 6 months. Conclusions: Sleepy driving and a high risk of OSA was prevalent among the study population of male truck drivers in Saudi Arabia. Not getting good-quality sleep and driving experience from 6 to 10 years contributes to the accident risk among these truck drivers.

The role of gender and menopause in obstructive sleep apnoea is well known; however, no study has reported the impact of gender on the clinical presentation and the nocturnal respiratory events in patients with obesity hypoventilation syndrome. Therefore, this study prospectively evaluated differences in the clinical characteristics of women and men with obesity hypoventilation syndrome in a large cohort of patients with obstructive sleep apnoea. During the study period, a total of 1973 patients were referred to the sleep clinic with clinical suspicion of obstructive sleep apnoea. All patients underwent overnight polysomnography, during which time spirometry, arterial blood samples and thyroid tests were routinely obtained. Among 1973 consecutive patients, 1693 (617 women) were diagnosed with obstructive sleep apnoea, among whom 144 suffered from obesity hypoventilation syndrome (96 women). The prevalence of obesity hypoventilation syndrome among women and men was 15.6% and 4.5%, respectively (P

Purpose This study aimed to assess the effect of diurnal intermittent fasting (DIF) during and outside of the month of Ramadan on plasma levels of interleukin (IL)-1β, IL-6, and IL-8, while controlling for sleep/wake pattern, sleep length and quality, meal composition, energy consumption and expenditure, and light exposure. DIF outside of the month of Ramadan was performed to evaluate the effect of DIF in the absence of the way of life accompanying Ramadan. Methods Twelve healthy male volunteers with a mean age of 25.1 ± 2.5 years arrived to the sleep laboratory on 4 times: 1) adaptation, 5 weeks before Ramadan; 2) 4 weeks before Ramadan while performing DIF for 1 week (fasting outside of Ramadan; FOR); 3) 1 week before Ramadan (non-fasting baseline; non-fasting BL); and 4) After completing 2 weeks of Ramadan while performing DIF. Plasma levels of cytokines were assessed using enzyme-linked immunoassays at 22:00, 02:00, 04:00, 06:00, and 11:00. Results During DIF, there was a significant decrease in the levels of cytokines, particularly, IL-1β and IL-6, in most measurements compared to non-fasting BL. This reduction was more obvious during the FOR period. There were no significant changes in the circadian phase of the measured cytokines reflected by the acrophase of the measured variables during fasting (FOR and Ramadan) compared to non-fasting BL. Conclusion Under controlled conditions, DIF led to significantly decreased plasma levels of cytokines (IL-1β, IL-6, and IL-8), particularly IL-1β and IL-6 across 24 h. DIF had no effect on the circadian patterns of the measured cytokines as shown by cosinor analysis.

Background: Autoimmunity has been proposed as a cause of narcolepsy. A few studies have assessed comorbid autoimmune diseases in patients with narcolepsy, with conflicting results; however, no study has assessed autoimmune diseases in Arab narcolepsy patients. This study aimed to assess the coexistence of immune-mediated conditions such as allergies, autoimmune diseases, and autoinflammatory diseases in patients with narcolepsy type 1 (with cataplexy) (NT1) and narcolepsy type 2 (without cataplexy) (NT2). Methods: Personal and family history of autoimmune/autoinflammatory and allergic disorders was collected using a questionnaire in 80 consecutive Saudi patients with narcolepsy (46 NT1 and 24 NT2), who were diagnosed according to the International Classification of Sleep Disorders, Third Edition. The control group comprised 222 adults from the general population. Results: Comorbid autoimmune/autoinflammatory diseases were reported by 21.4% of the NT1 patients, and 12.2% of the controls, with no significant difference between cases and controls in a model adjusted for confounding covariates. However, allergic disorders were significantly more prevalent among NT1 patients. Both comorbid autoimmune/autoinflammatory and allergic disorders were significantly more prevalent among NT2 patients compared to controls. No differences in demographic and clinical characteristics were detected between narcolepsy patients with and without autoimmune/autoinflammatory diseases. Conclusion: NT1 is not associated with increased comorbid autoimmune diseases in the studied sample of Saudi patients. However, autoimmune diseases are associated with NT2, and allergic disorders are associated with both NT1 and NT2. These findings suggest the existence of dysregulation in the immune system of narcolepsy patients that requires further research.

Narcolepsy is an uncommon neurological disorder characterized by excessive daytime sleepiness (EDS) and multiple other symptoms. Due to the under-recognition of narcolepsy symptoms, patients are often misdiagnosed. This study aimed to assess the types of specialties visited and the diagnoses received by Saudi patients prior to their narcolepsy diagnosis. The study included 55 consecutive patients with type-1 and type-2 narcolepsy who attended the narcolepsy clinic between August 2017 and December 2017. Narcolepsy was diagnosed according to the International Classification of Sleep Disorders–third edition criteria. We evaluated sociodemographic data, the specialties visited, and diagnoses and treatments received prior to visiting a sleep specialist. The mean diagnostic delay was 9.1 ± 8.4 years (1–43 years). Multiple linear regression analysis identified early onset as the only predictor of a delayed diagnosis (β coefficient = − 0.262, p = 0.03). EDS was the main symptom that prompted patients to seek medical consultation, and only one patient had been (1.8%) referred with the diagnosis of narcolepsy. In the study group, 82% of the patients were misdiagnosed with a mental or neurological disorder or were thought to be afflicted by “envy,” “evil eye,” or “black magic” before receiving a correct diagnosis. No significant differences were detected between patients with narcolepsy type-1 and narcolepsy type-2. Delays in diagnosing narcolepsy remain a major problem for Saudi patients with this disorder. We found that Saudi patients with narcolepsy had visited several medical specialists and faith healers and were misdiagnosed prior to visiting a sleep specialist.

Background Obesity hypoventilation syndrome (OHS) can be complicated by several cardiovascular conditions. We assessed the prevalence and factors associated with left ventricular diastolic dysfunction (LVDD) in patients with OHS. Methods In this prospective observational study, all consecutive OHS patients referred to the sleep disorders clinic between January 2002 to December 2016 were included (n=113). Demographic data, echocardiography, sleep parameters, arterial blood gases (ABGs), and lung functions were recorded. Results Of 113 patients with OHS who participated, 76 patients (67%) had LVDD. More than two-thirds had grade 1 LVDD. Median body mass index (BMI) was 42.8 kg/m2. Median PaCO2 was 55.8 mmHg. Median apnea hypopnea index (AHI) was 52 (25-38.5). Eighty-four (75.7%) patients were hypertensive, and 60 (54.1%) were diabetic. To minimize the effect of fluctuations in intrathoracic pressure during the obstructive respiratory events on the cardiac function, 38 OHS patients with mild to moderate OSA (AHI

Objectives: To evaluate continuous positive airway pressure (CPAP) compliance and define predictors of CPAP compliance among Saudi patients with obstructive sleep apnea (OSA) after applying an educational program. Methods: This prospective cohort study included consecutive patients diagnosed to have OSA based on polysomnography between January 2012 and January 2014 in King Saud University, Riyadh, Kingdom of Saudi Arabia. All patients had educational sessions on OSA and CPAP therapy before sleep study, and formal hands-on training on CPAP machines on day one, day 7, and day 14 after diagnosis. The follow-up in the clinic was carried out at one, 4, and 10 months after initiating CPAP therapy. Continuous positive airway pressure compliance was assessed objectively. Logistic regression model was used to assess the predictors of CPAP adherence. Results: The study comprised 156 patients with a mean age of 51.9±12.1 years, body mass index of 38.4±10.6 kg/m 2 , and apnea hypopnea index of 63.7±39.3 events/hour. All patients were using CPAP at month one, 89.7% at month 4, and 83% at month 10. The persistence of CPAP-related side effects and comorbid bronchial asthma remained as independent predictors of CPAP compliance at the end of the study. Conclusion: With intensive education, support, and close monitoring, more than 80% of Saudi patients with OSA continued to use CPAP after 10 months of initiating CPAP therapy. Saudi Med J 2015; Vol. 36 (8): 911-919 doi: 10.15537/smj.2015.8.11716

Background:Obstructive sleep apnea (OSA) is a common, serious, under-recognized and under-diagnosed medical disorder. Polysomnography (PSG) is the gold standard diagnostic test for OSA; however, the cost of testing and the shortage of sleep disorders laboratories limit access to this tool. Therefore, there is a need for a simple and reliable diagnostic tool to screen patients at risk of OSA.Objective:This study was conducted to evaluate the validity and reliability of an Arabic version of the STOP-Bang questionnaire (SBQ) as a screening tool for OSA.Methods:This study was conducted in three steps, as follows: Step 1: the SBQ was translated from English to Arabic (examining both forward and backward translations); Step 2: the test-retest reliability of the questionnaire was investigated; and Step 3: the questionnaire was validated against PSG data prospectively on 100 patients attending a sleep disorders clinic who were subjected to a full-night PSG study after completing the translated version of the SBQ. The validity of the test was tested against the apnea-hypopnea index (AHI).Results:The study group had a mean age of 46.6 ± 14.0 years and a mean AHI of 50.0 ± 37.0/hour. The study demonstrated a high degree of internal consistency and stability over time for the translated SBQ. The Cronbach’s alpha coefficient for the 8-item tool was 0.7. Validation of the SBQ against the AHI at a cut-off of 5 revealed a sensitivity of 98% and positive and negative predictive values of 86% and 67%, respectively.Conclusion:The Arabic version of the SBQ is an easy-to-administer, simple, reliable and valid tool for the identification of OSA in the sleep disorders clinic setting.

Obstructive sleep apnea (OSA) during rapid eye movement (REM) sleep is a special form of OSA that occurs predominantly during REM sleep. No study has assessed the long-term adherence to continuous positive airway pressure (CPAP) among patients with REM-only OSA. To objectively assess the long-term adherence to CPAP therapy among patients with REM-predominant (REM-only) OSA.This was a prospective observational cohort study that included consecutive patients who were diagnosed with OSA. Patients were divided into the following two groups: (I) REM-only OSA [an apnea hypopnea index (AHI) of ≥5, with a REM-AHI/NREM-AHI of2, an NREM-AHI of15, and a minimum of 15 min of REM-sleep duration], and (II) non-stage specific OSA. Follow-up was performed at 1, 6 and 12 months after the initiation of CPAP-therapy.The study included 175 patients; 30 met the criteria for REM-only OSA, and the remaining patients constituted the non-stage specific OSA group. The number of hours of CPAP use per day was significantly lower in the REM-only OSA group at 1, 6 and 12 months compared to the non-stage specific OSA group. At 12 months, the number of hours used per day was 3.8±1.8 and 5.1±2.1 hours in the REM-only and non-stage specific OSA groups, respectively (P=0.003). Approximately 80% of the enrolled participants in both groups were still using CPAP at the end of the study; 23.3% of REM-only OSA patients met the criteria for good adherence (4 hours/day), and 56.7% met the criteria for partial adherence.CPAP adherence is lower among patients with REM-only OSA compared to patients with non-stage specific OSA.

BACKGROUND: This cross-sectional case–control study aimed to assess the prevalence of restless legs syndrome (RLS) and its correlates and severity among Arab (Saudi) pregnant women attending antenatal care clinics. METHODS: We interviewed 742 consecutive pregnant women attending antenatal clinics face-to-face using the International RLS Study Group (IRLSSG) criteria. We assessed the severity of RLS using the IRLSSG severity scale for RLS (IRLS). A similar number of age-matched nonpregnant women were enrolled in a control group. RESULTS: Among the cases, 104 (14%) were in the first trimester, 232 (31.3%) in the second trimester, and 406 (54.7%) in the third trimester. The RLS prevalence in cases and controls was 30% and 26.5%, respectively, (P = 0.134). Among cases, severe/very severe RLS was diagnosed in 25% and mild/moderate in 75%, compared with 15% of controls having severe/very severe RLS and 85% having mild/moderate RLS (P < 0.001). Multivariate binary logistic regression analysis identified the following parameters as independent predictors of RLS: parity (odds ratio [OR] 1.113 [confidence intervals [CI] 1.012–1.223], P = 0.027), anemia (OR 1.452 [1.033–2.042], P = 0.03), diabetes mellitus (OR 1.734 [CI 1.084–2.774], P = 0.022), Vitamin D deficiency (OR 2.376 [CI 1.488–3.794],P < 0.001), and smoking (OR 3.839 [CI 1.463–10.074], P = 0.006). None of the cases had been diagnosed or treated for RLS in the antenatal clinics. CONCLUSION: RLS is common, but underdiagnosed, among Saudi pregnant women and nonpregnant women of childbearing age. The study revealed that RLS during pregnancy is linked to parity, anemia, diabetes mellitus, Vitamin D deficiency, and smoking.

To explore and validate the factor structure of the Pittsburgh Sleep Quality Index (PSQI) in young collegiate adults. Six hundred university students were initially contacted and invited to participate in a survey of their sleep experience and history. Of this preliminary sample 418 of the students (age = 20.92 ± 1.81 years, BMI = 23.30 ± 2.57 kg/m2) fulfilled the screening criteria and ultimately completed the Pittsburgh Sleep Quality Index (PSQI), a self-report survey of respondents’ sleep habits and sleep quality. The students were enrolled in various undergraduate and postgraduate programs at Jamia Millia Islamia, New Delhi, India. Exploratory factor analysis (EFA) investigated the latent factor structure of the scale. Confirmatory factor analysis evaluated both of the models found by EFA. The Kaiser’s criteria, the Scree test, and the cumulative variance rule revealed that a 2-factor model accounted for most of the variability in the data. However, a follow up Parallel Analysis found a 1-factor model. The high correlation coefficient (r = 0.91) between the two factors of the 2-factor model and almost similar values of the fit indices supports the inference that the PSQI is a unidimensional scale. The findings validate the 1-factor model of the PSQI in young collegiate adults.

Objectives: With the increased volume of referrals of patients with obstructive sleep apnea (OSA) for sleep studies, there is a great need for alternatives of the standard two-night polysomnography (PSG) like split-night PSG. Therefore, we conducted this study to determine the success rate of continuous positive airway pressure (CPAP) titration during split-night PSG, and to determine the predictors of titration success and the impact on subsequent CPAP compliance in Saudi patients with OSA. Materials And Methods: This is a prospective cohort study that included consecutive patients who were diagnosed with OSA and underwent a split-night PSG (n = 454). A subgroup of patients who used CPAP therapy, agreed to come for follow-up after 4 and 10 months (n = 130). This subgroup was compared with a matched group of OSA patients who underwent a two-night sleep study protocol (n = 80). Results: The study group had a mean age of 48.7 ± 13.3 years, body mass index (BMI) of 37.5 ± 10.1 kg/m 2 and apnea hypopnea index of 58.4 ± 35.0 events/h. Successful CPAP titration was achieved in 350 (77%) patients. In a full adjusted model, "BMI >35 kg/m 2" and "known cardiac disease" remained significant predictors of a lower success rate of CPAP titration. After 10 months, 88% of the patients in the split-night protocol met the set criteria for good compliance versus 85% in the two-night protocol. Conclusion: Split-night protocol is an effective protocol for diagnosing OSA and titrating CPAP. CPAP compliance rate showed no difference between the split-night and the two-night protocols.

To compare the apnea–hypopnea indices (AHIs) derived using three hypopnea definitions published by the American Academy of Sleep Medicine (AASM) and to determine the impact of the new modifications of the definition on AHIs and the diagnosis of obstructive sleep apnea (OSA). The study comprised 100 consecutive patients who were investigated for OSA using overnight diagnostic polysomnography (PSG). The hypopneas were scored in three passes by two certified sleep technologists; in the first pass, the hypopneas were scored using the 2007 AASM “Alternative” (H Alt) criteria. In the second pass, the hypopneas were scored using the 2007 AASM “Recommended” (H Rec) criteria. In the third pass, the hypopneas were scored according to the new AASM “2012” (H 2012) criteria. Agreement analysis of the results obtained using the three scoring criteria was performed using the Bland–Altman plot methodology. The studied group had a mean age of 45.5 ± 12.6 years and a body mass index of 30.2 ± 5.8 kg/m2. Using the H 2012, H Rec and H Alt criteria, the AHIs were 37.9 ± 27.6, 14.8 ± 22.4 and 29.6 ± 27.0/h, respectively (p