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This sub-study of the SERVE-HF study found unchanged peripheral nervous sympathetic activity (MSNA) in heart failure patients on medical treatment or on ASV after 12 weeks. Reduced MSNA was associated with worse prognosis only in the ASV group

Study Objectives: Patients with chronic kidney disease (CKD) often report poor sleep quality, but they commonly exhibit OSA. The aim of this study was to evaluate the influence of OSA severity and of estimated glomerular filtration rate impairment on objective sleep quality in nondialyzed patients with CKD, defined as an estimated glomerular filtration rate, ResMed Foundation ResMed Foundation European Respiratory Society, ERS European Cooperation in Science and Technology, COST, All authors have seen and approved the manuscript. By submitting the manuscript to the journal, the authors affirm that it is an original manuscript, is unpublished work if not as an abstract, and is not under consideration elsewhere. Work for this study was performed at institutions listed in the acknowledgments. This study was funded by support for the European Sleep Apnea Database network from the European Union COST Action B26 and the European Respiratory Society–funded Clinical Research Collaboration (funding 2015–2020). Unrestricted seed grants from the ResMed Foundation and the Philips Respironics Foundation for the establishment of the database in 2007 and 2011 are gratefully acknowledged. The European Sleep Apnea Database has a scientific collaboration with Bayer AG. O.M., F.C, G.R., P.S., P.J., O.K.B., I.B., S.S., A.P., R.S., and J.V. do not have any financial interests or connections, direct or indirect, or other situations that might raise the question of bias in the work reported or the conclusions, implications, or opinions stated. J.H. reports grants from ResMed, Philips Respironics, Bayer, and the European Respiratory Society related to maintenance of the database on behalf of the European Sleep Apnea Database group. L.G. reports a collaboration between the European Sleep Apnea Database network and Bayer. M.R.B. reports research financial support by Vivisol and Medicair Italy and honoraria from ResMed and Bioproject.

Purpose of Review There are some uncertainties about the interactions between obstructive sleep apnea (OSA) and chronic kidney disease (CKD). We critically reviewed recent studies on this topic with a focus on experimental and clinical evidence of bidirectional influences between OSA and CKD, as well as the effects of treatment of either disease. Recent Findings Experimental intermittent hypoxia endangers the kidneys, possibly through activation of inflammatory pathways and increased blood pressure. In humans, severe OSA can independently decrease kidney function. Treatment of OSA by CPAP tends to blunt kidney function decline over time, although its effect may vary. OSA may increase cardiovascular complications and mortality in patients with end-stage renal disease (ESRD), while it seems of little harm after renal transplantation. Excessive fluid removal may explain some of the improvements in OSA severity in ESRD and after transplantation. Summary Severe OSA and CKD do interact negatively, mainly through hypoxia and fluid retention. The moderate mutually interactive benefits that treatment of each disease exerts on the other one warrant further studies to improve patient management.

Obstructive sleep apnea is associated with excessive daytime sleepiness in about 50% of cases, and with increased risk of driving accidents. Treatment with continuous positive airway pressure effectively decreases such risk, but compliance with continuous positive airway pressure treatment is often suboptimal. According to the European Union Directive on driving risk, retention of a driving license in patients with obstructive sleep apnea requires assessment of sleepiness and adherence to continuous positive airway pressure treatment, but there remains uncertainty on the optimal methods to assess sleepiness on a large scale.

Background and Objectives: Obstructive sleep apnea syndrome (OSAS) and chronic obstructive pulmonary disease (COPD) are usually associated with multi-morbidity. The aim of this study was to retrospectively investigate the prevalence of comorbidities in a cohort of patients with OSAS and COPD-OSAS overlap syndrome (OS) patients and to explore differences between these two groups. Materials and Methods: Included were consecutive OS patients and OSAS patients who had been referred to our sleep laboratory, and were matched in terms of sex, age, BMI, and smoking history. Presence of comorbidities was recorded based on their medical history and after clinical and laboratory examination. Results: The two groups, OS patients (n = 163, AHI &gt, 5/h and FEV1/FVC &lt, 0.7) and OSAS patients (n = 163, AHI &gt, 5/h, and FEV1/FVC &gt, 0.7), did not differ in terms of apnea hypopnea index (p = 0.346), and oxygen desaturation index (p = 0.668). Compared to OSAS patients, OS patients had lower average SpO2 (p = 0.008) and higher sleep time with oxygen saturation &lt, 90% (p = 0.002) during sleep, and lower PaO2 (p &lt, 0.001) and higher PaCO2 (p = 0.04) in wakefulness. Arterial hypertension was the most prevalent comorbidity for both OS and OSAS, followed by dyslipidemia, cardiovascular disease (CVD) and diabetes. OS was characterized by a higher prevalence of total comorbidities (median (IQR):2 (1–3) vs. 2 (1–2), p = 0.033), which was due to the higher prevalence of CVD (p = 0.016) than OSAS. No differences were observed in other comorbidities. Conclusions: In OS patients, nocturnal hypoxia and impaired gas exchange in wakefulness are more overt, while a higher burden of CVD is observed among them in comparison to sex-, age- and BMI-matched OSAS patients.

Sleepiness at the wheel (SW) is recognized as an important factor contributing to road traffic accidents, since up to 30 percent of fatal accidents have been attributed to SW. Sleepiness-related motor vehicle accidents may occur both from falling asleep while driving and from behavior impairment attributable to sleepiness. SW can be caused by various sleep disorders but also by behavioral factors such as sleep deprivation, shift work and non-restorative sleep, as well as chronic disease or the treatment with drugs that negatively affect the level of vigilance. An association between obstructive sleep apnea (OSA) and motor vehicle accidents has been found, with an increasing risk in OSA patients up to sevenfold in comparison to the general population. Regular treatment with continuous positive airway pressure (CPAP) relieves excessive daytime sleepiness and reduces the crash risk. Open questions still remain about the physiological and clinical determinants of SW in OSA patients: the severity of OSA in terms of the frequency of respiratory events (apnea hypopnea index, AHI) or hypoxic load, the severity of daytime sleepiness, concomitant chronic sleep deprivation, comorbidities, the presence of depressive symptoms or chronic fatigue. Herein, we provide a review addressing the epidemiological, physiological and clinical aspects of SW, with a particular focus on the methods to recognize those patients at risk of SW.

The bidirectional relationship between sleep disordered breathing and chronic kidney disease (CKD) has recently gained a lot of interest. Several lines of evidence suggest the high prevalence of coexistent obstructive sleep apnea (OSA) in patients with CKD and end-stage renal disease (ESRD). In addition, OSA seems to result in loss of kidney function in some patients, especially in those with cardio-metabolic comorbidities. Treatment of CKD/ESRD and OSA can alter the natural history of each other; still better phenotyping with selection of appropriate treatment approaches is urgently needed. The aim of this narrative review is to provide an update of recent studies on epidemiological associations, pathophysiological interactions, and management of patients with OSA and CKD or ESRD.

Recent studies indicate that ambient temperature may modulate obstructive sleep apnoea (OSA) severity. However, study results are contradictory warranting more investigation in this field. We analysed 19,293 patients of the European Sleep Apnoea Database (ESADA) cohort with restriction to the three predominant climate zones according to the Koppen-Geiger climate classification: Cfb (warm temperature, fully humid, warm summer), Csa (warm temperature, summer dry, hot summer), and Dfb (snow, fully humid, warm summer). Average outside temperature values were obtained and several hierarchical regression analyses were performed to investigate the impact of temperature on the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), time of oxygen saturation, Fundacao para a Ciencia e a Tecnologia (FCT), Portugal; European Union; ResMed Foundation; Philips Respironics Foundation; European Respiratory Society (ERS), RS received financial support by the Fundacao para a Ciencia e a Tecnologia (FCT), Portugal. We would like to thank the members of the Pneumology Department of the University Hospital Lisbon, in particular to Andreia Colaco (RN), Claudia Pereira (RN), Dina Fernandes (RN), and Cristina Barbara (MD, Professor) for their support. The ESADA network was founded during the COST action B26 supported by the European Union and is one of the Clinical Research Collaborations (CRC) funded by the European Respiratory Society (ERS). Unrestricted seeding grants from the ResMed Foundation and the Philips Respironics Foundation for establishment of the database in 2007 and 2011 are gratefully acknowledged. Non--financial support was provided by the European Sleep Research Society (ESRS) and the European Respiratory Society (ERS) in terms of logistics for communication, meetings, and data presentations for the ESADA collaborators.

The clinical activities regarding sleep disordered breathing (SDB) have been sharply interrupted during the initial phase of the COVID-19 epidemic throughout Europe. In the last months, activities have gradually restarted, according to epidemiological phase of COVID-19 and National recommendations. The recent increase in cases throughout Europe obliges to reconsider management strategies of SDB accordingly. Diagnosis of SDB and initiation of treatment pose some specific problems to be addressed to preserve safety of the patients and health personnel. This perspective document by a group of European sleep experts aims at summarising some different approaches followed in Europe and United States, which reflect National recommendations according to the epidemiological phase of the COVID-19 infection. Respiratory sleep medicine will likely change in the near future, and use of telemedicine will grow to avoid unnecessary risks and continue to provide optimal care to the patients. The document also covers pediatric sleep studies and indications for titration of noninvasive ventilation, as well as precautions to be followed by patients who are already on positive airway pressure treatment. A single consensus document developed by the European Respiratory Society and National Societies would be desirable to harmonise SDB management throughout Europe., Specific precautions should be applied for starting activities in respiratory Sleep Centres during the COVID-19 epidemic

Objective The COVID-19 pandemic has strongly affected daily habits and psychological wellbeing, and many studies point to large modifications in several sleep and sleep-related domains. Nevertheless, pre-sleep arousal during the pandemic has been substantially overlooked. Since hyperarousal represents one of the main factors for the development and the perpetuation of chronic insomnia disorder, the assessment of variables associated with high levels of pre-sleep arousal during the pandemic is clinically relevant. The study aimed to assess the prevalence and predictors of perceived sleep quality and pre-sleep arousal in an Italian sample during the COVID-19 lockdown. Methods We used an online survey to collect self-reported sociodemographic, environmental, clinical, sleep, and sleep-related data. Our final sample included 761 participants. Results Beyond a high frequency of poor sleep quality, depressive and stress symptoms, our results show that almost half of the sample suffered from clinically relevant levels of at least one component (ie, cognitive, somatic) of pre-sleep arousal. Subjects with greater pre-sleep arousal exhibited poorer sleep quality. Also, sleep quality was strongly associated with somatic and cognitive pre-sleep arousal. Regarding the predictors of sleep and sleep-related measures, depressive and event-related stress symptoms were the main factors associated with both poor sleep quality and pre-sleep arousal components. Moreover, specific sociodemographic and environmental variables were uniquely related to sleep quality, cognitive or somatic pre-sleep arousal. Conclusions These findings suggest that the assessment of specific sleep-related factors (ie, pre-sleep arousal), together with more global measures of sleep quality, may be crucial to depict the complex impact of the pandemic on sleep, and to help prevent and counteract the spread of insomnia symptoms.

Obstructive sleep apnoea (OSA) is highly prevalent and is a recognised risk factor for motor vehicle accidents (MVA). Effective treatment with continuous positive airway pressure has been associated with a normalisation of this increased accident risk. Thus, many jurisdictions have introduced regulations restricting the ability of OSA patients from driving until effectively treated. However, uncertainty prevails regarding the relative importance of OSA severity determined by the apnoea–hypopnoea frequency per hour and the degree of sleepiness in determining accident risk. Furthermore, the identification of subjects at risk of OSA and/or accident risk remains elusive. The introduction of official European regulations regarding fitness to drive prompted the European Respiratory Society to establish a task force to address the topic of sleep apnoea, sleepiness and driving with a view to providing an overview to clinicians involved in treating patients with the disorder. The present report evaluates the epidemiology of MVA in patients with OSA; the mechanisms involved in this association; the role of screening questionnaires, driving simulators and other techniques to evaluate sleepiness and/or impaired vigilance; the impact of treatment on MVA risk in affected drivers; and highlights the evidence gaps regarding the identification of OSA patients at risk of MVA.

Excessive daytime sleepiness (EDS) is a symptom of obstructive sleep apnea (OSA) that resolves under treatment with continuous positive airway pressure (CPAP). In some patients, sleepiness persists despite CPAP treatment. We retrospectively analyzed data on subjective residual EDS, assessed as an Epworth Sleepiness Scale score (ESS) >10, in patients from the European Sleep Apnea Database (n = 4,853, mean age +/- SD 54.8 +/- 11.8 years, 26.1% females), at baseline and at the first visit (median follow-up: 5 months, interquartile range 3-13). An ESS > 10 occurred in 56% of patients at baseline and in 28.2% of patients at follow-up. Residual EDS was analyzed in 2,190 patients (age: 55.1 +/- 12.0 years, 26.1% females) with sleep monitoring data (median follow-up: 3 months, interquartile range 1-15). Sleep studies during CPAP use were obtained in 58% of these patients; EDS was reported by 47.2% of patients at baseline and by 30.3% at follow-up. Residual OSA, defined as an apnea-hypopnea index >10/h, and insufficient CPAP adherence, defined as nightly use 10 at the first follow-up visit was associated directly with ESS at baseline and inversely with duration of follow-up, and CPAP use (R-2 of themodel: 0.417). EDS showed heterogeneity in different European countries both at baseline and at the first follow-up visit, suggesting modulation by cultural and lifestyle factors. In conclusion, residual EDS in CPAP-treated OSA occurred in approximately one in four patients at follow-up; its prevalence was highest (40%) in the first 3 months of treatment and subsequently decreased. The finding of residual EDS in a significant percentage of optimally treated OSA patients suggests that wake-promoting agents may be useful, but their indication should be evaluated after at least 3 months of treatment., European Respiratory Society; ResMed; Philips; Bayer Pharmaceuticals; MIAI @ Grenoble Alpes [ANR19P3IA0003], The ESADA study is a Clinical Research Collaboration funded by the European Respiratory Society and by grants from ResMed, Philips and Bayer Pharmaceuticals. JP and SB are partly supported by MIAI @ Grenoble Alpes (ANR19P3IA0003) . The funders were not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

The effects of the COVID-19 pandemic on sleep have been widely documented, but longitudinal evaluations during different phases of the “COVID-19 era” are needed to disentangle the specific consequences of the r145estrictive measures on sleep variables. The aim of this study was to assess the immediate effect of the lockdown’s end on sleep and sleep-related dimensions in an Italian sample, also considering the stress and depressive symptoms. We used an online survey to longitudinally collect data on sociodemographic, environmental, clinical, sleep, and sleep-related variables in two time points: during and immediately after the lockdown. The final sample included 102 participants. The large prevalence of poor sleep quality, clinically relevant pre-sleep arousal, and depressive symptoms, as well as poor sleep quality and pre-sleep arousal score observed during the lockdown, remained stable after its end. On the other hand, the prevalence of moderate-to-severe event-related stress and intrusive symptom scores exhibited a drastic reduction after the end of home confinement. Both bedtime and rise time were anticipated after the lockdown, while sleep quality exhibited only a trend of post-lockdown sleep disturbance reduction. Our findings point to a reduced stress level (specific for the intrusive symptomatology) after the end of the lockdown and persistence of sleep problems, suggesting two non-mutually exclusive hypotheses: (a) the strict restrictive measures are not the main cause of sleep problems during the pandemic and (b) home confinement induces long-lasting effects on sleep observable after its end, and a longer period of time might be needed to observe an improvement.

International audience; Excessive daytime sleepiness (EDS) is a major symptom of obstructive sleep apnoea (OSA), defined as the inability to stay awake during the day. Its clinical descriptors remain elusive, and the pathogenesis is complex, with disorders such as insufficient sleep and depression commonly associated. Subjective EDS can be evaluated using the Epworth Sleepiness Scale, in which the patient reports the probability of dozing in certain situations; however, its reliability has been challenged. Objective tests such as the multiple sleep latency test or the maintenance of wakefulness test are not commonly used in patients with OSA, since they require nocturnal polysomnography, daytime testing and are expensive. Drugs for EDS are available in the United States but were discontinued in Europe some time ago. For European respiratory physicians, treatment of EDS with medication is new and they may lack experience in pharmacological treatment of EDS, while novel wake-promoting drugs have been recently developed and approved for clinical use in OSA patients in the USA and Europe. This review will discuss 1) the potential prognostic significance of EDS in OSA patients at diagnosis, 2) the prevalence and predictors of residual EDS in treated OSA patients, and 3) the evolution of therapy for EDS specifically for Europe.

CPAP treatment decreases BP in OSA patients, especially in severe OSA, and in patients with poorly controlled BP. OSA adversely affects heart function and remodelling, but its role in the pathogenesis of HF remains unclear. Similarly, the impact of CPAP is uncertain, and results of the ongoing ADVENT-HF trial will provide more information. Several experimental studies in animals and humans indicate a central role of intermittent hypoxia in atherogenesis through multiple mechanisms. However, randomised controlled trials (RCTs) in patients with CAD and OSA found no difference in outcomes between CPAP-treated and untreated patients. The negative results of secondary prevention RCTs may be the result of exclusion of severely sleepy patients and poor compliance with CPAP treatment. In addition, room for improvement after substantial cardiac interventions may be very limited. Knowledge on arrhythmias in OSA has expanded in recent years, especially regarding AF and ventricular arrhythmias including sudden cardiac death. However, studies on the effects of CPAP are limited and controversial.

STUDY OBJECTIVES: The association of mild obstructive sleep apnea (OSA) with important clinical outcomes remains unclear. We aimed to investigate the association between mild OSA and systemic arterial hypertension (SAH) in the European Sleep Apnea Database cohort. METHODS: In a multicenter sample of 4,732 participants, we analyzed the risk of mild OSA (subclassified into 2 groups: mild(AHI 5

Obstructive sleep apnea (OSA) is often associated with hypertension and other cardiovascular diseases. Blood pressure (BP) variability is part of the assessment of cardiovascular risk. In OSA, BP variability has been studied mainly as very short-term (beat-by-beat) and short-term (24-hour BP profile) variability. BP measured on consecutive heartbeats has been demonstrated to be highly variable, due to repeated peaks during sleep, so that an accurate assessment of nocturnal BP levels in OSA may require peculiar methodologies. In 24-hour recordings, BP frequently features a "nondipping" profile, ie

BACKGROUND Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality. AIM Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology to critically evaluate the evidence regarding potential links and the impact of therapy. MATERIALS AND METHODS Thirteen research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies post-dating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 were included. Statements were generated regarding current evidence and clinical practice. RESULTS Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, whilst CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, whilst the pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, whilst treatment data are scarce. DISCUSSION/CONCLUSION Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.

Obstructive sleep apnoea (OSA) is a highly prevalent disease, and there is an increased demand for OSA diagnosis and treatment. However, resources are limited compared with the growing needs for OSA diagnosis and management, and alternative strategies need to be developed to optimise the OSA clinical pathway. In this review, we propose a management strategy for OSA, and in general for sleep-disordered breathing, to be implemented from diagnosis to follow-up. For this purpose, the best current options seem to be: 1) networking at different levels of care, from primary physicians to specialised sleep laboratories; and 2) use of telemedicine. Telemedicine can contribute to the improved cost-effectiveness of OSA management during both the diagnostic and therapeutic phases. However, although the technology is already in place and different commercial platforms are in use, it is still unclear how to use telemedicine effectively in the sleep field. Application of telemedicine for titration of positive airway pressure treatment, follow-up to improve compliance to treatment through early identification and solution of problems, and teleconsultation all appear to be promising areas for improved OSA management.

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea/hypopnoea syndrome (OSAHS) have long been considered predominantly male-related conditions. The clinical presentation of sleep disordered breathing in females differs from males and can vary with age and physiological status,e.g.menopause and pregnancy. Overall, females appear to be more symptomatic, with lower apnoea–hypopnoea index scores compared to males. Furthermore, they appear to have more prolonged partial upper airway obstruction, and may report insomnia as a symptom of OSAHS more frequently. As a consequence of these differences in clinical presentation, females with sleep disordered breathing are often underdiagnosed and undertreated compared to males. This review is aimed at discussing the epidemiology, clinical presentation, pathophysiology and hormonal and metabolic differences in females who present with OSA/OSAHS in comparison to males.

We thank doctors Park and Kang for their editorial that well summarized our article. Our common belief is that one of the possible consequences of untreated obstructive sleep apnea (OSA) is an accelerated deterioration of kidney function, and that more knowledge would be necessary on the possible protective effects of OSA treatments. To our knowledge, so far the only OSA therapy whose effects on renal function have been tested is continuous positive airway pressure (CPAP), and most , although not all studies, have demonstrated its benefits. Our own study, while confirming benefits of fixed CPAP, has demonstrated little effect of auto-adjusting CPAP (APAP). This finding may be of relevance as, at present, OSA treatment by APAP is largely used. Then, should we ban APAP as a therapeutic modality for patients with renal problems? Most studies comparing fixed CPAP and APAP have focused on correction of respiratory events during sleep, relief of sleepiness, tolerability and patients’ compliance in subjects with typical pure OSA. In fact, APAP devices have been designed as treatment tools for this subgroup of patients, and not for patients with comorbid OSA with other types of respiratory disorders. Accordingly, current guidelines do not recommend APAP therapy for OSA patients with comorbidities like chronic obstructive pulmonary disease (COPD) or congestive heart failure although, more recently, small studies have been published suggesting effectiveness of APAP in patients with both OSA and COPD (overlap syndrome). Other diseases are not specifically mentioned in guidelines as contraindications to APAP. However, efficacy of OSA treatment should not be evaluated just in terms of polysomnographic parameters or symptoms, but also for its ability to prevent or counteract OSA deleterious effects on various organs and functions. In that respect, many studies have been published about effects of CPAP treatment, but few of them compared effects of fixed CPAP and APAP. We are aware of some studies comparing effects of these treatment modalities on blood pressure, autonomic activity or insulin resistance. Most of them showed superiority of fixed CPAP but, altogether, they are few, and more data would be required. Inflammatory activation and enhanced renin aldosterone angiotensin system activity in OSA may contribute to accelerate the age-related decline in estimated glomerular filtration rate (eGFR). Several, although not all, studies suggested beneficial effects of CPAP treatment on those factors, but to our knowledge possible differential effects of fixed CPAP and APAP have not been investigated, and could account for a different evolution of renal function in patients treated by each CPAP modality. Investigations should be extended to effects of APAP devices working with different algorithms. Besides, effects of setting different pressure ranges on the APAP machines, implying different degrees of variability of the administered pressure, should be tested. Although changes in eGFR over time differed significantly between our patients treated by fixed CPAP and APAP, standard deviations of changes were large in both groups. This finding suggests that the rate of eGFR decline may show high interindividual variability in treated OSA patients. What could make an OSA patient more susceptible to renal injury is not entirely clear. One longitudinal study showed that spending ≥12% of sleep time with an oxygen saturation

Obstructive sleep apnea (OSA) is a highly prevalent disease, and is traditionally associated with increased cardiovascular risk. The role of comorbidities in OSA patients has emerged recently, and new conditions significantly associated with OSA are increasingly reported. A high comorbidity burden worsens prognosis, but some data suggest that CPAP might be protective especially in patients with comorbidities. Aim of this narrative review is to provide an update on recent studies, with special attention to cardiovascular and cerebrovascular comorbidities, the metabolic syndrome and type 2 diabetes, asthma, COPD and cancer. Better phenotypic characterization of OSA patients, including comorbidities, will help to provide better individualized care. The unsatisfactory adherence to CPAP in patients without daytime sleepiness should prompt clinicians to examine the overall risk profile of each patient in order to identify subjects at high risk for worse prognosis and provide the optimal treatment not only for OSA, but also for comorbidities.

Air pollution is a major problem worldwide, which could be even more serious for athletes who train in urban environments. Exercise increases minute ventilation and exposure to pollutants, but the literature on the effects of air pollution in athletes is relatively scarce, with the exception of chlorine exposure in athletes of aquatic sports and air pollution secondary to ice resurfacing in athletes performing in ice arenas. Although air pollution may exert detrimental effects on athletic performance, little has been published on this topic. The largest body of information regards the impact of air pollution during urban active transport, i.e., walking and cycling in cities, due to the potential risk of air pollution in citizens and the need to rethink urban transportation strategies accordingly. In healthy subjects, the benefits of physical activity largely outweigh the disadvantages of exposure to air pollutants. In susceptible individuals, however, such as patients with cardiac or respiratory disease and children, detrimental effects have been demonstrated. Improvement in air quality, individual protective behaviors, and prompt communication to the population of dangerous air quality may help to limit the negative effects of air pollution on respiratory health.

Insomnia, vasomotor symptoms (VMS) and depression often co-occur after the menopause, with consequent health problems and reductions in quality of life. The aim of this position statement is to provide evidence-based advice on the management of postmenopausal sleep disorders derived from a systematic review of the literature. The latter yielded results on VMS, insomnia, circadian rhythm disorders, obstructive sleep apnea (OSA) and restless leg syndrome (RLS). Overall, the studies show that menopausal hormone therapy (MHT) improves VMS, insomnia, and mood. Several antidepressants can improve insomnia, either on their own or in association with MHT; these include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and mirtazapine. Long-term benefits for postmenopausal insomnia may also be achieved with non-drug strategies such as cognitive behavioral therapy (CBT) and aerobic exercise. Continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) both reduce blood pressure and cortisol levels in postmenopausal women suffering from OSA. However, the data regarding MHT on postmenopausal restless legs syndrome are conflicting.

High blood pressure (BP) and non-dipping 24-hour BP profile may help to predict BP decrease after obstructive sleep apnoea treatment by CPAP. However, specific, highly reproducible traits associated with BP responsiveness to CPAP must still be identified.http://bit.ly/2LbS4uV

Obstructive sleep apnoea (OSA) syndrome affects about 13% of the male and 7–9% of the female population. Hypoxia, oxidative stress and systemic inflammation link OSA and cardiovascular and metabolic consequences, including coronary artery disease. Current research has identified several clinical phenotypes, and the combination of breathing disturbances during sleep, systemic effects and end-organ damage might help to develop personalised therapeutic approaches. It is unclear whether OSA is a risk factor for acute coronary syndrome (ACS) and might affect its outcome. On the one hand, OSA in patients with ACS may worsen prognosis; on the other hand, OSA-related hypoxaemia could favour the development of coronary collaterals, thereby exerting a protective effect. It is unknown whether positive airway pressure treatment may influence adverse events and consequences of ACS. In non-sleepy patients with OSA and stable coronary artery disease, randomised controlled trials failed to show that continuous positive airway pressure (CPAP) treatment protected against cardiovascular events. Conversely, uncontrolled studies suggested positive effects of CPAP treatment in such patients. Fewer data are available in subjects with ACS and OSA, and results of randomised controlled studies on the effects of CPAP are expected shortly. Meanwhile, the search for reliable markers of risk continues. Recent studies suggest that daytime sleepiness may indicate a more severe OSA phenotype with regard to cardiovascular risk. Finally, some studies suggest sex-related differences. The picture is still incomplete, and the potential role of OSA in patients with ACS awaits confirmation, as well as clear definition of subgroups with different degrees of risk.

Introduction: Automatic event detection (AED) of residual apnea-hypopnea index (AHI) by ventilators is a current practice in sleep and mechanical ventilation Units but this methodology has not been validated in an unselected population of OSA patients. Aim of the present study was to assess in a “real-life” condition the reliability of AED during PAP therapy by the in-built software compared to full polysomnography during follow-up. Methods: We enrolled 300 OSA patients (105 F; AHI 45.3 ± 27.8) already on Positive airway pressure (PAP) therapy: 53% of the patients were on CPAP while other modalities were used in the rest of the sample. Results: Overall, the built-in software identified residual obstructive AHI (AHIPAP) > 5, 10 or 15 in 18.7, 8.6 or 4.6% of patients, respectively. By using AHIPAP, 28.4% of patients were wrongly classified as “well controlled” despite a residual AHIPSG>5 (6% considering a residual AHIVENT >15); 7% of patients were classified as not controlled while AHIPSG was 15). Type of ventilation, ventilator parameters, adherence to treatment and level of baseline or follow-up Epworth Sleepiness Scale score were similar between groups. The sensitivity and positive predicted values were very low. Positive likelihood ratio appears adequate only for residual AHIPAP ≥10, but negative likelihood ratio was inconclusive for all the cut-off considered. Discussion: The results of the present study suggest a more cautious approach in the follow-up of OSA patients, since a protocol based only on AED detection and symptoms assessment may not be accurate especially for AHIPAP

Background Cigarette smoke may accelerate cellular senescence by increasing oxidative stress. Altered proliferation and altered expression of anti-aging factors, including SIRT1 and FoxO3, characterise cellular senescence. The effects of carbocysteine on the SIRT1/FoxO3 axis and on downstream molecular mechanisms in human bronchial epithelial cells exposed to cigarette smoke are largely unknown. Aims Aim of this study was to explore whether carbocysteine modulated SIRT1/FoxO3 axis, and downstream molecular mechanisms associated to cellular senescence, in a bronchial epithelial cell line (16-HBE) exposed to cigarette smoke. Methods 16HBE cells were stimulated with/without cigarette smoke extracts (CSE) and carbocysteine. Flow cytometry and clonogenic assay were used to assess cell proliferation; western blot analysis was used for assessing nuclear expression of SIRT1 and FoxO3. The nuclear co-localization of SIRT1 and FoxO3 was assessed by fluorescence microscopy. Beta galactosidase (a senescence marker) and SIRT1 activity were assessed by specific staining and colorimetric assays, respectively. ChiP Assay and flow cytometry were used for assessing survivin gene regulation and protein expression, respectively. Results CSE decreased cell proliferation, the nuclear expression of SIRT1 and FoxO3 and increased beta galactosidase staining. CSE, reduced SIRT1 activity and FoxO3 localization on survivin promoter thus increasing survivin expression. In CSE stimulated bronchial epithelial cells carbocysteine reverted these phenomena by increasing cell proliferation, and SIRT1 and FoxO3 nuclear expression, and by reducing beta galactosidase staining and survivin expression. Conclusions The study shows for the first time that carbocysteine may revert some senescence processes induced by oxidative stress due to cigarette smoke exposure.

Objective In obstructive sleep apnea (OSA), while both hypothyroidism and hyperthyroidism have been studied, the occurrence of non-thyroidal illness syndrome (NTIS) (normal thyroid stimulating hormone [TSH] with low triiodotironine) has not been investigated. We explored the occurrence of NTIS in patients with moderate to severe OSA and its relationship to the severity of nocturnal respiratory disorders. We also studied the occurrence of subclinical hypothyroidism (SH, ie, high TSH with normal thyroxine) in OSA and changes in circulating TSH, free triiodotironine (fT3) and free thyroxine (fT4) after CPAP treatment. Methods After a nocturnal respiratory polysomnography, 125 consecutive patients with moderate to severe OSA and 60 control subjects with normal nocturnal respiration were recruited. Morning circulating TSH, fT3, and fT4 were measured in all subjects. In a subsample of patients, nocturnal polysomnography and hormonal determinations were repeated after CPAP treatment for five months. Results NTIS was found in 13 (10.4%), and SH in ten (8%) OSA subjects, but not in any control subjects. Patients with NTIS showed worse mean nocturnal oxygen saturation and time with saturation

Background: Obstructive sleep apnea (OSA) is associated with nocturnal intermittent hypoxia, which may be responsible for increased circulating levels of vascular endothelial growth factor (VEGF) and inflammatory mediators, such as metalloproteinases (MMPs), and which contributes to the pathogenesis of systemic hypertension. Why some OSA patients remain normotensive is poorly understood. Relaxin-2, a pregnancy hormone, may sometimes circulate in men and could increase in hypoxic conditions. It exerts a vasodilatory activity and can modulate the release of molecules, such as MMPs and VEGF. Objectives: The objective of this study was to explore if circulating relaxin-2 in male OSA subjects may be related to OSA severity, to circulating levels of MMPs, of their inhibitors (tissue inhibitors of metalloproteinases; TIMPs), and of VEGF, and if it may protect from hypertension. Patients andMethods: Fifty untreated male subjects with suspected OSA were recruited. After nocturnal polysomnography, a morning venous blood sample was withdrawn. Then, 24-hour ambulatory blood pressure (BP) monitoring was performed. Results: The respiratory disturbance index in the sample was 30.4 [interquartile range (IQR) 15.6-55.2]. Relaxin-2 was detectable in 20 subjects. These subjects did not differ in OSA severity or diurnal and nocturnal BP from subjects with undetectable relaxin-2, but they showed lower TIMP-1 (126.8 ± 29.1 vs. 156.9 ± 41.7 pg/ml, respectively; p = 0.007) and a marginally higher MMP-9/TIMP-1 molar ratio [0.58 (IQR 0.23-1.35) vs. 0.25 (IQR 0.15-0.56); p = 0.052]. Conclusions: Relaxin-2 in male subjects was not related to OSA severity, but it was associated with lower TIMP-1. As it was often undetectable, even when BP values were normal, it is unlikely that it plays a role as a major factor protecting from hypertension in OSA.

There are suggestions that the loss of female sex hormones following menopause is critical for the development or progression of sleep-disordered breathing (SDB). We conducted a review of the literature on the role of menopause and hormone replacement therapy (HRT) in SDB risk. There is an increase in SDB during the menopausal transition period, but data on an effect beyond that of increasing age and changes in body habitus are weak or absent. Early community-based, observational studies reported a protective effect by HRT on SDB prevalence, but this could possibly be explained as a healthy user effect. Interventional studies of the effect of HRT on SDB are sparse, with only a few randomized placebo-controlled studies, often performed on small samples of women without clinically significant SDB. HRT regimens have varied and all the studies are fairly old. They do not definitely assure the alleviation of SDB and HRT cannot thus be recommended as treatment for SDB. It is concluded that there is no evidence that female sex hormone changes during menopause per se are able to explain the increase in SDB in midlife women and conclusions on the effect of HRT on SDB cannot be drawn from the current literature.

Prevalence of both chronic kidney disease (CKD) and obstructive sleep apnea (OSA) is continuously increasing. Moreover, the prevalence of OSA increases as kidney function declines and is higher among patients with end-stage renal disease (ESRD). In addition, OSA is recognized as a potential nontraditional risk factor for development and progression of CKD. Continuous positive airway pressure (CPAP) plays a pivotal role in the management of OSA, eliminating patients' symptoms and improving their quality of life. Recent studies suggested that CPAP treatment may have beneficial effects on kidney function among patients with OSA. This narrative review summarizes the existing knowledge on the association between CKD and OSA, with emphasis on the epidemiology, the pathophysiology of the development of CKD in OSA and vice versa, as well as the effect of CPAP on renal function.

the clinical and pathophysiological links between obstructive sleep apnea (OSA) and cardiovascular

Obstructive sleep apnoea (OSA) is a major challenge for physicians and healthcare systems throughout the world. The high prevalence and the impact on daily life of OSA oblige clinicians to offer effective and acceptable treatment options. However, recent evidence has raised questions about the benefits of positive airway pressure therapy in ameliorating comorbidities.An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field, and proposed topics for future research on epidemiology, phenotyping, underlying mechanisms, prognostic implications and optimal treatment of patients with OSA.The group concluded that a revision to the diagnostic criteria for OSA is required to include factors that reflect different clinical and pathophysiological phenotypes and relevant comorbidities (e.g.nondipping nocturnal blood pressure). Furthermore, current severity thresholds require revision to reflect factors such as the disparity in the apnoea–hypopnoea index (AHI) between polysomnography and sleep studies that do not include sleep stage measurements, in addition to the poor correlation between AHI and daytime symptoms such as sleepiness. Management decisions should be linked to the underlying phenotype and consider outcomes beyond AHI.

To determine the relationship between obstructive sleep apnea (OSA) and chronic kidney disease (CKD). Previous population studies of the association are sparse, conflicting and confined largely to studies of administrative data.Cross-sectional analysis in unselected participants of the Men Androgens Inflammation Lifestyle Environment and Stress (MAILES) study, aged40 years. Renal data were available for 812 men without a prior OSA diagnosis who underwent full in-home polysomnography (Embletta X100) in 2010-2011. CKD was defined as an estimated glomerular filtration rate (eGFR)60 mL/min/1.73m2 or eGFR≥60 and albuminuria (albumin-creatinine ratio ≥3.0 mg/mmol).CKD (10.5%, n = 85 [Stage 1-3, 9.7%; Stage 4-5, 0.7%]) of predominantly mild severity showed significant associations with OSA (apnea-hypoapnea index [AHI] ≥ 10): odds ratio (OR) = 1.9, 95% confidence interval (CI): 1.02-3.5; severe OSA (AHI ≥ 30/h): OR = 2.6, 95% CI: 1.1-6.2; and respiratory-related arousal index: ≥7.6/h, OR = 2.3, 95%CI: 1.1-4.7; but not measures of hypoxemia after adjustment for age, hypertension, diabetes, smoking, obesity, and NSAID use. There was no association of CKD with daytime sleepiness. In men with CKD, those with OSA were not significantly more likely to report symptoms (sleepiness, snoring, and apneas) or be identified with the STOP OSA screening questionnaire, compared to men without OSA.Predominantly mild CKD is associated with severe OSA and arousals. Further population studies examining the longitudinal relationship between CKD and OSA are warranted. Better methods are needed to identify OSA in CKD which may have few symptoms.

BACKGROUND: The impact of treating OSA on renal function decline is controversial. Previous studies usually included small samples and did not consider specific effects of different CPAP modalities. The aim of this study was to evaluate the respective influence of fixed and autoadjusting CPAP modes on estimated glomerular filtration rate (eGFR) in a large sample of patients derived from the prospective European Sleep Apnea Database cohort. METHODS: In patients of the European Sleep Apnea Database, eGFR prior to and after follow-up was calculated by using the Chronic Kidney Disease-Epidemiology Collaboration equation. Three study groups were investigated: untreated patients (n = 144), patients receiving fixed CPAP (fCPAP) (n = 1,178), and patients on autoadjusting CPAP (APAP) (n = 485). RESULTS: In the whole sample, eGFR decreased over time. The rate of eGFR decline was significantly higher in the subgroup with eGFR above median (91.42 mL/min/1.73 m(2)) at baseline (P < .0001 for effect of baseline eGFR). This decline was attenuated or absent (P < .0001 for effect of treatment) in the subgroup of patients with OSA treated by using fCPAP. A follow-up duration exceeding the median (541 days) was associated with eGFR decline in the untreated and APAP groups but not in the fCPAP group (P < .0001 by two-way ANOVA for interaction between treatment and follow-up length). In multiple regression analysis, eGFR decline was accentuated by advanced age, female sex, cardiac failure, higher baseline eGFR, and longer follow-up duration, whereas there was a protective effect of fCPAP. CONCLUSIONS: fCPAP but not APAP may prevent eGFR decline in OSA.

In recent decades, the study of sleep breathing disorders has accelerated and increased our overall knowledge of sleep disorders in general. This now represents a real challenge to the health system due to the high prevalence, morbidity and mortality with concomitant social and economic repercussions [1]., Sleep medicine: a new approach http://ow.ly/qzVh30iVkWL

The 2017 Annual Congress of the European Respiratory Society (ERS) held in Milan has featured the latest research on clinical physiology and sleep.

The background and purpose of the HERMES (Harmonising Education in Respiratory Medicine for European Specialists) initiative has been discussed at length in previous articles [1–3]. This article aims to provide more detailed and specific insight into the process and methodology of the Sleep HERMES Task Force in developing a core curriculum in respiratory sleep medicine.

Maurizio Vignola was a superb and innovative researcher, who wrote seminal papers on the biology of airway epithelium in asthma. Inflammation and remodelling were the main topics of his research, mostly conducted in biopsy specimens from patients with asthma of variable severity, encompassing the entire spectrum of the disease from mild to severe asthma. His observations contributed to define the biology of asthma as we know it today, and opened the way to the personalised treatment of asthma. His group has successfully continued to investigate the biology and clinical aspects of bronchial asthma, with major interest in the clinical use of biomarkers to monitor disease activity, and in the development of new therapeutic perspectives. This review summarises the latest work on these topics proudly conducted by Maurizio's closest collaborators. The results indicate significant progress in our understanding of asthma in the last 10 years, in particular increased knowledge of the complex interaction between inflammatory and remodelling pathways, improved recognition of biological and clinical asthma phenotypes, and development of new treatment strategies, especially for patients with severe corticosteroid-resistant asthma.

Continuous positive airway pressure (CPAP) is the first-choice treatment for obstructive sleep-disordered breathing. Automatic bilevel ventilation can be used to treat obstructive sleep-disordered breathing when CPAP is ineffective, but clinical experience is still limited. To assess the outcome of titration with CPAP and automatic bilevel ventilation, the charts of 356 outpatients (obstructive sleep apnea, n = 242; chronic obstructive pulmonary disease + obstructive sleep apnea overlap, n = 80; obesity hypoventilation syndrome [OHS], n = 34; 103 females) treated for obstructive sleep-disordered breathing from January 2014 to April 2017 were reviewed. Positive airway pressure titration was considered successful in the case of sleep-disordered breathing resolution (apnea-hypopnea index 40 kg/m2(odds ratio 6.16, confidence interval 1.50-25.17, p = 0.011) and CT90% >42% (odds ratio 5.87, confidence interval 1.39-24.83, p = 0.016). During follow-up, automatic bilevel ventilation treatment failed in seven patients (10%), and compliance was similar in CPAP (4.5 ± 2.2 hr) and automatic bilevel ventilation (5.2 ± 2.3 hr, p = 0.09) groups. Automatic bilevel ventilation was useful to treat sleep-disordered breathing, but failed in patients with severe OHS.

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Obstructive sleep apnea (OSA) is a main cause of excessive daytime sleepiness and increases the risk for driving accidents, which can be normalized by treatment with continuous positive airway pressure ventilation. Since it is estimated that OSA is not diagnosed in about 80% of cases, recognition of patients at risk for driving accidents is a problem from both medical and societal points of view. Strategies to screen and identify subjects at high risk for driving accidents are under study in order to improve safety on the road, especially for commercial drivers, who show a high prevalence of OSA.

In the mdx mice model of Duchenne Muscular Dystrophy (DMD), mild endurance exercise training positively affected limb skeletal muscles, whereas few and controversial data exist on the effects of training on the diaphragm. The diaphragm was examined in mdx (C57BL/10ScSn-Dmdmdx) and wild-type (WT, C57BL/10ScSc) mice under sedentary conditions (mdx-SD, WT-SD) and during mild exercise training (mdx-EX, WT-EX). At baseline, and after 30 and 45 days (training: 5 d/wk for 6 weeks), diaphragm muscle morphology and Cx39 protein were assessed. In addition, tissue levels of the chaperonins Hsp60 and Hsp70 and the p65 subunit of nuclear factor-kB (NF-kB) were measured in diaphragm, gastrocnemius, and quadriceps in each experimental group at all time points. Although morphological analysis showed unchanged total area of necrosis/regeneration in the diaphragm after training, there was a trend for larger areas of regeneration than necrosis in the diaphragm of mdx-EX compared to mdx-SD mice. However, the levels of Cx39, a protein associated with active regeneration in damaged muscle, were similar in the diaphragm of mdx-EX and mdx-SD mice. Hsp60 significantly decreased at 45 days in the diaphragm, but not in limb muscles, in both trained and sedentary mdx compared to WT mice. In limb muscles, but not in the diaphragm, Hsp70 and NF-kB p65 levels were increased in mdx mice irrespective of training at 30 and 45 days. Therefore, the diaphragm of mdx mice showed little inflammatory and stress responses over time, and appeared hardly affected by mild endurance training. J. Cell. Physiol. 232: 2044-2052, 2017. © 2016 Wiley Periodicals, Inc.

Obstructive sleep apnea is associated with increased motor vehicle accident risk, and improved detection of patients at risk is of importance. The present study addresses potential risk factors in the European Sleep Apnea Database and includes patients with suspected obstructive sleep apnea [n = 8476, age 51.5 (12.5) years, body mass index 31.0 (6.6) kg m(-2) , 82.4% driver's licence holders]. Driving distance (km year(-1) ), driver's licence type, sleep apnea severity, sleepiness and comorbidities were assessed. Previously validated risk factors for accident history: Epworth Sleepiness Scale ≥16; habitual sleep time ≤5 h; use of hypnotics; and driving ≥15 000 km year(-1) were analysed across European regions. At least one risk factor was identified in male and female drivers, 68.75 and 51.3%, respectively. The occurrence of the risk factors was similar across Europe, with only a lower rate in the eastern region (P = 0.001). The mean number of risk factors increased across classes of sleep apnea severity. Frequent driving was prevalent [14.0 (interquartile range 8.0-20.0) × 10(3) km year(-1) ] and 32.7% of drivers had severe obstructive sleep apnea [apnea-hypopnea index 50.3 (38.8-66.0) n h(-1) ]. Obesity, shorter sleep time and younger age were associated with increased traffic exposure (P ≤ 0.03). In conclusion, the risk factors associated with accident history were common among European patients with suspected obstructive sleep apnea, but varied between geographical regions. There was a weak covariation between occurrence of risk factors and clinically determined apnea severity but frequent driving, a strong risk factor for accidents, was over-represented. Systematic evaluation of accident-related risk factors is important to detect sleep apnea patients at risk for motor vehicle accidents.

Obstructive sleep apnoea (OSA) is associated with increased risk of dysglycaemia but the intimate link of these conditions with obesity makes discerning an independent relationship between them challenging. Glycosylated haemoglobin (HbA1c) levels predict adverse cardiovascular outcomes in nondiabetics but there is a lack of population-level data exploring the relationship of HbA1c with OSA. A cross-sectional analysis of 5294 participants in the multinational European Sleep Apnoea Cohort (European Sleep Apnoea Database) study was performed, assessing the relationship of OSA severity with HbA1c levels in nondiabetic subjects, with adjustment for confounding factors. HbA1c levels correlated significantly with OSA severity in univariate analysis. Following adjustment for confounding factors, apnoea-hypopnoea index (AHI) (standardised beta 0.158; p= 6.0% than those in the first quartile. In stratified analyses, OSA severity predicted glycaemic health irrespective of sleep study modality, sex, obesity or daytime sleepiness. OSA severity independently predicts glycaemic health in nondiabetic subjects. Further studies should assess the impact of OSA treatment on glycaemic health and elucidate underlying mechanisms.

Obstructive sleep apnea often coexists with visceral adiposity and metabolic syndrome. In this study, we analysed gender-related differences in anthropometrics according to sleep apnea severity and metabolic abnormalities. In addition, the visceral adiposity index, a recently introduced marker of cardiometabolic risk, was analysed. Consecutive subjects with suspected obstructive sleep apnea (n = 528, 423 males, mean age ± standard deviation: 51.3 ± 12.8 years, body mass index: 31.0 ± 6.2 kg m(-2) ) were studied by full polysomnography (apnea-hypopnea index 43.4 ± 27.6 h(-1) ). Variables of general and visceral adiposity were measured (body mass index, neck, waist and hip circumferences, waist-to-hip ratio). The visceral adiposity index was calculated, and metabolic syndrome was assessed (NCEP-ATP III criteria). The sample included controls (apnea-hypopnea index 30 h(-1) , n = 329). When anthropometric variables were entered in stepwise multiple regression, body mass index, waist circumference and diagnosis of metabolic syndrome were associated with the apnea-hypopnea index in men (adjusted R(2) = 0.308); by contrast, only hip circumference and height-normalized neck circumference were associated with sleep apnea severity in women (adjusted R(2) = 0.339). These results changed little in patients without metabolic syndrome; conversely, waist circumference was the only correlate of apnea-hypopnea index in men and women with metabolic syndrome. The visceral adiposity index increased with insulin resistance, but did not predict sleep apnea severity. These data suggest gender-related interactions between obstructive sleep apnea, obesity and metabolic abnormalities. The visceral adiposity index was a good marker of metabolic syndrome, but not of obstructive sleep apnea.

Context: High altitude (HA) is a model of severe hypoxia exposure in humans. We hypothesized that nocturnal hypoxemia or acute maximal exercise at HA might affect plasma leptin and VEGF levels. Objectives: Plasma leptin, VEGF and other metabolic variables were studied after nocturnal pulse oximetry and after maximal exercise in healthy lowlanders on the 3rd-4th day of stay in Lobuche (5050 m, HA) and after return to sea level (SL). Results: Leptin was similar at SL or HA in both pre- and post-exercise conditions. Pre-exercise VEGF at HA was lower, and cortisol was higher, than at SL, suggesting that nocturnal intermittent hypoxia associated with periodic breathing at HA might affect these variables. Conclusions: Leptin levels appear unaffected at HA, whereas nocturnal hypoxic stress may affect plasma VEGF. Future HA studies should investigate the possible role of nocturnal intermittent hypoxemia on metabolism.

Background: In moderately to severely obese patients with obstructive sleep apnea (OSA), the effects of long-term positive airway pressure (PAP) treatment on cardiovascular risk are poorly defined. Purpose: To assess the effect of continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) on the occurrence of cardiovascular events in obese OSA patients. Methods: We performed a noninterventional observational study in obese OSA patients recruited between 2007 and 2010 at the Sleep Center, University of Grenoble, treated with CPAP or NIV, and followed for 5.6 years by a single home care provider. Baseline clinical characteristics, blood chemistry, and respiratory and vascular function were assessed. Incident cardiovascular events were investigated by phone interviews. Results: A total of 103 patients (55 men, 48 women; age and body mass index [BMI] at diagnosis 54.1 ± 10.5 years and 40.3 ± 5.5, respectively [mean ± standard deviation]; CPAP: n = 75; NIV: n = 28) agreed to participate in the study. Grade I, II, and III obesity occurred in 17.5, 33.0, and 49.5% of the sample, respectively. In patients using PAP treatment (n = 69), the mean nightly use was 6.3 ± 2.4 h. Thirty-one patients stopped PAP treatment during follow-up. Three patients on NIV died. Nonfatal cardiovascular events (n = 27) occurred in 19 patients, who were older and showed higher number of comorbidities and triglyceride levels than patients without events. In the patients who interrupted treatment, the event rate was high and increased with the number of comorbidities, while BMI at baseline did not predict events. Conclusions: The study suggests that regular PAP treatment may be associated with protection against cardiovascular risk in obese OSA patients, especially in the presence of multiple comorbidities.