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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

Ahmed S BaHammam,1,2 Salih Aleissi,1 Awad H Olaish,1 Aljohara S Almeneessier,1,3 Anwar A Jammah4 1University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia, Riyadh, Saudi Arabia; 3Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 4Endocrinology Unit, Thyroid Diseases Section, Department of Medicine, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Ahmed S BaHammamUniversity Sleep Disorders Center, College of Medicine, King Saud University, Box 225503, Riyadh 11324, Saudi ArabiaTel +966-11-467-9495Fax +966-11-467-9179Emails ashammam2@gmail.comAljohara S AlmeneessierFamily and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi ArabiaTel +966-11-467-9495Fax +966-11-467-9179Email aljoharas@yahoo.comPurpose: 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.Keywords: menopause, obstructive sleep apnoea, subclinical hypothyroidism, TSH, thyroxine

Aljohara S Almeneessier,1,2 Nouf S Alballa,1 Budoor H Alsalman,1 Salih Aleissi,1 Awad H Olaish,1 Ahmed S BaHammam1 1Department of Medicine, College of Medicine, the University Sleep Disorders Center, Riyadh, Saudi Arabia; 2Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Ahmed S BaHammam; Aljohara S AlmeneessierSleep Disorders Center, College of Medicine, King Saud University, Box 225503, Riyadh 11324, Saudi ArabiaTel +966-11-467-9495Fax +966-11-467-9179Email ashammam2@gmail.com; aljoharas@yahoo.comPurpose: Narcolepsy type 1 (NT1) is thought to have a chronic persistent course. This study aimed to assess the natural course of cataplexy in patients with NT1 at 2, 6, and 10 years after stabilizing symptoms. Other secondary objectives included assessing sleep quality, body mass index (BMI), and comorbidities at recruitment and 10 years later.Patients and methods: Cataplexy symptoms, the Epworth sleepiness scale (ESS), sleep quality (assessed using the Pittsburgh sleep quality index [PSQI]), BMI, and comorbid conditions were prospectively monitored in 38 patients with NT1. The study sample comprised 38 patients with narcolepsy (males=27). The mean ages at disease onset and recruitment were 17.7 ± 5.6 years and 24.3 ± 8.6 years, respectively.Results: In 42% of the cohort, the anti-cataplectic medications were stopped at the end of the study without disturbing symptoms of cataplexy. Additionally, there was an apparent significant reduction in the frequency of cataplexy over time. The mean ESS score decreased by more than 4 points from 19.4 ± 2.9 to 15 ± 4.3 (p

Almeneessier AS, Alballa NS, Alsalman BH, Aleissi S, Olaish AH, BaHammam AS. Nat Sci Sleep. 2019;11:231– 239. The authors have advised affiliation 1 on page 231 is incorrect. The correct affiliation should read “ 1Department of Medicine, College of Medicine, the University Sleep Disorders Center, King Saud University, Riyadh, Saudi Arabia”. The authors apologize for this error. Read the original article

Ahmed S BaHammam,1 Salih A Aleissi,1 Samar Z Nashwan,1 Awad H Olaish,1 Aljohara S Almeneessier1,2 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 BaHammam, University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia, Tel +966-11-467-9495, Fax +966-11-467-9179, Email ashammam2@gmail.comAbstract: Purpose: No study has assessed the titration success of CPAP therapy in patients with obesity hypoventilation syndrome (OHS) and an apnea-hypopnea index (AHI) < 30 event/h. This study aimed to assess the titration success of CPAP therapy under polysomnography and subsequent short-term adherence (1 month) in patients with OHS and an AHI < 30 event/h.Methods: Consecutive OHS patients with an AHI < 30 events/h between 2010 and 2019 were included (n=54). All OHS patients were first started on CPAP during the therapeutic sleep-study. If the therapeutic-study showed that the SpO2 remained < 90% for 20% of the total sleep time, a second therapeutic study was arranged with bi-level PAP (BPAP). Thirty patients agreed to participate in the 1-month follow-up adherence study. We applied the American-Thoracic-Society criteria for PAP adherence.Results: The mean age was 54.8± 14.6 years, and the mean BMI was 45.9± 12.2 kg/m2. Successful titration on CPAP was attained in 36 (66.7%) patients, and 18 (33.3%) required BPAP. Patients who failed the CPAP trial had a significantly higher PaCO2 and bicarbonate, a more restrictive respiratory pattern on spirometry, and a significantly higher time with SpO2< 90% (mins) during sleep. The only independent correlate of CPAP-titration success on the multivariable regression analysis was the desaturation index (OR: 1.33 [1.033– 1.712]). More than 80% of the participants were using CPAP therapy after one-month with no differences in adherence between the CPAP and BPAP groups.Conclusions: The current results suggest that CPAP therapy could be an acceptable alternative therapy to BPAP in patients with OHS without severe OSA.Keywords: CPAP, bi-level positive airway pressure, compliance, obstructive sleep apnea, desaturation, titration

Rakan A Bahammam,1 Khalid M Al-Qahtani,1 Salih A Aleissi,1 Awad H Olaish,1 Aljohara S Almeneessier,1,2 Ahmed S Bahammam1 1Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Riyadh, Saudi Arabia; 2Family Medicine, College of Medicine, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Ahmed S BahammamDepartment of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh 11324, Saudi ArabiaTel +966-11-467-9495Fax +966-11-467-9179Email ashammam2@gmail.comPurpose: 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 < 15/h, and a minimum of 15 min of REM sleep. Patients who had an AHI> 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), female sex (OR: 6.95 [4.86– 9.93], p> 0.01), REM sleep duration (min) (OR: 1.02 [1.02– 1.03], < 0.01), and time with SpO2 < 90% (mins) (OR: 0.97 [0.95– 0.99], < 0.01), hypertension (OR:0.67 [0.45– 0.99], 0.04) and asthma (OR: 2.19 [1.56– 3.07], < 0.01). The prevalence of REM-predominant OSA in premenopausal and postmenopausal women was 35% and 18.6% (p< 0.01), respectively. Among women, age was an independent correlate (OR: 0.97 [0.94– 0.99], p=0.03; however, menopausal status was not.Conclusion: REM-predominant OSA is prevalent among clinic-based patients with OSA. A younger age and female sex were independent correlates of REM-predominant OSA. Among women, a younger age but not menopausal status was a correlate of REM-predominant OSA. Asthma was independently associated with REM-predominant OSA.Keywords: female sex, phenotype, rapid eye movement sleep, hypertension, menopause, apnea-hypopnea index

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.