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Ahmed Salem BaHammam1– 3 1Editor-in-Chief Nature and Science of Sleep; 2Department of Medicine, University Sleep Disorders Center and Pulmonary Service, King Saud University, Riyadh, Saudi Arabia; 3King Saud University Medical City, Riyadh, Saudi ArabiaCorrespondence: Ahmed Salem 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.com

Ahmed S BaHammam,1,2 Haitham Jahrami3,4 1The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia; 3Department of Psychiatry, Government Hospitals, Manama, Bahrain; 4Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, BahrainCorrespondence: Ahmed S BaHammam, Department of Medicine, College of Medicine, University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia, Tel +966-11-467-9495, Fax +966-11-467-9179, Email ashammam2@gmail.comAbstract: Mendelian randomization (MR) has become an influential method for elucidating causal links between sleep traits and disorders, and health outcomes. This article provides sleep medicine specialists with an overview of MR, emphasizing its applications and limitations in health research, particularly in the context of sleep research. The article addresses key challenges in conducting and interpreting MR studies on sleep, focusing on the core assumptions of relevance, exchangeability, and exclusion restriction. The importance of proper genetic instrument selection, bias mitigation, and cautious result interpretation is emphasized. Strategies are recommended to enhance the quality of MR studies in sleep medicine, including collaborations between MR experts and sleep specialists. The paper also explores sleep medicine-specific issues like analyzing binary traits and addressing heterogeneity in pooled analyses. Guidance is provided on transparent reporting of MR findings, stressing the need for comprehensive effect estimates, confidence intervals, and p-values. We conclude by advocating for rigorous MR implementation in sleep research to deepen our understanding of sleep-health relationships. By following best practices in study design, analysis, and reporting, researchers can reinforce the credibility and impact of MR findings in sleep medicine, ultimately improving patient care and public health strategies.Keywords: causal inference, genetic epidemiology, pleiotropy, GWAS, sleep disorders

Aseel AlSaleh,1 Waqar Husain,2 Khaled Trabelsi,3,4 Hadeel Ghazzawi,5 Achraf Ammar,6,7 Zahra Saif,8 Seithikurippu R Pandi-Perumal,9,10 Maha M AlRasheed,11 Ahmed S BaHammam,12,13 Haitham Jahrami8,14 1Department of Family and Community Medicine, College of Medicine and Health Sciences, Arabian Gulf University, Manama, Bahrain; 2Department of Humanities, COMSATS University Islamabad, Islamabad Campus, Islamabad, Pakistan; 3High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, 3000, Tunisia; 4Research Laboratory: Education, Motricity, Sport and Health, EM2S, LR19JS01, University of Sfax, Sfax, 3000, Tunisia; 5Nutrition and Food Technology Department, Agriculture School, The University of Jordan, Amman, Jordan; 6Department of Training and Movement Science, Institute of Sport Science, Johannes Gutenberg-University Mainz, Mainz, 55099, Germany; 7Research Laboratory, Molecular Bases of Human Pathology, LR19ES13, Faculty of Medicine of Sfax, University of Sfax, Sfax, 3000, Tunisia; 8Department of Psychiatry, Government Hospitals, Manama, Bahrain; 9Centre for Research and Development, Chandigarh University, Mohali, Punjab, 140413, India; 10Division of Research and Development, Lovely Professional University, Phagwara, Punjab, 144411, India; 11Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, 11451, Saudi Arabia; 12The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, King Saud University, Riyadh, Saudi Arabia; 13King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia; 14Department of Psychiatry, College of Medicine and Health Sciences, Arabian Gulf University, Manama, BahrainCorrespondence: Haitham Jahrami, Department of Psychiatry, College of Medicine and Health Sciences, Arabian Gulf University, Manama, Bahrain, Email haitham.jahrami@outlook.comPurpose: The Pre-Sleep Arousal Scale (PSAS) is a well-recognized instrument utilized for measuring cognitive and somatic arousal before sleep. Although the PSAS is useful, an Arabic version of the scale has not yet been developed and validated. The current study aimed to translate the PSAS into Arabic language and evaluate its psychometric properties, such as reliability and validity, in an Arabic-speaking population.Patients and Methods: A cross-sectional survey was conducted with 438 participants who completed the Arabic version of the PSAS, along with other validated measures of insomnia, anxiety, and sleep effort.Results: The results indicated that the Arabic version of the PSAS maintained the original scale’s two-factor structure. The factor loadings for PSAS-Cognitive ranged from 0.57 to 0.75, and for PSAS-Somatic, from 0.45 to 0.70, with all loadings being statistically significant (p < 0.001). The Arabic version of the PSAS exhibited high internal consistency (McDonald’s ω = 0.86; Cronbach’s α = 0.86; Guttman’s λ 2 = 0.86; Greatest Lower Bound = 0.90) and test–retest reliability (ICC = 0.88) over two weeks. The PSAS demonstrated good concurrent and convergent validity. We documented significant large differences between individuals with “no insomnia” and those with “insomnia” symptoms across cognitive, somatic, and total pre-sleep arousal (all p < 0.001). The insomnia group consistently scored higher scores for PSAP and its subscales.Conclusion: These findings suggest that the Arabic version of the PSAS is a reliable and valid tool for assessing pre-sleep arousal in Arabic-speaking individuals.Keywords: Arabic version, insomnia, pre-sleep arousal, PSAS, psychometric properties, reliability, validity

Amjaad Muhammad Ar Reshaid,1 Yasser Abdulathim Alshawakir,2 Mohammed A Almuayrifi,2 Omar Salem Al-Attas,1 Ahmed S BaHammam,3,4 Reem Abdullah Al Khalifah4– 6 1Department of Biochemistry, College of Science, King Saud University, Riyadh, Saudi Arabia; 2Experimental Surgery and Animal Lab, College of Medicine, King Saud University, Riyadh, 11451, Saudi Arabia; 3The University Sleep Disorders Centre, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 4King Saud University Medical City, Riyadh, Saudi Arabia; 5Division of Pediatric Endocrinology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 6University Diabetes Centre, King Saud University Medical City, Riyadh, Saudi ArabiaCorrespondence: Reem Abdullah Al Khalifah, Division of Pediatric Endocrinology, Department of Pediatrics, College of Medicine, P.O Box 2925, Riyadh, 11461, Saudi Arabia, Tel +0118066750, Email reem_ah@yahoo.comObjective: We aimed to evaluate the effect of light–dark cycle alteration and soft drink consumption on the acceleration of type 1 diabetes mellitus (T1DM) development among non-obese diabetic (NOD) mice model.Methods: We exposed female NOD and C57BL/6 mice from the age of 5 weeks to either adlib soft drink consumption and/or T20 light–dark cycle alteration until the development of diabetes, or the mice reached the age of 30 weeks. Each group consisted of 7– 15 mice. We monitored weight, length, blood glucose level, and insulin autoantibody (IAA) levels weekly.Results: Out of 75 NOD and 22 C57BL/6 mice, 41 NOD mice developed diabetes, and 6 mice died between 7 and 8 weeks of age. The mean time to development of T1DM among NOD control mice was 20 weeks. The time to development of T1DM was accelerated by two weeks in the NOD mice exposed to light–dark cycle alteration, hazard ratio of 2.65,95th CI (0.70, 10.04) p = 0.15). The other groups developed T1DM, similar to the control group.Conclusion: There was a trend toward earlier development of T1DM among NOD mice exposed to light–dark cycle alteration, but this difference was not statistically significant. Further studies are needed to confirm our findings using larger sample sizes and different animal species.Keywords: type 1 diabetes mellitus, soft drink, sugar, light-dark cycle alteration, NOD/ShiLtJ

Amin Ramezani,1– 4 Amir Sharafkhaneh,1,4 Ahmed S BaHammam,5,6 Samuel T Kuna,7 Javad Razjouyan1– 4 1VA’s Health Services Research and Development Service (HSR&D), Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, 77030, USA; 2Big Data Scientist Training Enhancement Program, VA Office of Research and Development, Washington, DC, 20420, USA; 3VA Quality Scholars Coordinating Center, Iquest, Michael E. DeBakey VA Medical Center, Houston, TX, 77030, USA; 4Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA; 5Department of Medicine, College of Medicine, University Sleep Disorders Center, King Saud University, Riyadh, Saudi Arabia; 6The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia, Riyadh, Saudi Arabia; 7Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USACorrespondence: Amir Sharafkhaneh, VA’s Health Services Research and Development Service (HSR&D), Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, 77030, USA, Email amirs@bcm.eduPurpose: The COVID-19 pandemic affected the utilization of various healthcare services differentially. Sleep testing services utilization (STU), including Home Sleep Apnea Testing (HSAT) and Polysomnography (PSG), were uniquely affected. We assessed the effects of the pandemic on STU and its recovery using the Veterans Health Administration (VHA) data.Patients and Methods: A retrospective cohort study from the VHA between 01/2019 and 10/2023 of veterans with age ≥ 50. We extracted STU data using Current Procedural Terminology codes for five periods based on STU and vaccination status: pre-pandemic (Pre-Pan), pandemic sleep test moratorium (Pan-Mor), and pandemic pre-vaccination (Pan-Pre-Vax), vaccination (Pan-Vax), and postvaccination (Pan-Post-Vax). We compared STU between intervals (Pre-Pan as the reference).Results: Among 261,371 veterans (63.7± 9.6 years, BMI 31.9± 6.0 kg/m², 80% male), PSG utilization decreased significantly during Pan-Mor (− 56%), Pan-Pre-Vax (− 61%), Pan-Vax (− 42%), and Pan-Post-Vax (− 36%) periods all compared to Pre-Pan. HSAT utilization decreased significantly during the Pan-Mor (− 59%) and Pan-Pre-Vax (− 9%) phases compared to the Pre-Pan and subsequently increased during Pan-Vax (+6%) and Pan-Post-Vax (− 1%) periods. Over 70% of STU transitioned to HSAT, and its usage surged five months after the vaccine Introduction.Conclusion: Sleep testing services utilization recovered differentially during the pandemic (PSG vs HSAT), including a surge in HSAT utilization post-vaccination.Keywords: home sleep apnea testing, polysomnography, COVID-19, pandemic, current procedural terminology

Ahmed Salem BaHammam1,2 1Department of Medicine, University Sleep Disorders Center and Pulmonary Service, King Saud University, Riyadh, Saudi Arabia; 2King Saud University Medical City, Riyadh, Saudi ArabiaCorrespondence: Ahmed Salem 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.com

Abdulmajeed Abdullah Alghamdi,1 Abdulmalik Abdulrahman Abanumai,1 Meshal Fawaz Althobaiti,2 Meshari Salem Alzahrani,1 Salma Yasser Abu-Saleh,3 Achraf Ammar,4,5 Hadeel Ghazzawi,6 Khaled Trabelsi,7,8 Nicola Bragazzi,9 Ahmed S BaHammam,10,11 Haitham Jahrami,1,12 Maha M AlRasheed13 1Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain; 2Department of Medicine, College of Medicine, Taif University, Taif, Saudi Arabia; 3Department Nutrition and Food Technology, Jordan University of Science and Technology, Irbid, Jordan; 4Department of Training and Movement Science, Institute of Sport Science, Johannes Gutenberg-University Mainz, Mainz, Germany; 5Interdisciplinary Laboratory in Neurosciences, Physiology, and Psychology: Physical Activity, Health, and Learning (LINP2), UFR STAPS (Faculty of Sport Sciences), UPL, Paris Nanterre University, Nanterre, France; 6Nutrition and Food Science Department, Agriculture School, The University of Jordan, Amman, Jordan; 7High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia; 8Research Laboratory: Education, Motricity, Sport and Health, EM2S, LR19JS01, University of Sfax, Sfax, Tunisia; 9Human Nutrition Unit (HNU) and Department of Food and Drugs, University of Parma, Medical School, Building C, Parma, Italy; 10The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, King Saud University, Riyadh, Saudi Arabia; 11King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia; 12Department of Psychiatry, Government Hospitals, Manama, Bahrain; 13Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Maha M AlRasheed, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, PO Box 2457, Riyadh, 11451, Saudi Arabia, Tel +966-114678707, Fax +966-114677480, Email mahalrasheed@ksu.edu.saBackground: Insomnia disorder is a common health condition; it has a role in increasing the possibility of developing other psychological disorders, including anxiety and depression. Anxiety and preoccupation with sleep are two examples of common cognitive factors that contribute to the development of chronic insomnia; thus, it is important to have a tool that assesses worry in insomnia. There is no comprehensive psychiatric measure to assess anxiety and preoccupation with sleep in Arabic. We conducted this study to translate, adapt, and validate the Arabic version of the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), providing a reliable psychometric tool to assess concerns regarding sleep within Arabic-speaking communities.Methods: The translation process of the scale involved several steps, including forward and backward translation. A cross-sectional study was conducted using an online survey completed by 523 participants from various Arabic-speaking countries. Psychometric analysis was performed utilizing the R software, including internal consistency, test-retest reliability, and confirmatory factor analysis. In addition, convergent and divergent against the Athens insomnia scale (AIS) and general anxiety disorder (GAD) were conducted.Results: The Arabic-translated form of the APSQ expresses excellent internal consistency with a value of 0.91 for both Cronbach’s α and McDonald’s ω. The test-retest reliability of a subsample showed an excellent coefficient of 0.93 (p< 0.01). A good fit of the APSQ was observed by CFI = 0.93, TLI = 0.91, SRMR = 0.05, and RMSEA = 0.1. Convergent and divergent against AIS and GAD showed statistically significant correlations of 0.85 (p< 0.01) and 0.69 (p< 0.01), respectively. Our sample showed a mean APSQ score of 31.28 ± 8.31, and the mean age was 23.62 ± 7.5.Conclusion: The Arabic APSQ is reliable and valid for measuring anxiety and preoccupation with sleep in Arabic countries. Using translated APSQ for clinical diagnosis and research is currently trustworthy.Keywords: anxiety, insomnia, sleep quality, daily performance, general health

Ahmed S BaHammam1– 3 1Editor-in-Chief Nature and Science of Sleep; 2Department of Medicine, University Sleep Disorders Center and Pulmonary Service, King Saud University, Riyadh, Saudi Arabia; 3King Saud University Medical City, Riyadh, Saudi ArabiaCorrespondence: Ahmed S BaHammam, Professor of Medicine, 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.com

Ahmed S BaHammam,1 Michael WL Chee2 1Department of Medicine, University Sleep Disorders Center and Pulmonary Service, King Saud University, Riyadh, Saudi Arabia; 2Centre for Sleep and Cognition, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, SingaporeCorrespondence: 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.com

Haitham Jahrami,1,2 Khaled Trabelsi,3,4 Michael V Vitiello,5 Ahmed S BaHammam6,7 1Department of Psychiatry, Ministry of Health, Manama, Kingdom of Bahrain; 2Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain; 3High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, 3000, Tunisia; 4Research Laboratory: Education, Motricity, Sport and Health, EM2S, LR19JS01, University of Sfax, Sfax, 3000, Tunisia; 5Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, USA; 6Department of Medicine, College of Medicine, University Sleep Disorders Center, King Saud University, Riyadh, Saudi Arabia; 7The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia, Riyadh, Saudi ArabiaCorrespondence: Haitham Jahrami, Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, P.O. Box 26671, Manama, Kingdom of Bahrain, Tel +973 17286334, Fax +973 17270637, Email HJahrami@health.gov.bh

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

Md Dilshad Manzar,1 Abdulrhman Albougami,1 Hamid Yimam Hassen,2 Mohamed Yacin Sikkandar,3 Seithikurippu R Pandi-Perumal,4,5 Ahmed S Bahammam6,7 1Department of Nursing, College of Applied Medical Sciences, Majmaah University, Al Majmaah, 11952, Saudi Arabia; 2Department of Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, 2610, Belgium; 3Department of Medical Equipment Technology, College of Applied Medical Sciences, Majmaah University, Al Majmaah, 11952, Saudi Arabia; 4Somnogen Canada Inc, Toronto, ON, Canada; 5Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India; 6The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, 11324, Saudi Arabia; 7National Plan for Science and Technology, College of Medicine, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Md Dilshad Manzar, Department of Nursing College of Applied Medical Sciences, Majmaah University, Al Majmaah, 11952, Saudi Arabia, Email m.manzar@mu.edu.saPurpose: Few studies have investigated the validity of the Athens insomnia scale (AIS) using a robust approach of both classical theory and the rating scale model. Therefore, in this study, we investigated psychometric validation of the AIS using both of these approaches in nurses.Methods: Nurses (n= 563, age= 33.2± 7.1 years) working in health facilities in Saudi Arabia participated in a cross-sectional study. Participants completed the AIS, socio-demographics tool, and sleep health-related questions.Results: Confirmatory factor analysis (CFA) favored a 2-factor structure with both comparative fit index (CFI), and incremental fit index (IFI) having values above 0.95. The 2-factor model had the lowest values of Akaike information criterion (AIC), root mean square error of approximation (RMSEA), χ2, and χ2/df. This 2-factor structure showed configural invariance (CFI more than 0.95, RMSEA less than 0.08, and &KHgr;2/df less than 3), and metric, scalar, and strict invariance (based on Δ CFI ≤-0.01, and Δ RMSEA ≥ 0.015 criteria). No ceiling/floor effects were seen for the AIS total scores. Infit and outfit mean square values for all the items were within the acceptable range (< 1.4, > 0.6). The threshold estimates for each item were ordered as expected. Cronbach’s α for the AIS tool, factor-1 score, factor-2 score was 0.86, 0.82, and 0.72, respectively. AIS factor scores-1/2 were significantly associated with a habitual feeling of tiredness after usual night sleep (p< 0.001), Impairment of daytime socio-occupational functioning (p< 0.05), and with a feeling of daytime fatigue, irritability, and restlessness (p< 0.05).Conclusion: The findings favor the validity of a 2-factor structure of the AIS with adequate item properties, convergent validity, and reliability in nurses.Keywords: insomnia, reliability, factor analysis, sleep, validity

Haitham Jahrami,1,2 Mona Rashed,1,2 Maha M AlRasheed,3 Nicola Luigi Bragazzi,4 Zahra Saif,1 Omar Alhaj,5 Ahmed S BaHammam,6,7 Michael V Vitiello8 1Ministry of Health, Manama, Bahrain; 2Department of Psychiatry, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain; 3Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; 4Department of Mathematics and Statistics, Laboratory for Industrial and Applied Mathematics (LIAM), York University, Toronto, ON, Canada; 5Department of Nutrition, Faculty of Pharmacy and Medical Sciences, University of Petra, Amman, Jordan; 6Department of Medicine, College of Medicine, University Sleep Disorders Center, King Saud University, Riyadh, 11324, Saudi Arabia; 7The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia, Riyadh, Saudi Arabia; 8Psychiatry & Behavioral Sciences, Gerontology & Geriatric Medicine, and Biobehavioral Nursing, University of Washington, Seattle, WA, 98195-6560, USACorrespondence: Haitham JahramiMinistry of Health, Manama, Bahrain, P.O. Box: 12 Tel +973 17286334Fax +973 17270637Email hjahrami@health.gov.bhPurpose: NOMOPHOBIA (NO MObile PHone PhoBIA) or problematic smartphone use is a psychological disorder in which people are afraid of being cut off from their mobile phones. Currently, there has been no direct assessment of mobile phone screen size in the home setting and its effect on nomophobia and related symptoms, such as insomnia. Thus, we investigated the association between nomophobia, insomnia, and mobile phone screen size in a young adult population in Bahrain.Patients and Methods: Using a descriptive, cross-sectional design, we surveyed participants aged 18 to 35 between August and September 2020 using an online questionnaire. Participants completed demographic questions and questions about personal mobile phones, the Nomophobia Questionnaire (NMP-Q), and the Insomnia Severity Index (ISI). The mobile phone screen size was determined using an open-source online database. Crude and adjusted regression analyses were fitted to examine the associations between the study variables.Results: A total of 549 individuals, 54% females, were included in the final analyses. One hundred and fourteen participants (21%) had severe nomophobia, and 81 (14%) had clinical insomnia. A strong positive pair-wise linear association was observed between NMP-Q and ISI β 0.15, P = 0.001. Age, sex, BMI, and mobile phone screen size showed no association with the NMP-Q.Conclusion: Nomophobia is very prevalent in young adult men and women, and it is closely associated with insomnia, regardless of mobile phone screen size, suggesting that mobile phone screen size should not be used as a proxy for hazardous usage.Keywords: blue light, insomnia, ISI, no mobile phone phobia, problematic smartphone use, sleep problems

Maha M AlRasheed,1 Afnan M Alkadir,1 Khulood I Bin Shuqiran,1 Sinaa Al-Aqeel,1 Haitham A Jahrami,2,3 Ahmed S BaHammam4,5 1Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; 2Ministry of Health, Manama, Kingdom of Bahrain; 3College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain; 4University Sleep Disorders Centre, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 5The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia, Riyadh, Saudi ArabiaCorrespondence: Maha M AlRasheedClinical Pharmacy Department, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi ArabiaTel +96611 4678707Fax +966-11-4677480Email mahalrasheed@ksu.edu.saPurpose: We investigated the impact of isolation on sleep quality and psychological distress during the COVID-19 pandemic in Saudi Arabia.Methods: An online survey was conducted on 353 (88 isolated and 265 not isolated) individuals from May to June 2020. Subjective sleep quality was determined using the Pittsburgh sleep quality index (PSQI), and psychological distress measured using the Kessler psychological distress scale (K10).Results: The mean age of the isolated group was 28.6 years versus 27.5 years for the non-isolated group, with male participants accounting for 37% in both groups. The mean PSQI score was 8.5± 3.6 and 8.4± 3.5 for the isolated and non-isolated groups, respectively (P= 0.92). The mean K-10 score was 27.6± 9.4 and 25.3± 9.5 for the isolated and non-isolated groups, respectively (P= 0.04). Poor sleep (PSQI ≥ 6) was reported in 235 (66.6%) and psychological distress (K-10 ≥ 20) in 244 (69.1%) participants. Isolation was not associated with poor sleep (OR: 0.73 (95% CI: 0.41– 1.3), P=0.29), but was statistically significant with psychological distress (OR: 2.12 (95% CI: 1.10– 4.08), P=0.03).Conclusion: Poor sleep and psychological distress symptoms were highly prevalent in our study population. Isolation may influence psychological distress but not sleep quality during the COVID-19 pandemic.Keywords: SARS-CoV-2, COVID-19, pandemic, quarantine, sleep quality, psychological distress, self-isolation

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

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

Md Dilshad Manzar,1 Mohammed Salahuddin,2,3 Seithikurippu R Pandi-Perumal,4 Ahmed S Bahammam5,6 1Department of Nursing, College of Applied Medical Sciences, Majmaah University, Al Majmaah 11952, Saudi Arabia; 2Department of Pharmacy, College of Medicine and Health Sciences, Mizan-Tepi University (Mizan Campus), Mizan-Aman, Ethiopia; 3Pharmacology Division, Department of BioMolecular Sciences, University of Mississippi, Oxford, MS, USA; 4Somnogen Canada Inc, Toronto, ON, Canada; 5The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh 11324, Saudi Arabia; 6National Plan for Science and Technology, College of Medicine, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Md Dilshad ManzarDepartment of Nursing, College of Applied Medical Sciences, Majmaah University, Al Majmaah 11952, Saudi ArabiaTel +966-551923468Email m.manzar@mu.edu.saBackground: High perceived stress and anxiety disorders are usually comorbid with each other, with stress often sequentially preceding the development of anxiety. While prior findings showed a causal role of sleep problems in anxiety, no study has assessed the role of insomnia as a mediator in the relationship between stress and anxiety.Methods: A cross-sectional study on university students (n = 475, age = 21.1+2.6 years) was conducted over 3 months. Participants completed self-report measures of Leeds Sleep Evaluation Questionnaire-Mizan (LSEQ-M), Perceived Stress Scale-10 (PSS-10), generalized anxiety disorder-7 scale (GAD-7), and a sociodemographic tool. The mediation effect model given by Baron and Kelly was used to determine the relationship.Results: The prevalence of insomnia and anxiety disorder was 43.6% and 21.9%, respectively. Stress was significantly associated with LSEQ-M (insomnia measure) (b = − .44, SE = 0.16, p< 0.01), and high levels of anxiety (b = 0.25, SE = 0.03, p < 0.01). The indirect effect of stress on anxiety through LSEQ-M (insomnia measure) was significant (95% confidence interval [0.01, 0.04]). However, the indirect effect of anxiety on stress through LSEQ-M (insomnia measure) was non-significant (95% confidence interval [− .01, 0.04]).Conclusions: Students having higher perceived stress levels and comorbid insomnia were also likely to have a higher anxiety level.Keywords: stress, anxiety, insomnia, mediator

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

Md Dilshad Manzar,1 Majumi M Noohu,2 Mohammed Salahuddin,3,4 Dejen Nureye,3 Abdulrhman Albougami,1 David Warren Spence,5 Seithikurippu R Pandi-Perumal,6 Ahmed S Bahammam7,8 1Department of Nursing, College of Applied Medical Sciences, Majmaah University, Al Majmaah, Saudi Arabia; 2Centre for Physiotherapy and Rehabilitation Sciences, Jamia Milia Islamia, New Delhi, India; 3Mizan-Tepi University, Mizan-Aman, Ethiopia; 4Department of Bio-Molecular Sciences, Pharmacology Division, University of Mississippi, Oxford, MS, USA; 5Independent Researcher, Toronto, ON, Canada; 6Somnogen Canada Inc, Toronto, ON, Canada; 7The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 8The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in Saudi Arabia (MED511-02-08), Riyadh, Saudi ArabiaCorrespondence: Md Dilshad Manzar Department of Nursing, College of Applied Medical SciencesMajmaah University, Al Majmaah 11952, Saudi ArabiaEmail m.manzar@mu.edu.saObjective: There is a paucity of research evidence available regarding the impact of anxiety and sleep hygiene on insomnia and related sleep complaints among collegiate students in lower-income countries. The purpose of this study was to investigate if insomnia and insomnia-related sleep complaints are associated with anxiety, age, and sleep hygiene practices among a sample of university students in Ethiopia.Design, Measures, Setting, and Participants: The participants were young adults (n=525; mean age 21.5 ± 3.0 years; mean BMI of 20.7 ± 2.7kg/m2). Young collegiate adults at Mizan-Tepi University in southwestern Ethiopia were randomly selected to participate in this cross-sectional study. The measures included the Leeds Sleep Evaluation Questionnaire-Mizan (LSEQ-M), the Generalized Anxiety Disorder– 7 Scale (GAD-7), and the Sleep Hygiene Index (SHI). Descriptive statistics, binary logistic regression, and multiple linear regressions were used.Results: Insomnia was associated with young age group (≤ 25 years) (odds ratio (OR) = 2.20, 95% confidence interval (CI) 1.04– 4.66), higher GAD-7 (anxiety) (OR = 1.05, 95% CI 1.0– 1.10) and SHI (poor sleep hygiene) (OR = 1.15, 95% CI 1.05– 1.26) scores. All four insomnia-related sleep complaints were associated with increasing GAD-7 scores, as well as higher SHI scores (p< 0.001).Conclusion: Insomnia was associated with younger age group (≤ 25 years), higher anxiety level, and poor sleep hygiene. Four major sleep complaints in insomnia, ie, sleep onset problems, poor sleep quality, awakening problems, and daytime disturbances, were all associated with higher anxiety levels and poor sleep hygiene.Keywords: sleep, sleepiness, daytime dysfunction, young adults, low-income country

BACKGROUND: This study aimed to examine the impact of the COVID-19 lockdown on adherence to continuous positive airway pressure (CPAP) therapy among Saudi patients with obstructive sleep apnea (OSA). It also sought to assess the influence of demographic variables and comorbidities on CPAP adherence. METHODS: A prospective cohort study was conducted at the University Sleep Disorders Center at King Saud University Medical City. The study included 67 OSA patients who exclusively used CPAP for treatment across three distinct intervals: prelockdown, during lockdown, and postlockdown. Adherence to CPAP therapy was objectively measured using 'mask-on on-time monitoring' data from the CPAP machines. RESULTS: The study found a significant decrease in the number of days with CPAP usage during the lockdown period, which persisted postlockdown. Approximately half of the patients adhered to CPAP treatment throughout the three study intervals. The decrease in CPAP usage days during lockdown was particularly noticeable among patients younger than 50 and older than 65 years of age. The presence of comorbidities, body mass index, and sex did not significantly influence CPAP treatment adherence. CONCLUSION: The COVID-19 lockdown significantly impacted CPAP treatment adherence among OSA patients, with a decrease in adherence persisting postlockdown. This highlights the need for interventions to support CPAP adherence during challenging times such as a pandemic. Further research is needed to understand the long-term effects of the pandemic on CPAP therapy adherence. Keywords: Compliance, culture, positive airway pressure therapy, sleep disorders, sleep-disordered breathing, Author(s): Abdulaziz O. BaHammam [1,2]; Fawaz Alhuqayl [1,2]; Ibrahim Alzaid [1,2]; Ziyad Alzammam [1,2]; Faisal Alhuqayl [1,2]; Bader Rajeh [1,2]; Galal Eldin Abbas Eltayeb [3]; Samar Nashwan [1]; Salih Aleissi [...]

Nevin FW Zaki,1,2 Yomna M Sabri,2 Omar Farouk,3 Amany Abdelfatah,4 David Warren Spence,5 Ahmed S Bahammam,6,7 Seithikurippu R Pandi-Perumal8 1Sleep Research Unit, Department of Psychiatry, Faculty of Medicine, Mansoura University, Mansoura, Egypt; 2Department of Psychiatry, Faculty of Medicine, Mansoura University, Mansoura, Egypt; 3Mansoura University Oncology Center, Mansoura, Egypt; 4Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt; 5Independent Researcher, Toronto, ON, Canada; 6University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 7The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia, Riyadh, Saudi Arabia; 8Somnogen Canada Inc, Toronto, ON, CanadaCorrespondence: Nevin FW ZakiDepartment of Psychiatry, Faculty of Medicine, Mansoura University, PO Box 36551, Mansoura, EgyptTel +201283339789Email mernakero@mans.edu.egBackground: Chronobiological changes have been detected in various physiological functions of patients with breast cancer, suggesting dysregulation in the pineal gland and melatonin secretion. This study aimed to assess and measure serum melatonin levels pre- and postoperatively in patients who had been diagnosed for the first time with breast cancer.Methods: A sample of first-time breast cancer patients, consisting of 45 women aged 25– 65 years, was evaluated and psychometric assessment was completed using the Beck Depression Inventory (BDI), Insomnia Severity Index (White, Weinberg et al) and the Epworth Sleepiness Scale (Cardoso, Spence et al). The Morningness-Eveningness questionnaire (MEQ) was used to assess the chronotype. Serum melatonin levels were measured by radioimmunoassay.Results: Morning and moderately morning chronotypes were prevalent among the sample (25%, 45.8%, respectively). The finding of a mean BDI score of 13.5± 11.2 indicated that depressive symptoms were prevalent among the sample. Despite the finding that a mean of the participants apparently had no symptoms of daytime sleepiness (the mean and standard deviations of the ESS were 7.5± 4.4), scores on the ISI (a mean of 16.7±SD 7.3) indicated that insomnia symptoms were prevalent in the sample. Melatonin levels showed an inverse relationship with insomnia severity as measured by the ISI and depression severity, as assessed by the BDI. The postoperative melatonin levels were higher than the preoperative levels. Additionally, the psychometric profile differed among various pathological types of breast cancer according to their hormone receptor profile.Conclusion: Serum melatonin levels correlated significantly with self-reported sleep quality and psychometric profiles of depression in the present sample of breast cancer patients. The melatonin assay, which is relatively easy to carry out, provided a convenient, objective measure of an important biological correlate of sleep quality and depression. This assay thus represented a confirmatory alternative to the self-report instruments, which may sometimes be unreliable. Future studies should further evaluate the utility of melatonin measures in psychiatric and sleep complaints of breast cancer patients.Keywords: beck depression, breast cancer, chronotype, circadian, melatonin

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

Majed Alomar,1 Aljohara S Almeneessier,1,2 Awad H Olaish,1 Abdulrahman Alshiban,1 Abdullah Alomar,1 Ahmed S BaHammam1,31The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 3The Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia, King Saud University, Riyadh, Saudi ArabiaBackground: 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.Keywords: cataplexy, hypersomnolence, hypersomnia, allergy, narcolepsy

Aljohara S Almeneessier,1,2 Ahmed S BaHammam1 1Department of Medicine, University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Department of Family Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia Abstract: Mealtimes and feeding schedules may interfere with the circadian system and impact sleep. The practice of intermittent fasting (IF) in its different formats is increasing worldwide. However, most studies addressing the effect of IF on circadian rhythms, daytime sleepiness, and sleep architecture have been conducted during diurnal IF for Ramadan. In this article, we analyze the effect of diurnal IF on the circadian clock, sleep, and daytime sleepiness. In free-living, unconstrained environments that do not control for lifestyle changes such as sleep/wake schedules, sleep duration, and light exposure, studies have demonstrated sudden and significant delays in bedtime and wake time during diurnal intermittent fasting for Ramadan. However, subsequent studies that accounted for lifestyle factors and sleep/wake patterns have reported no changes in markers of the biological clock, daytime sleepiness, or sleep parameters. Nevertheless, several researchers have demonstrated a reduction in the proportion of rapid eye movement stage sleep as the significant alteration in sleep architecture during fasting. Keywords: mealtime, Ramadan, chronotype, sleep architecture, alertness, food, light, caloric restriction

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

Ramanujam Karthikeyan,1 Ganapathy Marimuthu,1 Chellamuthu Ramasubramanian,2 Gautham Arunachal,2 Ahmed S BaHammam,3 David Warren Spence,4 Daniel P Cardinali,5 Gregory M Brown,6 Seithikurippu R Pandi-Perumal7 1Department of Animal Behaviour and Physiology, School of Biological Sciences, Madurai Kamaraj University, Madurai, India; 2MS Chellamuthu Trust and Research Foundation, KK Nagar, Madurai, India; 3University Sleep Disorders Center, College of Medicine, National Plan for Science and Technology, King Saud University, Riyadh, Saudi Arabia; 4Independent researcher, Toronto, Ontario, Canada; 5Department of Teaching and Research, Faculty of Medical Sciences, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina; 6Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada; 7Center for Healthful Behavior Change (CHBC), Division of Health and Behavior, Department of Population Health, NYU Langone Medical Center, Clinical and Translational Research Institute, New York, New York, USA Background: Sleep–wake disturbances have frequently been reported in bipolar disorder and schizophrenia, and are considered to be caused by an underlying circadian rhythm disorder. The study presented here was designed to investigate the existence of Per3 polymorphism in bipolar disorder type I (BD-I) and schizophrenic patients in South India.Methods: Blood samples were collected from 311 BD-I patients, 293 schizophrenia patients, and 346 age- and sex-matched normal controls. Per3 genotyping was performed on DNA by polymerase chain reaction using specific primers.Results: An increased prevalence of five repeat homozygotes was seen in BD-I patients as compared with healthy controls (odds ratio =1.72 [95% confidence interval: 1.08–2.76, P=0.02]). In BD-I patients, the frequency of the five repeat allele was higher (allele frequency =0.41), and that of the four repeat allele lower (allele frequency =0.36) (χ2=4.634; P

Ahmed S BaHammam,1 David Gozal21The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Department of Pediatrics, Comer Children’s Hospital, Biological Sciences Division, The University of Chicago, Chicago, IL, USAAbstract: Sleep has preoccupied and fascinated many civilizations since the dawn of mankind. Here, we critically review the various elements pertaining to sleep in the context of early Islamic religion and culture. The many principles of sleep hygiene, wellbeing and health associated with adequate sleep, and the understanding of sleep as a dynamic state are all apparent from such explorative process of Islamic tradition.Keywords: sleep, Islam, Qur’an, fasting, Hadith, Ramadan

Sleep medicine is a relatively new specialty in the medical community. The practice of sleep medicine in Saudi Arabia (KSA) began in the mid to late nineties. Since its inception, the specialty has grown, and the number of specialists has increased. Nevertheless, sleep medicine is still underdeveloped in the KSA, particularly in the areas of clinical service, education, training and research. Based on available data, it appears that sleep disorders are prevalent among Saudis, and the demand for sleep medicine service is expected to rise significantly in the near future. A number of obstacles have been defined that hinder the progress of the specialty, including a lack of trained technicians, specialists and funding. Awareness about sleep disorders and their serious consequences is low among health care workers, health care authorities, insurance companies and the general public. A major challenge for the future is penetrating the educational system at all levels to demonstrate the high prevalence and serious consequences of sleep disorders. To attain adequate numbers of staff and facilities, the education and training of health care professionals at the level of sleep medicine specialists and sleep technologists is another important challenge that faces the specialty. This review discusses the current position of sleep medicine as a specialty in the KSA and the expected challenges of the future. In addition, it will guide clinicians interested in setting up new sleep medicine services in the KSA or other developing countries through the potential obstacles that may face them in this endeavor.

Background and Objectives: There are no published data on the chronotypes of young Saudi adults. This study assessed the distribution of chronotypes in college-aged Saudis. Design and Setting: Cross-sectional survey of college students Patients and Methods: A validated abridged version of the original Horne and Ostberg morningness-eveningness questionnaire (MEQr) was used to assess the chronotype of 759 subjects. Results: Of 540 (71.1%) males and 219 (28.9%) females participated in this study ( age range, 18-32 years), 138 (18.2%) were "morning-types," 417 (54.9%) were "neither-types" and 204 (26.9%) were "evening-types." There was no significant gender difference in MEQr typology. In Saudis, particularly males, the frequency of morning typology was somewhat higher than that reported for individuals in similar age groups in some Western countries. Conclusion: Most Saudi college students had no preference for morningness or eveningness and were classified as "intermediate-types." Morningness appears to be slightly more common in Saudis, especially males, than in individuals of some Western societies.

Obesity is becoming a major medical concern in several parts of the world, with huge economic impacts on health- care systems, resulting mainly from increased cardiovascular risks. At the same time, obesity leads to a number of sleep-disordered breathing patterns like obstructive sleep apnea and obesity hypoventilation syndrome (OHS), leading to increased morbidity and mortality with reduced quality of life. OHS is distinct from other sleep- related breathing disorders although overlap may exist. OHS patients may have obstructive sleep apnea/hypopnea with hypercapnia and sleep hypoventilation, or an isolated sleep hypoventilation. Despite its major impact on health, this disorder is under-recognized and under-diagnosed. Available management options include aggressive weight reduction, oxygen therapy and using positive airway pressure techniques. In this review, we will go over the epidemiology, pathophysiology, presentation and diagnosis and management of OHS.

Background:Pulmonary embolism (PE) is an important cause of in-hospital mortality. Many patients are admitted to the intensive care unit (ICU) either due to hemodynamic instability or severe hypoxemia. Few reports have addressed the outcome of patients with PE; however, none were from ICUs in the Middle East. Objectives:To describe the demographics, clinical presentation, risk factors and outcome of patients with PE admitted to the medical ICU and to identify possible factors associated with poor prognosis. Materials and Methods:Data were collected retrospectively by reviewing the records of patients admitted to the medical ICU with primary diagnosis of PE between January 2001 and June 2007. Demographic, clinical, radiological and therapeutic data were collected on admission to ICU. Results: Fifty-six patients (43% females) with PE were admitted to the ICU during the study period. Their mean age was 40.6 ± 10.6 years. Seven patients (12.5%) had massive PE with hemodynamic instability and 15 (26.8%) had submassive PE. The remaining patients were admitted due to severe hypoxemia. Recent surgery followed by obesity were the most common risk factors (55.4 and 28.6%, respectively). Four patients with massive PE received thrombolysis because the remaining three had absolute contraindications. Fatal gastrointestinal bleeding occurred in one patient post thrombolysis. Additionally, two patients with massive PE and five with submassive PE died within 72 h of admission to the ICU, resulting in an overall mortality rate of 14%. Nonsurvivors were older and had a higher prevalence of immobility and cerebrovascular diseases compared with survivors. Conclusions: The mortality rate of patients with PE admitted to the ICU in our center was comparable to other published studies. Older age, immobility as well as coexistent cerebrovascular diseases were associated with a worse outcome.

Background: Sleep problems in children vary not only with age, but also with ethnic and sociocultural background. No research has been conducted to assess sleep problems in Saudi elementary school children. This study surveyed parents (or guardians) about their elementary school children′s sleep to assess the prevalence of certain sleep problems. Methods: The study population comprised boys and girls attending regular public elementary schools in all grades and was conducted during springtime of the year 1999. A questionnaire inquiring about demographic data, specific sleep problems and habits and home environment was distributed and completed by the parents or guardians. Results: A total of 1012 complete questionnaires were included in the analysis. The sample comprised 511 boys (50.5%) and 501 girls (49.5%). The mean age was 9.5±1.9 years, ranging from 5 to 13 years. Daytime fatigue was the most prevalent sleep problem (37.5%) followed by bedtime resistance (26.2%), difficulty rising in the morning during weekdays (20.7%), and sleep-onset delay (11.8%). Cosleeping with parents was reported in 12.4% of children. The study revealed some differences between boys and girls. Napping during the daytime was reported in 40.8% of children. Conclusion: The study showed that sleep problems are prevalent among Saudi elementary school children. Moreover, the study shed some light on sleep habits and practices in this age group in Saudi Arabia, like the high prevalence of daytime napping.

Background: Because little has been reported about the outcome of severe asthma outside the US and western Europe, we performed a retrospective case analysis of patients treated in the medical intensive care unit (MICU) of a university hospital in Riyadh, Saudi Arabia, to de-termine the management, complications and outcome of severe asthma requiring ICU admission. Methods: The records of patients with severe asthma admitted to the MICU between the periods of January 1996 to December 2003 were re-viewed. Sixty-one episodes from 54 patients were studied, of which 27 (44%) were male. Results: All patients were hypercapnic; 23 (38%) were ventilated. The Acute Physiological and Health Evaluation (APACHE) score II was significantly higher in the ventilated group (P< 0.0001). The pH was sig-nificantly lower and PaCO 2 was significantly higher in the ventilated group (P< 0.0001). All patients survived. Only 42% of patients our series received inhaled corticosteroids before admission. Conclusion: Our results suggestthat severe asthma requiring ICU ad-mission is now safely managed in ICUs. Our results are comparable to recently published data on the treatment of severe asthma in the ICU.

We report a young lady, who was labeled as a case of refractory asthma for a few years, based on history of shortness of breath on minimal exertion, noisy breathing and normal chest radiograph. Repeated upper airway exam by an otolaryngologist and computerized tomography scan, were normal. On presentation to our hospital, she was diagnosed to have fixed upper airway obstruction, based on classical flow-volume loop findings. Fibroptic bronchoscopy revealed a web-shaped subglottic stenosis. The histopathology of a biopsy taken from that area, showed non-specific inflammation. No cause for this stenosis could be identified. The patient was managed with rigid bronchoscopy dilatation, without recurrence. We report this case as idiopathic subglottic stenosis, that was misdiagnosed as refractory bronchial asthma, stressing the importance of performing spirometry in the clinic.