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Background: Mechanical insufflation/exsufflation (MI-E) devices are often prescribed to patients with inefficient cough and recurrent infections, but their use in the home setting is not well characterized. Objective: The objective of this study was to report a real-life experience and identify factors that are associated with home MI-E use in adult patients. Methods: This is a cross-sectional observational study of adult subjects with neurological disease using MI-E at home for more than 3 months. Results: A total of 43 patients were included. Median age (interquartile range) was 48 (31–64) years. The most common diagnosis was muscular dystrophy (n = 15), followed by multiple sclerosis (n = 7) and amyotrophic lateral sclerosis (n = 7). 24 subjects (56%) reported using the MI-E at least once weekly. Based on device data downloads, the median objective use was 23% of days analysed (approximately 2 times per week). The vast majority (94%) of all participants reported using the device at least daily during an infectious episode, while 62% reported having used the device in emergency situations such as bronchoaspiration. Reported use correlated well with objective use (r = 0.82). Most subjects reported an improvement in their respiratory health (64%) and were satisfied with the device (78%). Higher reported and objective use were associated with increased symptoms (p = 0.001) and higher satisfaction with the device (p = 0.008). We found no association between frequency of use and baseline cough peak flow (CPF), bulbar impairment, non-invasive ventilation use, living environment, or supervised administration. Conclusion: Regular home MI-E use was associated with greater symptom burden and overall satisfaction with the device and was not influenced by baseline CPF. Patients without substantial bronchorrhea might not use the MI-E regularly but might still need to use the device at home during acute events. Therefore, familiarity with the MI-E via appropriate and repeated practical training is crucial.

BACKGROUND: Oropharyngeal myofunctional therapy is a multi-component therapy effective to reduce the severity of obstructive sleep apnoea (OSA). However, existing protocols are difficult to replicate in the clinical setting. There is a need to isolate the specific effectiveness of each component of the therapy. OBJECTIVE: To assess the effects of a 6 weeks tongue elevation training programme in patients with OSA. METHODS: We conducted a multicentre randomised controlled trial. Eligible participants were adults diagnosed with moderate OSA who presented low adherence to continuous positive airway pressure therapy (mean use

Background and ObjectivesRecent studies fueled doubts as to whether all currently defined central disorders of hypersomnolence are stable entities, especially narcolepsy type 2 and idiopathic hypersomnia. New reliable biomarkers are needed, and the question arises of whether current diagnostic criteria of hypersomnolence disorders should be reassessed. The main aim of this data-driven observational study was to see whether data-driven algorithms would segregate narcolepsy type 1 and identify more reliable subgrouping of individuals without cataplexy with new clinical biomarkers.MethodsWe used agglomerative hierarchical clustering, an unsupervised machine learning algorithm, to identify distinct hypersomnolence clusters in the large-scale European Narcolepsy Network database. We included 97 variables, covering all aspects of central hypersomnolence disorders such as symptoms, demographics, objective and subjective sleep measures, and laboratory biomarkers. We specifically focused on subgrouping of patients without cataplexy. The number of clusters was chosen to be the minimal number for which patients without cataplexy were put in distinct groups.ResultsWe included 1,078 unmedicated adolescents and adults. Seven clusters were identified, of which 4 clusters included predominantly individuals with cataplexy. The 2 most distinct clusters consisted of 158 and 157 patients, were dominated by those without cataplexy, and among other variables, significantly differed in presence of sleep drunkenness, subjective difficulty awakening, and weekend-week sleep length difference. Patients formally diagnosed as having narcolepsy type 2 and idiopathic hypersomnia were evenly mixed in these 2 clusters.DiscussionUsing a data-driven approach in the largest study on central disorders of hypersomnolence to date, our study identified distinct patient subgroups within the central disorders of hypersomnolence population. Our results contest inclusion of sleep-onset REM periods in diagnostic criteria for people without cataplexy and provide promising new variables for reliable diagnostic categories that better resemble different patient phenotypes. Cluster-guided classification will result in a more solid hypersomnolence classification system that is less vulnerable to instability of single features.

Davide Sparasci,1 Francesco Fanfulla,2 Raffaele Ferri,3 Debora Aricò,3 Daniela Distefano,4 Emanuele Pravatà ,4 Raphael Heinzer,5 José Haba-Rubio,5 Mathieu Berger,5 Gianna Carla Riccitelli,6– 8 Claudio Gobbi,6,8 Chiara Zecca,6,8,* Mauro Manconi1,8,* 1Sleep Medicine Unit, Neurocenter of Southern Switzerland, Lugano, Switzerland; 2Sleep Medicine Unit, Istituti Clinici Scientifici Maugeri, IRCCS, Scientific Institute of Pavia, Pavia, Italy; 3Sleep Research Centre; Department of Neurology I.C., Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Troina, Italy; 4Neuroradiology Clinic, Ospedale Regionale di Lugano, Neurocenter of Southern Switzerland, Lugano, Switzerland; 5Center for Investigation and Research in Sleep (CIRS), Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland; 6Multiple Sclerosis Center, Neurocenter of Southern Switzerland, Lugano, Switzerland; 7Neuropsychology and Behavioural Neurology Research Unit, Neurocenter of Southern Switzerland, Lugano, Switzerland; 8Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland*These authors contributed equally to this workCorrespondence: Raffaele Ferri, Sleep Research Centre; Department of Neurology I.C., Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Via Conte Ruggero 73, Troina, 94018, Italy, Email rferri@oasi.en.itBackground: Multiple sclerosis (MS) represents a risk factor for sleep disorders, but there are conflicting results about the prevalence and severity of sleep-related breathing disorders (SRBD) in MS. Most available data come from self-administered questionnaires.Objective: To conduct a polysomnographic study in MS focused on SRBD, compared to a group of healthy controls (HC), also considering the neuroimaging findings. To evaluate the impact of SRBD on vigilance, fatigue and depression in MS.Methods: In this cross-sectional, observational, instrumental study, 67 MS patients (men/women: 20/47; mean age: 50.6± 8.2 years) underwent PSG and maintenance of wakefulness test. Findings were compared to 67 age-, sex-, BMI-matched HC, by using parametric (Student’s t-test) and nonparametric statistics (chi-squared test). A subgroup analysis was then performed, evaluating the influence of brainstem (mesencephalic, pontine and medullary) lesions at neuroimaging on instrumental and clinical data: MS patients with at least one brainstem lesion vs MS patients without vs HC.Results: The frequency of SRBD was comparable in MS patients and HC. No MS patient had a central apnea index ≥ 2/h. The respiratory disturbance index (RDI) did not correlate to clinical parameters such as fatigue and depression. Patients with MS were drowsier than HC (47% vs 26%, p = 0.019) and showed a worse sleep pattern, in terms of duration, efficiency and architecture.Conclusion: Our study does not provide evidence of an association between MS-specific symptoms such as fatigue, sleepiness, depression and central or obstructive apneas, even in the presence of brainstem lesions.Keywords: sleep-related breathing disorders, multiple sclerosis, sleep quality, polysomnography

Introduction: Evidence on the link between sleep habits and cardiovascular diseases (CVD) in the community predominantly relies on studies that have investigated only one sleep habit, measure at one timepoint. Therefore, this study examined the joint effect of five sleep habits at baseline and at follow-up with incident CVD events. Hypothesis: We assessed the hypothesis that change in sleep habits over time including improvement in sleep habits and maintenance of a high level of sleep habits are related to reduced CVD risk. Methods: We combined data from two large independent community-based cohorts, the Paris Prospective Study 3 (France) and the CoLaus/PsyCoLaus study (Switzerland), involving 11 347 participants in total, aged 53–64 and comprising 44.6% women, initially free from CVD at baseline (respectively 2008-2012 and 2003-2006). Information on participants’ sleep habits were collected twice (median time interval between the 2 time points=2.0; interquartile range [IQR]: 2.0-5.2) by validated questionnaires. A healthy sleep score (HSS) combining five sleep habits (early chronotype, sleep duration of 7-8 h/day, never/rarely insomnia, no sleep apnea, and no frequent excessive daytime sleepiness) was calculated at baseline and follow-up. Each sleep habit was scored 1 point if optimal, otherwise 0 point. The score ranged from 0 to 5, reflecting the number of optimal sleep habits. Associations of HSS at baseline and the change in the score over time with CVD events (coronary heart disease, CHD, or stroke) were examined using Cox proportional hazard models. Results: During a median follow-up of 8.9 years (IQR: 8.0-10.0), 499 first CVD events occurred (339 CHD and 175 stroke). In multivariate Cox analysis, the risk of CVD decreased by 18% per one-point increment in the HSS (hazard ratio, HR=0.82 [95% confidence interval, CI, 0.76-0.89]). At follow-up, 38% remained in stable high score (score≥3 at both time points, the median of the baseline HSS), 11% had a stable low HSS (score Conclusions: Higher HSS and increase in the HSS are associated with a lower risk of CHD and stroke in the community. This study supports the promotion of healthy sleep habits in the population and strong collaboration between sleep medicine and CVD medicine.

Although excessive daytime sleepiness (EDS) attributable to obstructive sleep apnea (OSA) can be resolved by consistent usage of and effective treatment (often with the use of continuous positive airway pressure therapy), 12-58% of patients report residual EDS (REDS). While REDS is difficult to treat, a proportion of cases are possibly due to reversible issues, and wake-promoting medications can prove useful for the remaining cases. Given the challenges associated with effective management of REDS and its relationship to multiple comorbidities, multidisciplinary management of patients with REDS is often recommended. Here we aim to bridge the knowledge gap on the burden, risk factors, prevalence, and potential pathophysiologic mechanisms of REDS in patients with OSA after first-line treatment. The roles of primary care physicians and sleep specialists, as well as the importance of the use of objective assessment tools for the evaluation of REDS and the effective management of comorbidities, are discussed. An update of approved treatments and emerging candidate treatments is also presented.

Obstructive sleep apnea syndrome (OSA) may be a risk factor for Alzheimer's disease. One of the hallmarks of Alzheimer's disease is disturbed iron homeostasis leading to abnormal iron deposition in brain tissue. To date, there is no empirical evidence to support the hypothesis of altered brain iron homeostasis in patients with obstructive sleep apnea as well. Data were analysed from 773 participants in the HypnoLaus study (mean age 55.9 ± 10.3 years) who underwent polysomnography and brain MRI. Cross-sectional associations were tested between OSA parameters and the MRI effective transverse relaxation rate (R2*) - indicative of iron content - in 68 grey matter regions, after adjustment for confounders. The group with severe OSA (apnea-hypopnea index ≥30/h) had higher iron levels in the left superior frontal gyrus (F 3,760 = 4.79, p = 0.003), left orbital gyri (F 3,760 = 5.13, p = 0.002), right and left middle temporal gyrus (F 3,760 = 4.41, p = 0.004 and F 3,760 = 13.08, p < 0.001, respectively), left angular gyrus (F 3,760 = 6.29, p = 0.001), left supramarginal gyrus (F 3,760 = 4.98, p = 0.003), and right cuneus (F 3,760 = 7.09, p < 0.001). The parameters of nocturnal hypoxaemia were all consistently associated with higher iron levels. Measures of sleep fragmentation had less consistent associations with iron content. This study provides the first evidence of increased brain iron levels in obstructive sleep apnea. The observed iron changes could reflect underlying neuropathological processes that appear to be driven primarily by hypoxaemic mechanisms.

Background Because of their high costs and low availability, sleep recordings cannot be used as routine procedures for sleep apnea screening. Therefore, it is important to have a performant screening tool allowing to select patients at higher risk for sleep apnea who need further investigations. The goal of the study is to compare the performances of the three commonly used sleep disordered breathing (SDB) screening questionnaires in a clinical sample. Methods Clinical data and sleep studies performed in consecutive adult patients referred to the Lausanne University sleep center for sleep recordings between November 2016 and February 2018 were analysed. Berlin, STOP-Bang and NoSAS screening scores were calculated and compared with the sleep studies’ results. Results NoSAS score showed a NPV of 0.88, a PPV of 0.43 and a correctly classified rate of 71% for an AHI >15/h. STOP-Bang score had a slightly higher negative predictive value (0.92) but a very low positive predictive value (0.30) and a poor correctly classified rate (47%). Berlin score showed globally poor results (NPV:0.85, PPV: 0.29 and a correctly classified rate: 56%). NoSAS score had the highest area under ROC curves (0.78) compared to STOP-bang (0.71) and Berlin (0.62). NoSAS score however yielded a slightly higher rate of false negative than STOP-Bang score. NoSAS false negatives were mainly female snorers with a low neck circumference. Conclusion NoSAS score showed a better discrimination capacity compared to Berlin and STOP Bang scores in an unselected clinical population referred to a sleep center.

Study Objectives Periodic limb movement in sleep is a common sleep phenotype characterized by repetitive leg movements that occur during or before sleep. We conducted a genome-wide association study (GWAS) of periodic limb movements in sleep (PLMS) using a joint analysis (i.e., discovery, replication, and joint meta-analysis) of four cohorts (MrOS, the Wisconsin Sleep Cohort Study, HypnoLaus, and MESA), comprised of 6843 total subjects. Methods The MrOS study and Wisconsin Sleep Cohort Study (N = 1745 cases) were used for discovery. Replication in the HypnoLaus and MESA cohorts (1002 cases) preceded joint meta-analysis. We also performed LD score regression, estimated heritability, and computed genetic correlations between potentially associated traits such as restless leg syndrome (RLS) and insomnia. The causality and direction of the relationships between PLMS and RLS was evaluated using Mendelian randomization. Results We found 2 independent loci were significantly associated with PLMS: rs113851554 (p = 3.51 × 10−12, β = 0.486), an SNP located in a putative regulatory element of intron eight of MEIS1 (2p14); and rs9369062 (p = 3.06 × 10−22, β = 0.2093), a SNP located in the intron region of BTBD9 (6p12); both of which were also lead signals in RLS GWAS. PLMS is genetically correlated with insomnia, risk of stroke, and RLS, but not with iron deficiency. Pleiotropy adjusted Mendelian randomization analysis identified a causal effect of RLS on PLMS. Conclusions Because PLMS is more common than RLS, PLMS may have multiple causes and additional studies are needed to further validate these findings.

AIMS: Heart failure (HF) is an ongoing epidemic and a serious clinical and public health issue. Currently, little is known about prospective associations between insomnia symptoms and HF incidence. We investigated the longitudinal associations between time-varying insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, non-restorative sleep) and incident HF. METHODS AND RESULTS: Data were obtained from the Health and Retirement Study in the US for a population-representative sample of 12,761 middle-aged and older adults (age ≥ 50 years; mean [SD] age, 66.7 [9.4] years; 57.7% females) who were free from HF at baseline in 2002. Respondents were followed for 16 years for incident HF. We employed marginal structural discrete-time survival analyses to adjust for potential time-varying biological, psycho-cognitive, and behavioral factors and to account for bias due to differential loss to follow-up. At baseline, 38.4% of the respondents reported experiencing at least one insomnia symptom. During the 16-year follow-up, 1,730 respondents developed incident HF. Respondents experiencing one (hazard ratio [HR]=1.22; 95% CI: 1.08–1.38), two (HR=1.45; 95% CI: 1.21–1.72), three (HR=1.66; 95% CI: 1.37–2.02), or four (HR=1.80; 95% CI: 1.25–2.59) insomnia symptoms had a higher hazard of incident HF than asymptomatic respondents. Respondents that had trouble initiating sleep (HR=1.17; 95%CI: 1.01–1.36), maintaining sleep (HR=1.14; 95% CI: 1.01–1.28), early-morning awakening (HR=1.20; 95% CI: 1.02–1.43), or non-restorative sleep (HR=1.25; 95% CI: 1.06–1.46) had a higher hazard of incident HF than asymptomatic respondents. CONCLUSION: Insomnia symptoms, both cumulatively and individually, are associated with incident HF. Public health awareness and screening for insomnia symptoms in at-risk populations should be encouraged to reduce HF incidence.

Resume L’objectif de cet article de mise au point est de discuter de la place de l’activite physique dans la strategie therapeutique du syndrome d’apnees obstructives du sommeil (SAOS). Une revue de litterature sur le niveau d’activite physique et l’incidence du SAOS a ete effectuee et montre qu’un faible niveau d’activite physique est associee a la presence d’un SAOS. Le SAOS d’intensite severe est associe a une modification de la reponse cardiorespiratoire a l’exercice se caracterisant par une baisse de la consommation maximale d’oxygene, de la frequence cardiaque de recuperation ainsi que de la dysfonction neuromusculaire. La litterature existante montre que la mise en place d’une activite physique, seule ou en complement d’un traitement par pression positive continue, permet de diminuer dans une certaine mesure la severite du SAOS et la somnolence. Aussi, l’activite physique ameliore la qualite de vie et le profil cardio-metabolique des patients SAOS. Les patients en surpoids ou obeses sont probablement les meilleurs candidats pour cette prise en charge en activite physique. Une prise en charge dietetique complementaire avec des conseils comportementaux est recommandee chez ces patients et devrait avoir un effet synergique. En conclusion, l’activite physique devrait etre consideree comme un des elements importants dans la prevention et la prise en charge des formes legeres et moderees de SAOS. Dans les formes severes de SAOS, l’activite physique devrait egalement etre integree en complement de la pression positive continue ou de l’orthese d’avancee mandibulaire afin de reduire le risque cardiovasculaire et les comorbidites associes.

Fluid overload has been associated with a high prevalence of sleep apnea (SA) in patients with end-stage kidney disease (ESKD). In this prospective study, we hypothesized that improvement in kidney function and hydration status after kidney transplantation (Tx) may result in an improvement in SA severity. A total of 196 patients on the kidney Tx waiting list were screened for SA using home nocturnal polysomnography (PSG) to measure the apnea-hypopnea index (AHI) and underwent bioimpedance to assess body composition. Of 88 participants (44.9%) with SA (AHI ≥ 15/h), 42 were reassessed 6 months post-Tx and were compared with 27 control patients. There was a significant, but small, post-Tx improvement in AHI (from 44.2 ± 24.3 to 34.7 ± 20.9/h, P = .02) that significantly correlated with a reduction in fluid overload (from 1.8 ± 2.0 to 1.2 ± 1.2 L, P = .02) and body water (from 54.9% to 51.6%, P = .003). A post-Tx increase in body fat mass (from 26% to 30%, P = .003) possibly blunted the beneficial impact of kidney Tx on SA. All parameters remained unchanged in the control group. In conclusion, SA is a frequent condition in ESKD patients and partially improved by kidney Tx. We suggest that SA should be systematically assessed before and after kidney Tx. ClinicalTrials.gov Identifier: NCT02020642.

OBJECTIVE There is much controversy about the neurobiological mechanisms underlying the effects of sleep-disordered breathing on the brain. The aim of this study was to investigate the association between markers of sleep-related hypoxemia and brain anatomy. METHODS We used data from a large-scale cohort from the general population (n = 775, 50.6% males, age range = 45-86 years, mean age = 60.3 ± 9.9) that underwent full polysomnography and brain magnetic resonance imaging to correlate respiratory variables with regional brain volume estimates. RESULTS After adjusting for age, gender, and cardiovascular risk factors, only mean oxygen saturation during sleep was associated with bilateral volume of hippocampus (right: p = 0.001; left: p

Rationale: High altitude-induced hypocapnic alkalosis generates central sleep apnea (CSA). In Nepal, two ethnic groups live at medium-to-high altitude: Tamangs originate from low-altitude Tibeto-Burman populations, whereas Sherpas descend from high-altitude Tibetans. Objective: To compare apnea severity at low and high altitude between Sherpas and Tamangs. Methods: Polygraphy recordings, including airflow and oxygen saturation, were performed in Nepal at "low " (2,030 m) and "high " (4,380 m) altitudes. Resting ventilation (V?E) and mixed-exhaled CO2 (FECO2) were also measured at the same altitudes. Differences in apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and % of nocturnal periodic breathing (NPB) at the two altitudes were compared between ethnicities. Measurements and Main Results: Twenty Sherpas and 20 Tamangs were included (males, median [interquartile range] age: 24.5 [21.5-27.8] years vs. 26.0 [21.5-39.8] years, body mass index: 23.9 [22.1-26.1] kg/m(2) vs. 25.21 [20.6-27.6] kg/m(2)). Compared with Tamangs, Sherpas showed a lower increase in AHI (+7.5 [2.6-17.2]/h vs. +31.5 [18.2-57.3]/h, p < 0.001), ODI (+13.8 [5.5-28.2]/h vs. +42.0 [22.6-77.6]/h, p < 0.001), and NPB proportion (+0.9 [0-3.5]% vs. +12.8 [3.1-27.4]%, p < 0.001) from low to high altitude. Resting V?E was higher in Sherpas versus Tamangs at both low (8.45 [6.89-10.70] l/min vs. 6.3 [4.9-8.3] l/min, p = 0.005) and high (9.7 [8.5-11] l/min vs. 8.74 [7.39-9.73] l/min, p = 0.020) altitudes, whereas the mean +/- standard deviation FECO2 decrease between low and high altitude was greater in Tamangs versus Sherpas (-0.50% +/- 0.44% vs. -0.80% +/- 0.33%, p < 0.023). Conclusion: Overall, altitude-adapted Sherpas showed a 3.2-times smaller increase in sleep-disordered breathing between low and high altitude compared with Tamangs, and higher ventilation and a smaller drop in FECO2 at high altitude. These data suggest that genetic differences in breathing control can be protective against CSA.

BackgroundThe relationship between obstructive sleep apnoea (OSA) and cognitive decline remains controversial, especially in the elderly population. We used data from the HypnoLaus study to assess associations between OSA and longitudinal cognitive changes in a sample of community-dwelling elderly individuals.MethodsWe studied associations between polysomnographic OSA parameters (of breathing/hypoxaemia and sleep fragmentation) and cognitive changes over a 5-year period, after adjustment for potential confounders. The primary outcome was the annual change in cognitive scores. The moderating effects of age, sex and apolipoprotein E4 (ApoE4) status were also examined.Results358 elderly individuals without dementia were included (mean±sdage 71.0±4.2 years; 42.5% males). A lower mean peripheral oxygen saturation (SpO2) during sleep was associated with a steeper decline in Mini-Mental State Examination (B= −0.12, p=0.004), Stroop test condition 1 (B=0.53, p=0.002) and Free and Cued Selective Reminding Test delayed free recall (B= −0.05, p=0.008). A longer time spent asleep withSpO2B=0.47, p=0.006). Moderation analysis showed that apnoea–hypopnoea index and oxygen desaturation index were associated with a steeper decline in global cognitive function, processing speed and executive function only in older participants, men and ApoE4 carriers.ConclusionsOur results provide evidence of the contribution of OSA and nocturnal hypoxaemia to cognitive decline in the elderly population.

We thank Drs Esquinas and Nilius for their interest in our article [1]. They suggest that transnasal insufflation (TNI) should not be used in severe OSA cases or in cases requiring intubation. We fully agree that the patient who can tolerate CPAP should use it, and we never proposed TNI as an alternative to intubation. Our results, however, suggest that TNI could be an alternative treatment to CPAP for sleep-disordered breathing (SDB) after a stroke. Concerning their comments on our methodology, patients with severe neurologic deficits, including aphasia, were excluded in this preliminary study. Nevertheless, there are nonverbal ways to communicate with patients with aphasia in order to determine their tolerance to TNI (or other treatment), and we believe that even aphasic patients could be included in a further protocol on TNI. We agree that it would have been interesting to have sleep studies prior to the stroke in these patients, but obviously, this could not be done in this protocol since patients were recruited after the stroke. Moreover, the objective of our study was not to determine the effect of stroke on SDB. We agree that a randomized study against CPAP would be interesting, but the aim of the present study was only to determine if TNI could be a usable treatment alternative in the acute phase of stroke. As mentioned in the discussion of our article, we used a fixed and relatively low flow rate of 18 L/min to guarantee a maximum of comfort with the TNI, but it is possible that with a higher flow rate, a further reduction of SDB could have been achieved. Finally, we agree with Drs Esquinas and Nilius that further studies with a clinical follow-up are necessary to determine if treatment with TNI in the acute phase of stroke can improve the long-term outcome of these patients.

Data on the prevalence of sleep-disordered breathing (SDB) in the African general population are scarce, and a better understanding is urgently needed. Our study aimed to objectively determine the prevalence of, and factors associated with, SDB in a large sample in Benin, west Africa.In the Benin Society and Sleep (BeSAS) cross-sectional study, participants aged 25 years and older were recruited from both urban and rural areas. Rural participants were recruited from Tanve, a village located 200 km north of Cotonou, and urban participants were recruited from Cotonou. The participants underwent respiratory polygraphy at home using a type-3 device that measures airflow through a nasal pressure sensor, respiratory effort (thoracic movement), and pulse oximetry. Clinical and morphometric data were also collected. SDB severity categories were defined according to the apnoea-hypopnoea index (AHI), with mild-to-severe SDB (AHI ≥5/h), moderate-to-severe SDB (AHI ≥15/h), and severe SDB (AHI ≥30/h).The study was completed from April 4, 2018 to Jan 15, 2021. Of 2909 participants recruited in the BeSAS study, 2168 (74·5%) underwent respiratory polygraphy. For the 1810 participants with complete polygraphic data (mean age 46 years, SD 15; 1163 [64·2%] women), the prevalence of mild-to-severe SDB (AHI ≥5/h) was 43·2% (95% CI 40·9-45·5), of moderate-to-severe SDB (AHI ≥15/h) was 11·6% (10·2-13·1), and of severe SDB (AHI ≥30/h) was 2·7% (2·0-3·5). Factors independently associated with SDB were advanced age, male sex, large neck circumference, abdominal obesity, overweight or obesity, and snoring. After multivariable adjustment, severe SDB was independently associated with hypertension in women (odds ratio 3·99, 95% CI 1·04-15·33; pThe BeSAS study provides the first large-scale objective evaluation of SDB prevalence and associated factors in Africa. The high prevalence of SDB identified should stimulate the development of public health policies to prevent and treat this condition in African countries.Ligue Pulmonaire Vaudoise, Switzerland.

Existing data suggest that smoking may be associated with sleep disturbances. This study aimed to determine the association between smoking and both subjective and objective sleep quality.Cross-sectional analysis of sleep characteristics in 3233 participants from the population-based CoLaus-HypnoLaus cohort (52.2% women, mean age 56.6 ± 10.2 years) who completed questionnaires on sleep quality, of whom 1489 (46%) had a full polysomnography. Smoking data were self-reported; participants were classified by smoking status as current, former or never smokers. Primary outcomes were subjective sleep quality assessed by sleep questionnaires, and objective sleep quality based on polysomnography (sleep macrostructure), including power spectral analysis of the electroencephalogram on C4 electrode (sleep microstructure), quantifying the relative amount of delta power (1-4 Hz), a marker of sleep depth, and arousal-associated alpha power (8-12 Hz).Current smokers had a shift toward faster sleep electroencephalogram activity with lower delta power in non-REM sleep compared with former and never smokers (-2.8 ± 0.4% and -2.4 ± 0.4%, respectively; both p 0.001) and higher alpha power (+0.8 ± 0.2%; p 0.001) compared with never smokers. There was a dose-dependent negative association between electroencephalogram delta power and smoking intensity (rCurrent smokers had decreased objective sleep quality, with a dose-dependent association between smoking intensity and decrease in electroencephalogram delta power during non-REM sleep, in addition to an increase in alpha power. Considering the importance of sleep quality for wellbeing and health, these results provide further data to support smoking cessation.

This systematic review summarizes the prevalence of treatment-emergent central sleep apnea (TECSA) occurring with therapies other than positive airway pressure (PAP) for the management of obstructive sleep apnea (OSA). We describe its natural course as well as the proposed underlying pathophysiological mechanisms and the clinical management of affected patients. A systematic search of PubMed, Embase, Web of science, and the Cochrane Library was performed until June 2020. Eighteen studies (n = 284 patients) were included. TECSA was observed in 31 patients with the use of four different medical devices (mandibular advancement device, hypoglossal nerve stimulation, tongue stabilizing device and nasal expiratory PAP) and after three different types of surgical treatments (tracheostomy, maxillofacial surgery and oro-nasal surgery). Due to the paucity of data available, it was not possible to establish a clear prevalence rate of TECSA for each alternative treatment. After the initiation of non-PAP treatments, a systematic reassessment of the treatment efficacy with follow-up sleep studies will be helpful to identify TECSA. A spontaneous resolution over time was described as well as a persistence of TECSA. In this case, treatment should focus on patients' specific underlying pathophysiology. Overall, the limited current literature suggests that this phenomenon is rare (

The aim of this study was to assess the trends and determinants of sleeping pill consumption in the general population.This was a prospective study that included 4329 participants (2379 women, 51.9 ± 10.4 years) living in the city of Lausanne, Switzerland, followed up for an average of 10.9 years. Benzodiazepines and benzodiazepine receptor agonists were considered as sleeping pills.The prevalence (95% confidence interval [CI]) of sleeping pills use was 8.0% (7.2-8.9) at baseline and 8.4 (7.6-9.3) after 10.9 years. Overall, sleeping pills use was higher among women, elderly individuals, and individuals reporting a history of anxiety and depression. During the 10.9-year follow-up, 85.8% of participants never used sleeping pills, 2.7% used the sleeping pills at all assessments, and 11.5% shifted from using to quitting (and vice versa). On multivariate analysis, the factors associated with "always" sleeping pills use were as follows: female gender (relative risk ratio and [95% CI] = 1.80 [1.14-2.85]); older age (7.05 [3.56-14.0] for 65 + vs 45 years); lower educational level (2.06 [1.06-3.99] for mandatory vs university); anxiety (5.61 [3.61-8.71] for yes/no); and depression (3.75 [2.47-5.69] for yes/no). The same factors were also associated with occasional sleeping pills use (ie, shifters): relative risk ratios and 95% CI = 1.56 (1.26-1.94), 2.37 (1.72-3.26), 1.35 (0.98-1.87), 3.40 (2.59-4.45), and 2.50 (1.99-3.15) for female gender, older age, lower educational level, and anxiety and depression, respectively.During a 10.9-year follow-up, one out of seven participants (14.2%) used sleeping pills at least once during the study period. Sleeping pills use is more frequent among individuals with anxiety or depression, elderly individuals, and women.

Aims: Sleep disturbances exhibit a strong social patterning, and inadequate sleep has been associated with adverse health outcomes, including cardiovascular disorders (CVD). However, the contribution of sleep to socioeconomic inequalities in CVD is unclear. This study pools data from eight European cohorts to investigate the role of sleep duration in the association between life-course socioeconomic status (SES) and CVD. Methods and results: We used cross-sectional data from eight European cohorts, totalling 111 205 participants. Life-course SES was assessed using father’s and adult occupational position. Self-reported sleep duration was categorized into recommended (6–8.5 h/night), long (>8.5 h/night), and short (

To examine the association between older persons’ sleep characteristics and subjective health. Older persons with good self-rated health are more likely to report a good sleep quality and less likely to take naps or sleep medication, even when accounting for comorbidity, depressive symptoms and cognitive difficulties. While sleep efficiency is positively associated with subjective health, napping and use of sleep medication are negatively associated to rating one’s health as good. These associations need to be further investigated in longitudinal analyses to better understand causality. It remains unclear, how much older persons’ sleep problems are due to age-related changes in sleep architecture and pattern, or whether they are a consequence of health problems. This work aimed to examine the association between sleep characteristics and self-rated health, taking into account potential confounders. Data about sleep, including sleep efficiency (ratio of sleep duration to the amount of time spent in bed, considered as good if > 85%), as well as health-rated characteristics were self-reported by community-dwelling persons enrolled in the Lausanne cohort 65+ study (n = 2712, age 66–75 years). Participants’ subjective health was categorized as good versus poor. The cross-sectional association between good self-rated health and sleep characteristics was examined in bivariate and multivariate analysis. The majority of participants (68.4%) rated their health as good. Compared to the participants with poor-rated health, they more often reported a good sleep efficiency (59.5% vs 45.0%, p

Publisher's version (útgefin grein)., Both short and long sleep are associated with an adverse lipid profile, likely through different biological pathways. To elucidate the biology of sleep-associated adverse lipid profile, we conduct multi-ancestry genome-wide sleep-SNP interaction analyses on three lipid traits (HDL-c, LDL-c and triglycerides). In the total study sample (discovery + replication) of 126,926 individuals from 5 different ancestry groups, when considering either long or short total sleep time interactions in joint analyses, we identify 49 previously unreported lipid loci, and 10 additional previously unreported lipid loci in a restricted sample of European-ancestry cohorts. In addition, we identify new gene-sleep interactions for known lipid loci such as LPL and PCSK9. The previously unreported lipid loci have a modest explained variance in lipid levels: most notable, gene-short-sleep interactions explain 4.25% of the variance in triglyceride level. Collectively, these findings contribute to our understanding of the biological mechanisms involved in sleep-associated adverse lipid profiles., This project was supported by a grant from the US National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (R01HL118305). This research was supported in part by the Intramural Research Program of the National Human Genome Research Institute, National Institutes of Health. Tuomas O. Kilpeläinen was supported by the Danish Council for Independent Research (DFF–6110-00183) and the Novo Nordisk Foundation (NNF18CC0034900, NNF17OC0026848 and NNF15CC0018486). Diana van Heemst was supported by the European Commission funded project HUMAN (Health-2013-INNOVATION-1-602757). Susan Redline was supported in part by NIH R35HL135818 and HL11338. Study-specific acknowledgements can be found in the Supplementary Notes 2 and 4. The data on coronary artery disease have been contributed by the Myocardial Infarction Genetics and CARDIoGRAM investigators, and have been downloaded from www.CARDIOGRAMPLUSC4D.ORG.

ObjectiveThere is controversy regarding the effect of napping on cardiovascular disease (CVD), with most studies failing to consider napping frequency. We aimed to assess the relationship of napping frequency and average nap duration with fatal and non-fatal CVD events.Methods3462 subjects of a Swiss population based cohort with no previous history of CVD reported their nap frequency and daily nap duration over a week, and were followed over 5.3 years. Fatal and non-fatal CVD events were adjudicated. Cox regressions were performed to obtain HRs adjusted for major cardiovascular risk factors and excessive daytime sleepiness or obstructive sleep apnoea.Results155 fatal and non-fatal events occurred. We observed a significantly lower risk for subjects napping 1–2 times weekly for developing a CVD event (HR 0.52, 95% CI 0.28 to 0.95) compared with non-napping subjects, in unadjusted as well as adjusted models. The increased HR (1.67, 95% CI 1.10 to 2.55) for subjects napping 6–7 times weekly disappeared in adjusted models (HR 0.89, 95% CI 0.58 to 1.38). Neither obstructive sleep apnoea nor excessive daytime sleepiness modified this lower risk. No association was found between nap duration and CVD events.ConclusionSubjects who nap once or twice per week have a lower risk of incident CVD events, while no association was found for more frequent napping or napping duration. Nap frequency may help explain the discrepant findings regarding the association between napping and CVD events.

STUDY OBJECTIVES: To evaluate continuous positive airway pressure (CPAP) treatment in patients with moderate to severe sleep-disordered breathing (SDB) after an ischemic stroke. METHODS: We identified patients included in the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) who underwent polysomnography after an ischemic stroke. We compared patients without significant SDB (apnea-hypopnea index [AHI] < 15 events/h: SDB−), with AHI ≥ 15 events/h who refused CPAP or with poor CPAP adherence (SDB+ CPAP−), and patients with SDB effectively treated by CPAP (SDB+ CPAP+). RESULTS: We analyzed data from 101 patients (age 68.5 ± 11.1 years, 84.1% men). In multivariate analysis the SDB+ CPAP+ group was associated with a significant reduction of stroke recurrence and mortality (odds ratio 0.13, 95% confidence interval 0.00–0.86, P = .031), whereas atrial fibrillation was independently associated with a higher risk (odds ratio 4.32, 95% confidence interval 1.51–12.33, P = .006). Event-free survival analysis (stroke recurrence and death) after 2-year follow-up showed that those in the SDB+ CPAP+ group had significantly higher cardiovascular survival, and Cox proportion hazard model identified CPAP treatment as significantly associated with survival time (P = .025). The AHI and the National Institutes of Health Stroke Scale subacute score were independently associated with CPAP adherence among patients with SDB. CONCLUSIONS: This observational study shows that CPAP treatment in stroke patients with moderate to severe SDB is associated with lower rates of stroke recurrence and death. CITATION: Haba-Rubio J, Vujica J, Franc Y, Michel P, Heinzer R. Effect of CPAP treatment of sleep apnea on clinical prognosis after ischemic stroke: an observational study. J Clin Sleep Med. 2019;15(6):839–847.

IMPORTANCE The association of positive airway pressure (PAP) with reduced mortality in patients with obstructive sleep apnea (OSA) remains uncertain.OBJECTIVE To investigate the association between PAP prescription and mortality.DESIGN, SETTING, AND PARTICIPANTS This multicenter, population-based cohort study evaluated data from the Sleep Heart Health Study (SHHS), a long-term observational cohort study that included participants between 1995 and 1998, with a mean follow-up of 11.1 years. Analyses were performed in September 2018. Within the SHHS, we compared patients with obesity and severe OSA with (n=81) and without (n=311) prescription of PAP therapy, after matching patients from each group by age, sex, and apnea-hypopnea index.EXPOSURES Self-reported use of PAP.MAIN OUTCOMES AND MEASURES All-cause mortality.RESULTS Of 392 study participants, 316 (80.6%) were men, and mean (SD) age was 63.1 (11.0) years. Ninety-six deaths occurred; 12 among the prescribed-PAP group and 84 among the nonprescribed-PAP group, yielding crude incidence rates of 12.8 vs 24.7 deaths per 1000 person-years. In Cox multivariate analysis, the hazard ratio (HR) of all-cause mortality for prescribed PAP therapy was 0.38 (95% CI, 0.18-0.81). After propensity matching, the HR of all-cause mortality for prescribed PAP therapy was 0.58 (95% CI, 0.35-0.96). According to survival curves, the difference in mortality appears 6 to 7 years after initiation of PAP therapy.CONCLUSIONS AND RELEVANCE Positive airway pressure prescription is associated with reduced all-cause mortality, and this association appears several years after PAP initiation. If replicated, these findings may have strong clinical implications.

ObjectiveWe aimed to investigate the association between cardiovascular health (CVH), as defined by the American Heart Association, and several sleep disturbances.MethodsTwo community-based cohorts, the Paris Prospective Study 3 (PPS3, France, n=6441) and the CoLaus study (Switzerland, n=2989) were analysed. CVH includes 7 metrics which all can be classified as poor, intermediate and ideal. Global CVH score was categorised into poor (0–2 ideal metrics), intermediate (3–4 ideal metrics) and ideal (≥5 ideal metrics). Associations between global CVH and self-reported sleep disturbances (proxy of sleep-disordered breathing [SDB], excessive daytime sleepiness, insomnia symptoms and short/long sleep duration) and SDB severity measured by polysomnography (PSG) were investigated. Adjusted OR/relative risk ratio (RRR) and 95% CIs were estimated. Subjects with previous cardiovascular disease were excluded.ResultsCompared with poor CVH, subjects with intermediate and ideal global CVH had lower odds of self-reported SDB in both cohorts (ORs 0.55; 95% CI 0.44 to 0.68 and 0.35; 95% CI 0.22 to 0.53, respectively) and had lower SDB severity measured by PSG (RRR 0.07; 95% CI 0.02 to 0.20) in CoLaus. Subjects with intermediate and ideal global CVH had lower odds of excessive daytime sleepiness in PPS3 (ORs 0.82; 0.72 to 0.95 and 0.80; 0.82 to 1.02, respectively). No consistent associations were found between CVH and sleep duration or insomnia symptoms.ConclusionsHigher levels of CVH are associated with lower odds of SDB and excessive daytime sleepiness. However, causal interpretation cannot be made and associations might be bidirectional.

Study Objectives To determine if a novel EEG-derived continuous index of sleep depth/alertness, the odds ratio product (ORP), predicts self-reported daytime sleepiness and poor sleep quality in two large population-based cohorts. Methods ORP values which range from 0 (deep sleep) to 2.5 (fully alert) were calculated in 3s intervals during awake periods (ORPwake) and NREM sleep (ORPNREM) determined from home sleep studies in the HypnoLaus (N = 2162: 1106 females, 1056 males) and men androgen inflammation lifestyle environment and stress (MAILES) cohorts (N = 754 males). Logistic regression was used to examine associations between ORPwake, ORPNREM, and traditional polysomnography measures (as comparators) with excessive sleepiness (Epworth sleepiness scale >10) and poor sleep quality (Pittsburgh sleep quality index >5) and insomnia symptoms. Results High ORPwake was associated with a ~30% increase in poor sleep quality in both HypnoLaus (odds ratio, OR, and 95% CI) 1.28 (1.09, 1.51), and MAILES 1.36 (1.10, 1.68). High ORPwake was also associated with a ~28% decrease in excessive daytime sleepiness in the MAILES dataset. ORPNREM was associated with a ~30% increase in poor sleep quality in HypnoLaus but not in MAILES. No consistent associations across cohorts were detected using traditional polysomnography markers. Conclusions ORP, a novel EEG-derived metric, measured during wake periods predicts poor sleep quality in two independent cohorts. Consistent with insomnia symptomatology of poor perceived sleep in the absence of excessive daytime sleepiness, ORPwake may provide valuable objective mechanistic insight into physiological hyperarousal.

Background Although heart rate variability (HRV) is widely used to assess cardiac autonomic function, few studies have specifically investigated nocturnal HRV. Objective We aimed to assess the association between nocturnal HRV and cardiovascular disease (CVD) incidence over 4 years in a population-based sample. Methods 1784 participants (48.2% male, 58±11 years) from the HypnoLaus population-based cohort free of CVD at baseline were included. Polysomnography-based electrocardiograms were exported to analyse time and frequency-domain HRV, Poincare plots indices, detrended fluctuation analysis, acceleration (AC) and deceleration capacities (DC), entropy, heart rate fragmentation (HRF), and heart rate turbulence. Multivariable-adjusted cox regression analysis was used to assess the association between HRV indices and incident CVD events. Results 67 participants (3.8%) developed a CVD over a mean follow-up time of 4.1±1.1 years. In a fully adjusted model, AC (hazard ratio per one SD increase [95% confidence interval]: 1.59 [1.17-2.16]; p=0.004), DC (0.63 [0.47-0.84]; p=0.002) and HRF (1.41 [1.11-1.78]; p=0.005) were the only HRV metrics significantly associated with incident CVD events after controlling for false discovery rate. Conclusion Nocturnal novel HRV parameters such as AC, DC and HRF are better predictors of CVD events than time and frequency traditional HRV parameters. These findings suggest a form of dysautonomia and fragmented rhythms but further experimental studies are needed to delineate the underlying physiological mechanisms of these novel HRV parameters.

Introduction: Sleep-disordered breathing (SDB) is associated with dementia. Increased brain iron accumulation has been suggested as a biomarker of neurodegeneration. Objectives: To investigate the link between SDB and brain iron content. We hypothesized that specific brain structures, such as hippocampus, basal ganglia, and frontoparietal cortex, will demonstrate higher iron levels in participants with SDB. Methods: We included participants of the CoLaus|PsyCoLaus population-based study who underwent polysomnography and brain MRI (N=776). We studied the association between SDB markers and MRI-based quantification of brain iron content using flat maps of transverse relaxation rate R2* whilst adjusting for the effects of age, sex, and cardiovascular risk factors. Results: Mean oxygen saturation during sleep was associated with iron content in neocortex (B=-0.061; p=0.001), caudate (B=-0.193; pl0.001), pallidum (B=-0.261; p=0.011), and putamen (B=-0.257; pl0.001). Sleep time with oxygen saturation l90% was associated with iron content in caudate (B=0.020; p=0.004), pallidum (B=0.039; p=0.020), and putamen (B=0.027; p=0.015). Apnea-hypopnea index and oxygen desaturation index were associated with iron content in neocortex (B=0.006; p=0.004, and B=0.007; p=0.005) and pallidum (B=0.038; p=0.002, and B=0.040; p=0.004). Variables of sleep architecture - sleep efficiency, slow wave sleep, wake after sleep onset, arousal index - did not show any association with brain iron content. Conclusions: Sleep-related hypoxemia is associated with increased iron accumulation in neocortex and basal ganglia. Our findings hint towards the usefulness of MRI-based iron quantification as a biomarker of SDB-related brain pathology.

We aimed to determine whether bone-conducted acoustic stimulation could prematurely terminate sleep apnea events, thereby decreasing amplitude and duration of subsequent oxygen desaturation. As oxygen desaturation has been linked to cardiovascular consequences, we postulate this could be a viable therapy in some cases. Eight patients with severe Obstructive Sleep Apnea (2 women, 45 [20-68] y.o. Apnea-Hypopnea Index: 77.7 ± 22.3/h) underwent polysomnography at the Lausanne University Sleep Center. Short acoustic stimulations were administered by bone conduction every second event of sleep apnea. Sounds were remotely administered using a Dreem® headband worn by patients while undergoing nocturnal polysomnography. Amplitude (%) and duration(s) of oxygen desaturations following terminated apneas were compared to that of non-stimulated previous and subsequent events. 549 stimulations (68.6 ± 38 sounds per patient) in N1 (16.2%), N2 (69.9%), N3 (4.2%), and REM(9.6%) were conducted. Compared to the previous and subsequent non-stimulated apnea, stimulations reduced event duration by 21.4% (-3.4 ± 7.2 s, p < 0.0001) while oxygen desaturation amplitude and duration were reduced by 30.4% (mean absolute difference ± SD: -1.9 ± 2.8%, p < 0.0001), and 39.6% (-5.7 ± 9.2 s, p < 0.0001) respectively. For these variables, each patient showed a significant improvement following acoustic stimulation. Sound-associated discomfort was rated 1.14 ± 1.53 on an 8 points scale (8 = worst) and only 6.8% of emitted sounds were perceived by the patients, suggesting a well-tolerated intervention. Bone-conducted sound stimuli decreased apnea events duration as well as duration and amplitude of associated oxygen desaturations. Stimulations were well tolerated and rarely perceived by patients. This therapeutic approach deserves further investigation, with monitoring of effects on sleep quality, daytime function/sleepiness and cardiovascular parameters.