Beyond Counting Sheep: Exploring the Link between Polycystic Ovary Syndrome and Sleep Health.

Polycystic ovary syndrome (PCOS) is a common hormonal condition with reproductive, metabolic, and psychological sequelae that affects 8 to 13% of reproductive-aged women and 3 to 11% of adolescent girls. Sleep is often compromised in women with PCOS due to increased rates of sleep problems, with the most established problem being obstructive sleep apnea (OSA). OSA is highly prevalent in reproductive-aged adult women with PCOS, but not so in adolescence. The international evidence-based PCOS guideline to improve health outcomes in women with PCOS indicated routine screening to identify and alleviate symptoms of OSA. The guidelines, however, did not weigh other multidimensional constructs of sleep health such as sleep disturbances (e.g., sleep quality and quantity), beyond OSA. This is perhaps due to the lack of research and existing mixed findings in the area of PCOS and sleep health. This narrative review summarizes the current knowledge about OSA and expands further to include the limited knowledge about other sleep problems in PCOS among reproductive-aged women and adolescent girls. We broadly cover the prevalence, risk factors, and mechanisms of sleep problems in PCOS and their relationship with cardiometabolic and psychological health. A brief summary on treatment and intervention strategies for sleep problems in PCOS and future recommendations will be deliberated.

Examining the impact of multilevel upper airway surgery on the obstructive sleep apnoea endotypes and their utility in predicting surgical outcomes.

BACKGROUND AND OBJECTIVE: Upper airway surgery for obstructive sleep apnoea (OSA) is an alternative treatment for patients who are intolerant of continuous positive airway pressure (CPAP). However, upper airway surgery has variable treatment efficacy with no reliable predictors of response. While we now know that there are several endotypes contributing to OSA (i.e., upper airway collapsibility, airway muscle response/compensation, respiratory arousal threshold and loop gain), no study to date has examined: (i) how upper airway surgery affects all four OSA endotypes, (ii) whether knowledge of baseline OSA endotypes predicts response to surgery and (iii) whether there are any differences when OSA endotypes are measured using the CPAP dial-down or clinical polysomnographic (PSG) methods. METHODS: We prospectively studied 23 OSA patients before and ≥3 months after multilevel upper airway surgery. Participants underwent clinical and research PSG to measure OSA severity (apnoea-hypopnoea index [AHI]) and endotypes (measured in supine non-rapid eye movement [NREM]). Values are presented as mean ± SD or median (interquartile range). RESULTS: Surgery reduced the AHITotal (38.7 [23.4 to 79.2] vs. 22.0 [13.3 to 53.5] events/h; p = 0.009). There were no significant changes in OSA endotypes, however, large but variable improvements in collapsibility were observed (CPAP dial-down method: ∆1.9 ± 4.9 L/min, p = 0.09, n = 21; PSG method: ∆3.4 [-2.8 to 49.0]%Veupnoea , p = 0.06, n = 20). Improvement in collapsibility strongly correlated with improvement in AHI (%∆AHISupineNREM vs. ∆collapsibility: p < 0.005; R2  = 0.46-0.48). None of the baseline OSA endotypes predicted response to surgery. CONCLUSION: Surgery unpredictably alters upper airway collapsibility but does not alter the non-anatomical endotypes. There are no baseline predictors of response to surgery.

Obstructive sleep apnoea predicted by the STOP-BANG questionnaire is not associated with higher rates of post-operative complications among a high-risk surgical cohort.

PURPOSE: The purpose of this study is to establish if obstructive sleep apnoea (OSA) predicted by the STOP-BANG questionnaire would be associated with higher rates of post-operative cardiac, respiratory or neurological complications among a selected high-risk population with established major comorbidities undergoing major surgery. We hypothesise that a cohort selected for major comorbidities will show a higher post-operative complication rate that may power any potential association with co-existent OSA and identify an important target group for OSA screening and treatment pathways in preparation for major surgery. METHODS: Patients attending a high-risk preadmission clinic prior to major surgery from May 2015 to November 2015 were prospectively screened for OSA using the STOP-BANG questionnaire. Patients with treated OSA were excluded. Patient data and complications were attained from the pre-admission clinic and subsequent inpatient medical record at discharge. RESULTS: Three-hundred-and-ten patients were included in the study (age 68.6 ± 13.1 years, body mass index [BMI] 30.6 ± 7.4 kg/m2; 52.9% female). Sixty-four patients (20.6%) experienced 82 post-operative complications. Seventy-five percent of the cohort had a STOP-BANG ≥ 3. There was no association between the STOP-BANG score (unadjusted and adjusted for comorbidity) with the development of post-operative complications. CONCLUSIONS: OSA predicted by the STOP-BANG score was not associated with higher rates of post-operative complications in patients with major comorbidities undergoing high-risk surgery. As the findings from this cohort contrast with other observational studies, more definitive studies are required to establish a causative link between OSA and post-operative complications and determine whether treating OSA reduces this complication rate.

Sleep disturbances in women with and without polycystic ovary syndrome in an Australian National Cohort.

BACKGROUND: Polycystic ovary syndrome (PCOS) is a common condition in reproductive-aged women. Sleep disturbances may be more prevalent in PCOS. It is not known if this relationship is independent of other factors. AIM: To examine the prevalence of sleep disturbances in a large community-based cohort study in women with and without PCOS and its relationship to clinical, demographic and comorbid factors. METHODS: We examined data from survey 5 (2009) of the Australian Longitudinal Study on Women's Health (n = 6578, n = 484 PCOS and n = 6094 non-PCOS). Sleep duration and disturbances were self-reported. Three classes of sleep pattern were derived during latent class analysis (normal sleep duration with average sleep, normal sleep duration with sleep symptoms and short sleep duration with sleep symptoms) and compared between women with and without PCOS using multivariate regression, adjusting for body mass index (BMI), depressive symptoms, demographic and comorbid factors. RESULTS: Women with PCOS had similar sleep duration but were more likely to experience difficulty sleeping often (RRR 1.67, 1.20-2.33, P = 0.003) and sometimes (RRR 1.39, 1.07-1.80, P = 0.015), with restless sleep reported occasionally (RRR, 1.35 1.00-1.83, P = 0.049). They reported severe tiredness often (RRR 1.48, 95% CI 1.08-2.04, P = 0.016) and described more sleep difficulties within the last 12 months (OR 1.29, 1.04-1.60, P = 0.018) on adjusted analyses. Compared to the class of average sleep duration with no sleep disturbances, PCOS was associated with increased relative risk of having average sleep duration with sleep symptoms (RRR 1.40, 95%CI 1.11-1.77, P = 0.004) and short sleep duration with sleep symptoms (RRR 1.46, 95%CI 1.07-1.99, P = 0.016) on adjusted analyses. CONCLUSION: Sleep disturbances are more prevalent amongst women with PCOS after adjusting for BMI, depressive symptoms, demographic and comorbid factors. Targeted screening and management of sleep disturbances is warranted in PCOS.

The effect of surgical weight loss on obstructive sleep apnoea: A systematic review and meta-analysis.

This review aimed to examine the relationship between surgical weight loss and obstructive sleep apnoea (OSA) severity (i.e., apnoea-hypopnoea index [AHI]), and how this relationship is altered by the various respiratory events scoring (RES) criteria used to derive the AHI. A systematic search of the literature was performed up to December 2017. Before-and-after studies were considered due to a paucity of randomised controlled trials (RCTs) available to be reviewed in isolation. Primary outcomes included pre- and post-surgery AHI and body mass index (BMI). Secondary outcomes included sleep study type and RES criteria. Meta-analysis was undertaken where possible. Overall, surgical weight loss resulted in reduction of BMI and AHI, however, OSA persisted at follow-up in the majority of subjects. There was high between-study heterogeneity which was largely attributable to baseline AHI and duration of follow-up when analysed using meta-regression. There was insufficient data to evaluate the impact of different RES criteria on OSA severity. Therefore, more RCTs are needed to verify these findings given the high degree of heterogeneity and future studies are strongly encouraged to report the RES criteria used to enable fair and uniform comparisons of the impact of any intervention on OSA severity.

Primary tracheobronchial amyloidosis associated with tracheobronchomegaly evaluated by novel four-dimensional functional CT.

Amyloid is a heterogeneous family of extracellular proteinaceous deposits characterized by apple-green birefringence on polarized light microscopy. There are rare case reports of these extracellular deposits accumulating in the upper and central airways. Progressive infiltration may impair glottic and airway function with some cases requiring intervention to improve flow. Bronchoscopy and lung function testing provide dynamic information to monitor for disease progression; however, the recent development of 320 multislice computed tomography (320 CT) enables dynamic, four-dimensional (4-D) evaluation of laryngeal and tracheal structure and function and presents as a noninvasive, low-radiation dose surveillance tool. We reviewed a 43-year-old man with primary amyloidosis of the larynx and central airways who presented with an 18-year history of progressive dysphonia without breathlessness and preserved lung function. 4-D CT demonstrated marked thickening of supraglottic folds and trachea with marked tracheal dilatation. Despite gross structural abnormalities, dynamic function assessed throughout inspiration and expiration was normal, demonstrating neither rigidity nor dynamic collapse. This combination of structural and functional assessment of the proximal airway by 4-D CT is a novel application to surveillance for laryngeal and tracheal amyloid.

How to assess, diagnose, refer and treat adult obstructive sleep apnoea: a commentary on the choices.

Obstructive sleep apnoea (OSA) determined by polysomnography is highly prevalent, affecting about 25% of men and 10% of women in the United States, although most have few or no symptoms. Symptomatic moderate to severe OSA has major health implications related to daytime sleepiness, such as increased accidents, altered mood and loss of productivity in the workplace. Severe OSA may increase the risk of cardiovascular disease independent of daytime sleepiness. A major challenge is to correctly identify, from the large community pool of disease, people with symptoms and those at risk of long-term complications. For treatment plans to achieve quality patient outcomes, clinicians must have a clear understanding of patients' symptoms and their motivations for presentation, and be knowledgeable about the evidence surrounding the health risks of OSA and the relative merits of the various diagnostic and treatment options available. The diagnosis of OSA represents a teachable moment to target adverse lifestyle factors such as excessive weight, excessive alcohol consumption and smoking, which may be contributing to OSA and long-term cardiometabolic risk. OSA assessment and management has traditionally involved specialist referral and in-laboratory polysomnography. However, these services may not always be easy to access. Controlled studies have shown that patients with a high pretest probability of symptomatic, moderate to severe OSA can be managed well in primary care, or by skilled nurses with appropriate medical backup, using simplified ambulatory models of care. The future of sleep apnoea assessment and management will likely include models of care that involve early referral to specialists of patients with complex or atypical presentations, and an upskilled and supported primary care workforce to manage symptomatic, uncomplicated, high pretest probability disease.