Association between obstructive sleep apnea and gastroesophageal reflux disease: A systematic review and meta-analysis.

BACKGROUND AND AIM: We aim to conduct a systematic review and determine the association between obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD). METHODS: Literature search for eligible studies was performed across major databases. The main endpoint was to assess the association between GERD and OSA. Subgroup analyses were performed to determine this strength of the association stratified by the diagnostic tools used for OSA (nocturnal polysomnogram or Berlin questionnaire) and GERD (validated reflux questionnaire or esophagogastroduodenoscopy). We also compared sleep efficiency, apnea hypopnea index, oxygen desaturation index, and Epworth Sleepiness Scale in OSA patients with or without GERD. Results were pooled together using Reviewer Manager 5.4. RESULTS: Six studies involving 2950 patients with either GERD or OSA were included in the pooled analysis. Our findings suggest that there was a statistically significant unidirectional association between GERD and OSA (odds ratio [OR] = 1.53, P = 0.0001). Subgroup analyses redemonstrated an OSA-GERD association irrespective of the tools used for diagnosing either GERD or OSA (P = 0.24 and P = 0.82, respectively). Sensitivity analyses demonstrated the same association after controlling for gender (OR = 1.63), BMI (OR = 1.81), smoking (OR = 1.45), and alcohol consumption (OR = 1.79). In patients with OSA, there were no statistically significant differences between patients with or without GERD in terms of apnea hypopnea index (P = 0.30), sleep efficiency (P = 0.67), oxygen desaturation index (P = 0.39), and Epworth Sleepiness Scale (P = 0.07). CONCLUSION: There exists an association between OSA and GERD that is independent of the modalities used for screening or diagnosing both disorders. However, the presence of GERD did not affect the severity of OSA.

Association of obstructive sleep apnea and sleep quality with cognitive function: a study of middle-aged and elderly persons in India.

INTRODUCTION: Symptoms of obstructive sleep apnea (OSA) and poor sleep quality affect around one in ten people in India. We aimed to determine if OSA symptoms and poor sleep quality are independently associated with cognition in middle-aged and elderly urban Indian populations. METHODS: We studied the cross-sectional association between OSA symptoms (by Berlin Questionnaire), poor sleep quality (by Pittsburgh Sleep Quality Index), and cognitive function in adults ≥ 50 years. Using a standard neuropsychological battery for cognitive function, a G-factor was derived as the first rotated principal component assessing domains of information processing, memory, and executive function. The associations of exposures with cognitive measures were modeled using linear regression, adjusted for metabolic risk factors, lifestyle factors, and psychosocial problems, followed by stratified analysis by decadal age group. RESULTS: A total of 7505 adults were enrolled. Excluding those with MMSE < 26 (n 710), of 6795 individuals (49.2% women), mean (SD) age 64.2 (9.0) years, 38.3% had high risk of OSA symptoms, and 15.9% had poor sleep quality. OSA symptoms were negatively associated with cognitive domains of information processing (adjusted beta coefficient of z-score - 0.02, p-value 0.006), memory (- 0.03, 0.014), and G-factor (- 0.11, 0.014) in full-model. Stratified analysis by age group showed significant adverse effects of OSA symptoms on cognition for middle-aged people (50-60 years) (- 0.26, 0.001), but not in later age groups. Poor sleep quality was also associated with lower cognitive scores for G-factor (- 0.48, < 0.001), memory (- 0.08, 0.005), and executive domains (- 0.12, < 0.001), but not with information domain. CONCLUSION: The findings suggest that both symptoms of OSA and poor sleep quality have a direct adverse impact on cognition in an Indian setting. A modest effect of age on the relationship of OSA and cognition was also observed.

Sleep habits and problems across gestational progress in Japanese women.

BACKGROUND: Pregnancy-related anatomic, physiologic, and hormonal factors can occur at different stages of pregnancy and affect sleep disturbances. Sleep problems and habits among Japanese women across gestational stages have not been described. This study aimed to elucidate sleep problems, including a high risk of sleep-disordered breathing and sleep habits, among Japanese women across gestational progress, including postpartum. METHODS: A questionnaire survey using the Pittsburgh Sleep Quality Index (PSQI) and Berlin Questionnaire was conducted for 683 pregnant women (223 in the second trimester, 453 in the third trimester) and 386 postpartum (within 1 week after delivery). RESULTS: The total PSQI score was 5.3 [2.6] in the second trimester, 6.1 [2.8] in the third trimester, and 6.8 [3.1] in the first week postpartum. The percentage of those at high risk for sleep-disordered breathing, as determined by the Berlin Questionnaire, was 11.8% in the second trimester, 21.3% in the third trimester, and 19.2% in the first week postpartum, with the highest percentage of those at high risk in the third trimester of pregnancy. CONCLUSION: The PSQI total score exceeded the cut-off value in the third trimester and the first week postpartum, suggesting sleep deterioration. Therefore, it is necessary to understand and support sleep in pregnant women to ensure safe delivery, postpartum recovery, and health.

Dysphagia and obstructive sleep apnoea in post-extubated intensive care unit patients.

OBJECTIVE: To determine the relationship between dysphagia and obstructive sleep apnoea and its association with age, gender and Glasgow Coma Scale in post-extubated patients in an intensive care setting. METHODS: The correlational study was conducted from July 1 to October 31, 2021, at the intensive care unit of Evercare Hospital, Lahore, Pakistan, and comprised post-extubated patients of either ender aged 45-70 years within 72 hours following extubation and having Glasgow comma scale score 11-15. Gugging Swallowing Screen and Obstructive Sleep Apnoea questionnaires were used for data collection. Data was analysed using SPSS 25. RESULTS: Of the 29 patients with a mean age of 57.45±8.74 years, 18(62.1%) were males. There was a significant correlation between dysphagia and obstructive sleep apnoea (p=0.005). The Obstructive Sleep apnoea score had a significant negative correlation with Glasgow Coma Scale score (p=0.01), while dysphagia revealed a significant positive correlation (p<0.001) with Glasgow Coma Scale score. Age and gender had no significant association with either dysphagia or obstructive sleep apnoea (p>0.05). CONCLUSIONS: There was a significant correlation between dysphagia and obstructive sleep apnoea in post-extubated patients under intensive care. Both dysphagia and obstructive sleep apnoea had a significant correlation with Glasgow Coma Scale score.

Association between the high risk for obstructive sleep apnea and intracranial carotid artery calcification in patients with acute ischemic stroke.

PURPOSE: Obstructive sleep apnea (OSA) is an independent risk factor for stroke. Furthermore, intracranial carotid artery calcification (ICAC) is a marker for subclinical atherosclerosis and future cardiovascular events. We investigated the association between the high risk for OSA and ICAC in patients with acute ischemic stroke. METHODS: We retrospectively investigated 73 patients who were admitted to the hospital with acute ischemic stroke in the internal carotid artery (ICA) territory due to large-artery atherosclerosis. The risk for OSA was assessed using the Berlin Questionnaire, and patients were classified into low-risk (LR-OSA) and high-risk groups (HR-OSA). We compared the burden of ICAC between the two groups. Univariable and multivariable analyses were conducted to investigate the association of high risk for OSA with the presence of calcium in intracranial ICA. RESULTS: The HR-OSA group of 35 patients (48%) was significantly older and had a higher rate of hypertension and diabetes mellitus than the LR-OSA group. The HR-OSA group had more frequent ICAC (92% vs. 63%, p < 0.001), higher Agatston score (162.0 vs. 8.5, p < 0.001), and greater total volume of ICAC (261.2 mm3 vs. 20.1 mm3, p < 0.001) in the intracranial ICA. Presence of calcium in symptomatic intracranial ICA was positively correlated with age (odds ratio, OR, 1.432; 95% confidence interval, CI, 1.098-1.868) and HR-OSA (OR, 18.272; 95% CI, 0.500-668.401) in multivariable logistic regression analysis. CONCLUSIONS: This study showed that the presence of calcium in symptomatic intracranial ICA was related to high risk for OSA in patients with acute ischemic stroke.

Diagnostic accuracy of the Berlin questionnaire and therapeutic effect of nasal continuous positive airway pressure in OSAHS patients with glucose metabolic dysfunction.

PURPOSE: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with alterations in glucose metabolism. The Berlin questionnaire (BQ) is effective in identifying subjects with high risk of OSAHS. However, its validity in patients with glucose metabolic dysfunction remains unclear. Our study aims to examine the diagnostic efficacy of the BQ in detecting OSAHS in patients with glucose metabolic dysfunction and to explore the effect of nasal CPAP on glucose metabolism. METHODS: Patients with glucose metabolic dysregulation were first asked to complete the BQ and then recruited for polysomnogram (PSG). The diagnostic accuracy of the BQ and the relationships between groups with normal glucose tolerance (NGT), elevated fasting blood glucose (IFG), impaired glucose tolerance (IGT), and diabetes mellitus (DM) were analyzed. Subjects with both OSAHS and glucose dysregulation received CPAP treatment and underwent an oral glucose tolerance test. Changes in apnea-hypopnea indices (AHI) and glycemic parameters were calculated to determine the efficacy of CPAP. RESULTS: Glycosylated hemoglobin and insulin levels were statistically different between the high-risk and low-risk groups according to the BQ. For diagnosis of subjects with OSAHS who also had glucose metabolic dysfunction, the sensitivity and specificity of the BQ using AHI cut-off values at 5 events per hour were 73% and 67%. CPAP therapy effectively reduced the blood glucose, HOMA-IR, and insulin levels. CONCLUSIONS: The BQ can be considered to be an effective and economical screening tool for patieints with OSAHS who also have glucose metabolic dysfunction. Treatment with CPAP may improve glycemic parameters.

Effect of arterial blood bicarbonate (HCO3-) concentration on the accuracy of STOP-Bang questionnaire screening for obstructive sleep apnea.

BACKGROUND: To evaluate the effect of arterial bicarbonate (HCO3-) concentration on the accuracy of STOP-Bang questionnaire (SBQ) screening for obstructive sleep apnea (OSA). METHODS: A total of 144 patients with suspected OSA were included. Polysomnograms (PSG) and blood gas analysis were performed, and the Epworth Sleepiness Scale (ESS), STOP-Bang questionnaire, and Berlin questionnaire were completed. The correlation between the arterial HCO3- concentration, apnea hypopnea index (AHI), and other related indicators was analyzed. The scoring results of the ESS, SBQ, and Berlin questionnaire were compared with the PSG results, and the sensitivity and specificity were calculated in the form of a four-cell table. The changes in the sensitivity and specificity of OSA screening after SBQ alone and combined with HCO3- concentration were compared, and ROC curves were drawn. RESULTS: Arterial HCO3- concentration was positively correlated with AHI (r = 0.537, P < 0.001). The ratio of HCO3- concentration ≥ 24.6 mmol/L in the non-OSA group was significantly lower than that in the OSA group (25.0% VS 80.8%, P < 0.001). The sensitivity of the SBQ was higher than that of the ESS (97.5% VS 81.7%, P < 0.001) and the Berlin questionnaire (97.5% VS 79.2%, P < 0.001). There was no statistical significance in the specificity of the three scales (25%, 37.5%, 37.5%). A combined SBQ score ≥ 3 and HCO3- concentration ≥ 24.6 mmol/L showed increased specificity and decreased sensitivity compared with an SBQ score ≥ 3 alone, with a corresponding AUC of 0.771 (P < 0.01) and 0.613 (P > 0.05), respectively. CONCLUSION: The sensitivity of the SBQ was better than that of the Berlin questionnaire and ESS. After combining arterial blood HCO3- concentration, the SBQ questionnaire increased the specificity of OSA prediction and decreased the sensitivity, which improved the accuracy of screening.

Validation of the NoSAS score for screening sleep-disordered breathing: A sleep clinic- based study in Turkey

Background/aim: The NoSAS score is a new tool for the identification of high-risk patients for sleep-disordered breathing (SDB). The aim of this study was to validate the NoSAS score in a sleep clinical population in Turkey and compare its performance with the Epworth Sleepiness Scale (ESS), STOP-Bang, and Berlin questionnaires for high-risk SDB. Materials and methods: This was a retrospective study. Patients who had a full-night PSG examination between 01.03.2017 and 01.01.2018 at the sleep center of our hospital were included in the study. Demographic characteristics, anthropometrics measurements, ESS, STOP-Bang, and Berlin scores were collected from the existing data of the patients. The NoSAS score was subsequently calculated based on available data. Predictive parameters for each screening questionnaires were calculated to compare the discriminative power of those for high-risk SDB. Results: A total of 450 patients were included in the study. The sensitivity, specificity, PPV, and NPV of the NoSAS score were 81%, 51.2%, 88.2%, and 37.5% for an AHI (apnea­hypopnea index) ≥ 5 event/h and 84.5%, 38.2%, 66%, and 63.4% for an AHI ≥ 15 event/h, respectively. AUC percentages for the NoSAS score, STOP-Bang questionnaire, Berlin questionnaire, and ESS were 0.740, 0.737, 0.626, and 0.571 for an AHI ≥ 5 events/h and 0.715, 0.704, 0.574, and 0.621 for an AHI ≥ 30 events/h. The NoSAS score had a false negative rate of 2.9% for severe SDB. Conclusion: The NoSAS score had a good degree of differentiation for SDB and can be used as an easily applicable, subjective, and effective screening tool in a sleep clinical population in Turkey. Not only in moderate to severe SDB but also in mild SDB, the NoSAS score performed better than the other 3 screening tools.

Stroke during sleep and obstructive sleep apnea: there is a link.

OBJECTIVES: The onset of ischemic stroke symptoms has been established to have a diurnal variation, with a sizeable proportion (8-28%) occurring during sleep. Obstructive sleep apnea (OSA) has been established as an important risk factor for ischemic stroke. However, data on the relationship between OSA and wake-up stroke (WUS) has been scarce. The aim of our study is to determine the relationship between OSA and WUS. METHODS: This is a case-control study conducted on acute stroke patients who presented to one of two major medical centers in Riyadh of Saudi Arabia. Those who woke up with the symptoms were labeled as WUS, and those whose stroke occurred while awake were labeled as non wake-up stroke (NWUS). The Berlin Questionnaire, which was submitted to either the patient or his/her partner, was used to determine the frequency of OSA in the two groups. RESULTS: One hundred seven patients (60% males) with acute stroke were admitted between March 2016 and March 2017. Of the 40 patients with WUS, 29 (72.5%) had underlying OSA based on the Berlin Questionnaire, whereas only 30 (45%) of the 67 patients with NWUS have underlying OSA. Logistic regression analysis showed OSA is highly prevalent in the patients with WUS (OR = 3.25; 95% CI = 1.397-8.38; p = 0.0053). CONCLUSION: OSA is an important risk factor for ischemic stroke during sleep. Health care providers must be vigilant in inquiring about symptoms suggestive of OSA in every ischemic stroke patient, especially the patient whose stroke occurred during sleep.

Obstructive sleep apnea as a risk factor for preeclampsia-eclampsia.

PURPOSE: Preeclampsia-eclampsia remains one of the leading causes of maternal and perinatal morbidity and mortality. Emerging evidence suggests that obstructive sleep apnea (OSA), which has been linked to hypertension in the general population, may play role in hypertensive disorders in pregnancy, including preeclampsia-eclampsia. However, little research has been conducted in Asia (no data in Thailand) on the effects of OSA on preeclampsia-eclampsia. We aimed to examine the association between OSA and preeclampsia-eclampsia among Thai pregnant women. METHODS: We conducted a large prospective cohort study among Thai pregnant women who were in the second trimester of singleton pregnancy. The Berlin Questionnaire was administered to evaluate the risk for OSA. Preeclampsia-eclampsia was diagnosed by standard clinical assessment. Multivariate models were applied in adjustment for confounding factors. RESULTS: Enrolled were 1345 pregnant women. The overall prevalence of high risk for OSA was 10.1% (95% confidence intervals [CIs] 8.5-11.7), and it was significantly associated with pre-pregnancy body mass index and score on the Perceived Stress Scale. An adjusted odds ratio (OR) for preeclampsia-eclampsia in women with high risk for OSA was 2.72 (95% CI 1.33-5.57). CONCLUSIONS: Pregnant women with high risk for OSA are at increased risks for preeclampsia-eclampsia compared to those with low risk for OSA. Our results support a role for screening for OSA by BQ during antenatal care.

A validation study on three screening questionnaires for obstructive sleep apnea in a Korean community sample.

PURPOSE: Obstructive sleep apnea (OSA) is highly prevalent and causes serious cardiovascular complications. Several screening questionnaires for OSA have been introduced, but only few validation studies have been conducted in general population. The aim of the present study was to assess the diagnostic value of three OSA screening questionnaires (Berlin Questionnaire, BQ; STOP-Bang Questionnaire, STOP-B; Four-Variable Screening Tool, Four-V) in a Korean community sample. METHODS: A total of 1148 community-dwelling participants completed the BQ, STOP-B, and Four-V. An overnight in-laboratory polysomnography (PSG) was conducted in randomly selected 116 participants. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and area under the curve (AUC) were calculated. RESULTS: The Four-V with cutoff ≥ 8 showed high sensitivity for overall OSA (69.4%), and the Four-V with cutoff ≥ 9 showed high specificity for both overall OSA (81.5%) and moderate to severe OSA (69.0%). On the other hand, the STOP-B showed acceptable sensitivity and specificity for both overall OSA (61.3 and 79.6%, respectively) and moderate to severe OSA (72.4 and 67.8%, respectively). The STOP-Bang also showed the largest area under the receiver-operator characteristic curve for both overall OSA (0.752) and moderate to severe OSA (0.750). The BQ showed the lowest performance in predicting OSA. CONCLUSIONS: Among the three questionnaires, the STOP-B was revealed as the most useful screening tool for OSA in terms of sensitivity, specificity, and area under the receiver-operator characteristic curve in the population of South Korea.

Magnitude and Determinants of Patients at Risk of Developing Obstructive Sleep Apnea in a Non-Communicable Disease Clinic.

Background and Objective: Obstructive sleep apnea (OSA) is a common chronic disorder worldwide, which can adversely affect the cardiovascular system among non-communicable disease (NCD) patients. It is underdiagnosed-or rather not diagnosed-in primary care settings due to the costly diagnostic techniques involved. This study aimed to assess the number of study participants at risk of developing OSA and to assess and quantify the risk factors associated with this disorder. Materials and Methods: A cross-sectional study was performed in an NCD clinic of a rural health training center, Karikalampakkam, Puducherry of South India from August 2018 to October 2018. A Modified Berlin Questionnaire (MBQ) was used to screen the study participants at risk for OSA. Four-hundred-and-seventy-three people aged 18 years and above were included in the study, using systematic random sampling. Respondents' socio-demographic and morbidity characteristics, as well as clinical and anthropometric parameters including body weight, height, blood pressure, neck, hip and waist circumference were collected. Data was captured using Epicollect5 and analyzed using SPSS version 20.0. Results: One-fourth (25.8%) of the respondents were at high risk of developing OSA. In terms of gender, 27.9% of the men and 23.8% of the women were at high risk for OSA. In univariate analyses, the risk of developing OSA was significantly associated with a history of diabetes mellitus, hypertension, dyslipidemia and gastro-esophageal reflux disease, weight, body mass index, neck, waist and hip circumference, waist-hip ratio, and systolic and diastolic blood pressure. Multivariate logistic regression analysis showed that a history of dyslipidemia (aOR, 95% CI = 2.34, 1.22-4.48), body mass index (aOR, 95% CI = 1.15, 1.06-1.22) and waist circumference (aOR, 95% CI = 1.10, 1.07-1.14) emerged as significant predictors of risk for OSA. Conclusions: A considerable proportion of NCD patients with easily detectable attributes are at risk of developing OSA, but still remain undiagnosed at a primary health care setting. The results obtained using MBQ in this study were comparable to studies performed using polysomnography. Dyslipidemia, body mass index and waist circumference were independent risk factors for predicting a risk of developing OSA. Prospective studies are needed to confirm whether a reduction in these risk factors could reduce the risk for OSA.

Risk Assessment for Self Reported Obstructive Sleep Apnea and Excessive Daytime Sleepiness in a Greek Nursing Staff Population.

Background and objectives: The risk assessment of Obstructive Sleep Apnea (OSA) and Excessive Daytime Sleepiness (EDS) in specific occupational populations is important due to its association with morbidity. The aim of the present study was to identify the risk of OSA development and EDS in a Greek nursing staff population. Materials and Methods: In this cross-sectional study a total of 444 nurses, 56 males (age = 42.91 ± 5.76 years/BMI = 27.17 ± 4.32) and 388 females (age = 41.41 ± 5.92 years/BMI = 25.08 ± 4.43) working in a Greek secondary and tertiary hospital participated during the period from 18 January 2015 to 10 February 2015. The participants completed the Berlin Questionnaire (BQ), concerning the risk for OSA and the Epworth Sleepiness Scale (ESS), concerning the EDS. The work and lifestyle habits of the participants were correlated with the results of the questionnaires. Results: According to the BQ results 20.5% (n = 91) of the nursing staff was at high risk for OSA. Increased daytime sleepiness affected 27.7% (n = 123) of the nurses according to ESS results. Nurses at risk for Obstructive Sleep Apnea Syndrome (OSAS), positive for both BQ and ESS, were 7.66% (n = 34). Out of the nurses that participated 77% (n = 342) were working in shifts status and had significant meal instability (breakfast p < 0.0001, lunch p < 0.0001, dinner p = 0.0008). Conclusions: The population at high risk for OSA and EDS in the nursing staff was found to be 20% and 28% respectively. High risk for OSAS was detected in 7.66% of the participants. The high risk for OSA and EDS was the same irrespective of working in shift status. In specific, nursing population age was an independent predictor for high risk for OSA and skipping lunch an independent predictor of daytime sleepiness.

Screening extremely obese pregnant women for obstructive sleep apnea.

BACKGROUND: Obesity is prevalent among pregnant women in the United States; obstructive sleep apnea is highly comorbid with obesity and is associated with adverse pregnancy outcomes. Screening for obstructive sleep apnea in pregnant women has remained a challenge because of a lack of validated screening tools. OBJECTIVE: The purpose of this study was to evaluate established obstructive sleep apnea screening tools, a sleepiness scale, and individual component items in a cohort of pregnant women with extreme obesity in mid pregnancy with the use of objective testing to determine obstructive sleep apnea status and to describe the prevalence of obstructive sleep apnea among women with extreme obesity. STUDY DESIGN: Adult pregnant subjects, between 24 and 35 weeks gestation, with a body mass index ≥40 kg/m2 at the time of enrollment completed obstructive sleep apnea screening tools (Berlin Questionnaire, American Society of Anesthesiologists checklist, and STOP-BANG questionnaire) and the Epworth Sleepiness Scale; they also underwent physical examination of the neck, mouth, and airway. The published obstructive sleep apnea in pregnancy prediction score was calculated for each subject. Obstructive sleep apnea status for each subject was determined by the results of an overnight, unattended type III home sleep apnea test. RESULTS: Twenty-four percent of pregnant women with extreme obesity had obstructive sleep apnea on home sleep apnea testing in mid pregnancy (Apnea-Hypopnea Index, ≥5 events per hour]. Established obstructive sleep apnea screening tools performed very poorly to screen for obstructive sleep apnea in this cohort. Age, body mass index, neck circumference, frequently witnessed apneas, and highly likely to fall asleep while driving were associated most strongly with obstructive sleep apnea status in this cohort. CONCLUSION: We found that 24% of pregnant women with body mass index ≥40 kg/m2 between 24 and 35 weeks gestation have obstructive sleep apnea, defined as Apnea-Hypopnea Index ≥5 events per hour on an overnight type III home sleep apnea test. We found the Berlin Questionnaire, American Society of Anesthesiologists checklist, STOP-BANG, obstructive sleep apnea in pregnancy score by Facco et al, and the Epworth Sleepiness Scale were not useful screening tools for obstructive sleep apnea in a cohort of obese pregnant women. However, age, body mass index, neck circumference, frequently witnessed apneas, and likely to fall asleep while driving were associated with obstructive sleep apnea in this cohort. Further studies are needed to adjust the criteria and thresholds within the available screening tools to better predict obstructive sleep apnea in pregnant women with obesity.

[Comparison of the NoSAS score with four different questionnaires as screening tools for obstructive sleep apnea-hypopnea syndrome].

Objective: To evaluate the clinical utility of the NoSAS score in the screening of patients with obstructive sleep apnea-hypopnea syndrome(OSAHS), and to compare the performance of the NoSAS score with other tools including Epworth Sleepiness Scale(ESS), STOP, STOP-Bang(SBQ) and Berlin questionnaires. Methods: A total of 444 consecutive patients(328 males and 116 females) with suspected OSAHS who underwent an overnight polysomnography(PSG) were recruited into this study. Five questionnaires including the NoSAS score, ESS, STOP, SBQ and Berlin were completed. Based on the severity of OSAHS which was determined by apnea-hypopnea index(AHI), the patients were classified into 4 groups: normal(<5 events/h), mild(5-15 events/h), moderate(15-30 events/h) and, severe (≥30 events/h) OSA.Sensitivity, specificity, positive predictive values, negative predictive values and the area under the receiver operating characteristics curve of 5 questionnaires were calculated. Results: With AHI≥5 events/h as the standard diagnosis of OSAHS, the NoSAS score and SBQ questionnaire showed a moderate performance, with the NoSAS score having the largest area under the ROC curve(0.753, P<0.001), followed by the SBQ questionnaire (0.727, P<0.001). The performance of the ESS, Berlin, and the STOP questionnaire was not high. Using mild moderate-severe(≥5 events/h), moderate-severe(≥15 events/h), and severe(≥30 events/h)OSAHS as cutoffs, NoSAS had the highest specificity and positive predictive values(80.2% and 88%, 72% and 69.8%, 66.3% and 50.5%), and the sensitivity and negative predictive values were (51.5% and 36.9%, 56.5% and 59.1%, 66.3% and 74.2%) .SBQ had the highest sensitivity and the negative predictive values(80.2% and 88%, 72% and 69.8%, 66.3% and 50.5%), and the specific and positive predictive values were (45.7% and 81.0%, 39.1% and 61.9%, 34.8% and 44.4%). The NoSAS score ≥ 7 had higher sensitivity and negative predictive value(75.0% and 47.1%, 78.1% and 66.5%, 82.7% and 81.9%)than the NoSAS socre ≥ 8. With AHI≥5 events/h as the standard diagnosis of OSAHS, the NoSAS score and the SBQ questionnaire had a higher accuracy than the other 3 questionnaires as screening questionnaires for diagnosing OSAHS, and the value of DOR were 4.298 and 3.758 respectively. Conclusions: The NoSAS score and the SBQ questionnaire have a moderate performance in diagnosing OSAHS. The NoSAS score is a new screening tool, and it is similar to the SBQ questionnaire, being also simple and effective. While the SBQ questionnaire is more widely used, it is necessary to further evaluate the diagnostic value of NoSAS score.

Validation of NoSAS score for screening of sleep-disordered breathing in a multiethnic Asian population.

PURPOSE: The NoSAS score was developed to identify subjects at high risk of sleep-disordered breathing (SDB). We aimed to validate the NoSAS score in a multiethnic Asian cohort and compare its performance to the STOP-Bang and Berlin questionnaires. METHODS: A sample of 242 subjects selected from a population-based cohort in Singapore completed home-based sleep testing with an Embletta device (type 3 monitor). All subjects were given the STOP-Bang and Berlin questionnaires for self-administration prior to the sleep study. The NoSAS score was subsequently calculated based on available demographic data and Berlin questionnaire responses. RESULTS: The prevalence of severe SDB, defined as an apnea-hypopnea index cutoff of ≥30 events/h, was 10.7%. The number of subjects who were classified as high risk by the NoSAS score and STOP-Bang and Berlin questionnaires were 76 (31.4%), 89 (36.8%), and 79 (32.6%), respectively. The sensitivity, specificity, and negative and positive predictive values of the NoSAS score to predict severe SDB were 69.2, 73.1, 95.2, and 23.7%, respectively. The STOP-Bang and Berlin questionnaires performed similarly to the NoSAS score, with area under the curve (AUC) values of all three questionnaires clustered around 0.682-0.748. Compared to the STOP-Bang (94.8%) and Berlin questionnaires (96.3%), the NoSAS score (95.2%) had equally high negative predictive value in ruling out severe SDB. CONCLUSIONS: The NoSAS score performed similarly to the STOP-Bang and Berlin questionnaires in a multiethnic Asian cohort. All three questionnaires had high negative predictive values in ruling out severe SDB and may have utility as screening tools.

Multiple strategy peer-taught evidence-based medicine course in a poor resource setting.

BACKGROUND: Teaching Evidence Based Medicine (EBM) is becoming a priority in the healthcare process. For undergraduates, it has been proved that integrating multiple strategies in teaching EBM yields better results than a single, short-duration strategy. However, there is a lack of evidence on applying EBM educational interventions in developing countries. In this study, we aim to evaluate the effectiveness of a multiple strategy peer-taught online course in improving EBM awareness and skills among medical students in two developing countries, Syria and Egypt. METHODS: We conducted a prospective study with pre- and post- course assessment of 84 medical students in three universities, using the Berlin questionnaire and a set of self-reported questions which studied the students' EBM knowledge, attitude and competencies. The educational intervention was a peer-taught online course consisting of six sessions (90 min each) presented over six weeks, and integrated with assignments, group discussions, and two workshops. RESULTS: The mean score of pre- and post-course Berlin tests was 3.5 (95% CI: 2.94-4.06) and 5.5 (95% CI: 4.74-6.26) respectively, increasing by 2 marks (95% CI: 1.112-2.888; p-value <0.001), which indicates a statistically significant increase in students' EBM knowledge and skill, similar to a previous expert-taught face to face contact course. Self-reported confidences also increased significantly. However, our course did not have a major effect on students' attitudes toward EBM (1.9-10.8%; p-value: 0.12-0.99). CONCLUSION: In developing countries, multiple strategy peer-taught online courses may be an effective alternative to face to face expert-taught courses, especially in the short term.

Obstructive sleep apnea and the risk of preterm delivery.

OBJECTIVE: The aim of this study was to evaluate the risk of obstructive sleep apnea (OSA) to preterm delivery (PTD), using the Berlin Questionnaire (BQ). METHODS: This was a large, prospective cohort study among pregnant Thai women. The BQ was employed for symptom-based OSA screening during the second trimester, and PTD was recorded in 1345 pregnant women. Multivariate models were applied in controlling for potential confounders. RESULTS: The overall prevalence of the high risk of OSA was 10.1 %, and it was significantly associated with pre-pregnancy body mass index and score on the Perceived Stress Scale. An adjusted odds ratio for PTD in women with a high risk of OSA was 2.00 (95 % confidence intervals (CIs) = 1.20, 3.34). Stratified analyses, after adjusting for confounding factors, indicated that a high risk of OSA was associated with an increased risk of spontaneous preterm delivery (odds ratio (OR) = 2.45, 95 % CI = 1.20, 5.02), but not with preterm premature rupture of membranes (OR = 1.61, 95 % CI = 0.61, 4.26), and medically indicated preterm delivery (OR = 1.83, 95 % CI = 0.72, 4.64). CONCLUSION: Pregnant women with a high risk of OSA are at an increased risk of having PTD, compared with pregnant women with a low risk of OSA.

An epidemiological survey of obstructive sleep apnea-hypopnea syndrome among edentulous population based on modified Berlin questionnaire.

PURPOSE: This study aims to investigate the percentage of people in high risk of obstructive sleep apnea-hypopnea syndrome (OSAHS) in edentulous population using the modified Berlin questionnaire (MBQ), to identify sex difference in percentage of edentulous people at high risk of OSAHS, and to analyze the occurrence rate of OSAHS-related symptoms that were not included in the MBQ in this group of people. METHODS: Five hundred and forty patients (edentulous in mandible or maxilla or both) were recruited to participate in this study. Demographic information, nocturnal denture wearing habit, and sleeping posture were recorded. Meanwhile, subjects completed the MBQ in which participants' snoring behavior, wake-time sleepiness or fatigue, and the presence of obesity or hypertension were investigated. RESULTS: Four hundred qualified questionnaires were obtained. According to the MBQ, about 31 % of the subjects were classified at high risk of OSAHS. No significant difference in the percentage of people at high risk of OSAHS was found between male and female groups. Dry or sore mouth and throat, polyuria during sleep, and difficult to fall asleep/easy to wake up showed high occurrence rate equal to or higher than 60 % in the high-risk group. CONCLUSIONS: According to the MBQ, about 31 % of the edentulous population was identified as high risk of OSAHS. Equal attention should be given to elderly edentulous female and male since they are at the same level of risk of developing OSAHS.

Sleep disorders in pregnancy and their association with pregnancy outcomes: a prospective observational study.

PURPOSE: Sleep disturbances such as insomnia, nocturnal awakenings, restless legs syndrome, habitual snoring, and excessive daytime sleepiness are frequent during pregnancy, and these have been linked to adverse maternal and fetal outcomes. METHODS: A prospective observational study was performed in high-risk Indian pregnant women. We used modified Berlin questionnaire (MBQ), Pittsburgh sleep quality index (PSQI), International Restless Legs Syndrome Study Group 2011 criteria, and Epworth sleepiness scale to diagnose various sleep disorders, such as symptomatic OSA, poor sleep quality and insomnia, RLS, and excessive daytime sleepiness, respectively, in successive trimesters of pregnancy. Outcome variables of interest were development of gestational hypertension (GH), gestational diabetes mellitus (GDM), and cesarean delivery (CS); the Apgar scores; and low birth weight (LBW). The relationship between sleep disorders and outcomes was explored using logistic regression analysis. RESULTS: Outcome data were obtained in 209 deliveries. As compared to nonsnorers, women who reported snoring once, twice, and thrice or more had odds ratios for developing GH-4.0 (95 % CI 1.3-11.9), 1.5 (95 % CI 0.5-4.5), and 2.9 (95 % CI 1.0-8.2) and for undergoing CS-5.3 (95 % CI 1.7-16.3), 4.9 (95 % CI 1.8-13.1), and 5.1 (95 % CI 1.9-14.9), respectively. Pregnant women who were persistently positive on MBQ had increased odds for GH and CS. CONCLUSIONS: Snoring and high-risk MBQ in pregnant women are strong risk factors for GH and CS. In view of the significant morbidity and health care costs, simple screening of pregnant women with questionnaires such as MBQ may have clinical utility.