The relationship between pain and sleep in pediatric sickle cell disease.

BACKGROUND: Pain and sleep disturbances are prevalent complications experienced by pediatric patients with sickle cell disease (SCD). This study aims to identify associations between pain and sleep, and to characterize sleep chronotype and social jetlag in children and adolescent patients with SCD. METHODS: We performed a cross-sectional survey of 105 pediatric patients with SCD aged 8-17 years using PROMIS (Patient Reported Outcomes Measurement System) pain interference, sleep disturbance, and sleep-related impairment item banks. The µMCTQ (Ultra-short Munich Chronotype Questionnaire) assessed chronotype and social jetlag. Analyses were performed to assess associations between PROMIS measures, sleep patterns, and clinical variables. RESULTS: Female participants reported higher T-scores for sleep-related impairment than males (females: 56.7 ± 10 vs. males 50.2 ± 9.4, p = .0009). Patients with one or more emergency department (ED) visits for pain in the last 12 months reported greater sleep disturbance (55.0 ± 8.5 vs. 50.7 ± 10, p = .046) and sleep-related impairment (57.1 ± 9.3 vs. 52.1 ± 10.2, p = .03) than patients without any ED visits for pain in the last 12 months. Pain interference was significantly associated with both sleep disturbance (r = .49, p < .0001) and sleep-related impairment (r = .46, p < .0001). The average mid-sleep time was 4:14 ± 1:44 a.m. and the average social jetlag (hh:mm) was 2:32 ± 1:35. CONCLUSION: Our study demonstrates that pain interference is associated with both sleep disturbance and sleep-related impairment. PROMIS measures can identify patients that suffer from pain and sleep disturbances and highlights the need to conduct longitudinal prospective studies to define the directionality of pain and sleep in SCD.

Adapting Brief Behavioral Treatment for Insomnia for Former National Football League Players: A Pilot Study.

OBJECTIVES: Insomnia is highly prevalent among persons with chronic pain. Although cognitive behavioral therapy for insomnia is recommended as first-line treatment for insomnia, it is underutilized. We tested the feasibility of a potentially scalable alternative - Brief Behavioral Therapy for Insomnia (BBTI) for former National Football League (NFL) players, a group with a high prevalence of chronic pain. We assessed changes in sleep, pain, and psychological health. METHODS: Single-arm clinical trial of an adapted telephone-delivered BBTI intervention in 40 former NFL players with insomnia. We collected data on changes in sleep, pain, and psychological health outcomes. RESULTS: Among former players (30% racial/ethnic minorities), BBTI was both acceptable and feasible. BBTI was associated with improvements in sleep disturbance (primary exploratory sleep outcome, mean T-score change -6.2, 95% CI: -7.6, -4.8), sleep-related impairment (mean T-score change -5.7, 95% CI: -7.9, -3.5) and insomnia severity (mean change -5.3, 95% CI: -6.8, -3.5) post-intervention. Improvements were maintained at 2-months. BBTI was also associated with improvements in pain interference and intensity, but not psychological health. CONCLUSION: An adapted telephone-delivered BBTI is acceptable and feasible among retired players with a range of insomnia symptoms and shows promise for improving sleep and pain. These data support the need for future trials assessing BBTI's effect on both sleep and pain outcomes.

Eliminating Sleep Health Disparities and Achieving Health Equity: Seven Areas for Action in the Behavioral Sleep Medicine Community.

Racial and ethnically minoritized and under-resourced populations do not reap the same benefits of sufficient sleep as their white counterparts resulting in insufficient sleep and sleep health disparities. Research exploring these disparities have documented a plethora of factors including social determinants of health, community violence, and structural issues - all of which are associated with adverse sleep. There are robust evidence base behavioral intervention that can be leveraged to improve sleep health among racial and ethnic groups. However, EBIs are not well leveraged. In 2021, with participation from members of the society of behavioral sleep medicine, we conducted this report to bring together the field of behavioral sleep medicine including researchers, clinicians and trainees to discuss gaps and opportunities at the intersection of the COVID-19 pandemic, systemic racism, and sleep health. The goals were anchored around seven recommendations toward reducing disparities in the near-term and longer-term approaches to eliminating disparities. Furthermore, we acknowledge that reducing and eliminating disparities in sleep health requires a multifaceted approach that includes a focus on individual, community, health care and societal levels of influence with participation from diverse partners including federal, state and local.

Association Between Sleep Apnea and Blood Pressure Control Among Blacks.

BACKGROUND: Blacks have a high prevalence of hypertension and uncontrolled blood pressure (BP), each of which may be partially explained by untreated sleep apnea. We investigated the association of sleep apnea with uncontrolled BP and resistant hypertension in blacks. METHODS: Between 2012 and 2016, Jackson Heart Sleep Study participants (N=913) underwent an in-home Type 3 sleep apnea study, clinic BP measurements, and anthropometry. Moderate or severe obstructive sleep apnea (OSA) was defined as a respiratory event index ≥15, and nocturnal hypoxemia was quantified as percent sleep time with <90% oxyhemoglobin saturation. Prevalent hypertension was defined as either a systolic BP ≥130 mm Hg or diastolic BP >80mm Hg, use of antihypertensive medication, or self-report of a diagnosis of hypertension. Controlled BP was defined as systolic BP <130 mm Hg and diastolic BP <80 mm Hg; uncontrolled BP as systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg with use of 1 to 2 classes of antihypertensive medication; and resistant BP as systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg with the use of ≥3 classes of antihypertensive medication (including a diuretic) or use of ≥4 classes of antihypertensive medication regardless of BP level. Multinomial logistic regression models were fit to determine the association between OSA severity and uncontrolled BP or resistant hypertension (versus controlled BP) after multivariable adjustment. RESULTS: The analytic sample with hypertension (N=664) had a mean age of 64.0 (SD,10.6) years, and were predominately female (69.1%), obese (58.6%), and college educated (51.3%). Among the sample, 25.7% had OSA, which was untreated in 94% of participants. Overall, 48% of participants had uncontrolled hypertension and 14% had resistant hypertension. After adjustment for confounders, participants with moderate or severe OSA had a 2.0 times higher odds of resistant hypertension (95% confidence interval [CI], 1.14-3.67). Each standard deviation higher than <90% oxyhemoglobin saturation was associated with an adjusted odds ratio for resistant hypertension of 1.25 (95% CI 1.01-1.55). OSA and <90% oxyhemoglobin saturation were not associated with uncontrolled BP. CONCLUSION: Untreated moderate or severe OSA is associated with increased odds of resistant hypertension. These results suggest that untreated OSA may contribute to inadequate BP control in blacks.

Circadian Regulation of Blood Pressure: of Mice and Men.

PURPOSE OF REVIEW: Blood pressure (BP) exhibits strong diurnal variations that have been shown to be important for normal physiology and health. In this review, we highlight recent advances in both basic and clinic research on how the circadian clock affects these BP rhythms. RECENT FINDINGS: Tissue-specific and inducible knockout rodent models have provided novel ways to dissect how circadian clocks regulate BP rhythms and demonstrated that loss of these rhythms is associated with the development of disease. The use of circadian-specific research protocols has translated findings from rodent models to humans, providing insight into circadian control of BP, as well as how sleep, activity, and other factors influence diurnal BP rhythms. Circadian mechanisms play an important role in the regulation of diurnal BP rhythms. Future research needs to extend these findings to clinical populations and determine the extent to which circadian factors may play a role in the development of novel treatment approaches to the management of hypertension.

Effects of Integrated Telehealth-Delivered Cognitive-Behavioral Therapy for Depression and Insomnia in Rural Older Adults.

BACKGROUND: We examined the effects of integrated cognitive-behavioral therapy for depression and insomnia (CBT-D + CBT-I) delivered via videoconferening in rural, middle aged and older adults with depressive and insomnia symptoms. METHOD: Forty patients with depressive and insomnia symptoms were randomized to receive either 10 sessions of CBT-D + CBT-I or usual care (UC). Patients in the integrated CBT condition were engaged in telehealth treatment through Skype at their primary care clinic. Assessments were conducted at baseline, post-treatment, and 3-month follow-up. RESULTS: CBT-D +CBT-I participants had significantly greater improvements in sleep at post-treatment and 3-month follow-up as compared to the UC participants. The time by group interaction for depression was not significant; both the CBT-D + CBT-I and UC conditions had a decrease in depressive symptoms over time. CONCLUSION: While integrated CBT benefits both depression and insomnia symptoms, its effects on depression are more equivocal. Further research should consider expanding the depression treatment component of integrated CBT to enhance effectiveness.

Epidemiology of bedtime, arising time, and time in bed: analysis of age, gender, and ethnicity.

This study investigated the epidemiology of bedtime (BT), arising time (AT), and time in bed (TIB) as a function of age, gender, and ethnicity. Sleep diary data were analyzed for 746 randomly selected community participants. This sample was comprised of 364 men (48.8%) and 382 women (51.2%), 532 Caucasians (71.3%) and 214 African Americans (28.7%), and participant ages ranged from 20 to 98 years. Regression analyses showed a main effect of age on subjective BT, AT, and TIB. The addition of gender and ethnicity to the regression model added significant variance for TIB, but not BT or AT. In general, BT declined across the lifespan, but AT showed a quadratic pattern that peaked in young adulthood, was stable in the middle years, and peaked again in the later years. This age-related combination of BT and AT resulted in greater TIB for older adults than other age groups. Women spent significantly greater TIB than men, and African Americans spent significantly more TIB than Caucasians. These results suggest that there are distinct behavioral sleep patterns associated with age and, in the case of TIB, gender and ethnicity. These patterns may have significant clinical implications, particularly with respect to age.

Effects of exercise on sleep in patients with epilepsy: A systematic review.

Exercise interventions in epilepsy have been shown to improve seizure frequency, physical capacity, quality of life, mood, and cognitive functioning. However, the effectiveness of exercise in improving sleep in epilepsy is less clear. The purpose of this report is to identify the published literature regarding exercise interventions in people with epilepsy to determine 1) what proportion of published clinical trials assess sleep as an outcome, and 2) what benefits of exercise interventions on sleep have been observed. We searched the PubMed, PsycINFO, and SCOPUS electronic databases using the search terms "epilepsy AND [exercise OR physical activity]" and identified 23 articles reporting on 18 unique clinical trials. Nine studies were conducted in adults, five in children, and four in adults and children with active seizures, controlled seizures, or both. Exercise modalities included aerobic exercise, strength training, walking, and yoga, among others, and some also included educational and motivational components. Exercise effects on sleep were tested in four studies, two of which only included indirect measures of sleep- and rest-related fatigue, with mixed results. Of the two reports assessing sleep directly, one reported marginal non-significant improvements in subjective sleep quality and no improvements in objective sleep quality in children after twelve weeks of walking, and the other reported no benefits in subjective sleep quality after twelve weeks of combined aerobic, strength, and flexibility training in adults. Given the health benefits of sleep and detrimental effects of sleep deprivation in epilepsy, epilepsy researchers need to assess the effects of exercise interventions on sleep.

Disruptions in Sleep Health and Independent Associations with Psychological Distress in Close Family Members of Cardiac Arrest Survivors: A Prospective Study.

Background: While recent guidelines have noted the deleterious effects of poor sleep on cardiovascular health, the upstream impact of cardiac arrest-induced psychological distress on sleep health metrics among families of cardiac arrest survivors remains unknown. Methods: Sleep health of close family members of consecutive cardiac arrest patients admitted at an academic center (8/16/2021 - 6/28/2023) was self-reported on the Pittsburgh Sleep Quality Index (PSQI) scale. The baseline PSQI administered during hospitalization was cued to sleep in the month before cardiac arrest. It was then repeated one month after cardiac arrest, along with the Patient Health Questionnaire-8 (PHQ-8) to assess depression severity. Multivariable linear regressions estimated the associations of one-month total PHQ-8 scores with changes in global PSQI scores between baseline and one month with higher scores indicating deteriorations. A prioritization exercise of potential interventions categorized into family's information and well-being needs to alleviate psychological distress was conducted at one month. Results: In our sample of 102 close family members (mean age 52±15 years, 70% female, 21% Black, 33% Hispanic), mean global PSQI scores showed a significant decline between baseline and one month after cardiac arrest (6.2±3.8 vs. 7.4±4.1; p<0.01). This deterioration was notable for sleep quality, duration, and daytime dysfunction components. Higher PHQ-8 scores were significantly associated with higher change in PSQI scores, after adjusting for family members' age, sex, race/ethnicity, and patient's discharge disposition [ß=0.4 (95% C.I 0.24, 0.48); p<0.01]. Most (n=72, 76%) prioritized interventions supporting information over well-being needs to reduce psychological distress after cardiac arrest. Conclusions: There was a significant decline in sleep health among close family members of cardiac arrest survivors in the acute phase following the event. Psychological distress was associated with this sleep disruption. Further investigation into their temporal associations is needed to develop targeted interventions to support families during this period of uncertainty. WHAT IS KNOWN: Sleep health has been identified as a key element in maintaining cardiovascular health.Close family members of critically ill patients experience suboptimal sleep health and psychological distress may contribute to it. WHAT THE STUDY ADDS: It is breaking new ground in understanding the sleep health dynamics of close family members of cardiac arrest survivors, a critical but often overlooked group of caregivers.The study highlights significant associations between psychological distress and poor sleep that further deteriorates within the first month after a loved one's cardiac arrest.Families of cardiac arrest survivors expressed a high priority for information-based interventions to help alleviate psychological distress during the initial month following the cardiac event emphasizing the need for targeted, accessible, resources to address their psychological and potentially sleep-related challenges.

Telehealth cognitive behavior therapy for co-occurring insomnia and depression symptoms in older adults.

OBJECTIVE: Telehealth has proven effective with a wide range of disorders, but there is a paucity of data on the use of telehealth using cognitive-behavior therapy (CBT) with late-life insomnia and depression. This pilot study was designed to examine the feasibility and effectiveness of using telehealth to treat older adults with comorbid insomnia and depression living in rural Alabama. METHOD: Five patients received 10 sessions of CBT for insomnia and depression. Patients were engaged in treatment via Skype from their primary care physician's office. Assessments were conducted at baseline, posttreatment, and 2-month follow-up. RESULTS: Patients exhibited clinically significant improvement in both insomnia (sleep diaries and Insomnia Severity Index) and depression (Hamilton Rating Scale for Depression) at posttreatment, and these gains were well maintained at 2-month follow-up. CONCLUSIONS: These preliminary data suggest that telehealth may be an effective means of providing treatment to older adults, including underserved populations.

Discrimination and insomnia: Examining depressive symptoms and nicotine withdrawal through a serial mediation model in a sample of smokers.

Insomnia is a common sleep disorder associated with poor health outcomes. Individuals from racially underrepresented groups as well as women tend to report more severe insomnia symptoms, and frequent experiences of discrimination have been found to drive such disparities. Smokers commonly experience sleep problems since nicotine can alter the sleep-wake cycle. Discrimination is associated with increased nicotine dependence, and such discrimination may also intensify tobacco withdrawal, specifically mood and cognitive-related aspects of withdrawal. The potential impact of discrimination on withdrawal symptoms and related mood symptoms like depression may lead to increases in insomnia symptoms. However, no studies to date have evaluated the indirect association of discrimination with insomnia severity through nicotine withdrawal and depressive symptoms. Therefore, this cross-sectional survey of n = 110 non-Hispanic Black and White current smokers (48.2 % Black, 69.1 % women) investigated these associations through a serial mediation model. Controlling for race, gender, nicotine dependence levels, and income, multivariate analyses supported a significant indirect effect of discrimination on insomnia severity through depressive symptoms. Analyses supported the hypothesized serial mediation model whereby discrimination is positively associated with depressive symptoms, which in turn are linked to more severe nicotine withdrawal, leading to greater insomnia severity. Smokers encountering frequent experiences of discrimination might be at increased risk of suffering insomnia as a result of their increased depressive and withdrawal symptoms. Future work is necessary to understand the role of depressive symptoms in these associations as well as possible implications for smoking relapse and success of smoking cessation programs.

Method for Activity Sleep Harmonization (MASH): a novel method for harmonizing data from two wearable devices to estimate 24-h sleep-wake cycles.

Background: Daily 24-h sleep-wake cycles have important implications for health, however researcher preferences in choice and location of wearable devices for behavior measurement can make 24-h cycles difficult to estimate. Further, missing data due to device malfunction, improper initialization, and/or the participant forgetting to wear one or both devices can complicate construction of daily behavioral compositions. The Method for Activity Sleep Harmonization (MASH) is a process that harmonizes data from two different devices using data from women who concurrently wore hip (waking) and wrist (sleep) devices for ≥ 4 days. Methods: MASH was developed using data from 1285 older community-dwelling women (ages: 60-72 years) who concurrently wore a hip-worn ActiGraph GT3X + accelerometer (waking activity) and a wrist-worn Actiwatch 2 device (sleep) for ≥ 4 days (N = 10,123 days) at the same time. MASH is a two-tiered process using (1) scored sleep data (from Actiwatch) or (2) one-dimensional convolutional neural networks (1D CNN) to create predicted wake intervals, reconcile sleep and activity data disagreement, and create day-level night-day-night pairings. MASH chooses between two different 1D CNN models based on data availability (ActiGraph + Actiwatch or ActiGraph-only). MASH was evaluated using Receiver Operating Characteristic (ROC) and Precision-Recall curves and sleep-wake intervals are compared before (pre-harmonization) and after MASH application. Results: MASH 1D CNNs had excellent performance (ActiGraph + Actiwatch ROC-AUC = 0.991 and ActiGraph-only ROC-AUC = 0.983). After exclusions (partial wear [n = 1285], missing sleep data proceeding activity data [n = 269], and < 60 min sleep [n = 9]), 8560 days were used to show the utility of MASH. Of the 8560 days, 46.0% had ≥ 1-min disagreement between the devices or used the 1D CNN for sleep estimates. The MASH waking intervals were corrected (median minutes [IQR]: -27.0 [-115.0, 8.0]) relative to their pre-harmonization estimates. Most correction (-18.0 [-93.0, 2.0] minutes) was due to reducing sedentary behavior. The other waking behaviors were reduced a median (IQR) of -1.0 (-4.0, 1.0) minutes. Conclusions: Implementing MASH to harmonize concurrently worn hip and wrist devices can minimizes data loss and correct for disagreement between devices, ultimately improving accuracy of 24-h compositions necessary for time-use epidemiology.

Sleep quality and pain in adolescents and young adults with sickle cell disease.

STUDY OBJECTIVES: This study evaluated sleep quality in relation to pain and pain-related impairment in adolescents and young adults with sickle cell disease. The purpose was to examine whether increased age was associated with poorer sleep quality and pain and to examine the sleep quality-pain association in this age group. METHODS: Eighty-nine adolescents and young adults with sickle cell disease between the ages of 13 and 25 completed ratings of sleep quality, overall pain, and 2 measures of pain-related impairment (pain impact and pain burden) as part of their clinical care. Retrospective chart reviews were completed to match ratings to demographic and medical characteristics. Correlations and multiple regression were used to examine associations between age, sleep quality, and pain variables, including an exploratory analysis of the sleep-pain association by age. RESULTS: Increased age was associated with poorer sleep quality, worse overall pain, and higher pain burden. Poorer sleep quality was also associated with worse overall pain and pain burden. Using multiple regression, a small, but not statistically significant trend was observed for the interaction of increased age and strengthening of the sleep quality-pain burden association. CONCLUSIONS: Sleep quality and pain are important challenges for adolescents and young adults with sickle cell disease that may persist or worsen with increased age. Early identification of these difficulties in pediatric populations as well as continued screening and intervention as adolescents transition into adult care is important. Additional longitudinal research is needed to better understand the progression of the sleep-pain relationship over time. CITATION: Schlenz AM, Thomas SJ, Gloston G, Lebensburger J, Maxwell SL, Kanter J. Sleep quality and pain in adolescents and young adults with sickle cell disease. J Clin Sleep Med. 2022;18(12):2845-2853.

Nightshift Work and Nighttime Eating Are Associated With Higher Insulin and Leptin Levels in Hospital Nurses.

Background: Circadian misalignment between behaviors such as feeding and endogenous circadian rhythms, particularly in the context of shiftwork, is associated with poorer cardiometabolic health. We examined whether insulin and leptin levels differ between dayshift versus nightshift nurses, as well as explored whether the timing of food intake modulates these effects in nightshift workers. Methods: Female nurses (N=18; 8 dayshift and 10 nightshift) completed daily diet records for 8 consecutive days. The nurses then completed a 24-h inpatient stay, during which blood specimens were collected every 3 h (beginning at 09:00) and meals were consumed at regular 3-h intervals (09:00, 12:00, 15:00, and 18:00). Specimens were analyzed for insulin and leptin levels, and generalized additive models were used to examine differences in mean insulin and leptin levels. Results: Mean insulin and leptin levels were higher in nightshift nurses by 11.6 ± 3.8 mU/L (p=0.003) and 7.4 ± 3.4 ng/ml (p=0.03), respectively, compared to dayshift nurses. In an exploratory subgroup analysis of nightshift nurses, predominately eating at night (21:00 - 06:00) was associated with significantly higher insulin and leptin levels than consuming most calories during the daytime (06:00 - 21:00). Conclusions: In our study of hospital nurses, working the nightshift was associated with higher insulin and leptin levels, and these effects were driven by eating predominately at night. We conclude that although nightshift work may raise insulin and leptin levels, eating during the daytime may attenuate some of the negative effects of nightshift work on metabolic health.

Insomnia Diagnosis, Prescribed Hypnotic Medication Use, and Risk for Serious Fall Injuries in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

STUDY OBJECTIVES: Insomnia is common among older adults and associated with an increased risk for falls. Determining if falls are more strongly associated with insomnia or prescribed hypnotic medications could be used to guide interventions to reduce falls risk. METHODS: We examined the prospective association of a diagnosis of insomnia and/or prescribed hypnotic medication use with the risk for serious fall injuries among 9087 Reasons for Geographic and Racial Differences in Stroke (REGARDS) study participants aged 65 years or older with Medicare fee-for-service health insurance at baseline (2003-2007). A diagnosis of insomnia was based on ICD-9 codes in Medicare claims and prescribed hypnotic medication use was determined through a pill bottle review. Serious fall injuries were identified by Medicare claims between baseline and December 31, 2018. RESULTS: Over a median of 6.8 years, 1660 (18.3%) participants had a serious fall injury. The incidence rates for a serious fall injury per 1000 person-years were 24.8 (95%CI: 23.5, 26.1), 28.8 (95%CI: 18.6, 38.9), 32.6 (95%CI: 28.2, 37.0), and 46.6 (95%CI: 26.7, 66.5) for participants without insomnia or taking prescribed hypnotic medication (-insomnia/-hypnotics), with insomnia only (+insomnia/-hypnotics), taking prescribed hypnotic medication only (-insomnia/+hypnotics), and with insomnia and taking prescribed hypnotic medication (+insomnia/+hypnotics), respectively. Compared with the -insomnia/-hypnotic group, the multivariable-adjusted hazard ratios for a serious fall injury were 1.13 (95%CI: 0.79, 1.61), 1.29 (95%CI: 1.11, 1.50), and 1.60 (95%CI: 1.01, 2.56) for +insomnia/-hypnotics, -insomnia/+hypnotics, and +insomnia/+hypnotics, respectively. CONCLUSIONS: The risk for serious fall injuries was higher for those taking prescribed hypnotic medications but not with an insomnia diagnosis.

Sleep Disturbances and Chronic Pain in People with HIV: Implications for HIV-Associated Neurocognitive Disorders.

Purpose of Review: Antiretroviral therapy has significantly reduced morbidity and mortality in people with HIV. Despite being virally suppressed, sleep disturbances, chronic pain, and neurocognitive impairments persist which can negatively impact quality of life for people with HIV. This article presents relevant literature related to sleep disturbances and chronic pain in people with HIV. The potential impact of these comorbidities on cognition is discussed with implications for managing HIV-associated neurocognitive disorder (HAND). Recent Findings: People with HIV and chronic pain report greater insomnia and depressive symptoms compared to those without chronic pain. The neurotoxic effects of HIV itself and sleep and chronic pain induced inflammation can contribute to poorer cognitive outcomes. Summary: Sleep disturbances and chronic pain are prevalent conditions in people with HIV that may perpetuate the development and exacerbation of HAND. Sleep and pain interventions may preserve cognitive function and improve quality of life for people aging with HIV.

The stress, salt excretion, and nighttime blood pressure (SABRE) study: Rationale and study design.

Background: Abnormal diurnal patterns of blood pressure (BP) on ambulatory BP monitoring (ABPM), defined by reduced BP dipping or elevated nighttime BP, are associated with increased risk for adverse cardiovascular events. Psychological stress is associated with abnormal diurnal patterns of BP. Exposure to an acute stressor (e.g., mental stress task) normally increases urinary sodium excretion. However, some individuals have sodium retention after stress provocation, revealing substantial between-person variability in the degree of stress-induced sodium excretion. Prior research suggests urinary sodium excretion that does not occur during the daytime may shift toward the nighttime, accompanied by an increase in nighttime BP. Associations between psychological stress and the diurnal patterns of sodium excretion and BP are not yet fully understood. Design: The study is conducted in both the laboratory and naturalistic environment with a multi-racial/ethnic sample of 211 healthy adults. In the laboratory, change in urinary sodium excretion in response to mental stress tasks is examined with pre-/post-stress assessments of sodium excretion. Changes in angiotensin-II, catecholamines, BP, heart rate, endothelin-1, and cortisol are also assessed. In the 24-hour naturalistic environment, the diurnal patterns of sodium excretion and systolic BP are assessed as daytime-to-nighttime ratio of sodium excretion and ABPM, respectively. Ecological momentary assessments of perceived stress are also collected. Summary: The SABRE study investigates previously unexplored associations between stress-induced urinary excretion in the laboratory, diurnal patterns of sodium excretion and BP in the naturalistic environment, and ecological stress. It has high potential to advance our understanding of the role of psychological stress in hypertension.

Obstructive sleep apnea is more severe in men but not women with refractory hypertension compared with controlled resistant hypertension.

OBJECTIVES: Obstructive sleep apnea (OSA) is associated with treatment-resistant hypertension (RHTN) and may contribute to refractory hypertension (RfHTN). The objective of the current study was to test the hypothesis that patients with RfHTN have more severe OSA compared with patients with controlled RHTN. METHODS: Patients (n = 187) referred to the University of Alabama at Birmingham Hypertension Clinic for evaluation and treatment of RHTN, defined as uncontrolled blood pressure (BP) (SBP ≥ 130 mmHg or DBP ≥ 80 mmHg) despite the use of at least three antihypertensive medications including a diuretic, were enrolled following completion of at least three follow-up clinic visits. RfHTN was defined as uncontrolled high BP despite treatment with five or more antihypertensive agents of different classes, including a long-acting thiazide-type diuretic and a mineralocorticoid receptor antagonist. Following enrollment, all patients (n = 130) completed 24-h ambulatory BP measurement and overnight diagnostic polysomnography during normal nightly use of continuous positive airway pressure. Analyses examined the severity of OSA and related sleep characteristics among patients with RfHTN versus controlled RHTN. RESULTS: Of the 130 evaluated patients, 37 (28.5%) had RfHTN and 93 (71.5%) had controlled RHTN. In unadjusted analyses, there was not a significant difference in OSA severity, oxygen saturation, or hypoxemia time in patients with RfHTN versus controlled RHTN (P > 0.05). Men with RfHTN had more severe OSA compared with men with controlled RHTN (P = 0.044). In adjusted analyses, OSA severity was associated with sex (P < 0.0001), but not hypertension phenotype (P = 0.17). CONCLUSION: The severity of OSA may contribute to RfHTN status in men but not women.

The association of actigraphy-assessed sleep duration with sleep blood pressure, nocturnal hypertension, and nondipping blood pressure: the coronary artery risk development in young adults (CARDIA) study.

OBJECTIVE: Nocturnal hypertension and nondipping systolic blood pressure (SBP) are associated with increased cardiovascular disease (CVD) risk. Short and long sleep duration (SSD and LSD) are also associated with increased CVD risk and may be risk factors for nocturnal hypertension and nondipping SBP. We examined the association between SSD and LSD with sleep BP, nocturnal hypertension, and nondipping SBP among 647 white and African American Coronary Artery Risk Development in Young Adults (CARDIA) study participants who completed 24-h ambulatory BP monitoring, wrist actigraphy, and sleep diaries in 2015-2016. METHODS: The times when participants were asleep and awake were determined from actigraphy complemented by sleep diaries. Nocturnal hypertension was defined as sleep BP ≥120/70 mmHg and nondipping SBP as mean sleep-to-awake SBP ratio >0.90. Sleep duration was categorized as SSD (<6 h), normal sleep duration (NSD: 6-8.9 h), and LSD (≥9 h). RESULTS: The prevalence of SSD and LSD were 13.9 and 21.1%, respectively. Compared to participants with NSD, participants with LSD had higher mean sleep SBP (2.1 mmHg, 95% confidence interval [CI] 0.2, 4.1 mmHg) and diastolic BP (1.7 mmHg, 95% CI 0.5, 3.0 mmHg). Participants with LSD had a higher prevalence of nocturnal hypertension (prevalence ratio [PR]: 1.26, 95% CI 1.03-1.54) and nondipping SBP (PR 1.33, 95% CI 1.03-1.72) compared to participants with NSD. There was no evidence of an association between SSD and sleep SBP or DBP, nocturnal hypertension, or nondipping SBP. CONCLUSIONS: These findings suggest that LSD may be associated with nocturnal hypertension and nondipping SBP.

Twenty-Five-Year Changes in Office and Ambulatory Blood Pressure: Results From the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

BACKGROUND: Blood pressure (BP) measured in the office setting increases from early through later adulthood. However, it is unknown to what extent out-of-office BP derived via ambulatory BP monitoring (ABPM) increases over time, and which participant characteristics and risk factors might contribute to these increases. METHODS: We assessed 25-year change in office- and ABPM-derived BP across sex, race, diabetes mellitus (DM), and body mass index (BMI) subgroups in the Coronary Artery Risk Development in Young Adults study using multivariable-adjusted linear mixed effects models. RESULTS: We included 288 participants who underwent ABPM at the Year 5 Exam (mean [SD] age, 25.1 [3.7]; 45.8% men) and 455 participants who underwent ABPM at the Year 30 Exam (mean [SD] age, 49.5 [3.7]; 42.0% men). Office, daytime, and nighttime systolic BP (SBP) increased 12.8 (95% confidence interval [CI], 7.6-17.9), 14.7 (95% CI, 9.7-19.8), and 16.6 (95% CI, 11.4-21.8) mm Hg, respectively, over 25 years. Office SBP increased 6.5 (95% CI, 2.3-10.6) mm Hg more among black compared with white participants. Daytime SBP increased 6.3 (95% CI, 0.2-12.4) mm Hg more among participants with a BMI ≥25 vs. <25 kg/m2. Nighttime SBP increased 4.7 (95% CI, 0.5-8.9) mm Hg more among black compared with white participants, and 17.3 (95% CI, 7.2-27.4) mm Hg more among participants with vs. without DM. CONCLUSIONS: Office- and ABPM-derived BP increased more from early through middle adulthood among black adults and participants with DM and BMI ≥25 kg/m2.