The beneficial effects of massage therapy for insomnia in postmenopausal women.

With increases life expectancy, the incidence of undesirable manifestations of menopause has increased as well. The effects of lost ovarian function include progressive decrease in estradiol secretion, trophic changes in the breast, vasomotor symptoms, anxiety, depression, and sleep disorders. Insomnia, which has physiological consequences and can result in a loss of quality of life, is prevalent in women after menopause. Hormone therapy has been widely used to reduce menopausal symptoms, but its use in recent years has been questioned because of the reported risks of cardiovascular events and increased incidence of tumors. This controversy has generated significant interest in non-hormonal treatments among both physicians and patients. Our previous research has shown a positive effect of massage therapy on menopausal symptoms. We explored the hypothesis that massage therapy would produce beneficial effects in postmenopausal women through inflammatory and immunological changes. Recent results from self-report questionnaires have shown improvements in sleep pattern and quality of life following massage therapy. These findings demonstrate the effectiveness of massage therapy for the treatment of postmenopausal symptoms, particularly insomnia, and indicate that it is a promising line of research.

Effect of therapeutic massage on insomnia and climacteric symptoms in postmenopausal women.

INTRODUCTION: Physiological and psychological alterations in the climacteric period frequently influence women's quality of life. Hot flushes, nocturia, mood alterations, respiratory disturbances, insomnia and restless leg syndrome all affect sleep, and the altered hormonal state in this period impacts the aging process. As hormonal therapy is not indicated in some cases, the search for complementary therapies, such as massage therapy, to improve insomnia in the climacteric period is increasing. OBJECTIVE: To evaluate the effect of therapeutic massage on insomnia and climacteric symptoms in postmenopausal women. METHODS: Forty-four volunteers were randomly distributed into three groups: therapeutic massage (TM), passive movement (PM) and control (CTL). The women received 32 therapeutic massage sessions and passive movement twice a week. Questionnaires were given in the pre-trial and the 16th and 32nd sessions. The Insomnia Severity Index (ISI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Menopause Quality of Life questionnaire (MENQOL), Kupperman Menopausal Index and Lipp Symptoms of Stress Inventory were assessed. In addition, the women underwent polysomnography at baseline and post-treatment. Statistical analyses were calculated using Friedman and Wilcoxon non-parametric tests. The level of significance was fixed at p ≤ 0.05. RESULTS: There was an improvement in ISI in the TM group (p = 0.000) and in the PM group (p = 0.001). A decrease in the BDI occurred in the TM group (p = 0.004), and the MENQOL improved in the TM group (p = 0.015). Furthermore, there were no significant differences in polysomnography parameters in the TM group, with only an increase in minimal saturation (p = 0.053). CONCLUSION: The TM group exhibited improved subjective data considering the changes in symptoms according to the ISI and the MENQOL and a decrease in symptoms according to the BDI.

Sleep pattern in women with menstrual pain.

BACKGROUND: Menstrual pain is a common problem in women of reproductive age and often interferes with the ability to work and with general well-being. Because painful conditions frequently affect sleep, we investigated the impact of this menstrual disorder on sleep patterns in adult women. Additionally, we examined whether medications used to alleviate menstrual pain promoted changes in sleep. METHODS: According to their hormone profiles and menstrual histories, a total sample of 24 women (25-48 years old) who were experiencing their menstrual periods on the day of the polysomnogram (PSG) were included in the study. All of the participants answered questions regarding the presence of menstrual pain and use of medication. RESULTS: Menstrual pain was reported by 66.6% of the women on the night of the PSG. No marked effects were observed on the sleep pattern of these subjects compared with women without menstrual pain. The use of medication did not promote significant changes in the sleep pattern. None of the women were taking oral contraceptives. CONCLUSIONS: The presence of menstrual pain or the use of medication to alleviate pain did not significantly alter sleep patterns. Thus, the results suggest that the presence of self-described menstrual pain does not affect sleep patterns in adult women.

Apolipoprotein E polymorphisms and sleep quality in obstructive sleep apnea syndrome.

BACKGROUND: The purpose of this study was to evaluate the influence of polymorphism on sleep parameters of Obstructive Sleep Apnea Syndrome (OSAS) patients. METHODS: Patients were genotyped after a full-night polysomnography using the large Epidemiologic Sleep Study of São Paulo population-based sample. RESULTS: Individuals who carry the APOE ε2 allele showed longer sleep latency, lower sleep efficiency and higher numbers of arousals/hour, when compared to ε3 allele homozygous and carriers of ε4 allele (p<0.05). These findings remained significant even after correction for potential confounders, such as sex, age and African genetic ancestry. CONCLUSION: The APOE polymorphisms may modulate the effects of intermittent hypoxia and sleep fragmentation in the sleep architecture of OSAS patients, and that the presence of the ε2 allele may serve as a biological marker for the identification of a subgroup of patients who are more likely to suffer with OSAS detrimental effects on sleep, impacting not only the daily functioning, but also their quality of life.

Influence of genetic ancestry on the risk of obstructive sleep apnoea syndrome.

The aim of the present study was to evaluate the influence of ethnicity on the risk of developing obstructive sleep apnoea syndrome (OSAS) using genomic analysis methods to estimate ancestry. DNA samples were obtained from 1,010 individuals participating in the São Paulo Epidemiologic Sleep Study, who underwent full-night polysomnography. A total of 31 genetic ancestry-informative markers were selected in order to estimate individual admixture proportions. Of patients with a diagnosis of OSAS, a higher number self-reporting Caucasian ethnicity (65.3%), as well as an increased percentage of European ancestry (78.2±16.7%) and lower percentage of West African ancestry (16.1±15.3%), than among individuals without OSAS (53.6, 73.5±18.1 and 20.1±16.8%, respectively) (p<0.001) was observed. Moreover, after correcting for sex, age, body mass index and socioeconomic status, logistic regression demonstrated that European ancestry was significantly associated with an increased risk of manifesting OSAS (OR 2.80, 95% CI 1.11-7.09). Conversely, West African ancestry was associated with a reduced risk of the OSAS phenotype (OR 0.26, 95% CI 0.09-0.72). This is the first study to incorporate genomic analysis methods to measure the influence of ethnicity on the risk of OSAS. Since genetically determined ancestry may not capture unmeasured cultural and lifestyle differences, the contribution of environmental factors to the current findings should not be disregarded.

Does the reproductive cycle influence sleep patterns in women with sleep complaints?

OBJECTIVE: The aim of the present study was to investigate how prominent gynecological factors (regular/irregular menstrual cycle, premenstrual complaints, or menopause) can influence both subjective and objective sleep data. METHODS: A total of 931 women who sought clinical assistance because of a sleep complaint were included in the investigation. All subjects filled out a sleep and gynecological questionnaire prior to undergoing a polysomnography (PSG) recording. RESULTS: Premenopausal women with an irregular menstrual cycle were more likely to report sleep difficulties (related to falling sleep and insomnia symptoms) than those with a regular cycle (odds ratio 2.1; 95% confidence interval 1.2-3.5). These women showed increased light sleep stages and awakenings. Premenstrual complaints were reported by a higher percentage of women with periodic leg movement, lower time in saturation under 90%, and higher sleep efficiency. A lower percentage of women who took hormonal contraceptives reported snoring, had fewer arousals and longer REM latency compared to those not taking hormonal contraceptives. Menopausal women with hot flushes had more restless leg complaints. Awake time was shorter in hormone therapy users compared with non-users. Women with menopause are more likely to have an apnea-hypoapnea index greater than 5/h. CONCLUSION: The present findings suggest that gynecological status is associated with subjective sleep quality and objective sleep parameters in women with sleep complaints.

Sleep, ageing and night work

Studies have shown that the frequency or worsening of sleep disorders tends to increase with age and that the ability to perform circadian adjustments tends to decrease in individuals who work the night shift. This condition can cause consequences such as excessive sleepiness, which are often a factor in accidents that occur at work. The present study investigated the effects of age on the daytime and nighttime sleep patterns using polysomnography (PSG) of long-haul bus drivers working fixed night or day shifts. A total of 124 drivers, free of sleep disorders and grouped according to age (<45 years, N = 85, and ≥45 years, N = 39) and PSG timing (daytime (D) PSG, N = 60; nighttime (N) PSG, N = 64) participated in the study. We observed a significant effect of bedtime (D vs N) and found that the length of daytime sleep was shorter [D: <45 years (336.10 ± 73.75 min) vs N: <45 years (398 ± 78.79 min) and D: ≥45 years (346.57 ± 43.17 min) vs N: ≥45 years (386.44 ± 52.92 min); P ≤ 0.05]. Daytime sleep was less efficient compared to nighttime sleep [D: <45 years (78.86 ± 13.30 percent) vs N: <45 years (86.45 ± 9.77 percent) and D: ≥45 years (79.89 ± 9.45 percent) and N: ≥45 years (83.13 ± 9.13 percent); P ≤ 0.05]. An effect of age was observed for rapid eye movement sleep [D: <45 years (18.05 ± 6.12 percent) vs D: ≥45 years (15.48 ± 7.11 percent) and N: <45 years (23.88 ± 6.75 percent) vs N: ≥45 years (20.77 ± 5.64 percent); P ≤ 0.05], which was greater in younger drivers. These findings are inconsistent with the notion that older night workers are more adversely affected than younger night workers by the challenge of attempting to rest during the day.

Sleep, ageing and night work.

Studies have shown that the frequency or worsening of sleep disorders tends to increase with age and that the ability to perform circadian adjustments tends to decrease in individuals who work the night shift. This condition can cause consequences such as excessive sleepiness, which are often a factor in accidents that occur at work. The present study investigated the effects of age on the daytime and nighttime sleep patterns using polysomnography (PSG) of long-haul bus drivers working fixed night or day shifts. A total of 124 drivers, free of sleep disorders and grouped according to age (<45 years, N = 85, and > or =45 years, N = 39) and PSG timing (daytime (D) PSG, N = 60; nighttime (N) PSG, N = 64) participated in the study. We observed a significant effect of bedtime (D vs N) and found that the length of daytime sleep was shorter [D: <45 years (336.10 +/- 73.75 min) vs N: <45 years (398 +/- 78.79 min) and D: > or =45 years (346.57 +/- 43.17 min) vs N: > or =45 years (386.44 +/- 52.92 min); P < or = 0.05]. Daytime sleep was less efficient compared to nighttime sleep [D: <45 years (78.86 +/- 13.30%) vs N: <45 years (86.45 +/- 9.77%) and D: > or =45 years (79.89 +/- 9.45%) and N: > or =45 years (83.13 +/- 9.13%); P < or = 0.05]. An effect of age was observed for rapid eye movement sleep [D: <45 years (18.05 +/- 6.12%) vs D: > or =45 years (15.48 +/- 7.11%) and N: <45 years (23.88 +/- 6.75%) vs N: > or =45 years (20.77 +/- 5.64%); P < or = 0.05], which was greater in younger drivers. These findings are inconsistent with the notion that older night workers are more adversely affected than younger night workers by the challenge of attempting to rest during the day.

Systematic head and neck physical examination as a predictor of obstructive sleep apnea in class III obese patients

Our aim was to determine if anatomical abnormalities of the upper airway (UA) and facial skeleton of class III severely obese patients are related to the presence and severity of obstructive sleep apnea syndrome (OSAS). Forty-five patients (69 percent females, mean age 46.5 ± 10.8 years) with a body mass index (BMI) over 40 kg/m² underwent UA and facial skeletal examinations as well as polysomnography. Mean BMI was 49 ± 7 kg/m² and mean neck circumference was 43.4 ± 5.1 cm. Polysomnographic findings showed that 22 percent had a normal apnea-hypopnea index (AHI) and 78 percent had an AHI over 5. The presence of OSAS was associated with younger age (P = 0.02), larger neck circumference (P = 0.004), presence of a voluminous lateral wall (P = 0.0002), posteriorized soft palate (P = 0.0053), thick soft palate (P = 0.0014), long uvula (P = 0.04), thick uvula (P = 0.0052), and inferior turbinate hypertrophy (P = 0.04). A larger neck circumference (P = 0.02), presence of a voluminous lateral wall (P = 0.04), posteriorized soft palate (P = 0.03), and thick soft palate (P = 0.04) were all associated with OSAS severity. The prevalence of OSAS in this group was high. A larger neck circumference and soft tissue abnormalities of the UA were markers for both the presence and severity of OSAS. Conversely, no abnormalities in the facial skeleton were associated with OSAS in patients with morbid obesity.

Gender and age differences in polysomnography findings and sleep complaints of patients referred to a sleep laboratory

Our objective was to examine the effet of gender on the sleep pattern of patients referred to a sleep laboratory. The data (questionnaires and polysomnographic recordings) were collected from a total of 2365 patients (1550 men and 815 women). The polysomnography permits an objective assessment of the sleep pattern. We included only polysomnography exams obtained with no more than one recording system in order to permit normalization of the data. Men had a significantly higher body mass index than women (28.5 ± 4.8 vs 27.7 ± 6.35 kg/m²) and had a significantly higher score on the Epworth Sleepiness Scale (10.8 ± 5.3 vs 9.5 ± 6.0), suggesting daytime sleepiness. Women had a significantly higher sleep latency than men, as well as a higher rapid eye movement (REM) latency. Men spent more time in stages 1 (4.6 ± 4.1 vs 3.9 ± 3.8) and 2 (57.0 ± 10.5 vs 55.2 ± 10.1) of non-REM sleep than women, whereas women spent significantly more time in deep sleep stages (3 and 4) than men (22.6 ± 9.0 vs 19.9 ± 9.0). The apnea/hypopnea and arousal indexes were significantly higher and more frequent in men than in women (31.0 ± 31.5 vs 17.3 ± 19.7). Also, periodic leg movement index did not differ significantly between genders, but rather differed among age groups. We did not find significant differences between genders in the percentage of REM sleep and sleep efficiency. The results of the current study suggest that there are specific gender differences in sleep pattern.

Relationship between Brazilian airline pilot errors and time of day

Flight safety is one of the most important and frequently discussed issues in aviation. Recent accident inquiries have raised questions as to how the work of flight crews is organized and the extent to which these conditions may have been contributing factors to accidents. Fatigue is based on physiologic limitations, which are reflected in performance deficits. The purpose of the present study was to provide an analysis of the periods of the day in which pilots working for a commercial airline presented major errors. Errors made by 515 captains and 472 copilots were analyzed using data from flight operation quality assurance systems. To analyze the times of day (shifts) during which incidents occurred, we divided the light-dark cycle (24:00) in four periods: morning, afternoon, night, and early morning. The differences of risk during the day were reported as the ratio of morning to afternoon, morning to night and morning to early morning error rates. For the purposes of this research, level 3 events alone were taken into account, since these were the most serious in which company operational limits were exceeded or when established procedures were not followed. According to airline flight schedules, 35 percent of flights take place in the morning period, 32 percent in the afternoon, 26 percent at night, and 7 percent in the early morning. Data showed that the risk of errors increased by almost 50 percent in the early morning relative to the morning period (ratio of 1:1.46). For the period of the afternoon, the ratio was 1:1.04 and for the night a ratio of 1:1.05 was found. These results showed that the period of the early morning represented a greater risk of attention problems and fatigue.

Relationship between the quality of life and the severity of obstructive sleep apnea syndrome

The effects of sleep disorders on the quality of life (QOL) have been documented in the literature. Excessive sleepiness and altered circadian rhythms may negatively affect ability to learn, employment, and interpersonal relations, and directly degrade QOL. The objective of the present study was to evaluate the impact of obstructive sleep apnea syndrome of varying severity on QOL. The study was conducted on 1892 patients aged 18 years or older referred by a physician to the Sleep Institute, São Paulo, with complaints related to apnea (snoring, excessive daytime sleepiness, hyperarousal, and fatigue). They were submitted to overnight polysomnography for the diagnosis of sleep disorders from August 2005 through April 2006. The patients completed the Epworth Sleepiness Scale and QOL SF-36 sleep questionnaires. They were classified as non-physically active and physically active and not-sleepy and sleepy and the results of polysomnography were analyzed on the basis of the apnea hypopnea index (AHI). The apneic subjects showed a reduction in QOL which was proportional to severity. There was a significant decrease in all domains (physical functioning, role physical problems, bodily pain, general health perceptions, vitality, social functioning, emotional problems, general mental health) for apneics with AHI >30, who generally were sleepy and did not participate in physical activities (P < 0.05). The present study provides evidence that the impact of sleep disorders on QOL in apneics is not limited to excessive daytime sleepiness and that physical activity can contribute to reducing the symptoms. Thus, exercise should be considered as an adjunct interventional strategy in the management of obstructive sleep apnea syndrome.

Relationship between the quality of life and the severity of obstructive sleep apnea syndrome.

The effects of sleep disorders on the quality of life (QOL) have been documented in the literature. Excessive sleepiness and altered circadian rhythms may negatively affect ability to learn, employment, and interpersonal relations, and directly degrade QOL. The objective of the present study was to evaluate the impact of obstructive sleep apnea syndrome of varying severity on QOL. The study was conducted on 1892 patients aged 18 years or older referred by a physician to the Sleep Institute, São Paulo, with complaints related to apnea (snoring, excessive daytime sleepiness, hyperarousal, and fatigue). They were submitted to overnight polysomnography for the diagnosis of sleep disorders from August 2005 through April 2006. The patients completed the Epworth Sleepiness Scale and QOL SF-36 sleep questionnaires. They were classified as non-physically active and physically active and not-sleepy and sleepy and the results of polysomnography were analyzed on the basis of the apnea hypopnea index (AHI). The apneic subjects showed a reduction in QOL which was proportional to severity. There was a significant decrease in all domains (physical functioning, role physical problems, bodily pain, general health perceptions, vitality, social functioning, emotional problems, general mental health) for apneics with AHI >30, who generally were sleepy and did not participate in physical activities (P < 0.05). The present study provides evidence that the impact of sleep disorders on QOL in apneics is not limited to excessive daytime sleepiness and that physical activity can contribute to reducing the symptoms. Thus, exercise should be considered as an adjunct interventional strategy in the management of obstructive sleep apnea syndrome.

Effect of smoking habits on sleep.

To evaluate the effect of smoking habits on sleep, data from 1492 adults referred to the Sleep Institute were accessed and divided into 3 categories of smoking status: current, former and non-smokers. Categories of pack-years (<15 and > or =15) defined smoking severity. The association of smoking status and smoking severity with sleep was analyzed for sleep parameters, especially apnea and hypopnea index (AHI) > or =5, more than 5% of total sleep time (TST) spent with oxyhemoglobin saturation (SaO2) <90%, and arousal index. The arousal index was higher among current (21 +/- 17) and former smokers (20 +/- 17) than non-smokers (17 +/- 15; P < 0.04). Former smokers had a higher percent of TST at SaO2 <90% than non-smokers (9 +/- 18 vs 6 +/- 13; P < 0.04). Former smokers with pack-years > or =15 compared to <15 exhibited higher AHI (22 +/- 24 vs 16 +/- 21; P < 0.05) and arousal index (22 +/- 19 vs 18 +/- 15; P < 0.05). Current smokers with pack-years > or =15 compared to <15 exhibited higher arousal index (23 +/- 18 vs 18 +/- 16; P < 0.05) and percent of TST at SaO2 <90% (11 +/- 17 vs 6 +/- 13; P < 0.05). Smoking status and pack-years were not associated with AHI > or =5 on logistic regression analysis, but current smokers with pack-years > or =15 were 1.9 times more likely to spend more than 5% of TST at SaO2 <90% than non-smokers (95%CI = 1.21-2.97; P = 0.005). The variability of arousal index was influenced by gender, AHI and current smokers with pack-years > or =15 (all P < 0.01). Smoking habits seem to be associated with arousal and oxyhemoglobin desaturation during sleep, but not with AHI. The effect was more pronounced in current than former smokers.

Effect of smoking habits on sleep

To evaluate the effect of smoking habits on sleep, data from 1492 adults referred to the Sleep Institute were accessed and divided into 3 categories of smoking status: current, former and non-smokers. Categories of pack-years (<15 and greater than or equal to 15) defined smoking severity. The association of smoking status and smoking severity with sleep was analyzed for sleep parameters, especially apnea and hypopnea index (AHI) greater than or equal to 5, more than 5 percent of total sleep time (TST) spent with oxyhemoglobin saturation (SaO2) <90 percent, and arousal index. The arousal index was higher among current (21 plus or minus 17) and former smokers (20 plus or minus 17) than non-smokers (17 plus or minus 15; P < 0.04). Former smokers had a higher percent of TST at SaO2 <90 percent than non-smokers (9 more less 18 vs 6 more less 13; P < 0.04). Former smokers with pack-years greater than or equal to 15 compared to <15 exhibited higher AHI (22 plus or minus 24 vs 16 plus or minus 21; P < 0.05) and arousal index (22 plus or minus 19 vs 18 plus or minus 15; P < 0.05). Current smokers with pack-years greater than or equal to 15 compared to <15 exhibited higher arousal index (23 plus or minus 18 vs 18 plus or minus 16; P < 0.05) and percent of TST at SaO2 <90 percent (11 plus or minus 17 vs 6 more less 13; P < 0.05). Smoking status and pack-years were not associated with AHI greater than or equal to 5 on logistic regression analysis, but current smokers with pack-years greater than or equal to 15 were 1.9 times more likely to spend more than 5 percent of TST at SaO2 <90 percent than non-smokers (95 percentCI = 1.21-2.97; P = 0.005). The variability of arousal index was influenced by gender, AHI and current smokers with pack-years greater than or equal to 15 (all P < 0.01). Smoking habits seem to be associated with arousal and oxyhemoglobin desaturation during sleep, but not with AHI. The effect was more pronounced in current than former smokers.

Gastroesophageal reflux episodes in asthmatic patients and their temporal relation with sleep architecture.

Gastroesophageal reflux (GER) is common in asthma patients and can contribute to sleep disruption. The aim of the present study was to determine the time-related distribution of GER events together with their impact on sleep in asthmatic subjects with GER disease symptoms. The inclusion criteria were: 18-65 years, controlled moderate to severe asthma and GER-compatible clinical evidence. The exclusion criteria were: chronic obstructive lung disease, smoking, infections of the upper airways, use of oral corticosteroids, other co-morbidities, pregnancy, sleep-related disorders, night-time shift work, and the use of substances with impact on sleep. Asthmatic patients with nocturnal symptoms were excluded. All-night polysomnography and esophageal pH monitoring were recorded simultaneously. Of the 147 subjects selected, 31 patients and 31 controls were included. Seventeen patients were classified as DeMeester positive and 14 as DeMeester negative. Both groups displayed similar outcomes when general variables were considered. Sleep stage modification one minute prior to GER was observed in the DeMeester-positive group. Awakening was the most frequent occurrence at GER onset and during the 1-min period preceding 38% of the nocturnal GER. Sleep stage 2 was also prevalent and preceded 36% of GER events. In the DeMeester-negative group, awakening was the most frequent response before and during GER. Modifications in sleep stages, arousals or awakenings were associated with 75% of the total GER events analyzed during the period of one minute before and after the fall of esophageal pH below 4 in the DeMeester-positive group. These data provide evidence that sleep modifications precede the GER events in asthmatic patients.

Gastroesophageal reflux episodes in asthmatic patients and their temporal relation with sleep architecture

Gastroesophageal reflux (GER) is common in asthma patients and can contribute to sleep disruption. The aim of the present study was to determine the time-related distribution of GER events together with their impact on sleep in asthmatic subjects with GER disease symptoms. The inclusion criteria were: 18-65 years, controlled moderate to severe asthma and GER-compatible clinical evidence. The exclusion criteria were: chronic obstructive lung disease, smoking, infections of the upper airways, use of oral corticosteroids, other co-morbidities, pregnancy, sleep-related disorders, night-time shift work, and the use of substances with impact on sleep. Asthmatic patients with nocturnal symptoms were excluded. All-night polysomnography and esophageal pH monitoring were recorded simultaneously. Of the 147 subjects selected, 31 patients and 31 controls were included. Seventeen patients were classified as DeMeester positive and 14 as DeMeester negative. Both groups displayed similar outcomes when general variables were considered. Sleep stage modification one minute prior to GER was observed in the DeMeester-positive group. Awakening was the most frequent occurrence at GER onset and during the 1-min period preceding 38 percent of the nocturnal GER. Sleep stage 2 was also prevalent and preceded 36 percent of GER events. In the DeMeester-negative group, awakening was the most frequent response before and during GER. Modifications in sleep stages, arousals or awakenings were associated with 75 percent of the total GER events analyzed during the period of one minute before and after the fall of esophageal pH below 4 in the DeMeester-positive group. These data provide evidence that sleep modifications precede the GER events in asthmatic patients.

Gender and age differences in polysomnography findings and sleep complaints of patients referred to a sleep laboratory.

Our objective was to examine the effet of gender on the sleep pattern of patients referred to a sleep laboratory. The data (questionnaires and polysomnographic recordings) were collected from a total of 2365 patients (1550 men and 815 women). The polysomnography permits an objective assessment of the sleep pattern. We included only polysomnography exams obtained with no more than one recording system in order to permit normalization of the data. Men had a significantly higher body mass index than women (28.5 +/- 4.8 vs 27.7 +/- 6.35 kg/m(2)) and had a significantly higher score on the Epworth Sleepiness Scale (10.8 +/- 5.3 vs 9.5 +/- 6.0), suggesting daytime sleepiness. Women had a significantly higher sleep latency than men, as well as a higher rapid eye movement (REM) latency. Men spent more time in stages 1 (4.6 +/- 4.1 vs 3.9 +/- 3.8) and 2 (57.0 +/- 10.5 vs 55.2 +/- 10.1) of non-REM sleep than women, whereas women spent significantly more time in deep sleep stages (3 and 4) than men (22.6 +/- 9.0 vs 19.9 +/- 9.0). The apnea/hypopnea and arousal indexes were significantly higher and more frequent in men than in women (31.0 +/- 31.5 vs 17.3 +/- 19.7). Also, periodic leg movement index did not differ significantly between genders, but rather differed among age groups. We did not find significant differences between genders in the percentage of REM sleep and sleep efficiency. The results of the current study suggest that there are specific gender differences in sleep pattern.

Systematic head and neck physical examination as a predictor of obstructive sleep apnea in class III obese patients.

Our aim was to determine if anatomical abnormalities of the upper airway (UA) and facial skeleton of class III severely obese patients are related to the presence and severity of obstructive sleep apnea syndrome (OSAS). Forty-five patients (69% females, mean age 46.5 +/- 10.8 years) with a body mass index (BMI) over 40 kg/m(2) underwent UA and facial skeletal examinations as well as polysomnography. Mean BMI was 49 +/- 7 kg/m(2) and mean neck circumference was 43.4 +/- 5.1 cm. Polysomnographic findings showed that 22% had a normal apnea-hypopnea index (AHI) and 78% had an AHI over 5. The presence of OSAS was associated with younger age (P = 0.02), larger neck circumference (P = 0.004), presence of a voluminous lateral wall (P = 0.0002), posteriorized soft palate (P = 0.0053), thick soft palate (P = 0.0014), long uvula (P = 0.04), thick uvula (P = 0.0052), and inferior turbinate hypertrophy (P = 0.04). A larger neck circumference (P = 0.02), presence of a voluminous lateral wall (P = 0.04), posteriorized soft palate (P = 0.03), and thick soft palate (P = 0.04) were all associated with OSAS severity. The prevalence of OSAS in this group was high. A larger neck circumference and soft tissue abnormalities of the UA were markers for both the presence and severity of OSAS. Conversely, no abnormalities in the facial skeleton were associated with OSAS in patients with morbid obesity.

Relationship between Brazilian airline pilot errors and time of day.

Flight safety is one of the most important and frequently discussed issues in aviation. Recent accident inquiries have raised questions as to how the work of flight crews is organized and the extent to which these conditions may have been contributing factors to accidents. Fatigue is based on physiologic limitations, which are reflected in performance deficits. The purpose of the present study was to provide an analysis of the periods of the day in which pilots working for a commercial airline presented major errors. Errors made by 515 captains and 472 co-pilots were analyzed using data from flight operation quality assurance systems. To analyze the times of day (shifts) during which incidents occurred, we divided the light-dark cycle (24:00) in four periods: morning, afternoon, night, and early morning. The differences of risk during the day were reported as the ratio of morning to afternoon, morning to night and morning to early morning error rates. For the purposes of this research, level 3 events alone were taken into account, since these were the most serious in which company operational limits were exceeded or when established procedures were not followed. According to airline flight schedules, 35% of flights take place in the morning period, 32% in the afternoon, 26% at night, and 7% in the early morning. Data showed that the risk of errors increased by almost 50% in the early morning relative to the morning period (ratio of 1:1.46). For the period of the afternoon, the ratio was 1:1.04 and for the night a ratio of 1:1.05 was found. These results showed that the period of the early morning represented a greater risk of attention problems and fatigue.