Adherence to continuous positive airway pressure treatment in a cohort of elderly adults with newly diagnosed obstructive sleep apnea.

PURPOSE: To evaluate adherence to continuous positive airway pressure (CPAP) treatment in elderly patients newly diagnosed with obstructive sleep apnea syndrome (OSAS). METHODS: Consecutive patients ≥ 70 years attending one of the participating centers, requiring CPAP treatment and agreeing to participate, were included. Mean hours of CPAP during the first 5 months of treatment defined adherence as CPAP ≥ 4 h/day on 70% of nights over a 30-day period. RESULTS: From January 2014 to April 2019, 262 patients aged between 76.7 and 87.7 years (mean age, 82.6 years) were included and fully evaluated; 224 (85.5%) were adherent. Mean adherence time was 6.9 h in adherent patients, vs 2 h in non-adherent patients (p < 0.0001). Compared to non-adherent patients, adherent patients tended to have higher baseline AHI without reaching statistical significance (44.7 vs 39.5, p = 0.0913). They less frequently presented with dementia (3.7% vs 21.6%, p < 0.0001). The somnolence (ODSI and Epworth), nocturia, and depression (QD2A) scores of adherent patients improved significantly from baseline to the fifth month: ODSI decreased from 7 to 3.7 (p < 0.0001), Epworth from 8.7 to 6.2 (p < 0.0001), nocturia from 6.6 to 4.1 (p = 0.0015), and QD2A from 3.7 to 3 (p = 0.0025). Many more patients in the non-adherent group used nasal plugs than in the adherent group (14.7% vs 2.1%, p = 0.0006). CONCLUSION: The present real-world study showed the ability of newly diagnosed elderly adults (including the very old) to adhere to CPAP therapy and the benefit of 5 months' well-conducted CPAP treatment. REGISTRATION NUMBER: Not applicable.

Risk Factors for Sleepiness at the Wheel and Sleep-Related Car Accidents Among Patients with Obstructive Sleep Apnea: Data from the French Pays de la Loire Sleep Cohort.

PURPOSE: We aimed to determine the risk factors of sleepiness at the wheel among patients with obstructive sleep apnea (OSA) and to determine factors that were independently associated with reported sleep-related near-miss accidents or car accidents. PATIENTS AND METHODS: This retrospective study was conducted on 843 OSA patients from the French Pays de la Loire sleep cohort database. Each patient completed surveys including anthropometric data, medical history, professional status, and data on alcohol and tobacco use. Epworth sleepiness scale (ESS) and sleep quality questionnaires were administered. Regarding driving, data were collected on occurrence of sleepiness-related near-misses or car accidents, and on distance driven per year. The primary dependent variable of interest was reported sleepiness at the wheel. RESULTS: On multivariable regression analysis, reported sleepiness at the wheel (n=298) was independently associated with younger age (p=0.02), male gender (p=0.009), marked nocturnal hypoxemia (p=0.006), lower BMI (p=0.03), absence of cardiovascular disease (p=0.022), executives or high degree jobs (p=0.003) and reported difficulty-maintaining sleep (p=0.03). Only past experience of sleepiness at the wheel (OR 12.18, [6.38-23.25]) and an ESS ≥11 (OR 4.75 [2.73-8.27]) were independently associated with reported car accidents (n=30) or near-miss accidents (n=137). CONCLUSION: In patients newly diagnosed with OSA, the risk of car accident seems multifactorial, and its evaluation should include multiple parameters such as patient self-reported sleepiness at the wheel, occurrence of sleepiness-related accidents, anthropometry, professional status, and insomnia complaints. Thus, it is possible to evaluate this risk and advise patients as early as the first visit at the sleep medicine clinic without waiting for the results of the sleep study.

Predicting treatment response to mandibular advancement therapy using a titratable thermoplastic device.

OBJECTIVES: Mandibular advancement device (MAD) therapy is the most commonly used second-line treatment for obstructive sleep apnea (OSA), but MAD may be ineffective in a subgroup of patients. We describe the use of a trial of a titratable thermoplastic MAD to predict treatment outcomes with a custom-made MAD. MATERIALS AND METHODS: Patients treated with a thermoplastic MAD as a trial before custom-made MAD manufacturing were included in the study. Sleep recordings and clinical outcomes assessed after 6 months of treatment with each device were compared. Predictive utility of thermoplastic MAD to identify custom-made MAD treatment success defined as a reduction greater than 50% and final apnea-hypopnea index (AHI) less than 10 events/h was evaluated. RESULTS: Thermoplastic MADs were installed in 111 patients, but only 36 patients were finally treated with both devices and were included in the analysis. A significant correlation was observed between the impact of the two devices on the AHI (r=0.85, p<0.0001), oxygen desaturation index (r=0.73, p<0.0001), snoring index (r=0.85, p<0.0001), and Epworth sleepiness scale (r=0.77, p<0.0001). A high positive predictive value (86%) but a low negative predictive value (46%) was observed regarding AHI decrease. CONCLUSIONS: Similar impacts of both MADs were observed on major OSA severity markers and symptoms. The ability of thermoplastic MAD to indicate likelihood of success with custom-made MAD will require further controlled studies. CLINICAL RELEVANCE: Thermoplastic MADs could represent a useful and easily implemented tool to predict the likelihood of success of a custom-made MAD as treatment for OSA.

Association of Nocturnal Hypoxemia and Pulse Rate Variability with Incident Atrial Fibrillation in Patients Investigated for Obstructive Sleep Apnea.

Rationale: Nocturnal hypoxemia and sympathetic/parasympathetic imbalance might contribute to the occurrence or atrial fibrillation (AF) in patients with obstructive sleep apnea (OSA). During sleep recordings, pulse rate variability (PRV) derived from oximetry might provide an accurate estimation of heart rate variability, which reflects the autonomic cardiovascular control. Objectives: We aimed to evaluate whether indices of oxygen desaturation and PRV derived from nocturnal oximetry were associated with AF incidence in patients investigated for OSA. Methods: Data from a large multicenter cohort of AF-free patients investigated for OSA between May 15, 2007, and December 31, 2017, were linked to health administrative data to identify hospitalized and nonhospitalized patients with new-onset AF. Cox proportional hazards models were used to evaluate the association between AF incidence and oximetry-derived indices automatically generated from sleep recordings. Results: After a median (interquartile range) follow-up of 5.34 (3.3-8.0) years, 181 of 7,205 patients developed AF (130 were hospitalized for AF). After adjusting for confounders, including anthropomorphic data, alcohol intake, cardiac, metabolic and respiratory diseases, ß blocker/calcium channel blocker medications, type of sleep study, study site, and positive airway pressure adherence, AF risk was associated with increasing nocturnal hypoxemia (P trend = 0.004 for quartiles of percentage of recording time with oxygen saturation <90%) and PRV (P trend < 0.0001 for quartiles of root mean square of the successive normal-normal beat interval differences), and decreasing sympathetic/parasympathetic tone (P trend = 0.0006 for quartiles of low-frequency power/high-frequency power ratio). The highest risk of AF was observed in patients with the highest quartiles of both the percentage of recording time with oxygen saturation <90% and the root mean square of the successive normal-normal beat interval differences compared with those with neither of these conditions (adjusted hazard ratio, 3.61; 95% confidence interval, 2.10-6.22). Similar associations were observed when the analyses were restricted to hospitalized AF. Conclusions: In patients investigated for OSA, nocturnal hypoxemia and PRV indices derived from single-channel pulse oximetry were independent predictors of AF incidence. Patients with both marked nocturnal hypoxemia and high PRV were at higher risk of AF. Oximetry may be used to identify patients with OSA at greatest risk of developing AF.

Obstructive sleep apnea, chronic obstructive pulmonary disease and NAFLD: an individual participant data meta-analysis.

RATIONALE: Chronic intermittent hypoxia occurring in obstructive sleep apnea (OSA) is independently associated with nonalcoholic fatty liver disease (NAFLD). Chronic obstructive pulmonary disease (COPD) has also been suggested to be linked with liver disease. OBJECTIVE: In this individual participant data meta-analysis, we investigated the association between liver damage and OSA and COPD severity. METHODS AND MEASUREMENTS: Patients suspected of OSA underwent polysomnography (PSG) or home sleep apnea testing (HSAT). Non-invasive tests were used to evaluate liver steatosis (Hepatic Steatosis Index) and fibrosis (Fibrotest or FibroMeter). An individual participant data meta-analysis approach was used to determine if the severity of OSA/COPD affects the type and severity of liver disease. Results were confirmed by multivariate and causal mediation analysis. Sub-group analyses were performed to investigate specific populations. MAIN RESULTS: Among 2120 patients, 1584 had steatosis (75%). In multivariable analysis, risk factors for steatosis were an apnea-hypopnea index (AHI) > 5/h, body mass index (BMI) > 26 kg/m2, age, type 2 diabetes (all p-values <0.01) and male gender (p = 0.02). Concerning fibrosis, among 2218 patients 397 had fibrosis (18%). Risk factors associated with fibrosis were BMI>26 kg/m2, age, male gender, and type 2 diabetes (all p-values <0.01). AHI severity was not associated with fibrosis. A combination of AHI >30/h and COPD stage 1 was associated with an increased risk of steatosis. CONCLUSION: This meta-analysis confirms the strong association between steatosis and the severity of OSA. The relation between OSA and fibrosis is mainly due to BMI as shown by causal mediation analysis.

Risk-seeking attitude in health and safety domain is associated with continuous positive airway pressure discontinuation in patients with obstructive sleep apnea-a multicenter prospective cohort study.

STUDY OBJECTIVES: Many studies have already looked at factors that may influence adherence to continuous positive airway pressure (CPAP) (severity of obstructive sleep apnea (OSA), patients' age, technical aspects, socioeconomic factors, living conditions, psychological factors). Although it has been shown that individuals' preference for risky behaviors in daily life can influence the use of care or adherence to drug therapies in care settings, this has never been tested in OSA. This study aims to analyze the association between risk attitude in the health/safety domain and CPAP discontinuation in a cohort of OSA patients. METHODS: In a prospective multicenter cohort study nested within the IRSR sleep cohort, consecutive patients who were prescribed CPAP were monitored for at least 6 months. In addition to the data usually collected in the IRSR sleep cohort at baseline, patients also completed a risk-taking questionnaire using the Domain-Specific Risk-Taking (DOSPERT) scale. Cox's proportional hazards regression was used to model the risk of CPAP discontinuation as a function of a linear combination of variables hypothetically related to this risk including health risk attitude. RESULTS: Of the 489 patients under CPAP, 12.1% (n = 59) were risk-seeking, 87.9% (n = 430) were risk-neutral, and none were risk-averse. Cox's model indicated that a risk-seeking attitude (p = 0.04) and an AHI <30 (p < 0.01) were significantly associated with CPAP discontinuation. CONCLUSIONS: Patients with risk-seeking behaviors in daily life have been shown to be more likely to discontinue CPAP. The DOSPERT scale can be a useful tool for screening this specific group of patients in clinical practice.

A CPAP data-based algorithm for automatic early prediction of therapy adherence.

OBJECTIVE: Adherence is a critical issue in the treatment of obstructive sleep apnea with continuous positive airway pressure (CPAP). Approximately 40% of patients treated with CPAP are at risk of discontinuation or insufficient use (< 4 h/night). Assuming that the first few days on CPAP are critical for continued treatment, we tested the predictive value at day 14 (D14) of the Philips Adherence Profiler™ (AP) algorithm for adherence at 3 months (D90). METHOD: The AP™ algorithm uses CPAP machine data hosted in the database of EncoreAnywhere™. This retrospective study involved 457 patients (66% men, 60.0 ± 11.9 years; BMI = 31.2 ± 5.9 kg/m2; AHI = 37.8 ± 19.2; Epworth score = 10.0 ± 4.8) from the Pays de la Loire Sleep Cohort. At D90, 88% of the patients were adherent as defined by a mean daily CPAP use of ≥ 4 h. RESULTS: In a univariate analysis, the factors significantly associated with CPAP adherence at D90 were older age, lower BMI, CPAP adherence (≥ 4 h/night) at D14, and AP™ prediction at D14. In a multivariate analysis, only older age (OR 2.10 [1.29-3.41], p = 0.003) and the AP™ prediction at D14 (OR 16.99 [7.26-39.75], p < 0.0001) were significant predictors. CPAP adherence at D90 was not associated with device-derived residual events, nor with the levels of pressure or leakage except in the case of very significant leakage when it persisted for 90 days. CONCLUSION: Automatic telemonitoring algorithms are relevant tools for early prediction of CPAP therapy adherence and may make it possible to focus therapeutic follow-up efforts on patients who are at risk of non-adherence.

Positional obstructive sleep apnea within a large multicenter French cohort: prevalence, characteristics, and treatment outcomes.

STUDY OBJECTIVES: To assess, in a large cohort of patients with obstructive sleep apnea, the factors that are independently associated with positional obstructive sleep apnea (POSA) and exclusive POSA (e-POSA) and determine their prevalence. The secondary objective was to evaluate the outcome of positive airway pressure (PAP) therapy for patients with POSA and e-POSA. METHODS: This retrospective study included 6,437 patients with typical mild-to-severe OSA from the Pays de la Loire sleep cohort. Patients with POSA and e-POSA were compared to those with non-POSA for clinical and polysomnographic characteristics. In a subgroup of patients (n = 3,000) included in a PAP follow-up analysis, we determined whether POSA and e-POSA phenotypes were associated with treatment outcomes at 6 months. RESULTS: POSA and e-POSA had a prevalence of 53.5% and 20.1%, respectively, and were independently associated with time in supine position, male sex, younger age, lower apnea-hypopnea index and lower body mass index. After adjustment for confounding factors, patients with POSA and e-POSA had a significantly lower likelihood of treatment adherence (PAP daily use ≥ 4 h) at 6 months and were at higher risk of PAP treatment withdrawal compared to those with non-POSA. CONCLUSIONS: The prevalence and independent predictors of POSA and e-POSA were determined in this large clinical population. Patients with POSA and e-POSA have lower PAP therapy adherence, and this choice of treatment may not be optimal. Thus, there is a need to offer these patients an alternative therapy.

Association Between Nocturnal Hypoxemia and Cancer Incidence in Patients Investigated for OSA: Data From a Large Multicenter French Cohort.

BACKGROUND: Previous studies have yielded inconsistent findings regarding the association between OSA and cancer in humans. RESEARCH QUESTION: Is there an association between indexes of sleep-disordered breathing severity and cancer incidence in patients investigated for suspected OSA? STUDY DESIGN AND METHODS: Data from a large multicenter cohort of cancer-free patients investigated for OSA were linked to health administrative data to identify new-onset cancer. Kaplan-Meier survival analysis and Cox proportional hazards models were used to evaluate the association of cancer incidence with OSA severity and nocturnal hypoxemia. RESULTS: After a median follow-up period of 5.8 years (interquartile range, 3.8-7.8), 718 of 8,748 patients (8.2%) had received a diagnosis of cancer. On unadjusted Kaplan-Meier survival analyses, cancer incidence was associated with increasing severity of OSA (log-rank test, P < .0005) and nocturnal hypoxemia (log-rank test, P < .0001 for both oxygen desaturation index and percent night time with oxygen saturation < 90% [T90]). After adjustment for anthropomorphic data, smoking and alcohol consumption, comorbid cardiac, metabolic, and respiratory diseases, marital status, type of sleep study, and study site, only T90 was associated with cancer incidence (adjusted hazard ratio, 1.33; 95% CI, 1.05-1.68 for T90 ≥ 13% vs < 0.01%; P = .02). On stratified analyses, the association between T90 and cancer appeared stronger in older patients with obesity and no adequate OSA therapy. Among the most frequent cancer sites, nocturnal hypoxemia was associated with lung and breast malignancies. INTERPRETATION: Nocturnal hypoxemia was associated with all-cancer incidence in patients investigated for OSA. Whether OSA therapy might reduce the risk of cancer needs further evaluation.

Sleep apnoea and endothelial dysfunction: An individual patient data meta-analysis.

We performed an individual patient data meta-analysis to investigate the association between obstructive sleep apnoea (OSA) severity and the reactive hyperaemia index (RHI) measured by peripheral arterial tonometry (PAT), a validated measurement of endothelial function, and a strong predictor of late cardiovascular (CV) events. Patients from 12 studies underwent PAT and overnight polysomnography or respiratory polygraphy for suspected OSA. Endothelial dysfunction was defined by a log-transformed RHI<0.51. Subgroup analyses were performed to investigate this relationship in specific populations. Among 730 patients without overt CV disease, 387 (53.0%) had severe OSA (apnoea-hypopnea index ≥30) and 164 (22.5%) exhibited endothelial dysfunction. After adjustment for age, gender, diastolic blood pressure, obesity, diabetes and chronic obstructive pulmonary disease, endothelial dysfunction was associated with severe OSA (odds ratio, OR [95% confidence interval]: 2.27 [1.12-4.60]; p = 0.02), and nocturnal hypoxemia defined by >20 min with oxygen saturation <90% (OR: 1.83 [1.22-2.92]; p = 0.004) or mean oxygen saturation <92% (OR: 1.52 [1.17-1.96]; p = 0.002). On subgroup analyses, the association between severe OSA and endothelial dysfunction was not significant in patients with hypertension, obesity and/or diabetes. Among adults without overt CV disease, severe OSA is independently associated with an increased risk of endothelial dysfunction that may predispose to late CV events.

Automatic identification of sleep and wakefulness using single-channel EEG and respiratory polygraphy signals for the diagnosis of obstructive sleep apnea.

Polysomnography (PSG) is necessary for the accurate estimation of total sleep time (TST) and the calculation of the apnea-hypopnea index (AHI). In type III home sleep apnea testing (HSAT), TST is overestimated because of the lack of electrophysiological sleep recordings. The aim of this study was to evaluate the accuracy and reliability of a novel automated sleep/wake scoring algorithm combining a single electroencephalogram (EEG) channel with actimetry and HSAT signals. The study included 160 patients investigated by PSG for suspected obstructive sleep apnea (OSA). Each PSG was recorded and scored manually using American Academy of Sleep Medicine (AASM) rules. The automatic sleep/wake-scoring algorithm was based on a single-channel EEG (FP2-A1) and the variability analysis of HSAT signals (airflow, snoring, actimetry, light and respiratory inductive plethysmography). Optimal detection thresholds were derived for each signal using a training set. Automatic and manual scorings were then compared epoch by epoch considering two states (sleep and wake). Cohen's kappa coefficient between the manual scoring and the proposed automatic algorithm was substantial, 0.74 ± 0.18, in separating wakefulness and sleep. The sensitivity, specificity and the positive and negative predictive values for the detection of wakefulness were 76.51% ± 21.67%, 95.48% ± 5.27%, 81.84% ± 15.42% and 93.85% ± 6.23% respectively. Compared with HSAT signals alone, AHI increased by 22.12% and 27 patients changed categories of OSA severity with the automatic sleep/wake-scoring algorithm. Automatic sleep/wake detection using a single-channel EEG combined with HSAT signals was a reliable method for TST estimation and improved AHI calculation compared with HSAT.

Increased liver stiffness in patients with severe sleep apnoea and metabolic comorbidities.

The goal of this study was to assess the relationship between the severity of obstructive sleep apnoea (OSA) and liver stiffness measurement (LSM), one of the most accurate noninvasive screening tools for liver fibrosis in nonalcoholic fatty liver disease.The study included 147 patients with at least one criterion for the metabolic syndrome, assessed by polysomnography for suspected OSA. LSM was performed using transient elastography (FibroScan). Significant liver disease and advanced liver fibrosis were defined as LSM ≥7.3 and ≥9.6 kPa, respectively.23 patients were excluded because of unreliable LSM. Among 124 patients, 34 (27.4%) had mild OSA, 38 (30.6%) had moderate OSA and 52 (42.0%) had severe OSA. LSM values were 7.3- <9.6 kPa in 18 (14.5%) patients and ≥9.6 kPa in 15 (12.1%) patients. A dose-response relationship was observed between OSA severity and LSM values (p=0.004). After adjustment for age, sex, metabolic syndrome and insulin resistance, severe OSA was associated with an increased risk of LSM ≥7.3 kPa (OR 7.17, 95% CI 2.51-20.50) and LSM ≥9.6 kPa (OR 4.73, 95% CI 1.25-17.88).In patients with metabolic comorbidities, severe OSA is independently associated with increased liver stiffness, which may predispose to a higher risk of significant liver disease and poorer prognosis.

Travel Time to Hospital for Childbirth: Comparing Calculated Versus Reported Travel Times in France.

Objectives Timely access to health care is critical in obstetrics. Yet obtaining reliable estimates of travel times to hospital for childbirth poses methodological challenges. We compared two measures of travel time, self-reported and calculated, to assess concordance and to identify determinants of long travel time to hospital for childbirth. Methods Data came from the 2010 French National Perinatal Survey, a national representative sample of births (N = 14 681). We compared both travel time measures by maternal, maternity unit and geographic characteristics in rural, peri-urban and urban areas. Logistic regression models were used to study factors associated with reported and calculated times ≥30 min. Cohen's kappa coefficients were also calculated to estimate the agreement between reported and calculated times according to women's characteristics. Results In urban areas, the proportion of women with travel times ≥30 min was higher when reported rather than calculated times were used (11.0 vs. 3.6%). Longer reported times were associated with non-French nationality [adjusted odds ratio (aOR) 1.3 (95% CI 1.0-1.7)] and inadequate prenatal care [aOR 1.5 (95% CI 1.2-2.0)], but not for calculated times. Concordance between the two measures was higher in peri-urban and rural areas (52.4 vs. 52.3% for rural areas). Delivery in a specialised level 2 or 3 maternity unit was a principal determinant of long reported and measured times in peri-urban and rural areas. Conclusions for Practice The level of agreement between reported and calculated times varies according to geographic context. Poor measurement of travel time in urban areas may mask problems in accessibility.

Comparison of titrable thermoplastic versus custom-made mandibular advancement device for the treatment of obstructive sleep apnoea.

BACKGOUND AND OBJECTIVES: The disadvantages of custom-made mandibular advancement devices (MAD) for obstructive sleep apnoea (OSA) therapy are the cost and delay required to manufacture the device. This study aimed to evaluate the efficacy of a titrable, thermoplastic MAD compared to a custom-made MAD for OSA therapy. METHODS: In this prospective nonrandomized study, 158 patients with OSA from two French sleep centers were treated for 6 months with a titrable thermoplastic MAD (n = 86) or a custom-made MAD (n = 72). The primary outcome was the change in sleep-disordered breathing (SDB) severity. RESULTS: After adjustment for baseline values, age, body mass index and study site, no significant intergroup differences were observed between thermoplastic and custom-made MAD for the outcome of apnoea, hypopnoea and oxygen desaturation indices. No between treatment differences were observed for the outcome of subjective sleepiness, symptoms of snoring and fatigue, depressive symptoms, and quality of life. Thermoplastic MAD therapy was associated with higher side effects scores for tooth pain (p < 0.0001) and self-reported occlusal changes (p = 0.0069). Mean (SD) reported compliance was lower in the thermoplastic MAD group than in the custom-made MAD group (6.4 [0.2] vs 7.1 [0.1] h/night; p = 0.035). CONCLUSIONS: This study demonstrates the efficacy of a titrable thermoplastic MAD in reducing SDB and related symptoms in patients with mild to severe OSA. Reported compliance at 6 months was high despite more dental discomfort than with custom-made MAD.

Association between obstructive sleep apnea severity and endothelial dysfunction in patients with type 2 diabetes.

BACKGROUND: Obstructive sleep apnea (OSA) and type 2 diabetes (T2D) are associated with endothelial dysfunction a main predictor of late cardiovascular (CV) events. Despite the high prevalence of OSA in patients with T2D, the impact of OSA severity on endothelial function has not been clearly elucidated. The aim of this cross-sectional study was to determine whether increasing OSA severity is associated with poorer endothelial function in patients with T2D. METHODS: 140 patients with T2D and no overt CV disease underwent polysomnography, peripheral arterial tonometry, clinic blood pressure (BP) measurement, biological assessment for CV risk factors, daytime sleepiness and health related quality of life (HRQL) questionnaires. The following commonly used cut-offs for apnea-hypopnea index (AHI) were used to define 3 categories of disease severity: AHI < 15 (no OSA or mild OSA), 15 ≤ AHI < 30 (moderate OSA), and AHI ≥ 30 (severe OSA). The primary outcome was the reactive hyperemia index (RHI), a validated assessment of endothelial function. RESULTS: 21.4% of patients had moderate OSA and 47.6% had severe OSA. Increasing OSA severity and nocturnal hypoxemia were not associated with a significant decrease in RHI. Endothelial dysfunction (RHI < 1.67) was found in 47.1, 44.4 and 39.2% of patients with no OSA or mild OSA, moderate OSA and severe OSA, respectively (p = 0.76). After adjustment for confounders including body mass index, increasing OSA severity was associated with higher systolic BP (p = 0.03), lower circulating levels of adiponectin (p = 0.0009), higher levels of sP-selectin (p = 0.03), lower scores in 3 domains of HRQL including energy/vitality (p = 0.02), role functioning (p = 0.01), and social functioning (p = 0.04). CONCLUSIONS: Moderate to severe OSA is very common but has no impact on digital micro-vascular endothelial function in patients with T2D.

Association Between Severity of Obstructive Sleep Apnea and Blood Markers of Liver Injury.

Obstructive sleep apnea (OSA) may contribute to the development of nonalcoholic fatty liver disease. We performed a multisite cross-sectional study to evaluate the association between the severity of OSA and blood markers of liver steatosis (using the hepatic steatosis index), cytolysis (based on alanine aminotransferase activity), and significant liver fibrosis (based on the FibroMeter [Echosens] nonalcoholic fatty liver disease score) in 1285 patients with suspected OSA in France. After adjusting for confounders including central obesity, the risk of liver steatosis increased with the severity of OSA (P for trend < .0001) and sleep-related hypoxemia (P for trend < .0003 for mean oxygen saturation). Decreasing mean oxygen saturation during sleep also was associated independently with a higher risk of liver cytolysis (P for trend < .0048). Severe OSA conferred an approximate 2.5-fold increase in risk for significant liver fibrosis compared with patients without OSA, but the association between OSA severity and liver fibrosis was not maintained after adjusting for confounders.

Socio-Economic Status: A Barrier to Access to Mandibular Advancement Device Therapy for Patients with Obstructive Sleep Apnea Syndrome in France.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a major public health problem which affects between 5 to 10% of the general population. OSAS is known to be associated with high rates of morbidity and mortality mainly due to cardiovascular diseases and traffic accidents. The burden of illness is high for the individual and society. There are 2 treatment options for OSAS, Continuous Positive Airway Pressure (CPAP) and Mandibular Advancement Device therapy (MAD). CPAP is known to be an effective but very constraining treatment. Patients are usually poorly adherent. MAD is a more recent treatment easier to use and consequently better tolerated, but MAD can only be prescribed to patients with satisfactory oral hygiene. Oral health constitutes a real issue particularly among underprivileged groups in France. Through this link, the question of whether low socio-economic status constitutes a barrier to access to care for patients with OSAS is raised. METHODS AND PRINCIPAL FINDINGS: In a multicenter prospective cohort of 2822 consecutive OSAS patients in whom MAD has been proposed as an alternative to CPAP between May 15, 2007 and December 1st, 2014, we identified the factors that lead to a patient diagnosed with OSAS to be treated by MAD instead of CPAP. A logistic regression was performed using a stepwise forward procedure. The main outcome of the study was that treatment by MAD was significantly associated with both educational attainment, as determined by the age at which the patient left full-time education, ≥18 years compared with <18 (adjusted odds ratio (aOR): 1.64, 95% CI 1.23 to 2.20), and the patient's occupational category. Executives and higher intellectual professions, intermediate professions, technicians, foremen and employees were significantly more likely to be treated by MAD than workers (aOR: 2.21, 95% CI 1.88 to 2.58; aOR: 1.74, 95% CI 1.15 to 2.63; aOR: 1.96, 95% CI 1.11 to 3.47, respectively). CONCLUSIONS: Overall, these results suggest that low socio-economic status constitutes a barrier to access to MAD for patients with OSAS in France. MAD use in patients with OSAS highlights inequalities in health care access.