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

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

Validation of a single-use and reusable home sleep apnea test based on peripheral arterial tonometry compared to laboratory polysomnography for the diagnosis of obstructive sleep apnea.

STUDY OBJECTIVES: The objective of this study was to independently validate a disposable and a reusable home sleep apnea test (HSAT) recording on peripheral arterial tonometry, compared to laboratory polysomnography (PSG), for the diagnosis of obstructive sleep apnea (OSA). METHODS: 115 participants undergoing PSG for suspected OSA were recruited and fitted with the two study devices (NightOwl, Ectosense, Belgium). After exclusions were applied and device failures were removed, data from 100 participants were analyzed. HSAT-derived apnea-hypopnea index (AHI), OSA severity category, total sleep time, and oxygen desaturation index 3% were compared to PSG. RESULTS: Both study devices demonstrated satisfactory levels of agreement with minimal mean bias for determination of AHI and oxygen desaturation index 3% (disposable: AHI mean bias 2.04 events/h [95% limits of agreement -20.9 to 25.0], oxygen desaturation index 3% mean bias -0.21/h [-18.1 to 17.7]; reusable: AHI mean bias 2.91 events/h [-16.9 to 22.7], oxygen desaturation index 3% mean bias 0.77/h [-15.7 to 17.3]). Level of agreement diminished at higher AHI levels although misclassification for severe OSA occurred infrequently. Total sleep time level of agreement for the reusable HSAT was also satisfactory with minimal mean bias (4.18 minutes, -125.1 to 112.4), but the disposable HSAT was impacted by studies with high signal rejection (23.7 minutes, -132.7 to 180.1). Categorization of OSA severity demonstrated moderate agreement with laboratory PSG, with a kappa of 0.52 and 0.57 for the disposable and reusable HSATs respectively. CONCLUSIONS: The two HSAT devices were comparable and performed well compared to laboratory PSG for the diagnosis of OSA. CLINICAL TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Registry; Identifier: ANZCTR12621000444886. CITATION: Lyne CJ, Hamilton GS, Turton ARE, et al. Validation of a single-use and reusable home sleep apnea test based on peripheral arterial tonometry compared to laboratory polysomnography for the diagnosis of obstructive sleep apnea. J Clin Sleep Med. 2023;19(8):1429-1435.

Nocturnal Wakefulness and Suicide Risk in the Australian Population.

Objective: Temporal patterns for suicide over a 24-hour period have shown mixed results among prior studies. However, analyses of 24-hour temporal patterns for wakeful actions including suicidal behavior should adjust for expected sleep requirements that inherently skew such activities to conventional wakeful times. This study analyzed the time-of-day for suicide cases from the Australian population for the year 2017, adjusting for expected sleep patterns. Identification of time-of-day trends using this methodology may reveal risk factors for suicide and potentially modifiable contributors.Methods: The Australian National Coronial Information System database was accessed, and data for completed suicide were extracted for the most recent completed year (2017). Time of suicide was allocated to one of four 6-hourly time bins across 24 hours, determined from time last seen alive and time found subsequently. Prevalence of suicide for each time bin was adjusted for the likelihood of being awake for each bin according to sleep-wake norms published from a large Australian community survey. Observed prevalence of suicide was compared to expected values predicted from likelihood of being awake across each time bin calculated as a standardized incidence ratio (SIR).Results: For the year 2017, there were 2,808 suicides, of which 1,417 were able to be allocated into one of four 6-hourly time bins. When compared to expected values, suicides were significantly more likely to occur in the overnight bin (2301-0500; SIR = 3.93, P < .001).Conclusions: Higher-than-expected rates of suicide overnight associated with nocturnal wakefulness may represent a modifiable risk factor for triggering suicide events.

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

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

Sleep disturbances may influence lifestyle behaviours in women with self-reported polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is associated with a higher prevalence of sleep disturbances and obesity. Treatment of PCOS includes modifying lifestyle behaviours associated with weight management. However, poor sleep in the non-PCOS population has been associated with poorer lifestyle behaviours. The aim was to investigate whether sleep disturbance confounds or modifies the association between lifestyle factors and PCOS. This was a cross-sectional analysis from the Australian Longitudinal Study on Women's Health cohort aged 31-36 years in 2009 were analysed (n 6067, 464 PCOS, 5603 non-PCOS). Self-reported data were collected on PCOS, anthropometry, validated modified version of the Active Australia Physical Activity survey, validated FFQ and sleep disturbances through latent class analysis. Women with PCOS had greater adverse sleep symptoms including severe tiredness (P = 0·001), difficulty sleeping (P < 0·001) and restless sleep (P < 0·001), compared with women without PCOS. Women with PCOS also had higher energy consumption (6911 (sd 2453) v. 6654 (sd 2215) kJ, P = 0·017), fibre intake (19·8 (sd 7·8) v. 18·9 (sd 6·9) g, P = 0·012) and diet quality (dietary guidelines index (DGI)) (88·1 (sd 11·6) v. 86·7 (sd 11·1), P = 0·008), lower glycaemic index (50·2 (sd 4·0) v. 50·7 (sd 3·9), P = 0·021) and increased sedentary behaviour (6·3 (sd 2·8) v. 5·9 (sd 2·8) h, P = 0·009). There was a significant interaction between PCOS and sleep disturbances for DGI (P = 0·035), therefore only for women who had adequate sleep was PCOS associated with a higher DGI. For women with poorer sleep, there was no association between PCOS and DGI. The association between PCOS and improved diet quality may only be maintained if women can obtain enough good quality sleep.

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

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

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

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

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

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

Guideline-based intervention to reduce telemetry rates in a large tertiary centre.

BACKGROUND: Inappropriate cardiac telemetry use is associated with reduced patient flow and increased healthcare costs. AIM: To evaluate the outcomes of guideline-based application of cardiac telemetry. METHODS: Phase I involved a prospective audit (March to August 2011) of telemetry use at a tertiary hospital. Data were collected on indication for telemetry and clinical outcomes. Phase II prospectively included patients more than 18 years under general medicine requiring ward-based telemetry. As phase II occurred at a time remotely from phase I, an audit similar to phase I (phase II - baseline) was completed prior to a 3-month intervention (May to August 2015). The intervention consisted of a daily telemetry ward round and an admission form based on the American Heart Association guidelines (class I, telemetry indicated; class II, telemetry maybe indicated; class III, telemetry not indicated). Patient demographics, telemetry data, and clinical outcomes were studied. Primary endpoint was the percentage reduction of class III indications, while secondary endpoint included telemetry duration. RESULTS: In phase I (n = 200), 38% were admitted with a class III indication resulting in no change in clinical management. A total of 74 patients was included in phase II baseline (mean ± standard deviation (SD) age 73 years ± 14.9, 57% male), whilst 65 patients were included in the intervention (mean ± SD age 71 years ± 18.4, 35% male). Both groups had similar baseline characteristics. There was a reduction in class III admissions post-intervention from 38% to 11%, P < 0.001. Intervention was associated with a reduction in median telemetry duration (1.8 ± 1.8 vs 2.4 ± 2.5 days, P = 0.047); however, length of stay was similar in both groups (P > 0.05). CONCLUSION: Guideline-based telemetry admissions and a regular telemetry ward round are associated with a reduction in inappropriate telemetry use.

Oxygen Desaturation Index Differs Significantly Between Types of Sleep Software.

STUDY OBJECTIVES: The aim of this study was to compare the oxygen desaturation index (ODI) generated by two different sleep software systems. METHODS: Participants undergoing diagnostic polysomnography for suspected obstructive sleep apnea underwent simultaneous oximetry recording using the ResMed ApneaLink Plus device (AL) and Compumedics Profusion PSG3 system (Comp). The ODI was calculated by the algorithms in the respective software of each system. To determine if differences were due to algorithm or recording devices, the Comp software was also used to generate ODI values using oximetry data from the AL. RESULTS: In 106 participants, there was good correlation but poor agreement in the ODI generated by the two systems. AL ODI values tended to be higher than Comp ODI values, but with significant variability. For ODI4%, bias was 4.4 events/h (95% limits of agreement -5.8 to 14.6 events/h). There was excellent correlation and agreement when the same oximetry raw data was analyzed by both systems. For ODI4%, bias was 0.03 events/h (95% limits of agreement -2.7 to 2.8 events/h). Similar results were evident when the ODI3% was used. CONCLUSIONS: There is a clinically significant difference in ODI values generated by the two systems, likely due to device signal processing, rather than difference in ODI calculation algorithms.

Oronasal Masks Require a Higher Pressure than Nasal and Nasal Pillow Masks for the Treatment of Obstructive Sleep Apnea.

STUDY OBJECTIVES: Oronasal masks are frequently used for continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). The aim of this study was to (1) determine if CPAP requirements are higher for oronasal masks compared to nasal mask interfaces and (2) assess whether polysomnography and patient characteristics differed among mask preference groups. METHODS: Retrospective analysis of all CPAP implementation polysomnograms between July 2013 and June 2014. Prescribed CPAP level, polysomnography results and patient data were compared according to mask type (n = 358). RESULTS: Oronasal masks were used in 46%, nasal masks in 35% and nasal pillow masks in 19%. There was no difference according to mask type for baseline apnea-hypopnea index (AHI), body mass index (BMI), waist or neck circumference. CPAP level was higher for oronasal masks, 12 (10-15.5) cm H2O compared to nasal pillow masks, 11 (8-12.5) cm H2O and nasal masks, 10 (8-12) cm H2O, p < 0.0001 (Median [interquartile range]). Oronasal mask type, AHI, age, and BMI were independent predictors of a higher CPAP pressure (p < 0.0005, adjusted R(2) = 0.26.). For patients with CPAP ≥ 15 cm H2O, there was an odds ratio of 4.5 (95% CI 2.5-8.0) for having an oronasal compared to a nasal or nasal pillow mask. Residual median AHI was higher for oronasal masks (11.3 events/h) than for nasal masks (6.4 events/h) and nasal pillows (6.7 events/h), p < 0.001. CONCLUSIONS: Compared to nasal mask types, oronasal masks are associated with higher CPAP pressures (particularly pressures ≥ 15 cm H2O) and a higher residual AHI. Further evaluation with a randomized control trial is required to definitively establish the effect of mask type on pressure requirements. COMMENTARY: A commentary on this article appears in this issue on page 1209.

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

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

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

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

Controlled trial of continuous positive airway pressure in obstructive sleep apnea and heart failure.

Obstructive sleep apnea (OSA) is highly prevalent among patients with congestive heart failure (CHF) and may contribute to progression of cardiac dysfunction via hypoxia, elevated sympathetic nervous system activity, and systemic hypertension. Our aim was to assess the long-term effect of OSA treatment with nocturnal continuous positive airway pressure (CPAP) on systolic heart function, sympathetic activity, blood pressure, and quality of life in patients with CHF. Fifty-five patients with CHF and OSA were randomized to 3 months of CPAP or control groups. End points were changes in left ventricular ejection fraction, overnight urinary norepinephrine excretion, blood pressure, and quality of life. Nineteen patients in the CPAP group and 21 control subjects completed the study. Compared with the control group, CPAP treatment was associated with significant improvements in left ventricular ejection fraction (delta 1.5 +/- 1.4% vs. 5.0 +/- 1.0%, respectively, p = 0.04), reductions in overnight urinary norepinephrine excretion (delta 1.6 +/- 3.7 vs. -9.9 +/- 3.6 nmol/mmol creatinine, p = 0.036), and improvements in quality of life. There were no significant changes in systemic blood pressure. In conclusion, treatment of OSA among patients with CHF leads to improvement in cardiac function, sympathetic activity, and quality of life.