Clinical features, polysomnography, and genetics association study of restless legs syndrome in clinic based Chinese patients: A multicenter observational study.

STUDY OBJECTIVES: To systemically describe the clinical features, polysomnography (PSG) finding, laboratory tests and single-nucleotide polymorphisms (SNPs) in a clinic based Chinese primary restless legs syndrome (RLS) population. METHODS: This observational study, conducted from January 2020 to October 2021 across 22 sleep labs in China, recruited 771 patients diagnosed with RLS following the 2014 RLSSG criteria. Clinical data, PSG testing, and laboratory examination and SNPs of patients with RLS were collected. A total of 32 SNPs in 24 loci were replicated using the Asian Screening Array chip, employing data from the Han Chinese Genomes Initiative as controls. RESULTS: In this study with 771 RLS patients, 645 had primary RLS, and 617 has DNA available for SNP study. Among the 645 primary RLS, 59.7% were women. 33% had a family history of RLS, with stronger familial influence in early-onset cases. Clinical evaluations showed 10.4% had discomfort in body parts other than legs. PSG showed that 57.1% of RLS patients had periodic leg movement index (PLMI) of >5/h and 39.1% had PLMI >15/h, respectively; 73.8% of RLS patients had an Apnea-Hypopnea Index (AHI) > 5/h, and 45.3% had an AHI >15/h. The laboratory examinations revealed serum ferritin levels <75 ng/ml in 31.6%, and transferrin saturation (TSAT) of <45% in 88.7% of RLS patients. Seven new SNPs in 5 genes showed a significant allelic association with Chinese primary RLS, with one previously reported (BTBD9) and four new findings (TOX3, PRMT6, DCDC2C, NOS1). CONCLUSIONS: Chinese RLS patients has specific characters in many aspects. A high family history with RLS not only indicates strong genetic influence, but also reminds us to consider the familial effect in the epidemiological study. Newly developed sequencing technique with large samples remains to be done.

Telemedicine management of obstructive sleep apnea disorder in China: a randomized, controlled, non-inferiority trial.

PURPOSE: Previous studies assessed different components of telemedicine management pathway for OSA instead of the whole pathway. This randomized, controlled, and non-inferiority trial aimed to assess whether telemedicine management is clinically inferior to in-person care in China. METHODS: Adults suspected of OSA were randomized to telemedicine (web-based questionnaires, self-administered home sleep apnea test [HSAT], automatically adjusting positive airway pressure [APAP], and video-conference visits) or in-person management (paper questionnaires, in-person HSAT set-up, APAP, and face-to-face visits). Participants with an apnea-hypopnea index (AHI) ≥ 15 events/hour received APAP for 3 months. The non-inferiority analysis was based on the change in Functional Outcomes of Sleep Questionnaire (FOSQ) score and APAP adherence. Cost-effectiveness analysis was performed. RESULTS: In the modified intent-to-treat analysis set (n = 111 telemedicine, 111 in-person), FOSQ scores improved 1.73 (95% confidence interval [CI], 1.31-2.14) points with telemedicine and 2.05 (1.64-2.46) points with in-person care. The lower bound of the one-sided 95% non-inferiority CI for the difference in change between groups of - 0.812 was larger than the non-inferiority threshold of - 1. APAP adherence at 3 months was 243.3 (223.1-263.5) minutes/night for telemedicine and 241.6 (221.3-261.8) minutes/night for in-person care. The lower bound of the one-sided 95% non-inferiority CI of - 22.2 min/night was higher than the non-inferiority delta of - 45 min/night. Telemedicine had lower total costs than in-person management (CNY 1482.7 ± 377.2 vs. 1912.6 ± 681.3; p < 0.0001), driven by patient costs, but no significant difference in QALYs. CONCLUSIONS: Functional outcomes and adherence were not clinically inferior in patients managed by a comprehensive telemedicine approach compared to those receiving in-person care in China. CLINICAL TRIAL REGISTRATION: https://www.chictr.org.cn , Registration number ChiCTR2000030546. Retrospectively registered on March 06, 2020.

Home monitoring for clinically suspected obstructive sleep apnea in pregnancy.

STUDY OBJECTIVES: To determine if a home sleep apnea test (HSAT) using a type III portable monitor (PM), Nox-T3 (Nox Medical, Inc., Reykjavik, Iceland), detects obstructive sleep apnea in pregnant women. METHODS: Ninety-two pregnant women (34.5 ± 4.3 years; gestational age 25.4 ± 8.9 weeks; body mass index 29.9 ± 4.7 kg/m2) with suspected obstructive sleep apnea underwent HSAT with the Nox-T3 PM followed by overnight polysomnography (PSG) and PM recording simultaneously in the laboratory within 1 week. PMs were scored automatically and manually using a 3% criteria and compared with PSGs scored by following guidelines. RESULTS: Apnea-hypopnea indexes were 8.56 ± 10.42, 8.19 ± 13.79, and 8.71 ± 14.19 events/h on HSAT, in-laboratory PM recording, and PSG (P = .955), respectively. Bland-Altman analysis of the apnea-hypopnea index on PSG vs HSAT showed a mean difference (95% confidence interval) of -0.15 (-1.83, 1.53); limits of agreement (± 2 SD) were -16.26 to 16.56 events/h. Based on a threshold apnea-hypopnea index ≥ 5 events/h, HSAT had 91% sensitivity, 85% specificity, 84% positive-predictive value, and 92% negative-predictive value compared with PSG. When comparing the simultaneous recordings, closer agreement was observed. Automated vs manual analysis of PM showed no significant difference. CONCLUSIONS: A type III PM had an acceptable failure rate and high diagnostic performance operating as a reasonable alternative for in-laboratory PSG in pregnant women. CITATION: Wang J, Zhang C, Xu L, et al. Home monitoring for clinically suspected obstructive sleep apnea in pregnancy. J Clin Sleep Med. 2023;19(11):1951-1960.

Validation of a portable monitor compared with polysomnography for screening of obstructive sleep apnea in polio survivors.

Subjective: Sleep-disordered breathing (SDB) is highly prevalent in polio survivors. Obstructive sleep apnea (OSA) is the most frequent type. Full polysomnography (PSG) is recommended for OSA diagnosis in patients with comorbidities by current practice guidelines, but it is not always accessible. The purpose of this study was to evaluate whether type 3 portable monitor (PM) or type 4 PM might be a viable alternative to PSG for the diagnosis of OSA in postpolio subjects. Methods: A total of 48 community-living polio survivors (39 men and 9 women) with an average age of 54.4 ± 5.3 years referred for the evaluation of OSA and who volunteered to participate were recruited. First, they completed the Epworth Sleepiness Scale (ESS) questionnaire and underwent pulmonary function testing and blood gas tests the day before PSG night. Then, they underwent an overnight in-laboratory PSG with a type 3 PM and type 4 PM recording simultaneously. Results: The AHI from PSG, respiratory event index (REI) from type 3 PM, and ODI3 from type 4 PM was 30.27 ± 22.51/h vs. 25.18 ± 19.11/h vs. 18.28 ± 15.13/h, respectively (P < 0.001). For AHI ≥ 5/h, the sensitivity and specificity of REI were 95.45 and 50%, respectively. For AHI ≥ 15/h, the sensitivity and specificity of REI were 87.88% and 93.33%, respectively. The Bland-Altman analysis of REI on PM vs. AHI on PSG showed a mean difference of -5.09 (95% confidence interval [CI]: -7.10, -3.08; P < 0.001) with limits of agreement ranging from -18.67 to 8.49 events/h. ROC curve analysis for patients with REI ≥ 15/h showed an area under the curve (AUC) of 0.97. For AHI ≥ 5/h, the sensitivity and specificity of ODI3 from type 4 PM were 86.36 and 75%, respectively. For patients with AHI ≥ 15/h, the sensitivity was 66.67%, and the specificity was 100%. Conclusion: Type 3 PM and Type 4 PM could be alternative ways to screen OSA for polio survivors, especially for moderate to severe OSA.

Changed epidemiology of narcolepsy before, during, and after the 2009 H1N1 pandemic: a nationwide narcolepsy surveillance network study in mainland China, 1990-2017.

STUDY OBJECTIVES: Increased incidence of narcolepsy was reported in children during the 2009 H1N1 pandemic following Pandemrix, a H1N1 flu vaccine. A link with A(H1N1) pdm09 infections remains controversial. Using nationwide surveillance data from China (1990 to 2017), the epidemiology of narcolepsy was analyzed. METHODS: Individual records of narcolepsy patients were collected from 15 of 42 hospitals across China known to diagnose cases. Incidence was estimated assuming the representativeness of these hospitals. Age-specific incidence, epidemiological and clinical characteristics of patients were evaluated before, during, and after the 2009 H1N1 pandemic. Sensitivity analyses were conducted by including NT1 cases only and excluding the effect of the 2009 H1N1 vaccination. RESULTS: Average annual incidence was 0.79 per 100 000 person-years (PY) from 1990 to 2017 and 1.08 per 100 000 PY from 2003 to 2017. Incidence increased 4.17 (95% CI 4.12, 4.22) and 1.42 (95% CI 1.41, 1.44) fold during and after the 2009 H1N1 pandemic when compared to baseline. These results were robust in sensitivity analyses. Patients with the onset of narcolepsy during the pandemic period were younger (notably in 5-9-year-old strata), and the age shift toward younger children reversed to baseline following the pandemic. CONCLUSIONS: Increased incidence of narcolepsy was observed during the 2009 H1N1 pandemic period. This is likely to be associated with the circulation of the wild type A(H1N1)pdm09 virus. This observation should be considered for future influenza pandemic preparedness plans.

The Impact of Symptom Severity on Health-Related Quality of Life in People with Narcolepsy Type 1.

OBJECTIVE: To assess the impact of symptom severity on health-related quality of life (HRQoL) in people with narcolepsy type 1 (NT1). METHODS: A total of 174 people with NT1 were enrolled. They completed the Narcolepsy Severity Scale (NSS) and EQ-5D-3L consisting of five dimensions (EQ-5D utility values) and a visual analog scale (EQ-5D VAS). The relationship between severity of symptoms and HRQoL dimensions was evaluated by Pearson correlation analyses. Logistic regression was used to identify significant predictors of HRQoL. Nomogram was established based on results of independent predictors of factors on logistic regression analyses. RESULTS: The mean score for NSS, EQ-5D utility values, and EQ-5D VAS were 29.8 (10.08), 0.78 (0.09), and 64.30 (19.84) in people with NT1, respectively. NSS score showed a significant correlation with self-care (r = 0.157, p < .05), usual activities (r = 0.236, p < .01), pain/discomfort (r = 0.174, p < .05), anxiety/depression (r = 0.2, p < .01), and EQ-5D utility values (r = -.261, p < .01). EDS (excessive daytime sleep), cataplexy, hallucinations, paralysis, and disrupted nocturnal sleep (DNS) were significantly associated to EQ-5D VAS (r ranged from -0.154 to -0.354, p < .05). EDS (OR = -0.297) and DNS (OR = -0.16) were predictors of HRQoL. NSS score (OR = -0.360) and treatment (OR = 0.215) were predictors of the metrics of HRQoL. The C-indices of the nomogram were 0.726. CONCLUSION: The severity of symptoms could disrupt self-care and usual activities, and increase pain/discomfort and anxiety/depression. HRQoL might be improved by alleviating symptom severity.

Diurnal changes in blood pressure and heart rate in children with narcolepsy with cataplexy.

The hypocretin neurons in the lateral hypothalamus are connected not only to brain alertness systems but also to brainstem nuclei that regulate blood pressure and heart rate. The premise is that regulation of blood pressure and heart rate is altered and affected by methylphenidate, a stimulant drug in children with narcolepsy with cataplexy. The changes in 24-hr ambulatory systolic and diastolic blood pressure and heart rate were compared among pre-treated narcolepsy with cataplexy patients (40 males, 10 females), with mean age 10.4 ± 3.5 years (M ±â€…SD, range 5-17 years) with values from 100 archival age-sex-body mass index matched controls. Patients had a lower diurnal systolic blood pressure (-6.5 mmHg; p = 0.000) but higher heart rate (+11.0 bpm; p = 0.000), particularly evident in the waketime, while diastolic blood pressure was comparable. With methylphenidate (18 mg sustained release at 08:00 hours), patients with narcolepsy with cataplexy had higher systolic blood pressure (+4.6 mmHg, p = 0.015), diastolic blood pressure (+3.3 mmHg, p = 0.005) and heart rate (+7.1 bpm, p = 0.028) during wake time, but nighttime cardiovascular values were unchanged from pre-treated values; amplitude variation in cardiovascular values was unchanged over 24 hr. In conclusion, children with narcolepsy with cataplexy had downregulation blood pressure profile but a higher heart rate, and lesser non-dipping profiles. Daytime methylphenidate treatment increases only waketime blood pressure and further elevated heart rate values.

Identifying longitudinal patterns of CPAP treatment in OSA using growth mixture modeling: Disease characteristics and psychological determinants.

In this study, we aim to identify the distinct subtypes of continuous positive airway pressure (CPAP) user profiles based on the telemedicine management platform and to determine clinical and psychological predictors of various patterns of adherence. A total of 301 patients used auto-CPAP (Autoset 10, Resmed Inc.) during the treatment period. Four categories of potential predictors for CPAP adherence were examined: (1) demographic and clinical characteristics, (2) disease severity and comorbidities, (3) sleep-related health issues, and (4) psychological evaluation. Then, growth mixture modeling was conducted using Mplus 8.0 to identify the unique trajectories of adherence over time. Adherence data were collected from the telemedicine management platform (Airview, Resmed Inc.) during the treatment. Three novel subgroups were identified and labeled "adherers" (53.8% of samples, intercept = 385, slope = -51, high mean value, negative slope and moderate decline), "Improvers" (18.6%, intercept = 256, slope = 50, moderate mean value, positive slope and moderate growth) and "non-adherers" (27.6%, intercept = 176, slope = -31, low mean value, negative slope and slight decline). The comorbidities associated with OSA and the apnea-hypopnea index (AHI), which reflects the objective severity of the disease, did not differ significantly among the subgroups. However, "improvers" showed higher levels of daytime sleepiness (8.1 ± 6.0 vs. 12.1 ± 7.0 vs. 8.0 ± 6.1 in SWIFT, p = 0.01), reduced daytime function (4.6 ± 1.6 vs. 3.8 ± 1.6 vs. 4.2 ± 1.8 in QSQ daytime symptoms, p = 0.02), and characteristics of positive coping style (1.8 ± 0.5 vs. 1.9 ± 0.5 vs. 1.7 ± 0.5 in SCSQ positive coping index, p = 0.02). Negative emotion was more pronounced in patients with "non-adherers" (12.9 ± 3.8 vs. 13.7 ± 3.3 vs. 14.6 ± 3.5, p = 0.02 in the HADS depression dimension; 9.0 ± 6.1 vs. 9.8 ± 5.1 vs. 11.5 ± 6.3, p = 0.01 with Negative Affectivity in DS14, and 9.3 ± 6.1 vs. 10.3 ± 5.1 vs. 11.7 ± 6.5, p = 0.01 with Social Inhibition in DS14). Overall, our study demonstrated that CPAP therapy may present distinct trajectories of adherence over time in addition to the traditional binary classification. Self-reported sleep health issues (diurnal sleepiness and daytime dysfunction) as well as psychological characteristics (negative emotions and coping style) were predictors of different adherence subtypes in patients with OSA. Understanding CPAP use profiles and their predictors enable the identification of those who may require additional intervention to improve adherence and further enhance the therapeutic effect in OSA patients.

Case Report: Considerations of nocturnal ventilator support in ROHHAD syndrome in chronic care of childhood central hypoventilation with hypothalamus dysfunction.

Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) is a rare life-threatening disorder that can occur during childhood. All children with ROHHAD develop alveolar hypoventilation during wakefulness and sleep. The key treatment for these patients is the optimization of oxygenation and ventilation. Here, we report the case of a 5-year-old girl with suspected ROHHAD, with rapid weight gain, breathing cessation, decreased height, hypoventilation, central hypothyroidism, hyperprolactinemia, and absolute deficiency of growth hormone, and negative PHOX2B sequencing results. The presentation met the diagnostic criteria for ROHHAD syndrome. During the 5-year follow-up, she presented with progressive deterioration of the function of the hypothalamus and respiratory center, hypoxemia (PO2 < 60 mmHg), and hypercapnia [transcutaneous carbon dioxide (TcPCO2) > 70 mmHg] during the first two cycles of N3 sleep with a poor response to ventilatory support. Early diagnosis and application of non-invasive positive pressure ventilation during sleep can improve the quality of life and outcomes of patients with ROHHAD, and polysomnography and TcPCO2 should be repeated every 3-6 months to follow the progress and regulate ventilator support. Multidisciplinary care is crucial for the successful management of these patients.

A systematic review of deep learning methods for modeling electrocardiograms during sleep.

Sleep is one of the most important human physiological activities, and plays an essential role in human health. Polysomnography (PSG) is the gold standard for measuring sleep quality and disorders, but it is time-consuming, labor-intensive, and prone to errors. Current research has confirmed the correlations between sleep and the respiratory/circulatory system. Electrocardiography (ECG) is convenient to perform, and ECG data are rich in breathing information. Therefore, sleep research based on ECG data has become popular. Currently, deep learning (DL) methods have achieved promising results on predictive health care tasks using ECG signals. Therefore, in this review, we systematically identify recent research studies and analyze them from the perspectives of data, model, and task. We discuss the shortcomings, summarize the findings, and highlight the potential opportunities. For sleep-related tasks, many ECG-based DL methods produce more accurate results than traditional approaches by combining multiple signal features and model structures. Methods that are more interpretable, scalable, and transferable will become ubiquitous in the daily practice of medicine and ambient-assisted-living applications. This paper is the first systematic review of ECG-based DL methods for sleep tasks.

A comparison of mood, quality of life and executive function among narcolepsy type 1 patients with or without ADHD symptoms in China.

OBJECTIVE: To investigate the prevalence of core attention-deficit/hyperactivity disorder (ADHD) symptoms in Chinese narcolepsy type 1 (NT1) patients and to explore mood, quality of life, and executive function in narcolepsy patients with or without ADHD and the response to Methylphenidate Hydrochloride Extended-release tablets (ER-MPH) treatment. METHOD: A total of 267 pediatric NT1 patients (194 males and 73 females, 5-17 years old) were evaluated for ADHD symptoms by a psychiatrist using the DSM-IV diagnostic criteria of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) from February 2011 to July 2013 at Peking University People's Hospital. All patients underwent Stanford Sleep Inventory (SSI) evaluation and polysomnography followed by multiple sleep latency tests (MSLT) before ER-MPH treatment. Neuropsychological evaluations, including the Inventory of Subjective Life Quality (ISLQ), Depression Self-resting Scale for Children (DSRS-C), Screening for Child Anxiety-related Emotional Disorders (SCARED) and Barratt Impulsiveness Scale (BIS), were performed before and after 16 weeks of ER-MPH treatment. Executive abilities were assessed by the Behavior Rating Inventory of Executive Function-parent version (BRIEF-P). The narcolepsy symptoms, evaluated by the Pediatric Sleep Questionnaire (PSQ), and ADHD symptoms were assessed before and after treatment in NT1 patients with ADHD. RESULT: Seventy-seven of 267 (28.8%) NT1 patients had ADHD symptoms, with 73 patients being inattentive type (ADHD-I) and 4 patients being combined type (ADHD-C). Despite similar objective sleep parameters, NT1 patients with ADHD symptoms experienced higher anxiety levels, more impulsive behaviors, lower health-related quality of life and worse executive functions than those without ADHD (p<0.05). Methylphenidate treatment was effective in improving daytime sleepiness in NT1 patients with ADHD (PSQ, 16.7 ± 2.1 vs 13.5 ± 1.9, p<0.05) but was ineffective on ADHD symptoms (ADHD-RS, 25.3 ± 9.1 vs 26.4 ± 8.9, p>0.05). CONCLUSION: A high prevalence of ADHD (28.8%) was identified in children and adolescents with NT1. Comorbid ADHD symptoms were associated with increased levels of mood disorders and lower quality of life. ER-MPH treatment could reduce daytime sleepiness but not ADHD symptoms in narcolepsy patients with ADHD, suggesting that new treatment strategies are needed for this group of patients.

Study on adherence to positive airway pressure treatment for patients with obstructive sleep apnea using real-world big data in a telemedicine management system.

Obstructive Sleep Apnea (OSA) is a disorder that is characterized by obstructive apneas and hypopneas/respiratory effort-related arousals caused by upper airway collapse during sleep. Positive Airway Pressure (PAP) is the first-line treatment for moderate to severe OSA. However, the effectiveness of PAP therapies is contingent on treatment adherence. With the implementation of the wireless transmission for PAP treatment, it is possible to evaluate the objective adherence to PAP use. The purpose of this study is to assess the adherence to PAP therapy of Chinese OSA patients in a telemedicine management system which could fulfill automatic transmission of PAP treatment data. First, we use the telemedicine management system to extract PAP adherence information of OSA adult patients in one week, one month, three months, six months and 12 months. Second, we describe the general profile of PAP therapy adherence. Third, the latent class growth modeling and growth mixture modeling was conducted using Mplus 8.0 to identify the trajectories of adherence over time. Of all the 662 patients involved in our study, PAP adherence declined over time. After one year, the proportion of days compliant was 53.7%, the proportion of good compliance was 45.2%, the daily usage (all days) was 3.9 h/night, slightly lower than subjective adherence reported in the previous literatures. In addition, we identified three patterns of adherence over time: great users (39.9%; high mean value and level, negative slope, slow decline), good users (34.8%; moderate mean value and level, negative slope, rapid decline) and low users (25.3%; low mean value and level, negative slope, rapid decline). In brief, telemedicine management system provides a convenient platform for monitoring the treatment compliance of OSA patients powerfully and accurately. To improve the low PAP adherence in China, we should make good use of the PAP therapy telemedicine management platform to detect patients with poor adherence and provide timely intervention. Besides, our research provides a foundation for future studies to explore the determinants of observed trajectories of PAP adherence based on the telemedicine platforms.

The month of birth has a seasonal effect in Chinese patients with narcolepsy and cataplexy.

STUDY OBJECTIVES: We assessed the yearly seasonal, environmental effects on birth pattern in Chinese patients later diagnosed with narcolepsy and cataplexy and explored if this effect persisted in patients with symptoms onset date before, following, and after the 2009 H1N1 pandemic. METHODS: A total of 1,942 patients with birth data information and diagnosed narcolepsy with cataplexy were included in this study. The birth month and seasonal effect of 1,064 patients born from 1970 to 2000 were compared to controls (n = 2,028,714) from the general population. Furthermore, birth season effect in 1,373 patients with definite disease onset month were compared among patients with onset date before (n = 595), following (from January 2010 to December 2010) (n = 325), and after (n = 453) the H1N1 pandemic. RESULTS: Patients with narcolepsy and cataplexy had a significantly different seasonality from the general population (P = .027). The monthly distribution of birth month yielded a peak in November (odds ratio = 1.23 [95% confidence interval, 1.01-1.49], P = .042) and a trough in April (odds ratio = 0.68 [95% confidence interval, 0.52-0.88], P = .004). No significant difference was observed in the birth month across patients with symptom onset dates before, following, and after the 2009 H1N1 pandemic (P = .603). CONCLUSIONS: This finding across many years of seasonal effect in Chinese narcolepsy cataplexy supports a role for early-life environmental influences on disease development. CITATION: Guo J, Xu L, Wang J, et al. The month of birth has a seasonal effect in Chinese patients with narcolepsy and cataplexy. J Clin Sleep Med. 2022;18(2):461-467.

Narcolepsy Quality-of-Life Instrument with 21 Questions: A Translation and Validation Study in Chinese Pediatric Narcoleptics.

OBJECTIVE: This study aimed to translate and validate the narcolepsy quality-of-life instrument with 21 questions (NARQoL-21) in Chinese pediatrics with narcolepsy. METHODS: NARQoL-21 was translated following the 10 steps of scale translation. The translated version was tested by exploratory factor analysis (EFA), confirmatory factor analysis (CFA), known-group validity, criterion validity, Cronbach's α and test-rest reliability. RESULTS: The Chinese version of NARQoL-21 consisted of two factors: (psychosocial factors and future outlook factor), including 20 items. EFA yielded 3 domains for psychosocial factors and 1 domain for future outlook factor. The Chinese version had a negative correlation with the overall Modified Epworth Sleepiness Scale (r = -0.518, p<0.001) and meaningful difference in score between drug naïve and treated group (p<0.05). The Cronbach's α coefficient was higher than 0.7 and intraclass correlation coefficient (ICC) ranged from 0.75 to 0.905, indicating that it had good reliability. CONCLUSION: The Chinese version of the NARQoL-21 is available and can be used to evaluate the health-related quality of life (HRQoL) of pediatric narcoleptics, despite that there is a shift in factors compared to the English version due to cultural differences. Future studies are recommended to further validate the scale in Chinese pediatrics with narcolepsy.

Impact of China's waste import policy on the scrap copper recovery pattern and environmental benefits.

The international trade weight of scrap copper has exceeded 6 million tons annually over the past two decades. China introduced the "National Sword" policy in 2017, which brought uncertainty to the international recycling of scrap copper. We use the international scrap copper trade figures from 1998 to 2019 in UN Comtrade, and seek to analyze the impact of China's import ban by setting up a difference-in-differences (DID) model based on the gravity model. The results show that 1) The ban has promoted the development of regional trade and improved the quality of scrap copper in international trade. The unit value of imported scrap copper in China has risen by 58%. 2) China's import ban has reduced the import weight of scrap copper by 68.6% and its value by 44.4% without the influence of other socioeconomic factors. 3) China's import of copper scrap is concentrated in coastal provinces. Guangdong Province has been most heavily affected. The imports of low-quality copper scrap in Guangdong have decreased by 94%. 4) The import ban reduced the environmental impact in China by 36.6%, but the global environmental impact has increased because of the gap in recycling technology, especially in developing countries. These discoveries will be beneficial to predict the future of international scrap copper recovery, and help rule makers formulate trade and environmental policies.

Home sleep apnea testing of adults with chronic heart failure.

STUDY OBJECTIVES: To evaluate home sleep apnea testing (HSAT) using a type 3 portable monitor to help diagnose sleep-disordered breathing (SDB) and identify respiratory events including obstructive sleep apnea, central sleep apnea, and Cheyne-Stokes respiration in adults with stable chronic heart failure. METHODS: Eighty-four adults with chronic heart failure (86.9% males, age [mean ± standard deviation] 58.7 ± 16.3 years, body mass index 29.4 ± 13.0 kg/m², left ventricular ejection fraction 40.3% ± 11.5%) performed unattended HSAT followed by an in-laboratory polysomnography (PSG) with simultaneous portable monitor recording. RESULTS: The apnea-hypopnea index was 22.0 ± 17.0 events/h according to HSAT, 26.8 ± 20.5 events/h on an in-laboratory portable monitor, and 23.8 ± 21.3 events/h using PSG (P = .373). A Bland-Altman analysis of the apnea-hypopnea index using HSAT vs PSG showed a mean difference (95% confidence interval) of -2.4 (-4.9 to 0.1) events/h and limits of agreement (±2 standard deviations) of -24.1 to 19.2 events/h. HSAT underestimated the apnea-hypopnea index to a greater extent at a higher apnea-hypopnea index (rho = -.358; P < .001). Similar levels of agreement from HSAT vs PSG were observed when comparing the obstructive apnea index, central apnea index, and percentage of time in a Cheyne-Stokes respiration pattern. When we used an apnea-hypopnea index ≥ 5 events/h to diagnose SDB, HSAT had 86.7% sensitivity, 76.5% specificity, 92.9% positive predictive value, and 61.9% negative predictive value compared to PSG. Detection of Cheyne-Stokes respiration using HSAT showed 94.6% sensitivity, 91.1% specificity, 88.6% positive predictive value, and 97.6% negative predictive value compared to PSG. CONCLUSIONS: HSAT with a type 3 portable monitor can help diagnose SDB and identify obstructive sleep apnea, central sleep apnea, and Cheyne-Stokes respiration events in adults with chronic heart failure.

Reliability and validity of the Chinese version of Narcolepsy Severity Scale in adult patients with narcolepsy type 1.

OBJECTIVE: To evaluate reliability and validity of the Chinese version of Narcolepsy Severity Scale (NSS) in adult patients with narcolepsy type 1 (NT1). METHODS: One hundred and fifty-one adult patients (≥18 years) with NT1 were recruited. All filled out the 15-item Chinese version of NSS. Item analysis included critical ratio and correlation analysis. The validity of NSS was assessed by exploratory factor analysis, discriminant validity and convergent validity. Reliability of NSS was assessed by Cronbach's α coefficient, spilt-half reliability and test-retest reliability. RESULTS: Critical value of all 15 items ranged from 3.01 to 13.36. Each item was significantly correlated with the total score by a correlation coefficient (r) ranging from 0.219 to 0.700. Three common domains were extracted and 15 items explained 54.86% of the total variance. There was a shift in domains compared to the English version likely due to cultural differences. Cronbach's α coefficient for the total scale of 15 items was 0.821 and for three factors was 0.726, 0.748 and 0.760 respectively. The NSS had good correlation with Epworth sleepiness scale scores, Insomnia severity index scores and moderate correlation with mean the sleep latency of polysomnographic recording, and European Quality of Life-5 Dimensions Questionnaire. The Chinese version of NSS showed good spilt-half reliability and test-retest reliability. CONCLUSION: The Chinese version of NSS shows satisfactory psychometric properties with good validity and reliability. It is applicable to evaluate the severity and consequences of symptoms in Chinese adult patients with NT1.

Lipocalin-type prostaglandin D synthase levels increase in patients with narcolepsy and idiopathic hypersomnia.

STUDY OBJECTIVES: Excessive daytime sleepiness (EDS) is a frequent cause for consultation and a defining symptom of narcolepsy and idiopathic hypersomnia (IH). The associated mechanisms remain unclear. Lipocalin-type prostaglandin D synthase (LPGDS) is a plausible sleep-inducing candidate. This study is to compare cerebral spinal fluid (CSF) and serum LPGDS levels in patients group with hypersomnia of central origin, including those with narcolepsy type 1 (NT1) and type 2 (NT2) and IH, to those in healthy controls (Con). METHODS: Serum LPGDS, CSF LPGDS, and CSF hypocretin-1(Hcrt-1) levels were measured by ELISA in 122 narcolepsy patients (106 NT1 and 16 NT2), 27 IH, and 51Con. RESULTS: LPGDS levels in CSF (p = 0.02) and serum (p < 0.001) were 22%-25% lower in control subjects than in patients with EDS complaints, including NT1, NT2, and IH. In contrast to significant differences in CSF Hcrt-1 levels, CSF L-PGDS levels and serum L-PGDS were comparable among NT1, NT2, and IH (p > 0.05), except for slightly lower serum LPGDS in IH than in NT1 (p = 0.01). Serum L-PGDS correlated modestly and negatively to sleep latency on MSLT (r = -0.227, p = 0.007) in hypersomnia subjects. CONCLUSIONS: As a somnogen-producing enzyme, CSF/serum LPGDS may serve as a new biomarker for EDS of central origin and imply a common pathogenetic association, but would complement rather than replaces orexin markers.

Anti-streptococcal antibodies in Chinese patients with type -1 narcolepsy.

BACKGROUND: Narcolepsy type 1 (NT1) is considered to be an autoimmune disease, and streptococcal infection may be an environmental trigger. However, previous studies from Asian narcolepsy patients did not reveal elevated anti-streptolysin O [ASO]. The aim is to investigate whether large sample Chinese patients with NT1 have an increase in antistreptococcal antibody titers. METHODS: A total of 214 narcolepsy patients and 360 healthy controls were recruited. All patients were DQB1∗0602 positive with clear-cut cataplexy or had low CSF hypocretin-1. Participants were tested for ASO and anti DNAse B [ADB]. These patients were divided into five groups according to disease duration, including 29 patients less than 3 months; 25 from 3 months to 1 year; 40 from 1 to 3 years; 61 from 3 to 10 years and 59 patients over 10 years. Comparison was also made between children and adults with age matched controls, respectively. RESULTS: There were no significant differences between patients and healthy controls in regard to both ASO ≥200 IU (19.2% vs. 16.9%, p = 0.50) and ADB≥480IU (9.8% vs. 10.3%, p = 0.86). For children narcolepsy patients, ASO positive rates (19.8% vs. 18%, p = 0.68) and ADB positive rates (10.4% vs. 12%, p = 0.72) had no differences compared to age matched controls. No difference was observed in adult narcolepsy patients either, with ASO positive rates (18.5% vs. 13.8%, p = 0.39) and ADB positive rates (9.3% vs. 5.3%, p = 0.42) compared to age matched controls, respectively. ASO and ADB positive rates had no significant differences among different disease duration groups (p = 0.55 and 0.9, respectively). CONCLUSION: Streptococcus infection reflected by increase of ASO and ADB levels was not found in Chinese patients with type 1 narcolepsy, additional triggers for narcolepsy need to be addressed in this population.