Preferable forms of relaxation for health promotion, and the association between recreational activities and self-perceived health.

Little research has been done on the association between relaxation and health. In the present study, by conducting a nationwide cross-sectional survey, we aimed to obtain scientific data on the preferable forms of relaxation for health promotion, and to clarify the associations between specific recreational activities and self-perceived mental and physical health. We selected 4,000 households by stratified random sampling from across Japan in November 2009 and used the interview method to collect data (number of subjects: 2,206). The questionnaire contained items on sleep, recreation status, recreational activities, and self-perceived mental and physical health status. We obtained responses from 1,224 adults (response rate: 55.5%). Insufficient rest from sleep, short sleep duration (<6 h/day), ineffective use of free time, and less free time used for activities other than rest showed independent positive associations with poor mental and physical health. The results of the logistic regression analyses showed significantly low adjusted odds ratios with regard to the status of poor mental and physical health for outings/walking among men (0.33 [95% confidence interval; 0.16-0.68] and 0.49 [0.26-0.90], respectively), and for community activities among women (0.19 [0.04-0.79] and 0.27 [0.09-0.77], respectively). Relaxation for the promotion of health should include both passive relaxation (rest) and active relaxation (recreation). In addition, ensuring sufficient sleep duration is important for passive relaxation, and engaging in outings/walking for men and community activities for women are important for active relaxation.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020.

The prevalence of sleep disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared in order to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Because sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020.

The prevalence of sleep-disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Since sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

[Exercise test and respiratory muscle function test].

Dyspnea on exertion is a chief complaint of patients with COPD, and it has a major effect on the quality of their lives. Dyspnea is, by definition, subjective, but objective approaches are needed for a comprehensive understanding of these patients' conditions. Thus, measuring changes in cardiopulmonary variables during exercise can be very helpful when evaluating patients with COPD. The main purpose of exercise testing is to evaluate exercise tolerance and to identify the factors limiting exercise. Although incremental exercise testing is ideal for these purposes, simple walking tests such as 6-minute walking test, are also useful.

Obstructive sleep apnoea is associated with risk factors comprising the metabolic syndrome.

BACKGROUND AND OBJECTIVE: Several features of OSA syndrome suggest that it is a manifestation of the metabolic syndrome (MS). In this study, we investigated the prevalence of the MS among male Japanese patients with OSA, as well as the relationship between OSA in non-obese patients and components of the MS other than obesity (hypertension, dyslipidaemia and glucose intolerance). METHODS: The study included 416 Japanese men who were diagnosed as having OSA by polysomnography. Among these, 101 non-obese patients were selected and the severity of OSA, as well as the prevalence of hypertension, dyslipidaemia and glucose intolerance, was assessed. RESULTS: The MS was associated with OSA in 218/416 patients (52.4%). A significant increase in the prevalence of the MS was associated with increased severity of OSA, as categorized according to AHI. In the non-obese patients with OSA (mean age 57.6 years, BMI 22.7 kg/m(2), AHI 34.3 events/h), hypertension, dyslipidaemia and glucose intolerance were identified in 70 (69.3%), 43 (42.6%) and 20 patients (19.8%), respectively. At least two of these factors were identified in 40 patients (39.6%). Non-obese patients with severe OSA had a significantly higher prevalence of two or more of these factors (33/59 patients, 55.9%). CONCLUSIONS: Although Asians are generally less obese than Caucasians, the prevalence of the MS was high among Japanese patients with OSA, and even among non-obese patients, OSA was associated with risk factors for the MS.

Simple four-variable screening tool for identification of patients with sleep-disordered breathing.

OBJECTIVES: To aid in the identification of patients with moderate-to-severe sleep-disordered breathing (SDB), we developed and validated a simple screening tool applicable to both clinical and community settings. METHODS: Logistic regression analysis was used to develop an integer-based risk scoring system. The participants in this derivation study included 132 patients visiting one of 2 hospitals in Japan, and 175 residents of a rural town. The participants in the present validation study included 308 employees of a company in Japan who were undergoing a health check. RESULTS: The screening tool consisted of only 4 variables: sex, blood pressure level, body mass index, and self-reported snoring. This tool (screening score) gave an area under the receiver operating characteristic curve (ROC) of 0.90, sensitivity of 0.93, and specificity of 0.66, using a cutoff point of 11. Predicted and observed prevalence proportions in the validation dataset were in close agreement across the entire spectrum of risk scores. In the validation dataset, the area under the ROC for moderate-to-severe SDB and severe SDB were 0.78 and 0.85, respectively. The diagnostic performance of this tool did not significantly differ from that of previous, more complex tools. CONCLUSION: These findings suggest that our screening scoring system is a valid tool for the identification and assessment of moderate-to-severe SDB. With knowledge of only 4 easily ascertainable variables, which are routinely checked during daily clinical practice or mass health screening, moderate-to-severe SDB can be easily detected in clinical and public health settings.

Predicting optimal continuous positive airway pressure in Japanese patients with obstructive sleep apnoea syndrome.

BACKGROUND AND OBJECTIVE: Several algorithms that predict the optimal CPAP have been developed for Caucasian patients with OSA syndrome, but these algorithms do not allow for racial differences in craniofacial anatomy. We investigated whether an equation that included data on craniofacial structure, physique and severity of OSA could more accurately predict the optimal CPAP for Japanese patients with OSA syndrome. METHODS: In 170 Japanese patients with OSA syndrome, the optimal CPAP was determined by manual titration during polysomnography. An equation predicting the optimal pressure was derived from anthropometric, polysomnographic and cephalometric data. This equation was validated in another 110 Japanese patients with OSA syndrome. RESULTS: Stepwise multiple regression analysis identified AHI, BMI, mean SaO(2) and a cephalometric parameter: the angle between a line from point B to the menton (Me) and a line from Me to the hyoid bone (H) (BMeH), as independent predictors of optimal CPAP. The following equation was constructed to predict the optimal CPAP: 27.78 + (0.041 x BMeH) + (0.141 x BMI) + (0.040 x AHI) - (0.312 x mean SaO(2)). This equation accounted for 47% of the variance in optimal pressure (R(2) = 0.47, P < 0.0001). The measured optimal pressure and the pressure calculated using this equation were very similar in the other 110 patients with OSA syndrome (9.5 +/- 3.0 and 9.2 +/- 2.1 cmH(2)O, respectively). CONCLUSION: Optimal CPAP was more accurately predicted by combining a cephalometric parameter with BMI and polysomnographic data in Japanese patients with OSA, suggesting that craniofacial structure may be important in the pathogenesis of OSA syndrome among Asians.

Sleep disordered breathing in cardiac surgery patients: The NU-SLEEP trial.

BACKGROUND: Sleep disordered breathing (SDB) is associated with lifestyle-related diseases and its treatment influence the prognosis of cardiac disease, but little investigation of SDB has been conducted in cardiac surgery patients. METHODS AND RESULTS: A prospective study was performed in 1005 patients undergoing cardiac surgery. The primary endpoint was the severity of SDB determined from the apnea/hypopnea index. The secondary endpoints were patient background factors, cardiovascular risk factors, ejection fraction, atrial and brain natriuretic peptides, oxidative stress and inflammatory markers, and postoperative atrial fibrillation. While 227 patients (22.6%) did not have SDB, there were 361 patients (35.9%) with mild SDB, 260 patients (25.9%) with moderate SDB, and 157 patients (15.6%) with severe SDB. Patients with severe SDB had a lower ejection fraction and higher levels of atrial and brain natriuretic peptides than the other groups. Postoperative atrial fibrillation occurred in 28 patients without SDB (13.6%), 43 patients with mild SDB (13.5%), 74 patients with moderate SDB (31.9%), and 73 patients with severe SDB (52.5%), being significantly more frequent in the severe group than the other groups. CONCLUSIONS: SDB was frequent in cardiac surgery patients. Activation of the renin-angiotensin-aldosterone system, postoperative atrial fibrillation atrial, and cardiac dysfunction were associated with severe SDB. Markers of inflammation and oxidative stress also increased as SDB became more severe.

Nasal CPAP improves the quality of life and lessens the depressive symptoms in patients with obstructive sleep apnea syndrome.

OBJECTIVE: To assess changes in response to nasal continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea syndrome (OSAS) concerning excessive daytime sleepiness (EDS), depressive state, and quality of life (QOL). PATIENTS AND METHODS: We assessed for EDS using the Epworth sleepiness scale (ESS), for mood using The Zung self-depression scale (SDS), and for QOL using Short-Form 36 (SF-36) in 132 patients with obstructive sleep apnea syndrome (OSAS) and control subjects. Patients had severe OSAS (apnea-hypopnea index, 59.4+/-23.8/h) and were more hypersomnolent and depressed, and had poorer QOL than 38 age- and gender-matched controls. RESULTS: Before treatment most QOL domains in the SF-36 were significantly associated with patients' SDS scores. With nasal CPAP, ESS and SDS scores were respectively decreased from 9.7+/-4.5 to 4.0+/-2.4 (p<0.0001) and from 49.2+/-10.4 to 45.1+/-9.6 (p<0.0005). Total SF-36 score and scores for seven of eight domains were increased significantly with treatment. Thus, nasal CPAP lessens EDS and depression, and improves QOL, in patients with severe OSAS. Further, magnitudes of changes in total SF-36 scores and in five of eight domains correlated significantly with magnitude of change in SDS score upon nasal CPAP treatment. No relationship was evident between treatment-associated score changes in SF-36 domains and ESS score change. CONCLUSION: Although patients with severe OSAS have poorer QOL than control subjects, nasal CPAP appears to improve QOL by alleviating depression.

Effects of long-term nasal continuous positive airway pressure on C-reactive protein in patients with obstructive sleep apnea syndrome.

Serum levels of C-reactive protein (CRP) were measured in 96 consecutive patients with obstructive sleep apnea syndrome (OSAS) before and after nasal continous positive airway pressure treatment. CRP levels only displayed significant correlations with body mass index (BMI) before treatment. No significant changes were observed in BMI and CRP levels after 9 months of treatment. These data suggest that CRP levels in patients with OSAS may be associated with obesity rather than OSAS itself.

[Bronchoesophageal fistula in a patient with untreated malignant lymphoma].

Bronchoesophageal fistulae associated with lymphomas are generally associated with chemo-radiotherapy. We report here an unusual case of lymphoma with a therapy-unrelated bronchoesophageal fistula. Previously, only 10 similar cases have been reported. A 70-year-old male was diagnosed as having gastric diffuse large B-cell lymphoma in May 1998. In January 1999, he noted a cough after eating and drinking. Because of the presence of a febrile temperature, productive cough and dyspnea, he was referred to our hospital and diagnosed as having aspiration pneumonia. Antibiotics did not improve his symptoms. When tracheal intubation was performed with bronchoscopy, a bronchoesophageal fistula was revealed. Malignant lymphoma cells were found around the fistula in the biopsy specimen. The patient died of pneumonia after treatment with airway stenting and chemotherapy. Induction of necrosis by chemotherapy or low blood flow with stenting and dopamine probably caused enlargement of the fistula.

Prevalence of chronic kidney diseases in patients with chronic obstructive pulmonary disease: assessment based on glomerular filtration rate estimated from creatinine and cystatin C levels.

BACKGROUND: Cardiovascular diseases, osteoporosis, and depression are identified comorbidities of chronic obstructive pulmonary disease (COPD), but there have been few reports of chronic kidney disease (CKD) as a comorbidity of COPD. The objective of this study was to investigate the prevalence of CKD in COPD patients using estimated glomerular filtration rate (eGFR) based on creatinine (Cr) and cystatin C (Cys) levels. METHODS: The prevalence of CKD and the values of various CKD-related parameters were compared between 108 stable COPD outpatients (COPD group) and a non-COPD control group consisting of 73 patients aged 60 years or more without a history of COPD or kidney disease. CKD was defined as an eGFR less than 60 mL/min/1.73 m(2). RESULTS: The Cr level was significantly higher in the COPD group, but eGFR based on serum Cr (eGFRCr) was not significantly different between the two groups (73.3±25.3 vs 79.7±15.5 mL/min/1.73 m(2)). The Cys level was significantly higher and eGFR based on serum Cys (eGFRCys) was significantly lower in the COPD group (60.0±19.4 vs 74.0±13.5 mL/min/1.73 m(2), P<0.0001). The prevalence of CKD evaluated based on eGFRCr was 31% in the COPD group and 8% in the non-COPD group with an odds ratio of 4.91 (95% confidence interval, 1.94-12.46, P=0.0008), whereas the evaluated prevalence based on eGFRCys was 53% in the COPD group and 15% in the non-COPD group with an odds ratio of 6.30 (95% confidence interval, 2.99-13.26, P<0.0001), demonstrating a higher prevalence of CKD when based on eGFRCys rather than on eGFRCr. CONCLUSION: CKD is a comorbidity that occurs frequently in COPD patients, and we believe that renal function in Japanese COPD patients should preferably be evaluated based not only on Cr but on Cr in combination with Cys.

Relationship between quality of life and mood or depression in patients with severe obstructive sleep apnea syndrome.

STUDY OBJECTIVES: To assess the quality of life (QOL) in patients with severe obstructive sleep apnea (OSAS), and the relationship between the QOL and severity of OSAS, excessive daytime sleepiness (EDS), and mood. METHODS: Sixty patients with OSAS and 34 normal control subjects were assessed for QOL using the Medical Outcomes Study Short-Form 36 Health Survey questionnaire (SF-36), for EDS using the Epworth sleepiness scale (ESS), and for mood using the Zung self-rated depression scale (SDS). The associations between each domain and the total score on the SF-36 and the baseline characteristics, polysomnographic parameters, ESS score, and SDS score were examined by simple regression analysis and stepwise multiple regression analysis. RESULTS: Six of eight domains and the total score on the SF-36 were significantly lower than those in the control subjects. The ESS and SDS scores were also more impaired in the patients than in the control subjects. There was no relationship between each domain on the SF-36 and the severity of OSAS and ESS score. Five of eight domains and the total score on the SF-36 were significantly correlated with the SDS score. Stepwise multiple regression analysis selected three variables, the SDS score (partial R(2) = 0.505), the lowest arterial oxygen saturation during sleep (partial R(2) = 0.064), and ESS score (partial R(2) = 0.053), as independent factors for predicting the total score on the SF-36. These three variables accounted for 62.2% of the total variance in the total score on SF-36 (R(2) = 0.622, p < 0.0001) CONCLUSIONS: The QOL of patients with severe OSAS was decreased compared with normal control subjects. The QOL of patients was strongly correlated with the depression scale on simple regression analysis. However, EDS score and oxygen desaturation during sleep also affected the QOL, although the magnitude of its effect was small.

Determinants of chronic hypercapnia in Japanese men with obstructive sleep apnea syndrome.

STUDY OBJECTIVE: To identify the determinants of chronic hypercapnia (ie, PaCO(2), > or = 45 mm Hg) in men with obstructive sleep apnea syndrome (OSAS) without airflow obstruction. DESIGN: An analysis was conducted of 143 male patients with OSAS, which had been diagnosed by polysomnography (PSG), who had been referred to a university hospital. Patients were classified as hypercapnic (ie, PaCO(2), > or = 45 mm Hg) and normocapnic (ie, PaCO(2), < 45 mm Hg), and obese (ie, body mass index [BMI], > or = 30 kg/m(2)) or nonobese (ie, BMI, < 30 kg/m(2)). Patients with airflow obstruction (ie, FEV(1)/FVC ratio, < 70%) were excluded from the study. Baseline clinical characteristics, pulmonary function, PSG data, and blood gas data were compared between hypercapnic and normocapnic patients. Correlations between PaCO(2) and several anthropometric, respiratory, and polysomnographic variables were determined by stepwise multiple regression analysis. RESULTS: Fifty-five patients (38%) were hypercapnic. Hypercapnic patients were younger and heavier, and had more abnormalities on pulmonary and PSG testing. Stepwise multiple regression analysis revealed that the PaCO(2) level was influenced significantly by the mean level of arterial oxygen saturation (SaO(2)) during sleep and by the percent of vital capacity (%VC) (R(2) = 0.430; p < 0.0001), indicating that 43% of the total variance in the PaCO(2) could be explained by the mean SaO(2) and %VC in hypercapnic patients. In contrast, only 13% of the total variance in the PaCO(2) was accounted for by the mean SaO(2) and BMI in normocapnic patients (R(2) = 0.134; p = 0.0034). The mean SaO(2), %VC, and PaO(2) were selected as independent variables for predicting the PaCO(2) in obese patients. These variables explained 41% of the total variance in the PaCO(2) (R(2) = 0.407; p < 0.0001), whereas the mean SaO(2) only accounted for 13% of the total variance in PaCO(2) levels in nonobese patients (R(2) = 0.134; p = 0.0064). CONCLUSION: Nocturnal desaturation and restrictive pulmonary impairment play major roles in determining the PaCO(2) in hypercapnic and obese OSAS patients without airflow obstruction.

[Clinical usefulness of a cardiopulmonary sleep study in patients with sleep apnea syndrome].

Although polysomnography is indispensable in the diagnosis of sleep apnea syndrome (SAS), a common disease in Japan, it is a time-consuming procedure. We therefore assessed the clinical usefulness of a cardiopulmonary sleep study (CPSS), which monitors indices of respiratory and circulatory kinetics during sleep. Of ninety male patients (50 +/- 11 years old, BMI: 27 +/- 4), those with apnea indices (AI) > 5, as determined using an apnomonitor, underwent CPSS with a Night Watch System. Sixty-nine patients with indications for nasal CPAP (NCPAP) therapy underwent overnight CPSS and the optimum pressure was determined. AI was 31 +/- 17, whereas CPSS showed an apnea-hypopnea index of 49 +/- 24, a mean SaO2 of 93 +/- 3%, and a minimum SaO2 of 71 +/- 11%, indicating severe OSAS. The mean optimum pressure was 10 +/- 2 cm H2O, and the compliance was 86%, which was comparatively good. As CPSS can be performed on many patients in a short time, it may be useful for the early diagnosis and initial treatment of SAS.

[Risk factors in development of sleep apnea syndrome--a large population study using a simple monitoring system].

We studied the risk factors in the development of sleep apnea syndrome (SAS) in 779 patients (705 males and 74 females) using Apnomonitor R. The apnea index (AI) significantly correlated with the body mass index (BMI), and was higher in obese patients (BMI > or = 25 kg/m2) than in non-obese patients. The prevalence of SAS increased with patient age. Obesity was less common in older than in younger patients. The AI was significantly higher in smokers than in non-smokers, as was the prevalence of SAS. The AI and the prevalence of SAS were higher in smokers than in non-smokers in both obese and non-obese patients. The AI was significantly higher in males than in females, and so was the prevalence of SAS. The AI and the prevalence of SAS were always higher in male obese patients, non-obese patients, smokers, and non-smokers than in female patients in the same categories. These results suggest that obesity, age, smoking, and gender were independent risk factors in the development of SAS.

[A case report of intralobar pulmonary sequestration with an anomalous artery originating from the celiac artery].

A 43-year-old female was admitted to our hospital because of an abnormality detected in chest radiography. Chest radiographs showed a nodular shadow behind the heart. Chest CT revealed a nodule connected to the descending aorta with increased blood flow in left lower lobe, suggesting the presence of a pulmonary sequestration. Bronchography showed an intralobar sequestrated lung in the left lower lobe. Aortography demonstrated that the sequestrated lung was fed by an anomalous artery 20 mm in diameter, originating from the celiac artery. From those findings, Pryce type IIintralobar pulmonary sequestration was diagnosed, and the left lower lobe was removed. Histological findings from the excised tissues showed mild dilatation of the bronchioles and hypervascularity.

[Stage and prognosis of COPD].

Clinical stages of chronic obstructive pulmonary disease(COPD) have been described in the guideline by American Thoracic Society(ATS), European Respiratory Society(ERS), and Japanese Respiratory Society. Recently, the clinical stage in GOLD(Global Initiative Obstructive Lung Disease) was also published in the guideline as an international standard. Although severity or clinical stages of COPD in ATS, ERS, and JRS guidelines is determined by only % predicted FEV1.0/FVC(%FEV1.0), GOLD guideline added clinical symptoms to %FEV1.0 for determining clinical stages of COPD. Prognosis is also correlated with %FEV1.0 in COPD patients. Prognosis of COPD patients shows a clear decline in proportion to that of %FEV1.0. However, pulmonary circulation disorder also affects the prognosis of COPD. Pulmonary hypertension is often found in severe COPD.

A cross-sectional study of the association between working hours and sleep duration among the Japanese working population.

OBJECTIVES: This study aimed to clarify the association between long working hours and short sleep duration among Japanese workers. METHODS: We selected 4,000 households from across Japan by stratified random sampling and conducted an interview survey of a total of 662 participants (372 men; 290 women) in November 2009. Logistic regression analyses were performed using "sleep duration <6 hours per day" as a dependent variable to examine the association between working hours/overtime hours and short sleep duration. RESULTS: When male participants who worked for ≥7 but <9 hours per day were used as a reference, the odds ratio (OR) for short sleep duration in those who worked for ≥ 11 hours was 8.62 (95% confidence interval [CI]: 3.94-18.86). With regard to overtime hours among men, when participants without overtime were used as a reference, the OR for those whose period of overtime was ≥ 3 hours but <4 hours was 3.59 (95% CI: 1.42-9.08). For both men and women, those with long weekday working hours tended to have a short sleep duration during weekdays and holidays. CONCLUSIONS: It is essential to avoid working long hours in order to prevent short sleep duration.