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Study Objectives: Apnea-hypopnea index (AHI) is the main polysomnographic measure to diagnose obstructive sleep apnea (OSA). We aimed to evaluate the effect of three standard hypopnea definitions on the prevalence of OSA and its association with cardiometabolic outcomes in the general population. Methods: We analyzed data from the HypnoLaus study (Lausanne, Switzerland), in which 2,162 participants (51% women, 57 ± 19 years) underwent in-home full polysomnography. AHI was calculated using three hypopnea definitions: AASM 1999 (≥ 50% decrease in airflow or lower airflow reduction associated with oxygen desaturation ≥ 3% or an arousal), AASM 2007 (≥ 30% airflow reduction associated with ≥ 4% oxygen desaturation), and AASM 2012 (≥ 30% airflow reduction associated with ≥ 3% oxygen desaturation or an arousal). Participants underwent clinical assessment for hypertension, diabetes, and metabolic syndrome. Results: Median AHI of AASM 1999 , AASM 2007 and AASM 2012 criteria were 10.9, 4.4, and 10.1 events/h, respectively. OSA prevalence defined as AHI ≥ 5, ≥ 15, and ≥ 30 events/h was 74.5%, 39.3%, and 16.3% using AASM 1999 ; 46.9%, 18.8%, and 6.8% using AASM 2007 ; and 72.2%, 36.6%, and 14.9% using AASM 2012 . Different AHI thresholds derived from AASM 1999 , AASM 2007 , and AASM 2012 criteria , respectively, were associated with hypertension (11.5, 4.8, 10.7 events/h), diabetes (15.7, 7.1, 14.4 events/h), and metabolic syndrome (12.8, 5.5, 11.8 events/h). Conclusions: Hypopnea definition has a major effect on AHI and on OSA prevalence in the general population and, hence, important implications for public health policies. There is a twofold difference in the threshold above which an association with diabetes, hypertension, and metabolic syndrome is observed using AASM 2007 compared to AASM 1999 or AASM 2012 criteria. Citation: Hirotsu C, Haba-Rubio J, Andries D, Tobback N, Marques-Vidal P, Vollenweider P, Waeber G, Heinzer R. Effect of three hypopnea scoring criteria on OSA prevalence and associated comorbidities in the general population. J Clin Sleep Med 2019;15(2):183–194.

Studies demonstrate an association between vitamin D (25(OH)D) deficiency and sleep disturbances, such as obstructive sleep apnea (OSA) and short sleep duration. However, to date, no studies have concurrently and objectively evaluated the effect of these factors on 25(OH)D. To evaluate whether OSA and objective short sleep duration are independently associated with reduced 25(OH)D in an adult population sample. A cross-sectional study included 657 individuals from the city of Sao Paulo, Brazil, as part of the ERA project. Participants fulfilled questionnaires and underwent clinical evaluation, polysomnography and blood sample collection for 25(OH)D quantification. OSA was classified into three categories (mild, moderate and severe). The risk of 25(OH)D deficiency was considered as levels<30 ng/mL. Short sleep duration was defined as total sleep time<6 hours. The risk of 25(OH)D deficiency was observed in 59.5% of the sample, affecting more individuals of the female gender, obese, with African American ethnicity, and those that were smokers, sedentary and presented hypertension and diabetes. In the final logistic model adjusted for age, gender, ethnicity, obesity, smoking, hypertension, diabetes, sedentary lifestyle, seasonality and creatinine serum levels, both OSA and short sleep duration showed significant independent associations with the risk of 25(OH)D deficiency (moderate OSA: OR for 25(OH)D<30 = 2.21, 95% CI: 1.35-3.64, p<0.01; severe OSA: OR for 25(OH)D<30 = 1.78, 95% CI: 1.06-3.00, p = 0.03; short sleep duration: OR for 25(OH)D<30 = 1.61, 95% CI: 1.15-2.26, p = 0.01). After a subgroup analysis, similar results were observed only in participants ≥50 years. OSA and short sleep duration are independently associated with the risk of 25(OH)D deficiency in an adult population. Age-related changes in vitamin D metabolism and the frequency of sleep disorders may be involved in these associations. Future studies exploring whether 25(OH)D levels may modulate OSA and sleep curtailment-related outcomes are needed.

Background Evidence suggests anthropometric indicators of obesity are associated with changes in sleep quality and quantity, and the presence of obstructive sleep apnoea (OSA). Investigations including diverse and objective evaluations of sleep and body composition are scarce. We aimed to evaluate the associations between indicators of sleep impairment and body composition states in a sample from a population‐based study. Methods Participants of the first follow‐up of the EPISONO (São Paulo, Brazil) >50 years were cross‐sectionally evaluated. Sleep was assessed through questionnaires, actigraphy, and polysomnography. Body composition was evaluated by bioelectrical impedance analysis. Appendicular skeletal muscle mass adjusted for body mass index defined sarcopenia (men <0.789 and women <0.512). Total body fat defined obesity (men >30% and women >40%). The overlap between both conditions defined sarcopenic obesity (SO). Final results were obtained by multinomial logistic regression analysis. Results Three hundred fifty‐nine adults [mean (standard deviation) age, 61 (8.8) years; 212 (59.1%) female] were enrolled. Obesity was detected in 22.6% of the sample, sarcopenia in 5.6%, and SO in 16.2%. After controlling for covariates, OSA was associated with SO [odds ratio = 3.14, 95% confidence interval (CI) = 1.49–6.61]. Additionally, nocturnal hypoxaemia was associated with both obesity (adjusted odds ratio = 2.59, 95% CI = 1.49–4.49) and SO (odds ratio = 2.92, 95% CI = 1.39–6.13). Other indicators of poor sleep/sleep disorders were not associated with body composition states. Conclusions Sarcopenic obesity but not obesity alone was associated with OSA. Both obesity and SO but not sarcopenia were associated with nocturnal hypoxaemia. The findings suggest a complex pathophysiologic relationship between adverse body composition states and OSA. Upcoming research on risk factors and therapeutic interventions for OSA should target synchronically the lean and adipose body tissues.

Recurrent hypoxia, which is associated with obstructive sleep apnea syndrome (OSAS), leads to an increase in the degradation of adenosine triphosphatase into xanthine, which in turn increases uric acid concentrations. The current study aimed to determine whether an association exists between OSAS and uric acid levels in the peripheral blood from a representative population of Sao Paulo (Brazil). A population-based survey adopting a probabilistic 3-stage cluster sample of Sao Paulo was used to represent the population according to gender, age, and socioeconomic class. A total of 1,042 volunteers underwent polysomnography recordings for OSAS diagnosis, blood pressure assessment, and biochemical blood analysis, and answered questionnaires. Uric acid levels were correlated with most important risk factors for OSAS, such as AHI, desaturation time and index, minimum oxyhemoglobin saturation (SpO2), blood pressure, cholesterol, BMI, triglycerides and arousal, and with OSAS itself. Also, uric acid was increased in OSAS volunteers even after controlling for all confounders. Hyperuricemic volunteers presented lower mean and minimum SpO2 and increased desaturation index. Importantly, minimum SpO2 was a significant predictor of uric acid levels, which in turn was considered an independent predictor for OSAS in the binary logistic model. However, a ROC curve analysis for establishing cut-off points for uric acid levels as a biomarker of OSAS revealed moderate sensitivity and specificity. A strong association was found between uric acid levels and OSAS in a representative sample of the population of Sao Paulo. Although they do not qualify for a biomarker alone, uric acid levels may be involved in OSAS severity and should be considered in sleep apnea management in the future.

Up to 80% of people develop a cutaneous condition closely connected to their exposure to stressful life events. Psoriasis is a chronic recurrent inflammatory skin disorder with multifactorial etiology, including genetic background, environmental factors, and immune system disturbances with a strong cytokine component. Moreover, psoriasis is variably associated with sleep disturbance and sleep deprivation. This study evaluated the influence of sleep loss in the context of an animal model of psoriasis by measuring cytokine and stress-related hormone levels. Male adult Balb/C mice with or without psoriasis were subjected to 48 h of selective paradoxical sleep deprivation (PSD). Sleep deprivation potentiated the activities of kallikrein-5 and kallikrein-7 in the skin of psoriatic groups. Also, mice with psoriasis had significant increases in specific pro-inflammatory cytokines (IL-1β, IL-6 and IL-12) and decreases in the anti-inflammatory cytokine (IL-10) after PSD, which were normalized after 48 h of sleep rebound. Linear regression showed that IL-2, IL-6 and IL-12 levels predicted 66% of corticosterone levels, which were selectively increased in psoriasis mice subject to PSD. Kallikrein-5 was also correlated with pro-inflammatory cytokines, explaining 58% of IL-6 and IL-12 variability. These data suggest that sleep deprivation plays an important role in the exacerbation of psoriasis through modulation of the immune system in the epidermal barrier. Thus, sleep loss should be considered a risk factor for the development of psoriasis.

Sleep disorders are highly prevalent in patients with fibromyalgia (FM). Many of the daytime symptoms, such as chronic pain and fatigue, may be related to the non-restorative sleep patterns associated with the disease. Pain influences the sleep process and sleep disturbances decrease the pain threshold in a reciprocal framework. Thus, understanding the link between sleep and FM has become an important research topic in basic science. Therefore, in the current review we connect these topics and provide some insights into the cyclic relationship between sleep and pain, which has been addressed mainly in animal models. Additionally, we highlight the urgent need for sleep studies in FM animal models, which might improve the knowledge base and accelerate advances in this field.

Abstract Study Objectives To explore the clinical significance of pulse wave amplitude (PWA)-drops during sleep as a biomarker for cardiometabolic disorders and describe their main characteristics in a general population sample. Methods Cross-sectional study of HypnoLaus cohort, in which 2162 individuals underwent clinical assessment and in-home full polysomnography. PWA-drops were derived from photoplethysmography and processed using a validated automated algorithm. Associations between PWA-drop features (index, mean duration, and mean area under the curve [AUC]) with hypertension, diabetes, and previous cardiovascular (CV) event were analyzed using multivariable-adjusted logistic regression. Results Two thousand one hundred forty-nine participants (59 ± 11 years, 51% women, 9.9% diabetes, 41.3% hypertension, 4.4% CV event) were included. Mean ± standard deviation (SD) of PWA-drop index, duration, and AUC during sleep were 51.0 ± 20.3 events/hour, 14.0 ± 2.7 seconds, and 527±115 %seconds, respectively. PWA-drop index was lower in women and decreased with age, while its mean duration and AUC increased in men and elderly. Overall, lower PWA-drop index, longer duration and greater AUC were associated with increased odds of hypertension, diabetes, or CV event after adjustment for confounders. Participants in the lowest quartile of mean duration-normalized PWA-drop index had a significantly higher odds ratio (OR) of hypertension (OR = 1.60 [1.19–2.16]), CV event (OR = 3.26 [1.33–8.03]), and diabetes (OR = 1.71 [1.06–2.76]) compared to those in the highest quartile. Similar results were observed for mean AUC-normalized PWA-drop index regarding hypertension (OR = 1.59 [1.19–2.13]), CV event (OR = 2.45 [1.14–5.26]) and diabetes (OR = 1.76 [1.10–2.83]). Conclusions PWA-drop features during sleep seem to be an interesting biomarker independently associated with cardiometabolic outcomes in the general population.

the accumulation of visceral fat in kidney disease. The rise in obesity may result, at least in part, from changes in lifestyle, currently characterized by sedentary, poor eating, and sleep habits. The reduction in sleep duration is known to predispose individuals to obesity by increasing the white adipose tissue deposits such as visceral fat.4,5 Of note, obesity and visceral fat accumulation are etiopathological factors for both chronic kidney disease (CKD) and sleep disorders.6,7 View the original paper by Xu et al

Abstract Study Objectives To determine if a novel EEG-derived continuous index of sleep depth/alertness, the odds ratio product (ORP), predicts self-reported daytime sleepiness and poor sleep quality in two large population-based cohorts. Methods ORP values which range from 0 (deep sleep) to 2.5 (fully alert) were calculated in 3s intervals during awake periods (ORPwake) and NREM sleep (ORPNREM) determined from home sleep studies in the HypnoLaus (N = 2162: 1106 females, 1056 males) and men androgen inflammation lifestyle environment and stress (MAILES) cohorts (N = 754 males). Logistic regression was used to examine associations between ORPwake, ORPNREM, and traditional polysomnography measures (as comparators) with excessive sleepiness (Epworth sleepiness scale >10) and poor sleep quality (Pittsburgh sleep quality index >5) and insomnia symptoms. Results High ORPwake was associated with a ~30% increase in poor sleep quality in both HypnoLaus (odds ratio, OR, and 95% CI) 1.28 (1.09, 1.51), and MAILES 1.36 (1.10, 1.68). High ORPwake was also associated with a ~28% decrease in excessive daytime sleepiness in the MAILES dataset. ORPNREM was associated with a ~30% increase in poor sleep quality in HypnoLaus but not in MAILES. No consistent associations across cohorts were detected using traditional polysomnography markers. Conclusions ORP, a novel EEG-derived metric, measured during wake periods predicts poor sleep quality in two independent cohorts. Consistent with insomnia symptomatology of poor perceived sleep in the absence of excessive daytime sleepiness, ORPwake may provide valuable objective mechanistic insight into physiological hyperarousal.

Study Objectives: To investigate the temporal association between chronic musculoskeletal pain (CMP) and sleep in women who are postmenopausal in a 10-day actigraphic study. This is a microlongitudinal study in which 52 participants were allocated to 4 groups women who are postmenopausal: control (CTRL, n = 10), chronic musculoskeletal pain (CMP, n = 12), insomnia (INS, n = 15) and chronic musculoskeletal pain+insomnia (CMP+INS, n = 15). Methods: All volunteers underwent a clinical interview and completed questionnaires, used an actigraph, and kept sleep diaries for 10 consecutive days. Results: Women in the CMP+INS group presented more sleep episodes (mean of 1.02 episodes) and longer sleep latency (8.97 minutes), as well as higher pain intensity during the day compared to the other groups. Sleep duration recorded by actigraphy directly predicted pain intensity the following morning on waking, with a 1-unit increase in pain intensity, for every 6.9 minutes more of sleep. Higher pain intensity at bedtime was a significant predictor of both increased time in bed and sleep duration, meaning that for each 1-unit increase in pain intensity at bedtime, sleep duration increased by an average of 6.7 minutes. Conclusions: Data showed that the coexistence of insomnia and CMP results in greater pain intensity and alterations in sleep homeostasis. Collectively, the data indicate that there is a bidirectional and directly proportional relationship between sleep duration and pain intensity in women who are postmenopausal with insomnia. This result strongly suggests that both sleep and pain conditions should be targeted in the treatment of women who are postmenopausal. Citation: Frange C, Hachul H, Hirotsu C, Tufik S, Andersen ML. Temporal analysis of chronic musculoskeletal pain and sleep in postmenopausal women. J Clin Sleep Med 2019;15(2):223–234.