Modifiable risk factors for sleep apnea: evidence from meta-analysis of traditional observational studies and 2-sample mendelian randomization.

Rationale: Growing evidence has suggested that body water content plays a critical role in sleep apnea. However, the causal relationship has not been established. Objectives: This study aimed to investigate whether increased whole-body water mass is causally associated with a higher risk of sleep apnea using two-sample Mendelian randomization (MR) analysis. Methods: Body water mass (BWM)-associated genetic instruments were extracted from a genome-wide association study conducted by Neale Lab, which incorporates 331,315 individuals of European ancestry. Genetic variants for sleep apnea were derived from the FinnGen dataset. MR analysis was performed using inverse variance-weighted and weight median methods, respectively. MR-Egger regression and MR-Pleiotropy Residual Sum and Outlier tests were applied to evaluate the directional pleiotropy. In addition, we performed a multivariable MR analysis that includes body mass index, snoring, and waist-to-hip ratio as covariate exposures to address their confounding effects. To elucidate mechanisms of the association between BWM and sleep apnea, we further conducted MR analysis on common edematous diseases. Results: MR estimates showed that per standard deviation increase in BWM led to an increase in the risk of sleep apnea by 49% (odds ratio [OR], 1.490; 95% confidence interval [CI], 1.308-1.696; P = 1.75 × 10-9). The result after MR-Pleiotropy Residual Sum and Outlier correction further supports their causal association (OR, 1.414; 95% CI, 1.253-1.595; P = 1.76 × 10-8). In addition, the multivariable MR analysis indicates a significant causal association between a higher BWM and increased risk of sleep apnea (OR, 1.204; 95% CI, 1.031-1.377; P = 0.036). Genetic predisposition to a higher BWM was also causally related to increased risk of edematous diseases. Conclusions: Our results suggested that increased BWM is a potential risk factor for sleep apnea. Pathologic edema is a possible intermediate factor mediating this causal association.

Prevalence and Predictors of Sleep Apnea Risk among Ghanaian Stroke Survivors

Osteoarthritis (OA) is the most common joint disease, leading to pain and inflammation, two risk factors for sleep apnea (SA). We aimed to examine whether OA may increase the risk of incident SA, a common source of mortality and sudden death. Using data from the IQVIA Medical Research Database, we conducted three cohort studies (i.e., knee, hip, and hand cohort) among individuals aged 50years or older. For each patient with incident OA, up to five non-OA individuals were matched by age, sex, entry-time, and BMI. We calculated the incidence rate of SA for the OA and non-OA cohorts, respectively, and examined the relation of OA to the risk of incident SA using a Cox proportional hazard model adjusting for potential confounders. During the follow-up, 869 SA cases occurred in 58,674 patients with knee OA and 2,186 in 235,850 non-OA individuals (2.29 vs. 1.41/1000 person-years). Compared with the non-OA cohort, the multivariable-adjusted hazard ratio (HR) of SA in the knee OA cohort was 1.45 (95% confidence interval [CI]: 1.34-1.56). A higher risk of SA was also observed among patients with incident hip OA (adjusted HR: 1.45, 95%CI: 1.28-1.66) and hand OA (adjusted HR: 1.50, 95%CI: 1.26-1.78) than the matched non-OA individuals. This general population-based study provides the first evidence that patients with knee, hip, and hand OA may have an increased risk of incident SA. Strategies aimed at screening, prevention, and treatment of SA could be developed to reduce the disease burden in OA patients.

Preoperative identification of sleep apnea risk in elective surgical patients, using the Berlin questionnaire

BackgroundPrevious observational studies have found that lower levels of circulating polyunsaturated fatty acids (PUFAs) were associated with a higher risk of sleep apnea (SA). However, the causality of the association remains unclear.Materials and methodsWe used the two-sample Mendelian randomization (MR) study to assess the causal association of omega-3 and omega-6 fatty acids with SA. Single-nucleotide polymorphisms (SNPs) predicting the plasma level of PUFAs at the suggestive genome-wide significance level (p < 5 × 10–6) were selected as instrumental variables (IVs) from the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) (n = ∼8,000) Consortium. For outcomes, the summary-level statistics of SA were obtained from the latest genome-wide association study (GWAS), which combined five cohorts with a total number of 25,008 SA cases and 172,050 snoring cases (total = 523,366).ResultsWe found no association of α-linolenic acid (ALA) [odds ratio (OR) = 1.09 per% changed, 95% confidence interval (CI) 0.67–1.78], eicosapentaenoic acid (EPA) (OR = 0.94, 95% CI 0.88–1.01), docosapentaenoic acid (DPA) (OR = 0.95, 95% CI 0.88–1.02), and docosahexaenoic acid (DHA) (OR = 0.99, 95% CI 0.96–1.02) with the risk of SA using inverse-variance weighted (IVW) method. Moreover, for omega-6 PUFAs, no association between linoleic acid (LA) (OR = 0.98, 95% CI 0.96–1.01), arachidonic acid (AA) (1.00, 95% CI 0.99–1.01), and adrenic acid (AdrA) (0.93, 95% CI 0.71–1.21) with the risk of SA was found. Similarly, no associations of PUFAs with SA were found in single-locus MR analysis.ConclusionIn the current study, we first found that there is no genetic evidence to support the causal role of omega-3 and omega-6 PUFAs in the risk of SA. From a public health perspective, our findings refute the notion that consumption of foods rich in PUFAs or the use of PUFAs supplementation can reduce the risk of SA.

Diet as adjunctive therapy for sleep apnea risk: not only how much but also what to eat.

Sleep apnea is a potentially serious but under-diagnosed sleep disorder. Saudi Arabia has a high prevalence of hypertension, diabetes, obesity, and smoking, which are all major risk factors for sleep apnea. However, few studies report screening for sleep apnea in Saudi Arabia. A three-month prospective, questionnaire-based study, using the Berlin Questionnaire (BQ) and the Epworth Sleepiness Scale (ESS), screened 319 patients attending a family medicine clinic in Saudi Arabia for risk of sleep apnea. The results showed that when using the BQ and the ESS, 95 (29.8%) and 102 (32.0%) respondents were at high risk of sleep apnea. Taken together, the BQ and the ESS combined measure showed that 41 (12.9%) respondents were classified as high risk for sleep apnea. Logistic regression revealed that the high risk of sleep apnea was statistically significantly (p < 0.05) associated with respondent characteristics of obesity and hypertension. No associations were found between high risk for sleep apnea and: Smoking, diabetes mellitus, hypothyroidism or hyperlipidemia. Screening for sleep apnea using the BQ and ESS questionnaires, particularly among those who are obese or hypertensive, can be a fast, valid and acceptable way of alerting the physician to this disorder among patients.

ObjectiveTo assess whether the Berlin Sleep Questionnaire and the Snoring, Tired, Observed, Pressure, Body mass, Age, Neck, and Gender questionnaire (STOP-BANG) might be suitable replacements for an overnight sleep pulse oximetry as screening tools for sleep disordered breathing in patients with fibromyalgia.Participants: From June 8, 2018 through July 25, 2018, adult patients with a confirmed diagnosis of fibromyalgia (via the 1990 and/or 2010 American College of Rheumatology Fibromyalgia Classification Criteria) who attended Mayo Clinic’s Fibromyalgia Treatment Program were invited to participate in the study.Methods: The design was a prospective comparative study with a retrospective chart review component. Participants completed 2 validated surveys: the Berlin Sleep Questionnaire and the STOP-BANG. Medical records were reviewed for demographic information and overnight pulse oximetry test results.Results: Results from both questionnaires indicate that there is an association between sleep apnea risk category (defined by questionnaire) and oximetry results. Fisher’s exact test for STOP-BANG and Berlin Sleep Questionnaire are statistically significant (P < .001), indicating that participants at high risk for sleep apnea (based on the questionnaires) had a greater prevalence of abnormal oximetry results than those at low risk for sleep apnea. Participants who were classified as high risk (85.7%) or intermediate risk (61.5%) on the STOP-BANG questionnaire for sleep apnea had abnormal oximetry results. Participants who scored as high risk (85.7%) for sleep apnea on the Berlin Sleep Questionnaire had abnormal oximetry results.Conclusions: In patients with fibromyalgia, the Berlin Sleep Questionnaire and the STOP-BANG questionnaires could be beneficial in determining the probability of obstructive sleep apnea and the subsequent need for pulse oximetry testing, in higher risk patients.

Sleep apnea lead to sudden death associated with breathing during sleep(Kim et.al,2015) Aim: To investigate sleep apnea status and related factors in patients with respiratory failure Method: The sampleof study consists of 86 people who received treatment in chest clinic and voluntarily agreed to participate. Data were collected by using interview form with sociodemographic characteristics, Pittsburg Sleep Quality Index, Berlin Sleep Apnea Index Result: The mean age was 58±12, 66,3%were male, 55.8%had quit smoking due to disease.54.7%of the participants had COPD,26.7% had pneumonia,10.5%had asthma. 67.4%of patients had high riskof sleep apnea,55.8%had poor sleep quality,31.4%had severe dyspnea Men had higher riskof sleep apnea. The riskof sleep apnea was higher inpatients diagnosed with COPD and pneumonia. Those who didnot participate social activities were found to have higher riskof sleep apnea than those who participated1or2 times a month. Asignificant difference was found between smoking cessation rate, daily consumption of smoking and sleep apnea. Patients with low or no physical power loss had lower risk of sleep apnea. Individuals with comorbidity(DM,HT,HF)had high riskof sleep apnea. Sleep apnea risk was found to be high in76.8%of individuals with poor sleep quality. Individuals with moderate or higher intensity dyspne had higher rate of sleep apnea than those with no dyspne or mild dyspne(p Conclusion: Age, gender, smoking, daily smoking rate, participation in social activities, physical power loss, BMI, comorbidities, sleep quality, dyspine level increase risk of sleep apnea. Quit smoking, using CPAP and oxygen condenser reduce risk of sleep apnea

To determine the prevalence and risk factors for sleep apnea in a keratoconus population. Ninety-two keratoconus patients and 92 controls were classified as high risk or low risk for sleep apnea, using the Berlin Questionnaire (BQ) or individual history of sleep apnea. Logistic regression was used to investigate the risk factors associated with high risk of sleep apnea in keratoconus patients and controls. Of the 92 keratoconus patients, 18 (19.6%) had a positive known history for sleep apnea, and 49 (53.3%) were categorized to be at high risk by the BQ. Of the 92 control patients, 6 (6.5%) had a positive known history for sleep apnea, and 25 (27.2%) were categorized to be at high risk by the BQ. In keratoconus patients, body mass index was the only risk factor for sleep apnea, whereas in control patients, age, body mass index, and family history of sleep apnea were the risk factors for sleep apnea. Keratoconus patients are at increased risk for sleep apnea, and different risk factors are associated with sleep apnea in keratoconus patients and controls. Ophthalmologists should consider screening keratoconus patients for obstructive sleep apnea, if appropriate.

Background Obstructive sleep apnea is a risk factor for ischemic stroke and may play a role in post-stroke outcomes. Ascertaining self-reported information about pre-stroke sleep apnea risk in the acute stroke period is challenging as many stroke patients have deficits that hinder communication. We examined agreement between stroke patients and family members (proxy) with respect to pre-stroke risk of sleep apnea and hypothesized that agreement would be good. Methods Patient-proxy pairs (n=38) were interviewed as part of the Brain Attack Surveillance in Corpus Christi Project from May 2010 - April 2011. The Berlin Questionnaire was used to measure high risk of sleep apnea defined as at least two of the following: 1) snoring behaviors and witnessed apneas 2) daytime sleepiness and 3) hypertension or obesity. Patient-proxy agreement was assessed using a kappa coefficient. Results Average patient age was 70 (SD=12 years), 68% (n=26) were Mexican American and 32% (n=12) non-Hispanic white. An equal number of male and female patients participated (n=19), and average NIH Stroke Scale value at admission was 5.5 (SD = 6.4). Proxies were spouses (n=24) or children (n=14). Proxies had known patients for an average of 40 years (SD=15) and spoke with the patient daily (n=37) or weekly (n=1). Forty percent of patients (n=15) self-identified as high risk for sleep apnea and 52% of proxies (n=20) identified patients as high risk. Patient-proxy agreement for high risk of sleep apnea was fair (kappa=0.43; table 1 ) and was the same for both spouses and children. Conclusions Proxies can be used to assess pre-stroke risk of sleep apnea when a stroke patient is unable to participate as agreement for high risk of sleep apnea was fair. Proxies reported a high risk for sleep apnea with greater frequency than patients, suggesting there may be differences in observation of specific high-risk characteristics between proxies and patients. Table 1. Patient-Proxy Agreement for Risk of Sleep Apnea (n=38) Patient Risk Assessment Proxy Risk Assessment Total Low High Low 15 8 23 High 3 12 15 Total 18 20 38

Introduction Health promotion (HP) is an important goal of Occupational Medicine. Workplace interventions showed their effectiveness in improving employees’ health. However, studies on health workers (HW) are few and limited, involving small groups. The aim of this research was to evaluate the usefulness of HP programs (HPP) in a large University Hospital. Methods In 2020, two online screening questionnaires were addressed to the over 4,900 HW belonging to the University Hospital of Verona. Salt consumption (SC) was assessed through MINISAL questionnaire, while the risk of sleep apnea (SA) was evaluated through STOP-BANG. HW at high risk for high SC were invited to an individual counseling session and a 6-month follow-up, while polygraphy was offered to HW at high risk for SA. Results MINISAL and STOP-BANG were filled out by 34% and 31% of the study population. In particular, 350 were included in the high SC category and 212 in the high risk for SA. Follow-up examinations were performed in 95 HW; 83% showed a reduction in SC. Polygraphy was performed in 64 HW; 69% were diagnosed with SA and a pulmonological examination was therefore recommended. Discussion The prevalence of HW at high risk for high SC or SA was low, as compared to the general population. The percentage of HW participating in HP programs and the adherence to counseling recommendations were good, showing a high awareness among HW. Conclusion Our studies confirmed the effectiveness of HPP among HW. Screening questionnaires are low-cost and easy-to-perform tools, very useful in involving large working populations.

Objectivesα1-Antitrypsin deficiency is a disease characterized by increased neutrophil elastase activity leading to tissue getting less elastic and robust. It is known that if tissue in the pharynx becomes less elastic and robust, it could contribute to obstructive sleep apnea. This paper seeks to investigate whether patients with α1-antitrypsin deficiency have an increased risk of sleep apnea.MethodsWe tested this hypothesis by doing a nationwide cohort study of 2702 individuals diagnosed with α1-antitrypsin deficiency compared with 26,750 individuals without α1-antitrypsin deficiency matched on sex, age, and municipality. All individuals were followed from birth and were censored at the time of outcome, emigration, death, or end of follow-up 31st of December 2018, whichever came first.ResultsIndividuals with α1-antitrypsin deficiency had a higher risk of sleep apnea with an adjusted hazard ratio of 1.81 (95% CI 1.36–2.40) compared to controls without α1-antitrypsin deficiency. Similarly, the risk of obstructive sleep apnea was nominally higher in individuals with α1-antitrypsin deficiency compared to controls without the disease (1.47, 95% CI 0.95–2.28). In stratified analysis, the risk of sleep apnea was higher in individuals without chronic obstructive pulmonary disease (2.33, 95% CI 1.54–3.51) (P for interaction < 0.05). The increased risk of SA was unaffected when the analysis was stratified by ischemic heart disease, ischemic cerebrovascular disease, type 2 diabetes, hypertension, and liver cirrhosis.ConclusionIndividuals with α1-antitrypsin deficiency have a higher risk of sleep apnea in the Danish population.

Patients with rheumatoid arthritis (RA) have an increased risk for developing cardiovascular disease (CVD) compared to subjects in the general population. The development of CVD has also been linked to chronic sleep apnea. The purpose of this study was to examine the risk for sleep apnea in patients with RA compared to subjects without RA. We recruited RA patients and non-RA subjects who were age and sex matched from the same population. These persons completed the Berlin Sleep Questionnaire, which evaluated their level of risk (high or low) for sleep apnea. In addition, there were 3 subscales evaluating snoring, fatigue, and relevant comorbidities [i.e., high blood pressure and obesity [body mass index (BMI) > or = 30 kg/m(2))]. Chi-squared tests were used for comparisons. The study population consisted of 164 patients with RA and 328 patients without RA. Age, sex and BMI were similar for both groups. There was no difference in snoring (p = 0.31) or in the comorbidities subscale (p = 0.37). However, RA patients reported more fatigue (38%) than subjects without RA (13%; p < 0.001). Overall, the risk for sleep apnea was significantly higher for the RA patients (50%) than the non-RA subjects (31%; p < 0.001). Patients with RA may be at a higher risk for sleep apnea compared to non-RA subjects. This apparent risk difference may be attributed to reports of fatigue in RA patients, which may be associated with sleep apnea or RA disease itself.

Objective This study examines associations between sleep apnea risk and hypertension in a sample of immigrant Chinese and Korean Americans. Design The dataset included Chinese and Korean patients ages 50–75 recruited from primary care physicians’ offices from April 2018 to June 2020 in the Baltimore-Washington DC Metropolitan Area (n = 394). Hypertension risk was determined using a combination of blood pressure measurements, self-reported diagnosis of hypertension by a medical professional, and/or self-reported use of antihypertensive medications. Linear regression models examined the associations between sleep apnea risk and blood pressure (systolic blood pressure [SBP] and diastolic blood pressure [DBP]). Poisson regression models examined associations sleep apnea risk and hypertension. Models controlled for body mass index (BMI), demographic, and socioeconomic risk factors. We further examined models for potential effect modification by age, gender, Asian subgroup, and obesity, as well as effect modification of daytime sleepiness on the association between snoring and hypertension risk. Results High risk of sleep apnea appeared to be associated positively with SBP (β = 6.77, 95% CI: 0.00–13.53), but not with DBP. The association was positive for hypertension, but it was not statistically significant (PR = 1.11, 95% CI: 0.87–1.41). We did not find effect modification of the associations between sleep apnea and hypertension risk, but we did find that daytime sleepiness moderated the effect of snoring on SBP. Snoring was associated with higher SBP, primarily in the presence of daytime sleepiness, such that predicted SBP was 133.27 mmHg (95% CI: 126.52, 140.02) for someone with both snoring and daytime sleepiness, compared to 123.37 mmHg (95% CI: 120.40, 126.34) for someone neither snoring nor daytime sleepiness. Conclusion Chinese and Korean immigrants living in the U.S. who are at high risk of sleep apnea have higher SBP on average, even after accounting for sociodemographic characteristics and BMI. Clinical Trail Registration : NCT03481296, date of registration: 3/29/2018