Dissertations / Theses on the topic 'Sleep outcomes'

Introduction: Type 2 Diabetes (T2DM) and sleep-related disorders share common risk factors such as obesity; but the interrelationships between T2DM and sleep disorders are not well examined. Aims: In this thesis I aimed to assess: 1. The longitudinal impact of obstructive sleep apnoea (OSA) on micro vascular complications in patient with T2DM. 2. The relationship between sleep quality, sleep duration and adiposity in patients with T2DM Methods: To examine the first aim, I utilized the data collected from a previous project that examined the cross-sectional associations between OSA and micro vascular complications in patients with T2DM and followed up the study participants longitudinally using 1-2-1 interviews and electronic health records. For aim 2, I conducted a crosssectional study in patients with young-onset T2DM who were recruited from Heart of England NHS Foundation Trust and primary care. Result: For Aim 1: Depending on the micro vascular outcome examined, we had approximately 200 patients in the analysis. Patients were followed up for 2.5 years for renal outcomes, and 4-4.5 years for retinopathy and neuropathy outcomes. The prevalence of OSA was 63%. I found that baseline OSA was significantly associated with greater decline of eGFR and greater progression to pre-proliferative and proliferative retinopathy. I also found that OSA was associated with progression to a combined outcome of foot insensitivity or diabetic foot ulceration but this was a non-significant trend (p=0.06). In addition, I found that patients who received and were compliant with continuous positive airway pressure (CPAP) treatment (delivered during routine care) had improvements in heart rate variability parameters by study end. For Aim 2: Poor sleep quality and shorter sleep duration were associated with increased total body fat% after adjustment for potential confounders. Conclusion: I found that OSA plays an important role in the progression of micro vascular complications in patients with T2DM. Whether treatment with CPAP has a favourable impact on micro vascular complications is currently being examined in a randomized controlled trial. I also found that sleep duration and quality are associated with increased adiposity. The direction of this relationship need to be examined in longitudinal studies and interventional trials.

Although sleep has been linked to changes in positive and negative affect across the lifespan, the prediction of sleep from affect has not been explored completely. As such, the main objective of this study was to examine the association between affect and sleep across the adult lifespan, using a novel gauge of affect, the positivity ratio. Both subjective and objective assessments of sleep were used in analyses. This study was an archival analysis of data collected as a part of the Midlife in the United States Study (MIDUS-II), with participants ranging from 34 to 83 years of age. Results revealed the positivity ratio to be a significant predictor of self-reported sleep quality and global sleep, but not of objective sleep measures. Additionally, the positivity ratio was found to increase with age and appears to predict better global sleep and sleep quality across all age groups. Implications of the findings are discussed.

Research indicates that law enforcement officers (LEOs) have a higher prevalence of developing coronary artery disease (CAD) compared to the general population. Sleep deprivation and physical inactivity have been found to be related to many risk factors for CAD. This cross-sectional study examined the health status and the relationship between sleep and physical activity outcomes versus CAD risk factors among 27 University LEOs. The subjects’ health behaviors, and CAD and metabolic syndrome risk factors were described using basic statistics. Accelerometer derived sleep and physical activity outcomes were correlated to measures of health to identify potential relationships. 33% of LEOs were classified as moderate risk for CAD; 92% had dyslipidemia, 58% had elevated triglycerides, 23% had prediabetes, and 22% suffered from obesity. The administrators and first shift LEOs slept more compared to second or third shift LEOs. The LEOs were more sedentary while on-duty. In addition, sedentary time was correlated to systolic blood pressure. LEOs accumulated 24.4 min·d-1 of moderate-to-vigorous physical activity (MVPA), but only spent 9.3 min·d-1 in continuous bouts of MVPA. In conclusion, multiple CAD risk factors were present in these LEOs and achieving adequate amounts of physical activity and sleep may decrease their risk of developing chronic diseases.

Sleep disturbance is common in patients with heart failure (HF) and the family caregivers. Sleep disturbance is known as a predictor of poor quality of life (QoL) in individual level. The manner in which patients’ and caregivers’ sleep disturbances influence each other’s QoL has not been determined. The purpose of this dissertation was to investigate the associations of sleep disturbance and outcomes in patients with HF and their primary family caregivers. The specific aims were to: 1) examine whether sleep disturbance of patients and their family caregivers predict their own and their partners’ QoL; 2) examine the mediator effects of depressive symptoms on the association between sleep disturbance and QoL in patients and family caregivers; and 3) provide evidence of the psychometric priorities of the Zarit Burden Interview (ZBI) as a measure of caregiving burden in caregivers of patients with HF. The three specific aims were addressed using secondary analyses of cross-sectional data available from 143 patients with HF and their primary family caregivers. To accomplish Specific Aim One, multilevel dyadic analysis, actor-partner interdependence model was used for 78 patient- caregiver dyads. Individuals’ sleep disturbance predicted their own poor QoL. Caregivers’ sleep disturbance predicted patients’ mental aspect of QoL. For Specific Aim Two, a series of multiple regressions was used to examine the mediation effect in patients and caregivers separately. Depressive symptoms significantly mediated the relationship between sleep disturbance and mental aspect of QoL in patients. The mediation effect was similar in caregivers. For Specific Aim Three, the internal consistency and convergent and construct validity of the ZBI in 124 family caregivers of patients with HF were examined. The results showed that the ZBI is a reliable and valid measure of caregiving burden in this population. This dissertation has fulfilled important gaps in the evidence base for the QoL outcome in patients with HF and caregivers. The findings from this dissertation provided evidence of the importance of monitoring sleep disturbance for better QoL in both patients and caregivers and the importance of assessing caregivers’ sleep disturbance for improving patients’ QoL. It also provided evidence of the importance of managing depressive symptoms when targeting sleep disturbance to improve QoL in both patients and caregivers.

Background: Sleep has a complex nature that is thought to make it a risk factor for many health concerns, which have recently included poor pregnancy outcomes. Aim: Studying the association between sleep and poor pregnancy outcomes in pregnant women. Methods: To achieve this aim, several studies were done. First, the literature was searched to examine and critically evaluate the quality of current evidence in regards to sleep and pregnancy outcomes. Second, the latent complex nature of sleep was defined using latent class analysis and the UKHLS data set before examining the association between the generated patterns and socio-demographic features and health. Third, sleep events present in the UKHLS sleep module and the generated latent sleep patterns were examined in women from the UK population who were presented in the UKHLS study, and in women at risk of gestational diabetes (GDM) presented in the Scott/Ciantar study, in relation to poor pregnancy outcomes. Results: In the literature there was ‘positive’ evidence of an association between sleep and poor pregnancy outcomes. However, the evidence suffered from limitations, and the complex nature of sleep was not considered. Our definition of sleep as a latent variable revealed six latent sleep patterns which were associated with individual socio-demographic features and health. Sleep events and latent patterns did not always elevate the risk of poor pregnancy outcomes in women from the UK population or women at risk of GDM, as sleep lowered the risk on some occasions. Conclusion: Sleep might increase the risk of poor pregnancy outcomes, according to evidence from the literature review and the two empirical studies. However, the current evidence had many limitations, and further research is required in this area.

Social jetlag refers to the chronic shift in sleep timing between work and free days and has been associated with a variety of negative physical and psychological outcomes. Existing research on social jetlag has relied heavily on cross-sectional studies, preventing researchers and practitioners from assessing the effects of social jetlag over time. The current study used longitudinal data to explore the directionality of the association between social jetlag and depressive symptoms as well as the longitudinal associations between social jetlag, academic performance, and wellbeing in college students. Gender and race were also assessed as potential moderators of these associations. Cross-lagged panel analysis using Amos for SPSS revealed that social jetlag predicted depressive symptoms both concurrently adjusting for covariates and longitudinally in unadjusted models. This finding suggests that sleep disturbances may precede mood concerns, although causality cannot be proven due to the design of the current study. PROCESS moderation analyses indicated that social jetlag did not significantly predict academic performance or wellbeing over time, and neither gender nor race moderated these associations. Future research is needed to further assess the short- and long-term outcomes of social jetlag using prospective, well-controlled studies and objective measures of sleep timing.

Mental health problems are the leading causes of disability in Canada. Nearly 70% of mental health problems have their onset during childhood or adolescence. Thus, identifying modifiable determinants of mental health problems in children and adolescents can inform future interventions intended to prevent them in this age group. Until recently, research has examined relationships of movement behaviours, including sleep, sedentary behaviour and physical activity mainly with physical health indicators (e.g., adiposity, cardiovascular disease risk factors, etc.). The few studies that have examined the relationships between movement behaviours and mental health indicators have considered the former individually and in isolation of each other, ignoring the intrinsic and empirical interactions between these behaviours. Adjusting for all these behaviours in a traditional regression model that assumes independence between variables has been shown to produce flawed and inconsistent findings. The purpose of this doctoral dissertation is to examine how the combinations of physical activity, sedentary behaviour, and sleep duration are associated with depression and other mental health outcomes in children and adolescents, through a series of five research studies (one systematic review, 3 cross-sectional studies, and one longitudinal study). Empirical studies used data from 3 large and diverse samples of children and adolescents from Canada and the United States. Conventional regression models and structural equation modelling, and novel analytical techniques, including compositional data analysis were used to analyze the data. The systematic review confirmed the paucity of existing research in this area and identified important research gaps to be filled. Collectively, the results from cross-sectional studies showed that meeting all three recommendations was associated with lower odds of depressive symptoms and other mental health outcomes. However, this association appeared to be mainly driven by meeting the sleep duration recommendation, and to a lesser extent the screen time + sleep duration recommendations. There was a dose-response gradient from meeting none of the recommendations up to meeting two recommendations. Results from the longitudinal study using compositional data analysis provided further evidence suggesting that increasing sleep duration relative to the remaining behaviours (i.e. screen time and physical activity) was associated with lower depressive symptoms among all age/sex subgroups. Results further indicated that predicted changes in depressive symptoms were strongest and most beneficial when removing screen time while adding sleep duration. Finally, results from both cross-sectional and longitudinal analyses suggest that age and sex moderate the association between movement behaviour recommendations (individual or combined) and mental health indicators, depending on the type of movement behaviour and the type of mental health indicators. The findings from this body of work have shed new light on the association between movement behaviours and mental health indicators in children and adolescents by demonstrating that meeting all three movement behaviour recommendations is associated with better mental health, and that sleep duration and screen time were more strongly associated with mental health compared with physical activity in our studies.

Sleep impairments for caregivers are multifactorial. Assumptions are that caregivers of those with primary malignant brain tumors (PMBT) are similar to caregivers of persons with dementia as cognitive impairments are present at diagnosis. The shorter trajectory of PMBTs and rapid deterioration of recipients’ health may influence sleep in caregivers of persons with a PMBT. The purposes of this study were to use a sleep impairment model to characterize caregiver sleep using objective and subjective measures, and to examine sleep loss effects on psychosocial and physiologic health outcomes. A secondary data analysis using baseline data from a larger study of mind-body interactions in caregivers of family members with PMBTs was used. Caregiver data included standardized questionnaires, serum blood draw, and three-day sleep-wake activity data from an accelerometer. Analyses included descriptive statistics, correlations, t-tests, and hierarchical regression models. Caregivers (N = 133) were White (94%), female (69.2%) spouses (75.2) and on average 52 years old (SD = 11.8). Care recipients were mainly White males of similar age with a highly malignant glioma (57.4%). Sleep latency was longer (35 min, SD = 34.5), with shorter total sleep time (TST) (357 min, SD = 84.6) and more frequent wake after sleep onset (WASO; 15.1%, SD = 9.2) than in the general population. Caregivers reported high anxiety (59.4%). Caregiver comorbidities and care recipient functioning explained higher perceptions of health (R2 = 26, F(2, 84) = 14.94, p < .001). Whereas, longer TST, more WASO and poorer sleep quality explained poorer quality of life (R2 = .27, F(4, 66) = 6.19, p < .001). Sleep loss variables explained little variance in physical health status, interleukin-1ra and interleukin-6 levels, fatigue, depressive symptoms, spiritual health, social support, and work limitations. Nurses need to assist caregivers with anxiety management and ways to improve sleep at time of PMBT diagnosis. Sleep impairments place these caregivers at risk for physical and mental health problems, and compromise their ability to continue in the role.

Recent research found insomnia is a risk factor for psychiatric disorders in adults. To see if the same would be true in adolescents, the current study re-analyzed data from a national longitudinal study collected by ADDHealth that evaluated health behaviors in 4552 adolescents (mean age 14.9 years [SD 1.7]) at baseline and again 7-8 years later (n = 3489) during young adulthood. Insomnia was reported by 9.2% of the adolescents. Cross-sectionally, adolescent insomnia was associated with alcohol, cannabis, non-cannabis drugs, and tobacco use, and depression after controlling for gender and ethnicity. Prospectively, adolescent insomnia was a significant risk factor for depression diagnosis, suicidal ideation, and the use of depression and stress prescription medications in young adulthood after controlling for gender, ethnicity, and significant baseline variable. In addition, a trend was noted for suicidal attempts.

Perceived job insecurity (JI) among employees is a common problem in our globalized economy that is characterized by competition and demands flexibility from both employees and employers. The existing literature presents a lot of evidence for the impact of JI on general physical health and psychological well-being outcomes, but asks for more longitudinal research on the impact of JI on specific outcomes, controlled for their baseline levels. The current study addresses this gap in existing research and investigates the associations between JI and diagnosed major depression, diagnosed acute stress, sleep quality, and the health-related behaviors of smoking and snussing in two Swedish samples from Stockholm and Norrland, over long time spans (up to 17 years for the Stockholm sub-sample). Data was obtained from the WOLF study. Results are mixed. For the Stockholm sub-sample, job insecurity correlates with most outcome measures except diagnosed stress, and predicts small shares of variance of sleep quality, the number of cigarettes participants smoke, and if participants use snus. The Norrland sub-sample replicates the impact of JI on general health and hints at a relationship between JI and sleep quality, but no other correlations with health-related behaviors or diagnoses were significant. Reasons for the differences among the sub-samples and limitations of the study are discussed.

Self-regulation refers to our individual capacities to regulate our behaviours, emotions, and thoughts, with these skills developing rapidly across early childhood. This thesis examined sleep, emotional, and cognitive regulation development, and related parental influences, for children participating in the Longitudinal Study of Australian Children. Important longitudinal associations among children's self-regulation, maternal mental health, parenting, and later behaviour problems for children were also investigated. A unique contribution of this research was a prevalence estimate of early childhood self-regulation problems in Australian children that was documented for the first time.

Psychology
Ph.D.
Bipolar Disorder is frequently associated with a number of poor outcomes including, but not limited to, a significant impairment in the ability to return to premorbid levels of occupational and psychosocial functioning, often despite the remission of mood symptoms. An extensive line of research has pointed toward deficits in cognitive functioning as playing an important role in this persistent disability, with a number of studies demonstrating the presence of numerous cognitive impairments during the inter-episode period. Also present during affective episodes as well as the inter-episode periods are reports of pervasive sleep disturbance. Sleep disturbance has been associated with the onset of manic episodes and is an oft-reported prodrome of illness onset. Despite the presence of deficits in these two domains of functioning during affective episodes as well as the inter-episode phase, there has been no evaluation of the degree to which these systems may interact to maintain such high rates of functional disability. The current study attempted to integrate these three separate lines of research to examine the role sleep disruption plays in both cognitive and occupational functioning in individuals with bipolar disorder. Seventy-two males and females with bipolar disorder in the euthymic phase (n=24), primary insomnia (n=24) or no psychological or medical diagnoses (n=24) completed a week of prospective assessment of sleep disruption via self-report and actigraphy. At the culmination of the sleep assessment period, all participants were administered a battery of neuropsychological tests of executive functioning, working memory, verbal learning, and attention. Additionally, participants completed self-reports of mood symptoms and current and lifetime occupational functioning. Results were mixed relative to hypotheses. Data supports persistent sleep disturbance among individuals with bipolar disorder when assessed via self-report, but no significant differences were observed compared to controls when assessed via actigraphy. Bipolar participants exhibited significantly poorer performance on measures of verbal learning and working memory, but no other cognitive deficits were observed relative to insomnia and control participants. Bipolar participants had a greater lifetime history of being fired compared to insomnia or control participants, and deficits in executive inhibition and switching were associated with increased lifetime firings across the sample. Sleep disturbance, either subjective or objective, failed to mediate this association. Findings are partially consistent with previous reports of persistent sleep disturbance and cognitive impairment among individuals with BD in the euthymic phase. More research should be conducted to better understand the underpinnings of functional impairment in BD.
Temple University--Theses

While the importance of assessing the occupational consequences of insomnia and other sleep disorders is emphasised in clinical nosologies and research guidelines, there is little consensus on which aspects of occupational performance should be assessed, how such impairment should be measured, and how outcomes should be reported. The research programme described in this thesis aimed to address this issue. Chapter 1 presents a systematic review and methodical critique of studies reporting those aspects of occupational performance most impacted by (or most frequently associated with) insomnia symptoms and degraded sleep quality. Equivocal results, wide variations in reporting conventions, and the overall lack of comparability among studies, strongly indicated the need to develop a standardised metric able to quantify sleep related occupational performance and serve as an assessment and outcome instrument suitable for use in research and clinical settings. Informed by the literature review, Chapters 2-4 describe the development and validation of the Loughborough Occupational Impact of Sleep Scale ( LOISS ), a unidimensional 19 item questionnaire that captures sleep-related occupational impairment across a number of workplace domains over a 4-week reference period. Chapters 5-7 describe LOISS outcomes from: i) surveys in a random population sample; ii) a representative sample of the UK workforce; and iii) a clinical sample of patients with obstructive sleep apnoea (before and after treatment with CPAP). Overall, the scale showed strong internal consistency (Cronbach s alpha range=0.84-0.94) and test-retest reliability (r=0.77, r2=0.59, p<0.001), high levels of criterion validity (significantly discriminating between good and poor sleepers), and proved an effective outcome measure in OSA. From the survey data reported in Chapters 2-7, LOISS score distributions showed no consistent gender difference but did show a significant ageing gradient, with sleep-related occupational impairment declining with increasing age. In conclusion, the work presented here supports the usability, validity and reliability of the LOISS as an assessment and outcome instrument, and also demonstrates the utility of this instrument in exploring the dynamics of sleep-related occupational performance

Sleep problems in babies and young children are extremely prevalent, yet until recently little attention has been paid to them by health professionals. Sleep problems have often been accepted as part of a developmental process, however research has shown that they are often not transitory, and if not treated effectively in the early years, may have long term consequences for later life. Health visitors are in an ideal position to offer treatment at a primary care level, as they are in regular contact with the families of young children. Existing research has shown that the employment of a behavioural approach is the treatment of choice for childhood sleep problems. The aims of this study were three-fold. Firstly to evaluate the efficacy of a sleep clinic run by health visitors employing behavioural techniques in the treatment of pre-school children with sleep problems. Secondly to assess what aspects of the treatment process result in the outcomes achieved; and finally to make a formal attempt to explore the influence of an improved sleeping pattern on general behaviour. Findings, using a series of n=1 studies that allowed within subject comparisons suggest that field health visitors who have received in-service training on the use of behavioural approaches are able to offer an effective service to the families of children with sleep problems. Parents identified both the behavioural and nonspecific aspects of treatment as being equally helpful, but it remains unclear what actually did help. An improvement in general behaviour was noted for all children, although this was not found to be associated with changes in sleep pattern. Due to the small number of participants, caution must be taken in generalising from the findings. The study is critically evaluated and suggestions for future research together with implications for clinical practice are discussed.

L’insuffisance cardiaque est un problème de santé publique dans les pays développés, touchant 1 à 2% de la population générale, mais dont la prévalence atteint 10% après 70 ans. Les progrès thérapeutiques ont permis d’améliorer le pronostic des patients, notamment ceux ayant une altération de la fonction systolique ventriculaire gauche. Les troubles du rythme sont fréquents et nécessitent une pris en charge particulière au cours des situations d’insuffisance cardiaque. Cependant, il reste des questions non résolues : comment améliorer l’efficacité du traitement de l’insuffisance cardiaque à fonction systolique préservée, comment mieux sélectionner les patients pouvant bénéficier de la prévention primaire de la mort subite par un défibrillateur implantable, les patients âgés peuvent-ils bénéficier de la même prise en charge que les patients plus jeunes, et pour finir comment améliorer les résultats de l’ablation de fibrillation auriculaire dans les situations d’insuffisance cardiaque. Nous avons mis en place une étude prospective chez des patients présentant une dysfonction diastolique pour évaluer l’intérêt de l’algorithme de surveillance de l’apnée du sommeil disponible dans des stimulateurs cardiaques. En parallèle, nous avons analysé l’impact de l’évaluation par résonance magnétique des patients candidats à un défibrillateur sur la prédiction des évènements rythmiques, mais aussi le devenir des patients de plus de 75 ans appareillés avec un système de resynchronisation cardiaque. Enfin, nous nous sommes intéressés aux résultats d’un nouveau système de cartographie électroanatomique ultra-haute densité pour guider les procédures d’ablation de troubles du rythme supraventriculaires complexes chez des patients insuffisants cardiaques comparés à des patients contrôles
Heart failure is a major public health issue in developed countries, with a prevalence of 1-2% of global population, rising to 10% after 70 years of age. Therapeutic progresses have succeeded in improving patients’ prognosis, particularly in case of reduced left ventricular ejection fraction. Rhythm abnormalities are frequent, and need special consideration in case of heart failure. Meanwhile, there are still some gaps in the evidence: heart failure with preserved systolic function is complex and difficult to treat, primary prevention of sudden cardiac death is effective but there is a need to better select candidates, whether elderly patients should be treated as younger individuals, and finally how to improve outcomes of atrial fibrillation catheter ablation. Firstly, we have conducted a prospective study to evaluate the Sleep Apnea Monitoring algorithm provided in a novel pacemaker in patients with diastolic dysfunction. Besides, we analyzed whether magnetic resonance imaging could predict cardiac outcomes in patients with an implantable cardioverter defibrillator better than echocardiography. We also reported the outcomes of the cardiac resynchronization therapy in patients ≥75 years old compared to younger patients. Finally, we studied the results of a novel ultra-high density mapping system to guide ablation procedures of complex atrial arrhythmias in heart failure patients compared to controls

Background: Settling and waking difficulties are common among infants and children. Although there is robust evidence for behavioural approaches to sleep management, a significant number of parents find these difficult to adhere to. Furthermore, other parents will actively choose co-sleeping approaches. A number of psychological factors may be associated with recommendations of, and outcome expectancies for, such interventions. Methods: First-time mothers of infants aged six to 36 months were recruited from support groups. A correlational design explored whether mothers’ sleep attributions and personality (coping style and trait anxiety) related to, and predicted, recommendations of, and outcome expectancies for, differing sleep management methods. The Modified Illness Perception Questionnaire (IPQ) and fictional vignettes depicting infants with sleep difficulties were used to access these attributions. Trait anxiety and coping style were also measured. Results: The Modified IPQ proved to be an adequate means to access maternal attributions about the infant sleep difficulties depicted in the fictional vignettes. Maternal attributions of controllability, external cause, negative consequences and stability were associated with participants recommending behavioural sleep management approaches. There was also some evidence that ‘problem focused’ coping and higher levels of trait-anxiety had some influence on participants’ expectancies of positive outcome for ‘behavioural’ approaches. Conclusion: Future research should examine the actual choices that mothers make in relation to their own infant’s sleep. The influence of psychological factors in fathers, or other care-givers, should also be considered. Gaining further understanding about what factors affect whether a parent would choose to use a ‘behavioural’ approach, with an expectation of success, may help healthcare professionals understand why some parents may find adherence particularly difficult. This may allow them to support parents to use these approaches in clinical treatment.

The prevalence of sleep-disordered breathing (SDB) in stroke is high. We hypothesised that treatment of SDB in stroke patients would improve rehabilitation. 71 patients were recruited for overnight limited sleep study 14-19 days following stroke. Sixty-six patients with adequate recording were included in the study, 45 men and 21 women, median age 74yrs. The sleep study showed 50% of patients had more than 30 apnoeas + hypopnoeas per hour in bed [expressed as (A+H)•h^-1]. Pulse oximetry alone had lower sensitivity (70%) but high specificity (90%) to predict (A+H)•h^-1 ³ 30. Thirty patients who had (A+H)•h^-1 ³ 30, with < 30% central apnoea or Cheyne-Stoke respiration, proceeded to a randomized controlled trial starting from the 4th week after stroke with 15 patients randomized to CPAP and 15 to conventional stroke treatment only. Duration of treatment was 8 weeks and blind outcome assessment was performed at 3 months and 6 month after stroke. The result showed compliance with CPAP was poor with mean 1.40 hours and median 0.16 hours per night. There was no statistically significant difference in the outcomes, sleepiness and ambulatory blood pressure with CPAP therapy. Increased length of keeping CPAP was correlated with higher score of language subscale in the Addenbrooke’s Cognitive Examination (Spearman’s rho = 0.544, p = 0.036) and lower score in the depression subscale of the Hospital Anxiety and Depression Scale (HADS, Spearman’s rho =-0.538, p = 0.039). All 66 patients with adequate sleep studies received longitudinal follow-up at 3, 6 12 and 18 months following stroke. The patients with (A+H)•h^-1 ³ 30 had a trend to worse functional capacity in both Barthel Index and Nottingham Extended ADL Index (EADL) than patients with (A+H)•h^-1< 30 but there was only a statistically significant difference in the mobility subscale of EADL. The negative influence of (A+H)•h^-1 ³ 30 on functional capacity and health-related quality of life following stroke was only statistically significant in patients with mild stroke (NIH Stroke Scale, NIHSS < 7) at both 3 and 6 months, lesser emotional distress (HADS < 8) at both 3 and 6 months and lesser cognitive impairment (Mini Mental State Examination ³ 28) at 6 months after stroke in subgroup analysis. The difference of Modified Rankin Scale between groups was significant at 6 months after stroke (p = 0.026). There was no difference in cognitive or emotional outcome. No significant difference of mortality rate was noted. We focused on a group of patients with mild to moderate stroke (median NIHSS = 6) in a narrow time span (14-19 days) and confirmed a high prevalence of SDB in stroke. CPAP compliance was a major problem but might be enhanced by selecting patients with higher functional capacity, higher cognitive function especially language and less depression in the acute or subacute phase of stroke.

Introdução: A apnéia obstrutiva do sono é um problema de saúde pública dada sua alta prevalência e morbidade. O tratamento de escolha para casos graves é o uso de máscara ligado à pressão positiva contínua na via aérea (CPAP). Nos casos de apnéia obstrutiva do sono moderada, a adesão ao CPAP é variável, e outras formas alternativas de tratamento são necessárias. A disfunção da musculatura de via aérea superior participa na gênese da apnéia obstrutiva do sono. Exercícios orofaríngeos (terapia miofuncional) são derivados da terapia fonoaudiológica dentro da especialidade de motricidade orofacial, e foram desenvolvidos para o tratamento da apnéia obstrutiva do sono. A terapia miofuncional consiste em exercícios isométricos e isotônicos dirigidos para a língua, palato mole e paredes laterais faríngeas, incluindo a adequação das funções de sucção, deglutição, mastigação, respiração e fala. Objetivo: Testar a hipótese de que a terapia miofuncional reduz a gravidade da apnéia obstrutiva do sono. Métodos: Pacientes com apnéia obstrutiva do sono moderada, determinada através de polissonografia (índice de apnéia-hipopnéia entre 15 e 30 eventos/hora) foram sorteados para 3 meses de medidas gerais incluindo lavagem nasal, orientação da mastigação bilateral alternada e exercícios de inspiração e expiração nasal na posição sentado (grupo controle), ou tratamento com terapia miofuncional. Além das orientações recebidas pelo grupo controle, a terapia miofuncional incluiu exercícios orofaríngeos diários sem supervisão e sob supervisão uma vez por semana (sessões de 20 minutos). Foram realizadas na entrada e final do estudo medidas antropométricas, questionários avaliando a freqüência e intensidade do ronco, sonolência subjetiva diurna (Epworth), qualidade do sono (Pittsburgh) e polissonografia completa. Resultados: Foram incluídos no estudo 45 pacientes; 8 foram excluídos por falta de adesão ao protocolo. O grupo final se constituiu de 37 pacientes com idade (média ± desvio padrão) = 51±9 anos, índice de massa corpórea = 30±4 Kg/m2 e índice de apnéia e hipopnéia = 23±5 apnéias/hora, sendo 17 do grupo controle e 20 do grupo tratamento. O grupo controle não teve mudança significativa em todos os parâmetros. Em contraste, os pacientes tratados com terapia miofuncional apresentaram melhora significante (p<0.05) na circunferência cervical (39.5±3.4 vs. 38.3±3.7 cm), na sonolência diurna (13.2±5.4 vs. 8.2±6.0), na qualidade do sono (10.3±3.5 vs. 7.1±2.3), na freqüência do ronco (3.9±0.5 vs. 2.7±1.1), na intensidade do ronco (3.4±0.5 vs. 1.8±0.9) e no índice de apnéia e hipopnéia (23.2±4.8 vs. 14.6±8.1 eventos/hora; p<0.01). Considerando todo o grupo, as mudanças na circunferência cervical se correlacionaram com as mudanças no índice de apnéia e hipopneia (r=0.55; p<0.001). Conclusões: A terapia miofuncional por 3 meses reduz os sintomas e a gravidade da apnéia obstrutiva do sono moderada. A melhora da apnéia se correlaciona com a diminuição do diâmetro cervical, sugerindo que o tônus da musculatura da via aérea superior durante a vigília se correlaciona com a gravidade da apnéia obstrutiva do sono e pode ser modificada com a terapia miofuncional.
Introduction: Obstructive sleep apnea is a public health problem due to the high prevalence and high morbidity. Continuous positive airway pressure (CPAP) is the treatment of choice for severe cases. However, adherence to CPAP is variable among moderate obstructive sleep apnea patients and alternative treatments are necessary. Upper airway muscle weakness plays an important role in the genesis of obstructive sleep apnea. Oropharyngeal exercises (myofunctional therapy) are derived from phonoaudiological therapy within orofacial motricity specialty, and were developed for the treatment of sleep obstructive apnea. The myofunctional therapy consists of isometric and isotonic exercises directed to tongue, soft palate and lateral pharyngeal wall, including adequate functioning of suction, swallowing, chewing, breathing and speech. Objective: To test the hypothesis that myofunctional therapy will attenuate obstructive sleep apnea syndrome severity. Methods: We included 37 moderate obstructive sleep apnea patients apnea-hypopnea index (AHI) between 15 and 30 events/hour that were randomized to 3 months of general measures, including nasal lavage, orientation of alternated bilateral chewing and exercises of inspiration and expiration in the seated position (control group). The treatment with myofunctional therapy consisted of oropharyngeal exercises performed without supervision daily and under supervision once a week (20 minutes), in adition to the orientations given to the control group. Anthropometric measurements, questionnaires evaluating snoring frequency and intensity (Berlin), daytime subjective sleepiness (Epworth), sleep quality (Pittsburgh) and full polysomnography were performed at baseline and in the end of the study. Results: 45 patients were included in the study, 8 were excluded because they failed to return regularly. The final group consisted of 37 patients age (mean ± SD) = 51±9 years, body mass index = 30±4 Kg/m2 and apnea hypopnea index = 23±5 apneas/hour), seventeen were randomized to the control group and twenty to the treatment group. The control group did not changes in all parameters along the study. In contrast, the patients treated with myofunctional therapy presented a significant decrease (p<0.05) in neck circumference (39.5±3.4 vs. 38.3±3.7 cm), daytime somnolence (13.2±5.4 vs. 8.2±6.0), sleep quality (10.3±3.5 vs. 7.1±2.3), snoring frequency (3.9±0.5 vs. 2.7±1.1), snoring intensity (3.4±0.5 vs. 1.8±0.9) and apnea hypopnea index (23.2±4.8 vs. 14.6±8.1 events/hour; p<0.01). Considering the entire group, changes in neck circumference correlated with the changes in AHI (r=0.55; p <0.001). Conclusions: Myofunctional therapy, over 3 months, reduce symptons and severity of moderate obstructive sleep apnea. The improvement correlates with the decrease of cervical diameter, suggesting that the musculature tonus of upper airway while awake correlates with the severity of obstructive sleep apnea and can be modified with myofunctional therapy.

O ronco é gerado pela obstrução parcial e vibração da faringe durante o sono. Apesar de causar graves problemas sociais e poder indicar presença de apneia obstrutiva do sono (AOS), o ronco não é medido de forma objetiva. O tratamento do ronco primário ou associado a formas leves de AOS é controverso. A Terapia Miofuncional Orofacial consiste em exercícios isotônicos e isométricos para língua e palato mole desenvolvidos para o tratamento da AOS moderada. No entanto, os efeitos da Terapia Miofuncional Orofacial sobre o ronco não foram medidos de forma objetiva. OBJETIVOS: Primário: determinar a eficiência da Terapia Miofuncional Orofacial em reduzir o ronco de pacientes com ronco primário, AOS leve e moderada. Secundários: desenvolver uma metodologia de quantificação objetiva do ronco; avaliar a relação das características do ronco com a gravidade da AOS; avaliar o efeito da terapia miofuncional orofacial sobre a percepção do ronco e sobre a qualidade de sono do parceiro de quarto. MÉTODOS: Foram incluídos pacientes de ambos os sexos, com idade entre 20 e 65 anos com diagnóstico polissonográfico de ronco primário, AOS leve ou AOS moderada. Os pacientes foram randomizados por 3 meses para tratamento com Terapia Miofuncional Orofacial ou Controle (uso de dilatador nasal e exercícios respiratórios). Os pacientes foram avaliados no início e final do estudo por questionários de grau de sonolência (Epworth), qualidade de sono (Pittsburgh), percepção do próprio ronco e avaliação de motricidade orofacial, bem como polissonografia completa com registro contínuo do ronco. Os parceiros de quarto avaliaram o ronco do parceiro incluído no estudo e a sua própria qualidade do sono (Pittsburgh). RESULTADOS: Foram incluídos 39 pacientes com idade (média ± desvio padrão) = 46 ± 13 anos e índice de massa corpórea (IMC) = 28,2 ± 3,1 Kg/m2, Índice de apneia e hipopneia (IAH) = 15,3 ± 9,3 eventos/hora, sendo 6 pacientes com ronco primário, 17 com AOS leve e 16 com AOS moderada. Os pacientes não tiveram mudança de IMC, sendo que no Grupo Controle todos os parâmetros avaliados não se modificaram significativamente. Em contraste, os pacientes tratados com Terapia Miofuncional Orofacial apresentaram, em relação ao basal, melhora significativa (p < 0.05) na circunferência cervical ( 38,0 [36,4-39,5] vs. 37,5 [36,0-39,0] cm), na avaliação miofuncional orofacial (37,0 [23,0-42,0] vs. 19 [13,0-24,0]), no Índice de Roncos (99,5 [49,6-221,3] vs. 48,2 [25,5-219,2]) e no Índice Potência Total dos Roncos. (60,4 [21,8-220,6] vs. 31,0 [10,1-146,5]). Os parceiros de quarto dos pacientes tratados com terapia miofuncional orofacial (n=13), relataram melhora significativa na percepção da intensidade (4,0 [2,5-4,0]) vs. 1,0 [1,0-2,0]) e frequência do ronco (4,0 [3,0-4,0] vs. 2,0 [1,5-3,0]). A melhora da qualidade de sono dos parceiros de quarto dos pacientes tratados com Terapia Miofuncional Orofacial tiveram uma tendência a melhorar, porém não atingiu significância estatística (p=0,0618). O Índice de Ronco e o Índice Potência total do Ronco no basal e após 3 meses apresentaram uma correlação moderada com a gravidade da AOS, mensurada pelo IAH (r variando entre 0,505 a 0,603). CONCLUSÕES: A Terapia Miofuncional Orofacial por 3 meses foi efetiva em reduzir a frequência e intensidade do ronco, mensurados objetivamente. A Terapia Miofuncional Orofacial portanto pode ser efetiva para uma grande parcela da população que apresenta ronco primário ou formas leves de AOS
Snoring is generated by pharyngeal obstruction and vibration during sleep. Snoring is extremely common and may cause severe social problems and may indicate obstructive sleep apnea (OSA). However, there are no standardized methods for measuring snoring and the treatment of primary snoring or snoring associated with mild forms of OSA is controversial. Orofacial Myofunctional Therapy consists of isometric and isotonic exercises directed to tongue and soft palate for the treatment of moderated OSA. However, the effects of Orofacial Myofunctional Therapy on snoring were not objectively measured. OBJECTIVES: Primary: to determine the efficiency of Orofacial Myofunctional Therapy in reducing snoring of patients with primary snoring, mild and moderated OSA. Secondary: to develop a methodology to objectively quantify snoring; to assess the relation of snoring characteristics with OSA severity; to assess the effect of Orofacial Myofunctional Therapy upon the perception of snoring and sleep quality of the bed partner. METHODS: We included patients of both genders aged between 20 to 65 years old with polissomnographyc diagnoses of primary snoring, mild or moderated OSA. Patients were randomized for treatment with Orofacial Myofunctional Therapy or Control (use of nasal dilator strips and respiratory exercises) for 3 months. All patients were evaluated at the beginning and end of the study by questionnaires (Epworth, Pittsburgh), orofacial motricity assessment and complete polysomnography with the register of snoring. Bed partners assessed snoring and their own sleep quality (Pittsburgh). RESULTS: Thirty nine patients aged (mean ± standard deviation) =46 ± 13 yeas old and body mass index (BMI) (mean ± standard deviation) = 28,2 ± 3,1 Kg/m2, apnea hypopnea index (AHI)= 15,3 ± 9,3 events/hour, being 6 patients with primary snoring, 17 with mild OSA and 16 with moderated OSA completed the study. No significant change occurred in the Control Group in all variables. In contrast, patients treated with Orofacial Myofunctional Therapy presented (as compared to baseline) a significant decrease (p < 0.05) in neck circumference (38,0 [36,4-39,5] vs. 37,5 [36,0-39,0] cm), Orofacial Motricity Assessment (37,0 [23,0-42,0] vs. 19 [13,0-24,0]), Snoring Index (99,5 [49,6-221,3] vs. 48,2 [25,5-219,2]) and Total Snoring (60,4 [21,8-220,6] vs. 31,0 [10,1-146,5]). Bed partners of patients treated with Orofacial Myofunctional Therapy (n=13) reported a significant improvement in the perceived intensity (4,0 [2,5-4,0]) vs. 1,0 [1,0-2,0]) and snoring frequency (4,0 [3,0-4,0] vs. 2,0 [1,5-3,0]). Sleep quality of bed partners also improved but did not reach statistical significance (p=0.0618). Snoring Index and Total Snoring at basal and after 3 months presented a moderated correlation to OSA severity, measured by AHI (r between 0,505 to 0,603). CONCLUSIONS: Orofacial Myofunctional Therapy for 3 months is effective in reducing objectively measured snoring frequency and intensity. Orofacial Myofunctional Therapy can be effective for a great number of the population who present primary snoring or mild OSA forms

Objetivos: Comparar os efeitos de um mês de tratamento com aparelho de pressão aérea positiva (CPAP) e com placebo sobre a aparência e características objetivas da pele da face de pacientes com apneia obstrutiva do sono (AOS), num estudo randomizado e cruzado. Métodos: Foram incluídos pacientes consecutivos com AOS grave e sonolentos. Os pacientes realizaram três polissonografias (PSG): a primeira para confirmação da AOS e outras duas adicionais com uso de placebo (dilatador nasal) e para titulação de CPAP, antes do início de cada tratamento. Todos os pacientes foram aleatoriamente alocados em dois grupos de tratamento: 1) uso do placebo e 2) uso do CPAP. Após um mês com o primeiro tratamento e 15 dias de washout, houve cruzamento para o segundo tratamento. A face dos pacientes foi fotografada de modo padronizado nos três momentos experimentais. As fotografias foram apresentadas, em ordem aleatória, pelo Qualtrics Survey Software, e avaliadas on-line por 704 observadores para quantificação da aparência saudável (nada saudável até extremamente saudável), atraente (nada atraente até extremamente atraente) e cansada (nada cansada até extremamente cansada). A idade aparente também foi perguntada para cada observador. Foram realizadas avaliações quantitativas das características da pele da face dos pacientes, em cada momento experimental, incluindo a presença de acne, manchas, porosidade, rugas, textura, e uniformidade do tom da pele, por meio da captação de imagens pelo equipamento VISIATM System. Resultados: Foram avaliados 30 pacientes (idade=46±9 anos; 21 homens). Os pacientes utilizaram o placebo em 98% das noites do período de tratamento e a adesão ao CPAP foi de 94% das noites, com média de 6,0 ± 1,7 horas de uso por dia de tratamento. Após o tratamento com CPAP, em comparação ao momento basal e após tratamento placebo, foi observada melhora na qualidade objetiva do sono, sonolência, qualidade de vida e sintomas depressivos (P < 0,05). A avaliação das fotografias pelos observadores mostrou que os pacientes foram identificados como mais jovens após o uso de CPAP (P < 0,001), mas não foram observadas alterações quantitativas das características da pele da face, em comparação com o momento basal e após o uso de placebo. A análise de regressão linear identificou que a quantidade de dias de tratamento com CPAP, o tempo total de sono e a porcentagem do tempo total de sono com saturação de oxihemoglobina abaixo de 90% foram preditores da diminuição da idade atribuída após o uso de CPAP. Conclusão: Os pacientes com AOS graves e sonolentos apresentaram aparência mais jovem após um mês de tratamento com CPAP
Objectives: To compare the effects of one month with continuous positive airway pressure (CPAP) treatment and placebo intervention on the appearance and objective facial skin characteristics of patients with obstructive sleep apnea (OSA) in a randomized crossover study. Methods: Consecutive sleepy patients with severe OSA were included. The patients underwent three polysomnograms (PSG): first one to confirm OSA and two additional ones using placebo (nasal dilator) and for CPAP titration before starting each treatment period. All patients were randomly included into two treatment groups: 1) placebo use and 2) CPAP use. After one month with the first treatment and 15 days of washout, patients were crossed-over for the second treatment. Photographs from the patients\' faces were obtained in the three experimental moments. The photographs were presented in a random order by the Qualtrics Survey Software, and were evaluated online by 704 observers for quantifying healthy appearance (unhealthy to extremely healthy), attractive (unattractive to extremely attractive) and tired (not tired to extremely tired). Apparent age was also rated for each observer. Quantitative evaluations of the skin characteristics of the patients\' faces were also carried out at each experimental moment, including the presence of acne, patches, porosity, wrinkles, texture, and skin tone uniformity, through the capture of images by VISIATM System equipment. Results: 30 patients (age = 46±9 years, 21 men) were evaluated. During treatment period, the patients wearing placebo intervention on 98% of the nights and adherence to CPAP was 94%, with a mean of 6.0 ± 1.7 hours of use per day of treatment. After CPAP treatment, compared to baseline and after placebo treatment, improvement in the objective sleep quality, sleepiness, quality of life and depressive symptoms were observed (P <0.05). Observational assessment of the photographs showed that patients were evaluated as being younger after using CPAP (P < 0.001), but no quantitative changes in face skin characteristics were observed compared to the baseline and after the use of placebo. Linear regression analysis identified the number of days with CPAP treatment, total sleep time and percentage of total sleep time with oxyhemoglobin saturation below 90% were predictors of decreasing of rated age after CPAP treatment. Conclusion: Sleepy patients with severe OSA had a younger appearance after one month of CPAP treatment

INTRODUÇÃO: A apneia obstrutiva do sono (AOS) é um problema de saúde pública, com grande prevalência e graves consequências. O tratamento considerado padrão-ouro para AOS grave é a aplicação do aparelho de pressão positiva aérea contínua (CPAP) durante o sono. Porém a adesão ao CPAP é baixa, em especial nos pacientes com ronco primário e AOS leve. Estudo prévio do nosso laboratório demonstrou que a terapia miofuncional orofacial (TMO) é efetiva em pacientes com AOS moderada (Guimaraes et. al, AJRCCM 2009:(179);962-966). No entanto, no trabalho inicial o número de pacientes foi relativamente pequeno (n=31), avaliou-se apenas pacientes com AOS moderada. Adicionalmente, a quantidade de exercícios orofaríngeos realizados foi relativamente grande (n=10) dificultando a adesão ao tratamento e os potenciais mecanismos de ação da terapia não foram elucidados. OBJETIVO: O objetivo primário do trabalho é avaliar a efetividade na redução da gravidade da AOS de um programa com um número reduzido de exercícios de TMO (6 exercícios) em pacientes com ronco primário, AOS leve, moderada e grave. Os objetivos secundários foram avaliar o impacto da TMO no índice de apneia hipopneia (IAH) em pacientes estratificados pelo IAH basal, a anatomia da via aérea superior (VAS) por meio da ressonância magnética (RM), a fisiologia da VAS por meio da força e fadiga da língua e a pressão crítica de fechamento (Pcrit). METODOLOGIA: Foram incluídos pacientes de ambos os sexos, com idade entre 20 e 65 anos, recentemente diagnosticados com ronco primário, AOS leve, moderada ou pacientes com AOS grave que se recusaram a utilizar o CPAP. Foram excluídos pacientes com índice de massa corpórea (IMC) >= 35 kg/m2, malformações craniofaciais, desdentados, uso regular de medicação hipnótica, doença obstrutiva nasal grave, pacientes já submetidos a outros tipos de tratamentos e pacientes com indisponibilidade de comparecimento semanal durante o estudo. Os pacientes foram avaliados no início e final do estudo por questionário de sonolência (Epworth, variando de 0 a 24 pontos), qualidade de sono (Pittsburgh, variando de 0 a 21 pontos), avaliação fonoaudiológica específica para AOS (variando de 0 a 20 pontos), RM da via aérea superior, força e fadiga de língua, Pcrit e polissonografia. Os pacientes foram sorteados para 3 meses de TMO (6 exercícios) ou controle (dilatador nasal durante o sono e exercícios respiratórios inespecíficos). Todos os pacientes foram acompanhados semanalmente por uma fonoaudióloga e orientados a realizar os exercícios três vezes por dia. Foi realizada ANOVA de dois caminhos para medidas repetidas para avaliar a eficácia dos tratamentos nos diferentes desfechos. Secundariamente também avaliamos o efeito dos tratamentos por meio do teste t pareado. RESULTADOS: Inicialmente 251 pacientes foram avaliados, e após avaliação dos critérios de inclusão e exclusão, 60 pacientes entraram no estudo, sendo que 30 foram randomizados para TMO e 30 para o grupo Controle. Os dois grupos foram semelhantes para todos os parâmetros na entrada. Finalizaram o estudo 58 pacientes (58,6% do sexo masculino, média de idade 45,9 ± 12,2 anos, IMC 28,8 ± 4,3 kg/m2, IAH=18,4 ± 12,6 eventos/h e saturação mínima de oxigênio 84,6 ± 6,4%). O grupo Controle não teve modificações em nenhuma das variáveis ao longo do estudo. O grupo TMO não modificou o IMC e não apresentou mudança significativa nos questionários Epworth e Pittsburgh. Em relação ao início do estudo, o grupo TMO apresentou uma redução significativa na circunferência cervical (38,8±3,3 vs 38,4±4 cm), índice de despertar (21,3±10,9 vs 16,9±7,9 despertares/h), IAH (19,5 ± 14,2 vs 15 ± 10,2 eventos/h) e avaliação fonoaudiológica específica para AOS (9,3 ± 2,9 vs 3,6 ± 2,4). O efeito da TMO sobre o IAH foi significativo somente nos pacientes que apresentavam na entrada AOS moderada (23,8 ± 5,2 vs 17,7 ± 5,2) e grave (43,9 ± 19,5 vs 24,7 ± 21,4). Não foram observadas modificações significativas quando avaliado por meio do teste de ANOVA de duas vias para medidas repetidas na RM da via aérea superior em 24 pacientes (10 Controle e 14 TMO) e fisiologia avaliados por força e fadiga de língua em 38 pacientes (19 Controle e 19 TMO) e Pcrit em 17 pacientes (7 Controle e 10 TMO). No entanto, observamos uma redução significativa (teste t pareado) com diminuição do volume da língua (p=0.031), quantidade de gordura da língua (p=0.008) e aumento significativo da força da língua (p=0,046) no grupo TMO. CONCLUSÃO: Um programa reduzido de TMO é efetivo e capaz de reduzir a gravidade da apneia do sono em pacientes com AOS moderada e grave. A tendência ao aumento da força de língua e redução da gordura de língua podem auxiliar a explicar os efeitos benéficos da TMO em pacientes com AOS
INTRODUCTION: Obstructive sleep apnea (OSA) is a public health problem, with high prevalence and severe consequences. The gold standard treatment for severe OSA is the application of continuous positive airway pressure (CPAP) during sleep. However, adherence to CPAP is low, especially in patients with primary snore and mild OSA. A previous study from our laboratory demonstrated that oropharyngeal exercises are effective in patients with moderate OSA (Guimaraes et. al, AJRCCM 2009:(179);962-966). Nonetheless, in this first study the number of patients included in the randomized trial was relatively small (n=31) and evaluated only patients with moderate OSA. Moreover, the number of oropharyngeal exercises the patients had to do 3 times a day was large (n=10) and raised doubt about the compliance to treatment, and the mechanism by which the therapy was effective was not elucidated. OBJECTIVE: The primary objective was to evaluate the effectiveness to reduce OSA severity of a short program of oropharyngeal exercises (6 exercises) in patients with primary snore, mild, moderate and severe OSA. The secondary objective was to evaluate the impact of reduced oropharyngeal exercises program on apnea hypopnea index (AHI) in patients stratified by baseline AHI, the anatomy of upper airway by magnetic resonance (MR), strength and fatigue of the tongue and critical closing pressure (Pcrit). METHODOLOGY: Patients of both sexes, with age between 20 and 65 years old, recently diagnosed with primary snore, mild, moderate or severe OSA who refused to use CPAP were included. Patients with body mass index (BMI) >= 35kg/m2, craniofacial deformities, edentulous, regular use of hypnotic medication, severe nasal obstruction, patients undergoing other treatments for OSA and patients with unavailability to comply with the protocol were excluded. The patients were evaluated at the beginning and end of the study by questionnaire of daytime sleepiness (Epworth, ranging from 0 to 24 points), quality of sleep (Pittsburgh, ranging from 0 to 21 points), oral myofunctional evaluation for OSA (ranging from 0 to 20 points), MR of the upper airway, tongue strength and fatigue, critical closing pressure (Pcrit) and polysomnography. The patients were randomized to 3 months of oropharyngeal exercises (6 exercises) or Control (use of nasal dilator strip and respiratory non specific respiratory exercises). All patients were instructed to perform the exercises 3 times a day and evaluated by a speech pathologist once a week. The primary endpoints were evaluated primarily by two-way repeated-measures ANOVA. A paired t test was also used as a secondary evaluation. RESULTS: A total of 251 patients were evaluated and 60 patients were randomized. The 2 groups (n=30) were similar at study entry for all the parameters and 58 patients completed the study (58.6% males, age: 45.9±12.2 years, BMI: 28.8±4.3 kg/m2, AHI=18.4±12.6 events/h and minimum saturation84.9±6.4%). All variables remained unchanged in the Control group. There were no changes in Epworth and Pittsburgh questionnaires as well as BMI in patients randomized to oropharyngeal exercises. As compared to study entry, there was a significantly reduction on neck circumference (38.8 ± 3.3 vs 38.4±4.4cm), arousals index (21.3 ± 10.9 vs 16.9 ± 7.9 arousals/h), AHI (19.5 ± 14.2 vs 15 ± 10.2 events/h), oral myofunctional evaluation for OSA (9.3 ± 2.9 vs 3.6 ± 2.4) in the patients randomized for oropharyngeal exercises. Oropharyngeal exercises only reduced AHI significantly among patients with moderate OSA (23.8 ± 5.2 vs 17.7 ± 5.2) and severe OSA (43.9 ± 19.5 vs 24.7 ± 21.4) at study entry. No significantly changes as evaluated by two-way repeated-measures ANOVA were observed on upper airway MR anatomy (10 Control and 14 oropharyngeal exercises), tongue force and fatigue (19 Control and 19 oropharyngeal exercises) and Pcrit (7 Control and 10 oropharyngeal exercises). As compared to study entry there was a significant reduction as evaluated by paired T test on tongue volume (p=0.031), tongue fat (p=0.008) and a significant increase of tongue strength (p=0.046) of patients randomized to oropharyngeal exercises. CONCLUSION: A short program of oropharyngeal exercises is effective to reduce OSA severity in patients with moderate and severe OSA. The trend to increase tongue strength and reduce tongue fat may explain the beneficial effects of oropharyngeal exercises

The objective of this study was to examine possible correlations between sleep duration and sleep quality on health outcomes in the Marshallese community members in Northwest Arkansas. Little research has been conducted on the association between sleep health and health outcomes in Native Hawaiian Pacific Islanders, and even less so in the Marshallese populations. Using cross sectional date from a cluster randomized controlled trial study (n=374), I will examine whether sleep duration and sleep quality are associated with hypertension, type 2 diabetes, body mass index, and overall self-reported health rating in the Marshallese. Systolic and diastolic blood pressure, HbA1c levels, and height and weight were all measured for hypertension, type II diabetes, and BMI, respectively. General health status was determined by self-reported measures from the National Health and Nutritional Examination survey-derived questions. Sleep duration was categorized as very short sleep (0-4 hours), short sleep (4-7 hours), normal sleep (7-9 hours), and long sleep (9 or more hours). Sleep quality was determined by answers to the question: “Over the last two weeks, how many days have you had trouble sleeping or staying asleep?” For the continuous dependent variables (BMI, blood pressure, and HbA1c), median and interquartile range values were examined. For non-continuous variable (general health outcomes), the Spearman Correlation Coefficient was examined to determine association. Statistically significant associations were found between sleep duration and diastolic blood pressure and HbA1c, and sleep quality and general health. These associations among the Marshallese provide foundation for further longitudinal and intervention research on health disparities in Marshallese residents of the United States.

Traumatic brain injury (TBI) is a major health problem affecting the adult and pediatric population. Scientists and clinicians are working diligently to discover possible therapeutics for the treatment of TBI. Two possible treatments to deal with TBI include sleep and the administration of progesterone. Yet, there are conflicting results from studies regarding the efficacy of either treatment. Sleep appears to reduce neuroinflammation and reduce axonal damage in the brain following TBI. Sleep deprivation, however, may have neuroprotective effects after TBI. Progesterone has also been shown to have neuroprotective effects following TBI. But, there are no sufficient data from animal studies to determine if progesterone is an effective therapeutic. More research studies will have to be conducted to further understand the role of sleep and progesterone in alleviating TBI.

Background and objectives: The overall objective of this thesis is to investigate readmissions in Australian hospitals in patients previously admitted with heart failure (HF) or an acute myocardial infarction (AMI). The specific aims of this thesis are: 1. To conduct a scoping review of the contemporary Australian literature regarding readmissions with an index admission of any cardiovascular disease (CVD). 2. To determine the rates of readmission and mortality in Australian and New Zealand HF patients between 2010-15. 3. To determine the accuracy of the LACE index score (a prediction tool) for predicting 30-day all-cause mortality and readmission rates (independently and combined) in South Australian AMI patients who had an angiogram between 2015-6. 4. To conduct a pilot clinical study to determine whether an association exists between a) the quantity and b) the quality of sleep time in hospital and 30-day all-cause unplanned readmission in a South Australian cohort of cardiovascular inpatients. Methods: The thesis employs multiple methodological approaches including a scoping review (Chapter II), ‘big data’ techniques (Chapter III), registry data analysis (Chapter IV) and a prospective clinical observational cohort study (Chapter V). Summary of major findings: Chapter II: The scoping review of contemporary Australian literature found limited literature on the topic of readmissions following hospitalisation for a CVD or condition. Furthermore, it xi found that the methods used in prior studies lacked uniformity and standardisation which was reflected in the large range of readmission rates observed (from 6.3% to 27%, median 13%). Chapter III: The hospital-level analysis of administrative data found that Australian and New Zealand HF inpatients had a 30-day all-cause mortality rate of 10.7% across 392 hospitals and a 30-day all-cause readmission rate of 22.3% across 391 hospitals. Additionally, readmission rates remained stable whilst an overall improvement in the mortality rates were seen over the study period. Chapter IV: Analysis of registry patients found a 30-day unplanned readmission rate of 11.8% and mortality rate of 0.7%. Moreover, the LACE index was a moderate predictor (Cstatistic= 0.62) of readmissions in this cohort and a score ≥10 indicated moderate discriminatory capacity to predict 30-day readmissions. The two variables with the best predictive variables were length of stay and admissions to the emergency department in the prior six months. Chapter V: The clinical study found an association between the quality of sleep in hospital and 30-day all-cause unplanned readmissions as measured by the Pittsburgh Sleep Quality Index. This study also found trends but no statistically significant association between any objective measure of sleep quantity and 30-day all-cause unplanned readmissions. Conclusions This thesis has contributed to the literature by determining the rate of readmission in HF patients, incorporating predictive models into medicine and exploring a hypothesised variable (disrupted sleep) in clinical practice to help reduce the burden of readmissions. It supports the importance of measuring 30-day all-cause unplanned readmissions as an objective, broad, generic measure of hospital care quality and safety, and promotes efforts to improve this outcome.
Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 2019

博士
國立臺灣大學
流行病學與預防醫學研究所
103
Sleep problems are commonly observed in mood disorder patients, the sleep profiles among subgroups (major depressive (MDD), bipolar disorder (BD) patients, their relatives, and controls) and the familiality of sleep problems in MDD and BD families have not been well known. Sleep disturbance is important because it impairs quality of life (QOL), contributes to relapse, and has adverse consequences. Moreover, less is known about the longitudinal time effect between sleep and mood change. Sleep disturbance has caused by abnormal circadian function in mood disorders. Several genes that are involved in the regulation of circadian rhythms implicated in the susceptibility to mood disorders and sleep related problems. This suggests a connection between proper mood regulation and a normal functioning circadian clock. While sleep disturbance and circadian dysregulation are critical pathophysiological elements in mood disorders, many questions about the sleep profiles and the mechanisms remain. The current study aimed to explore the role of sleep in clinical outcomes and genetic contribution in mood disorders. First, we compare the sleep disturbances among subgroups and evaluated familiality in MDD and BD families. We examined the associations of sleep quality and patients’ QOL and functional impairment. Second, we evaluated the time effects of sleep and mood, and whether poor sleepers predict poorer clinical outcomes at follow up period. Third, we investigated the relationships between genetic variants in circadian genes with BD and with sleep phenotypes in the Han Chinese population. We recruited around ~1300 participants, including around ~700 probands ( ~350 DSM-IV diagnosed BD-I, 150 BD-II, and 200 MDD), 618 relatives and 235 healthy controls were completed structural diagnostic interview, sleep measurements including Pittsburgh Sleep Quality Index (PSQI), and Mornigness－Eveningness scale (M/E scale); the severity of symptoms measurements including Beck Depression Inventory (BDI-II), and Young Mania Rating Scale (YMRS); and World Health Organization Quality of Life brief version (WHOQOL) questionnaires. Single nucleotide polymorphisms in the circadian genes were genotyped using Affymetrix Genome-Wide CHB Array. Familiality of components of sleep was evaluated using mixed regression models and intraclass correlation coefficients (ICC). The relation of sleep on symptom severity and impairments during the same interval longitudinally across the 6-month period was also examining by mixed regression models. Genetic association analyses were performed using PLINK software. Three-quarter of mood disorder patients divided to “poor sleepers”, and with worse QOL and more functional impairment (p<0.01) than good sleepers. MDD patients had significantly worse sleep quality than BD patients, whereas there was no difference between unaffected relatives and controls. Moderate familial aggregation observed in subjective sleep quality, sleep latency and disturbance. Sleep disturbances such as poor sleep quality and nightmares increased the risk for suicidal ideation and suicide attempts. After a six month follow up, the persistence rates of sleep disturbance were 77.8% and 82.60% in BD and MDD, respectively. Multivariate analyses in linear/logistic regression models revealed that sleep disturbances at baseline including global score and frequent nightmares were significantly increased the consequence of depression (OR=1.07-4.56), suicide ideation (OR= 1.25-3.35) and suicide plan (OR= 1.20-6.21). A longitudinal relationship was showed of global score with poor clinical outcomes expect mania during the follow up. Our data suggested the idea that chronotypes have an impact on depressive features, with higher severity of depressive and suicide ideation for the eveningness type. For genetic association analysis, there were five genes (ARNTL2, BHLHE41, CNR1, RORA, RORB) showed significant with BD. Our results support for the involvement of RORs family in the risk of developing BD. For sleep phenotypes, we found ARNTL, ARNTL2, CNR1, CRY1, CSNK1E, CSNK2A1, GSK3b, NPAS2, PER3, RORA, RORB, TIMELESS, TIPIN genes with positive associations. Due to the notable sleep problems in mood disorders and the patients with sleep disturbances heightened the risk of recurrence and suicidality was demonstrated in the study. The special sleep intervention in mood disorders is required in clinical settings. The genes in circadian pathway may be an important candidate. Further replication studies are needed to investigate the functional properties of the genes in studying the pathogenesis of mood disorders and sleep problems.

碩士
慈濟大學
公共衛生學系碩士班
104
Abstract Background: Pyrethroids and organophosphate insecticides are commonly used in residential environment. Previous studies revealed that organophosphate insecticides have negative effects on infant birth outcomes and neurobehavioral development, but few studies focused on pyrethroids. According to the report from National Sleep Foundation, 79% of the pregnant women has changes in sleeping habits. Furthermore, 25% of the pregnant women has sleep disturbance in second trimester; and the percentage increased to 75% in third trimester. There are studies investigating the associations between sleep disturbance and preterm birth and low birth weight, however, inconsistent results were reported. Therefore, the objective of this study is to explore the effects of residential insecticide exposure and sleep disturbance during pregnancy on birth outcomes. Materials and Methods: This study is a prospective birth cohort study initiated from October 2013 to June 2016. Pregnant women were recruited from the department of obstetrics and gynecology in a medical center in east Taiwan. In second trimester (25 weeks), we used a structural questionnaire to collect the information of insecticide using habits, types, formulations, and frequencies before and during pregnancy. Additionally, we used the Pittsburgh Sleep Quality Index to measure the sleep characteristics such as sleep duration and quality. The birth outcomes including birth weight, length, head circumference, and chest circumference were obtained from medical records. Independent t-test and chi-square test were used to analyze the associations between demographic variables and exposure variables. Multiple linear regressions were used to explore the synergic effects of residential insecticide exposure and sleep disturbance during pregnancy on birth outcomes with adjusted maternal age, parity, pre-pregnancy BMI, education, passive smoking and newborn sex. Besides, we applied land use survey data to calculate the percentage of the agriculture area in different buffer zones as the proxy of pesticides exposure. Results: We found residential mosquito coil use during pregnancy may decrease chest circumference 0.791± 0.414 cm (0.05