Sleep Apnea Syndromes: Quan SF

Kushida CA, Chediak A, Berry RB, Brown LK, Gozal D, Iber C, Parthasarathy S, Quan SF, Rowley JA, Anonymous00026, Anonymous00027. · Stanford University Center of Excellence for Sleep Disorders, 401 Quarry Road, Suite 3301, Stanford, CA 94305-5730, USA. · J Clin Sleep Med. · Pubmed #18468315 links to  free full text

Abstract: Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBDs), including obstructive sleep apnea (OSA). After a patient is diagnosed with OSA, the current standard of practice involves performing attended polysomnography (PSG), during which positive airway pressure is adjusted throughout the recording period to determine the optimal pressure for maintaining upper airway patency. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) represent the two forms of PAP that are manually titrated during PSG to determine the single fixed pressure of CPAP or the fixed inspiratory and expiratory positive airway pressures (IPAP and EPAP, respectively) of BPAP for subsequent nightly usage. A PAP Titration Task Force of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Task Force developed these recommendations for conducting CPAP and BPAP titrations. Major recommendations are as follows: (1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration. (2) CPAP (IPAP and/or EPAP for patients on BPAP) should be increased until the following obstructive respiratory events are eliminated (no specific order) or the recommended maximum CPAP (IPAP for patients on BPAP) is reached: apneas, hypopneas, respiratory effort-related arousals (RERAs), and snoring. (3) The recommended minimum starting CPAP should be 4 cm H2O for pediatric and adult patients, and the recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively, for pediatric and adult patients on BPAP. (4) The recommended maximum CPAP should be 15 cm H2O (or recommended maximum IPAP of 20 cm H2O if on BPAP) for patients < 12 years, and 20 cm H2O (or recommended maximum IPAP of 30 cm H2O if on BPAP) for patients > or = 12 years. (5) The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O (6) CPAP (IPAP and/or EPAP for patients on BPAP depending on the type of event) should be increased by at least 1 cm H2O with an interval no shorter than 5 min, with the goal of eliminating obstructive respiratory events. (7) CPAP (IPAP and EPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 obstructive apnea is observed for patients < 12 years, or if at least 2 obstructive apneas are observed for patients > or = 12 years. (8) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 hypopnea is observed for patients < 12 years, or if at least 3 hypopneas are observed for patients > or = 12 years. (9) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 3 RERAs are observed for patients < 12 years, or if at least 5 RERAs are observed for patients > or = 12 years. (10) CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 1 min of loud or unambiguous snoring is observed for patients < 12 years, or if at least 3 min of loud or unambiguous snoring are observed for patients > or = 12 years. (11) The titration algorithm for split-night CPAP or BPAP titration studies should be identical to that of full-night CPAP or BPAP titration studies, respectively. (12) If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP. (13) The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient's obstructive respiration by a low (preferably < 5 per hour) respiratory disturbance index (RDI) at the selected pressure, a minimum sea level SpO2 above 90% at the pressure, and with a leak within acceptable parameters at the pressure.) (14) An optimal titration reduces RDI < 5 for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings. (15) A good titration reduces RDI < or = 10 or by 50% if the baseline RDI < 15 and should include supine REM sleep that is not continually interrupted by spontaneous arousals or awakenings at the selected pressure. (16) An adequate titration does not reduce the RDI < or = 10 but reduces the RDI by 75% from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressure. (17) An unacceptable titration is one that does not meet any one of the above grades. (18) A repeat PAP titration study should be considered if the initial titration does not achieve a grade of optimal or good and, if it is a split-night PSG study, it fails to meet AASM criteria (i.e., titration duration should be > 3 hr).

Babar SI, Quan SF. · No affiliation provided · Arch Intern Med. · Pubmed #12622598 No free full text.

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Quan SF, Gillin JC. · No affiliation provided · Sleep. · Pubmed #10577171 No free full text.

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Budhiraja R, Parthasarathy S, Quan SF. · Division of Pulmonary and Critical Care, Department of Medicine, Southern Arizona Veterans Affairs Health Care System, Tucson, AZ 85723, USA. · J Clin Sleep Med. · Pubmed #17694731 links to  free full text

Abstract: Obstructive sleep apnea (OSA) is a common disorder and is associated with adverse cardiovascular consequences, including hypertension and coronary artery disease. While the mechanisms responsible for increased risk of cardiovascular events in OSA have not yet been fully elucidated, hypoxia, inflammation, obesity, metabolic dysregulation, and sympathetic activation, may contribute to these consequences. Endothelial dysfunction may be another link between OSA and cardiovascular disease. Dysfunctional endothelium is characterized by an imbalance in production of vasoactive hormones, increased adherence of inflammatory mediators to endothelial cells and hypercoagulability, and is a known risk factor for cardiovascular events. Studies have directly measured vascular endothelial function in patients with OSA and found a muted response compared to controls. Other studies have evaluated biochemical markers of endothelial function including circulating levels of vasoactive and thrombosis mediators and provide further proof of endothelial dysfunction in this disorder. A better appreciation of the role of the dysfunctional endothelium in OSA will help shed light on the pathogenesis of cardiovascular disease in this disorder and may lead to development of novel therapies aimed at preventing untoward outcomes.

Budhiraja R, Sharief I, Quan SF. · Division of Pulmonary & Critical Care, Southern Arizona Veterans Affairs Health Care System (SAVAHCS), Tucson, AZ 85723, USA. · J Clin Sleep Med. · Pubmed #17564410 No free full text.

Abstract: Sleep disordered breathing is frequently associated with repeated arousals and hypoxia resulting from intermittent partial or complete collapse of upper airway during sleep. There is an emerging recognition of the association of this disorder with metabolic abnormalities, coronary artery disease, congestive heart failure and hypertension. Of these conditions, the data associating obstructive sleep apnea and hypertension are the most compelling. This review evaluates the recent literature investigating this association and identifies areas where additional research is needed.

Redline S, Budhiraja R, Kapur V, Marcus CL, Mateika JH, Mehra R, Parthasarthy S, Somers VK, Strohl KP, Sulit LG, Gozal D, Wise MS, Quan SF. · Department of Pediatrics, Case Western Reserve University, Cleveland, OH, WA 44106-6033, USA. · J Clin Sleep Med. · Pubmed #17557426 No free full text.

Abstract: The American Academy of Sleep Medicine Task Force on Respiratory Scoring reviewed the evidence that addresses: the validity of specific sensors in detecting airflow, tidal volume, oxyhemoglobin saturation, and CO2; the reliability of specific scoring approaches for quantifying sleep related breathing disorders (SRBD); and the validity of using various definitions of the apnea hypopnea index (AHI) as assessed by the strength and consistency of associations with several comorbidities (hypertension, cardiovascular disease, sleepiness, impaired quality of life, and accidents). The evidence was based on a literature search of relevant articles published through December 2004, which resulted in identifying and extracting data from 182 articles, which were graded using standardized approaches. Diverse physiological sensors have been utilized to quantify airflow limitation in patients with suspected SRBD. Although thermistry appears appropriate for identifying apneas, the available evidence did not indicate it provides valid quantification of airflow reduction. The emerging evidence evaluating the accuracy of signal detection against the gold standard measurements (e.g., pneumotachography) suggested the superiority of inductance plethysmography and nasal pressure transducers for detection of hypopneas, with some evidence that recordings from a nasal pressure transducer may better approximate flow/volume than uncalibrated inductance plethysmography. However, since the nasal pressure transducer has only recently been incorporated into large-scale studies, there are as of yet few data that address the predictive value of transducer-identified events relative to clinical or physiological outcomes. Very few studies directly compared the validity of alternative approaches for defining the duration, amplitude change, and use of corroborative data from desaturation or arousal for defining hypopneas. Many observational studies utilizing various designs and approaches for event detection have shown significant associations between measures of SRBD and health outcomes. Data from the 2 largest sleep cohort studies, the Sleep Heart Health Study and the Wisconsin Sleep Cohort, both used definitions of hypopneas based on "discernible" reductions of inductance plethysmography signals with associated desaturation and showed that the derived AHIs using these hypopnea definitions correlated with various indices of morbidity. However, it is not clear whether alternative definitions would provide comparable if not better prediction, or whether optimal approaches for event identification would vary for different outcomes. Despite these limitations, forming a consensus on optimal approaches for recording and measuring respiratory events is an important step toward generating data from different clinical or research laboratories that can be compared. However, additional research is needed, including direct comparisons of alternative measuring approaches for predicting clinical outcomes, with a need to address these issues in large samples across the age spectrum and with inclusion of promising new technology.

Baldwin CM, Bootzin RR, Schwenke DC, Quan SF. · College of Nursing, Arizona State University Southwest Borderlands, P.O. Box 872602, Tempe, AZ 85287-2602, USA. · Sleep Med Rev. · Pubmed #16242980 No free full text.

Abstract: Cognitive deficits and cardiovascular disease (CVD) are comorbid conditions frequently associated with obstructive sleep apnea (OSA). Oxygen free radical release and its differential regulation of cytokine synthesis and immune modulation resulting from OSA-related hypoxic events have been hypothesized as the underlying mechanism(s) for the cognitive deficits and CVD in OSA. A number of studies have suggested that increased levels of oxidative stress and/or antioxidant deficiencies may also be risk factors in cognitive decline and CVD. The influence of antioxidant nutrients and supplements, such as Vitamins B6, B12, C, E, folic acid, alpha-lipoic acid and Coenzyme Q(10) on cognitive decline and CVD have been investigated. The influence of antioxidant nutrients or supplements on OSA remains to be investigated. Even if dietary or supplemental antioxidants do not prove to be effective therapies for OSA, dietary assessment and prescription to increase dietary intake of neuro- and cardio-protective nutrients may make it possible to reduce some of the cognitive and cardiovascular sequelae associated with OSA.

Budhiraja R, Quan SF. · Division of Pulmonary and Critical Care, Southern Arizona Veterans Affairs Health Care System, University of Arizona College of Medicine, Tucson, Arizona 85723, USA. · Curr Opin Pulm Med. · Pubmed #16217175 No free full text.

Abstract: PURPOSE OF REVIEW: Sleep-disordered breathing is a widely prevalent condition and may have serious medical, social, and economic consequences. This review evaluates the role of sleep-disordered breathing in cardiovascular morbidity and mortality on the basis of recent literature. RECENT FINDINGS: Epidemiologic studies, retrospective reviews, and prospective clinical trials suggest a strong association between sleep-disordered breathing and adverse cardiovascular events. Individuals with sleep-disordered breathing have a higher prevalence of hypertension, which attenuates with treatment. Furthermore, the presence of sleep-disordered breathing augurs an increased risk of coronary artery disease, cardiac arrhythmias, and heart failure. SUMMARY: Recent research provides an emerging evidence of the role of sleep-disordered breathing as a risk factor for diverse cardiovascular disorders.

Stephen GA, Eichling PS, Quan SF. · Department of Medicine, Arizona Respiratory and Sleep Disorders Centers, University of Arizona College of Medicine, Tucson, AZ, USA. · Minerva Med. · Pubmed #15334045 links to  free full text

Abstract: The management of sleep disordered breathing (SDB) and obstructive sleep apnea (OSA) in adults can be challenging. Treatment recommendations are based on a number of factors including the severity of SDB, the existence and extent of comorbid conditions, the severity of presenting symptoms and patient preference. General management includes addressing lifestyle issues, particularly weight loss and the avoidance of sedatives. The primary specific treatment modality for SDB is continuous positive airway pressure (CPAP). However, for selected patients that cannot accept this therapy, other modalities such as upper airway surgery and oral appliances should be considered.

Baldwin CM, Quan SF. · Arizona Respiratory Center, 1501 North Campbell Avenue, Tucson, AZ 85724-5030, USA. · Nurs Clin North Am. · Pubmed #12587365 No free full text.

Abstract: Cause and effect relationships between sleep disordered breathing (SDB) and illness, poorer quality of life, and public health have been largely overlooked and undertreated by healthcare providers. Obstructive sleep apnea (OSA), central sleep apnea, upper airway resistance syndrome, and obesity hypoventilation are the primary syndromes that fall under the rubric of SDB. Each of these syndromes is defined; however, OSA is the most common form of SDB, and is the focus of this article. Epidemiology, pathophysiology, behavioral manifestations, cardiovascular comorbidity, clinical evaluation, and treatment for OSA are the main topics covered. The article concludes with the role of the nurse in SDB.

Iber C, Redline S, Kaplan Gilpin AM, Quan SF, Zhang L, Gottlieb DJ, Rapoport D, Resnick HE, Sanders M, Smith P. · Department of Medicine, University of Minnesota, Minneapolis, MN, USA. · Sleep. · Pubmed #15164911 No free full text.

Abstract: STUDY OBJECTIVE: To compare polysomnographic recordings obtained in the home and laboratory setting. DESIGN AND SETTING: Multicenter study comparing unsupervised polysomnography performed in the participant's home with polysomnography supervised at an academic sleep disorders center, using a randomized sequence of study setting. Sleep Heart Health Study (SHHS) standardized polysomnographic recording and scoring techniques were used for both settings. PARTICIPANTS: 64 of 76 non-SHHS participants recruited from 7 SHHS field sites who had both a laboratory and home polysomnogram meeting acceptable quality criteria. MEASUREMENTS AND RESULTS: Median sleep duration was greater in the home than in the laboratory (375 vs 318 minutes, respectively, P < .0001) as was sleep efficiency (86% vs 82%, respectively, P < .0024). Very small, but significant increases in percentage of rapid eye movement sleep and decreases in stage 1 sleep were noted in the laboratory. Employing multiple definitions of respiratory disturbance index (RDI), median RDI was similar in both settings (for example, RDI with 3% desaturation: home 12.4, range 0.6-67; laboratory 9.5, range 0.1-93.4, P = .41). Quartile analysis of laboratory RDI showed moderate agreement with home RDI measurements. Based on the mean of laboratory and home RDI and using a cutpoint of 20, there was a biphasic distribution, with the RDI 3% above 20 being more common in the recordings performed in the laboratory than in the home and below 20 being more common in the recordings performed in the home than in the laboratory. These differences could not be attributed to quality of recording, age, sex, or body mass index. CONCLUSIONS: Using SHHS methodology, median RDI was similar in the unattended home and attended laboratory setting with differences of small magnitude in some sleep parameters. Differences in RDI between settings resulted in a rate of disease misclassification that is similar to repeated studies in the same setting.

Lind BK, Goodwin JL, Hill JG, Ali T, Redline S, Quan SF. · Center for Health Policy and Research, College of Health Sciences, Boise State University, Boise, Idaho, USA. · Sleep Breath. · Pubmed #12712393 No free full text.

Abstract: The Sleep Heart Health Study (SHHS) is a prospective cohort study using participants from several ongoing cardiovascular and respiratory disease research projects to investigate the relationship between sleep-disordered breathing and cardiovascular disease. This study design required unusual and different recruiting techniques to meet the study's enrollment goal of between 6000 and 6600 participants. Individuals were recruited to undergo an overnight home polysomnogram, completion of several questionnaires, and collection of a small amount of physical examination data. This article describes the methods used to recruit these participants and how these procedures influenced the final participation rate and the representativeness of SHHS to its parent cohorts. Of 30,773 people eligible for recruitment into SHHS, attempts were made to enroll 11,145 (36%). Of those contacted, 6441 ultimately agreed to participate (58%). Recruitment rates (38 to 91%) varied among sites. SHHS participants were slightly younger (63.0 vs. 65.0 years, p < 0.001), had more years of education (14.1 vs. 13.7, p < 0.001), more likely to snore (34% vs. 23%, p < 0.001), had higher Epworth sleepiness scores (7.7 vs. 6.5, p < 0.001), slightly higher higher systolic and diastolic blood pressures (127.6/73.9 vs. 127.2/72.1, p < 0.001 for diastolic only), and a slightly higher body mass index (BMI) (28.5 vs. 27.5, p < 0.001). We conclude that it is feasible to recruit existing participants from one large-scale epidemiologic study into another with a high degree of success. However, the characteristics of the new cohort may vary in several respects from their original cohorts and therefore interpretation of study results will have to consider these differences.

Quan SF, Griswold ME, Iber C, Nieto FJ, Rapoport DM, Redline S, Sanders M, Young T, Anonymous00002. · Arizona Respiratory Center and Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA. · Sleep. · Pubmed #12489889 No free full text.

Abstract: STUDY OBJECTIVES: To determine the short-term variability of indices of disturbed respiration and sleep during 2 nights of unattended nonlaboratory polysomnography conducted several months apart. DESIGN: Participants were randomly selected using a block design with stratification on preliminary estimates of 2 criteria: respiratory disturbance index [RDI3% (apnea or hypopnea events associated with > or = 3% O2 desaturation): < 15/hour total sleep time, > or = 15/hour total sleep time] and sleep efficiency (SEff: < 85% and > or = 85%). The RDI and sleep data from initial and repeated polysomnography were compared. SETTING: NA. PARTICIPANTS: A subset of 99 participants in the Sleep Heart Health Study who agreed to have a repeat polysomnogram within 4 months of their original study. INTERVENTIONS: NA. MEASUREMENTS AND RESULTS: Acceptable repeat polysomnograms were obtained in 91 subjects (mean study interval: 77 +/- 18 [sd] days; range: 31-112 days). There was no significant bias in RDI between study nights using several different RDI definitions including RDI3% and RDI4% (apnea or hypopnea events associated with > or = 4% O2 desaturation). Variability between studies estimated using intraclass correlations (ICC) ranged from 0.77 to 0.81. For subjects with a RDI3% < 15, variability increased as a function of increasing RDI, but for those with a RDI3% > or = 15, variability was constant. Body mass index, SEff, gender, or age did not directly predict RDI variability. Using RDI4% cutpoints of < or = 5, < or = 10 and < or = 15 events per hour of sleep demonstrated that 79.1%, 85.7%, and 87.9% of subjects, respectively, had the same classification of SDB status on both nights of study. There also was no significant bias in sleep staging, sleep efficiency, or arousal index between studies. However, variability was greater with ICC values ranging from 0.37 (% time in REM) to 0.76 (arousal index). CONCLUSION: In the Sleep Heart Health Study, accurate estimates of the severity of sleep-disordered breathing and the quality of sleep were obtained from a single night of unattended nonlaboratory polysomnography. These findings may be applicable to other large epidemiologic studies provided that similar recording techniques and quality-assurance procedures are followed.

O'Connor GT, Caffo B, Newman AB, Quan SF, Rapoport DM, Redline S, Resnick HE, Samet J, Shahar E. · Pulmonary Center, Boston University School of Medicine, 715 Albany St., Boston, MA 02118, USA. · Am J Respir Crit Care Med. · Pubmed #19264976 No free full text.

Abstract: RATIONALE: Cross-sectional epidemiologic studies show an association between sleep-disordered breathing and hypertension, but only one cohort study has examined sleep-disordered breathing as a risk factor for incident hypertension. OBJECTIVES: To examine whether sleep-disordered breathing increases the risk of incident hypertension among persons 40 years of age and older. METHODS: In a prospective cohort study, we analyzed data from 2,470 participants who at baseline did not have hypertension, defined as blood pressure of at least 140/90 mm Hg or taking antihypertensive medication. The apnea-hypopnea index (AHI), the number of apneas plus hypopneas per hour of sleep, was measured by overnight in-home polysomnography. We estimated odds ratios for developing hypertension during 5 years of follow-up according to baseline AHI. MEASUREMENTS AND MAIN RESULTS: The odds ratios for incident hypertension increased with increasing baseline AHI; however, this relationship was attenuated and not statistically significant after adjustment for baseline body-mass index. Although not statistically significant, the observed association between a baseline AHI greater than 30 and future hypertension (odds ratio, 1.51; 95% confidence interval, 0.93-2.47) does not exclude the possibility of a modest association. CONCLUSIONS: Among middle-aged and older persons without hypertension, much of the relationship between AHI and risk of incident hypertension was accounted for by obesity. After adjustment for body mass index, the AHI was not a significant predictor of future hypertension, although a modest influence of an AHI greater than 30 on hypertension could not be excluded.

Sharief I, Silva GE, Goodwin JL, Quan SF. · Department of Medicine, University of Arizona, Tucson, AZ, USA. · Sleep. · Pubmed #18853943 links to  free full text

Abstract: OBJECTIVE: To study the sleep quality of bed partners of persons with sleep disordered breathing in a non-clinical population based sample in a home environment. DESIGN: Cross-sectional study in a community sample. METHODS: 110 pairs of subjects living in the same household from the Tucson, Minnesota, and Pittsburgh sites of the Sleep Heart Health Study (SHHS) were included if both partners had an in-home, unattended polysomnogram (PSG) performed as a part of SHHS exam cycle 2. Sleep disordered breathing (SDB) was considered present if the respiratory disturbance index (RDI) was > or =10 events/h and no SDB if RDI was <5 events/h. Pairs were classified according to their SDB status and assigned to one of 3 groups: 1) NoSDB-NoSDB (n = 46), 2) NoSDB-SDB (n = 42), and 3) SDB-SDB (n = 22). RESULTS: There were no differences between the NoSDB-NoSDB and the SDB-SDB partners in their demographic, PSG, or quality of life variables. However, within the NoSDB-SDB group, NoSDB in comparison to their SDB partners weighed less (mean BMI: 26 vs. 29 kg/m2, P < 0.0003), had decreased stage 2% (55 vs. 64, P < 0.0001), increased stage 3 and 4% (21 vs. 11, P <0.0005) and a lower arousal index (13.8 vs. 20 events/h, P < 0.0001). When comparing the NoSDB subjects from the NoSDB-SDB group to subjects in the NoSDB-NoSDB group and to subjects in the SDB-SDB group, significant differences were seen for RDI and BMI but not for any other parameter. CONCLUSION: In a non-clinical population based sample, the sleep quality of bed partners of SDB subjects without SDB is better than their SDB bed partner. However, their sleep quality was not different in comparison to the sleep of those without SDB who also had a bed partner without SDB.

Vasquez MM, Goodwin JL, Drescher AA, Smith TW, Quan SF. · Sleep and Arizona Respiratory Centers, University of Arizona College of Medicine, Tucson, AZ, USA. · J Clin Sleep Med. · Pubmed #18853696 links to  free full text

Abstract: The purpose of this study was to examine whether dietary habits and physical activity patterns were independently associated with severity of sleep disordered breathing (SDB) in adults diagnosed with obstructive sleep apnea. Data collected from 320 adults participating in an ancillary study of The Apnea Positive Pressure Long-term Efficacy Study were analyzed as a cross-sectional assessment at study baseline. The respiratory disturbance index (RDI) was used as a measure of the severity of sleep disordered breathing. Separate linear regression models were fitted using RDI as the independent variable and various preselected components of dietary intake and physical activity as the dependent variables. The results indicated that even after adjusting for BMI, age, and daytime sleepiness, subjects with very severe and extremely severe SDB (RDI > or =50) consumed a diet that was higher in cholesterol, protein, total fat, and total saturated fatty acids. These findings were most evident among women. For all participants, those with RDI > or =50 in comparison to those <50, on average consumed 88.16 more mg of cholesterol per day (95% CI: 44.45 to 131.86, p < 0.001). Among the women participants only, those with RDI > or =50 in comparison to those <50, on average consumed 21.96 more grams of protein (95% CI: 2.64 to 41.29, p = 0.026), 27.75 more grams of total fat (95% CI: 3.38 to 52.11, p = 0.026), and 9.24 more grams of saturated fatty acids (95% CI: 0.67 to 17.80, p = 0.035). Furthermore, those with an RDI > or =50 had a 224.58 greater caloric expenditure than those with RDI <50 from all activities including work and sleep (95% CI: 40.98 to 408.18, p = 0.017). Although significant results were seen in a reduction of physical activity from recreational activities, this finding was explained by the increase in BMI associated with higher levels of RDI.

Quan SF, Budhiraja R, Parthasarathy S. · Division of Sleep Medicine, Harvard Medical School, Boston, MA 02215, USA. · J Clin Sleep Med. · Pubmed #18595432 links to  free full text

This publication has no abstract.

Dickman R, Green C, Fass SS, Quan SF, Dekel R, Risner-Adler S, Fass R. · Neuro-Enteric Clinical Research Group, Section of Gastroenterology, Southern Arizona VA Health Care System, Tucson, AZ 85723-0001, USA. · J Clin Sleep Med. · Pubmed #17803014 links to  free full text

Abstract: BACKGROUND: Nighttime reflux has been shown to be associated with esophageal mucosal injury, complications, and extra-esophageal manifestations. However, few studies have assessed the impact of gastroesophageal reflux on reported quality of sleep and quality of sleep on gastroesophageal reflux. AIMS: The aims of this study were (1) to determine the correlation between the severity of gastroesophageal reflux disease (GERD) symptoms and esophageal acid contact time and subjects' perceived quality of sleep; (2) to investigate the correlation between reported quality of sleep of the night prior and severity of GERD symptoms and esophageal acid contact time the following day; and (3) to define in a sleep laboratory the correlation between acid reflux events and sleep architecture. METHODS: Subjects with typical GERD symptoms > or =3 times a week underwent upper endoscopy and pH monitoring. These subjects subsequently completed the GERD Symptom Assessment Score (GSAS), and the Sleep Heart Health Study Sleep Habits (SHHS) Questionnaire to assess baseline sleep symptoms and GERD symptoms, including an index of GERD symptom severity (GERD symptom index). Before and after the pH test, the patients completed a different instrument, the Sleep Quality Questionnaire, utilized specifically to assess the quality of each subject's sleep before and after pH testing. Fifteen randomly selected subjects also underwent a polysomnographic study during the pH test. RESULTS: Forty-eight (33 males/15 females, mean age 48.8 +/- 17.1 y) subjects were prospectively recruited. Using data from the GSAS and SHHS questionnaires, disorders of initiating and maintaining sleep were found to be positively associated with greater severity of the GERD symptom index (r = 0.33, p <0.05). More frequent awakenings also correlated with a higher GERD symptom index (r = 0.4, p <0.01). Correlations between the Sleep Quality Questionnaire on the night before sleep testing and pH monitoring data showed that subjects with poorer sleep quality had longer acid reflux events (r=-0.34, p<0.05). More perceived awakenings also were correlated with the number of supine acid reflux events > 5 min (r=0.31, p<0.05) and the duration of the longest supine acid reflux event (r = 0.28, p = 0.05). Inverse correlations were observed between overall sleep quality on the pH testing night and a higher percentage of time spent with pH<4 supine (r=-0.432, p <0.002), and the duration of the longest acid reflux event during the entire night (r = -0.38, p <0.01) and supine (r=-0.37, p<0.02). CONCLUSIONS: Persons with worse GERD symptoms report poorer subject sleep quality. Poor sleep quality on the night prior to pH testing was associated with more acid exposure the following day. Greater acid exposure at night was related to a worse perception of sleep quality the next day. These findings suggest important interactions between GERD and sleep quality.

Kushida CA, Nichols DA, Quan SF, Goodwin JL, White DP, Gottlieb DJ, Walsh JK, Schweitzer PK, Guilleminault C, Simon RD, Leary EB, Hyde PR, Holmes TH, Bloch DA, Green S, McEvoy LK, Gevins A, Dement WC. · Stanford Universit)y, Stanfbrd, CA, USA. · J Clin Sleep Med. · Pubmed #17561541 No free full text.

Abstract: STUDY OBJECTIVE: To assess the size, time course, and durability of the effects of long-term continuous positive airway pressure (CPAP) therapy on neurocognitive function, mood, sleepiness, and quality of life in patients with obstructive sleep apnea. DESIGN: Randomized, double-blinded, 2-arm, sham-controlled, multicenter, long-term, intention-to-treat trial of CPAP therapy. SETTING: Sleep clinics and laboratories at 5 university medical centers and community-based hospitals. Patients or Participants: Target enrollment is 1100 randomly assigned subjects across 5 clinical centers. INTERVENTIONS: Active versus sham (subtherapeutic) CPAP. Measurements and Results: A battery of conventional and novel tests designed to evaluate neurocognitive function, mood, sleepiness, and quality of life. CONCLUSIONS: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) is designed to study obstructive sleep apnea and test the effects of CPAP through a comprehensive, controlled, and long-term trial in a large sample of subjects with obstructive sleep apnea.

Parthasarathy S, Haynes PL, Budhiraja R, Habib MP, Quan SF. · Southern Arizona Veterans Administration Health Care System, Tucson, AZ 85723, USA. · J Clin Sleep Med. · Pubmed #17557485 No free full text.

Abstract: STUDY OBJECTIVES: To study the effect of American Academy of Sleep Medicine accreditation of sleep centers and sleep-medicine certification of physicians on the management of patients with obstructive sleep apnea (OSA). DESIGN: Cross-sectional study. SETTING: National web-based survey. PATIENTS: Six hundred thirty-two patients with OSA. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Self-reported data on details of whether patients with OSA were using positive airway pressure (PAP) devices, timeliness of the initiation of PAP therapy, and overall satisfaction of care received from physicians and centers. After adjusting for covariates, lack of accreditation or certification status of providers was independently associated with discontinuation of PAP therapy (odds ratio [OR] 1.9, 95% confidence interval [CI], 1.1-3.2; p = .03). Patient education leading to perception of risk associated with OSA (OR 0.5, 95% CI, 0.2-0.9) and medications for nasal congestion (OR 0.3, 95% CI, 0.1-0.8) "protected" against discontinuation of PAP therapy, whereas nasal congestion (OR 1.6, 95% Cl, 1.0-2.4) increased the likelihood for discontinuation of PAP therapy. Certified physicians and accredited centers were more likely to educate their patients and received greater satisfaction ratings than non-certified physicians and nonaccredited centers (p < .05). Time delays in instituting PAP therapy were not influenced by accreditation or certification status, but such delays diminished patient satisfaction. CONCLUSIONS: In this web-based survey, accreditation or certification status of sleep centers and physicians was associated with better indexes of clinical management in patients with OSA. Better patient education that fostered risk perception may have been partly responsible for such an association. Prospective studies designed to collect objective data regarding the effect of accreditation or certification status on outcomes in patients with OSA are still needed.

Venker CC, Goodwin JL, Roe DJ, Kaemingk KL, Mulvaney S, Quan SF. · College of Public Health, University of Arizona, Tucson, AZ 85724, USA. · Sleep Breath. · Pubmed #17333098 No free full text.

Abstract: Although the psychomotor vigilance task (PVT) is commonly used in sleep and other research settings, normative data for PVT performance in children have not been published. This report presents normal PVT performance measures among children without a sleep disorder participating in the Tucson Children's Assessment of Sleep Apnea (TuCASA) study. TuCASA is a community-based, prospective study of sleep-disordered breathing in Caucasian and Hispanic children ages 6 to 11 years. A standard 10-min PVT trial was completed by 360 participants-48% female and 36% Hispanic; mean age 8.9 years. Detailed analyses were performed for 162 children with respiratory disturbance indices <1 and no parent-reported sleep problems. Mean and median reaction times (RT) decreased with increasing age (p trend < 0.001). Children ages 6 and 11 had median RTs of 544.24 and 325.70 ms, respectively. Standard deviations in RTs also decreased with increasing age (p trend = 0.001), as did lapses (p trend < 0.001), but no trend was apparent in total errors. There were statistically significant (p = 0.006) differences in the performance of boys and girls. Gender differences were greatest at age 6, where boys had shorter RTs, and decreased with age until performance was approximately equal by age 11. No ethnic differences were detected. Children's PVT performance improves with age and differs by gender. These differences should be considered when the PVT is utilized in pediatric populations.

Quan SF, O'Connor GT, Quan JS, Redline S, Resnick HE, Shahar E, Siscovick D, Sherrill DL. · Arizona Respiratory Center, University of Arizona Health Sciences Center, 1501 N. Campbell, Tucson, AZ 85724, USA. · Sleep Breath. · Pubmed #17221274 No free full text.

Abstract: This study was performed to determine whether there is a protective association between participation in vigorous or vigorous/moderately vigorous physical activity and the prevalence of sleep-disordered breathing (SDB). Polysomnographic and questionnaire data from the baseline examination of 4,275 participants in the Sleep Heart Health Study (SHHS) were analyzed in relation to information on amount of physical activity and other potentially relevant factors collected from five SHHS parent cohorts (Atherosclerosis Risk in Communities Study, Cardiovascular Health Study, Framingham Heart Study, Strong Heart Study, and Tucson Epidemiologic Study of Airways Obstructive Diseases). Logistic regression models were fitted to determine if amount and strenuousness of physical activity was associated with the presence of SDB. At least 3 h per week of vigorous physical activity reduced the odds of SDB, defined as a respiratory disturbance index (RDI) of at least 15 apneas/hypopneas per hour (Adjusted OR, 0.68; 95%CI, 0.51-0.91). A qualitatively similar but slightly weaker association was observed when SDB was defined as a RDI > or = 10 per hour (Adjusted OR, 0.81; 95%CI, 0.64-1.02). These findings remained after adjustment for sleepiness and restricting analyses to participants with good health. Three or more hours of moderately vigorous or vigorous physical activity also appeared to confer some protection against SDB, but these associations were weaker. Gender- and obesity-stratified analyses suggested that the protective association between physical activity and SDB occurred primarily in men and those who were obese. A program of regular vigorous physical activity of at least 3 h per week may be a useful adjunctive treatment modality for SDB, but this association needs confirmation with a prospective clinical trial.

Mulvaney SA, Kaemingk KL, Goodwin JL, Quan SF. · School of Nursing and Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA. · BMC Pediatr. · Pubmed #17169161 links to  free full text

Abstract: BACKGROUND: Researchers and clinicians are seeking to develop efficacious behavioral interventions to treat overweight children; however, few studies have documented the behavioral correlates of overweight children in community samples. The goal of this study was to determine the nature and prevalence of behavior problems for overweight school-aged children versus normal weight peers before and after controlling for the effect of sleep disordered breathing. METHODS: Hispanic and Caucasian children were invited to participate in a study of sleep through public elementary school classrooms. Anthropometric evaluation and behavioral ratings were collected for 402 children aged 6-11 years. Overweight was calculated using the Centers for Disease Control age- and gender-specific guidelines. Children were classified as overweight if they were at or above the 95th percentile for their age and gender group. Behavior problems were measured using the Conners' Parent Rating Scales-Revised and the Child Behavior Checklist. Sleep disordered breathing was assessed using in-home overnight polysomnography. RESULTS: Approximately 15% (59/402) of the sample was classified as overweight. Simple odds ratios indicated that overweight children were more likely to have clinically relevant levels of internalizing symptoms (OR 2.23, CI 1.05-4.72), psychosomatic complaints (OR 2.15, CI 1.02-4.54), withdrawal (OR 4.69, CI 2.05-10.73), and social problems (3.18, 1.53-6.60). When odds ratios were adjusted for level of sleep disordered breathing, withdrawal (OR 3.83 CI 1.59-9.22) and social problems (OR 2.49 CI 1.14-5.44) remained significantly higher for overweight subjects. CONCLUSION: After controlling for the effect of sleep disordered breathing, behaviors such as withdrawal and social problems, are common in overweight children and need to be taken into account in the design of interventions and services as they may act to moderate the efficacy of behavioral treatments.

Goodwin JL, Silva GE, Kaemingk KL, Sherrill DL, Morgan WJ, Quan SF. · Arizona Respiratory Center, College of Medicine, University of Arizona, Box 245030, 1501 N. Campbell, Room 2329, Tucson, AZ 85724, USA. · Sleep Breath. · Pubmed #17165092 No free full text.

Abstract: Research comparing parental report of sleep times to objectively obtained polysomnographic evidence of sleep times in schoolchildren is lacking. This report compares habitual sleep time and objectively recorded sleep time and sleep latency with parental reports of sleep time immediately after a night of polysomnography in elementary schoolchildren. Unattended home polysomnograms (PSG) were obtained from 480 children. On the night of the PSG, a parent was asked to complete a Sleep Habits Questionnaire, which inquired about the habitual total sleep time (HABTST) and habitual sleep onset latency (HABSOL) of his/her child on both school days and nonschool days. On the morning after the PSG, the parent was asked to estimate the total sleep time (ESTTST) and sleep onset latency (ESTSOL) of his/her child on the night of the recording. Comparisons were made to actual total sleep time (PSGTST) and sleep latency (PSGSOL) on the PSG. The sample was comprised of 50% girls, 42.3% Hispanic, and 53% aged 6-8 years. The mean HABTST, ESTTST, and PSGTST were 578, 547, and 480 min, respectively. HABTST was greater than both ESTST and PSGTST (p < 0.001). Moreover, ESTTST was greater than PSGTST (p < 0.001). The mean HABSOL, ESTSOL, and PSGSOL were 15, 17, and 11 min. ESTSOL was longer than PSGSOL (p < 0.001). There were no gender differences. However, Hispanic parents reported significantly less HABTST in their children than Caucasian parents (566 vs 587 min, p < 0.001). Parents of schoolchildren in this population-based sample substantially overestimated their children's actual total sleep time and sleep onset latency.

Quan SF, Wright R, Baldwin CM, Kaemingk KL, Goodwin JL, Kuo TF, Kaszniak A, Boland LL, Caccappolo E, Bootzin RR. · Department of Medicine, Arizona Respiratory, Sleep Disorders and General Clinical Research Centers, University of Arizona College of Medicine, 1501 North Campbell, Room 2305 Tucson, AZ 85724, USA. · Sleep Med. · Pubmed #16815753 No free full text.

Abstract: BACKGROUND AND PURPOSE: Obstructive sleep apnea-hypopnea (OSAH) is associated with sleep fragmentation and nocturnal hypoxemia. In clinical samples, patients with OSAH frequently are found to have deficits in neuropsychological function. However, the nature and severity of these abnormalities in non-clinical populations is less well defined. PATIENTS AND METHODS: One hundred and forty-one participants from the Tucson, AZ and New York, NY field centers of the Sleep Heart Health Study completed a battery of neuropsychological tests for 9-40 months (mean=24 months, SD=7 months) after an unattended home polysomnogram. Sixty-seven participants had OSAH (AHI>10) and 74 did not have OSAH (control (CTL), apnea-hypopnea index (AHI)<5). In addition to the individual tests, composite variables representing attention, executive function, MotorSpeed and processing speed were constructed from the neuropsychological test battery. RESULTS: There were no significant differences in any individual neuropsychological test or composite variable between the OSAH and CTL groups. However, when time spent with O(2) saturations less than 85% was dichotomized into those participants in the top quartile of the distribution and those in the lower three quartiles, motor speed was significantly impaired in those who were more hypoxemic. In addition, poorer motor speed (model adjusted R(2)=0.242, P<0.001) and processing speed performance (model adjusted R(2)=0.122, P<0.001) were associated with more severe oxygen desaturation even after controlling for degree of daytime sleepiness, age, gender and educational level. CONCLUSIONS: Mild to moderate OSAH has little impact on the selected measures of attention, executive function, motor speed and processing speed. However, hypoxemia adversely affects both motor and processing speed. These results suggest that in middle-aged to elderly adults the neuropsychological effects of clinically unrecognized mild to moderate OSAH are neither global nor large.