By Alan Z. Segal, MD
Associate Professor of Clinical Neurology, Weill Cornell Medical College
Dr. Segal reports no financial relationships relevant to this field of study.
SOURCE: Jara SM, Hopp ML, Weaver EM. Association of continuous positive airway pressure treatment with sexual quality of life in patients with sleep apnea: Follow-up study of a randomized clinical trial. JAMA Otolaryngol Head Neck Surg 2018;144:587-593.
When faced with the possibility of continuous positive airway treatment (CPAP) therapy for obstructive sleep apnea (OSA), patients commonly balk, especially if they fear that this potentially unromantic therapy will affect their sex life adversely. This report from Jara et al suggests otherwise. Data were derived from a 25-point Snore Outcome Scale (SOS), which included two sex-related options: “Because of medical problem, unable to have sexual relations” and “Lack of desire for sexual relations.” This was scored on a 0-5 scale (with 5 being worst). Specifics regarding sexual function were limited, as data were derived from only these two points on a general scale (the SOS-25) rather than a predetermined sex-specific questionnaire. The cohort included 182 participants (63% men) with severe OSA. There was a significant improvement in SOS score of -0.7 among CPAP users compared with -0.1 among nonusers. This effect persisted in a multivariate analysis. However, in a specific subgroup analysis using only gender, the benefit was restricted to women. There was a 1.3-point improvement in women (95% confidence interval [CI], 0.5-2.18), but only a 0.16-point difference in men (95% CI, -0.26 to 0.58). The authors did not provide any theories to explain this sex difference.
COMMENTARY
Among men using CPAP, prior noncontrolled case series have suggested an improvement in sexual function, although primarily among subjects who reported prior sexual difficulties. Although hormonal effects have been implicated in OSA, it never has been confirmed that low testosterone is a consequence of sleep-disordered breathing or that testosterone can rise with the use of CPAP. However, factors that clearly can improve with CPAP, such as weight gain and poor sleep quality, have shown a definite relationship to testosterone levels.
Among women, other studies have contradicted this study, failing to show improvements in sexual function or distress with CPAP use. Taking a more granular approach than merely two questions from the SOS-25, other studies used detailed female-specific scales of sexual function, distress, and overall satisfaction.
SOURCE: Braley TJ, Huber AK, Segal BM, et al. A randomized, subject and rater-blinded, placebo-controlled trial of dimethyl fumarate for obstructive sleep apnea. Sleep 2018;41. doi: 10.1093/sleep/zsy109.
Inflammation may be both a downstream effect of OSA as well as a contributor to OSA severity. Proinflammatory cytokines are elevated in the serum of patients with OSA, a process that specifically may be driven by the nuclear transcription factor NFκB. Furthermore, inflammation repeatedly has been implicated as a driving factor in the consequences of OSA, such as cardiovascular disease and stroke. Previous studies of OSA in patients with rheumatological disease have shown than biologics such as the TNF-inhibitor etanercept (Enbrel) may ameliorate OSA. Braley et al randomized patients to the multiple sclerosis (MS) drug dimethyl fumarate (DMF; Tecfidera). Previous observational studies among MS patients with OSA had shown improvements in respiratory status among those treated with DMF compared with matched MS patients who were not on immunomodulatory therapy. In this study of neurologically normal patients, 50 subjects were randomized to DMF (n = 35) or placebo (n = 15), in a planned 2:1 ratio. All of the patients either were unwilling or unable to use CPAP and had moderate to severe OSA (apnea hypopnea index on average of 27 events per hour). There was an improvement in the hypopnea index of 3.1 among treated patients, compared with a 10-point worsening in the placebo group (absolute difference = 13.1; P = 0.033). There were favorable trends, but no significant effect of DMF on cytokine levels (TNF, IL-10, IL-13) and no specific relationship between cytokines and clinical outcomes. In an interesting exploratory analysis of NFκB levels, the authors found a correlation between levels of this transcription factor and subjects whose OSA was affected most favorably by DMF therapy.
COMMENTARY
Although the effects of DMF did not eradicate OSA, this pharmacological therapy has promise, especially among the large subset of patients who cannot comply with CPAP therapy.
SOURCE: Wesselius HM, van den Ende ES, Alsma J, et al. Quality and quantity of sleep and factors associated with sleep disturbance in hospitalized patients. JAMA Intern Med 2018;178:1201-1208.
Poor sleep among hospitalized patients adversely affects their well-being and more importantly may lead to unfavorable medical outcomes. Wesselius et al studied 2,005 patients using sleep diaries and sleep-related questions from the validated PROMIS (patient-reported outcomes measurement information system) questionnaire. Using “flash mob” methodology, data from a single day, Feb. 22, 2017, were collected throughout the Netherlands, using word of mouth and social media to create the cohort. Sleep on the previous night of the patient’s hospitalization was compared to habitual sleep at home during the month before the hospitalization. Total sleep time in the hospital decreased by 83 minutes on average, compared to sleep at home. The average number of awakenings was 3.3 in the hospital compared with two at home. Patients woke up 44 minutes earlier in the hospital compared with their usual wake-up time. Patients reported that 70% of awakenings could be attributed to “hospital staff,” with a variety of other factors, such as noise of other patients, medical devices, pain, and toilet visits, noted.
COMMENTARY
Both the public and medical professionals recognize that patients “can’t get a good night’s sleep in the hospital.” Although the findings of this study support this contention, the magnitude of these effects (e.g., less than a 1.5 hour decrease in overall sleep and less than an hour earlier wake-up time) actually are less than one might expect. While beeping monitors and other noise disruptions were noted, planned interruptions of sleep by staff for vital sign checks or blood draws may represent modifiable low-hanging fruit for improvement.
SOURCE: Dominguez Rodriguez F, Fernandez Alvira JM, Fernandez Friera L, et al. Association of actigraphy-measured sleep parameters and subclinical atherosclerotic burden: The PESA study. Eur Heart J 2018;39(Suppl 1):P2466.
Insufficient and poor quality sleep can lead to significant medical complications including atherosclerotic disease. Dominguez Rodriguez et al studied 2,974 patients in the Progression and Early Detection of Subclinical Atherosclerosis (PESA) cohort. Subjects were screened using 2D/3D ultrasound in the carotid, abdominal aorta, and iliofemoral arteries. A coronary artery calcium score on CT also was calculated. Movement sensors (actigraphy) were used to measure sleep duration during a one-week period. Actigraphy is a useful surrogate for more invasive types of sleep monitoring such as polysomnography. Subjects were stratified into four groups: markedly short sleep (< 6 hours), short sleep (6-7 hours), average reference (7-8 hours), and long sleep (> 8 hours). Sleep duration of less than six hours was associated with a mildly increased odds of atherosclerosis on ultrasound, although not on cardiac calcium (odds ratio [OR], 1.27; 95% CI, 1.06-1.52). Subjects with the most fragmented sleep (bottom 20%) had an increased risk of atherosclerosis as well (OR, 1.35; 95% CI, 1.05-1.65). The diagnosis of metabolic syndrome also was made more frequently in the subjects with short or disrupted sleep.
COMMENTARY
This research corroborates prior data, although some previous studies have suggested a more complex U-shaped curve, putting both short sleepers and excessively long sleepers at risk for atherosclerotic disease. Regardless, these data provide further support for the importance of sleep in the optimization of medical outcomes.
