Nasal Continuous Positive Airway Pressure Improves Quality of Life in Obesity Hypoventilation Syndrome

We studied the quality of life of obesity hypoventilation syndrome (OHS) by comparing it with age- and body mass index-matched patients without hypoventilation and age-matched obstructive sleep apnea (OSA) patients with body mass index (BMI) under 30, and the efficacy of nasal continuous positive airway pressure (CPAP) therapy for 3 to 6 months on the quality of life in these patients. Prospectively recruited patients from six sleep laboratories in Japan were administered assessments of the general health status by the Short-Form 36 Health Survey (SF-36) and subjective sleepiness by the Epworth Sleepiness Scale (ESS). Compared with matched healthy subjects, OHS and OSA patients not yet treated had worse results on the ESS scores and the SF-36 subscales for physical functioning, role limitations due to physical problems, general health perception, energy/vitality, role limitations due to emotional problems, and social functioning. The ESS scores of OHS patients were worse than those of the OSA groups including the age- and BMI-matched OSA patients. In the SF-36 subscales of OHS patients, only the subscale of social functioning showed worse results compared with that of BMI-matched OSA patients. After 3 to 6 months of treatment, ESS scores and these SF-36 subscales in all three patient groups improved to the normal level. These results suggested that the quality of life of OHS before nasal CPAP was significantly impaired and that nasal CPAP for OHS improved the quality of life associated with the improvement of daytime sleepiness to the level of the other OSA patients.     

Quality of Life in Obesity Hypoventilation Syndrome

The first paper of this issue of Sleep and Breathing reports that the quality of life (QOL) assessed by the SF-36 and the Epworth Sleepiness Scale (ESS) in obesity hypoventilation syndrome (OHS) was compared with age- and body mass index-matched patients without hypoventilation (obese OSA), nonobese OSA patients, and healthy subjects. The QOL in OHS was worst among these four groups. After 3 to 6 months of nasal continuous positive airway pressure (CPAP) treatment, the QOL in OHS improved to the normal level similar to the two other OSA groups. We have observed severe nonobese OSA patients with hypoventilation. One of the risk factors, which related to a severe general condition, seems to be a small craniomandibular structure, which could induce an increase in upper airway resistance during sleep. Characteristics of Japanese OSA patients may be different from those in other countries. Although belatedly, the clinical study and management of sleep disordered breathing have just begun.     

通心络胶囊对老年睡眠期陈-施呼吸患者呼吸的影响

目的观察通心络胶囊对老年睡眠期陈-施呼吸（CSR）患者的影响。方法根据多导睡眠图监测（PSG）结果,除外心力衰竭病因者,入选老年睡眠期CSR患者30例,按呼吸暂停低通气指数分为轻度（n=11）、中度（n=9）及重度（n=10）CSR组,均予口服通心络胶囊2粒／次,3次,d,共30d。分析治疗前后PSG指标及症状的变化及与日间嗜睡程度的相关关系。日间嗜睡程度以Epworth嗜睡评分（ESS）评定。结果通心络胶囊治疗前后比较显示,3组中仅重度组呼吸暂停低通气指数显著降低[（37．4±4．3）vs（30．8±4．5）,P〈0．05];3组的日间ESS均有改善（P〈0．05）,轻度组由（8．8±2．0）降低到（6．0＋1．9）,中度组由（10．7±2．1）降至（8．0±2．3）,重度组由（13．4±2．4）降至（10．2±3．0）。相关性分析显示轻度组ESS与微觉醒指数呈正相关（r=0．775,P〈0．05）,而中重度组日间嗜睡评分与最低血氧饱和度呈负相关（分别为r=-0．751,P〈0．05;r=-0．739,P〈0．05）。结论通心络胶囊可改善老年睡眠期CSR者的日间嗜睡症状,可能部分降低重度老年睡眠期CSR的呼吸暂停低通气指数。     

Low sleep quality and daytime sleepiness in obese patients without obstructive sleep apnoea syndrome

OBJECTIVES: To evaluate sleep quality, sleep-related symptoms, and degree of excessive daytime sleepiness (EDS) in severe obesity, independently of obstructive sleep apnoea syndrome (OSAS). DESIGN: A cross-sectional study. SETTING: Primary-care setting. SUBJECTS, MAIN OUTCOME MEASURES: Anthropometric parameters, respiratory function data and sleep related symptoms were evaluated in 78 severely obese patients (aged 16-75 years) without OSAS and in 40 healthy sex- and age-matched normal weight subjects, who underwent a full-night polysomnography. RESULTS: Obese patients and control subjects had similar sleep latency and rapid eye movement (REM) latency, but they showed lower percentage of REM (P < 0.01) and sleep efficiency (P < 0.05) than controls. All sleep-related symptoms (observed or reported apnoea, awakenings, choking and unrefreshing sleep) were significantly more frequent in obese patients than in control subjects. Loud snoring was present in 46.7% of the obese patients and in 8.1% of the control individuals (P < 0.01). Excess daytime sleepiness was reported by 34.7% of the obese patients and by 2.7% of the normal weight subjects (P < 0.01). The Epworth Sleepiness Scale (ESS) was higher in the obese group than in the control group (P < 0.01), whereas arousals were not different between the two groups. CONCLUSIONS: This study clearly shows that severe obesity, even in the absence of OSAS, is associated with sleep-related disorders and EDS. All these alterations may be partly responsible for a lower quality of life, a higher prevalence of medical complications, an increased risk of occupational injury, and both social and family problems characterizing obese patients, independently of the presence of OSAS.     

Somatic Diseases and Sleep Complaints

ABSTRACT. Gislason T, Almqvist M (Departments of Lung Medicine and Psychiatry, University Hospital, University of Uppsala, Uppsala, Sweden). Somatic diseases and sleep complaints. An epidemiological study of 3201 Swedish men. Acta Med Scand 1987; 221:475–81. The prevalence of sleep complaints and somatic diseases was estimated in a random sample of 4064 Swedish men aged 30–69 years. Great difficulty initiating sleep (DIS) was experienced by 6.9% and moderate problems in DIS by 14.3%. Complaints of major difficulty maintaining sleep (DMS) were reported by 7.5% of the men and of moderate DMS by 14.9%. DMS was more frequent with increasing age. Excessive daytime sleepiness (EDS) was reported by 5.7%. Altogether 879 men were attending regular medical examinations for somatic diseases. Among the 299 hypertensive men, major complaints of DMS (13.5%), DIS (8.4%) and EDS (8.8%) were more common, but the 167 men treated with β-blockers rather showed a proportionally somewhat lower prevalence of sleep complaints. Men with obstructive pulmonary disease (n=113) had a higher prevalence of DMS (18.8%) and EDS (12.4%). Diabetic men (n=74) complained also more often of DMS (21.9%), DIS (21.1%) and EDS (12.2%). Men with rheumatic disease (n=176) and obesity (n=221) also had increased prevalence of sleep complaints.     

Twenty-four-hour ambulatory oxygen desaturation and electrocardiographic recording in obstructive sleep apnea syndrome

Background: Although nocturnal pulseoximetry is routinely performed in obstructive sleep apnea syndrome (OSAS), pulseoximetry over a 24-h period has not been studied. Hypothesis: The purpose of the study was to determine whether simultaneous 24-h oxygen desaturation and electrocardiographic (ECG) recording might be used to screen for daytime sleep sequelae in patients with OSAS. Methods: Simultaneous recording of arterial oxygen saturation (SpO2) and ECG was conducted over a 24-h period in 18 male patients with OSAS (mean age 51.3 years) who were diagnosed by standard polysomnography (PSG), and in 15 agematched healthy subjects (mean age 52.7 years) as controls to evaluate circadian variation of these parameters. The measures of heart rate variability (HRV) were calculated from 24-h ambulatory ECGs. Seventeen patients with OSAS showed excessive daytime sleepiness (EDS). We calculated the duration in which SpO₂ decreased to <90% (duration of SpO₂ > 90%). The number of apnea/hypopneas per hour (AHI) during sleep was investigated with Apnomonitors (Chest MI, Co., Tokyo) on the same day as the SpO₂ recordings. Results: Controls showed no episodes of oxygen desaturation. in patients with OSAS, driving (33.3% of patients with OSAS) was the most common activity in which SpO₂ decreased to <90%, followed by daytime napping (27.8%) and resting after meals (22.2%). The duration of SpO₂ < 90% over a 24-h period correlated significantly with the duration levels recorded during sleep (r = 0.99, p < 0.05) and in the afternoon (r = 0.62, p <0.05), and with the AHI (r = 0.55, p>0.05), but not with the duration of SpO²> 90% in the morning. The number of ventricular premature beats correlated significantly with the duration of SpO²>90% for a 24-h period, but not with measures of HRV. Ventricular tachycardia was found in two (11.1 %) and ST-T depression in three patients (16.6%) with underlying cardiac diseases. Conclusion: Our results suggest that daytime sleep attacks accompanied by oxygen desaturation in patients with moderate to severe OSAS may contribute to the occurrence of traffic or cardiovascular accidents. We conclude that 24-h ambulatory recordings of SpO² and ECG are useful for screening for daytime sleep sequelae associated with the potential risk of this pathology in OSAS during social activities.     

A Broader View of Change in Drinking Behavior

Most research concerning change in drinking behavior has taken place within the context of specialized treatment for a help-seeking population. However, treatment approaches with different purported mechanisms of action yield very similar results, suggesting that common elements, rather than specific mechanisms, may be responsible for the bulk of the individual change process. Mechanisms of change have not been explicitly examined. Other factors such as social pressure may be more important mediators of change, which may occur prior to treatment entry. Also, most change occurs outside the context of specific treatment. A broader perspective focusing on mechanisms of change will need to account for change occurring both with and without professional treatment. Future research must be interdisciplinary in nature, seeking to relate social, behavioral, and neurophysiologic correlates of behavior change.     

Tai chi and self-rated quality of sleep and daytime sleepiness in older adults: a randomized controlled trial

OBJECTIVES: To determine the effectiveness of tai chi on self-rated sleep quality and daytime sleepiness in older adults reporting moderate sleep complaints. DESIGN: Randomized, controlled trial with allocation to tai chi or exercise control. SETTING: General community. PARTICIPANTS: One hundred eighteen women and men aged 60 to 92. INTERVENTION: Participants were randomized into tai chi or low-impact exercise and participated in a 60-minute session, three times per week, for 24 consecutive weeks. MEASUREMENTS: Primary outcome measures were the seven subscales of the Pittsburgh Sleep Quality Index (PSQI), PSQI global score, and Epworth Sleepiness Scale (ESS). Secondary outcome measures were physical performance (single leg stand, timed chair rise, 50-foot speed walk) and 12-item short form (SF-12) physical and mental summary scores. RESULTS: Tai chi participants reported significant improvements in five of the PSQI subscale scores (sleep quality, sleep-onset latency, sleep duration, sleep efficiency, sleep disturbances) (P<.01), PSQI global score (P=.001), and ESS scores (P=.002) in comparison with the low-impact exercise participants. Tai chi participants reported sleep-onset latency of about 18 minutes less per night (95% confidence interval (CI)=-28.64 to -7.12) and sleep duration of about 48 minutes more per night (95% CI=14.71-82.41) than low-impact exercise participants. Tai chi participants also showed better scores in secondary outcome measures than low-impact exercise participants. Both groups reported improvements in SF-12 mental summary scores. CONCLUSION: Older adults with moderate sleep complaints can improve self-rated sleep quality through a 6-month, low- to moderate-intensity tai chi program. Tai chi appears to be effective as a nonpharmacological approach to sleep enhancement for sleep-disturbed elderly individuals.     

调免素的临床研究

本文报告调免素治疗消化系统及内科其它系统疾病319例的临床疗效与机体免疫功能变化,与对照组60例,分析、探讨了调免素的临床应用价值。两组病人治疗后总有效率分别为84.0％和63.68％(P<0.05)。调免素治疗组细胞免疫功能有明显改变(P<0.01),对照组不明显。调免素在临床上使用是安全的。     

Prevalence of sleepiness in surviving drivers of motor vehicle collisions

Background: Although alcohol and recreational drugs are recognized as significant risk factors for motor vehicle collisions (MVC), the contribution of sleepiness alone is less clear. We therefore sought to identify the contribution of sleepiness to the risk of a MVC in injured drivers, independent of drugs and alcohol. Methods: A prospective questionnaire and examination of sleep‐related risk factors in drivers surviving MVC in a major hospital‐based trauma centre was carried out. Results: Forty of 112 injured drivers screened were interviewed, of whom approximately 50% had at least one sleep‐related risk factor, 20% having two or more. Of the MVC deemed sleep‐related by questionnaire, only 25% were identified by the Australian Transport Safety Bureau definitions. Shift work was the greatest sleep‐related factor identified contributing to MVC. Conclusion: Sleepiness, particularly related to shift work, needs to be emphasized as a risk factor for MVC. Australian Transport Safety Bureau definitions of sleep‐related MVC are too lenient.     

Clinical impact of screening for sleep related breathing disorders in atrial fibrillation

Objective

The aim of this study was to quantify daytime symptoms in atrial fibrillation (AF) patients with and without sleep related breathing disorders (SRBD).

Background

SRBD are common in patients with AF but little is known about daytime symptoms among those with SRBD.

Methods

Patients with AF admitted to clinics of two tertiary referral hospitals for a variety of different cardiovascular diseases were screened with a trans-nasal airflow measurement device allowing measurement of the apnea-hypopnea-index. Data on cardiac risk factors, left ventricular ejection fraction (LVEF) and cardiac medication were collected. Presence of SRBD was defined as an AHI ≥ 15/h. The Epworth sleepiness scale (ESS) was used to quantify daytime symptoms.

Results

Of 102 screened patients 8 were excluded due to device malfunction (n = 1), dislocation of nasal cannula (n = 6), or hyperthyroidism (n = 1). Among the remaining 94 patients, 40 (43%) were diagnosed with SRBD. Patients with and without SRBD had similar age, body mass index, LVEF and cardiac medication. The prevalence of coronary artery disease was higher in patients with SRBD than in those without (50 vs. 17%; p = 0.0007). ESS score was low and similar in both groups (no SRBD: median 4, interquartile range (IQR) 2-4 vs. SRBD: 5, IQR 3-8; p = 0.14). Only 6/40 (5%) of the patients underwent overnight polysomnography and 2 (5%) started CPAP ventilation during follow-up.

Conclusions

Even though SRBD are common in patients with AF, the prevalence of daytime symptoms is rare. Consequently, most patients will not initiate CPAP ventilation after positive SRBD screening.     

Spirituality and Aging

A faith based discussion group can do much to en- hance the quality of life of residents within the long t e n care set- ting. Each rndividual's spirituality is a link between self and others, past and present. The facilitator of such a group can use validation techniques and socio-therapeutic principles to lead members toward feelings of community wholeness, outwardly focused behavior and a rencwed desire to contribute to society.     

中风急性期外周血象动态变化观察

目的 观察中风急性期病人外周血象动态变化规律,分析其临床意义。方法 105例急性期中风病人按出血与梗塞分为两组,于入院时及病程第10天测定外周血象及红细胞与血小板电泳时,并与正常医学参考值进行对比分析。结果 两组外周血象均有明显改变,尤以白细胞计数、粒细胞百分率,红细胞及血小板电泳时更为显著。结论 急性期中风病人外周血象均有显著的动态改变,提示整个血液系统均参与了中风急性期病理衍变,而不是单纯限于血液的高凝状态而已,故本组资料有助对血液系统在中风急性期发病机制中的作用认识,同时其动态变化规律,亦具指导临床诊断治疗与预后评估的价值。     

Urban growth, climate change, and freshwater availability

Nearly 3 billion additional urban dwellers are forecasted by 2050, an unprecedented wave of urban growth. While cities struggle to provide water to these new residents, they will also face equally unprecedented hydrologic changes due to global climate change. Here we use a detailed hydrologic model, demographic projections, and climate change scenarios to estimate per-capita water availability for major cities in the developing world, where urban growth is the fastest. We estimate the amount of water physically available near cities and do not account for problems with adequate water delivery or quality. Modeled results show that currently 150 million people live in cities with perennial water shortage, defined as having less than 100 L per person per day of sustainable surface and groundwater flow within their urban extent. By 2050, demographic growth will increase this figure to almost 1 billion people. Climate change will cause water shortage for an additional 100 million urbanites. Freshwater ecosystems in river basins with large populations of urbanites with insufficient water will likely experience flows insufficient to maintain ecological process. Freshwater fish populations will likely be impacted, an issue of special importance in regions such as India's Western Ghats, where there is both rapid urbanization and high levels of fish endemism. Cities in certain regions will struggle to find enough water for the needs of their residents and will need significant investment if they are to secure adequate water supplies and safeguard functioning freshwater ecosystems for future generations.