Diagnostic criteria and treatment for sleep-disordered breathing: obstructive sleep apnea syndrome

In this chapter, the principal approaches to the diagnosis and treatment of patients with obstructive sleep apnea syndrome (OSAS) are presented. The diagnosis should be carried out by the taking of a thorough clinical history and by physical examination. For diagnostic confirmation, it is necessary to perform supervised overnight polysomnography. For patients in whom clinical suspicion is high, a simplified home study can be an alternative. The treatment of OSAS requires general measures and the use of positive pressure devices. In moderate and severe cases, CPAP is the method of choice, whereas oral appliances can be used in mild cases. Surgical procedures are recommended when anatomical alterations are evident or as an auxiliary method in combination with other types of treatment.Neste capítulo são apresentadas as principais abordagens para o diagnóstico e tratamento dos pacientes com SAOS. O diagnóstico deve ser realizado através de uma minuciosa história clínica e exame físico. Para a confirmação diagnóstica, é necessária a realização da polissonografia completa de noite inteira sob supervisão, sendo que em pacientes cuja suspeita clínica é alta, registros simplificados domiciliares podem ser uma alternativa. O tratamento da SAOS requer medidas gerais e o uso de aparelhos de pressão positiva. Em casos moderados e graves, CPAP é o mais indicado, enquanto aparelhos intraorais são indicados em casos leves. Os procedimentos cirúrgicos são indicados quando alterações anatômicas são evidentes ou como auxílio aos demais tratamentos.Universidade Federal de São Paulo (UNIFESP)Faculdade de Ciências Médicas de Minas GeraisUNIFESPSciEL

Biofilm phenotype potentiates virulence transduction in Acinetobacter baumannii

Portuguese Foundation for Science and Technology (FCT) under the scope of the strategic funding UID/BIO/04469/2013 unit, COMPETE 2020 (POCI-01-0145- FEDER-006684) and the Project PTDC/BBB-BSS/6471/2014 (POCI- 01-0145-FEDER-016678). This work was also supported by BioTecNorte operation (NORTE-01-0145-FEDER-000004) funded by the European Regional Development Fund under the scope of Norte2020 - Programa Operacional Regional do Norte. Ana Rita Costa acknowledges FCT for grant SFRH/BPD/94648/2013info:eu-repo/semantics/publishedVersio

The role of prophages on virulence transduction in Acinetobacter baumannii biofilms

Recent years have observed an alarming increase on bacterial resistance to antibiotics. Many factors contribute to this, mainly antibiotics misuse but also an intrinsic capacity of bacteria to trade genetic material. These exchanges are emphasized in biofilms due to bacteria proximity, and involve several mechanisms including prophage-mediated transduction. Prophages are bacteriophages that incorporate into the bacterial genome, being able to excise and enter other bacteria. They are found in many bacterial species, being particularly frequent in Acinetobacter baumannii. This bacterial species is emerging as an important nosocomial pathogen worldwide especially due to a rapid acquisition of antibiotic resistance, in which prophage-mediated transduction may play a key role.The aim of this work was to evaluate the role of prophages on virulence transduction in A. baumannii biofilms. For this, an A. baumannii strain (ANC 4097) enclosing a prophage codifying a beta-lactam resistance gene and a receptor A. baumannii strain (NIPH 146) were selected based on biofilm-forming capacity. Strain susceptibility was tested for selecting a beta-lactam antibiotic to assess transduction. Both strains were genetically modified to follow transduction by fluorescence microscopy (mCherry inserted in the prophage and gfp in 146) and 146 was further modified to allow strain distinction on plate (lacZ). Levels of transduction were evaluated in mixed biofilms under different stress conditions (sub-MIC, light, and temperature).This work provides new insights into the importance of prophage transduction in virulence acquisition in mixed A. baumannii biofilms

Repercussions of a sleep medicine outreach program

Despite the high prevalence of sleep disorders, many healthcare professionals and lay people have little knowledge of Sleep Medicine. Mindful of such a reality, in 2001 the Sleep Institute of the Associação Fundo de Incentivo à Psicofarmacologia launched a campaign to increase Sleep Medicine awareness. Media features, exhibitions, inserts, and classes were used to reach 2,000,000 people and 55,000 healthcare professionals during the period from 2001 to 2004. To evaluate this program, we compared data for polysomnography referrals to the Institute in 2000 and in 2004. A total of 8805 referrals were evaluated (2000: 2164; 2004: 6641). Over the 4 years of the program, the number of beds increased by 43%; more women were referred (31 vs 37%; P < 0.001), mainly with a diagnostic hypothesis of sleep-disorder breathing (SDB). SDB was the most frequent diagnostic hypothesis in 2000 and 2004. In 2004 there were fewer referrals without a diagnostic hypothesis (27 vs 21%; P < 0.001) and for controlling surgically treated SDB (2.3 vs 1.6%; P < 0.05), and an increase in the following diagnostic hypotheses: non-invasive treatment of SDB (8.3 vs 12.3%; P < 0.001) and insomnia (3.5 vs 6.5%; P < 0.001). Insomnia diagnostic hypothesis was better correlated with SDB on referral documents in 2004 and less with a diagnostic hypothesis of limb movement disturbance. The program helped increase polysomnography referrals, particularly among women. Healthcare professionals appear to have a more developed understanding of sleep disorders.Universidade Federal de São Paulo (UNIFESP) Departamento de PsicobiologiaUniversidade Federal de São Paulo (UNIFESP) Departamento de FarmacologiaUNIFESP, Depto. de PsicobiologiaUNIFESP, Depto. de FarmacologiaSciEL

Frequency of sleep disturbances in overweight/obese postmenopausal women

PURPOSE:To evaluate the frequency of sleep disorders, such as obstructive sleep apnea, restless leg syndrome and insomnia in overweight/obese postmenopausal women seen in a climacteric sleep disorders clinic.METHODS:Thirty-four postmenopausal women were selected using the following inclusion criteria: age between 50 and 70 years; at least 12 months of amenorrhea; body mass index (BMI) greater than or equal to 25 kg/m2; and sleep-related complaints with at least one previous polysomnography. Patients provided responses to 6 questionnaires related to sleep characteristics and menopausal symptoms. Weight and height were measured using standardized scales, and abdomen and hip circumferences were also measured. The statistical analyses were performed using the χ2 test for qualitative variables and using Student's t-test for quantitative variables.RESULTS:Patients' characteristics were as follows: mean age of 60.35 years; mean BMI of 31.62; an average of 11.61 postmenopausal years and an average Kupperman Index of 19. A total of 85.2% of the patients had a waist/hip ratio of less than 0.8. The Epworth Scale score was greater than or equal to 9 in 50% of patients; 68% had sleep disturbances according to the Pittsburgh Index, and 68% were classified as high-risk for sleep apnea by the Berlin Questionnaire. On polysomnography, 70.58% of the patients had a sleep efficiency lower than 85%; 79.41% had a sleep latency of less than 30 min; 58.82% had a REM sleep latency of less than 90 min, and 44.11% had mild apnea. When the groups were compared, a linear association was identified between BMI and the AHI average, and a relationship between high BMI and use of drugs for thyroid treatment was found.CONCLUSION:There was a high prevalence of sleep-disordered breathing, initial insomnia, fragmented sleep, and thyroid disorders in the group with higher BMI.OBJETIVOS:Avaliar a frequência dos distúrbios do sono, como apneia obstrutiva do sono, síndrome das pernas inquietas e insônia, em pacientes na pós-menopausa com sobrepeso/obesidade no ambulatório de distúrbios do sono no climatério.MÉTODOS:Foram selecionadas 34 pacientes na pós-menopausa, e os seguintes critérios de inclusão foram adotados: idade entre 50 e 70 anos, mínimo de 12 meses de amenorreia, Índice de Massa Corporal igual ou superior a 25 kg/m2, pacientes com queixas relacionadas ao sono e que tivessem sido submetidas a pelo menos uma polissonografia. As pacientes responderam a seis questionários sobre características do sono e sintomas do climatério e uso de medicações. Foram aferidos o peso e a altura em balança padronizada e as medidas das circunferências do abdome e do quadril. Para a análise estatística, o teste do χ2 foi utilizado para variáveis qualitativas, e o teste t de Student, para análise das variáveis quantitativas.RESULTADOS:A média de idade foi de 60,3 anos, o Índice de Massa Corporal médio de 31,6, o tempo de pós-menopausa médio de 11,6 anos e o Índice Menopausal de Kupperman médio de 19. Da amostra, 85,2% apresentou relação cintura/quadril igual ou superior a 0,8; metade apresentou escore igual ou superior a 9 na Escala de Epworth; 68% apresentou distúrbio do sono de acordo com o índice de Pittsburgh e 68% dos casos foram classificados como de alto risco para apneia do sono pelo Questionário Berlin. Na polissonografia, 70,5% apresentou eficiência do sono menor que 85%; 79,4% com latência do sono menor que 30 min; 58,8% com latência para sono REM menor que 90 min e 44,1% com apneia leve. Comparando os grupos, houve associação linear média entre IMC e IAH e relação entre IMC elevado e uso de medicações para distúrbios da tireoide.CONCLUSÃO:Foi observada alta prevalência de distúrbio respiratório do sono, sono fragmentado e insônia de início, bem como maior incidência de distúrbios da tireoide no grupo com IMC mais elevado.Universidade Federal de São Paulo (UNIFESP)Universidade Federal de São Paulo (UNIFESP) Departamento de PsicobiologiaUniversidade Federal de São Paulo (UNIFESP) Departamento de Ginecologia e Ambulatorio de Disturbios do Sono no ClimaterioUNIFESP, Depto. de PsicobiologiaUNIFESP, Depto. de Ginecologia e Ambulatorio de Disturbios do Sono no ClimaterioSciEL

Sleep disturbance prevalence in postmenopausal women

PURPOSE: to evaluate the prevalence of reported sleep disturbances through polysomnographic recording (PSG) in a sample of postmenopausal women. METHODS: thirty-three postmenopausal women with a mean age of 56 years, a mean body mass index (BMI) of 27 kg/m², with 7.7 years of recognized postmenopausal period, and a mean Kupperman index of 17, were selected. The inclusion criteria were: age range from 50 to 65 years, at least one year of amenorrhea and an FSH which equaled or exceeded 30 mU/ml; they should not be undergoing hormone therapy, and should display normal laboratory test results. The patients with severe clinical diseases and/or decompensated were excluded; also the ones with suspicion of carcinoma of endometrium and/or breast cancer, a BMI over 30 kg/m² and those who ingested hypnotic drugs. The patients followed a routine climacteric check-up, answered a questionnaire about sleep and underwent an all-night PSG recording. Frequencies in percentage of emerging sleep complaints based on the questionnaire and those pertaining to PSG diagnosis were then calculated separately. RESULTS: the subjective prevalence of insomnia was 61% against 83% in the PSG recordings. The prevalence of apnea reported was 23% against 27% in the PSG. The subjective restless legs syndrome prevalence was 45%, and the objective, 27%. CONCLUSION: there was a high prevalence of sleep disturbances in postmenopausal patients, specially insomnia, apnea and restless legs.OBJETIVO: avaliar a prevalência das queixas de distúrbios do sono pela polissonografia em amostra de mulheres na pós-menopausa. MÉTODOS: foram selecionadas 33 mulheres na pós-menopausa com média de idade de 56 anos, índice de massa corporal médio de 27, tempo de pós-menopausa de 7,7 anos e índice de Kupperman de 17. Adotaram-se os seguintes critérios de inclusão: idade entre 50 e 65anos, no mínimo um ano de amenorréia e FSH plasmático superior ou igual a 30 mU/mL, sem uso de terapia hormonal prévia e exames laboratoriais normais. Foram excluídas as pacientes com doenças clínicas graves e/ou descompensadas, suspeita de câncer de endométrio e/ou mama; índice de massa corporal maior ou igual a 30 e uso de hipnóticos. As pacientes responderam a questionário específico contendo perguntas sobre as características do sono e foram submetidas a polissonografia completa durante uma noite inteira. Foram calculadas separadamente as freqüências em porcentagens das queixas de sono e dos diagnósticos polissonográficos. RESULTADOS: a prevalência de insônia subjetiva foi 61%, sendo que na polissonografia foi de 83%. A queixa de apnéia foi registrada em 23% e, na polissonografia, em 27%. A prevalência subjetiva de movimentos periódicos de pernas foi de 45% e a objetiva foi de 27%. CONCLUSÃO: houve alta prevalência de distúrbios do sono na pós-menopausa, em especial de insônia, apnéia e de movimentos periódicos das pernas. Nesta fase da vida, ocorre piora da qualidade do sono.Universidade Federal de São Paulo (UNIFESP) Departamento de Ginecologia ambulatório de Distúrbios do SonoUniversidade Federal de São Paulo (UNIFESP) Departamento de Psicobiologia Medicina e Biologia do SonoUNIFESP, Depto. de Ginecologia ambulatório de Distúrbios do SonoUNIFESP, Depto. de Psicobiologia Medicina e Biologia do SonoSciEL

Gender and age differences in polysomnography findings and sleep complaints of patients referred to a sleep laboratory

Our objective was to examine the effet of gender on the sleep pattern of patients referred to a sleep laboratory. The data (questionnaires and polysomnographic recordings) were collected from a total of 2365 patients (1550 men and 815 women). The polysomnography permits an objective assessment of the sleep pattern. We included only polysomnography exams obtained with no more than one recording system in order to permit normalization of the data. Men had a significantly higher body mass index than women (28.5 ± 4.8 vs 27.7 ± 6.35 kg/m²) and had a significantly higher score on the Epworth Sleepiness Scale (10.8 ± 5.3 vs 9.5 ± 6.0), suggesting daytime sleepiness. Women had a significantly higher sleep latency than men, as well as a higher rapid eye movement (REM) latency. Men spent more time in stages 1 (4.6 ± 4.1 vs 3.9 ± 3.8) and 2 (57.0 ± 10.5 vs 55.2 ± 10.1) of non-REM sleep than women, whereas women spent significantly more time in deep sleep stages (3 and 4) than men (22.6 ± 9.0 vs 19.9 ± 9.0). The apnea/hypopnea and arousal indexes were significantly higher and more frequent in men than in women (31.0 ± 31.5 vs 17.3 ± 19.7). Also, periodic leg movement index did not differ significantly between genders, but rather differed among age groups. We did not find significant differences between genders in the percentage of REM sleep and sleep efficiency. The results of the current study suggest that there are specific gender differences in sleep pattern.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de PsicobiologiaUniversidade Estadual de Campinas Faculdade de Odontologia de Piracicaba Departamento de PeriodontiaUNIFESP, EPM, Depto. de PsicobiologiaSciEL

Influence of genetic ancestry on the risk of obstructive sleep apnoea syndrome

The aim of the present study was to evaluate the influence of ethnicity on the risk of developing obstructive sleep apnoea syndrome (OSAS) using genomic analysis methods to estimate ancestry.DNA samples were obtained from 1,010 individuals participating in the São Paulo Epidemiologic Sleep Study, who underwent full-night polysomnography. A total of 31 genetic ancestry-informative markers were selected in order to estimate individual admixture proportions.Of patients with a diagnosis of OSAS, a higher number self-reporting Caucasian ethnicity (65.3%), as well as an increased percentage of European ancestry (78.2 +/- 16.7%) and lower percentage of West African ancestry (16.1 +/- 15.3%), than among individuals without OSAS (53.6, 73.5 +/- 18.1 and 20.1 +/- 16.8%, respectively) (p < 0.001) was observed. Moreover, after correcting for sex, age, body mass index and socioeconomic status, logistic regression demonstrated that European ancestry was significantly associated with an increased risk of manifesting OSAS (OR 2.80, 95% CI 1.11-7.09). Conversely, West African ancestry was associated with a reduced risk of the OSAS phenotype (OR 0.26, 95% CI 0.09-0.72).This is the first study to incorporate genomic analysis methods to measure the influence of ethnicity on the risk of OSAS. Since genetically determined ancestry may not capture unmeasured cultural and lifestyle differences, the contribution of environmental factors to the current findings should not be disregarded.Psychopharmacology Incentive FundFundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Universidade Federal de São Paulo, Dept Psychobiol, Escola Paulista Med, BR-04024002 São Paulo, BrazilInst Pesquisas Tecnol & Inovacao, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Psychobiol, Escola Paulista Med, BR-04024002 São Paulo, BrazilFAPESP: CEPID 98/14303-3Web of Scienc

Upper airway dimensions in patients with craniocervical junction malformations with and without sleep apnea. A pilot case-control study

Objective: Patients with craniocervical junction malformations (CCJM) tend to suffer more frequently from sleep respiratory disturbances, which are more frequent and severe in patients with basilar invagination. Here we evaluate if patients with CCJM and sleep respiratory disorders (SRD) present smaller airway dimensions than patients without SRD. Method: Patients with CCCM with and without sleep respiratory disturbances were evaluated clinically by Bindal's score, modified Mallampati classification, full-night polysomnography and upper airway cone beam tomography. Results: Eleven patients had sleep respiratory disorders (SRD), and nine patients performed control group without SRD. CCJM patients with SRD were predominantly female, older, had higher BMI, were more likely to have Mallampati grades 3 and 4 and had statistically significant smaller anteroposterior diameter of the upper airway than patients without SRD. Conclusion: Patients with CCJM and sleep respiratory disturbances have higher BMI, higher Mallampati score and smaller anterior posterior diameter of the upper airway.Inst Assistencia Med Servidor Publ Estadual, Posgrad Ciencias Saude, São Paulo, SP, BrazilUniversidade Federal de São Paulo, Dept Psicobiol, São Paulo, SP, BrazilHosp Serv Publ Estadual São Paulo, Dept Neurocirurg, São Paulo, SP, BrazilUniversidade Federal de São Paulo, Dept Psicobiol, São Paulo, SP, BrazilWeb of Scienc

Narcolepsy

BACKGROUND: Narcolepsy is a chronic neurological syndrome with prevalence between 0.018% and 0.040% without important ethnic differences. Narcolepsy is characterized by excessive daytime sleepiness and cataplexy. The pathophysiology of the illness is not known; even so it possesses genetic marker (allele HLA DQB1 *0602) and with abnormalities in the neurotransmission of hypocretin has been described in patients with narcolepsy. OBJECTIVES: Resume news discoveries in narcolepsy and show diagnoses and treatment options. METHODS: Bibliographic review. RESULTS AND DISCUSSION: The diagnoses of narcolepsy must be done with The International Classification of Sleep Disorders criteria. The hypocretin dosage is the best exam to confirm diagnose in narcoleptic patients with typical cataplexy. The treatment is carried through with behavior actions and symptomatic drugs that promote the vigil and control the cataplexy. Differential diagnoses as schizophrenia, epilepsy, depression and others sleep disorders need to be eliminated.CONTEXTO: Narcolepsia é uma síndrome neurológica crônica com prevalência entre 0,018% e 0,040% da população, sem diferenciações étnicas importantes. Caracteriza-se por sonolência e cataplexia. A fisiopatologia da doença não é totalmente conhecida, embora possua marcador genético (alelo HLA DQB1 *0602) e anormalidades na neurotransmissão de hipocretina descritos recentemente. OBJETIVOS: Resumir as recentes descobertas na narcolepsia e expor possibilidades diagnósticas e terapêuticas. METODOLOGIA: Revisão bibliográfica. RESULTADOS E DISCUSSÃO: O diagnóstico deve seguir os critérios da Classificação Internacional de Sono. A dosagem de hipocretina é o melhor exame para confirmar narcolepsia em pacientes com cataplexia típica. O tratamento deve ser realizado com medidas comportamentais e drogas sintomáticas que promovem a vigília e controlam a cataplexia. Diagnósticos diferenciais como esquizofrenia, epilepsia, depressão e doenças do sono devem ser descartados.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaHospital Israelita Albert Einstein Setor de UrgênciasUniversidade de São Paulo Hospital da Clínicas Serviço de HemodiáliseInstituto do SonoUNIFESP-EPM Departamento de PsicobiologiaUNIFESP, EPM, Depto. de PsicobiologiaSciEL