Publications by authors named "Indira Gurubhagavatula"

47 Publications

Opportunities and unknowns in adapting pediatric sleep practices to a pandemic world.

J Clin Sleep Med 2021 Mar;17(3):361-362

Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.5664/jcsm.9068DOI Listing
March 2021

The impact of the COVID-19 pandemic on sleep medicine practices.

J Clin Sleep Med 2021 01;17(1):79-87

Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Study Objectives: The COVID-19 pandemic required sleep centers to consider and implement infection control strategies to mitigate viral transmission to patients and staff. Our aim was to assess measures taken by sleep centers due to the COVID-19 pandemic and plans surrounding reinstatement of sleep services.

Methods: We distributed an anonymous online survey to health care providers in sleep medicine on April 29, 2020. From responders, we identified a subset of unique centers by region and demographic variables.

Results: We obtained 379 individual responses, which represented 297 unique centers. A total of 93.6% of unique centers reported stopping all or nearly all sleep testing of at least one type, without significant differences between adult and pediatric labs, geographic region, or surrounding population density. By contrast, a greater proportion of respondents continued home sleep apnea testing services. A total of 60.3% reduced home sleep apnea testing volume by at least 90%, compared to 90.4% that reduced in-laboratory testing by at least 90%. Respondents acknowledged that they implemented a wide variety of mitigation strategies. While no respondents reported virtual visits to be ≥ 25% of clinical visits prior to the pandemic, more than half (51.9%) anticipated maintaining ≥ 25% virtual visits after the pandemic.

Conclusions: Among surveyed sleep centers, the vast majority reported near-cessation of in-laboratory sleep studies, while a smaller proportion reported reductions in home sleep apnea tests. A large increase in the use of telemedicine was reported, with the majority of respondents expecting the use of telehealth to endure in the future.
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http://dx.doi.org/10.5664/jcsm.8830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849634PMC
January 2021

Daylight saving time: an American Academy of Sleep Medicine position statement.

J Clin Sleep Med 2020 Oct;16(10):1781-1784

Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

None: The last several years have seen intense debate about the issue of transitioning between standard and daylight saving time. In the United States, the annual advance to daylight saving time in spring, and fall back to standard time in autumn, is required by law (although some exceptions are allowed under the statute). An abundance of accumulated evidence indicates that the acute transition from standard time to daylight saving time incurs significant public health and safety risks, including increased risk of adverse cardiovascular events, mood disorders, and motor vehicle crashes. Although chronic effects of remaining in daylight saving time year-round have not been well studied, daylight saving time is less aligned with human circadian biology-which, due to the impacts of the delayed natural light/dark cycle on human activity, could result in circadian misalignment, which has been associated in some studies with increased cardiovascular disease risk, metabolic syndrome and other health risks. It is, therefore, the position of the American Academy of Sleep Medicine that these seasonal time changes should be abolished in favor of a fixed, national, year-round standard time.
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http://dx.doi.org/10.5664/jcsm.8780DOI Listing
October 2020

Exhaled air dispersion and use of oronasal masks with continuous positive airway pressure during COVID-19.

Eur Respir Rev 2020 Sep 18;29(157). Epub 2020 Aug 18.

Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1183/16000617.0144-2020DOI Listing
September 2020

OSA in Professional Transport Operations: Safety, Regulatory, and Economic Impact.

Chest 2020 Nov 12;158(5):2172-2183. Epub 2020 Jun 12.

Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ.

OSA is common among commercial vehicle operators (CVOs) in all modes of transportation, including truck, bus, air, rail, and maritime operations. OSA is highly prevalent and increases the risk of drowsiness-related crashes in CVOs. Internationally, specific regulations regarding its identification and management vary widely or do not exist; medical examiners and sleep medicine specialists are urged to use available guidance documents in their absence. Education, screening, prompt identification and treatment, and ongoing surveillance to ensure effective therapy can lower the risk of fatigue-related crashes.
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http://dx.doi.org/10.1016/j.chest.2020.05.582DOI Listing
November 2020

Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement.

J Clin Sleep Med 2020 05 28;16(5):803-805. Epub 2020 Feb 28.

Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

None: Physician burnout is a serious and growing threat to the medical profession and may undermine efforts to maintain a sufficient physician workforce to care for the growing and aging patient population in the United States. Burnout involves a host of complex underlying associations and potential for risk. While prevalence is unknown, recent estimates of physician burnout are quite high, approaching 50% or more, with midcareer physicians at highest risk. Sleep deprivation due to shift-work schedules, high workload, long hours, sleep interruptions, and insufficient recovery sleep have been implicated in the genesis and perpetuation of burnout. Maladaptive attitudes regarding sleep and endurance also may increase the risk for sleep deprivation among attending physicians. While duty-hour restrictions have been instituted to protect sleep opportunity among trainees, virtually no such effort has been made for attending physicians who have completed their training or practicing physicians in nonacademic settings. It is the position of the American Academy of Sleep Medicine that a critical need exists to evaluate the roles of sleep disruption, sleep deprivation, and circadian misalignment in physician well-being and burnout. Such evaluation may pave the way for the development of effective countermeasures that promote healthy sleep, with the goal of reducing burnout and its negative impacts such as a shrinking physician workforce, poor physician health and functional outcomes, lower quality of care, and compromised patient safety.
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http://dx.doi.org/10.5664/jcsm.8408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849815PMC
May 2020

What is the role of sleep in physician burnout?

J Clin Sleep Med 2020 05 28;16(5):807-810. Epub 2020 Feb 28.

Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

None: The occurrence of physician burnout is widespread among clinicians and academic faculty, who report indicators such as low quality of life and poor work-life balance. Chronic insufficient sleep, whether due to extended work hours, circadian misalignment, or unrecognized sleep disorders, is a critically important risk factor for burnout that is overlooked and under-studied, and interventions to promote healthy sleep may reduce burnout susceptibility among attending physicians. While strategies to reduce burnout among resident and attending physicians have been under-evaluated, evidence suggests a need to address burnout at both individual and organizational levels. Solutions have been offered that are applicable to many stakeholders, including employers; payers; licensing and certification boards; state and federal regulatory agencies; and physicians and researchers. As more studies are undertaken to evaluate how these approaches impact burnout, two questions need to be addressed: (1) What is the role of sleep in the crisis of burnout, specifically among attendings, who are particularly under-studied? (2) Is restoration of healthy sleep the fundamental mechanism by which burnout interventions work? It is essential for key stakeholders to consider the role of sleep, sleepiness, and sleep disorders in order to optimize any efforts to mitigate the present crisis in physician burnout, particularly among attending physicians, an understudied group.
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http://dx.doi.org/10.5664/jcsm.8412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849805PMC
May 2020

Screening for Sleepiness and Sleep Disorders in Commercial Drivers.

Sleep Med Clin 2019 Dec 27;14(4):453-462. Epub 2019 Sep 27.

SleepEval Research Institute, 3430 West Bayshore Road, Palo Alto, CA 94303, USA.

Sleep disorders in commercial drivers are common and treatable. Left unidentified, they lead to a host of adverse consequences, including daytime sleepiness, adverse health effects, economic costs, and public safety risks owing to sleepiness-related crashes. The best studied of these is obstructive sleep apnea, which is common and identifiable among commercial drivers. This article provides an overview of screening, and specific approaches to screen for and manage obstructive sleep apnea in commercial drivers with the goal of reducing the risk of vehicular crashes.
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http://dx.doi.org/10.1016/j.jsmc.2019.08.002DOI Listing
December 2019

Evaluation and Management of Obesity Hypoventilation Syndrome. An Official American Thoracic Society Clinical Practice Guideline.

Am J Respir Crit Care Med 2019 08;200(3):e6-e24

The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS). A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations. After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: ) clinicians use a serum bicarbonate level <27 mmol/L to exclude the diagnosis of OHS in obese patients with sleep-disordered breathing when suspicion for OHS is not very high (<20%) but to measure arterial blood gases in patients strongly suspected of having OHS, ) stable ambulatory patients with OHS receive positive airway pressure (PAP), ) continuous positive airway pressure (CPAP) rather than noninvasive ventilation be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea, ) patients hospitalized with respiratory failure and suspected of having OHS be discharged with noninvasive ventilation until they undergo outpatient diagnostic procedures and PAP titration in the sleep laboratory (ideally within 2-3 mo), and ) patients with OHS use weight-loss interventions that produce sustained weight loss of 25% to 30% of body weight to achieve resolution of OHS (which is more likely to be obtained with bariatric surgery). Clinicians may use these recommendations, on the basis of the best available evidence, to guide management and improve outcomes among patients with OHS.
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http://dx.doi.org/10.1164/rccm.201905-1071STDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6680300PMC
August 2019

A Screening Algorithm for Obstructive Sleep Apnea in Pregnancy.

Ann Am Thorac Soc 2019 10;16(10):1286-1294

School of Medicine, John Hopkins University, Baltimore, Maryland.

Obstructive sleep apnea (OSA) is common in pregnancy and associated with maternal and fetal complications. Early detection of OSA may have important implications for maternal-fetal well-being. A screening tool combining several methods of assessment may better predict OSA among pregnant women compared with tools that rely solely on self-reported information. To develop a screening tool combining subjective and objective measures to predict OSA in pregnant women. This study is a secondary analysis using data collected from a completed cohort of pregnant women ( = 121 during the first and  = 87 during the third trimester). Participants underwent full polysomnography and completed the Multivariable Apnea Prediction Questionnaire. The Obstructive Sleep Apnea/Hypopnea Syndrome Score and Facco apnea predictive model were obtained. Logistic regression analysis and area under the curve (AUC) were used to identify models predicting OSA risk. Participants' mean age was 27.4 ± 7.0 years. The prevalence of OSA during the first and third trimester was 10.7% and 24.1%, respectively. The final model predicting OSA risk consisted of body mass index, age, and presence of tongue enlargement. During the first trimester, the AUC was 0.86 (95% confidence interval [CI], 0.76-0.96). During the third trimester, the AUC was 0.87 (95% CI, 0.77-0.96). When the first-trimester data were used to predict third-trimester OSA risk, the AUC was 0.87 (95% CI, 0.77-0.97). This model had high sensitivity and specificity when used during both trimesters. The negative posttest probabilities (probability of OSA given a negative test result) ranged from 0.03 to 0.07. A new model consisting of body mass index, age, and presence of tongue enlargement provided accurate screening of OSA in pregnant women, particularly African-Americans. This tool can be easily and rapidly administered in busy clinical practices without depending on patients' awareness of experiencing apnea symptoms.
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http://dx.doi.org/10.1513/AnnalsATS.201902-131OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812170PMC
October 2019

Teen Crash Risk and Insufficient Sleep.

J Adolesc Health 2019 05;64(5):671

University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.jadohealth.2019.01.025DOI Listing
May 2019

Industrial Regulation of Fatigue: Lessons Learned From Aviation.

J Clin Sleep Med 2019 04 15;15(4):537-538. Epub 2019 Apr 15.

Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.5664/jcsm.7704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457508PMC
April 2019

Screening for Obstructive Sleep Apnea in Commercial Drivers Using EKG-Derived Respiratory Power Index.

J Clin Sleep Med 2019 01 15;15(1):23-32. Epub 2019 Jan 15.

Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Study Objectives: Obstructive sleep apnea (OSA) is common in commercial motor vehicle operators (CMVOs); however, polysomnography (PSG), the gold-standard diagnostic test, is expensive and inconvenient for screening. OSA is associated with changes in heart rate and voltage on electrocardiography (EKG). We evaluated the utility of EKG parameters in identifying CMVOs at greater risk for sleepiness-related crashes (apnea-hypopnea index [AHI] ≥ 30 events/h).

Methods: In this prospective study of CMVOs, we performed EKGs with concurrent PSG, and calculated the respiratory power index (RPI) on EKG, a surrogate for AHI calculated from PSG. We evaluated the utility of two-stage predictive models using simple clinical measures (age, body mass index [BMI], neck circumference, Epworth Sleepiness Scale score, and the Multi-Variable Apnea Prediction [MVAP] score) in the first stage, followed by RPI in a subset as the second-stage. We assessed area under the receiver operating characteristic curve (AUC), sensitivity, and negative posttest probability (NPTP) for this two-stage approach and for RPI alone.

Results: The best-performing model used the MVAP, which combines BMI, age, and sex with three OSA symptoms, in the first stage, followed by RPI in the second. The model yielded an estimated (95% confidence interval) AUC of 0.883 (0.767-0.924), sensitivity of 0.917 (0.706-0.962), and NPTP of 0.034 (0.015-0.133). Predictive characteristics were similar using a model with only BMI as the first-stage screen.

Conclusions: A two-stage model that combines BMI or the MVAP score in the first stage, with EKG in the second, had robust discriminatory power to identify severe OSA in CMVOs.
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http://dx.doi.org/10.5664/jcsm.7562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329542PMC
January 2019

The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. An Official American Thoracic Society Clinical Practice Guideline.

Am J Respir Crit Care Med 2018 09;198(6):e70-e87

Background: Overweight/obesity is a common, reversible risk factor for obstructive sleep apnea severity (OSA). The purpose of this guideline is to provide evidence-based recommendations for the management of overweight/obesity in patients with OSA.

Methods: The Grading of Recommendations, Assessment, Development and Evaluation approach was used to evaluate the literature. Clinical recommendations were formulated by a panel of pulmonary, sleep medicine, weight management, and behavioral science specialists.

Results: Behavioral, pharmacological, and surgical treatments promote weight loss and can reduce OSA severity, reverse common comorbidities, and improve quality of life, although published studies have methodological limitations. After considering the quality of evidence, feasibility, and acceptability of these interventions, the panel made a strong recommendation that patients with OSA who are overweight or obese be treated with comprehensive lifestyle intervention consisting of 1) a reduced-calorie diet, 2) exercise or increased physical activity, and 3) behavioral guidance. Conditional recommendations were made regarding reduced-calorie diet and exercise/increased physical activity as separate management tools. Pharmacological therapy and bariatric surgery are appropriate for selected patients who require further assistance with weight loss.

Conclusions: Weight-loss interventions, especially comprehensive lifestyle interventions, are associated with improvements in OSA severity, cardiometabolic comorbidities, and quality of life. The American Thoracic Society recommends that clinicians regularly assess weight and incorporate weight management strategies that are tailored to individual patient preferences into the routine treatment of adult patients with OSA who are overweight or obese.
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http://dx.doi.org/10.1164/rccm.201807-1326STDOI Listing
September 2018

Evaluation of Clinical Tools to Screen and Assess for Obstructive Sleep Apnea.

J Clin Sleep Med 2018 07 15;14(7):1239-1244. Epub 2018 Jul 15.

University of Pennsylvania, Philadelphia, Pennsylvania.

Abstract: Obstructive sleep apnea (OSA) is a globally recognized medical condition, associated with development of long-term adverse health consequences, including cardiovascular disease, cerebrovascular disease, neurocognitive deficiencies, and vehicular and occupational accidents. OSA can be screened effectively, because it can be identified well before the manifestation of the aforementioned poor health and public safety consequences. Additionally, appropriate management of OSA includes an assessment of outcomes before and after therapeutic intervention initiation. OSA clinical screening and outcome assessment tools exist; however, a key existing knowledge gap is identifying which tools are most clinically relevant and efficient to use in clinical practice models. The American Academy of Sleep Medicine (AASM) commissioned a task force (TF) of sleep medicine experts to identify and evaluate current OSA screening and assessment tools for adult patients and determine if they are reliable, effective, and feasible for use in clinical settings. No single tool met all the TF's objective criteria and subjective evaluation for clinical validity and feasibility to be recommended by the AASM. The TF provides several suggestions for the development of new tools or modifications to existing tools that would enhance their functionality in adults.
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http://dx.doi.org/10.5664/jcsm.7232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6040793PMC
July 2018

Withdrawal of Advanced Notice of Proposed Rulemaking (ANPRM) on Obstructive Sleep Apnea (OSA) Does Not Mean Examiners and Employers Should Ignore Safety Risks.

J Occup Environ Med 2018 08;60(8):e431

Department of Psychiatry and Behavioral Sciences, Stanford University, Division of Sleep Medicine, Stanford, California Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1097/JOM.0000000000001375DOI Listing
August 2018

The Risk of Fatigue and Sleepiness in the Ridesharing Industry: An American Academy of Sleep Medicine Position Statement.

J Clin Sleep Med 2018 04 15;14(4):683-685. Epub 2018 Apr 15.

Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Abstract: The ridesharing-or ride-hailing-industry has grown exponentially in recent years, transforming quickly into a fee-for-service, unregulated taxi industry. While riders are experiencing the benefits of convenience and affordability, two key regulatory and safety issues deserve consideration. First, individuals who work as drivers in the ridesharing industry are often employed in a primary job, and they work as drivers during their "off" time. Such a schedule may lead to driving after extended periods of wakefulness or during nights, both of which are factors that increase the risk of drowsy driving accidents. Second, these drivers are often employed as "independent contractors," and therefore they are not screened for medical problems that can reduce alertness, such as obstructive sleep apnea. Some ridesharing companies now require a rest period after an extended driving shift. This measure is encouraging, but it is insufficient to impact driving safety appreciably, particularly since many of these drivers are already working extended hours and tend to drive at non-traditional times when sleepiness may peak. Therefore, it is the position of the American Academy of Sleep Medicine (AASM) that fatigue and sleepiness are inherent safety risks in the ridesharing industry. The AASM calls on ridesharing companies, government officials, medical professionals, and law enforcement officers to work together to address this public safety risk. A collaborative effort is necessary to understand and track the scope of the problem, provide relevant education, and mitigate the risk through thoughtful regulation and effective fatigue risk management systems.
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http://dx.doi.org/10.5664/jcsm.7072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5886447PMC
April 2018

Knowledge Gaps in the Perioperative Management of Adults with Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome. An Official American Thoracic Society Workshop Report.

Ann Am Thorac Soc 2018 02;15(2):117-126

The purpose of this workshop was to identify knowledge gaps in the perioperative management of obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS). A single-day meeting was held at the American Thoracic Society Conference in May, 2016, with representation from many specialties, including anesthesiology, perioperative medicine, sleep, and respiratory medicine. Further research is urgently needed as we look to improve health outcomes for these patients and reduce health care costs. There is currently insufficient evidence to guide screening and optimization of OSA and OHS in the perioperative setting to achieve these objectives. Patients who are at greatest risk of respiratory or cardiac complications related to OSA and OHS are not well defined, and the effectiveness of monitoring and other interventions remains to be determined. Centers involved in sleep research need to develop collaborative networks to allow multicenter studies to address the knowledge gaps identified below.
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http://dx.doi.org/10.1513/AnnalsATS.201711-888WSDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850745PMC
February 2018

Effect of CPAP, Weight Loss, or CPAP Plus Weight Loss on Central Hemodynamics and Arterial Stiffness.

Hypertension 2017 12 16;70(6):1283-1290. Epub 2017 Oct 16.

From the Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (S.J.); Divisions of Sleep Medicine (I.G., G.M., S.T.K, A.I.P.), Nephrology (R.T) and Cardiovascular Medicine (J.A.C., Z.A.), Department of Medicine and Center for Weight and Eating Disorders, Department of Psychiatry (T.A.W), University of Pennsylvania Perelman School of Medicine, Philadelphia; Hospital of University of Pennsylvania, Philadelphia (R.T., S.T.K., T.A.W., A.I.P., J.A.C.); Corporal Michael Crescenz VA Medical Center, Philadelphia, PA (I.G.); Division of Diabetes, National Institutes of Health, Bethesda, MD (K.T.); Departments of Biostatistics Consulting Unit (J.C.) and Family and Community Health, (A.L.H.), School of Nursing, University of Pennsylvania, Philadelphia; Department of Cardiology, Lehigh Valley Health Network, Allentown, PA (H.S.); and Johns Hopkins University Technology and Innovation Center, Johns Hopkins University, Baltimore, MD (P.B.).

Obesity and obstructive sleep apnea tend to coexist. Little is known about the effects of obstructive sleep apnea, obesity, or their treatment on central aortic pressures and large artery stiffness. We randomized 139 adults with obesity (body mass index >30 kg/m) and moderate-to-severe obstructive sleep apnea to (1) continuous positive airway pressure (CPAP) therapy (n=45), (2) weight loss (WL) therapy (n=48), or (3) combined CPAP and WL (n=46) for 24 weeks. We assessed the effect of these interventions on central pressures and carotid-femoral pulse wave velocity (a measure of large artery stiffness), measured with arterial tonometry. Central systolic pressure was reduced significantly only in the combination arm (-7.4 mm Hg; 95% confidence interval, -12.5 to -2.4 mm Hg; =0.004), without significant reductions detected in either the WL-only (-2.3 mm Hg; 95% confidence interval, -7.5 to 3.0; =0.39) or the CPAP-only (-3.1 mm Hg; 95% confidence interval, -8.3 to 2.0; =0.23) arms. However, none of these interventions significantly changed central pulse pressure, pulse pressure amplification, or the central augmentation index. The change in mean arterial pressure (=0.008) and heart rate (=0.027) induced by the interventions was significant predictors of the change in carotid-femoral pulse wave velocity. However, after adjustment for mean arterial pressure and heart rate, no significant changes in carotid-femoral pulse wave velocity were observed in any group. In obese subjects with obstructive sleep apnea, combination therapy with WL and CPAP is effective in reducing central systolic pressure. However, this effect is largely mediated by changes in mean, rather than central pulse pressure. WL and CPAP, alone or in combination, did not reduce large artery stiffness in this population.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00371293.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.117.09392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726418PMC
December 2017

Depressive symptoms in patients with obstructive sleep apnea: biological mechanistic pathways.

J Behav Med 2017 Dec 21;40(6):955-963. Epub 2017 Jun 21.

School of Medicine/Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA.

This study examined the association between depressive symptoms, as well as depressive symptom dimensions, and three candidate biological pathways linking them to Obstructive sleep apnea (OSA): (1) inflammation; (2) circulating leptin; and (3) intermittent hypoxemia. Participants included 181 obese adults with moderate-to-severe OSA enrolled in the Cardiovascular Consequences of Sleep Apnea (COSA) trial. Depressive symptoms were measured using the Beck Depression Inventory-II (BDI-II). We assessed inflammation using C-reactive protein levels (CRP), circulating leptin by radioimmunoassay using a double antibody/PEG assay, and intermittent hypoxemia by the percentage of sleep time each patient had below 90% oxyhemoglobin saturation. We found no significant associations between BDI-II total or cognitive scores and CRP, leptin, or percentage of sleep time below 90% oxyhemoglobin saturation after controlling for relevant confounding factors. Somatic symptoms, however, were positively associated with percentage of sleep time below 90% saturation (β = 0.202, P = 0.032), but not with CRP or circulating leptin in adjusted models. Another significant predictor of depressive symptoms included sleep efficiency (β = -0.230, P = 0.003; β = -0.173, P = 0.030 (β = -0.255, P = 0.001). In patients with moderate-to-severe OSA, intermittent hypoxia may play a role in somatic rather than cognitive or total depressive symptoms.
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http://dx.doi.org/10.1007/s10865-017-9869-4DOI Listing
December 2017

Symptomless Multi-Variable Apnea Prediction Index Assesses Obstructive Sleep Apnea Risk and Adverse Outcomes in Elective Surgery.

Sleep 2017 Mar;40(3)

Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Study Objective: To validate that the symptomless Multi-Variable Apnea Prediction index (sMVAP) is associated with Obstructive Sleep Apnea (OSA) diagnosis and assess the relationship between sMVAP and adverse outcomes in patients having elective surgery. We also compare associations between Bariatric surgery, where preoperative screening for OSA risk is mandatory, and non-Bariatric surgery groups who are not screened routinely for OSA.

Methods: Using data from 40 432 elective inpatient surgeries, we used logistic regression to determine the relationship between sMVAP and previous OSA, current hypertension, and postoperative complications: extended length of stay (ELOS), intensive-care-unit-stay (ICU-stay), and respiratory complications (pulmonary embolism, acute respiratory distress syndrome, and/or aspiration pneumonia).

Results: Higher sMVAP was associated with increased likelihood of previous OSA, hypertension and all postoperative complications (p < .0001). The top sMVAP quintile had increased odds of postoperative complications compared to the bottom quintile. For ELOS, ICU-stay, and respiratory complications, respective odds ratios (95% CI) were: 1.83 (1.62, 2.07), 1.44 (1.32, 1.58), and 1.85 (1.37, 2.49). Compared against age-, gender- and BMI-matched patients having Bariatric surgery, sMVAP was more strongly associated with postoperative complications in non-Bariatric surgical groups, including: (1) ELOS (Orthopedics [p < .0001], Gastrointestinal [p = .024], Neurosurgery [p = .016], Spine [p = .016]); (2) ICU-stay (Orthopedics [p = .0004], Gastrointestinal [p < .0001], and Otorhinolaryngology [p = .0102]); and (3) respiratory complications (Orthopedics [p =.037] and Otorhinolaryngology [p =.011]).

Conclusions: OSA risk measured by sMVAP correlates with higher risk for select postoperative complications. Associations are stronger for non-Bariatric surgeries, where preoperative screening for OSA is not routinely performed. Thus, preoperative screening may reduce OSA-related risk for adverse postoperative outcomes.
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http://dx.doi.org/10.1093/sleep/zsw081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806575PMC
March 2017

Management of Obstructive Sleep Apnea in Commercial Motor Vehicle Operators: Recommendations of the AASM Sleep and Transportation Safety Awareness Task Force.

J Clin Sleep Med 2017 May 15;13(5):745-758. Epub 2017 May 15.

University of Washington Medicine Sleep Disorders Center and Department of Neurology, University of Washington, Seattle, Washington.

Abstract: The American Academy of Sleep Medicine Sleep and Transportation Safety Awareness Task Force responded to the Federal Motor Carrier Safety Administration and Federal Railroad Administration Advance Notice of Proposed Rulemaking and request for public comments regarding the evaluation of safety-sensitive personnel for moderate-to-severe obstructive sleep apnea (OSA). The following document represents this response. The most salient points provided in our comments are that (1) moderate-to-severe OSA is common among commercial motor vehicle operators (CMVOs) and contributes to an increased risk of crashes; (2) objective screening methods are available and preferred for identifying at-risk drivers, with the most commonly used indicator being body mass index; (3) treatment in the form of continuous positive airway pressure (CPAP) is effective and reduces crashes; (4) CPAP is economically viable; (5) guidelines are available to assist medical examiners in determining whether CMVOs with moderate-to-severe OSA should continue to work without restrictions, with conditional certification, or be disqualified from operating commercial motor vehicles.
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http://dx.doi.org/10.5664/jcsm.6598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406951PMC
May 2017

Blind Spot: Are We Neglecting House Staff Driving Safety in the Era of Duty Hour Regulations? Driving Performance of Residents after Six Consecutive Overnight Work Shifts.

Anesthesiology 2016 06;124(6):1210-2

From the Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and Sleep Section, Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania (I.G.); Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, and the University of Pennsylvania, Philadelphia, Pennsylvania (V.N.); and Division of General Pediatrics, Department of Pediatrics and Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, and Center for Injury Research and Prevention at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (F.W.).

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http://dx.doi.org/10.1097/ALN.0000000000001105DOI Listing
June 2016

Sleep apnea in total joint arthroplasty patients and the role for cardiac biomarkers for risk stratification: an exploration of feasibility.

Biomark Med 2016 ;10(3):265-300

Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Obstructive sleep apnea (OSA) is highly prevalent in patients undergoing total joint arthroplasty (TJA) and is a major risk factor for postoperative cardiovascular complications and death. Recognizing this, the American Society of Anesthesiologists urges clinicians to implement special considerations in the perioperative care of OSA patients. However, as the volume of patients presenting for TJA increases, resources to implement these recommendations are limited. This necessitates mechanisms to efficiently risk stratify patients having OSA who may be susceptible to post-TJA cardiovascular complications. We explore the role of perioperative measurement of cardiac troponins (cTns) and brain natriuretic peptides (BNPs) in helping determine which OSA patients are at increased risk for post-TJA cardiovascular-related morbidity.
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http://dx.doi.org/10.2217/bmm.16.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5493965PMC
December 2016

Sleep Apnea Evaluation of Commercial Motor Vehicle Operators.

J Clin Sleep Med 2015 Mar 15;12(3):285-6. Epub 2015 Mar 15.

University of Washington, UW Medicine Sleep Center, Seattle, WA.

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http://dx.doi.org/10.5664/jcsm.5560DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773613PMC
March 2015

CPAP, weight loss, or both for obstructive sleep apnea.

N Engl J Med 2014 Jun;370(24):2265-75

From the Philadelphia Veterans Affairs Medical Center (J.A.C., I.G.), Perelman School of Medicine, University of Pennsylvania-Hospital of the University of Pennsylvania (J.A.C., I.G., D.J.R., T.A.W., R.T., G.M., H.S., P.B., A.I.P.), Monell Chemical Senses Center (K.T.), Temple University School of Medicine (G.D.F.), and University of Pennsylvania School of Nursing (J.C., A.L.H.) - all in Philadelphia.

Background: Obesity and obstructive sleep apnea tend to coexist and are associated with inflammation, insulin resistance, dyslipidemia, and high blood pressure, but their causal relation to these abnormalities is unclear.

Methods: We randomly assigned 181 patients with obesity, moderate-to-severe obstructive sleep apnea, and serum levels of C-reactive protein (CRP) greater than 1.0 mg per liter to receive treatment with continuous positive airway pressure (CPAP), a weight-loss intervention, or CPAP plus a weight-loss intervention for 24 weeks. We assessed the incremental effect of the combined interventions over each one alone on the CRP level (the primary end point), insulin sensitivity, lipid levels, and blood pressure.

Results: Among the 146 participants for whom there were follow-up data, those assigned to weight loss only and those assigned to the combined interventions had reductions in CRP levels, insulin resistance, and serum triglyceride levels. None of these changes were observed in the group receiving CPAP alone. Blood pressure was reduced in all three groups. No significant incremental effect on CRP levels was found for the combined interventions as compared with either weight loss or CPAP alone. Reductions in insulin resistance and serum triglyceride levels were greater in the combined-intervention group than in the group receiving CPAP only, but there were no significant differences in these values between the combined-intervention group and the weight-loss group. In per-protocol analyses, which included 90 participants who met prespecified criteria for adherence, the combined interventions resulted in a larger reduction in systolic blood pressure and mean arterial pressure than did either CPAP or weight loss alone.

Conclusions: In adults with obesity and obstructive sleep apnea, CPAP combined with a weight-loss intervention did not reduce CRP levels more than either intervention alone. In secondary analyses, weight loss provided an incremental reduction in insulin resistance and serum triglyceride levels when combined with CPAP. In addition, adherence to a regimen of weight loss and CPAP may result in incremental reductions in blood pressure as compared with either intervention alone. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT0371293 .).
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http://dx.doi.org/10.1056/NEJMoa1306187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4138510PMC
June 2014

Rationale for broader testing of drivers for obstructive sleep apnea: a response to Hartenbaum and colleagues.

J Occup Environ Med 2014 Feb;56(2):121-2

Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.

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http://dx.doi.org/10.1097/JOM.0000000000000106DOI Listing
February 2014

Habitual sleep duration associated with self-reported and objectively determined cardiometabolic risk factors.

Sleep Med 2014 Jan 28;15(1):42-50. Epub 2013 Oct 28.

Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, United States; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, United States; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.

Background: Self-reported short or long sleep duration has been associated with adverse cardiometabolic health outcomes in laboratory and epidemiologic studies, but interpretation of such data has been limited by methodologic issues.

Methods: Adult respondents of the 2007-2008 US National Health and Nutrition Examination Survey (NHANES) were examined in a cross-sectional analysis (N=5649). Self-reported sleep duration was categorized as very short (<5 h), short (5-6 h), normal (7-8 h), or long (≥9 h). Obesity, diabetes mellitus (DM), hypertension, and hyperlipidemia were objectively assessed by self-reported history. Statistical analyses included univariate comparisons across sleep duration categories for all variables. Binary logistic regression analyses and cardiometabolic factor as outcome, with sleep duration category as predictor, were assessed with and without covariates. Observed relationships were further assessed for dependence on race/ethnicity.

Results: In adjusted analyses, very short sleep was associated with self-reported hypertension (odds ratio [OR], 2.02, [95% confidence interval {CI},1.45-2.81]; P<0.0001), self-reported hyperlipidemia (OR, 1.96 [95% CI, 1.43-2.69]; P<0.0001), objective hyperlipidemia (OR, 1.41 [95% CI, 1.04-1.91]; P=0.03), self-reported DM (OR, 1.76 [95% CI, 1.13-2.74]; P=0.01), and objective obesity (OR, 1.53 [95% CI, 1.03-1.43]; P=0.005). Regarding short sleep (5-6 h), in adjusted analyses, elevated risk was seen for self-reported hypertension (OR, 1.22 [95% CI, 1.02-1.45]; P=0.03) self-reported obesity (OR, 1.21 [95% CI, 1.03-1.43]; P=0.02), and objective obesity (OR, 1.17 [95% CI, 1.00-1.38]; P<0.05). Regarding long sleep (≥9 h), no elevated risk was found for any outcomes. Interactions with race/ethnicity were significant for all outcomes; race/ethnicity differences in patterns of risk varied by outcome studied. In particular, the relationship between very short sleep and obesity was strongest among blacks and the relationship between short sleep and hypertension is strongest among non-Hispanic whites, blacks, and non-Mexican Hispanics/Latinos.

Conclusions: Short sleep duration is associated with self-reported and objectively determined adverse cardiometabolic outcomes, even after adjustment for many covariates. Also, these patterns of risk depend on race/ethnicity.
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http://dx.doi.org/10.1016/j.sleep.2013.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3947242PMC
January 2014