Publications by authors named "Khosro Sadeghniiat-Haghighi"

51 Publications

The effect of group cognitive behavioural therapy for insomnia in postmenopausal women.

J Sleep Res 2021 Apr 5:e13345. Epub 2021 Apr 5.

Faculty of Public Health, Department of Statistics and Epidemiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

The menopausal period is associated with several complications in women. One of these complications is sleep disorders including insomnia disorder that can affect all aspects of personal life. The present study aimed to evaluate the effectiveness of cognitive behavioural therapy for insomnia (CBT-I) on insomnia severity and sleep quality among postmenopausal women. This was a randomised clinical trial in which 46 women were recruited and randomly allocated into two groups, one receiving CBT-I and a control group. The CBT-I group received six sessions of training, while the control group received only usual care. A demographic questionnaire, Insomnia Severity Index (ISI), and Pittsburgh Sleep Quality Index (PSQI), were used to collect the data. The ISI and PSQI were measured at baseline, 3 and 6 weeks after intervention, and in a 4-week follow-up. The Independent t test, the chi-square test, generalised estimating equation models, and Bonferroni correction were applied to analyse the data. According to our results, in the CBT-I group compared to the control group, the mean ISI, PSQI, sleep onset latency, sleep time, and sleep quality score reduced continuously from baseline to week 3 and from week 3 to week 6, and remained constant from week 6 to week 10. The mean sleep efficiency score improved significantly from baseline to week 3 in the CBT-I group and remained unchanged until the end of the study. CBT-I could significantly improve insomnia severity and sleep quality in postmenopausal women. Therefore, using this method is recommended for menopausal women with insomnia.
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http://dx.doi.org/10.1111/jsr.13345DOI Listing
April 2021

COVID-19: sleep research perspectives.

Sleep Sci 2020 Jul-Sep;13(3):184-185

Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran.

Coronavirus disease of 2019 (COVID-19) pandemic originated from Wuhan in December 2019 and has been spread in whole China and the world. Worldwide outbreaks of COVID-19 triggered a large number of morbidities and mortalities beside its economic and social burdens, which are discussed a lot, in scientific literature and different types of media. As a sleep medicine specialist, we may wonder how we can be involved in this field. In this short theoretical essay, we will discuss about the known facts as well as the hypotheses, which associate the sleep medicine to COVID-19. The discussed points may provide a source of research ideas throughout the world for better understanding of novel coronavirus-19 that has devastating effects on humanity.
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http://dx.doi.org/10.5935/1984-0063.20200033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755263PMC
December 2020

Cardioprotective effects of acute sleep deprivation on ischemia/reperfusion injury.

Auton Neurosci 2021 01 4;230:102761. Epub 2020 Dec 4.

Department of Physiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

Objectives: Modulation of sympathetic activity during acute sleep deprivation can produce various effects on body functions. We studied the effects of acute sleep deprivation before ischemia/reperfusion on myocardial injury in isolated rat hearts, and the role of sympathetic nervous system that may mediate these sleep deprivation induced effects.

Methods: The animals were randomized into four groups (n = 11 per group): Ischemia- Reperfusion group (IR), Acute sleep deprivation group (SD), Control group for sleep deprivation (CON-SD) and Sympathectomy + ASD group (SYM-SD). In SD group, sleep deprivation paradigm was used 24 h prior to induction of ischemia/reperfusion. In SYM-SD group, the animals were chemically sympathectomized using 6-hydroxydopamine, 24 h before sleep deprivation. Then, the hearts of animals were perfused using Langendorff setup and were subjected to 30 min regional ischemia followed by 60 min of reperfusion. Throughout the experiment, the hearts were allowed to beat spontaneously and left ventricular developed pressure (LVDP) and rate pressure product (RPP) were recorded. At the end of study, infarct size and percentage of the area at risk were determined.

Results: We found that SD increased LVDP and RPP, while reducing the myocardial infarct size. Moreover, sympathectomy reversed SD induced reduction in infarct size and showed no differences as compared to IR.

Conclusion: This study shows cardioprotective effects of acute sleep deprivation, which can be abolished by chemical sympathectomy in isolated hearts of rats.
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http://dx.doi.org/10.1016/j.autneu.2020.102761DOI Listing
January 2021

Clinical Characteristics and Outcomes of 905 COVID-19 Patients Admitted to Imam Khomeini Hospital Complex in the Capital City of Tehran, Iran.

Arch Iran Med 2020 11 1;23(11):766-775. Epub 2020 Nov 1.

Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran.

Background: We studied the clinical characteristics and outcomes of 905 hospitalized coronavirus disease 2019 (COVID-19) patients admitted to Imam Khomeini Hospital Complex (IKHC), Tehran, Iran.

Methods: COVID-19 patients were recruited based on clinical symptoms and patterns of computed tomography (CT) imaging between February 20 and March 19. All patients were tested for the presence of COVID-19 RNA. The Poisson regression model estimated the incidence rate ratio (IRR) for different parameters.

Results: The average age (± standard deviation) was 56.9 (±15.7) years and 61.77% were male. The most common symptoms were fever (93.59%), dry cough (79.78%), and dyspnea (75.69%). Only 43.76% of patients were positive for the RT-PCR COVID-19 test. Prevalence of lymphopenia was 42.9% and more than 90% had elevated lactate dehydrogenase (LDH) or C-reactive protein (CRP). About 11% were severe cases, and 13.7% died in the hospital. The median length of stay (LOS) was 3 days. We found higher risks of mortality in patients who were older than 70 years (IRR = 11.77, 95% CI 3.63-38.18), underwent mechanical ventilation (IRR = 7.36, 95% CI 5.06-10.7), were admitted to the intensive care unit (ICU) (IRR = 5.47, 95% CI 4.00-8.38), tested positive on the COVID-19 test (IRR = 2.80, 95% CI 1.64-3.55), and reported a history of comorbidity (IRR = 1.76, 95% CI 1.07-2.89) compared to their corresponding reference groups. Hydroxychloroquine therapy was not associated with mortality in our study.

Conclusion: Older age, experiencing a severe form of the disease, and having a comorbidity were the most important prognostic factors for COVID-19 infection. Larger studies are needed to perform further subgroup analyses and verify high-risk groups.
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http://dx.doi.org/10.34172/aim.2020.102DOI Listing
November 2020

Glasgow Sleep Effort Scale: Translation, Test, and Evaluation of Psychometric Properties of the Persian Version.

Nat Sci Sleep 2020 28;12:843-854. Epub 2020 Oct 28.

Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran.

Purpose: The purpose of the current study is to translate, test and evaluate the psychometric properties of the Glasgow Sleep Effort Scale (GSES) in Persian language.

Methods: Participants consisted of two samples: a clinical sample of 120 patients (58%) with insomnia disorder meeting DSM-5 criteria for insomnia and a non-clinical sample of 110 participants (42%) with normal sleep. Both samples completed the following measures: GSES, Pittsburg Sleep Quality Index, Insomnia Severity Index, Dysfunctional Beliefs and Attitudes about Sleep Scale-10, Pre Sleep Arousal Scale-cognitive subscale, Depression-Anxiety-Stress Scale-21 and sleep diary.

Results: Significant correlations were found between GSES and related measures in both groups. Principal component analysis indicated a single component accounted for 64.77% of total variance in the clinical group. Results of the fit estimates for the one-factor model were consistent with the previously specified fit criteria and adequately fitted the data in the non-clinical group. Statistical analyses showed that the GSES has acceptable internal consistency in terms of Cronbach's Alpha in the clinical (0.75) and non-clinical (0.77) samples. Test-retest reliability for a 4-week interval was significant (r = 0.70). The cut-off point, sensitivity, and specificity of the scale were 6, 85% and 94.5%, respectively.

Conclusion: The Persian translated and validated version of the GSES obtained adequate values in psychometric properties in both clinical and non-clinical samples and it can be used for research and clinical purposes in Iran.
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http://dx.doi.org/10.2147/NSS.S258471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643769PMC
October 2020

The effect of apnea management on novel coronavirus infection: A study on patients with obstructive sleep apnea.

Sleep Health 2021 02 3;7(1):14-18. Epub 2020 Nov 3.

Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran. Electronic address:

Objective: To assess the frequency of coronavirus disease-2019 (COVID-19) and the effect of obstructive sleep apnea (OSA) management on COVID-19 among patients with confirmed OSA.

Design: Cross-sectional telephone interview survey.

Setting: Academic sleep labs.

Participants: Iranian adults ≥ 18 years old with confirmed OSA.

Results: Among 275 participants with OSA, 20% (n = 55) were suspected to have history of COVID-19 but had no positive test, and 18% (n = 51) were in the definite COVID-19 group according to their reported symptoms or confirmed positive test. Having severe OSA (apnea hypopnea index ≥ 30) was associated with an increased risk of definite COVID-19, with an odds ratio (OR) with 95% confidence interval (95% CI) of 2.31 (0.87-5.55) compared to having mild OSA in definite COVID-19 group. Those not undergoing treatment for OSA had an OR (95% CI) of 2.43 (1.26-4.67) for definite COVID-19 compared to those accepting treatment in definite COVID-19 group. Total sleep times (TSTs) were 354, 340, and 320 minutes in healthy, suspected, and COVID-19 groups, respectively; TST was associated with COVID-19 (P-value = .04). Similarly, sleep efficiency (SE) scores were 75.7, 74.2, and 67.9% for the healthy, suspected, and COVID-19 groups, respectively (P-value = .005); Beck Depression scores were 13.8, 13.0, and 17.7, respectively (P-value = .056).

Conclusions: OSA as a proinflammatory condition with multiple comorbidities may be a contributing factor to developing COVID-19. Greater OSA severity, no treatment for OSA, and lower TST and SE were associated with increased COVID-19 prevalence among patients with OSA.
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http://dx.doi.org/10.1016/j.sleh.2020.09.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607233PMC
February 2021

The impact of the HLA DQB1 gene and amino acids on the development of narcolepsy.

Int J Neurosci 2020 Oct 22:1-8. Epub 2020 Oct 22.

Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

Introduction: Narcolepsy is a chronic neurological and a genetic disorder of autoimmune origin, which is characterized by five main symptoms, including excessive day time sleepiness, sudden loss of muscle tone or cataplexy, sleep paralysis, hypnagogic hallucinations, and disturbed nocturnal sleep. While there are several diagnostic tests for Narcolepsy such as MSLT (mean sleep latency test), polysomnography and low range of hypocretin in cerebrospinal fluid (CSF), sensitivity and specificity in these methodologies are not sufficient enough. Therefore, methods with higher sensitivity for the accurate diagnosis and confirmation of the disease are necessary.

Methods: According to the infrequent prevalence of narcolepsy disease, we scheduled a case-control association study with 20 narcoleptic patients and 150 healthy individuals in a high-resolution HLA typing procedure employing SSP-PCR.

Results: Our study demonstrates that the DQB1*06:02 allele provides the highest susceptibility with absolute risk of 0.13%, for Narcolepsy (P = 1x10, RR = 60.5, PcPPV = 0.13%), while, HLA-DQB1* 03:05 allele presents protection to Narcolepsy (P = 1x10, PcPPV = 3.19x10%). Furthermore, for the first time, the AA analysis displayed that AA serine and threonine located on epitope of DQβ1 chain receptor (DQB1) present significant susceptibility for Narcolepsy (Pc= 87.03 × 10, PcPPV = 0.024%) while, asparagine located on epitope of DQβ1 protein receptor (DQB1 ) confers the highest protection against development of Narcolepsy (Pc= 2.16 × 10, PcPPV = 0.0012%).

Conclusion: Thus, this can be proposed that the polymorphic differences in the epitope of the HLA receptor could contribute to their differential association with the Narcolepsy in Iranian population.
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http://dx.doi.org/10.1080/00207454.2020.1835903DOI Listing
October 2020

Treatment emergent obstructive sleep apnea after Chiari surgery: A case report.

Sleep Sci 2020 Apr-Jun;13(2):176-180

Tehran University of Medical Sciences, Occupational Sleep Research Center, Baharloo Hospital - Tehran - Iran.

Patients with Chiari type I malformation may also present with sleep disordered breathing mainly central sleep apnea. Here, we report a patient with Chiari I malformation referred to our clinic because of snoring and sleep disordered breathing. He was a 28-year-old man referred to us for evaluation of snoring. An overnight polysomnography revealed central sleep apnea. On further evaluation of central sleep apnea, the patient found to have Chiari malformation type I on brain MRI. The patient developed obstructive sleep apnea after surgery for Chiari malformation. Accordingly, pap titration was performed for the patient's obstructive sleep apnea. In patients with central sleep apnea comprehensive evaluation of predisposing causes is required. Lesions of central nervous system including Chiari malformation should not be overlooked. Furthermore, after treatment of central sleep apnea follow up PSG is warranted to confirm newly emerged sleep breathing disorder such as obstructive sleep apnea.
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http://dx.doi.org/10.5935/1984-0063.20190140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384529PMC
August 2020

Validity and reliability of the Persian version of the Insomnia Diurnal Impact Scale (IDIS).

Sleep Breath 2021 Mar 9;25(1):449-457. Epub 2020 Jul 9.

Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: Insomnia disorder is characterized by nighttime and daytime symptoms. The aim of this study was to assess the validity and reliability of a Persian version of the Insomnia Diurnal Impact Scale (IDIS) as a screening tool to evaluate diurnal effects of sleep fragmentation in Iranians.

Methods: Of 300 individuals recruited, 150 had insomnia disorder based on DSM-5 criteria and 150 were good sleepers based on research diagnostic criteria. All subjects completed the IDIS, Pittsburg Sleep Quality Index, Insomnia Severity Index, Depression-Anxiety-Stress Scale-21, and sleep diaries.

Results: The Persian version of the IDIS showed adequate psychometric properties for internal consistency and test-retest reliability. The result of principal component analysis confirmed a single component with six items as the final structure of the scale in the insomniac group. The total IDIS score significantly correlated with the Pittsburg Sleep Quality Index, Insomnia Severity Index, and subscales of Depression-Anxiety-Stress Scale-21 verifying the convergent validity of the scale. The Persian version of the IDIS significantly discriminated the insomniac group from the non-insomniac group. The result of the fit estimates for the one-factor unidimensional model met the previously specified fit criteria and adequately fit the data in the non-insomniac group.

Conclusion: The Persian version of the IDIS was shown to be a valid and reliable clinical tool in evaluating the daytime consequences of insomnia in Iranians.
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http://dx.doi.org/10.1007/s11325-020-02116-yDOI Listing
March 2021

Twelve Lessons on Hospital Leadership during COVID-19 Pandemic.

Arch Bone Jt Surg 2020 Apr;8(Suppl1):277-280

Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.

Coronavirus pandemic has been announced by World Health Organization Director General on March 11th, 2020. Imam Khomeini Hospital Complex, affiliated to Tehran University of Medical Sciences, was one the first referral hospitals in the capital city of Tehran, I.R.Iran that entered the crisis and started a serious battle with the disease. The hospital had to change many routine operations to cope with the situation and during this journey, we used published leadership principles and reached to some new experiences. As this is probably the most severe health-related crisis in Iran in the past 100 years, we gathered our lessons learned in the first fifty days of epidemic from the leadership point of view to share those with all colleagues worldwide. We know that leadership is of pivotal role in such a massive crisis and focused leadership experiences can help health care providers to manage the crisis while we are in the middle of it.
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http://dx.doi.org/10.22038/abjs.2020.47829.2363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296595PMC
April 2020

Evaluation of forced oscilometry technique's parameters in severe obstructive sleep apnea patients without breathing disorder.

J Family Med Prim Care 2020 Mar 26;9(3):1492-1496. Epub 2020 Mar 26.

Advance Thoracic Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Background: Forced oscillometry technique (FOT) is a noninvasive technique that measures reactance and resistance capacity of the lung and is a practical and less time-consuming technique for respiratory effort assessment. Recently, FOT has provided beneficial data regarding the screening of the patients with obstructive sleep apnea (OSA) and assessing the disease progression. The current study aimed to evaluate the correlation of FOT parameters with severity of the apnea-hypnea index (AHI).

Methods: In the current case series, all patients who had a body mass index ranging between 30 and 35, suffering severe OSA with AHI of more than 30 times per hour, were enrolled. Patients underwent FOT before treatment to measure the following FOT parameters: Respiratory resistance at 5 and 20 Hz (R5 and R20, respectively), resistance difference between R5 and R20, reactance at 5 Hz (X5), and resonant frequency (Fres).

Results: In the current study, 22 patients were enrolled; whereas 12 (54.5%) were male and 10 (45.5%) were female with a mean age of 5.27 ± 4.34. A statistically significant, strong negative correlation was observed between Fres and AHI, during Pearson correlation analysis ( (20) =0.59, < 0.0001). However, the relationship between the AHI and R5, R20, R5-R20 and X5 was not statistically significant. Similarly, the multiple regression model showed that, only Fres variable added statistically significantly to the prediction, = 0.01.

Conclusion: FOT is a useful tool in evaluation of AHI severity in patients suffering OSA and can be used as a diagnostic material in monitoring and management of these patients.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_954_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266221PMC
March 2020

Evaluating the quality and duration of sleep using actigraphy in petroleum industry shift workers.

Sleep Health 2020 06 5;6(3):407-410. Epub 2020 Jun 5.

Department of Occupational Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

Introduction: Increased use of shift work has led to more and more people working outside a traditional daytime schedule. Currently, approximately 20% of the labor force in developed countries is shift workers. Shift work can have devastating effects on employees' quality of life and sleep, leading to negative consequences for individuals and their families. This study evaluates the effect of different shift schedules (seven days/seven nights, fixed-day or fixed-night, and stand-by shift) on the sleep of oil rig shift workers.

Participants And Methods: In this cross-sectional study, 43 offshore workers from the National Iranian Drilling Company were enrolled. Subjects were asked to complete a questionnaire package consisting of the Epworth Sleepiness scale and Pittsburgh Sleep Quality Index (PSQI). Changes in sleep patterns were measured using actigraphy for different shift schedules.

Results: The mean age of the participants was 35.9 ± 7.9 years and the mean tenure with the drilling company was 10 ± 6.8 years. The mean total sleep time was 353 ± 58 min. The seven day/seven night shift workers had less total sleep time than the other three groups of shift workers. The mean PSQI and Epworth Sleepiness scale scores were 6.77 ± 3.1 and 7.49 ± 4.3, respectively. Twelve shift workers (27%) were diagnosed with shift work disorder in the current study and 31 participants had poor sleep quality according to PSQI score (≥5).

Conclusion: Poor sleep quality is common in oil rig shift workers. Further research is needed to evaluate sleep problems in oil rig shift workers.
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http://dx.doi.org/10.1016/j.sleh.2020.04.010DOI Listing
June 2020

Assessment of the relationship between metabolic syndrome and obstructive sleep apnea in male drivers of Shahroud city in 2018: a cross sectional study.

BMC Public Health 2019 Aug 6;19(1):1058. Epub 2019 Aug 6.

Environmental and Occupational Health Research centre, Shahroud University of Medical Sciences, Shahroud, Iran.

Background: Metabolic syndrome involves a set of metabolic risk factors that directly increases the risk of atherosclerotic cardiovascular disease. Physical inactivity due to driving can increase the risk of metabolic syndrome. It is also known that sleep disorders (sleep apnea) can result in MetS. Driving in Iran is considered a very popular but risky occupation, so paying attention to this profession is of special importance. Therefore, the researchers aimed to investigate the association between sleep disorders and metabolic syndrome in drivers in Shahroud city in 2018.

Methods: This cross-sectional study was carried out on 948 drivers from Shahroud city in 2018. After obtaining consent from participants, 3 questionnaires including demographic, Epworth Sleepiness Scale and STOP-BANG were completed. Clinical and anthropometric measurements were assessed, including blood pressure, waist circumference, hip circumference, weight, height, and body mass index. In addition, blood was drawn to measure High Density Lipoprotein, Low Density Lipoprotein, Triglyceride, cholesterol, and Fasting Blood Sugar levels. The relationship between metabolic syndrome and sleep disorders was then studied. In this study, statistical analyses were performed using SPSS software version 23 at a significance level of 0.05.

Results: Mean age of drivers was 44.15 ± 11.66 (years). The mean waist circumference and mean hip circumference in subjects with a Class 1 Driver's License (a certificate for trucks and buses) were higher than those with a Class 2 Driver's License (a certificate for motorcars, minibuses, vans, etc. (seating< 20)) (P = 0.01 and P = 0.003, respectively). Moreover, the BMI in subjects with a Class 1 Driver's License was higher compared to subjects with a Class 2 Driver's License. The correlation between metabolic syndrome with sleep apnea based on STOP-BANG questionnaire was significant (p < 0.001) irrespective of definition (ATP and IDF).

Conclusions: According to the results of this study, there was a bi-directional association between sleep disorders and Mets, so this group should pass periodic medical examinations and training courses. Moreover, their families should be informed of prevention and treatment of this syndrome.
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http://dx.doi.org/10.1186/s12889-019-7361-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6685249PMC
August 2019

Investigating the Prevalence of Sleep Disorder and the Impact of Sweet Almond on the Quality of Sleep in Students of Tehran, Iran.

Iran J Public Health 2019 Jun;48(6):1149-1154

Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran.

Background: Insomnia is an important problem in medical sciences students and has implications for their educational progress. The current study aimed to estimate the prevalence of sleep disorders and investigating the impact of sweet almond on quality of sleep in students of the Tehran University of Medical Sciences (TUMS), Tehran, Iran who live in dormitories.

Methods: This is a before-after study conducted in 2017. At first, using the ISI questionnaire prevalence of sleep disorders was determined. Sweet almond was the study intervention. Each day, 10 almonds were given to 446 students for 14 d. At the end of the second week, again ISI questionnaire was filled. SPSS was used to analyze data. The McNemar, Wilcoxson Signed Ranks, and Repeated Measures tests were used.

Results: Out of 442 participants, 217 (49.1%) were female. Before intervention, 343 (77.6%) had insomnia and 99 (22.4%) had normal sleep. After intervention, 306 (69.2%) had insomnia and 136 (30.8%) had normal sleep. Having sweet almond for two weeks is associated with reducing insomnia (<0.05). Investigating the almond impact in different categories also showed that it has a reducing impact on severe, mild, weak and normal sleep categories (<0.05).

Conclusion: Sweet almond has impacts on quality of sleep of those students of the TUMS that are living in dormitories. Intervention programs to improve quality of sleep are necessary and with regard to the high prevalence of insomnia, students must be protected, guided and consulted.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635337PMC
June 2019

Effects of Herbal combination ( L. and Boiss. & Buhse) on insomnia severity, anxiety and depression in insomniacs: Randomized placebo controlled trial.

Integr Med Res 2018 Dec 10;7(4):328-332. Epub 2018 Aug 10.

Persian Medicine and Pharmacy Research Center, School of Traditional Medicine, Tehran University of Medical Sciences, Tehran, Iran.

Background: Insomnia is a prevalent disorder leading to psychological problems such as anxiety and depression.

Methods: This study investigates the effect of a combination of herbs ( L. and Boiss. & Buhse) on anxiety and depression for insomniacs and on insomnia severity. This study is a double-blind randomized placebo-controlled clinical trial. A total number of 67 participants met the inclusion criteria who were diagnosed as cases of insomnia. The patients were randomized into the herbal treatment or placebo groups. The herbal treatment group received a combination of and Boiss. & Buhse. The primary outcomes were insomnia, depression and anxiety. We used per-protocol analysis.

Results: The all outcomes of herbal treatment were significantly improved compared with placebo in the ISI, BAI and BDI scores after four weeks' treatment ( value: 0.008, 0.005 and <0.001 respectively).

Conclusion: A combination of L. and Boiss. & Buhse may improve insomnia and its comorbid depression and anxiety.
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http://dx.doi.org/10.1016/j.imr.2018.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303415PMC
December 2018

Obstructive sleep apnea and severity of coronary artery disease.

Caspian J Intern Med 2018 ;9(3):276-282

Cardiac Primary Prevention Research Center (CPPRC), Tehran Heart Center, Tehran University of Medical Sciences Tehran, Iran.

Background: It has been implicated that obstructive sleep apnea (OSA) is associated with increased risk of cardiovascular disease including stroke, myocardial infarction, coronary artery disease (CAD) and hypertension. The aim of this study was to investigate the correlation between OSA and severity of atherosclerosis assessed by angiography.

Methods: This study included 337 patients undergoing diagnostic coronary angiography at Tehran Heart Center, Iran. The Gensini score was obtained from each patient for coronary angiogram, and OSA were assessed by using Multivariable apnea prediction (MAP) risk index on the day of cardiac catheterization. The Gensini scores increased in accordance with increases in the MAP value.

Results: The prevalence rates of three-vessel disease were 68.0% in OSA group and 32.0% in non-OSA group. The MAP index was the most significant independent determinant for the Gensini score.

Conclusions: The independent association between OSA and CAD, even after adjustment for traditional confounders, suggests that, OSA should be taken into account when considering risk factors for CAD.
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http://dx.doi.org/10.22088/cjim.9.3.276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121336PMC
January 2018

Efficacy of a Combination of Melissa officinalis L. and Nepeta Menthoides Boiss. & Buhse on Insomnia: A Triple-Blind, Randomized Placebo-Controlled Clinical Trial.

J Altern Complement Med 2018 May 9. Epub 2018 May 9.

2 Research Centre for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences , Shiraz, Iran .

Background: Insomnia is a prevalent sleep disorder that has not been well managed thus far. There are numerous medicaments for treatment of insomnia, but they have undesirable side effects that make herbal medicine a more viable option.

Objectives: The effectiveness of a combination of Melissa officinalis L. (dry powder) and Nepeta menthoides Boiss. & Buhse (freeze-dried aqueous extract) on insomnia was evaluated.

Design And Setting: Insomniacs who met the entry criteria participated in a triple-blind randomized placebo-controlled clinical trial at the Persian Medicine (PM) clinic in Tehran.

Interventions: The subjects received either 1000 mg of M. officinalis plus 400 mg N. menthoides or a placebo nightly for four weeks in accordance with prescriptions from the pharmaceutical manuscripts on PM and the results of previous studies.

Outcome Measures: The Pittsburgh Sleep Quality Index (PSQI), sleep diary, and Insomnia Severity Index (ISI) were used for assessment of insomnia.

Results: Comparison of the treatment and placebo groups showed a significant decrease in the mean difference of ISI (4.97 ± 4.69 vs. 1.60 ± 3.70; p =; 0.002) and total PSQI (4.14 ± 3.69 vs. 1.42 ± 2.81; p = 0.001) scores in the treatment group. A significant increase was also observed in total sleep time of treatment group (p < 0.001) based on the sleep diary.

Conclusions: A combination of M. officinalis and N. menthoides Boiss. & Buhse could be an alternative sleep improvement therapy.
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http://dx.doi.org/10.1089/acm.2017.0153DOI Listing
May 2018

Relationship Between Sleep Quality, Obstructive Sleep Apnea and Sleepiness During Day With Related Factors in Professional Drivers.

Acta Med Iran 2017 Nov;55(11):690-695

Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.

One of the important reasons for accidents is sleepiness.With this description, the sleep disorders are associated with health and mortality, and not only affect the person but also the family and the whole society. Aim of this study was assessing of relationship between Sleep Quality, Obstructive sleep Apnea and Sleepiness during day with related factors in professional drivers. This was a cross-sectional study measuring correlation between sleep quality questionnaire (Pittsburgh Sleep Quality Index or PSQI), Epworth Sleepiness Scale (ESS) and Stop Bang questionnaire (STOP BANG).the appropriate sample size to achieve a 95% confidence level was 943 people. The study population was chosen among qualified drivers using a convenience sampling method that took place over 12 months duration. Exclusion criterion consisted of the presence of a physical or mental disability. Data analyzed by software SPSS, version 15. In this study, all drivers were men with mean of age 36±9/5 year (minimum 22 year and maximum 72 year), 799 (84.7%) were married, 535 (56.7%) had high school education. Also, 96.4 % of drivers had undesirable sleep quality, 25.8% obstructive sleep apnea and 6.8% abnormal sleepiness during day. Multiple linear regression test showed, Score of STOP-Bang was correlated with smoking (OR (β)=0/2, P=0.006) and history of hurt disease (OR (β)=0.95, P=0.003), shift work (OR (β)=0.19, P=0.006) more probability. Moreover, PSQI was statistically significant with shift work (OR (β)=0.44, P=0.02), smoking (OR (β)=0.98, P=0.001), history of pulmonary disease (OR (β)=3.58, P=0.009) more probability , and ESS was statistically significant with smoking (OR (β)=0.64, P=0.007) and history of pulmonary disease(OR (β)=2.82, P=0.006), shift work (OR (β)=0.59, P=0.008) more probability. In our study, according to the results, it should be planning to reduce the driving time in day and night and also it are recommended short breaks during driving. It is suggested the more widespread and prospective studies, as well as informing the drivers about the benefits of proper sleep and annual checkup drivers of health.
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November 2017

Association Study of HLA-DQB1*0602 Allele in Iranian Patients with Narcolepsy.

Iran J Allergy Asthma Immunol 2017 Oct;16(5):452-456

Department  of  Immunology,  School  of  Medicine,  International  Campus,  Tehran  University  of  Medical  Sciences, Tehran, Iran.

Narcolepsy is a rare, disabling disorder characterized by excessive daytime sleepiness, cataplexy, hypnagogic hallucinations and sleep paralysis. Several studies demonstrated its association with HLA-DQB1*0602 in various ethnic groups. Our study aimed to determine the prevalence of HLA-DQB1*0602 allele in Iranian patients with narcolepsy and assess its predictive parameters for diagnosing narcolepsy. In addition, car accidents and job problems were assessed among narcoleptic patients. We studied 44 narcoleptic patients, 30 patients with other types of excessive daytime sleepiness (EDS)  and 50 healthy age and sex matched individuals in this case-control study. Patients and controls filled out a questionnaire including items about car accidents due to sleepiness and job problems. International classification of sleep disorders-2 criteria was used as the gold standard for diagnosis of narcolepsy. The DNAs isolated from whole blood samples were collected from the patients and controls to assess the presence of HLA-DQB1*0602. The results showed that HLA DQB1*0602 was present in 4 (8%) individual of controls and 20 (45.5%) patients with higher prevalence in patients with cataplexy (78.9%) than patients without cataplexy (p<0.001). The sensitivities of the DQB1*0602 for diagnosing narcolepsy with cataplexy and narcolepsy without cataplexy were 78.9 and 20; specificities were 88 and 72.4, respectively. 18.2% of patients had car accidents due to sleepiness and 68.2% suffered from job problems. Our study shows that evaluation of DQB1*0602 in patients suspected to narcolepsy could be helpful especially in complex cases with atypical cataplexy and indistinguishable multiple sleep latency test MSLT results. Moreover, high rates of car accidents and job problems are found among narcoleptic patients.
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October 2017

Melatonin therapy in shift workers with difficulty falling asleep: A randomized, double-blind, placebo-controlled crossover field study.

Work 2016 Sep;55(1):225-230

Occupational Sleep Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Background: Disturbed sleep is common in shift work. It is hypothesized that administration of exogenous melatonin could reduce the sleep latency and improve the sleep quality.

Objective: To evaluate the efficacy of 3 mg melatonin taken 30 min before night time sleep on shift workers with difficulty falling asleep.

Methods: Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) were applied to find out shift workers with difficulty falling asleep. A randomized, double-blind, placebo-controlled crossover study with periods of 3 night and washouts of 2 weeks comparing melatonin with placebo was performed. Night time sleep parameters obtained from somnowatch including total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE) and wakening after sleep onset (WASO) were analyzed.

Results: Among 295 workers, 103 had difficulty falling asleep. Finally, from 50 randomly selected workers with difficulty falling asleep, 39 workers completed the study. Melatonin treatment significantly increased SE and decreased SOL in comparison with baseline and taking placebo. SE was increased from 82.1% at baseline to 85.5% after melatonin therapy. Also SOL was decreased from 0.27 h at baseline to 0.20 h after melatonin therapy. Effects of Melatonin administration on TST and WASO were not significant.

Conclusions: This study showed that melatonin therapy in shift workers with difficulty falling asleep significantly improved the sleep onset latency and sleep efficiency.
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http://dx.doi.org/10.3233/WOR-162376DOI Listing
September 2016

Sleep quality in long haul truck drivers: A study on Iranian national data.

Chin J Traumatol 2016 Aug;19(4):225-8

Occupational Sleep Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Purpose: Iran has a high rate of road traffic accidents. Poor quality of sleep brings about loss of attention, which is an important cause of road traffic accidents particularly in monotonous roads. The causes of poor quality of sleep in occupational drivers are multifactorial. The objective of the present study was to assess the prevalence of poor sleep quality among occupational drivers with rotating work schedules and analyze its different risk factors.

Methods: 2200 professional long-haul truck drivers who had been referred to the Occupational Health Clinic for routine education course were invited. We obtained data from eight provinces from various parts of Iran during 2012-2013. Data were collected using a questionnaire including questions about demographic and job characteristics. Pittsburg Sleep Quality Index (PSQI) was used to assess drivers' sleep quality.

Results: Mean working (driving) time was (9.3±2.5) hours daily and (55.5 ± 18.29) hours weekly. About 23.5% of the drivers reported history of smoking, 14.5% had low job satisfaction and 60% had irregular work schedule. 16.4% of drivers had an accidents leading to injury during the past five years. The mean PSQI score was 4.2 ± 2.7; 54% had a PSQI>5 (poor quality of sleep). Multivariate logistic regression showed that smoking, job satisfaction, history of accidents, shift work and work hours per day were the most important risk factors for poor sleep quality.

Conclusion: Results obtained from the current study showed a high prevalence of poor quality of sleep among professional drivers. It warrants more attention to this significant problem using some measures to improve working conditions in professional drivers, as well as health promotion interventions.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992135PMC
http://dx.doi.org/10.1016/j.cjtee.2016.01.014DOI Listing
August 2016

Effect of Zolpidem on Sleep Quality of Professional Firefighters; a Double Blind, Randomized, Placebo-Controlled Crossover Clinical Trial.

Acta Med Iran 2015 ;53(9):573-8

Department of Occupational Medicine, School of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.

Professional firefighting is among the most demanding jobs. Prior studies have showed the notable prevalence of poor sleep quality among professional firefighters that may result in catastrophes. The aim of this study was in field confirmation of zolpidem usage (10 mg/PO/bed time) for short term management of poor sleeps quality among professional firefighters. In a double-blind, randomized, placebo-controlled crossover clinical trial among professional firefighters, 27 poor sleepers were assigned randomly to one of the two groups. Two 14 days experimental periods were separated by a 14-day washout phase. Sleep quality was assessed using the Persian version of Pittsburgh Sleep Quality Index (PSQI). Six of the 27 enrolled voluntaries dropped out. Two rare side effects of zolpidem occurred in the study. A significant improvement of the PSQI score was detected in zolpidem period versus placebo in both groups (7.14 ± 3.02 vs 12.38 ± 2.51, P<0.001) although zolpidem had no significant effect on time of waking up (6.76 ± 1.21 vs.6.64 ± 1.27, P=0.89). Zolpidem significantly improved all components of PSQI (Subjective sleep quality, Sleep latency, Sleep duration, Habitual sleep efficiency, Sleep disturbances and Daytime dysfunction) in the current study except the use of sleep medication. Sleep onset latency was the component of PSQI with the greatest degree of abnormality among firefighters in a previous study. Interestingly, sleep latency was the component of PSQI with the most treatment effect of zolpidem in the current study. Zolpidem can be used asa part of treatment regimens in short time management of poor sleep quality among professional firefighters.
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May 2016

Respiratory Symptoms and Pulmonary Function Tests among Galvanized Workers Exposed To Zinc Oxide.

J Res Health Sci 2015 ;15(3):159-62

Center for Research on Occupational Diseases, Tehran University of Medical Sciences, Tehran, Iran.

Background: Galvanization is the process of coating steel or cast iron pieces with a thin layer of zinc allowing protection against corrosion. One of the important hazards in this industry is exposure to zinc compounds specially zinc oxide fumes and dusts. In this study, we evaluated chronic effects of zinc oxide on the respiratory tract of galvanizers.

Methods: Overall, 188 workers were selected from Arak galvanization plant in 2012, 71 galvanizers as exposed group and 117 workers from other departments of plants as control group. Information was collected using American Thoracic Society (ATS) standard questionnaire, physical examination and demographic data sheet. Pulmonary function tests were measured for all subjects. Exposure assessment was done with NIOSH 7030 method.

Results: The Personal Breathing Zone (PBZ) air sampling results for zinc ranged from 6.61 to 8.25 mg/m³ above the permissible levels (Time weighted average; TWA:2 mg/m³). The prevalence of the respiratory symptoms such as dyspnea, throat and nose irritation in the exposed group was significantly (P<0.01) more than the control group. Decreasing in average percent in all spirometric parameters were seen in the galvanizers who exposed to zinc oxide fumes and dusts. The prevalence of obstructive respiratory disease was significantly (P=0.034) higher in the exposed group.

Conclusions: High workplace zinc levels are associated with an increase in respiratory morbidity in galvanizers. Therefore administrators should evaluate these workers with periodic medical examinations and implement respiratory protection program in the working areas.
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July 2016

Fatigue management in the workplace.

Ind Psychiatry J 2015 Jan-Jun;24(1):12-7

Occupational Medicine Specialist, Metabolic Disease Research Center, Qazvin University of Medical Sciences, Qazvin, Iran.

Workers' fatigue is a significant problem in modern industry, largely because of high demand jobs, long duty periods, disruption of circadian rhythms, and accumulative sleep debt that are common in many industries. Fatigue is the end result of integration of multiple factors such as time awake, time of day, and workload. Then, the full understanding of circadian biologic clock, dynamics of transient and cumulative sleep loss, and recovery is required for effective management of workplace fatigue. It can be more investigated in a new field of sleep medicine called occupational sleep medicine. Occupational sleep medicine is concerned with maintaining best productivity and safety in the industrial settings. The fatigue risk management system (FRMS) is a comprehensive approach that is based on applying scientific evidence of sleep knowledge to manage workers fatigue. It is developing rapidly in the highly safety demand jobs; especially truck drivers, pilots, and power plant workers. The objective of this review is to explain about fatigue in the workplace with emphasis on its association work performance and errors/accidents. Also, we discussed about different methods of fatigue measurement and management.
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http://dx.doi.org/10.4103/0972-6748.160915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4525425PMC
August 2015

Adaptation of the 10-Item Functional Outcomes of Sleep Questionnaire to Iranian Patients with Obstructive Sleep Apnea.

Qual Life Res 2016 Feb 28;25(2):337-341. Epub 2015 Jul 28.

Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran.

Purpose: The purpose of this study was to evaluate the psychometric properties of the Farsi version of 10-item Functional Outcomes of Sleep Questionnaire (FOSQ-10) in Iranian patients with obstructive sleep apnea (OSA).

Methods: The FOSQ-10 was translated into Farsi using the standard forward-backward method. One hundred patients who fulfilled the inclusion criteria completed a series of questionnaires including IR-FOSQ-10, Medical Outcome Survey Short Form 12 (SF-12) and Epworth Sleepiness Scale (ESS). Internal consistency, test-retest reliability, concurrent validity, discriminant validity and responsiveness of IR-FOSQ-10 were investigated.

Results: The Cronbach's alpha coefficient was 0.85 in IR-FOSQ-10 total score and ranged from 0.78 to 0.83 in each subscale. The test-retest reliability demonstrated by intraclass coefficient was 0.92. There were significant moderate-to-good negative correlations between IR-FOSQ-10 subscales and ESS except for sexual relationship subscale. FOSQ-10 subscales generally correlated higher with related subscales of SF-12. The IR-FOSQ-10 was able to distinguish patients with abnormal sleepiness score from those with normal sleepiness score. The results of sensitivity to change proved that the IR-FOSQ-10 was able to detect changes after continuous positive airway pressure therapy.

Conclusion: The psychometric properties of the IR-FOSQ-10 suggest that it is a reliable and valid measure among Iranian patients with OSA.
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http://dx.doi.org/10.1007/s11136-015-1081-9DOI Listing
February 2016

Translation, cultural adaptation, and validation of the Sleep Apnea Quality of Life Index (SAQLI) in Persian-speaking patients with obstructive sleep apnea.

Sleep Breath 2016 May 21;20(2):523-8. Epub 2015 Jul 21.

Epidemiology and Biostatistics Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Purpose: The aim of this study was the translation, cross-cultural adaptation, and validation of the Sleep Apnea Quality of Life Index (SAQLI) in Persian-speaking patients with obstructive sleep apnea (OSA).

Methods: Ninety-six patients with OSA completed a series of questionnaires including SAQLI, Epworth Sleepiness Scale (ESS),10-item Functional Outcomes of Sleep Questionnaire (FOSQ-10), and Medical Outcome Survey Short form 12 (SF-12) for assessment of reliability, validity, and responsiveness of Persian version of SAQLI.

Results: The Persian version of SAQLI had a very good internal consistency and also demonstrated good test-retest reliability. Concurrent validity was confirmed by significant correlations with ESS, FOSQ-10 and SF-12 subscale scores. Comparison of SAQLI scores in groups of patients categorized by ESS showed the high discriminative power of this instrument. However, there was no significant difference in the SAQLI scores of patients with mild, moderate, and severe sleep apnea. The results of sensitivity to change verified that the SAQLI was able to detect changes after continuous positive airway pressure (CPAP) treatment.

Conclusion: The findings of this study indicate that the Persian version of SAQLI is a reliable, valid, and responsive measure for evaluation of quality of life in patients with OSA.
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http://dx.doi.org/10.1007/s11325-015-1228-5DOI Listing
May 2016

Traffic crash accidents in Tehran, Iran: Its relation with circadian rhythm of sleepiness.

Chin J Traumatol 2015 ;18(1):13-7

Occupational Sleep Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Purpose: Road traffic accidents are one of main problems in Iran. Multiple factors cause traffic accidents and the most important one is sleepiness. This factor, however, is given less attention in our country. Road traffic accidents relevant to sleepiness are studied.

Methods: In this cross-sectional study, all road traffic accidents relevant to sleepiness, which were reported by police, were studied in Tehran province in 2009.

Results: The risk of road traffic accidents due to sleepiness was increased by more than sevenfold (odds ratio = 7.33) in low alertness hours (0:00-6:00) compared to other time of day. The risk of road traffic accidents due to sleepiness was decreased by 0.15-fold (odds ratio = 0.15) in hours with maximum of alertness (18:00-22:00) of circadian rhythm compared to other time of day.

Conclusion: The occurrence of road traffic accidents due to sleepiness has significant statistical relations with driving during lowest point of alertness of circadian rhythm.
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http://dx.doi.org/10.1016/j.cjtee.2014.09.001DOI Listing
January 2017

Poor Sleep Quality in Patients after Coronary Artery Bypass Graft Surgery: An Intervention Study Using the PRECEDE-PROCEED Model.

J Tehran Heart Cent 2015 8;10(1):1-8. Epub 2015 Jan 8.

Department of Biostatistics, School of Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: Poor sleep quality (SQ) is common among patients after coronary artery bypass graft surgery (CABG). This study attempted to determine the status of SQ following an intervention based on the PRECEDE-PROCEED model in patients with poor SQ after CABG.

Methods: This study was a randomized clinical trial. The study sample, including 100 patients referred to the Cardiac Rehabilitation Clinic of Tehran Heart Center, was assigned either to the intervention (recipient of exercise and lifestyle training plus designed intervention based on the PRECEDE-PROCEED model) or to the control group (recipient of exercise and lifestyle training). Eight training sessions over 8 weeks were conducted for the intervention group. Predisposing, enabling, and reinforcing factors as well as social support and SQ were measured in the intervention group before and one month after the intervention and compared to those in the control group at the same time points.

Results: The mean age of the patients in the intervention (24% women) and control (24% women) groups was 59.3 ± 7.3 and 59.5 ± 9.3 years, respectively. The results showed that the mean scores of SQ (p value < 0.001), knowledge (p value < 0.001), beliefs (p value < 0.001), sleep self-efficacy (p value < 0.001), enabling factors (p value < 0.001), reinforcing factors (p value < 0.001), and social support (p value < 0.001) were significantly different between the intervention and control groups after the intervention.

Conclusion: Adding an intervention based on the PRECEDE-PROCEED model to the cardiac rehabilitation program may further improve the SQ of patients.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4494514PMC
July 2015

Presenting a model for dynamic facial expression changes in detecting drivers' drowsiness.

Electron Physician 2015 Apr-Jun;7(2):1073-7. Epub 2015 Jun 5.

Associate Professor, Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Drowsiness while driving is a major cause of accidents. A driver fatigue detection system that is designed to sound an alarm, when appropriate, can prevent many accidents that sometime leads to the loss of life and property. In this paper, we classify drowsiness detection sensors and their strong and weak points. A compound model is proposed that uses image processing techniques to study the dynamic changes of the face to recognize drowsiness during driving.
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http://dx.doi.org/10.14661/2015.1073-1077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477768PMC
June 2015

Restless leg syndrome in hemodialysis patients: A disorder that should be noticed.

Saudi J Kidney Dis Transpl 2015 May-Jun;26(3):625-50

Metabolic Disease Research Center, Qazvin University of Medical Sciences, Qazvin, Iran.

Restless leg syndrome (RLS) is a distressing sleep disorder that is commonly experienced by patients undergoing maintenance hemodialysis. The aim of this study was to assess the prevalence of RLS and its related factors among hemodialysis patients. This was an analytical cross-sectional study that was performed on hemodialysis patients of the Bu"Ali Hospital of Qazvin during 2009 and 2010. One hundred and twelve patients were selected by the census sampling method as the study sample. Data collection was performed using the Insomnia Severity Index (ISI), Pittsburg Sleep Quality Index (PSQI), Berlin, Epworth Sleepiness Scale (ESS) and International Restless Leg Syndrome Study Group criteria (IRRLS) questionnaires. Student's ttest and chi-square test were applied to analyze the collected data. RLS complaints were very common among patients on long-term dialysis therapy and were reported in about 42.9% of the patients. Patients with RLS had higher daytime sleepiness, insomnia complaints and poorer sleep quality. Percentage of patients in the high-risk group was higher in the RLS group. RLS symptoms appear to be correlated with age (P = 0.012) and use of sedative drugs (P = 0.035). RLS is common in dialysis patients and is associated with a higher prevalence of other sleep disturbances. Therefore, the effective assessment and management of this sleep disturbance has the potential to significantly enhance patient outcomes.
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http://dx.doi.org/10.4103/1319-2442.157431DOI Listing
May 2015