Naresh M Punjabi

Johns Hopkins University, Baltimore, Maryland, United States

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Publications (132)816.79 Total impact

  • Bruce J. Swihart · Naresh M. Punjabi · Ciprian M. Crainiceanu
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    ABSTRACT: Methods are introduced for the analysis of large sets of sleep study data (hypnograms) using a 5-state 20-transition-type structure defined by the American Academy of Sleep Medicine. Application of these methods to the hypnograms of 5598 subjects from the Sleep Heart Health Study provide: the first analysis of sleep hypnogram data of such size and complexity in a community cohort with a range of sleep-disordered breathing severity; introduce a novel approach to compare 5-state (20-transition-type) to 3-state (6-transition-type) sleep structures to assess information loss from combining sleep state categories; extend current approaches of multivariate survival data analysis to clustered, recurrent event discrete-state discrete-time processes; and provide scalable solutions for data analyses required by the case study. The analysis provides detailed new insights into the association between sleep-disordered breathing and sleep architecture. The example data and both R and SAS code are included in online supplementary materials.
    Computational Statistics & Data Analysis 09/2015; 89. DOI:10.1016/j.csda.2015.03.001 · 1.15 Impact Factor
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    ABSTRACT: We examined cross-sectional and longitudinal associations between neighborhood socioeconomic status, social cohesion and safety and features of the diurnal cortisol curve including: area under the curve (AUC), wake-to-bed slope, wake-up, cortisol awakening response (CAR, wake-up to 30min post-awakening), early decline (30min to 2h post-awakening) and late decline (2h post-awakening to bed time). In cross-sectional analyses, higher neighborhood poverty was associated with a flatter early decline and a flatter wake-to-bed slope. Higher social cohesion and safety were associated with higher wake-up cortisol, steeper early decline and steeper wake-to-bed slope. Over 5 years, wake-up cortisol increased, CAR, early decline, late decline and wake-to-bed slope became flatter and AUC became larger. Higher poverty was associated with less pronounced increases in wake-up and AUC, while higher social cohesion was associated with greater increases in wake-up and AUC. Adverse neighborhood environments were cross-sectionally associated with flatter cortisol profiles, but associations with changes in cortisol were weak and not in the expected direction. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Health & Place 07/2015; 34. DOI:10.1016/j.healthplace.2015.05.017 · 2.44 Impact Factor
  • Hassan A Chami · Daniel J Gottlieb · Susan Redline · Naresh M Punjabi
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    ABSTRACT: Sleep-disordered breathing (SDB) has been associated with impaired glucose metabolism. It is possible that the association between SDB and glucose metabolism is distinct for NREM vs. REM sleep because of differences in sleep-state dependent sympathetic activation and/or degree of hypoxemia. Thus, the primary objective of the current study was to characterize the association between REM-related SDB, glucose intolerance, and insulin resistance in a community-based sample. A cross-sectional analysis that included 3,310 participants from the Sleep Heart Health Study was undertaken (53% women, mean age 66.1years). Full montage home-polysomnography and fasting glucose were available on all participants. SDB severity during REM and NREM sleep was quantified using the apnea-hypopnea index in REM (AHIREM) and NREM sleep (AHINREM), respectively. Fasting and 2-hour post-challenge glucose levels were assessed during a glucose tolerance test (N=2264). The homeostatic model assessment index for insulin resistance (HOMA-IR) was calculated (N=1543). Linear regression was used to assess the associations of AHIREM and AHINREM with fasting and post-prandial glucose levels and HOMA-IR. AHIREM and AHINREM were associated with fasting glycemia, post-prandial glucose levels and HOMA-IR in models that adjusted for age, sex, race, and site. However, with additional adjustment for BMI, waist circumference and sleep duration, AHIREM was only associated with HOMA-IR (β=0.04, 95%CI:[0.1-0.07] p=0.01), while AHINREM was only associated with fasting (β=0.93, 95%CI:[0.14-1.72] p=0.02) and post-prandial glucose levels (β=3.0, 95%CI:[0.5-5.5] p=0.02). AHIREM is associated with insulin resistance but not with fasting glycemia or glucose intolerance.
    American Journal of Respiratory and Critical Care Medicine 07/2015; DOI:10.1164/rccm.201501-0046OC · 11.99 Impact Factor
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    ABSTRACT: Although empirical evidence is limited, critical illness in children is associated with disruption of the normal sleep-wake rhythm. The objective of the current study was to examine the temporal characteristics of the sleep electroencephalogram (EEG) in a sample of children with critical illness. Limited montage EEG recordings were collected for at least 24 hours from 8 critically ill children on mechanical ventilation for respiratory failure in a pediatric intensive care unit (PICU) of a tertiary-care hospital. Each PICU patient was age- and gender-matched to a healthy subject from the community. Power spectral analysis with the fast Fourier transform (FFT) was used to characterize EEG spectral power and categorized into 4 frequency bands: δ (0.8 to 4.0 Hz), θ (4.1 to 8.0 Hz), α (8.1 to 13.0 Hz), and β1/β2 (13.1 to 20.0 Hz). PICU patients did not manifest the ultradian variability in EEG power spectra including the typical increase in δ-power during the first third of the night that was observed in healthy children. Differences noted included significantly lower mean nighttime δ and θ power in the PICU patients compared to healthy children (p < 0.001). Moreover, in the PICU patients, mean δ and θ power were higher during daytime hours than nighttime hours (p < 0.001). The results presented herein challenge the assumption that children experience restorative sleep during critical illness, highlighting the need for interventional studies to determine whether sleep promotion improves outcomes in critically ill children undergoing active neurocognitive development. Copyright © 2015 American Academy of Sleep Medicine. All rights reserved.
    Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 07/2015; · 2.83 Impact Factor
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    ABSTRACT: To evaluate associations between obesity measures and sleep-disordered breathing severity among White, Black, Hispanic, and Chinese Americans.
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    ABSTRACT: No data exist as to the role of ethnicity in the associations between obstructive sleep apnea (OSA), sleep duration, and metabolic dysfunction. To examine links between OSA, objectively-measured habitual sleep duration, and fasting glucose in United States ethnic groups. The Multi-Ethnic Study of Atherosclerosis is a multi-site community-based study which conducted polysomnography and wrist-actigraphy. In 2,151 subjects (1,839 in fully-adjusted models), the apnea-hypopnea index was used to classify OSA as none (0-4.9 /hour), mild (5-14.9 /hour), or moderate-to-severe (≥15 /hour). Actigraphic sleep duration was classified as short (≤5 hours/night), intermediate (>5, <8 hours/night), or long (≥8 hours/night). Subjects were classified as having normal fasting glucose (<100mg/dL and no hypoglycemic medication use) or abnormal fasting glucose (≥100mg/dL and/or hypoglycemic medication use). Measurements & Main Results: The sample was 45.8% male, age 68.5±9.2 (mean±SD) years, and 27.3% African-American, 37.2% Caucasian, 11.8% Chinese, 23.8% Hispanic. The prevalence of abnormal fasting glucose was 40.2%. Relative to non-apneics, moderate-to-severe OSA was significantly associated with abnormal fasting glucose in African-Americans (odds ratio [OR] 2.14, 95% CI 1.12 - 4.08) and Caucasians (OR 2.85, 95% CI 1.20-6.75), but not among Chinese or Hispanic subjects, after adjusting for site, age, gender, waist circumference, and sleep duration (p=0.06 for ethnicity-by-OSA severity interaction). In contrast, sleep duration was not significantly associated with abnormal fasting glucose after considering the influence of OSA. This large multi-ethnic study confirmed previous reports of an independent association between OSA and metabolic dysfunction, and suggested that this association may vary by ethnicity.
    American Journal of Respiratory and Critical Care Medicine 06/2015; DOI:10.1164/rccm.201502-0366OC · 11.99 Impact Factor
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    ABSTRACT: The association between sleep apnea and atrial fibrillation (AF) has not been examined in a multiethnic adult population in prospective community-based studies. We prospectively (2000-2011) investigated the associations of physician-diagnosed sleep apnea (PDSA), which is considered more severe sleep apnea, and self-reported habitual snoring without PDSA (HS), a surrogate for mild sleep apnea, with incident AF in white, black, and Hispanic participants in the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of clinical cardiovascular disease at baseline (2000-2002). Cox proportional hazards models were used to assess the associations, with adjustment for socioeconomic status, traditional vascular disease risk factors, race/ethnicity, body mass index, diabetes, chronic kidney disease, alcohol intake, and lipid-lowering therapy. Out of 4,395 respondents to a sleep questionnaire administered in MESA, 181 reported PDSA, 1,086 reported HS, and 3,128 reported neither HS nor PDSA (unaffected). Over an average 8.5-year follow-up period, 212 AF events were identified. As compared with unaffected participants, PDSA was associated with incident AF in the multivariable analysis, but HS was not (PDSA: hazard ratio = 1.76, 95% confidence interval: 1.03, 3.02; HS: hazard ratio = 1.02, 95% confidence interval: 0.72, 1.44). PDSA, a marker of more severe sleep apnea, was associated with higher risk of incident AF in this analysis of MESA data. © The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
    American journal of epidemiology 05/2015; 182(1). DOI:10.1093/aje/kwv004 · 4.98 Impact Factor
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    ABSTRACT: Manual scoring of polysomnograms is a time-consuming and tedious process. To expedite the scoring of polysomnograms, several computerized algorithms for automated scoring have been developed. The overarching goal of this study is to determine the validity of the Somnolyzer system, an automated system for scoring polysomnograms. The analysis sample comprised 97 sleep studies. Each polysomnogram was manually scored by certified technologists from four sleep laboratories and concurrently subjected to automated scoring by the Somnolyzer system. Agreement between manual and automated scoring was examined. Sleep staging and scoring of disordered breathing events was conducted using the 2007 American Academy of Sleep Medicine criteria. Clinical sleep laboratories. A high degree of agreement was noted between manual and automated scoring of the apnea-hypopnea index (AHI). The average correlation between the manually scored AHI across the four clinical sites was 0.92 (95% confidence interval: 0.90-0.93). Similarly, the average correlation between the manual and Somnolyzer-scored AHI values was 0.93 (95% confidence interval: 0.91-0.96). Thus, interscorer correlation between the manually scored results was no different than that derived from manual and automated scoring. Substantial concordance in arousal index, total sleep time, and sleep efficiency between manual and automated scoring was also observed. In contrast, differences were noted between manually and automated scored percentages of sleep stages N1, N2, and N3. Automated analysis of polysomnograms using the Somnolyzer system provides results that are comparable to manual scoring for commonly used metrics in sleep medicine. Although differences exist between manual versus automated scoring for specific sleep stages, the level of agreement between manual and automated scoring is not significantly different than that between any two human scorers. In light of the burden associated with manual scoring, automated scoring platforms provide a viable complement of tools in the diagnostic armamentarium of sleep medicine. Copyright © 2015 Associated Professional Sleep Societies, LLC. All rights reserved.
    Sleep 03/2015; · 5.06 Impact Factor
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    ABSTRACT: Usual sleep duration is a heritable trait correlated with psychiatric morbidity, cardiometabolic disease and mortality, although little is known about the genetic variants influencing this trait. A genome-wide association study (GWAS) of usual sleep duration was conducted using 18 population-based cohorts totaling 47 180 individuals of European ancestry. Genome-wide significant association was identified at two loci. The strongest is located on chromosome 2, in an intergenic region 35- to 80-kb upstream from the thyroid-specific transcription factor PAX8 (lowest P=1.1 × 10(-9)). This finding was replicated in an African-American sample of 4771 individuals (lowest P=9.3 × 10(-4)). The strongest combined association was at rs1823125 (P=1.5 × 10(-10), minor allele frequency 0.26 in the discovery sample, 0.12 in the replication sample), with each copy of the minor allele associated with a sleep duration 3.1 min longer per night. The alleles associated with longer sleep duration were associated in previous GWAS with a more favorable metabolic profile and a lower risk of attention deficit hyperactivity disorder. Understanding the mechanisms underlying these associations may help elucidate biological mechanisms influencing sleep duration and its association with psychiatric, metabolic and cardiovascular disease.Molecular Psychiatry advance online publication, 2 December 2014; doi:10.1038/mp.2014.133.
    Molecular Psychiatry 12/2014; DOI:10.1038/mp.2014.133 · 15.15 Impact Factor
  • R Nisha Aurora · Rachel Swartz · Naresh M Punjabi
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    ABSTRACT: Background:The advent of home sleep testing has allowed for the development of an ambulatory care model for obstructive sleep apnea (OSA) that is easily deployed by most healthcare providers. While automated algorithms that accompany home sleep monitors can identify and classify disordered breathing events, it is unclear if manual scoring followed by expert review of home sleep recordings is of any value. Thus, the current study examined the agreement between automated and manual scoring of home sleep recordings. Methods:Two type III monitors (ApneaLink Plus and Embletta) with distinct study samples were used. Data from manual and automated scoring were available for 200 subjects. Two thresholds for oxygen desaturation (≥3% and ≥4%) were used to define disordered breathing events. Agreement between manual and automated scoring was examined using Pearson's correlation coefficients and Bland-Altman analyses. Results:Automated scoring consistently underscored disordered breathing events compared with manual scoring for both sleep monitors irrespective of whether a ≥3% or ≥4% oxygen desaturation threshold was used to define the apnea-hypopnea index (AHI). Bland-Altman analyses revealed that for the ApneaLink Plus, the average AHI difference between the manual and automated scoring was 6.1 events/hr (95% CI: 4.9-7.3) and 4.6 events/hr (95% CI: 3.5-5.6) for the ≥3% and ≥4% oxygen desaturation threshold, respectively. Similarly, for the Embletta, the average difference between the manual and automated scoring was 5.3 events/hr (95% CI: 3.2-7.3) and 8.4 events/hr (95% CI: 7.2-9.6), respectively. Conclusions:While agreement between automated and manual scoring of home sleep recordings varies based on the device used, modest agreement was observed between the two approaches. However, manual review of HST recordings can decrease the misclassification of OSA severity, particularly for those with mild disease. Study Registration:http://www.clinicaltrials.gov (NCT01503164). The advent of home sleep testing has allowed for the development of an ambulatory care model for obstructive sleep apnea (OSA) that is easily deployed by most healthcare providers. While automated algorithms that accompany home sleep monitors can identify and classify disordered breathing events, it is unclear if manual scoring followed by expert review of home sleep recordings is of any value. Thus, the current study examined the agreement between automated and manual scoring of home sleep recordings. Two type III monitors (ApneaLink Plus and Embletta) with distinct study samples were used. Data from manual and automated scoring were available for 200 subjects. Two thresholds for oxygen desaturation (≥3% and ≥4%) were used to define disordered breathing events. Agreement between manual and automated scoring was examined using Pearson's correlation coefficients and Bland-Altman analyses. Automated scoring consistently underscored disordered breathing events compared with manual scoring for both sleep monitors irrespective of whether a ≥3% or ≥4% oxygen desaturation threshold was used to define the apnea-hypopnea index (AHI). Bland-Altman analyses revealed that for the ApneaLink Plus, the average AHI difference between the manual and automated scoring was 6.1 events/hr (95% CI: 4.9-7.3) and 4.6 events/hr (95% CI: 3.5-5.6) for the ≥3% and ≥4% oxygen desaturation threshold, respectively. Similarly, for the Embletta, the average difference between the manual and automated scoring was 5.3 events/hr (95% CI: 3.2-7.3) and 8.4 events/hr (95% CI: 7.2-9.6), respectively. While agreement between automated and manual scoring of home sleep recordings varies based on the device used, modest agreement was observed between the two approaches. However, manual review of HST recordings can decrease the misclassification of OSA severity, particularly for those with mild disease. http://www.clinicaltrials.gov (NCT01503164).
    Chest 11/2014; 147(3). DOI:10.1378/chest.14-0929 · 7.13 Impact Factor
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    ABSTRACT: Objectives To determine the association between sleep-disordered breathing (SDB) and decline in instrumental activities of daily living (IADLs) and mobility in older women.DesignProspective cohort.SettingMinneapolis and Pittsburgh sites of the Study of Osteoporotic Fractures, participants' homes.ParticipantsWomen with a mean age ± standard deviation of 82.3 ± 3.2 (N = 302).MeasurementsParticipants completed a single night of unattended polysomnography and provided data regarding difficulty with IADLs and mobility. They repeated IADL and mobility measures 5.0 ± 0.7 years later.ResultsAfter adjustment for age, obesity, Mini-Mental State Examination score, depressive symptoms, history of hypertension and chronic obstructive pulmonary disease, and number of IADL impairments at baseline, women with an apnea-hypopnea index (AHI) of 15 or greater at baseline had more than twice the odds of an increase in number of IADL difficulties (adjusted odds ratio (aOR) = 2.22, 95% confidence interval (CI) = 1.09-4.53) and of incident IADL difficulty (aOR = 2.43, 95% CI = 1.00-5.92), of women with an AHI less than 5. There was no association between AHI and mobility difficulty. Women in the middle and highest tertiles of oxygen desaturation index had more than double the odds as those in the lowest tertile of an increase in number of IADL difficulties (middle tertile aOR = 2.64, 95% CI = 1.38-5.04, highest tertile aOR = 2.17, 95% CI = 1.13-4.17) and approximately three times the odds of incident IADL difficulty (middle tertile aOR = 2.84, 95% CI = 1.27-6.36, highest tertile aOR = 3.07, 95% CI = 1.31-7.18). Neither sleep fragmentation nor sleep duration was associated with IADL outcomes.ConclusionSDB and associated hypoxemia are risk factors for functional decline in older women. Research is needed to determine whether treatment of SDB prevents functional decline.
    Journal of the American Geriatrics Society 11/2014; 62(11). DOI:10.1111/jgs.13108 · 4.22 Impact Factor
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    ABSTRACT: Blood pressure (BP) may be adversely affected by a variety of sleep disturbances, including sleep fragmentation, hypoxemia, respiratory disturbances, and periodic limb movements. We aim to identify which polysomnography indices are most strongly and consistently associated with systolic and diastolic blood pressure (SBP, DBP) levels in a population-based sample.
    Sleep 10/2014; DOI:10.5665/sleep.4576 · 5.06 Impact Factor
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    ABSTRACT: Analysis of brain recurrence (ABR) is a novel computational method that uses two variables for sleep depth and two for sleep fragmentation to quantify temporal changes in non-random brain electrical activity. We postulated that ABR of the sleep-staged EEG could identify an EEG signature specific for the presence of mental health symptoms. Using the Mental Health Inventory Questionnaire (MHI-5) as ground truth, psychological distress was assessed in a study cohort obtained from the Sleep Heart Health Study. Subjects with MHI-5 <50 (N=34) were matched for sex, BMI, age, and race with 34 subjects who had MHI-5 scores >50. Sixteen ABR markers derived from the EEG were analyzed using linear discriminant analysis to identify marker combinations that reliably classified individual subjects. A biomarker function computed from 12 of the markers accurately classified the subjects based on their MHI-5 scores (AUROC=82%). Use of additional markers did not improve classification accuracy. Subgroup analysis (20 highest and 20 lowest MHI-5 scores) improved classification accuracy (AUROC=89%). Biomarker values for individual subjects were significantly correlated with MHI-5 score (r=0.36, 0.54 for N=68, 40, respectively). ABR of EEGs obtained during sleep successfully classified subjects with regard to the severity of mental health symptoms, indicating that mood systems were reflected in brain electrical activity.
    Psychiatry Research: Neuroimaging 10/2014; 224(3). DOI:10.1016/j.pscychresns.2014.10.004 · 2.83 Impact Factor
  • 2014 American Academy of Pediatrics National Conference and Exhibition; 10/2014
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    ABSTRACT: Obstructive sleep apnea causes intermittent hypoxia (IH) and is associated with insulin resistance and type 2 diabetes. IH increases plasma catecholamine levels, which may increase insulin resistance and suppress insulin secretion. The objective of this study was to determine if adrenal medullectomy (MED) prevents metabolic dysfunction in IH. MED or sham surgery was performed in 60 male C57BL/6J mice, which were then exposed to IH or control conditions (intermittent air) for 6 weeks. IH increased plasma epinephrine and norepinephrine levels, increased fasting blood glucose and lowered basal and glucose-stimulated insulin secretion. MED decreased baseline epinephrine and prevented the IH induced increase in epinephrine, whereas the norepinephrine response remained intact. MED improved glucose tolerance in mice exposed to IH, attenuated the impairment in basal and glucose-stimulated insulin secretion, but did not prevent IH-induced fasting hyperglycemia or insulin resistance. We conclude that the epinephrine release from the adrenal medulla during IH suppresses insulin secretion causing hyperglycemia.
    Respiratory Physiology & Neurobiology 08/2014; 203. DOI:10.1016/j.resp.2014.08.018 · 1.97 Impact Factor
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    ABSTRACT: Rationale: We hypothesized that untreated severe obstructive sleep apnea (OSA) is associated with elevated ambulatory blood pressure (BP) in subjects with high cardiovascular disease (CVD) risk despite medical management. Methods: Data from the baseline examination of the Heart Biomarker Evaluation in Apnea Treatment (HeartBEAT) study, a 4-site randomized controlled trial were analyzed. Individuals with moderate-severe OSA (apnea hypopnea index, AHI = 15-50) and cardiovascular risk were recruited from cardiology practices. Those with hypertension were included. Intensive antihypertensive regimen (IAR) was defined as >= 3 antihypertensives including a diuretic. Definitions were: controlled BP (BP < 130/80), uncontrolled elevated BP (BP >= 130/80 not on IAR) and resistant elevated BP (BP >= 130/80 mm Hg despite IAR). Associations of untreated severe OSA (AHI >= 30) and uncontrolled and resistant elevated BP were evaluated using logistic regression analyses adjusted for age, sex, race, body mass index, smoking status, diabetes, and CVD. Results: Among the 284 participants (mean age 63.1 +/- 7.2 years, 23.6% with severe OSA), 61.6% had controlled BP, 28.5% had uncontrolled elevated BP, and 9.9% had resistant elevated BP. Among participants prescribed IAR, resistant elevated BP was more prevalent in those with severe compared to moderate OSA (58.3% vs. 28.6%, p = 0.01). Participants with severe OSA had a 4-fold higher adjusted odds of resistant elevated BP (OR 4.1, 95% CI: 1.7-10.2), a fi nding not reproduced in the absence of IAR use. Conclusions: Among patients with increased cardiovascular risk and moderate to severe OSA, untreated severe compared to moderate OSA was associated with elevated BP despite IAR suggesting untreated severe OSA contributes to poor BP control despite aggressive medication use. Commentary: A commentary on this article appears in this issue on page 845.
    Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 08/2014; 10(8):835-43. DOI:10.5664/jcsm.3946 · 2.83 Impact Factor
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    ABSTRACT: Background: Intermittent hypoxemia is a fundamental pathophysiological consequence of sleep-disordered breathing and may alter glucose metabolism. To characterize the association between sleep-related intermittent hypoxemia and glucose metabolism, overnight pulse-oximetry and an oral glucose tolerance test were completed in a cohort of middle-aged and older Japanese adults. Methods: The study sample consisted of 1836 community-dwelling Japanese (age, 30-79 years; women, 65.5%; mean body mass index, 23.1 kg/m(2)). The oxygen desaturation index (ODI) was quantified during sleep using a >= 3% oxygen desaturation threshold and categorized as normal (< 5.0 events/h), mild (5.015.0 events/h), and moderate to severe (>= 15.0 events/h). The independent associations between the ODI and the prevalence of impaired fasting glucose, impaired glucose tolerance, diabetes, and two metrics of insulin resistance [homeostasis model assessment index for insulin resistance (HOMA-IR) and Matsuda index] were examined. Results: Compared with subjects with an ODI < 5 events/h, the adjusted odds ratio for prevalent impaired fasting glucose, glucose intolerance, and diabetes for subjects with an ODI >= 15.0 events/h were 1.27 (95% confidence interval, 0.72-2.23), 1.69 (1.03-2.76), and 1.28 (0.59-2.79), respectively. Both HOMA-IR and Matsuda index were significantly associated with the severity of sleep-related intermittent hypoxemia as assessed by the ODI (P for trend >= 0.03 and 0.007, respectively). Conclusion: Among middle-aged and older Japanese adults, sleep-related intermittent hypoxemia is associated with glucose intolerance and insulin resistance, and may contribute to the development of type 2 diabetes mellitus.
    Sleep Medicine 06/2014; 15(10). DOI:10.1016/j.sleep.2014.05.027 · 3.10 Impact Factor
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    ABSTRACT: Background Obstructive sleep apnea is associated with hypertension, inflammation, and increased cardiovascular risk. Continuous positive airway pressure (CPAP) reduces blood pressure, but adherence is often suboptimal, and the benefit beyond management of conventional risk factors is uncertain. Since intermittent hypoxemia may underlie cardiovascular sequelae of sleep apnea, we evaluated the effects of nocturnal supplemental oxygen and CPAP on markers of cardiovascular risk. Methods We conducted a randomized, controlled trial in which patients with cardiovascular disease or multiple cardiovascular risk factors were recruited from cardiology practices. Patients were screened for obstructive sleep apnea with the use of the Berlin questionnaire, and home sleep testing was used to establish the diagnosis. Participants with an apnea-hypopnea index of 15 to 50 events per hour were randomly assigned to receive education on sleep hygiene and healthy lifestyle alone (the control group) or, in addition to education, either CPAP or nocturnal supplemental oxygen. Cardiovascular risk was assessed at baseline and after 12 weeks of the study treatment. The primary outcome was 24-hour mean arterial pressure. Results Of 318 patients who underwent randomization, 281 (88%) could be evaluated for ambulatory blood pressure at both baseline and follow-up. On average, the 24-hour mean arterial pressure at 12 weeks was lower in the group receiving CPAP than in the control group (-2.4 mm Hg; 95% confidence interval [CI], -4.7 to -0.1; P=0.04) or the group receiving supplemental oxygen (-2.8 mm Hg; 95% CI, -5.1 to -0.5; P=0.02). There was no significant difference in the 24-hour mean arterial pressure between the control group and the group receiving oxygen. A sensitivity analysis performed with the use of multiple imputation approaches to assess the effect of missing data did not change the results of the primary analysis. Conclusions In patients with cardiovascular disease or multiple cardiovascular risk factors, the treatment of obstructive sleep apnea with CPAP, but not nocturnal supplemental oxygen, resulted in a significant reduction in blood pressure. (Funded by the National Heart, Lung, and Blood Institute and others; HeartBEAT ClinicalTrials.gov number, NCT01086800 .).
    New England Journal of Medicine 06/2014; 370(24):2276-2285. DOI:10.1056/NEJMoa1306766 · 54.42 Impact Factor
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    Pediatric Critical Care Medicine 05/2014; 15:20. DOI:10.1097/01.pcc.0000448795.68719.f2 · 2.33 Impact Factor
  • Article: ABSTRACT 61
    Pediatric Critical Care Medicine 05/2014; 15:18-19. DOI:10.1097/01.pcc.0000448790.45849.13 · 2.33 Impact Factor

Publication Stats

7k Citations
816.79 Total Impact Points

Institutions

  • 2002–2015
    • Johns Hopkins University
      • • Division of Pulmonary and Critical Care Medicine
      • • Department of Medicine
      Baltimore, Maryland, United States
  • 2007–2014
    • Johns Hopkins Medicine
      • • Division of Pulmonary and Critical Care Medicine
      • • Department of Medicine
      Baltimore, Maryland, United States
  • 2013
    • Charles University in Prague
      • Department of Sport Medicine (3. LF)
      Praha, Praha, Czech Republic
  • 2004–2012
    • Johns Hopkins Bloomberg School of Public Health
      • • Department of Biostatistics
      • • Department of Epidemiology
      Baltimore, Maryland, United States
  • 2003–2006
    • Boston University
      Boston, Massachusetts, United States
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States