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Sijana Demirovic,1,2 Linda Lusic Kalcina,1,2 Ivana Pavlinac Dodig,1,2 Renata Pecotic,1,2 Maja Valic,1,2 Natalija Ivkovic,2 Zoran Dogas1,2 1Department of Neuroscience, University of Split School of Medicine, Split, Croatia; 2Split Sleep Medicine Center, University Hospital Center Split, Split, CroatiaCorrespondence: Zoran DogasDepartment of Neuroscience, University of Split School of Medicine, Soltanska 2, Split, 21000, CroatiaTel + 385 21 557 858Fax + 385 21 557 955Email zoran.dogas@mefst.hrPurpose: Due to the possible interplay of factors predisposing to severe COVID-19 outcomes and negative health consequences of poorly controlled OSA, adherence to continuous positive airway pressure (CPAP) therapy among OSA patients might be crucial during COVID-19 pandemics. Lockdown-related changes in CPAP adherence were investigated in CPAP users willing to participate in this study. Pre-lockdown adherence, age, gender, comorbidities and anxiety were analyzed as predictors of COVID-19 lockdown adherence.Patients and Methods: A cross-sectional study performed at Split Sleep Medicine Center included 101 severe OSA patients (78.2% male). CPAP memory cards were assessed during 6 months of pre-lockdown and 40 days of lockdown (March/April 2020) period. A total of 81 patients in pre-lockdown met good CPAP adherence criteria (≥ 4 hours/night on 70% nights).Results: CPAP adherence improved during COVID-19 lockdown in the total sample of severe OSA patients. The percentage of adherent nights and CPAP usage hours per night increased during lockdown in good pre-lockdown CPAP adherers (p=0.011 and p=0.001, respectively), women (p=0.003 and p=0.001, respectively) and respondents younger than 58 years (p=0.007 and p< 0.001, respectively). Out of 20/101 poor pre-lockdown CPAP adherers, 9 have shifted to good lockdown adherence. When comorbidities, BMI and anxiety were taken into account, older and male respondents were recognized as less likely to improve CPAP usage hours during lockdown (R2=9.4%; p=0.032).Conclusion: The lockdown-related CPAP adherence improved in severe OSA patients, with a shift in almost half of poor pre-lockdown adherers towards good lockdown CPAP adherence. Women, younger and good pre-lockdown CPAP adherers were more adherent during lockdown. Despite being vulnerable groups for both OSA and COVID-19, no expected adherence improvements were observed in men and older patients.Keywords: OSA, CPAP, CPAP adherence, COVID-19, lockdown

Linda Lusic Kalcina, Ivana Pavlinac Dodig, Renata Pecotic, Maja Valic, Zoran Dogas Department of Neuroscience, Split Sleep Medicine Center, University of Split School of Medicine, Split, CroatiaCorrespondence: Zoran DogasDepartment of Neuroscience, Split Sleep Medicine Center, University of Split School of Medicine, Soltanska 2, Split 21000, CroatiaTel +38521557905Fax +38521557955Email zdogas@mefst.hrPurpose: Determinants of obstructive sleep apnea (OSA) are hypoxemia and hypercapnia, as well as (micro) arousals from sleep, resulting in chronic sleep fragmentation, sleep deprivation, and excessive daytime sleepiness (EDS). All of the above-mentioned factors might contribute to psychomotor impairment seen in OSA patients. Additionally, this study aimed to assess the contribution of BMI, age, EDS assessed with Epworth sleepiness scale (ESS), and severity of OSA assessed with apnea-hypopnea index (AHI) to the reaction time on chronometric tests in OSA patients and controls. It is hypothesized that moderate and severe OSA have adverse effects on reaction time of perception to visual stimulus, of solving simple arithmetic operations, and of psychomotor limbs coordination assessed by chronometric psychodiagnostic test battery.Patients and Methods: This study was conducted on 206 male participants; 103 of them had moderate or severe OSA diagnosed by whole-night polysomnography/polygraphy. Control participants (N=103), matched to patients with OSA by age and BMI, had no reported OSA in their medical history, no increased risk for OSA, nor EDS. All participants were assessed with three chronometric psychodiagnostic tests, measuring the reaction time of perception to visual stimulus, of solving simple arithmetic operations, and of psychomotor limbs coordination.Results: Participants from the OSA group achieved impaired results compared to control participants in minimum single task solving time in speed of solving simple arithmetic operations (3± 0.9 and 2.6± 0.6, P< 0.001), and in minimum solving time of a single task in complex psychomotor limbs coordination (0.69± 0.2 and 0.61± 0.1, P=0.007). Regression analysis revealed no significant contribution of daytime sleepiness to the results achieved in each of the tests.Conclusion: It is concluded that severe OSA impaired speed of perception, convergent, and operative thinking. Moreover, it is suggested that EDS did not contribute to poor psychomotor outcome in patients with OSA in this study, when age was controlled for.Keywords: obstructive sleep apnea syndrome, overnight polysomnography, psychomotor performance, psychodiagnostic test, daytime sleepiness

Background: Palliative care provides holistic support, addressing physical, psychological, social, emotional, and spiritual dimensions of suffering, known as "total pain", to improve patients' quality of life. Patients often rely on healthcare professionals, particularly nurses, for support. This study aimed to develop and validate questionnaires assessing nurses' perceptions of psychological, social, and spiritual issues in palliative care and their effectiveness in managing them., Methods: Two self-rated questionnaires were created: the Psychological, Social, and Spiritual Problems of Palliative Patients' Questionnaire and the Effectiveness in Coping with the Psychological, Social, and Spiritual Challenges of Palliative Care Patients. The study surveyed 237 nurses caring for palliative patients in Split Dalmatian County, Croatia., Results: The questionnaires demonstrated high reliability with Cronbach's α values of 0.98 and 0.99. Factor analysis revealed four factors for the first questionnaire and three for the second. Nurses primarily perceived patients as experiencing fear and emotional/spiritual suffering, with the greatest difficulty coping with the fear of the disease outcomes. Nurses acknowledged the need for improvement in addressing patient challenges, highlighting gaps in the Croatian system., Conclusions: Ongoing efforts are crucial to prioritize palliative care globally, with nursing professionals playing a vital role in symptom management., Competing Interests: The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

This cross-sectional study investigated the level of daytime sleepiness and sleep-related behaviors in preschool children and compared their self-evaluations with the evaluations of their parents. It was conducted in Split-Dalmatian County, Croatia, among 196 preschool children aged 6-7 years seen at regular medical examinations, accompanied by their parents, using the Epworth sleepiness scale for children and parents/caregivers. Compared to their child's reports, parents tended to underestimate their child's sleepiness while sitting in a classroom at school ( p = 0.001) and overestimate their child's sleepiness when lying down to rest or nap in the afternoon ( p < 0.001). Boys were sleepier while sitting in a classroom at school during the morning than girls ( p = 0.032). As much as 48.2% of preschool children had their own cellphones/tablets. Boys used video games ( p < 0.001) and cellphones/tablets more than girls did ( p = 0.064). Parental estimation of children playing video games at bedtime was lower than the child's report ( p < 0.001). Children who had a TV in their bedroom reported more daytime sleepiness ( p = 0.049), and those who played video games at bedtime went to sleep later during the weekend ( p = 0.024). Also, children owning cellphone/tablets had longer sleep latency during the weekend compared to children not owning a cellphone ( p = 0.015). This study confirmed that parents tend to underestimate children's habits of playing video games at bedtime and children's sleepiness during morning classes. Preschool children who use electronic devices at bedtime more frequently have prolonged sleep latency. These findings provide further evidence of the effects of electronic media devices on preschoolers' sleep patterns and daytime sleepiness.

Background: The recognition of comorbidities is relevant for asthma management, especially if these conditions/diseases are treatable traits such as anxiety. This study aimed to explore the associations between asthma severity and child and parent asthma-related anxiety and to recognize the most common specific fears., Methods: This cross-sectional study consisted of 150 parents and their children diagnosed with asthma, and was conducted at the Pediatric Clinic of the University Hospital Center Split in Croatia. All children, from ages 3 to 17 years, underwent a thorough clinical examination. A total of 150 parents and 108 children filled out an asthma-related anxiety questionnaire in paper form., Results: Parents of children with moderate and severe asthma had higher asthma-related anxiety due to restrictions related to asthma symptoms ( p = 0.032), and children diagnosed with moderate and severe asthma had greater anxiety due to restrictions related to asthma symptoms than children diagnosed with mild asthma ( p = 0.004). Children's anxiety was the highest when they experienced an asthmatic attack during physical activity (PA), and they fear that they will not be successful in sports or dancing due to asthma. Parents commonly reported the fear of an asthma attack without warning signs ( p < 0.001), fear of drug side effects ( p < 0.001), fear of absence from school ( p = 0.006), and fear of an asthma attack during PA ( p < 0.001)., Conclusions: The current study reports findings of increased parental levels of anxiety when compared to their children, related to fear of an asthma attack occurring without warning signs, fear of side effects and fear of absence from school, as well as the fear of an asthma attack occurring during sports activities. When assessing individual items on anxiety associated with asthma, children most commonly reported concern related to physical activity.

Introduction: This research was performed to examine the effects of air and oxygen prebreathing on bubble formation, flow-mediated dilatation, and psychomotor performance after scuba dives. Methods: Twelve scuba divers performed two dives using a gas mixture of oxygen, nitrogen, and helium (trimix). In a randomized protocol, they breathed air or oxygen 30 min before the trimix dives. Venous bubble formation, flow-mediated dilatation, and psychomotor performance were evaluated. The participants solved three psychomotor tests: determining the position of a light signal, coordination of complex psychomotor activity, and simple arithmetic operations. The total test solving time, minimum single-task solving time, and median solving time were analyzed. Results: The bubble grade was decreased in the oxygen prebreathing protocol in comparison to the air prebreathing protocol (1.5 vs. 2, p < 0.001). The total test solving times after the dives, in tests of complex psychomotor coordination and simple arithmetic operations, were shorter in the oxygen prebreathing protocol (25 (21-28) vs. 31 (26-35) and 87 (82-108) vs. 106 (90-122) s, p = 0.028). Conclusions: In the oxygen prebreathing protocol, the bubble grade was significantly reduced with no change in flow-mediated dilatation after the dives, indicating a beneficial role for endothelial function. The post-dive psychomotor speed was faster in the oxygen prebreathing protocol.

Background: Water-polo is an official competitive olympic sport with high energy and technical-tactical demands. The aim of this study was to evaluate the influence of cognitive performance and specific swimming capacities on the selection of youth water polo players to the national water polo team., Methods: There were 83 youth water polo players (mean age 13.61±0.67 years) who attended the Croatian Water Polo Foundation training camps included in this cross-sectional study. Testing included anthropometric measurements, specific swimming capacities and cognitive performance (Stroop test)., Results: Among 83 youth water polo players included in this study there were 13 goalkeepers, 13 center-defenders, 13 centers, 31 perimeter players and 13 wings. Selected players (N.=40) performed faster in OffTime (selected 62.99±10.21 s vs. non-selected 69.98±8.93 s, P=0.002) and OnTime (selected 75.61±15.85 s vs. non-selected 86.01±15.40 s, P=0.004) of the Stroop test than non-selected players (N.=43). Logistic regression analysis showed significant association between selection of youth water polo players to the national team and swimming results in 400 m crawl and 100 m crawl, as well as OffTime, OnTime and OnTime minus OffTime on the Stroop test., Conclusions: The results of this study showed that psychomotor ability, inhibition, motor speed and cognitive flexibility were found to be the most important predictors for the selection of youth water polo players to the national water polo team. Furthermore, selected water polo players demonstrated better psychomotor abilities, inhibition, and motor speed, as well as better results in all specific swimming tests in comparison to non-selected players.

The aim of this cross-sectional study was to objectively assess the salivary flow rate and composition and periodontal inflammation in obstructive sleep apnoea (OSA) patients. The subjects, who underwent whole-night polysomnography or polygraphy, were referred for saliva sampling and periodontal examination. According to the severity of OSA based on the Apnoea Hypopnea Index (AHI) value, the subjects were classified into groups: no OSA (AHI < 5; N = 17), mild to moderate OSA (AHI 5-29.9; N = 109), and severe OSA (AHI > 30; N = 79). Salivary flow rate, pH, salivary electrolytes, and cortisol were measured from collected saliva samples. Periodontal examination included assessment of the number of teeth, dental plaque, bleeding on probing and periodontal measurements: gingival recession, probing pocket depth, clinical attachment level (CAL) and periodontal inflamed surface area (PISA) score. There were no significant differences in salivary flow rate, salivary pH, salivary electrolyte concentrations or electrolyte ratios among the groups classified according to the severity of OSA. However, subjects without OSA had higher salivary cortisol concentrations than OSA groups (p < 0.001). Increased plaque scores were associated with a higher AHI (r = 0.26; p = 0.003). According to the salivary flow rate, subjects with hyposalivation and reduced salivation had higher concentrations of salivary electrolytes and lower salivary pH than subjects with normal salivation. Subjects with hyposalivation had an increased Mg/PO 4 ratio (p < 0.001) and a reduced Ca/Mg ratio (p < 0.001). Furthermore, subjects with severe OSA tended to have higher CALs and plaque volumes. In conclusion, under pathological conditions, such as OSA, multiple interactions might impact salivary flow and electrolyte composition. Complex interrelationships might affect the integrity of oral health, especially considering OSA severity, inflammation, concomitant diseases and medications., (© 2022. The Author(s).)

Aim: To investigate the effects of the coronavirus disease 2019 (COVID-19) lockdown on sleep habits in the Croatian general population., Methods: In this cross-sectional study, 1173 respondents from the general population (809 women) completed a self-report online questionnaire that gathered demographic data and data on sleep habits and mood changes before and during the COVID-19 lockdown., Results: During the lockdown, bedtime (from 23:11±1:07 to 23:49±1:32 h, P<0.001) and waketime were delayed (from 6:51±1:09 to 7:49±1:40 h, P<0.001). Sleep latency increased from 10 (5-20) to 15 (10-30) minutes (P<0.001). Bedtime and waketime delays were more pronounced in women and respondents younger than 30. Compared with other age groups, respondents younger than 30 more frequently reported insomnia for the first time during the lockdown and had less frequent night-time awakenings (P<0.001), less common problems falling asleep (P<0.001), less frequently felt calm (P<0.001) and rested (P<0.001), but more frequently felt sadness (P<0.001) and fear (P=0.028)., Conclusion: The effect of the lockdown on sleep needs to be better understood. Sleep hygiene education could serve a first-line lifestyle intervention for people in lockdown experiencing sleep disruption.

Aim: To construct a single-format questionnaire on sleep habits and mood before and during the COVID-19 pandemic in the general population., Methods: We constructed the Split Sleep Questionnaire (SSQ) after a literature search of sleep, mood, and lifestyle questionnaires, and after a group of sleep medicine experts proposed and assessed questionnaire items as relevant/irrelevant. The study was performed during 2021 in 326 respondents distributed equally in all age categories. Respondents filled out the SSQ, the Pittsburgh Sleep Quality Index (PSQI), and State Trait Anxiety Inventory (STAI), and kept a seven-day sleep diary., Results: Cronbach alpha for Sleep Habits section was 0.819, and 0.89 for Mood section. Test-retest reliability ranged from 0.45 (P=0.036) for work-free day bedtime during the pandemic to 0.779 (P<0.001) for sleep latency before the pandemic. Workday and work-free day bedtime during the COVID-19 pandemic assessed with SSQ were comparable to the sleep diary assessment (P=0.632 and P=0.203, respectively), as was the workday waketime (P=0.139). Work-free day waketime was significantly later than assessed in sleep diary (8:19±1:52 vs 7:45±1:20; P<0.001). No difference in sleep latency was found between the SSQ and PSQI (P = 0.066)., Conclusion: The SSQ provides a valid, reliable, and efficient screening tool for the assessment of sleep habits and associated factors in the general population during the COVID-19 pandemic.

Objectives: This cross-sectional study investigated the stages of periodontitis in obstructive sleep apnea (OSA) patients and risk factors associated with periodontitis severity among them., Materials and Methods: A total of 194 patients underwent a polysomnography/polygraphy and were referred to periodontal examination. According to apnea-hypopnea index (AHI), patients were classified as mild OSA (AHI < 15) and moderate to severe OSA (AHI ≥ 15), whereas periodontitis severity was determined by the clinical attachment level (CAL) according to the recent Classification of Periodontal Diseases and Conditions. Patients were grouped into two categories: stages 1 and 2, and stages 3 and 4., Results: Higher AHI values were reported in OSA patients exhibiting periodontitis stages 3 and 4 compared to OSA patients with periodontitis stages 1 and 2 (p = 0.043) and the non-periodontitis group (p = 0.044). A positive correlation was found between AHI and mean CAL (r = 0.215; p = 0.004), and between AHI and plaque scores (r = 0.292; p < 0.001). Following a multivariable regression analysis, AHI was a significant predictor of mean CAL (β = 0.169; p = 0.031), explaining 16.4% of variability in mean CAL (adjusted R 2  = 0.164; p < 0.001). Older patients had higher odds for an increased mean CAL (β = 0.266; p = 0.001), as well as patients smoking or formerly smoking (β = 0.305; p < 0.001) whereas visiting a dental medicine doctor once a year or more often was associated with a decreased mean CAL (β =  - 0.182; p = 0.02)., Conclusions: OSA was associated with severe stages of periodontitis along with increased age, smoking, low frequency of dental visits, and poor oral hygiene., Clinical Relevance: Screening for periodontitis is recommended for patients with more severe forms of OSA., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: To investigate the effect of the coronavirus 2019 (COVID-19) lockdown on lifestyle behaviors and mood changes in the Croatian general population., Methods: During ten days of the COVID-19 lockdown in Croatia, 3027 respondents (70.3% female) from the general population completed an online, self-report questionnaire. Demographic data and data on lifestyle habits and mood changes before and during the COVID-19 lockdown were collected., Results: A total of 95.64% of respondents reported to follow most or all restrictions, with female sex (P<0.001) and higher education level (P<0.001) being associated with higher restriction compliance. Women smoked an increased number of cigarettes (P<0.001). The proportion of respondents of both sexes who did not drink or drank 7 drinks per week or more increased (P<0.001). Women also reported lower frequency (P=0.001) and duration of physical exercise (P<0.001). In total, 30.7% of respondents gained weight, with female sex (OR, 2.726) and higher BMI (OR, 1.116; both P<0.001) being associated with an increased likelihood of gaining weight. Both men and women felt more frequently afraid (P<0.001), discouraged (P<0.001), and sad (P<0.001)., Conclusion: Public health authorities should promote the adoption of healthy lifestyles in order to reduce long-term negative effects of the lockdown.

Aim: To assess age- and gender-associated differences in cognitive and psychomotor abilities measured by the Complex Reactionmeter Drenovac (CRD-series) tests., Methods: This cross-sectional study, conducted between 2009 and 2019, enrolled 3420 participants (2012 women) in the age ranging from 18 to 88 years. The participants solved three CRD-series chronometric tests: discrimination of the light signal position (CRD311), complex psychomotor coordination (CRD411), and simple arithmetic operations (CRD11). We analyzed total test solving time (TTST), minimum single task solving time (MinT), number of errors, initial dissociation, and start, end, and total ballasts as measures of wasted time in the first half of the test, second half of the test, and total test time, respectively., Results: Age was positively associated with MinT and TTST in all used tests (P<0.001), while initial dissociation, start ballast, and end ballast significantly increased with age (P<0.001). On the CRD11 test, men had shorter TTST than women (P=0.012), shorter start, end, and total ballasts (P<0.001), and made fewer errors than women (P<0.001). On the CRD311 test, women had shorter start (P=0.002), end, and total ballast (P<0.001) than men. On the CRD411 test, men performed better than women on all variables (P<0.001)., Conclusion: Decreased cognitive and psychomotor abilities measured by the CRD-series tests were associated with advanced age. Men performed better than women on simple arithmetic and complex psychomotor coordination tests, whereas women lost less time on the test of light signal position discrimination.