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Objectives: This study aimed to elucidate whether a comprehensive intervention focusing on individual characteristics could enhance adherence to Continuous Positive Airway Pressure (CPAP) in patients with Obstructive Sleep Apnea (OSA).Methods: We conducted a single-arm, pilot intervention study, recruiting participants aged ≥20 years with suspected OSA. All participants underwent split-night polysomnography and received standardized CPAP treatment. We identified five categories of factors contributing to poor CPAP adherence: mouth breathing, high CPAP pressure causing sleep initiation difficulties, bradypnea or hyperpnea before sleep onset, postarousal central apnea, and nasal dryness and obstruction. We objectively measured CPAP adherence data at 1, 3, 6 and 12 months after a comprehensive intervention targeting individual characteristics. We analyzed the trends in CPAP adherence rates over 1 year.Results: A total of 48 participants (74.0% males; 56.9±13.9 years old) were followed up for 12 months. CPAP adherence rate was 77.1% at 1 month; declined to 60.4%, 39.6%, and 31.3% at 3, 6, and 12 months, respectively. There was no significant difference in demographic and psychological factors, sleep-related symptoms, and sleep characteristics between the adherence and the non-adherence groups. Low body mass index was an independent risk factor affecting CPAP adherence (odds ratios 0.78, p=0.04).Conclusions: Although our study did not yield significant improvements in CPAP adherence through the comprehensive intervention that targeted individual characteristics, it is significant because it attempted to provide a multidimensional approach to intervention, rather than targeting a single aspect, in promoting CPAP adherence.

Information on obstructive sleep apnea (OSA) is often latently detected in diagnostic tests conducted for other purposes, providing opportunities for maximizing value. This study aimed to develop a convolutional neural network (CNN) to identify the risk of OSA using lateral cephalograms.The lateral cephalograms of 5,648 individuals (mean age, 49.0±15.8 years; men, 62.3%) with or without OSA were collected and divided into training, validation, and internal test datasets in a 5:2:3 ratio. A separate external test dataset (n=378) was used. A densely connected CNN was trained to diagnose OSA using a cephalogram. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC). Gradient-weighted class activation mapping (Grad-CAM) was used to evaluate the region of focus, and the relationships between the model outputs, anthropometric characteristics, and OSA severity were evaluated.The AUROC of the model for the presence of OSA was 0.82 (95% confidence interval [CI], 0.80-0.84) and 0.73 (95% CI, 0.65-0.81) in the internal and external test datasets, respectively. Grad-CAM demonstrated that the model focused on the area of the tongue base and oropharynx in the cephalogram. Sigmoid output values were positively correlated with OSA severity, body mass index, and neck and waist circumference.Deep learning may help develop a model that classifies OSA using a cephalogram, which may be clinically useful in the appropriate context. The definition of ground truth was the main limitation of this study.

Obstructive sleep apnea (OSA) and atrial fibrillation (AF) are associated with increased morbidity and mortality. OSA and AF share multiple risk factors, including hypertension, cardiovascular disorders, congestive heart failure, and metabolic syndrome. Although the two conditions are likely to have a bidirectional association, recent studies have suggested that OSA contributes to the development of AF through direct mechanical effects on cardiac remodeling. We report a patient with severe OSA showing immediate conversion of AF to normal sinus rhythm with optimal continuous positive airway pressure (CPAP) therapy. This supports that OSA may lead to AF, which can be effectively reversed with CPAP therapy.

Obesity hypoventilation syndrome (OHS) is defined as the combination of daytime hypercapnia (awake PaCO2 ≥45 mm Hg) and obesity (body mass index ≥30 kg/m2). Untreated OHS is associated with comorbidities, including cardiovascular diseases, heart failure, pulmonary hypertension, and metabolic syndrome. Continuous positive airway pressure (PAP) therapy with non-invasive ventilation is the gold standard for treating OHS. PAP therapy is highly effective; however, some adverse effects can affect long-term compliance. Air leakage through the mouth or around a mask is a common adverse effect of PAP therapy. Air leakage through the nasolacrimal duct or due to unsealed circuits has also been reported as a complication of PAP therapy; however, it is relatively rare. Considering the negative association between the level of air leakage and adherence to PAP therapy, clarifying the cause of air leakage during PAP therapy and minimizing it are key to successful outcomes. We report a case of air leakage through the nasolacrimal duct that was improved by inserting a gel foam patch inside the lacrimal sac of a patient with OHS with a history of reconstructive surgery for nasolacrimal duct obstruction.

To examine the association of subjective age (SA) with sleep quality in an adult population.In the Korean Sleep and Headache Study, 2,349 participants (49.2% men; 48.1 ± 16.4 years old) were interviewed face-to-face using structured questionnaires between September and December 2018. SA was assessed by asking participants their perceived age in years and then compared with their chronological age (CA). Participants were assigned to three groups: feeling younger, feeling their age, and feeling older. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Association between SA and sleep quality was analyzed with multiple linear regression controlling for demographics, psychosocial, and sleep characteristics.The group feeling older (n = 404, 17.2%; men, 58.2%; age, 46.5 ± 16.2 years) had worse sleep quality than the groups feeling younger and feeling their age (PSQI score, 4.3 ± 2.7, 3.8 ± 2.4, 3.4 ± 2.1, respectively, p.001; prevalence of poor sleep quality, 29.0%, 18.4%, 13.5% respectively, p.001). The association between SA and the PSQI score remained significant after adjusting for confounders (β = 1.05, 95% confidence interval 0.26, 1.83; p.001). Stratified analyses by sex and CA showed that the association between SA and the PSQI score was significant only in women and in middle-aged and older group (aged 50-79), suggesting that sex and CA modified the association.Age perception was associated with self-reported sleep quality, independent of CA. SA may be a useful marker that complements the conventional assessment of subjective sleep quality.

Min-Hee Lee,1 Seung Ku Lee,1 Robert J Thomas,2 Jee-Eun Yoon,3 Chang-Ho Yun,4,* Chol Shin1,5,* 1Institute of Human Genomic Study, College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea; 2Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; 3Department of Neurology, Uijeongbu Eulji Medical Center, Uijeongbu, Republic of Korea; 4Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; 5Department of Pulmonary Sleep and Critical Care Medicine Disorder Center, College of Medicine, Korea University, Ansan, Republic of Korea*These authors contributed equally to this workCorrespondence: Chang-Ho YunDepartment of Neurology, Bundang Clinical Neuroscience Institute, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam, 13620, Republic of KoreaTel +82 31 787 7469Fax +82 31 787 4059Email ych333@gmail.comChol ShinDivision of Pulmonary, Sleep, and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital and Institute of Human Genomic Study, Korea University Ansan Hospital, 516, Gojan-1-dong, Danwon-gu, Ansan, Gyeonggi-do, 15355, Republic of KoreaTel +82 31 412 5541Fax +82 31 412 5604Email chol-shin@korea.ac.krPurpose: Obstructive sleep apnea (OSA) is associated with altered pairwise connections between brain regions, which might explain cognitive impairment and daytime sleepiness. By adopting a deep learning method, we investigated brain connectivity related to the severity of OSA and daytime sleepiness.Patients and Methods: A cross-sectional design applied a deep learning model on structural brain networks obtained from 553 subjects (age, 59.2 ± 7.4 years; men, 35.6%). The model performance was evaluated with the Pearson’s correlation coefficient (R) and probability of absolute error less than standard deviation (PAE

This study aimed to evaluate the effect of sleep duration on brain structures in the presence versus absence of sleep apnea in middle-aged and older individuals. The study investigated a population-based sample of 2,560 individuals, aged 49-80 years. The presence of sleep apnea and self-reported sleep duration were examined in relation to gray matter volume (GMV) in total and lobar brain regions. We identified ranges of sleep duration associated with maximal GMV using quadratic regression and bootstrap sampling. A significant quadratic association between sleep duration and GMV was observed in total and lobar brain regions of men with sleep apnea. In the fully adjusted model, optimal sleep durations associated with peak GMV between brain regions ranged from 6.7 to 7.0 hours. Shorter and longer sleep durations were associated with lower GMV in total and 4 sub-regions of the brain in men with sleep apnea.

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is known as a maternally inherited mitochondrial disease with a m.3243A>G mutation in the MT-TL1 gene. Here, we report a case of targeted temperature management in a MELAS patient who had a cardiac arrest and severe lactic acidosis after recurrent seizures.

A close association has been reported between depression and migraine. However, information concerning the impacts of migraine on the clinical presentation and prevalence of depression in a population-based study is currently limited.Data from the Korean Headache-Sleep Study, a nationwide survey about headache and sleep for adults aged 19-69 years were used. Depression was defined when Patient Health Questionnaire-9 score ≥ 10.Of 2,695 participants who included in this study, 116 (4.3%), 143 (5.3%), and 1130 (41.9%) had depression, migraine, and non-migraine headache, respectively. Migraine (24/116 [20.5%] vs. 119/2579 [4.7%], p 0.001) and non-migraine headache (67/116 [58.1%] vs. 1063/2579 [41.3%], p 0.001) was more prevalent in the group of participants with depression than among participants without depression. Among participants with depression, there was no statistically differences in total Patient Health Questionnaire-9 (PHQ-9) scores among migraine, non-migraine headache, and non-headache groups (median with interquartile range, 12.0 [10.2-18.0] vs. 13.0 [11.0-16.0] vs. 12.0 [10.0-15.2], p = 0.514). Among subcomponent scores of PHQ-9, all subcomponent scores did not significantly differ by headache status except feeling tired or having little energy scores (non-migraine headache 2.0 [2.0-3.0] vs. non-headache 2.0 [1.0-2.0], p = 0.010).Diagnosis of depression based on PHQ-9 questionnaire and small sample size in subgroup analyses.Participants with depression exhibit an increased risk of migraine and non-migraine headache compared with participants without depression. Among participants with depression, the severity of depression did not significantly differ on the basis of headache status.

Background While obesity is linked with brain atrophy and dementia incidence, associations with regional adiposity are uncertain. Our goal was to determine whether cerebral gray matter volume is related to neck circumference (NC), a measure of regional adiposity having unique relationships with metabolic disorders and cardiovascular disease. Methods Magnetic resonance imaging and NC were cross-sectionally assessed from 2011 to 2014 in a population-based sample of 2916 men and women in the Korean Genome and Epidemiology Study. Results For men, NC was inversely associated with total and regional gray matter in the frontal, temporal, and occipital lobes after adjusting for age and intracranial brain volume. Associations were especially strong in the presence of diabetes. With further adjustment for indices of body composition and other characteristics, total and frontal gray matter in diabetic men were lowered by 6.1 mL (95% confidence interval: 2.5-9.7, P=0.004) and 2.9 mL (95% confidence interval: 1.0-4.9, P=0.017), respectively, per SD increase in NC (2.3 cm). For men without diabetes, and in all women, associations were less apparent. Conclusions In men with diabetes, NC was inversely associated with cerebral gray matter volume. The link between neck anthropometry and brain aging in diabetic men warrants further consideration.

Migraine neither presents with a definitive single symptom nor has a distinct biomarker; thus, its diagnosis is based on combinations of typical symptoms. We aimed to identify natural subgroups of migraine based on symptoms listed in the diagnostic criteria of the third edition of the International Classification of Headache Disorders. Latent class analysis (LCA) was applied to the data of the Korean Sleep-Headache Study, a nationwide population-based survey. We selected a three-class model based on Akaike and Bayesian information criteria and characterized the three identified classes as “mild and low frequency,” “photophobia and phonophobia,” and “severe and high frequency.” In total, 52.0% (65/125) of the participants were classified as “mild and low frequency,” showing the highest frequency of mild headache intensity but the lowest overall headache frequency. Meanwhile, “photophobia and phonophobia” involved 33.6% (42/125) of the participants, who showed the highest frequency of photophobia and phonophobia. Finally, “severe and high frequency” included 14.4% (18/125) of the participants, and they presented the highest frequency of severe headache intensity and highest headache frequency. In conclusion, LCA is useful for analyzing the heterogeneity of migraine symptoms and identifying migraine subtypes. This approach may improve our understanding of the clinical characterization of migraine.

The relationship between napping and cognition remains controversial. This study aimed to investigate the association between napping and cognition according to sleep debt in the Korean adult population.A population-based nationwide cross-sectional survey was conducted in 2018. A two-stage stratified random sample of Koreans aged ≥19 years was selected and evaluated using questionnaires by trained interviewers. Cognitive function was assessed using the Mail-In Cognitive Function Screening Instrument (MCFSI). Sleep habits on weekdays and weekends, napping, and subjective sleep requirements were assessed using the questionnaires. Accumulated sleep debt was calculated by subtracting the weekly average sleep duration from subjective sleep requirements. Sleep quality, daytime sleepiness, insomnia, depression, demographics, and comorbidities were assessed. Participants were grouped into those with sleep debt ≤60 min and those with sleep debt60 min. Multiple linear regression was used to estimate the independent association between the factors and cognition.In total, 2,501 participants were included in the analysis. Naps were reported in 726 (29.0%) participants (nappers). The mean MCFSI score was higher in nappers (3.4±3.6) than in non-nappers (2.3±3.0) (In general, naps are associated with worse cognitive function in the Korean adult population. However, for those with sleep debt of60 min, naps for60 min were associated with better cognitive function.

Lemborexant (LEM) is a dual orexin receptor antagonist approved for treating adults with insomnia. We analyzed the efficacy (subjective sleep outcomes) and safety of LEM over 12 months in the subgroup of Asian subjects from Study E2006-G000-303 (Study 303).Study 303 was a 12-month, randomized, placebo-controlled (first 6 months), double-blind, parallel-group, phase 3 study of adults with insomnia disorder. During the 6-month Period 1, subjects were randomized (1:1:1) to placebo, LEM 5 mg (LEM5), or LEM 10 mg (LEM10); LEM subjects continued treatment in the following 6-month Period 2. Outcome measures included subject-reported (subjective) sleep onset latency (sSOL), sleep efficiency (sSE), wake after sleep onset (sWASO), total sleep time (sTST), Insomnia Severity Index (ISI), and Patient Global Impression-Insomnia version (PGI-I). Treatment-emergent adverse events (TEAEs) were assessed.Overall, 178 Asian subjects (Japanese,LEM improved subjective sleep parameters and was well-tolerated in Asian subjects with insomnia disorder over 12 months.ClinicalTrials.gov, NCT02952820; ClinicalTrialsRegister.eu, EudraCT Number 2015-001463-39.

Objective: Insomnia and depression are prevalent disorders that often co-occur. This study aimed to investigate the impact of clinically significant insomnia symptoms on the prevalence and clinical presentation of clinically significant depressive symptoms and vice versa.Methods: This study used data from the Korean Headache-Sleep Study (KHSS), a nationwide cross-sectional population-based survey regarding headache and sleep. Clinically significant insomnia symptoms were defined as Insomnia Severity Index (ISI) scores ≥ 10 and clinically significant depressive symptoms were defined as Patient Health Questionnaire-9 (PHQ-9) scores ≥ 10, respectively. We referred clinically significant insomnia symptoms and clinically significant depressive symptoms as insomnia symptoms and depressive symptoms, respectively.Results: Of 2,695 participants, 290 (10.8%) and 116 (4.3%) were classified as having insomnia and depressive symptoms, respectively. The prevalence of depressive symptoms was higher among participants with insomnia symptoms than in those without insomnia symptoms (25.9 vs. 1.7%, respectively, P < 0.001). Among participants with depressive symptoms, the PHQ-9 scores were not significantly different between participants with and without insomnia symptoms (P = 0.124). The prevalence of insomnia symptoms was significantly higher among participants with depressive symptoms than in those without depressive symptoms (64.7 vs. 8.3%, respectively, P < 0.001). The ISI scores were significantly higher among participants with insomnia and depressive symptoms than in participants with insomnia symptoms alone (P < 0.001).Conclusions: Participants with depressive symptoms had a higher risk of insomnia symptoms than did those without depressive symptoms. The severity of depressive symptoms did not significantly differ based on insomnia symptoms among participants with depressive symptoms; however, the severity of insomnia symptoms was significantly higher in participants with depressive symptoms than in those without depressive symptoms.

Sleep fragmentation (SF) commonly occurs in several pathologic conditions and is especially associated with impairments of hippocampus-dependent neurocognitive functions. Although the effects of SF on hippocampus in terms of protein or gene levels were examined in several studies, the impact of SF at the metabolite level has not been investigated. Thus, in this study, the differentially expressed large-scale metabolite profiles of hippocampus in a rat model of SF were investigated using untargeted metabolomics approaches. Forty-eight rats were divided into the following 4 groups: 4-day SF group, 4-day exercise control (EC) group, 15-day SF group, and 15-day EC group (n = 12, each). SF was accomplished by forced exercise using a walking wheel system with 30-s on/90-s off cycles, and EC condition was set at 10-min on/30-min off. The metabolite profiles of rat hippocampi in the SF and EC groups were analyzed using liquid chromatography/mass spectrometry. Multivariate analysis revealed distinctive metabolic profiles and marker signals between the SF and corresponding EC groups. Metabolic changes were significant only in the 15-day SF group. In the 15-day SF group, L-tryptophan, myristoylcarnitine, and palmitoylcarnitine were significantly increased, while adenosine monophosphate, hypoxanthine, L-glutamate, L-aspartate, L-methionine, and glycerophosphocholine were decreased compared to the EC group. The alanine, aspartate, and glutamate metabolism pathway was observed as the common key pathway in the 15-day SF groups. The results from this untargeted metabolomics study provide a perspective on metabolic impact of SF on the hippocampus.

We investigated the prevalence of sleep problems, such as obstructive sleep apnea (OSA), insomnia, and daytime sleepiness in commercial motor vehicle (CMV) drivers compared with that in the general population. This is a cross-sectional study comparing sleep habits and sleep problems in 110 truck drivers with 1001 matched controls from the general population. The assessment was based on self-administered questionnaires that included the Berlin questionnaire, the insomnia severity index, and the Epworth sleepiness scale (ESS). Multivariate regression analysis was performed to determine whether CMV drivers were independently associated with these sleep problems compared with controls. The prevalence of a high risk of OSA and insomnia was 35.5% and 15.2%, respectively, in CMV drivers, which was significantly higher than in controls with a prevalence of 12.2% and 4.1%, respectively (P

OBJECTIVE This study was conducted to investigate sex differences in the prevalence and clinical presentation of migraine and probable migraine in a general population-based sample. BACKGROUND While there is research on sex differences in clinical characteristics and their impact on migraine headache, only few studies have investigated sex differences in probable migraine in population-based settings. Moreover, compared with Western countries, the prevalence of probable migraine in Asia is relatively high. This cross-sectional study was designed to investigate sex differences in the prevalence and clinical presentation of migraine and probable migraine in a general population-based sample. METHODS We used the data of the Korean Headache-Sleep Study, which is a nationwide survey on headache and sleep. RESULTS We interviewed 7430 people, and 3114 of them agreed to participate in our study (rejection rate, 58.1%). Among these people, 419 withdrew their participation during the interview. Ultimately, 2695 people completed our survey (cooperation rate, 36.3%). The prevalence of overall migraine and probable migraine was 350/1350 (25.9%) for women and 172/1345 (12.8%) for men (P

Instantaneous drowsiness ( i.e., lapse or micro-sleep) during various activities such as driving or construction causes enormous socioeconomic losses. Thus, a virtuous cycle system that monitors a subject’s drowsiness can improve work efficiency and safety. We propose a novel framework to detect instantaneous drowsiness with only a two-second length of electroencephalography (EEG). To achieve reliable performance, we use multitaper power spectral density for feature extraction along with extreme gradient boosting as a machine learning classifier. In addition, we introduce a novel phenotype labeling of instantaneous drowsiness by combining both task dependent and independent measures of alertness (psychomotor vigilance task and electrooculography technique, respectively). The results show that our techniques outperform others used in previous studies. We also identified which spectral components ( $\theta $ , $\alpha $ , and $\gamma $ ) and channels (Fp1, Fp2, T3, T4, O1, O2, and electrocardiogram) play important roles in our drowsiness detection framework. To verify the applicability for a mobile environment, we implemented our framework on a wireless EEG, as well as on a wired EEG. We hereby present our successful results.

Obstructive sleep apnea (OSA) is associated with cognitive impairment and brain structural alterations, but longitudinal outcomes are understudied.To examine the associations of OSA with cognition and white matter (WM) integrity over a 4-year period.This prospective cohort study was conducted in a community-based adult population among participants who had both baseline (2011-2014) and 4-year follow-up (2015-2018) polysomnography, diffusion tensor imaging, and cognitive assessment data. Participants with neurological disorders, anomalous findings on brain magnetic resonance imaging, or inadequate quality of the evaluations were excluded. Data were analyzed from March to November 2021.Participants were categorized depending on the presence vs absence of OSA at baseline and follow-up polysomnographic analysis.The main outcomes were proportional changes over a 4-year period in neuropsychological performance and WM integrity. The neuropsychological assessment battery included verbal and visual memory, verbal fluency, Digit Symbol-coding, Trail Making Test-A, and Stroop Test. WM integrity was assessed by fractional anisotropy, axial, and radial diffusivity. To examine interactions with age and sex, participants were subgrouped by age older than 60 years vs 60 years or younger and men vs women.A total of 1998 individuals were assessed for eligibility, and 888 were excluded based on exclusion criteria, leaving 1110 participants (mean [SD] age, 58.0 [6.0] years; 517 [46.6%] men) for analysis, including 458 participants grouped as OSA-free, 72 participants with resolved OSA, 163 participants with incident OSA, and 417 participants with persistent OSA. Incident OSA was associated with altered WM integrity and with concomitant changes in sustained attention compared with participants without OSA (eg, change in Digit Symbol-coding test score, -3.2% [95% CI, -5.2% to -1.2%]). Participants with resolved OSA showed better visual recall at the follow-up (change in Visual Reproduction-immediate recall test, 17.5% [95% CI, 8.9% to 26.1%]; change in Visual Reproduction-delayed recall test, 33.1% [95% CI, 11.3% to 54.9%]), with concordant changes in diffusion parameters at the relevant anatomic areas. In the older group only (age60 years), persistent OSA was associated with altered WM integrity and cognition (eg, Visual Reproduction-recognition test: β = -24.2 [95% CI, -40.7 to -7.7]). Sex also was associated with modifying the association of OSA with WM integrity of the left posterior internal capsule, the left genu of corpus callosum, and the right middle cerebellar peduncle only in men and with cognition only in women (eg, Visual Reproduction-immediate recall test: β = 33.4 [95% CI, 19.1 to 47.7]).These findings suggest that dynamic changes in OSA status were significantly associated with WM integrity and cognition, which varied by age and sex. It is possible that adequate interventions for OSA could better preserve brain health in middle to late adulthood.

The fine structure of sleep electrocortical activity reflects health and disease. The current study provides normative data for sleep structure and electroencephalography (EEG) spectral power measures derived from overnight polysomnography (PSG) and examines the effect of age and sex among Korean middle-aged and older adults with or without obstructive sleep apnea (OSA). We analysed home PSG data from 1,153 adult participants of an ongoing population-based cohort study, the Korean Genome and Epidemiology Study. Sleep stages were visually scored and spectral power was measured on a single-channel EEG (C4-A1). We computed spectral power for five frequency ranges. The EEG power was reported in relative (%) and log-transformed absolute values (µV2 ). With ageing, the proportion of N1 sleep increased, whereas N3 decreased, which is more noticeable in men than in women. The amount of N3 was relatively low in this cohort. With ageing, relative delta power decreased and alpha and sigma power increased for the whole sleep period, which was more pronounced during REM sleep in non-OSA. For men compared with women, relative theta power was lower during REM and sigma and beta were higher during N1 sleep. The differences of relative powers by age and sex in OSA were comparable to those in non-OSA. In a community-based Korean population, we present normative data of sleep structure and spectral power for middle-aged or older adults of a non-Caucasian ethnicity. The values varied with age and sex and were not influenced by sleep apnea.