Epidemiological studies in a wide range of ethnic and cultural settings show that obstructive sleep apnea (OSA) (defined as >15 obstructive events/ hour of sleep) affects about 5-10% of the population. The rising tide of obesity is almost certainly driving an increase in the prevalence of OSA in emerging economies such as India as well as in more developed countries. An increasing body of evidence over the last 15-20 years suggests that OSA is an independent risk factor for cardiovascular disease. Most of this evidence comes from population or clinic based cohort studies, although there are also a number of short-term randomised controlled trials of OSA treatment showing benefit for intermediate cardiovascular risk markers such as blood pressure, glucose metabolism and arterial vascular reactivity. Also, sudden death and acute myocardial infarction tend to occur preferentially in the nighttime amongst OSA sufferers. While this evidence points strongly to a possible causal link between OSA and cardiovascular diseases such as myocardial infarction and stroke, the international consensus is that definitive evidence for such a link is currently lacking and can only be obtained by rigorously planned and executed large-scale randomised controlled trials. Unfortunately, too often in the past, results from observational data or short term treatment studies have shown “compelling” evidence in favour of a causal relationship between a putative causal factor and cardiovascular disease only to find that properly conducted randomised controlled trials targeting hard endpoints show no such effect and in some instances even harm resulting from the treatment. The Sleep Apnea cardio Vascular Endpoints (SAVE) study is an investigator designed and led multi-centre, international, randomised controlled trial of continuous positive airway pressure (CPAP) treatment plus usual care versus usual care alone in patients with co-occurring OSA and cardiovascular disease, which is designed to help fill this evidence gap. The SAVE trial will extend over 5 years and involve approximately 5000 subjects. It commenced in China and Australia in late 2008 and plans are underway to involve investigators and recruitment sites in India and New Zealand in 2009.

Sleep disordered breathing (SDB) in children has been recognized over the past two decades due to research and clinical advances in pediatric sleep medicine. Pediatric SDB comprises of central apnoea/hypoventilation, apnoea of prematuriry, the spectrum of obstructive sleep hypoventilation disorders and hypoventilation during sleep due to chronic pulmonary disease. Obstructive sleep hypoventilation syndromes have a clinical range from primary snoring, through upper airway resistance syndrome to obstructive sleep apnoea syndrome (OSAS). Though, the exact prevalence of SDB and obstructive sleep hypoventilation syndrome is not known, the prevalence of OSAS in children varies between 1-4%. Pathophysiology, clinical manifestation, diagnosis and treatment of pediatric SDB which differs from adult SDB is reviewed along with its recent advances.

Rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by loss of muscular atonia and prominent motor behaviors during REM sleep, associated with excessive motor activity while dreaming. Behaviors can cause injuries to the patient or sleeping partner. RBD is associated with neurodegenerative diseases, such as multiple system atrophy, Parkinson's disease, dementia with Lewy bodies, and progressive supranuclear palsy. In many cases, the symptoms of RBD occur before other symptoms of these neurodegenerative disorders by several years. RBD was noted for the first time after the patient developed cancer of the prostate. The fact that PCa develops one year after the onset of RBD is of significance. Could RBD be a forerunner for PCa, or could a PCa that has not yet clinically surfaced have given rise to RBD? Some diseases associated with voltage gated potassium (K) channel antibody also had RBD. The possible contribution of voltage gated K channel activity in metastatic process was emphasized in PCa model in rats. Apparently, being able to explain the development mechanism of RBD by PCa and K channel antibody might be a possible viewpoint. Although our hypotheses can be explained by voltage gated K channel activity, yet there are still numerous ambiguities. This case brings to focus several unanswered questions related to the pathogenesis of RBD.

Sleep apnoea is a common condition within the community. The consequences of untreated sleep apnoea are far-reaching and they include cardiovascular and cerebrovascular morbidity and mortality, neurocognitive impairment, increased risk of motor vehicle accidents, occupational injuries, lower quality of life (QOL), and mood disorders. It is an important public safety issue in light of its prevalence in certain subgroups. Untreated sleep apnoea has substantial safety and psychosocial impairments, which translate to major health care costs. Continuous positive airway pressure (CPAP) treatment for sleep apnoea has been shown to have a positive impact on subjective quality of life and depression, and is cost effective.

Background: Obstructive sleep apnea (OSA), a complex disease is a growing health concern globally. Various global epidemiological studies have demonstrated prevalence of obstructive sleep apnea to vary from 0.3% to 5.1 %. Clinical scores (CS) are useful to estimate individuals at risk for OSA and predict prevalence of OSA in community based studies. Waist circumference, diabetes mellitus and metabolic syndrome are emerging as important risk factors for OSA. During a preventive health check Octroi employees were found to have sedentary habits and were hence assessed for OSA and its risk factors. Aims and objective: The aims of the study were i) study the overall health status ii) estimate individuals at risk for OSA using the CS and iii) study waist circumference, diabetes mellitus and metabolic syndrome as a risk factor for OSA. Methods: 262 Octroi employees, who received preventive health check up at the tertiary care hospital in Mumbai, were invited to participate in the study. A questionnaire was used to assess their demographic characteristics, diet, life styles, and medical history. Body mass index (BMI) was calculated as (weight in kg) / (height in meter)². Waist circumference measurements were made directly above the iliac crest with minimal respiration. Laboratory investigations included complete haemogram, blood sugar estimation, and lipid profile and thyroid function tests. CS included the following parameters 1) loud, habitual snoring 2) interrupted breathing, both reported to the patient by spouse or family members 3) excessive day time sleepiness as evidenced by napping in company or while driving, and/or difficulty in staying awake in quiet surroundings 4) obesity, defined as BMI ≥25kg/m² 5) essential hypertension, identified by the use of hypotensive medications or a BP >/= 140/90 mm of Hg on more than two separate occasions. Each feature was assigned a score of 1 with a possible maximum score of 5. A score of more than 3 was used to predict individuals at risk for presence of OSA. Metabolic syndrome was diagnosed if 3 out of 5 following variables were present 1) hypertension (BP ≥130/≥85mm of Hg), 2) insulin resistance or glucose intolerance BS≥110 mg%), 3) Low HDL cholesterol <40mg% (men), <50mg% (women), 4) elevated triglycerides (>150mg%), 5) abdominal obesity – waist circumference >35inches. Statistical analysis was employed to estimate the association of significant CS with waist circumference, diabetes mellitus and metabolic syndrome. Results: CS >3 indicating at risk for OSA was present in 12 (4.58%) employees. Ten (83.33%) patients with CS >3, had waist circumference >35 inches. The association of waist circumference was superior to body mass index (table 1). Metabolic syndrome (p 0.0000353), waist circumference (p 0.0015) but not diabetes mellitus (p 0.6374) showed statistically significant correlation with CS. (table 2) Conclusion: The risk for OSA using CS was thus 4.58% in the study population. Waist circumference and metabolic syndrome were independent risk factors for OSA.

Introduction There are several changes which occur during the pregnant state that can impact directly or indirectly on breathing. A questionnaire based survey of sleep disorders amongst pregnant subjects attending a tertiary care hospital in New Delhi. Material & Methods The study was based on a questionnaire. It contained, besides personal identification of the subject, a set of 35 questions. In addition it also had the Epworth Sleep Questionnaire. A validated questionnaire for anxiety and depression was also used. Details of present pregnancy (parity, gravida, last menstrual period, expected date of delivery and period of gestation) was also recorded. The total number of pregnant subjects interviewed was 325. They were selected randomly from those attending the ante-natal clinic of Safdarjang Hospital & Vardhman Mahavir Medical College, New Delhi. Observations The overall prevalence of snoring was 13.5%. It correlated positively with depression (p<0.075) and gestation period (p<0.016). The overall prevalence of SDB was 9.5%. It correlated positively with gestation period (p<0.042) BMI (p<0.05) and disorders of initiation & maintenance of sleep (DIMS) (p<0.005) and depression (p<0.021). The overall prevalence of DIMS was 47.6%. The prevalence of DIMS was maximum in the third trimester; and it showed a positive correlation with rising gestation period. The overall prevalence of Restless Leg Syndrome (RLS) was 15.7%. It was most prevalent in age group 21-25 years (p<0.045). It showed rising trend with increase in gestation period (p<0.049), increasing parity (p<0.071) and decreasing hemoglobin concentration (p<0.047). The overall prevalence of depression was 11.4%. It correlated positively with increasing parity (p<0.045). The overall prevalence of anxiety was 18.1%. It correlated negatively with increasing age (p<0.057) & BMI (p<0.067) and positively with increasing gestation period (p<0.099). The overall prevalence of excessive daytime sleepiness (EDS) was 30.5%. It correlated negatively, with gestation period (p<0.005) and parity (p<0.001). The overall prevalence of Sleep Deprivation was 11.0%. It correlated with the presence of disorders of initiation and maintenance of sleep (DIMS). Sleep deprivation was also found to the maximally present in the third trimester. Conclusions SDB that develops or worsens during pregnancy affects a significant number of pregnant subjects and can predispose them to pre-eclampsia. It can serve as a pointer towards a sinister maternal and/or fetal complication and necessary action may be taken early. In our country, women are less likely than men to report symptoms of snoring/snorting and gasping due to social/ cultural reasons. Hence OSA in pregnant women is likely to go undiagnosed. Moreover, symptoms like EDS and nocturnal insomnia are often assumed to be less discriminatory for OSA in pregnant women. Hence a high index of suspicion and vigilance is required. The indications for polysomnography in pregnant women should probably include those with hypertension, previous babies with unexplained IUGR, and persistent sleep-related symptoms (hypersomnia or insomnia) associated with snoring and/or obesity. The prevalence of such complications during pregnancy is significant in our country. In view of these facts, an awareness needs to be created amongst pregnant subjects, their caregivers and the healthcare community at large to detect typical and atypical manifestation of SDB (like anxiety, depression, RLS, DMIS, fatigue) early and undertake remedial measures.