OBJECTIVE:Sleep problems like obstructive sleep apnea (OSA) are common in polycystic ovary syndrome (PCOS), although the underlying mechanisms are not well understood. We aimed to determine the prevalence of sleep problems, synthesise and appraise studies analysing the associations between serum sex hormones, sex hormone-binding globulin (SHBG) and sleep problems in females with PCOS. DESIGN:Systematic review and meta-analysis. METHODS:A systematic search using MEDLINE, Embase, PsycInfo, CINAHL, Scopus, and Google Scholar was performed till 3 August 2024. Studies that examined serum sex hormones, SHBG or hyperandrogenism with sleep disorders and/or sleep disturbances in PCOS were eligible. Random effects meta-analyses of sex hormones and SHBG among females with PCOS with compared to without OSA were conducted. RESULTS:From 4487 screened studies, 24 were included, with nine suitable for meta-analyses. Among females with PCOS, 46.0% had OSA and 56.0% had other sleep disturbances. SHBG levels were significantly lower in women with PCOS and OSA compared to those without OSA (standardised mean difference = -0.62; 95% CI = -0.82 to -0.42; I2 = 0%; 179 participants; p < 0.00001), but no differences were seen in total and free testosterone, dehydroepiandrosterone sulfate, androstenedione, and oestradiol. No significant associations between serum sex hormones, SHBG or hyperandrogenism with sleep disturbances in PCOS were observed. CONCLUSION:SHBG, rather than hyperandrogenism, may play a more important mechanistic role for OSA in PCOS, while other sleep disturbances exhibit a less severe SHBG profile. These findings enhance comprehension of underlying pathophysiology of sleep problems in PCOS. Further validation across PCOS populations is warranted.

Obstructive sleep apnoea is the most common form of sleep-disordered breathing. It is characterised by recurrent occlusion of the airway during sleep. Ensuing apnoeas terminate in arousal from sleep and lead to non-restorative sleep, excessive daytime sleepiness and adverse cardiovascular and neurocognitive effects. A sleep study should be offered to patients reporting witnessed apnoeas or symptoms related to non-restorative sleep. It should also be considered in the presence of predisposing factors for obstructive sleep apnoea (e.g. obesity, tonsillar hypertrophy, retrognathia, refractory hypertension). Treatment should aim to improve symptoms and reduce cardiovascular and neurocognitive risk. The treatment approach should consider the symptom burden, severity, anatomical factors, and patient preference. Positive airway pressure is the most effective treatment option, although intolerance and non-adherence are common. Other options include positional therapy, oral appliances and upper airway surgery. Weight loss and optimisation of cardiovascular disease risk should be considered in selected patients.

Abstract Introduction Inadequate sleep duration and quality increases the risk and severity of depressive symptoms. Sex differences may influence these associations, but research findings are inconsistent and largely based on healthy populations. This study examined sex differences in the association between sleep and depressive symptoms in people seeking treatment primarily for sleep disorders at an outpatient clinic. Methods 1806 participants were recruited from an outpatient multidisciplinary sleep clinic (48% female; Mean-age = 43.93±16.00 years). Participants self-reported sleep duration, sleep quality (rated 1-4, higher scores represent better sleep quality), and depressive symptoms (PROMIS Short Form v1.0 - Depression 8a) prior to receiving treatment. Results Participants self-reported sleeping 6.49±1.73 hours and depressive symptoms were above population mean (55.95±10.09). Males reported more depressive symptoms than females (p <.001), however there were no significant sex differences in the association between sleep variables and depressive symptoms. Overall, lower sleep quality was associated with greater depressive symptoms (p <.001); and there was a U-shape relationship between sleep duration and depressive symptoms (p =.003), in which both shorter and longer sleep are associated with greater depressive symptoms. Conclusion This study revealed that depressive symptoms were elevated in an outpatient sleep clinic sample compared to population norm, underscoring the importance of recognising and addressing mental health symptoms that coexist with sleep problems. Associations between sleep and depressive symptoms were similar between males and females, but males reported significantly higher depressive symptoms than females. Future studies should explore biopsychosocial factors that may contribute to sex differences in depressive symptoms.

Abstract Background Obstructive Sleep Apnoea (OSA) is a common condition that is associated with poorer perioperative outcomes including higher rates of cardiac complications, an increased risk of intensive care admissions and a longer hospital length of stay. While there is growing evidence in support of a perioperative sleep service, there is limited published data on an effective model of care. Monash Health has established a perioperative sleep clinic with the goal to identify patients with high probability of moderate/severe OSA to improve perioperative OSA workup and management without causing surgical delays. Methods This retrospective study includes all patients reviewed in the perioperative sleep clinic over 8 months (60 patients). We reviewed patient characteristics, scores from screening tools and severity of OSA. Time from referral to initial clinic review, evaluation with polysomnography and subsequent surgery was measured. Progress to date Data collection to date shows a patient population with a median age of 63 years and BMI of 37kg/m2. Over 90% of new referrals were for patients awaiting category 2 (90 days) or 3 surgeries. The median time from clinic referral to polysomnography was 45 days. A new diagnosis of moderate/severe OSA was made in 52% of patients tested. Intended outcome and impact Despite growing evidence in support of perioperative OSA services, there is limited published data in support of a specific model of care. This study aims to provide a detailed overview of a newly established service in an Australian setting that will examine screening and diagnostic rates, treatment effectiveness and postoperative outcomes.

AIM or PURPOSE Aim of study was to evaluate the acceptance, compliance and efficacy of Oral Appliance Therapy (OAT) intervention for patients suffering from obstructive sleep apnoea (OSA)in public dental health setting. MATERIALS and METHOD ♣ Sleep Physicians conducted the sleep study for patients using the Apnoea Hypopnoea Index (AHI), Functional Outcomes of SleepQuestionnaire (FOSQ) and Epworth Sleepiness Score (ESS).♣ Sleep Physician/Dentist conducted assessment to determine the eligibility.♣ Oral appliance had an electronic tracker to collect objective compliance data.♣ Compliance was also measured subjectively.♣ Participants were reviewed at regular intervals for effectiveness, appliance activation, and adjustments.Self-documented data and electronic tracker compliance data was compared at each appointment.Review sleep study was conducted in three months to measure efficacy. RESULTS ♣ Out of 53 participants,34 completed the sleep study with pre- and post-data recorded and all acknowledged improvements after the intervention with an acceptance rate of 97% particularly from those who had previously refused the use of CPAP.♣ ESS analysis indicated that after the intervention, participants had significantly lower EES scores compared to their baseline scores (12.7 vs.6.9;p<0.001).♣ AHI analysis showed participants had significantly lower AHI scores compared to their baseline scores (19.2 vs.3.8;p<0.001).CONCLUSION(S): Present findings indicate that the OAT is not only safe, effective and feasible but also readily acceptable treatment option for sleep apnoea patients. This project has also provided valuable insights into how the OAT can be incorporated into dental practice and be a tool to guide clinical care for patients who suffer from OSA in the public health setting.

Abstract Study question What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference? Summary answer International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS. What is known already The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from 6 continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low- to low-quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus-based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, the evidence quality was low, and evidence-practice gaps persist. Study design, size, and duration The 2023 International Evidence-based Guideline update re-engaged the 2018 network across professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation, and ultimately recommendation strength, and diversity and inclusion were considered throughout. Participants/materials, setting, and methods This summary should be read in conjunction with the full guideline for detailed participants and methods. Governance included a 6-continent international advisory and management committee, 5 guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health, and other experts, alongside consumers, project management, evidence synthesis, statisticians, and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and 5 face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across 5 guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council. Main results and the role of chance The evidence in the assessment and management of PCOS has generally improved in the past 5 years but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include the following: (1) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm, and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only; (2) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnoea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; (3) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care, and shared decision-making to improve patient experience, alongside greater research; (4) maintained emphasis on healthy lifestyle, emotional well-being, and quality of life, with awareness and consideration of weight stigma; and (5) emphasizing evidence-based medical therapy and cheaper and safer fertility management. Limitations and reasons for caution Overall, recommendations are strengthened and evidence is improved but remains generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided. Wider implications of the findings The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input, and consumer preferences. Research recommendations have been generated, and a comprehensive multifaceted dissemination and translation programme supports the guideline with an integrated evaluation programme.

Abstract Background Obstructive Sleep Apnoea (OSA) represents an established risk factor for several medical conditions. The evidence demonstrates that OSA can be effectively treated by an oral appliance. However, there less information about the role of an oral appliance in a clinical care model in terms of uptake and efficacy. This study aimed at examining the efficacy of an intervention in dental public health settings in Melbourne, Australia. Methods Data were collected from the 2018-2021. Participants who fitted inclusions criteria completed two instruments. The Epworth Sleepiness Score (ESS) was used to assess the Subjective daytime sleepiness, and the Apnoea Hypopnea Index (AHI) objectively evaluated the severity of OSA. Participants were further asked to self-report felt improvements post intervention. Paired t-tests were used to compare pre-test and the post-test results. Results 34 participants had complete before and after data recorded. The mean age of the final samples of 66.4 (s.d., 14.2), the majority were female (67.7%). Participants unanimously acknowledged improvements after the intervention. Findings also indicated that after the intervention, participants had significantly lower EES scores compared to their baseline scores (6.9 vs 12.7; p<0.001). Regarding the AHI, at post-test, participants had significantly lower AHI scores compared to their baseline scores (13.8 vs. 19.2; p<0.001). Conclusions Present results indicate the use of oral appliance will ultimately benefit public patients who suffer from OSA. After the intervention, there were both objective and subjective improvements in OSA. Thus, findings provide valuable inputs and guidance for the design and implementation for larger efficacy trial.

Abstract Introduction Chronotype (or morningness-eveningness), individuals’ time-of-the-day preference for activity, has been associated with depressive symptoms. This cross-sectional study examined the association between chronotype and symptoms of depression in outpatients attending a sleep disorders clinic. Method The sample included individuals attending an outpatient sleep disorders clinic and provided opt-out consent for their data to be used for research purposes. Individuals included in the analyses provided demographic data, their typical weekly total sleep time (TST), and complete responses prior to treatment on the reduced Morningness-Eveningness Questionnaire (rMEQ; for chronotype), and the PROMIS depression scale. Results A total of 1641 (44.5% female, Mage = 45.20 years, SDage = 16.06 years) participants were included. On average, the sample scored intermediate chronotype (M = 14.73, SD = 4.35) and higher depressive symptom scores that were half a standard deviation higher compared to community norms (M = 55.80, SD = 10.01). Multiple linear regression controlling for age, sex, and TST showed that greater eveningness preferences predicted higher symptoms of depression, p<0.01, explaining 2.76% additional variance in depression scores above that of the covariates. Discussion Overall, sleep clinic outpatients had an intermediate chronotype and above average depressive symptoms. The findings are consistent with existing literature in other populations indicating that eveningness may be a risk factor for greater symptoms of depression. Future studies need to explore whether interventions to alter chronotype may benefit symptoms of depression in individuals with sleep complaints.

The objective of this study was to independently validate a disposable and a reusable home sleep apnea test (HSAT) recording on peripheral arterial tonometry, compared to laboratory polysomnography (PSG), for the diagnosis of obstructive sleep apnea (OSA). 115 participants undergoing PSG for suspected OSA were recruited and fitted with the two study devices (NightOwl, Ectosense, Belgium). After exclusions were applied and device failures were removed, data from 100 participants were analyzed. HSAT-derived apnea-hypopnea index (AHI), OSA severity category, total sleep time, and oxygen desaturation index 3

Abstract Introduction Limited channel home sleep apnoea test (HSAT) devices are an emerging alternative to laboratory-based PSG. Despite increasingly commercially availability, there is limited external validation of their diagnostic performance. We recently independently validated the Night Owl Mini HSAT (NOM) against in-lab PSG and demonstrated a satisfactory level of agreement (LOA) of 63.8% overall. However, lower rates of agreement were observed for severe OSA. We speculated that signal artefact may have contributed to reduced concordance. Methods Data was drawn from our previously published prospective cohort of 100 participants undergoing PSG for suspected OSA, simultaneously fitted with the NOM. PSG and NOM studies were re-processed, manually remarking artefact. LOA was recalculated comparing only temporally aligned data segments for which both devices provided intact signals, this allowed direct comparison of pulse oximetry data and software algorithms that generated the ODI3%. Two new datasets were generated for PSG and NOM for which combined artefact was deleted (COM-PSG, COM-NOM). Results To date, datasets from 12 participants have been assessed. The mean difference in ODI3% between PSG and NOM was 5.25/hr (95% limits of agreement -0.73 – 11.23), while the mean difference in ODI3% between COM-PSG and COM-NOM was 2.53/hr (95% limits of agreement -1.77 – 6.83). In our previous study, the overall mean difference in ODI3% was –0.21/hr (95% limits of agreement -18.1 – 17.7). Conclusion Preliminary results may indicate signal artefact contributes to reduced level of agreement between PSG and NOM.

Polycystic ovary syndrome (PCOS) is a common hormonal condition with reproductive, metabolic, and psychological sequelae that affects 8 to 13% of reproductive-aged women and 3 to 11% of adolescent girls. Sleep is often compromised in women with PCOS due to increased rates of sleep problems, with the most established problem being obstructive sleep apnea (OSA). OSA is highly prevalent in reproductive-aged adult women with PCOS, but not so in adolescence. The international evidence-based PCOS guideline to improve health outcomes in women with PCOS indicated routine screening to identify and alleviate symptoms of OSA. The guidelines, however, did not weigh other multidimensional constructs of sleep health such as sleep disturbances (e.g., sleep quality and quantity), beyond OSA. This is perhaps due to the lack of research and existing mixed findings in the area of PCOS and sleep health. This narrative review summarizes the current knowledge about OSA and expands further to include the limited knowledge about other sleep problems in PCOS among reproductive-aged women and adolescent girls. We broadly cover the prevalence, risk factors, and mechanisms of sleep problems in PCOS and their relationship with cardiometabolic and psychological health. A brief summary on treatment and intervention strategies for sleep problems in PCOS and future recommendations will be deliberated.

this to be an effective strategy. On-line CBT-I 29 tools have shown early promise and could be adopted in primary care, although lim-itations in on-line behaviour change strategies are well described, and motivational drivers such as rapport and accountability with a healthcare provider remain integral. 30 Finally, further research is required to assist the one third who insufficiently respond to CBT-I as well as position state-ments that clearly define the role of supplementary or alter-native treatments including pharmacotherapy in this group. Despite there being opportunities for better coordina-tion, there have been remarkable advances in the diagnosis and treatment of OSA. Moving forward however, peak bodies in sleep health have considerable challenges ahead in driving the systems change needed to manage the remaining substantial burden of non-respiratory sleep disorders. More-over, there are learning opportunities from OSA management to ensure that treatment approaches are targeted to ensure greatest impact. Implementation research is now essential to identify, train and remunerate the required workforce to take evidence of efficacy into practice. Alongside this further research, guideline development and close engagement with funders and policy makers will be essential.

Only a fit-tested N95 mask provided protection against virus aerosol; surgical masks and non-fit-tested N95 masks were not superior to no-mask control. The combination of air purification and fitted N95 mask provided protection against very high virus aerosol load. Background Healthcare workers (HCWs) are at risk from aerosol transmission of severe acute respiratory syndrome coronavirus 2. The aims of this study were to (1) quantify the protection provided by masks (surgical, fit-test(FAILED) N95, fit-test(PASSED) N95) and personal protective equipment (PPE), and (2) determine if a portable high-efficiency particulate air (HEPA) filter can enhance the benefit of PPE. Methods Virus aerosol exposure experiments using bacteriophage PhiX174 were performed. An HCW wearing PPE (mask, gloves, gown, face shield) was exposed to nebulized viruses (10(8) copies/mL) for 40 minutes in a sealed clinical room. Virus exposure was quantified via skin swabs applied to the face, nostrils, forearms, neck, and forehead. Experiments were repeated with a HEPA filter (13.4 volume-filtrations/hour). Results Significant virus counts were detected on the face while the participants were wearing either surgical or N95 masks. Only the fit-test(PASSED) N95 resulted in lower virus counts compared to control (P = .007). Nasal swabs demonstrated high virus exposure, which was not mitigated by the surgical/fit-test(FAILED)N95 masks, although there was a trend for the fit-test(PASSED) N95 mask to reduce virus counts (P = .058). HEPA filtration reduced virus to near-zero levels when combined with fit-test(PASSED) N95 mask, gloves, gown, and face shield. Conclusions N95 masks that have passed a quantitative fit-test combined with HEPA filtration protects against high virus aerosol loads at close range and for prolonged periods of time.

Background: There has been a rapid growth in wearables marketed to measure sleep. Fitbit trackers collect data through an internal accelerometer and use heart rate variability to estimate the sleep-wake state. There is a paucity of “real-world” data in patients who are being evaluated for sleep disorders. Aim: To evaluate the agreement between Fitbit Charge3TM & in-lab polysomnography (PSG) in patients who require a PSG for assessment. Methods: A prospective study of patients attending a PSG through Epworth Camberwell Sleep Lab between 2020-2021 was conducted. Fitbit Charge3TM was worn on the dominant wrist with concurrent PSG monitoring. Parameters measured included total sleep time; TST (min), Sleep onset latency; SOL (min), sleep efficiency; SE (%), wake after sleep onset; WASO (min) and time spent in N1, N2, N3 and REM sleep (min). 30 second epoch-by-epoch analyses were conducted. Results: Seventy patients (male=52), median age of 55 years; IQR(45,67) completed the study. On average, the Fitbit significantly overestimated light sleep by 62.99 min, TST by 29.50 min, and SE by 3.33% and underestimated deep sleep by 40.55 min WASO by 28 min. Fitbit and PSG did not significantly differ on REM or SOL measurements. Conclusion: Our findings may support the use of Fitbit Charge3TM as an initial screening device to assess sleep duration and architecture in select patients attending sleep clinics Table 1: Comparison of sleep variables between PSG and Fitbit Charge 3TM

We present a 43-year-old woman, with a history of allergic bronchopulmonary aspergillosis and a chronic bronchocoele, who was admitted to hospital with an infection of the bronchocoele, progressing to a pulmonary abscess and polymicrobial empyema, following dental extraction and regular Lactobacillus probiotic ingestion. Interval chest imaging following this procedure demonstrated worsening right upper lobe opacities and a right-sided pleural effusion. Bronchoscopies identified copious mucoid secretions and an infected bronchocoele with a right upper lobe airways impaction. Oral cavity organisms including Actinomyces odontolyticus were cultured on bronchial washings. Streptococcus mitis and Lactobacillus rhamnosus were cultured in pleural fluid. Treatment with endoscopic mucoid secretion suctioning; intercostal catheter insertion and therapeutic drainage; and antibiotic, glucocorticoid and anti-IgE therapy resulted in clinical and radiological improvement. Our case illustrates the potential pulmonary complications from oral cavity organisms following tooth extraction and probiotic use in patients with chronic lung disease associated with mucoid lesions and airways obstruction.

Upper airway surgery for obstructive sleep apnoea (OSA) is an alternative treatment for patients who are intolerant of continuous positive airway pressure (CPAP). However, upper airway surgery has variable treatment efficacy with no reliable predictors of response. While we now know that there are several endotypes contributing to OSA (i.e., upper airway collapsibility, airway muscle response/compensation, respiratory arousal threshold and loop gain), no study to date has examined: (i) how upper airway surgery affects all four OSA endotypes, (ii) whether knowledge of baseline OSA endotypes predicts response to surgery and (iii) whether there are any differences when OSA endotypes are measured using the CPAP dial‐down or clinical polysomnographic (PSG) methods.

Supine-predominant obstructive sleep apnea (OSA) is highly prevalent. The proportion of time spent in the supine position may be overrepresented during polysomnography, which would impact on the apnea-hypopnea index (AHI) and have important clinical implications. We aimed to investigate the difference in body position during laboratory or home polysomnography compared to habitual sleep and estimate its effect on OSA severity. Secondary aims were to evaluate the consistency of habitual sleeping position and accuracy of self-reported sleeping position. Patients undergoing diagnostic laboratory or home polysomnography were recruited. Body position was recorded using a neck-worn device. Habitual sleeping position was the average time spent supine over 3 consecutive nights at home. Primary outcomes were the proportion of sleep time spent supine ( https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374873 isReview=true Yo SW, Joosten SA, Wimaleswaran H, et al. Body position during laboratory and home polysomnography compared to habitual sleeping position at home. J Clin Sleep Med. 2022;18(9):2103–2111.

Rationale: We recently demonstrated that a patient hood with a high efficiency particulate air filter eliminates virus aerosol contamination when very large quantities of bacteriophage virus are aerosolised into a clinical room. While this containment method is relatively low cost, it is unclear whether similar efficacy can be achieved with lower cost/commercial grade air purifiers, or if such an approach protects healthcare workers against virus aerosol contamination. Method: A total of 109 (10 ml of 108) PhiX174 bacteriophages was nebulized into a sealed clinical room. Surface contamination was detected by settle plates left uncovered during exposure. A healthcare worker remained in the room, personal exposure was determined by skin swabs after exiting the room, following doffing of personal protective equipment (PPE). Four skin areas were swabbed: forearms/hands, neck, forehead, under N95 mask. Three conditions were tested, 1) hood with hospital grade air purifier (IQ Air Health Pro 250), 2) hood with commercial air purifier (Philips 1000i), and 3) control (no hood/air-purification). Findings: The control condition demonstrated extensive environmental and limited skin contamination underneath PPE, which was highest under an N95 mask. The commercial air purifier and hood provided environmental control of virus aerosol and almost zero skin contamination. In comparison, the hospital grade purifier provided complete environmental and skin contamination protection, despite a lower clean air filtration rate (240m3/hr vs 270m3/hr). Virus counts on plates and swabs were significantly lower for both air purifiers and across neck, forehead, and under the N95. There were no statistically significant differences in detected virus counts between air purifiers. Conclusion: This cheap and scalable method may be an effective way to reduce the spread of COVID-19 in hospitals by enhancing the effectiveness of PPE worn by health care workers who care for COVID-19 patients and who are exposed to virus aerosol.