"Sleep and wakefulness, both of them, when immoderate constitute disease"

(Hippocrates)

Oriella Gnarra

Lyudmila Korostovtseva

Rana Rezaei

Millene Camilo

Dear Readers,

It gives us great pleasure to welcome you to the 8th issue of our newsletter. We have summarized the most prominent events that took place recently and would like to share our views with you.

We keep on with introducing the new young board members of the foundation. In this issue, you can know better our new talented member Rana Rezaei. 

In the interview led by Dr. Camilo, Ms. Rezaei talks about her career experiences. In the newsletter, you will also find Rezaei’s notes about her immersion journey to the world of “Neurology beyond the big data” at the European Academy of Neurology (EAN) Congress held in Budapest in the early July.  

EAN Congress was followed by the Sleep Medicine Summer School (SMSS) in Lugano. We are glad to present an overview of this educational event including the feedback from participants of the SMSS prepared by Dr. Oriella Gnarra.

We are delighted to share the news on the progress of the project “Sleep and Sport” coordinated by Dr. Albrecht Vorster who presents the first results and future perspectives in this field. 

We are excited to announce a new section of the Newsletter “Clinical Trials at a Glance” where we aim to give a brief overview of the ongoing clinical studies. In this issue, you will find information about the trials investigating sleep-disordered breathing in post-stroke patients. 

If you are interested in joining the Young section of the European Sleep Foundation and to benefit from the membership, fill in the online application  and become a part of the community. Your active involvement is essential for a change in the field and success! 
Last but not least, we have established a Linkedin account and Whatsapp group (SMSS Lugano 2023: https://chat.whatsapp.com/G7aPSrAHCFMEkrdg44UWyf) for the young members for sharing news and ideas. We encourage you to join it to remain connected throughout the year.


We hope that you will enjoy reading this issue of the newsletter and we gladly welcome any comments you may have as a reader.

Best regards,

The editorial team!

Biosketch and interview of the month

Rana Rezaei

Research assistant at the Center for Narcolepsy and Hypersomnias, Clinical Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Germany - Interview by Millene Camilo

Sleep and Sport

Interview to Dr Albrecht Vorster (Head of the Swiss Sleep House Bern) - Interview by Rana Rezaei

Report from the 3rd Sleep Medicine Summer School

Oriella Gnarra

The third edition of the Sleep Medicine Summer School held in Lugano was a resounding success, providing an enriching and comprehensive learning experience in sleep medicine. The event, hosted by Università della Svizzera Italiana (USI) and spearheaded by Professor Mauro Manconi and ESF President Professor Claudio Bassetti, took place from July 10 to 14.

Throughout the five-day course, participants delved into various aspects of sleep physiology and disorders through a well-structured scientific program divided into five modules:

1. Sleep physiology and chronobiology
2. Insomnia, mental health, and circadian disorders
3. Hypersomnia and neurological disorders
4. Sleep-related movement disorders, parasomnia, and epilepsy
5. Sleep-related breathing disorders

Eminent speakers of international recognition presented the latest advancements in diagnosing and managing sleep-related conditions, keeping the participants abreast with cutting-edge developments in the field. 

The event boasted an impressive turnout, with over 100 students attending the school either in person amid the enchanting setting of Lugano or remotely through virtual platforms. This was made possible by the unwavering support of Andrea Barzago and his skilled technical team, ensuring that participants worldwide could access the valuable insights shared during the summer school.

From theory to practice! Emphasizing the practical aspects of sleep medicine, the afternoon sessions were dedicated to keynote lectures, pediatric sessions organized by Professor Silvia Miano, satellite-sponsored lectures on new medication from Bioprojet and Idorsia, and practical exercises on scoring sections and clinical cases discussions organized by MD Ph.D. Markus Schmidt. These sessions gave participants a well-rounded understanding of sleep disorders and their management, preparing them for real-world challenges.

Networking and fun! In addition to theoretical lectures and practical sessions, the summer school fostered networking opportunities highly appreciated by attendees. Each day concluded with an aperitif with the experts, offering an informal setting for question-and-answer sessions and discussions. These opportunities for interaction were not only valuable for clarifying doubts but also facilitated the preparation phase for the European Sleep Expert Certification. Leading experts were fully available for a profitable intellectual exchange with the attendees. Through networking, multiple doctors and researchers came into contact, bringing together different parts of the world and minds.

The Sleep Medicine Summer School in Lugano was an exceptional event that enhanced participants' knowledge of sleep physiology and disorders and fostered a sense of collaboration within the sleep medicine community. The dedication of the organizing team, the contribution of renowned speakers, and the active participation of attendees - all contributed to the overwhelming success of this educational initiative. With the ripple effect of this summer school, one can expect to see further advancements in the field of sleep medicine and the improved well-being of patients with sleep-related conditions across Europe and beyond

Gabriela Tsalamandris medical student from Cyprus, says, “While completing the neurology but also psychiatry rotations, I was fascinated by the complex physiology of sleep and the various factors and neurological states that influence and are influenced by sleep. During the SMSS, I enjoyed the range of expertise, the fields relating to the speakers’ knowledge, and how the days were structured to fully develop each subcategory of the course and allow participants to test their knowledge through the practical sections."

Adriano Dos Santos, from Brazil with a background in sport and nutrition science, about the SMSS says, “I liked the quality of the speakers, the topics that were presented and the amazing lunch menus, that from a nutritionist who likes high-quality food is a key factor!” He also suggested, “A booklet with all the presentation slides in miniature so we can follow the presentations better could be a great improvement for the next year.” No doubt your suggestion, Adriano, will be taken on board for the next edition

My sustainable trip to Budapest (EAN Congress)

Rana Rezaei

I had the privilege of attending the European Academy of Neurology (EAN) Congress in Budapest. As a neurology enthusiast and aspiring medical professional, I was eager to immerse myself in the cutting-edge research and learn from esteemed specialists. In this review, I would like to share my experience and insights with you.

The overarching theme of the EAN Congress this year was “Neurology beyond the big data” with sessions linking neurology and artificial intelligence. Interesting topics were addressed, for example how the use of digital health technologies and telemedicine can be optimized as well as the question of how data science can be used to transition to an era of precision health.

During the congress, neurology was represented in all its dimensions. I was particularly interested in the presentations on sleep medicine and learned a lot during the lectures, also because the speakers worked with case studies. What I liked best was that certain neurological topics were combined, for example the relation between sleep and headache or sleep quality and brain clearance. I feel that this broadens the ability to think outside the box and learn across disciplines.

Another innovative aspect that impressed me greatly throughout the conference was the focus on sustainability. There were no plastic bottles, water dispensers were everywhere to be found, lunch was vegetarian, also not too many flyers were being handed out. As the world faces pressing environmental challenges and climate change, it has become essential for global events like congresses to take a proactive approach towards sustainability. I congratulate the hosting town and the EAN for having achieved this standard. 

For the first time, I also gave a poster presentation myself as part of my doctoral studies in sleep medicine which was a valuable experience for me. As attendees started to gather, I stood next to my poster, ready to explain my research to anyone who showed interest. This was an excellent opportunity to network and discuss my findings with fellow researchers and professionals in the field. Sociodemographic characteristics of female narcolepsy patients add another little piece to the puzzle and I was delighted to share it with my peers.

During the conference I met people from all over Europe and beyond and am very happy to have had the opportunity to exchange ideas with them. Connecting with the other participants is my personal highlight of the EAN Congress 2023!

Certainly, I couldn't pass up the opportunity to do some sight-seeing in Budapest. A truly memorable experience for me was witnessing the city while the sun was setting during a boat trip on the Danube River. Such a vibrant, colorful and inspiring town, excellent to be there and absorb energy.

All in all, attending the Neurology Congress in Budapest was an exceptional experience that expanded my knowledge and fueled my passion for neuroscience. The plenary sessions, symposia, workshops, poster presentations, case studies and keynote lectures - all contributed to a comprehensive exploration of the field. The Congress not only showcased the progress made in neurology but also highlighted the collaborative nature of the scientific community. 

I left the congress with a renewed sense of purpose, eager to apply the knowledge gained to my future endeavors in the field of neurology.
I am pleased to have had this experience and will keep my trip in very good memory. If you are looking for a great learning opportunity and getting in touch with many interesting people in the field of neurology, I highly recommend attending the EAN Congress and join our ESF Young Section to remain connected throughout the year!

Clinical Trial at a Glance - Sleep-disordered Breathing in Stroke

Lyudmila Korostovtseva

Sleep-disordered breathing (SDB) is common after stroke, being found in up to 71% of post-stroke patients, and its prevalence remains high both in the subacute and chronic phase of stroke (1 - Seiler et al., 2019). SDB is associated with worse functional outcomes, more severe cognitive dysfunction and disability, and lower quality of life. However, the randomized clinical trials provide inconsistent and underpowered results regarding the benefit of SDB treatment among stroke patients (2 - Brill et al., 2018).

The largest clinical trial, the SAVE study (1448 out of 2687 patients had previous cerebrovascular events), failed to demonstrate the benefit of continuous positive airway pressure (CPAP) therapy for secondary cardiovascular prevention (3 - McEvoy et al., 2016). This result is mainly explained by poor compliance with less than 50% of patients assigned to CPAP used for >4h per night. However, other factors may also interfere, e.g., selection bias, heterogeneity of study populations with regard to SDB and stroke characteristics, diagnostic criteria for SDB definition based on the frequency of desaturation per hour, and timing of CPAP initiation after stroke onset. Therefore, there is no strong recommendation from the recent stroke guidelines regarding obstructive sleep apnea (OSA) treatment for secondary stroke prevention. This issue is still debatable, and further research is needed. 

In order to answer the question whether treatment of OSA improves prognosis in patients who survived a stroke, several trials have been initiated and are still ongoing. One is a multicenter, phase III, the Sleep for Stroke Management and Recovery Trial (Sleep SMART), with a prospective, randomized, open-label, parallel-group design (NCT03812653). The purpose is to detect a difference in recurrent stroke, acute coronary syndrome, and all-cause mortality with CPAP use 6 months after ischemic event, as well as the difference in stroke outcomes at 3 months. Having started in 2019, it is expected to be completed in late 2023, and it anticipates the enrollment of over 3,000 patients at 110 sites in the USA (4 - Brown et al., 2020).

Millene Camilo

Another randomized controlled trial, the Recovery in Stroke Using PAP Study (RISE-UP), conducted at Yale University, USA (NCT04130503), aimed to enroll 360 patients with ischemic stroke. The study was designed to answer the question whether PAP therapy for OSA in poststroke improves functional recovery and whether initiation of PAP therapy in the acute versus subacute phase of stroke is beneficial. This study started in 2019, and the completion is anticipated at the end of 2024.

The early Sleep Apnoea Treatment in Stroke study (eSATIS) is an open-label, multicenter (6 centres in 4 countries), randomized controlled trial (NCT02554487), in which the primary outcome is the impact of immediate SDB treatment with adaptive servo-ventilation on infarct progression measured with neuroimaging in the first 3 months after ischemic stroke (5 - Duss et al., 2021). It started in 2015, and the enrollment has already ended. We eagerly await the publication of its results! 

In Brazil, there is one ongoing randomized clinical trial coordinated by the centre of the Ribeirão Preto Medical School, University of São Paulo. The Obstructive Sleep Apnea Treatment from Acute to Chronic Phase of Stroke study (ATACS) will assess whether the early OSA treatment with CPAP has a favorable impact on functional recovery among ischemic stroke patients. More details of this study protocol will be published soon. 

Observational studies, although providing lower-quality evidence, are nonetheless important providing information obtained in clinical routine practice. The prospective, observational trial ASCENT (“Apnea, Stroke and Incident Cardiovascular Events” - NCT04399200), coordinated by the centre of the University Hospital in Grenoble (France), has been ongoing since 2020. As a primary outcome, it will assess the rates of major adverse cardiovascular events one year after the first stroke/first or recurrent TIA in patients with SDB (apnea-hypopnea index (AHI) > 15 events/hour) versus patients without SDB (AHI ≤ 15 events/hour). In addition, in an ancillary substudy CAtSS (Carotid, Atherosclerosis, Stroke, and Sleep apnea), the impact of SDB on the evolution of the carotid plaque after endarterectomy will be assessed in a subgroup of patients eligible for post-stroke carotid surgery. In total, 1,620 patients are expected to be included, and with the 5-year follow-up period, the trial is anticipated to be completed by 2035. Importantly, in this cohort, the patients with SDB will be offered SDB treatment according to the standard care approach. 

These trials will add to our understanding of the role of SDB in stroke evolution and outcomes, and potentially will help to reduce future stroke occurrence and burden. 

References

1. Seiler A, Camilo M, Korostovtseva L, Haynes AG, Brill AK, Horvath T, Egger M, Bassetti CL. Prevalence of sleep-disordered breathing after stroke and TIA: A meta-analysis. Neurology. 2019 Feb 12;92(7):e648-e654. doi: 10.1212/WNL.0000000000006904.
2. Brill AK, Horvath T, Seiler A, Camilo M, Haynes AG, Ott SR, Egger M, Bassetti CL. CPAP as treatment of sleep apnea after stroke: A meta-analysis of randomized trials. Neurology. 2018 Apr 3;90(14):e1222-e1230. doi: 10.1212/WNL.0000000000005262.
3. McEvoy RD, Antic NA, Heeley E, Luo Y, Ou Q, Zhang X, Mediano O, Chen R, Drager LF, Liu Z, Chen G, Du B, McArdle N, Mukherjee S, Tripathi M, Billot L, Li Q, Lorenzi-Filho G, Barbe F, Redline S, Wang J, Arima H, Neal B, White DP, Grunstein RR, Zhong N, Anderson CS; SAVE Investigators and Coordinators. CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea. N Engl J Med. 2016 Sep 8;375(10):919-31. doi: 10.1056/NEJMoa1606599.
4. Brown DL, Durkalski V, Durmer JS, Broderick JP, Zahuranec DB, Levine DA, Anderson CS, Bravata DM, Yaggi HK, Morgenstern LB, Moy CS, Chervin RD. Sleep for Stroke Management and Recovery Trial (Sleep SMART): Rationale and methods. Int J Stroke. 2020 Oct;15(8):923-929. doi: 10.1177/1747493020903979.
5. Duss SB, Brill AK, Baillieul S, Horvath T, Zubler F, Flügel D, Kägi G, Benz G, Bernasconi C, Ott SR, Korostovtseva L, Sviryaev Y, Salih F, Endres M, Tamisier R, Gouveris H, Winter Y, Denier N, Wiest R, Arnold M, Schmidt MH, Pépin JL, Bassetti CLA. Effect of early sleep apnoea treatment with adaptive servo-ventilation in acute stroke patients on cerebral lesion evolution and neurological outcomes: study protocol for a multicentre, randomized controlled, rater-blinded, clinical trial (eSATIS: early Sleep Apnoea Treatment in Stroke). Trials. 2021 Jan 22;22(1):83. doi: 10.1186/s13063-020-04977-w.

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