Interaction of positive airway pressure mask magnets with cardiac implantable electronic devices.

STUDY OBJECTIVES: To evaluate for potential interactions between magnetic positive airway pressure (mPAP) masks and cardiac implantable electronic devices (CIEDs) for patients with sleep apnea. METHODS: Adult patients with a CIED who used an mPAP mask were recruited from our sleep clinic to undergo a safety visit at our pacemaker clinic. We tested whether the mPAP interacted with the implanted device at home during normal use and in the clinic during simulated normal use and with direct contact. The magnetic field strength of 6 mPAP masks was tested with a gaussmeter. RESULTS: Of 13 patients tested, 1 (8%), wearing a full face mask (ResMed AirFit F30 [ResMed, San Diego, California]), had a magnet response event (interaction) with direct contact, but no interactions were identified during normal or simulated normal use in any patient. The magnetic field strength of the mPAP masks increased the closer the mask got to the CIED, from 0.4 mT (4 G) at the mask manufacturer's recommended 5.1-cm (2-inch) distance from an implanted medical device up to 291 mT (2,910 G) at 0 cm (0 inches; direct contact). CONCLUSIONS: An mPAP mask may interact with a CIED if placed directly on the skin overlying the CIED. The use of Philips Respironics (Philips, Cambridge, Massachusetts) mPAP masks is now contraindicated in patients with a CIED. Until additional studies are conducted to better document the risks and benefits of mPAP masks, we recommend discouraging patients with CIEDs from using any mPAP mask. CITATION: Ruoff CM, Tashman YS, Cheema KPK, et al. Interaction of positive airway pressure mask magnets with cardiac implantable electronic devices. J Clin Sleep Med. 2023;19(5):941-946.

Kidney Allograft and Recipient Survival After Heart Transplantation by Induction Type in the United States.

BACKGROUND: Induction choices for kidney-after-heart transplant recipients are variable. We examined the impact of kidney induction types on kidney graft and patient survival in heart transplant recipients. METHODS: We analyzed the Scientific Registry of Transplant Recipient database from inception through the end of 2018 to study kidney and patient outcomes in the United States after heart transplantation. We only included recipients who were discharged on tacrolimus and mycophenolate maintenance. We grouped recipients by induction type into 3 groups: depletional (N = 307), nondepletional (n = 253), and no-induction (steroid only) (n = 57). We studied patients and kidney survival using Cox PH regression, with transplant centers included as a random effect. We adjusted the models for heart induction, recipient and donor age, gender, time between heart and kidney transplant, heart transplant indication, HLA mismatches, payor, live-donor kidney, transplant year, dialysis status, and diabetes mellitus at the time of kidney transplant. RESULTS: The 1-y kidney rejection rates and creatinine levels were similar in all groups. The 1-y rehospitalization rate was higher in the depletional group (51.7%) and nondepletional group (50.7%) than in the no-induction group (39.1%) although this was not statistically significant. There were no differences in recipient or kidney survival by kidney induction type. Live-donor kidney was associated with improved patient (hazard ratio, 0.74; 95% confidence interval, 0.54-1.0; P = 0.05) and kidney survival (hazard ratio, 0.45; 95% confidence interval, 0.24-0.84; P = 0.012]. CONCLUSIONS: Type of kidney induction did not influence patient or kidney graft survival in heart transplant recipients. No-induction may be the preferred choice due to the lack of clinical benefits associated with induction use.

Restless legs syndrome associated with use of stevia nonnutritive sweetener.

None: Restless legs syndrome is a common sensorimotor movement disorder affecting an estimated 15-20% of the general adult population in the United Sates. Several drugs and drug classes have been shown to either cause and/or exacerbate symptoms of restless legs syndrome. With the epidemic of obesity and the heightened awareness of the harmful effects of added sugars, the consumption of low and no-calorie sweeteners has substantially increased. We report a case where the patient developed restless legs syndrome symptoms with the use of a stevia extract-based no calorie sweetener. To our knowledge, this is the first case report of restless legs syndrome possibly associated with low or no-calorie sweetener use.

Induction type and outcomes for kidney graft and patient survival in recipients with prior lung transplantation in the United States.

BACKGROUND: Induction immunosuppression regimens for kidney transplants in lung transplant recipients vary widely. We studied the impact of induction types for kidney after lung transplant recipients. METHODS: Using the Scientific Registry of Transplant Recipients database between 1994 and 2015, we studied outcomes of patients and kidney grafts for 330 kidney after lung transplant recipients for whom induction before kidney transplant included depletional (n = 115), non-depletional (n = 170), or no induction (steroids only; n = 45). We studied risk factors for recipient and graft survival using Cox proportional hazards model adjusted for kidney and lung induction, kidney donor type, dialysis status, recipient and donor ages, time from lung to kidney transplant, cause of lung disease, bilateral vs single lung transplant, diabetes, and human leukocyte antigen mismatches before kidney transplant, with transplant center as a random effect. RESULTS: There was no difference between groups in patient survival or death-censored kidney allograft survival. The 1-year kidney acute rejection rates were 15.5%, 7.14%, and 0% in depletional, non-depletional, and no induction groups, respectively. In the Cox model for patient survival, living kidney donor recipients and bilateral lung transplant recipients were favorable predictors. For death-censored graft survival, kidney induction type did not predict graft survival. Results did not change when models only included recipients on tacrolimus and mycophenolate based maintenance. CONCLUSIONS: The type of kidney induction did not influence patient or kidney graft survival following kidney transplants for those with previous lung transplants. No induction may be the preferred choice for kidney after lung transplant because of the lack of benefits from biologic induction in this large cohort.

Need for tracheostomy after lung transplant predicts decreased mid- and long-term survival.

BACKGROUND: Tracheostomy is an important adjunct for lung transplant patients requiring prolonged ventilation. We explored the effects of post-transplant tracheostomy on survival and bronchiolitis obliterans syndrome after lung transplant. METHODS: A retrospective, single center analysis was performed on all lung transplant recipients during the Lung Allocation Score (LAS) era. Risk factors for post-transplant tracheostomy or death within 30 days were assessed. Kaplan-Meier estimates and Cox proportional hazards models were used to examine the association between tracheostomy within 30 days after transplant and survival at 1 and 3 years. A total of 403 patients underwent single or bilateral lung transplant between May 2005 and February 2016 with complete data for 352 cases, and 35 patients (9.9%) underwent tracheostomy or died (N = 10, 2.8%) within 30 days. RESULTS: In adjusted analyses, primary graft dysfunction grade 3 (PGD3) was associated with a composite end point of tracheostomy or death within 30 days (HR 3.11 (1.69, 5.71), P-value < .001). Tracheostomy within 30 days was associated with decreased survival at 1(HR 4.25 [1.75, 10.35] P-value = .001) and 3 years (HR 2.74 [1.30, 5.76], P-value = .008), as well as decreased bronchiolitis obliterans (BOS)-free survival at 1 (HR 1.87 [1.02, 3.41] P-value = .042) and 3 years (HR 2.15 [1.33, 3.5], P-value = .002). CONCLUSION: Post-transplant tracheostomy is a marker for advanced lung allograft dysfunction with significant reduction in long-term overall and BOS-free survival.

Greater survival despite increased complication rates following lung transplant for alpha-1-antitrypsin deficiency compared to chronic obstructive pulmonary disease.

BACKGROUND: Alpha-1-antitrypsin (A1AT) deficiency (A1ATD) is characterized by accelerated degradation of lung function. We examined our experience with lung transplantation for chronic obstructive pulmonary disease (COPD) with and without A1ATD to compare survival and rates of postoperative surgical complications. METHODS: Patients with A1ATD and non-A1ATD COPD undergoing lung transplantation from 1988-2015 at our institution were analyzed. Complications were categorized into non-gastroenteritis gastrointestinal (GI), wound, airway, and reoperation for bleeding. Overall and complication-free survival were evaluated using Kaplan-Meier curves and Cox proportional hazards models. RESULTS: Three hundred and eighty-five patients underwent lung transplant for COPD (98 A1ATD). For A1ATD, 56.1% underwent single lung transplantation (80.6% for COPD). Early overall and complication-free survival was worse for A1ATD, but this trend reversed at longer follow up. Unadjusted estimated survival showed advantage for COPD at 90 days and 1 year, which attenuated by 5 years and reversed at 10 years (P<0.001). On adjusted analysis, A1ATD was associated with a trend toward lower complication-free survival at 90 days and 1 year, due partly to increased rates of post-transplant GI pathology, particularly in the era of the lung allocation score (LAS). CONCLUSIONS: A1ATD lung recipients had worse short-term complication-free survival but improved long-term survival compared to COPD patients. A1ATD was associated with greater risk of new GI pathology after transplant. Close monitoring of A1ATD patients with timely evaluation of GI complaints after transplant is warranted.

Smartphone-based delivery of oropharyngeal exercises for treatment of snoring: a randomized controlled trial.

PURPOSE: Upper airway exercises for snoring treatment can be effective but difficult to administer and monitor. We hypothesized that a brief, relatively simple daily upper airway exercise regimen, administered by a smartphone application, would reduce snoring and encourage compliance. METHODS: Targeted vowel sounds causing tongue base movements were incorporated into a voice-controlled smartphone game application. Participants with habitual snoring, apnea hypopnea index (AHI) ≤ 14 events/h, and BMI ≤ 32 kg/m2 were randomly assigned to perform 15 min of daily gameplay (intervention group) or 5 s of daily voice recording (control group) and to audio record their snoring for 2 nights/week for up to 12 weeks. Sounds above 60 dB were extracted from recordings for snore classification with machine learning support vector machine classifiers. RESULTS: Sixteen patients (eight in each group) completed the protocol. Groups were similar at baseline in gender distribution (five males, three females), mean BMI (27.5 ± 3.8 vs 27.4 ± 3.8 kg/m2), neck circumference (15.1 ± 1.6 vs 14.7 ± 1.7 in.), Epworth Sleepiness Score (8 ± 3.5 vs 7 ± 4.0), and AHI (9.2 ± 4.0 vs 8.2 ± 3.2 events/h). At 8 weeks, the absolute change in snoring rate (> 60 dB/h) was greater for the intervention group than the control group (- 49.3 ± 55.3 vs - 6.23 ± 23.2; p = 0.037), a 22 and 5.6% reduction, respectively. All bed partners of participants in the intervention group reported reduced snoring volume and frequency, whereas no change was reported for the control group. CONCLUSIONS: Smartphone application-administered upper airway training reduces objective and subjective snoring measures and improves sleep quality. TRIAL REGISTRATION: ClinicalTrials.gov ; no.: NCT03264963; URL: www.clinicaltrials.gov.

Vitamin D Concentrations and Obstructive Sleep Apnea in a Multicenter Cohort of Older Males.

RATIONALE: Seasonal nadirs in 25-hydroxyvitamin D (25[OH]D) concentrations overlap with increased incidence and severity of obstructive sleep apnea (OSA) in winter. We hypothesized that, because lower 25(OH)D concentrations might lead to upper airway muscle dysfunction, low 25(OH)D would be associated with higher apnea-hypopnea index (AHI), a measure of OSA severity. OBJECTIVES: To determine if lower 25(OH)D concentration is associated with greater prevalence and increased severity of OSA, independent of established OSA risk factors. METHODS: Using unconditional logistic regression, we performed a cross-sectional analysis in the Outcomes of Sleep Disorders in Older Men study, which included in-home overnight polysomnography, serum 25(OH)D measurement, and collection of demographic and comorbidity data. The primary outcome was severe sleep apnea, as defined by AHI of 30/h or more. MEASUREMENTS AND MAIN RESULTS: Among 2,827 community-dwelling, largely white (92.2%), elderly (aged 76.4 ± 5.5 yr [mean±SD]) males, mean 25(OH)D concentration was 28.8 (±8.8) ng/ml. Subjects within the lowest quartile of 25(OH)D (6-23 ng/ml) had greater odds of severe sleep apnea in unadjusted analyses (odds ratio = 1.45; 95% confidence interval = 1.02-2.07) when compared with the highest 25(OH)D quartile (35-84 ng/ml). However, further adjustment for established OSA risk factors strongly attenuated this association (multivariable adjusted odds ratio = 1.05; 95% confidence interval = 0.72-1.52), with body mass index and neck circumference as the main confounders. There was also no evidence of an independent association between lower 25(OH)D levels and increased odds of mild (AHI = 5.0-14.9/h) or moderate (AHI = 15.0-29.9/h) sleep apnea. CONCLUSIONS: Among community-dwelling older men, the association between lower 25(OH)D and sleep apnea was largely explained by confounding by larger body mass index and neck circumference.

Sleep Apnea Symptoms as a Predictor of Fatigue in an Urban HIV Clinic.

Fatigue is common among persons living with HIV (PLWH), and risk factors for obstructive sleep apnea (OSA) such as older age and obesity are increasingly prevalent. Studies of OSA among PLWH are lacking, so we aimed to characterize OSA symptoms and associated clinical consequences (e.g., fatigue) among a contemporary population of PLWH. Self-administered surveys containing 23 items that included self-reported snoring, witnessed apneas, estimated sleep duration, the Epworth Sleepiness Score (ESS), and the FACIT-Fatigue score were mailed to PLWH receiving care at an urban HIV clinic. Clinical/demographic data were collected from the medical record. Multivariable linear regression models were created to study relationships between fatigue, clinical variables, and OSA symptoms. Of 535 surveys, 203 (38%) responded. Eight patients (3.9%) had known OSA. Among those without known OSA, mean respondent characteristics included: age 47 years; 80% male, 41% African American, 48% Caucasian, BMI 26.4 kg/m(2), duration of HIV diagnosis 12 years, 93% on antiretroviral therapy, and 81% with <50 HIV RNA copies/mL. 27% reported snoring, 24% reported witnessed apneas, and 38% had excessive daytime sleepiness. Witnessed apnea was the strongest independent predictor of fatigue (lower FACIT-Fatigue score; ß = -6.49; p < 0.001); this difference of 6.49 points exceeds the accepted minimal clinically important difference of 3.0 points. Other predictors included opioid use (ß = -5.53; p < 0.001), depression (ß = -4.18; p = 0.02), antidepressant use (ß = -4.25; p = 0.02), and sleep duration < 6 h (ß = -3.42; p = 0.02). Our data strongly support the need for increased efforts directed at OSA screening and treatment in PLWH.

Analysis of Gill Structure from a Fresh Water Fish (Heteropneustes fossilis) Exposed to Bleached Sulfite Pulp Mill Effluents.

The present communication reports toxic effects of bleached sulfite pulp mill effluents in fish (Heteropneustes fossilis) gills, with optical, scanning electron, and transmission electron microscopy. The general adverse effects include dilation of the primary lamellar wall, curling of secondary lamellar terminals, displacement of epithelial cell layers, degeneration of secondary lamella, deposition of mucous, and severe congestion in the gill arch. The significant shortening of secondary lamellae, widening of lamellar tips, and significant decrease in the number of mitochondria in chloride cells as compared to controls are some specific effects of bleached sulfite pulp mill effluents. Scanning electron microscopy demonstrated tearing of tissues in gill lamellae and arches. Transmission electron microscopy revealed membrane distortion of mitochondria in chloride cells, loss of uniformity of microvilli in pavement cells, and abnormalities in nuclear shape in different cells of effluent-exposed fish gills. Toxicity of the bleached sulfite pulp mill effluents and its impact on fish are discussed in the light of existing literature. Further, the importance of microscopy in toxicological evaluation of environmental pollutants is emphasized in view of its specific application potential.

Associations and outcomes of septic pulmonary embolism.

BACKGROUND: Septic pulmonary embolism is a serious but uncommon syndrome posing diagnostic challenges because of its broad range of clinical presentation and etiologies. OBJECTIVE: To understand the clinical and radiographic associations of septic pulmonary embolism in patients presenting to an acute care safety net hospital. METHODS: We conducted a retrospective analysis of imaging and electronic health records of all patients diagnosed with septic pulmonary embolism in our hospital between January 2000 and January 2013. RESULTS: 41 episodes of septic pulmonary embolism were identified in 40 patients aged 17 to 71 years (median 46); 29 (72%) were men. Presenting symptoms included: febrile illness (85%); pulmonary complaints (66%) including pleuritic chest pain (22%), cough (19%) and dyspnea (15%); and those related to the peripheral foci of infection (24%) and shock (19%). Sources of infection included: skin and soft tissue (44%); infective endocarditis (27%); and infected peripheral deep venous thrombosis (17%). 35/41 (85%) were bacteremic with staphylococcus aureus. All patients had peripheral nodular lesions on chest CT scan. Treatment included intravenous antibiotics in all patients. Twenty six (63%) patients required pleural drainage and/or drainage of peripheral abscesses. Seven (17%) patients received systemic anticoagulants. Eight (20%) patients died due to various complications. CONCLUSION: The epidemiology of septic pulmonary embolism has broadened over the past decade with an increase in identified extrapulmonary, non-cardiac sources. In the context of an extrapulmonary infection, clinical features of persistent fever, bacteremia and pulmonary complaints should raise suspicion for this syndrome, and typical findings on the chest CT scans confirm the diagnosis. Antibiotics, local drainage procedures and increasingly, anticoagulation are keys to successful outcomes.

Functional ureogenesis and changes of amino acid metabolism in amphihaline shad hilsa (Tenualosa ilisha, Hamilton-Buchanan) while inhabiting in estuary and freshwater habitats.

The possible occurrence of a functional ornithine-urea cycle (OUC) and changes of activity of key amino acid metabolism-related enzymes were studied in the amphihaline shad hilsa (Tenualosa ilisha) that were collected from estuarine water of Kakdwip and from freshwater river basin of Bhrahmaputra during the breeding season. Very high concentration of urea was detected in different tissues and plasma of shad hilsa collected from estuarine water compared to the one collected from freshwater river basin. This observation clearly suggests that the shad hilsa has the potential of synthesizing and retaining urea inside the body for the purpose of osmoregulation while living in hypertonic saline environment of estuary. This was accompanied by the presence of high activity of all the five OUC enzymes in hepatic and in certain non-hepatic tissues such as the kidney and muscle of shad hilsa in support of its potential ureogenic capacity while inhabiting in estuarine water. The activities of different key amino acid metabolism-related enzymes such as glutamine synthetase, glutamate dehydrogenase, alanine aminotransaminase and aspartate aminotransaminase were also found to be significantly higher in shad hilsa of estuarine water compared to the one collected from freshwater habitat. Thus the adjustment to amino acid metabolism in shad hilsa in different environmental salinities appears to play significant roles for osmotic balance and also for proper energy supply in addition to the presence of a functional OUC while migrating between marine and freshwater habitats throughout their life cycle.

The association of septic thrombophlebitis with septic pulmonary embolism in adults.

BACKGROUND: There have been an increasing number of pediatric reports of septic pulmonary embolism in the setting of septic thrombophlebitis adjacent to a primary infectious source. METHODS: Retrospective review at an urban hospital. A total of five adults with a documented primary infectious source, adjacent septic thrombophlebitis and septic pulmonary embolism were identified between 2000 and 2011. RESULTS: The predominant symptoms on presentation were fever and pleuritic chest pain, followed by chills and cough. S. aureus was the pathogen in 4 patients. Only one case had echocardiographic evidence of endocarditis. All patients received IV antibiotics and anticoagulation therapy. No new embolic events or central nervous system complications were noted. CONCLUSIONS: The triad of extrapulmonary infection, contiguous septic thrombophlebitis and septic pulmonary embolism is present in adult as well as pediatric populations. The use of systemic anticoagulation with appropriate antibiotics resulted in clinical and radiologic improvement but no significant complications.

Efficiency of a few retinoids and carotenoids in vivo in controlling benzo[a]pyrene-induced forestomach tumour in female Swiss mice.

The anticarcinogenic effect of vitamin A2 (dehydroretinol and 3-hydroxyretinol) compounds was studied and compared with that of vitamin A1 (retinoic acid, retinol and retinal) and carotenoids (lutein and beta-carotene) in the benzo[a]pyrene (B(a)P)-induced forestomach tumour model of female Swiss mice in vivo. Tumour growth and gross tumour incidence observed after the administration of B(a)P (eight doses of 1 mg, twice weekly for 4 weeks) and retinoids/carotenoids (2.5 and 4.7 microm per animal per d, 2 weeks before, during and 2 weeks after B(a)P) showed that the groups supplemented with lutein and 3-hydroxyretinol produced the best results in inhibiting tumour growth and had low tumour incidence compared with the control group given B(a)P only (P<0.05). Weights recorded after the different treatments showed that the beta-carotene-supplemented group exhibited maximum weight gain, followed by retinal, retinol, retinoic acid, lutein, dehydroretinol and 3-hydroxyretinol. These results indicate that the anticarcinogenicity of the compounds is not related to the vitamin A biopotencies. Vitamin A2 compounds having half the biopotency of the vitamin A1 compounds were seen to be anticarcinogenic. Again, among the carotenoids, lutein, having 50 % less biopotency, showed more significant results than beta-carotene. Thus it is imperative to conclude that the low animal growth achieved with these compounds has a correlation with the highest suppression of tumour occurrence in the present experiment. Therefore, the daily consumption of foods having high content of lutein and vitamin A2 should be given due importance and weight in further studies.