Dysphagia Assessments as Criteria in the 'Decision-Making Process' for Percutaneous Endoscopic Gastrostomy Placement in People with Amyotrophic Lateral Sclerosis: A Systematic Review.

To review the assessment methods of dysphagia as a criterion for the decision-making process for Percutaneous Endoscopic Gastrostomy (PEG) placement in patients with Amyotrophic Lateral Sclerosis (ALS). Systematic review. A search was conducted in three databases (EMBASE, CINAHL, PUBMED) in December 2022 and updated in July 2023. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools. Systematic review registration number in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42022385461. The searches identified 240 records. The 10 eligible studies included 2 case reports, 4 retrospective studies, 3 prospective studies, and 1 cohort observational study. Study quality was low, with most studies having moderate to high risk of bias. Dysphagia is a common criterion for decision-making. Dysphagia assessment is usually in the form of either self-reports, objective instrumental assessments, or both. Dysphagia is a common criterion for the decision-making process, yet is missing in clinical guidelines. Establishing the optimal means of dysphagia assessment is important for timely decision-making procedures, so that life-threatening consequences of dysphagia are minimized.

Development of novel calibration model(s) to predict whole-body density in professional football players.

INTRODUCTION: Questions continue to be raised about the validity that is in existence to estimate Db, in professional male footballer players. METHODS: Phase 1: n = 28 anthropometric variables were used on n = 206 footballers, using regression analyses to determine standard error of estimate and R2. A cut-off correlation coefficient set at r = 0.950 and 90% R2. Phase 2: all variables (z-scores, x- = 0.0, SD = ±1.0) to help reduce heteroscedasticity, ß, r, t, significance of t and P-values were calculated. Phase 3: a forced stepwise-backwards regression analysis approach with nine predictors which met the acceptance criteria (r = 0.950, R2 = 90% and ß weights) was used to develop a 'best fit' and a 'practical' calibration model. Phase 4: cross-validation of the two newly developed calibration method using LoA. RESULTS: The 'best fit' model SEM (0.115 g ml-1), the highest R2 (6.6%) (P ≤ 0.005), whereas the 'practical' calibration model SEM (0.115 g ml-1), R2 (4.7%) (P ≤ 0.005) with r values = 0.271 and 0.596 and R2 (%) coefficients = 0.3526 for the 'best fit' and 'practical' calibration models, respectively (P = 0.01). CONCLUSIONS: The two calibration models supported an ecologically and statistically valid contribution and can provide sound judgements about professional footballers' body composition.

Associations between a Novel Measure of Census Tract-Level Credit Insecurity and Frequent Mental Distress in US Urban Areas, 2020.

Access to and utilization of consumer credit remains an understudied social determinant of health. We examined associations between a novel, small-area, multidimensional credit insecurity index (CII), and the prevalence of self-reported frequent mental distress across US cities in 2020. The census tract-level CII was developed by the Federal Reserve Bank of New York using Census population information and a nationally representative sample of anonymized Equifax credit report data. The CII was calculated for tracts in 766 cities displayed on the City Health Dashboard at the time of analysis, predominantly representing cities with over 50,000 residents. The CII combined data on tract-level participation in the formal credit economy with information on the percent of individuals without revolving credit, percent with high credit utilization, and percent with deep subprime credit scores. Tracts were classified as credit-assured, credit-likely, mid-tier, at-risk, or credit-insecure. We used linear regression to examine associations between the CII and a modeled tract-level measure of frequent mental distress, obtained from the CDC PLACES project. Regression models were adjusted for neighborhood economic and demographic characteristics. We examined effect modification by US region by including two-way interaction terms in regression models. In adjusted models, credit-insecure tracts had a modestly higher prevalence of frequent mental distress (prevalence difference = 0.38 percentage points; 95% CI = 0.32, 0.44), compared to credit-assured tracts. Associations were most pronounced in the Midwest. Local factors impacting credit access and utilization are often modifiable. The CII, a novel indicator of community financial well-being, may be an independent predictor of neighborhood health in US cities and could illuminate policy targets to improve access to desirable credit products and downstream health outcomes.

Worth a try or a last resort: Healthcare professionals' experiences and opinions of above cuff vocalisation.

BACKGROUND: Above cuff vocalisation (ACV) involves the application of an external flow of air via the subglottic port of a tracheostomy. ACV can facilitate vocalisation and may improve swallowing and quality of life for patients with a tracheostomy. A recent systematic review highlighted the limited evidence available for the acceptability, effectiveness, safety or optimal implementation of ACV. AIMS: To explore the experience of healthcare professionals (HCPs) using ACV and their perceptions of best practice. METHODS AND PROCEDURES: Semi-structured interviews were conducted with a range of HCPs with experience using ACV. Topics included: experiences with ACV, management of ACV, opinions about ACV, impact of COVID-19, future directions for ACV and impact on length of stay. Interviews were conducted online from December 2020 to March 2022. Data were analysed using reflexive thematic analysis. OUTCOMES AND RESULTS: Twenty-four HCPs were interviewed from seven countries and five professional groups. Four interconnected themes were developed: (1) moral distress amplifying the need to fix patients; (2) subjectivity and uncertainty leading to variations in practice and purpose; (3) knowledge and experience leading to control and caution; and (4) worth a try or a last resort. Theme four contained three sub-themes: (a) part of the toolbox; (b) useful but limited tool; and (c) following the patient's lead. The moral distress experienced by HCPs and their essential 'need to fix' patients seems to underpin the varied opinions of ACV. These opinions appear to be formed primarily on the basis of experience, because of the underlying subjectivities and uncertainties. As knowledge and experience with ACV increased, and adverse events were experienced, most HCPs became more cautious in their approach to ACV. CONCLUSIONS AND IMPLICATIONS: More research is needed to reduce the subjectivities and uncertainties surrounding ACV. The implementation of standardised procedures, processes, and competencies may help to reduce the frequency of adverse events and support a more controlled approach. Widening the focus of the purpose of ACV to include swallowing may help to maximise the potential benefits. WHAT THIS PAPER ADDS: What is already known on the subject There is limited and low-quality evidence for above cuff vocalisation (ACV) and clinical application and practice varies substantially. However, the reasons for this variation in practice and healthcare professionals' (HCPs') opinions of ACV were unclear. What this study adds HCPs' experiences and opinions of ACV vary as a result of the uncertainty and subjectivity surrounding ACV compounded by their personal experiences with it. A need for caution also appears to emerge as HCPs become more familiar and experienced with using ACV. What are the clinical implications of this work? Implementing standardised procedures, safety processes and competencies may help to compensate for the uncertainty and subjectivity surrounding ACV and may reduce the frequency of adverse events. Widening the focus of purpose of ACV, including swallowing in addition to communication, may increase the number of potential candidates and increase the potential benefits of ACV. Using multidisciplinary team (MDT) simulation training for ACV competency development might help to improve MDT working and ACV implementation.

A successful implant-supported fixed prosthesis in a patient with osteopetrosis: A clinical report.

Osteopetrosis (marble bone disease) is a family of rare genetic disorders characterized by impaired osteoclast function leading to hyperdense, hypovascular, brittle bone. Typical imaging shows increased bone mass and thickened cortical and trabecular bone. Bones are more prone to fracture and osteomyelitis may develop. When considering dental implant placement in a patient with osteopetrosis, the potential for bony fracture and/or osteomyelitis should be considered along with the decreased likelihood of successful osseointegration because of hypovascularity. This clinical report describes an unusual imaging presentation and successful osseointegration of multiple dental implants supporting an implant-supported fixed mandibular prosthesis with long-term survival.

Perspectives on speech and language pathology practices and service provision in adult critical care settings in Ireland and international settings: A cross-sectional survey.

PURPOSE: Patients admitted to critical care (CC) are at risk of impaired swallowing and communication function. Speech-language pathologists (SLPs) play an important role in this context. In Ireland and internationally speech-language pathology CC guidelines are lacking, with possible variations in practice. To compare clinical practices in dysphagia, communication and tracheostomy management among SLPs working in adult CC units in Ireland and internationally, and explore their perspectives on training, skills and resources. METHOD: Participants were SLPs working in CC. An international online survey sought information on (i) SLP workforce demographics and staffing levels, (ii) current dysphagia and communication assessment and management practices, (iii) practices and perspectives on training, skills and resources. RESULT: 366 responses were received across 29 countries. 18.03% (66/366) of these respondents worked in Ireland. Findings showed similarities and differences in practices. Total CC SLP whole-time equivalent (WTE) at each staff grade was lower (mean difference: -0.21 to -0.65 WTE p <.001) than desired for optimal service delivery. Negative effects of under-staffing were reported. Recommendations that all tracheostomised patients receive SLP input was unmet in 66% (220/334) of services. CONCLUSION: SLP input in CC is limited in terms of dedicated posts, multidisciplinary team (MDT) involvement, consistent management approaches and training opportunities internationally. Implications of findings are discussed.

The adaptation of the Leeds Post-Extubation Dysphagia Screen: Lessons learned during the COVID-19 pandemic.

Introduction: Post-extubation dysphagia (PED) can have serious consequences for critically unwell patients. COVID-19 has resulted in an increasing need for a PED screen in order to effectively identify patients and mitigate risk, whilst balancing under-resourced services. Online training provides the advantage of reducing time pressures on staff and supporting social distancing. This project aimed to adapt the Leeds Post-Extubation Dysphagia Screen (L-PEDS) and the associated training package to be more suitable and effective for use during COVID-19 pandemic. Methods: The screen was modified to a digital format with additional guidance for users. The training package was shortened and converted to an online package while keeping the interactive mode of training. Results: Preliminary results of 14 staff members indicate that the median confidence levels for screening patients for PED improved from 5 to 8 (on a scale of 0 to 10) after completing the L-PEDS-COVID training package. Likewise, knowledge of PED improved from a median of 4 to 8 (on a scale of 0 to 10). Training quality was rated at a median of 8 on a scale of 0 to 10 (0 being very poor; 10 being very good). Conclusions: Preliminary evidence demonstrated increased knowledge of PED and confidence in screening. The development of an adapted version of the L-PEDS and online training package may allow easier implementation of post-extubation dysphagia screening. This could help to compensate for insufficient speech and language therapy critical care staffing, assist in identifying patients at risk and improve outcomes by enabling earlier and safe resumption of oral intake.

Left atrial strain is associated with adverse cardiovascular events in patients with end-stage renal disease: Findings from the Cardiac, Endothelial Function and Arterial Stiffness in ESRD (CERES) study.

INTRODUCTION: We lack cardiovascular (CV) markers for patients with end-stage renal disease (ESRD), and left atrial (LA) strain has not been studied definitively in this population. We examined associations of LA reservoir, conduit, and booster strain with major adverse cardiovascular events (MACE) among stable patients with ESRD on dialysis. METHODS: One hundred and ninety patients in the Cardiac, Endothelial and Arterial Stiffness in ESRD study underwent echocardiography, including strain imaging. The primary outcome was 2-year composite non-fatal MACE or CV death. We performed Cox proportional hazards regression for LA strain measures, adjusting for demographics, comorbidities, left ventricular global longitudinal strain (LV GLS), E/e' and LA volume index. FINDINGS: Mean ± SD LA reservoir strain was 24.1 ± 7.0%, and LA conduit strain 11.9 ± 5.1%. In age-adjusted analyses, lower LA reservoir strain and LA conduit strain were associated with the primary outcome (HR per 1-SD worsening LA strain parameter = 1.57 [95% CI 1.2-2.1], p = 0.003 and 1.68 [95% CI 1.2-2.3], p = 0.002, respectively). After adjusting for comorbidities, LA reservoir strain remained associated with the primary outcome and with deaths alone, and LA conduit strain with the primary outcome and hospitalizations alone (p < 0.05 for all). Associations of LA conduit strain were independent of LV GLS. Associations were stronger in participants with serum albumin <3.6 mg/dl (p for interaction 0.008). DISCUSSION: Left atrial reservoir strain and conduit strain were independently associated with MACE among patients with ESRD. Our study provides unique ascertainment of CV hospitalizations not attributed to missed dialysis, and LA conduit strain was a strong marker for this outcome.

Evidence for Above Cuff Vocalization in Patients With a Tracheostomy: A Systematic Review.

OBJECTIVES/HYPOTHESIS: To determine how above cuff vocalization (ACV) is implemented in clinical practice, to identify what evidence exists on the effectiveness and safety of ACV, and to evaluate the acceptability of ACV. STUDY DESIGN: Systematic review. METHODS: A literature search was conducted in eight databases (MEDLINE, Embase, AMED, CINAHL, Cochrane Library, PsycINFO, Scopus, and Web of Science) in May 2019 and updated in June 2020. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools and a narrative synthesis was conducted. Systematic review registration number: CRD42019133942. RESULTS: The searches identified 1327 records. The 13 eligible studies included four case studies, three case series, four observational studies without a control group, one quasi-experimental study, and one randomized controlled trial. Study quality was low, with most studies having high risk of bias. There was a high level of heterogeneity in study design and outcome measures used. Detailed information on ACV application and dose-delivered was lacking in 12 studies. Positive effects were reported for communication (n = 7), swallowing (n = 4), cough response (n = 2), and quality-of-life (n = 2), but with inconsistent use of objective outcome measures. There is limited quantitative or qualitative evidence for acceptability. Adverse events and complications were reported in nine studies, and four highlighted the importance of involving an experienced speech and language therapist. CONCLUSIONS: There is limited evidence for the acceptability, effectiveness, safety, or optimal implementation of ACV. The evidence is insufficient to provide recommendations regarding optimal intervention delivery. Future research should ensure detailed recording of ACV delivery and utilize a core outcome set. Laryngoscope, 132:600-611, 2022.

Determining the Prevalence, Implementation Approaches, and Opinions of Above Cuff Vocalization: A Survey of Health Care Professionals.

OBJECTIVE: To conduct an international survey to investigate the use of above cuff vocalization (ACV) and how practice and opinion differs. DESIGN: Observational, cross-sectional online survey. SETTING: Critical care, acute, rehabilitation, long-term care, and community. PARTICIPANTS: Health care professionals involved in tracheostomy care or weaning (N=243). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Tracheostomy management, prevalence, personal experiences and opinions, and barriers to use. Quantitative data were reported descriptively, and content analysis was conducted with qualitative data. RESULTS: The survey was completed by 243 health care professionals from 9 professional groups and 25 countries, with most responses from the United Kingdom (54%) and speech and language therapists (55%). ACV was used in 39% of services (n=93). Sixty percent (n=50/83) of health care professionals with direct experience of ACV had used it with <10 people. Implementation of ACV varied widely concerning procedures, contraindications, safety processes, professionals involved, competencies, staff training, delivery, and outcome measures. The top benefits were communication (n=76/93; 82%), mood (n=62/93; 67%), and laryngeal sensation (n=49/93; 53%). Complications included discomfort (n=54/93; 58%) and strained vocal quality (n=39/93; 42%). Barriers to ACV implementation included lack of knowledgeable staff (n=92/238; 39%) and lack of access to training (n=73/238; 31%). CONCLUSIONS: ACV uptake varies internationally with no standardized approach to ACV delivery. Diversity of opinions on approaches and benefits exist. Serious complications are infrequent, but minor complications are common. Future research is needed to establish optimal ACV implementation to maximize benefits and minimize risks.

Are Oral Antibiotics an Effective Alternative to Intravenous Antibiotics in Treatment of Osteomyelitis of the Jaw?

PURPOSE: To review treatment of osteomyelitis of the jaw (OMJ) and determine whether antibiotic route and/or length of administration impacts resolution of infection postsurgically. METHODS: The investigators designed a retrospective cohort study enrolling a sample of patients treated at Harborview Medical Center from January 1, 2009 to December 31, 2019. The primary predictor variable was antibiotic administration route: oral (PO) only, intravenous (IV) only, IV transitioned to PO (IV + PO), or none. The secondary predictor was duration of antibiotic therapy (≤6 weeks or >6 weeks). The primary outcome variable was resolution of infection at 2 months follow-up posttreatment completion. The secondary outcome variable was number of surgeries to resolution of infection. Descriptive, bivariate, and multiple linear regression statistics were computed, with statistical significance set at P < .05. RESULTS: Sixty-seven individuals met inclusion criteria (38 male), mean age 51 years (18 to 88). Forty-nine (73%) received PO antibiotics, 12 (18%) IV + PO, 3 (4%) IV, and 3 (4%) none. Both PO and IV antibiotics were associated with clinical resolution (P = .022, .005, respectively) compared with debridement alone. Antibiotic duration of ≤6 weeks compared with >6 weeks was not significant. Seventy-six percent (51 of 67) required only 1 surgery. In the multivariate logistic regression, PO was associated with clinical resolution (P = .025, OR = 5.05). Penicillin allergy (P = 0.049, OR = 0.223) and diabetes (P = .008, OR = 0.104) were adversely associated with outcome. CONCLUSIONS: OMJ was successfully treated with oral antibiotics and surgery. Prescribing 6 weeks of IV antibiotics may be antiquated. Clinicians should consider oral penicillins as first line whenever possible. Further studies are recommended.

Association of Viral Persistence and Atherosclerosis in Adults With Treated HIV Infection.

Importance: Persons living with HIV (PLWH) have increased risk for cardiovascular disease, and inflammation is thought to contribute to this excess risk. Production of HIV during otherwise effective antiretroviral therapy (ART) has been associated with inflammation. Objective: To determine whether higher levels of viral persistence are associated with atherosclerosis as assessed by changes in carotid artery intima-media thickness (IMT) over time. Design, Setting, and Participants: In this cohort study, intima-media thickness, a validated marker of atherosclerosis, was assessed over time in a cohort of treated PLWH with viral suppression. Cell-associated HIV DNA and RNA and change in IMT, adjusted for demographics, cardiovascular risk factors, and HIV-related factors, were examined, as well as which factors were associated with viral persistence. One hundred fifty-two PLWH with undetectable viral loads for at least 6 months before study enrollment were recruited from HIV clinics affiliated with 2 hospitals in San Francisco, California, from January 1, 2003, to December 31, 2012. Data were analyzed from February 7, 2018, to May 12, 2020. Exposures: Cell-associated HIV RNA and DNA were measured using enriched CD4+ T cells from cryopreserved peripheral blood mononuclear cells. Main Outcomes and Measures: Carotid IMT was measured at baseline and the last visit, with a mean (SD) follow-up of 4.2 (2.7) years, using high-resolution B mode ultrasonography. The main study outcomes were baseline IMT, annual IMT progression, and incident plaque, defined as a focal region of carotid IMT of greater than 1.5 mm. Results: The analysis included 152 PLWH (140 [92.1%] male; median age, 48.5 [interquartile range {IQR}, 43.3-53.7] years). Older age, smoking, medications for hypertension, higher low-density lipoprotein levels, and higher interleukin 6 levels were associated with higher baseline mean IMT, whereas cell-associated HIV DNA (estimate, -0.07% [95% CI, -6.1% to 6.4%]; P = .98), and HIV RNA levels (estimate, -0.8% [95% CI, -5.9% to 4.4%]; P = .75) were not. Levels of HIV RNA (0.017 [95% CI, 0.000-0.034] mm/y; P = .047) and HIV DNA (0.022 [95% CI, 0.001-0.044] mm/y; P = .042) were significantly associated with annual carotid artery IMT progression in unadjusted models only. Both HIV RNA (incidence risk ratio [IRR], 3.05 [95% CI, 1.49-6.27] per IQR; P = .002) and HIV DNA (IRR, 3.15 [95% CI, 1.51-6.57] per IQR; P = .002) were significantly associated with incident plaque, which remained significant after adjusting for demographics, cardiovascular risk factors, and HIV-related factors (IRR for HIV RNA, 4.05 [95% CI, 1.44-11.36] per IQR [P = .008]; IRR for HIV DNA, 3.35 [95% CI, 1.22-9.19] per IQR [P = .02]). Higher C-reactive protein levels were associated with higher cell-associated HIV RNA (estimate, 20.7% [95% CI, 0.9%-44.4%] per doubling; P = .04), whereas higher soluble CD14 levels were associated with HIV DNA (estimate, 18.6% [95% CI, 3.5%-35.8%] per 10% increase; P = .01). Higher soluble CD163 levels were associated with a higher HIV RNA:DNA ratio (difference, 63.8% [95% CI, 3.5%-159.4%]; P = .04). Conclusions and Relevance: These findings suggest that measurements of viral persistence in treated HIV disease are independently associated with incident carotid plaque development. The size and transcriptional activity of the HIV reservoir may be important contributors to HIV-associated atherosclerosis.

Plasma tissue factor and immune activation are associated with carotid intima-media thickness progression in treated HIV infection.

OBJECTIVES: We evaluated the roles of biomarkers of immune activation with carotid intima-media thickness (CIMT) progression in treated HIV infection. DESIGN: Longitudinal observational study of 118 treated and virologically suppressed individuals. METHODS: We measured biomarkers of immune activation at baseline using cryopreserved samples. CIMT was measured at baseline and longitudinally using high-resolution ultrasound. Linear regression was used to estimate biomarker associations with CIMT progression, and logistic regression was used to model plaque progression. RESULTS: The median duration of follow-up was 2.0 years. The median annual rate of change in mean CIMT was 6.0%. Rates of progression were more rapid in the bifurcation (5.6%/year, P = 0.006) and internal (6.5%/year, P = 0.0008) than common CIMT (4.3%/year). Incident plaque occurred in 13 of the 52 individuals without baseline plaque. In multivariable adjusted analysis, plasma tissue factor and monocyte chemoattractant protein-1 were associated with more rapid common CIMT progression (0.058 mm/year, P = 0.0004 and 0.067 mm/year, P = 0.017; all estimates per doubling). CD8 T-cell count and percentage of HLA-DRCD38CD8 T cells were associated with more rapid internal CIMT progression (0.10 mm/year, P = 0.008 and 0.054 mm/year, P = 0.045). CD8 T-cell count was also associated with 0.068 mm/year more rapid mean CIMT progression (P = 0.011). Each 10% increase in CD4 T-cell count at baseline was associated with a 34% reduced odds of plaque progression (P = 0.018). CONCLUSION: Residual immune activation and plasma tissue factor are independently associated with CIMT progression in treated HIV infection. Interventions targeting coagulation and inflammatory pathways to reduce cardiovascular disease risk in HIV merit additional investigations.

Associations of microvascular dysfunction with cardiovascular outcomes: The cardiac, endothelial function and arterial stiffness in ESRD (CERES) cohort.

INTRODUCTION: Patients with end-stage renal disease (ESRD) have reduced endothelial function, but whether macro- and microvascular endothelial function correlate with baseline risk factors and cardiovascular outcomes in this population is not well understood. METHODS: Among 146 participants of the Cardiac, Endothelial Function and Arterial Stiffness in ESRD (CERES) study, we evaluated macro- and microvascular endothelial dysfunction as flow-mediated dilation (FMD) and velocity time integral (VTI), respectively. We examined cross-sectional correlations of baseline characteristics, inflammatory and cardiac markers with FMD and VTI. We followed participants for the composite outcome of cardiovascular hospitalization or all-cause death over fourteen months. Cox survival analyses were adjusted for demographics, comorbidities, medications, systolic blood pressure, inflammation, high-sensitivity troponin T (hs-TnT), and N-terminal pro B-type natriuretic peptide (NT-proBNP). FINDINGS: Impaired VTI was associated with older age and Black race (P < 0.05), as well as female gender, atherosclerosis, and hemodialysis (as opposed to peritoneal dialysis) (P < 0.2). Myocardial injury, measured as hs-TnT, inflammatory markers and NT-proBNP correlated with impaired VTI. In unadjusted analyses, VTI was significantly associated with the composite outcome (HR per SD VTI 0.65 [95%CI 0.45, 0.95]), but FMD was not (HR per SD FMD 0.97 [95%CI 0.69, 1.4]). When VTI was calculated as the ratio of (hyperemic VTI-baseline VTI)/baseline VTI, its association with the outcome persisted after multivariable adjustment. DISCUSSION: Microvascular function was associated with higher rates of cardiovascular hospitalizations and all-cause mortality among individuals with ESRD on dialysis. Further research is needed to learn whether novel therapies that target microvascular endothelial function could improve outcomes in this high-risk population.

Vascular Aging Is Accelerated in Flight Attendants With Occupational Secondhand Smoke Exposure.

OBJECTIVE: To determine whether early vascular aging may be present in flight attendants with remote in-cabin secondhand smoke (SHS) exposure. METHODS: Twenty-six flight attendants with a history of in-cabin SHS exposure prior to the airline smoking bans were recruited. Pulse wave analysis, peripheral arterial tonometry, and brachial artery reactivity testing evaluated their arterial compliance and endothelial function. RESULTS: Flight attendants with remote in-cabin SHS exposure have normal blood pressure, pulse wave velocity, and reactive hyperemia index, but abnormal pulse pressure, augmentation index, flow-mediated dilation, and hyperemic mean flow ratio. CONCLUSION: These preliminary findings suggest that flight attendants with remote in-cabin SHS exposure have preclinical signs of accelerated vascular aging and raise new questions about the relationship between remote SHS exposure and vascular health.

Sex differences in vascular dysfunction and cardiovascular outcomes: The cardiac, endothelial function, and arterial stiffness in ESRD (CERES) study.

INTRODUCTION: Recent studies suggest that women with end-stage renal disease (ESRD) may have higher rates of mortality than men, but it is unknown whether sex differences in vascular function explain this disparity. The cardiac, endothelial function, and arterial stiffness in ESRD (CERES) study is an ongoing, prospective observational study designed to investigate vascular function, myocardial injury, and cardiovascular outcomes in ESRD. METHODS: Among 200 CERES participants (34% women), we evaluated arterial wave reflections as augmentation index normalized to a heart rate of 75 (AIx75), arterial stiffness as pulse wave velocity, and macro- and microvascular endothelial dysfunction as flow-mediated dilation and velocity time integral (VTI). Over a median of 14 months, participants were followed for the composite outcome of cardiovascular hospitalization or all-cause death. FINDINGS: Women had higher arterial wave reflection (Mean, SD AIx75 30% ± 9% for women vs. 21% ± 10% for men; P < 0.001) and worse microvascular function (VTI 55 ± 30 cm for women vs. 70 ± 27 cm for men; P = 0.007). After multivariable adjustment, female sex remained associated with a 0.5-SD higher AIx75 (95% CI [0.01, 0.9]) and 0.3-SD lower VTI (95%CI [0.1, 0.7]). Women experienced higher adjusted rates of the composite outcome (HR 2.5; 95%CI [1.1, 5.6]; P = 0.03), and further adjustment for arterial wave reflection attenuated this risk. DISCUSSION: Vascular dysfunction may partly explain the association of female sex with higher cardiovascular risk and mortality in patients with ESRD. Further studies are needed to explore whether sex differences in vascular function predict long-term outcomes, and whether hormonal or inflammatory factors explain these associations.

Measuring voluntary and reflexive cough strength in healthy individuals.

BACKGROUND: Cough reflex testing is a validated tool for identifying patients at risk of silent aspiration. However, inter- and intra-rater reliabilities of perceptual judgements of cough strength are sub-optimal. Although there are clinically established methods for measuring volitional cough strength, no similar methods are identified for reflexive cough strength. This study evaluated three measurement methods of voluntary and suppressed reflexive cough strength. METHODS: Fifty-three healthy subjects (≥50 years) participated in this study. Participants produced 'strong' and 'weak' voluntary coughs and suppressed reflexive coughs to incremental doses of citric acid. Peak and area under the curve (AUC) measurements were taken of pressure, airflow, and acoustics. RESULTS: There was no dose effect of citric acid on measures of reflexive cough strength. Strong voluntary coughs were stronger than reflexive coughs for all measures (p < 0.001) and weak voluntary coughs were stronger than reflexive coughs for two measures (AUC pressure: p < 0.020; peak flow: p < 0.004). AUC pressure and peak flow had the highest correlations and effect sizes. Correlations were low between voluntary and reflexive cough strength for all measures (r ≤ 0.46). CONCLUSION: Assessing strength of reflexive cough, rather than voluntary cough, is highly desirable in the dysphagic population. Pressure and flow provide the most useful objective measurements.