Surge of Sympathetic Activity during Hyperventilation at the End of Apnea for Patients with Obstructive Sleep Apnea.

Background and Objectives: The mechanisms connecting obstructive sleep apnea (OSA) and cardiovascular disease are multifactorial, involving intermittent hypoxia, hypercapnia, and sympathetic activation. The aim of this study was to explore the oscillations of sympathetic activity during the sleep apnea episodes throughout the entire night in patients with OSA. Materials and Methods: The participants received whole-night polysomnography (PSG), and electrocardiogram (EKG) data from the PSG were collected for heart rate variability (HRV) analysis. HRV measurements were conducted in the time and frequency domains. The root mean square of successive differences between normal heartbeats (RMSSD), which reflects parasympathetic activity, and the ratio of the absolute power of the low-frequency band (0.04-0.15 Hz) to the absolute power of the high-frequency band (0.015-0.4 Hz) (LF/HF ratio), which indicates sympathetic activity, were computed. Results: A total of 43 participants (35 men and 8 women) were included in the analysis. The mean age of the participants was 44.1 ± 11.3 years old, and the mean BMI was 28.6 ± 5.4 kg/m2. The sleep apnea episodes throughout the entire night in patients with OSA were selected randomly and occurred most frequently during the non-REM stages (39, 90.7%). The selected sleep apnea episodes typically exhibited multiple apneas, often interrupted by snoring respiration and followed by hyperventilation at the end of the episode (HE). Our findings indicate that the centers of the 5 min HRV window for the lowest and highest LF/HF ratios, at 111.8 ± 88.2 and 117.4 ± 88.6 min after sleep onset, respectively, showed a statistically significant difference (p < 0.001). Similarly, the ratios of the lowest and highest LF/HF, at 0.82 ± 0.56 and 3.53 ± 2.94, respectively, exhibited a statistically significant difference (p < 0.001). Conclusions: In the current study, the selected sleep apnea episodes throughout the entire night in patients with OSA occurred primarily during the non-REM stages. Additionally, we observed that sympathetic activity reached its peak in the window that includes hyperventilation at the end stage of apnea, potentially posing a cardiovascular risk. However, additional studies are needed to validate these results.

The Impact on Autonomic Nervous System Activity during and Following Exercise in Adults: A Meta-Regression Study and Trial Sequential Analysis.

Background and Objectives: Exercise enhances cardiovascular health through various mechanisms, including the modulation of autonomic nervous system activity. This study aimed to systematically examine the impact of exercise on heart rate variability (HRV) in adults during and within one hour after exercise (WHAE). Materials and Methods: A comprehensive literature review was conducted using the MEDLINE, Embase, Cochrane Library, Scopus, and PubMed databases to identify published studies that reported the impact of exercise on autonomic nervous system activity in adults. The studies measured the absolute power of the low-frequency band (0.04-0.15 Hz) to the absolute power of the high-frequency band (0.015-0.4 Hz) (LF/HF ratio) to assess sympathetic activity and the root mean square of successive differences between normal heartbeats (RMSSD) to assess parasympathetic activity. Results: A total of 3329 studies were screened for relevance, and finally, 10 articles that utilized methods for measuring autonomic nervous system activity, such as the LF/HF ratio and RMSSD, covering 292 adult patients, were included for meta-analysis. In the current meta-analysis, we observed a significant decrease in parasympathetic activity during and after exercise, as indicated by RMSSD, compared to pre-exercise levels (mean difference [MD] = -4.96, 95% confidence interval [CI]: -8.00 to -1.91, p = 0.003). However, sympathetic activity after exercise, represented by the LF/HF ratio, showed a borderline significant increase compared to pre-exercise levels (MD = 1.06, 95% CI: -0.01 to 2.12, p = 0.052). The meta-regression model found that factors associated with RMSSD included mean age, male gender, and duration post-exercise. Additionally, the factor associated with the LF/HF ratio was the healthy condition of participants. The trial sequential analysis provided robust evidence of a decrease in RMSSD and an increase in the LF/HF ratio during and WHAE. Conclusions: Given the limitations of the current study, the findings suggest that a significant decrease in parasympathetic activity and a borderline significant increase in sympathetic activity in adults during and WHAE, as confirmed by trial sequential analysis. Meta-regression analysis indicated that parasympathetic activity was negatively associated with participant age and male gender, but positively associated with duration post-exercise. Additionally, increased sympathetic activity was linked to the healthy conditions of participants. This study suggests that exercise might differentially affect autonomic balance in individuals with chronic conditions compared to healthy individuals. This highlights the potential need for tailored exercise interventions to improve autonomic function across different populations.

Association of Heart Rate Variability with Obstructive Sleep Apnea in Adults.

Background and Objectives: Heart rate variability (HRV) analysis is a noninvasive method used to examine autonomic system function, and the clinical applications of HRV analysis have been well documented. The aim of this study is to investigate the association between HRV and the apnea-hypopnea index (AHI) in patients referred for polysomnography (PSG) for obstructive sleep apnea (OSA) diagnosis. Materials and Methods: Patients underwent whole-night PSG. Data on nocturnal HRV and AHI were analyzed. We determined the correlation of time- and frequency-domain parameters of HRV with the AHI. Results: A total of 62 participants (50 men and 12 women) were enrolled. The mean age, body mass index (BMI), neck circumference, and AHI score of the patients were 44.4 ± 11.5 years, 28.7 ± 5.2, 40.2 ± 4.8 cm, and 32.1 ± 27.0, respectively. The log root mean square of successive differences between normal heartbeats (RMSSD) were negatively correlated with BMI (p = 0.034) and neck circumference (p = 0.003). The log absolute power of the low-frequency band over high-frequency band (LF/HF) ratio was positively correlated with the AHI (p = 0.006). A higher log LF/HF power ratio (ß = 5.01, p = 0.029) and BMI (ß = 2.20, p < 0.001) were associated with a higher AHI value in multiple linear regression analysis. Conclusions: A higher log LF/HF power ratio and BMI were positively and significantly associated with the AHI during whole-night PSG in adult patients.

Validation of snoring detection using a smartphone app.

PURPOSE: Snoring is closely related to obstructive sleep apnea in adults. The increasing abundance and availability of smartphone technology has facilitated the examination and monitoring of snoring at home through snoring apps. However, the accuracy of snoring detection by snoring apps is unclear. This study explored the snoring detection accuracy of Snore Clock-a paid snoring detection app for smartphones. METHODS: Snoring rates were detected by smartphones that had been installed with the paid app Snore Clock. The app provides information on the following variables: sleep duration, snoring duration, snoring loudness (in dB), maximum snoring loudness (in dB), and snoring duration rate (%). In brief, we first reviewed the snoring rates detected by Snore Clock; thereafter, an ear, nose, and throat specialist reviewed the actual snoring rates by using the playback of the app recordings. RESULTS: In total, the 201 snoring records of 11 patients were analyzed. Snoring rates measured by Snore Clock and those measured manually were closely correlated (r = 0.907). The mean snoring detection accuracy rate of Snore Clock was 95%, with a positive predictive value, negative predictive value, sensitivity, and specificity of 65% ± 35%, 97% ± 4%, 78% ± 25%, and 97% ± 4%, respectively. However, the higher the snoring rates, the higher were the false-negative rates for the app. CONCLUSION: Snore Clock is compatible with various brands of smartphones and has a high predictive value for snoring. Based on the strong correlation between Snore Clock and manual approaches for snoring detection, these findings have validated that Snore Clock has the capacity for at-home snoring detection.

Comparison of medical outcomes and health care costs at the end of life between dialysis patients with and without cancer: a national population-based study.

BACKGROUND: Palliative care has improved the quality of end-of-life (EOL) care and lowered the health care cost of cancer, and these benefits should be extended to patients with other serious illnesses including end-stage kidney disease. We evaluated the quality of EOL care, survival probabilities, and health care costs for dialysis patients in their last month of life. METHODS: We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information of patient medical records, health care costs, and insurance system exit dates (our proxy for death between 2006 and 2011). RESULTS: Data of 1177 adult patients who died of chronic hemodialysis or peritoneal dialysis were investigated. The mean age of these patients was 69.7 ± 11.9 years, and 585 (49.7%) were women. Some patients with dialysis received cardiopulmonary resuscitation (66.9%), died in a hospital (65.0%), or were admitted to an intensive care unit (51.0%) in the last month of life. We further classified these patients into two groups, namely dialysis with cancer (DC) (n = 149) and dialysis without cancer (D) (n = 1028). Only 19 dialysis patients received palliative care, and the proportion of patients receiving palliative care was higher in the DC group than in the D group (11.4% vs. 0.2%). The mean health care costs per person during the final month of life was similar between the DC and D groups (USD 2755 ± 259 vs. USD 2827 ± 88). Multivariate logistic regression showed that the DC group had lower odds of receiving cardiopulmonary resuscitation (CPR) (OR: 0.39, CI = 0.26-0.56, p < 0.001) procedures, higher odds of longer hospital stays than the third quartile (> 25 days) (OR: 1.52, CI = 1.01-2.29, p = 0.0046), and higher odds of being hospitalized more than once (OR: 2.26, CI = 1.42-3.59, p = 0.001) than the D group in the last month of life after adjustments. CONCLUSIONS: DC patients received hospice care more frequently, received CPR less frequently, and had similar health care costs. DC patients also had a higher risk of a hospital stay that lasted more than 25 days and more than one hospitalization compared with D patients in the final month of life.

End-of-Life Care for Patients With Advanced Ovarian Cancer Is Aggressive Despite Hospice Intervention: A Population-Based Study.

OBJECTIVE: To date, few studies have examined end-of-life (EOL) care and healthcare costs for patients with ovarian cancer. We evaluated the effects of hospice care on the quality of EOL care and healthcare costs for patients with ovarian cancer in the final month of life. MATERIALS AND METHODS: We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information for medical records of patients, healthcare costs, and insurance system exit dates: our proxy for death between 1997 and 2011. RESULTS: A total of 176 women who died of ovarian cancer were investigated. Of these patients, 32 (18.2%) had received hospice care. Univariate analysis revealed that the patients with hospice care (H group) had lower proportions of intensive care unit admission (0% vs 15.3%) and cardiopulmonary resuscitation (0% vs 18.1%). The mean health care cost per person during the final month of life for H group was approximately 5.5% significantly higher than patients without hospice care (non-H group) (US $3121 ± $376 vs $2957 ± $347). The effects of hospice care on intensive care unit admission, receipt of cardiopulmonary resuscitation, and more than 1 emergency room visit could not be assessed because no cases of these 3 occurrences were observed among the H group by the multivariate regression model. No significant difference was observed between the H and non-H groups in terms of chemotherapy during the final 2 weeks of life. The H group had higher probabilities for more than 1 hospitalization and death in acute hospitals after adjusting for confounders. CONCLUSIONS: The aggressiveness of EOL cancer care and healthcare costs could not be offset in the final month of life among women with advanced ovarian cancer who received hospice care. The factors of more hospitalizations and dying in hospital warrant further investigation.

Factors associated with emergency services use in Taiwanese advanced cancer patients receiving palliative home care services during out-of-hours periods: a retrospective medical record study.

BACKGROUND: For patients receiving palliative home care, the need to visit the emergency department is considered to be an indicator of poor quality care. The situation can be particularly distressing when it occurs outside of normal hours of palliative home care service. The aim of this study was to investigate the factors for emergency department use during out-of-hours periods of palliative home care service among advanced cancer patients in Taiwan. METHODS: This case-control study was based on a retrospective medical chart review (January 2010 to December 2012) of advanced cancer patients who were receiving palliative home care in a community hospital in south Taiwan. The use of emergency medical services by these patients was dichotomized into either normal hours (8 a.m. to midnight, Monday to Friday, excluding public holidays) of palliative home care or outside normal hours. Logistic regression analyses were performed to evaluate factors associated with emergency services use during out-of-hours period of palliative home care. RESULTS: Of the 94 patients receiving palliative home care, 65 had used emergency services at least once during the 3-year study period. Of these 65 patients, 40% used emergency services during out-of-hours of palliative home care. Patients with distressing conditions (defined as the occurrence of any two conditions of dyspnea, change of consciousness, or gastrointestinal bleeding) were significantly more likely to use emergency services during out-of-hours of palliative home care. CONCLUSIONS: Patients at risk of developing dyspnea, change of consciousness, or gastrointestinal bleeding should be provided with relevant information regarding these symptoms and signs.

Predictors of high healthcare costs in elderly patients with liver cancer in end-of-life: a longitudinal population-based study.

BACKGROUND: Studies have indicated a pervasive pattern of decreasing healthcare costs during elderly patients' last year of life. The aim of this study was to explore the predictors of high healthcare costs (HC) in elderly liver cancer patients in Taiwan during their last month of life (LML). METHODS: Costs of hospitalization, outpatient visits, aggressiveness of care, and associated costs for elderly (age ≥ 65 y) patients with liver cancer in the LML were analyzed using a national insurance database. An HC was defined as being greater than the 90th percentile (US $5093) in the LML, amounting to 38.95% of total healthcare costs. RESULTS: We enrolled 2121 subjects who died during 1997-2011. Mean healthcare costs per person in their LML were US $8042 ± 3477 in the HC group and US $1407 ± 1464 in the non-HC group (p < 0.001). For patients receiving aggressive end-of-life (EOL) cancer care (e.g. intensive care, cardiopulmonary resuscitation, anticancer treatment, and a high number of admission days), comorbidities of chronic kidney disease, esophageal bleeding, and receiving opioids in the LML, were significantly independent positive predictors of HCs; but admission times, comorbidities of ascites, and hypertension were negative predictors. CONCLUSION: These findings could inform healthcare providers by avoiding aggressive treatments during EOL for elderly patients with liver cancer and to save on healthcare costs. Shorter admission days and more admission times in the last month of life could decrease healthcare costs.

Association of Paroxysmal Supraventricular Tachycardia with Ischemic Stroke: A National Case-Control Study.

BACKGROUND AND PURPOSE: Cardioembolic stroke accounts for approximately 15%-20% of all ischemic strokes. Atrial fibrillation constitutes one-half to two-thirds of all cardioembolic stroke events. The association of paroxysmal supraventricular tachycardia (PSVT) with ischemic stroke remains unclear. A national case-control study was conducted to identify the risk factors, including PSVT, for ischemic stroke in Taiwan. METHODS: We designed a national case-control study comprising patients diagnosed with ischemic stroke (n = 5633) from 1997 to 2011; each patient from the case group was randomly matched with the control group (n = 30,895) in Taiwan. Data were retrospectively collected from Taiwan's National Health Insurance Research Database, which contains not only claims data on hospitalization, emergency room visits, and outpatient department visits, but also patient characteristics. RESULTS: Logistic regression analysis was used to identify the risk factors for ischemic stroke. Independent risk factors for ischemic stroke included age (in 5-year intervals; odds ratio [OR], 1.76; 95% confidence interval [CI], 173-1.78), the male sex (versus the female sex; OR, 1.88; 95% CI, 1.74-2.01), chronic kidney disease (OR, 3.09; 95% CI, 2.67-3.57), PSVT (OR, 2.05; 95% CI, 1.30-3.19), and aspirin use (OR, .04; 95% CI, .03-0.05). CONCLUSIONS: Our study is the first in Taiwan to identify PSVT as a significant risk factor for ischemic stroke. New antithrombotic regimens, including aspirin, can be recommended for the primary prevention of stroke and for reducing the burden of stroke for patients with PSVT.

Higher blood aldosterone level in metabolic syndrome is independently related to adiposity and fasting plasma glucose.

BACKGROUND: Hypoadiponectinemia is a well-known state associated with metabolic syndrome (MetS) and insulin resistance (IR). Recently aldosterone has been highly associated with high blood pressure, and may thus be a possible biomarker for MetS and IR. In this study, we investigate the association of aldosterone with MetS and IR, and compare it with that of adiponectin. METHODS: In this cross-sectional study, we recruited 556 women receiving physical examinations at a general hospital in central Taiwan. At the time of examination, we collected data on various demographic and physical characteristics and measured blood levels of aldosterone, adiponectin and a variety of metabolic factors. Multiple linear regression analysis was performed using adiponectin or aldosterone as the dependent variables. RESULTS: We found an inverse correlation between blood adiponectin and aldosterone (γ = -0.11, P = 0.009). Adiponectin levels were lower and aldosterone levels higher in women with MetS that those without (8.1 ± 0.4 vs. 11.5 ± 0.2 µg/mL, P < 0.001 and 691 ± 50 vs. 560 ± 11 pmol/L, P = 0.013, respectively), as they were in women with and without IR (adiponectin 10.4 ± 0.5 vs. 11.3 ± 0.2 µg/mL, P = 0.003 and aldosterone 635 ± 31 vs. 560 ± 11 pmol/L, P = 0.022). Although aldosterone was significantly related to body fat %, fasting plasma glucose and serum creatinine levels, the relationship between adiponectin and aldosterone was not obvious after adjustment in the multivariate analysis. CONCLUSION: Although aldosterone was related to metabolic factors, including body fat % and fasting plasma glucose in our female subjects, the relationship between aldosterone and adiponectin remains unclear.

The impact of hospice care on survival and cost saving among patients with liver cancer: a national longitudinal population-based study in Taiwan.

PURPOSE: The aim of this study was to compare health-care expenditures and survival of these terminally ill patients receiving or not receiving hospice care in their last month of life. METHODS: Using Taiwan's National Health Insurance Claims Database, we analyzed hospitalizations, OPD visits, associated costs, and survival. Logistic regression was used to identify predictors of high cost. RESULTS: We identified 3850 liver cancer patients who died during the 1997-2011 study period, 644 (16.6 %) of whom were hospice care patients. No significant difference was found in mean survival time between the hospice and non-hospice groups (1.77 ± 2.44 vs. 1.84 ± 2.37 years, p = 0.217). The mean health-care expenditures per person were US$2370 ± 3421 and US$2072 ± 1900 (p = 0.130). A total of 385 patients (10 %) received high-cost care (above US$5422) using 38.6 % of the total health-care expenditures spent on the entire population. The significant predictors of high costs were non-hospice care [odds ratio (OR) = 3.06, 95 % confidence interval (CI) 2.09-4.60], days of admission [risk increase per admission day being (OR = 1.19, 95 % CI 1.17-1.21)], admission into an intensive care unit (OR = 3.17, 95 % CI 1.94 to 5.15), use of ventilator (OR = 3.54, 95 % CI 1.91-6.52), cancer therapy (OR = 1.82, 95 % CI 1.33-2.48), hemodialysis (OR = 2.62, 95 % CI 1.07-6.02), and higher socioeconomic status (OR = 1.65, 95 % CI 1.10-2.45). CONCLUSION: Hospice care did not significantly affect survival, and hospice patients had lower per-patient expenditures and were less likely to require high-cost medical care than their non-hospice counterparts.

Effect of hospice care on quality indicators of end-of-life care among patients with liver cancer: a national longitudinal population-based study in Taiwan 2000-2011.

BACKGROUND: Quality of near end-of-life (EOL) care is typically evaluated using six accepted quality indicators (QIs). Research has yet to evaluate the quality of EOL care for liver cancer patients in Taiwan. We evaluated the effect of hospice care on the quality of EOL care for patients with advanced liver cancer. METHODS: Using claims data obtained from the Taiwan National Health Insurance Research Database, we analyzed the QIs of EOL care for patients who died between 2000 and 2011. Logistic regression was performed to identify predictors for QIs of EOL care. RESULTS: A total of 3092 adult patients died of liver cancer during the study period. The patients were divided into those who received hospice care for a period longer than 1 month (long-H group), shorter than 1 month (short-H group), and not at all (non-H group). There was no significant difference in survival probability among the three groups (p = 0.212). Compared with the non-H group, the long- and short-H groups exhibited a significantly lower risk of being admitted to an intensive care unit (ICU) (odds ratios [ORs] = 0.25 and 0.26, respectively, p < 0.001) and requiring cardiopulmonary resuscitation (CPR) during the final month of life (ORs = 0.21 and 0.09, respectively, p < 0.001). Compared with the non-H group, the short-H group had a higher risk of more than one emergency room (ER) visit, and more than one hospital admission (OR = 1.97, p = 0.003; and OR = 1.56, p = 0.001, respectively), but the long-H group did not differed significantly from the non-H group on these measures. CONCLUSIONS: Patients with liver cancer who received hospice care were less likely to be admitted to ICUs or require CPR compared with those who received no hospice care. A longer duration of hospice care was associated with reduced risks of more than one ER visit and more than one hospital admission. We conclude that EOL cancer care in Taiwan might be improved by implementing policies encouraging early hospice referral programs.

Development of a User-Friendly Graphic Tool to Estimate Individualized Survival Curves for Advanced Cancer Patients in Hospice Care.

This prospective study aimed to develop an individualized prognostic tool for predicting the survival probability at any given point for a hospice patient with advanced cancer. A total of 286 patients with advanced cancer were included in the study. Median observational time was 18 days (range: 1 to 60 days). Cox proportional hazards regression analysis revealed that faster heart rate (hazard ratio [HR] = 1.01), jaundice (HR = 2.32), poorer performance status (HR = 2.01), and antifungal treatment (HR = 1.62) were independent predictors of shorter survival time. Patients with infections who received aminoglycoside treatments (HR = 0.45) were associated with longer survival times. Based on this model, we could construct a covariate-adjusted individualized survival curve for a given patient according to his or her clinical condition. This user-friendly tool for estimating the survival probability of patients with advanced cancer in hospice settings could facilitate clinical decision making and medical care planning.

Prediction of patient survival by change in daily opioid dosage in advanced cancer patients: a prospective hospital-based epidemiologic study.

OBJECTIVE: Pain control helps improve quality of life for advanced cancer patients, yet it is unknown whether opioid use increases risk of death. Analyzing the association between time-varying pain medication and the risk of death presents a challenge. This prospective observational study examined the predictability of the patients' survival by variations of daily opioid dosage during the last few days of life. METHODS: Of the 231 cancer patients admitted to a hospice ward between July 2007 and June 2008 was conducted using Cox's model and adjusting for the effects of demography, clinical symptoms/signs, intravenous fluid supplements, antibiotics use and laboratory tests. RESULTS: We found a 3-day negative slope in daily oral morphine equivalent 1 day before each death event to be an independently significant predictor of short time to death (hazard ratio = 1.55; 95% confidence interval: 1.06-2.27). The other significant predictors including faster heart-rate (hazard ratio = 1.01, 95% confidence interval: 1.00-1.02), comorbidity with diabetes (hazard ratio = 1.57, 95% confidence interval: 1.00-2.47), Eastern Cooperative Oncology Group with performance status of 3 or 4 (hazard ratio = 1.78, 95% confidence interval: 1.23-2.58), jaundice (hazard ratio = 2.01, 95% confidence interval: 1.29-3.15), hypercalcemia (hazard ratio = 2.05, 95% confidence interval: 1.40-3.00) and higher serum creatinine level (hazard ratio = 1.36, 95% confidence interval: 1.18-1.57), but use first generation of cephalosporin was a negative predictor of short time to death (hazard ratio = 0.44, 95% confidence interval: 0.28-0.68). CONCLUSION: A reduction of daily oral morphine equivalent over three consecutive days suggests worsening physical condition significantly and independently predicting imminent death ∼1 day later.

Factors Associated with Hospitalized Community-Acquired Pneumonia among Elderly Patients Receiving Home-Based Care.

(1) Background: Pneumonia stands as a prevalent infectious disease globally, contributing significantly to mortality and morbidity rates. In Taiwan, pneumonia ranks as the third leading cause of death, particularly affecting the elderly population (92%). This study aims to investigate factors associated with community-acquired pneumonia (CAP) among elderly individuals receiving home-based care. (2) Methods: Conducted between January 2018 and December 2019, this retrospective study involved a medical chart review of elderly patients under home-based care. A multiple logistic regression model was employed to identify factors associated with CAP in this demographic. (3) Results: Analysis encompassed 220 elderly patients with an average age of 82.0 ± 1.1 years. Eighty-five patients (38.6%) were hospitalized for CAP. Predominant diagnoses included cancer (32.3%), stroke (24.5%), and dementia (23.6%). Significant predictors of CAP for elderly patients under home-based care included male gender (odds ratio [OR] = 4.10, 95% confidence interval [CI]: 1.95-8.60, p < 0.001), presence of a nasogastric (NG) tube (OR = 8.85, 95% CI: 3.64-21.56, p < 0.001), and a borderline negative association with the use of proton pump inhibitors (PPIs) (OR = 0.37, 95% CI: 0.13-1.02, p = 0.0546). End-of-life care indicators for these patients with CAP included an increased number of hospital admission days in the last month of life (OR = 1.13, 95% CI: 1.08-1.18, p < 0.001) and a higher likelihood of hospital death (OR = 3.59, 95% CI: 1.51-8.55, p = 0.004). (4) Conclusions: In the current study, significant predictors of CAP among elderly patients receiving home-based care included the presence of an NG tube and male gender, while the use of PPIs was borderline inversely associated with the risk of CAP. Notably, more admission days in the last month of life and death in the hospital were found to be associated with end-of-life care for this group.

Exercise Effects on Autonomic Nervous System Activity in Type 2 Diabetes Mellitus Patients over Time: A Meta-Regression Study.

BACKGROUND: Diabetic autonomic neuropathy is a common complication of type 2 diabetes mellitus (T2DM), especially in patients with long-term, poorly controlled diabetes. This study investigates the effects of exercise on autonomic nervous system activity in T2DM patients over time. METHODS: A literature review using MEDLINE, Embase, Cochrane Library, Scopus, and PubMed identified studies assessed via heart rate variability. Papers were categorized into three groups: immediate effects (within 60 min), short-term effects (2-3 months), and long-term effects (over 4 months). RESULTS: Nine articles with 161 T2DM patients were included in the meta-analysis. RMSSD changes after exercise were -4.3 (p = 0.227), 8.14 (p < 0.001), and 4.17 (p = 0.002) for the immediate, short-term, and long-term groups, respectively. LF/HF ratio changes were 0.21 (p = 0.264), -3.04 (p = 0.102), and -0.05 (p = 0.006) for the respective groups. Meta-regression indicated age, male gender, and exercise duration were associated with increased RMSSD, with coefficients of 2.36 (p = 0.001), 13.76 (p = 0.008), and 1.50 (p = 0.007), respectively. Age positively correlated with the LF/HF ratio, with a coefficient of 0.049 (p = 0.048). CONCLUSIONS: Regular exercise (≥3 times per week) for over 2 months increases parasympathetic activity in T2DM patients, while sympathetic activity decreases significantly after 4 months. Further study is needed to validate these findings.

Oscillation of Sympathetic Activity in Patients with Obstructive Sleep Apnea during the First Hour of Sleep.

(1) Background: Snoring is a cardinal symptom of obstructive sleep apnea (OSA) and has been suggested to potentially increase sympathetic activity. On the other hand, sleep itself usually leads to a decrease in sympathetic activity. Heart rate variability (HRV) analysis is a non-invasive technique used to assess autonomic nervous system function. However, there is limited research on the combined impact of sleep and snoring on sympathetic activity in individuals with OSA, particularly during the first hour of sleep (non-rapid eye movement sleep). The current study aims to investigate the net effect of sleep and snoring on sympathetic activity and explore factors that might contribute to increased sympathetic activity in individuals with OSA during the first hour of sleep. (2) Methods: The participants were referred from the outpatient department for OSA diagnosis and underwent whole-night polysomnography (PSG). Electrocardiogram (EKG) data from the PSG were downloaded for HRV analysis. HRV measurements were conducted in both the time and frequency domain, including the root mean square of successive differences between normal heartbeats (RMSSD) and the ratio of the absolute power of the low-frequency (LF) band (0.04-0.15 Hz) to the absolute power of the high-frequency (HF) band (0.15-0.4 Hz) (LF/HF ratio), respectively. (3) Results: A total of 45 participants (38 men and 7 women) were included in the analysis. The RMSSD gradually increased from 0-5 min to 50-60 min (p = 0.024), while the LF/HF ratio decreased (p < 0.001) during the first hour of sleep (non-rapid eye movement sleep). The LF/HF ratios of the "S" (snoring) episodes were compared with those of the pre-S episodes. An elevated LF/HF ratio during the S episode was associated with the first snoring episode occurring more than 20 min after lying down to sleep (Odds ratio, OR = 10.9, p = 0.004) and with patients diagnosed with severe OSA (OR = 5.01, p = 0.045), as determined by logistic regression. (4) Conclusions: The study observed an increase in the value of RMSSD and a decrease in the value of the LF/HF ratio during the first hour of sleep for patients with OSA. Higher LF/HF ratios were associated with the first occurrence of snoring while lying down for more than 20 min and with patients with severe OSA.

Lipid accumulation product: a simple and accurate index for predicting metabolic syndrome in Taiwanese people aged 50 and over.

BACKGROUND: Lipid accumulation product (LAP) has been advocated as a simple clinical indicator of metabolic syndrome (MS). However, no studies have evaluated the accuracy of LAP in predicting MS in Taiwanese adults. The aim of our investigation was to use LAP to predict MS in Taiwanese adults. METHODS: Taiwanese adults aged 50 years and over (n = 513) were recruited from a physical examination center at a regional hospital in southern Taiwan. MS was defined according to the MS criteria for Taiwanese people. LAP was calculated as (waist circumference [cm] - 65) × (triglyceride concentration [mM]) for men, and (waist circumference [cm] - 58) × (triglyceride concentration [mM]) for women. Simple logistic regression and receiver-operating characteristic (ROC) analyses were conducted. RESULTS: The prevalence of MS was 19.5 and 21.5% for males and females, respectively. LAP showed the highest prediction accuracy among adiposity measures with an area under the ROC curve (AUC) of 0.901. This was significantly higher than the adiposity measure of waist-to-height ratio (AUC = 0.813). CONCLUSIONS: LAP was a simple and accurate predictor of MS in Taiwanese people aged 50 years and over. LAP had significantly higher predictability than other adiposity measures tested.

Association of sleep duration and insulin resistance in Taiwanese vegetarians.

BACKGROUND: Short sleep duration has been reported to associate with increased insulin resistance. However, no studies have investigated whether such association exists in vegetarians. The aim of this study was to investigate the association between sleep duration and insulin resistance in Taiwanese vegetarians. METHODS: A total of 1290 individuals were recruited from a regional hospital in south Taiwan during their regular routine physical examination. Only individuals who described themselves as Buddhist vegetarians were included in the study. Demographic information and clinical characteristics were collected and multiple logistic regression analysis was used to evaluate the association between sleep duration and insulin resistance. RESULTS: A total of 433 vegetarians were included in the study. Results from univariate logistic regression indicated that insulin resistance was significantly associated with male sex, greater waist circumference, higher triglyceride levels, lower high-density lipoprotein cholesterol levels, higher plasma creatinine levels, higher alanine transaminase levels, greater energy expenditure, and sleep duration of more than 8 hours per night. Multiple logistic regression revealed that insulin resistance was significantly and independently associated with sleep duration of more than 8 hours per night (odd ratios = 2.27, 95% confidence interval = 1.24, 4.11) after adjusting for waist circumference and levels of alanine transaminase. CONCLUSIONS: Sleep duration of more than 8 hours per night is an independent risk factor associated with increased insulin resistance in vegetarians.

Factors associated with death places among elderly patients receiving home-based care.

The quality of end-of-life (EOL) care for patients receiving home-based care is a critical issue for health care providers. Dying in a preferred place is recognized as a key EOL care quality indicator. We explore the factors associated with death at home or nursing facilities among elderly patients receiving home-based care. This retrospective study was based on a medical chart review between January 2018 and December 2019 of elderly patients. Multivariate analysis was conducted by fitting multiple logistic regression models with the stepwise variable selection procedure to explore the associated factors. The 205 elderly patients receiving home-based care were enrolled for analysis. The mean participant age was 84.2 ± 7.8 years. Multiple logistic regression indicated that significant factors for elderly home-based patients who died at home or nursing facilities were receiving palliative service (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.37-7.51; P = .007), symptoms of nausea or vomiting (OR, 5.38; 95% CI, 1.12-25.84; P = .036), fewer emergency department visits (OR, 0.07; 95% CI, 0.03-0.16; P < .001), and less intravenous third-generation cephalosporin use (OR, 0.15; 95% CI, 0.03-0.75; P = .021) in the last month of life. Patients with dementia had a lower probability of dying at home or nursing facilities than patients with other diagnosis (OR, 0.34, 95% CI, 0.13-0.90; P = .030). Among elderly home-based patients, receiving palliative service, with nausea or vomiting, and fewer emergency department visits in the last month of life favored home or nursing facilities deaths. Practitioners should be aware of the factors with higher probabilities of dying at home and in nursing facilities. We suggested that palliative services need to be further developed and extended to ensure that patients with dementia can receive adequate EOL care at home and in nursing facilities.