An evidence-based checklist for the postoperative management of obstructive sleep apnea.

Obstructive sleep apnea (OSA) can present significant challenges in providing postoperative care. OSA policies have been developed and are in place within many facilities; however, a standard OSA protocol ensuring the safe delivery of postoperative care has not been universally accepted into practice. A synthesis of current OSA literature led to the development of a comprehensive evidence-based checklist to improve patient safety and direct the management of postoperative care for diagnosed or suspected OSA patients throughout their hospitalization. The checklist describes interventions for providing care in the immediate postoperative phase and sleep-specific interventions. These interventions include guidelines for postoperative assessment, continuous monitoring, extubation readiness, pain management, sleep positioning, respiratory monitoring, and continuous positive airway pressure therapy. The implementation of this checklist with the synergistic effect of the combined interventions may lead to a greater improvement in the care, safety, satisfaction, and clinical outcomes of OSA patients.

Ischemic stroke in South Asians: a review of the epidemiology, pathophysiology, and ethnicity-related clinical features.

BACKGROUND AND PURPOSE: Within the United Kingdom, mortality from stroke is higher among South Asians compared to European whites. The reasons for this excess cerebrovascular risk in South Asians remain unclear. The aim of this review is to present a comprehensive and systematic overview of the available literature relating to ischemic stroke among South Asian populations identifying distinct features of stroke epidemiology in this group. SUMMARY OF REVIEW: A high frequency of lacunar strokes is a familiar pattern among South Asians, which suggests a greater prevalence of small-vessel disease in South Asians. This may be a consequence of abnormal metabolic and glycemic processes. In addition, stroke mortality among South Asians appears to be explained by glycemic status, which is an independent predictor of long-term stroke mortality. Within India, there is a perceptible rural-urban gradient in stroke prevalence, underlying the dangers of the rapid transition in socioeconomic circumstances seen across the Indian subcontinent. CONCLUSIONS: This review emphasizes the importance of further research into ischemic stroke for South Asians given their higher cardiovascular disease burden and necessity for targeted healthcare approaches.

Glycemic status underlies increased arterial stiffness and impaired endothelial function in migrant South Asian stroke survivors compared to European Caucasians: pathophysiological insights from the West Birmingham Stroke Project.

BACKGROUND: The pathophysiology of an increased risk of cerebrovascular disease mortality among South Asians (SA) remains unclear. Indices of arterial stiffness and endothelial dysfunction are independent markers of vascular disease, having both prognostic and diagnostic implications. We hypothesized that there are ethnic variations in indices of arterial stiffness and endothelial dysfunction between SA and European Caucasian (EC) stroke patients, which may underline a poorer prognosis in the former, and further investigated promoters of vessel wall abnormalities. METHODS: Using a cross-sectional approach, a total of 100 SA stroke survivors were prospectively recruited from the ongoing West Birmingham Stroke Project. Indices of vessel wall characteristics (arterial stiffness and endothelial function [change in reflective index]) were measured noninvasively using the digital volume pulse analysis technique in a temperature-controlled environment, using a direct standardized approach. SA stroke subjects were compared to 60 EC stroke survivors, 60 SA with risk factors, and 73 healthy controls. RESULTS: Among stroke patients, both ethnic groups were comparable for cardiovascular risk profile, except for more diabetes mellitus in SA (P=0.007) subjects and a higher prevalence of atrial fibrillation in EC (P=0.04) subjects. According to the TOAST and Bamford classifications, SA subjects had more small vessel (P=0.04) and lacunar infarctions (P=0.01). SA subjects had higher measurements of arterial stiffness (P<0.001) and impaired endothelial-dependent vascular function (change in reflective index %; P<0.001). On univariate analysis, endothelial function was negatively correlated with fasting plasma glucose (r=-0.4; P<0.001) and total cholesterol level (r=-0.2; P<0.001). On multivariate analysis, glycemic status was independently associated with impaired endothelial function (P=0.008) and increased arterial stiffness (P<0.001) among SA subjects. CONCLUSIONS: SA stroke survivors had more small vessel disease-related cerebrovascular events compared to EC subjects. Underlying glycemic status in SA subjects had an adverse impact on the vascular system, leading to abnormal vessel wall characteristics.

Impact of mean arterial blood pressure on higher arterial stiffness indices in South Asians compared to white Europeans.

BACKGROUND: The pathophysiology of excessive premature coronary heart disease mortality among South Asians living in Britain remains unclear. We hypothesized that higher measures of arterial stiffness among South Asians compared with their white European counterparts would reflect an earlier progression of atherosclerosis, even in the absence of established coronary heart disease risk indices. METHODS: Arterial stiffness was measured by digital volume pulse photoplethysmography in 90 healthy South Asians and compared with 62 matched white Europeans in a temperature-controlled environment using a direct, standardized approach. RESULTS: Both ethnic groups were comparable for coronary heart disease risk profiles and had similar 10-year coronary heart disease risk estimates, but South Asians had a greater mean (SD) stiffness index compared with white Europeans [9.39 (0.22) vs. 8.43 (0.23) m/s; P = 0.007]. On linear regression analysis, mean arterial blood pressure (beta = 0.06; P = 0.03) and age (beta = 0.11; P = 0.002) were independent predictors of arterial stiffness in South Asians. Among white Europeans, age was an independent predictor of arterial stiffness (beta = 0.05; P = 0.01). CONCLUSION: Healthy South Asians have increased systemic arterial stiffness measured by stiffness index compared with white Europeans. There was an adverse and disproportional impact of age and mean arterial pressure on the vascular system in South Asians. Increased indices of arterial stiffness may explain their increased susceptibility to coronary heart disease.

Is the higher risk of cardiovascular disease amongst South Asian populations linked to abnormalities of haemoglobin? A preliminary case control study.

The elevated burden of cardiovascular disease (CVD) amongst South Asian populations is a complex and multi-factorial phenomenon. South Asians evolved from environments where malaria was endemic, and while haemoglobin disorders frequent this group, a link to CVD has not been described. Using a case-control feasibility study, haemoglobin abnormalities identified by mass spectrometry were compared between South Asian patients with CVD (n = 72) and non-CVD controls (n = 84). Carotid-artery intima media thickness (CIMT) was used as a marker of vascular damage. Ultracentrifugation was used to separate lipoprotein subfractions, which were analysed for iron. Haemoglobin anomalies were more frequent for CVD patients than controls (34.7% vs. 14.3%, P < 0.001), as were subfractionated lipoprotein concentrations of iron (P < 0.001). Patients with haemoglobin disorders had greater CIMT (0.75 vs. 0.65 mm, P = 0.008), and lower HDL cholesterol (0.78 vs. 1.03 mmol/l, P = 0.003). These preliminary data suggest that haemoglobin disorders contribute to atherosclerotic disease in South Asians and further research is warranted.