The utility of diaphragm ultrasound thickening indices for assessing respiratory decompensation in amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Amyotrophic lateral sclerosis (ALS) leads to diaphragmatic weakness at some point during its course, which is a major cause of respiratory insufficiency. The aim of this study was to evaluate ultrasound-based measures for assessing the diaphragmatic competency and the need for ventilatory support. METHODS: Twenty-six subjects with ALS and 12 healthy controls were enrolled. All participants underwent B-mode diaphragm ultrasound (DUS). Diaphragm thickness and thickening indices were recorded. In the subjects with ALS, further assessments included functional scales and spirometry. We investigated the diagnostic accuracy of DUS thickening indices in predicting diaphragmatic dysfunction and the correlation between clinical, spirometric, and DUS data. RESULTS: Significant relationships were found between forced vital capacity and all diaphragmatic thickening indices. Similarly, all diaphragmatic thickening indices correlated with both Milano Torino staging and disease progression rate. Only thickening fraction (TFdi) correlated with score on the revised ALS Functional Rating Scale (r = 0.459, P = .024). TFdi had better accuracy in predicting diaphragmatic dysfunction (area under the curve [AUC] = 0.839, 95% confidence interval [CI] 0.643 to 0.953) and the need for initiation of noninvasive ventilation (NIV) (AUC = 0.989, 95% CI 0.847 to 1.000) compared with the other indices. A TFdi cut-off point of 0.50 was a sensitive threshold to consider NIV. DISCUSSION: DUS successfully identifies diaphragmatic dysfunction in ALS, being a valuable accessory modality for investigating respiratory symptoms. TFdi was found to be the most useful DUS index, which encourages further investigation.

The Presence of Smoking and Alcohol Imaginary in Popular Movies Available in Netflix Online Streaming Platform.

Exposure of tobacco and alcohol consumption in media and filmmaking has been related to promotion of smoking and drinking in adults. Current regulation aims to restrict tobacco and alcohol advertising in order to avoid alcohol consumption and smoking habits. We aimed to assess the impact of smoking and drinking habits in video-on-demand services. Three independent investigators watched the 50 most popular movies available in Netflix streaming platform, according to York Times and recorded incidence of smoking and drinking scenes for both primary and secondary actors. 45 movies were included in our analysis. Main characters appeared to smoke in 19 movies and to consume alcohol in 33 movies, while secondary characters in 32 movies with 121 scenes and consumed alcohol in 38 movies, respectively. First actors were males in 22 movies, females in 7 movies and both males and females in 6 movies. Movies' directors were males in 29 movies and females in 6 movies. Our analysis found increased content of smoking and drinking scenes in online movies and showed that recently released movies presented with increased incidence of drinking and smoking scenes, while era depicted in movies also affects smoking and drinking content.

EBUS: Faster, cheaper and most effective in lung cancer staging.

The use of endobronchial ultrasound trans-bronchial needle aspiration (EBUS-TBNA) as the initial diagnostic and staging procedure in patients with suspected, non-metastatic lung cancer has gained substantial support, and is now recommended by numerous guidelines. Whereas considerable attention has been pointed to the reductions in costs achieved by EBUS-TBNA, that has not been the case for some of its more significant benefits, namely the reduction of the diagnostic work-up time and its ability to accurately assess and restage lymph nodes, which were previously stated incorrectly by CT or PET scan. Both these benefits translate into improved outcomes for patients, as delays are reduced, futile surgeries are prevented and curable operations can be performed on patients previously excluded by CT or PET scan. Indeed, the use of EBUS as the initial diagnostic and staging procedure has been proven to significantly increase survival, compared with conventional diagnostic and staging procedures, in a pragmatic, randomised controlled trial (Navani N. et al, 2015). The instalment of EBUS will have the greatest effect on overwhelmed, suboptimally functioning national healthcare systems, by decreasing the number of required diagnostic and staging procedures, therefore reducing both treatment delays and costs. The improved selection of surgical candidates by EBUS will result in improved patient outcomes. The latest findings regarding the benefits of EBUS are outlined in this review, which, to the best of our knowledge, is the first to emphasise the impact of the procedure, both on timing and costs of lung cancer staging, as well as on survival.

Computed tomography cephalometric and upper airway measurements in patients with OSA and erectile dysfunction.

PURPOSE: Erectile dysfunction (ED) has been linked to obstructive sleep apnea (OSA). This study used computed tomography (CT) to identify cephalometric and upper airway anatomic features in patients with OSA that correlate with the presence of ED. METHODS: In this prospective study, 20 CT cephalometric and upper airway measurements, most commonly associated with OSA, were analyzed in 53 age- and BMI-matched consecutive eligible subjects. Twenty-two were diagnosed with OSA and ED (OSA+/ED+), 17 with OSA without ED (OSA+/ED-), and 14 without OSA and ED (OSA-/ED-) serving as a control group. RESULTS: Although OSA+/ED+ did not differentiate significantly in CT measurements from OSA+/ED-, they showed more alterations when compared to OSA-/ED-, which included narrower bony oropharynx, longer soft palate and uvula (PNS-P), and narrower retropalatal and retrolingual airway diameter (p < 0.05). Binary forward stepwise model analysis showed that PNS-P was the only significant variable in the predictive model for ED in patients with OSA (OR = 1.129, 95 % CI = 1.0005-1.268, p = 0.041). In the OSA+/ED+ group, PNS-P correlated with the percentage of total sleep time with oxygen saturation <90 % (r = 0.61, p < 0.01) and was the only determinant in the relevant predictive model (n = 22, model R = 0.612, adjusted R (2) = 0.337, F = 10.167, p < 0.005). CONCLUSIONS: Characteristics of the craniofacial and upper airway structures suggest that a longer soft palate and uvula may be important risk factors for the concurrence of ED in patients with OSA. Only OSA+/ED+ showed significant narrowing in the retropalatal, retrolingual, and bony oropharynx level when compared with BMI-matched OSA-/ED-.

"The Saint" gone good. Smoking and drinking over time in the popular series.

BACKGROUND: Alcohol-related health and social problems are prevalent in almost all societies that consume alcohol and the presence of alcohol use in the movies is a known issue. The same holds true for smoking prevalence in film-making. OBJECTIVES: The aim of this study is to assess tobacco-related content and alcohol consumption in "The Saint" series and movies. METHODS: Five episodes from each "The Saint" TV series, from the '60s, were randomly selected. A predefined template was used for data collection and multiple variables were recorded and then analyzed. RESULTS: The main character was reported to smoke in 81.9% of episodes and consume alcohol in 87.1% episodes and similar were the results for supporting actors. Mean time to first cigarette and first drink ranged from 0.5 to 40 minutes and from 0.5 to 40.5 minutes, respectively. CONCLUSION: The prevalence of smoking and drinking in "The Saint" movies is high on average; however, the main character has ceased smoking and reduced alcohol consumption in the two contemporary movies, probably following the changes in the era and respecting the law.

Cardiopulmonary exercise testing in people with minimally impaired multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is a chronic demyelinating inflammatory disorder of the central nervous system that may affect respiratory system at the later stages of the disease. The aim of our study was to evaluate respiratory function and cardiopulmonary exercise testing in ambulatory without aid people with MS (pwMS), and to investigate quality of life parameters and fatigue in this population. METHODS: 25 pwMS and 16 healthy controls were included in this study. Pulmonary function tests were performed and were followed by proper cardiopulmonary exercise testing with the use of treadmill. Quality of life assessment was done with SF-36 questionnaire. RESULTS: The mean age of the patient group was 38.4 ± 8.2 years. Spirometric values were within normal limits, and so did lung diffusion capacity, while maximal voluntary ventilation was reduced. In cardiopulmonary exercise testing the patient group showed impairment compared to control group. The statistically significant lower parameters were V'O2 peak, V'CO2 peak, RER, V'O2/kg peak, V'CO2/kg peak, oxygen pulse peak and V'E/V'CO2 slope. Moreover, there was a negative and statistically significant correlation between CPET values and BMI and MFIS, while there was a positive and statistically significant correlation with quality of life, evaluated by SF-36. CONCLUSION: Our study showed that the main cardiopulmonary exercise testing parameters were affected in ambulatory pwMS, even without evidence of respiratory symptoms. Therefore, these people should be evaluated for pulmonary function compromise.

Exercise Limitation in Children and Adolescents with Mild-to-Moderate Asthma.

BACKGROUND: Children with uncontrolled asthma are less tolerant to exercise due to ventilatory limitation, exercise-induced bronchoconstriction (EIB), or physical deconditioning. The contribution of these factors in children with controlled mild-to-moderate asthma is unknown. OBJECTIVE: To explore the underlying mechanisms of reduced exercise capacity in children with controlled mild-to-moderate asthma. METHODS: This was a cross-sectional study of 45 children and adolescents (age 8-18 years) with controlled mild-to-moderate asthma (asthma control test score 21-25) and 61 age-matched healthy controls. All participants completed a physical activity questionnaire and performed spirometry and cardiopulmonary exercise testing (CPET; maximal incremental protocol). Spirometric indices and CPET parameters were compared between the two groups. The effect of EIB (FEV1 decrease >10% post CPET), ventilatory limitation and physical deconditioning on maximum oxygen uptake (O2peak), was assessed by multivariable linear regression. RESULTS: 62.2% of children with asthma and 29.5% of controls (P = 0.002) were categorized as inactive. Reduced exercise capacity (O2peak <80%) was noted in 53.3% of asthmatics and 16.4% of controls (P < 0.001). EIB was documented in 11.1% of participants with asthma. Physical deconditioning was noted in 37.8% of children with asthma and in 14.8% of controls (P = 0.013). Physical deconditioning emerged as the only significant determinant of O2peak, irrespective of asthma diagnosis, body mass index, ventilatory limitation and EIB. CONCLUSION: Children with controlled mild-to-moderate asthma are less tolerant to strenuous exercise than their healthy peers. The decreased exercise capacity in this population should mainly be attributed to physical deconditioning, while the contribution of ventilatory limitation and EIB is rather small.

Shifting gears: Study of immune system parameters of male habitual marathon runners.

Aim: Marathon is a running event in which athletes must cover a distance of 42.195 km. In addition to participating in marathons, marathoners have incorporated extensive running into their lifestyle. In the present study, we investigated the effect of long-term strenuous exercise in the form of marathon running on the immune system. Methods & Results: We collected peripheral blood samples from 37 male marathoners before/after a race and 37 age/sex/body mass index (BMI)-matched healthy sedentary controls. Hematological and biochemical tests revealed race-induced leukocytosis attributable to neutrophilia and significant increases in plasma lactate dehydrogenase (LDH), creatine phosphokinase (CPK), and cortisol concentrations. Phenotypic analysis of lymphocytes revealed race-induced significant decrease in the number of lymphocytes, memory helper T (Th) cells, naive, memory and activated cytotoxic T (Tc) cells, natural killer (NK), NKT, and B1 cells, and a significant increase in the number of activated Th and regulatory Th cells (Tregs). Compared with controls, marathoners maintained significantly lower levels of memory and activated Th cells and higher levels of activated Tc and B1 cells. Measurement of plasma cytokine levels revealed a pro-inflammatory cytokine polarization that increased after the race. Examination of gene expression of cytokines and Th-cell signature transcription factors in peripheral blood mononuclear cells revealed a significant decrease in tumor necrosis factor α (TNF-α) and interleukin (IL)-17, and a significant increase in IL-6, IL-10 and forkhead box P3 (FoxP3) after the race. Compared with controls, marathoners maintained significantly higher levels of TNF-α. Assessment of the suppressive capacity of Tregs in co-cultures of isolated effector Th cells and Tregs showed significantly increased suppressive capacity of marathoners' Tregs after the race. Conclusions: Compared with controls, marathoners live with permanent changes in certain immune parameters. Marathoners exhibit a stable pro-inflammatory cytokine polarization that increases after the race and is counterbalanced by increased numbers of Tregs overexpressing FoxP3 and having increased suppressive capacity.

The Role of Interleukin-6 in the Pathogenesis, Prognosis and Treatment of Severe COVID-19.

A newly identified virus appeared in Wuhan, China, in December 2019, was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and caused the coronavirus disease 2019 (COVID-19). SARS-CoV-2 presents similarities with two previous coronavirus pandemics, MERS (Middle East Respiratory Syndrome) and SARSCoV, concerning phylogenetic origin, structural composition, and clinical symptoms, thus, leading to common pathogenic mechanisms. The purpose of this review is to declare the role of interleukin-6 (IL-6) in the pathogenesis, prognosis, and treatment of COVID-19 by comparing its effect on SARS-CoV and MERS cases. Increased levels of IL-6 comprise the key for the stimulation of cytokine storm and the progression of SARS, MERS, and COVID-19 cases. Especially, in COVID-19 patients, the overactivation of NF-kΒ, which is caused by the binding of coronavirus spike protein S to alveolar epithelial cells, up-regulates IL-6 and promotes its systematic circulation, causing alveolar damage and extrapulmonary injury. Additionally, IL-6 can be used to evaluate respiratory failure and identify asymptomatic patients. Tocilizumab (TCZ), a monoclonal antibody which blocks IL-6 signaling, comprises a remedial option against COVID-19. TCZ improves oxygenation, reduces fever, and decreases levels of IL-6. IL-6 plays a major role in the pathogenesis of cytokine storm and the progression of COVID-19 and may be used as a therapeutic target against COVID-19. However, further research is needed concerning the relation of IL-6 in COVID-19 cases, and more clinical trials are required to declare TCZ as a treatment option.

Oesophageal atresia without major cardiovascular anomalies: Is management justified at a district paediatric surgical institution?

BACKGROUND: Oesophageal atresia lacks sufficiently documented treatment approach, as guidelines are based rather on the opinion of experts than on systematic data. We aimed to answer the question if treatment of patients without major cardiovascular anomalies could be justified at a peripheral paediatric surgical institution, by evaluating the outcome of surgical correction. METHODS: Thirty-three neonates underwent surgery for correction of oesophageal atresia during a period of 20 years. They were categorised into two time-period groups, to follow-up the evolution of surgical intervention and complications through time. Evaluation of post-operative outcome and morbidity was performed. The results were related to those of our recent cross-sectional study on families having experienced oesophageal atresia performed years after repair, regarding the long-term quality of life. RESULTS: A shift from staged to primary repair occurred throughout time in the patients with a marginal long gap between proximal and distal oesophagus (P = 0.008). Anastomotic stenosis was the major short-term complication encountered, treated with post-operative dilation sessions. Dysphagia and reflux were the most common long-term complications. CONCLUSIONS: Oesophageal atresia without severe cardiovascular abnormalities could be treated at a peripheral paediatric surgical department with satisfactory outcomes. However, qualified paediatric surgeons, anaesthesiologists and neonatologists and the availability of neonatal intensive care unit should be definitively required.

Tuberculosis of the parotid gland.

Tuberculosis (Tbc) presented as an isolated parotid mass is rare. Preoperative diagnosis is difficult and the symptomatology is nonspecific. In the majority of the cases an initial diagnosis of a parotid tumor, often a pleomorphic adenoma, is made. We present a 35-year old woman with a six months duration right parotid lump. The mass was firm and nontender without ipsilateral cervical lymphadenopathy, suggesting a parotid neoplasm. The computerized tomography scan showed an intraparotideal tumor resembling a pleomorphic adenoma and thus the patient underwent to a superficial parotidectomy. Fine needle aspiration biopsy was performed but it was not diagnostic. Histological examination revealed an intraparotideal lymph node with changes of granulomatous lymphadenopathy type, like those demonstrated in the tuberculosis and sarcoidosis. Ziehl-Nielsen staining was negative, while the tuberculin skin test (PPD, 5 IU) was positive. The patient's treatment regimen consisted of a 2-month initial phase of isoniazid, rifampin, pyrazinamide and ethambutol followed by a 7 month continuation phase of isoniazid and rifampin. Postoperatively, there was only a mild paresis of the facial nerve resolved a week after. Parotid Tbc is very rare but should be considered as a differential diagnosis of parotid lumps. Fine needle aspiration biopsy (FNAB) is of outmost importance for diagnosis, since the treatment of this entity is primarily conservative. However, surgery could be both therapeutic and diagnostic, especially when other diagnostic examinations fail.

Role and pharmacogenomics of TNF-alpha in asthma.

Asthma is a chronic heterogeneous inflammatory disease of the respiratory system in which numerous cytokines play a significant role. Among them TNF-alpha (tumour necrosis factor alpha), a proinflammatory cytokine, has a predominant role in orchestrating airway inflammation and affecting treatment outcome. In this review we attempt to summarize the involvement of TNF-alpha in the pathogenesis of asthma, illustrate variations of TNF-alpha gene that potentially influence asthma phenotype and highlight promising therapies by blocking the production of TNF-alpha or inhibiting its action. A cytokine specific target therapy seems to be very promising since agents that block TNF-alpha slow disease progression, suppress inflammation and in some cases induce remission of chronic inflammation.

Lung function measurements in traditional bakers.

BACKGROUND: Respiratory disease is common and amenable to early detection and management in the primary care setting. Spirometric and phlethysmographic evaluation of ventilatory function plays a critical role in the diagnosis, differentiation and management of respiratory illness such as asthma, chronic obstructive pulmonary disease and restrictive disorders. METHODS: Study subjects consisted of 58 workers in the production of bread and 45 salesclerks of bread from the same bakeries. The lung function of employees was checked using a spirometry and body phlethysmography, calculating the indexes Forced expiratory volume 1 sec (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, residual volume (RV), total lung capacity (TLC), and RV/TLC ratio. The percentage of the obstructive and the restrictive impairment both in the bread producers and sellers was also searched as well as the percentage of response in the bronchodilation. RESULTS: Bread producers recorded significantly lower mean lung functions compared with salesclerks, for FEV1, FVC and FEV1/FVC ratio, when observed values were expressed as percentages of predicted normal values. Furthermore the percentage of obstructive impairment among the bread producers was 12.6%, while a percentage of 20.68% of them presented a response in bronchodilation (while the percentage in salesclerks was 6.6% respectively). The percentage of restrictive impairment was similar in both groups (12.6% for bread producers and 11.1% for salesclerks). CONCLUSION: The study concluded that bread producers in traditional bakeries in Greece are at increased risk of developing airway obstruction compared with salesclerks of bread from the same bakeries. A different degree of smoking status and of wheat flour dust exposure may explain this difference. Technical preventive measures such as well ventilated work areas and appropriate respiratory protective devices should be adopted.

The alcoholic lung disease: historical background and clinical features.

SUMMARY: The purpose of this review article is to prove the damage that alcohol causes to the respiratory system. We will make a brief review of alcohols history in the course of the centuries till nowadays. The problem of addiction to alcohol (alcoholism) will be examined for several countries. Alcohol's metabolism is another topic to be discussed parallel to its pharmacological action. In addition, alcohol's impact on the respiratory system varies from damaging the mucociliary system to the regulation of breathing and from the sleep apnea syndrome to diffusion disorders. "Alcoholic lung disease" constitutes a syndrome despite the fact that the damage of the lung due to concurrent smoking and drug use is often indistinguishable.

Pulmonary alveolar microlithiasis in a patient with rheumatic valvular heart disease.

Pulmonary alveolar microlithiasis is a rare disease characterized by widespread intra-alveolar calcification of both lungs that is asymptomatic in the early stages. The disease typically follows a protracted course, and death can occur in 5 to 41 years after the initial diagnosis. Rheumatic fever is a multisystemic inflammatory disease that afflicts the child and juvenile population, and it is still very common in developing countries. Valve failure is the condition most linked to increased morbidity and mortality rates in this population and is the most severe complication of rheumatic fever, with consequent onset of chronic heart valve disease. We present a case of a female patient with a potential diagnosis of pulmonary alveolar microlithiasis with concurrent rheumatic valvular disease.

DNA sequence variations of metalloproteinases: their role in asthma and COPD.

Asthma and chronic obstructive pulmonary disease (COPD) are complex genetic diseases that cause considerable morbidity and mortality worldwide. Genetic variability interacting with environmental and ethnic factors is presumed to cause tobacco smoke susceptibility and to influence asthma severity. A disintegrin and metalloproteinase 33 (ADAM33) and matrix metalloproteinase-9 (MMP9) appear to have important roles in asthma and COPD pathogenesis. ADAM33 and MMP9 genetic alterations could possibly contribute to the establishment and progression of these multifactorial diseases, although their association with the clinical phenotypes has not yet been elucidated. However, the occurrence of these alterations does not always result in clear disease, implying that either they are an epiphenomenon or they are in proximity to the true causative alteration. This review summarises the most recent literature dealing with the genetic variations of metalloproteinases and outlines their potential pathogenetic outcome.

Aseptic femoral head necrosis in a patient receiving long term courses of inhaled and intranasal corticosteroids.

Aseptic (avascular) necrosis of the femoral head in adults has been associated with a variety of disease entities. It is also recognized as a potential complication of systemic corticosteroid therapy. Inhaled corticosteroids are the first line anti-inflammatory agents for the long term treatment of asthma. However, long term treatment of asthma with inhaled corticosteroids has been accompanied by concern about both systemic and topical side effects. The most worrying potential systemic effects are adrenal insufficiency, growth suppression, glaucoma and osteoporosis. Fluticasone proprionate may be prescribed at higher doses to relieve respiratory symptoms in the belief that it generates fewer side effects than other inhaled steroids. Studies have shown that fluticasone is safer than beclomethasone or budesonide, with limited oral absorption and extensive hepatic first pass metabolism leading to a lower systemic bioavailability. However growth retardation and asymptomatic adrenal suppression in children receiving high-dose fluticasone have been reported. We report a rare case of avascular osteonecrosis of the femoral head associated with the use of long term inhaled fluticasone propionate along with the intranasal application of triamcinolone acetonide.

Genetics of chronic obstructive pulmonary disease, beyond a1-antitrypsin deficiency.

It is known that only 10-20% of smokers develop COPD, implying that apart from environmental features, additional factors such as genetic variability contribute to smoke susceptibility. This proposal is in compatibility with the "Dutch Hypothesis", formulated in the early 60's. Alpha-1-antitrypsin gene was implicated in the pathogenesis of COPD, especially the homozygous state of z allele. Since then many other genes have stepped forward as possible contributors to COPD development. In the present review we attempt to summarize the majority of these, including the genes of matrix metalloproteinases and their inhibitors, elastin, serpine2, tumor necrosis factor - a, transforming growth factor beta, a variety of interleukins and their receptors and antagonists, high affinity IgE receptor , human calcium-activated chloride channel 1, heme oxygenase, vascular endothelial growth factor, microsomal epoxide hydrolase, glutathione S-transferase, cytochrome P45O, superoxide dismutase, vitamin D binding protein, beta2-adrenergic receptor, Toll like receptor, human B defensins, mucins, cystic fibrosis transmembrane regulator, surfactant protein and Nuclear Factor E2 Related Factor 2.

Derived Arterial Stiffness is Increased in Patients with Obstructive Sleep Apnea and Periodic Limb Movements during Sleep.

STUDY OBJECTIVES: Both periodic limb movements during sleep (PLMS) and obstructive sleep apnea (OSA) have been associated with increased risk of cardiovascular disease (CVD). OSA has also been linked to increased large arterial stiffness, which is considered an independent risk factor for CVD. We utilized a previously validated index of large artery stiffness (SIDVP) derived from the digital volume pulse (DVP) to seek comparison in patients with PLMS and OSA. METHODS: Forty-nine adult male subjects, without known comorbidities that could affect arterial stiffness or on vasoactive medication, were retrospectively identified and categorized into controls (n = 8), PLMS (n = 13), OSA (n = 17), and OSA/PLMS (n = 11). The cutoff for PLMS was a periodic limb movement index (PLMI) > 15 events/h, and for OSA an apnea-hypopnea index (AHI) > 10 events/h. SIDVP was derived from the raw data of photoplethysmography of the nocturnal polysomnography, averaged for 2 min prior to sleep study initiation (baseline), after completion in the morning, and every half hour after sleep onset. RESULTS: The groups were age/body mass index-matched. Controls showed lower baseline, morning, and overall SIDVP compared to the other groups (p < 0.01). Patients with PLMS (PLMI: 50.69 ± 9.7 events/h) and the OSA group (AHI: 29.7 ± 2 events/h) demonstrated similar overall SIDVP (6.78 ± 0.08 versus 6.94 ± 0.04, respectively, p = 0.5), whereas the OSA/PLMS (AHI: 29.35 ± 8, PLMI: 50.63 ± 7.2) group demonstrated the highest (7.40 ± 0.06, p < 0.001). CONCLUSIONS: Based on an easily reproducible and applicable marker of large arterial stiffness, patients with significant PLMS had higher SIDVP when compared to controls and comparable to those with moderate/severe OSA. The OSA/PLMS group had the highest SIDVP, implying a possible additive effect of OSA and PLMS on arterial stiffness.