Snoring severity is associated with carotid vascular remodeling in young adults with overweight and obesity.

BACKGROUND: Snoring is often used as a surrogate measure for obstructive sleep apnea (OSA), a sleep disorder associated with cardiovascular disease (CVD) risk. Whether snoring is linked to CVD independent of OSA remains unclear. We aimed to explore the snoring and subclinical CVD association in adults with and without OSA. METHODS: We conducted a cross-sectional study in 122 overweight/obese participants (24% male; mean age 40.1 years) attending the 24-month follow-up visit of a lifestyle intervention. Using home-based objective measures of sleep-disordered breathing, we stratified participants into 3 snoring/OSA categories using the snoring index (SI), a measure of snoring vibration, and oxygen desaturation index (ODI): (1) OSA (ODI ≥ 5), (2) non-OSA heavy snorer (ODI <5, above-median SI), and (3) non-OSA low snorer (ODI <5, below-median SI). Vascular measures including pulse wave velocity ([PWV]; carotid-femoral [cf], femoral-ankle [fa], brachial-ankle [ba]), carotid intima-media thickness (IMT), and carotid interadventitial diameter (IAD) were compared across snoring/OSA categories. Linear regressions assessed the association between snoring and subclinical CVD independent of traditional CVD risk factors. RESULTS: Compared to non-OSA low snorers, common carotid IMT and IAD were higher in non-OSA heavy snorers, and faPWV, IMT, and IAD were higher among those with OSA. The difference between non-OSA heavy snorers and low snorers persisted after adjusting for age, race, sex, blood pressure, body mass index, lipids, and insulin resistance (P < .05 for IMT and IAD). CONCLUSIONS: In overweight/obese young to middle-aged adults, objectively measured snoring was related to vascular remodeling in those without OSA. Snoring may contribute to CVD risk but warrants further examination in larger prospective cohorts.

Early Enteral Nutrition Is Associated With Significantly Lower Hospital Charges in Critically Ill Children.

BACKGROUND: Previous studies have shown that early enteral nutrition (EEN) is associated with lower mortality in critically ill children. The purpose of this study was to determine the association between EEN (provision of 25% of goal calories enterally over the first 48 hours) and pediatric intensive care unit (PICU) and hospital charges in critically ill children. METHODS: We conducted a supplementary study to our previous multicenter retrospective study of nutrition and outcomes in critically ill patients who had a PICU length of stay (LOS) ≥96 hours for the years 2007-2008. From 2 centers, we obtained additional data for all charges incurred during the PICU and hospital stay, respectively, from administrative data sets at each institution. RESULTS: We obtained data for 859 patients who met the inclusion criteria (615 from the first center and 244 from the second center). In the combined data from both centers, total (P = .0006, adjusted for Pediatric Index of Mortality-2 [PIM-2] and center) and daily hospital charges (P < .001, adjusted for PIM-2 and center) were significantly lower in patients who met the EEN goal than in patients who did not. Hospital LOS did not differ between patients who met the EEN goal and patients who did not. A significant interaction between EEN and centers prevented any comparison of PICU charges, daily PICU charges, and PICU LOS between those patients who met the EEN goal and those who did not. CONCLUSION: In critically ill children who stay in the PICU >96 hours, EEN is associated with significantly lower hospital charges.

The Association of Central-Line-Associated Bloodstream Infections With Central-Line Utilization Rate and Maintenance Bundle Compliance Among Types of PICUs.

OBJECTIVE: Central-line-associated bloodstream infections comprise 25% of device-associated infections. Compared with other units, PICUs demonstrate a higher central-line-associated bloodstream infections prevalence. Prior studies have not investigated the association of central-line-associated bloodstream infections prevalence, central-line utilization, or maintenance bundle compliance between specific types of PICUs. DESIGN: This study analyzed monthly aggregate data regarding central-line-associated bloodstream infections prevalence, central-line utilization, and maintenance bundle compliance between three types of PICUs: 1) PICUs that do not care for cardiac patients (PICU); 2) PICUs that provide care for cardiac and noncardiac patients (C/PICU); or 3) designated cardiac ICUs (CICU). SETTING: The included units submitted data as part of The Children's Hospital Association PICU central-line-associated bloodstream infections collaborative from January 1, 2011, to December 31, 2013. PATIENTS: Patients admitted to PICUs in collaborative institutions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall central-line-associated bloodstream infections prevalence was low (1.37 central-line-associated bloodstream infections events/1,000 central-line days) and decreased over the time of the study. Central-line-associated bloodstream infections prevalence was not related to the type of PICU although C/PICU tended to have a higher central-line-associated bloodstream infections prevalence (p = 0.055). CICU demonstrated a significantly higher central-line utilization ratio (p < 0.001). However, when examined on a unit level, central-line utilization was not related to the central-line-associated bloodstream infections prevalence. The central-line maintenance bundle compliance rate was not associated with central line-associated bloodstream infections prevalence in this unit-level investigation. Neither utilization rate nor compliance rate changed significantly over time in any of the types of units. CONCLUSIONS: Although this unit-level analysis did not demonstrate an association between central-line-associated bloodstream infections prevalence and central-line utilization and maintenance bundle compliance, optimization of both should continue, further decreasing central-line-associated bloodstream infections prevalence. In addition, investigation of patient-specific factors may aid in further central-line-associated bloodstream infections eradication.

The Effect of Changes in Cardiorespiratory Fitness and Weight on Obstructive Sleep Apnea Severity in Overweight Adults with Type 2 Diabetes.

STUDY OBJECTIVES: To examine the effect of changes in cardiorespiratory fitness on obstructive sleep apnea (OSA) severity prior to and following adjustment for changes in weight over the course of a 4-y weight loss intervention. METHODS: As secondary analyses of a randomized controlled trial, 263 overweight/obese adults with type 2 diabetes and OSA participated in an intensive lifestyle intervention or education control condition. Measures of OSA severity, cardiorespiratory fitness, and body weight were obtained at baseline, year 1, and year 4. Change in the apnea-hypopnea index (AHI) served as the primary outcome. The percentage change in fitness (submaximal metabolic equivalents [METs]) and change in weight (kg) were the primary independent variables. Primary analyses collapsed intervention conditions with statistical adjustment for treatment group and baseline METs, weight, and AHI among other relevant covariates. RESULTS: At baseline, greater METs were associated with lower AHI (B [SE] = -1.48 [0.71], P = 0.038), but this relationship no longer existed (B [SE] = -0.24 [0.73], P = 0.75) after adjustment for weight (B [SE] = 0.31 [0.07], P < 0.0001). Fitness significantly increased at year 1 (+16.53 ± 28.71% relative to baseline), but returned to near-baseline levels by year 4 (+1.81 ± 24.48%). In mixed-model analyses of AHI change over time without consideration of weight change, increased fitness at year 1 (B [SE] = -0.15 [0.04], P < 0.0001), but not at year 4 (B [SE] = 0.04 [0.05], P = 0.48), was associated with AHI reduction. However, with weight change in the model, greater weight loss was associated with AHI reduction at years 1 and 4 (B [SE] = 0.81 [0.16] and 0.60 [0.16], both P < 0.0001), rendering the association between fitness and AHI change at year 1 nonsignificant (B [SE] = -0.04 [0.04], P = 0.31). CONCLUSIONS: Among overweight/obese adults with type 2 diabetes, fitness change did not influence OSA severity change when weight change was taken into account. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identification number NCT00194259.

Pulmonary symptoms and diagnoses are associated with HIV in the MACS and WIHS cohorts.

BACKGROUND: Several lung diseases are increasingly recognized as comorbidities with HIV; however, few data exist related to the spectrum of respiratory symptoms, diagnostic testing, and diagnoses in the current HIV era. The objective of the study is to determine the impact of HIV on prevalence and incidence of respiratory disease in the current era of effective antiretroviral treatment. METHODS: A pulmonary-specific questionnaire was administered yearly for three years to participants in the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS). Adjusted prevalence ratios for respiratory symptoms, testing, or diagnoses and adjusted incidence rate ratios for diagnoses in HIV-infected compared to HIV-uninfected participants were determined. Risk factors for outcomes in HIV-infected individuals were modeled. RESULTS: Baseline pulmonary questionnaires were completed by 907 HIV-infected and 989 HIV-uninfected participants in the MACS cohort and by 1405 HIV-infected and 571 HIV-uninfected participants in the WIHS cohort. In MACS, dyspnea, cough, wheezing, sleep apnea, and incident chronic obstructive pulmonary disease (COPD) were more common in HIV-infected participants. In WIHS, wheezing and sleep apnea were more common in HIV-infected participants. Smoking (MACS and WIHS) and greater body mass index (WIHS) were associated with more respiratory symptoms and diagnoses. While sputum studies, bronchoscopies, and chest computed tomography scans were more likely to be performed in HIV-infected participants, pulmonary function tests were no more common in HIV-infected individuals. Respiratory symptoms in HIV-infected individuals were associated with history of pneumonia, cardiovascular disease, or use of HAART. A diagnosis of asthma or COPD was associated with previous pneumonia. CONCLUSIONS: In these two cohorts, HIV is an independent risk factor for several respiratory symptoms and pulmonary diseases including COPD and sleep apnea. Despite a higher prevalence of chronic respiratory symptoms, testing for non-infectious respiratory diseases may be underutilized in the HIV-infected population.

Snoring, daytime sleepiness, and incident cardiovascular disease in the health, aging, and body composition study.

OBJECTIVES: To examine the association between snoring and incident cardiovascular disease (CVD). DESIGN SETTINGS AND PARTICIPANTS: This is a prospective study in which community dwelling older adults were evaluated at baseline, and followed up for an average of 9.9 years. MEASUREMENTS: Data on snoring, daytime sleepiness, as well as demographic and clinical characteristics of study participants was collected at baseline, and participants were followed up every six months for an average of 9.9 years. Based on snoring and sleepiness status, 4 groups of participants were created: (1) No Snoring, No Sleepiness; (2) No Snoring, Sleepiness; (3) Snoring, No Sleepiness; (4) Snoring, Sleepiness. Incident CVD was defined as a diagnosis of myocardial infarction, angina pectoris, or congestive heart failure that resulted in overnight hospitalization during the follow-up period. Cox proportional hazard was used to estimate the risk of incident cardiovascular disease during follow-up by baseline snoring and sleepiness status. RESULTS: A total of 2,320 participants with a mean age of 73.6 (2.9) years at baseline were included in the analysis. Fifty-two percent were women, and 58% were white. A total of 543 participants developed CVD events during the follow-up period. Participants who reported snoring associated with daytime sleepiness had significantly increased hazard ratio for CVD events (HR = 1.46 [1.03-2.08], P = 0.035) after adjusting for demographic and clinical confounding factors. CONCLUSION: The results suggest that self-reported snoring and daytime sleepiness status are associated with an increased risk of future cardiovascular disease among older adults.

The relationship between obstructive sleep apnea and self-reported stroke or coronary heart disease in overweight and obese adults with type 2 diabetes mellitus.

STUDY OBJECTIVES: Type 2 diabetes mellitus (T2DM) and obstructive sleep apnea (OSA) are common, increasingly recognized as comorbid conditions, and individually implicated in the development of cardiovascular disease (CVD). We sought to determine the association between OSA and CVD in an overweight and obese population with T2DM. DESIGN: Cross-sectional. SETTING: Ancillary study to the Look AHEAD trial. PARTICIPANTS: Three hundred five participants of the Sleep AHEAD study who underwent unattended full polysomnography at home with measurement of the apnea-hypopnea index (AHI). MEASUREMENTS AND RESULTS: Self-reported prevalent CVD was obtained at the initial assessment of the parent study and included a history of the following conditions: stroke, carotid endarterectomy, myocardial infarction, coronary artery bypass grafting, and percutaneous coronary intervention. Logistic regression was used to assess the association of OSA, measured continuously and categorically, with prevalent CVD. OSA was present (AHI ≥ 5) in 86% of the population, whereas the prevalence of all forms of CVD was just 14%. The AHI was associated with stroke with an adjusted odds ratio (95% confidence interval) of 2.57 (1.03, 6.42). Neither the continuously measured AHI nor the categories of OSA severity were significantly associated with the other forms of CVD assessed. CONCLUSIONS: We found suggestive evidence of a greater prevalence of stroke at greater values of the AHI. OSA was not associated with prevalent coronary heart disease in the Sleep AHEAD trial. Future studies should confirm the link between OSA and stroke and examine mechanisms that link OSA to stroke in adults with T2DM.

The influence of abdominal visceral fat on inflammatory pathways and mortality risk in obstructive lung disease.

BACKGROUND: Low-grade systemic inflammation, particularly elevated IL-6, predicts mortality in chronic obstructive pulmonary disease (COPD). Although altered body composition, especially increased visceral fat (VF) mass, could be a significant contributor to low-grade systemic inflammation, this remains unexplored in COPD. OBJECTIVE: The objective was to investigate COPD-specific effects on VF and plasma adipocytokines and their predictive value for mortality. DESIGN: Within the Health, Aging, and Body Composition (Health ABC) Study, an observational study in community-dwelling older persons, we used propensity scores to match n = 729 persons with normal lung function to n = 243 persons with obstructive lung disease (OLD; defined as the ratio of forced expiratory volume in 1 s to forced vital capacity < lower limit of normal). Matching was based on age, sex, race, clinic site, BMI, and smoking status. Within this well-balanced match, we compared computed tomography-acquired visceral fat area (VFA) and plasma adipocytokines, analyzed independent associations of VFA and OLD status on plasma adipocytokines, and studied their predictive value for 9.4-y mortality. RESULTS: Whereas whole-body fat mass was comparable between groups, persons with OLD had increased VFA and higher plasma IL-6, adiponectin, and plasminogen activator inhibitor 1 (PAI-1). Both OLD status and VFA were independently positively associated with IL-6. Adiponectin was positively associated with OLD status but negatively associated with VFA. PAI-1 was no longer associated with OLD status after VFA was accounted for. Participants with OLD had increased risk of all-cause, respiratory, and cardiovascular mortality, of which IL-6 was identified as an independent predictor. CONCLUSION: Our data suggest that excessive abdominal visceral fat contributes to increased plasma IL-6, which, in turn, is strongly associated with all-cause and cause-specific mortality in older persons with OLD.

Sleep apnea is related to the atherogenic phenotype, lipoprotein subclass B.

STUDY OBJECTIVES: Sleep apnea has been implicated as an independent risk factor for atherosclerotic coronary artery disease (CAD). An association between the severity of sleep apnea and total cholesterol levels has previously been reported. However, the association with small dense low density lipoprotein (LDL) cholesterol concentration (subclass B), one of the strongest predictors of atherosclerosis, is unknown. We examined the relationship between sleep apnea and LDL subclass B, considering body size. METHODS: This is a cross-sectional observational cohort of participants enrolled in a cardiovascular health study. Sleep apnea was assessed with a validated portable monitor. Lipid panels included total cholesterol, triglycerides, high density lipoprotein cholesterol, LDL cholesterol, and LDL subclasses A, B, and A/B. Sleep apnea was analyzed categorically using the apnea hypopnea index (AHI). RESULTS: A total of 519 participants were evaluated. Mean age was 58.7 ± 7.4 years; BMI was 29.6 ± 5.7; 65% were female; 59% were Caucasian, and 37% were African American. Among participants with abnormal waist circumference by ATP III criteria, moderate to severe sleep apnea (AHI ≥ 25) was not independently associated with LDL subclass B. In contrast, among participants with normal waist circumference, moderate to severe sleep apnea was associated with 4.5-fold odds of having LDL subclass B. CONCLUSIONS: Sleep apnea is independently associated with an atherogenic phenotype (LDL subclass B) in non-obese individuals. The association between sleep apnea and LDL subclass B in those with normal waist circumference may account, in part, for the increased risk of atherosclerosis and subsequent vascular events.

Evaluation of a single-channel portable monitor for the diagnosis of obstructive sleep apnea.

STUDY OBJECTIVE: To validate the ApneaLINK (AL) as an accurate tool for determining the presence of obstructive sleep apnea (OSA) in an at-risk sleep clinic population in a home test environment. METHODS: Consecutive participants referred with the suspicion of OSA were evaluated in the home with the AL portable monitor (AL Home), followed by simultaneous data collection with diagnostic polysomnography (PSG) and AL in the sleep laboratory (AL Lab). Prevalence, sensitivity, specificity, and ROC curves were calculated for PSG vs. AL Lab, PSG vs. AL Home, and AL Lab vs. AL Home test. Pearson correlations and Bland-Altman plots were constructed. RESULTS: Fifty-three (55% female) participants completed the entire study. The mean age of the population was 45.1 ± 11.3 years, and body mass index was 35.9 ± 9.1 kg/m(2). The prevalence of an apnea hypopnea index (AHI) ≥ 15 in the cohort was 35.9%. The results demonstrated a high sensitivity and specificity of the AL respiratory disturbance index (RDI-AL) compared with the AHI from the PSG. The AL Lab had the highest sensitivity and specificity at RDI-AL values ≥ 20 events/h (sensitivity 100%, specificity 92.5%). The AL Home was most sensitive and specific at an RDI-AL ≥ 20 events/h (sensitivity 76.9%, specificity 92.5%). The Pearson correlations for PSG vs. AL Lab and PSG vs. AL Home were ρ = 0.88 and ρ = 0.82, respectively. The Bland-Altman Plots demonstrated good agreement between the methodologies. CONCLUSION: The AL home test is an accurate alternative to PSG in sleep clinic populations at risk for moderate and severe OSA. TRIAL REGISTRATION: clinicaltrials.gov ID: NCT00354614.

Are all ICUs the same?

The ability to compare intensive care units (ICUs) and determine whether they provide the same level of care with regard to efficacy, efficiency, and quality is a cornerstone of understanding critical care and improving the quality of that care. Without collecting high-quality data, adjusted for severity of illness and analyzed in a comparative fashion, it would not be possible to describe best practices objectively, to identify which ICUs are doing a good job or to learn from those units that are. This review article discusses how and why ICUs are compared. Particular attention is focused on the severity of illness scores, standardized mortality, and comparative reporting. A data collecting network, Virtual Pediatric Systems, limited liability corporation (VPS, LLC), designed for the purposes of determining where differences in critical care can be identified and the value that this adds in improving quality is discussed. Finally, results from this large data sharing collaborative describing the practice of pediatric critical care are included for the purpose of pediatric intensive care units practice benchmarks.

Sleep-disordered breathing in the National Football League.

STUDY OBJECTIVES: Prior studies have suggested that the prevalence of sleep disordered breathing (SDB) among players in the National Football League (NFL) is disproportionately high. SDB can increase cardiovascular disease risk and is correlated with hypertension. NFL players have a higher prevalence of hypertension, and we sought to determine the prevalence of SDB among players the NFL and the associations of SDB with anthropometric measures and cardiovascular risk factors. DESIGN: Cross-sectional cohort study. SETTING: NFL athletic training facilities from April to July 2007. PARTICIPANTS: A total of 137 active veteran players from 6 NFL teams. MEASUREMENTS: This evaluation of SDB among players in the NFL used a single-channel, home-based, unattended, portable, sleep apnea monitor. Multiple domains of self-reported sleep were assessed. Weight, body mass index, body fat percentage, neck circumference, waist circumference, and waist-to-hip ratio, as well as blood pressure, cholesterol, and fasting glucose concentrations were measured. RESULTS: The mean respiratory disturbance index was 4.7 (+/- 12), with a median (interquartile range) of 2 (1,4). The prevalence of at least mild SDB (RDI > or = 5) was 19% (95% confidence interval, 12.8%-26.6%). Only 4.4% (95% confidence interval, 1.6%-9.2%) of participants had respiratory disturbance index of 15 or greater. Linemen and non-linemen were not different in their prevalence or severity of SDB. No single anthropometric measure was highly associated with SDB, and SDB was not well correlated with cardiovascular risk factors. CONCLUSIONS: The prevalence of SDB in active NFL players was modest, predominately mild, and positively associated with several measures of adiposity. SDB did not account for excess cardiovascular risk factors.

Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease--the perspective of critical care.

The development of databases to track the outcomes of children with cardiovascular disease has been ongoing for much of the last two decades, paralleled by the rise of databases in the intensive care unit. While the breadth of data available in national, regional and local databases has grown exponentially, the ability to identify meaningful measurements of outcomes for patients with cardiovascular disease is still in its early stages. In the United States of America, the Virtual Pediatric Intensive Care Unit Performance System (VPS) is a clinically based database system for the paediatric intensive care unit that provides standardized high quality, comparative data to its participants [https://portal.myvps.org/]. All participants collect information on multiple parameters: (1) patients and their stay in the hospital, (2) diagnoses, (3) interventions, (4) discharge, (5) various measures of outcome, (6) organ donation, and (7) paediatric severity of illness scores. Because of the standards of quality within the database, through customizable interfaces, the database can also be used for several applications: (1) administrative purposes, such as assessing the utilization of resources and strategic planning, (2) multi-institutional research studies, and (3) additional internal projects of quality improvement or research.In the United Kingdom, The Paediatric Intensive Care Audit Network is a database established in 2002 to record details of the treatment of all critically ill children in paediatric intensive care units of the National Health Service in England, Wales and Scotland. The Paediatric Intensive Care Audit Network was designed to develop and maintain a secure and confidential high quality clinical database of pediatric intensive care activity in order to meet the following objectives: (1) identify best clinical practice, (2) monitor supply and demand, (3) monitor and review outcomes of treatment episodes, (4) facilitate strategic healthcare planning, (5) quantify resource requirements, and (6) study the epidemiology of critical illness in children.Two distinct physiologic risk adjustment methodologies are the Pediatric Risk of Mortality Scoring System (PRISM), and the Paediatric Index of Mortality Scoring System 2 (PIM 2). Both Pediatric Risk of Mortality (PRISM 2) and Pediatric Risk of Mortality (PRISM 3) are comprised of clinical variables that include physiological and laboratory measurements that are weighted on a logistic scale. The raw Pediatric Risk of Mortality (PRISM) score provides quantitative measures of severity of illness. The Pediatric Risk of Mortality (PRISM) score when used in a logistic regression model provides a probability of the predicted risk of mortality. This predicted risk of mortality can then be used along with the rates of observed mortality to provide a quantitative measurement of the Standardized Mortality Ratio (SMR). Similar to the Pediatric Risk of Mortality (PRISM) scoring system, the Paediatric Index of Mortality (PIM) score is comprised of physiological and laboratory values and provides a quantitative measurement to estimate the probability of death using a logistic regression model.The primary use of national and international databases of patients with congenital cardiac disease should be to improve the quality of care for these patients. The utilization of common nomenclature and datasets by the various regional subspecialty databases will facilitate the eventual linking of these databases and the creation of a comprehensive database that spans conventional geographic and subspecialty boundaries.

Integrated selective: an innovative teaching strategy for sleep medicine instruction for medical students.

OBJECTIVES: Sleep disorders are common among all age groups, but repeated studies have demonstrated that physicians underdiagnose sleep disorders. Lack of curriculum time and the limited number of faculty with expertise in sleep medicine have been cited as major barriers for sleep medicine instruction. This paper describes the development, implementation, and evaluation of an integrated selective in sleep medicine for fourth-year medical students. METHODS: A one-month required fourth-year integrated selective in sleep medicine was implemented at Medical College of Wisconsin (MCW). A curriculum was developed, incorporating core competencies of sleep medicine and using a combination of instructional strategies. Three sources of data were used to evaluate the selective: an elective-specific questionnaire, learner ratings, and performance on a pre- and post-knowledge test. RESULTS: Twenty medical students (13 male; 7 female) have completed the selective to date. Lack of exposure to sleep medicine during the first three years of medical school was the most common reason for taking the elective. Student evaluation of the rotation averaged 1.5 on a five-point scale (1=best), above the average for fourth-year rotations. The mean examination scores increased significantly from pre- (56%) to post- (86%) selective (p<.05). Unanticipated but associated positive outcomes included (a) an invitation to teach a 1h lecture to third-year medical students and pediatric residents, (b) a 2h workshop on sleep medicine for internal medicine residents, and (c) grant funding from the medical college's Curriculum and Evaluation Committee to support the development of on-line sleep medicine instruction. CONCLUSIONS: A well-designed fourth-year integrated selective improves student knowledge in sleep medicine and may provide an opening for additional inclusion of sleep medicine instruction for various trainees.