Traffic-related air pollution and dementia incidence in the Adult Changes in Thought Study.

BACKGROUND: While epidemiologic evidence links higher levels of exposure to fine particulate matter (PM2.5) to decreased cognitive function, fewer studies have investigated links with traffic-related air pollution (TRAP), and none have examined ultrafine particles (UFP, ≤100 nm) and late-life dementia incidence. OBJECTIVE: To evaluate associations between TRAP exposures (UFP, black carbon [BC], and nitrogen dioxide [NO2]) and late-life dementia incidence. METHODS: We ascertained dementia incidence in the Seattle-based Adult Changes in Thought (ACT) prospective cohort study (beginning in 1994) and assessed ten-year average TRAP exposures for each participant based on prediction models derived from an extensive mobile monitoring campaign. We applied Cox proportional hazards models to investigate TRAP exposure and dementia incidence using age as the time axis and further adjusting for sex, self-reported race, calendar year, education, socioeconomic status, PM2.5, and APOE genotype. We ran sensitivity analyses where we did not adjust for PM2.5 and other sensitivity and secondary analyses where we adjusted for multiple pollutants, applied alternative exposure models (including total and size-specific UFP), modified the adjustment covariates, used calendar year as the time axis, assessed different exposure periods, dementia subtypes, and others. RESULTS: We identified 1,041 incident all-cause dementia cases in 4,283 participants over 37,102 person-years of follow-up. We did not find evidence of a greater hazard of late-life dementia incidence with elevated levels of long-term TRAP exposures. The estimated hazard ratio of all-cause dementia was 0.98 (95 % CI: 0.92-1.05) for every 2000 pt/cm3 increment in UFP, 0.95 (0.89-1.01) for every 100 ng/m3 increment in BC, and 0.96 (0.91-1.02) for every 2 ppb increment in NO2. These findings were consistent across sensitivity and secondary analyses. DISCUSSION: We did not find evidence of a greater hazard of late-life dementia risk with elevated long-term TRAP exposures in this population-based prospective cohort study.

[Compliance with CPAP treatment in patients with obstructive sleep apneas during the COVID-19 pandemic in two hospitals in the Federal Capital] / Cumplimiento del tratamiento con CPAP en pacientes con apneas obstructivas del sueño durante la pandemia COVID-19 en dos hospitales de Capital Federal.

Introduction: CPAP therapy is the first line treatment for sleep apnea and its effectiveness depends on adherence. Face to face control and follow-up was limited due to the fact that our country was immersed in social isolation due to the COVID-19 pandemic as of March 2020. In order to assess whether CPAP adherence was maintained in patients with obstructive sleep apnea (OSA), in two hospitals during the COVID-19 pandemic and compare it with the pre-pandemic situation on a historical control basis in the city of Buenos Aires. Methods: Observational and retrospective study based on systematic data collection of adherence to CPAP and residual apnea-hypopnea index (AHI). For comparison, a historical control corresponding to the specular period (May to December of each year between 2016 and 2019) was used as a reference. Patients over 18 years ago with OSA on CPAP therapy more than 30 days of treatment were included. Patients with other chronic respiratory diseases requiring ventilation therapy (Bi-level, servo ventilation, volume-assured ventilation) were excluded. Results: 151 pre-pandemic patients and 127 from the pandemic period, respectively, were evaluated. Men 98 (65%) vs. 50 (60.3%) p: 0.9, age: 65.4 ± 11.9 vs. 63.6 ± 12.6 p: 0.22, body mass index 31.5 ± 5.0 vs. 31.2 ± 5.3 kg/m2 p: 0.6, respectively. In both centers, the most used treatment was fixed CPAP; 90 (59.6%) vs. 96 (75.6%) p: 0.005. There was an increase in compliance with it compared to the pre-pandemic period in minutes/night [341.4 95% CI 292.4 - 340.6 vs. 274.3 95% CI 208.5 - 267.4, p: 0.001] and residual AHI reduction [3.3 IC 95% 2.0 - 3.05 vs. 6.3 IC 95% 2.6 - 4.3 p: 0.006]. Conclusions: In the period of the COVID-19 pandemic, greater adherence to CPAP treatment was observed in patients with sleep apnea.

Introducción: La terapia con CPAP es el tratamiento de primera línea para la apnea del sueño y su eficacia depende de la adherencia. El control y seguimiento de forma presencial fue limitado debido a que nuestro país se vio inmerso en aislamiento social debido a la pandemia por COVID-19 a partir de marzo del 2020. Con el objeto de evaluar si se mantuvo la adherencia de la CPAP en pacientes con apnea obstructiva del sueño (AOS), en dos hospitales durante la pandemia COVID-19 y compararlo con la situación prepandemia sobre una base de control histórico de la ciudad de Buenos Aires. Métodos: Estudio observacional y retrospectivo basado en datos de recolección sistemática de adherencia a la CPAP e índice de apnea-hipopnea (IAH) residual. Para la comparación, se utilizó como referencia un control histórico correspondiente al periodo especular (mayo a diciembre de cada año entre el 2016 y 2019). Se incluyeron pacientes de más de 18 años de edad, con AOS con terapia con CPAP de más de 30 días de tratamiento. Se excluyeron pacientes con otras patologías respiratorias crónicas que requerían de terapias de ventilación (Bi-level, servo ventilación, ventilación con volumen asegurado). Resultados: Fueron evaluados 151 pacientes prepandemia y 127 del periodo pandemia respectivamente. Hombres 98 (65%) vs. 50 (60.3%) p: 0.9, edad de 65.4± 11.9 vs 63.6 ± 12.6 p: 0.22, índice de masa corporal 31.5 ± 5.0 vs. 31.2 ± 5.3 kg/m2 p: 0.6, respectivamente En ambos centros, el tratamiento más utilizado fue CPAP fijo; 90 (59.6%) vs. 96 (75.6%) p: 0.005. Existió un aumento en el cumplimiento del mismo en comparación al periodo prepandémico en minutos/noche [341.4 IC 95% 292.4 - 340.6 vs. 274.3 IC 95% 208.5 - 267.4, p: 0.001] y reducción del IAH residual [3.3 IC 95% 2.0 - 3.05 vs. 6.3 IC 95% 2.6 - 4.3 p: 0.006]. Conclusiones: En el periodo de pandemia COVID-19 se observó mayor adherencia al tratamiento con CPAP en pacientes con apneas del sueño.

Exposure Disparities by Income, Race and Ethnicity, and Historic Redlining Grade in the Greater Seattle Area for Ultrafine Particles and Other Air Pollutants.

BACKGROUND: Growing evidence shows ultrafine particles (UFPs) are detrimental to cardiovascular, cerebrovascular, and respiratory health. Historically, racialized and low-income communities are exposed to higher concentrations of air pollution. OBJECTIVES: Our aim was to conduct a descriptive analysis of present-day air pollution exposure disparities in the greater Seattle, Washington, area by income, race, ethnicity, and historical redlining grade. We focused on UFPs (particle number count) and compared with black carbon, nitrogen dioxide, and fine particulate matter (PM2.5) levels. METHODS: We obtained race and ethnicity data from the 2010 U.S. Census, median household income data from the 2006-2010 American Community Survey, and Home Owners' Loan Corporation (HOLC) redlining data from the University of Richmond's Mapping Inequality. We predicted pollutant concentrations at block centroids from 2019 mobile monitoring data. The study region encompassed much of urban Seattle, with redlining analyses restricted to a smaller region. To analyze disparities, we calculated population-weighted mean exposures and regression analyses using a generalized estimating equation model to account for spatial correlation. RESULTS: Pollutant concentrations and disparities were largest for blocks with median household income of <$20,000, Black residents, HOLC Grade D, and ungraded industrial areas. UFP concentrations were 4% lower than average for non-Hispanic White residents and higher than average for racialized groups (Asian, 3%; Black, 15%; Hispanic, 6%; Native American, 8%; Pacific Islander, 11%). For blocks with median household incomes of <$20,000, UFP concentrations were 40% higher than average, whereas blocks with incomes of >$110,000 had UFP concentrations 16% lower than average. UFP concentrations were 28% higher for Grade D and 49% higher for ungraded industrial areas compared with Grade A. Disparities were highest for UFPs and lowest for PM2.5 exposure levels. DISCUSSION: Our study is one of the first to highlight large disparities with UFP exposures compared with multiple pollutants. Higher exposures to multiple air pollutants and their cumulative effects disproportionately impact historically marginalized groups. https://doi.org/10.1289/EHP11662.

Characterizing Ultrafine Particle Mobile Monitoring Data for Epidemiology.

Mobile monitoring is increasingly used to assess exposure to traffic-related air pollutants (TRAPs), including ultrafine particles (UFPs). Due to the rapid spatial decrease in the concentration of UFPs and other TRAPs with distance from roadways, mobile measurements may be non-representative of residential exposures, which are commonly used for epidemiologic studies. Our goal was to develop, apply, and test one possible approach for using mobile measurements in exposure assessment for epidemiology. We used an absolute principal component score model to adjust the contribution of on-road sources in mobile measurements to provide exposure predictions representative of cohort locations. We then compared UFP predictions at residential locations from mobile on-road plume-adjusted versus stationary measurements to understand the contribution of mobile measurements and characterize their differences. We found that predictions from mobile measurements are more representative of cohort locations after down-weighting the contribution of localized on-road plumes. Further, predictions at cohort locations derived from mobile measurements incorporate more spatial variation compared to those from short-term stationary data. Sensitivity analyses suggest that this additional spatial information captures features in the exposure surface not identified from the stationary data alone. We recommend the correction of mobile measurements to create exposure predictions representative of residential exposure for epidemiology.

La edad y el uso de máscara oronasal se asocian con menor calidad en la titulación con CPAP autoajustable en domicilio en pacientes sin adaptación / Age and Oronasal Mask are Associated with Lower Quality in Automatic CPAP Titration at Home in Patients without Previous Adaptation

Introducción: se considera aceptable (TitAcept) una prueba con CPAP automático en domicilio (APAP) cuando su uso es ≥ a 4 horas/noche y el índice de apneas residuales (IAHr) ≤ 10 eventos/hora (AASM). Sin embargo, todas las variables relacionadas con la calidad de este procedimiento no se conocen completamente. Objetivo: evaluar la cali-dad de la titulación con APAP en el domicilio. Material y métodos: estudio retrospectivo en pacientes "naïve" de CPAP. El criterio de TitAcept seleccionó dos grupos y la regresión logística múltiple identificó predictores de prueba no aceptables. Resultados: incluimos 1325 TitAcept; 941 hombres (71%), edad: 57 ± 12,4 años, IMC: 32,3 ± 8,8 kg/m2, IAH: 34,2 ± 19 ev/h. La titulación alcanzó 3,4 ± 3,5 noches, adherencia: 379 minutos/noche; pre-sión efectiva: 8,7 ± 1,7 cm H2O, IAHr; 3,1 ± 2,4 ev/h y fugas 16,1 ± 8,7 litros/min. Fueron predictores; edad ≥ 50 años; OR: 1,62 (IC95%: 1,23-3,46), p: 0.0005 y máscara orona-sal; OR: 2,49 (IC95%: 1,79-3,46), p: 0.0001. Conclusiones: una significativa proporción de pacientes que realizaron una titulación no vigilada con APAP en domicilio no alcan-zaron criterios de calidad adecuada. La edad ≥ 50 años y el uso de máscara oronasal se asocian con menor calidad en la prueba, de acuerdo a criterios preestablecidos. (AU)

Introduction: automated CPAP (APAP) titration at home is considered acceptable (Tit-Accept) when its device is used ≥ 4 hours/night and the residual apnea index (AHIr) es ≤ 10 events/hour (AASM). However, all the variables related to quality of this procedure are not fully known. Objective: to assess the quality of the titration with APAP at home.Material and Methods: retrospective study in CPAP "naïve" patients. The TitAccept criteri-on selected two groups and multiple logistic regression identified predictors of non-ac-ceptable titration. Results: we included 1325 TitAccept; 941 men (71%), age: 57 ± 12.4 years, BMI: 32.3 ± 8.8 kg/m2, baseline AHI: 34.2 ± 19 ev/h. The titration reached 3.4 ± 3.5 nights, adherence: 379 minutes/night; effective pressure: 8.7 ± 1.7 cmH2O, AHIr; 3.1 ± 2.4 ev/h and leaks 16.1 ± 8.7 liters/min. The predictors were; age ≥ 50 years; OR: (AU)

Hipoxemia y el riesgo de hipertensión arterial en apnea obstructiva del sueño / Hypoxemia and the Hypertension Risk in Obstructive Sleep Apnea

Hay poca información sobre el rol de la hipoxemia como factor de riesgo de hipertensión arterial (HTA) en pacientes con apnea obstructiva del sueño. El objetivo de este estudio fue evaluar la hipoxemia como factor de riesgo independiente de HTA en un modelo de trabajo basado en pacientes reales examinados en una unidad de sueño. Métodos: estudio retrospectivo. Modelo predictivo mediante regresión logística múltiple para establecer la relación entre HTA y edad, sexo, índice de masa corporal (IMC), índice de apneas e hipopneas por hora de registro (IAH) y tiempo de saturación de oxígeno debajo de 90% (T90 > 3%). Resultados: incluimos 3854 pacientes (edad mediana 55 años), predominio varones (61.5%). Según el modelo, las variables asociadas con HTA fueron: edad (OR 3.27 ­ 3.29, IC95% 2.83 ­ 3.80, p < 0.0001), sexo masculino (OR 1.35, IC95% 1.17 ­ 1.56, p < 0.001), obesidad (OR 1.83, IC95% 1.59 ­ 2.11, p < 0.0001), IAH ≥ 15 eventos por hora (OR 1.22, IC95% 1.05 ­ 1.43, p < 0.01) y T90 ≥ 3% (OR 1.56 ­ 1.57, IC95% 1.32 ­ 1.84, p < 0.0001). Conclusiones: en una población clínica con sospecha de apnea obstructiva del sueño, la hipoxemia (T90 ≥ 3%) se asoció con hipertensión arterial. (AU);

There is limited information about the role of hypoxemia degree as a risk factor for hypertension (HTN) in patients with obstructive sleep apnea (OSA). The objective of this study is to assess hypoxemia as an independent risk factor for HTN in a work model based on real-life patients examined at sleep unit. Methods: this retrospective study consisted of a predictive model using multiple logistic regression to establish the relationship between HTN and age, sex, body mass index (BMI), apnea/hypopnea index (AHI) and time below SO2 ≤ 90% (T90 ≥ 3%). Results: we included 3.854 patients (median age: 55 years), mostly men (61.5%). According to the model, the variables that were significantly associated with HTN were: age (OR: 3.27 ­ 3.29, CI95% 2.83 ­ 3.80, p < 0.0001), male sex (OR 1.35, CI95% 1.17 ­ 1.56, p < 0.001), Obesity (OR 1.83, CI95% 1.59 ­ 2.11, p < 0.0001), AHI > 15 events per hour (OR 1.22, CI95% 1.05 ­ 1.43, p < 0.01) and T90 ≥ 3% (OR 1.56 ­ 1.57, CI95% 1.32 ­ 1.84, p < 0.0001). Conclusion: in a clinical population of subjects suspected of OSA, nocturnal hypoxemia measure as T90 ≥ 3% was associated with HTN. (AU);

Exposure assessment for air pollution epidemiology: A scoping review of emerging monitoring platforms and designs.

BACKGROUND: Both exposure monitoring and exposure prediction have played key roles in assessing individual-level long-term exposure to air pollutants and their associations with human health. While there have been notable advances in exposure prediction methods, improvements in monitoring designs are also necessary, particularly given new monitoring paradigms leveraging low-cost sensors and mobile platforms. OBJECTIVES: We aim to provide a conceptual summary of novel monitoring designs for air pollution cohort studies that leverage new paradigms and technologies, to investigate their characteristics in real-world examples, and to offer practical guidance to future studies. METHODS: We propose a conceptual summary that focuses on two overarching types of monitoring designs, mobile and non-mobile, as well as their subtypes. We define mobile designs as monitoring from a moving platform, and non-mobile designs as stationary monitoring from permanent or temporary locations. We only consider non-mobile studies with cost-effective sampling devices. Then we discuss similarities and differences across previous studies with respect to spatial and temporal representation, data comparability between design classes, and the data leveraged for model development. Finally, we provide specific suggestions for future monitoring designs. RESULTS: Most mobile and non-mobile monitoring studies selected monitoring sites based on land use instead of residential locations, and deployed monitors over limited time periods. Some studies applied multiple design and/or sub-design classes to the same area, time period, or instrumentation, to allow comparison. Even fewer studies leveraged monitoring data from different designs to improve exposure assessment by capitalizing on different strengths. In order to maximize the benefit of new monitoring technologies, future studies should adopt monitoring designs that prioritize residence-based site selection with comprehensive temporal coverage and leverage data from different designs for model development in the presence of good data compatibility. DISCUSSION: Our conceptual overview provides practical guidance on novel exposure assessment monitoring for epidemiological applications.

Design and evaluation of short-term monitoring campaigns for long-term air pollution exposure assessment.

BACKGROUND: Short-term mobile monitoring campaigns to estimate long-term air pollution levels are becoming increasingly common. Still, many campaigns have not conducted temporally-balanced sampling, and few have looked at the implications of such study designs for epidemiologic exposure assessment. OBJECTIVE: We carried out a simulation study using fixed-site air quality monitors to better understand how different short-term monitoring designs impact the resulting exposure surfaces. METHODS: We used Monte Carlo resampling to simulate three archetypal short-term monitoring sampling designs using oxides of nitrogen (NOx) monitoring data from 69 regulatory sites in California: a year-around Balanced Design that sampled during all seasons of the year, days of the week, and all or various hours of the day; a temporally reduced Rush Hours Design; and a temporally reduced Business Hours Design. We evaluated the performance of each design's land use regression prediction model. RESULTS: The Balanced Design consistently yielded the most accurate annual averages; while the reduced Rush Hours and Business Hours Designs generally produced more biased results. SIGNIFICANCE: A temporally-balanced sampling design is crucial for short-term campaigns such as mobile monitoring aiming to assess long-term exposure in epidemiologic cohorts. IMPACT STATEMENT: Short-term monitoring campaigns to assess long-term air pollution trends are increasingly common, though they rarely conduct temporally balanced sampling. We show that this approach produces biased annual average exposure estimates that can be improved by collecting temporally-balanced samples.

Impact of Mobile Monitoring Network Design on Air Pollution Exposure Assessment Models.

Short-term mobile monitoring campaigns are increasingly used to assess long-term air pollution exposure in epidemiology. Little is known about how monitoring network design features, including the number of stops and sampling temporality, impacts exposure assessment models. We address this gap by leveraging an extensive mobile monitoring campaign conducted in the greater Seattle area over the course of a year during all days of the week and most hours. The campaign measured total particle number concentration (PNC; sheds light on ultrafine particulate (UFP) number concentration), black carbon (BC), nitrogen dioxide (NO2), fine particulate matter (PM2.5), and carbon dioxide (CO2). In Monte Carlo sampling of 7327 total stops (278 sites × 26 visits each), we restricted the number of sites and visits used to estimate annual averages. Predictions from the all-data campaign performed well, with cross-validated R2s of 0.51-0.77. We found similar model performances (85% of the all-data campaign R2) with ∼1000 to 3000 randomly selected stops for NO2, PNC, and BC, and ∼4000 to 5000 stops for PM2.5 and CO2. Campaigns with additional temporal restrictions (e.g., business hours, rush hours, weekdays, or fewer seasons) had reduced model performances and different spatial surfaces. Mobile monitoring campaigns wanting to assess long-term exposure should carefully consider their monitoring designs.

Performance of the NOSE Questionnaire in Mask Selection for Home CPAP Titration.

Introduction Many patients abandon CPAP treatment because they find the mask uncomfortable. Therefore, specialists may benefit from the predictive value of airway assessment tools. Objective To identify nasal ventilation failure through the Nasal Obstruction Symptom Evaluation (NOSE) scale in patients with obstructive sleep apnea (OSA) who undergo home-based auto-adjusting CPAP titration and to determine whether there is a correlation between NOSE score and the type of mask selected. Materials and Methods In this prospective correlational study, the NOSE scale was used in terms of mask selection and titration indicators. Patients were classified based on their NOSE score: > or < 50. Results We included 303 patients; 226 men (74.5%), BMI: 33.2 ± 6.1 kg/m 2 , neck circumference (cm): 42.8 ± 3.6 and Epworth (ESS) score: 9.2 ± 5.6, mild OSA: 12 (3.9%), moderate OSA: 127 (41.9%), and severe OSA: 164 (54.1%). The mean NOSE score was 24.3 ± 22.8 and 42 patients (13.8%) had NOSE scores > 50. Indicators for both groups were: compliance (5.9 ± 1.3 vs. 5.8 ± 1.4 hours) p: 0.41, therapeutic pressure (9.1 ± 2.0 vs. 8.8 ± 1.6 cm of H 2 O) p: 0.23, residual AHI (2.3 ± 1.8 vs. 2.8 ± 2.6 events/hour) p: 0.25, and leaks (20.5 ± 10.6 vs. 21.3 ± 10.7 liters/minute) p: 0.64. According to adjusted multiple regression, a NOSE of > 50 was not a predictor of mask selection. Conclusions A > 50 NOSE score was not a predictor of mask selection, and it was not correlated to titration performance.

[Life care of a cohort of patients with home chronic ventilatory support]. / Trayectoria vital de pacientes con soporte ventilatorio crónico domiciliario.

INTRODUCTION: Home mechanical ventilation in chronic respiratory failure improves quality of life and decreases hospitalizations. In order to know clinical characteristics, resource consumption and survival, we proposed an analysis of the vital trajectory during six years. METHODS: Descriptive and retrospective study. Information was obtained from the clinical history of the day hospital program. Kaplan Meier type survival curves were made. We included 100 patients, 57% men, age 65 ± 13 years and body mass index of 29.1 ± 8.6 kg/m2. Thirty had chronic obstructive pulmonary disease (COPD), 23 had amyotrophic lateral sclerosis, 18 obesity hypoventilation syndrome, other neuromuscular diseases in 16 cases, diaphragmatic dysfunction in 10, and chest wall restriction in 3 patients. Ninety-eight received non-invasive ventilation and two invasive cases through tracheostomy. 80% used spontaneous-timed mode (S/T); 14.6%, spontaneous (S); 4% average volume-assured pressure support ventilation (AVAPS) and 1.3% control pressure. Non-invasive compliance was: 7.8 ± 2.6 hours/day. RESULTS: After the start of home ventilation, hospitalizations were reduced (0.2, SD: 0.38 vs. 0.5 SD: 0.5, p < 0.001) and days of hospitalization per episode (5.14, SD: 17.7 vs. 10.45 SD: 16.69, p < 0.001). Median survival was two years with a better vital prognosis in COPD (3 years on average) vs. neuromuscular disease (< 2 years) p < 0.05. CONCLUSIONS: patients with home mechanical ventilation showed a reduction in the days of hospitalization after starting ventilation. Better survival was observed in COPD in relation to neuromuscular disease.

Introducción: La ventilación mecánica domiciliaria en insuficiencia respiratoria crónica, mejora calidad de vida y disminuye hospitalizaciones. Para conocer características clínicas, consumo de recursos y supervivencia, propusimos un análisis de la trayectoria vital durante seis años. Métodos: Estudio descriptivo y retrospectivo. Se obtuvo información de la historia clínica del programa de hospital de día. Se confeccionaron curvas de supervivencia tipo Kaplan Meier. Incluimos 100 pacientes, 57% hombres, edad 65 ± 13 años e índice de masa corporal de 29.1 ± 8.6 kg/m2. Treinta tenían enfermedad pulmonar obstructiva crónica (EPOC), 23 esclerosis lateral amiotrófica, 18 síndrome obesidad hipoventilación, otras enfermedades neuromusculares (ENM) en 16 casos, disfunción diafragmática en 10 y restricción por caja torácica en 3 pacientes. Noventa y ocho recibieron ventilación no invasiva y en dos casos invasiva mediante traqueostomía. El 80% utilizó modo spontaneous-timed (S/T); 14.6%, spontaneous (S); 4% average volume-assured pressure support ventilation ("AVAPS") y 1.3% presión control. El cumplimiento en no invasiva fue: 7.8 ± 2.6 horas/día. Resultados: Luego del inicio de la ventilación domiciliaria se redujeron las hospitalizaciones (0.2, DS: 0.38 vs. 0.5 DS: 0.5, p < 0.001) y los días de internación por episodio (5.14, DS: 17.7 "vs." 10.45 DS: 16.69, p < 0.001). La supervivencia media fue de dos años con mejor pronóstico vital en EPOC (3 años de media) vs. enfermedad neuromuscular (< 2 años) p < 0.05. Conclusiones: los pacientes con ventilación mecánica domiciliaria mostraron reducción de los días de hospitalización luego de comenzado el soporte ventilatorio. Se observó mejor supervivencia en EPOC en relación a enfermedad neuromuscular.

Trayectoria vital de pacientes con soporte ventilatorio crónico domiciliario / Life care of a cohort of patients with home chronic ventilatory support

Resumen Introducción: La ventilación mecánica domiciliaria en insuficiencia respiratoria crónica, mejora calidad de vida y disminuye hospitalizaciones. Para conocer características clínicas, consumo de recursos y supervivencia, propusimos un análisis de la trayectoria vital durante seis años. Métodos: Estudio descriptivo y retrospectivo. Se obtuvo información de la historia clínica del programa de hospital de día. Se confeccionaron curvas de supervivencia tipo Kaplan Meier. Incluimos 100 pacientes, 57% hombres, edad 65 ± 13 años e índice de masa corporal de 29.1 ± 8.6 kg/m2. Treinta tenían enfermedad pulmonar obstructiva crónica (EPOC), 23 esclerosis lateral amiotrófica, 18 síndrome obesidad hipoventilación, otras enfermedades neuromus culares (ENM) en 16 casos, disfunción diafragmática en 10 y restricción por caja torácica en 3 pacientes. Noventa y ocho recibieron ventilación no invasiva y en dos casos invasiva mediante traqueostomía. El 80% utilizó modo spontaneous-timed (S/T); 14.6%, spontaneous (S); 4% average volume-assured pressure support ventilation ("AVAPS") y 1.3% presión control. El cumplimiento en no invasiva fue: 7.8 ± 2.6 horas/día. Resultados: Luego del inicio de la ventilación domiciliaria se redujeron las hospitalizaciones (0.2, DS: 0.38 vs. 0.5 DS: 0.5, p < 0.001) y los días de internación por episodio (5.14, DS: 17.7 "vs." 10.45 DS: 16.69, p < 0.001). La supervivencia media fue de dos años con mejor pronóstico vital en EPOC (3 años de media) vs. enfermedad neuromuscular (< 2 años) p < 0.05. Conclusiones: los pacientes con ventilación mecánica domiciliaria mostraron reducción de los días de hospitalización luego de comenzado el soporte ventilatorio. Se observó mejor supervivencia en EPOC en relación a enfermedad neuromuscular.

Abstract Introduction: Home mechanical ventilation in chronic respiratory failure improves quality of life and decreases hospitalizations. In order to know clinical characteristics, resource consumption and survival, we pro posed an analysis of the vital trajectory during six years. Methods: Descriptive and retrospective study. Information was obtained from the clinical history of the day hospital program. Kaplan Meier type survival curves were made. We included 100 patients, 57% men, age 65 ± 13 years and body mass index of 29.1 ± 8.6 kg/m2. Thirty had chronic obstructive pulmonary disease (COPD), 23 had amyotrophic lateral sclerosis, 18 obesity hypoventilation syndrome, other neuromuscular diseases in 16 cases, diaphragmatic dysfunction in 10, and chest wall restriction in 3 patients. Ninety-eight received non-invasive ventilation and two invasive cases through tracheostomy. 80% used spontaneous-timed mode (S/T); 14.6%, spontaneous (S); 4% average volume-assured pressure support ventilation (AVAPS) and 1.3% control pressure. Non-invasive compliance was: 7.8 ± 2.6 hours/day. Results: After the start of home ventilation, hospitalizations were reduced (0.2, SD: 0.38 vs. 0.5 SD: 0.5, p < 0.001) and days of hospitalization per episode (5.14, SD: 17.7 vs. 10.45 SD: 16.69, p < 0.001). Median survival was two years with a better vital prognosis in COPD (3 years on average) vs. neuromuscular disease (< 2 years) p < 0.05. Conclusions: patients with home mechanical ventilation showed a reduction in the days of hospitalization after starting ventilation. Better survival was observed in COPD in relation to neuromuscular disease.

Ventilación no invasiva en sala de hospitalización general / Non-Invasive Ventilation in a Regular Hospital Ward

Introducción: La experiencia clínica ha permitido la ventilación no invasiva fuera de unidades críticas. Describimos el perfil clínico y evolución de pacientes que recibieron ventilación no invasiva en sala general. Material y métodos: Estudio retrospectivo en pacientes con soporte ventilatorio du rante un año en un hospital general. Resultados: Se utilizó ventilación no invasiva en 43 pacientes, 67,4% con hipercap nia. La relación hombre/mujer fue 1:1. La edad y el IMC fueron 68,3 ± 12,4 años y 30,1 ± 12,3 kg/m2 y los diagnósticos principales, enfermedad pulmonar obstructiva crónica, enfermedad neuromuscular y obesidad-hipoventilación. Un tercio inició la ventilación no invasiva en la unidad de cuidados intensivos, y dos tercios usaban ventilación no invasiva en domicilio antes del ingreso por exacerbación de la enfermedad pulmonar obstructiva crónica (39,5%) o progresión de la enfermedad (14%). La estancia hospi talaria fue 12,1 ± 7 d (14 ± 9 en supervivientes y 5,7 ± 3 en pacientes fallecidos). La gasometría arterial al ingreso reveló PaCO2: 52,7 ± 13,7 mmHg; PaO2: 72,2 ± 16,2 mmHg y pH de 7,36 ± 0,08. Se halló pH < 7,35 en el 18,6% y PaCO2 > 45 en el 57,4%. La PaCO2 al alta fue menor (46,1 ± 4,6; p > 0,05). El modo ST se utilizó en 34 (79%) pacientes. El período de ventilación fue 12,7 ± 10,2 días con uso de 6,9 ± 3,1 h/d. Un tercio recibió cuidados paliativos (13,9% de mortalidad). Tres pacientes (7%) fueron transferidos a la unidad de cuidados intensivos por deterioro clínico y treinta y cinco egresaron con ventilación crónica (94,6%). Conclusiones: Hubo escasas transferencias a la unidad de cuidados intensivos. La mortalidad hospitalaria fue baja y los que fallecieron tenían instrucciones anticipadas.

Introduction: Clinical experience has allowed the use of non-invasive ventilation out side the acute-care setting. We describe the clinical profile and evolution of patients who received non-invasive ventilation in a regular ward. Materials and methods: Retrospective study in patients with ventilatory support for one year in a general hospital. Results: Non-invasive ventilation was delivered to 43 patients, 67.4% of which had hy percapnia. The male/female ratio was 1:1. Age and BMI (Body Mass Index) were 68.3 ± 12.4 years and 30.1 ± 12.3 kg/m2, and the main diagnoses were chronic obstructive pulmonary disease, neuromuscular disease and obesity-hypoventilation. One third of patients began non-invasive ventilation in the Intensive Care Unit, and two thirds had been using non-invasive ventilation at their homes before being admitted with exacerba tion of chronic obstructive pulmonary disease (39.5%) or disease progression (14%). Hospital length of stay was 12.1 ± 7 d (14 ± 9 in survivors and 5.7 ± 3 in deceased patients). Arterial blood gas analysis on admission showed: PaCO2 (partial pressure of arterial carbon dioxide), 52.7 ± 13.7 mmHg; PaO2 (partial pressure of arterial oxygen), 72.2 ± 16.2 mmHg, and pH, 7.36 ± 0.08. A pH level < 7.35 was found in 18.6%, and PaCO2 > 45 in 57.4%. PaCO2 values upon discharge were lower (46.1 ± 4.6; p > 0.05). The ST (spontaneous-timed) mode was used in 34 patients (79%). The ventilation period was 12.7 ± 10.2 days, using 6.9 ± 3.1 h/d. One third of patients received palliative care (13.9% of mortality). Three patients (7%) were transferred to the Intensive Care Unit due to clinical decline, and thirty-five were discharged with chronic ventilation (94.6%). Conclusions: there were few referrals to the Intensive Care Unit. Hospital mortality was low, and patients who died had advance directives.

Characterization of Annual Average Traffic-Related Air Pollution Concentrations in the Greater Seattle Area from a Year-Long Mobile Monitoring Campaign.

Growing evidence links traffic-related air pollution (TRAP) to adverse health effects. We designed an innovative and extensive mobile monitoring campaign to characterize TRAP exposure levels for the Adult Changes in Thought (ACT) study, a Seattle-based cohort. The campaign measured particle number concentration (PNC) to capture ultrafine particles (UFP), black carbon (BC), nitrogen dioxide (NO2), fine particulate matter (PM2.5), and carbon dioxide (CO2) at 309 roadside sites within a large, 1200 land km2 (463 mi2) area representative of the cohort. We collected about 29 two-minute measurements at each site during all seasons, days of the week, and most times of the day over a 1-year period. Validation showed good agreement between our BC, NO2, and PM2.5 measurements and monitoring agency sites (R2 = 0.68-0.73). Universal kriging-partial least squares models of annual average pollutant concentrations had cross-validated mean square error-based R2 (and root mean square error) values of 0.77 (1177 pt/cm3) for PNC, 0.60 (102 ng/m3) for BC, 0.77 (1.3 ppb) for NO2, 0.70 (0.3 µg/m3) for PM2.5, and 0.51 (4.2 ppm) for CO2. Overall, we found that the design of this extensive campaign captured the spatial pollutant variations well and these were explained by sensible land use features, including those related to traffic.

Publicly available low-cost sensor measurements for PM2.5 exposure modeling: Guidance for monitor deployment and data selection.

High-resolution, high-quality exposure modeling is critical for assessing the health effects of ambient PM2.5 in epidemiological studies. Using sparse regulatory PM2.5 measurements as principal model inputs may result in two issues in exposure prediction: (1) they may affect the models' accuracy in predicting PM2.5 spatial distribution; (2) the internal validation based on these measurements may not reliably reflect the model performance at locations of interest (e.g., a cohort's residential locations). In this study, we used the PM2.5 measurements from a publicly available commercial low-cost PM2.5 network, PurpleAir, with an external validation dataset at the residential locations of a representative sample of participants from the Adult Changes in Thought - Air Pollution (ACT-AP) study, to improve the accuracy of exposure prediction at the cohort participant locations. We also proposed a metric based on principal component analysis (PCA) - the PCA distance - to assess the similarity between monitor and cohort locations to guide monitor deployment and data selection. The analysis was based on a spatiotemporal modeling framework with 51 "gold-standard" monitors and 58 PurpleAir monitors for model development, as well as 105 home monitors at the cohort locations for model validation, in the Puget Sound region of Washington State from June 2017 to March 2019. After including calibrated PurpleAir measurements as part of the dependent variable, the external spatiotemporal validation R2 and root-mean-square error, RMSE, for two-week concentration averages improved from 0.84 and 2.22 µg/m3 to 0.92 and 1.63 µg/m3, respectively. The external spatial validation R2 and RMSE for long-term averages over the modeling period improved from 0.72 and 1.01 µg/m3 to 0.79 and 0.88 µg/m3, respectively. The exposure predictions incorporating PurpleAir measurements demonstrated sharper urban-suburban concentration gradients. The PurpleAir monitors with shorter PCA distances improved the model's prediction accuracy more substantially than the monitors with longer PCA distances, supporting the use of this similarity metric.

Fine Particulate Matter and Dementia Incidence in the Adult Changes in Thought Study.

BACKGROUND: Air pollution may be associated with elevated dementia risk. Prior research has limitations that may affect reliability, and no studies have evaluated this question in a population-based cohort of men and women in the United States. OBJECTIVES: We evaluated the association between time-varying, 10-y average fine particulate matter (PM2.5) exposure and hazard of all-cause dementia. An additional goal was to understand how to adequately control for age and calendar-time-related confounding through choice of the time axis and covariate adjustment. METHODS: Using the Adult Changes in Thought (ACT) population-based prospective cohort study in Seattle, we linked spatiotemporal model-based PM2.5 exposures to participant addresses from 1978 to 2018. Dementia diagnoses were made using high-quality, standardized, consensus-based protocols at biennial follow-ups. We conducted multivariable Cox proportional hazards regression to evaluate the association between time-varying, 10-y average PM2.5 exposure and time to event in a model with age as the time axis, stratified by apolipoprotein E (APOE) genotype, and adjusted for sex, education, race, neighborhood median household income, and calendar time. Alternative models used calendar time as the time axis. RESULTS: We report 1,136 cases of incident dementia among 4,166 individuals with nonmissing APOE status. Mean [mean ± standard deviation (SD)] 10-y average PM2.5 was 10.1 (±2.9) µg/m3. Each 1-µg/m3 increase in the moving average of 10-y PM2.5 was associated with a 16% greater hazard of all-cause dementia [1.16 (95% confidence interval: 1.03, 1.31)]. Results using calendar time as the time axis were similar. DISCUSSION: In this prospective cohort study with extensive exposure data and consensus-based outcome ascertainment, elevated long-term exposure to PM2.5 was associated with increased hazard of all-cause dementia. We found that optimal control of age and time confounding could be achieved through use of either age or calendar time as the time axis in our study. Our results strengthen evidence on the neurodegenerative effects of PM2.5. https://doi.org/10.1289/EHP9018.

Contribution of pulse oximetry in relation to respiratory flow events in a home-based approach aimed at diagnosing obstructive sleep apnea.

OBJECTIVE: To compare pulse oximetry with manual analysis against all signals of respiratory polygraphy. MATERIAL AND METHODS: This retrospective study estimated sensitivity (S), specificity (Sp) and positive/negative likelihood ratio (LR+/-) of the oxygen desaturation index (ODI-test) and apnea-hypopnea index (AHI-reference). RESULTS: 3854 patients (61.5% men) were included. Age, BMI, Epworth sleepiness scale and AHI were: 55 years (44-65), 30.9kg/m2 (27-36), 7 points (4-11), and 14 events/hour (6-25), respectively. 18% showed an AHI <5 events/hour, 34% = 5 and <15, 27% = or > 15 and < 30, and 31% > 30. The S, Sp, and LR+/- of ODI for AHI = 5 events/hour was 93%, 92%, 12 and 0.08 with an accuracy of 93%. For AHI = 15 events/hour, the values were: S 94%, Sp 94%, LR+ 15 and LR- 0.06 and 94% accuracy (r(2) Spearman: 0.92). CONCLUSION: In a population at a high risk for OSA, home-based pulse oximetry had a diagnostic accuracy > 90% when is compared against all respiratory signals obtained from simplified home sleep testing.

Cumplimiento e intolerancias durante el tratamiento con presión positiva en las vías aéreas Perfil de consultas externas en una unidad de sueño

Resumen Introducción: El tratamiento con presión positiva puede generar efectos adversos. Para conocer el perfil de cumplimiento e intole rancias analizamos conductas instituidas por kinesiólogos de una Unidad de Sueño. Material y Métodos: Estudio retrospectivo, trasversal y observacional. Se incluyeron pacientes > 18 años con presión positiva derivados a la consulta kinésica. Resultados: Durante cuatro años se evaluaron 244 pacientes; 165 hombres (67%), edad; 65.7 ± 11.6 años, IMC (kg/m2) 31.0 ± 5.4, de los cuales 61% utilizaba CPAP fija, 29% autoajustable, 8% dispositivos binivelados, máscaras nasales 147 (60%), oronasales 52 (21%); almohadillas 37 (15%) y termohumidificador 92 (36%). Los motivos de consultas fueron; control de la terapia (239; 61%), intolerancias (67; 17%) y calibración (51; 13%). El cumplimiento (horas/noche) fue de 4.61 ± 2.1 con un % de noches > 4 horas de 67 ± 36 %. No hallamos diferencias de cumplimiento entre primer y segundo año (4.5 vs. 5.0 horas/noche) p > 0.13, aunque este fue mayor a partir de 600 días de uso de la terapia (p < 0.05). 141 pacientes (57%) presentaban dificultades siendo más frecuentes las fugas (19%) o intolerancias a la máscara (10%). Un (97%) de los pacientes resolvieron intolerancias con 194 conductas; demostración de máscaras (94; 48%), calibración (44; 22%), educación (45; 23%), titulación (13; 6%) y derivación al neumonólogo (14; 7%). Conclusiones: Dos terceras partes de los pacientes cumplen el tratamiento con presión positiva y la mitad presenta intolerancias. La consulta kinésica especializada puede contribuir a la identificación y resolución de dificultades durante la terapia.

Patient Intolerance and Compliance with Positive Airway Pressure Treatment Outpatient Consultations Profile in a Sleep Unit

Abstract Introduction: Treatment with positive pressure may cause adverse effects. In order to know the compliance and intolerance profile, we analyzed the behaviors established by physiotherapists of a Sleep Unit. Materials and Methods: Observational, retrospective, cross-sectional study. We included patients older than 18 years with positive pressure referred to the kinesiological consultation. Results: 244 patients were evaluated during four years: 165 men (67%), age 65.7 ± 11.6 years, BMI (Body Mass Index) 31.0 ± 5.4 (kg/m2), 61% of which used fixed CPAP (Continuous Positive Airway Pressure), 29% auto-adjusting CPAP, 8% bilevel devices, 147 (60%) nasal masks, 52 (21%) oronasal masks; 37 pads (15%), and 92 (36%) thermohumidifiers. Reasons for consultation were: therapy control, 239 (61%); intolerance, 67 (17%), and calibration, 51 (13%). Compliance (hours/night) was 4.61 ± 2.1, with a percentage of nights > 4 hours of 67 ± 36%. We didn't find any difference in the com pliance of the first and the second year (4.5 vs. 5.0 hours/night) p > 0.13, but the value was higher after 600 days of therapy (p < 0.05). 141 patients (57%) showed some complications, the most frequent being leaks (19%) or intolerance to the masks (10%). 97% of the patients resolved the intolerance with 194 behaviors: explanation of how to use the mask, 94 (48%); calibration, 44 (22%); information, 45 (23%); titration, 13 (6%), and referral to the pulmonologist, 14 (7%). Conclusions: Two thirds of the patients complied with the positive pressure treatment and half of the patients showed intolerance. The specialized kinesiological consultation can contribute to the identification and resolution of difficulties that may arise during therapy.

Compliance to Continuous Positive Airway Pressure therapy in patients with obstructive sleep apnea - long-term assessment.

INTRODUCTION: To assess CPAP acquirement, compliance, and dropout rates among OSA patients three years after the prescription. MATERIAL AND METHODS: We assessed CPAP acquirement (Acq), compliance (Comp), and dropout (Dout) through a telephone survey. We interviewed 156 patients; ESS: 9.9±5.7, AHI>15ev/hour in 96.4%. 92 patients had accessed CPAP therapy (58.9%) and 67 (72.8%) were still using it. Dropout was reported by 25 (27.2%). The Comp group was older (p<0.01), had more men (p<0.001), higher ESS scores (p<0.03) and a higher level of specialist follow-up (p<0.001). Multivariate analysis adjusted showed; follow-up by experts (OR: 4.39; p<0.05) and ESS>10 (OR: 1.25; p<0.05) increased CPAP compliance. CONCLUSION: There is a high number of patients without CPAP therapy acquirement. Long-term compliance was found in ¾ of the study population in symptomatic patients followed up by specialists. Finally, 43% had effective treatment.