Right Versus Left Cuff Position for Upper Airway Stimulation.

OBJECTIVE: Upper airway stimulation (UAS) is a treatment option for obstructive sleep apnea in which electrical stimulation is applied to the hypoglossal nerve. Nerve branches that control tongue protrusion are located inferiorly. Due to positioning, left-sided implants are typically placed with an inferiorly oriented electrode cuff (L-down) as opposed to superiorly on the right (R-up). In this study, we assess the impact of left- versus right-sided UAS on patient outcomes. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary Academic Medical Center. METHODS: Patients who underwent UAS implantation between 2016 and 2021 with an L-down or R-up oriented cuff as confirmed by X-ray were included. Data were collected retrospectively. Most recent sleep study variables were used for analysis. RESULTS: A total of 190 patients met the inclusion criteria. The average age was 61.0 ± 11.0 years, with 55 (28.9%) females. L-down orientation was present in 21 (11.1%) patients vs 169 (88.9%) R-up. Indications for L-down included hunting/shooting (n = 15), prior radiation/surgery (n = 4), central port (n = 1), and brachial plexus injury (n = 1). Adherence was higher among L-down patients (47.1 vs 41.0 hours use/week, P = .037) in univariate analysis, with a similar time to adherence data collection (4.4 vs 4.2 months, P = .612), though this finding was not maintained in the multivariate regression analysis. Decrease in apnea-hypopnea index (21.3 vs 22.8, P = .734), treatment success (76.5% vs 84.0%, P = .665), functional threshold (1.5 vs 1.6, P = .550), therapeutic amplitude (2.3 vs 2.4, P = .882), and decrease in Epworth Sleepiness Scale (4.9 vs 2.6, P = .060) were not significantly different between cohorts. CONCLUSION: This study is the first to examine the orientation of the UAS electrode cuff concerning the electrodes' natural position and the potential effect on postoperative outcomes. Our study found no significantly different treatment outcomes between the L-down versus R-up cohort, with the exception of device adherence, which was significantly higher in the L-down group on univariate analysis though not on multivariate analysis. Future studies with larger patient cohorts are needed to further investigate this potential relationship between treatment outcomes and electrode cuff orientation.

Upper airway stimulation device failure: A 7-year single center experience.

OBJECTIVE: To identify and report a single center experience with upper airway stimulator device-related failures. STUDY DESIGN: Retrospective case series. SETTING: Single tertiary academic center. METHODS: Retrospective data on 352 patients who underwent UAS surgery with an Inspire device from 2016 to 2023 was collected, including demographics, comorbidities, and nature of device failure requiring revision surgery. RESULTS: Out of the 348 patients included in our analysis, 16 (4.6 %) required revision due to device failure, with an average interval of 772 days (∼2 years) between initial implant and revision. Most failures were attributed to respiratory sensing lead damage (n = 11, 68.8 %), resulting in high system impedance and subsequent device malfunction. Lead fracture causes varied, including idiopathic occurrences and potential trauma. Lead migration was noted in one case (6.3 %), where the hypoglossal electrode detached from the nerve. Two patients (12.3 %) required implantable pulse generator (IPG) replacement, one after experiencing trauma and the other due to unclear source of malfunction. One patient (6.3 %) required complete system replacement following high lead impedance and absent tongue motion. The last patient required replacement of both the IPG and respiratory lead after experiencing high lead impedance (6.3 %). CONCLUSION: Respiratory sensing lead fracture emerged as the leading cause of device failure in this cohort, underscoring the need to address this under-reported issue, potentially linked to the time lapse after device implantation.

Long-term trends in body mass index throughout upper airway stimulation treatment: does body mass index matter?

STUDY OBJECTIVES: Upper airway stimulation is a surgical option for patients with obstructive sleep apnea who fail other forms of noninvasive treatment. Current guidelines recommend a baseline body mass index (BMI) below 32 kg/m2 for eligibility. In this study, we identify trends in BMI before and after upper airway stimulation to characterize the influence of BMI on treatment success. METHODS: Patients underwent upper airway stimulation implantation between 2016 and 2021. Sleep study data were collected from preoperative and most recent postoperative sleep study. BMI data were collected and compared across the following time points: preoperative sleep study (BMI-1), initial surgeon consultation (BMI-2), surgery (BMI-3), titration polysomnogram (BMI-4), and second postoperative sleep study (BMI-5). Patients were categorized into groups (BMI ≥32 [BMI32], 25 ≤ BMI <32 [BMI25], BMI <25 [BMI18]) based BMI-1, and clinical outcomes were compared. RESULTS: 253 patients were included. The BMI32 group showed a significant decrease in BMI between BMI-1 and BMI-3 (33.9 vs 32.2; P < .001) and a significant increase in BMI between BMI-3 and BMI-5 (32.2 vs 33.0; P = .047). Apnea-hypopnea index improvement and treatment success rate were not significantly different between groups. On univariate and multivariable logistic regression, a lower BMI-5 was significantly predictive of treatment success (odds ratio: 0.88; 95% confidence interval: 0.79-0.97; P = .016). BMI-5 was also significantly associated with improvement in apnea-hypopnea index (P = .002). Other BMI time points were not associated with measures of treatment success. CONCLUSIONS: Reduced BMI after upper airway stimulation implantation, as opposed to baseline BMI, predicted treatment success. These findings may guide patient counseling, with implications for long-term adherence and therapy success. CITATION: Renslo B, Virgen CG, Sawaf T, et al. Long-term trends in body mass index throughout upper airway stimulation treatment: does body mass index matter? J Clin Sleep Med. 2023;19(6):1061-1071.

The Effect of Lateral Pharyngeal Collapse Patterns on Therapy Response in Upper Airway Stimulation Surgery.

OBJECTIVES: Obstructive sleep apnea (OSA) is characterized by repeated upper airway collapse while sleeping which leads to intermittent hypoxemia. Upper airway stimulation (UAS) is a commonly practiced modality for treating OSA in patients who cannot tolerate, or do not benefit from, positive airway pressure (PAP). The purpose of this study is to identify the effect of lateral pharyngeal collapse patterns on therapy response in UAS. METHODS: A retrospective cohort study from a single, tertiary-care academic center was performed. Patients who underwent UAS between October 2016 and July 2019 were identified and analyzed. Drug-induced Sleep Endoscopy (DISE) outcomes between Apnea-Hypopnea Index (AHI) responders and AHI non-responders were compared. Those with complete concentric collapse at the velopharynx were not candidates for UAS. RESULTS: About 95 patients that underwent UAS were included in this study. Pre- to Post-UAS demonstrated significant improvements in Epworth Sleepiness Scale (12.0 vs 4.0, P = .001), AHI (29.8 vs 5.4, P < .001) and minimum oxygen saturation (79% vs 83%, P < .001). No DISE findings significantly predicted AHI response after UAS. Specifically, multiple types of lateral pharyngeal collapse patterns did not adversely effect change in AHI or AHI response rate. CONCLUSION: Demonstration of lateral pharyngeal collapse on DISE, in the absence of complete concentric velopharyngeal obstruction, does not appear to adversely affect AHI outcomes in UAS patients. LEVEL OF EVIDENCE: VI.

Estimating the usefulness of distorted natural images using an image contour degradation measure.

Quality estimators aspire to quantify the perceptual resemblance, but not the usefulness, of a distorted image when compared to a reference natural image. However, humans can successfully accomplish tasks (e.g., object identification) using visibly distorted images that are not necessarily of high quality. A suite of novel subjective experiments reveals that quality does not accurately predict utility (i.e., usefulness). Thus, even accurate quality estimators cannot accurately estimate utility. In the absence of utility estimators, leading quality estimators are assessed as both quality and utility estimators and dismantled to understand those image characteristics that distinguish utility from quality. A newly proposed utility estimator demonstrates that a measure of contour degradation is sufficient to accurately estimate utility and is argued to be compatible with shape-based theories of object perception.

Nanostructural characterization of catfish skin gelatin using atomic force microscopy.

To determine the nanostructure of gelatin from catfish (Ictalurus punctatus) skin, atomic force microscopy (AFM) was used to study gelatin aggregates. The gelatin was extracted at an optimized acid concentration after alkaline processing. First, the AFM imaging parameters were optimized to obtain high-quality images. Then height mode with a 2-dimensional plane, 3-dimensional topographical images, and error signal mode images, which removed slow variations in surface topography but highlighted the edges of sample features, were used to analyze the structure of particles. The results describe fish gelatin at a nanoscale level for the first time and are compared with AFM images of mammalian gelatins. Both annular pores with diameters averaging 118 nm and spherical aggregates with an average diameter of 267 nm were seen in the AFM images of fish gelatin. From the AFM images, we propose that the structures formed were determined by whether the solution penetrated into the gelatin molecules evenly or not during hydrolysis. A scheme for the formation of annular pores and spherical aggregates is proposed.

Toxicity of fipronil and its enantiomers to marine and freshwater non-targets.

Fipronil is a phenylpyrazole insecticide used in agricultural and domestic settings for controlling various insect pests in crops, lawns, and residential structures. Fipronil is chiral; however, it is released into the environment as a racemic mixture of two enantiomers. In this study, the acute toxicity of the (S,+) and (R,-) enantiomers and the racemic mixture of fipronil were assessed using Simulium vittatum IS-7 (black fly), Xenopus laevis (African clawed frog), Procambarus clarkii (crayfish), Palaemonetes pugio (grass shrimp), Mercenaria mercenaria (hardshell clam), and Dunaliella tertiolecta (phytoplankton). Results showed that S. vittatum IS-7 was the most sensitive freshwater species to the racemic mixture of fipronil (LC50 = 0.65 microg/L) while P. pugio was the most sensitive marine species (LC50 = 0.32 microg/L). Procambarus clarkii were significantly more sensitive to the (S,+) enantiomer while larval P. pugio were significantly more sensitive to the (R,-) enantiomer. Enantioselective toxicity was not observed in the other organisms tested. Increased mortality and minimal recovery was observed in all species tested for recovery from fipronil exposure. These results indicate that the most toxic isomer of fipronil is organism-specific and that enantioselective toxicity may be more common in crustaceans than in other aquatic organisms.

Allergy symptom response to intradermal testing-based immunotherapy: a retrospective study of clinical practice.

OBJECTIVE: Evaluate the multiple end-organ targets affected by intradermal testing (IDT)-based immunotherapy. Study design and setting We conducted a retrospective medical record review of 139 patients, as well as a follow-up questionnaire in a university setting. RESULTS: Statistically significant differences (t-tests, P < 0.05) were observed in the prevalence of symptoms after IDT-based immunotherapy for each category (ear, eye, nasal, and throat). When divided into treatment time groups, the reduction was less in the first group (0-6 months therapy), than the subsequent groups (6-24 months and >24 months). The reduction leveled off after 6 months of therapy, with no difference seen between the 6- to 24-month and >24-month groups. CONCLUSIONS: IDT-based immunotherapy has a broad response on otolaryngic allergy symptoms that appears to be consistent over time. SIGNIFICANCE: IDT-based immunotherapy is an effective form of treatment for allergy-induced diseases of the head and neck.