Preoperative sleep apnea screening protocol reduces medical emergency team activation in patients with atrial fibrillation.

STUDY OBJECTIVES: The association of in-hospital medical emergency team activation (META) among patients with atrial fibrillation (AF) at risk for obstructive sleep apnea (OSA) is unclear. This study evaluates the performance of the DOISNORE50 sleep questionnaire as an OSA screener for patients with AF and determines the prevalence of META among perioperative patients with underlying AF who have a diagnosis or are at risk for OSA. METHODS: A prospective perioperative cohort of 2,926 patients with the diagnosis of AF was assessed for DOISNORE50 questionnaire screening. Propensity-score matching was used to match patients' physical characteristics, comorbidities, length of stay, and inpatient continuous positive airway pressure device usage. META and intensive care unit admissions during the surgical encounter, 30-day hospital readmissions, and 30-day emergency department visits were evaluated. RESULTS: A total of 1,509 out of 2,926 AF patients completed the DOISNORE50 questionnaire and were enrolled in the OSA safety protocol. Following propensity-score matching, there were reduced adjusted odds of META in the screened group of 0.69 (95% confidence interval: 0.48-0.98, P < .001) in comparison to the unscreened group. The adjusted odds of intensive care unit admissions and emergency department visits within 30 days of discharge were statistically lower for the screened group compared with the unscreened group. CONCLUSIONS: Among perioperative AF patients, evidence supports DOISNORE50 screening and implementation of an OSA safety protocol for reduction of META. This study identified decreased odds of META, intensive care unit admissions, and emergency department visits among the screened group. The high-risk and known OSA group showed reduced odds of META following the implementation of an OSA safety protocol. CITATION: Saha AK, Sheehan KN, Xiang KR, et al. Preoperative sleep apnea screening protocol reduces medical emergency team activation in patients with atrial fibrillation. J Clin Sleep Med. 2024;20(5):783-792.

DOISNORE50: a perioperative sleep questionnaire predictive of obstructive sleep apnea and postoperative medical emergency team activation. A learning health system approach to sleep questionnaire development and screening.

STUDY OBJECTIVES: Patients with obstructive sleep apnea (OSA) have a disproportionate increase in postoperative complications and medical emergency team activation (META). We previously introduced DOISNORE50 (Diseases, Observed apnea, Insomnia, Snoring, Neck circumference > 18 inches, Obesity with BMI > 32, R = are you male, Excessive daytime sleepiness, 50 = age ≥ 50) from sleep questionnaire ISNORED using features associated with increased odds of META in perioperative patients. Performance of DOISNORE50 (DOISNORE) had yet to be tested. METHODS: The performance of DOISNORE was tested along with questionnaire ISNORED and STOP-BANG questionnaires among 300 out of 392 participants without known OSA referred to the sleep lab. In study 2, the performance of DOISNORE was tested among 64,949 lives screened in perioperative assessment clinic from 2016 to 2020. RESULTS: Receiver operating characteristic curve demonstrated that best performance was achieved with responses, with area under curve of 0.801. DOISNORE's predictability of OSA risk remained stable from 2018 to 2020 with area under curve of 0.78 and a Cronbach alpha of 0.65. Patients at high risk for OSA (DOISNORE ≥ 6) were associated with an increase of META (odds ratio 1.30, 95% confidence interval 1.12-1.45). Higher relative risk was noted among patients with congestive heart failure and hypercapnia. CONCLUSIONS: DOISNORE is predictive of OSA and postoperative META. Perioperative strategies against META should consider DOISNORE questionnaire and focused screening among patients with heart failure and hypercapnia. CITATION: Namen AM, Forest D, Saha AK, et al. DOISNORE50: a perioperative sleep questionnaire predictive of obstructive sleep apnea and postoperative medical emergency team activation. A learning health system approach to sleep questionnaire development and screening. J Clin Sleep Med. 2022;18(8):1909-1919.

Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is an under-recognized condition that results in morbidity and mortality. Postoperative complications, including medical emergency team activation (META), are disproportionally increased among surgical patients at risk for OSA. A systematic approach is needed to improve provider recognition and treatment, but protocols that demonstrate improvement in META are lacking. As part of a multidisciplinary quality improvement project, DOISNORE50 (DIS), a sleep apnea questionnaire and proactive safety measure, was algorithmically applied to all perioperative patients. METHODS: Consecutive sleep screening was conducted among perioperative patients. Of the 49,567 surgical navigation center patients, 11,932 had previous diagnosis of OSA. Of the 37,572 (96%) patients screened with DIS, 25,171 (66.9%) were Low Risk (DIS < 4), 9,211 (24.5%) were At Risk (DIS ≥ 4), and 3,190 (8.5%) were High Risk (DIS ≥ 6) for OSA, respectively. High Risk patients received same-day sleep consultation. On the day of surgery, patients with Known OSA, At Risk, and High Risk for OSA received an "OSA Precaution Band." An electronic chart reminder alerted admission providers to order postoperative continuous positive airway pressure (CPAP) machine and sleep consult for patients High Risk for OSA. RESULTS: Implementation of a comprehensive program was associated with increased sleep consultation, sleep testing, and inpatient CPAP use (P < .001). For every 1,000 surgical patients screened, 30 fewer META, including rapid responses, reintubation, code blues, and code strokes, were observed. However, inpatient sleep consultation and inpatient CPAP use were not independently associated with reduced META. In the subgroup of patients hospitalized longer than 3 days, inpatient CPAP use was independently associated with reduced META. CONCLUSIONS: In this single-center, institution-wide, multidisciplinary-approach, quality improvement project, a comprehensive OSA screening process and treatment algorithm with appropriate postoperative inpatient CPAP therapy and inpatient sleep consultations was associated with increased CPAP use and reduced META. Further prospective studies are needed to assess cost, feasibility, and generalizability of these findings. CITATION: Namen AM, Forest D, Saha AK, et al. Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2022;18(8):1953-1965.

Prognostic value of Goldberger's electrocardiographic criteria for left ventricular dysfunction.

BACKGROUND: The ability of the Goldberger electrocardiographic (ECG) triad criteria to detect left ventricular dysfunction (LVD) is well-established. However, the prognostic significance of this triad as a predictor of poor outcomes is not known. OBJECTIVE: We explored the association between the Goldberger ECG-LVD triad with all-cause mortality and cardiovascular mortality in the general population. METHODS: This analysis included 8426 participants (60.5 ±â€¯13.6 years, 51.5% women, 50% non-Hispanic white) from the Third National Health and Nutrition Examination Survey. The Goldberger ECG-LVD triad was defined as follows: high precordial QRS voltage (SV1 or SV2 + RV5 or RV6 ≥ 3500 µV); low limb lead QRS voltage (mean QRS amplitude in each of the limb leads ≤800 µV); and poor R wave progression (RV4/SV4 < 1). Mortality was ascertained using the National Death Index. RESULTS: At baseline, 1384 (47.3%) of the participants had at least one of the criteria of Goldberger triad (1193 had only one and 191 participants had 2 or more). During a median follow up of 13.8 years, 3184 deaths occurred, of which 1405 were cardiovascular. In multivariable-adjusted Cox proportional hazards models, presence of at least one of the Goldberger triad criteria (vs. none) was associated with increased risk of all-cause (HR 1.17, 95% CI 1.08-1.26, p ≤0.0001) and cardiovascular mortality (1.19, 1.06-1.33, p = 0.003). CONCLUSION: The Goldberger ECG-LVD triad for left ventricular dysfunction may offer prognostic value in addition to its reported diagnostic utility.

On the formation of a protic ionic liquid in nature.

The practical utility of ionic liquids (ILs) makes the absence (heretofore) of reported examples from nature quite puzzling, given the facility with which nature produces many other types of exotic but utilitarian substances. In that vein, we report here the identification and characterization of a naturally occurring protic IL. It can be formed during confrontations between the ants S. invicta and N. fulva. After being sprayed with alkaloid-based S. invicta venom, N. fulva detoxifies by grooming with its own venom, formic acid. The mixture is a viscous liquid manifestly different from either of the constituents. Further, we find that the change results as a consequence of formic acid protonation of the N centers of the S. invicta venom alkaloids. The resulting mixed-cation ammonium formate milieu has properties consistent with its classification as a protic IL.

(1S*,2R*,3S*,4R*,5R*)-5-Tetra-decyloxy-methyl-7-oxabicyclo-[2.2.1]heptane-2,3-dicarb-oxy-lic anhydride.

In the title compound, C23H38O5, the oxabicyclo-[2.2.1]heptane-2,3-dicarb-oxy-lic anhydride unit has a normal geometry and the tetra-decoxymethyl side chain is fully extended. In the crystal, mol-ecules are linked head-to-head by C-H⋯O hydrogen bonds, forming two-dimensional networks propagating along the a and c-axis directions.

Tris(thio-cyanato-κN)tris-(triphenyl-phosphine oxide-κO)europium(III)-(nitrato-κ(2) O,O')bis-(thio-cyanato-κN)tris-(triphenyl-phosphine oxide-κO)europium(III) (1/1).

The title co-crystal, [Eu(NCS)3(C18H15OP)3][Eu(NCS)2(NO3)(C18H15OP)3], contains two distinct neutral complexes. Each complex has threefold symmetry about its central Eu(3+) ion. As a result, the nitrate-containing mol-ecule contains disorder of its bidentate nitrate and two N-bound thio-cyanate anions, while the [Eu(NCS)3(OPPh3)3] complex is fully ordered. There is a weak π-π stacking inter-action between the phenyl rings of the two mol-ecules [centroid-centroid distance = 4.138 (4) Å].

Tris(thio-cyanato-κN)tris-(triphenyl-phosphine oxide-κO)terbium(III).

The title compound, [Tb(NCS)3(C18H15OP)3], contains a six-coordinate Tb(II) cation surrounded by three O-bound triphenyl-phosphine oxide ligands and three N-bound thio-cyanate ligands, each in a fac arrangement. There are two crystallographically unique Tb(III) atoms in the asymmetric unit. One Tb(III) atom resides on a threefold rotation axis, while the other has no imposed crystallographic symmetry. The thio-cyanate ligands are bound through N atoms, illustrating the hard-hard bonding principles of metal complex chemistry.