Do symptoms of sleepiness and insomnia in US veterans with obstructive sleep apnea vary by age?

INTRODUCTION: The influence of aging on the clinical presentation of obstructive sleep apnea (OSA) is not well characterized in US veterans. Our aims were to (1) examine age and established predictors of sleepiness and insomnia symptoms in veterans with OSA and (2) determine if the relationship between predictors of the Epworth sleepiness scale (ESS) and insomnia severity index (ISI) depended on age. METHODS: We performed a retrospective analysis of veterans diagnosed with OSA at the Miami VA in 2014. On polysomnography (PSG) night, questionnaires were completed querying socio-demographics, insomnia (ISI), sleepiness (ESS), and self-reported sleep duration. Regression modeling was performed to explore association of variables with (1) ESS and (2) ISI. Analyses were performed in two steps: (1) variables were tested for main effects and (2) product of age and each variable found to have an association at a significance level of p < 0.10 with primary outcome were entered separately to test for interaction. RESULTS: The sample consisted of 483 veterans (93% male, age 52 ± 13 years, 41% black, 34% Hispanic). Having a regular bed partner, higher weighted medical comorbidities, chronic pain diagnosis, and shorter sleep duration were associated with ESS. Age did not moderate the relationship between these variables and ESS. Younger age, Hispanic ethnicity, higher educational level, shorter sleep duration, mood, and pain diagnoses were each associated with the ISI. Furthermore, an age-sleep duration interaction term was associated with the ISI (b = - 0.03; p = 0.005). For all participants, there was an inverse relationship between sleep duration and ISI. However, for any sleep duration, older veterans reported lower levels of insomnia than younger veterans. DISCUSSION: Older veterans with OSA may report lower ISI scores. Alternative assessment methods for comorbid insomnia among older individuals with OSA may be needed.

Education Coupled With In-Situ High Fidelity Simulation Improves Medical-Surgical RN Code Blue Comfort Levels.

Pediatric, cardiopulmonary arrest is a rare event outside intensive care units in children's hospitals. Medical-surgical RNs rarely are involved in code situations and are often uncomfortable in performing necessary tasks. We implemented a multi-disciplinary educational plan, coupled with in-situ high-fidelity simulation, aimed at improving medical-surgical, RN comfort levels during codes. 260 medical surgical RNs on 10 separate hospital units parficipated. Pre and post intervention surveys were collected and compared. Results revealed a significant increase in the proportion of RNs responding "very comfortable" in all categories. Education, coupled with in-situ high-fidelity simulation, is an effective tool to increase RN comfortable levels during codes.

Insomnia symptoms in South Florida military veterans with epilepsy.

BACKGROUND: Despite the high prevalence of insomnia in veterans with epilepsy, it remains understudied. Our aim was to identify the associations of insomnia with epilepsy, comorbidities, and treatment-related variables in South Florida veterans. METHODS: We performed a cross-sectional analysis of veterans attending an epilepsy clinic over 18 months. Participants completed standardized assessments of seizure and sleep. Insomnia was defined as 1) difficulty with sleep onset, maintenance, or premature awakenings with daytime consequences or 2) sedative-hypnotic use on most nights of the previous month. RESULTS: One hundred sixty-five veterans (87% male, age 56 ± 15 years) were included: 66 reporting insomnia (40%). In logistic regression analysis, insomnia was significantly associated with post-traumatic seizure etiology, lamotrigine prescription, and mood and psychotic disorders. Female gender and levetiracetam treatment were associated with lower odds for insomnia. CONCLUSION: Insomnia was associated with post-traumatic epilepsy, mood/psychotic comorbidities, and antiepileptic regimen. Insomnia represents an under-recognized opportunity to improve comprehensive epilepsy care.

Determinants of continuous positive airway pressure adherence in a sleep clinic cohort of South Florida Hispanic veterans.

PURPOSE: There are little existing data on continuous positive airway pressure (CPAP) adherence in US Hispanic veterans with obstructive sleep apnea (OSA). Our aim was to describe determinants of 1-month adherence in a sleep clinic cohort of South Florida Hispanic veterans. METHODS: Hispanic veterans referred to the Miami VA sleep clinic were recruited and completed questionnaires about sleep apnea risk, sleep quality, insomnia symptoms, sleepiness, depression/anxiety, acculturation, personality traits, and cognitions about OSA and CPAP. Individuals at risk for OSA were scheduled for baseline polysomnography (PSG), followed by in-lab CPAP titration or a trial of auto-CPAP. Participants with OSA accepting CPAP therapy were asked to return after 7 and 30 days of treatment for adherence verification and to repeat questionnaires. RESULTS: One hundred twenty-four participants (94 % men) were enrolled with 114 completing overnight PSG. Eighty-six out of 95 participants (91 %) with sleep apnea syndrome or moderate to severe OSA accepted CPAP treatment. Fifty-nine participants completed both follow-up visits with a mean CPAP use at 30 days of 3.6 ± 2.0 h. The only independent predictor of 7-day mean daily CPAP use was the baseline Insomnia Severity Index while the best predictor of 30-day mean daily CPAP use was the 7-day mean daily use. CONCLUSIONS: Our study suggests that South Florida Hispanic veterans with OSA evaluated in a sleep clinic show poor CPAP adherence. Insomnia and poor early use predicted poor adherence overall. Larger prospective studies with other race-ethnic groups are needed to determine the role of ethnicity and race in CPAP adherence among US veterans with OSA.

Oxidative stress, mitochondrial dysfunction and calcium overload in human lamina cribrosa cells from glaucoma donors.

PURPOSE: Oxidative stress is implicit in the pathological changes associated with glaucoma. The purpose of this study was to compare levels of oxidative stress in glial fibrillary acid-negative protein (GFAP) lamina cribrosa (LC) cells obtained from the optic nerve head (ONH) region of 5 normal (NLC) and 4 glaucomatous (GLC) human donor eyes and to also examine mitochondrial function and calcium homeostasis in this region of the ONH. METHODS: Intracellular reactive oxygen species (ROS) production was examined by a thiobarbituric acid reactive substances (TBARS) assay which measures malondialdehyde (MDA), a naturally occurring product of lipid peroxidation and is used as an indicator of oxidative stress. Mitochondrial membrane potential (MMP) and intracellular calcium ([Ca(2+)](i)) levels were evaluated by flow cytometry using the JC-1 (5,5',6,6'-tetrachloro-1,1',3,3'-tetrabenzimidazolecarbocyanine iodide) and fluo-4/AM probes respectively. Anti-oxidant and Ca(2+) transport system gene and protein expression were determined by real time polymerase chain reaction (RT-PCR) using gene-specific primer/probe sets and western immunoblotting, respectively. RESULTS: Intracellular ROS production was increased in GLC compared to NLC (27.19 ± 7.05 µM MDA versus 14.59 ± 0.82 µM MDA, p < 0.05). Expression of the anti-oxidants Aldo-keto reductase family 1 member C1 (AKR1C1) and Glutamate cysteine ligase catalytic subunit (GCLC) were significantly lower in GLC (p = 0.02) compared to NLC control. MMP was lower in GLC (57.5 ± 6.8%) compared to NLC (41.8 ± 5.3%). [Ca(2+)](i) levels were found to be higher (p < 0.001) in GLC cells compared to NLC. Expression of the plasma membrane Ca(2+)/ATPase (PMCA) and the sodium-calcium (NCX) exchangers were lower, while intracellular sarco-endoplasmic reticulum Ca(2+)/ATPase 3 (SERCA) expression was significantly higher in GLC compared to NLC. Subjection of NLC cells to oxidative stress (200 µM H(2)0(2)) reduced expression of Na(+)/Ca2(+) exchanger 1 (NCX 1), plasma membrane Ca2+ ATPase 1 (PMCA 1), and PMCA 4 as determined by RT-PCR. CONCLUSIONS: Our data finds evidence of oxidative stress, mitochondrial dysfunction and impaired calcium extrusion in GLC cells compared to NLC cells and suggests their importance in the pathological changes occurring at the ONH in glaucoma. Future therapies may target reducing oxidative stress and / or [Ca(2+)](i).

Bicalutamide (Casodex) 150 mg plus standard care in early non-metastatic prostate cancer: results from Early Prostate Cancer Trial 24 at a median 7 years' follow-up.

Trial 24, one of three ongoing trials in the Early Prostate Cancer programme, is evaluating the efficacy and tolerability of bicalutamide (Casodex) 150 mg following standard care (radiotherapy, radical prostatectomy or watchful waiting) in patients with early, non-metastatic prostate cancer. At 7 years' median follow-up, addition of bicalutamide significantly improved objective progression-free survival (PFS) for patients with locally advanced disease, reducing the risk of progression by 34% versus standard care alone (hazard ratio 0.66; 95% confidence interval 0.55, 0.79; P<0.001). In localized disease, a significant difference in objective PFS was not found. There was no significant difference in overall survival.

Local control of T2/3 transitional cell carcinoma of bladder is correlated to differences in DNA supercoiling: evidence for two discrete tumor populations.

Single cell tumor suspensions were prepared from biopsy and urine samples from 48 patients with muscle invasive transitional cell carcinoma of the bladder. Prior to therapy, samples were irradiated in vitro with the condensation of DNA supercoils measured by the light scattered within a flow cytometer. Six months after completing a course of radiotherapy, the in vitro data were correlated with the presence or absence of local disease. After 12-Gy irradiation, nucleoid extraction and staining with 50 micrograms/ml ethidium bromide, 2 predominant forms of supercoiling behavior were seen. Nucleoids scattered either approximately 10% (Type I) or 35% (Type II) more light than unirradiated controls. Those patients with residual disease showed more Type I behavior (21 of 25; 84%) than those patients clear of disease (9 of 23; 39%) (P = 0.02). It is proposed that the ability of these tumor samples to adopt positive supercoiling after irradiation is related to a stronger association between individual DNA loops and their attachment to the nuclear matrix. This difference in nucleoid response within these tumor samples may be related both to intrinsic cellular radiosensitivity and, subsequently, to clinical radiocurability.

Urologist led one-stop testicular clinic: the UK 'gold standard'.

Prompt diagnosis and early treatment for testicular cancer is vital. To help with this a one-stop, urologist run, testicular clinic with testicular ultrasound scanning as an integral part of the clinic format was introduced to investigate patients in an efficient and timely manner. The aim of this study was to assess the feasibility and efficiency of running a one-stop testicular clinic. A prospectively collected electronic database of all patients attending a one-stop testicular clinic at a busy university hospital was interrogated over a 6-year period. Only new referral males, above the age of 15 years old were included. Case notes were reviewed retrospectively. A total of 1757 patients were found with a median age of 36. 6.3 % had a suspicious ultrasound scan and overall 5.6 % were found to have malignancy histologically. In addition a significant proportion of men with a history of testicular maldescent went on to develop testicular cancer (p < 0.01). Median time from referral to clinic and clinic to orchidectomy for suspected testicular cancers was 9 and 5 days respectively (95 % CI). Some of the benefits of a urologist run one-stop testicular clinic include: timely diagnosis and treatment, early reassurance with normal investigations, the discovery of clinically unsuspecting malignancy and the increase in teaching opportunities. These collective benefits must improve patient experience and benefit the department as a whole. A urologist led one-stop testicular clinic should be regarded as the gold standard.

The role of apolipoprotein E in Alzheimer's disease: pharmacogenomic target selection.

The association of inheritance of different apolipoprotein E (APOE, gene; apoE, protein) alleles with the risk and rate of onset of Alzheimer's disease (AD) is now well established and widely confirmed. While there are now a collection of hypotheses concerning the specific relationship of APOE polymorphisms to various phenotypic manifestations of AD, no single compelling theory has been tested and universally accepted. The only clear fact emerging during the past 6 years is that differences in APOE genotype affect the average rate of disease onset as a predictable function of the inheritance of this polymorphic gene. Methods now exist to enable experimental designs to study the metabolic effects of inheriting different APOE alleles, addressing what differences that may be present for many years, perhaps over the entire lifetime, can lead to earlier or later manifestations of the disease and are therapeutically tractable. This review summarizes part of an experimental approach to identify biological pathways influenced by the different APOE polymorphisms that are relevant to the pathogenesis of AD.

Bicalutamide ('Casodex') 150 mg in addition to standard care in patients with nonmetastatic prostate cancer: updated results from a randomised double-blind phase III study (median follow-up 5.1 y) in the early prostate cancer programme.

Trial 24 is one of three placebo-controlled trials within the ongoing bicalutamide ('Casodex') Early Prostate Cancer (EPC) programme evaluating bicalutamide 150 mg/day in addition to radical prostatectomy, radiotherapy or watchful waiting for T1b-4, any N, M0 prostate cancer. In Trial 24, at 5.1 y median follow-up, the addition of bicalutamide significantly (P < 0.0001) improved objective progression-free survival (PFS) and prostate-specific antigen PFS compared with standard care alone. There was no significant difference in overall survival (P = 0.746). In the context of the whole EPC programme, long-term bicalutamide is not appropriate for localised disease, yet provides advantages in delaying disease progression in patients with locally advanced prostate cancer.

Calcium channel blockade reduces mechanical strain-induced extracellular matrix gene response in lamina cribrosa cells.

PURPOSE: This study examines the effect of the L-type calcium channel blocker verapamil on mechanical strain-induced extracellular matrix genes in optic nerve head lamina cribrosa (LC) cells. METHODS: Changes in LC cell intracellular calcium [Ca(2+)]i following hypotonic cell membrane stretch were measured with the fluorescent probe fura-2/AM. Fluorescence intensity was measured, after labelling, by calcium (Ca2+) imaging confocal microscopy. Confluent human LC cell cultures were serum starved for 24 h prior to exposure to cyclical mechanical strain (1 Hz, 15%) for 24 h in the presence or absence of verapamil (10 mm). Transforming growth factor-ß 1 (TGF-ß1), collagen 6A3 (COL6A3) and chondroitin sulfate proteoglycan 2 (CSPG2) mRNA expression levels were assessed by quantitative RT-PCR. RESULTS: Hypotonic cell membrane stretch of LC cells from normal donors significantly increased [Ca2+]i (p<0.05). Exposure to cyclical mechanical strain (15% strain) produced a statistically significant increase in the three matrix genes that were examined (TGF-ß1, COL6A3 and CSPG2). This response in both cyclical and mechanical stretch was significantly reduced by pretreating LC cells with the L-type calcium channel blocker verapamil (p<0.05). CONCLUSIONS: This study provides evidence of a novel mechanotransduction pathway linking mechanical strain, cation channel function and the induction of LC cell matrix gene transcription. This highlights the potential involvement of calcium influx in the activation of matrix remodelling responses in the optic nerve head and supports the rationale that calcium channel blockers may attenuate disease progression in glaucoma.

Efficacy and safety of oral anticoagulation in patients with cancer.

The treatment of venous thrombosis in patients with cancer is a common clinical problem. It appears that long term oral anticoagulant therapy with coumadin does not carry a significantly increased risk of major bleeding compared with the risk in patients without cancer. However, the risk of recurrent thrombosis in these individuals appears to be higher than in those patients without cancer. Nevertheless, the treatment of most patients with cancer and venous thrombosis with standard anticoagulant therapy is reasonable. Prospective, randomized trials are required to determine the optimal therapy for these patients, and, in particular, those that have failed traditional anticoagulation.

The efficacy and safety of oral anticoagulation in patients with cancer.

OBJECTIVES: To compare the complication rate (bleeding and thrombosis) of oral anticoagulation in a cohort of patients with cancer to a cohort without cancer. DESIGN: Prospective cohort study. SETTING: Outpatient anticoagulation clinic in a community hospital. PATIENTS: Consecutive patients enrolled in an anticoagulation clinic: 44 with cancer, 64 without cancer. INTERVENTIONS: Patients received prophylactic doses of Warfarin (target INR 2-3 in the majority of instances) and complication rates were assessed. MEASUREMENTS: Major bleeding (strictly defined), minor bleeding, recurrent thrombosis, proportion of time with therapeutic INR, frequency of clinic visits. RESULTS: The rates of major bleeding, minor bleeding, and recurrent thrombosis were not statistically significantly different in the two groups of patients. Therapeutic INR's were more difficult to sustain in the cancer patients as compared to the non-cancer patients (43.3% vs 56.9%, p < 0.0001). There was a non significant trend towards more frequent monitoring for the cancer patients compared with the non-cancer patients (4.6 vs 3.5 visits per treatment month, p = 0.14). CONCLUSIONS: Oral anticoagulation is safe and effective in the patient with cancer. It is more difficult to sustain a therapeutic INR in the cancer patients and they may need more frequent monitoring to achieve a low complication rate.

Characterization of three non-peptide endothelin receptor ligands using human cloned ETA and ETB receptors.

1. A number of putative endothelin (ET) receptor ligands were synthesized with a view to assessing their relative affinity for human recombinant ET receptors. 2. Human (h) and endothelin ETA and ETB receptor open reading frames were cloned by reverse transcription-polymerase chain reaction into the mammalian expression vector pcDNA1 and stable cell lines were created by transfection of Chinese hamster ovary cells. 3. Scatchard analyses of saturation isotherms for the specific binding of [125I]-endothelin-1 ([125I]-ET-1) to membranes, prepared from Chinese hamster ovary cells transfected with hETA or hETB receptors, yielded values for equilibrium dissociation constants (Kd) of 20.5 +/- 1.8 pM and 25.5 +/- 5.5 pM, respectively. Hill coefficients did not differ significantly from unity, suggesting binding to homogeneous, non-interacting receptor populations. 4. Pharmacological characterization of the transfected hETA and hETB receptors was undertaken by measuring the relative abilities of ETA and ETB receptor-selective peptide ligands to inhibit binding of [125I]ET-1. For interaction with hETA receptors, the relative order of potency was ET-1 > ET-3 = FR139317 = BQ123 >[Ala1,3,11,15]-ET-1 = sarafotoxin S6c (S6c). In contrast, the relative order of potency, at hETB receptors, was ET-1 = ET-3 = [Ala1,3,11,15]-ET-1 = S6c >> FR139317 = BQ123. 5. The novel non-peptide ligands, Ro 46-2005, SB 209670 and BMS 182874, were found to inhibit [125I]-ET-1 binding to human recombinant ETA and ETB receptors. At hETA receptors, the calculated pIC50 values were 6.7 (Ro 46-2005), 8.7 (SB 209670) and 5.8 (BMS 182874), while at hETB receptors, the corresponding pIC50 values were 6.8, 7.5 and <5, respectively.6. In conclusion, we have characterized the pharmacology of human cloned ETA and ETB receptors and used these in membrane binding assays to determine the affinity and selectivity of three structurally diverse non-peptide ET receptor ligands. SB 209670 is, to date, the highest affinity non-peptide ligand to be described for ET receptors. As such, it may prove to be a valuable tool in further examination of the physiological and pathophysiological roles of endothelins.

HMFG-2 as a prognostic indicator in superficial bladder cancer.

A series of transitional cell carcinomas and mucosal biopsy specimens of bladder were stained immunohistochemically with the monoclonal antibody HMFG-2. Staining characteristics ranged from luminal staining in well differentiated, superficial lesions to staining of all cells in invasive carcinomas. Invasive tumour nests also stained strongly with the antibody. There was good correlation between the staining pattern and histological assessment of both tumours and mucosal biopsy specimens. Correlation with clinical course showed that it was also a good predictor of subsequent disease progression of superficial tumours. It is suggested that HMFG-2 staining is a sensitive indictor of malignant transformation and that it may have a role as an adjunct to conventional histological examination in the assessment of urothelial carcinomas.

Identification of two novel diurnal genes by screening of a rat brain cDNA library.

While the hypothalamus is fundamental for sleep and circadian regulation, the molecular mechanisms involved are poorly understood. We have used a differential gene expression technique to identify hypothalamic genes which have altered expression in rat sleep periods. Complex cDNA probes from rat hypothalami removed at Zeitgeber times 4 and 15 were hybridised to rat brain cDNA library girds. From 30 differentially expressed clones, six were further analysed and two were confirmed to exhibit increased expression at Zeitgeber time 4. A Northern blot hybridization of brain, heart, kidney, lung, testis and skin mRNA showed that both clones were brain specific. Therefore, we have identified two novel brain specific diurnally expressed hypothalamic genes. Both genes may have roles in sleep or circadian regulation.

Identification of two novel diurnal genes by screening of a rat brain cDNA library.

While the hypothalamus is fundamental for sleep and circadian regulation, the molecular mechanism involved are poorly understood. We have used a differential gene expression technique to identify hypothalamic genes which have altered expression in rat sleep periods. Complex cDNA probes from rat hypothalami removed at Zeitgeber times 4 and 15 were hybridised to rat brain cDNA library girds. From 30 differentially expressed clones, six were further analysed and two were confirmed to exhibit increased expression at Zeitgeber time 4. A Northern blot hybridization of brain, heart, kidney, lung, testis and skin mRNA showed that both clones were brain specific. Therefore, we have identified two novel brain specific diurnally expressed hypothalamic genes. Both genes may have roles in sleep or circadian regulation.

Doppler evaluation of umbilical venous and arterial blood flow in the second and third trimesters of normal pregnancy.

Duplex Doppler ultrasound was used to measure umbilical venous blood flow in 209 normal pregnant women between 20-40 weeks' gestation. The relationship between umbilical venous blood flow and gestational age increased with gestational age, and is described by the equation y = -187.02 + 12.7x. The relationship between flow per kilogram fetal weight and gestational age (y = 198.629 - 2.24x) yielded values of 153 mL/minute/kg at 20 weeks, 131 mL/minute/kg at 30 weeks, and 108 mL/minute/kg at 40 weeks. Doppler ultrasound was also used to evaluate umbilical arterial waveforms (systolic/diastolic ratio) in 171 normal pregnant women between 20-40 weeks. The relationship between systolic/diastolic ratios and gestational age (y = 6.46 - 0.12x) decreased with advancing gestational age, yielding mean systolic/diastolic ratios (+/- 2 SD) of 4.1 (5.6, 2.6) at 20 weeks, 3.6 (5.1, 2.1) at 24 weeks, 3.1 (4.6, 1.6) at 28 weeks, 2.6 (4.1, 1.1) at 32 weeks, 2.1 (3.6, 0.6) at 36 weeks, and 1.7 (3.1, 0.1) at 40 weeks.

Duplex Doppler ultrasound in the evaluation of growth in twin pregnancies.

Fifty-six multiple pregnancies were evaluated for evidence of discordant growth using traditional ultrasonic methods and duplex Doppler ultrasound. The pregnancies consisted of 52 sets of twins and four sets of triplets. Duplex Doppler ultrasound predicted normal growth in 44 of 45 normal sets of fetuses, and correctly predicted discordant growth in nine of 11 discordant sets of twins. Among those nine abnormal sets, Doppler ultrasound predicted that six would become discordant before this was recognized by traditional ultrasonic measurements. Duplex Doppler ultrasound is useful in predicting and confirming concordant and discordant growth, and defining the cause of fetal discordancy.