Anemia of aging and obstructive sleep apnea.

INTRODUCTION: World Health Organization defined anemia of aging (AOA) when men and women greater than 65 years, respectively, have unexplained hemoglobin (Hgb) less than 13 and 12 g/dl. Recent evidence suggests that this is likely a chronic inflammatory process involving interleukins (IL) 6, 12, and C-reactive protein. Among elderly with obstructive sleep apnea (OSA), hypoxic stimulation of erythropoiesis may obscure AOA. Treatment of OSA may paradoxically restore AOA. We sought to identify OSA and AOA coexistence and OSA treatment AOA interaction. METHODS: Records of 101 successive patients older than 65 years and with OSA who were treated with continuous positive airway pressure were analyzed retrospectively. Differences among pre/post-treatment of OSA hemograms were assessed using paired two-tailed Student's t test. Hemogram changes were compared to apnea-hypopnea index (AHI), respiratory effort related arousals (RERA), and duration patients slept with oxyhemoglobin saturation <89% (hypoxic time (HT)) and were assessed for correlative significance using Pearson coefficient correlation. RESULTS: Eighty-two of one hundred one patients (27 men, 55 women; average age 71 years) had charted all the study data variables cited above. Mean pre-treatment and mean 1-year post-treatment of OSA Hgb/hematocrit (Hct) for men and women, respectively, were 13 g/dl/40.7% to 12.7 g/dl/39.1% and 12.1 g/dl/38.1% to 11.9 g/dl/37.6%. Hct changed significantly among both men and women (p < 0.05). Among 56% and 30% of the 82 patient study cohort, 1-year post-treatment of OSA, Hct declined (mean 4.8%) and increased (mean 3.7%), respectively; both changes were statistically significant (p < 0.01). These changes did not correlate significantly with AHI, RERA, or HT. DISCUSSION: Among the entire cohort for both men and women, we did not see AOA before OSA treatment and we did see AOA 1 year after OSA treatment. However, post-treatment of OSA Hct distributed bimodally, with significant increases and declines of Hct. While these Hct changes did not correlate significantly with selected sleep-breathing variables, we remain intrigued by a possible AOA-OSA interaction. AOA and OSA share common inflammatory processes. We believe OSA inflammatory processes interact with OSA hypoxia-induced erythropoiesis. The balance of these sets of processes determines the effect of OSA and OSA treatment on AOA.

Sleep Apnea Is Associated with Hearing Impairment: The Hispanic Community Health Study/Study of Latinos.

STUDY OBJECTIVE: Sleep apnea (SA) may promote hearing impairment (HI) through ischemia and inflammation of the cochlea. Our objective was to assess an independent association between SA and HI in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) participants. METHODS: We used data from the HCHS/SOL, a multicenter population-based study of self- identifying Hispanic/Latinos 18- to 74-y-old adults from four US urban communities. We performed home SA testing and in-clinic audiometry testing in all participants. SA was defined as an apnea-hypopnea index (AHI) ≥ 15 events/h. HI was defined as a mean hearing threshold > 25 dB hearing level in either ear at the frequencies: 3,000 to 8,000 Hz for high-frequency HI (HF-HI) and 500 to 2,000 Hz for low-frequency HI (LF-HI). Combined-frequency HI (CF-HI) was defined as both conditions present, and Any-HI was considered as HI in either low or high frequencies. RESULTS: Of 13,967 participants, 9.9% had SA and 32.3% had Any-HI. Adjusted for risk factors for HI, those with SA had a 30% higher odds of Any-HI (95% confidence interval [CI] = 8% to 57%), 26% higher odds of HF-HI (CI = 3% to 55%), 127% higher odds of LF-HI (CI = 21% to 326%), and 29% higher odds of CF-HI (CI = 0% to 65%). A dose-response association was observed between AHI severity and Any-HI (versus no SA, OR for AHI ≥ 15 and < 30 = 1.22, CI = 0.96 to 1.54, and OR for AHI ≥ 30 = 1.46, CI = 1.11 to 1.91, p = 0.002). CONCLUSION: SA is associated with HF-HI and LF-HI, independent of snoring and other confounders. COMMENTARY: A commentary on this article appears in this issue on page 641.

Smoking cessation in the elderly.

Today, two generations after the first Surgeon General's report, and with abundant evidence of the catastrophic consequences of smoking, no serious person can be unaware that smokers risk their lives and health. We also know that quitting smoking--at any age--promises significant health benefits. When offered the tools they need, older smokers quit smoking at rates comparable to those of younger smokers despite their skepticism, fatalism, and self-doubt. Older smokers should be encouraged to enter programs that stress the health benefits derived and identify the risks they are avoiding by quitting smoking. These programs establish quit dates, use sound behavioral modification techniques, provide strategies for stress management and relaxation, treat withdrawal symptoms, and provide regular and continuing follow-up. The patient is asked to make an existential change, and the physician should provide encouragement and promote self-confidence by emphasizing that, despite setbacks, with repeated efforts, success can be achieved. Clinicians can influence patients to quit smoking, and they should.

Obstructive sleep apnea and World Trade Center exposure.

OBJECTIVES: To describe the proportion of at-risk World Trade Center (WTC)-exposed rescue/recovery workers with polysomnogram-confirmed obstructive sleep apnea (OSA) and examine the relationship between WTC exposure, physician-diagnosed gastroesophageal reflux disease (GERD), and rhinosinusitis and OSA. METHODS: A total of 636 male participants completed polysomnography from September 24, 2010, to September 23, 2012. Obstructive sleep apnea was classified as mild, moderate, or severe. Associations were tested using nominal polytomous logistic regression. RESULTS: Eighty-one percent of workers were diagnosed with OSA. Using logistic regression models, severe OSA was associated with WTC exposure on September 11, 2001 (odds ratio, 1.91; 95% confidence interval, 1.15 to 3.17), GERD (odds ratio, 2.75; 95% confidence interval, 1.33 to 5.70), and comorbid GERD/rhinosinusitis (odds ratio, 2.31; 95% confidence interval, 1.22 to 4.40). CONCLUSIONS: We found significant associations between severe OSA and WTC exposure, and with diseases prevalent in this population. Accordingly, we recommend clinical evaluation, including polysomnography, for patients with high WTC exposure, other OSA risk factors, and a physician diagnosis of GERD or comorbid GERD and rhinosinusitis.

Surviving severe acute respiratory distress syndrome: utility of open-lung biopsy and large doses of dexamethasone.

The etiology of acute respiratory distress syndrome is wide and mortality is extremely high. We describe a patient dying from severe acute respiratory distress syndrome who had a tremendous recovery after receiving dexamethasone (1 g daily). This patient required positive end-expiratory pressure (up to 18 mm/Hg) and fractional inspiratory oxygen (up to 100%). Thirty-six hours after the large dose of corticosteroids, the respiratory mechanics and oxygenation were acceptable for extubation. Acute respiratory distress syndrome was proven and other etiologies of respiratory failure were ruled out by a bedside open-lung biopsy. The biopsy proven acute respiratory distress syndrome dramatically resolved with this salvage therapy. High-dose usage of corticosteroids for acute respiratory distress syndrome has tremendous potential.