Laparoscopic Sleeve Gastrectomy Improves Excessive Daytime Sleepiness and Sleep Quality 6 Months Following Surgery: A Prospective Cohort Study

Introduction

Obstructive sleep apnea (OSA) is one of the most important co-morbid conditions related with morbid obesity. Bariatric procedures are associated with significant improvement in OSA. The aim of the current study was to evaluate the effect of bariatric surgery on daytime sleepiness and quality of sleep in patients that had undergone laparoscopic sleeve gastrectomy.

Methods

Fifty-nine patients were prospectively enrolled in the study. Pre-operative and post-operative (6 months) demographics, medical history, weight, and height of the patients were recorded, and patients were asked to complete Pittsburg Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) questionnaires. OSA screenings were performed using the STOP-Bang questionnaire.

Results

The mean age of the patients was 37.1 ± 1.2 years and 76% were female. Pre-operative and post-operative median (range) BMIs were 47 kg/m² (39–67 kg/m²) and 35 kg/m² (25–44 kg/m²), respectively (P < 0.001). The mean ± standard deviation excess weight loss was 51.6 ± 13.2%. In univariate analysis, total PSQI, STOP-Bang, and ESS scores were found to significantly improve 6 months after surgery (all P < 0.001). Multivariate mixed-model analysis showed a high correlation between the decrease in BMI and all key predictors. Mixed-model analysis revealed that every 1 kg/m² decrease in BMI was associated with a 0.32, 0.13, and 0.26 improvements in PSQI, STOP-Bang, and ESS scores, respectively (all P < 0.001).

Conclusion

Laparoscopic sleeve gastrectomy is associated with rapid weight loss and improvements in sleep quality, daytime sleepiness, and the risk of OSA 6 months after surgery.

     

Mean platelet volume is increased in patients with severe obstructive sleep apnea

Abstract

Increased platelet activation and aggregation which are closely related to cardiovascular complications have been reported in patients with obstructive sleep apnea (OSA). The aim of this study was to assess the mean platelet volume (MPV), an indicator of platelet activation in patients with OSA. The 95 subjects referred for evaluation of OSA underwent overnight polysomnography. Blood samples were taken for MPV determination. According to the apnea-hypopnea index (AHI), subjects were divided into three groups; group 1: control subjects without OSA (AHI < 5, n = 24), group 2: patients with mild to moderate OSA (AHI: 5–30, n = 42), and group 3: severe OSA (AHI > 30, n = 29). Body mass index (BMI) of patients with severe OSA was significantly higher than control subjects (31.5 ± 4.0 vs. 28.2 ± 5.0; p = 0.02). The MPV was significantly higher in patients with severe OSA than in the control group (8.9 ± 1.0 vs. 8.2 ± 0.7 fl; p = 0.01). Correlation analysis within 71 patients with OSA indicated that MPV was correlated with AHI (p < 0.001, r = 0.44) and DI (p = 0.001, r = 0.37). In multivariate regression analysis, when MPV was taken as independent with other study variables which are potential confounders such as age, gender and BMI, MPV was independently correlated with both AHI (β = 0.44, p < 0.001) and DI (β = 0.38, p < 0.001). We have shown that MPV was significantly higher in patients with severe OSA when compared with control subjects and MPV was correlated with AHI and DI.     

Bidirectional Relationships Between Weight Change and Sleep Apnea in a Behavioral Weight Loss Intervention

Objective

To examine the bidirectional relationship between weight change and obstructive sleep apnea (OSA) in the context of a behavioral weight loss intervention.

Predictive abilities of the STOP‐Bang and Epworth Sleepiness Scale in identifying sleep clinic patients at high risk for obstructive sleep apnea

This study compared the predictive abilities of the STOP‐Bang and Epworth Sleepiness Scale (ESS) for screening sleep clinic patients for obstructive sleep apnea (OSA) and sleep‐disordered breathing (SDB). Forty‐seven new adult patients without previous diagnoses of OSA or SDB were administered the STOP‐Bang and ESS and were assigned to OSA or SDB risk groups based on their scores. STOP‐Bang responses were scored with two Body Mass Index cut points of 35 and 30 kg/m² (SB35 and SB30). The tools' predictive abilities were determined by comparing patients' predicted OSA and SDB risks to their polysomnographic results. The SB30 correctly identified more patients with OSA and SDB than the ESS alone. The ESS had the highest specificity for OSA and SDB. © 2012 Wiley Periodicals, Inc. Res Nurs Health 36:84–94, 2013     

Sleep-disordered breathing in patients undergoing transfemoral aortic valve implantation for severe aortic stenosis

Background

We examined the prevalence of sleep-disordered breathing (SDB) in patients with severe aortic valve stenosis (AS) and the impact of transfemoral aortic valve implantation (TAVI) on SDB.

Methods

79 patients underwent cardiorespiratory polygraphy (PG) before TAVI (CoreValve?), 62 of them a second PG after the procedure.

Results

Forty-nine (62 %) patients had obstructive sleep apnea (OSA), 25 (32 %) central sleep apnea (CSA), and 5 (6 %) presented without significant SDB (apnea–hypopnea index (AHI) < 5/h). Among the 62 patients evaluated before and after TAVI, 36 (58 %) had OSA, 22 (36 %) CSA, and 4 patients (7 %) no SDB. AHI was significantly higher in CSA patients than in OSA patients (34.5 ± 18.3 vs. 18.0 ± 12.6/h, p < 0.001). Successful TAVI had a significant impact on CSA but not on OSA: CSA patients with optimal TAVI results experienced a significant reduction in central respiratory events (AHI 39.6 ± 19.6–23.1 ± 16.0/h, p = 0.035), while no changes were detected in OSA patients (AHI 18.8 ± 13.0–20.25 ± 13.4/h, p = 0.376). In contrast, in patients who developed at least moderate periprosthetic aortic regurgitation (AR > I), CSA increased significantly (AHI 26.3 ± 13.2–39.2 ± 18.4/h, p = 0.036), whereas no acute change was seen in patients with OSA (AHI 10.5 ± 7.8–12.5 ± 5.0/h, p = 0.5).

Conclusion

OSA and CSA are prevalent in more than 90 % of patients undergoing TAVI for severe aortic valve stenosis. Successful TAVI had no significant impact on OSA but improved CSA. In case of an acute change from pressure overload (aortic stenosis) to acute volume overload (aortic regurgitation after TAVI), central, but not obstructive, sleep apnea deteriorated.     

The influence of age and BMI on intervertebral disc height and oropharyngeal airway in Japanese men and women

Objective

Intervetebral disc height changes with both age and increasing body mass index (BMI), known risk factors for obstructive sleep apnea (OSA). We studied the relationship of body mass index (BMI) and aging in the neck structures to disc compression and oropharyngeal airway size and shape.

Materials and methods

The intervertebral disc (IVD), neck and airway volumes were measured at the C2 level only from Computerized Tomography scans using a semi-automatic segmentation tool. The change of intervertebral disc height/volume with age and BMI were examined in 38 consecutive Japanese patients (Male: 19, Female: 19), group matched for age (men: 52.2 ± 15.36 years; women: 52.4 ± 17.37) and BMI (men: 23.1 ± 2.97 m/kg²; women: 21.6 ± 4.03 m/kg²).

Results

In this study, the intervertebral disc volume as a percent of neck volume was larger in men than in women (P = 0.039), and the intervertebral disc volume (r = ?0.588; P = 0.013) and height (r = ?0.510; P = 0.037) decreased with increasing age-adjusted BMI in males only. Age was not significantly correlated with any of the volumes. The intervertebral airway volume significantly decreased with increasing age-adjusted BMI in our female subjects (r = ?0.588; P = 0.013).

Conclusion

In our Japanese volunteer population, the intervertebral disc is compressed vertically with the increase of BMI in males only, and the oropharyngeal airway volume decreases with increasing BMI in females only. These results may be useful in assessment of OSA risk.     

Reduced cardiac sympathetic autonomic tone after long-term nasal continuous positive airway pressure in obstructive sleep apnoea syndrome

The increased sympathetic activation that occurs in obstructive sleep apnoea (OSA) may play an important role in associated morbidity. We investigated the effect of long-term (3 month) nasal continuous positive airway pressure (CPAP) on the autonomic nervous system assessed by heart rate variability (HRV). Fourteen patients (12 men), mean age 61·4 ± 8·1 years, with OSA underwent continuous synchronized electrocardiographic and polysomnographic monitoring. The apnoea/hypopnoea index (AHI) decreased from 50·6 ± 13·7 to 2·2 ± 2·5 events h^?1 after CPAP. HRV analysis showed significant decreases in low frequency (LF; from 7·12 ± 1·06 to 6·22 ± 1·18 ln ms² Hz^?1; P<0·001), high frequency (HF; from 5·91 ± 0·87 to 5·62 ± 0·92 ln ms² Hz^?1; P<0·05) and LF/HF (from 1·21 ± 0·12 to 1·11 ± 0·15 ln ms² Hz^?1; P<0·001) when the patients were asleep. The decrease in LF/HF was prolonged into the daytime (from 1·33 ± 0·22 to 1·24 ± 0·21 ln ms² Hz^?1; P<0·001). Treatment of OSA by CPAP significantly reduced the parameters of cardiac sympathetic tone, a favourable effect.     

Analysis of sleep characteristics and clinical outcomes of 139 adult patients with infective endocarditis after surgery

BACKGROUNDLittle is known about the postoperative sleep quality of infective endocarditis patients during hospitalization and after discharge. AIMTo investigate the sleep characteristics of infective endocarditis patients and to identify potential risk factors for disturbed sleep quality after surgery. METHODSThe Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale were used to assess patient sleep quality. Logistic regression was used to explore the potential risk factors. RESULTSThe study population (n = 139) had an average age of 43.40 ± 14.56 years, and 67.6% were men (n = 94). Disturbed sleep quality was observed in 86 patients (61.9%) during hospitalization and remained in 46 patients (33.1%) at 6 mo after surgery. However, both PSQI and Epworth Sleepiness Scale scores showed significant improvements at 6 mo (P < 0.001 and P = 0.001, respectively). Multivariable logistic regression analysis showed that the potential risk factors were age (odds ratio = 1.125, 95% confidence interval: 1.068-1.186) and PSQI assessed during hospitalization (odds ratio = 1.759, 95% confidence interval: 1.436-2.155). The same analysis in patients with PSQI ≥ 8 during hospitalization suggested that not using sleep medication (odds ratio = 15.893, 95% confidence interval: 2.385-105.889) may be another risk factor. CONCLUSIONThe incidence of disturbed sleep after infective endocarditis surgery is high. However, the situation improves significantly over time. Age and early postoperative high PSQI score are risk factors for disturbed sleep quality at 6 mo after surgery.     

Obstructive Sleep Apnea Among Obese Patients With Type 2 Diabetes

OBJECTIVE

To assess the risk factors for the presence and severity of obstructive sleep apnea (OSA) among obese patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Unattended polysomnography was performed in 306 participants.

RESULTS

Over 86% of participants had OSA with an apnea-hypopnea index (AHI) ≥5 events/h. The mean AHI was 20.5 ± 16.8 events/h. A total of 30.5% of the participants had moderate OSA (15 ≤ AHI <30), and 22.6% had severe OSA (AHI ≥30). Waist circumference (odds ratio 1.1; 95% CI 1.0–1.1; P = 0.03) was significantly related to the presence of OSA. Severe OSA was most likely in individuals with a higher BMI (odds ratio 1.1; 95% CI 1.0–1.2; P = 0.03).

CONCLUSIONS

Physicians should be particularly cognizant of the likelihood of OSA in obese patients with type 2 diabetes, especially among individuals with higher waist circumference and BMI.We report the prevalence of obstructive sleep apnea (OSA) and the factors that increase the risk and severity of OSA among 306 obese patients with type 2 diabetes enrolled in Sleep AHEAD, a four-site ancillary study of the Look AHEAD Trial (Action for Health in Diabetes).     

Assessment of the role of serum ischemia-modified albumin in obstructive sleep apnea in comparison with interleukin-6

Objectives: There is limited and contradictory information regarding the role of serum ischemia-modified albumin (IMA) in obstructive sleep apnea (OSA). In this study we examine the effects of OSA and obesity on IMA and interleukin-6 (IL-6), and detect whether IMA and IL-6 may be potential biomarkers in OSA.

Methods: Fifty-one males who underwent all night polysomnography test were included into the study. Body-mass index (BMI) and apnea-hypopnea index (AHI) of all patients were determined. Serum IMA and IL-6 levels, erythrocyte sedimentation rate (ESR), complete blood count, routine blood biochemistry and thyroid function tests were performed.

Results: Mean IMA [0.36 (± 0.04) U/ml, 0.89 (± 0.15) U/ml], mean IL-6 [1.01 (± 0.19) pg/ml, 2.02 (± 1.19) pg/ml] and mean ESR [4.14 (± 2.5) mm/h, 14.35 (± 13.7) mm/h] levels showed significant difference between non-OSA and OSA groups (P = 0.005, P < 0.001, P < 0.001, respectively). Sensitivity of IMA in distinction of non-OSA/OSA was equal to IL-6 and higher than ESR. IMA was also a stronger predictive factor than IL-6 and ESR in the evaluation of OSA groups (severe/mild/moderate OSA and non-OSA). IMA was the sole distinctive biomarker in assessment of obese and non-obese cases. IMA correlated with IL-6, AHI and ESR.

Conclusion: Serum IMA may be a valuable oxidative stress indicator for OSA and could act as a better biomarker than IL-6 for reflecting the presence and the severity of OSA.     

磁敏感加权成像诊断慢性大脑中动脉狭窄或闭塞

目的 利用SWI评价慢性大脑中动脉(MCA)狭窄或闭塞患者相应供血区域的脑氧代谢,检出易损脑组织。方法 对单侧慢性MCA重度狭窄或闭塞患者11例(患病组)和性别、年龄与之相匹配的正常人10名(正常对照组)行TOF-MRA及SWI检查,选取相同大小的ROI测量,并比较患者患侧、健侧以及正常对照组两侧脑组织的相位弧度值及SWI信号值。结果 患者患侧、健侧、正常对照组左侧及右侧的相位弧度值分别为(6.00±2.10)×10^-3、(11.66±3.52)×10^-3、(12.08±2.86)×10^-3、(10.51±2.30)×10^-3(F=13.48,P<0.05),SWI信号值分别为194.29±28.08、238.33±24.76、245.05±8.76、233.06±11.66(F=13.36,P<0.05),差异均有统计学意义。患侧相位弧度值及SWI信号值均低于健侧及正常对照组(P<0.05)。患病组患者中2例大脑后动脉侧支循环丰富区域(枕叶为主)SWI信号及相位弧度值高于健侧。结论 SWI能间接反映慢性缺血脑组织氧摄取分数升高及脑血流量降低,可代替CT或MR灌注成像评价MCA狭窄或闭塞患者缺血范围及缺血程度,指导临床治疗。     

d-Dimer and simplified pulmonary embolism severity index in relation to right ventricular function

BackgroundRight ventricular (RV) involvement in pulmonary embolism (PE) is an ominous sign. The aim of this study was to investigate the extent to which the d-dimer level or simplified PE severity index (sPESI) indicates RV dysfunction in patients with preserved systemic arterial pressure.MethodsRight ventricular function was studied in 34 consecutive patients with acute nonmassive PE by echocardiography including Doppler tissue imaging within 24 hours after arrival to the hospital. d-Dimer and sPESI were assessed upon arrival.Resultsd-Dimer correlated with RV pressure (R_s, 0.60; P < .001) and pulmonary vascular resistance (PVR; R_s, 0.68; P < .0001) and tended to be related to myocardial performance index (MPI; R_s, 0.31; P = .067). Compared to a level less than 3.0 mg/L, patients with d-dimer 3.0 mg/L or higher had lower systolic tricuspid annular velocity (11.3 ± 2.7 vs 13.5 ± 2.7 cm/s; P < .05), a prolonged MPI (0.8 ± 0.3 vs 0.5 ± 0.2; P < .01), increased RV pressure (58 ± 13 vs 37 ± 12 mm Hg; P < .001), and increased PVR (3.3 ± 1.1 vs 1.8 ± 0.4 Woods units; P < .001). Patients in the high-risk sPESI group had higher filling pressure than those in the low risk sPESI group.ConclusionsIn the acute stage of PE, a d-dimer level 3 mg/L or higher may identify nonmassive PE patients with RV dysfunction and thereby help to determine their risk profile. We found no additional value for sPESI in this context.     

Uvulopalatopharyngoplasty in the Management of Obstructive Sleep Apnea: The Mayo Clinic Experience

OBJECTIVE: To assess the role of uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnea (OSA) using polysomnography (PSG) data within 6 months before and after surgery.PATIENTS AND METHODS: We analyzed PSG and body mass index (BMI) data from patients with OSA who were 18 years or older and who underwent UPPP between January 1, 1988, and August 31, 2006.RESULTS: Sixty-three patients (51 men [81.0%]; mean ± SD age, 42.1±13.9 years; mean ± SD BMI, 34.9±7.2) underwent PSG a mean ± SD of 50±47 days before and 88.5±34.0 days after UPPP. Surgical cure was defined as a postoperative apnea-hypopnea index (AHI) of 5 or less. Fifteen patients (24%) achieved a surgical cure. Twenty-one patients (33%) had a postoperative AHI of 10 or less, whereas 32 (51%) achieved a 50% or greater reduction in AHI and/or an AHI of 20 or less. No significant changes were noted in BMI before and 6 months after UPPP. Patients who attained an AHI of 5 or less were younger (mean ± SD age, 35.9±13.1 vs 44±13.7 years; P=.05), had lower BMIs (mean ± SD, 30.8±6.5 vs 34.6±6.6; P=.05), and had less severe OSA (mean ± SD AHI, 38.1±33.6 vs 69.6±32.8; P=.004). Of the 48 patients (76%) with a post-UPPP AHI greater than 5, 35 (56%) received continuous positive airway pressure, with a mean reduction in pressure of 1.4 cm H₂O (95% confidence interval, -0.4 to -2.4 cm H₂O).CONCLUSION: Independent of changes in BMI, in our retrospective analysis, UPPP achieved an AHI of 5 or less in 24% and an AHI of 10 or less in 33% of patients with OSA who underwent PSG 6 months before and after surgery. In those with residual OSA who received continuous positive airway pressure, the required pressure setting decreased by 1.4 cm H₂O.AHI = apnea-hypopnea index; BMI = body mass index; CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; PSG = polysomnography; UPPP = uvulopalatopharyngoplastyObstructive sleep apnea (OSA) is highly prevalent, affecting 4% of men and 2% of women who meet a disease-defining threshold of at least 5 episodes of apnea or hypopnea per hour of sleep (apnea-hypopnea index [AHI] ≥5) and excessive daytime sleepiness.¹ Continuous positive airway pressure (CPAP), a technique that pneumatically supports the upper airway, is a therapeutic mainstay for OSA. It has been shown to reduce the AHI, improve sleepiness and quality of life, and reduce cardiovascular risk.^2,3 Despite demonstrable benefits and technological equipment advances, compliance with CPAP therapy varies, with 29% to 83% of patients using CPAP for less than 4 hours a night in various studies.⁴ Accordingly, physicians may recommend other options for their patients with OSA, including risk factor modification such as weight loss, oral appliances that advance the mandible or tongue during sleep,⁵ or a variety of surgical procedures to bypass or expand the upper airway.⁶The most common surgical procedure performed for OSA is uvulopalatopharyngoplasty (UPPP).^7,8 Introduced by Fujita et al⁹ in 1981, UPPP involves tonsillectomy (if not previously performed), trimming and reorientation of the posterior and anterior tonsillar pillars, and excision of the uvula and posterior palate. Often, UPPP is combined with other nasopharyngeal or oropharyngeal procedures. The reported success of UPPP as a treatment of OSA is between 16% and 83%, depending on the definition of a positive outcome.^7,10 Some authors have defined surgical success or cure after UPPP as a 50% reduction in the AHI, whereas others combine this criterion with an absolute AHI of 20 or less.^11-14 Unfortunately, use of these criteria means that successfully treated patients may still have mild to moderate residual OSA. Increasing evidence shows that, when treating OSA, reducing the AHI to less than 5 is necessary to improve health care-related outcome measures, such as hypertension.¹⁵ Accordingly, there have been calls for caution about UPPP as first-line therapy for OSA and for all future studies of UPPP to base surgical success on AHI outcomes of 5 or less or 10 or less, targets typically expected from CPAP therapy.^7,16 Therefore, to better define response to UPPP, we reviewed the UPPP experience at Mayo Clinic''s site in Rochester, MN, using these more stringent and contemporary criteria.     

Obstructive Sleep Apnea,Glucose Tolerance,and β-Cell Function in Adults With Prediabetes or Untreated Type 2 Diabetes in the Restoring Insulin Secretion (RISE) Study

OBJECTIVEObstructive sleep apnea (OSA) is associated with insulin resistance and has been described as a risk factor for type 2 diabetes. Whether OSA adversely impacts pancreatic islet β-cell function remains unclear. We aimed to investigate the association of OSA and short sleep duration with β-cell function in overweight/obese adults with prediabetes or recently diagnosed, treatment-naive type 2 diabetes.RESEARCH DESIGN AND METHODSTwo hundred twenty-one adults (57.5% men, age 54.5 ± 8.7 years, BMI 35.1 ± 5.5 kg/m²) completed 1 week of wrist actigraphy and 1 night of polysomnography before undergoing a 3-h oral glucose tolerance test (OGTT) and a two-step hyperglycemic clamp. Associations of measures of OSA and actigraphy-derived sleep duration with HbA_1c, OGTT-derived outcomes, and clamp-derived outcomes were evaluated with adjusted regression models.RESULTSMean ± SD objective sleep duration by actigraphy was 6.6 ± 1.0 h/night. OSA, defined as an apnea-hypopnea index (AHI) of five or more events per hour, was present in 89% of the participants (20% mild, 28% moderate, 41% severe). Higher AHI was associated with higher HbA_1c (P = 0.007). However, OSA severity, measured either by AHI as a continuous variable or by categories of OSA severity, and sleep duration (continuous or <6 vs. ≥6 h) were not associated with fasting glucose, 2-h glucose, insulin sensitivity, or β-cell responses.CONCLUSIONSIn this baseline cross-sectional analysis of the RISE clinical trial of adults with prediabetes or recently diagnosed, untreated type 2 diabetes, the prevalence of OSA was high. Although some measures of OSA severity were associated with HbA_1c, OSA severity and sleep duration were not associated with measures of insulin sensitivity or β-cell responses.     

Gait Function in Adults Aged 50 Years and Older With Spina Bifida

ObjectiveTo study gait function among individuals with spina bifida (SB) aged 50 years or older.DesignA cross-sectional study conducted in 2017.SettingHome-dwelling participants from all regions in Norway.ParticipantsIndividuals between the ages of 51 and 76 years (N=26; 16 women) categorized as independent walkers (n=9), walkers with aids (n=10) and nonwalkers (n=7).InterventionsNot applicable.Main Outcome MeasuresQuestionnaire, pain assessment, anthropometry, Falls Efficacy Scale International (FES-I), objective gait analysis, 6-minute walk test (6MWT), and timed Up and Go (TUG).ResultsWalking speed correlated with SB severity (ρ=–.59; P=.008). Individuals who walked slower than 0.81 m/s had a higher body mass index (BMI) than those who walked faster (P=.008). Independent walkers walked slower than healthy age-matched walkers (P=.046); spatiotemporal variables showed that this was owing to shorter steps rather than cadence. The mean TUG was 10.6±2.6 seconds in independent walkers and 20.2±6.5 in walkers with aids (P<.01). The mean 6MWT was 504±126 meters in independent walkers and 316±88 in walkers with aids (P<.01). The mean pain intensity (numeric rating scale) was 4.9±2.2 in independent walkers and 4.2±1.6 in walkers with aids, but the difference was not statistically significant. FES-I was significantly lower among independent walkers (mean, 23.6±3.9) than walkers with aids (mean, 31.4±10.0) (P=.042).ConclusionsParticipants commonly experienced an early onset deterioration in gait function, and walking speed was influenced by SB severity and BMI. This highlights the importance of early monitoring and weight management during follow-up for SB.     

Urine activity of cathepsin B,collagenase and urine excretion of TGF-β 1 and fibronectin in membranous glomerulonephritis

In 30% of cases nephrotic syndrome is caused by membranous glomerulonephritis (MG). Protein accumulation in glomeruli leads to progressive loss of kidney function and damage of structure in MG. The role of tissue proteolytic systems and growth factors in this process is not known. The purpose of the study was to estimate urine cathepsin B, collagenase activity and urine excretion of TGF-β ₁ and fibronectin in MG. Cathepsin B activity was greater in the urine of MG patients than in the control group (10.58±8.73 pmol AMC/mg creatinine per min^?1 vs control 7.11±2.05 pmol AMC/mg creatinine per min^?1; P<0.05). Urine collagenase activity was higher in the group of patients than in the control group (8.59±4.26 pmol AMC/ mg creatinine per min^?1 vs control 3.84±2.09 pmol AMC/ mg creatinine per min^?1 P<0.02). Urine excretion of fibronectin (45.60 ng/mg creatinine vs control 10.30 ng/mg creatinine; P<0.04) and TGF-β ₁ levels in the urine were higher than in controls (283.55±248.13 pg/ml vs 36.11±48.01 pg/ml; P<0.01). Results suggest glomerular overproduction of TGF-β ₁ and urinary leak of proteolytic enzymes (PE). This may result in decreased glomerular PE activity in MG and, with time, may lead to protein accumulation in renal glomeruli and to progressive loss of kidney function and damage of structures as the course of MG progresses. PE urine composition as well as ECM protein and cytokine urine excretion may alow noninvasive glomerulopathy course monitoring in humans in the future.     

Tracking Dynamic Tongue Motion in Ultrasound Images for Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a breathing disorder characterized by repetitive collapse of the pharyngeal airway during sleep, can cause intermittent hypoxemia and frequent arousal. The evaluation of dynamic tongue motion not only provides the biomechanics and pathophysiology for OSA diagnosis, but also helps doctors to determine treatment strategies for these patients with OSA. The purpose of this study was to develop and verify a dedicated tracking algorithm, called the modified optical flow (OF)-based method, for monitoring the dynamic motion of the tongue base in ultrasound image sequences derived from controls and patients with OSA. The performance of the proposed method was verified by phantom and synthetic data. A common tracking method, the normalized cross-correlation method, was included for comparison. The efficacy of the algorithms was evaluated by calculating the estimated displacement error. All results indicated that the modified OF-based method exhibited higher accuracy in verification experiments. In the human subject experiment, all participants performed the Müller maneuver (MM) to simulate the contour changes of the tongue base with a negative pharyngeal airway pressure in sleep apnea. Ultrasound image sequences of the tongue were obtained during 10 s of a transition from normal breathing to the MM, and these were measured using the modified OF-based method. The results indicated that the displacement of the tongue base during the MM was larger in the controls than in the patients with OSA (p < 0.05); the calculated areas of the tongue in the controls and patients with OSA were 24.9 ± 3.0 and 27.6 ± 3.3 cm², respectively, during normal breathing (p < 0.05), and 24.7 ± 3.6 and 27.3 ± 3.8 cm², respectively, at the end of the MM. The percentage changes in the tongue area were 2.2% and 1.3% in the controls and patients with OSA, respectively. We found that quantitative assessment of tongue motion by ultrasound imaging is suitable for evaluating pharyngeal airway behavior in OSA patients with minimal invasiveness and easy accessibility.     

Impact of Cardiorespiratory Fitness on the Obesity Paradox in Patients With Heart Failure

ObjectiveTo determine the impact of cardiorespiratory fitness (FIT) on survival in relation to the obesity paradox in patients with systolic heart failure (HF).Patients and MethodsWe studied 2066 patients with systolic HF (body mass index [BMI] ≥18.5 kg/m²) between April 1, 1993 and May 11, 2011 (with 1784 [86%] tested after January 31, 2000) from a multicenter cardiopulmonary exercise testing database who were followed for up to 5 years (mean ± SD, 25.0±17.5 months) to determine the impact of FIT (peak oxygen consumption <14 vs ≥14 mL O₂ ? kg^?1 ? min^?1) on the obesity paradox.ResultsThere were 212 deaths during follow-up (annual mortality, 4.5%). In patients with low FIT, annual mortality was 8.2% compared with 2.8% in those with high FIT (P<.001). After adjusting for age and sex, BMI was a significant predictor of survival in the low FIT subgroup when expressed as a continuous (P=.03) and dichotomous (<25.0 vs ≥25.0 kg/m²) (P=.01) variable. Continuous and dichotomous BMI expressions were not significant predictors of survival in the overall and high FIT groups after adjusting for age and sex. In patients with low FIT, progressively worse survival was noted with BMI of 30.0 or greater, 25.0 to 29.9, and 18.5 to 24.9 (log-rank, 11.7; P=.003), whereas there was no obesity paradox noted in those with high FIT (log-rank, 1.72; P=.42).ConclusionThese results indicate that FIT modifies the relationship between BMI and survival. Thus, assessing the obesity paradox in systolic HF may be misleading unless FIT is considered.     

Cardiac resynchronization therapy and obstructive sleep-related breathing disorder in patients with congestive heart failure

Objectives: To assess the impact of cardiac resynchronization therapy (CRT) with or without atrial overdrive pacing, on sleep‐related breathing disorder (SRBD). Introduction: CRT may have a positive influence on SRBD in patients who qualify for the therapy. Data are inconclusive in patients with obstructive SRBD. Methods: Consenting patients eligible for CRT underwent a baseline polysomnography (PSG) 2 weeks after implantation during which pacing was withheld. Patients with an apnea hypopnea index (AHI) ≥15 but <50 were enrolled and randomized to atrial overdrive pacing (DDD) versus atrial synchronous pacing (VDD) with biventricular pacing in both arms. Patients underwent two further PSGs 12 weeks apart. Results: Nineteen men with New York Heart Association class III congestive heart failure participated in the study (age 67.2 ± 7.5, Caucasian 78.9%, ischemic 73.7%). The score on Epworth Sleepiness Score was 7.3 ± 4.0, Pittsburgh Sleep Quality Index 7.4 ± 3.1, and Minnesota Living with Heart Failure Questionnaire 36.9 ± 21.9. There were no differences between the groups. At baseline, patients exhibited poor sleep efficiency (65.3 ± 16.6%) with nadir oxygen saturation of 83.5 ± 5.3% and moderate to severe SRBD (AHI 21.5 ± 15.3) that was mainly obstructive (central apnea index 3.3 ± 6.7/hour). On both follow‐up assessments, there was no improvement in indices of SRBD (sleep efficiency [68.3 ± 17.9%], nadir oxygen saturation of 82.8 ± 4.6%, and AHI 24.9 ± 21.9). Conclusion: In a cohort of elderly male CHF patients receiving CRT, CRT had no impact on obstructive SRBD burden with or without atrial overdrive pacing. (PACE 2011; 34:593–603)