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Karper J, De Jager SCA, Ewing MM, De Vries MR, Arens R, Bot I, Jukema JW, Kuiper J, Quax P. RP105 (cd180) as a TLR-4 regulator ameliorates atherosclerosis via its role on B-cells. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht308.p2389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Karper JC, de Jager SCA, Ewing MM, de Vries MR, Bot I, van Santbrink PJ, Redeker A, Mallat Z, Binder CJ, Arens R, Jukema JW, Kuiper J, Quax PHA. An unexpected intriguing effect of Toll-like receptor regulator RP105 (CD180) on atherosclerosis formation with alterations on B-cell activation. Arterioscler Thromb Vasc Biol 2013; 33:2810-7. [PMID: 24115036 DOI: 10.1161/atvbaha.113.301882] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE In atherosclerosis, Toll-like receptors (TLRs) are traditionally linked to effects on tissue macrophages or foam cells. RP105, a structural TLR4 homolog, is an important regulator of TLR signaling. The effects of RP105 on TLR signaling vary for different leukocyte subsets known to be involved in atherosclerosis, making it unique in its role of either suppressing (in myeloid cells) or enhancing (in B cells) TLR-regulated inflammation in different cell types. We aimed to identify a role of TLR accessory molecule RP105 on circulating cells in atherosclerotic plaque formation. APPROACH AND RESULTS Irradiated low density lipoprotein receptor deficient mice received RP105(-/-) or wild-type bone marrow. RP105(-/-) chimeras displayed a 57% reduced plaque burden. Interestingly, total and activated B-cell numbers were significantly reduced in RP105(-/-) chimeras. Activation of B1 B cells was unaltered, suggesting that RP105 deficiency only affected inflammatory B2 B cells. IgM levels were unaltered, but anti-oxidized low-density lipoprotein and anti-malondialdehyde-modified low-density lipoprotein IgG2c antibody levels were significantly lower in RP105(-/-) chimeras, confirming effects on B2 B cells rather than B1 B cells. Moreover, B-cell activating factor expression was reduced in spleens of RP105(-/-) chimeras. CONCLUSIONS RP105 deficiency on circulating cells results in an intriguing unexpected TLR-associated mechanisms that decrease atherosclerotic lesion formation with alterations on proinflammatory B2 B cells.
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Ong BA, Caboot J, Jawad A, McDonough J, Jackson T, Arens R, Marcus CL, Smith-Whitley K, Mason TBA, Ohene-Frempong K, Allen JL. Respiratory muscle force and lung volume changes in a population of children with sickle cell disease. Br J Haematol 2013; 163:112-7. [PMID: 23869561 PMCID: PMC3776481 DOI: 10.1111/bjh.12481] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 06/19/2013] [Indexed: 11/29/2022]
Abstract
Sickle cell disease (SCD) is a disorder known to impact the respiratory system. We sought to identify respiratory muscle force and lung volume relationships in a paediatric SCD population. Thirty-four SCD-SS subjects underwent pulmonary function testing. Height, weight, age, and gender-adjusted percent predicted maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) values were compared to spirometry and lung volumes. Statistical analyses were performed using Pearson's correlation coefficient and paired two-tailed t-test. The mean ± standard deviation (SD) MIP and MEP was 69·6 ± 31·6 cm H2 O and 66·9 ± 22·9 cm H2 O, respectively, and mean ± SD percent predicted MIP (101·3 ± 45·9) exceeded MEP (72·1 ± 26·0) (P = 0·002). MIP correlated with forced vital capacity (FVC; r = 0·51, P = 0·001) and TLC (r = 0·54, P < 0·0001). MEP also correlated with FVC (r = 0·43, P = 0·011) and total lung capacity (TLC; r = 0·42, P = 0·013). Pearson's correlation coefficient testing yielded relationships between MIP and MEP (r = 0·64, P < 0·0001). SCD-SS patients showed correlations between respiratory muscle force and lung volume, and reduced percent predicted expiratory muscle force compared to inspiratory muscle force. Respiratory muscle strength may affect lung volumes in these patients, and expiratory muscles may be more susceptible than the diaphragm to SCD-induced vaso-occlusive damage.
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Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, Mitchell RB, Amin R, Katz ES, Arens R, Paruthi S, Muzumdar H, Gozal D, Thomas NH, Ware J, Beebe D, Snyder K, Elden L, Sprecher RC, Willging P, Jones D, Bent JP, Hoban T, Chervin RD, Ellenberg SS, Redline S. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 2013; 368:2366-76. [PMID: 23692173 PMCID: PMC3756808 DOI: 10.1056/nejmoa1215881] [Citation(s) in RCA: 857] [Impact Index Per Article: 77.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes. METHODS We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months. RESULTS The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P=0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). CONCLUSIONS As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.).
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Nandalike K, Shifteh K, Sin S, Strauss T, Stakofsky A, Gonik N, Bent J, Parikh SR, Bassila M, Nikova M, Muzumdar H, Arens R. Adenotonsillectomy in obese children with obstructive sleep apnea syndrome: magnetic resonance imaging findings and considerations. Sleep 2013; 36:841-7. [PMID: 23729927 DOI: 10.5665/sleep.2708] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The reasons why adenotonsillectomy (AT) is less effective treating obese children with obstructive sleep apnea syndrome (OSAS) are not understood. Thus, the aim of the study was to evaluate how anatomical factors contributing to airway obstruction are affected by AT in these children. METHODS Twenty-seven obese children with OSAS (age 13.0 ± 2.3 y, body mass index Z-score 2.5 ± 0.3) underwent polysomnography and magnetic resonance imaging of the head during wakefulness before and after AT. Volumetric analysis of the upper airway and surrounding tissues was performed using commercial software (AMIRA®). RESULTS Patients were followed for 6.1 ± 3.6 mo after AT. AT improved mean obstructive apnea-hypopnea index (AHI) from 23.7 ± 21.4 to 5.6 ± 8.7 (P < 0.001). Resolution of OSAS was noted in 44% (12 of 27), but only in 22% (4 of 18) of those with severe OSAS (AHI > 10). AT increased the volume of the nasopharynx and oropharynx (2.9 ± 1.3 versus 4.4 ± 0.9 cm(3), P < 0.001, and 3.2 ± 1.2 versus 4.3 ± 2.0 cm(3), P < 0.01, respectively), reduced tonsils (11.3 ± 4.3 versus 1.3 ± 1.4 cm(3), P < 0.001), but had no effect on the adenoid, lingual tonsil, or retropharyngeal nodes. A small significant increase in the volume of the soft palate and tongue was also noted (7.3 ± 2.5 versus 8.0 ± 1.9 cm(3), P = 0.02, and 88.2 ± 18.3 versus 89.3 ± 24.4 cm(3), P = 0.005, respectively). CONCLUSIONS This is the first report to quantify volumetric changes in the upper airway in obese children with OSAS after adenotonsillectomy showing significant residual adenoid tissue and an increase in the volume of the tongue and soft palate. These findings could explain the low success rate of AT reported in obese children with OSAS and are important considerations for clinicians treating these children.
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Muzumdar H, Arens R. Physiological effects of obstructive sleep apnea syndrome in childhood. Respir Physiol Neurobiol 2013; 188:370-82. [PMID: 23707879 DOI: 10.1016/j.resp.2013.05.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 05/06/2013] [Accepted: 05/07/2013] [Indexed: 01/30/2023]
Abstract
Sleep disordered breathing in children refers to a group of respiratory disorders that occur or are exacerbated during sleep. Obstructive sleep apnea syndrome (OSAS) is one of the most significant disorders in this group. OSAS can present in all age groups from early infancy to adolescent years. The cardinal feature of OSAS is limitation of inspiratory flow and volume during sleep resulting in abnormal gas exchange and/or alteration of sleep patterns. When OSAS is a chronic condition it often results in adverse physiological effects that impact on health and development. The present review discusses genesis of OSAS in children and consequent end organ injury with special emphasis on behavior and cognition, cardiovascular function, autonomic regulation, inflammation, endothelial function and metabolic syndrome.
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Parikh SR, Sadoughi B, Sin S, Willen S, Nandalike K, Arens R. Deep cervical lymph node hypertrophy: a new paradigm in the understanding of pediatric obstructive sleep apnea. Laryngoscope 2013; 123:2043-9. [PMID: 23666635 DOI: 10.1002/lary.23748] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 07/16/2012] [Accepted: 08/24/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine if adenotonsillar hypertrophy is an isolated factor in pediatric obstructive sleep apnea (OSA), or if it is part of larger spectrum of cervical lymphoid hypertrophy. STUDY DESIGN Prospective case control study. METHODS A total of 70 screened patients (mean age 7.47 years) underwent polysomnography to confirm OSA, and then underwent MRI of the upper airway. Seventy-six matched controls (mean age 8.00 years) who already had an MRI underwent polysomnography. Volumetric analysis of lymphoid tissue volumes was carried out. Chi-square analysis and Student's t test were used to compare demographic data and lymph node volumes between cohorts. Fisher's Exact test and Chi-square analysis were used to compare sleep data. RESULTS Patients and controls demonstrated no significant difference in mean age (7.47 vs. 8.00 yrs), weight (44.87 vs. 38.71 kg), height (124.68 vs. 127.65 cm), or body-mass index (23.63 vs. 20.87 kg/m(2)). OSA patients demonstrated poorer sleep measures than controls (P < 0.05) in all polysomnography categories (sleep efficiency, apnea index, apnea-hypopnea index, baseline SpO2, SpO2 nadir, baseline ETCO2, peak ETCO2 , and arousal awakening index). Children with OSA had higher lymphoid tissue volumes than controls in the retropharyngeal region (3316 vs. 2403 mm(3), P < 0.001), upper jugular region (22202 vs. 16819 mm(3), P < 0.005), and adenotonsillar region (18994 vs. 12675 mm(3), P < 0.0001). CONCLUSIONS Children with OSA have larger volumes of deep cervical lymph nodes and adenotonsillar tissue than controls. This finding suggests a new paradigm in the understanding of pediatric OSA, and has ramifications for future research and clinical care.
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Wagshul ME, Sin S, Lipton ML, Shifteh K, Arens R. Novel retrospective, respiratory-gating method enables 3D, high resolution, dynamic imaging of the upper airway during tidal breathing. Magn Reson Med 2013; 70:1580-90. [PMID: 23401041 DOI: 10.1002/mrm.24608] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 11/29/2012] [Accepted: 11/30/2012] [Indexed: 12/27/2022]
Abstract
PURPOSE A retrospective, respiratory-gated technique for measuring dynamic changes in the upper airway over the respiratory cycle was developed, with the ultimate goal of constructing anatomically and functionally accurate upper airway models in obstructive sleep apnea patients. METHODS Three-dimensional cine, retrospective respiratory-gated, gradient echo imaging was performed in six adolescents being evaluated for polycystic ovary syndrome, a disorder with a high obstructive sleep apnea prevalence. A novel retrospective gating scheme, synchronized to flow from a nasal cannula, limited image acquisition to predefined physiological ranges. Images were evaluated with respect to contrast, airway signal leakage, and demonstration of dynamic airway area changes. RESULTS Two patients were diagnosed with obstructive sleep apnea. Motion artifacts were absent in all image sets. Scan efficiency ranged from 48 to 88%. Soft tissue-to-airway contrast-to-noise ratio varied from 6.1 to 9.6. Airway signal leakage varied between 10 and 17% of soft tissue signal. Automated segmentation allowed calculation of airway area changes over the respiratory cycle. In one severe apnea patient, the technique allowed demonstration of asynchronous airway expansion and contraction above and below a severe constriction. CONCLUSIONS Retrospective, respiratory gated imaging of the upper airway has been demonstrated, utilizing a gating algorithm to ensure acquisition over specified ranges of respiratory rate and tidal volume.
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Muzumdar H, Nandalike K, Bent J, Arens R. Obstructive sleep apnea due to extrathoracic tracheomalacia. J Clin Sleep Med 2013; 9:163-4. [PMID: 23372471 DOI: 10.5664/jcsm.2418] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report obstructive sleep apnea in a 3-year-old boy with tracheomalacia secondary to tracheotomy that resolved after placement of a metallic stent in the region of tracheomalacia. The tracheal location of obstruction during sleep in this case contrasts with the usual location in the pharynx or, less often, the larynx. This case also demonstrates the utility of polysomnography in managing decannulation of tracheostomies.
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Vo P, Makker K, Matta-Arroyo E, Hall CB, Arens R, Rastogi D. The association of overweight and obesity with spirometric values in minority children referred for asthma evaluation. J Asthma 2012. [PMID: 23189981 DOI: 10.3109/02770903.2012.744035] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Overweight, obesity, and asthma are more prevalent in minority children; yet, the association of overweight and obesity with spirometric values in asthmatic minorities is not well characterized. OBJECTIVE To study the relationship between weight, ethnicity, and spirometric values in children referred for asthma evaluation to a large inner-city hospital in Bronx, NY. METHODS Retrospective review of spirometry done at the first pulmonary clinic visit of 980 asthmatic children, aged 7-20 years, was conducted. Linear regression analysis was performed to elucidate the association of overweight and obesity with pulmonary function among Whites, African Americans, and Hispanics compared with their normal weight counterparts. RESULTS More African Americans (58%) and Hispanics (65.4%) were overweight and obese than Whites (51.2%) (p < .05). Compared with their normal weight counterparts, percent forced expiratory volume in the 1st second (FEV(1))/forced vital capacity (FVC) ratio was lower in both overweight and obese African Americans (2.99%, p < .05 and 3.56%, p < .01, respectively) and Hispanics (2.64%, p < .05 and 2.36%, p < .05, respectively); these differences were found in obese (3.73%, p < .05) but not in overweight (0.68%, p = .7) Whites. CONCLUSIONS FEV(1)/FVC ratio was lower in both overweight and obese African American and Hispanic children, while this association was present only among obese Whites compared with their normal weight counterparts. These results suggest that spirometric measures of lower airway obstruction decrease with smaller weight increments in minority children when compared with White children. In the context of the higher prevalence of overweight and obesity among African Americans and Hispanics, our findings offer one potential explanation for increased asthma among minority children.
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Strauss T, Sin S, Marcus CL, Mason TBA, McDonough JM, Allen JL, Caboot JB, Bowdre CY, Jawad AF, Smith-Whitley K, Ohene-Frempong K, Pack AI, Arens R. Upper airway lymphoid tissue size in children with sickle cell disease. Chest 2012; 142:94-100. [PMID: 22241762 DOI: 10.1378/chest.11-2013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The prevalence of obstructive sleep apnea syndrome (OSAS) is higher in children with sickle cell disease (SCD) as compared with the general pediatric population. It has been speculated that overgrowth of the adenoid and tonsils is an important contributor. METHODS The current study used MRI to evaluate such an association. We studied 36 subjects with SCD (aged 6.9 ± 4.3 years) and 36 control subjects (aged 6.6 ± 3.4 years). RESULTS Compared with control subjects, children with SCD had a significantly smaller upper airway (2.8 ± 1.2 cm(3) vs 3.7 ± 1.6 cm(3), P < .01), and significantly larger adenoid (8.4 ± 4.1 cm(3) vs 6.0 ± 2.2 cm(3), P < .01), tonsils (7.0 ± 4.3 cm(3) vs 5.1 ± 1.9 cm(3), P < .01), retropharyngeal nodes (3.0 ± 1.9 cm(3) vs 2.2 ± 0.9 cm(3), P < .05), and deep cervical nodes (15.7 ± 5.7 cm(3) vs 12.7 ± 4.0 cm(3), P < .05). Polysomnography showed that 19.4% (seven of 36) of children with SCD had OSAS compared with 0% (zero of 20) of control subjects (P < .05) and that in children with SCD the apnea-hypopnea index correlated positively with upper airway lymphoid tissues size (r = 0.57, P < 001). In addition, children with SCD had lower arterial oxygen saturation nadir (84.3% ± 12.3% vs 91.2% ± 4.2%, P < .05), increased peak end-tidal CO(2) (53.4 ± 8.5 mm Hg vs 42.3 ± 5.3 mm Hg, P < .001), and increased arousals (13.7 ± 4.7 events/h vs 10.8 ± 3.8 events/h, P < .05). CONCLUSIONS Children with SCD have reduced upper airway size due to overgrowth of the surrounding lymphoid tissues, which may explain their predisposition to OSAS.
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Muzumdar H, Arens R. Restoration of autonomic dysfunction in children with obstructive sleep apnea after adenotonsillectomy. Sleep 2012; 35:1311-2. [PMID: 23024424 DOI: 10.5665/sleep.2094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Nandalike K, Agarwal C, Strauss T, Coupey SM, Isasi CR, Sin S, Arens R. Sleep and cardiometabolic function in obese adolescent girls with polycystic ovary syndrome. Sleep Med 2012; 13:1307-12. [PMID: 22921588 DOI: 10.1016/j.sleep.2012.07.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 07/05/2012] [Accepted: 07/12/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To compare the polysomnography findings and cardiometabolic function among adolescent girls with polycystic ovary syndrome (PCOS) and matched female and male controls. METHOD Retrospective chart review of electronic medical records of 28 girls with PCOS (age: 16.8±1.9 years, body mass index (BMI) Z-score 2.4±0.4), 28 control females (age: 17.1±1.8, BMI Z-score 2.4±0.3) and 28 control males (age: 16.6±1.6, BMI Z-score 2.5±0.5) in a tertiary care centre. RESULTS The prevalence of obstructive sleep apnoea (OSA) was higher in girls with PCOS compared to control females (16/28 (57%) vs. 4/28(14.3%), p<0.01); however, it was comparable to that of the control males (16/28(57%) vs. 21/28(75%), p=0.4). Girls with PCOS had a significantly higher prevalence of insulin resistance compared to control females and control males (20/28 (71.4%) vs. 9/22 (41.0%) (p=0.04) vs. 8/23 (34.8%) (p=0.01). Among girls with PCOS, those with OSA had significantly higher proportions of metabolic syndrome (MetS) (9/16 (56.3%) vs. 1/12 (8.3%) p=0.03), higher insulin resistance (14/16 (87.5%) vs. 6/12 (50%), p=0.04), elevated daytime systolic blood pressure (128.4±12.8 vs. 115.6±11.4, p<0.01), lower high-density lipoprotein (HDL) (38.6±8.7 vs. 49±10.9, p=0.01) and elevated triglycerides (TG) (149.7±87.7 vs. 93.3±25.8, p=0.03) compared to those without OSA. CONCLUSIONS We report a higher prevalence of OSA and metabolic dysfunction in a selected group of obese girls with PCOS referred with sleep-related complaints compared to BMI-matched control girls without PCOS. We also report higher prevalence of cardiometabolic dysfunction in girls with PCOS and OSA compared to girls with PCOS without OSA.
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Caboot JB, Jawad AF, McDonough JM, Bowdre CY, Arens R, Marcus CL, Mason TBA, Smith-Whitley K, Ohene-Frempong K, Allen JL. Non-invasive measurements of carboxyhemoglobin and methemoglobin in children with sickle cell disease. Pediatr Pulmonol 2012; 47:808-15. [PMID: 22328189 PMCID: PMC3368100 DOI: 10.1002/ppul.22504] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 12/17/2011] [Accepted: 12/18/2011] [Indexed: 11/10/2022]
Abstract
Assessment of oxyhemoglobin saturation in patients with sickle cell disease (SCD) is vital for prompt recognition of hypoxemia. The accuracy of pulse oximeter measurements of blood oxygenation in SCD patients is variable, partially due to carboxyhemoglobin (COHb) and methemoglobin (MetHb), which decrease the oxygen content of blood. This study evaluated the accuracy and reliability of a non-invasive pulse co-oximeter in measuring COHb and MetHb percentages (SpCO and SpMet) in children with SCD. We hypothesized that measurements of COHb and MetHb by non-invasive pulse co-oximetry agree within acceptable clinical accuracy with those made by invasive whole blood co-oximetry. Fifty children with SCD-SS underwent pulse co-oximetry and blood co-oximetry while breathing room air. Non-invasive COHb and MetHb readings were compared to the corresponding blood measurements. The pulse co-oximeter bias was 0.1% for COHb and -0.22% for MetHb. The precision of the measured SpCO was ± 2.1% within a COHb range of 0.4-6.1%, and the precision of the measured SpMet was ± 0.33% within a MetHb range of 0.1-1.1%. Non-invasive pulse co-oximetry was useful in measuring COHb and MetHb levels in children with SCD. Although the non-invasive technique slightly overestimated the invasive COHb measurements and slightly underestimated the invasive MetHb measurements, there was close agreement between the two methods.
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Redline S, Amin R, Beebe D, Chervin RD, Garetz SL, Giordani B, Marcus CL, Moore RH, Rosen CL, Arens R, Gozal D, Katz ES, Mitchell RB, Muzumdar H, Taylor HG, Thomas N, Ellenberg S. The Childhood Adenotonsillectomy Trial (CHAT): rationale, design, and challenges of a randomized controlled trial evaluating a standard surgical procedure in a pediatric population. Sleep 2011; 34:1509-17. [PMID: 22043122 PMCID: PMC3198206 DOI: 10.5665/sleep.1388] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Each year, over 500,000 adenotonsillectomies (AT), mostly for the treatment of pediatric obstructive sleep apnea (OSA) are performed in the US in children under 15 years of age. No definitive study, however, has been yet conducted that has rigorously evaluated the effectiveness of AT for not only improving sleep disordered breathing, but also for improving clinically relevant outcomes, such as neurocognitive function, behavior, and quality of life. The Childhood Adenotonsillectomy Trial (CHAT) was designed to assess neuropsychological and health outcomes in children randomized to receive early AT (eAT) as compared to Watchful Waiting with Supportive Care (WWSC). Important secondary goals of the study are to evaluate outcomes in subgroups defined by obesity and race. This paper addresses key elements in the design and implementation of a controlled trial for a widely used "standard practice" surgical intervention in a pediatric population, that include establishment of standardized data collection procedures across sites for a wide variety of data types, establishment of equipoise, and approaches for minimizing unblinding of selected key personnel. The study framework that was established should provide a useful template for other pediatric controlled studies or other studies that evaluate surgical interventions.
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Rastogi D, Canfield SM, Andrade A, Isasi CR, Hall CB, Rubinstein A, Arens R. Obesity-associated asthma in children: a distinct entity. Chest 2011; 141:895-905. [PMID: 21980061 DOI: 10.1378/chest.11-0930] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Obesity-associated asthma has been proposed to be a distinct entity, differing in immune pathogenesis from atopic asthma. Both obesity-mediated inflammation and increase in adiposity are potential mechanistic factors that are poorly defined among children. We hypothesized that pediatric obesity-associated asthma would be characterized by T helper (Th) 1, rather than the Th2 polarization associated with atopic asthma. Moreover, we speculated that Th1 biomarkers and anthropometric measures would correlate with pulmonary function tests (PFTs) in obese asthmatic children. METHODS We recruited 120 children, with 30 in each of the four study groups: obese asthmatic children, nonobese asthmatic children, obese nonasthmatic children, and nonobese nonasthmatic children. All children underwent pulmonary function testing. Blood was collected for measurement of serum cytokines. T-cell responses to mitogen, phorbol 12-myristate 13-acetate (PMA), or antigens tetanus toxoid or Dermatophagoides farinae were obtained by flow cytometric analysis of intracellular cytokine staining for interferon-γ (IFN-γ) (Th1) or IL-4 (Th2) within the CD4 population. RESULTS Obese asthmatic children had significantly higher Th1 responses to PMA (P < .01) and tetanus toxoid (P < .05) and lower Th2 responses to PMA (P < .05) and D farinae (P < .01) compared with nonobese asthmatic children. Th-cell patterns did not differ between obese asthmatic children and obese nonasthmatic children. Obese asthmatic children had lower FEV(1)/FVC (P < .01) and residual volume/total lung capacity ratios (P < .005) compared with the other study groups, which negatively correlated with serum interferon-inducible protein 10 and IFN-γ levels, respectively. PFTs, however, did not correlate with BMI z score or waist to hip ratio. CONCLUSIONS We found that pediatric obesity-associated asthma differed from atopic asthma and was characterized by Th1 polarization. The altered immune environment inversely correlated with PFTs in obese asthmatic children.
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Nandalike K, Strauss T, Agarwal C, Coupey SM, Sin S, Rajpathak S, Cohen HW, Arens R. Screening for sleep-disordered breathing and excessive daytime sleepiness in adolescent girls with polycystic ovarian syndrome. J Pediatr 2011; 159:591-6. [PMID: 21645911 PMCID: PMC3169731 DOI: 10.1016/j.jpeds.2011.04.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 04/07/2011] [Accepted: 04/19/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine the prevalence and clinical and metabolic correlates of sleep-disordered breathing (SDB) and excessive daytime sleepiness (EDS) in adolescent girls with polycystic ovarian syndrome (PCOS). STUDY DESIGN Standardized questionnaires were administered to participants with PCOS and age-, sex-, ethnicity-, and body mass index (BMI) z score-matched controls. Medical records were reviewed for anthropometric and metabolic data. RESULTS We studied 103 participants with PCOS (16.9 ± 1.5 years) and 90 controls (16.8 ± 1.7 years). Compared with controls, girls with PCOS had a higher prevalence of SDB (45.6% vs 27.8%; P = .01) and EDS (54.4% vs 35.6%; P < .01). Within PCOS, those with SDB had higher BMI z score (2.1 ± 0.5 vs 1.7 ± 0.6; P < .01), higher homeostatic model assessment index (5.1 ± 2.3 vs 4.1 ± 3.5; P < .01), and higher prevalence of the metabolic syndrome (MetS) (42.6% vs 16.1%; P = .003) compared with those without SDB. Similarly, participants with PCOS and EDS had a higher BMI z score (2.0 ± 0.6 vs 1.7 ± 0.6; P = .03), higher homeostatic model assessment index (5.1 ± 2.9 vs 3.8 ± 3.1; P = .01), and higher rate of MetS (39.3% vs. 14.9%; P < .01) compared with those without EDS. MetS was independently associated with SDB (OR, 3.2; 95% CI, 1.0-10.1) and EDS (OR, 4.5; 95% CI, 1.2-16). CONCLUSIONS SDB and EDS are highly prevalent in adolescent girls with PCOS compared with matched controls. The MetS is independently associated with SDB and EDS in this group.
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Mason TBA, Arens R, Sharman J, Bintliff-Janisak B, Schultz B, Walters AS, Cater JR, Kaplan P, Pack AI. Sleep in children with Williams Syndrome. Sleep Med 2011; 12:892-7. [PMID: 21940205 PMCID: PMC3210863 DOI: 10.1016/j.sleep.2011.05.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 05/21/2011] [Accepted: 05/22/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To analyze sleep in children with Williams Syndrome (WS) compared to normal healthy controls in order to determine whether particular sleep features are characteristic of WS, and to explore associations between disturbed sleep and behavior. METHODS Thirty-five children with genetically-confirmed WS and 35 matched controls underwent overnight polysomnography and performance testing in the Sleep Center at the Children's Hospital of Philadelphia. Parents completed questionnaires regarding the subjects' sleep and behavior. RESULTS WS subjects had significantly different sleep than controls, with decreased sleep efficiency, increased respiratory-related arousals and increased slow wave sleep on overnight polysomnography. WS subjects were also noted to have more difficulty falling asleep, with greater restlessness and more arousals from sleep than controls. Fifty-two percent of WS subjects had features of attention deficit-hyperactivity disorder. CONCLUSION Children with WS had significantly different sleep than controls in our sample. These differences demonstrated in our study may reflect genetic influences on sleep.
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Persak SC, Sin S, McDonough JM, Arens R, Wootton DM. Noninvasive estimation of pharyngeal airway resistance and compliance in children based on volume-gated dynamic MRI and computational fluid dynamics. J Appl Physiol (1985) 2011; 111:1819-27. [PMID: 21852407 DOI: 10.1152/japplphysiol.01230.2010] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Computational fluid dynamics (CFD) analysis was used to model the effect of collapsing airway geometry on internal pressure and velocity in the pharyngeal airway of three sedated children with obstructive sleep apnea syndrome (OSAS) and three control subjects. Model geometry was reconstructed from volume-gated magnetic resonance images during normal tidal breathing at 10 increments of tidal volume through the respiratory cycle. Each geometry was meshed with an unstructured grid and solved using a low-Reynolds number k-ω turbulence model driven by flow data averaged over 12 consecutive breathing cycles. Combining gated imaging with CFD modeling created a dynamic three-dimensional view of airway anatomy and mechanics, including the evolution of airway collapse and flow resistance and estimates of the local effective compliance. The upper airways of subjects with OSAS were generally much more compliant during tidal breathing. Compliance curves (pressure vs. cross-section area), derived for different locations along the airway, quantified local differences along the pharynx and between OSAS subjects. In one subject, the distal oropharynx was more compliant than the nasopharynx (1.028 vs. 0.450 mm(2)/Pa) and had a lower theoretical limiting flow rate, confirming the distal oropharynx as the flow-limiting segment of the airway in this subject. Another subject had a more compliant nasopharynx (0.053 mm(2)/Pa) during inspiration and apparent stiffening of the distal oropharynx (C = 0.0058 mm(2)/Pa), and the theoretical limiting flow rate indicated the nasopharynx as the flow-limiting segment. This new method may help to differentiate anatomical and functional factors in airway collapse.
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Rogers VE, Marcus CL, Jawad AF, Smith-Whitley K, Ohene-Frempong K, Bowdre C, Allen J, Arens R, Mason TBA. Periodic limb movements and disrupted sleep in children with sickle cell disease. Sleep 2011; 34:899-908. [PMID: 21731140 DOI: 10.5665/sleep.1124] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
STUDY OBJECTIVES To describe the rate, distribution and correlates of periodic limb movements in sleep (PLMS) in children with sickle cell disease (SCD). DESIGN Prospective, cross-sectional. SETTING Hospital-based sleep laboratory. PARTICIPANTS Sixty-four children aged 2-18 years with SCD, hemoglobin SS-type who had an overnight polysomnogram and a parent-completed Pediatric Sleep Questionnaire. Mean age was 8.4 years (SD 4.8); 50% were male. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS The mean PLMS index was 3.7 (6.6) and ranged from 0 to 31.8, with 23.4% of the sample having PLMS ≥ 5/h. Sleep efficiency was decreased (P = 0.03), and the total arousal index (P = 0.003) and PLMS arousal index (P < 0.001) were increased in children with PLMS ≥ 5/h compared to those with PLMS < 5/h. PLMS were most frequent in NREM stage 2 sleep and during the fourth hour of sleep. Inter-movement interval duration peaked at 25-30 s. "Growing pains worst in bed" or "restlessness of the legs", suggesting restless legs syndrome (RLS), were reported in 12.5% of the total sample and were more common in children with elevated PLMS. A PLMS score for identifying elevated PLMS in children, based on items from the Pediatric Sleep Questionnaire, did not significantly predict PLMS ≥ 5/h. CONCLUSIONS Elevated PLMS are common in children with SCD and are associated with sleep disruption and symptoms of RLS. Future research into the time structure of PLMS, their causes and consequences, and development of a disease-specific sleep disorders screening questionnaire, is needed in children with SCD.
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Huang J, Pinto SJ, Allen JL, Arens R, Bowdre CY, Jawad AF, Mason TBA, Ohene-Frempong K, Smith-Whitley K, Marcus CL. Upper airway genioglossal activity in children with sickle cell disease. Sleep 2011; 34:773-8. [PMID: 21629365 DOI: 10.5665/sleep.1046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES The prevalence of obstructive sleep apnea syndrome (OSAS) in sickle cell disease (SCD) has been reported to be higher than that in the general pediatric population. However, not all subjects with SCD develop OSAS. We hypothesized that SCD patients with OSAS have a blunted neuromuscular response to subatmospheric pressure loads during sleep, making them more likely to develop upper airway collapse. DESIGN Subjects with SCD with and without OSAS underwent pressure-flow measurements during sleep using intraoral surface electrodes to measure genioglossal EMG (EMGgg). Two techniques were applied to decrease the nasal pressure (P(N)) to subatmospheric levels, resulting in an activated and relatively hypotonic upper airway. The area under the curve of the inspiratory EMGgg moving time average was analyzed. EMGgg activity was expressed as a percentage of baseline. Changes in EMGgg in response to decrements in nasal pressure were expressed as the slope of the EMGgg vs. nasal pressure (slope of EMGgg-P(N)). SETTING Sleep laboratory. PARTICIPANTS 4 children with SCD and OSAS and 18 children with SCD but without OSAS. RESULTS THE MAJOR FINDINGS OF THIS STUDY WERE: (1) using the activated but not the hypotonic technique, the slope of EMGgg-P(N) was more negative in SCD controls than SCD OSAS; (2) the slope of EMGgg-P(N) was significantly lower using the activated technique compared to the hypotonic technique in SCD controls only; (3) similarly, the critical closing pressure, Pcrit, was more negative using the activated technique than the hypotonic technique in SCD controls but not in SCD OSAS. CONCLUSION This preliminary study has shown that children with SCD but without OSAS have more prominent upper airway reflexes than children with SCD and OSAS.
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Muzumdar HV, Sin S, Nikova M, Gates G, Kim D, Arens R. Changes in Heart Rate Variability After Adenotonsillectomy in Children With Obstructive Sleep Apnea. Chest 2011; 139:1050-1059. [DOI: 10.1378/chest.10-1555] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Arens R, Sin S, McDonough JM. Upper Airway Lymphoid Tissues in Obese Children with Sleep Apnea: Clinical Implications. Am J Respir Crit Care Med 2011. [DOI: 10.1164/ajrccm.183.7.951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Arens R, Sin S, Nandalike K, Rieder J, Khan UI, Freeman K, Wylie-Rosett J, Lipton ML, Wootton DM, McDonough JM, Shifteh K. Upper airway structure and body fat composition in obese children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2010; 183:782-7. [PMID: 20935105 DOI: 10.1164/rccm.201008-1249oc] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Mechanisms leading to obstructive sleep apnea syndrome (OSAS) in obese children are not well understood. OBJECTIVES The aim of the study was to determine anatomical risk factors associated with OSAS in obese children as compared with obese control subjects without OSAS. METHODS Magnetic resonance imaging was used to determine the size of upper airway structure, and body fat composition. Paired analysis was used to compare between groups. Mixed effects regression models and conditional multiple logistic regression models were used to determine whether body mass index (BMI) Z-score was an effect modifier of each anatomic characteristic as it relates to OSAS. MEASUREMENTS AND MAIN RESULTS We studied 22 obese subjects with OSAS (12.5 ± 2.8 yr; BMI Z-score, 2.4 ± 0.4) and 22 obese control subjects (12.3 ± 2.9 yr; BMI Z-score, 2.3 ± 0.3). As compared with control subjects, subjects with OSAS had a smaller oropharynx (P < 0.05) and larger adenoid (P < 0.01), tonsils (P < 0.05), and retropharyngeal nodes (P < 0.05). The size of lymphoid tissues correlated with severity of OSAS whereas BMI Z-score did not have a modifier effect on these tissues. Subjects with OSAS demonstrated increased size of parapharyngeal fat pads (P < 0.05) and abdominal visceral fat (P < 0.05). The size of these tissues did not correlate with severity of OSAS and BMI Z-score did not have a modifier effect on these tissues. CONCLUSIONS Upper airway lymphoid hypertrophy is significant in obese children with OSAS. The lack of correlation of lymphoid tissue size with obesity suggests that this hypertrophy is caused by other mechanisms. Although the parapharyngeal fat pads and abdominal visceral fat are larger in obese children with OSAS we could not find a direct association with severity of OSAS or with obesity.
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Arens R, Sin S, Willen S, Bent J, Parikh SR, Freeman K, Wootton DM, McDonough JM, Shifteh K. Rhino-sinus involvement in children with obstructive sleep apnea syndrome. Pediatr Pulmonol 2010; 45:993-8. [PMID: 20648667 DOI: 10.1002/ppul.21284] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Obstructive sleep apnea syndrome (OSAS) is commonly associated with adenotonsillar hypertrophy. We hypothesized that respiratory perturbations extend to other regions of the upper respiratory tract in such children, particularly to rhino-sinus regions. STUDY DESIGN A prospective case control study using Magnetic Resonance Imaging (MRI) of the upper airway and surrounding tissues of OSAS and controls. Magnetic resonance imaging was used to evaluate radiographic changes within the: paranasal sinuses, middle ear and mastoid air cells, and the nasal passages. RESULTS We studied 54 OSAS (age 5.7 ± 3.0 years) and 54 controls (age 6.2 ± 2.0 years, P = NS). Children with OSAS had significantly more opacification of: maxillary sinuses (P < 0.05), sphenoid sinuses (P < 0.01), and mastoid air cells (P < 0.01). They also had significantly more: middle ear effusions, (P < 0.001), prominence of inferior nasal turbinate(s) (P < 0.05), and deviation of the nasal septum (P < 0.05). CONCLUSIONS Childhood OSAS is associated with a wide range of upper respiratory tract perturbations and is not limited to adenoid and tonsillar hypertrophy.
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Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, Kaditis AG, Splaingard D, Splaingard M, Brooks LJ, Marcus CL, Sin S, Arens R, Verhulst SL, Gozal D. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med 2010; 182:676-83. [PMID: 20448096 DOI: 10.1164/rccm.200912-1930oc] [Citation(s) in RCA: 476] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown. Although success rates are likely lower than previously estimated, factors that promote incomplete resolution of OSAS after AT remain undefined. OBJECTIVES To quantify the effect of demographic and clinical confounders known to impact the success of AT in treating OSAS. METHODS A multicenter collaborative retrospective review of all nocturnal polysomnograms performed both preoperatively and postoperatively on otherwise healthy children undergoing AT for the diagnosis of OSAS was conducted at six pediatric sleep centers in the United States and two in Europe. Multivariate generalized linear modeling was used to assess contributions of specific demographic factors on the post-AT obstructive apnea-hypopnea index (AHI). MEASUREMENTS AND MAIN RESULTS Data from 578 children (mean age, 6.9 +/- 3.8 yr) were analyzed, of which approximately 50% of included children were obese. AT resulted in a significant AHI reduction from 18.2 +/- 21.4 to 4.1 +/- 6.4/hour total sleep time (P < 0.001). Of the 578 children, only 157 (27.2%) had complete resolution of OSAS (i.e., post-AT AHI <1/h total sleep time). Age and body mass index z-score emerged as the two principal factors contributing to post-AT AHI (P < 0.001), with modest contributions by the presence of asthma and magnitude of pre-AT AHI (P < 0.05) among nonobese children. CONCLUSIONS AT leads to significant improvements in indices of sleep-disordered breathing in children. However, residual disease is present in a large proportion of children after AT, particularly among older (>7 yr) or obese children. In addition, the presence of severe OSAS in nonobese children or of chronic asthma warrants post-AT nocturnal polysomnography, in view of the higher risk for residual OSAS.
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Abstract
The increasing prevalence of obesity in children seems to be associated with an increased prevalence of obstructive sleep apnea syndrome (OSAS) in children. Possible pathophysiological mechanisms contributing to this association include the following: adenotonsillar hypertrophy due to increased somatic growth, increased critical airway closing pressure, altered chest wall mechanics, and abnormalities of ventilatory control. However, the details of these mechanisms and their interactions have not been elucidated. In addition, obesity and OSAS are both associated with metabolic syndrome, which is a constellation of features such as hypertension, insulin resistance, dyslipidemia, abdominal obesity, and prothrombotic and proinflammatory states. There is some evidence that OSAS may contribute to the progression of metabolic syndrome with a potential for significant morbidity. The treatment of OSAS in obese children has not been standardized. Adenotonsillectomy is considered the primary intervention followed by continuous positive airway pressure treatment if OSAS persists. Other methods such as oral appliances, surgery, positional therapy, and weight loss may be beneficial for individual subjects. The present review discusses these issues and suggests an approach to the management of obese children with snoring and possible OSAS.
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Marcus CL, Smith RJH, Mankarious LA, Arens R, Mitchell GS, Elluru RG, Forte V, Goudy S, Jabs EW, Kane AA, Katz E, Paydarfar D, Pereira K, Reeves RH, Richtsmeier JT, Ruiz RL, Thach BT, Tunkel DE, Whitsett JA, Wootton D, Blaisdell CJ. Developmental aspects of the upper airway: report from an NHLBI Workshop, March 5-6, 2009. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2009; 6:513-20. [PMID: 19741259 PMCID: PMC3136952 DOI: 10.1513/pats.200905-024cb] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 07/17/2009] [Indexed: 11/20/2022]
Abstract
The upper airway serves three important functions: respiration, swallowing, and speech. During development it undergoes significant structural and functional changes that affect its size, shape, and mechanical properties. Abnormalities of the upper airway require prompt attention, because these often alter ventilatory patterns and gas exchange, particularly during sleep when upper airway motor tone and ventilatory drive are diminished. Recognizing the relationship of early life events to lung health and disease, the National Heart, Lung, and Blood Institute (NHLBI), with cofunding from the Office of Rare Diseases (ORD), convened a workshop of extramural experts, from many disciplines. The objective of the workshop was: (1) to review the state of science in pediatric upper airway disorders; (2) to make recommendations to the Institute to fill knowledge gaps; (3) to prioritize new research directions; and (4) to capitalize on scientific opportunities. This report provides recommendations that could facilitate translation of basic research findings into practice to better diagnose, treat, and prevent airway compromise in children.
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van Heijst JWJ, Gerlach C, Swart E, Sie D, Nunes-Alves C, Kerkhoven RM, Arens R, Correia-Neves M, Schepers K, Schumacher TNM. Recruitment of Antigen-Specific CD8+ T Cells in Response to Infection Is Markedly Efficient. Science 2009; 325:1265-9. [DOI: 10.1126/science.1175455] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Muzumdar H, Arens R. Diagnostic issues in pediatric obstructive sleep apnea. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2008; 5:263-73. [PMID: 18250220 PMCID: PMC2645257 DOI: 10.1513/pats.200707-113mg] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 10/27/2007] [Indexed: 01/01/2023]
Abstract
Obstructive sleep apnea syndrome (OSAS) in children includes a spectrum of respiratory disorders with significant morbidities. Diagnosis of OSAS is based on clinical suspicion, history, and physical findings, and confirmation is made by polysomnography. There has been significant progress in recent years in technologies available for diagnosis of OSAS since the consensus statement of the American Thoracic Society in 1996. The current review describes methodologies that are available today for assessment and diagnosis of OSAS in children and summarizes the most recent recommendations of the American Academy of Sleep Medicine Task Force regarding scoring sleep-related respiratory events in children.
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Muzumdar H, Arens R. Pleural fluid. Pediatr Rev 2007; 28:462-4. [PMID: 18055645 DOI: 10.1542/pir.28-12-462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Ruotolo RA, Veitia NA, Corbin A, McDonough J, Solot CB, McDonald-McGinn D, Zackai EH, Emanuel BS, Cnaan A, LaRossa D, Arens R, Kirschner RE. Velopharyngeal anatomy in 22q11.2 deletion syndrome: a three-dimensional cephalometric analysis. Cleft Palate Craniofac J 2006. [PMID: 16854203 DOI: 10.1597/04-193r.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE 22q11.2 deletion syndrome is the most common genetic cause of velopharyngeal dysfunction (VPD). Magnetic resonance imaging (MRI) is a promising method for noninvasive, three-dimensional (3D) assessment of velopharyngeal (VP) anatomy. The purpose of this study was to assess VP structure in patients with 22q11.2 deletion syndrome by using 3D MRI analysis. DESIGN This was a retrospective analysis of magnetic resonance images obtained in patients with VPD associated with a 22q11.2 deletion compared with a normal control group. SETTING This study was conducted at The Children's Hospital of Philadelphia, a pediatric tertiary care center. PATIENTS, PARTICIPANTS The study group consisted of 5 children between the ages of 2.9 and 7.9 years, with 22q11.2 deletion syndrome confirmed by fluorescence in situ hybridization analysis. All had VPD confirmed by nasendoscopy or videofluoroscopy. The control population consisted of 123 unaffected patients who underwent MRI for reasons other than VP assessment. INTERVENTIONS Axial and sagittal T1- and T2-weighted magnetic resonance images with 3-mm slice thickness were obtained from the orbit to the larynx in all patients by using a 1.5T Siemens Visions system. OUTCOME MEASURES Linear, angular, and volumetric measurements of VP structures were obtained from the magnetic resonance images with VIDA image-processing software. RESULTS The study group demonstrated greater anterior and posterior cranial base and atlanto-dental angles. They also demonstrated greater pharyngeal cavity volume and width and lesser tonsillar and adenoid volumes. CONCLUSION Patients with a 22q11.2 deletion demonstrate significant alterations in VP anatomy that may contribute to VPD.
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Ruotolo RA, Veitia NA, Corbin A, McDonough J, Solot CB, McDonald-McGinn D, Zackai EH, Emanuel BS, Cnaan A, LaRossa D, Arens R, Kirschner RE. Velopharyngeal anatomy in 22q11.2 deletion syndrome: a three-dimensional cephalometric analysis. Cleft Palate Craniofac J 2006; 43:446-56. [PMID: 16854203 PMCID: PMC2813062 DOI: 10.1597/04-193.1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE 22q11.2 deletion syndrome is the most common genetic cause of velopharyngeal dysfunction (VPD). Magnetic resonance imaging (MRI) is a promising method for noninvasive, three-dimensional (3D) assessment of velopharyngeal (VP) anatomy. The purpose of this study was to assess VP structure in patients with 22q11.2 deletion syndrome by using 3D MRI analysis. DESIGN This was a retrospective analysis of magnetic resonance images obtained in patients with VPD associated with a 22q11.2 deletion compared with a normal control group. SETTING This study was conducted at The Children's Hospital of Philadelphia, a pediatric tertiary care center. PATIENTS, PARTICIPANTS The study group consisted of 5 children between the ages of 2.9 and 7.9 years, with 22q11.2 deletion syndrome confirmed by fluorescence in situ hybridization analysis. All had VPD confirmed by nasendoscopy or videofluoroscopy. The control population consisted of 123 unaffected patients who underwent MRI for reasons other than VP assessment. INTERVENTIONS Axial and sagittal T1- and T2-weighted magnetic resonance images with 3-mm slice thickness were obtained from the orbit to the larynx in all patients by using a 1.5T Siemens Visions system. OUTCOME MEASURES Linear, angular, and volumetric measurements of VP structures were obtained from the magnetic resonance images with VIDA image-processing software. RESULTS The study group demonstrated greater anterior and posterior cranial base and atlanto-dental angles. They also demonstrated greater pharyngeal cavity volume and width and lesser tonsillar and adenoid volumes. CONCLUSION Patients with a 22q11.2 deletion demonstrate significant alterations in VP anatomy that may contribute to VPD.
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Abstract
Cytotoxic (CD8+) and helper (CD4+) T cells play a crucial role in resolving infections by intracellular pathogens. The development of technologies to visualize antigen-specific T cell responses in mice and men over the past decade has allowed a dissection of the formation of adaptive T cell immunity. This review gives a brief overview of the currently used detection techniques and possible future additions. Furthermore, we discuss our current understanding of the formation of antigen-specific T cell responses, with particular attention to the similarities and differences in CD4+ and CD8+ T cell responses, the functional heterogeneity within responder T cell pools and the regulation of CD8+ T cell responses by dendritic cells and CD4+ helper T cells.
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Xu C, Sin S, McDonough JM, Udupa JK, Guez A, Arens R, Wootton DM. Computational fluid dynamics modeling of the upper airway of children with obstructive sleep apnea syndrome in steady flow. J Biomech 2006; 39:2043-54. [PMID: 16098533 DOI: 10.1016/j.jbiomech.2005.06.021] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Accepted: 06/10/2005] [Indexed: 10/25/2022]
Abstract
Computational fluid dynamic (CFD) analysis was used to model the effect of airway geometry on internal pressure in the upper airway of three children with obstructive sleep apnea syndrome (OSAS), and three controls. Model geometry was reconstructed from magnetic resonance images obtained during quiet tidal breathing, meshed with an unstructured grid, and solved at normative peak resting flow. The unsteady Reynolds-averaged Navier-Stokes equations were solved with steady flow boundary conditions in inspiration and expiration, using a two-equation low-Reynolds number turbulence model. Model results were validated using an in-vitro scale model, unsteady flow simulation, and reported nasal resistance measurements in children. Pharynx pressure drop strongly correlated to airway area restriction. Inspiratory pressure drop was primarily proportional to the square of flow, consistent with pressure losses due to convective acceleration caused by area restriction. On inspiration, in OSAS pressure drop occurred primarily between the choanae and the region where the adenoids overlap the tonsils (overlap region) due to airway narrowing, rather than in the nasal passages; in controls the majority of pressure drop was in the nasal passages. On expiration, in OSAS the majority of pressure drop occurred between the oropharynx (posterior to the tongue) and overlap region, and local minimum pressure in the overlap region was near atmospheric due to pressure recovery in the anterior nasopharynx. The results suggest that pharyngeal airway shape in children with OSAS significantly affects internal pressure distribution compared to nasal resistance. The model may also help explain regional dynamic airway narrowing during expiration.
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Schwab RJ, Pasirstein M, Kaplan L, Pierson R, Mackley A, Hachadoorian R, Arens R, Maislin G, Pack AI. Family aggregation of upper airway soft tissue structures in normal subjects and patients with sleep apnea. Am J Respir Crit Care Med 2005; 173:453-63. [PMID: 16210668 PMCID: PMC2662941 DOI: 10.1164/rccm.200412-1736oc] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Sleep apnea is believed to be a genetic disorder. Thus, we hypothesized that anatomic risk factors for sleep apnea would demonstrate family aggregation. OBJECTIVES We used volumetric magnetic resonance imaging in a sib pair "quad" design to study the family aggregation of the size of upper airway soft tissue structures that are associated with increased risk for obstructive sleep apnea. METHODS We examined 55 sleep apnea probands (apnea-hypopnea index [AHI]: 43.2 +/- 26.3 events/h), 55 proband siblings (AHI: 11.8 +/- 16.6 events/h), 55 control subjects (AHI: 2.1 +/- 1.7 events/h), and 55 control siblings (AHI: 4.2 +/- 4.0 events/h). The study design used exact matching on ethnicity and sex, frequency matching on age, and statistical control for visceral neck fat and craniofacial dimensions. MEASUREMENTS AND MAIN RESULTS The data support our a priori hypothesis that the volume of the important upper airway soft tissue structures is heritable. The volume of the lateral pharyngeal walls (h(2) = 36.8%; p = 0.001), tongue (h(2) = 36.5%; p = 0.0001), and total soft tissue (h(2) = 37.5%; p = 0.0001) demonstrated significant levels of heritability after adjusting for sex, ethnicity, age, visceral neck fat, and craniofacial dimensions. In addition, our data indicate that heritability of the upper airway soft tissue structures is found in normal subjects and patients with apnea. Thus, it is not simply a consequence of the prevalence of apnea. CONCLUSIONS This is the first time family aggregation of size of the upper airway soft tissue structures has been demonstrated.
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Litman RS, Wake N, Chan LML, McDonough JM, Sin S, Mahboubi S, Arens R. Effect of Lateral Positioning on Upper Airway Size and Morphology in Sedated Children. Anesthesiology 2005; 103:484-8. [PMID: 16129971 DOI: 10.1097/00000542-200509000-00009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background
Lateral positioning decreases upper airway obstruction in paralyzed, anesthetized adults and in individuals with sleep apnea during sleep. The authors hypothesized that lateral positioning increases upper airway cross-sectional area and total upper airway volume when compared with the supine position in sedated, spontaneously breathing children.
Methods
Children aged 2-12 yr requiring magnetic resonance imaging examination of the head or neck region using deep sedation with propofol were studied. Exclusion criteria included any type of anatomical or neurologic entity that could influence upper airway shape or size. T1 axial scans of the upper airway were obtained in the supine and lateral positions, with the head and neck axes maintained neutral. Using software based on fuzzy connectedness segmentation (3D-VIEWNIX; Medical Imaging Processing Group, University of Pennsylvania, Philadelphia, PA), the magnetic resonance images were processed and segmented to render a three-dimensional reconstruction of the upper airway. Total airway volumes and cross-sectional areas were computed between the nasal vomer and the vocal cords. Two-way paired t tests were used to compare airway sizes between supine and lateral positions.
Results
Sixteen of 17 children analyzed had increases in upper airway total volume. The total airway volume (mean +/- SD) was 6.0 +/- 2.9 ml in the supine position and 8.7 +/- 2.5 ml in the lateral position (P < 0.001). All noncartilaginous areas of the upper airway increased in area in the lateral compared with the supine position. The region between the tip of the epiglottis and vocal cords demonstrated the greatest relative percent change.
Conclusions
The upper airway of a sedated, spontaneously breathing child widens in the lateral position. The region between the tip of the epiglottis and the vocal cords demonstrates the greatest relative percent increase in size.
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Arens R. Is It Time to Consider a New Treatment for Children with Sleep-disordered Breathing? Am J Respir Crit Care Med 2005; 172:264-5. [PMID: 16040789 DOI: 10.1164/rccm.2505006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Traeger N, Schultz B, Pollock AN, Mason T, Marcus CL, Arens R. Polysomnographic values in children 2-9 years old: additional data and review of the literature. Pediatr Pulmonol 2005; 40:22-30. [PMID: 15858805 DOI: 10.1002/ppul.20236] [Citation(s) in RCA: 228] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The establishment of normal pediatric polysomnographic parameters is important for both clinical and research interests. Our objectives were to describe respiratory events, paradoxical breathing, periodic limb movements, and sleep architecture of children at the age of peak incidence of obstructive sleep apnea syndrome. We performed a retrospective cross-sectional analysis of a prospective cohort study of 66 children, 2-9 years old, at the Sleep Disorders Center at the Children's Hospital of Philadelphia. Subjects screened by questionnaire underwent a standard polysomnogram. The percent of total sleep time spent in sleep stages 1, 2, 3, 4, and rapid eye movement (REM) were 4 +/- 3%, 44 +/- 10%, 10 +/- 6%, 22 +/- 8%, and 21 +/- 6%, respectively. The arousal and awakening index was 11.2 +/- 4.3/hr. Respiratory events included a central apnea index of 0.08 +/- 0.14/hr, obstructive apnea index of 0.01 +/- 0.03/hr, and obstructive hypopnea index of 0.3 +/- 0.5/hr. The baseline arterial oxygen saturation (SpO2) was 97 +/- 1%, with a nadir of 92 +/- 3%. The index of periodic limb movements in sleep (PLMS) was 1.3 +/- 2.2/hr. Paradoxical breathing appeared significantly more frequent with piezo crystal effort belts (40 +/- 24% of epochs) than with respiratory inductive plethysmography (1.5 +/- 3% of epochs). We describe the occurrence of hypopneas during sleep, arousals and awakenings, and PLMS. We illustrate how different technologies can vary the apparent amount of paradoxical breathing. We also confirm previous data on the frequency distribution of sleep stages, SpO2, and relative rarity of respiratory events in this age group.
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Arens R, Sin S, McDonough JM, Palmer JM, Dominguez T, Meyer H, Wootton DM, Pack AI. Changes in upper airway size during tidal breathing in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2005; 171:1298-304. [PMID: 15750038 PMCID: PMC2718463 DOI: 10.1164/rccm.200411-1597oc] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED We performed respiratory-gated magnetic resonance imaging to evaluate airway dynamics during tidal breathing in 10 children with obstructive sleep apnea syndrome (OSAS; age, 4.3 +/- 2.3 years) and 10 matched control subjects (age, 5.0 +/- 2.0 years). We hypothesized that respiratory cycle fluctuations in upper airway cross-sectional area would be larger in children with OSAS. METHODS Studies were performed under sedation. Respiratory gating was performed automatically at 10, 30, 50, 70, and 90% of inspiratory and expiratory volume. Airway cross-sectional area was measured at four ascending oropharyngeal levels at each increment of the respiratory cycle. RESULTS We noted the following in subjects with OSAS compared with control subjects: (1) a smaller upper airway cross-sectional area, particularly during inspiration; (2) airway narrowing occurred during inspiration without evidence of complete airway collapse; (3) airway dilatation occurred during expiration, particularly early in the phase; and (4) magnitude of cross-sectional areas fluctuations during tidal breathing noted in OSAS at levels 1 through 4 were 317, 422, 785, and 922%, compared with 19, 15 17, and 24% in control subjects (p < 0.001, p < 0.005, p < 0.001, and p < 0.001, respectively). CONCLUSIONS Fluctuations in airway area during tidal breathing are significantly greater in subjects with OSAS compared with control subjects. Resistive pressure loading is a probable explanation, although increased airway compliance may be a contributing factor.
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Uong EC, Jeffe DB, Gozal D, Arens R, Holbrook CR, Palmer J, Cleveland C, Schotland HM. Development of a Measure of Knowledge and Attitudes About Obstructive Sleep Apnea in Children (OSAKA-KIDS). ACTA ACUST UNITED AC 2005; 159:181-6. [PMID: 15699313 DOI: 10.1001/archpedi.159.2.181] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Primary care physicians play an important role in screening for childhood obstructive sleep apnea syndrome (OSAS) that, if untreated, can result in serious complications. OBJECTIVE To describe the development of the Obstructive Sleep Apnea Knowledge and Attitudes in Children (OSAKA-KIDS) questionnaire for use in measuring physicians' knowledge and attitudes about childhood OSAS and its treatment. DESIGN Cross-sectional survey to pilot administration of the 23-item OSAKA-KIDS questionnaire, mailed to 1195 community- and academic-based physicians in Louisville, Ky; Philadelphia, Pa; and St Louis, Mo. MAIN OUTCOME MEASURES Analysis of variance measured differences in knowledge and attitudes between academic- and community-based physicians and between pediatricians and family practitioners. Using stepwise multiple linear regression, we analyzed the associations between various predictors (including specialty, practice setting, and years since medical school graduation) and each item of knowledge and attitudes. All tests were 2-tailed. RESULTS Questionnaires for 497 respondents (44% female; mean [SD] age, 45.7 [10.5] years; and mean [SD] number of years since medical school graduation, 18.7 [11.0] years) were analyzed. The mean (SD) knowledge score (percentage of 18 possible) was 69.6% (14.6%). In regression analyses, more knowledge was associated with more positive attitudes overall and more recent graduation from medical school; having a more positive attitude was associated with having completed a pediatrics residency and more knowledge about OSAS. CONCLUSIONS Deficits in basic knowledge about childhood OSAS were observed regardless of physician practice setting and specialty training. More education focusing on the diagnosis and treatment of childhood OSAS and identifying children at risk for OSAS is recommended.
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Ruotolo R, LaRossa D, Arens R, Kirschner R, Veitia N, Corbin A, McDonough J, Solot C, McDonald-McGinn D, Zackai E, Emanuel B, Cnaan A. Velopharyngeal Anatomy in 22q11.2 Deletion Syndrome: A Three-Dimensional Cephalometric Analysis. Cleft Palate Craniofac J 2005. [DOI: 10.1597/04-193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
The obstructive sleep apnea syndrome (OSAS) occurs in patients of all ages, from the premature infant to the elderly. Much remains unknown about the pathophysiology of the syndrome. However, research suggests that OSAS in all age groups is due to a combination of both anatomic airway narrowing and abnormal upper airway neuromotor tone. The anatomic predisposing factors for OSAS differ over the lifespan. However, a smaller upper airway is noted in all age groups and probably predisposes to airway collapse during sleep. Despite the known anatomic factors, such as craniofacial anomalies, obesity, and adenotonsillar hypertrophy, that contribute to OSAS throughout life, a clear anatomic factor cannot always be identified. This suggests that alterations in upper airway neuromotor tone also play an important role in the etiology of OSAS. Infants and children are less likely than adults to arouse in response to upper airway obstruction and do not compensate for prolonged increases in inspiratory resistive load. The overall ventilatory drive is probably normal in patients of all ages with OSAS. However, upper airway neuromotor tone and reflexes during sleep vary with age and are increased in normal infants and children compared to adults, perhaps as a compensatory response for their relatively narrow airway. This compensatory response appears to be blunted in children with OSAS. Further research is needed to fully understand the complexities of upper airway structure and function during both normal development and disease.
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Schiffman PH, Rubin NK, Dominguez T, Mahboubi S, Udupa JK, O'Donnell AR, McDonough JM, Maislin G, Schwab RJ, Arens R. Mandibular Dimensions in Children with Obstructive Sleep Apnea Syndrome. Sleep 2004; 27:959-65. [PMID: 15453555 DOI: 10.1093/sleep/27.5.959] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We hypothesized that mandibular size may play a role in the etiology of obstructive sleep apnea syndrome (OSAS) in children, since a smaller mandible may reduce airway size. We used magnetic resonance imaging to determine the mandible dimensions of children with OSAS. DESIGN Case control study. SETTING Tertiary-care pediatric hospital. PARTICIPANTS Twenty-four subjects (mean age 4.9 +/- 1.7 years) with mild to moderate OSAS (Apnea Index 3.5 +/- 5.1), and 24 matched controls (mean age 4.9 +/- 1.8 years). INTERVENTION Magnetic resonance imaging of the upper airway under sedation. MEASUREMENTS Eight measurements were obtained from a 3-dimensional segmentation of the mandible using 3DVIEWNIX software. Measurements included length, height, width, midsymphysis menti angle, angle of mandible, enclosure area, surface area, and volume. Descriptive comparisons using Student t test and multivariate analyses of variance were performed. RESULTS Individual measurement comparisons revealed no significant differences between groups. Multivariate analysis showed a lower bound of a 95% confidence interval for an effect size measure for "general mandibular size," including all 6 linear, the area, and the volume measurements, to be -0.25. CONCLUSION Our study shows that a smaller mandible is not a feature in children with OSAS who do not have apparent craniofacial abnormalities.
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Schwab RJ, Pasirstein M, Pierson R, Mackley A, Hachadoorian R, Arens R, Maislin G, Pack AI. Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am J Respir Crit Care Med 2003; 168:522-30. [PMID: 12746251 DOI: 10.1164/rccm.200208-866oc] [Citation(s) in RCA: 522] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
We used sophisticated volumetric analysis techniques with magnetic resonance imaging in a case-control design to study the upper airway soft tissue structures in 48 control subjects (apnea-hypopnea index, 2.0 +/- 1.6 events/hour) and 48 patients with sleep apnea (apnea-hypopnea index, 43.8 +/- 25.4 events/hour). Our design used exact matching on sex and ethnicity, frequency matching on age, and statistical control for craniofacial size and visceral neck fat. The data support our a priori hypotheses that the volume of the soft tissue structures surrounding the upper airway is enlarged in patients with sleep apnea and that this enlargement is a significant risk factor for sleep apnea. After covariate adjustments the volume of the lateral pharyngeal walls (p < 0.0001), tongue (p < 0.0001), and total soft tissue (p < 0.0001) was significantly larger in subjects with sleep apnea than in normal subjects. These data also demonstrated, after covariate adjustments, significantly increased risk of sleep apnea the larger the volume of the tongue, lateral pharyngeal walls, and total soft tissue: (1) total lateral pharyngeal wall (odds ratio [OR], 6.01; 95% confidence interval [CI], 2.62-17.14); (2) total tongue (OR, 4.66; 95% CI, 2.31-10.95); and (3) total soft tissue (OR, 6.95; 95% CI, 3.08-19.11). In a multivariable logistic regression analysis the volume of the tongue and lateral walls was shown to independently increase the risk of sleep apnea.
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Liu J, Udupa JK, Odhnera D, McDonough JM, Arens R. System for upper airway segmentation and measurement with MR imaging and fuzzy connectedness. Acad Radiol 2003; 10:13-24. [PMID: 12529024 DOI: 10.1016/s1076-6332(03)80783-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to evaluate whether a computerized system developed to help delineate the upper airway and surrounding structures with magnetic resonance (MR) imaging was effective for aiding in the diagnosis of upper airway disorders in children. MATERIALS AND METHODS The authors performed axial T2-weighted MR imaging to gather information about different aspects of the airway and its surrounding soft-tissue structures, including the adenoid and palatine tonsils, tongue, and soft palate. Images were processed and segmented to compute the architectural parameters of the airway (eg, surface description, volume, central [medial] line, and cross-sectional areas at planes perpendicular to the central line). The authors built a software package for the visualization, segmentation, registration, prefiltering, interpolation, standardization, and quantitative analysis of the airway and tonsils. RESULTS The system was tested with 40 patient studies. For every study, the system segmented and displayed a smooth three-dimensional rendition of the airway and its central line and a plot of the cross-sectional area of the airway orthogonal to the central line as a function of the distance from one end of the central line. The precision and accuracy for segmentation was 97%. The mean time taken per study was about 4 minutes and included the operator interaction time and processing time. CONCLUSION This method provides a robust and fast means of assessing the airway size, shape, and level of restriction, as well as a structural data set suitable for use in modeling studies of airflow and mechanics.
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Arens R, McDonough JM, Corbin AM, Rubin NK, Carroll ME, Pack AI, Liu J, Udupa JK. Upper airway size analysis by magnetic resonance imaging of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2003; 167:65-70. [PMID: 12406826 DOI: 10.1164/rccm.200206-613oc] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Detailed analysis of the upper airway has not been performed in children with obstructive sleep apnea. We used magnetic resonance imaging and automatic segmentation to delineate the upper airway in 20 children with obstructive sleep apnea and in 20 control subjects (age, 3.7 +/- 1.4 versus 3.9 +/- 1.7 years, respectively). We measured mean and minimal cross-sectional area, length, and volume of: (1) the total airway; (2) regions along the adenoid, tonsils, and where adenoid and tonsils overlap; and (3) 10 segments at 10% increments along the airway. The mean cross-sectional area of the total airway of the obstructive sleep apnea group was significantly smaller in comparison with the control group, 28.1 +/- 12.6 versus 47.1 +/- 18.2 mm2, respectively (p < 0.0005). Minimal cross-sectional area and airway volume were smaller in this group, 4.6 +/- 3.3 versus 15.7 +/- 12.7 mm2 (p < 0.0005), and 1,129 +/- 515 versus 1,794 +/- 846 mm3 (p < 0.005), respectively. Regional analysis suggested that the upper airway in children with obstructive sleep apnea is most restricted where adenoid and tonsils overlap. Segmental analysis demonstrated that the upper airway is restricted throughout the initial two-thirds of its length and that the narrowing is not in a discrete region adjacent to either the adenoid or tonsils, but rather in a continuous fashion along both.
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Welch KC, Foster GD, Ritter CT, Wadden TA, Arens R, Maislin G, Schwab RJ. A Novel Volumetric Magnetic Resonance Imaging Paradigm to Study Upper Airway Anatomy. Sleep 2002. [DOI: 10.1093/sleep/25.5.530] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Welch KC, Foster GD, Ritter CT, Wadden TA, Arens R, Maislin G, Schwab RJ. A novel volumetric magnetic resonance imaging paradigm to study upper airway anatomy. Sleep 2002; 25:532-42. [PMID: 12150320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
STUDY OBJECTIVES We utilized novel three-dimensional volumetric analysis techniques with magnetic resonance imaging (MRI) to study the upper airway and surrounding soft-tissue structures. These MRI techniques allowed us to objectively quantify the volume of the tongue, soft palate, parapharyngeal fat pads, and lateral pharyngeal walls. DESIGN We first validated our volumetric imaging techniques on a phantom and then demonstrated that our results were reliable and reproducible in normal subjects who did not lose weight. Finally, we studied 12 obese, nonapneic women during wakefulness before and after weight loss. We hypothesized that our novel magnetic-resonance computer-reconstruction techniques would allow us to detect small reductions in the volume of the tongue, soft palate, lateral pharyngeal walls, and parapharyngeal fat pads and increases in the volume of the upper airway with weight loss. SETTING University medical center. PARTICIPANTS Normal controls and 12 obese nonapneic women. INTERVENTIONS Weight loss. MEASUREMENTS AND RESULTS Following a mean 17.1+/-8.62 kg (17.3%) reduction in weight, upper airway volume increased (p = 0.06) in both the retropalatal and retroglossal regions. This increase in upper airway volume was mediated by significant reductions in the volume of the lateral pharyngeal wall (p = 0.0001) and parapharyngeal fat pads (p = 0.001). However, the volume of the tongue (p = 0.35) and soft palate (p = 0.39) were not reduced significantly with weight loss. CONCLUSIONS These data indicate that volumetric MRI is a powerful tool to study anatomic changes in the upper airway and surrounding soft-tissue structures and is sensitive enough to detect changes in these structures.
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