0687 Comparative Changes Of Patient Reported Outcomes In Positive Airway Pressure And Upper Airway Stimulation For Obstructive Sleep Apnea

Introduction

Upper Airway Stimulation (UAS) is increasingly being used for obstructive sleep apnea (OSA) treatment, however, data comparing changes in patient reported outcomes (PROs) in response to positive airway pressure (PAP) versus UAS are limited. We hypothesize that there will be no difference in PROs between the two groups after treatment.

Methods

UAS and PAP groups were 1:3 matched on age, sex, Body Mass Index (BMI) and Apnea Hypopnea Index (AHI, category 15-30, >30). Linear mixed models assessed the difference of change in Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Patient Health Questionnaire (PHQ9) and Insomnia Severity Index (ISI) measures on matched strata of UAS versus PAP groups with adjustment of baseline and matching factors. All analysis was performed in SAS software (version 9.4, Cary, NC).

Results

The analytic sample comprised 193 PAP patients and 69 UAS patients, with mean age=62.9+/-9.4 years, 27.5% female, mean BMI=29.1+/-3.2kg/m2, and median AHI 42.7, IQR: 31.5, 57.2. ESS in PAP (n=190) reduced by -2.63 (-3.38,-1.88) and in UAS (n=56) reduced by -2.22 (-3.34, -1.10), with a mean difference of 0.41 (-0.70, 1.52, p=.46). FOSQ in PAP (n=188) showed a change of 1.38 (0.99, 1.78) and in UAS (n=49) a change of 1.82 (1.17, 2.46), with a mean difference of 0.43 (-0.23, 1.09, p=.19). PHQ9 in PAP (n=185) showed a significant change of -2.24(-3.00, 1.47) and in UAS (n=45) a change of -3.75(-5.07,-2.42), with a mean difference of -1.51(-2.93,-0.088, p=.038). ISI in PAP (n=193) showed a significant change of -3.20(-4.39,-2.02) and in UAS (n=47) a change of -4.83(-6.77,-2.90), with a mean difference of -1.63(-3.62, 0.37, p=.11).

Conclusion

Similar improvements in PROs were observed in both UAS and PAP patient groups, however UAS appeared to confer greater benefit in depressive symptoms relative to PAP. Randomized clinical trials should be designed to confirm these findings.

Support

N/A

The association between platelet dysfunction and adverse outcomes in cardiac surgical patients

Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.

Uncertainties in internal doses calculated for Mayak workers--a study of 63 cases

This study makes use of 63 cases of Mayak workers exposed to Pu-239 with autopsy data and some late-time urine bioassay data. In addition, air-concentration data--used to construct monthly average values--are available for each case, which provide the time dependence and potential magnitudes of normal inhalation intakes for each case. The purpose of the study is to develop and test Bayesian methods of dose calculation for the Mayak workers. The first part of the study was to quantitatively characterise the uncertainties of the bioassay data. Then, starting with three different published biokinetic models, the data are fit by varying intake and model perturbation parameters, e.g., parameters influencing the lung, thoracic lymph nodes, liver and bone retention. Statistical self-consistency arguments are used to check the measurement uncertainty parameters within the Poisson-lognormal model. The second part of the study is to set up and test Bayesian dose calculations, which use the point determinations of biokinetic parameters from the study cases within a discrete, empirical Bayes approximation. The main conclusion of the study is that these methods are now ready to be applied to the entire Mayak worker population.

The economic impact of intermittent high-dose intravenous versus oral corticosteroid treatment of juvenile dermatomyositis

OBJECTIVE

To perform a cost-identification and cost-effectiveness analysis comparing oral corticosteroids (OCS) with high-dose intermittent intravenous corticosteroid (IVCS) regimens in the treatment of juvenile dermatomyositis (JDM).

METHODS

Children previously diagnosed and treated for JDM (without myositis-specific or myositis-associated autoantibodies) at a single medical center by a single provider were identified. Two treatment protocols were compared: OCS and IVCS. Data on initial disease severity, time to remission, resource use, and costs generated were collected from patient records. Incremental cost-effectiveness ratios (ICE) were constructed.

RESULTS

Patients treated with IVCS achieved median remission 2 years earlier at median increased cost of $13,736. The ICE ratio comparing IVCS to OCS is $6,868 per year of disease avoided.

CONCLUSION

This study suggests that, although IVCS treatments are costly, they are cost-effective.

Overexertion injuries in home health care workers and the need for ergonomics

Home health care workers have high rates of back injuries and other musculoskeletal problems. This article addresses issues surrounding work-related overexertion injuries in home health care workers, including summaries of relevant research on workers in home settings as well as in traditional health care settings such as hospitals and nursing homes. The main work factors associated with these injuries are forceful exertions and awkward postures during patient- care tasks, especially while lifting and moving patients. Ergonomics-the design of work tasks to best accommodate natural human capabilities-is the most promising approach for preventing injuries, and for enhancing the comfort and safety of workers and patients.

Impact of vaginal antifungal products on utilization of health care services: evidence from physician visits

BACKGROUND

Recently many medications formerly available only by prescription have been approved for over-the-counter (OTC) status. In 1990, clotrimazole became the first available OTC drug to treat candidal vaginitis. Subsequently several other prescription antifungal medications have also been available in OTC products. One proposed benefit of these switches from prescription to OTC status is a reduction in the utilization of health care services.

METHODS

Using National Ambulatory Medical Care Survey data, the average numbers of annual visits for vaginal complaints were estimated for 1985, 1990, and 1994. These years were chosen because they represented periods before, close to, and after the approval of the OTC antifungal preparations. The estimated visits for each year were compared using a chi-square analysis with a sample weight correction.

RESULTS

There was a 15% decline in the number of vaginitis visits from 1990 to 1994 that potentially could be attributed to the availability of the OTC antifungal preparations. The decrease in physician visits results in approximately $45 million in direct cost savings and another $18.75 million in indirect savings by reducing time lost from work.

CONCLUSIONS

It appears that the availability of OTC anticandidal fungal preparations reduces the number of physician visits for vaginitis, resulting in cost savings.

Valuing clinical strategies early in development: a cost analysis of allogeneic peripheral blood stem cell transplantation

Allogeneic peripheral blood stem cell transplantation (alloPBSCT) is an emerging technology. As this technology develops, transplant centers are concerned with looking for technologic advances that will result in improvements in clinical outcomes and lower costs. We provide comparative estimates of costs and resource use for alloPBSCT in comparison to allogeneic bone marrow transplantation (alloBMT) for persons with hematologic malignancies from the time of harvest to 100 days post transplant. A retrospective, cost-identification analysis was conducted for patients in two consecutive phase II clinical trials at the University of Nebraska Medical Center. Identical preparative regimens, graft-versus-host disease prophylaxis, post-transplant hematopoietic colony-stimulating factor treatment regimens, and discharge criteria were used. Total median costs were $18,304 lower for alloPBSCT, with lower costs during recovery; specifically for hospitalization, platelet products, hematopoietic growth factors, intravenous hyperalimentation, supportive care agents, supplies, and antibacterial agents. This study provides preliminary evidence for short-term cost savings associated with alloPBSCT. However, concerns exist over the potential for higher costs due to preliminary reports of higher rates of chronic graft-versus-host disease, as well as more intensive induction regimens that may result in lower relapse rates. The premature adoption of new technologies based on short-term economic factors, in the absence of adequate clinical trial data, may prove to be ill-advised, particularly for complex medical treatments such as allogeneic transplantation.

The "prescription-to-OTC switch" movement. Its effects on antifungal vaginitis preparations

More than 600 over-the-counter (OTC) products have ingredients or dosages that were previously available by prescription only. The criteria for switching drugs include a low potential for misuse or abuse, safety and efficacy, and the ability for effective use by the average person. In addition, the conditions the drugs treat should be benign and self-limited. In 1990, the first topical imidazole for candidal vaginitis was approved by the Food and Drug Administration for over-the-counter use. Suggested benefits of this switch were increased patient autonomy and reduced costs. Risks include potential for misdiagnoses, resulting in inappropriate use, unnecessary use, or delay in treatment, which could lead to increased cost and morbidity. Despite the wide use of these products, there is little evidence examining the outcome of the switch. Limited available data suggest that the switch of the antifungal preparations reduces costs with little objective evidence of harm resulting from the switch.

Patients' and caregivers' transition from hospital to home: needs and recommendations

Given the greatly decreased length of hospital stays, concern about the transition from hospital to home has increased. This descriptive study focused on a sample of hospitalized patients discharged to home with home care services. Patient and caregiver interviews revealed that satisfaction with home care services was positively related to receipt of information from the home care staff about medications, equipment/supplies, and self-care. Caregiver burden was inversely related to receiving this information. Recommendations for improving the transition from hospital to home included providing more information, more reassurance and emotional support, and more household assistance. Several possible methods of implementing these recommendations are proposed.

Motor feedback physiological control for a continuous flow ventricular assist device

The response of a continuous flow magnetic bearing supported ventricular assist device, the CFVAD3 (CF3) to human physiologic pressure and flow needs is varied by adjustment of the motor speed. This paper discusses a model of the automatic feedback controller designed to develop the required pump performance. The major human circulatory, mechanical, and electrical systems were evaluated using experimental data from the CF3 and linearized models developed. An open-loop model of the human circulatory system was constructed with a human heart and a VAD included. A feedback loop was then closed to maintain a desired reference differential pressure across the system. A proportional-integral (PI) controller was developed to adjust the motor speed and maintain the system reference differential pressure when changes occur in the natural heart. The effects of natural heart pulsatility on the control system show that the reference blood differential pressure is maintained without requiring CF3 motor pulsatility.

The role of the nurse practitioner in the gastroenterology setting

The purpose if this qualitative study was to explore the role of a nurse practitioner who is currently functioning in the specialized setting of gastroenterology. Naturalistic inquiry was the research methodology used. This study was guided by the American Nurses Association Social Policy Statement (American Nurses Association, 1995) and posed the question: What is the role of the nurse practitioner in the gastroenterology setting? Data collection involved researcher-designed open-ended interview methods and content analysis. The results of this study contribute information regarding the role of a nurse practitioner in the specialized setting of a gastroenterology practice.

Comprehensive manual handling limits for lowering, pushing, pulling and carrying activities

The objective of this study was to develop a set of mathematical models for manual lowering, pushing, pulling and carrying activities that would result in establishing load capacity limits to protect the lower back against occupational low-back disorders. In order to establish safe guidelines, a three-stage process was used. First, psychophysical data was used to generate the models' discounting factors and recommended load capacities. Second, biomechanical analysis was used to refine the recommended load capacities. Third, physiological criteria were used to validate the models' discounting factors. Both task and personal factors were considered in the models' development. When compared to the results from prior psychophysical research for these activities, the developed load capacity values are lower than previously established limits. The results of this study allowed the authors to validate the hypothesis proposed and tested by Karwowski (1983) that states that the combination of physiological and biomechanical stresses should lead to the overall measure of task acceptability or the psychophysical stress. This study also found that some of the discounting factors for the task frequency parameters recommended in the prior psychophysical research should not be used as several of the high frequency factors violated physiological limits.

Thiopentone pretreatment for propofol injection pain in ambulatory patients

This study investigated propofol injection pain in patients undergoing ambulatory anaesthesia. In a randomized, double-blind trial, 90 women were allocated to receive one of three treatments prior to induction of anaesthesia with propofol. Patients in Group C received 2 ml normal saline, Group L, 2 ml, lidocaine 2% (40 mg) and Group T, 2 ml thiopentone 2.5% (50 mg). Venous discomfort was assessed with a visual analogue scale (VAS) 5-15 sec after commencing propofol administration using an infusion pump (rate 1000 micrograms.kg-1.min-1). Loss of consciousness occurred in 60-90 sec. Visual analogue scores (mean +/- SD) during induction were lower in Groups L (3.3 +/- 2.5) and T (4.1 +/- 2.7) than in Group C (5.6 +/- 2.3); P = 0.0031. The incidence of venous discomfort was lower in Group L (76.6%; P < 0.05) than in Group C (100%) but not different from Group T (90%). The VAS scores for recall of pain in the recovery room were correlated with the VAS scores during induction (r = 0.7045; P < 0.0001). Recovery room discharge times were similar: C (75.9 +/- 19.4 min); L 73.6 +/- 21.6 min); T (77.1 +/- 18.9 min). Assessing their overall satisfaction, 89.7% would choose propofol anaesthesia again. We conclude that lidocaine reduces the incidence and severity of propofol injection pain in ambulatory patients whereas thiopentone only reduces its severity.

The effect of GM-CSF and G-CSF on human neutrophil function

A direct comparison of GM-CSF and G-CSF in a panel of in vitro neutrophil-function assays was performed to investigate any differences in activity profiles. In our modified chemotactic assay, GM-CSF rapidly increased the migratory capacity of polymorphonuclear cells (PMNs) to move toward fMLP and LTB4. In contrast, G-CSF only stimulated PMN migration towards fMLP. GM-CSF, but not G-CSF, increased PMN cytotoxic killing of C. albicans blastospores. The expression of PMN surface antigens associated with Fc- and complement-mediated cell-binding (Fc gamma R1, CR-1 and CR-3), and adhesion signalling (ICAM-1), was increased after the exposure of GM-CSF, but not to G-CSF. In contrast these CSFs demonstrated relative equipotency in their ability to induce PMN anti-bacterial phagocytosis, and to restore the Staphylococcus aureus killing capacity of dexamethasone-suppressed neutrophils. The phagocytic activity of PMNs for opsonized yeast, as well as hexose-monophosphate shunt activity, was equivalent following GM-CSF or G-CSF treatment. We discuss the significance of the difference in activity profiles in this article.

Facilitated distortion of the DNA site enhances EcoRI endonuclease-DNA recognition

We have measured the binding of EcoRI endonuclease to a complete set of purine-base analogue sites, each of which deletes one functional group that forms a hydrogen bond with the endonuclease in the canonical GAATTC complex. For five of six functional group deletions, the observed penalty in binding free energy is +1.3 to +1.7 kcal/mol. For two of these cases (replacement of adenine N7 with carbon) a single protein-base hydrogen bond is removed without deleting an interstrand Watson-Crick hydrogen bond or causing structural "adaptation" in the complex. This observation establishes that the incremental energetic contribution of one protein-base hydrogen bond is about -1.5 kcal/mol. By contrast, deletion of the N6-amino group of the inner adenine in the site improves binding by -1.0 kcal/mol because the penalty for deleting a protein-base hydrogen bond is outweighed by facilitation of the required DNA distortion ("kinking") in the complex. This result provides direct evidence that the energetic cost of distorting a DNA site can make an unfavorable contribution to protein-DNA binding.

The parameters of refugeeism and flight: the case of laos

The circumstances of the flight of four ethnic groups from Laos are described and cornpared. It is found that different ethnic groups defined the fall of the Laotian government in 1975 differently. This affected why, how and when they fled. It is stressed that any explanation of refugee behavior must be in terms not only of individual motivation but also of group behavior. Conclusions are drawn about the role that social networks, sanctuary opportunities, perceptions of family unity, class, clanship, patron-client relationships and traditions of mobility can play in making the decision to flee.

Speech therapy with cochlear implant wearers

The speech production of three post-lingually deafened adults, who derived no benefit from wearing hearing aids, was assessed. Individual therapy programmes were devised based on these assessments and the subjects participated in a course of speech therapy. They then received cochlear implants and had a further course of speech therapy using their implants. Changes in speech production were judged by trained listeners, who heard tape-recorded samples of the subjects' speech. These samples were taken at various intervals before and after therapy alone, and with the cochlear implant. Significant improvement was heard in the speech production of two of the subjects following speech therapy alone. All three subjects were judged to have improved production of speech after using their cochlear implants for 6 months.

IgE synthesis in man. I. Development of specific IgE antibodies after immunization with tetanus-diphtheria (Td) toxoids

Specific IgE and IgG antibodies were measured in 39 adolescent and adult humans preselected to have less than 0.125 antitoxin units (AU) ml to tetanus antitoxin (IgG) irrespective of previous immunization history. Mean antitoxin values (IgG) measured by sheep red cell hemagglutination (SRBC) increased by 2 logs to 1.49 AU/ml sera for tetanus and by 1 log to 0.025 AU/ml sera for diphtheria. Specific tetanus IgE was noted to increase after immunization from a mean 2.0 +/- 0.2% counts bound to 3.1 +/- 0.6% counts bound, but was not statistically significant. Diphtheria-specific IgE rose significantly (p less than 0.05) from a mean 1.5 +/- 0.2% counts bound to a mean 4.0 +/- 1.2% counts bound in atopic individuals and from a mean 1.2 +/- 0.0% counts bound to a mean 2.2 +/- 0.5% counts bound in nonatopics. These data document the development of tetanus and diphtheria IgE antibodies after booster immunization.

Reagin synthesis in inbred rats. II. Genetic control of reaginic antibody synthesis

Specific reaginic (IgE) and hemagglutinating (IgG) antibodies were quantified after immunization with ovalbumin aluminum hydroxide gel in BN and ACI inbred rats, as well as their F1, F1 X BN backcross, F2, and F3, and F3 progeny. The dissimilarity of these immune responses indicated that reaginic (IgE) antibody synthesis was influenced by polygenic factors, but not sex, and was controlled by loci different from that governing hemagglutinating (IgG) antibody synthesis. In addition, tissue typing of the BN, ACI, F1, and F3 hybrids suggested that reaginic antibody synthesis was not linked to the major rat histocompatibility locus.