International Consensus Statement on Obstructive Sleep Apnea.

BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Tailoring the Sleep Laboratory for Chronic Respiratory Failure.

"Many seemingly mundane aspects of the sleep laboratory can have outsized effects on the quality of polysomnographic data obtained from, and care provided to, patients. This is particularly true when performing polysomnography on patients with chronic respiratory failure due to various causes. This article uses a disease-based approach to review physical and protocol-based accommodations that should be considered when performing polysomnography on this patient population."

Extremely Elevated Erythrocyte Sedimentation Rates: Associations With Patients' Diagnoses, Demographic Characteristics, and Comorbidities.

OBJECTIVE: To study associations between extreme erythrocyte sedimentation rate (ESR) elevations (≥100 mm/h) and diseases, age, sex, race, Charlson Comorbidity Index (CCI), and C-reactive protein (CRP) level. PATIENTS AND METHODS: This was a retrospective cohort study of 4807 patients with extreme ESR values examined at Mayo Clinic, Rochester, Minnesota, from January 1, 2002, through December 31, 2011. Independent variables included diseases (infection, autoimmune, malignancy, renal disease, or miscellaneous), subcategories of diseases, patient demographic characteristics (age, sex, and race), CRP level, and CCI. The Wilcoxon rank sum test was used to assess comparisons of ESR between patients with and without disease as well as relationships between extreme ESR values and demographic characteristics of patients within disease categories. Associations between ESR and CRP level were determined using the Pearson correlation coefficient. RESULTS: The leading diagnosis associated with extreme ESR elevations (n [%]) was infection (1932 [40]), followed by autoimmune (1839 [38]) and malignancy (1736 [36]) (P<.01). Extreme elevations in ESR varied by sex, with higher ESRs in men (mean, 117±13.3 mm/h) than in women (mean, 115.9±12.5 mm/h) (P=.008). Extreme ESR elevations correlated inversely with the CCI (P=.008) and did not correlate with the CRP level. There were no correlations between extreme elevations in ESR and age or race. CONCLUSION: We found that almost all patients have an identifiable etiology for extreme ESR elevations and that infection is the most common disease association. Unlike previous research, we identified higher ESRs in men than in women and no associations with age, race, and comorbid illness. These findings may enhance the diagnostic evaluation of patients with extreme ESR elevations.

Restoration of Mitochondrial Cardiolipin Attenuates Cardiac Damage in Swine Renovascular Hypertension.

BACKGROUND: Renovascular hypertension (RVH) impairs cardiac structure and left ventricular (LV) function, but whether mitochondrial injury is implicated in RVH-induced myocardial damage and dysfunction has not been defined. We hypothesized that cardiac remodeling in swine RVH is partly attributable to cardiac mitochondrial injury. METHODS AND RESULTS: After 12 weeks of hypercholesterolemic (HC)-RVH or control (n=14 each), pigs were treated for another 4 weeks with vehicle or with the mitochondrial-targeted peptide (MTP), Bendavia (0.1 mg/kg subcutaneously, 5 days/week), which stabilizes mitochondrial inner-membrane cardiolipin (n=7 each). Cardiac function was subsequently assessed by multidetector-computed tomography and oxygenation by blood-oxygen-level-dependent magnetic resonance imaging. Cardiolipin content, mitochondrial biogenesis, as well as sarcoplasmic-reticulum calcium cycling, myocardial tissue injury, and coronary endothelial function were assessed ex vivo. Additionally, mitochondrial cardiolipin content, oxidative stress, and bioenergetics were assessed in rat cardiomyocytes incubated with tert-butyl hydroperoxide (tBHP) untreated or treated with MTP. Chronic mitoprotection in vivo restored cardiolipin content and mitochondrial biogenesis. Thapsigargin-sensitive sarcoplasmic reticulum Ca(2+)-ATPase activity that declined in HC-RVH normalized in MTP-treated pigs. Mitoprotection also improved LV relaxation (E/A ratio) and ameliorated cardiac hypertrophy, without affecting blood pressure or systolic function. Myocardial remodeling and coronary endothelial function improved only in MTP-treated pigs. In tBHP-treated cardiomyocytes, mitochondrial targeting attenuated a fall in cardiolipin content and bioenergetics. CONCLUSIONS: Chronic mitoprotection blunted myocardial hypertrophy, improved LV relaxation, and attenuated myocardial cellular and microvascular remodeling, despite sustained HC-RVH, suggesting that mitochondrial injury partly contributes to hypertensive cardiomyopathy.

Measuring Participants' Attitudes Toward Mobile Device Conference Applications in Continuing Medical Education: Validation of an Instrument.

INTRODUCTION: Mobile device applications (apps) may enhance live CME courses. We aimed to (1) validate a measure of participant attitudes toward using a conference app and (2) determine associations between participant characteristics and attitudes toward CME apps with conference app usage. METHODS: We conducted a cross-sectional validation study of participants at the Mayo Clinic Selected Topics in Internal Medicine Course. A conference app was developed that included presentation slides, note-taking features, search functions, social networking with other attendees, and access to presenter information. The CME app attitudes survey instrument (CMEAPP-10) was designed to determine participant attitudes toward conference apps. RESULTS: Of the 602 participants, 498 (82.7%) returned surveys. Factor analysis revealed a two-dimensional model for CMEAPP-10 scores (Cronbach α, 0.97). Mean (SD) CMEAPP-10 scores (maximum possible score of five) were higher for women than for men (4.06 [0.91] versus 3.85 [0.92]; P = .04). CMEAPP-10 scores (mean [SD]) were significantly associated (P = .02) with previous app usage as follows: less than once per month, 3.73 (1.05); monthly, 3.41 (1.16); weekly, 4.03 (0.69); and daily or more, 4.06 (0.89). Scores were unrelated to participant age, specialty, practice characteristics, or previous app use. DISCUSSION: This is the first validated measure of attitudes toward CME apps among course participants. App usage was higher among younger participants who had previously used educational or professional apps. Additionally, attitudes were more favorable among women and those who had previously used apps. These findings have important implications regarding efforts to engage participants with portable and accessible technology.