Does unconscious socioeconomic bias influence tele-evaluation of obstructive sleep apnea? An exploratory analysis.

STUDY OBJECTIVES: We examined the association between a patient's income and a provider's ability to identify risk for obstructive sleep apnea (OSA) when assessed in-person versus via telemedicine. METHODS: We utilized data from a randomized interrater reliability study of 58 patients who were referred to a university sleep center. Participants volunteered their annual income bracket as part of data collection, although raters were blinded to these data. We assessed the inter-method reliability between the clinical impressions of a telemedicine rater and those of an in-person rater for pretest probability of OSA, stratified by income levels. RESULTS: Inter-method reliabilities, assessed using weighted kappa, were 0.83, 0.24, and 0.66 for subjects with low (<$50,000/year), moderate ($50,000-$100,000/year) and high (>$100,000) incomes, respectively. The kappa statistics were significantly different (p = 0.005) between the low and moderate income groups. CONCLUSIONS: There was a significant difference in the reliability values of telemedicine versus in-person assessments between the low and middle income brackets. This is despite the raters being unaware of the patients' income levels. This association might suggest possible unconscious bias in evaluating for OSA. With telemedicine in early development, it is important to create processes that will minimize bias that might result from patients' economic disparities.

Interrater reliability between in-person and telemedicine evaluations in obstructive sleep apnea.

STUDY OBJECTIVES: We examined how telemedicine evaluation compares to face-to-face evaluation in identifying risk for sleep-disordered breathing. METHODS: This was a randomized interrater reliability study of 90 participants referred to a university sleep center. Participants were evaluated by a clinician investigator seeing the patient in-person, then randomized to a second clinician investigator who performed a patient evaluation online via audio-video conferencing. The primary comparator was pretest probability for obstructive sleep apnea. RESULTS: The primary outcome comparing pretest probability for obstructive sleep apnea showed a weighted kappa value of 0.414 (standard error 0.090, P = .002), suggesting moderate agreement between the 2 raters. Kappa values of our secondary outcomes varied widely, but the kappa values were lower for physical exam findings compared to historical elements. CONCLUSIONS: Evaluation for pretest probability for obstructive sleep apnea via telemedicine has a moderate interrater correlation with in-person assessment. A low degree of interrater reliability for physical exam elements suggests telemedicine assessment for obstructive sleep apnea could be hampered by a suboptimal physical exam. Employing standardized scales for obstructive sleep apnea when performing telemedicine evaluations may help with risk-stratification and ultimately lead to more tailored clinical management.

Failure of B Cell Tolerance in CVID.

Common variable immunodeficiency (CVID) comprises a group of related disorders defined by defects in B cell function and antibody production. Concurrent autoimmune features are common, but the underlying pathogenic mechanisms of autoimmunity in CVID are poorly understood. Overlap in some clinical and laboratory features suggests a shared pathogenesis, at least in part, with systemic lupus erythematosus (SLE). One important part of SLE pathogenesis is loss of B cell tolerance, an aspect that warrants further study in CVID. The study of inherently autoreactive 9G4+ B cells has led to a greater understanding of B cell tolerance defects in lupus. Study of these B cells in CVID has yielded conflicting results, largely due to differences in methodological approaches. In this study, we take a comprehensive look at 9G4+ B cells throughout B cell development in CVID patients and compare patients both with and without autoimmune features. Using flow cytometry to examine B cell subpopulations in detail, we show that only those CVID patients with autoimmune features demonstrate significant expansion of 9G4+ B cells, both in naïve and multiple memory populations. Examination of two autoreactive B cell subsets recently characterized in SLE, the activated naïve (aNAV) and double negative 2 (DN2) B cells, reveals an expanded 9G4+ DN2 population to be common among CVID patients. These results reveal that both multiple central and peripheral B cell tolerance defects are related to autoimmunity in CVID. Furthermore, these data suggest that the autoreactive DN2 B cell population, which has not previously been examined in CVID, may play an important role in the development of autoimmunity in patients with CVID.

The role of obesity and obstructive sleep apnea in the pathogenesis and treatment of resistant hypertension.

The incidence of resistant hypertension, obesity, and obstructive sleep apnea (OSA), three highly prevalent conditions in the United States, is rising. Approximately one in three adults in the US has hypertension, and a significant proportion of these individuals have hypertension that is difficult to treat, or resistant. Obesity and OSA are well-established risk factors for resistant hypertension, a condition that portends significant cardiovascular risk. Awareness of the various mechanisms by which obesity and OSA impact systemic blood pressure is essential to better understand how best to effectively care for patients with resistant hypertension. In this review, we discuss the clinical and pathophysiologic associations between obesity, OSA, and resistant hypertension. Furthermore, we will explore the effect of continuous positive airway pressure therapy (CPAP) and other therapeutic interventions on blood pressure control in patients with resistant hypertension.Key Points• Obesity, obstructive sleep apnea, and resistant hypertension are highly prevalent conditions, with increasing overall incidence [1-3].• Both obesity and obstructive sleep apnea are independent risk factors for the development of resistant hypertension.• OSA is characterized by a physiologic cascade of collapse of the upper airway, which can lead to intermittent hypoxia, hypercapnia, significant negative intra-thoracic pressure, and increased SNS output.• Intermittent hypoxia leads to activation of the endothelin system [17, 18, 19•], which can lead to the development of resistant hypertension.• Intermittent hypoxia can lead to the over activation of the SNS, which can also contribute to the development of resistant hypertension [20, 21].• OSA leads to state of elevated adrenergic tone, which in turn may contribute to resistant hypertension [25-27].• OSA patients have a higher incidence of "non-dipping" of nocturnal systolic blood pressure, a marker of increased adrenergic tone. This potentially represents a risk factor for hypertensive end organ disease [31, 32].• The prevalence of OSA is significantly higher in patients predisposed to fluid accumulation: including kidney disease, heart failure and resistant hypertension [33].• Interventions (such as the daytime use of compression stocking) which reduce daytime lower extremity fluid accumulation can significantly reduce the severity of OSA, particularly in patients with comorbid resistant hypertension [35, 36].• CPAP therapy can significantly reduce blood pressure in patients with comorbid hypertension and OSA. The treatment effect is most pronounced in those with resistant hypertension and OSA [16••, 38-42].