Continuous Glucose Monitoring in Pediatric Diabetic Ketoacidosis.

BACKGROUND: Use of real-time continuous glucose monitoring (rtCGM) in ambulatory settings improves overall glycemic control and reduces the incidence of diabetic ketoacidosis (DKA) in adults and children/adolescents with type 1 diabetes (T1D). However, the use of rtCGM in children with DKA has not been well studied. METHOD: This prospective, single-arm, single-center study assessed the accuracy, reliability, and feasibility of a commercially available rtCGM device compared with point-of-care (POC) capillary and serum glucose values in pediatric patients admitted to the pediatric intensive care unit for DKA. The primary outcome was the accuracy of rtCGM glucose values compared with POC capillary and serum glucose values during standard treatment of DKA as assessed by Clarke Error Grid (CEG) analysis. Secondary outcomes were assessment of the relationship between rtCGM readings and degree of acidosis and mean length of hospital stay (LOS). RESULTS: Data from 35 hospitalized children (mean ± SD age, 11.9 ± 4.1 years) with DKA were included in our analysis. Five hundred twenty-four time-matched glucose values between serum glucose and rtCGM and 91 time-matched glucose values between POC capillary glucose and rtCGM were obtained. The effect of acidosis on accuracy CEG analysis showed 95.4% of the 524 matched CGM/POC pairs and 95.6% of the 91 matched CGM/serum glucose pairs in the clinically acceptable A + B zones. The average LOS was 1.32 ± 0.73 days. Serum bicarbonate level did not appear to affect the accuracy of rtCGM in the setting of DKA. CONCLUSIONS: Continuous glucose monitoring use in inpatient pediatric DKA treatment was found to be feasible and reliable.

Provent therapy for obstructive sleep apnea: Impact of nasal obstruction.

OBJECTIVES/HYPOTHESIS: Determine the impact of nasal obstruction on efficacy, success, and adherence of Provent therapy in patients with obstructive sleep apnea (OSA). STUDY DESIGN: Prospective, two-arm, clinical pilot study at a single clinical site. METHODS: Patients with OSA who failed continuous positive airway pressure therapy were divided into two treatment arms: arm 1 were patients with no complaints of nasal obstruction and <50% nasal obstruction on exam, and arm 2 were patients with occasional complaints of nasal obstruction and 50% to 80% nasal obstruction on exam. Sleep testing at home was performed prior to the trial and on day 10 of the study with the use of Provent. RESULTS: Apnea-hypopnea index (AHI) decreased significantly from 20.5 ± 14.8 to 11.5 ± 16.6 (P < .001) in our total patient population. Patients in arm 1 had statistically significant improvement in their AHI (18.1 ± 13.0 to 7.4 ± 10.1, P < .001), oxygen desaturation index (ODI) (16.3 ± 10.8 to 8.2 ± 9.0, P < .001), and minimum oxygen saturation (81.3% ± 6.7% to 86.9% ± 5.6%, P = 0.008) from baseline sleep study to sleep study 2. Patients in arm 2 had improvements in their AHI (23.4 ± 16.6 to 16.5 ± 21.4), ODI (21.5 ± 14.8 to 17.0 ± 16.0) and minimum 02 %. However, none of these reached statistical significance. CONCLUSIONS: In this study, Provent therapy had a high failure rate. Patients without nasal obstruction showed greater improvements using Provent than patients with obstruction. Correction of nasal obstruction may be a useful prerequisite for treatment with Provent.

Impact of mandibular advancement devices on C-reactive protein levels in patients with obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To determine the effect of treatment of obstructive sleep apnea (OSA) with custom-made mandibular advancement devices (MADs) on C-reactive protein (CRP) levels in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN: Case series with chart review. METHODS: Charts of consecutive patients fitted with custom-made mandibular advancement devices for treatment of OSAHS between December 2011 and November 2012 were reviewed. Demographics such as age, sex, and body mass index (BMI) were collected. Prefitting and postfitting polysomnograms were reviewed. Pre- and posttreatment apnea-hypopnea index (AHI) and average O2 saturation were compared. Only patients with documented CRP levels determined prior to mandibular advancement device fitting and again after improvement of OSAHS symptoms were included. RESULTS: Forty-nine patients (77.6% male, age 47.4 ± 11.7 years, BMI 29.6 ± 5.0 kg/m(2)) were included in this study. Patients initially had elevated CRP levels (2.5 ± 1.8 mg/dl), which decreased significantly following use of their custom-made mandibular advancement device (1.9 ± 1.3 mg/dl, P = 0.006) by approximately 24%. AHI decreased significantly from 33.3 ± 21.7 pretreatment to 12.1 ± 22.3 posttreatment (P < 0.001). Treatment with MADs reduced AHI by approximately 69.3%. Minimum oxygen saturation significantly improved from 85.1% ± 5.9 pretreatment to 90.7% ± 3.6 posttreatment (P < 0.001). CONCLUSION: Treatment with custom-made mandibular advancement devices significantly reduced elevated CRP levels in patients with mild to severe OSAHS. Therapy achieves reasonable response and cure rates in the observed patients with a significant reduction in AHI.

Effects of Endoscopic Sinus Surgery and Nasal Surgery in Patients with Obstructive Sleep Apnea.

OBJECTIVES: To evaluate the impact of combined nasal surgery and endoscopic sinus surgery on the objective measurements of obstructive sleep apnea (OSA) and sleep architecture by comparing polysomnographic data before and after combined surgery in patients with OSA. STUDY DESIGN: Case series with chart review. SETTING: A single clinical site. SUBJECTS AND METHODS: Patients with OSA and chronic rhinosinusitis who underwent combined nasal surgery and endoscopic sinus surgery and preoperative and postoperative polysomnography were identified. Patient charts were reviewed and preoperative and postoperative body mass index, apnea-hypopnea index (AHI), mean and minimum oxygen saturation, sleep efficiency, and sleep staging were compared. RESULTS: Fifty-six patients were included in our study. Patients were divided into 3 groups on the basis of the severity of OSA: those with mild OSA (n = 9), those with moderate OSA (n = 23), and those with severe OSA (n = 24). After combined nasal and sinus surgery, the mean AHI significantly decreased from 33.5 ± 22.0 to 29.4 ± 20.8 (P = .009) in our overall population. Specifically, AHI improved significantly in patients with moderate OSA (from 22.3 ± 4.8 to 20.7 ± 8.2, P = .023) and severe OSA (from 52.3 ± 21.4 to 43.6 ± 23.9, P = .034), while patients with mild OSA did not have significant changes in AHI. Successful surgical procedures were achieved in only 2 of 56 patients. CONCLUSION: Although combined nasal and sinus surgery may slightly improve AHI in a certain group of patients, it does not cure OSA or have a significant clinical impact.

Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH.

OBJECTIVE: To determine the effect of twice-daily proton pump inhibitor (PPI) treatment on the relationship between laryngopharyngeal pH environment and symptoms in patients with laryngopharyngeal reflux (LPR). STUDY DESIGN AND SETTING: Retrospective analysis of records from consecutive patients seen at a single clinical site between 2009 and 2012. SUBJECTS AND METHODS: Forty-three records of patients diagnosed with LPR who underwent pre- and posttreatment pH studies were included. Prior to treatment, all had a Reflux Symptom Index (RSI) > 13 and an abnormal pH study. Patients were treated for ≥ 4 weeks with twice-daily PPIs. Following treatment, patients completed a second RSI and pH study. RESULTS: Most patients (67.4%) had symptom normalization; however, most patients (60.5%) did not have pH normalization. For all patients whose symptoms did not normalize, pH scores also did not normalize; 32.6% of patients showed no subjective or objective treatment response. For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score. For the entire group, pretreatment symptom and upright pH scores were strongly positively correlated. Improvements in symptom and upright pH scores following treatment were moderately positively correlated. CONCLUSION: Laryngopharyngeal pH failed to normalize for most individuals after PPI treatment; only pH improvement was necessary for symptom normalization. Many patients had no treatment response. Laryngopharyngeal reflux patients may make up a heterogeneous group, and PPI responsivity may help explain conflicting results from previous studies. Posttreatment pH monitoring is recommended in studies investigating the efficacy of PPI therapy for LPR.

Mandibular advancement for obstructive sleep apnea: relating outcomes to anatomy.

IMPORTANCE: This study provides insight into the response and cure rates of oral appliances (OAs) in patients with primary retropalatal, retroglossal, or retroepiglottic obstruction, as well as the effect of minimal cross-sectional area on the overall decrease in the apnea-hypopnea index (AHI) across all anatomical locations of collapse. OBJECTIVE: To examine the role of regional upper airway obstruction measured with acoustic pharyngometry as a determinant of OA success. DESIGN, SETTING, AND PARTICIPANTS: This retrospective case-series included patients with obstructive sleep apnea-hypopnea syndrome at a tertiary care center. INTERVENTIONS: Patients were fitted with a custom OA between July 1, 2011, and January 1, 2012. MAIN OUTCOMES AND MEASURES: Regions of maximal upper airway collapse were determined on acoustic pharyngometry: retropalatal, retroglossal, or retroepiglottic. Apnea-hypopnea index improvement at titration polysomnography was assessed against regional collapse. RESULTS: Seventy-five patients (56 [75%] men; mean [SD] age, 49.0 [13.6] years; mean body mass index [calculated as weight in kilograms divided by height in meters squared], 29.4 [5.2]; and mean AHI, 30.6 [20.0]) were assessed, and data were grouped on the basis of region of maximal collapse at pharyngometry (retropalatal in 29 patients, retroglossal in 28, and retroepiglottic in 18). The overall reduction in AHI at OA titration showed no significant difference between groups. There was no significant difference in the response rate to treatment, defined as more than 50% AHI reduction plus an AHI of less than 20 (response rate, 69% for retropalatal, 75% for retroglossal, and 83% for retroepiglottic collapse; P = .55) or the cure rate, defined as an AHI of less than 5 (cure rate, 52% for retropalatal, 43% for retroglossal, and 72% for retroepiglottic collapse; P = .15). The correlation between minimal cross-sectional area and response trended toward significance (r = 0.20; range -0.03 to 0.41; P < .10). CONCLUSIONS AND RELEVANCE: Oral appliance therapy achieves reasonable response and cure rates in patients with primary retropalatal, retroglossal, or retroepiglottic obstruction at the time of initial titration polysomnography. However, success is not predicted by identification of the region of maximal upper airway collapse measured with acoustic pharyngometry.

Diagnosis of obstructive sleep apnea by peripheral arterial tonometry: meta-analysis.

IMPORTANCE: Efficient diagnosis and early treatment of obstructive sleep apnea may help prevent the development of related morbidity and mortality. Compared with polysomnography (PSG), ambulatory sleep study devices offer the possibility of an accurate diagnosis with convenience and low cost. OBJECTIVE: To assess the correlation between sleep indexes measured by a portable sleep-testing device (peripheral arterial tonometry [PAT]) and those measured by PSG. DATA SOURCES: We searched PubMed, MEDLINE, the Cochrane Trial Registry (through May 2013), and relevant article bibliographies. STUDY SELECTION: Systematic review and meta-analysis of studies assessing correlation of sleep indexes between PAT devices and PSG in adults (aged >18 years). Included studies provided a bivariate correlation coefficient for sleep indexes, specifically the respiratory disturbance index (RDI), apnea-hypopnea index (AHI), and oxygen desaturation index (ODI). DATA EXTRACTION AND SYNTHESIS: Included studies were reviewed by 2 independent reviewers. Reported correlation values for the RDI, AHI, and ODI between a commercially available PAT device (WatchPAT) and PSG were systematically reviewed. A comprehensive meta-analysis software package was used for statistical analysis. MAIN OUTCOMES AND MEASURES: Assessment of the correlation between PAT and PSG as measured by AHI, RDI, and ODI. RESULTS: Fourteen studies met inclusion criteria and had data suitable for pooling (909 patients). Of these, 13 studies had blinded study designs, with PAT and PSG conducted simultaneously in the home or the laboratory setting. One study contained 2 trial phases for the same patient group (n = 29), one laboratory based and the other home based, which were analyzed separately. One study contained 2 different study groups based on age. Overall, correlation of the RDI and AHI was high (r = 0.889 [95% CI, 0.862-0.911]; P < .001). Studies comparing the RDI between PAT and PSG had a combined correlation of 0.879 (95% CI, 0.849-0.904; P < .001); those comparing the AHI, 0.893 (0.857-0.920; P < .001); and those comparing the ODI, 0.942 (0.894-0.969; P < .001). Analysis of publication bias revealed a nonsignificant Egger regression intercept. CONCLUSIONS AND RELEVANCE: Respiratory indexes calculated using PAT-based portable devices positively correlated with those calculated from the scoring of PSG. Strengthened by the blinded design of most of the included studies, this technology represents a viable alternative to PSG for confirmation of clinically suspected sleep apnea.

Effects of Pillar implants for sleep-related breathing disorders on middle ear function.

Pillar implants provide a reasonable outcome with minimal post-operative morbidity and complications in treating patients with sleep-disordered breathing (SDB) who had obvious palatal obstruction. The palatal structure is responsible for a normal functioning Eustachian tube; however, little is known if there is any potential otologic implication of minimally invasive palatal stiffening surgery for SDB. The aim of this study is to evaluate the effects of Pillar implantation on middle ear function. We performed a prospective study in a tertiary referral center. Thirty SDB patients (25 men, 5 women; mean age, 44.3 years) who underwent Pillar implants for treating palatal obstruction were enrolled. The subjects had normal otologic exam and no previous history of chronic ear disease. Pure-tone audiometry and tympanometry were performed pre-operatively, and post-operative days 1 and 7, and months 1 and 3. Baseline and post-operative middle ear pressures (MEPs) in decipascals were compared. Statistical analysis was performed by repeated measures of ANOVA. Eight patients (8/30, 26.7%) reported otologic complaints such as ear pressure and/or otalgia within 1 week post-operatively. No permanent otologic discomfort occurred. A trend toward reduced MEP was noted in this study. The decrease in MEP became apparent on post-operative day 1 after surgery. However, mean pressure changes were no longer significantly different from pre-operative values by 1 week after surgery. Pillar implantation for SDB induces changes in middle ear function. However, the changes were temporary and not significant 1 week after surgery.

Diagnostic value of the Friedman tongue position and Mallampati classification for obstructive sleep apnea: a meta-analysis.

OBJECTIVE: To assess the association between the Mallampati classification and Friedman tongue position for obstructive sleep apnea severity as determined by apnea-hypopnea index and to determine which method is most closely correlated with prediction of obstructive sleep apnea severity. DATA SOURCES: English-language searches of PubMed, MedLine, and the Cochrane database. Reference sections of identified studies were examined for additional articles. REVIEW METHODS: Databases through December 2011 were searched, combined with review of relevant article bibliographies, and assessed by 4 reviewers. Systematic review and random-effects meta-analysis of studies evaluating tongue position and obstructive sleep apnea severity were performed. Outcomes were reported as correlations. RESULTS: Ten studies met inclusion criteria and had data for pooling (2513 patients). Friedman tongue position and Mallampati classification were significantly associated with obstructive sleep apnea severity, with a correlation of 0.351 (0.094-0.564, P = .008). Analysis of the correlation of tongue position with obstructive sleep apnea severity reveals correlations of 0.184 (0.052, 0.310, P = .006) and 0.388 (0.049, 0.646, P = .026) for the Mallampati classification and Friedman tongue position, respectively. Publication bias does not yield a significant Egger regression intercept; however, 4 imputed values to the right of the mean were found using Duval and Tweedie's trim-and-fill method, yielding an overall correlation of 0.498 (confidence interval = 0.474-0.521). CONCLUSION: The Mallampati classification and Friedman tongue position assessment techniques are significantly correlated with predicting obstructive sleep apnea severity. Publication bias does not significantly affect our results. The strength of this correlation is higher for Friedman tongue position, although 95% confidence intervals for the respective correlation coefficients overlap.