History Of Obstructive Sleep Apnea Research Articles

Effect of Intravenous Dexmedetomidine Before Extubation on Emergence Delirium after Nasal Surgeries.

To investigate the role of single dose of dexmedetomidine (0.5 mcg/kg) in reducing the incidence and severity of postoperative emergence delirium (EmD). A randomised controlled trial. Place and Duration of the Study: Department of Anaesthesia, Security Forces Hospital, Riyadh, Saudi Arabia, from 1st December 2022 to 30th March 2023. Patients, aged between 18-65 years, with ASA 1-3 scheduled to undergo nasal surgeries under general anaesthesia, were inducted in the study. Exclusion criteria were patient refusal, later request for removal from the study, inability to give consent, known allergy to dexmedetomidine, body mass index (BMI) more than 35, history of obstructive sleep apnoea, history of psychiatric illness, pregnancy, and presence of liver and renal diseases. The primary outcome measure of the study was the incidence of emergence delirium in the postoperative period. The frequency of EmD after nasal surgery was 52.38% in the control group compared to 14.28% in the dexmedetomidine group (p = 0.01). Pain scores were not statistically different between the two groups. The duration of post anaesthesia care unit (PACU) stay was significantly lesser in dexmedetomidine group (p <0.001). The satisfaction score on the visual analogue scale (VAS) was also found to be higher in patients who received intravenous dexmedetomidine (p <0.001). The use of single dose dexmedetomidine before extubation in nasal surgeries reduces the EmD and improves patient satisfaction. Dexmedetomidine, Emergence delirium, Nasal surgery, Opioid consumption, Pain control.

The Association of Body Mass Index and Early Outcomes Following Orthognathic Surgery

The existing data on the link between body mass index (BMI), operative characteristics, and surgical outcomes across orthognathic surgery are limited. The purpose was to measure the association between BMI and early postoperative outcomes in orthognathic surgery. This is a retrospective cohort study of patients (n=118) aged > 14years undergoing bimaxillary orthognathic surgery between 2015 and 2018 by a single surgeon within the Kaiser Permanente Northern California-integrated healthcare system. Patients undergoing unilateral or additional procedures, history of prior orthognathic surgery, or pre-existing pain conditions were excluded. The predictor variable was BMI measured as a continuous (kg/m2) and categorical variable (underweight/normal, overweight, obese). The primary outcome variables were additional postoperative antibiotics, increased postoperative visits, wound dehiscence, and wound infection. The secondary outcome variables were total operative and anesthesia time. The demographic covariates included age, sex, and race/ethnicity. The clinical covariates included history of obstructive sleep apnea, Mallampati score, tobacco use, American Society of Anesthesia classification, thyromental distance, history of difficult intubation, and Angle's classification. Bivariate and multivariate analyses were performed to measure the associations between BMI and the primary and secondary outcomes. Multivariable logistic regression analyses were used to measure associations between BMI and the postoperative outcomes. Statistical significance was defined as P<.05. The study sample was composed of 118 subjects with a mean age of 26.91years (standard deviation 9.43). Forty-seven percent (n=55) were male, and the mean BMI was 25.13 (standard deviation 5.19). BMI category was significantly associated with age, with increasing age associated with higher BMI category (P=.02). According to the bivariate and multivariable logistic regression analyses, controlling for age, race/ethnicity, BMI, and total operative time, increased total operative time was associated with additional postoperative antibiotics (odds ratio=1.03, 95% confidence interval: 1.01, 1.05), and increased postoperative appointments (odds ratio=1.02, 95% confidence interval: 1.01, 1.04). No significant association between BMI and other clinical or operative characteristics was seen aside from American Society of Anesthesia classification. Elevated BMI was not associated with worsened operative characteristics or postoperative outcomes. This supports the suitability of orthognathic surgery in a BMI-diverse population.

Assessment of Different Indices as Predictors of Difficult Airway in Obese Patients.

Introduction Difficulties with tracheal intubation contribute to the morbidity and mortality associated with anesthesia. Suggested predictors for difficult airwayinclude, history of obstructive sleep apnea, high Mallampati score, elderly, male, short neck, and high Wilson score.However, none of these has high diagnostic accuracy particularly in obese population. Parameters used to quantify obesity such as Body Mass Index(BMI), mid arm circumference, skin fold thickness,etc. have not been used as independent predictors of difficult airway. This study has been designed to evaluate the accuracy of commonly used tools to assess difficult airway and to test other obesity markers as scale for assessing difficult airway i.e. Bag mask ventilation grade ≥3 or Cormack-Lehane Grade≥3 on Direct Laryngoscopy or number of intubation attempts ≥3. Aim To assess BMI, Mallampati grading, Neck circumference and Thyromental distance as predictors of difficult airway in obese patients and to validate neck circumference to thyromental distance ratio and skin fold thickness as a tool for assessment of difficult airway (Bag mask ventilation grade ≥3 or Cormack-Lehane Grade≥3 on Direct Laryngoscopy or number of intubation attempts ≥3.) in obese patients. Methods This prospective observational study was carried out on 51 obese patients (as per BMI) of ASA gradeII, either sex, aged 23 to 57 years posted for elective surgery under general anesthesia with endotracheal intubation. After subjective assessment of difficult airway following data sets and variables were obtained - sex, weight, height, body mass index (BMI),Modified Mallampati class (MPG), Cormack-Lehane (CL) grade, adequacy of bag mask ventilation (BMV), number of endotracheal intubation attempts, patient's neck circumference (NC), thyromental distance (TMD), waist-hip ratio (WHR) and Skin fold thickness. The observations made during the study were statistically analyzed and correlated as predictors for difficult airway. Result Correlation of MPG to CL-grade (r-0.41, p-0.003), BMV (r-0.31, p-0.028) & No. of intubationattempts (r-0.37, p-0.007) was mild & statistically significant. Correlation of Neck Circumference with CL-grade (r-0.57, p-0.000), & No. of intubation attempts (r-0.62, p-0.000), found moderate & statistically significant, & with BMV was mild and statistically significant (r-0.48, p-0.000). Correlation of Thyromental Distance to CL-grade (r-0.65, p-0.000), BMV (r-0.70, p-0.000) & No. of intubationattempts (r-0.61, p-0.000) was moderate & statistically significant. Correlation of BMI to CL-grade (r-0.11, p-0.428), BMV (r-0.04, p-0.757) & No. of intubation attempts (r-0.16, p-0.257) was weak & not significant. Skin Fold Thickness showed no significant association with Difficult airway i.e., CL Grade (p-0.478), BMV (p-0.101), and No. of intubation attempts (p-0.143). Correlation of NC/TMD ratio with BMV (r-0.74, p-0.000), CL-grade (r-0.76, p-0.000), & No. of intubation attempts (r-0.77, p-0.000) wasmoderate & statistically significant. Conclusion NC, TMDand NC/TMD Ratio depicted a close association with airway difficulty in obese patients. Obesity grade is a risk factor for difficult airway but predictors of obesity including Skin Fold Thickness, individually did not showassociation with difficult airway (small sample size may be a limiting factor). None of the commonly performed tests alone has proven to be adequate in predicting difficult intubation in the obese population.

History of obstructive sleep apnea associated with incident cognitive impairment in white but not black individuals in a US national cohort study

BackgroundWe sought to determine if risk for obstructive sleep apnea (OSA), a history of OSA, and/or treatment of OSA has a different association with incident cognitive impairment or cognitive decline in Black individuals and White individuals. MethodsTo determine whether the risk for OSA, a history of OSA, and/or treatment of OSA has a different association with incident cognitive impairment or cognitive decline in Black individuals and White individuals; data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) was used. Participants that completed the sleep questionnaire module, had baseline cognitive assessment, and at least one cognitive assessment during follow-up were included. Risk of OSA was determined based on Berlin Sleep Questionnaire. History of sleep apnea was determined based on structured interview questions. Optimally treated OSA was defined as treated sleep apnea as at least 4 h of continuous positive airway pressure use per night for ≥5 nights per week. ResultsIn 19,017 participants stratified by race, White participants with history of OSA were 1.62 times more likely to have incident cognitive impairment compared to White participants without history of OSA after adjusting for demographic characteristics, history, and lifestyle factors (OR = 1.62, 95% CI = 1.05–2.50, p-value = 0.03). This relationship was not seen in Black participants (OR = 0.92, 95% CI = 0.60–1.43, p-value = 0.72). DiscussionA previous diagnosis of OSA is associated with incident cognitive impairment in White Americans but not Black Americans. Further investigations are required to determine the mechanism for this difference.

1023 A Case of Stridor in the Sleep Clinic

Abstract Introduction Multisystem atrophy (MSA) is a neurological degenerative progressive disease affecting multiple systems. These patients are frequently seen in the sleep clinic at specialty centers by sleep neurologists for co-management of sleep disordered breathing and nocturnal respiratory issues. Stridor is a life-threatening condition seen in these patients and requires emergent action. We present a case of MSA with worsening stridor that was missed in the era of virtual telemedicine. Report of case(s) A 53-year-old female with a history of obstructive sleep apnea (OSA) on BiPAP S and multiple system atrophy with parkinsonian subtype presented virtually to sleep clinic for follow up evaluation of her sleep disordered breathing. Six months prior to her visit she was noted to have bilateral vocal fold hypomobility without stridor. At that time, she had a residual apnea-hypopnea index (AHI) of 1.4 with BiPAP-S 16/13 cm H2O and no nocturnal stridor. She was wheelchair bound. She had routine follow up visits with various providers however these were telemedicine visits with her husband doing most of the talking due to weakness. Over the next 5 months she had worsening fatigue and was using BiPAP S during the day intermittently and was referred to the sleep medicine clinic for consideration of supplemental oxygen at night. A repeat overnight oximetry revealed residual oxygen desaturation index (ODI) of 2.5/hr while on BiPAP S. Repeat pulmonary function testing was ordered and patient was recommended to return for immediate in person follow up. When seen in person, patient was noted to have significant stridor which had been ongoing and worsening over last few months including being appreciated while on PAP therapy. Emergent same-day ENT consultation was arranged by sleep providers. Posterior cordectomy was performed shortly thereafter. The patient was scheduled for an AVAPS titration study. Conclusion In cases with progressive neuromuscular disease, stridor may be missed during virtual appointments for a variety of reasons including technical difficulties, or the virtual medium not being sensitive enough to convey stridor. This case highlights the importance of having a high index of suspicion for stridor and impending respiratory failure requiring emergent intervention in patients with neuromuscular disease. Support (if any)

(343) Predictors of Corporo-venocclusive Dysfunction (CVOD) in Men with Bilateral Nerve-sparing Radical Prostatectomy (RP)

Abstract Introduction Nerve-sparing status (NSS) during RP is a significant predictor of erectile function recovery (EFR). Poor nerve sparing is associated with collagenization of cavernosal smooth muscle and CVOD development with typically poor response to PDE5 inhibitors (PDE5i) and intracavernosal injection therapy (ICI). Objective This study aimed to define factors predictive of CVOD in men with bilateral NS RP. Methods Study population consisted of (i) men who underwent bilateral NS (defined by the surgeon using an institutional grading system) RP (ii) with poor response to PDE5i and ICI (iii) ≥2 years post-RP (iv) who underwent penile duplex Doppler ultrasound (DUS) (v) using a vasoactive agent redosing schedule. CVOD diagnosis was made with end-diastolic velocity (EDV) values ≥5 cm/sec bilaterally. ADT and radiation therapy were exclusions. We used multivariable modeling to define factors predictive of CVOD. Factors included in the model: patient age, history of diabetes, history of obstructive sleep apnea, number of vascular comorbidities, baseline EF, peri-RP total testosterone (T) level, and total T at DUS (within 3 months). Results 201 men with a mean age of 66 ± 7 years. 25% of the patients reported 3 or more vascular comorbidities, 17% had diabetes, 36% obstructive sleep apnea, 39% were current or former smokers. Mean baseline PSA and pre-RP total T was 6.7 ± 6 ng/mL and 410 ± 211 ng/dL, respectively. Median baseline EFD score was 24 (13, 29). 49% of the men had an erection less than penetration rigidity during the DUS procedure with a mean total dose administered of 87 ± 21 units of trimix. 69% received 100 units. CVOD was diagnosed in 76%. Mean total T at DUS was 386 ± 177 ng/dL. 32% had low T. Significant predictors of CVOD after RP in men with BL NSS were: OSA (OR = 3.8, 95% CI = 1.7-8.7), ≥ 3 vascular comorbidities (OR = 5.0, 95% CI = 1.7-14.8), age at the time of DUS (per 10 years increase, OR = 1.9, 95% CI = 1.2-3.0), and pre-RP EF domain score (per 1 unit increase, OR = 0.93, 95% CI 0.88-0.98). There was a signal that in a larger sample size, diabetes may be a significant predictor of CVOD in this group of patients (OR = 2.7, 95% 0.9-8.0). Conclusions Baseline clinical comorbidities pre-RP have a significant impact on EFR post-RP, in particular, the presence of venous leak. Despite BL NSS, older patients, men with OSA, higher number of comorbidities pre-RP, and lower pre-RP EF increased the likelihood of developing CVOD post-RP. Disclosure No

Prevalence of secondary erythrocytosis in men receiving testosterone therapy: A matched-cohort analysis of intranasal gel, injections, and pellets.

Increased hematocrit (HCT) is a common adverse effect in men on testosterone therapy (TTh). We aimed to uncover differences in HCT changes among men receiving different forms of TTh, namely intranasal gels, intramuscular injections, and subcutaneous pellets. We conducted a single-center, retrospective, matched-cohort study of patients treated for testosterone deficiency (TD) to investigate the effect of three TTh regimens on HCT. We included men who received intranasal testosterone (NT), intramuscular testosterone (TC), or subcutaneous testosterone pellet (TP) regimens between January 2011 and December 2020. We matched treatment cohorts 1:1:1 for age, body mass index (BMI), and history of obstructive sleep apnea. Those taking TTh for less than 16 weeks were excluded. Comparison between groups was performed with U-Mann Whitney test, Student t-test, ANOVA, or Kruskal Wallis test as appropriate. Seventy-eight matched-cohort individuals with testosterone deficiency (TD) received either NT, TC, or TP. The most common TD symptoms prior to initiation of TTh were erectile dysfunction (38%), low libido (22%), and lack of energy (17%). Baseline serum testosterone and HCT were higher in NT (p<0.05) recipients. As expected, all men receiving TTh were found to have increased serum testosterone levels at followup (p<0.001). Relative to their respective baselines, men receiving TC experienced the greatest increase in serum testosterone (240.8 ng/dL to 585.5 ng/dL), followed by NT (230.3 ng/dL to 493.5 ng/dL) and TP (210.8 ng/dL to 360.5 ng/dL) (all p<0.001). TC and TP were associated with significant increases in HCT (4.4% and 1.7%), while NT was associated with a decrease in HCT (-0.8%) at 16-week followup. When controlled for age, BMI, and OSA, men receiving NT experienced decreased HCT compared to TC or TP at 16-week followup. Intranasal testosterone, while able to increase serum testosterone levels to reference range, does not appear to have a significant impact on HCT compared to the longer-acting forms of TTh.

384: ACTINOMYCES BRAIN ABSCESS AS SEQUELAE FROM PULMONARY ARTERIOVENOUS MALFORMATION: A CASE REPORT

Introduction: Most bacterial brain abscesses are a result of direct spread of bacteria, only a third are through hematogenous dissemination. A less common cause of hematogenous spread is via paradoxical embolism in the presence of a pulmonary arteriovenous malformation (PAVM). Currently PAVMs are not routinely screened for. Description: A 51-year-old male with past medical history of obstructive sleep apnea, and transient ischemic attack presented with left sided weakness. Initial CT head was concerning for subacute stroke. Patient’s physical exam was significant for 2/5 strength in left upper extremity, oral mucosa and skin findings were negative for telangiectasias. No significant family history reported. Initial white count negative. Worsening left sided numbness led to a repeat CT head which showed a 1.5 cm right posterior frontal/anterior mass lesion with surrounding edema. Patient underwent biopsy and drainage of brain abscess on hospital day 4, intraoperative pus was encountered. Patient was treated with ceftriaxone, metronidazole, and vancomycin. Cultures grew Actinomyces meyeri. On hospital day 8 a CT angiogram showed a PAVM in the medial middle lobe. Patient underwent right pulmonary artery angiogram on hospital day 12 which showed that the PAVM was fed by a branch of the right middle lobe pulmonary artery. After embolization follow-up angiogram showed cessation of flow through the PAVM. An MRI showed significantly less brain swelling around the cavity, based off the patient’s clinical and laboratory improvements patient was deemed stable for discharge to rehab facility on IV antibiotics. Discussion: A PAVM typically consists of afferent flow from a branch of the pulmonary artery to a branch of the pulmonary vein. Serious outcomes including strokes, seizures, and brain abscesses can arise from the right-to-left shunting of blood and paradoxical emboli. Most PAVMs are congenital associated with hereditary hemorrhagic telangiectasia, however, sporadic ones occur. Infections caused by Actinomyces are thought to induce hyperplastic changes in bronchial arteries which might lead to PAVMs. A PAVM should be considered in patients with a bacterial brain abscess and no identifiable site of infection. Treatment for PAVM include endovascular embolization vs thoracic surgery for removal.

DELAYED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) DIAGNOSIS IN A PATIENT WITH PULMONARY SARCOIDOSIS AND NEWLY DIAGNOSED T-CELL LYMPHOMA: A CASE REPORT

DELAYED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) DIAGNOSIS IN A PATIENT WITH PULMONARY SARCOIDOSIS AND NEWLY DIAGNOSED T-CELL LYMPHOMA: A CASE REPORT

Hardware Removal in Orthognathic Surgery Patients: A 20 Year Retrospective Study

In the United States, the standard of care for rigid fixation in orthognathic surgery is titanium plates and screws. This hardware is meant to remain implanted indefinitely, but the potential for hardware removal is always mentioned in preoperative discussions. The incidence of titanium hardware removal after orthognathic surgery has been reported to range from 0.4% to 27%, and the largest study previously published included 570 patients over 5 years.1,2 The purpose of this study is to examine the incidence of titanium hardware removal after orthognathic surgery over a 20-year period and to identify factors associated with removal. A retrospective study was performed involving subjects who underwent orthognathic surgery including a combination of Le Fort osteotomy, bilateral sagittal split osteotomy, genioplasty, subapical osteotomy, and vertical ramus osteotomy. The primary outcome variable was titanium hardware removal. Other predictor variables included age, sex, simultaneous removal of third molars, simultaneous bone grafting, and medical comorbidities. Patients met inclusion criteria if they had undergone orthognathic surgery with titanium fixation at a single institution by a single surgeon between the years of 2000 and 2020. Patients with cleft and craniofacial syndromes and those fixated with resorbable hardware were excluded. A total of 738 patients met inclusion criteria with 1,483 orthognathic surgery procedures performed. The mean age at the time of surgery was 23.2 years, and 57% of subjects were female. Ultimately, 43 of the 738 patients required hardware removal (5.8% of patients), and 48 of the 1,483 procedures resulted in hardware removal (3.4%). The average time to hardware removal was 2.3 years (ranging 6 weeks to 9.7 years) with a median of 1.3 years. The most common indication for removal was surgical site infection (17 patients), followed by palpable, painful hardware (12 patients), exposed hardware (6 patients), maxillary sinusitis (4 patients), adjacent tooth external root resorption (1 patient), loose hardware (1 patient), prophylactic removal after previous infection (1 patient), and thermal sensitivity (1 patient). Patients who required hardware removal were more often female (69.8%), were older (average 29.9 years), and were more likely to have multiple jaws operated (79.1%). Of the 43 patients with hardware removed, 19 had hardware removed from the mandible (44.2%), 18 from the maxilla (41.9%), 2 from the genioplasty (4.6%), and the remainder had multiple sites removed (9.3%). The laterality of hardware-associated symptoms was more often right-sided (51.1%) than left-sided (39.5%), and bilateral symptoms were less common (9.3%). A history of obstructive sleep apnea was documented in 9.3% of patients with hardware removed, as compared to 4.5% of the general population of orthognathic surgery patients. The population of patients with cleft and craniofacial syndromes was examined separately, and the rate of removal in this population of 121 patients was slightly lower than that of the general population (5%). The incidence of titanium hardware removal in this population of orthognathic surgery patients was 5.8%. Our findings suggest that there are patient-specific and procedure-specific factors associated with increased rates of titanium hardware removal after orthognathic surgery. Based on descriptive and multivariate analyses, higher risk groups include female patients, older patients, patients with obstructive sleep apnea, and patients in whom multiple jaws are operated. These patients may be counseled accordingly about the risk of future hardware removal.

Painless Rectal Bleeding in a Patient With Prostate Cancer

Painless Rectal Bleeding in a Patient With Prostate Cancer

0808 Worsening central sleep apnea: A sole diagnostic marker of a brain tumor in a child

Abstract Introduction Central sleep apnea (CSA) in children is a relatively uncommon and under-studied sleep disorder. A small subset of patients may have intracranial anomalies, but clinical presentation varies. We present a case of malignant intracranial tumor diagnosed primarily due to the unusual presentation and progression of CSA. Report of Cases: The presented patient is a 12-year-old developmentally appropriate female with a history of obstructive sleep apnea (OSA) status post adenotonsillectomy at two years of age who presented with snoring without witnessed apnea, sleep interruptions, and unrefreshing sleep. Other sleep-related history was unremarkable. No daytime sleepiness or behavioral or learning concerns were noted. Physical examination was unremarkable with normal growth parameters. Initial diagnostic PSG demonstrated severe OSA with an obstructive apnea-hypopnea index (OAHI) of 16/h and mild CSA (CAI:6.7/h); therefore, PAP therapy was pursued after ruling out adenoid regrowth. However, during the first PAP titration study(incomplete study due to mask intolerance), treatment-emergent central apneas were noted (OAHI: 9.8/h; CAI:25.8/h), which were noted even during the second titration study (OAHI:2.7/h; CAI:59.2/h). Even though ordered earlier, the brain MRI was not performed until after the repeat PSG one year later showed persistence of severe CSA (OAHI of 4.5/h and CAHI of 39.5/h) after much persuasion. Interestingly, snoring had reportedly improved with no daytime symptoms or neurologic complaints. The brain MRI demonstrated compressing brainstem lesion highly suspicious for glioma. The patient was emergently sent to neurosurgical care and had chosen hospice care after a few weeks. Conclusion CSA can be an early or the only finding in patients with brainstem tumors, even before neurologic signs and symptoms. The PSG findings changed from mild CSA to treatment-emergent CSA to severe CSA, possibly with the progression of underlying disease. Close follow-up and ensuring patient compliance are essential in CSA patients. CSA severity should prompt MRI brain even with an intact neurological examination. More research is needed to fully understand the link between cerebral disease and polysomnographic data. This could aid in early diagnosis and treatment. Support (If Any) no conflicting or financial interests to disclose

Dysphagia is a strong predictor of death and functional dependence at three months post-stroke.

Few Brazilian studies investigated risk factors for dysphagia and associated complications in a large cohort. To investigate frequency, predictors, and associated outcomes of dysphagia in patients up to three months post-stroke. Prospective cohort study of consecutively admitted patients in a specialized center for acute stroke. Patients with a transient ischemic attack, subarachnoid hemorrhage, cerebral venous thrombosis, hemorrhagic stroke with secondary cause, non-acute stroke, or those who did not consent to participate were excluded. Swallowing was evaluated by speech language pathologists using Volume-Viscosity Swallow Test. General function at three months post-stroke was assessed using the following instruments: Modified Rankin scale, Barthel Index and Functional Independence Measure. A total of 831 patients were admitted and 305 patients were included according to the inclusion and exclusion criteria. The mean age of patients was 63.6±13.3 years, mean time from stroke to swallowing assessment was 4.2±4.1 days, and 45.2% of the patients had dysphagia. Age (OR=1.02; 95%CI 1.00-1.04; p=0.017), known medical history of obstructive sleep apnea (OR=5.13; 95%CI 1.74-15.15; p=0.003), and stroke severity at hospital admission (OR=1.10; 95%CI 1.06-1.15; p<0.001) were independently associated with dysphagia. Dysphagia (OR=3.78; 95%CI 2.16-6.61; p<0.001) and stroke severity (OR=1.05; 95%CI 1.00-1.09; p=0.024) were independently associated with death or functional dependence at three months. Dysphagia was present in almost half of stroke patients. Age, obstructive sleep apnea, and stroke severity were predictors of dysphagia, which was independently associated with death or functional dependence at three months.

MP21-02 PREDICTORS OF CORPORO-VENOCCLUSIVE DYSFUNCTION (CVOD) IN MEN WITH BILATERAL NERVE-SPARING RADICAL PROSTATECTOMY (RP)

You have accessJournal of UrologyCME1 May 2022MP21-02 PREDICTORS OF CORPORO-VENOCCLUSIVE DYSFUNCTION (CVOD) IN MEN WITH BILATERAL NERVE-SPARING RADICAL PROSTATECTOMY (RP) Jose M. Flores, Carolyn A. Salter, Nicole Benfante, Elizabeth Schofield, and John P. Mulhall Jose M. FloresJose M. Flores More articles by this author , Carolyn A. SalterCarolyn A. Salter More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Elizabeth SchofieldElizabeth Schofield More articles by this author , and John P. MulhallJohn P. Mulhall More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002554.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nerve-sparing status (NSS) during RP is a significant predictor of erectile function recovery (EFR). Poor nerve sparing is associated with collagenization of cavernosal smooth muscle and CVOD development with typically poor response to PDE5 inhibitors (PDE5i) and intracavernosal injection therapy (ICI). This study aimed to define factors predictive of CVOD in men with bilateral NS RP. METHODS: Study population consisted of (i) men who underwent bilateral NS (defined by the surgeon using an institutional grading system) RP (ii) with poor response to PDE5i and ICI (iii) ≥2 years post-RP (iv) who underwent penile duplex Doppler ultrasound (DUS) (v) using a vasoactive agent redosing schedule. CVOD diagnosis was made with end-diastolic velocity (EDV) values ≥5 cm/sec bilaterally. ADT and radiation therapy were exclusions. We used multivariable modeling to define factors predictive of CVOD. Factors included in the model: patient age, history of diabetes, history of obstructive sleep apnea, number of vascular comorbidities, baseline EF, peri-RP total testosterone (T) level, and total T at DUS (within 3 months). RESULTS: 201 men with a mean age of 66 ± 7 years. 25% of the patients reported 3 or more vascular comorbidities, 17% had diabetes, 36% obstructive sleep apnea, 39% were current or former smokers. Mean baseline PSA and pre-RP total T was 6.7 ± 6 ng/mL and 410 ± 211 ng/dL, respectively. Median baseline EFD score was 24 (13, 29). 49% of the men had an erection less than penetration rigidity during the DUS procedure with a mean total dose administered of 87 ± 21 units of trimix. 69% received 100 units. CVOD was diagnosed in 76%. Mean total T at DUS was 386 ± 177 ng/dL. 32% had low T. Significant predictors of CVOD after RP in men with BL NSS were: OSA (OR = 3.8, 95% CI = 1.7-8.7), ≥ 3 vascular comorbidities (OR = 5.0, 95% CI = 1.7-14.8), age at the time of DUS (per 10 years increase, OR = 1.9, 95% CI = 1.2-3.0), and pre-RP EF domain score (per 1 unit increase, OR = 0.93, 95% CI 0.88-0.98). There was a signal that in a larger sample size, diabetes may be a significant predictor of CVOD in this group of patients (OR = 2.7, 95% 0.9-8.0). CONCLUSIONS: Baseline clinical comorbidities pre-RP have a significant impact on EFR post-RP, in particular, the presence of venous leak. Despite BL NSS, older patients, men with OSA, higher number of comorbidities pre-RP, and lower pre-RP EF increased the likelihood of developing CVOD post-RP. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e327 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jose M. Flores More articles by this author Carolyn A. Salter More articles by this author Nicole Benfante More articles by this author Elizabeth Schofield More articles by this author John P. Mulhall More articles by this author Expand All Advertisement PDF DownloadLoading ...

Abstract #1175969: Protein Energy Malnutrition Strongly Predicts Adverse Outcomes Across Different Hospitalizations

Protein Energy Malnutrition (PEM) is a common medical problem in hospitalized patients. In this study we aim to analyze the prevalence and impact of PEM diagnosis during 2019 hospitalizations. A retrospective study of 2019 data from the inpatient national sample (NIH) was performed. We identified all hospitalizations with PEM diagnosis using ICD 10 codes (International Classification of Diseases, Tenth Revision, Clinical Modification). We queried the 2019 National Inpatient Sample for primary diagnoses of either Sepsis or Pneumonia. Prevalence and predictors of mortality were noted in this cohort, using a multivariable-adjusted model to age, gender, Charlson Comorbidity Index, other comorbidities (Hyperlipidemia, Atrial fibrillation, History of stroke, Hypertension, Obstructive Sleep apnea history), hospitals region, socioeconomic status, insurance status and hospital size. We identified 1,856,025 adult hospitalizations with PEM as a secondary diagnosis (6.1% of the total adult hospitalizations in 2019), 50.6% female, mean age 67.6 years old, 9.9% of these hospitalizations for pneumonia and 17.6% for sepsis as primary diagnosis on discharge. Patients with PEM secondary diagnosis had higher odds for mortality in hospitalized adult patients (adjusted OR 2.11 (95% CI 2.06-2.17; p< 0.001), higher odds for pneumonia hospitalizations (adjusted OR 1.59 (95% CI 1.51-1.66; p< 0.001), higher odds for sepsis hospitalizations (adjusted OR 2.31 (95% CI 2.26 to 2.36; p< 0.001) compared to patients without PEM. PEM is associated with an increase in the mean length of stay by 4.2 days (95% CI 4.16 to 4.43; p< 0.001). Our analysis showed a large number of hospitalized adults with PEM, and is associated with poor outcomes for hospitalized patients with increased risk of in-hospital mortality, and increased length of in-hospital stay. Furthermore it is strongly associated with sepsis and pneumonia hospitalizations pointing to the importance of addressing this disease in hospitalized patients.

54-Year-Old Man With Acute Dyspnea on Exertion

54-Year-Old Man With Acute Dyspnea on Exertion

Feasibility of Single Lung Transplant for Post-COVID Fibrosis: A Case Report

IntroductionPreviously we reported bilateral lung transplantation is the last treatment option for irrecoverable COVID ARDS and post-COVID fibrosis. Now we report our first single lung transplant (SLTx) for post-COVID fibrosis.Case ReportA 59-year-old, never-smoker, female, with history of obstructive sleep apnea, hypertension and hyperlipidemia, presented to an outside hospital with COVID-19, shortness of breath, and bilateral pulmonary infiltrates on chest X-ray (CXR) (Figure 1a). She was admitted to the intensive care unit, never requiring intubation, for an overall 40-day hospitalization. At discharge, she had shortness of breath with minimal activity and required continuous oxygen (O2) therapy.One year later she presented to our institution for an outpatient lung transplant evaluation for her post-COVID fibrosis. Her cardiac work up was unremarkable, with the absence of pulmonary hypertension on echocardiogram and right heart catheterization. Computed Tomography of her chest showed only significant fibrosis in the upper lobes with traction bronchiectasis and volume loss (Figure 1c). Her lung ventilation perfusion scan showed grossly normal perfusion to both lungs. Thus, she was listed for left, right, and bilateral lungs with a Lung Allocation Score of 42.After 39 days of listing, she underwent left SLTx. Final pathology of her explanted lung (Figure 1d) showed both uninvolved lung parenchyma and interstitial fibrosis and capillary congestion (Figure 1e). Post-operatively, her course was unremarkable and she was discharged home on POD 19. She was seen in clinic on POD 22 and doing well with no need for supplemental O2 and improving CXR (Figure 1b).SummarySLTx can be used to treat debilitating post-COVID lung fibrosis when there is the absence of severe lung damage and pulmonary hypertension. Considering SLTx in these patients is necessary to expand the donor pool of lungs for a population of patients that will continue to grow with the continued COVID-19 pandemic.

Nasopharyngeal Angiofibroma- A case report

Nasopharyngeal angiofibroma (NA) is a rare, highly vascular, benign lesion typically affecting young males. It is prone to spontaneous bleeding even after minor trauma. Reported here is a case of an 18 years old male with almost 8x8cm swelling in the left cheek. There was nasal obstruction due to mass in the left nostril and he had a history of obstructive sleep apnea and frequent epistasis. Surgery was done through Weber- Ferguson approach.

Retrospective analysis of comorbidities in stroke patients with a history of obstructive sleep apnea treated with thrombolytic therapy

BackgroundThe eligibility criteria for thrombolytic therapy may differ between acute ischemic stroke patients (AIS) patients with and without incidence of obstructive sleep apnea (OSA). In this study, we determine the effect of specific comorbidities in the exclusion and inclusion for recombinant tissue plasminogen activator (rtPA) administration in the AIS population with OSA. MethodsRetrospective data from a stroke registry were analyzed for baseline clinical and demographic factors in AIS patients with OSA for rtPA therapy from January 2010 to June 2016. The logistic regression model was developed to identify each of the variables predicting inclusion for or exclusion from rtPA. We estimated the odds of the inclusion or exclusion of a particular demographic and clinical risk factor in AIS with and without OSA for rtPA therapy. The validity of the model was tested using a Hosmer-Lemeshow test and the sensitivity of the model was determined using a Receiver Operating Curve (ROC). ResultsA total of 170 AIS patients with OSA were identified, of which, 125 did not receive rtPA while 45 received rtPA. Adjusted analysis showed that in the AIS population with OSA, administration of rtPA was associated with a history of dyslipidemia (OR=3.192, 95% CI, 1.148-8.88, p=0.026), direct admission into a Comprehensive Stroke Center (OR=3.248, 95% CI, 1.06-9.95, p=0.039), and ambulatory improvement (OR=3.556, 95% CI, 1.428-8.86, p=0.006). There were no significant factors associated with rtPA exclusion in the AIS population with OSA. ConclusionThe prevalence of OSA in our AIS population was low and no clinical risk factor was associated with the exclusion of patients with AIS and OSA from thrombolytic therapy. Future studies are necessary to explore the effect of OSA in AIS patients to improve eligibility for rtPA therapy for more patients.

Association between sleep health and cognitive reserve in older adults with cognitive concerns

AbstractBackgroundWe examined the association between sleep health consequences and perceived fatigability within the context of carrying out everyday activities in non‐demented older adults and investigated whether cognitive reserve (CR; individual differences in susceptibility to cognitive decline due to brain aging, pathology, or insult) moderated this relationship.MethodThis was a cross‐sectional study. We prospectively screened adults age 55‐90 years at a Memory Research Clinic. An IRB approved the study protocol, and informed consent was obtained. Patients with cognitive concerns underwent neurocognitive testing to determine cognitive status based on the ADNI criteria. Inclusion criteria: the ADNI criteria for cognitively normal or MCI. Exclusion criteria: 1) depression assessed with the Geriatric Depression Scale (GDS&gt;5) and DSM‐5 criteria, 2) history of primary psychiatric illnesses, 3) medical conditions associated with fatigue, and 4) a history of obstructive sleep apnea diagnosed by a clinical sleep physician. Measures included the PROMIS Sleep‐related Impairment (SRI); the Neuro‐QOL Cognitive function (CogF) and Fatigue measure, which yields “fatigue symptom severity (Fat_Sx)” and “perceived fatigability (Fatiga)” subscales. CR was assessed with the CR Index questionnaire (CRIq). Linear regression models were fit to the fatigue outcomes and included the SRI, CR, and their interaction as predictors. If the interaction was significant, SRI slopes were assessed at CR=mean and mean ±1SD. All analyses were adjusted for age, sex, and education.ResultThere were 37 subjects in this study; mean age of 70.8 years (SD=9.3); 70.3% subjects were female; 86.5% white, 10.8% Hispanic, and 2.7% others. CR significantly moderated the relationship between SRI and perceived fatigability (F (1,32)=18.64, p=0.011). A higher SRI score was associated with a higher perceived fatigability severity with a low CR (CRIq mean‐1SD)=108.6; b(se)=.493(.089), p&lt;0.001) and a mean CR (CRIq mean=128.0; b(se)=.274(.076); p=0.001), but not a high CR (CRIg mean+1SD=147.4; b(se)=0.1278; p=0.636). Moreover, higher perceived fatigability was associated with lower cognitive function (b(se)=‐.24 2(0.077), p=0.004), controlling for age, gender, and education.ConclusionPoorer cognitive function was significantly associated with greater fatigability within the context of managing everyday activities. Greater cognitive reserve may reduce the detrimental influence of poor sleep health on perceived fatigability in managing daily function during the preclinical stages of dementia.