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Study Objectives: Obstructive sleep apnea (OSA) is associated with chronic inflammation likely triggered by nocturnal, intermittent hypoxemia and increased adrenergic tone. The neutrophil-to-lymphocyte ratio (NLR) was recently described as a measure of subclinical systemic inflammation. Studies on the effect of continuous positive airway pressure (CPAP) therapy in OSA on subclinical inflammation measured by NLR are lacking. We hypothesize that NLR levels would improve as chronic inflammation diminishes in patients with OSA treated with CPAP., Methods: We retrospectively reviewed patients in whom OSA was diagnosed and who were treated with CPAP therapy. Complete blood count (CBC) were obtained pretreatment and posttreatment for calculation of NLR, which was calculated by dividing the number of neutrophils by the number of lymphocytes. Patients with conditions known to affect NLR such as chronic infections, inflammatory diseases, active cardiovascular disease, and malignancies were excluded from the study. CPAP adherence downloads were obtained for all patients., Results: Out of 184 patients in whom OSA was diagnosed and who were treated with CPAP, 109 met our study criteria, including baseline polysomnogram, baseline and posttreatment CBC, and available adherence download. We compared the NLR before and after treatment with CPAP. There was a significant difference in NLR before and after treatment with CPAP (P < .0001). There was also a significant difference in apnea-hypopnea index before and after treatment (P < .0001). We also assessed the relationship between CPAP adherence (percentage of days used for > 4 hours) and the change in NLR. NLR decreased significantly in both the adherent (CPAP use ≥ 70% of days; P = .014) and nonadherent groups (CPAP use < 70% of days; P = .0003). Finally, we noticed a significant direct correlation between CPAP adherence beyond 70% and the change in NLR (ΔNLR) (P = .046) in patients who had ≥ 70% adherence with CPAP, which was not observed in patients with < 70% adherence., Conclusions: The NLR may be a useful marker for monitoring improvement, as CPAP had a desirable effect on the chronic inflammation induced by OSA when measured by NLR in this study. Our results specifically suggest that the NLR values decrease significantly in patients using CPAP regardless of adherence, but with a more direct relationship in those who use it beyond 70% of days, at least 4 hours a day., (© 2020 American Academy of Sleep Medicine.)

Background: Protease inhibitors (PIs) are a vital part of the antiretroviral therapy. Long-term use of PIs may cause lipodystrophy, a clinical syndrome characterized by peripheral lipoatrophy and central fat accumulation, which may increase the risk of developing obstructive sleep apnea (OSA) in HIV-infected patients. We hypothesize that a longer duration of PIs' use might be associated with increasing severity of OSA in HIV-infected patients., Materials and Methods: This was a retrospective cohort study of HIV-infected patients who were treated with PIs, who presented with symptoms suggestive of OSA, and underwent nocturnal polysomnography. The primary objective of the study is to evaluate the association between the duration of PIs' use and the severity of OSA. The duration of PIs' use measured in months was recorded for each patient. The primary outcome of interest was the apnea-hypopnea index (AHI) obtained at the time of the sleep study. Data were analyzed using univariate and multivariate linear regression between AHIs with PIs' use as well as other predictors., Results: A total of 54 patients diagnosed with HIV and OSA were included in the study cohort for the analysis. Sleep study body mass index (BMI; P = 0.042) and change in BMI (ΔBMI; P = 0.027) were the only statistically significant independent predictors of AHI. The association between AHI and PIs' use duration was found to be nonlinear and nonsignificant. Gender differences evaluation suggested possible duration-related effect relationship between PIs and OSA severity among HIV-infected men exposed to PIs within a 66-month duration., Conclusion: We did not observe a significant association between PIs' use duration and the severity of OSA., Competing Interests: There are no conflicts of interest.

Jet Propulsion Fuel 8 (JP-8) is a kerosene based fuel commonly used in aviation. Occupational exposure to JP-8 may lead to negative health outcomes, which were described in a small number of studies. We report a case of 33-year-old Caucasian male veteran with a history of JP-8 exposure who presented with chronic dyspnea and recurrent spontaneous pneumothorax. To our knowledge, this is the first case of chronic inhalation injury from JP-8 exposure complicated with recurrent secondary spontaneous pneumothorax., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Objectives: Centers for Medicare and Medicaid Services (CMS) reimbursement for positive airway pressure (PAP) devices for obstructive sleep apnea treatment is dependent on patients meeting adherence expectations within the first 3 months on therapy. Adherence is defined as usage of the device for at least 4 hours per night on 70% of nights during a consecutive 30-day period. We hypothesize that the adherence pattern may be established beyond this initial period, which may limit the opportunity to treat many patients., Methods: Treatment and adherence data from PAP devices were monitored via wireless modems for 42 consecutive PAP-naïve military veterans who completed 1 year of nightly monitoring. Their baseline characteristics were as follows: age (mean ± standard deviation) 58.5 ± 12.5 years; body mass index 33.7 ± 5.7 kg/m 2 ; diagnostic apnea-hypopnea index (pretreatment) 28.1 ± 18.5 events/h; apnea-hypopnea index on PAP: 4.3 ± 3.3 events/h. We examined daily, monthly, quarterly, semiannual, and annual reports, and the best 30-day adherence report for each quarter., Results: In the first 3 months, 19 of 42 participants were adherent by CMS criteria, and 23 of 42 participants were not. Of the 19 adherent participants, 13 remained adherent and 6 became nonadherent or stopped PAP treatment for the remainder of the year. In the 23 initially nonadherent participants, 16 stopped PAP treatment, and 7 participants (30.4%) became adherent (using CMS criteria) during the rest of the year. Thus, PAP adherence during the first 3 months was predictive for the rest of the year in only 68.4%. PAP nonadherence during the first 3 months was predictive for further nonadherence in only 69.6% of the cases. Overall, this led to a 65% sensitivity and 72% specificity of using adherence at 3 months in predicting adherence at 1 year., Conclusions: CMS adherence criteria affecting PAP coverage are restrictive and can result in the withholding of therapy in many patients who otherwise might become adherent., Clinical Trial Registration: Registry: ClinicalTrials.gov, Title: Remote Monitoring in Obstructive Sleep Apnea, Identifier: NCT01678560, URL: https:// clinicaltrials.gov/ct2/show/NCT01678560., (© 2019 American Academy of Sleep Medicine.)

Purpose: Obstructive sleep apnea has been associated with chronic inflammation triggered by nocturnal hypoxemia. The neutrophil-to-lymphocyte ratio (NLR) is a measure of subclinical systemic inflammation. We hypothesize that NLR levels would improve as chronic inflammation diminishes in obstructive sleep apnea (OSA) patients treated with mandibular advancement devices (MADs)., Methods: We studied patients with OSA who were treated with MAD as a first-line treatment or because they could not tolerate CPAP. We obtained pre-treatment and post-treatment complete blood counts. NLR was calculated by dividing the number of neutrophils by the number of lymphocytes obtained from the CBCs. Patients with other conditions known to affect NLR were excluded from the study., Results: We compared the values of NLR and oxygen desaturation index (ODI) before and after treatment with MAD in 22 patients who met inclusion criteria and completed the study protocol. There was a significant difference in NLR before and after treatment (p = 0.01). There was also a significant difference in the 3% ODI and 4% ODI before and after treatment with MAD (p = 0.014, 0.007), respectively. A subgroup analysis compared NLR in two groups of patients, the optimally treated and suboptimally treated. There was a significant decrease in the NLR in the optimally treated group (n = 10) (p < 0.01), whereas it did not change in the suboptimally treated group (n = 12) (p = 0.349)., Conclusion: The neutrophil-to-lymphocyte ratio may be useful in documenting improvement in inflammation for OSA patients treated with mandibular advancement devices. Our results specifically suggest that the NLR values are associated with the decrease in the ODI.

Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Oral appliance therapy (OAT) has become an increasingly popular nonsurgical option for the treatment of obstructive sleep disorders. Recent research supports its efficacy and high levels of compliance for patients with obstructive sleep disorders. Common side effects of OAT include temporomandibular joint-related symptoms, bite changes, and tooth movement. These side effects can be minimized by the use of exercises. The American Academy of Dental Sleep Medicine and the American Academy of Sleep Medicine have released joint clinical practice guidelines for the treatment of obstructive sleep apnea and snoring with OAT., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Acute colonic pseudoobstruction, also known as Ogilvie's syndrome, is characterized by distension of the colon in the absence of a mechanical obstruction as evident by abdominal radiography. This syndrome is usually treated conservatively; however, medical or surgical therapies can be employed in refractory cases. Ogilvie's syndrome has been reported following cardiac events, such as myocardial infarction, heart failure, and cardiac bypass surgeries. We report the first case of Ogilvie's syndrome following synchronized electric cardioversion for atrial fibrillation.