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Biomedical subjects

L J Epstein

Publications and source records attributed to L J Epstein.

At least 19 recordsLinked to original sources
PubMed2001

Proteinuria in obstructive sleep apnea.

BACKGROUND: Previous studies have reported an association between obstructive sleep apnea (OSA) and proteinuria, but are limited in their ability to assess proteinuria accurately, to adjust for confounders such as obesity, or to exclude confidently underlying renal disease in patients with OSA and nephrotic-range proteinuria. METHODS: The spot urine protein/creatinine ratio was measured in a prospective consecutive series of 148 patients referred for polysomnography who were not diabetic and had not been treated previously for OSA. The urine protein/creatinine ratio was compared across four levels of OSA severity, based on the frequency of apneas and hypopneas per hour: <5 (absent), 5 to 14.9 (mild), 15 to 29.9 (moderate), and > or =30 (severe). RESULTS: The median level of urine protein/creatinine ratio in all categories of OSA was <0.2 (range 0.03 to 0.69; median 0.06 in patients with normal apnea hypopnea index, 0.06, 0.07, 0.07 in patients with mild, moderate, and severe OSA, respectively). Eight subjects had a urine protein/creatinine ratio greater than 0.2. Univariate analysis showed a significant association between urine protein/creatinine ratio and older age (P < 0.0001), hypertension (P < 0.0001), coronary artery disease (P = 0.003), and arousal index (P = 0.003). Body mass index (P = 0.16), estimated creatinine clearance (P = 0.17), and apnea hypopnea index (P = 0.13) were not associated with the urine protein/creatinine ratio. In multiple regression analysis, only age and hypertension were independent positive predictors of the urine protein/creatinine ratio (P < 0.0001, R2 = 0.17). CONCLUSION: Clinically significant proteinuria is uncommon in sleep apnea. Nephrotic range proteinuria should not be ascribed to sleep apnea and deserves a thorough renal evaluation.

Adult↗
PubMed2001

Predictors of loud snoring in persons with spinal cord injury.

BACKGROUND: Predictors of loud snoring were examined in a cohort of 197 persons with chronic spinal cord injury (SCI) recruited by advertisement and from a Veterans Affairs Medical Center SCI Service. METHODS: Data were collected on age, marital status, antispasticity medications, duration of injury, level and completeness of injury, stature, and weight. Body mass index (BMI) was calculated for all participants. A health questionnaire was used to collect data on snoring and respiratory history. Habitual snorers were defined as those who reported loud snoring more than 1 night per week. RESULTS: The mean age (+/- SD) was 51.2 +/- 14.8 years, and 84 of 197 (42.6%) were habitual snorers. The most obese research subjects, regardless of antispasticity medication use, were more likely to report snoring, but the risk of snoring was greatest among subjects who were obese and used antispasticity medication. Subjects who used antispasticity medication and had a BMI above the median (> or = 25.3 kg/m2) had a 7-fold risk of reporting snoring compared with subjects below the median who did not use antispasticity medication (P = .001). The greatest risk occurred in those who used diazepam alone or baclofen and diazepam together and had a BMI at or above the median. Subjects who used these medications and had a BMI below the median did not have a significantly increased risk. Neurological motor completeness, level of injury, age, and years since injury were not significant predictors of snoring. CONCLUSION: Because snoring is a marker for obstructive sleep apnea (OSA), the data suggest that in obese individuals with SCI, the use of antispasticity medications may be a risk factor for OSA.

Adult↗
PubMed2001

Measurement of gastric P(CO2) as an index of tissue hypoxia during obstructive sleep apnea.

BACKGROUND: Gastric mucosal ischemia develops in critically ill patients in a number of clinical settings due to diversion of blood flow from the splanchnic bed to more vital organs, and can be detected by the measurement of gastric intramucosal pH (pHi). STUDY OBJECTIVE: We hypothesized that similar changes would occur during obstructive sleep apnea (OSA) due to increased respiratory work during the periods of apnea. METHODS: Gastric P(CO2), pHi and arterial blood gases were measured during 3 conditions in 8 patients with severe OSA: at baseline awake, while asleep with > or = 30 obstructive apneas or hypopneas per hour, and asleep after elimination of apneas with continuous positive airway pressure (CPAP). RESULTS: Significant changes between the baseline and apnea conditions were detected using ANOVA for repeated measures for gastric P(CO2), 40.2 +/- 5.3 vs. 85.4 +/- 34.0 (p < 0.001), pHi, 7.41 +/- 0.06 vs. 7.11 +/- 0.17 (p < 0.005), and the gastric-arterial P(CO2) difference (D(CO2)), -2.3 +/- 5.5 vs. 44.3 +/- 36.21 (p < 0.006). Nasal CPAP returned all measures back to baseline values. CONCLUSIONS: Gastric tissue hypoxia develops in patients with severe OSA and may be a marker of disease severity. Treatment of OSA with CPAP eliminates the regional tissue hypoxia.

Acid-Base Equilibrium↗
PubMed2000

The art and science of continuous positive airway pressure therapy in obstructive sleep apnea.

Despite the high prevalence of obstructive sleep apnea (OSA) syndrome, no ideal therapy has emerged to date. Based on recent randomized trials, continuous positive airway pressure (CPAP) therapy is the treatment of choice. Although CPAP can prevent pharyngeal collapse in virtually all patients who choose to wear it, poor patient adherence with treatment limits its effectiveness. Although convincing data exist that treatment with CPAP can alleviate the neurocognitive sequelae of OSA, data on cardiovascular complications are more limited. Several recent reports support a lowering of nocturnal and daytime blood pressure with CPAP, but data on the prevention of myocardial infarction and cerebrovascular events are currently lacking. Patient adherence with CPAP can be improved with optimization of mask comfort, heated humidification, and intensive support and education. For those who remain poorly compliant, alternative therapies such as autotitrating devices and oral positive airway pressure can be considered. Further research into the basic mechanisms underlying OSA will be required for new therapeutic targets to develop.

Humans↗
PubMed1999

Alternative therapies for sleep apnea.

Obstructive sleep apnea is characterized by the repetitive collapse of the upper airway during sleep. A variety of nonsurgical treatments for obstructive sleep apnea have been developed, including behavioral therapies, continuous positive airway pressure (CPAP) devices, oral appliances and medications. Presently, CPAP is considered the first-line treatment for moderate to severe sleep apnea and one of the first-line treatments for mild disease. However, the effectiveness of CPAP is compromised because a large proportion of patients cannot tolerate the devices. Oral appliances are one of the first-line therapies for mild sleep apnea and a treatment for more severe disease if CPAP cannot be tolerated. Medications have thus far been unsuccessful as a treatment option for sleep apnea. All patients should be counseled to avoid sleep deprivation and sedatives (including alcohol) and to lose weight if obese.

Journal Article↗
PubMed1998

Oral appliances in the treatment of obstructive sleep apnea and snoring.

Treatment of snoring and obstructive sleep apnea with oral appliances is a promising alternative to continuous positive airway pressure (CPAP) therapy. Although there is wide variability in appliance design, these devices produce enlargement of the upper airway by advancing the mandible, tongue, or both. Oral appliances effectively reduce snoring in a significant proportion of individuals. In general they are less effective than CPAP in eliminating obstructive sleep apnea, with approximately 50% of individuals experiencing resolution of their obstructive sleep apnea with these devices. Patients with milder disease have greater success with oral appliance therapy than those with more severe disease. A small proportion of patients will experience worsening of their sleep apnea with an oral appliance, and close follow-up after device prescription is mandatory. Patient satisfaction with oral appliances may be better than that with CPAP.

Female↗
PubMed1998

Cost-effectiveness analysis of nocturnal oximetry as a method of screening for sleep apnea-hypopnea syndrome.

STUDY OBJECTIVE: Determine the utility of nocturnal oximetry as a screening tool for sleep apnea-hypopnea syndrome (SAHS) compared with polysomnography (PSG). DESIGN: Cost-effectiveness analysis based on retrospective review of overnight sleep studies. SETTING: United States Air Force tertiary teaching hospital. PATIENTS: One hundred consecutive patients evaluated for SAHS by overnight sleep study. INTERVENTION: Participants underwent PSG and oximetry on the same night. Patients with obstructive sleep apnea had a continuous positive airway pressure trial. MEASUREMENTS: Oximetry was abnormal when > or =10 events per hour occurred. Two criteria were evaluated. A "deep" pattern of > 4% change in oxyhemoglobin saturation to < or =90%, and a "fluctuating" pattern of repetitive short-duration fluctuations in saturation. The diagnostic accuracy of both methods was compared with PSG. Cost-effectiveness of screening oximetry was compared with PSG alone and use of split-night studies. RESULTS: The fluctuating pattern had a greater sensitivity and negative predictive value, while the deep pattern had a greater specificity and positive predictive value. Oximetry screening using the fluctuating pattern was not as sensitive as PSG for detecting patients with mild disease; 17 of 28 patients (61%) with normal oximetry results had treatable conditions detected by PSG. Cost analysis showed that screening oximetry would save $4,290/100 patients but with considerable loss of diagnostic accuracy. CONCLUSION: Screening oximetry is not cost-effective because of poor diagnostic accuracy despite increased sensitivity using the fluctuating pattern. Greater savings, without loss of diagnostic accuracy, may be achieved through increased utilization of split-night PSGs.

Adult↗
PubMed1995

The effect of quiet tidal breathing on lateral cephalometric measurements.

PURPOSE: In the evaluation of the upper airway in patients with sleep apnea it has been suggested that cephalometric radiographs be performed at either end-inspiration or end-expiration during quiet tidal breathing. This study sought to determine if standard soft tissue cephalometric measurements vary significantly with tidal breathing. PATIENTS AND METHODS: In this prospective, controlled study 22 adult male patients with the sleep apnea/hypopnea syndrome and 27 nonapneic, nonsnoring male controls had cephalometric radiographs performed at end-tidal inspiration and end-tidal expiration. The measurements obtained from each radiograph included the posterior airway space distance, the mandibular plane to hyoid distance, and the posterior nasal spine to tip of palate (PNS-P) distance. RESULTS: There were no statistically significant differences between the inspiratory and expiratory measurements in either group. Only the PNS-P distance differed significantly between the two groups. Changes in cephalometric measurements did not occur uniformly in any one direction with tidal breathing. CONCLUSION: The data indicate that coordinating radiographic exposure to respiratory cycle phase is not necessary for soft-tissue measurements commonly used to assess upper airway patency in patients with the sleep apnea/hypopnea syndrome.

Adult↗
PubMed1995

Obstructive sleep apnea in patients with human immunodeficiency virus (HIV) disease.

Adenotonsillar hypertrophy has been identified as an early manifestation of human immunodeficiency virus (HIV) disease. Three patients with HIV disease were identified with obstructive sleep apnea (OSA) due to adenotonsillar hypertrophy. In order to examine the relationship between HIV-induced adenotonsillar hypertrophy and OSA, 134 patients with asymptomatic HIV disease were screened with a self-administered sleep survey designed to detect OSA and excessive daytime somnolence. Patients meeting trigger score criteria were studied with overnight polysomnography and nine additional patients were identified with OSA. The only consistent risk factor for OSA in this young and primarily nonobese population was the presence of adenotonsillar hypertrophy, found in 11 of 12 patients with OSA. Three patients had tonsillar biopsy or tonsillectomy and all displayed benign follicular lymphoid hyperplasia. Scores on the Epworth Sleepiness Scale (ESS) were significantly higher for patients with OSA, indicating a greater degree of hypersomnolence (mean ESS scores: OSA+ = 11.4 +/- 3.6, OSA- = 7.8 +/- 4.6, p = 0.012). In our population, patients with HIV disease had a prevalence of OSA of 7%. HIV-induced adenotonsillar hypertrophy is a risk factor for the development of OSA. HIV patients with complaints of excessive daytime sleepiness and snoring who are found to have adenotonsillar hypertrophy on exam should undergo a sleep evaluation to rule out the presence of OSA.

Adult↗
PubMed1994

Clinical experience with atovaquone: a new drug for treating Pneumocystis carinii pneumonia.

Atovaquone is a new hydroxynapthoquinone antiprotozoal agent active against Pneumocystis carinii in vitro and in animal models. The authors report an experience using atovaquone to treat 25 patients with mild to moderate P. carinii pneumonia. Eligible patients were treated for 21 days with 750 mg of atovaquone orally three times daily. Prednisone was added when the P(A-a)O2 gradient was between 35-45 mm Hg. Patients were treated under three treatment protocols. Patients in Group 1 participated in one of two randomized comparative drug trials, designed for patients with and without sulfonamide intolerance. Six of seven patients successfully completed treatment, and one patient discontinued treatment because of an adverse reaction (> 5 times baseline increase in transaminase level). Patients in Group 2 were treated with atovaquone for mild to moderate P. carinii pneumonia under a treatment Investigational New Drug protocol because of prior sulfonamide reactions. Fifteen of these 18 patients successfully completed treatment; one died from other complications during treatment and two discontinued treatment for adverse reactions (> 5 times baseline increase in transaminase levels, and a diffuse rash). Serum transaminase levels returned to normal at the end of treatment in all patients with elevated levels. All patients demonstrated clinical resolution of their pneumonia and improvement of pretreatment hypoxemia (Group 1: pretreatment PaO2 = 82 +/- 14 mm Hg, posttreatment PaO2 = 92 +/- 9 mm Hg). Overall, 21 (84%) of 25 patients successfully finished therapy without significant adverse reactions. Atovaquone appears to be an effective and well-tolerated oral treatment for mild to moderate P. carinii pneumonia.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Related Opportunistic Infections↗
PubMed1994

Persistence of Pneumocystis carinii in patients with AIDS receiving chemoprophylaxis.

Pneumocystis carinii organisms have been shown to persist throughout therapy in the majority of patients with Pneumocystis carinii pneumonia (PCP). This study evaluated the relationship between persistence of organisms and recurrence of disease, and the effect of chemoprophylaxis on bronchoalveolar lavage specimens. Seven patients receiving PCP chemoprophylaxis underwent serial bronchoalveolar lavage (BAL) examinations at 1, 4, and 7 mo after recovery from a first episode of PCP. Specimens were examined for persistent organisms with Gomori's methenamine silver stain and immunofluorescent antibody staining. There were no persistent organisms 1 mo after completion of antimicrobial treatment in six of the seven patients. The one patient with persistent organisms demonstrated clearance of organisms by 4 mo and had no recurrence of PCP. One patient had a recurrence of PCP at 4 mo, after a negative 1-mo BAL. We conclude that a positive BAL result by silver stain or immunofluorescent antibody staining more than a month after ending treatment may indicate clinical recurrence of PCP and not just persistence of nonpathologic cysts. These findings suggest that recurrences of PCP are more likely due to new infection than to relapse of prior disease.

AIDS-Related Opportunistic Infections↗
PubMed1993

Use of Nd:YAG laser in endobronchial granular cell myoblastoma.

Granular cell myoblastoma is an uncommon benign tumor that causes pulmonary complications due to obstruction of the airways. We report the first case of bronchial obstruction due to granular cell tumor treated with Nd:YAG laser. The Nd:YAG laser appears to be an effective new tool for relieving obstruction and, in some cases, preventing recurrence, and can be delivered with the use of a flexible bronchoscope.

Aged↗
PubMed1992

Noninvasive determinations of the anaerobic threshold. Reliability and validity in patients with COPD.

We compared the intraobserver and interobserver agreement of blood (BGT) and gas exchange (GET) methods for determination of the anaerobic threshold (AT) in patients with COPD. In addition, we determined the sensitivity and specificity of the gas exchange methods for determination of the AT. Two noninvasive methods, the V-slope (VS) and the ventilatory equivalents method (VEM) were compared with two blood sampling methods, the log standard HCO3 (SB) vs log VO2 (SBT) and base excess (BE) vs VO2 (BET). Twenty-nine patients with COPD (FEV1 < 60%) performed incremental exercise tests to exhaustion while breath-by-breath gas exchange measurements were made. Blood samples were drawn at the end of each minute for SB and BE. Two trained observers determined the VO2 at the threshold for each of the four indices on two separate occasions two weeks apart. Our results demonstrated the following: only modest interobserver and intraobserver agreement was noted by Spearman rank correlations; the VEM was as sensitive as the VS in COPD patients; and the presence of a true metabolic acidosis was not reliably predicted by GET methods. Moreover, although the blood methods accurately identified the presence of metabolic acidosis, there was disagreement on the actual point of the BGT. We conclude that gas exchange indices were not helpful for the determination of metabolic acidosis in patients with COPD.

Adult↗
PubMed1985

Changes in self-stimulatory behaviors with treatment.

For four of six autistic children who underwent intensive behavioral treatment, the nature of their self-stimulatory behavior changed from initial "low-level" motor behaviors (such as rocking, spinning, twirling) to differing kinds of "higher-level" behaviors (such as lining of objects, echolalic speech, and preoccupation with spelling and numerical values). The children who changed to the highest levels of self-stimulatory behavior also showed the largest gains in treatment (as determined by IQ scores, school placement, etc.). The changes in self-stimulatory behaviors were attributed to the intense teaching of appropriate social behaviors and the explicit therapeutic suppression of low-level, self-stimulatory behaviors. The long-term therapeutic effects of changing from lower- to higher-level forms of self-stimulatory behavior were discussed.

Achievement↗
PubMed1976

Depression in the elderly.

Depressions in the elderly have many similarities to depressions in other age groups, particularly in their episodic nature, their tendency to remit, and their potential for favorable immediate outcome. They may, however, be far more easily overlooked. They often are considered to be consistent with senescence because of their frequent association with metabolic disturbance, with a variety of physical illnesses, with impaired cerebral function, and with hypochondriacal manifestations that may be viewed as characteristic of old age. It is important, therefore, that the clinician who treats these older patients be aware that depression is the psychiatric symptom he will most often encounter in the elderly and that it is as distressing in this age group as it is in younger persons. It represents an entity that often is reversible with prompt and appropriate treatment.

Adjustment Disorders↗