Ali A. El-Solh

Association Between Pneumonia and Oral Care in Nursing Home Residents

Pneumonia remains the leading cause of death in nursing home residents. The accumulation of dental plaque and colonization of oral surfaces and dentures with respiratory pathogens serves as a reservoir for recurrent lower respiratory tract infections. Control of gingivitis and dental plaques has been effective in reducing the rate of pneumonia but the provision of dental care for institutionalized elderly is inadequate, with treatment often sought only when patients experience pain or denture problems. Direct mechanical cleaning is thwarted by the lack of adequate training of nursing staff and residents’ uncooperativeness. Chlorhexidine-based interventions are advocated as alternative methods for managing the oral health of frail older people; however, efficacy is yet to be demonstrated in randomized controlled trials. Development and maintenance of an oral hygiene program is a critical step in the prevention of pneumonia. While resources may be limited in long-term-care facilities, incorporating oral care in daily routine practice helps to reduce systemic diseases and to promote overall quality of life in nursing home residents.

Clinical outcomes of type III Pseudomonas aeruginosa bacteremia.

Background:Pseudomonas aeruginosa bacteremia is a serious and life-threatening infection associated with high mortality. Among the multitude of virulence determinants possessed by P. aeruginosa, the type 3 secretion system has been implicated with more acute and invasive infection in respiratory diseases. However, the relationship between the type 3 secretion system and clinical outcomes in P. aeruginosa bacteremia has not been investigated. Objectives:To determine the association between the type 3 secretion system virulence factor in P. aeruginosa bloodstream infection and 30-day mortality. Design:Retrospective analysis of 85 cases of P. aeruginosa bacteremia. Setting:Tertiary care hospital. Interventions:Bacterial isolates were assayed in vitro for secretion of type 3 exotoxins (ExoU, ExoT, and ExoS). Strain relatedness was analyzed using randomly amplified polymorphic DNA polymerase chain reaction genotyping. Antimicrobial susceptibilities were determined by means of the Kirby-Bauer disk-diffusion test. Measurements and Main Results:At least one of the type 3 secretion system proteins was detected in 37 out of the 85 isolates (44%). Septic shock was identified in 43% of bacteremic patients with type 3 secretion system+ isolates compared to 23% of patients with type 3 secretion system– isolates (p = .12). A high frequency of resistance in the type 3 secretion system+ isolates was observed to ciprofloxacin (59%), cefepime (35%), and gentamicin (38%). There was a significant difference in the 30-day cumulative probability of death after bacteremia between secretors and nonsecretors (p = .02). None of the type 3 secretion system+ patients who survived the first 30 days had a P. aeruginosa isolate which exhibited ExoU phenotype. Conclusions:The expression of type 3 secretion system exotoxins in bacteremic isolates of P. aeruginosa confers poor clinical outcomes independent of antibiotic susceptibility profile. (Crit Care Med 2012; 40:–1163)

Cardiovascular mortality in obstructive sleep apnoea treated with continuous positive airway pressure or oral appliance: an observational study.

The objective of this study was to evaluate the long‐term cardiovascular mortality in patients with severe obstructive sleep apnoea (OSA) treated with either continuous positive airway pressure (CPAP) or mandibular advancing device (MAD).

Effects of dietary weight loss on obstructive sleep apnea: a meta-analysis.

PurposeClinical and epidemiologic investigations suggest a strong association between obesity and obstructive sleep apnea (OSA). The purpose of this study is to evaluate the currently available literature reporting on the effectiveness of dietary weight loss in treating OSA among obese patients.MethodsRelevant studies were identified by computerized searches of PubMed, EMBASE, CINAHL, Web of Science, and The Cochrane Central Register of Controlled Trials through September 2011 as well as the reference lists of all obtained articles. Information on study design, patient characteristics, pre- and post-dietary weight loss measures of OSA and body mass index (BMI), and study quality was obtained. Data were extracted by two independent analysts. Weighted averages using a random-effects model are reported with 95 % confidence intervals.ResultsNine articles representing 577 patients were selected. Dietary weight loss program resulted in a pooled mean BMI reduction of 4.8xa0kg/m2 (95 % confidence interval [CI] 3.8-5.9). The random-effects pooled apnea hypopnea (AHI) indices at pre- and post-dietary intervention were 52.5 (range 10.0–91.0) and 28.3 events/h (range 5.4–64.5), respectively (pu2009<u20090.001). Compared to control, the weighted mean difference of AHI was decreased by −14.3 events/h (95 % CI −23.5 to −5.1; pu2009=u20090.002) in favor of the dietary weight loss programs.ConclusionsDietary weight loss programs are effective in reducing the severity of OSA but not adequate in relieving all respiratory events. Weight reduction programs should be considered as adjunct rather than curative therapy.

Combined oral appliance and positive airway pressure therapy for obstructive sleep apnea: a pilot study

BackgroundThe high efficacy of continuous positive airway pressure (CPAP) in treating obstructive sleep apnea (OSA) is limited by poor compliance often related to pressure intolerance. Mandibular advancement devices (MADs) are proven alternative therapy although not universally effective. A combination of nasal CPAP and MAD may provide another option for CPAP-intolerant patients with incomplete response to MAD.MethodsTen patients with residual apnea/hypopnea events on MAD who were intolerant to CPAP were recruited prospectively from the sleep clinic. After a washout period of 1xa0week off MAD, subjects were asked to use an auto-CPAP unit along with their prescribed MAD for three consecutive nights. Oxygen desaturations were obtained from overnight oximetry. Efficacy of the combination therapy was evaluated by the Epworth Sleepiness Scale and Smartcard data recordings.ResultsThe combination of MAD and nasal CPAP was well tolerated by all participants. Compared to CPAP alone, the optimal CPAP pressure required to eliminate all obstructive events on the combination therapy was reduced from 9.4u2009±u20092.3 to 7.3u2009±u20091.4xa0cm H2O (pu2009=u20090.001). The residual apnea hypopnea index on the MAD decreased from 11.2u2009±u20093.9 to 3.4u2009±u20091.5 on the combination therapy (pu2009<u20090.001). The number of oxygen desaturations was also less with the combination therapy than with MAD (pu2009<u20090.001). Both the MAD and the combination therapy were effective in reducing daytime sleepiness from 12.7u2009±u20092.1 at baseline to 9.7u2009±u20093.1 (pu2009=u20090.04) and 7.5u2009±u20094.1 (pu2009=u20090.007), respectively.ConclusionsCombination therapy of MAD and nasal CPAP is effective in normalizing respiratory disturbances of sleep apnea in selected OSA patients who are intolerant to CPAP.

Pharmacotherapy of insomnia

Introduction: Insomnia is one of the most prevalent sleep disorders in developed countries, being surpassed only by chronic sleep deprivation. Patients with insomnia tend to have an altered quality of life, impaired daytime functioning and an increased risk of work accidents and motor vehicle crashes. Insomnia is commonly associated with chronic medical conditions, metabolic illnesses and mental disorders (such as depression and anxiety), with which there is a dual, reciprocal relationship. Areas covered: This paper focuses on current pharmacotherapy options for the treatment of insomnia, particularly benzodiazepine receptor agonists, which nowadays represent the mainstay of hypnotic therapy. The melatonin receptor antagonist, ramelteon, is reviewed (an alternative for some patients with only sleep-onset difficulty), as are sedating antidepressants, which are commonly used ‘off-label’ to treat insomnia, despite limited efficacy data and potential significant safety concerns. Orexin (OX) antagonists are also discussed, especially those that block OX2 or both OX1 and OX2 receptors, as these are the most promising new agents for the treatment of insomnia, with encouraging results in preliminary clinical trials. Expert opinion: Research to evaluate and formulate treatments for insomnia is often complicated by the fact that insomnia is usually of multifactorial etiology. Understanding the molecular and receptor mechanisms involved in promoting sleep in varied disorders could provide future approaches in new drug development. In the long term, more randomized controlled trials are needed to assess both short-term and long-term effects of these medications and their efficacy in comorbid diseases that affect sleep quality or quantity.

A comparison of severity of illness scoring systems for elderly patients with severe pneumonia

Abstract. Objective: To evaluate the predictive ability of three severity of illness scoring systems in elderly patients with severe pneumonia requiring mechanical ventilation compared to a younger age group. Design: Prospective cohort study. Setting: Two university-affiliated tertiary care hospitals. Patients and participants: One hundred four patients 75xa0years of age and older and 253 patients younger than 75xa0years of age enrolled from medical intensive care units. Measurements and results: Probabilities of hospital death for patients were estimated by the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Mortality Probability Model (MPM) II and the Simplified Acute Physiology Score (SAPS) II. Predicted risks of hospital death were compared with observed outcomes using three methods of assessing the overall goodness of fit. The actual mortality of the elderly group was 54.87% (95% confidence interval [CI]: 45.2–64.4%) compared to 28.9% (95% CI, 23.3–34.4%) in the younger age group. There was a significant difference in the predictive accuracy of the scoring systems as assessed by the c-index, which is equivalent to the area under the receiver operator characteristics (ROC) curve, between the two groups, but not within individual groups. Calibration was insufficient for APACHE II and SAPS II in the elderly cohort as in-hospital mortality was lower than the predicted mortality for both models. Conclusions: Although the three severity of illness scoring systems (APACHE II, MPM II and SAPS II) demonstrated average discrimination when applied to estimate hospital mortality in the elderly patients with severe pneumonia, MPM II had the closest fit to our database. Alternative modeling approaches might be needed to customize the model coefficients to the elderly population for more accurate probabilities or to develop specialized models targeted to the designed population.

Postoperative complications in patients with obstructive sleep apnea: a meta-analysis

STUDY OBJECTIVEnTo determine whether a diagnosis of obstructive sleep apnea (OSA) imparts an increased risk of postoperative respiratory failure, cardiac events, and intensive care unit (ICU) transfer than patients with no OSA diagnosis.nnnDESIGNnSystematic review and meta-analysis.nnnSETTINGnAcademic Veterans Affairs Medical Center.nnnMEASUREMENTSnPubMed, EMBASE, CINAHL, and ISI Web of Knowledge databases were searched through April 2013 for studies that examined the relationship between OSA and postoperative respiratory and cardiac complications among adults. Either fixed or random-effects models were used to calculate the pooled risk estimates. Sensitivity analysis was conducted to examine the robustness of pooled outcomes.nnnMAIN RESULTSnSeventeen studies with a total of 7,162 patients were included. Overall, OSA was associated with significant increase in risk of respiratory failure [odds ratio (OR) 2.42; 95% confidence intervals (CI) 1.53 - 3.84; P = 0.0002] and cardiac events postoperatively (OR = 1.63; 95% CI 1.16 - 2.29; P = 0.005). Heterogeneity was low for these outcomes (I(2) = 5% and 0%, respectively). ICU transfer occurred also more frequently in patients with OSA (OR 2.46; 95% CI 1.29 - 4.68; P = 0.006). These results did not materially change in the sensitivity analyses according to various inclusion criteria.nnnCONCLUSIONSnSurgical patients with OSA are at increased risk of postoperative respiratory failure, cardiac events, and ICU transfer.

Colonization of Dental Plaques

STUDY OBJECTIVESnPoor dental hygiene has been linked to respiratory pathogen colonization in residents of long-term care facilities. We sought to investigate the association between dental plaque (DP) colonization and lower respiratory tract infection in hospitalized institutionalized elders using molecular genotyping.nnnMETHODSnWe assessed the dental status of 49 critically ill residents of long-term care facilities requiring intensive care treatment. Plaque index scores and quantitative cultures of DPs were obtained on ICU admission. Protected BAL (PBAL) was performed on 14 patients who developed hospital-acquired pneumonia (HAP). Respiratory pathogens recovered from the PBAL fluid were compared genetically to those isolated from DPs by pulsed-field gel electrophoresis.nnnMEASUREMENTS AND RESULTSnTwenty-eight subjects (57%) had colonization of their DPs with aerobic pathogens. Staphylococcus aureus (45%) accounted for the majority of the isolates, followed by enteric Gram-negative bacilli (42%) and Pseudomonas aeruginosa (13%). The etiology of HAP was documented in 10 patients. Of the 13 isolates recovered from PBAL fluid, nine respiratory pathogens matched genetically those recovered from the corresponding DPs of eight patients.nnnCONCLUSIONSnThese findings suggest that aerobic respiratory pathogens colonizing DPs may be an important reservoir for HAP in institutionalized elders. Future studies are needed to delineate whether daily oral hygiene in hospitalized elderly would reduce the risk of nosocomial pneumonia in this frail population.

Sleep disorders in morbid obesity

The increasing prevalence of obesity has lead to an increase in the prevalence of sleep disordered breathing in the general population. The disproportionate structural characteristics of the pharyngeal airway and the diminished neural regulation of the pharyngeal dilating muscles during sleep predispose the obese patients to pharyngeal airway collapsibility. A subgroup of obese apneic patients is unable to compensate for the added load of obesity on the respiratory system, with resultant daytime hypercapnia. Weight loss using dietary modification and life style changes is the safest approach to reducing the severity of sleep apnea, but its efficacy is limited on the long run. Although it has inherent risks, bariatric surgery provides the most immediate result in alleviating sleep apnea. Obesity has been linked also to narcolepsy. The loss of neuropeptides co-localized in hypocretin neurons is suggested as the potential mechanism. Poor sleep quality, which leads to overall sleep loss and excessive daytime sleepiness has also become a frequent complaint in this population. Identifying abnormal nocturnal eating is critically important for patient care. Both sleep related eating disorder and night eating syndrome are treatable and represent potentially reversible forms of obesity.