Solitary extramedullary plasmacytomas are uncommon neoplasms. They occur most frequently in the upper aerodigestive tract and account for 4% of the nonepithelial tumors in this site. The evolution of a plasmacytoma is unsteady and symptoms at presentation have included dystonia, dysphagia, oral pain, cough, and dyspnea on exertion. Plasmaeytoma of the upper aerodigestive tract has not been previously reported as a cause of obstructive sleep apnea.

Indiana University-Purdue University Indianapolis (IUPUI) / The study evaluated the effects of a mandibular repositioning appliance (MRA) in patients with obstructive sleep apnea. The MRA was designed to hold the mandible anteriorly in an attempt to maintain a patent airway. Eleven subjects completed a full-night polysomnogram wherein their normal sleep was recorded half the night without the appliance (control) and the other half with the appliance (test). The sequencing of test and control halves was randomly assigned to avoid bias. After seven subjects were tested with the MRA, the MRA was modified for four additional patients by placing anterior vertical elastics (MRA*) to minimize the opening of the mandible. The skeletal and soft tissue changes with both appliances were analyzed using lateral cephalometric radiographs. The MRA was found to have no significant effect on the obstructive sleep apnea patients as a group. Individual response to the appliance varied from noticeably worse to marked improvement. Subject #2A exhibited the reduction of a moderate-to-severe apnea (Apnea-hypopnea index 55.92) to a clinically acceptable level (Apnea-hypopnea index 9.57) with appliance wear. The treatment was considered successful. Significant cephalometric changes with appliance wear were increased lower facial height, a superiorly positioned hyoid bone relative to the mandibular plane, and a decreased posterior airway space. No cephalometric measurement could accurately predict the outcome of the treatment, and posterior airway space, commonly measured in sleep research, was not reliable. The mandibular repositioning appliance was effective in treating a small percentage of individuals with obstructive sleep apnea. A polysomnogram was needed to quantitatively measure the effectiveness of treatment. Under no circumstance should a subjective evaluation by the patient or the clinician be used to assess treatment results. Further investigation is required to evaluate the long-term effectiveness of this treatment. Periodic follow-up sleep studies are required for any patient treated with this appliance until more long term studies are completed.

Obstructive sleep apnea (OSA) is estimated to affect 2 to 4 percent of the adult population (Young T 1993, Skomro and Kryger 1999). However, an estimated 80 to 90 percent of adults with moderate to severe OSA may be clinically undiagnosed. Identification of those at risk and their subsequent diagnosis is, obviously, of great concern to clinicians. This investigation included three distinct research aims, which were the following: (1): In order to establish reliability of hemodynamic measures to be used during exercise testing, a study was conducted on the acetylene single-breath cardiac output (Qc) technique in 15 healthy subjects. This was completed in order to establish reliability of exercise Qc and total peripheral resistance (TPR), these responses could then be investigated acutely in the context of evaluating the relation of these measures to markers of disease in OSA patients. (2): The primary research aim was to describe the extent to which graded exercise testing may reveal abnormalities in hemodynamic function in obstructive sleep apnea (OSA) patients, particularly with respect to cardiac output (Qc), mean arterial pressure (MAP), and TPR that may be related to polysomnography (PSG) markers of OSA severity. Cardiorespiratory and hemodynamic responses that were evaluated included the following: peak oxygen consumption (VO2pk), end-tidal carbon dioxide production (PETCO2), end-tidal oxygen pressure (PETO2), heart rate (HR), blood pressure (systolic = SBP and diastolic = DBP), rate pressure product (RPP), TPR and its derivatives including MAP and Qc, in OSA patients. A global biochemical marker of vascular function, 24-hour urinary nitrite/ nitrate elimination was also determined for each patient. (3): The last aim was included in order to provide qualitative information concerning treatment, subjective sleep and daytime function, and physical activity levels of the OSA patients in this investigation as well as to give insights into the special challenges and potential for doing trials involving nCPAP and physical exercise training with OSA patients. Results from this study can be used to improve clinical evaluation procedures as well as to better understand underlying mechanisms relative to the link between cardiovascular disease and OSA / Ph. D.

Continuous positive airway pressure (CPAP) is the primary therapy administered for those afflicted with obstructive sleep apnea (OSA). We examined the effects of CPAP therapy on physiological variables during a ramped exercise. The five male, OSA patients had mean values and standard deviations for RDI=60.7 +/- 19.1, BMI=29.9 +/- 2.9, and age=56 +/- 16.1 yr. Subjects were examined before and after 4 wk of CPAP therapy. After 4 wk of CPAP therapy, patient responses to exercise showed a 17.6%, (p<0.05) improvement in rating of perceived exertion (RPE) at identical power outputs (60% of the individual's apparent functional capacity). Statistical significance was not attained (p>0.05) upon analysis of the following parameters at 60% of the individuals maximum workload although there was a trend showing a decrease in these variables: heart rate (6% improvement), VO2 (11.7% improvement) systolic blood pressure (4% improvement), and rate pressure product (8.6% improvement). This data shows that the decrease in RPE during 60% of the individual's maximum predicted HR reserve corresponded with an increase in sleep quality (mean increase of 40%, 3.2 units) as measured by the Pittsburgh Sleep Quality Index before and after 4 wk of CPAP therapy. It was concluded that the improvement in exercise tolerance could be attributed to the subjective feelings of improved sleep quality after 4 wk of CPAP therapy. Key Words: Obstructive sleep apnea---CPAP--- exercise---physiological responses. / Master of Science

In order to clarify the effects of a single night of CPAP titration on various cardiovascular, gas exchange, and perceptual measures, we conducted submaximal ramping exercise tests to an intensity of ~75% of the heart rate reserve in five male subjects. Means and standard deviation for their age and BMI were 57.0±14.7 years and 30.5±7.2, respectively. The baseline exercise test was administered immediately after the patients arose from bed, following an overnight PSG diagnostic evaluation. The exercise test was repeated within ~2 weeks of completion of an overnight CPAP evaluation trial. Patients reported experiencing improved sleep quality (50%) after the CPAP titration, based on comparison of morning questionnaire responses from the diagnostic PSG vs. CPAP titration. Statistical significance was not attained (p>0.05) upon analysis of the following parameters at 60% of the individuals maximum workload although there were changes in the mean values of the variables from the diagnostic PSG vs CPAP titration. The following changes were noted: heart rate increased by 6%, systolic blood pressure decreased by 6%, and the rate pressure product decreased by 5.8%. Respiratory variables changed as follows: VO2 decreased by 5.3% and VE decreased by 8.5%. The perceptual measure rate of perceived exertion (RPE) decreased by 17.5%. These preliminary findings demonstrate that self-reports of sleep quality in patients with diagnosed OSA improved after a single night of CPAP titration, even in a setting wherein the total time of CPAP sleep and reduction of apneas, hypopneas, and hypoxemic episodes are highly variable. Additionally, sleep structure revealed a marked increase in slow wave (53.2%) and REM (30.4%) sleep with CPAP titration in comparison to the diagnostic PSG. It was concluded that CPAP titration effectively improves sleep structure and patient ratings of sleep quality, but does not have significant effects on cardiorespiratory responses to submaximal endurance exercise. / Master of Science

Obstructive Sleep Apnea (OSA) is becoming an increasingly prevalent health problem, affecting 4% of men and 2% of women in North America. OSA is associated with many debilitating side-effects and co-morbidities; the most common being excessive daytime sleepiness (EDS), which effects the majority of OSA sufferers. EDS is negatively associated with physical activity (PA) and exercise. As a result, EDS may decrease the levels of PA performed by OSA patients. Previous research has revealed that the OSA population engages in less physical activity than the average healthy population. Studies show that CPAP treatment positively impacts EDS, and therefore; may impact PA. The primary purpose of this study was to objectively measure OSA patients' PA levels prior to CPAP treatment and 8 weeks after treatment initiation to assess whether CPAP treatment' impacts PA levels.Actigraph GT 1 M measures PA was assessed at baseline (prior to CPAP) and 8-weeks after. initiation of CPAP treatment. At each time frame, cardiovascular., blood data, body composition, and maximal cycle ergometer exercise measures were obtained. Also, subjective questionnaires, 1 reflective of sleep apnea and 1 regarding PA, were completed by the subjects.Six male subjects with severe OSA (AHI = 41.2 ± 28.4 events/hr) started and completed the study. No significant changes occurred in PA, represented as steps/day nor mean activity counts/day, throughout the 8 weeks of CPAP treatment. Significant changes were found in diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, and Epworth sleepiness scale scores. No significant changes occurred in any other body composition, heart rate, systolic blood pressure, triglycerides, and blood glucose. Exercise parameters, total test time, peak Watts, and V02max trended toward an increase and maximal heart rate and blood pressure toward a decrease, but none changed significantly.In conclusion, these results demonstrated that 8 weeks of CPAP treatment was not successful in increasing PA levels of severe OSA patients. The OSA subjects were categorized as sedentary according to their steps/day. Compliance to CPAP could have been an issue with subjects' average nightly usage ranging from 1.85 – 6.6hours/night. Consequently, more research regarding OSA patients PA habits and CPAP treatments effects on PA should be investigated. / School of Physical Education, Sport, and Exercise Science

Childhood OSA is increasingly recognized to be associated with a variety of complications including neurocognitive and cardiovascular diseases. The intermediate link between OSA and end organ damage has been suggested to be inflammation, and both local airway and systemic inflammation have been described in adults with OSA. A non-invasive technique of sputum induction was utilised to show that children with OSA also have airway inflammation, as characterized by a significant increase in neutrophils, and the severity of OSA also correlated significantly with the degree of neutrophilic inflammation (Chapter 7). This finding may lead to research on the use of anti-inflammatory therapeutic agents or antibiotics for the treatment of childhood OSA. Another marker of inflammation, C-reactive protein (CRP) was measured in a cohort of children with OSA before and after treatment (Chapter 8). Children with OSA had higher CRP levels compared to their non-OSA counterparts, and the raised CRP decreased significantly following treatment suggesting that the inflammatory response is potentially reversible. The cardiovascular risk factors of insulin levels and blood pressure (BP) were evaluated and children with OSA had higher serum insulin and greater systolic and diastolic BP compared to healthy controls (Chapters 9 and 10). These findings suggest that children with OSA may be at risk of developing metabolic syndrome and its devastating consequence. (Abstract shortened by UMI.) / The original research studies undertaken were based on nocturnal sleep examinations to explore childhood OSA in two main aspects, namely its assessment, and a better understanding of its complications in children. The gold standard for diagnosing OSA is overnight polysomnography (PSG), which is an expensive investigation that is not routinely available at all public hospitals in Hong Kong. Alternative valid assessment tools for OSA that are more cost-effective are needed. The feasibility of using radiographic techniques to assess severity of OSA was explored, and the size of the upper airway, as reflected by the tonsillar pharyngeal (TP) ratio obtained from lateral neck radiograph, correlated well with the severity of OSA (Chapter 4). A defined TP cutoff could accurately predict moderate-to-severe OSA with high sensitivity and specificity. This method could be used in clinical practice to prioritize patients with suspected OSA for further evaluation. A locally applicable questionnaire scale was examined for its validity and accuracy in diagnosing children with OSA (Chapter 5). The presence of three symptoms (snoring, mouth breathing and nocturnal sweating) was found to have high predictive value in correctly identifying children with the condition. The question of whether a single night PSG study is adequate in diagnosing OSA was examined together with the assessment for the presence of night-to-night variability in PSG and respiratory parameters in childhood sleep (Chapter 6). Forty-four obese children and 43 age and sex-matched healthy controls underwent two consecutive nights PSG examination. Although a first night effect was clearly documented, a single night PSG study would have correctly identified over 80% of children with OSA. This finding has significant resource implications. / Albert Martin Li. / Adviser: Tony Nelson. / Source: Dissertation Abstracts International, Volume: 70-06, Section: B, page: 3420. / Thesis (M.D.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves xxxv-lxxx). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract in English only. / School code: 1307.

Thesis (Ph. D.)--University of North Texas, Aug., 2009. / Title from title page display. Includes bibliographical references.

Thesis (Ph. D.)--University of Sydney, 2008. / Title from title screen (viewed Mar. 12, 2008). Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Discipline of Medicine, Faculty of Medicine. Degree awarded 2008; thesis submitted 2007. Includes bibliography. Also issued in print.

INTRODUCTION: Research has consistently shown that sleep apnea is strongly associated with atrial fibrillation, with several lines of evidence demonstrating that this relationship is bidirectional and that each condition predisposes to and/or exacerbates the other. Many studies have suggested potential pathophysiologic mechanisms underlying this relationship, and that sleep apnea and atrial fibrillation share many of the same cardiovascular risk factors further implies that multiple pathways are likely involved in the mechanistic link between the two. Although the sleep apnea-atrial fibrillation relationship is quite established, numerous aspects of this association still require further study, such as the role of gender and the potential impact of positive airway pressure therapy. A deeper understanding of how these individual factors may be involved in the interrelationship between sleep apnea and atrial fibrillation has important clinical implications, such as for risk stratification and screening of patients. Thus, this study aims to further understand the different aspects and modulating factors of the sleep apnea-atrial fibrillation link, focusing on central sleep apnea as less is known about the central sleep apnea-atrial fibrillation relationship. METHODS: A total of 153 patients, originally seen at the cardiac electrophysiology clinic at Beth Israel Deaconess Medical Center and subsequently offered home sleep apnea testing, were included in this study. Several databases – home sleep apnea testing results, polysomnography reports, electrocardiogram reports and patient management systems – were used to obtain a variety of data on sleep pathology, high loop gain status, left ventricular ejection fraction and positive airway pressure therapy efficacy and compliance. Patients were considered to have central sleep apnea if home testing results demonstrated a central apnea-hypopnea index of 5 or greater and/or if the patient was documented as having high loop gain on polysomnography. Data were analyzed using the Statistical Package for Social Sciences software in order to examine how factors such as gender and therapy use may affect the sleep apnea-atrial fibrillation relationship, in a patient population with sleep pathology of at least moderate severity. RESULTS: Statistical analysis revealed significant sleep disturbances in the central sleep apnea patients compared to the non-central sleep apnea patients. Gender was found to be significantly associated with central sleep apnea, but not obstructive sleep apnea. When postmenopausal (age≥51) women were analyzed, very few patients met the study criteria for central sleep apnea, yet the majority were documented as having atrial fibrillation. As expected, positive airway pressure therapy was found to be beneficial for all users, but the common pattern of declining compliance to therapy was seen as adherence decreased over the course of three months. Of the select central sleep apnea patients who had sufficient data available, comparison of positive airway pressure therapy and cardiac data revealed possible benefits to cardiac health with compliant use of positive airway pressure therapy. CONCLUSION: Through examining different aspects of the sleep apnea-atrial fibrillation relationship, this study found promising evidence showing that gender and positive airway pressure therapy play important roles. Further studies, with larger sample sizes, need to be conducted in order to fully understand the specific impact of factors such as gender, gender and age and positive airway pressure therapy on the risks and outcomes in patients with sleep apnea and/or atrial fibrillation, and how these factors may change depending on the type of sleep apnea. Finally, these results further highlight the growing need for an effective collaborative care model between cardiologists and sleep medicine clinicians, as the management of patients with sleep apnea and atrial fibrillation requires an interdisciplinary approach in order to deliver the most optimal patient care.