Gaylord Hospital

This review summarizes the recent literature on the epidemiology of adult obstructive sleep apnea (OSA) from various population-based studies. Despite methodologic differences, comparisons have yielded similar prevalence rates of the OSA syndrome in various geographic regions and amongst a number of ethnic groups. Risk factors for OSA including obesity, aging, gender, menopause, and ethnicity are analyzed. We also provide discussion on adverse medical conditions associated with OSA including hypertension, stroke, congestive heart failure, coronary artery disease, cardiovascular mortality, insulin resistance, and neurocognitive dysfunction. Finally with the progression of the global obesity epidemic, we focus on the economic health care burden of OSA and the importance of recognizing the largely undiagnosed OSA population with emphasis on strategies to improve access to diagnostic resources.

Sleep-related disorders are most prevalent in the older adult population. A high prevalence of medical and psychosocial comorbidities and the frequent use of multiple medications, rather than aging per se, are major reasons for this. A major concern, often underappreciated and underaddressed by clinicians, is the strong bidirectional relationship between sleep disorders and serious medical problems in older adults. Hypertension, depression, cardiovascular disease, and cerebrovascular disease are examples of diseases that are more likely to develop in individuals with sleep disorders. Conversely, individuals with any of these diseases are at a higher risk of developing sleep disorders. The goals of this article are to help guide clinicians in their general understanding of sleep problems in older persons, examine specific sleep disorders that occur in older persons, and suggest evidence- and expert-based recommendations for the assessment and treatment of sleep disorders in older persons. No such recommendations are available to help clinicians in their daily patient care practices. The four sections in the beginning of the article are titled, Background and Significance, General Review of Sleep, Recommendations Development, and General Approach to Detecting Sleep Disorders in an Ambulatory Setting. These are followed by overviews of specific sleep disorders: Insomnia, Sleep Apnea, Restless Legs Syndrome, Circadian Rhythm Sleep Disorders, Parasomnias, Hypersomnias, and Sleep Disorders in Long-Term Care Settings. Evidence- and expert- based recommendations, developed by a group of sleep and clinical experts, are presented after each sleep disorder.

Obesity hypoventilation syndrome (OHS) is characterized by obesity, daytime hypercapnia, and sleep-disordered breathing in the absence of significant lung or respiratory muscle disease. Compared with eucapnic morbidly obese patients and eucapnic patients with sleep-disordered breathing, patients with OHS have increased health care expenses and are at higher risk of developing serious cardiovascular disease leading to early mortality. Despite the significant morbidity and mortality associated with this syndrome, diagnosis and institution of effective treatment occur late in the course of the syndrome. Given that the prevalence of extreme obesity has increased considerably, it is likely that clinicians will encounter patients with OHS in their clinical practice. Therefore maintaining a high index of suspicion can lead to early recognition and treatment reducing the high burden of morbidity and mortality and related health care expenditure associated with undiagnosed and untreated OHS. In this review we define the clinical characteristics of the syndrome and review the pathophysiology, morbidity, and mortality associated with it. Last, we discuss currently available treatment modalities.

Abstract The reaction of molten HDPE with MAH at 215 and 250°C using di‐ t ‐amyl peroxide and t ‐butyl cumyl peroxide as catalysts yielded HDPE‐ g ‐MAH accompanied by crosslinked polymer. The formation of the latter, increased by the presence of MAH and insoluble in refluxing xylene, was prevented by the presence of electron donor additives, i.e., dimethylacetamide (DMAC), dimethyl sulfoxide (DMSO), and tri(nonylphenyl) phosphite (TNPP). A charge containing 0.0625–0.125% catalyst, 5% MAH and 0.5% additive, all based on HDPE and added to the molten HDPE in four portions, resulted in gel‐free polymer with an MAH content of 0.7–1.7%. HDPE‐ g ‐MAH with the least color was obtained with TNPP, followed by DMAC and DMSO. Notwithstanding the absence of gel in the HDPE‐ g ‐MAH prepared from HDPE with a melt flow of 17 g/10 min, the carboxylated HDPE had a melt flow of 0.0–1 g/10 min, indicative of an increase in the molecular weight of the product. This is attributed to a coupling reaction between MAH radicals appended to the HDPE backbone (HDPE–MAH·) and HDPE radicals formed as a result of hydrogen abstraction from HDPE by radicals from the catalyst and/or excited MAH.

It 4T otion, says Aristotle, the actualization of what potentially is, as such 'ro5 8uvu4a Ovroq E'vreXiXec, a 'rTOLi:irov.' If we are to believe Aristotle, this definition speaks to a problem which was perplexing and refractory to his predecessors, and it is itself complex and subtle, employing concepts which are, as he says, difficult to grasp.2 Given the intricacy of many of Aristotle's technical concepts, this claim might seem outrageous; for on the usual understanding, his definition of motion is straightforward and pellucid. I shall try to show that that understanding is wrong, and that Aristotle's definition is more subtle than it is usually taken to be.

A pantomime recognition test was developed to study the extent of impairment of pantomime recognition and the relationship between pantomime recognition and verbal deficits in asphasics. This test requires no verbal instructions to the subject and only a simple pointing response. A description and rationale for the test are presented. This new test and three tests of verbal abilities (Verbal Recognition Test, Naming Test, and the Porch Index of Communicative Ability) were administered to four groups of subjects: aphasics, right-hemisphere damaged, subcortically damaged, and normals. Results indicate (1) greater impairment of pantomime recognition ability in aphasics than the other groups of subjects and (2) high correlations between impairment of pantomime recognition and impairment of verbal abilities in aphasics. Our findings are consistent with previous clinical reports and experimental data showing that aphasics commonly demonstrate impairment in gesture and pantomime. We conclude that aphasia is best understood as a general impairment of symbolic communication that includes nonverbal as well as verbal deficits.

Abstract The crosslinking of LDPE resulting from reaction with dicumyl peroxide at 180°C is increased in the presence of maleic anhydride (MAH). The presence of electron‐donating nitrogen‐containing compounds (amides, lactams, disubstituted aromatic amines, and amine oxides), phosphorous‐containing compounds (phosphites, phosphates, phosphonates, phosphoramides, and phosphine oxides) and sulfur‐containing compounds (sulfoxides, aryl disulfides, and thiazyl disulfides) which inhibit the homopolymerization of MAH but not that of methyl methacrylate, prevents crosslinking and yields soluble PE containing MAH units. Crosslinking, due to coupling of PE ˙ macroradicals formed by hydrogen abstraction from PE by excited MAH, is prevented by electron donation from the additive to the MAH + cation which is present in the MAH+−MAH excimer as well as in the excimer which is appended to the PE.

Preliminary findings from an ongoing investigation of the potential relationship between narrative discourse performance and executive functions in adults with traumatic brain injuries (TBI) are reported. Narrative stories were elicited from 32 adults with TBI. Stories were analysed at three levels: sentence production, intersentential cohesive adequacy, and story episode structure. These measures were then correlated with scores from the Wisconsin Card Sorting Test (WCST), the primary measure of executive function. A significant correlation was noted between a factor score from the WCST and the measure of story structure, but not sentence production or cohesive adequacy. These results suggest that executive functions may be a promising avenue to pursue in the search for underlying causal factors of narrative discourse dysfunction and, therefore to better delineate the nature of communicative deficits secondary to TBI.

Stories were elicited under two conditions--story retelling and story generation--from a group of 23 normal young adults and 4 closed head-injured (CHI) adults who had reached a high level of language recovery. Sentence production, intersentential cohesion, and story grammar were analyzed. The results demonstrated that the two elicitation tasks differentially influenced the performance of both normal and CHI subjects at all levels of analysis, and the two groups differed in the cohesive and story grammar measures only in the story generation task. It is concluded that comparing performance across tasks of story retelling and story generation is a useful procedure for characterizing the discourse problems of CHI subjects with recovery of high-level language skills.

: This document provides provisional guidance with links to resources and established guidelines for telepsychology. Specific recommendations extend these practices to TeleNP. These recommendations may be revised as circumstances evolve, with updates posted continuously at OPC.online.

OBJECTIVE: The Inter Organizational Practice Committee convened a workgroup to provide rapid guidance about teleneuropsychology (TeleNP) in response to the COVID-19 pandemic. METHOD: A collaborative panel of experts from major professional organizations developed provisional guidance for neuropsychological practice during the pandemic. The stakeholders included the American Academy of Clinical Neuropsychology/American Board of Clinical Neuropsychology, the National Academy of Neuropsychology, Division 40 of the American Psychological Association, the American Board of Professional Neuropsychology, and the American Psychological Association Services, Inc. The group reviewed literature; collated federal, regional, and state regulations and information from insurers; and surveyed practitioners to identify best practices. RESULTS: Literature indicates that TeleNP may offer reliable and valid assessments, but clinicians need to consider limitations, develop new informed consent procedures, report modifications of standard procedures, and state limitations to diagnostic conclusions and recommendations. Specific limitations affect TeleNP assessments of older adults, younger children, individuals with limited access to technology, and individuals with other individual, cultural, and/or linguistic differences. TeleNP may be contraindicated or infeasible given specific patient characteristics, circumstances, and referral questions. Considerations for billing TeleNP services are offered with reservations that clinicians must verify procedures independently. Guidance about technical issues and "tips" for TeleNP procedures are provided. CONCLUSION: This document provides provisional guidance with links to resources and established guidelines for telepsychology. Specific recommendations extend these practices to TeleNP. These recommendations may be revised as circumstances evolve, with updates posted continuously at IOPC.online.

American Journal of Physical Medicine & Rehabilitation: August 2010 - Volume 89 - Issue 8 - p 687 doi: 10.1097/PHM.0b013e3181e722c8

Abstract The reaction of EPR with dicumyl peroxide at 180°C or t ‐butyl perbenzoate at 140°C resulted in the formation of a fraction insoluble in cyclohexane at 22°C. The presence of maleic anhydride (MAH) in the EPR‐peroxide reaction mixture increased the amount of insoluble polymer, whose concentration decreased as the peroxide concentration increased. The [η] of the cyclohexane‐soluble polymer decreased and the MAH content increased as the peroxide concentration increased at constant MAH concentration. The [η] and the MAH content of the soluble polymer increased as the MAH concentration increased at constant peroxide concentration. The EPR‐peroxide and EPR‐MAH‐peroxide reaction products were soluble in refluxing xylene and could be fractionated by precipitation with acetone. The presence of stearamide in the EPR‐MAH‐peroxide reaction mixture decreased the amount of cyclohexane‐insoluble polymer, indicative of decreased cross‐linking, but the [η] of the soluble EPR‐g‐MAH increased, indicative of decreased degradation, analogous to the effect of stearamide in the MAH‐peroxide reactions with LDPE and PP, respectively.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a common disorder that remains underdiagnosed in adult females. The Berlin Questionnaire is a validated tool for identifying people at risk for OSAS. The aim of this report was to evaluate the prevalence of common symptoms of OSAS in women and to estimate the risk for OSAS among females in the United States. METHODS: This is an analysis of data from the 2007 Sleep in America Poll of the National Sleep Foundation. The NSF Poll is an annual telephone survey of a representative sample of U.S. adults. The 2007 NSF Poll included 1254 women in the United States, with an oversample of pregnant and postpartum women. We used the Berlin Questionnaire to estimate the risk for OSAS among the U.S. female population. This instrument includes questions about self-reported snoring, witnessed apneas, daytime sleepiness, hypertension, and obesity. Also included were questions about sleep habits, sleep problems, menstrual cycle status, and other medical disorders. RESULTS: Twenty-five percent of the female population was found to be at high risk for OSAS. Among women at high risk, such common symptoms of OSAS as habitual snoring (61%), observed apneas (7%), and daytime sleepiness (24%) were highly prevalent. Sleep onset insomnia (32%) or maintenance insomnia symptoms (19%) and restless legs syndrome (RLS) symptoms (33%) or body movements (60%) also were frequently reported. The risk increased with age (p < 0.05), obesity (p < 0.001), and menopause (p < 0.001). The presence of chronic medical disorders was more frequently reported among women at high risk. CONCLUSIONS: One in four women in America is at high risk of having OSAS. Awareness by the primary care medical community of this disorder in females should thus be increased.

An efficient heuristic is presented for the problem of finding a minimum-size k-connected spanning subgraph of an (undirected or directed) simple graph G=(V,E). There are four versions of the problem, and the approximation guarantees are as follows:minimum-size k-node connected spanning subgraph of an undirected graph 1 + [1/k], minimum-size k-node connected spanning subgraph of a directed graph 1 + [1/k], minimum-size k-edge connected spanning subgraph of an undirected graph 1+[2/(k+1)], minimum-size k-edge connected spanning subgraph of a directed graph 1 + [4/\sqrt{k}]. The heuristic is based on a subroutine for the degree-constrained subgraph (b-matching) problem. It is simple and deterministic and runs in time O(k|E|2). The following result on simple undirected graphs is used in the analysis: The number of edges required for augmenting a graph of minimum degree k to be k-edge connected is at most k,|V|/(k+1). For undirected graphs and k=2, a (deterministic) parallel NC version of the heuristic finds a 2-node connected (or 2-edge connected) spanning subgraph whose size is within a factor of ($1.5+\epsilon$) of minimum, where $\epsilon > 0$ is a constant.

Abstract The concept that maleic anhydride cannot be homopolymerized is so widely accepted that it is cited in most textbooks on polymer science as an illustration of the steric hindrance imposed by 1,2-disubstitution of the double bond. However, in recent years it has been demonstrated that maleic anhydride readily undergoes polymerization under gamma and UV radiation as well as in the presence of free radical catalysts and various organic bases. In some cases the polymer contains cyclopentanone groups, resulting from decarboxylation, or unsaturated ketone groups, resulting from ring opening, in addition to the anhydride groups. Further interesting developments include the proposed participation of excited maleic anhydride in the polymerization process and of poly(maleic anhydride) in the grafting of maleic anhydride on various polymeric substrates.

Abstract The reaction of maleic anhydride (MAH) with molten 2 MI poly(ethylene‐ co ‐butene‐1) (LLDPE) at 160°C in the presence of peroxyesters ( t 1/2 &lt; 10 s) as catalysts resulted in the formation of a mixture of cross‐linked and trichlorobenzene‐soluble LLDPE‐ g ‐MAH. The soluble fraction constituted more than 50% of the mixture and had an MI of 0.0 and an MAH content ranging from 0.3 to 1.8 wt %. The presence of tri(nonylphenyl) phosphite (TNPP) in the LLDPE–MAH– t ‐butyl peroctoate ( t BPO) reaction at 160°C increased the MI of the soluble product to 0.7–2. The amount of soluble polymer increased at higher TNPP concentrations while its MAH content ranged from 0.05 to 0.54 wt %, with most contents in the 0.2–0.3 wt % range. The color development that usually occurs in polyolefin–MAH reactions was reduced by the presence of TNPP. However, the reaction of TNPP with the peroxide and from the thermal decomposition thereof reduced the availability of the excited species necessary for the appendage of MAH units onto the polyofin.

STUDY OBJECTIVES: Compare automatic event detection (AED) of respiratory events using a positive airway pressure (PAP) device with manual scoring of polysomnography (PSG) during PAP treatment of obstructive sleep apnea (OSA). DESIGN: Prospective PSGs of patients using a PAP device. SETTING: Six academic and private sleep disorders centers. PATIENTS: A total of 148 PSGs from 115 participants with OSA (apnea-hypopnea index [AHI] ≥ 15 events/hr) were analyzed. INTERVENTIONS: A signal generated by the PAP device identifying the AED of respiratory events based on airflow was recorded during PSG. MEASUREMENTS AND RESULTS: The PSGs were manually scored without visualization of the AED signal and scoring of a hypopnea required a ≥ 4% oxygen desaturation. The apnea index (AI), hypopnea index (HI), and AHI by manual score and PAP AED were compared. A customized computer program compared individual events by manual scoring and AED to determine the true positive, false positive, false negative, or true negative events and found a sensitivity of 0.58 and a specificity of 0.98. The AHI, AI, and HI by the two methods were highly correlated. Bland-Altman analysis showed better agreement for AI than HI. Using a manually scored AHI of ≥ 10 events/hr to denote inadequate treatment, an AED AHI ≥ 10 events/hr had a sensitivity of 0.58 and a specificity of 0.94. CONCLUSIONS: An AHI < 10 events/hr by PAP AED is usually associated with good treatment efficacy. Differences between manually scored and AED events were primarily due to different criteria for hypopnea detection.

Problem: Planning affects individual property rights, which have a special cultural significance in the United States, and it has often protected the interests of affluent and influential groups in the past. Thus, it is not surprising that many Americans perceive planning negatively. Purpose: We provide a perspective on the role of property rights in the history of American planning, arguing for confronting these issues as part of finding a better way forward. Methods: We reviewed primary and secondary historical sources and analyzed key legal cases and legislation. Results and conclusions: Planners should honestly acknowledge the role planning has played in protecting elite property rights and should consider taking three steps toward a more positive future. First, they should tell their own story, rather than leaving this to opponents of planning. Second, they should highlight both the rights and the duties of private property owners and of the larger community. Third, planners should not shy away from stating the impacts their proposals would have on property rights. Takeaway for practice: In order to accurately claim that planning manages property in the public interest, planners must understand and explain how planning proposals benefit and harm property owners. Research support: None.

We examined distribution and abundance of small, medium, and large American eels Anguilla rostrata in Virginia streams by comparing observed with expected null-model patterns. At large spatial scales (across drainages or physiographies), densities of small and medium American eels decreased with distance from the ocean, and densities were not strongly or consistently related to local habitat features (e.g., habitat type, abundance of cover, water temperature, density of predators). A mathematical function, analogous to diffusion of particles from a concentrated source, accounted for up to 85% of the variance in densities of small- or medium-sized eels at statewide, physiographic, or river-drainage scales. At smaller spatial scales (e.g., within a drainage in a particular physiography), we found few relations between American eel density and habitat features. Exceptions to this pattern occurred at Coastal Plain sites of the James River drainage, where American eel densities were exceptionally high. Such small-scale, nonrandom patterns may reflect local density-dependent processes that only rarely affect American eel distribution and abundance more than do ubiquitous, large-scale random processes. Parsimonious, large-scale models (e.g., diffusion models) may predict the distribution and abundance of American eels (and other widespread or generalist stream fishes) more reliably than do more typical, small-scale habitat models (e.g., habitat suitability models).