BackgroundObstructive sleep apnea (OSA) is associated with coronary artery disease (CAD). Intermittent hypoxia associated with OSA increases sympathetic activity and may cause systemic inflammation, which may contribute to CAD in patients with OSA. Treatment with continuous positive airway pressure (CPAP) has been shown to change levels of inflammatory markers. We analyzed data from published studies by a systematic meta-analysis.ObjectiveTo asses if treatment for sleep apnea by CPAP will affect levels of inflammatory markers.Data resourcesPubMed, Embase and Cochrane library.MethodsStudy eligibility criteria full text English studies of adult, human subjects, addressing values of at least one of the inflammatory markers before and after CPAP treatment. We used the definition of OSA as an apnea-hypopnea index (AHI) of ≥ 5/h, reported values in mean and standard deviation or median with range.ParticipantsAdult, human.InterventionsCPAP treatment for OSA.Study appraisal and synthesis methodA total of 3835 studies were reviewed for inclusion, while 23 studies pooled for analysis. A total of 14 studies with 771 patients were pooled for C-reactive protein (CRP); 9 studies with 209 patients were pooled for tumor necrosis factor-alpha (TNF-α); and 8 studies with 165 patients were pooled for interleukin-6 (IL-6).Endpoint definitionsThe following inflammatory markers were chosen: CRP, TNF-α, and IL-6.ResultsC-reactive protein: Study level means ranged from 0.18 to 0.85 mg/dl before CPAP treatment and 0.10 to 0.72 mg/dl after CPAP treatment. Mean differences, at a study level, ranged from −0.05 to 0.50. The pooled mean difference was 0.14 [95% confidence interval 0.08 to 0.20, p < 0.00001]. There was heterogeneity in this endpoint (df = 13, p < 0.00001, I2 = 95%).Tumor necrosis factor-α: Study level means ranged from 1.40 to 50.24 pg/ml before CPAP treatment and 1.80 to 28.63 pg/ml after CPAP treatment. Mean differences, at a study level, ranged from −1.23 to 21.61. The pooled mean difference was 1.14 [95% confidence interval 0.12 to 2.15, p = 0.03]. There was heterogeneity in this endpoint (df = 8, p < 0.00001, I2 = 89%).Interleukin-6: Study level means ranged from 1.2 to 131.66 pg/ml before CPAP treatment and 0.45 to 66.04 pg/ml after CPAP treatment. Mean differences, at a study level, ranged from −0.40 to 65.62. The pooled mean difference was 1.01 [95% confidence interval −0.00 to 2.03, p = 0.05]. There was heterogeneity in this endpoint (df = 7, p < 0.00001, I2 = 95%).LimitationsOnly published data. Studies pooled were mainly small, non-randomized trials.ConclusionSleep apnea treatment with CPAP improves levels of inflammatory markers.
Background: Liposomal bupivacaine (LB) theoretically is longer-acting compared with conventional bupivacaine. The purpose of this study was to compare conventional bupivacaine combined with dexamethasone (control group), LB combined with conventional bupivacaine (LB group), and LB combined with dexamethasone and conventional bupivacaine (LBD group) in a perineural interscalene nerve block during ambulatory arthroscopic rotator cuff repair to determine if LB decreased postoperative narcotic consumption and pain. The effect of supplemental dexamethasone on prolonging the analgesic effect of LB was also assessed. Methods: This was a prospective, double-blinded, randomized controlled trial of 76 consecutive patients who underwent outpatient arthroscopic rotator cuff repair. Patients were randomized into the 3 interscalene-block treatment groups: control group (n = 26), LB group (n = 24), and LBD group (n = 26). Outcome measures included pain measured with a visual analog scale (VAS; 0 to 10) and narcotic consumption measured in oral morphine milligram equivalents (MME). Both were measured daily on postoperative day 0 through postoperative day 4. Results: Generalized estimating equation modeling revealed that narcotic consumption across all time points (postoperative days 0 to 4) was significantly lower in the LB group compared with the control group (mean difference, −8.5 MME; 95% confidence interval, −15.4 to −1.6; p = 0.015). Narcotic consumption was significantly higher in the control group on postoperative days 2 and 3 compared with the LB group (p = 0.004 and p = 0.02, respectively) and the LBD group (p = 0.01 and p = 0.003, respectively). There was no difference in narcotic consumption between the LBD and LB groups on any postoperative day. VAS pain scores in all groups were similar across all postoperative days. Conclusions: Among patients undergoing outpatient arthroscopic rotator cuff repair, the addition of LB to conventional bupivacaine in interscalene nerve blocks appeared to be effective in controlling postoperative pain. Because LB with and without dexamethasone decreased postoperative narcotic use, LB should be considered for use in preoperative interscalene nerve blocks to reduce the reliance on narcotics for pain management. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
To evaluate the short-term outcomes of 10 patients with irreparable massive rotator cuff tears treated with arthroscopic superior capsular reconstruction (SCR) using dermal allograft. Methods: Between 2016 and 2018, patients with symptomatic irreparable rotator cuff tears were prospectively enrolled for treatment with arthroscopic SCR. Investigational review board approval was achieved. All patients were treated by a single fellowship-trained shoulder surgeon. Minimum follow-up was 1 year. Range of motion and functional outcome according to visual analog scale pain, American Shoulder and Elbow Surgeons, and Simple Shoulder Test scores were assessed preoperatively and at routine follow-up intervals. Magnetic resonance imaging (MRI) and ultrasound were obtained at a minimum of 1 year to assess graft integrity and to correlate clinical outcomes. Results: Ten patients with a mean age of 58.6 years had a minimum follow-up of 1 year. In all patients, preoperatively to postoperatively, mean forward flexion improved from 141 to 173 (P ¼ .018), mean visual analog scale pain score decreased from 6.5 to 1 (P ¼ .004), and mean American Shoulder and Elbow Surgeons score improved from 43 to 87 (P ¼ .005). At 1 year, ultrasound evaluation identified graft failure in 1 patient (10%), whereas MRI diagnosed graft failure in 7 patients (70%). Of the 7 failures diagnosed by MRI, 4 failed at the level of the glenoid, 2 failed mid-graft, and 1 failed at the humerus. Conclusions: Although clinical outcomes are statistically improved following arthroscopic SCR using a dermal allograft, the early high failure rates of the graft raise concerns about the long-term outcomes of the procedure. Furthermore, the use of ultrasound alone to validate an intact graft should be used with caution, as failures can occur at the glenoid and can be missed without MRI correlation.
Background. Obstructive sleep apnea (OSA) is associated with coronary artery disease. Intermittent hypoxia associated with OSA increases sympathetic activity and may cause systemic inflammation, which may contribute to atherosclerosis leading to an increase in the size of carotid intima media thickness (CIMT). Methods. PubMed and Cochrane library were reviewed by utilizing different combinations of key words: sleep apnea, carotid disease, intima media thickness, and carotid atherosclerosis. Inclusion criteria were English articles; studies with adult population with OSA and without OSA; CIMT recorded by ultrasound in mean and standard deviation or median with 95% confidence interval; and OSA defined as apnea hypopnea index of ≥5/h. A total of 95 studies were reviewed for inclusion, with 16 studies being pooled for analysis. Results. Ninety-five studies were reviewed, while 16 studies were pooled for analysis; since some studies have more than one data set, there were 25 data sets with 1415 patients being pooled for meta-analysis. All studies used ultrasound to measure CIMT. CIMT standardized difference in means ranged from −0.883 to 8.01. The pooled standardized difference in means was 1.40 (lower limit 0.996 to upper limit 1.803, (P < 0.0001). Conclusion. Patients with OSA appear to have increased CIMT suggestive of an atherosclerotic process.
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