Research on subthreshold compliance with positive airway pressure (PAP) therapy in sleep apnea patients may inform clinical sleep medicine practice. We retrospectively assessed compliant and ...subthreshold compliant sleep apnea subjects to test whether regular but fewer hours of PAP use would demonstrate clinically meaningful improvements and correlate with outcomes.
A chart review was conducted of 113 consecutive sleep apnea subjects, naive to treatment, who completed a titration study and filled a PAP therapy prescription. Objective data categorized subjects into 3 groups: compliant, subthreshold compliant, and minimal use. Outcome measures assessed changes in insomnia, sleepiness, and nocturia on average 7 months from PAP initiation. Correlation coefficients analyzed dose-response relationships between hours of use and changes in outcomes.
Among 113 PAP attempters, 104 (92%) were current users. Among 93 users with objective data, regular (consistent) PAP users included 59 compliant and 21 subthreshold compliant, and 13 subjects were minimal users. Compliant users averaging 6.6 ± 1.3 h/night and 42.0 ± 12.1 h/week showed the largest outcome improvements (all P < .05) with moderate to large effects for insomnia (d = 0.94), sleepiness (d = 0.58), and nocturia (d = 0.56). Subthreshold users averaging 4.1 ± 0.7 h/night but only 18.0 ± 5.6 h/week showed a large effect for insomnia (d = 0.76, P = .03) and nonsignificant, small effects for sleepiness (d = 0.38) and nocturia (d = 0.22). Correlation coefficients showed a trend for decrease in insomnia (P = .08; r = .20) and a significant decrease in nocturia (P = .034; r = 0.25), each in association with hours of PAP use.
In a clinical sample, 86% of sleep apnea subjects regularly used PAP, but adherence was 63%. Regular users showed clinical treatment effects and potential dose-response relationships, suggesting that the term use offers advantages over the term adherence. Currently, subthreshold compliance may not merit insurance coverage in many countries, an issue affecting many sleep apnea patients.
Re-titrations, an atypical approach to reverse PAP failure, was investigated retrospectively.
Application of our re-titration of PAP (REPAP) protocol in subjects with previous PAP failure assessed ...original technology (masks, modes, and pressures) in 273 subjects, of which 70% reported co-occurring psychiatric conditions. The REPAP protocol emphasized changes in pressure modes and settings to address expiratory pressure intolerance and residual breathing events; mask changes were facilitated. Objective sleep and breathing metrics and subjective post-titration ratings were analyzed in subsequent PAP users and non-users.
Following REPAP protocol (average follow-up = 2 y), 196 of 273 subjects with previous PAP failure were PAP users, and 77 were non-users. Previous PAP failure was attributed to technology factors, including pressure intolerance, mask discomfort, adaptation difficulties, and no benefits. At second opinion re-titration, mask changes resolved discomfort, mouth breathing, or leak (91.2% of sample); pressure mode changes resolved expiratory pressure intolerance (83.5%); and pressure setting changes decreased residual breathing events and improved air flow (96.7%), all of which were associated with renewed PAP use. PAP users showed objective sleep improvements on re-titrations and reported better sleep quality than non-users. Multiple logistic regressions showed 2 subjective, re-initiation predictors: (1) post-re-titration ratings of better sleep quality and (2) less anticipated difficulty in using PAP after initial or multiple re-titrations. User rates were significantly higher for subjects completing multiple (
= 158) versus one (
= 115) re-titration (80% vs 61%,
= .001). In multiple re-titration subjects, PAP users showed significance or a trend for lower apnea-hypopnea index (
= .02, g = 0.48) and respiratory disturbance index (
= .07, g = 0.36) compared with non-users. Available user downloads averaged >5 h/night.
Technology-related problems due to mask discomfort/leak, pressure intolerance, and residual breathing events were associated with PAP failure in subjects seeking second opinions. Technological solutions (changes in masks, modes, and pressures) were addressed during REPAP protocol, after which 72% of subjects re-initiated PAP use. These technological interventions were associated with improved objective and subjective sleep variables and reversal of PAP failure.
Genetic and environmental factors that increase the risk of late-onset Alzheimer disease are now well recognized but the cause of variable progression rates and phenotypes of sporadic Alzheimer's ...disease is largely unknown. We aimed to investigate the relationship between diverse structural assemblies of amyloid-β and rates of clinical decline in Alzheimer's disease. Using novel biophysical methods, we analysed levels, particle size, and conformational characteristics of amyloid-β in the posterior cingulate cortex, hippocampus and cerebellum of 48 cases of Alzheimer's disease with distinctly different disease durations, and correlated the data with APOE gene polymorphism. In both hippocampus and posterior cingulate cortex we identified an extensive array of distinct amyloid-β42 particles that differ in size, display of N-terminal and C-terminal domains, and conformational stability. In contrast, amyloid-β40 present at low levels did not form a major particle with discernible size, and both N-terminal and C- terminal domains were largely exposed. Rapidly progressive Alzheimer's disease that is associated with a low frequency of APOE e4 allele demonstrates considerably expanded conformational heterogeneity of amyloid-β42, with higher levels of distinctly structured amyloid-β42 particles composed of 30-100 monomers, and fewer particles composed of < 30 monomers. The link between rapid clinical decline and levels of amyloid-β42 with distinct structural characteristics suggests that different conformers may play an important role in the pathogenesis of distinct Alzheimer's disease phenotypes. These findings indicate that Alzheimer's disease exhibits a wide spectrum of amyloid-β42 structural states and imply the existence of prion-like conformational strains.
Purpose
Nonallergic rhinitis (NAR) is a common condition involving symptomatic nasal congestion, stuffiness, or rhinorrhea, which overlap with symptoms of allergic rhinitis. Scant research has ...examined NAR and sleep. The aim of this study was to assess the frequency of potential NAR symptoms in a large sample of sleep center patients.
Methods
A retrospective chart review was conducted on 2658 adult patients at our sleep center from 2008 to 2012; 1703 reported clinically relevant nasal congestion. For this subset, potential NAR status (NAR+ vs NAR−) was determined using a brief survey. NAR groups were further divided into three sub-groups based on presenting chief complaints: insomnia (INS), nonrestorative sleep (NRS), and sleep-disordered breathing (SDB). Patients objectively diagnosed with SDB were also analyzed by NAR status. Validated scales for sleepiness, insomnia, anxiety, and depression were compared among the groups.
Results
Potential NAR+ comprised 70 % (1194 of 1703) of patients with congestion and showed significantly higher congestion scores than NAR− status 11.97 (3.62) vs 10.47 (3.37);
p
= .001;
g
= 0.42; 95 % CI, 0.32–0.53. The proportion of potential NAR+ cases for each presenting chief complaint was nearly identical (range 69.6 to 71.2 %). However, the comparison of effects between NAR+ and NAR− cases within each presenting group (INS, NRS, SDB) was more consistently significant on the scales for insomnia, sleepiness, anxiety, and depression only in the SDB category. The same four symptoms, measured in those objectively diagnosed with SDB, were also significantly worse in NAR+ compared to NAR− patients.
Conclusions
Regardless of presenting chief complaint and ultimate diagnosis of sleep-disordered breathing, potential nonallergic rhinitis was common in patients at a sleep medical center at a rate possibly greater than twice that reported in the general population. Potential NAR+ was associated with worse sleep and distress symptoms. In both prevalence and treatment studies, research must further evaluate the potential impact of NAR on specific sleep disorders.
Purpose
– For many wineries, internationalisation strategies, particularly in the form of exports may provide opportunities and financial gains. However, as more wine producers enter and compete in ...an increasingly convoluted wine market, accordingly the “playing field” in the wine industry becomes increasingly complex. To shed more light into wineries’ internationalisation efforts through exports in the currently uncertain business climate, this preliminary study investigates a group of predominantly micro, small, and medium wineries from both New and Old Worlds of wine. The paper aims to discuss these issues.
Design/methodology/approach
– An online questionnaire was designed to gather data from winery owners and managers that invited to participate voluntarily in the study; a total of 499 usable responses were obtained.
Findings
– Diversifying and entering new markets, especially due to domestic competition are respondents’ main reasons for embarking in exports, while unfavourable currency exchange, issues of trust, or entry barriers are key challenges many of them face. Further, despite the relatively limited wine production of most participating wineries, respondents perceive a necessity to be present internationally. Indeed, rather than fitting into a specific business model/cycle, the current complex business environment is triggering export strategies among entrepreneurs.
Originality/value
– The fiercely competitive wine market and continuously changing consumer trends significantly contribute to the complexities the wine industry faces. However, few academic studies have investigated some of the complexities that wineries located in different geographic, economic, political, and social environments face. In this regard, the study makes a contribution by identifying several developments related to complexity theory, including the impacts of globalisation, competition, and change, and the resulting complexity in the wine sector.
In behavioral economic demand, the currently predominant conceptualization of unit price suggests that increasing lever weight or ratio requirement should result in equal changes in unit price and ...thus identical changes in consumption. Data from the few studies that have compared consumption under ratio progressions and force progressions tend to show differences in consumption across the two manipulations, even with unit price adjustments. These studies, however, failed to measure the broader operant class (i.e., subcriterion responses) and the force of individual responses, so the present experiments extend this work by using a force transducer to measure responding. In Experiment 1, six rats responded for sweetened condensed milk across ascending prices composed of ratio or force progressions equated based on unit price. Consistent with prior research, results showed consumption differed across progression types, with force progressions producing more inelastic consumption across low unit prices than ratio progressions. As force criterion increased, the proportion of subcriterion relative to total responses increased. Experiment 2 aimed to investigate how these subcriterion responses impacted the demand functions obtained from the force progressions. In Experiment 2, demand curves were obtained by yoking reinforcer-by-reinforcer to the total number of responses (i.e., subcriterion and criterion) per reinforcer delivery from the force progressions for each rat. Some similar patterns of consumption were observed across the force and yoked progressions, but deviations were noted. Convergence in consumption was assessed across several candidate alternatives to unit price, with the greatest convergence produced by measures of cumulative time integral of force per 0.05-ml unit of reinforcer and mean cumulative response duration per 0.05-ml unit of reinforcer.
This study had three goals: to examine differences between the amounts of time kindergarten teachers reported spending in instructional practices and their perceptions of students' social competence; ...to investigate differences between child and teacher characteristics and teachers' instructional practices; and to examine differences between demographic variables of children and teachers' perceptions of kindergartners' social competence. Data included information on 4,663 kindergarten children and 1,143 teachers from the Early Childhood Longitudinal Study, Kindergarten Cohort of 1998–1999 (ECLS-K). Results revealed differences in teachers' years of experience and the amount of time they reported spending in instructional practices. However; no differences were found based on teachers' certification and education level. Findings suggested differences in teachers' reported instructional practices and perceptions of children's social competence based on children's demographic characteristics. Differences also existed in teachers' perceptions of children's social competence based on the amount of time they reported spending in instructional practices.
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