Faculty Bibliography

Introduction: OSA is highly prevalent among WTC first-responders, but adherence to CPAP is often poor. In an ongoing study of nasal pathology and OSA and the effect of Cflex on adherence, we looked for correlations between prior physiological (AHI4%/RDI, gender, age, and treatment pressure) and psychological (subjective daytime sleepiness, insomnia, and depressed mood) factors and adherence to CPAP at one month. Methods: Subjects with OSA (AHI4% > 5/hr or AHIall > 15/hr) were recruited from the WTC Health Clinic. CPAP therapy was initiated at home with 3 or more days of autotitration, followed by fixed CPAP, randomly with/without Cflex. To date, 219 subjects (age 34-75, 27 female, AHI4% = 16.5 +/- 14.7, RDI = 32.3 +/- 16.4, ESS = 8.7 +/- 5) have completed a one-month treatment period. Mood and insomnia were assessed by questionnaire and subjective daytime sleepiness by Epworth Sleepiness Scale (ESS). CPAP adherence was assessed by %days > four hrs used in the last 2 weeks of treatment, and average hours used on all days or averaged on days CPAP was used. Independent sample t-tests were used to compare groups. Results: Subjects used CPAP for > 4hrs on 23.1 +/- 30.7% (mean +/- SD) of days used; average use-hours on all days were 1.8 +/- 2.3 hrs; and average use-hours on days CPAP was used were 2.6 +/- 2.3 hrs. Prior to CPAP, 35% of participants had significant sleep onset and/or maintenance insomnia. 31% had significant depressed mood scores. CPAP adherence did not differ between groups based on gender, severity of OSA, CPAP pressure > 10, ESS, or insomnia complaints. As in other studies, older age correlated weakly with CPAP adherence (r = 0.21, p < 0.01). Lower CPAP adherence may be associated with prior depressed mood (2.3 +/- 2.3hrs vs 2.7 +/- 2.3 hrs) but this did not reach significance (p = .24). Conclusion: CPAP adherence in these predominantly mild OSA subjects from a non-sleep-clinic population was poor and was not predicted by available physiological or psychological variables

INTRODUCTION: We present a case of disseminated MSSA infection causing devastating ischemic sequelae of septic emboli. CASE PRESENTATION: The patient is a 66 year-old man presenting to the ER after he fell off his couch and could not get up. He had chronic back pain and weakness and swelling of both legs. His medical history included recent dental work, acupuncture for shoulder pain, and ORIF for bilateral wrist fractures. On presentation, he was febrile, tachycardic, tachypneic, and hypoxemic, with 4/5 muscle strength throughout. Chest X-ray showed lower lobe infiltrates. Urinalysis suggested infection. He was given broad-spectrum antibiotics and IV fluids. He was transferred to the medical ICU for hypotension. His weakness rapidly progressed to quadriplegia, with shallow, labored breathing. He was intubated for hypoxemic respiratory failure and septic shock requiring vasopressors. CT imaging of the head, cervical and thoracic spine was negative. Lumbar puncture retrieved purulent CSF with a neutrophilic pleocytosis and gram-positive cocci. Dexamethasone was added for bacterial meningitis. A cervical spine MRI showed C3-C7 cord signal abnormality of the central gray matter, concerning for spinal cord infarction. MSSA grew from blood, urine and CSF cultures. Antibiotics were narrowed to nafcillin. A chest CT showed peripheral septic emboli in the lungs. A transthoracic echocardiogram showed large, shaggy aortic and tricuspid valve vegetations. The patient developed massive upper GI bleeding. Endoscopy revealed diffuse ischemic ulcerations, requiring radiologically-guided embolization for hemostasis. His mental status remained depressed; he intermittently answered questions by blinking. He did not regain any neurologic function. He developed progressive multiorgan system failure. After discussion with his family, in keeping with his known wishes in the case of a terminal condition, the patient was palliatively extubated and expired soon thereafter. DISCUSSION: Our patient represents an uncommon case of widely disseminated MSSA infection due to infective endocarditis of the tricuspid and aortic valves. The sequelae included a descending UTI, septic emboli to the lungs, and septic emboli causing ischemic ulceration of the duodenal mucosa, vertebral artery occlusion, and cervical spinal cord infarction resulting in quadriplegia. The patient's MSSA infection was likely due to bacteremia resulting from acupuncture treatments for shoulder pain. He was hyperglycemic on admission, his HbA1c was 6.7%. Impaired glucose tolerance or uncontrolled undiagnosed diabetes mellitus likely predisposed the patient to dissemination of MSSA infection. CONCLUSIONS: This case illustrates rapidly progressive MSSA infective endocarditis, with ischemic injury from septic emboli contributing to multiorgan system failure and devastating neurologic injury