disease state crossover managing the complex osa patient peter allen, bsrc, rst, rpsgt rrt-nps-sds...

Disease State CrossoverDisease State Crossover

Managing the Complex OSA Managing the Complex OSA PatientPatient

Peter Allen, BSRC, RST, RPSGTPeter Allen, BSRC, RST, RPSGT RRT-NPS-SDSRRT-NPS-SDS

Conflicts of InterestConflicts of Interest

Philips RespironicsPhilips Respironics ResMed CorpResMed Corp Fisher & PaykelFisher & Paykel DeVilbissDeVilbiss MVAPMVAP NatusNatus NovaSomNovaSom WatermarkWatermark

ContentContent

Co-Morbid disease state descriptions and the Co-Morbid disease state descriptions and the workflow of those disease states as they pass workflow of those disease states as they pass through the sleep disorders center.through the sleep disorders center.

COPDCOPD DiabetesDiabetes Morbid ObesityMorbid Obesity CardiovascularCardiovascular Stroke Stroke Gastroesophageal Reflux/GerdGastroesophageal Reflux/Gerd Metabolic Syndrome Metabolic Syndrome

Intake, Clinical and Marketing AspectsIntake, Clinical and Marketing Aspects

Learning ObjectivesLearning Objectives 1. Attendee will have a better understanding of 1. Attendee will have a better understanding of

the underlying physiology of the co-morbid OSA the underlying physiology of the co-morbid OSA patient and various aspects of overlap syndrome patient and various aspects of overlap syndrome between disease states.between disease states.

2. Attendee will be better able to plan and cope 2. Attendee will be better able to plan and cope with the complex patients in their sleep labs.with the complex patients in their sleep labs.

3. Attendee will learn to grow clinically while 3. Attendee will learn to grow clinically while realizing the financial opportunity that these realizing the financial opportunity that these patients represent to their sleep centers.patients represent to their sleep centers.

AttendeesAttendees Night TechnologistsNight Technologists EEG BackgroundEEG Background Respiratory BackgroundRespiratory Background Home Care DMEHome Care DME Home Sleep Testing Home Sleep Testing Lab ManagersLab Managers Lab OwnersLab Owners Hospital AdministratorsHospital Administrators NursingNursing Physician AssistantsPhysician Assistants

Co-Morbid Condition off Your Wing

IntroductionIntroduction

Since 1970 when Stanford opened the first sleep center and Dr. Guilleminault later described Obstructive Sleep Apnea(OSA), many studies have been conducted regarding associated disease states.

Introduction Cont’d

Many studies have linked OSA to co-morbid disease states and conditions such as:

Cardiovascular and Pulmonary Disease Congestive Heart Failure – 76% A-Fib, - 49% Diabetes – 48% Obesity - 77% Stroke Spinal Cord Injury Reflux/Gerd End Stage Renal – 10 times Greater than General Population Headaches, COPD, Cancer, Metabolic Syndrome

Medicare Readmissions Policy

Many Co-Morbid disease states that are associated with OSA are being targeted by Medicare as criteria, for financial penalties to Medical Centers where readmissions occurs, within 30 days of discharge.

This puts a spotlight on Diagnosis and Treatment of OSA and its associated co-morbid disease states as an integral part of a medical centers financial integrity plan.

COPDCOPD

Chronic Obstructive Pulmonary Disease Two Components

Chronic Bronchitis – Productive cough, three months of the year, two or more successive years.

Emphysema - Abnormal enlargement of the airspaces in the lungs with destruction to the cell walls.

Primarily caused by cigarette smoking.

COPD MedicationsCOPD Medications Oxygen – Physician’s Orders Theophylline Ipratropium bromide Advair’ Symbicort Daliresp Theophylline Atrovert Serevent Salmeterol Formeterol Proventol/Ventolin/Abuterol - Nebulizers

COPD Referral SourcesCOPD Referral Sources

Pulmonologists Hospitalists Internal Family Internal Medicine Oncologists

COPD Intake ConcernsCOPD Intake Concerns

Oxygen ? Liter Flow ? Hypoxic Drive Candidate Mobility ? Additional Caretakers? Medications?

Nebulizers Short Acting Acute Long Acting Maintenance

Recent Hospitalizations??

COPD Night of StudyCOPD Night of Study

Shortness of Breath (SOB) Ambulation Oxygen Protocols Emergency Protocols Detailed H&P in Chart Medication Schedules Thorough Chart Review Early!!!!!

COPD and the RecordCOPD and the Record

High CO2 – 35 Normal>>>50+ Low Spo2 – 90% to 97%>>>>88% or less Hypoventilation Centrals During Titration Supplemental Oxygen as needed PVCs, PACs, Uni and Multi-Focal, V-Tach High Heart Rates A-Fib

COPD OSA “Overlap SyndromeCOPD OSA “Overlap Syndrome””

1. Impaired Lungs plus OSA 2. COPD and OSA jointly contribute 3. More nocturnal desaturations 4. Reduction in respiratory drive-HV 5. Chest wall hyperinflation causes muscle

fatigue in these patients. 6. COPD has systemic consequences 7. CO2 High(Retainers), Spo2 Low

Overlap Syndrome Conclusions

Overlap syndrome increases risk of death and hospitalization due to COPD.

PAP treatment with or without oxygen is associated with better patient outcomes along with decreased hospitalizations.

Less readmissions for these patients

DiabetesDiabetes

Impairment of the body’s ability to use blood sugar for energy.

Type 1- Insulin producing Beta cells in pancreas destroyed.

Type 2- Most common 90% to 95%, Weight, Food Insulin resistance by body, so pancreas overproduces

Gestational - during pregnancy- Usually Temp

Over 6 million in the US alone

Diabetes MedicationsDiabetes Medications

Type I Insulin – Oral or Injection

Type II Metformin Victoza Glucophage Amaryl Glucotrol Januvia Novolin

Diabetes Referral SourcesDiabetes Referral Sources

Family Internal Medicine Endocrinologist Bariatric Medicine

Diabetes Intake ConcernsDiabetes Intake Concerns

Type 1: When do they take their meds? Reinforce that patient needs to bring

meds. Type II: When do they take their meds?

Labs are Out-Patient Facilities, So…

Diabetes Night of StudyDiabetes Night of Study

Tech needs to establish med routine Patient will always self-administer Refrigeration for meds

Do not let patients “Take a Night Off”

Call to Physician if need be to clarify/safety concerns/patient coherent?

Diabetes Sleep Loss EffectsDiabetes Sleep Loss Effects

Frequent urination common during PSG Sleep loss leads to: Altered glucose and metabolism Reduced Leptin/Increased Ghrelin Up regulation of appetite/weight gain Lower energy = Weight Gain(OSA Factor) Insulin resistance = Type 2 Increased Risk for Diabetes Adapted from Parker, K.P. (2011) Sleep disorders and sleep promotion in nursing practice; p.

180

Morbid ObesityMorbid Obesity

Co-Mobidities within a Co-Morbidity BMI > 32 – Doubles risk of death High Blood Pressure Heart Disease – Left and Right side - Lymphedema High Cholesterol Levels Diabetes- 10 times- 60% to 80% Gastroesophageal Reflux Urinary Stress Incontinence Degenerative Arthritis-Fall Risk Skin Infections, Fluid Retention

Morbid Obesity MedicationsMorbid Obesity Medications

1. Metformin – Type II 2. Diuretics - Lasix 3. Hypertensive Meds – Lisinopril 4. Pillows, Pillows, Pillows,- Orthopnea 5. Insulin – Type 1 6. Lymphedema Meds 7. Oxygen 8. Lipitor 9. Vaso…….Cardio Meds

Morbid Obesity ReferralsMorbid Obesity Referrals

Family Internal Medicine Endocrinologist – Metabolic Syndrome Bariatric Medicine – Pre and Post Surgical Nephrologist- Renal Disease Perioperative Referrals

Morbid Obesity IntakeMorbid Obesity Intake

Weight Bed Limits Toilet Limits Chairs Ambulation? Medications? Drs to be copied? Special Needs?

Morbid Obesity Night of StudyMorbid Obesity Night of Study

PSG Set-Up – Belts, leads, sensors… Titration Night Mask Fitting Concerns Headgear Big Enough?- Call Reps Does your lab have a weight limit? Bariatric Approved Beds? Fall Risk? Culture of Safety Concerns all Around Meds Frequent bathroom breaks Possible Incontinence

Morbid Obesity RecordMorbid Obesity Record

1. Loud Snoring 2. Deep Desaturations 3. Irregular EKG

4. Usually Severe OSA 5. CPAP to BI-Level Protocols? 6. Frequent breaks in recording 7. Artifact, movement, sweat 8. Speaking

Morbid Obesity OSA Overlap Morbid Obesity OSA Overlap

1. OSA Influence on other conditions, high 2. Cardio 3. Pulmonary 4. High Blood Pressure 5. Fluid Retention 6. Bariatric Surgery or Intensive Lifestyle Changes

Metabolic Syndrome, Insulin Resistance – Type 2

Haines et al. Surgery 2007; 141: 354-8 Look Ahead Research Group, Diabetes Care 2007

Cardiovascular Cardiovascular

1. 70% of patients admitted to the hospital for coronary artery disease were found to have sleep Apnea

2. Patients with OSA have a 50% risk of hypertension 3. OSA starves heart of oxygen while making it work

harder leading to higher blood pressures through the night.

4. Untreated OSA is well documented as a factor in causing heart disease

5. A patient’s chance of having OSA if they have heart failure is very high.

AM J Respir Crit Care Med Vol. 188, P1-P2, 2013 ATS Patient Education Series 2013 Chowdhuri, S., MD, Weingarten, J., MD

Congestive Heart FailureCongestive Heart Failure

Systolic Failure Failure to eject/pump blood out of the heart effectively

Diastolic Failure Heart muscles have become stiff and do not fill easily

Fluid builds up in the lungs, liver, gastrointestinal tract, arms and legs/ankles.

Zee, P & Naylor, E http://www.medscape.org/viewarticle/491026

CHF and Sleep

Shortness of Breath RLS Symptoms Diuretics = Increased Bathroom Breaks OSA and CSA Insomnia – Daytime Sleepiness Short Sleep Duration

Cardiovascular Medications Cardiovascular Medications 1. Lisinopril 2. Atenolol 3. Diovan 4. Norvasc 5. Clonidine 6. Azor 7. Verapamil 8. Furosemide 9. Lasix 10.Coreg 11. Zestril 12. Vasotec 13. Lopressor 14. Levatol 15. ……anybody

Cardiovascular ReferralCardiovascular Referral

Family Internal Medicine Cardiology Surgeons - Perioperative Hospitalist

Cardiovascular IntakeCardiovascular Intake

Oxygen? Get both Family and Specialists Last Hospitalization? Medications and average BP

Cardiovascular Night of StudyCardiovascular Night of Study

BP Pre and Post Study – Both Arms Ask when they last took their medications DeFib Unit Operational – Signed off on? Room Temp Important if Sweating Note any swelling in arms or legs Note Pacemaker and Type – Constant/As Need BLS, ACLS, PALS 911 , 711 depending on hospital/freestanding

Cardiovascular RecordCardiovascular Record Irregular EKG PVCs, PACs, V-Tach, A-Fib, Pauses Full or Partial Heart Block Breaks in record-Diuretics/Lazix Insomnia from Anxiety

Cheyne Stokes Breathing Pattern – 73% in CHF patients Left ventricular dysfunction-Hyper and Hypo ventilation Waxing and Waning breathing pattern

Pacing Spikes OSA and CSA

CSA sometimes evoked by O2 and PAP, Auto Servo Ventilation

Cardiovascular OSA OverlapCardiovascular OSA Overlap 1. Elevated Blood Pressure during Sleep 2. Elevated Sympathetic Tone leads to HBP 3. About 30% of patients with hypertension have OSA 4. Congestive Heart Failure well documented connection 5. Left ventricle enlargement/increased workload/events 6. Effects are both acute and chronic 7. Cessation of airflow and subsequent desat starves

heart of oxygen. 8. PAP Treatment is shown to have positive effect on all 9. Heart Failure associated with Cheyne Stokes Pattern 10. OSA occurs in 50% of atrial fibrillation patients

StrokeStroke

Hemorrhagic-Vessel breakdown Ischemic-transient ischemic attack (TIA) Narrowing Embolic-Clot local or from other area blocks flow

OSA and SDB contributes to increased risk of stroke.

Stroke can contribute to OSA or CSA Reduced muscle tone and control of upper airway

Stroke Onset Symptoms

Sudden Slurring of Speech Muscle control deficit in face/body

affecting one side or bilaterally

Stroke MedicationsStroke Medications

Anti-platelet Aspirin Plavis/Clopidogrel Ticlid/Ticiopidine

Anti-clot Warfarin/Coumadin Heparin-Hospital via IV

Acute Phase Thrombolytic Agents-”Clot Busters”

Stroke Patient Referral SourcesStroke Patient Referral Sources

Family Internal Medicine Neurology Hospitalist Case Managers CRNPs

Stroke IntakeStroke Intake

1. Hemorrhagic 2. Ischemia (TIA) or Embolic 3. Left or Right Side Deficit 4. Speech? 5. Ambulatory ?

6. Aide or Family Member

7. Time of Day or Night –Triggers

Stroke Night of StudyStroke Night of Study

Left side Right side? Full 10-20? Fall Risk? Medication Schedule? BP in the evening and morning Medical Director Parameters for BP Time of Day/Night-Triggers

Stroke Patient Record AspectsStroke Patient Record Aspects

1. Left Side or Right Side EEG differences 2. Non-Homologous electrodes can cause

voltage asymmetries. 3. Measure, Measure, Measure 4. Do not eye-ball EEG set-up 5. Full 10/20 frequently ordered

Stroke Patient OSA Overlap Stroke Patient OSA Overlap

OSA increase risk of stroke, independent of other risk factors.

Males with mild sleep apnea have doubled stroke risk

Stroke patients-63% have SDB Stroke patients w SDB have higher mortality, 1yr

Even higher frequency of SDB in stroke patients with high BMI and Type 2 Diabetes.

Gastroesophageal Reflux(Gerd)Gastroesophageal Reflux(Gerd)

1. Human PH – 1 TO 14 2. Arterial PH – Normal 7.35 – 7.45 3. Stomach PH – 4 or less 4. Adults and Infants 5. Apnea causes Reflux or is Reflux causing Apnea? 6. Heartburn most common symptom 7. Chronic Illness 5-7% Worldwide 8. Middle Age-Esophageal Valve Weakens 9. Opening pressure of that valve?? PAP concerns?

Reflux/Gerd MedicationsReflux/Gerd Medications

1. Zantac 2. Reglin 3. Nexium-Purple Pill 4. Pepto-Bismol 5. Ranitidine 6. Lansoprazole 7. Famotidine 8. Simethicone 9. Gavison 10. Maalox 11. Mylanta 12. Prevacid 13. Pepcid 14. Tums

Reflux/Gerd Referral SourcesReflux/Gerd Referral Sources

Family Internal Medicine Cardiology Gastroenterologists Neonatologists Pediatricians

Reflux/Gerd Intake ConcernsReflux/Gerd Intake Concerns

1. Medication Schedule 2. Physicians orders regarding meds 3. Hospitalizations? 4. Barrett’s esophagus or other Upper GI?

Reflux/Gerd Night of StudyReflux/Gerd Night of Study

1. Dr’s Orders Followed? 2. Last Meal time documented 3. Last Med 4. Does patient have a logbook? 5. Flat or Raised? 6. Document Patients Snacking/Eating 7. Spicy, acidic, fried foods, tomato based

Reflux/Gerd Record AspectsReflux/Gerd Record Aspects

1. Infant Study- Arousals, Body Posture 2. Adults- Arousals, Frequent breaks 3. Document Patient Observations 4. GERD with OSA events? 5. Choking Aspiration Risk? 6. Upright Posture 7. Left side/Right side/Recovery Position 8. Dr’s orders regarding food/meds/body

position

Reflux/Gerd OSA Overlap Reflux/Gerd OSA Overlap

1. Not a clear causal relationship 2. Chicken/Egg or Egg/Chicken 3. Hard breathing during events? 4. Different mechanisms can cause both 5. Multifactorial Origin – Shared risk factors 6. Aspiration risk at end of apnea is of concern

to the technologists.

Metabolic What???

Metabolic SyndromeMetabolic Syndrome

1. Systemic rather than local disorder 2. OSA & Metabolic = Syndrome Z 3. Causal Relationship Probable 4. Repetitive Hypoxia 5. Adipokines and Inflamatory Cytokines 6. Estimated 24% of US Population

Metabolic Syndrome

Three of the following five variables:

Hypertension Insulin resistance – Type 2 Low high-density lipoprotein cholesterol Elevated serum triglyceride Abdominal Obesity-Visceral Fat

Metabolic Syndrome

Multiple studies have shown that association between OSA plus Metabolic Syndrome increases as severity of the patient’s OSA increases.

PAP has been shown to improve high blood pressure but not insulin resistance or lipid profiles.

Coughlin et al.

Metabolic Syndrome

Studies are showing that OSA and Metabolic Syndrome are not separate co-morbidities but actually linked to each other very closely.

Metabolic Syndrome

The Sleep Heart Health Study found a significant association between the respiratory disturbance index and waist to hip ratio, hypertension, and hypercholesterolemia in men, and low HDL-C, and hypertriglyceridemia in women.

A matched control study found that OSA was associated with insulin resistance, total cholesterol, HDL-C and Leptin. A Japanese study showed that OSA may promote metabolic dysfunction and fat maldistribution.

Metabolic Syndrome

Linkage between OSA and Diabetes is very well documented and appears to play a role in Metabolic Syndrome.

Prevalence of OSA in obese Type 2 Diabetic patients with moderate to obstructive severe sleep apnea has been reported as high as 70%.

Metabolic Syndrome Hypothalmic-pituitary-Adrenal(HPA) Axis Cortisol – Hormone/Steroid is released – Adrenal Gland Cortisol secretion was increased by sleep apnea Study shows that obese men with OSA have abnormally higher

sympathetic nervous system activity and HPA. Autonomic(ANS), Sympathetic(SNS), Parasympathetic(PNS) OSA has inflamatory cascade component, although linkage to OSA

is still unclear. Repetitive hypoxia and reoxygenation lead to oxidative stress Oxidative stress appears to be a consequence of metabolic

syndrome and visceral obesity. Oxidative stress activates an inflammatory response.

Metabolic Syndrome Inflammatory responses activate Cytokines. Inflammation, metabolic syndrome ties in with atherosclerosis. Biomarkers are used by researchers to track the bodies

inflammatory responses and associate them with OSA. Obesity is the common factor that connects OSA TO Metabolic

syndrome. Monocytes and Macrophages abound and increase through what is

known as the “Cascade”. Monocytes>>Macrophages eat/destroy Adipokines-Fat derived Cytokines-One is Leptin. Leptin plays a role

in appetite and energy. Ghrelin-Hormone that also regulates appetite. High levels after

weight loss. CPAP reduces

Monocyte Responds

Macrophage Engulphs Pathogen

Exploding Macrophages

Metabolic Syndrome

Patients with sleep apnea have reduced Leptin levels.

Sleep deprivation unto itself,,, alone,,, contributes to increased levels of Ghrelin, increased appetite, higher glucose levels, insulin resistance, and therefore a higher risk of diabetes.

OSA compounds and contributes to most any other disease state a patient has. (Allen, P. et al)

Normalization of metbolic parameters often occurs after PAP tx.

Metabolic Syndrome Conclusion

Metabolic syndrome consists of a systemic and complicated chain of events and components, one of which can be the presence of Obstructive Sleep Apnea.

Research is showing that Sleep Disorder Medicine will be playing a major role in the diagnosis and treatment of patients with Metabolic Syndrome or Syndrome Z.

Overall Summary/ConclusionsOverall Summary/Conclusions

Sleep Technologists

You will be seeing more complex patients Get as much additional training as you can

Is your sales department, physician liaison, lab owner, hospital focusing on these patients?

They Should Be For Economic Survival of Your Sleep Lab

ReferencesReferences

AM j Resp Crit Care Med 2010 Aug 1;182(3):325-31AM j Resp Crit Care Med 2010 Aug 1;182(3):325-31Int J Chron Obstruct Pulmon Dis. Dece. 2008: 3(4): 671-682Int J Chron Obstruct Pulmon Dis. Dece. 2008: 3(4): 671-682Adaptation from Parker, K.P. (2011) Sleep disorders sleep, nursing P180Adaptation from Parker, K.P. (2011) Sleep disorders sleep, nursing P180ATS J Vol; 181, Issue 5(March1, 2010) Impact of Untreated OSA on Glucose ATS J Vol; 181, Issue 5(March1, 2010) Impact of Untreated OSA on Glucose

Control in Type 2 Diabetes Control in Type 2 Diabetes Grimaldi, D. et al. Diabetes Care February 2014 vol. 37 no. 2 355-363 Grimaldi, D. et al. Diabetes Care February 2014 vol. 37 no. 2 355-363

Glycemic Control in Type 2 DiabetesGlycemic Control in Type 2 DiabetesUniversity of Chicago, et al., Sleep Diagnosis and Therapy “Sleep Apnea Can University of Chicago, et al., Sleep Diagnosis and Therapy “Sleep Apnea Can

Worsen Blood Sugar Control in People with Type 2 Diabetes”Worsen Blood Sugar Control in People with Type 2 Diabetes”WebMD, Mann, Denise, Smith , Michael, MD Reviewed Jan10th 2010 “The WebMD, Mann, Denise, Smith , Michael, MD Reviewed Jan10th 2010 “The

Sleep-Diabetes ConnectionSleep-Diabetes ConnectionCoughlin, et al. Eur Heart J. 2004 International Diabetes Foundation BrusselsCoughlin, et al. Eur Heart J. 2004 International Diabetes Foundation BrusselsEinhorn et al. Edocr Pract. 2007Einhorn et al. Edocr Pract. 2007Resmed.comResmed.comWoidtke, Robyn, APSS Boston 2012Woidtke, Robyn, APSS Boston 2012

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Meslier N, et al. Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome Eur Respir J 2003;229(1):156-60

O’keeffe T, et al. “Evidence supporting routine polysomnography before bariatric surgery” Obesity Surgery 2004; 14(1):23-6

Foster, Gary, PhD, Temple University School of Medicine Diabetes Care. Net “Obstructive Sleep Apnea and Diabetes” 6/21/2010

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WebMD Drugs & Medications Search March 2004 Sleep Apnea and Heart Failure-ResMed Corp Ferreira, S et al. BMC Pulm Med 2010 Lanfranchi, PA et al Ciculation 2003 Javeheri, S et al. AM Col Cardiol. 2007 Garcia-Touchard, A. et al. Chest. 2008 Joseph et al. Tex Heart Inst. 2009 SDB and Hypertension-ResMed Corp Peppard, PE. Et al. N Eng J Med 2000 Lavie P et al. BMJ 2000 Nieto, FJ, Young TB et al. JAMA 2000

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Wuhl, J., MD “Obstructive Sleep Apnea’s Cardiovascular Effects” MLH 2/21/2012

Weingarten, J MD et al., Am j Respir Crit Care Med Vol 188, P1-P2, 2013 “Obstructive Sleep Apnea and Heart Disease”

Zee, P 7 Naylor, E medscape.org/viewarticle/491026 ‘Congestive Heart Failure”

Mark D. Elay, MS, RST, RPSGT, RRT-NPS, RPFT “Obstructive Sleep Apnea and Comorbidities: A Survey of Current Information” A2Zzz 23.1 March 2014

References Cont’d SDB and Stroke ResMed Corp Johnson, KG, et al. Clin Sleep Med. 2010 Martinez-Garcia MA, et al. AM J Resp Crit Care Med 2009 Wessendorf TE, et al. J Neurol 2000 Drager, LF, et al. Chest 2011 Jelic S, Trends Cardiovasc Med 2008

Kirschheimer, S. WebMD Health News “Are GERD and Sleep Apnea Related” 2014

“Gerd and Sleep” National Sleep Foundation Morse ca, et al. “Is there a relationship between obstructive sleep apnea

and gastroesophageal reflux disease?” Clin Gastroenterol Hepatol 2004 Sep;2(9):761-8

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Metabolic Syndrome” Mtab Syndr Relat Discord. Aug 2009; 7(4): 271-277

Vgontzas, AN. Et al. “Sleep apnea is a manifistation of the metabolic syndrome” Sleep Med Re. 2005 Jun;9(3):211-24. Abstract

Obesity and Inflammation APSS 2012 Boston Fantuzzi j All Clin Imunol 2005; 115:911-9 Christiansen, et al. Int J Obes Relat Metab Discord 2004; 29:146-50 Robker, et al. OBES Res 2004; 12:936-40

Thank YouThank You

Peter Allen, BSRC, RRT-NPS-SDS,Peter Allen, BSRC, RRT-NPS-SDS, RST, RPSGTRST, RPSGT

petersleep@comcast.netpetersleep@comcast.net