[Obesity in adolescents: physical correlated pathologies, and therapeutic state of art]

Obese adolescents are prone to several pathologies, which may begin in this period of life and have a continuity in adult age. In this review the author tries first to explain the obesity definition in infants, children, and adolescents. Some pathologies may appear in adolescent age. First of all, some features of the so called metabolic syndrome; furthermore, hormonal alteration during and after puberty, genital appearance in the obese adolescent male, respiratory problems as apnea, asthma, and the Pickwick syndrome. The non alcoholic fat liver disease is also described, and the orthopedic problems as well, owing to the overweight: from abnormal body posture to structural consequences on the skeleton. Finally, some remarks concerning pharmacological and surgical approach are presented.

Treatment refractory psychosis remitted upon treatment with continuous positive airway pressure: a case report

INTRODUCTION

Patients refractory, or responding only partially, to antipsychotic drugs are common in clinical practise. Medical diseases can present with psychotic symptoms or add to a psychotic picture and should not be missed. We report on a patient with schizophrenia whose treatment refractory psychosis remitted upon treatment of her obesity-hypoventilation syndrome (OHS).

CASE REPORT

A 63-year-old women previously diagnosed with hebephrenic schizophrenia developed treatment resistant auditory hallucinations along with extreme daytime fatigue and obesity. She was eventually diagnosed with Pickwickian syndrome or OHS and received treatment with continuous positive airway pressure (CPAP). Restoring the patient's alveolar hypoventilation with nocturnal CPAP led to the complete remission of hallucinations.

DISCUSSION

We suggest that this case highlights an issue that might become more common in the future with increasing prevalence of overweight. Indeed, some atypical neuroleptics might even counteract their own therapeutic effect by inducing excessive weight gain that increases the risk for OHS. We recommend taking a careful sleep history in schizophrenic patients with obesity and to perform a polysomnography in suspect cases.

[Obesity--hypoventilation syndrome: sometimes a difficult diagnosis]

Described in the specialty literature for over one century under the name of Pickwick syndrome, the obesity--hypoventilation syndrome (OHS) includes the triad: obesity--hypoventilation--hypersomnia. In Romania, this entity is rarely recognized and, despite the developments in specific investigations, the disease is frequently difficult to differentiate from other respiratory disorders during sleep. The authors try to clarify some issues related to pathophysiologic mechanism and contribution of mechanical factors or of respiratory nervous center etc. References are made about the leptin involvement. Clinical appearance and therapy modalities are added to the description of the disease.

[Chronic ronchopathy -- a nosological entity of pathological realization of upper airways obstruction]

A comprehensive examination and therapy of 90 snoring and apnea patients treated in an ENT clinic of the Russian State Medical University have established similar features of the diseases: pathological mechanisms, clinical manifestations, stages, outcome. This enables differential diagnosis and change of the syndromal diagnosis "pathological snoring" for a nosological one -- chronic ronchopathy. The term "ronchopathy" originates from a Greek word "ronhus"-- snoring; the term "chronic" means development of the disease due to chronic pathology of the upper airways and progression of a clinical symptom -- snoring.

Pickwickian syndrome: the challenge of severe sleep apnea

Pickwickian syndrome is a severe form of sleep apnea in obese persons which involves mechanical impairment of ventilation resulting in greatly compromised gas exchange. Manifestations of the syndrome are associated with deposits of adipose tissue around the abdomen and diaphragm and are completely reversible with weight loss. Since sleep apnea is now recognized as a significant chronic health problem, nurses in intensive care, medical-surgical, and home care settings are increasingly challenged to provide competent assessment, care, and rehabilitation of affected individuals.

Evaluation of patients with sleep apnea after tracheotomy

OBJECTIVE

To determine the effect of tracheotomy on polysomnographic and arterial blood gas data in patients with obstructive sleep apnea (OSA).

DESIGN

A retrospective study of all patients who underwent tracheotomy and were studied polysomnographically at the Johns Hopkins Sleep Disorders Center, Baltimore, Md, since 1981.

SETTING

A regional sleep disorders center.

PATIENTS

Twenty-eight patients (8 women and 20 men), aged 22 through 77 years. Patients were categorized into 2 groups on the basis of whether they had already undergone tracheotomy before polysomnography. Group 1 patients all had a polysomnographic diagnosis of OSA before tracheotomy. They were further subdivided on the basis of whether cardiopulmonary decompensation had been absent (group 1a, n=10) or present (group 1b, n=13). Group 2 patients (n=5) had undergone tracheotomy to treat upper airway obstruction that developed after non-apnea-related upper aerodigestive tract surgeries.

INTERVENTION

Tracheotomy.

MAIN OUTCOME MEASURES

Nocturnal non-rapid eye movement, apnea-hypopnea index, percentage oxyhemoglobin saturation, and arterial blood gas data.

RESULTS

Patients with OSA underwent tracheotomy as definitive treatment for the apnea (n=15), to prevent postoperative upper airway compromise after uvulopalatopharyngoplasty (n=7), and to treat upper airway compromise after non-apnea-related upper aerodigestive tract surgeries (n=6). Tracheotomy alleviated apnea in all 10 patients with uncomplicated sleep apnea (group 1a). For patients with OSA complicated by cardiopulmonary decompensation (group 1b), tracheotomy improved but did not eliminate sleep apnea in 7 of the 13 patients, despite overall improvement in arterial blood gas values. For patients whose sleep apnea had not been diagnosed polysomnographically before tracheotomy (group 2), tracheotomy was still required to treat OSA that had previously not been recognized.

CONCLUSIONS

Tracheotomy effectively treated patients with uncomplicated OSA, but was much less effective in treating patients with OSA and cardiopulmonary decompensation. In patients who underwent tracheotomy in conjunction with other upper aerodigestive tract surgeries, concomitant obstructive sleep apnea often required continued use of a tracheotomy to maintain upper airway patency.

Obesity hypoventilation [corrected] syndrome in the differential diagnosis of a pulmonary mass

Dyspnea and cyanosis are common presenting manifestations of cardiopulmonary disease. When these findings occur in a cigarette smoker with an apparent pulmonary mass on chest radiograph, the differential diagnosis rapidly narrows to a short list of possibilities that include pulmonary neoplasm, pulmonary infection and pulmonary infarction. Pulmonary hypertension with pulmonary arterial enlargement and hypoxia secondary to alveolar hypoventilation should also, however, be included as a diagnostic possibility in the appropriate setting because the evaluation and treatment of this entity may differ markedly.

[The Pickwick syndrome. From literary speculations to sleep research]

The "wonderfully fat boy" Joe described in The Pickwick Papers, by Charles Dickens, is remarkable for his glorious appetite and many attacks of sleep during the day. His medical condition was introduced as the Pickwick syndrome by Burwell et al. in 1956. For some 20 years this was an important stimulus for sleep research. Some literary and historical aspects of The Pickwick Papers are presented. The many diagnoses given to poor Joe are discussed. This diagnostic survey may still be of interest, even if the syndrome has virtually disappeared from medical literature. How does the Pickwick syndrome, as doctors today see it, fit Dickens' original description? Did Joe really suffer from the Pickwick syndrome?

Disk edema in an overweight woman

A 46-year-old extremely obese black woman presented with headaches, blurred vision, and visual obscurations. Her exam was notable for bilateral severe papilledema, retinal hemorrhages, and lethargy. Her CAT scan was normal, and a spinal tap revealed a very high opening pressure. Although this patient's presentation mimicked pseudotumor cerebri, the lethargy and retinal hemorrhages were atypical. Her hospital evaluation was notable for elevation of the serum bicarbonate level, and she was subsequently found to have hypoxia and hypercapnia on a blood gas. The patient was diagnosed as Pickwickian syndrome, with obstructive sleep apnea. Treatment of the pulmonary problem resulted in dramatic improvement in her eye findings and her lethargy, and optic nerve sheath fenestration was not necessary.

Airway management in obesity hypoventilation syndrome

The role of tracheostomy is limited in the obesity hypoventilation syndrome unless severe upper airway obstruction exists. If it is performed, special techniques must be applied to overcome the problems associated with tracheostomy in the morbidly obese patient. If attention is paid to these details, however, tracheostomy provides clinically important benefits in this difficult clinical situation.

"Near miss" death in obstructive sleep apnea: a critical care syndrome

OBJECTIVE

The objective of this study was to alert critical care physicians to the syndrome of obstructive sleep apnea with respiratory failure ("near miss" death) and to elucidate characteristics that might allow earlier recognition and treatment of such patients.

DESIGN

We examined clinical and laboratory characteristics of eight patients with obstructive sleep apnea presenting to the ICU with respiratory failure. These characteristics were compared with those of eight stable apnea patients of similar severity but without a history of presentation with respiratory failure.

SETTING

Medical ICU and pulmonary outpatient clinic at the Houston Veterans Administration Medical Center, a teaching hospital affiliated with Baylor College of Medicine.

PATIENTS

Eight patients with obstructive sleep apnea who presented in, or developed, acute respiratory failure requiring tracheal intubation and mechanical ventilation were matched to eight stable obstructive sleep apnea outpatients from the chest clinic.

MEASUREMENTS AND MAIN RESULTS

The records of these 16 patients were reviewed and multiple characteristics that might predict these obstructive sleep apnea patients prone to respiratory failure and death (called the "near miss" death group; n = 8) were examined. The mean age of the near miss group was 57 yrs. All eight patients presented with respiratory acidosis (mean pH 7.22), hypercarbia (mean PaCO2 82 torr [10.9 kPa]), and hypoxemia (mean PaO2 45 torr [6.0 kPa]). Six of the eight patients had concomitant chronic obstructive pulmonary disease as determined by clinical characteristics and spirometry. Predisposing factors included facial trauma, lower respiratory tract infections or bronchospasm, and use of pain medication. All but one of the near miss subjects had awake hypercarbia (mean PaCO2 49 torr [6.5 kPa]) and hypoxemia (mean PaO2 58 torr [7.7 kPa]) during periods of clinical stability while only two controls had concomitant chronic obstructive pulmonary disease and none had hypercarbia. The prevalence of a history of wheezing and prior hospitalization for "respiratory problems" were greater in the near miss group. Once cured of apnea, no patient presented with recurrence of respiratory failure in follow-up ranging from 6 to 80 months, and cor pulmonale recurred in only one patient during subsequent onset of central apneas.

CONCLUSION

Patients with obstructive sleep apnea who have concomitant chronic obstructive pulmonary disease or hypercarbia and hypoxemia are more prone to develop severe respiratory failure and probable death than those patients with apnea alone. The current study shows that recurrent respiratory failure and presumably mortality from this acute complication can be reversed with effective treatment of the obstructive apnea.