International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Effects of gut microbiota on obesity and atherosclerosis via modulation of inflammation and lipid metabolism

Recent studies have revealed a close relationship between inflammatory and metabolic pathways, and inflammation is now recognized to have a major role in obesity and metabolic diseases such as insulin resistance and atherosclerosis. The human body is home to a large number of distinct microbial communities, with the densest population in the distal gut (the gut microbiota). Bacteria have long been known to activate inflammatory pathways, and recent data demonstrate that the gut microbiota may affect lipid metabolism and function as an environmental factor that influences the development of obesity and related diseases. Here, we review how the gut microbiota may affect metabolic diseases by activating the innate immune system.

Dietary supplementation of tetradecylthioacetic acid increases feed intake but reduces body weight gain and adipose depot sizes in rats fed on high-fat diets

AIM

The pan-peroxisome proliferator-activated receptor (PPAR) ligand and fatty acid analogue tetradecylthioacetic acid (TTA) may reduce plasma lipids and enhance hepatic lipid metabolism, as well as reduce adipose tissue sizes in rats fed on high-fat diets. This study further explores the effects of TTA on weight gain, feed intake and adipose tissue functions in rats that are fed a high-fat diet for 7 weeks.

METHODS

The effects on feed intake and body weight during 7 weeks' dietary supplement with TTA ( approximately 200 mg/kg bw) were studied in male Wistar rats fed on a lard-based diet containing approximately 40% energy from fat. Adipose tissue mass, body composition and expression of relevant genes in fat depots and liver were measured at the end of the feeding.

RESULTS

Despite higher feed intake during the final 2 weeks of the study, rats fed on TTA gained less body weight than lard-fed rats and had markedly decreased subcutaneous, epididymal, perirenal and mesenteric adipose depots. The effects of TTA feeding with reduced body weight gain and energy efficiency (weight gain/feed intake) started between day 10 and 13. Body contents of fat, protein and water were reduced after feeding lard plus TTA, with a stronger decrease in fat relative to protein. Plasma lipids, including Non-Esterified Fatty Acids (NEFA), were significantly reduced, whereas fatty acid beta-oxidation in liver and heart was enhanced in lard plus TTA-fed rats. Hepatic UCP3 was expressed ectopically both at protein and mRNA level (>1900-fold), whereas Ucp1 mRNA was increased approximately 30-fold in epididymal and approximately 90-fold in mesenteric fat after lard plus TTA feeding.

CONCLUSION

Our data support the hypothesis that TTA feeding may increase hepatic fatty acid beta-oxidation, and thereby reduce the size of adipose tissues. The functional importance of ectopic hepatic UCP3 is unknown, but might be associated with enhanced energy expenditure and thus the reduced feed efficiency.

Treatment of gustatory hyperlacrimation (crocodile tears) with injection of botulinum toxin into the lacrimal gland

PURPOSE

To establish the efficacy and safety of botulinum toxin in the treatment of Crocodile Tear Syndrome and record any possible complications.

METHODS

Four patients with unilateral aberrant VII cranial nerve regeneration following an episode of facial paralysis consented to be included in this study after a comprehensive explanation of the procedure and possible complications was given. On average, an injection of 20 units of botulinum toxin type A (Dysport) was given to the affected lacrimal gland. The effect was assessed with a Schirmer's test during taste stimulation. Careful recording of the duration of the effect and the presence of any local or systemic complications was made.

RESULTS

All patients reported a partial or complete disappearance of the reflex hyperlacrimation following treatment. Schirmer's tests during taste stimulation documented a significant decrease in tear secretion. The onset of effect of the botulinum toxin was typically 24-48 h after the initial injection and lasted 4-5 months. One patient had a mild increase in his preexisting upper lid ptosis, but no other local or systemic side effects were experienced.

CONCLUSIONS

The injection of botulinum toxin type A into the affected lacrimal glands of patients with gusto-lacrimal reflex is a simple, effective and safe treatment.

An interim report on the development of the Psychological Trauma and Resources Scales

The William S. Hall Psychiatric Institute Psychological Trauma and Psychological Resources Scales is a preliminary measure for the assessment of psychological trauma and psychological health from a developmental perspective. This three-part article (1) discusses the various rationales leading to the development of the scales, (2) provides a factor-analysis of responses of 336 college students, and (3) addresses current (N = 37) and planned efforts to establish reliability and validity of a more refined version.

The selective use of dimercaptosuccinic acid renal scans in children with vesicoureteral reflux

Dimercaptosuccinic acid (DMSA) renal scans were performed on 75 children (115 refluxing renal units) to determine the efficacy of routine scanning in patients with various grades of vesicoureteral reflux. Cystourethrography demonstrated grades I and II reflux in 75 renal units and grades III to V in 40. Of the patients 51 presented with febrile urinary tract infection and 24 were asymptomatic (patients presenting with nonfebrile urinary tract infections or those undergoing sibling screening). Renal ultrasounds were performed in 60 patients. All patients were initially managed with medical therapy and 19 (25%) ultimately underwent antireflux surgery. DMSA scans demonstrated scarring in 17 of 40 renal units (43%) of patients with high grade vesicoureteral reflux and 6 of 75 renal units (8%) of those with low grade reflux. Renal ultrasounds that were interpreted as normal always correlated to a normal DMSA scan in asymptomatic patients. In patients presenting with febrile urinary tract infections the correlation between ultrasound and DMSA scan was inconsistent. We advocate a tailored approach in the evaluation of patients with vesicoureteral reflux. Renal sonography may be sufficient in the assessment of renal scarring in asymptomatic patients with reflux and those with low grade reflux. Conversely, in patients with high grade vesicoureteral reflux, a history of febrile urinary tract infections and abnormal renal ultrasound DMSA renal scans appear to be most useful.

Detection of human androgen receptor mRNA expression abnormalities by competitive PCR

A competitive polymerase chain reaction (PCR) method for analysis of androgen receptor (AR) mRNA expression is described. The technique involves the use of an in vitro-transcribed RNA (cRNA) corresponding to a region of the AR mRNA transcript as a competitor in reverse transcription and PCR (RT-PCR) using total cellular RNA. The competitor RNA contains a site-directed mutation that produces a restriction fragment length polymorphism after RT-PCR and endonuclease digestion. We demonstrate that incorporation of the competitor RNA into RT-PCR reactions allows rapid semiquantitative determination of relative AR mRNA levels without the necessity of following PCR product formation kinetically; reaction products are assessed at the conclusion of the reaction sequence and without the use of radioactive probes or other specialized detection systems. We have used competitive PCR to demonstrate low levels of AR mRNA in an androgen-unresponsive human prostate cell line (PC3). In addition, we have also used this method to confirm that genital fibroblasts obtained from a subject with penoscrotal hypospadias (a non-intersex masculinization defect) that exhibit low levels of high-affinity androgen binding also exhibit abnormally low AR mRNA levels. These last results suggest that some non-intersex malformations of the urogenital tract are associated with abnormalities in the expression of the androgen receptor.

[Collagenous colitis. Studies on the differentiation and incidence of the syndrome]

All colon biopsy specimens of 28 months collected in an institute of pathology, providing a region of 660,000 inhabitants were reviewed for thickening of the subepithelial layer above the normal range of 7 mu. 16 cases were found, eleven of them with mild, uncharacteristic symptoms, eight even without diarrhea. Of the five cases with collagen layers above 10 mu, three suffered from intestinal diseases (unspecific protocolitis, active ulcerative colitis and malabsorption after ileum resection); two showed chronic diarrhea as symptoms of collagenous colitis. We conclude, that a subepithelial collagen layer is without any significance. Above 10 mu, two forms can be postulated: a reactive one, following chronic intestinal diseases and the idiopathic collagenous colitis syndrome of unknown etiology and pathogenesis. The presence of 185 cases is assumed in Western Germany, five of them already published.

Encoding and retrieval processes in learning-disabled, head-injured, and nondisabled young adults

Using a multi-trial, free-recall paradigm (Rey Auditory-Verbal Learning Test; Lezak, 1983), the acquisition and retention by learning disabled (LD) young adults with a Halstead Impairment Index less than or equal to 0.3 (low LD) or greater than or equal to 0.4 (high LD) was compared with that of nondisabled and head-injured (HI) young adults. Significant group differences, particularly during the last three acquisition trials, confirmed the effectiveness of this method in revealing subtle learning and retention deficits. Analyses of Trial 1 recall showed group differences in the prerecency but not the recency portion of the serial position curve, thus implicating long-term but not short-term memory differences between the groups. Analyses of pair frequency (Sternberg & Tulving, 1977) data showed that the three clinical groups had difficulty organizing the to-be-learned material for effective retrieval. Following an interpolated task, retention was poorer for the clinical groups than for the nondisabled and varied inversely with the degree of neuropsychological impairment. Finally, during retention, the nondisabled and low LD groups retained and used the list organization established during acquisition whereas the high LD and HI groups did not.

Influence of the carboxylesterase inhibitor bis-p-nitrophenylphosphate on the rates of hydrolysis of various alpha-esters of 1-(N-methyl-N-nitrosamino)-methanol in vitro and in vivo and on the acute toxicity and carcinogenicity of 1-(N-methyl-N-nitrosamino)-methylacetate

The effect of an in vivo treatment with the carboxylesterase inhibitor bis-p-nitrophenylphosphate (BNPP) on the hydrolysis of 1-(N-methyl-N-nitrosamino)-methylacetate (NNMA), 1-(N-methyl-N-nitrosamino)-methylbutyrate (NNMB), 1-(N-methyl-N-nitrosamino)-methylbenzoate (NNMBz) and 1-(N-methyl-N-nitrosamino)-methylpivaloate (NMMP) in rat tissue homogenates was studied. The rates of hydrolysis were specific for each compound and different in every organ tested; the extent of inhibition of the hydrolysis by BNPP was also substrate and organ specific. In some cases no inhibition at all was observed. The rate of elimination of NNMA, NNMB, and NNMP from blood was not influenced by BNPP pretreatment. The LD50 of NNMA after i.v. application showed a rise of 85% with a BNPP pretreatment. BNPP also influenced the carcinogenicity of NNMA, whereby the total carcinogenic potency was not altered, but the organotropism had changed slightly.

Stability of various alpha-esters of 1-(N-methyl-N-nitrosamino)-methanol in vitro and in vivo

The hydrolytic activities of various rat tissue homogenates on the substrates 1-(N-methyl-N-nitrosamino)-methylacetate (NNMA), 1-(N-methyl-N-nitrosamino)-methylbutyrate (NNMB), 1-(N-methyl-N-nitrosamino)-methylbenzoate and 1-(N-methyl-N-nitrosamino)-methylpivaloate (NNMP) were investigated+. The hydrolytic enzymes of liver and serum showed similar activities toward all investigated compounds, while those of kidney, lung, heart, stomach and forestomach hydrolyzed the various esters differently. Differences in the in vivo elimination of NNMA, NNMB and NNMP from blood could not be found. After 20 s only 10% of the initial concentrations still occurred in blood after i.v. application.

Bulbar palsy with Rosenthal fiber formation in the medulla of a 15-year-old girl. Localized form of Alexander's disease?

A 15-year-old girl died of a long-standing bulbar palsy that had caused difficult swallowing since early infancy. She was severely malnourished and retarded in growth. Morphologically, the clinical symptoms corresponded to a circumscribed lesion in the enlarged medulla (mega-medulla) that consisted of proliferation of astrocytes, incomplete demyelination, perivascular infiltrates and abundant formation of Rosenthal fibers. Rosenthal fibers were also present in the subpial medullary region where inflammation and astrocytic proliferation were largely absent. This patient's disorder appears to be a localized form of alexander's disease because macrencephaly, Rosenthal fiber formation and leukodystrophy of the cerebral hemispheres and cerebellum were absent. The morphological spectrum of Alexander's disease may now comprise diffuse and localized forms both of adulthood and children.

[Treatment of abdominal liposarcoma in children (author's transl)]

A patient with abdominal liposarcoma is described, and the treatment of this in children extremely uncommon tumor is discussed. After complete surgical excision, local irradion with 5000-6000 rad should be considered only if no vital organs are irradiated. Because of the high tendency for local recurrence and for distant metastases of this tumor a primary polychemotherapy beginning immediately after surgical excision is proposed as in cases of other solid tumors in children for instance rhabdomyosarcoma or fibrosarcoma. 18 months after the surgical excision and after the beginning of polychemotherapy our patient is clinically well without demonstrable tumor growth.