[Diagnostic accuracy of outpatient polygraphy devices : A comparison with inpatient polysomnography in clinical routine]

BACKGROUND

Cardiorespiratory polysomnography (PSG) is considered the reference method for diagnosis of obstructive sleep apnea (OSA). Due to waiting times and high costs, payers increasingly request outpatient polygraphy (PG) as an alternative to inpatient PSG. The aim of the present study was to evaluate the diagnostic accuracy of different outpatient PG devices compared to stationary PSG in clinical practice.

MATERIALS AND METHODS

Externally collected outpatient PG findings of 406 patients were retrospectively compared with the corresponding PSG findings.

RESULTS

Among the 406 patients were 343 men (85%) and 63 women (15%), with mean age 50 years. Mean body mass index (BMI) was 30 kg/m². The rank correlation coefficient for PG- and PSG- derived apnea-hypopnea index (AHI) values was r = 0.574. On average, PG underestimated the AHI by 6.4 (±20.5) events/h. OSAS severity was determined correctly by PG in only 43% of cases. Sensitivity (90.7%) and specificity (45.2%) of ambulatory PG was calculated for the threshold value AHI ≥ 5/h. Based on the results of PG, an indicated therapy would have been omitted in 35 cases (9%) and unnecessary treatment initiated in 17 cases (4%). The PG devices used showed a comparable diagnostic accuracy (r = 0.513-0.657), with a sensitivity of 81.3-96.9% and a specificity of 33.3-50.0%.

CONCLUSION

Outpatient PG cannot reliably assess OSA severity in clinical routine. Confirmation by PSG in a sleep lab in symptomatic patients is obligatory. Outpatient PG devices should only be used as an upstream screening method. The automatic evaluation of the PG should always be proofed.

[Radiological findings of the nasal septum in CT scan in patients with deviated noses]

OBJECTIVE

The bony-cartilaginous crooked nose is characterized by a deviation of the nasal dorsum from the median sagittal plane. Since the nasal dorsum and the septum form an anatomical entity, a deviation of the external nose always results in a deviation of the cartilaginous and bony nasal septum. The aim of this study was to analyze the pathologies of the septum in patients with crooked noses based on CT images of the midface.

METHODS

The CT images of patients with a documented crooked nose, who presented between 2005 and 2011 in our hospital, were analyzed retrospectively considering photo documentation and nasal findings. The CT scans were performed due to suspected sinusitis unrelated to the study.

RESULTS

The study includes a total of 138 patients. In all patients a deviated septum was found in the CT. In particular, there was not only a deviation of the cartilaginous septum, but also a deviation of the perpendicular plate (PP) in 86% of the cases. This PP deviation distorted to the opposite side of the deviation of the crooked nose in 79% of the cases. However, the base of the PP at the cribriform plate was in a median position in 99% of the cases of the patients. Furthermore, in 96% of cases, the caudal septum was located in midline on the anterior nasal spine, -although 15% presented clinically a dislocation of the caudal septum.

CONCLUSIONS

The bony-cartilaginous crooked nose usually results in a deviation of the cartilaginous and bony septum. In particular, a high deviation of the PP to the opposite side of the deviation of the external nose was present in a majority of the -cases. Therefore, a septo-rhinoplasty with particular consideration of the deviation of the PP is necessary in patients with a deviated external nose.

Prolonged QRS duration (QRS >/=170 ms) and left axis deviation in the presence of left bundle branch block: A marker of poor left ventricular systolic function?

BACKGROUND

Left bundle branch block (LBBB) is commonly associated with structural heart disease and left ventricular dysfunction. We propose that the QRS duration and degree of left-axis deviation (LAD) identify significant left ventricular systolic dysfunction in patients with LBBB.

METHODS

In this prospective study the ejection fraction (EF) of 300 consecutive patients with LBBB was evaluated by echocardiography. The relationship between QRS duration and LAD (axis between -30 degrees and -90 degrees ) and EF were derived.

RESULTS

There was no significant difference in age, sex, presence of ischemic or nonischemic cardiomyopathy and valvular heart disease, and EF among the patients with or without LAD. The EF of patients with QRS >/=170 milliseconds with LAD (n = 20) and without LAD (n = 18) was 25% +/- 16% and 23% +/- 13%, respectively (P =.71). The mean EF (24% +/- 10%) of the patients with a QRS duration of >/=170 milliseconds (n = 38) was significantly lower than the mean EF (36% +/- 16%) of the patients with a QRS duration of <170 milliseconds (n = 262, P <.015). The QRS duration also had a significant (P <.001) inverse correlation with EF (R = 0.37, adjusted R (2) = 0.13, SE of estimate = 16.21). However, the QRS axis was not significantly correlated with EF and did not have added predictive value.

CONCLUSIONS

The QRS duration has a significant inverse relationship with EF and prolongation of QRS duration (>/=170 milliseconds) in the presence of LBBB is a marker of significant left ventricular systolic dysfunction. The presence of LAD in LBBB does not signify a further decrease in EF.

Novel GLRA1 missense mutation (P250T) in dominant hyperekplexia defines an intracellular determinant of glycine receptor channel gating

Missense mutations as well as a null allele of the human glycine receptor alpha1 subunit gene GLRA1 result in the neurological disorder hyperekplexia [startle disease, stiff baby syndrome, Mendelian Inheritance in Man (MIM) #149400]. In a pedigree showing dominant transmission of hyperekplexia, we identified a novel point mutation C1128A of GLRA1. This mutation encodes an amino acid substitution (P250T) in the cytoplasmic loop linking transmembrane regions M1 and M2 of the mature alpha1 polypeptide. After recombinant expression, homomeric alpha1(P250T) subunit channels showed a strong reduction of maximum whole-cell chloride currents and an altered desensitization, consistent with a prolonged recovery from desensitization. Apparent glycine binding was less affected, yielding an approximately fivefold increase in Ki values. Topological analysis predicts that the substitution of proline 250 leads to the loss of an angular polypeptide structure, thereby destabilizing open channel conformations. Thus, the novel GLRA1 mutant allele P250T defines an intracellular determinant of glycine receptor channel gating.

Postoperative mitral valve abscess. A case report

The authors report a case of a patient with postoperative perimitral bioprosthetic abscess and probable systemic embolization. The location of the abscess is not common and the use of porcine bioprostheses is supposedly associated with a low rate of embolic complications. Because of the high mortality and morbidity, it is stressed that patients with prosthetic valve endocarditis should be managed aggressively with surgery.

The frameshift mutation oscillator (Glra1(spd-ot)) produces a complete loss of glycine receptor alpha1-polypeptide in mouse central nervous system

Mice homozygous for the recessive mutation oscillator (Glra1(spd-ot)) suffer from a complex motor disorder leading to death within three weeks after birth. Symptoms of this disorder mimic poisoning by strychnine, the antagonist of the inhibitory glycine receptor. The syndrome has previously been correlated to a 7 base pair microdeletion within the Glra1 gene (chromosome 11) encoding the alpha1-subunit of the adult glycine receptor isoform. As shown by [3H]strychnine binding and western blot analysis employing subunit-specific antibodies, spinal cord of homozygous oscillator mice was totally devoid of alpha1-polypeptide, characterizing the Glra1(spd-ot) gene as a functional null allele of Glra1. Moreover, tissue levels of the postsynaptic anchoring protein gephyrin were drastically reduced in the Glra1(spd-ot)/Glra1(spd-ot) genotype. In contrast, immunoanalysis revealed a persisting low-level expression of non-alpha1 glycine receptor polypeptides. Spinal glycine receptor content was also significantly reduced in the +/Glra1(spd-ot) genotype. This reduction coincided with increased acoustic startle responses in heterozygous animals consistent with haplotype insufficiency of glycine receptor function. Lethality of the murine null allele Glra1(spd-ot) contrasts with the situation in the human, where homozygosity for a GLRA1 null allele produces the phenotype of the non-lethal disorder hyperekplexia (startle disease; stiff baby syndrome). This suggests a disparate regulation of glycine receptor subunit genes and/or diverse compensatory pathways in mice and humans.

A GLRA1 null mutation in recessive hyperekplexia challenges the functional role of glycine receptors

Dominant missense mutations in the human glycine receptor (GlyR) alpha 1 subunit gene (GLRA1) give rise to hereditary hyperekplexia. These mutations impair agonist affinities and change conductance states of expressed mutant channels, resulting in a partial loss of function. In a recessive case of hyperekplexia, we found a deletion of exons 1-6 of the GLRA1 gene. Born to consanguineous parents, the affected child is homozygous for this GLRA1(null) allele consistent with a complete loss of gene function. The child displayed exaggerated startle responses and pronounced head-retraction jerks reflecting a disinhibition of vestigial brain-stem reflexes. In contrast, proprio- and exteroceptive inhibition of muscle activity previously correlated to glycinergic mechanisms were not affected. This case demonstrates that, in contrast to the lethal effect of a null allele in the recessive mouse mutant oscillator (Glra1 spd-ot), the loss of the GlyR alpha 1 subunit is effectively compensated in man.

Point mutation of glycine receptor alpha 1 subunit in the spasmodic mouse affects agonist responses

Homozygotic spasmodic (spd/spd) mice suffer from a motor disorder resembling poisoning by the glycine receptor antagonist strychnine. Here, a point mutation was identified in the glycine receptor alpha 1 subunit gene of the spasmodic mouse which predicts an alanine-to-serine exchange at position 52 of the mature polypeptide. Upon expression in Xenopus laevis oocytes, alpha 1A52S receptor channels displayed reduced responses to glycine, beta-alanine and taurine when compared to recombinant alpha 1 glycine receptors. As glycine receptor content in spinal cord and native molecular weight appeared unaltered, this suggests that the spasmodic phenotype results from an altered neurotransmitter sensitivity of the mutant alpha 1A52S subunit.

Radionuclide simultaneous dual-isotope stress myocardial perfusion study using the "three window technique"

Several methods are available for performing radionuclide stress myocardial perfusion studies. All of these methods require two separate acquisition and processing iterations, which is time-consuming and inconvenient for the patient. The authors introduce a new method using the "three window technique" that they developed to perform simultaneous dual-isotope imaging for stress myocardial perfusion studies. In addition to Tl-201 and Tc-99m windows centered at 70 KeV and 140 KeV, respectively, a third window centered at 105 KeV, representing scattered radioactivity from Tc-99m, is established. By subtracting the radioactivity in the third window from the radioactivity in the Tl-201 window, "crosstalk" interference is significantly reduced. The simultaneous dual-isotope imaging method acquires and processes resting and stress myocardial perfusion images simultaneously. It halves imaging time and doubles patient throughput, improves scheduling flexibility, and reduces patient waiting time and discomfort.