Countermeasures for sleep loss and deprivation

Opinion statement Sleep deprivation is ubiquitous and carries profound consequences in terms of personal and public health and safety. There is no substitute for a good night’s sleep. Sleep that is optimal in quality and quantity for individuals, factoring in their age and personal sleep requirements, will minimize sleep debt and maximize daytime performance. Therefore, setting aside an adequate amount of time for sleep should be a priority; sleep should not be sacrificed at the expense of other activities of daily living. Nevertheless, there are certain therapeutic countermeasures available for individuals who are unable to obtain adequate sleep because of medical or sleep-related conditions (eg, narcolepsy, obstructive sleep apnea) when excessive daytime sleepiness is the main feature of the condition, or residual sleepiness despite treatment for the main conditions is present. These therapeutic countermeasures may also be considered in situations in which occupational constraints (eg, rotating shift work, military duty) dictate that constant or heightened vigilance is important or critical to work performance, crucial decision making, and/or survival. Exploration of the causes of sleep loss or deprivation, whether it is voluntary, or work or family induced, and/or the effects of a medical or sleep disorder, is a necessary first step in the evaluation of a patient who has significant daytime fatigue or sleepiness. Wake-promoting substances and medications such as caffeine, modafinil, methylphenidate, and dextroamphetamine may be considered in situations in which sleep loss is unavoidable or persists despite treatment of an underlying disorder that is characterized by or associated with daytime fatigue or sleepiness.     

Supracondylar fractures of the humerus in children.

Supracondylar fractures of the humerus in children are either flexion or extension in type. Associated nerve or vascular injury is common. Fractures that remain stable after reduction can be treated with elbow flexion. If the fracture is unstable or if circulation is compromised, percutaneous pinning or traction treatment is utilized. The ischemic hand is always evaluated for brachial artery damage or for the presence of a compartment syndrome. Varus positioning should always be avoided, but other malalignments either remodel or are not of functional significance.     

« B.A.-BA SANS EBM…» du traitement des abcès et des fistules anales: 10 questions basiques (… ou à se poser fréquemment)

Treatment of anal abscess is surgical incision. It is possible to treat a fistula at the stage of abscess if it seems clear that the origin of the abscess is a fistula or if it is a recurrence. The aim of fistula treatment is to cure the suppuration and to preserve continence, it must consider the type of fistula (height, complexity) and the patient’s history. Imaging is useful in complex anatomical situations or when the fistula has already been operated on several times. Fistulotomy is the most effective treatment for anal fistulas in the hands of a trained operator. It can be performed in one or several stages. The risk of impaired continence concerns mainly high, anterior fistulas in women, or occurring in a subject with diarrhea or already impaired continence. At the initial management of a high or complex anal fistula, it is important to plan already the nature of the subsequent surgery to be performed. A short tract is preferred if fistulotomy is considered, a long tract is better for gluing or plugging.     

Mathematic coupling of data: a common source of error.

The relationship between two variables may be mathematically coupled if either one or both variables are derived and/or calculated, and this can lead to erroneous results and invalid conclusions. The purpose of this report is to identify four types of mathematic coupling of data. Type 1 coupling involves directional changes in two variables which are mathematically coupled. Type 2 coupling is the functional relationship between two calculated variables which have one or more common component variables. Type 3, the most common type of mathematic coupling, is direct algebraic coupling between two variables, when one or more of the variables is derived and/or calculated. Type 4 is indirect coupling or physiologic coupling. The common problem in each type of mathematic coupling is that one variable either directly or indirectly contains the whole or components of the second variable. Statistical techniques, when properly applied to the relationship between the two variables, further obscure the underlying mathematic coupling, and tend to support the erroneous results. Recognition of mathematic coupling is imperative for correct data analysis and accurate interpretation.     

Primär neurogene und myogene Störungen der Körperhaltung

Disturbance of posture may occur in a variety of neurological disorders and occasionally is the presenting or even the only sign. In the majority of cases, the head or the trunk or both are bent forward (bent spine syndrome, dropped head syndrome). A feature of these primary neurogenic or myogenic postural disturbances that is in contrast to antalgic contraction or ankylosis is that they are not fixed, but the trunk or head are easily erected by the examiner and show a characteristic sagging. Neuromuscular disorders are a frequent cause. They may be confined to the paraspinal muscles. Axial computed tomography of the spine, electromyography of the involved muscles, and muscle biopsy help to make the diagnosis. However, also central movement disorders may lead to a sagging of the head or trunk or of both due to a lessened tone of the head and trunk extensors. This is frequently seen in the various parkinsonian syndromes which may, however, occur in association with a focal myopathy of the paraspinal muscles. Occasionally, sagging of the trunk is seen as a side effect of neuropharmacologic medication. Sagging of the trunk or head should be differentiated from a pathologically increased innervation of the ventral muscles in dystonic movement disorders such as antecollis or camptocormia.Pathologic reclination of the head or trunk or both is a rare disturbance of posture. It may occur in dystonia (retrocollis) or, occasionally, as a consequence of musculotendinous contractures secondary to certain neuromuscular disorders such as the rigid spine syndrome.     

The use of the fiberoptic bronchoscope to facilitate endotracheal intubation following head and neck trauma.

The fiberoptic bronchoscope is an invaluable aid in the difficult endotracheal intubation. Its successful use with three patient groups is described: those with soft-tissue contractures of the mouth or neck; those with severe fractures of facial bones and/or mandible; those with unstable fractures or fracture-dislocations of the cervical spine. Fiberoptic bronchoscopy is felt to be the technique of choice when intubation is difficult, especially when there are contractures or deformities of the larynx, manidible, or cervical spine.     

Ankle arthroscopy in the lateral decubitus position

Ankle or subtalar arthroscopy is a commonly performed procedure. It is often desirable to perform a diagnostic or therapeutic ankle arthroscopy followed by an open lateral ankle or hindfoot surgery. Standard positioning for ankle or subtalar arthroscopy is supine with or without the use of noninvasive distractor. In order to save operative time and avoid repositioning and redraping the patient intraoperatively, the authors have developed a positioning technique for performing ankle or subtalar arthroscopy, as well as anterior or medial procedures, followed by sequential procedures of the lateral ankle or hindfoot.     

Home study course: Spring 2002

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category I of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.     

Home study course: summer 2003

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category I of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.     

The clinical features of thin basement membrane nephropathy

Thin basement membrane nephropathy (TBMN) is a common, lifelong condition affecting the kidneys that is characterized by microscopic glomerular hematuria, minimal or no proteinuria, and normal renal function. It often is discovered incidentally, and usually has an excellent prognosis. Many cases are familial and show autosomal-dominant inheritance. The defining characteristic is a glomerular basement membrane (GBM) that is thinned to about half its normal thickness on ultrastructural examination of the renal biopsy specimen. However, occasionally patients with TBMN develop marked proteinuria or renal impairment. It is unclear whether individuals with TBMN and impaired renal function represent part of the spectrum of TBMN associated with heterozygous COL4A3 or COL4A4 mutations, or if their disease is caused by mutations of other genes, or whether it is caused by a second coexistent renal lesion or is misdiagnosed Alport syndrome.     

Fall 2002

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category I of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.     

Abdominal lavage for peritoneal cancer cell seeding prevention

Spontaneous or iatrogenous peritoneal seeding is responsible for locoregional recurrent cancer or peritoneal carcinomatosis. Few surgeons are used to wash the abdominal cavity to prevent peritoneal seeding. But experimentally, washing is not able to dislodge or destroy tumour cells adherent to the peritoneum or to the surgical wounds. The antitumoral effect of abdominal washing is increased by addition of antiseptics or anti-adherent agents.     

Percutaneous biopsies: indications and techniques

Breast inflammation is a difficult clinical problem as it can result from a variety of causes: specific or non-specific infectious mastitis, which may or may not be complicated, primary or secondary inflammatory mastitis or inflammatory cancer. The main objective of radiology is to eliminate an inflammatory cancer. Other objectives are to characterise an inflammatory condition (where the clinical context is valuable in guiding diagnosis but which often requires a micro- or macrobiopsy) or to obtain a microorganism in cases of complicated infectious mastitis (a diagnostic procedure but also comprising the first stage of treatment). Whether for bacteriological or histological purposes, percutaneous samples therefore play a large part in the diagnostic procedure, other than in the clinical context of pregnancy where mastitis is more easily diagnosed because of its frequency. The guidance method is usually ultrasound, and the needle chosen will depend on the radiological or ultrasound signal: puncture with an 18G needle will be used for a bacteriological sample, microbiopsy of a mass or lymph nodes, or macrobiopsy in the case of microcalcifications.     

Fibular hypoplasia with absent lateral rays of the foot

We describe 11 children with fibular hypoplasia and three- or four-ray feet, two bilaterally. This deformity is a less severe form of the better known congenital short tibia with absent or dysplastic fibula. If the leg-length discrepancy is minor, no treatment or a simple orthosis are used. Epiphysiodesis or leg lengthening by callotasis is appropriate for mild to moderate discrepancy. If the foot is non-functional, or the projected leg-length discrepancy is too great, early amputation and a prosthesis are advised.     

股前外侧游离皮瓣移植

作者采用游离股前外侧皮瓣移植治疗严重瘢痕挛缩畸形、深部溃疡等。结果显示４６例中４５例存活,有效率９７．８％。作者认为该皮瓣供区隐蔽,解剖方便,血管恒定,且切取后不会对供区造成外形上的影响,是一种理想的供瓣区。但在静脉曲张性溃疡及伴有心血管疾患病例应慎用。     

Mitral valve prolapse. A review

Primary mitral valve prolapse (MVP) or the disease known as MVP, consists of mixomatous degeneration of the mitral valve with systolic displacement of a portion or all of one or both mitral leaflets beyond mitral annulus into left atrium during systole, associated or not with mitral insufficiency. Prevalence in Mexican population is <2%. MVP behavior is benign unless associated with mitral insufficiency (MI, moderate-to-severe) or complications, or is associated with other syndromes. The major clinical feature of mitral valve prolapse syndrome is mid-to-late systolic clicks identified with auscultation of mitral valve. Echocardiography is usually employed for diagnosis and management. Two-dimensional echocardiography displays one or both leaflets prolapsing behind mitral annulus and into left atrium in systole. In the majority of cases, MVP is harmless and does not cause symptoms nor does it need to be treated. In a small number of cases, it can cause severe mitral regurgitation and needs surgical treatment. Complications derived from MVP must be treated independently. Secondary MVP also consist of displacement of one or both valves toward atrium, but this is due to pathologies such as rheumatic heart disease, ischemic heart disease, or others. In these situations, treatment will be that of the underlying diseases.     

Home study course: winter 2001

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management, or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category I of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.     

Home study course: spring 2001

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category 1 of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.     

Hom study course: winter 2004

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour Category I of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.     

Imaging techniques for infections in the surgical patient

Gallium-67 citrate is easy to use and readily available, but the need to delay imaging for 2 to 4 days after injection hinders rapid diagnosis. Moreover, normal gastrointestinal activity limits its usefulness in evaluating the abdomen. Labeling leukocytes with Indium-111 oxine is a time-consuming, technically involved process, yet the images obtained at 24 hours will usually reveal sites of inflammation or infection. Although the techniques have similar sensitivities, the higher specificity of In-111 makes it the superior agent for many clinical situations. When there are localizing signs or symptoms or a reason to suspect a specific body region, CT or ultrasonography is the imaging modality of choice. Guided needle aspiration can then be performed and is usually diagnostic. Radionuclide imaging with either Ga-67 or In-111 is available as an adjunct if needle aspiration cannot be performed or is inconclusive. Since it provides total-body surveillance, radionuclide imaging is particularly useful for screening when there are no localizing signs and in cases of occult sepsis or fever of unknown origin. If positive, it can direct further imaging with CT or ultrasound.