Continuous Positive Airway Pressure (CPAP) Changes in Bariatric Surgery Patients Undergoing Rapid Weight Loss

Background: Obstructive sleep apnea (OSA) is a common condition in morbidly obese patients, with the reported prevalence ranging from 12-78%. There is increasing recognition of the need to diagnose and treat/manage OSA both preoperatively and postoperatively. Nasal CPAP is the preferred treatment of OSA; however, weight loss is associated with a reduction in required pressures. We evaluated the CPAP pressure requirements in a group of patients undergoing rapid weight loss following Roux-en-Y gastric bypass . Methods: 15 patients who had been diagnosed with OSA before surgery were retrospectively evaluated. All patients had demonstrated compliance on home CPAP therapy, were minimally 3 months post-surgery and had follow-up reports that their CPAP was less effective. We obtained data on age, sex, weight, BMI, and apnea/hypopnea index (AHI). Optimal CPAP pressure was obtained initially through attended in-laboratory complex polysomnography. Follow-up CPAP pressure was obtained using an auto-titrating PAP device at home. These data were used to evaluate the pressure changes that accompanied weight loss. Results: This group of patients had lost an average of 44.5 ± 19.4 kg. Four patients had achieved their goal weight. Their starting CPAP pressures averaged 11 ± 3.0 cm H₂O, with a range of 7-18 cm H₂O. Follow-up CPAP pressures averaged 9 ± 2.7 cm H₂O, with a range of 4-12 cm H₂O, representing an overall reduction of 18%. The subgroup of patients who had achieved goal weight had a pressure reduction of 22% (9 ± 2.0 to 7 ± 1.0 cm H₂O). Conclusion: CPAP pressure requirements change considerably in bariatric surgery patients undergoing rapid weight loss. Auto-titrating PAP devices have promise for facilitating the management of CPAP therapy during this time. Consideration should also be given to the use of autotitrating PAP units as the treatment of choice in these patients.     

Thoracic outlet decompression for subclavian vein thrombosis: experience in 71 patients

HYPOTHESIS: There is a difference in outcomes when patients have neurogenic thoracic outlet syndrome in addition to subclavian vein thrombosis. METHODS: Analysis of a prospectively developed database, medical record review, and a patient questionnaire were used to summarize clinical experience from December 1990 to December 2001 on the basis of the patient's original evaluation. Patients were stratified on the presence (group 1) or absence (group 2) of additional neurogenic pathologic features. RESULTS: Of 928 patients evaluated for thoracic outlet syndrome, 71 underwent 73 operative procedures for subclavian vein obstruction. Men predominated (55%), and the mean age was 32 years. Group 1 (41%) had more preoperative disability, a higher incidence of persistent pain (24%), and less likelihood of returning to full activity compared with group 2 (67% vs 93%; P = .01). Catheter-directed thrombolysis was used in 65% of veins. Preoperative balloon angioplasty was used selectively (34%), and only 4% required stents. Supraclavicular decompression and venolysis were usually delayed 3 weeks to allow for healing of the venous endothelium. Complications included wound infection (3%) and postoperative hematoma (8%). CONCLUSIONS: Patients with isolated subclavian vein obstruction have a more favorable outcome relative to those with combined neurogenic and venous pathologic features. Decompression following thrombolysis should be delayed to reduce the incidence of postoperative complications.     

Protocol for bedside laparotomy in trauma and emergency general surgery: a low return to the operating room

Bedside laparotomy (BSL) was introduced as a heroic procedure in trauma patients too unstable for safe transport to the operating room (OR). We hypothesize a BSL protocol would maintain patient safety while reducing OR use. Patients were prospectively entered into a BSL protocol from July 2002 to June 2003 and retrospectively reviewed. Protocol indications for BSL were abdominal compartment syndrome, decompensation due to hemorrhage, washout/closure, and sepsis in a patient too unstable for safe transport to the OR. Primary outcomes were mortality, emergent return to OR, and primary fascial closure (PFC). Trauma operating room charges and OR time were analyzed. One hundred thirty-three BSL were performed on 60 patients with an overall mortality of 23.3 per cent (14/60). There was an average of 2.2 BSL per patient (range 1-8). Indications for BSL were 1) explore/washout (n = 100, 75.2%), 2) decompression (n = 14, 10.5%), 3) infection/abscess (n = 12, 9.0%), 4) hemorrhage (n = 7, 5.3%). Five of 133 BSL (5.8%) were emergently returned to the OR because of perforation or compromised bowel. Trauma OR charges were dollar 5,300 per cases with 2.12 hours per cases. The protocol standardized the conduct of BSL procedure to allow for a low return to OR rate of 5.8 per cent and had an overall in-hospital mortality rate of 23.3 per cent. Primary fascial closure of the abdomen had a significantly reduced hospital stay. BSL allowed trauma OR charges of dollar 5,300 per cases with 2.12 hours per cases savings.     

Effectiveness of a school-based intervention to increase health knowledge of cardiovascular disease risk factors among rural Mississippi middle school children

BACKGROUND: Few school-based interventions have been evaluated to assess health awareness among children in rural southern areas. The purpose of this controlled investigation was to increase health awareness among middle school-aged children residing in a racially diverse rural community in Mississippi. METHODS: This investigation assessed health knowledge before and after a 16-week school-based intervention in 205 fifth-grade students. Height, weight, BMI, body composition, waist circumference, dietary intake, blood lipids and lipoprotein concentrations, blood glucose concentrations, and resting blood pressure were measured to enhance student awareness of cardiovascular disease risk factors. Values in the intervention school were compared with those obtained simultaneously in a control school within the same community. RESULTS: The school-based intervention was effective in increasing health knowledge in the intervention as compared with the control school. Secondarily, it was effective in improving certain dietary behaviors. Utilizing health care professionals in the classroom to teach students appropriate lifestyles and actually measuring cardiovascular risk factors to increase awareness among students was effective in increasing overall health knowledge. CONCLUSIONS: Health knowledge of rural adolescents can be increased through partnerships with schools and multidisciplinary teams of health care professionals. Ongoing efforts to reduce childhood obesity and cardiovascular disease risk factors are urgently needed, and information obtained during this investigation may be used in planning school-based interventions in other diverse, rural communities.     

Intestinal parasitic infections in homosexual men: prevalence, symptoms and factors in transmission.

In a controlled study 67.5% of 200 homosexual men but only 16% of 100 heterosexual men were found to be infected with intestinal parasites. Entamoeba histolytica was isolated from 27% of the homosexual and 1% of the heterosexual men, and Giardia lamblia was isolated from 13% of the homosexual and 3% of the heterosexual men. The presence of symptoms could not be correlated with infection except when the infection was caused by more than one organism, including G. lamblia. Symptoms were much more common in both infected and uninfected homosexuals than in heterosexuals. Among the homosexual men recent foreign travel, living in a homosexual household and promiscuity were not correlated with intestinal parasitic infection, but cleansing of the anus before and sex was associated with a significantly lower prevalence of infection. These findings suggest that the male homosexual community may be an important reservoir of potentially pathogenic protozoa.     

Behavioural sensitivity to PIA in selectively bred mice is related to a number of A1 adenosine receptors but not to cyclic AMP accumulation in brain slices

In a dose of 0.1 mg/kg, PIA had marked behavioural effects in long-sleep mice (which show a high sensitivity to ethanol, while no significant effect was observed in short sleep mice (low sensitivity to ethanol). The number of [3H]PIA binding sites in cortex and subcortical brain regions was significantly higher in long-sleep than in short-sleep mice. The KD value was higher in cortex and cerebellum in the short-sleep mice, but there were no differences in the number of hippocampal beta-adrenoceptors or in the adenosine analogue-induced increase in cyclic AMP accumulation in slices of mouse hippocampus.     

Tissue oxygen available as a criterion for the effectiveness of continuous positive pressure breathing.

As little as 3-5 cm H2O increase in proximal airway pressure applied to normal lung reduces cardiac output. It is postulated that decreased pulmonary compliance in respiratory distress syndrome (RDS) acts as a barrier thus offsetting this effect. Since cardiac output is not routinely measured, severe reduction in it could accompany regression of disease while maintaining the same airway pressure. This study was undertaken to determine whether tissue oxygen available (O2a) could be used to detect changes in perfusion during continuous positive pressure breating (CPPB). CPPB was evaluated in 10 normal rabbits (CL = 9.5 +/- 1.8 cc/g at 25 cm H2O) and in 10 pulmonary-damaged rabbits (CL = 5.5 +/- 1.4 cc/g at 25 cm H2O) produced by subjecting them to 100% O2. Airway pressure was increased from 0-15 cm H2O in 3 cm H2O increments at 10-min intervals. O2a and PaO2 were monitored continuously. In the normal group, O2a decreased at 3 cm H2O airway pressure, reaching 22% of control at 12 cm H2O, at which pressure PaO2 decreased. Breathing 100% O2 at this airway pressure increased PaO2 to 408 mm Hg, whereas O2a returned to 45% of control. In the experimental group, O2a decreased at 9 cm H2O airway pressure, at 12 cm H2O it was 36% of control at which pressure PaO2 decreased slightly. Breathing 100% O2 at this airway pressure increased PaO2 to 316 mm Hg, and increased O2a to 200% of control. These data indicate that with excessive airway pressure, muscle hypoxia may exist during systemic hyperoxemia and that a low compliance lung exerts a protective effect on O2a. Since changes in cardiac output during CPPB are compliance dependent, and since O2a is perfusion dependent, tissue oxygen available could provide a means of selecting optimal airway pressure during CPPB.     

Cellular localization of immunoglobulin within human maglignant melanomata.

The presence of antibody in patients with malignant melanoma is well established if one examines the serum. In this report we have attempted to identify antibody within solid tumours showing that they are rarely present in any appreciable quantity on the surface of tumour cells but can be seen frequently on a number of different types of host cell within the tumours. This is discussed in the light of the role of antibody in the circulation and the possibility of antibody behaving as a blocking factor in vivo.