Videoendoscopic Assessment of Uncommon Sites of Upper Airway Obstruction during Sleep

Patients with sleep-disordered breathing (SDB) suffer from repetitive upper airway occlusion. Various techniques have been described to assess the site of upper airway collapse. In most cases the soft palate or the base of tongue, or both, are the major levels of obstruction; rarely, the larynx, including the epiglottis, are found to be involved. We present five cases in which sleep videoendoscopy finally revealed the true mechanism of the inspiratory airway behavior. Two patients were sent to our service because of inefficacy of nasal ventilation therapy. One had a floppy epiglottis that was being sucked into the glottis. The other had a normal larynx during videoendoscopy. Instead, common pharyngeal collapse could be detected. Increasing the pressure normalized sleep, breathing, and videoendoscopy. The third patient showed apneas due to the adduction of the lateral parts of his omega-shaped epiglottis. In another case, inspiratory fluttering of the vocal cords caused snoring and arousals. The last case came in for bilateral vocal cord palsy with heavy nocturnal desaturations suggesting airway closure. Yet, the pharynx and larynx remained open throughout the night. Sleep videoendoscopy is a convenient method to define the level and mechanism of occlusion in obstructive SDB, particularly if the larynx is involved. It is useful to rule out airway compromise in case of recurrent nocturnal hypoxemias. Thus the results of sleep videoendoscopy have a strong therapeutical impact.     

Elektrische Atemwegsstimulation zur Therapie der obstruktiven Schlafapnoe

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of pharyngeal collapse resulting from a decrease in tone of the dilatory musculature of the pharynx. Electrical stimulation of the hypoglossal nerve is a new clinical treatment modality for patients with moderate to severe OSA, who do not respond to standard therapy with continuous (CPAP) or automatically adjusted (APAP) positive airway pressure therapy or adjustable mandibular advancement devices. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation (HNS), the results of the large STAR multicenter prospective trial using the Inspire? device were recently published. The results show that HNS can prevent pharyngeal collapse without arousing patients from sleep and HNS with the Inspire? device led to a significant improvement of objective and subjective measurements of the severity of OSA. A limitation of available HNS remains the invasive procedure and the costs involved. Further research is required to define optimal patient selection and device performance and to investigate long-term effectiveness. The absence of a complete circular collapse at the level of the palate as documented during drug-induced sleep endoscopy can predict success with implanted HNS therapy and is therefore a requirement for the implantation of the Inspire? device, which is rarely effective in cases with complete concentric collapse at the level of the soft palate. It is strongly recommended that implantation of HNS devices is performed only in experienced centers with multidisciplinary sleep medicine teams. The recruitment of patients in clinical trials and enrollment in registries could help to control quality and costs.     

Osteoprotegerin: A novel biomarker for inflammatory bowel disease and gastrointestinal carcinoma

Osteoprotegerin (OPG) is a member of the tumor necrosis factor receptor superfamily of proteins. Although initial data illustrated the key role that OPG plays in bone turnover, numerous recent reports indicate that OPG is also an important factor in inflammatory pathways and tumor cell survival. OPG contributes directly to inflammatory processes and has been evaluated as a novel non‐invasive biomarker of gut inflammation. Furthermore, OPG affects cell turn‐over, differentiation, death, and survival via extracellular pathways, correlating with worse prognosis in inflammatory bowel diseases and several gastrointestinal carcinomas. It is now clear that OPG has multiple functions and characteristics. This review gives an overview of OPG, highlights its roles in different extracellular pathways, and outlines how OPG could be used as a novel non‐invasive biological marker in inflammatory bowel diseases and gastrointestinal carcinomas.     

Improvement of Risk Prediction After Transcatheter Aortic Valve Replacement by Combining Frailty With Conventional Risk Scores

Objectives

This study sought to evaluate whether frailty improves mortality prediction in combination with the conventional scores.

Combining bioengineered human dermal replacement and multilayered compression dressings to manage ulcers in a person with diabetes mellitus: a case study

Multiple modalities exist for the care of lower extremity ulcers associated with venous insufficiency and complications of diabetes mellitus, (eg, neuropathy). Although reports about the use of topical adjunctive treatment modalities in the treatment of foot ulcers in persons with diabetes mellitus exist, little is known about the safety of topical treatment when used in combination with compression therapy to manage venous insufficiency. A patient with diabetes mellitus, neuropathy, a 3.3 cm x 3.0 cm x 1 mm heel ulcer and a 8.1 cm x 4.9 cm x 3 mm lower leg ulcer secondary to venous insufficiency presented at the authors' clinic. After 8 weeks of therapy using a combination of bioengineered human dermal replacement and multilayered compression dressings, lower leg edema was reduced, the heel ulcer healed, and the leg ulcer continued to improve. No complications were observed. The results observed suggest that studies examining the effects of treatment regimens that address the multifactorial etiology of some lower extremity ulcers are warranted.     

Fleroxacin clinical pharmacokinetics.

Fleroxacin is a new member of the class of fluoroquinolones. The drug has good activity (i.e. minimum inhibitory concentrations at less than 2 mg/L against 90% of strains) against a wide range of Gram-positive and Gram-negative bacteria. High performance liquid chromatography is used to determine concentrations of fleroxacin and its metabolites in biological fluids. Absorption of orally ingested drug is rapid as the peak plasma concentration of approximately 5 mg/L is reached in 1 to 2h after a single dose of 400mg. The systemic availability is close to 100%. Fleroxacin is poorly bound to plasma proteins (23%) and exhibits excellent tissue distribution. Renal clearance accounts for 60 to 70% of elimination. The drug is metabolised to form antimicrobially active N-demethyl-fleroxacin and inactive N-oxide-fleroxacin. In multiple dose studies the accumulation ratio of a once-daily dosage regimen is about 1.3, as predicted from the elimination half-life of 10 to 12h. Compared with ciprofloxacin, fleroxacin has a greater systemic availability and a longer half-life. Fleroxacin concentrations are higher in elderly patients, but further studies are needed to establish whether a dosage reduction should be recommended for this age group. In patients with renal disease dosage adjustment is recommended since a decreased renal clearance of fleroxacin leads to a significant prolongation of the elimination half-life. Fleroxacin is only poorly eliminated by peritoneal dialysis or haemodialysis. The most important drug-drug interaction is a decrease in systemic availability of fleroxacin after ingestion of aluminium- or magnesium-containing antacids. There is no evidence of a significant interaction between fleroxacin and theophylline. Only limited data are available on adverse reactions of fleroxacin. The most important adverse effects appear to be photosensitivity and a dose-dependent incidence of central nervous system reactions including sleep disorders.     

Gene Probe Analysis in an Informative Family with Multiple Endocrine Neoplasia Syndrome Type 2A (MEN 2A). Improvement in Carrier Risk Estimation

Gene probe analysis of the MEN 2A locus on chromosome 10 hasbeen undertaken using the markers TB10.163, RBP 3 and TB14.34in a large kindred with familial medullary thyroid carcinomas,with or without phaeochromocytomas or primary hyperparathyroidism.A maximum LOD score of 2.97 gave strong evidence of close linkagewith zero recombination. For 12 members of the family so far not known to be affectedby any form of the disease the estimated risk of carrying thegene has been considerably decreased in all but one, whose riskhas been greatly increased.