The Shape of the Epiglottis Reflects Improvement in Upper Airway Obstruction after Weight Loss

Obstructive sleep apnea (OSA) is a sleep disorder characterized by recurrent episodes of closure of the upper airway during sleep, and is highly prevalent among overweight individuals. A significant percentage of patients with OSA remain undiagnosed. This condition creates chronic nighttime hypoxemia that can result in significant complications including systemic and pulmonary hypertension, cor pulmonale, and stroke. Polysomnography is still the most widely used method for diagnosing OSA. Studies have shown that in the majority of patients with OSA the airway obstruction involves the retroglossal region. Upon performing esophagogastroduodenoscopy on patients with a wide range of body mass indices (from 21 to 63), we noticed a gradual increase in the concavity of the posterior epiglottal surface as the BMI increases. Upon following some of the patients who underwent laparoscopic gastric banding and lost significant weight, we noticed a dramatic change in the shape of the epiglottis. This reflects a relief in the pressure on the epiglottis created by the collapsing airways in periods of apnea. Thus, the deformity in the shape of the epiglottis reflects the chronic airway collapse in obese patients, and improvement in this deformity after weight loss indicates a relief of the chronic upper airway obstruction.     

HIV-associated opportunistic infections. Bacterial infections

Bacterial infections are the most common opportunistic infections in HIV. Since the advent of highly active antiretroviral therapy (HAART), the incidence of these infections is on the decline. However, globally there is a significant lack of access to care among HIV patients because of limited drug availability and cost of treatment. Furthermore, non-compliance and drug resistance can hinder viral suppression, predisposing patients to opportunistic infections. We review the major bacterial opportunistic infections in HIV positive patients including tuberculosis, Mycobacterium avium complex infections, syphilis, bacterial enteric disease, bacterial pneumonia and bartonellosis. Epidemiology, clinical presentation, diagnosis, treatment and prophylaxis are also reviewed.     

The Jones compression bandage. Review and clinical applications

Lower-extremity edema is a common condition that can be caused by many pathophysiologic processes. Control of edema associated with surgery or trauma is important and will help minimize pain and discomfort and prevent wound complications and blisters. Many techniques are used to control edema. The Jones compression dressing is an excellent tool that has been used successfully by the senior author for 18 years. It continues to be a primary treatment technique for the control of edema.     

Towards PET imaging of the dynamic phenotypes of microglia

There is increasing evidence showing the heterogeneity of microglia activation in neuroinflammatory and neurodegenerative diseases. It has been hypothesized that pro‐inflammatory microglia are detrimental and contribute to disease progression, while anti‐inflammatory microglia play a role in damage repair and remission. The development of therapeutics targeting the deleterious glial activity and modulating it into a regenerative phenotype relies heavily upon a clearer understanding of the microglia dynamics during disease progression and the ability to monitor therapeutic outcome in vivo. To that end, molecular imaging techniques are required to assess microglia dynamics and study their role in disease progression as well as to evaluate the outcome of therapeutic interventions. Positron emission tomography (PET) is such a molecular imaging technique, and provides unique capabilities for non‐invasive quantification of neuroinflammation and has the potential to discriminate between microglia phenotypes and define their role in the disease process. However, several obstacles limit the possibility for selective in vivo imaging of microglia phenotypes mainly related to the poor characterization of specific targets that distinguish the two ends of the microglia activation spectrum and lack of suitable tracers. PET tracers targeting translocator protein 18 kDa (TSPO) have been extensively explored, but despite the success in evaluating neuroinflammation they failed to discriminate between microglia activation statuses. In this review, we highlight the current knowledge on the microglia phenotypes in the major neuroinflammatory and neurodegenerative diseases. We also discuss the current and emerging PET imaging targets, the tracers and their potential in discriminating between the pro‐ and anti‐inflammatory microglia activation states.     

A pilot trial of square biphasic pulse deep brain stimulation for dystonia: The BIP dystonia study

Background : Dystonia often has inconsistent benefits and requires more energy‐demanding DBS settings. Studies suggest that squared biphasic pulses could provide significant clinical benefit; however, dystonia patients have not been explored. Objectives : To assess safety and tolerability of square biphasic DBS in dystonia patients. Methods : This study included primary generalized or cervical dystonia patients with bilateral GPi DBS. Square biphasic pulses were implemented and patients were assessed at baseline, immediately postwashout, post–30‐minute washout, 1 hour post‐ and 2 hours postinitiation of investigational settings. Results : Ten participants completed the study. There were no patient‐reported or clinician‐observed side effects. There was improvement across time on the Toronto Western Spasmodic Torticollis Rating Scale (χ² = 10.7; P = 0.031). Similar improvement was detected in objective gait measurements. Conclusions : Square biphasic stimulation appears safe and feasible in dystonia patients with GPi DBS. Further studies are needed to evaluate possible effectiveness particularly in cervical and gait features. © 2016 International Parkinson and Movement Disorder Society     

Venous Thromboembolism in Cancer Patients Referred to the American University of Beirut—Medical Center Secondary to Deep Vein Thrombosis; Occurrence and Risk Factors

Background/objectives: Cancer is a very important risk factor for the development of thromboembolic disorders. We conducted a retrospective study, in order to examine the rate of Deep vein thrombosis occurrence in cancer patients, as well as the effects of risk factors for DVT in cancer patients affected with DVT. Methods: 148 patients were enrolled in this study. Several risk factors for DVT were retrospectively examined with the main emphasis being age, gender, obesity, previous history of past thromboembolic phenomena and metastatic disease. Results: 55.5% of the study group was older than 60 years of age. Gender did not appear to be a significant risk factor. As for obesity, only 23% of our patients were defined as obese. An examination of previous history of thromboembolic conditions revealed that 16.8% had previous history of DVT, 1.3% developed a PE prior to presentation and 3.4% were positive for both DVT and PE. As for metastasis, 33.7% of our study population exhibited metastatic cancer upon their presentation. One interesting finding was that only 13 patients out of the 148 had been on DVT-prophylaxis prior to their admission. Conclusion: Cancer is an important risk factor for the development of thromboembolic phenomena, yet in most parts of the world, prophylaxis is discerned mostly through clinical judgement or local guidelines. With this in mind, and the additive effects of other risk factors, stricter medical practices and well-defined regimens should be set forth to protect cancer patients from these conditions.     

Traumatic memory reactivation with or without propranolol for PTSD and comorbid MD symptoms: a randomised clinical trial

Post-traumatic stress disorder (PTSD) is difficult to treat but one promising strategy is to block memory reconsolidation of the traumatic event. This study aimed to evaluate the efficacy of traumatic memory reactivation under the influence of propranolol, a noradrenergic beta-receptor blocker, in reducing PTSD symptoms as well as comorbid major depression (MD) symptoms. We conducted a double blind, placebo-controlled, randomised clinical trial in 66 adults diagnosed with longstanding PTSD. Propranolol or a placebo was administered 90 min before a brief memory reactivation session, once a week for 6 consecutive weeks. Measures included the SCID PTSD module, the PTSD Check List (PCL-S) and the Beck Depression Inventory-II (BDI-II). PTSD symptoms decreased both in the pre-reactivation propranolol group (39.28%) and the pre-reactivation placebo group (34.48 %). During the 6 treatment sessions, PCL-S and BDI-II scores decreased to similar extent in both groups and there were no treatment differences. During the 3-month follow-up period, there were no treatment effects for the mean PCL-S and BDI-II scores. However, in patients with severe PTSD symptoms (PCL-S ≥ 65) before treatment, PCL-S and BDI-II scores continued to decline 3 months after the end of treatment in the propranolol group while they increased in the placebo group. Repeated traumatic memory reactivation seemed to be effective for PTSD and comorbid MD symptoms. However, the efficacy of propranolol was not greater than that of placebo 1 week post treatment. Furthermore, in this traumatic memory reactivation, PTSD symptom severity at baseline might have influenced the post-treatment effect of propranolol.Subject terms: Post-traumatic stress disorder, Medical research     

Influence of intense training cycle and psychometric status on technical and physiological aspects performed during the small-sided games in soccer players

The study investigated the effect of intense training cycle (IT) of early season preparation period (SPP) and psychological status on technical and physiological parameters during small-sided games (SSG) and the relationships between these variables. Sixteen professional soccer players participated in the study (mean±SD: age: 24.5±4.1). Training load (TL), Total quality recovery (TQR) and well-being indices were performed daily. TL increased progressively (%TL=31.56 [AU]). Physiological variables did not change after IT and were not influenced by well-being indices and TQR. Technical aspects were negatively altered after IT (p<0.05). TL was significantly correlated with successful passes (r=-0.57, p=0.02), interceptions (r=-0.83, p<0.001) and lost balls (r=0.73, p=0.002). Well-being and TQR were related to successful passes, interceptions and lost passes [(r=-0.55, p=0.03; r=-0.75, p=0.001; r=-0.69, p=0.004); (r=0.54, p=0.03; r=-0.76, p=0.001; r=-0.69, p=0.004), respectively]. TL, Well-being indices and TQR represent a useful strategy for coaches to control technical aspects in soccer players during SPP.     

Blood transfusions in colorectal cancer surgery: incidence,outcomes, and predictive factors: an American College of Surgeons National Surgical Quality Improvement Program analysis

Background

Data analyzing the short-term outcomes and predictors of blood transfusions (BTs) in colorectal cancer (CRC) surgery are limited.

Methods

The American College of Surgeons National Surgical Quality Improvement Program (2005 to 2010) was retrospectively reviewed for CRC cases performed with or without BT. Patient demographics, comorbidities, and operative variables were analyzed. Multivariate regression analysis was performed examining the effect of BT on outcomes. The LASSO algorithm for logistic regression was used to build a predictive model for BT taking into account preoperative and operative variables.

Results

A total of 27,120 patients underwent CRC, and 3,815 (14.07%) had BTs. Transfusions were associated with increased mortality (odds ratio [OR], 1.78), morbidity (OR, 2.38), length of stay (mean difference, 3.52 days), pneumonia (OR, 2.70), and surgical-site infection (OR, 1.45). This effect was “dose dependent,” as patients receiving ≥3 U of blood had increased morbidity (OR, 1.53), lengths of stay (mean difference, 1.82 days), pneumonia (OR, 2.52), and surgical-site infections (OR, 1.60) compared with those receiving 1 to 2 U. Predictors of BT were hematocrit <38%, open surgery, proctectomy, low platelet count, American Society of Anesthesiologists class IV or V, total colectomy, metastatic cancer, emergency, ascites, and infection. All P values were < .05.

Conclusions

BTs are associated with worse short-term outcomes after CRC surgery. Knowledge of predictive factors will help in risk stratification and counseling.