Cough and spontaneous rupture of a normal spleen.

Rupture of the spleen is a relatively common complication of trauma and many systemic disorders affecting the reticuloendothelial system, including infections and neoplasias. A rare subtype of rupture occurring spontaneously and arising from a normal spleen was recognized as a distinct clinicopathologic entity. The pathogenesis is debated in the absence of external trauma or predisposing disease. It has been reported in association with apparently trivial insults such as vomiting. We report a case of a patient with spontaneous rupture of a normal spleen. Interestingly, it was observed after severe coughing.

Exudative effusions in congestive heart failure.

OBJECTIVES: Pleural effusions due to congestive heart failure (CHF) typically are transudates, but an occasional patient with CHF is found to have an exudate in the absence of an apparent cause other than CHF. We sought to determine the incidence and clinical significance of such exudative effusions. DESIGN: Patients with CHF and effusions seen during the 7-year period from January 1994 through December 2000 were identified from their hospital discharge diagnoses and radiographs, while those who had undergone thoracentesis were identified from a review of the laboratory logs. The presenting symptoms and clinical course were determined from a review of the medical records. The effect of RBC contamination on pleural fluid lactate dehydrogenase (LDH) levels was determined by measuring the LDH activity of mock pleural fluid containing known amounts of RBC. RESULTS: Seven hundred seventy patients had CHF with an effusion, but only 175 patients underwent a thoracentesis. In this select group, 86 patients had transudates and 89 had exudates. A noncardiac cause for the exudate was readily identified in 59 patients by hospital discharge, and 7 more patients had an etiology found during follow-up. Eleven of the remaining 23 patients had undergone coronary artery bypass graft (CABG) surgery > or = 1 year prior to presentation, and 50% of the effusions in patients who had undergone CABG surgery were exudates. Thus, CHF-related exudates were identified in only 12 patients, and in 4 of these patients the exudates could be explained by RBC contamination of the pleural fluid. The clinical presentation of patients with CHF-associated exudates was similar to that of CHF patients with transudates. CONCLUSION: In most patients who have CHF and an exudative effusion, there is a noncardiac cause for the pleural effusion. The high frequency of exudates in patients with a history of CABG indicates a persistent impairment in lymphatic clearance from the pleural cavity. Exudative effusions due solely to CHF are rare.

Effects of nocturnal continuous positive airway pressure therapy in patients with resistant hypertension and obstructive sleep apnea.

STUDY OBJECTIVE: To examine the long-term effects of continuous positive airway pressure (CPAP) therapy on blood pressure (BP) in patients with obstructive sleep apnea and resistant hypertension. METHODS: Study subjects were 98 patients with obstructive sleep apnea syndrome and hypertension who had 3 or more documented daytime BP measurements taken within 3 months of enrollment and every 3 months after CPAP initiation for 1 year. Resistant hypertension was defined as daytime BP of at least 140 mm Hg systolic or 90 mm Hg diastolic, despite the use of 3 or more antihypertensive medications. Patients in the resistant hypertension group (n = 42) were compared with subjects with controlled hypertension (n = 56). RESULTS: Mean difference in mean arterial pressure was -5.6 (95% confidence interval [CI] -2.0 to -8.7 mm Hg; p = 0.03) in the resistant group and -0.8 mm Hg (95% CI -2.9 to 3.3 mm Hg; p = 0.53) in patients with controlled BP at the end of follow up period. CPAP permitted de-escalation of antihypertensive treatment in 71% of subjects with resistant hypertension but did not significantly alter the antihypertensive regimen in the controlled group. Multivariate regression analysis showed that baseline BP (odds ratio 5.4, 95% CI 2.3 to 8.9; p = 0.01) and diuretic therapy (odds ratio = 3.2, 95% CI 1.8 to 6.1; p = 0.02), but not apnea-hypopnea index or hours of CPAP use, were independently associated with a decrease in mean arterial pressure after 12 months of CPAP therapy. CONCLUSION: In this observational study, CPAP was associated with different effects on blood pressure control in hypertensive patients with sleep apnea. A beneficial response to CPAP therapy was found mainly in subjects with the most severe hypertensive disease.

The effect of acid suppression on upper airway anatomy and obstruction in patients with sleep apnea and gastroesophageal reflux disease.

STUDY OBJECTIVES: This study was designed to assess the effect of acid suppression on upper airway structure and function in patients with obstructive sleep apnea syndrome (OSAS) and gastroesophageal reflux disease (GERD). METHODS: This is a single-site within-subjects design. Twenty five patients with documented mild OSAS and objectively documented GERD via 24-hour pH measurement were included in the study. Patients were studied before and after 8 weeks of treatment with rabeprazole, 20 mg, twice a day. Subjects underwent laryngoscopy, polysomnography, and 24-hour pH monitoring. Subjective assessments of sleep obtained included the Pittsburg Sleep Quality Index and the Epworth Sleepiness Scale. RESULTS: Posterior commissure edema was significantly reduced (p < 0.05), and the Reflux Finding Score was improved (p < 0.07). Objective and subjective sleep parameters were significantly improved, sleep-onset latency was significantly reduced (26.2 vs 11.2, p < 0.05), and sleep-related acid contact time was significantly reduced (8.0% vs 1.7% p < 0.001). There was no significant change in the apnea-hypopnea index. CONCLUSIONS: In patients with mild OSAS and documented GERD, acid suppression improves upper airway abnormalities, as well as objective and subjective measures of sleep quality. Aggressive treatment of GERD in patients with OSAS may be helpful in the overall treatment of this select patient population.