Abnormal things happening during sleep: parasomnias.

Parasomnias are characterized by abnormal experiences, dreams, movements and behavior during sleep. They may occur in the middle of the sleep during REM (rapid eye movement) or NREM (non-rapid eye movement), during falling asleep or waking up. Characteristically for REM behavior disorder is an increased muscle tone although usually REM is defined by an absence of muscle tone. For these forms aggressive dreams may lead to violating bed partners or self-injury of the sleeping person. Even killing bed partners has been described. Many of the patients develop a kind of Parkinson's disease (synucleinopathies). The rate of phenoconversion is more than 30% in 5 years and nearly 100% after 15 years. There are several recommendations regarding a safe sleeping environment. Medicinal treatment consists of either melatonin or clonazepam.

[Guidelines for Non-Invasive and Invasive Home Mechanical Ventilation for Treatment of Chronic Respiratory Failure - Update 2017]. / S2k-Leitlinie: Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz ­ Revision 2017.

Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure". However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines.For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning.In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.The currently updated guidelines are valid for the next three years, following their first online publication on the home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future.

[Respiratory Muscle Training: State of the Art]. / Atemmuskeltraining: State-of-the-Art.

Specific respiratory muscle training (IMT) improves the function of the inspiratory muscles. According to literature and clinical experience, there are 3 established methods: 1.) resistive load 2.) threshold load and 3.) normocapnic hyperpnea. Each training method and the associated devices have specific characteristics. Setting up an IMT should start with specific diagnostics of respiratory muscle function and be followed by detailed individual introduction to training. The aim of this review is to take a closer look at the different training methods for the most relevant indications and to discuss these results in the context of current literature. The group of neuromuscular diseases includes muscular dystrophy, spinal muscular atrophy, amyotrophic lateral sclerosis, paralysis of the phrenic nerve, and injuries to the spinal cord. Furthermore, interstitial lung diseases, sarcoidosis, left ventricular heart failure, pulmonary arterial hypertension (PAH), kyphoscoliosis and obesity are also discussed in this context. COPD, asthma, cystic fibrosis (CF) and non-CF-bronchiectasis are among the group of obstructive lung diseases. Last but not least, we summarize current knowledge on weaning from respirator in the context of physical activity.

Life-threatening events in respiratory medicine: misconnections of invasive and non-invasive ventilators and interfaces.

PURPOSE: Both the parallel use of intensive care unit (ICU)-ventilators and ventilators dedicated to non-invasive ventilation (NIV), as well as the construction of some expiratory valves in single circuit breathing tubes may lead to misconnections which are potentially fatal for the patient. METHODS: We demonstrate first a case of a misconnected expiratory valve in a patient with invasive home ventilation. In a second case, the mistaken connection of a non-invasive ventilator to an endotracheal tube leading to carbon dioxide (CO2)-rebreathing is demonstrated. A third case describes a patient with home non-invasive ventilation who had been delivered a non-vented mask out-of-hospital, likewise leading to CO2-rebreathing. CONCLUSION: Human error is the main reason for critical incidents in medicine and the most serious unintended events often involve mechanical ventilation. A regular instruction of medical staff and patients is necessary. The demonstrated misconnections are examples of latent errors "waiting to happen". To prevent these errors from being made in the future, technological solutions similar to the aviation effort to improve safety are needed.

[Weaning failure: follow-up care by the weaning centres--home visits to patients with invasive ventilation]. / Frustranes Weaning: Nachsorge durch das Weaningzentrum--Hausbesuche bei invasiv beatmeten Patienten.

BACKGROUND: At present health-care at home for the majority of patients with invasive ventilation is mainly provided by nursing personnel. The reason for this unsatisfying condition is the lack of a basic medical supply for patients with invasive ventilation outside of hospitals. In contrast, current guidelines recommend a follow-up care by the weaning centres that applies for patients with invasive ventilation at home. In an case the practical implementation of the follow-up care is not specified. MATERIAL AND METHODS: In this paper we attempt to balance the reasons for the need of follow-up care for ventilated patients by the weaning centre on the basis of 6 cases. Furthermore, we want to report our experience with a weekly visitation of these patients as a basic structure of the follow-up care. RESULTS AND CONCLUSIONS: The necessity for a regular consultation by a pneumologist that can be established by weekly rounds has been demonstrated. In addition, it can be expected to reduce the costs of public health markedly if one takes data from ventilated patients living in specialised institutions into account. Nevertheless prospective studies are necessary to objectify the financial and medical benefits arising from this form of medical supply. These studies should be designed as multicentre studies because of the heterogenous population of ventilated patients and the fact that home ventilation is in general a seldom occurrence.

[Amyloidosis in pneumology]. / Amyloidose in der Pneumologie.

Amyloidosis is a rare disorder within the field of pneumology, however, it is estimated that there are a relevant number of unreported cases. In routine clinical practice, the disease is seldom considered in the diagnostic work-up of unclear respiratory symptoms and radiological findings. For amyloidosis to be considered as a differential diagnosis, the clinician must be aware of the broad variety of its clinical manifestations. In cases where amyloidosis is suspected, it is important to obtain an early tissue biopsy. If the diagnosis can be confirmed by Congo red staining, further subtyping of the amyloid protein is necessary in order to identify a treatable cause of the disease. The amyloidoses are classified according to the type of amyloid protein, with clinical subclassifications distinguishing hereditary from acquired forms and localised from generalised manifestations. Apart from causal therapy of the primary disease, the treatment of generalised amyloidosis includes specific systemic therapy. The majority of localised forms are treated with specific local interventions showing good long-term results. This review outlines the pathophysiology, classification, diagnostic pathways and therapeutic modalities in amyloidosis. Furthermore, typical manifestations of amyloidosis of the lung and the specific treatment options are discussed.

[Evaluation of a new automatic CPAP algorithm in the treatment of obstructive sleep apnoea syndrome]. / Evaluation eines neuen Algorithmus zur automatischen CPAP-Therapie beim obstruktiven Schlafapnoe-Syndrom.

BACKGROUND: Automatic continuous positive airway pressure (automatic CPAP, APAP) is an effective treatment option in the obstructive sleep apnoea syndrome (OSAS). The differentiation of obstructive and central respiratory events is crucial in adjusting the optimal pressure in this treatment mode. In this pilot study we evaluated a new automatic CPAP algorithm in OSAS patients. METHODS: 14 patients with newly diagnosed obstructive sleep apnoea syndrome were enrolled. After a diagnostic polysomnography, patients were treated for one night with a new APAP device based on flow, snoring, relative minute volume and the obstructive pressure peak signal. RESULTS: The total apnoea/hypopnoea index (AHI) was 30.0 +/- 21.4/h at baseline and 3.7 +/- 5.3/h with APAP ( P < 0.005). Both obstructive AHI (22.7 +/- 20.5/h at baseline, 1.5 +/- 3.5/h with APAP, P < 0.005) and central AHI (7.3 +/- 4.9/h and 2.2 +/- 2.5/h, respectively, P < 0.01) as well as the arousal index (25.4 +/- 18.1/h and 5.1 +/- 3.8/h, respectively, P < 0.005) were reduced significantly with the new algorithm. CONCLUSIONS: The new algorithm of an automatic CPAP device is effective in the treatment of obstructive sleep apnoea syndrome.

[Pathophysiology of the obesity hypoventilation syndrome]. / Obesitas-Hypoventilationssyndrom--Pathophysiologische Aspekte.

The obesity hypoventilation syndrome (OHS) is defined by extreme overweight (BMI 30 kg/m2), daytime hypoventilation (PaCO2 > 45 mm Hg, the absence of other known causes of hypoventilation) and sleep-related breathing disorders. Obesity impairs breathing due to a restrictive ventilatory disorder, reduction of the capacity of respiratory muscles and diminishment of the ventilatory response. The restriction cannot serve as the only explanation of OHS because body weight or compliance on the one hand and hypoventilation on the other hand only correlate weakly. Obesity increases the work of breathing by greater body mass with its increased oxygen demand, impaired diaphragmatic mobility, upper airway obstruction, and oxygen desaturation which result in an inadequacy of oxygen demand and supply. The adjustment of the chemoreceptors can avoid the overload on the capacity of the respiratory muscles, at least in a number of patients or in the course of the disease. This disproportion results in hypercapnia. Furthermore, the level of leptin is an important factor in the pathophysiology of OHS. The blood level of leptin correlates with the body fat mass in humans. However, there seems to be a relative leptin deficiency in the brain in overweight humans. Therefore, in contrast to animals, leptin cannot sufficiently increase ventilation in man to avoid hypercapnia.

[Telecommunication in trauma surgery. Communication networks of hospitals in East Bavaria]. / Telekommunikation in der Unfallchirurgie. Vernetzung medizinischer Versorgungseinrichtungen in Ostbayern.

The growing complexity of the performance processes in medicine makes it mandatory that the flow of information is faster and more consistent, especially when the sites of health care are far away from each other. The Regensburg model, a realization of lean telemedicine from a low-cost domain, using PC-based standard videoconferencing systems shows the use of modern telecommunications, especially in trauma surgery. In 203 prospectively evaluated teleconsultations between 15 participants a total of 697 images were transmitted via videoconferencing. In 95% of the trauma cases the transmitted material was judged as at least sufficient. In project-attending evaluations the efficacy of these systems and their use were clearly demonstrated. Savings in transportation costs of up to 4,400 DM per case were achieved. Through quicker flow of information quality improvements for all participants resulted; to some extent considerable costs for health care were avoided or reduced. Based on these thoughts, a new platform of communication will be established in Regensburg as a closed medical intranet for the region of eastern Bavaria.

[Utility of PC-based videoconference systems in surgery]. / Nutzen von PC-basierten Videokonferenzsystemen in der Chirurgie.

Growing complexity of performance processes in medicine require a quicker and more consistent flow of information, even between distant sites of health care. The Regensburg model, a realisation of lean telemedicine from a low-cost domain, using PC-based standard videoconferencing--systems shows the use of modern telecommunications especially in medical spheres. In project-related evaluations, the efficacy of these systems as well as their use can clearly be proven. Through a quicker flow of information, quality improvements for all participants resulted, and to some extent considerable costs for health care were avoided or lowered.

Intravenous lidocaine and bupivacaine dose-dependently attenuate bronchial hyperreactivity in awake volunteers.

BACKGROUND: In standard textbooks, intravenous lidocaine is recommended for intubation of patients with bronchial hyperreactivity. However, whether and to what extent intravenous local anesthetics attenuate bronchial hyperreactivity in humans is unknown. Accordingly, nine awake volunteers with known bronchial hyperreactivity were subjected to an inhalational challenge with acetylcholine before and during intravenous infusion of lidocaine, bupivacaine, or placebo in a randomized, double-blinded fashion. METHODS: Baseline acetylcholine threshold concentrations were determined 3-5 days before initiation of the investigation. The response to the acetylcholine challenge was defined as hyperreactive, if forced expiratory volume in 1 s decreased by at least 20%. In addition, the acetylcholine threshold for a 100% increase in airway resistance was obtained by body plethysmography. On seven different days, the acetylcholine challenge was repeated at the end of a 30-min intravenous infusion period of three doses of lidocaine (1, 3, and 6 mg.min(-1)) or bupivacaine (0.25, 0.75, and 1.5 mg.min(-1)), during saline placebo infusion, respectively. Acetylcholine-threshold concentrations were presented with the respective plasma concentrations of the local anesthetic. RESULTS: The infusion of lidocaine and bupivacaine resulted in plasma concentrations (means +/- SD) of 0.29 +/- 0.11, 1.14 +/- 0.39, and 2.02 +/- 0.5 microg.ml(-1) for lidocaine and 0.11 +/- 0.04, 0.31 +/- 0.09, and 0.80 +/- 0.18 microg.ml(-1) for bupivacaine, respectively. Compared to baseline, the acetylcholine threshold for a 20% decrease of forced expiratory volume in 1 s as well as the threshold for a 100% increase in total airway resistance increased significantly with increasing plasma concentrations of both local anesthetics. Compared to placebo, acetylcholine threshold was almost quadrupled for lidocaine and tripled for bupivacaine with the highest plasma concentration of each local anesthetic. CONCLUSIONS: In awake humans, intravenous lidocaine and bupivacaine both dose-dependently attenuated the hyperreactive response to a nonspecific inhalational challenge with acetylcholine.

The effects of finasteride on scalp skin and serum androgen levels in men with androgenetic alopecia.

BACKGROUND: Data suggest that androgenetic alopecia is a process dependent on dihydrotestosterone (DHT) and type 2 5alpha-reductase. Finasteride is a type 2 5alpha-reductase inhibitor that has been shown to slow further hair loss and improve hair growth in men with androgenetic alopecia. OBJECTIVE: We attempted to determine the effect of finasteride on scalp skin and serum androgens. METHODS: Men with androgenetic alopecia (N = 249) underwent scalp biopsies before and after receiving 0.01, 0.05, 0.2, 1, or 5 mg daily of finasteride or placebo for 42 days. RESULTS: Scalp skin DHT levels declined significantly by 13.0% with placebo and by 14.9%, 61.6%, 56. 5%, 64.1%, and 69.4% with 0.01, 0.05, 0.2, 1, and 5 mg doses of finasteride, respectively. Serum DHT levels declined significantly (P <.001) by 49.5%, 68.6%, 71.4%, and 72.2% in the 0.05, 0.2, 1, and 5 mg finasteride treatment groups, respectively. CONCLUSION: In this study, doses of finasteride as low as 0.2 mg per day maximally decreased both scalp skin and serum DHT levels. These data support the rationale used to conduct clinical trials in men with male pattern hair loss at doses of finasteride between 0.2 and 5 mg.