Incorporating body-type (apple vs. pear) in STOP-BANG questionnaire improves its validity to detect OSA.

STUDY OBJECTIVE: The aim of this study is to evaluate whether adding the item of "apple body type" to the STOP-BANG questionnaire enhances diagnostic performance of the questionnaire for detecting obstructive sleep apnea (OSA). DESIGN: Cross-sectional study. SETTING: Sleep center setting. PATIENTS: Two hundred and eight subjects who were referred for an evaluation of possible OSA at Tulane Comprehensive Sleep Center. The exclusion criteria were age<18years old, incomplete or absent questionnaire, incomplete body type identification, polysomnography (PSG) refusal, and pregnant women. INTERVENTIONS: STOP-BANG items and body type data were collected on the initial clinic visit. An overnight PSG was performed on every participant. MEASUREMENTS: Descriptive analyses of the demographic data and PSG variables were performed. The predictive parameters of STOP and STOP-BANG without and with body type score (STOP-Apple and STOPBANG-Apple) were compared. MAIN RESULTS: The STOP questionnaire's sensitivity/specificity/positive likelihood ratio (+LR) (cut-off=2) was 96%/11%/1.1, respectively whereas the STOP-Apple questionnaire (cut-off=3) was 88%/39%/1.5. The STOP-BANG's sensitivity/specificity/+LR (cut-off=3) was 96%/19%/1.2, respectively whereas the STOP-BANG-Apple questionnaire (cut-off=4) was 90%/39%/1.5. The area under the Receiver Operating Characteristic (ROC) curve of STOP-Apple was comparable to the STOP-BANG (P=0.25). The addition of the apple body type item to the STOP-BANG questionnaire in participants with a score≥3 led to increased specificity (67.4%), increased the odds ratio of having OSA of 2.5 (95% CI, 1.2-5.3) and odds ratio of having moderate-severe OSA of 4.7 (95% CI, 2.5-8.7). CONCLUSION: In the sleep center setting, adding the body type item to the STOP-BANG questionnaire improves not only clinical prediction for PSG confirmed OSA but also predicts moderate to severe of OSA.

A critical appraisal of a systematic review: Sokol J, Jacob SE, Bohn D: Inhaled nitric oxide for acute hypoxemic respiratory failure in children and adults. Cochrane Database Syst Rev 2003 (1): CD002787.

OBJECTIVE: To review the findings and discuss the implications of the use of inhaled nitric oxide for acute hypoxemic respiratory failure in patients beyond the neonatal period. DESIGN: A critical appraisal of a systematic review. FINDINGS: The authors conducted a systematic review with meta-analysis to determine the effect of inhaled nitric oxide on clinical outcomes of patients with acute hypoxemic respiratory failure. The outcomes included mortality, changes in oxygenation, ventilator-free days, duration of intensive care and hospital stays, and adverse effects. It was a high-quality systematic review provided with strict entry criteria, an extensive literature search, and thorough critical appraisals. Only five trials (n = 623) met entry criteria. Inhaled nitric oxide had no effect on mortality in studies without crossover of treatment failures to open-label inhaled nitric oxide (relative risk, 0.98; 95% confidence interval, 0.66-1.44). A statistically significant improvement in oxygenation was observed in one study. The effect, however, was observed only in the first 4 days of treatment and was not clinically significant. The heterogeneity in study findings precluded meta-analyses of other clinical outcomes and adverse effects in the selected studies. CONCLUSIONS: There is insufficient evidence to determine whether inhaled nitric oxide is beneficial or harmful for acute hypoxemic respiratory failure in children and adults. While awaiting further studies to prove its benefit, inhaled nitric oxide should not either be recommended as a standard management or excluded for the treatment of acute hypoxemic respiratory failure.

A Rare Case of ARDS From Human Anaplasmosis.

Human granulocytic anaplasmosis is a tick-borne bacterial disease caused by Anaplasma phagocytophilum. ARDS is a very rare presentation of human anaplasmosis. Early suspicion and empiric antibiotics usually prevent rapid progression of the disease. In our case, despite early initiation of empiric antibiotics, the clinical course of our patient continued to deteriorate but responded dramatically upon addition of steroids. Clinicians should be vigilant about the presentation, diagnostic workup, and treatment of human granulocytic anaplasmosis.

Diagnosing diagnostic error.

Diagnostic errors are the most common errors in primary care. Diagnostic errors have been found to be the leading cause of malpractice litigation, accounting for twice as many claims and settled cases as medication errors. Diagnostic error is common, harmful, costly, and very critical to the patient-safety issues in health care. Diagnostic errors have received relatively little attention, however. Of what is known, diagnostic errors are an important source of preventable harm. Focused research in this area is highly needed because the causes of diagnostic errors are subtle and solutions are less obvious than for other types of errors. As opposed to medication errors, where the factors predisposing to their occurrence and the resultant preventive strategies are better defined, the relationship between factors influencing the diagnostic reasoning or decision making and a diagnostic error are not as clear. This may include any failure in timely access to care; elicitation or interpretation of symptoms, signs, or laboratory results, formulation and weighing of differential diagnosis; and timely follow-up and specialty referral or evaluation. The literature reveals that diagnostic errors are often caused by the combination of cognitive errors and system failure. Increased understanding about diagnostic decision making, sources of errors, and applying some existing strategies into clinical practice would help clinicians reduce these types of errors and encourage more optimal diagnostic processes.

System-related factors contributing to diagnostic errors.

Several studies in primary care, internal medicine, and emergency departments show that rates of errors in test requests and result interpretations are unacceptably high and translate into missed, delayed, or erroneous diagnoses. Ineffective follow-up of diagnostic test results could lead to patient harm if appropriate therapeutic interventions are not delivered in a timely manner. The frequency of system-related factors that contribute directly to diagnostic errors depends on the types and sources of errors involved. Recent studies reveal that the errors and patient harm in the diagnostic testing loop have occurred mainly at the pre- and post-analytic phases, which are directed primarily by clinicians who may have limited expertise in the rapidly expanding field of clinical pathology. These errors may include inappropriate test requests, failure/delay in receiving results, and erroneous interpretation and application of test results to patient care. Efforts to address system-related factors often focus on technical errors in laboratory testing or failures in delivery of intended treatment. System-improvement strategies related to diagnostic errors tend to focus on technical aspects of laboratory medicine or delivery of treatment after completion of the diagnostic process. System failures and cognitive errors, more often than not, coexist and together contribute to the incidents of errors in diagnostic process and in laboratory testing. The use of highly structured hand-off procedures and pre-planned follow-up for any diagnostic test could improve efficiency and reliability of the follow-up process. Many feedback pathways should be established so that providers can learn if or when a diagnosis is changed. Patients can participate in the effort to reduce diagnostic errors. Providers should educate their patients about diagnostic probabilities and uncertainties. The patient-safety strategies focusing on the interface between diagnostic system and therapeutic intervention are strategies that involve both processes to facilitate appropriate follow-up and structural changes, such as the use of electronic tracking systems and patient navigation programs.

Right pulmonary artery agenesis presenting with uncontrolled asthma in an adult: a case report.

INTRODUCTION: Unilateral absence of the pulmonary artery (UAPA) or pulmonary artery agenesis is a rare congenital disorder presenting with a wide spectrum of symptoms. The clinical presentation is variable and many patients can be asymptomatic for many years and even throughout their lives. CASE PRESENTATION: We report the case of a 53-year-old African-American woman who was diagnosed with right pulmonary artery agenesis after presenting with uncontrolled asthma and recurrent bronchopulmonary infections. CONCLUSION: In an unexplained case of recurrent respiratory infections and shortness of breath, the possibility of a rare congenital anomaly like UAPA should be considered and an appropriate evaluation should be done.

Characterization of erectile function in monocrotaline-treated pulmonary hypertensive rats.

The aim of this study was to evaluate erectile function in monocrotaline (MCT)-treated rats with pulmonary hypertension (PH). Forty rats were divided into control (n = 20) and MCT-treated (n = 20) groups. Rats were treated with MCT (60 mg/kg subcutaneously) for 3 weeks to induce PH. Mean pulmonary arterial pressure (mPAP), medial hypertrophy index (percentage of wall thickness of pulmonary artery), and right ventricular hypertrophy (ratio of right ventricle [RV] to left ventricle + septum weight) were evaluated. In vivo erectile responses were assessed by measurement of intracavernosal pressure (ICP)/mean arterial pressure and total ICP (area under the curve). In vitro organ bath studies with corpus cavernosum smooth muscle strips were performed under both normoxic (95% O(2)/5% CO(2)) and hypoxic (by changing gas mixture to 95% N(2)/5% CO(2)) conditions. Erectile tissue was processed for immunohistochemistry. The MCT-treated group was associated with an increase in mPAP, medial hypertrophy index, and RV hypertrophy. MCT-induced PH rats had significantly reduced erectile responses compared with controls. Nitrergic, endothelium-dependent relaxations, as well as alpha-adrenergic contractile responses were significantly reduced in the corpus cavernosum of MCT rats. The functional responses during prolonged periods of hypoxia were similar to those observed in MCT-treated tissues. PH rats showed enhanced inducible nitric oxide synthase (NOS) protein localization, but endothelial NOS and neuronal NOS were unchanged. These results suggest changes in cavernosal physiology are caused by MCT acting on the penile tissues and the systemic vasculature.