An oral hypnotic medication does not improve continuous positive airway pressure compliance in men with obstructive sleep apnea.

BACKGROUND: Compliance with continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA) is highly variable. Recent studies suggest that the initial experience with CPAP may determine long-term success. We hypothesized that administration of a hypnotic medication to new CPAP users would facilitate acclimation and increase usage. METHODS: Seventy-two male OSA patients referred for CPAP treatment were randomized to also receive an oral hypnotic agent (zolpidem), placebo pill, or neither (standard care) for the first 14 days of CPAP treatment. CPAP usage (effective mask pressure [hours per day]) was recorded by an internal data chip. Patient symptoms were assessed with the Epworth sleepiness scale (ESS) and functional outcomes of sleep questionnaire (FOSQ). Treatment groups were matched for age, body mass index, and baseline ESS and FOSQ scores. Despite randomization, the standard care group had a higher apnea/hypopnea index than either the zolpidem or placebo pill groups (54.75 +/- 28.02 vs 32.61 +/- 25.12 vs 38.09 +/- 25.65, p = 0.012) [mean +/- SD]. Compared to placebo pill and standard care groups, the zolpidem group did not show greater CPAP usage in terms of total days used (zolpidem, 20.58 +/- 7.40 days; placebo pill, 17.83 +/- 9.33 days; standard care, 22.92 +/- 6.95 days; p = 0.198) or average time used per night (4.43 +/- 1.16 h vs 4.23 +/- 2.14 h vs 4.94 +/- 1.44 h, p = 0.361). All groups showed significant symptom improvements on both the ESS (p < 0.001) and FOSQ (p < 0.05). CONCLUSION: Administration of an oral hypnotic agent did not improve initial CPAP compliance in men with OSA.

Toxic inhalational injury: gas, vapor and vesicant exposure.

Terrorism poses a clear and present danger to civilian populations. Although terrorist cells may gain access to traditional chemical weapons,there are literally thousands of other industrial chemicals to choose from. Common chemicals used on a daily basis in an industrialized society can be readily obtained from the local shopping center, rail yard. or from nearby industrial parks. and terrorists may choose to use these agents in an attack. The medical implications of a major incident involving the accidental or intentional release of a dangerous chemical are significant, and all healthcare facilities should have a plan in place to manage the casualties of such an event. This plan should include event recognition, crowd control, primary triage, emergency treatment, decontamination of injured and uninjured patients, and secondary triage. Emergency health care providers should be prepared to respond to classic chemical agents such as mustard,chlorine, and phosgene and must also work carefully with law enforcement and public health agencies to keep abreast of new threats. The ability to recognize an event promptly, triage patients, decontaminate casualties,administer antidotes when available, and provide best supportive care will minimize the adverse outcomes.

Case report: Total knee arthroplasty polyethylene liner disengagement identified by arthrography.

We report a case of total knee arthroplasty polyethylene liner disengagement identified by plain film arthrography and CT arthrography.

In vitro and in vivo investigation of the influence of implant surface on the formation of bacterial biofilm in mammary implants.

BACKGROUND: Capsular contracture remains the most common complication following breast augmentation surgery, and evidence suggests that bacterial biofilm on the implant surface is responsible. The authors investigated whether the interaction of bacterial biofilm with implants independently determines progression to capsule formation. They also studied the rate of bacterial growth and adhesion to implants. METHODS: Sixteen adult female pigs had 121 breast implants inserted. Sixty-six implants-23 smooth and 43 textured-were inoculated with a human strain of Staphylococcus epidermidis and received no other treatment. After an average period of 19 weeks, Baker grading was performed and implants were retrieved. For the in vitro study, samples underwent both quantitative bacterial analysis and imaging using confocal laser scanning and scanning electron microscopy. RESULTS: At explantation, there was no significant difference (p = 1.0) in the presence of capsular contracture (Baker grade III and IV) between smooth (83 percent) and textured implants (84 percent). Biofilm was confirmed on 60 of the 66 capsules. Capsules from smooth and textured implants had the same number of infecting bacteria (textured: 3.01 × 10 bacteria/g; smooth: 3.00 × 10 bacteria/g). In vitro, the surface of textured implants showed 11-, 43-, and 72-fold more bacteria at 2, 6, and 24 hours, respectively, compared with smooth implants (p < 0.001). These findings were confirmed by imaging analysis. CONCLUSIONS: These results show that textured implants develop a significantly higher load of bacterial biofilm in comparison with smooth implants. Furthermore, in vivo, once a threshold of biofilm forms on either smooth or textured implant surfaces, there seems to be an equal propensity to progress to capsular contracture.

Severe mania complicating treatment of narcolepsy with cataplexy.

We report the case of a 22-year-old male who exhibited severe manic behavior shortly after beginning treatment with modafinil and venlafaxine for narcolepsy with cataplexy. The manic episode persisted several weeks after medication cessation and required management with a mood stabilizer. Reinstitution of modafinil and an alternate antidepressant for recurrent sleepiness and cataplexy was well tolerated and very effective. Sleep physicians should be aware that psychostimulants, including modafinil, and antidepressant medications commonly prescribed for treatment of narcolepsy may precipitate mania in patients with underlying bipolar disorder.

Pneumomediastinum complicating transbronchial needle aspiration.

Transbronchial needle aspiration (TBNA) is a safe procedure with a reported complication rate of less than 1%. Pneumomediastinum after TBNA has not been reported in the English literature in the past. We present the case of a 65-year-old woman with widely metastatic small cell carcinoma, who developed pneumomediastinum after flexible bronchoscopy with TBNA. A persistent visible defect in the bronchial wall at the site of the needle insertion strongly implicated the TBNA as the cause of the pneumomediastinum.

Nightly sleep duration in the 2-week period preceding multiple sleep latency testing.

STUDY OBJECTIVE: To assess usual nightly sleep duration of patients referred for a Multiple Sleep Latency Test (MSLT). DESIGN: Retrospective chart review. SETTING: Military, hospital-based, sleep center. PATIENTS: Fifty-four patients with excessive daytime sleepiness referred for an MSLT. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Self-reported average nightly sleep duration (6.13 +/- 1.23 hours), sleep log-recorded average nightly sleep duration (6.99 +/- 0.85 hours), and actigraphy-measured average nightly sleep duration (5.56 +/- 1.50 hours) were compared for the 2-week period immediately preceding an MSLT One-way analysis of variance revealed a significant difference in the 3 estimates of nightly sleep duration (p < 0.0001), and only actigraphy-measured average nightly sleep duration correlated with mean sleep latency on the MSLT (r = 0.4258, p = 0.0016). Subgroup analysis showed that patients with a mean sleep latency shorter than 8 minutes slept an average of 1.57 hours less per night than did those patients with a mean sleep latency of 8 minutes or longer (4.53 +/- 1.37 vs 6.10 +/- 1.37 hours per night, p < 0.001) as measured by actigraphy. There was no difference in either self-reported average nightly sleep duration or sleep log-recorded average nightly sleep duration between the 2 subgroups. CONCLUSIONS: Prolonged actigraphy monitoring may provide useful clinical information about pre-MSLT sleep not always obtainable from patient self-reporting or sleep logs.