ABSTRACT
OBJECTIVES: To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome. DESIGN: A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data. METHODS: The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results. RESULTS: Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion. CONCLUSION: Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.
Subject(s)
Sleep Apnea, Obstructive , Adult , Endoscopy/methods , Humans , Nose , Sleep , Sleep Apnea, Obstructive/diagnosis , Sleep Apnea, Obstructive/surgeryABSTRACT
1. We investigated the role of arachidonic acid metabolism and assessed the participation of mast cells and leukocytes in neurogenic inflammation in rat paw skin. We compared the effect of lipoxygenase (LOX) and cyclo-oxygenase (COX) inhibitors on oedema induced by saphenous nerve stimulation, substance P (SP), and compound 48/80. 2. Intravenous (i.v.) pre-treatment with a dual COX/LOX inhibitor (RWJ 63556), a dual LOX inhibitor/cysteinyl-leukotriene (CysLt) receptor antagonist (Rev 5901), a LOX inhibitor (AA 861), a five-lipoxygenase activating factor (FLAP) inhibitor (MK 886), or a glutathione S-transferase inhibitor (ethacrynic acid) significantly inhibited (40 to 60%) the development of neurogenic oedema, but did not affect cutaneous blood flow. Intradermal (i.d.) injection of LOX inhibitors reduced SP-induced oedema (up to 50% for RWJ 63556 and MK 886), whereas ethacrynic acid had a potentiating effect. 3. Indomethacin and rofecoxib, a highly selective COX-2 inhibitor, did not affect neurogenic and SP-induced oedema. Surprisingly, the structurally related COX-2 inhibitors, NS 398 and nimesulide, significantly reduced both neurogenic and SP-induced oedema (70% and 42% for neurogenic oedema, respectively; 49% and 46% for SP-induced oedema, respectively). 4. COX-2 mRNA was undetectable in saphenous nerves and paw skin biopsy samples, before and after saphenous nerve stimulation. 5. A mast cell stabilizer, cromolyn, and a H(1) receptor antagonist, mepyramine, significantly inhibited neurogenic (51% and 43%, respectively) and SP-induced oedema (67% and 63%, respectively). 6. The co-injection of LOX inhibitors and compound 48/80 did not alter the effects of compound 48/80. Conversely, ethacrynic acid had a significant potentiating effect. The pharmacological profile of the effect of COX inhibitors on compound 48/80-induced oedema was similar to that of neurogenic and SP-induced oedema. 7. The polysaccharide, fucoidan (an inhibitor of leukocyte rolling) did not affect neurogenic or SP-induced oedema. 8. Thus, (i) SP-induced leukotriene synthesis is involved in the development of neurogenic oedema in rat paw skin; (ii) this leukotriene-mediated plasma extravasation might be independent of mast cell activation and/or of the adhesion of leukocytes to the endothelium; (iii) COX did not appear to play a significant role in this process.
Subject(s)
Lipoxygenase/metabolism , Mast Cells/physiology , Neurogenic Inflammation/pathology , Peripheral Nerves/physiology , Prostaglandin-Endoperoxide Synthases/metabolism , Animals , Benzoquinones/pharmacology , Cromolyn Sodium/pharmacology , Cyclooxygenase Inhibitors/pharmacology , Electric Stimulation , Enzyme Inhibitors/pharmacology , Ethacrynic Acid/pharmacology , Gene Expression Regulation, Enzymologic/drug effects , Indoles/pharmacology , Lipoxygenase/drug effects , Lipoxygenase Inhibitors/pharmacology , Male , Mast Cells/cytology , Neurogenic Inflammation/physiopathology , Neurogenic Inflammation/prevention & control , Polysaccharides/pharmacology , Prostaglandin-Endoperoxide Synthases/drug effects , Prostaglandin-Endoperoxide Synthases/genetics , Pyrilamine/pharmacology , Quinolines/pharmacology , RNA, Messenger/drug effects , RNA, Messenger/genetics , RNA, Messenger/metabolism , Rats , Rats, Wistar , Signal Transduction , Sulfonamides/pharmacology , Thiophenes/pharmacology , Vasodilation/drug effectsABSTRACT
Within a 10 years period, 612 patients underwent an autopsy, in a geriatric hospital. Seventeen p. 100 were discovered to have a high blood pressure. Twenty-nine patients (that is about 4 p. 100) presented with a small unilateral kidney. The pathogenetic factors of these unilateral nephropathies were various, many causes of which were unilateral pielonephritis. Out of the patients exhibiting a small unilateral kidney, 62 p. 100 had a high blood pressure. Hypertension due to a unilateral nephropathy, when studied on a statistic level, does not induce any atheromatous lesion nor heart ponderal hypertrophy more acute than essential high blood pressure. The unilateral nephropathies hypertension would thus be compared to an hypertension "depending on sodium or volume" and not as an hypertension "depending on renin".
