Accuracy of WatchPAT for the Diagnosis of Obstructive Sleep Apnea in Patients with Chronic Obstructive Pulmonary Disease.

The co-existence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), termed the overlap syndrome (OVS), is associated with adverse outcomes that may be reversed with treatment. However, diagnosis is limited by the apparent need for in-laboratory polysomnography (PSG). WatchPAT is a portable diagnostic device that is validated for the diagnosis of OSA that might represent an attractive tool for the diagnosis of OVS.Subjects with established COPD were recruited from a general population. Subjects underwent PSG and simultaneous recording with WatchPAT. Pulmonary function testing and questionnaires were also performed.A total of 36 subjects were recruited and valid data was obtained on 33 (age 63 ± 7, BMI 28 ± 7, 61% male, FEV1 56 ± 20% predicted). There was no significant difference in the apnea-hypopnea index (AHI) between PSG and WatchPAT (19 ± 20 versus 20 ± 15 events/h; mean difference 2(-2, 5) events/h; p = 0.381). The AHI was not significantly different in rapid eye movement (REM) and non-rapid eye movement (NREM) determined by PSG versus REM and NREM determined by WatchPAT. WatchPAT slightly overestimated total and REM sleep time, and sleep efficiency. The sensitivity of WatchPAT at an AHI cut-off of ≥5, ≥15, and ≥30 events/h for corresponding PSG AHI cut-offs was 95.8, 92.3, and 88.9, respectively; specificity was 55, 65.0, and 95.8, respectively.WatchPAT is able to determine OSA reliably in patients with COPD. The availability of this additional diagnostic modality may lead to improved detection of OVS, which may in turn lead to improved outcomes for a group of COPD patients at high risk of poor outcomes.

Pilot study of the effects of bariatric surgery and continuous positive airway pressure treatment on vascular function in obese subjects with obstructive sleep apnoea.

BACKGROUND: The mechanisms by which obesity and obstructive sleep apnoea (OSA) may contribute to endothelial dysfunction are unclear. AIMS: We sought to follow up a sample of obese subjects undergoing either bariatric surgery or continuous positive airway pressure (CPAP) therapy to treat OSA. We hypothesised improved vascular function with both therapeutic approaches, consistent with a reversible OSA effect on the circulation. METHODS: Twenty-seven obese (BMI ≥30 kg/m(2)) subjects with OSA underwent either bariatric surgery without CPAP (n = 12, median BMI 43.7 kg/m(2) IQR 9.4) or CPAP (n = 15, median BMI 33.8 kg/m(2) IQR 6.6). Polysomnography and vascular testing (flow-mediated dilation of the brachial artery measured with high-resolution ultrasound, endothelium-dependent change in skin blood flow measured with laser Doppler flowmetry, and arterial stiffness measured with applanation tonometry) took place at baseline and after 6 months. RESULTS: Both groups showed significant improvements in the apnoea-hypopnea index and overnight oxygen saturation. Endothelium-dependent microvascular reactivity was 45.6% (IQR 37.5) at baseline in the CPAP group, which increased to 69.1% (IQR 62.3) post-treatment (P < 0.05). No significant changes were observed in the surgery group, despite significant weight loss (post-surgery BMI 32.7 kg/m2 IQR 8.6 (P < 0.01); no change in BMI was observed in the CPAP group. There were no significant changes in brachial artery flow-mediated dilation in either group. CONCLUSIONS: This pilot study demonstrates that 6 months of CPAP may be sufficient to improve endothelium-dependent microvascular reactivity, while substantial surgically induced weight loss did not result in improvements. Further research should be directed towards comparative effectiveness trials using these novel surrogate outcomes, as well as hard cardiovascular outcomes.

The effect of lung stretch during sleep on airway mechanics in overweight and obese asthma.

Both obesity and sleep reduce lung volume and limit deep breaths, possibly contributing to asthma. We hypothesize that increasing lung volume dynamically during sleep would reduce airway resistance in asthma. Asthma (n=10) and control (n=10) subjects were studied during sleep at baseline and with increased lung volume via bi-level positive airway pressure (BPAP). Using forced oscillations, respiratory system resistance (R(rs)) and reactance (X(rs)) were measured during sleep and R(rs) was partitioned to upper and lower airway resistance (R(up), R(low)) using an epiglottic pressure catheter. R(rs) and R(up) increased with sleep (p<0.01) and X(rs) was decreased in REM (p=0.02) as compared to wake. R(rs), R(up), and R(low), were larger (p<0.01) and X(rs) was decreased (p<0.02) in asthma. On BPAP, R(rs) and R(up) were decreased (p<0.001) and X(rs) increased (p<0.01), but R(low) was unchanged. High R(up) was observed in asthma, which reduced with BPAP. We conclude that the upper airway is a major component of R(rs) and larger lung volume changes may be required to alter R(low).

Flunitrazepam in terminal care.

Flunitrazepam is a benzodiazepine of long half-life with sedative, anxiolytic, muscle relaxant and anticonvulsant properties. It has proved effective in controlling terminal agitation, confusion, restlessness, dystonia and fitting in adults and can be given by subcutaneous infusion in combination with other drugs. Its use in children during their terminal illness is described. Good symptom control without excessive sedation was achieved over the 24 h prior to death.

Invasive carcinoma of the cervix in young women: clinical data and prognostic features.

One hundred and ninety-one women aged 35 years and under presented to the Royal Marsden Hospital during the 15-year period 1970-1984, with invasive carcinoma of the cervix, out of a total of 1799 cases registered (10.6%). From retrospective case record analysis of these young cases, it was found that 32 (17%) presented as a result of screening, but early stage disease predominated: Stage IB, 123 (64%); Stage II, 44 (23%) and Stage III and IV, 24 (13%). The overall 5-year survival was 64%; Stage IB 71%, Stage II 59%, Stage III and IV 32%. Adverse prognostic factors observed were: stage and bulk of the primary tumour, the presence of lymph node metastases demonstrated by lymphography and grade of histological differentiation. Changes in treatment policy should not be based on age alone. A national database for young cases of invasive carcinoma of the cervix is proposed.

The influence of age on prognosis in carcinoma of the cervix.

Of 385 new patients with invasive carcinoma of the cervix FIGO stages IB-IV treated between 1970-1984 inclusive, 11% (43 patients) were aged less than or equal to 35 years. During the period studied there was a gradual rise in the proportion of such young women from 2% for the triennium 1970-1972 to 18% for 1982-1984. In women aged less than or equal to 35 years early stage disease predominated, 72% presenting with stage IB disease, compared with 29% in the older age group. For FIGO stage IB there was no significant difference in actuarial survival between younger and older patients (P greater than 0.1), both age groups having a 5-year survival rate of 81%. Similarly for FIGO stage II there was no difference in actuarial survival (P greater than 0.1) between younger and older patients who had 5-year survival rates of 66% and 63% respectively. In our experience the incidence of invasive carcinoma of the cervix in young women is rising, but stage for stage their survival is similar to that of older women.

Chemotherapy of germ-cell ovarian tumours: first-line treatment with etoposide, bleomycin and cisplatin or carboplatin.

Of 9 patients with malignant ovarian germ-cell tumours (OGCT) treated with combination chemotherapy between 1980 and 1985, 8 are alive and disease-free at 6-62 months. All patients received etoposide and bleomycin and 8 out of 9 also received a platinum analogue; in one case carboplatin, in a second carboplatin plus cisplatin, and in the remainder, cisplatin. In one patient treated prior to the introduction of carboplatin, poor renal function precluded the use of cisplatin. Two patients with Stage III dysgerminomas are disease-free at 44 and 62 months after receiving chemotherapy followed by radiotherapy to the whole abdomen or pelvis. Of 7 patients with non-dysgerminomatous OGCT, including 2 dysgerminomas with raised serum alphafetoprotein, 6 are disease-free at 6-56 months. On the basis of these observations and experience reported elsewhere, surveillance after removal of the primary tumour is proposed for early-stage dysgerminoma, and chemotherapy is suggested for advanced presentations as an alternative to surgery and post-operative radiotherapy. Combination chemotherapy is indicated for all stages of non-dysgerminomatous OGCT.

The role of combined surgery and radiotherapy in the management of stage I and II carcinoma of the cervix.

The results are presented of 100 patients with stage I B, II A or II B carcinoma of the cervix treated by combined surgery and radiotherapy. The actuarial five year survival rates for FIGO stage I B (74 patients) was 85%, for selected stage II A (8 patients) 100%, and for selected early stage II B (18 patients) 72%. Within FIGO stage I B the five year survival for patients with negative nodes was 93% and for those with positive nodes 36%. The radiotherapy complication rate for patients treated with pre-operative radiotherapy followed by Wertheim's hysterectomy was 5%. However, when additional post-operative radiotherapy was given, the complication rate was 60%. It is concluded that pre-operative intracavitary radiotherapy followed by Wertheim's hysterectomy is suitable treatment for early-stage disease with negative nodes, but is unsatisfactory treatment for poor risk patients requiring additional post-operative radiotherapy, as their survival rate is poor and the complication rate is high.

The value of lymphography in the management of carcinoma of the cervix.

Lymphography has been used to evaluate the pelvic and para-aortic nodes in 205 patients with carcinoma of the cervix treated between 1970 and 1979. The incidence of positive nodes was found to be 17% for Stage I, 24% for Stage II, 52% for Stage III and 100% for Stage IV. Of 73 patients who had lymphograms before Wertheim's hysterectomy, four out of 59 patients (7%) with negative lymphograms had histologically positive nodes; four out of 14 (28%) with positive lymphograms had negative nodes. Within each FIGO stage a positive lymphogram indicated a poor prognosis. The actuarial 5-year survival rates for patients with negative and positive lymphograms were 94% and 55% respectively for Stage I, 72% and 64% for Stage II, and 34% and 17% for Stage III. Of 39 patients with positive lymphograms who died of tumour, 31 out of 39 (80%) had distant metastases, compared with nine out of 29 patients (31%) with negative lymphograms. It is concluded that lymphography is a valuable method of evaluating lymph node status in carcinoma of the cervix.