Effects of Obstructive Sleep Apnea and CPAP on Cognitive Function.

PURPOSE OF REVIEW: Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial upper airway obstruction during sleep. Studies indicate that OSA is an independent risk factor for cognitive decline in older patients. The purpose of this paper is to critically review the recent literature on the cognitive effects of untreated OSA and the benefits of treatment across cognitive domains. RECENT FINDINGS: OSA's greatest impact appears to be on attention, vigilance, and information processing speed. Furthermore, the presence of OSA seems to have a significant impact on development and progression of mild cognitive impairment (MCI). Impact of OSA treatment, particularly with CPAP, appears to mitigate and slow the rate of cognitive decline and may reduce the risk of dementia. Larger properly controlled studies, of a prospective nature, are required to further elucidate the degree of treatment effect. More studies are needed on other treatments for OSA such as oral mandibular devices and hypoglossal nerve stimulation.

Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

Augmenting Critical Care Capacity in a Disaster.

A health care facility must develop a comprehensive disaster plan that has a provision for critical care services. Mass critical care requires surge capacity: augmentation of critical care services during a disaster. Surge capacity involves staff, supplies, space, and structure. Measures to increase critical care staff include recalling essential personnel, using noncritical care staff, and emergency credentialing of volunteers. Having an adequate supply chain and a cache of critical care supplies is essential. Virtual critical care or tele-critical care can augment critical care capacity by assisting with patient monitoring, specialized consultation, and in pandemics reduces staff exposure.

Disasters Resulting from Radiologic and Nuclear Events.

Radiation accidents are rare, but can produce large numbers of casualties with predictable patterns of injury. Casualties may suffer from a wide range of radiation exposures. Triage based on presence or absence of conventional injuries and an accurate assessment of radiation dose based on event history, symptoms, and laboratory testing, is critical. Treatment of acute radiation syndrome is supportive: including fluids, antibiotics, blood products, colony-stimulating factors, and stem cell or bone marrow transplantation. Care of radiation-injured patients with conventional trauma or burns needs to be modified to account for adverse effects of radiation on wound healing and susceptibility to infections.

Chronic obstructive pulmonary disease and vascular disease delay timeliness of early stage lung cancer resectional surgery.

INTRODUCTION: Lung cancer remains the leading cause of cancer death in the United States and worldwide. Timeliness to diagnosis and referral for resectional surgery is key to successful management for early stage disease. METHODS: We investigated the contribution of medical co-morbidities in the timeliness to resectional surgery for non-small cell lung cancer (NSCLC). A retrospective record review of NSCLC surgery cases at Naval Medical Center San Diego (NMCSD) from 2004 to 2009 from the tumor registry was conducted. RESULTS: More than 75% of NSCLC patients exhibited at least one co-morbidity. Of the 84 patients, 26% of patients had diabetes, patients with different vascular co-morbidities accounted for 39%, whereas 33% of subjects had COPD. Patients with sleep apnea or liver disease each accounted for 6%. Vascular disease co-morbidity and COPD in NSCLC patients significantly delayed time from initial cardiothoracic surgery evaluation to thoracotomy (p = 0.01-0.02 and p < 0.05 respectively). CONCLUSION: Although significances of different co-morbities in the development NSCLC cannot be extrapolated, theses data show that COPD and vascular diseases are significant risk factors that delay surgical treatment of early stage lung cancer.

The immune response and its therapeutic modulation in bronchiectasis.

Bronchiectasis (BC) is a chronic pulmonary disease with tremendous morbidity and significant mortality. As pathogen infection has been advocated as a triggering insult in the development of BC, a central role for the immune response in this process seems obvious. Inflammatory cells are present in both the airways as well as the lung parenchyma, and multiple mediators of immune cells including proteases and cytokines or their humoral products are increased locally or in the periphery. Interestingly, a defect in the immune system or suppression of immune response during conditions such as immunodeficiency may well predispose one to the devastating effects of BC. Thus, the outcome of an active immune response as detrimental or protective in the pathogenesis of BC may be dependent on the state of the patient's immunity, the severity of infection, and the magnitude of immune response. Here we reassess the function of the innate and acquired immunity in BC, the major sites of immune response, and the nature of the bioactive mediators. Furthermore, the potential link(s) between an ongoing immune response and structural alterations accompanying the disease and the success of therapies that can modulate the nature and extent of immune response in BC are elaborated upon.

Population characterization, histological evaluation, and timeliness of care of surgical nonsmall cell lung cancer patients in a military academic medical center.

UNLABELLED: Lung cancer remains a major medical impediment in which early diagnosis and timely treatment are key factors in its management. This study evaluated nonsmall cell lung cancer (NSCLC) patients in a large military medical center to determine the timeliness to diagnosis and curative surgery in comparison with published guidelines. A retrospective record review of tumor registry NSCLC surgery cases at Navy Medical Center San Diego (NMCSD) from 2004 to 2009 was conducted. Of the 84 patients, 49% were women, the median age was 63, 58% were Caucasian, and 71% represented ex- or active smokers. A significant number of women were Asian (30%) and nonsmokers (77%). The predominant histology was adenocarcinoma (86%) with positron emission tomography-computed tomography (PET-CT) nonavid (57%). Median time for pulmonologist evaluation was 8 days, median time for PET-CT was 13 days, median time for cardiothoracic surgery evaluation to thoracotomy was 25 days, and median time from pulmonologist evaluation to thoractomy was 59 days. CONCLUSIONS: Except for the pulmonary specialist referral time (8 vs. 7 days), timeliness of diagnosis and curative surgery for NSCLC patients at NMCSD was within international guideline recommendations. Additional proposals have been made to improve the evaluation and treatment of lung cancer patients.

Acute respiratory distress following liposuction.

An active duty male presented to the emergency room with dyspnea for 2 days after undergoing liposuction surgery. Upon presentation, the patient was afebrile, tachycardic, tachypneic, and hypoxemic. The initial chest radiograph demonstrated bilateral patchy opacities and the PaO2/FiO2 ratio was <200. The patient was admitted to the medical intensive care unit for supportive care. He was treated empirically for pneumonia. Blood and sputum cultures were negative. A computed tomography angiogram of the chest was negative for pulmonary embolism but did reveal a bilateral, perihilar air space process. The patient's oxygen requirement improved and the abnormal chest radiographic findings resolved over the next 48 hours. Given his clinical presentation, negative workup, and rapid recovery, the patient was given a presumptive diagnosis of pulmonary fat embolism. Fat embolism occurs when adipocytes and small blood vessels are damaged during the liposuction procedure. Patients may present with low-grade fever, tachycardia, tachypnea, hypoxemia, and hypocapnia. The differential diagnosis includes venous thromboembolism, aspiration pneumonitis, and pneumonia. The mainstay of treatment for pulmonary fat embolism is supportive care. The risk of mortality is 5 to 15%.

A novel use for drotrecogin alfa (activated): successful treatment of septic shock associated with coccidioidomycosis.

We present 2 cases of septic shock associated with coccidioidomycosis that were successfully treated with drotrecogin alfa (activated) in combination with antifungal agents. The favorable outcomes, in light of the high mortality usually associated with this condition, suggest that drotrecogin alfa (activated) may be a valuable adjunct for treating septic shock due to endemic mycoses.

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.