Safety of Gastrointestinal Endoscopy With Conscious Sedation in Patients With and Without Obstructive Sleep Apnea.

BACKGROUND AND STUDY AIMS: Patients with obstructive sleep apnea (OSA) undergoing endoscopy with sedation are considered by practitioners to be at a higher risk for cardiopulmonary complications. The aim of the present study was to evaluate the safety of conscious sedation in patients with OSA undergoing gastrointestinal endoscopy. PATIENTS AND METHODS: This is an IRB-approved prospective cohort study performed at the James A. Haley VA. A total of 248 patients with confirmed moderate or severe OSA by polysomnography and 252 patients without OSA were enrolled. Cardiopulmonary variables such as heart rate, blood pressure, and level of blood oxygen saturation were recorded at 3-minute intervals throughout the endoscopic procedure. RESULTS: In total, 302 colonoscopies, 119 esophagogastroduodenoscopies, 6 flexible sigmoidoscopies, and 60 esophagogastroduodenoscopy/colonoscopies were performed. None of the patients in the study required endotracheal intubation, pharmacologic reversal, or experienced an adverse outcome as a result of changes in blood pressure, heart rate, or blood oxygen saturation. There were no significant differences in the rate of tachycardia (P=0.749), bradycardia (P=0.438), hypotension (systolic/diastolic, P=0.460; mean arterial pressure, P=0.571), or hypoxia (P=0.787) between groups. The average length of time spent in each procedure and the average dose of sedation administered also did not differ significantly between the groups. CONCLUSIONS: Despite the presumed increased risk of cardiopulmonary complications, patients with OSA who undergo endoscopy with conscious sedation have clinically insignificant variations in cardiopulmonary parameters that do not differ from those without OSA. Costly preventative measures in patients with OSA are not warranted.

Estimation of 24-hour urinary creatinine excretion from patient variables: A novel approach to identify patients with low muscle mass and malnutrition and relationship to outcomes.

BACKGROUND: Low muscle mass has been correlated with adverse outcomes in patients who are critically ill. Methods to identify low muscularity such as computed tomography scans or bioelectrical impedance analyses are impractical for admission screening. Urinary creatinine excretion (UCE) and creatinine height index (CHI) are associated with muscularity and outcomes but require a 24-h urine collection. The estimation of UCE from patient variables avoids the need for a 24-h urine collection and may be clinically useful. METHODS: Variables of age, height, weight, sex, plasma creatinine, blood urea nitrogen (BUN), glucose, sodium, potassium, chloride, and carbon dioxide from a deidentified data set of 967 patients who had UCE measured were used to develop models to predict UCE. The model identified with the best predictive ability was validated and then retrospectively applied to a separate sample of 120 veterans who were critically ill to examine if UCE and CHI predicted malnutrition or were associated with outcomes. RESULTS: A model was identified that included variables of plasma creatinine, BUN, age, and weight and was found to be highly correlated, moderately predictive of UCE, and statistically significant. Patients with model-estimated CHI ≤ 60% had significantly lower body weight, body mass index, plasma creatinine, and sera albumin and prealbumin levels; were 8.0 times more likely to be diagnosed with malnutrition; and were 2.6 times more likely to be readmitted in 6 months. CONCLUSION: A model that predicts UCE offers a novel method to identify patients with low muscularity and malnutrition on admission without the use of invasive tests.

Predictors of atypical squamous cell of undetermined significance cervical cytology with high-risk human papilloma virus genotypes.

OBJECTIVE: To investigate epidemiological factors that predicts high-risk human papillomavirus (HR-HPV) types among women with atypical squamous cells of undetermined significance (ASCUS). METHODS: Case-control study of women with ASCUS and 'reflex' HR-HPV DNA test results at the Prentice Ambulatory Care (PAC) outpatient clinic, Northwestern University, Chicago, USA. Univariate analysis and logistic regression were done to generate measures of association between various epidemiological variables and positive HR-HPV. RESULTS: A total of 2,539 women had liquid-based Pap smear and 126 (4.96%) were confirmed ASCUS. Of the 126 with ASCUS, 125 (99.2%) had 'reflex' HR-HPV results. The prevalence of HR-HPV among women with ASCUS was 43.2%. Among the 54 with a positive HR-HPV, 76.0% were women <30 years and 24.0% were ≥ 30 years. The prevalence of HR-HPV was 61.2% among women <30 years versus 22.4% among women ≥ 30 years (P < 0.001). The mean age and standard deviations (SD) was 26.5 (6.2 years) and 34.6 (10.2 years) for women with a positive HR-HPV and negative HR-HPV test, respectively (P < 0.001). Age category <30 years was independently predictive of HR-HPV (adjusted odds ratio 4.6, 95% CI 2.0-10.7; P < 0.001). CONCLUSION: Age <30 years significantly predicts presence of HR-HPV types among women with diagnosis of ASCUS. A strategy of limiting HPV testing to older women and referral of those <30 years for colposcopic assessment appears more effective.

Acute diabetes insipidus mediated by vasopressinase after placental abruption.

CONTEXT: Postpartum, diabetes insipidus (DI) can be part of Sheehan's syndrome or lymphocytic hypophysitis in combination with anterior pituitary hormone deficiencies. In contrast, acute onset of isolated DI in the postpartum period is unusual. CASE PRESENTATION: This patient presented at 33 weeks gestation with placental abruption, prompting a cesarean delivery of twins. Immediately after delivery, she developed severe DI. The DI could be controlled with the vasopressinase-resistant 1-deamino-8-D-arginine vasopressin (DDAVP), but not with arginine vasopressin (AVP), and it resolved within a few weeks. OBJECTIVE: The aim of this study was to demonstrate that the postpartum DI in this patient was caused by the release of placental vasopressinase into the maternal bloodstream. METHODS AND RESULTS: Cells were transiently transfected with the AVP receptor 2 (AVPR2) and treated with either AVP or DDAVP in the presence of the patient's serum collected postpartum or 10 weeks after delivery. The response to the different treatments was evaluated by measuring the activity of a cAMP-responsive firefly luciferase reporter construct. The in vitro studies demonstrate that the patient's postpartum serum disrupts activation of the AVPR2 by AVP, but not by the vasopressinase-resistant DDAVP. CONCLUSIONS: Placental abruption can rarely be associated with acute postpartum DI caused by release of placental vasopressinase into the bloodstream. This clinical entity must be considered in patients with placental abruption and when evaluating patients presenting with DI after delivery.

Web site development: applying aesthetics to promote breast health education and awareness.

This article describes the process of establishing a Web site as part of a collaborative project using visual art to promote breast health education. The need for a more "user-friendly" comprehensive breast health Web site that is aesthetically rewarding was identified after an analysis of current Web sites available through the World Wide Web. Two predetermined sets of criteria, accountability and aesthetics, were used to analyze these sites and to generate ideas for creating a breast health education Web site using visual art. Results of the analyses conducted are included as well as the factors to consider for incorporating into a Web site. The process specified is thorough and can be applied to establish a Web site that is aesthetically rewarding and informative for a variety of educational purposes.