OSA treatment with CPAP: Randomized crossover study comparing tolerance and efficacy with and without humidification by ThermoSmart.

OBJECTIVES: Adherence to continuous positive airway pressure (CPAP) remains an issue, as adverse effects (AE) such as rhinitis, dry/congested nose, dry mouth or throat are commonly experienced. The aim of the study was to compare CPAP efficacy and tolerance in severe obstructive sleep apnea (OSA) patients with or without (w/o) heated humidification using the ThermoSmart system. METHODS: Multicenter RCT study in which CPAP-naive patients with severe OSA and meeting one or more of the following criteria: >65 years, using >1 drying medication, previous nasal symptoms or nasal surgery, were included. Patients were randomized to CPAP w/o heated humidification for 1 month and then crossed-over to the other treatment arm for another month. Naso-pharyngeal symptoms, Quality of life (FOSQ-10), sleepiness (ESS) and CPAP compliance and efficacy data were collected. RESULTS: Forty patients were enrolled: age 62 ± 9 years, diagnostic AHI 46.7 ± 15.3/hour. About 70% were using >1 drying medication, mainly antihypertensives. Both treatment modalities were found to normalize AHI and decrease sleepiness with no differences between 2 modes, compliance (4.63 ± 0.39 vs 4.70 ± 0.36 h/night) or leaks (32.4 ± 2.0 versus 31.1 ± 1.7l/min). With heated humidification, there was a significant decrease in nasal symptoms such as dry/congested nose. At the study end, 26 patients preferred ThermoSmart ON, 3 did not have preference and 11 preferred ThermoSmart OFF. CONCLUSION: ThermoSmart helps to decrease nose and throat discomfort because of CPAP therapy, these effects did not translate to better compliance but patients had a preference for ThermoSmart.

Relationship between obstructive sleep apnea and liver abnormalities in morbidly obese patients: a prospective study.

BACKGROUND: Morbid obesity is a risk factor of nonalcoholic steatohepatitis (NASH). Obstructive sleep apnea (OSA) could also be an independent risk factor for elevated liver enzymes and NASH. The relationships between liver injuries and OSA in morbidly obese patients requiring bariatric surgery were studied prospectively. METHODS: Every consecutive morbidly obese patient (BMI > or =40 kg/m2 or > or =35 kg/m2 with severe comorbidities) requiring bariatric surgery was included between January 2003 and October 2004. Polygraphic recording, serum aminotransferases (ALT, AST), gamma-glutamyltransferase (GGT) and liver biopsy were systematically performed. OSA was present when the apnea-hypopnea index (AHI) was >10/h. RESULTS: 62 patients (54 F; age 38.5 +/- 11.0 (SD) yrs; BMI 47.8 +/- 8.4 kg/m2) were included. Liver enzymes (AST, ALT or GGT) were increased in 46.6%. NASH was present in 34.4% and OSA in 84.7%. Patients with OSA were significantly older (P = 0.015) and had a higher BMI (P = 0.003). In multivariate analysis, risk factors for elevated liver enzymes were the presence of OSA and male sex. The presence of NASH was similar in patients with or without OSA (32.7% vs 44.4% of patients, P = 0.76). CONCLUSION: In this cohort of morbidly obese patients requiring bariatric surgery, one-third of patients had NASH, a prevalence similar to previous studies. OSA was found to be a risk factor for elevated liver enzymes but not for NASH.

[Selection of medical students: a process influenced by history and culture]. / Sélection des étudiants en médecine: une procédure influencée par la liberté d'accès aux études et l'égalité des chances.

OBJECTIVES: Every medical school in the world has a procedure for selecting students for medical studies, intended to identify those who are capable of becoming doctors, according to specific expectations. The means of selection, however, vary significantly from one school to another and from one country to another. France has chosen to undertake this selection at the end of the first year of university studies. This method is costly in that it requires medical schools to organize a whole year of curriculum for thousands of students, fewer than 30% of whom will be chosen for further medical studies. It is also counterproductive for students, a significant proportion of whom are not admitted despite above-average results on their examinations. METHODS: This article examines the historical and cultural factors that have led to the current organization. Our study is based on an analysis of government archives dealing with medical education reforms from 1905-1970. RESULTS: We argue that the format of the current selection process is linked to ideas of freedom of access for students and of equal opportunity for admission to medical studies. CONCLUSION: We conclude that for any reform to be acceptable it must take into account the historical and cultural elements (for the most part stemming from the French Revolution) that form the basis of the current system.

Should flow-volume loop be monitored in sleep apnea patients treated with continuous positive airway pressure?

Nasal continuous positive airway pressure (nCPAP) has been widely established in the treatment of obstructive sleep apnea syndrome (OSAS). However, only few studies have evaluated long-term effects of this treatment on lung function. This study assesses the effect of nCPAP on lung function parameters and response to bronchodilators in 50 OSAS patients. Spirometry and arterial blood gas measurements were performed before starting nCPAP and after 16.8 +/- 8 months of treatment. Of the 50 study patients (55 +/- 12 years, with an apnea/hypopnea index of 47 +/- 34h(-1)), 15 had asthma, 13 had chronic obstructive pulmonary disease (COPD) and 22 had no obstructive airway disease (NOAD). In the entire population, significant decreases in FEF50 (from 69 +/- 38% to 61 +/- 30%, P < 0.005), FEF25 (from 53 +/- 34% to 46 +/- 28%, P < 0.05) and FEF25-75 (from 65 +/- 33% to 57 +/- 27%, P < 0.005) were observed after treatment. No impairment of lung function was found in COPD and asthmatic patients. In contrast, lung function was changed in the NOAD group where FEF50, FEF25 and FEF25-75 as well as FEV1 and FEV1/VC ratio were significantly reduced. Moreover, bronchial hyperresponsiveness occurred in five of 22 patients of this group. These results suggest that tolerance of nCPAP should be handled by long-term follow-up of flow-volume loops.

Country report: medical education in France.

CONTEXT: The last 10 years have represented a period of significant reform within both the health care and education systems in France. In terms of its workforce, France faces a shortage of doctors, particularly in primary care. METHODS: This paper examines the French medical curriculum, student selection, licensure and continuing medical education and discusses the challenges currently facing French medical faculties. RESULTS: The French medical curriculum is defined nationally, with methods adapted at medical school level. There has been some uptake of innovative methods such as problem-based learning, skills-based teaching and performance-based assessment. However, traditional didactic teaching of scientific medicine and the apprenticeship model remain dominant. France uses a unique method of selection, which is the subject of much debate. Following a general year, medical students are subject to a selection examination that permits only a small number to continue studies. Similarly, at the end of medical school, a written test is used to rank students for the purpose of matching to specialty training. France has no national colleges or licensing authorities and thus authorisation to practise rests on the diploma delivered by each faculty of medicine. From 2005, continuing medical education became compulsory for all doctors. It includes the evaluation of medical practice. CONCLUSIONS: French faculties of medicine face several challenges, including: rising numbers of students without a commensurate growth in the number of faculty members; an increasing emphasis on multidisciplinary health care; a drive towards mandatory continuing education and performance-based outcomes, and the development of national selection examinations that are knowledge-based.