bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of obstructive sleep apnoea on circadian blood pressure profile
Authors: PANKOW W. , NABE B. , LIES A. , KOHL F. V. , LOHMANN F. W.
Published: January 2009

SUMMARY  A high prevalence of systemic hypertension in obstructive sleep apnoea (OSA) has been described but data on circadian blood pressure (BP) profile are limited and give inconsistent results. The present study examines 24‐h BP in 106 patients referred because of loud snoring or excessive daytime sleepiness in combination with snoring. Patients were classified as OSA (n = 62) or habitual snorers (HS) (n = 44). Respiratory disturbance index (RDI) in OSA was 47 ± 24 vs. 2 ± 2 in HS. Mean age and body mass index in OSA was significantly higher.

BP was measured non‐invasively at 15‐min intervals during a 24‐h period. Daytime and night‐time BP was higher in OSA compared to HS. BP night/day ratio in OSA was 0.92 ± 0.07 vs. 0.86 ± 0.06 in HS (P < 0.05). To investigate the influence of variables other than breathing abnormalities during sleep on our results we compared BP profiles of 25 OSA and 25 HS matched for sex, age and body weight. Again differences in daytime and night‐time BP and BP night/day ratio were significant. Using a value of at least 10% fall in nocturnal BP to describe a regular BP profile (dipper) 68% of OSA were classified as non‐dippers vs. 24% of HS.

Influence of short‐term (2–4 days) nCPAP therapy on circadian BP profile was investigated in 34 patients with OSA. Systolic and diastolic nocturnal (but not daytime) BP was significantly reduced. The percentage of non‐dippers was 79% before and 50% after treatment. In conclusion results of this study indicate a causal link between OSA and abnormal circadian BP profile.
Regulation of plasma volume during obstructive sleep apnoea
Authors: KRIEGER JEAN
Published: January 2009

SUMMARY  The evidence that plasma volume is altered in obstructive sleep apnoea is an indirect one, based on the observation of a paradoxical elimination of peripheral oedema along with a decrease in water and sodium excretion and of a decrease in haematocrit when apnoeas are eliminated with continuous positive airway pressure (CPAP) treatment. A suggested interpretation of these observations is that in the untreated condition, increased renal sodium excretion and increased vascular membrane permeability lead to increased urine and salt excretion and to a fluid shift from the plasma to the extracellular space, causing nocturnal polyuria, peripheral oedema and haemoconcentration. Treatment with continuous positive airway pressure reverses the increased membrane permeability and urine excretion, allowing the peripheral oedema to resolve and the haematocrit to decrease. Increased atrial natriuretic peptide release and decreased renin‐angiotensin‐aldosterone activity, along with an increased release of thromboxane and of endothelin (which have been reported in untreated obstructive sleep apnoea), could be the mechanisms of the observed alterations in fluid distribution in obstructive sleep apnoea.
Arterial hypertension and sleep apnoea: effect of the angiotensin‐converting enzyme (ACE) Inhibitor cilazapril on continuously measured blood pressure during sleep and wakefulness
Authors: GROTE LUDGER , HEITMANN JÖRG , PENZEL THOMAS , CASSEL WERNER , PLOCH THOMAS , PETER JORG HERMANN , VON WICHERT PETER
Published: January 2009

SUMMARY  Male patients with arterial hypertension and obstructive sleep‐related breathing disorders (mean age 50 y, Body Mass Index (BMI) 32.4 kg m‐2, Respiratory Disturbance Index (RDI) 47.2 and systolic/diastolic blood pressure (SBD/DBD) 162/103 mmHg) were examined before and after 8 days of treatment with the long‐acting angiotensin‐converting‐enzyme (ACE) inhibitor cilazapril 2.5 mg vs. placebo in a double‐blind design with parallel groups. Cardiorespiratory polysom‐nography was carried out at night; during daytime wakefulness patients submitted to examinations of physical and mental exertion. Cilazapril reduced the mean pressure during the entire examination period (day and night) by 9.55 (SD±7.13) mmHg, compared to 4.57 (SD ±7.20) mmHg for placebo (P < 0.006), independently from systematic changes of heart rate (x = ‐3.3 and ‐3.5 bpm, respectively). During REM sleep, mean arterial pressure was significantly reduced by 8.63 (SD ±10.1) mmHg, compared to a reduction on placebo of 3.17 (SD 9.6) mmHg (P = 0.023). Under psychometric strain, the mean arterial pressure was reduced by 15.31 (SD ±8.7) mmHg with cilazapril; under placebo medication by 6.19 (SD ±7.3) mmHg (P < 0.0001). Heart rate was not significantly changed.
Cerebral perfusion during sleep‐disordered breathing
Authors: HAJAK GÖRAN , ELHÖFER JÜRGEN KLING , SCHULZ‐VARSZEGI MARIA , SANDER DIRK , STAEDT JÜRGEN , CONRAD BASTIAN , RÜTHER ECKART
Published: January 2009

SUMMARY  Snoring, a leading symptom of the sleep apnoea syndrome (SAS), has been reported to be one of the risk factors for sleep‐related cerebral strokes. Episodes of apnoea are accompanied by hypoxaemia as well as hypercapnia. As CO2 constitute a major regulatory factor controlling cerebral blood flow, it is likely that changes in cerebral perfusion are to be found in patients with SAS, which may be related to nocturnal stroke. A computer‐assisted pulsed (2 mHz) Doppler ultrasonography system has been modified for continuous long‐term and on‐line recording of cerebral haemodynamics together with simultaneous polysomnography, continuous blood pressure recordings, and measurement of the end‐expiratory CO2. The dynamics of cerebral blood flow velocity (CBFV) during sleep were measured in the right middle cerebral artery in 10 SAS patients.

CBFV showed a characteristic nocturnal pattern with decreases during non‐rapid eye movement (NREM) sleep and increases during REM sleep. Changes in sleep stage patterns as well as awakenings from NREM sleep were not regularly accompanied by corresponding changes in CBFV. Dramatic increases in CBFV could be observed during apnoeic episodes, with maximum increases during REM sleep. CO2 reactivity and changes in CBFV related to apnoea duration were markedly increased during sleep compared with the waking state in SAS patients.

The dynamic feature of CBFV in relation to sleep patterns reflects quantitative uncoupling between cerebral electrical activity and cerebral perfusion during sleep in SAS patients as has been previously reported for normal subjects (Hajak et al. 1994). It supports a dissociation in the activity of central regulatory mechanisms during human sleep which might cause abnormal cerebral perfusion under certain circumstances. The increased CO2 reactivity during sleep in SAS suggests a ‘hypersensitivity’ of intracranial vasoactive receptors and/or disturbances in the central autonomic control of cerebrovascular functions. It may be concluded that, under certain conditions, the interaction of decreased cerebral perfusion in SAS patients with sleep‐related cerebral perfusion patterns and haemodynamic changes during apnoeic episodes might lead to a critical reduction in cerebral perfusion.
Epidemiological aspects of snoring and hypertension
Authors: GISLASON THORARINN , JANSON CHIRSTER , TÓMASSON KRISTINN
Published: January 2009

SUMMARY  Previous studies have reported a great difference in snoring prevalence in different populations. In a recent study on men and women 20–45 y old, living in Sweden (Uppsala, Gothenbourg), Iceland (Reykjavík) and Belgium (Antwerp), data concerning snoring, etc., were collected using the same questions and scales in all the countries. In all four areas the prevalence of snoring was the same: 5% of men and 2–3% of women reported snoring every night. In all areas snoring was positively correlated with age, male sex and body mass index. It was therefore assumed that the previous difference in snoring prevalence is probably an artifact of different methodologies.

The connection between snoring and systemic hypertension has been much disputed during the last decade. The high prevalence of hypertension in the sleep apnoea syndrome has been explained by obesity/age/male gender/sleep apnoea and/or snoring. In one recent study snoring did not contribute independently to the prediction of hypertension, while other studies indicate that snoring is an independent risk factor for hypertension.

After reviewing some of the epidemiological literature it was found that these studies are bound to identify almost entirely different subgroups of the population as snorers since the prevalence of snoring is rated on different types of frequency scales with words like ‘never’, ‘often’ or the number of nights per week. The questions used are also different. In general it can be stated that the smaller the proportion of the population identified as snorers the more often there is a statistically significant association with hypertension.

The relationship between snoring and hypertension is considered to be unclear due to the different research methods used, and to the uncertain role played by confounding factors such as obesity. There is a need for population‐based, prospective, studies with more uniform definitions of the term ‘snoring’ based on objective measurements of upper airway resistance during sleep, together with haemodynamic studies.
Basic Nordic Sleep Questionnaire (BNSQ): a quantitated measure of subjective sleep complaints
Authors: PARTINEN MARKKU , GISLASON THORARINN
Published: January 2009

SUMMARY  Sleep‐related breathing disturbances, especially obstructive sleep apnoea syndrome (OSAS), are commonly encountered. Epidemiological studies from different countries have shown that poor sleep and complaints about insufficient sleep or poor sleep are often related to poor health. Different studies are, however, difficult to compare with each other. One of the main reasons for this is the frequent methodological differences between questionnaires. There is a need for uniform methods: we need to know the prevalence and incidence of sleep disorders, judged using the same criteria, and also the severity of each problem, i.e. how often a problem or a symptom happens/occurs.

In 1988 the Scandinavian Sleep Research Society formed a task group for developing a standardized questionnaire that could be used as a basis for questionnaires used in the Nordic countries. In this article we describe the Basic Nordic Sleep Questionnaire (BNSQ). The main change compared to many previous questionnaires is the five‐point scale (scale from 1 to 5) stressing on how many nights/days per week something happens. The basic scale is: 1, ‘never or less than once per month’; 2, ‘less than once per week’; 3, ‘on 1–2 nights per week’; 4, ‘on 3–5 nights per week’; and 5, ‘every night or almost every night’. For questions about specific rare events the first category may be divided into ‘never’ and ‘less than once per month’. Habitually occurring events such as ‘habitual snoring’ are defined here as snoring every night or almost every night. The BNSQ has been used widely in a variety of studies performed in Nordic countries during the last years, and it has proven to be a valid tool.
Invasive electrophysiological evaluation of patients with sleep apnoea‐associated ventricular asystole—methods and preliminary results
Authors: GRIMM WOLFRAM , HOFFMANN JÜRGEN , KÖHLER ULRICH , HEITMANN JÖRG , PETER JÖRG H. , VON WICHERT PETER , MAISCH BERNHARD
Published: January 2009

SUMMARY  Twelve patients (aged 48 ± 12 y) with ventricular asystole of >3s due to complete atrioventricular (AV) block (n = 8), sinoatrial (SA) block or sinus node arrest (n= 3) or both (n= 1) associated with obstructive sleep apnoea underwent invasive electrophysiological evaluation of sinus node function and AV conduction properties before and after administration of atropine (0.02 mg kg‐1). Ventricular asystole lasted for 5.9 ± 2.8 s (range 3.1–13 s). Sinus node function was assessed by measurement of sinus node recovery time, sinoatrial conduction time, and the response of sinus rate to atropine. Parameters of AV‐conduction assessment included AH‐ and HV‐intervals, AV‐ and VA‐Wenckebach periods, and effective refractory period of the AV node before and after atropine. Sinus node function was normal in 11 of the 12 study patients and moderately abnormal in 1 patient. AV‐nodal function was normal in 8 patients and moderately abnormal in 4 patients. A slightly prolonged HV‐interval (59–63 ms) was present in 6 patients. Intra‐ or infra His block was not observed in any patient. In conclusion, normal or only moderately abnormal electrophysiological findings in patients with sleep apnoea‐associated ventricular asystole suggest that a neurally mediated cardioinhibitory reflex may cause ventricular asystole in these patients. This sleep apnoea‐triggered ‘vasovagal’ reflex may unmask pre‐existing mild to moderate structural abnormalities of the AV conduction system.
Ventricular hypertrophy In sleep apnoea
Authors: DAVIDSON WILLIAM R.
Published: January 2009

SUMMARY  Ventricular hypertrophy is associated with an increased risk of cardiovascular death and cardiac events. In response to a haemodynamic load, ventricular hypertrophy may either be eccentric (dilation in response to volume overload) or concentric (increase in wall thickness in response to pressure overload). Ventricular hypertrophy increases with age, weight, blood pressure, and the presence of cardiovascular disease. It is greater in men than in women when adjusting for other variables. Echocardiography is the best method for accurate quantification of left ventricular mass and for detecting right ventricular hypertrophy. In obstructive sleep apnoea there are reports of both eccentric and concentric hypertrophy of the left ventricle. However, many of these reports have failed to control for patient weight or age. More recent reports indicate that much of the hypertrophy of the left ventricle reported in obstructive sleep apnoea can be related to patients' age, blood pressure, or size. However, right ventricular hypertrophy appears to be distinctly associated with the presence and severity of obstructive sleep apnoea. Right ventricular hypertrophy secondary to obstructive sleep apnoea may be the substrate for the eventual development of cor pulmonale and right heart failure. Its pathophysiological significance and potential use as a marker of severe OSA requires further investigation. Further investigation into left ventricular hypertrophy and sleep apnoea must control for the potentially confounding variables listed above and will require population‐based and/or carefully matched case control studies.
Pulmonary artery pressure in sleep apnoea and snoring
Authors: LAKS L.
Published: January 2009

SUMMARY  There is a renewed interest in pulmonary hypertension (PH) complicating obstructive sleep apnoea (OSA). The prevalence of PH in populations of patients with less severe OSA was documented to be around 10%. The most recent data from both catheterization and echocardiographic studies indicate that as many as 40% of patients with OSA have PH. It has been shown that non‐obese patients with normal respiratory function tests can develop pulmonary hypertension. One of the other possible mechanisms involved may be the presence of heightened pulmonary artery pressure response to hypoxia. There are now data available to indicate that treatment with nasal CPAP can decrease or even normalize pulmonary artery pressure in patients with sleep apnoea.
Coronary heart disease and upper airway obstruction
Authors: SCHÄFER HARALD , KÖHLER ULRICH , PLOCH THOMAS , PETER JÖRG HERMANN
Published: January 2009

SUMMARY  Coronary heart disease (CHD) is a leading cause of death among middle‐aged men. In the same age group the spectrum of upper airway obstruction from habitual snoring to obstructive sleep apnoea syndrome (OSAS) is frequent. In several studies snoring was found to be an important risk factor for ischaemic heart disease. The prevalence of OSAS in patients with CHD, profile of risk factors and ventricular arrhythmias was determined in a prospective manner in 78 patients with stenosis of one or more coronary arteries at coronary arterography. OSAS was found in 27 patients (34.6%). Mean respiratory disturbance index (RDI) was 23.9. RDI increased with higher age. No significant differences in both groups could be found in ventricular arrhythmias, left ventricular ejection fraction and risk factors, except hyperuricaemia and adiposity. OSAS is frequent in patients with CHD and may be an additional risk factor besides the known coronary risk factors. Patients with the combination of CHD and OSAS have to be regarded as a group at particular risk because of several interactions between OSAS and coronary haemodynamics. Furthermore the microstructure of sleep in patients with nocturnal myocardial ischaemia is disturbed.
Clinical significance of ventricular late potentials in patients with obstructive sleep apnoea
Authors: SANNER BERND , KONERMANN MARTIN , HÖRSTENSMEYER DIRK , KREUZER IMKE , BURMANN‐URBANEK MARION
Published: January 2009

SUMMARY  Patients with obstructive sleep apnoea (OSA) have an increased cardiovascular mortality and probably also an increased incidence of sudden cardiac death. Thus the question arises whether ventricular late potentials can constitute markers for an increased electric vulnerability in these patients. Signal‐averaged electrocardiograms were recorded in 64 patients (6 female, 58 male; mean age 53.2 y) with OSA (mean apnoea‐hypopnoea index (AHI) 41.7 h‐1± 24.3 h‐1). Furthermore, a continuous ambulatory electrocardiogram and gated radionuclide ventriculography were performed. Ventricular late potentials were recorded in 5 men out of 64 patients. Two of them had coronary artery disease (1 patient post‐myocardial infarction), 2 hypertension, and 1 nocturnal hypertension. No correlation could be traced between left ventricular ejection fraction, severity and extent of ventricular premature beats, or severity of OSA and occurrence of ventricular late potentials. It was noticeable, however, that the patients with ventricular late potentials had severe OSA (mean AHI 50.2/h vs. 40.9/h). Although OSA may lead to structural myocardial changes that could be the basis for re‐entrant circuits, ventricular late potentials were found in only 7.8% of these patients. The results of this study demonstrate that at present ventricular late potentials and signal‐averaged electrocardiograms do not prove useful as screening methods for risk stratification of patients with OSA.
Prevalence of nocturnal oxygen desaturation in patients admitted to a geriatric rehabilitation unit
Authors: ROTH THOMAS , HÖLTMANN BERNHARD J.
Published: January 2009

SUMMARY  Continuous oxygen measurement by digital oximetry is a well‐established and widely used method. As reports in patients with cardiac disease have shown high prevalences of nocturnal oxygen desaturation, this study aimed to screen the patients admitted to a geriatric rehabilitation unit. Oxygen saturation was con‐tinously recorded during sleeptime in 103 unselected patients (52 women, 51 men) with a mean age of 77 y (65–90 y). The records were analysed according to standard rules concerning the frequency, duration and severity of periodic or phasic oxygen desaturations (ODES). Significant desaturations were found in 50/103 (48%) patients (43% women, 57% men) with a mean desaturation index (DESI) of 9.2 h‐1. Periodic desaturations greater than 10 h‐1 were found in 33% (35/103) patients with a mean DESI of 26/h in women and 20/h in men. Severe periods of desaturation (<80%) were found in 33% of women and in 41% of men. Patients with cardiac diseases showed the highest prevalence of total ODES (61%) and of periodic ODES (44%). Patients with lung diseases showed the highest prevalence of phasic ODES (43%).

Patients admitted to the geriatric rehabilitation unit showed a considerably high prevalence of nocturnal oxygen desaturations. In contrast to earlier reports no significant influence of gender was found. The results presented here clearly support the urgent need for systematic sleep studies especially in elderly handicapped patients. Further investigations are needed to study clinical implications and the effects of therapeutic interventions.
An overview of sleepiness and accidents
Authors: DINGES DAVID F.
Published: January 2009

SUMMARY  This paper reviews the association between neurobiologically‐based sleepiness/fatigue and human‐error related accidents. It concludes that fatigue contributes to human error and accidents in technology‐rich, industrialized societies in terms of human, environmental and economic impacts. The cultural utilization of time as expressed in 24‐h work operations, combined with the widespread use of automation, will continue to escalate in the next century, further increasing the risks of fatigue‐related accidents, as more people conduct vigilance‐based activities at times other than the traditional daytime work hours. Fatigue management and prevention of fatigue‐related catastrophes need to become a sustained priority for government, industries, labour, and the public. Scientific data are urgently needed on the most likely areas in which sleepiness‐related performance failures contribute to accidents, and on the effectiveness of a wide range of potentially useful countermeasures.
Work hours, sleepiness and the underlying mechanisms
Authors: ÅKERSTEDT TQRBJÖRN
Published: January 2009

SUMMARY  Severe subjective and physiological sleepiness occur in night work, afflict almost all individuals and are associated with a performance impairment severe enough to explain night‐work accident data. The alertness deficit is caused by the displacement of work to the circadian phase which is least conducive to alert behaviour, by extension of the time spent awake and by the reduction of sleep length (due to circadian interference with sleep). Sleepiness will be extreme when the three causes are operative simultaneously. The three factors may be used quantitatively to predict sleepiness.
Driver sleepiness
Authors: HORNE J. A. , REYNER L. A.
Published: January 2009

SUMMARY Falling asleep at the wheel accounts for a sizeable number of vehicle accidents under monotonous driving conditions. The risk of driver death and serious injury is high. Circadian factors are profound and seem to be of equal (if not more) importance to the duration of the drive. Unfortunately, only the latter tends to be built into legislation. Young adults are the most likely to have these accidents, especially in the early morning, whereas older adults may be more vulnerable in the early afternoon. Drivers falling asleep are unlikely to recollect having done so, but they are aware of the precursory state of feeling sleepy, as normal sleep does not occur spontaneously without warning. Self‐awareness of sleepiness is a better method for alerting the driver than in‐car automatic devices. Car simulator studies show high inter‐correlations between driving performance, EEG measures of drowsiness and self‐assessments of sleepiness. Putative countermeasures to sleepiness during continued driving (for example cold air, playing car radio) have to be substantiated. The only safe countermeasure is to stop driving. At this point, a nap and/or coffee (caffeine) can be effective. Exercise is of little use. More driver education is needed about the dangers of driving whilst sleepy.
Sleepiness and its relation to the length, content, and continuity of sleep
Authors: GILLBERG MATS
Published: January 2009

SUMMARY  This review of experimental studies focuses on the disturbances of sleep that may occur in connection with irregular work hours and their relation to ensuing alertness. Three aspects of sleep are covered: the duration of sleep, the stages of sleep, and the continuity of sleep. A sleep curtailment as small as 2 h has clear negative effects on alertness. Sleep disturbed as frequently as every minute clearly affects alertness, but such procedures also affect the stages of sleep and decrease total sleep time. However, fragmentation rates of one per 10 minutes also induce sleepiness without affecting sleep content or duration. There is no clear evidence for slow‐wave sleep (SWS) being more important than other stages, but designs may not have been sensitive enough. In connection with fragmentation studies it is suggested, however, that the effects are stronger if more SWS is lost. In summary, the review suggests that the relatively mild disturbances of sleep in shift work may contribute to reduced alertness although there are probably other, more potent, factors.
Hypnotics and caffeine as countermeasures for shiftwork‐related sleepiness and sleep disturbance
Authors: WALSH JAMES K. , MUEHLBACH MARK J. , SCHWEITZER PAULA K.
Published: January 2009

SUMMARY  Hypnotic medication reliably improves sleep during the day, in terms of increasing total sleep time (TST) and reducing awakenings and light sleep. Middle‐aged individuals may benefit more than young adults. In addition, the time of day during which sleep is attempted may influence the efficacious dose of short‐acting drugs. Available data suggest that improving sleep during the day may improve alertness/performance at night to a mild degree, but significant circadian‐related sleepiness remains. Hypnotic medication may help minimize the cumulative effects of sleep loss associated with daytime sleep. Use for more than one week has not been adequately studied; however, as most night and rotating workers' schedules allow for night‐time sleep for two or more nights per week, available evidence indicates that hypnotics can be used effectively on an intermittent basis, e.g. for the first 2–4 day‐sleep periods of night shifts. Caffeine has been shown to increase alertness and improve psychomotor performance during usual night‐shift hours when taken between 22.30 and 01.20 hours. Available data indicate that at approximate dosages of 250–400 mg, the beneficial effects persist until at least 05.30 hours. For most subjects, caffeine taken at the start of the night‐shift does not interfere significantly with daytime sleep beginning at 09.00 hours. There is also some evidence that single doses of caffeine at the beginning of a night shift may be more alerting than divided doses. If caffeine is to be used therapeutically, avoidance of social use may be required to avoid tolerance to CNS stimulant effects. Despite the positive results of laboratory research examining hypnotics or caffeine as shiftwork countermeasures, field trials have not been conducted.
The HIV‐exposed, uninfected African child
Authors: Filteau Suzanne
Published: January 2009

The increasing success of prevention of mother‐to‐child HIV transmission programmes means that in Africa, very large numbers of HIV‐exposed, uninfected (HIV‐EU) children are being born. Any health problems that these children may have will thus be of enormous public health importance, but to date have been largely neglected. There is some evidence that HIV‐EU African children are at increased risk of mortality, morbidity and slower early growth than their HIV‐unexposed counterparts. A likely major cause of this impaired health is less exposure to breast milk as mothers are either less able to breastfeed or stop breastfeeding early to protect their infant from HIV infection. Other contributing factors are parental illness or death resulting in reduced care of the children, increased exposure to other infections and possibly exposure to antiretroviral drugs. A broad approach for psychosocial support of HIV‐affected families is needed to improve health of HIV‐EU children. High quality programmatic research is needed to determine how to deliver such care.
Human papillomavirus‐associated squamous cell carcinoma of the nail bed in African‐American patients
Authors: Turowski Cheryl Bansal , Ross Amy S. , Cusack Carrie Ann
Published: January 2009

Background  Human papillomavirus (HPV) has been implicated in the development of digital squamous cell carcinoma (SCC). Case reports in the literature mostly identify HPV type 16 present in tumors, but HPV types 2, 31, 34, 35, and 73 have also been isolated.

Methods  Two cases of digital SCC associated with HPV 16 in young African‐American men are presented.

Results and conclusions  Digital SCC associated with HPV may be difficult to evaluate and treat, particularly in African‐Americans and patients with human immunodeficiency virus (HIV). We discuss the need for careful evaluation, treatment, and follow‐up of these individuals.
Excision of Xanthelasmata – clamp, shave, and suture
Authors: Ghosh Yajati K. , Pradhan Eli , Ahluwalia Harpreet S.
Published: January 2009

Xanthelasma is a common disfiguring condition, which can be difficult to treat. Various treatments have been reported previously with varying degree of success.

We report a simple yet effective technique of excision of the lesions with excellent cosmetic outcome.
Outcome of influenza infections in outpatients after allogeneic hematopoietic stem cell transplantation
Authors: Khanna N. , Steffen I. , Studt J.‐D. , Schreiber A. , Lehmann T. , Weisser M. , Flückiger U. , Gratwohl A. , Halter J. , Hirsch H.H.
Published: January 2009

Background. Influenza can cause significant morbidity and mortality in patients after hematopoietic stem cell transplantation (HSCT). The diagnostic methods and antiviral treatment have scarcely been investigated.

Methods. We retrospectively identified influenza‐infected patients with upper or lower respiratory tract infection (RTI) diagnosed by culture and polymerase chain reaction (PCR) testing between November 2007 and April 2008. Treatment with oseltamivir 75 mg twice daily and serial nasal swabs were performed at the discretion of the treating physician.

Results. We identified 21 influenza infections in 19 patients: 19 with upper RTI and 2 with lower RTI. At diagnosis, all 21 samples were positive for PCR with a median influenza load of 5.9 log10 copies/mL. Culture was positive in 14 (67%) patients. Influenza A virus was diagnosed in 8 (38%) episodes and influenza B virus in 13 (62%) episodes. Two patients were sequentially infected by influenza A, followed by B after 38 and 47 days, respectively. Eighteen (86%) patients were treated with oseltamivir for 11 days (median, interquartile range [IQR]: 8–14). No progression to lower RTI or mortality occurred. Shedding persisted for 12 days (median, IQR: 8–13). Absolute lymphocyte count at diagnosis correlated inversely with shedding of the virus (P<0.001).

Conclusions. Oseltamivir is well tolerated and may reduce mortality of influenza virus‐infected patients after HSCT. PCR may help to optimize diagnosis and to monitor treatment strategies.
Primary cutaneous angioplasmocellular hyperplasia
Authors: Kumar Sandeep , Weedon David , De'Ambrosis Brian
Published: January 2009

Primary cutaneous angioplasmocellular hyperplasia is a plasmacellular infiltrate that has been reported only once previously in the literature, in a report of a case affecting two Latin American patients. In the present case, a systemically well 62‐year‐old Caucasian man presented with a nodule on the back of the neck. Histology showed a vascular proliferative process with an abundance of plasma cells in the stroma. There has been no recurrence of the lesion 2 years following curettage and diathermy. The clinicopathological presentation is consistent with primary cutaneous angioplasmocellular hyperplasia.
Management of imatinib‐related exacerbation of psoriasis in a patient with a gastrointestinal stromal tumour
Authors: Cheng Haiying , Geist David E , Piperdi May , Virk Renu , Piperdi Bilal
Published: January 2009

A 62‐year‐old woman with a pre‐existing psoriasis was treated with oral imatinib (400 mg/day) for a metastatic gastrointestinal stromal tumour. Within 4 weeks of starting therapy, she developed a guttate psoriasis flare. The eruption markedly improved within 2 weeks following cessation of imatinib. However, it recurred when imatinib was recommenced. She has been able to continue on imatinib (400 mg/day) with low‐dose oral methotrexate (12.5 mg/week) controlling the psoriasis.
Epidermodysplasia verruciformis‐like syndrome in association with systemic lupus erythematosus
Authors: Holmes Cara , Chong Alvin H , Tabrizi Sepehr N , Downes Nicholas , Nindl Ingo
Published: January 2009

A 43 year‐old immunosuppressed woman presented with a widespread macular scaly rash, clinically and histologically consistent with epidermodysplasia verruciformis. She had no family history of epidermodysplasia verruciformis. Human papillomavirus typing was performed on both biopsied skin from clinical lesions and on plucked body hairs. The lesional skin from the arm and knee showed predominantly human papillomavirus‐20 and ‐47 respectively. Human papillomavirus genotyping from the hair follicles revealed that human papillomavirus‐20 had the highest viral load, irrespective of body site.
Azathioprine hypersensitivity presenting as a neutrophilic dermatosis in a man with ulcerative colitis
Authors: Yiasemides Eleni , Thom Graham
Published: January 2009

We report a case of a 46‐year‐old man with ulcerative colitis being treated with oral prednisolone and azathioprine. Two weeks after the initiation of azathioprine he presented with fever, fatigue, myalgias and arthralgias and a painful cutaneous eruption that was most marked in a sun‐exposed distribution. This was accompanied by loose, non‐bloody diarrhoea. Histopathological assessment of a skin biopsy supported a diagnosis of a neutrophilic dermatosis. The azathioprine was temporarily withheld and oral prednisolone was increased as it was thought that the neutrophilic dermatosis was associated with the underlying ulcerative colitis. The patient's symptoms and cutaneous eruption resolved quickly and azathioprine was re‐introduced. Within 24 h, systemic symptoms returned along with a florid recrudescence of his cutaneous eruption. This rapidly improved upon withdrawal of azathioprine.
A novel model of wound healing in the SCID mouse using a cultured human skin substitute
Authors: Windsor Martin L , Eisenberg Mark , Gordon‐Thomson Clare , Moore Geoffrey PM
Published: January 2009

Studies of skin graft behaviour in rodent excisional wound models are limited by the dominance of wound contracture and graft sloughing as primary healing responses. To slow skin contraction, polytetrafluoroethylene (Teflon) rings were inserted into dorso‐lateral full‐thickness wounds in SCID mice. Cultured skin substitutes (OrCel), composed of cultured human keratinocytes and fibroblasts in a bovine collagen sponge, were implanted within the rings. Examination and histology of grafts 14 days later showed graft take in four of six recipients, with 90% epithelialization and wound contraction of 31–47%. Immunohistochemical studies, using human‐specific antisera to distinguish graft from host tissues, showed that regenerated tissue was predominantly human. Staining with anticytokeratin, revealed a multilayered, stratified neoepidermis. HBG were identified in keratinocytes in all epidermal layers. Langerhans cells were absent. Antihuman vimentin, used as a fibroblast marker, confirmed that cells of the neodermis were primarily of human origin. Neoepidermal keratinocytes, primarily in the basal and suprabasal layers, were also stained. Results suggest that the poly(tetrafluoroethylene) ring inhibited graft sloughing and provided a more favourable environment for the skin substitute to regenerate a substantially normal human skin.
Breastfeeding practices among Jordanian women
Authors: Oweis Arwa , Tayem Asmahan , Froelicher Erika Sivarajan
Published: January 2009

The purpose of the study was to explore Jordanian women's breastfeeding beliefs and practices including exclusive breastfeeding. A descriptive cross‐sectional design with a convenience sample of 200 Jordanian mothers was used. The majority of mothers were muliparous and were recruited from primary health‐care centres within 6 weeks of a normal vaginal birth or an instrumental delivery. Eligible women, who met the inclusion criteria, were invited to participate in the study. A sociodemographic data form and a 14‐item questionnaire concerning different aspects of breastfeeding beliefs and practices were developed for self administration. This study indicated high early initiation of breastfeeding. Most mothers gave supplements other than breastfeeding, including water without knowing that this supplementation could affect exclusive breastfeeding or the continuation of breastfeeding. Finding of this study shed some light on the current breastfeeding practices including exclusive breastfeeding among Jordanian women. Women need to be better educated about breastfeeding. Therefore, more efforts and resources should be put into providing opportunities for education to discuss breastfeeding during antenatal care. This Jordanian study could be relevant to Arabic women in the West, because cultural beliefs and practices are likely to be part of immigrant woman's perceptions about breastfeeding practices.
Medication non‐adherence—exploring the conceptual mire
Authors: Lehane Elaine , McCarthy Geraldine
Published: January 2009

It is well established that pharmacotherapy is fundamental to disease and symptom management. Adherence to medication regimens is therefore essential for improved patient health outcomes. In reality, however, many patients experience difficulty with medication taking resulting in suboptimal adherence. Given the consequences of this pervasive problem, non‐adherence is increasingly recognized as one of the leading challenges that professionals face in contemporary health care. As health‐care professionals, nurses have an important role in combating this problem. This paper therefore examines the literature surrounding medication adherence for the purposes of enhancing professional knowledge and practice in this area. Specifically, the impact of poor adherence from the patient's, health‐care professional and health‐care system perspective is detailed to highlight the significance of this issue. The underlying philosophical attributes of adherence and the interchangeable concepts of compliance and concordance are explored, with the implications of the meanings attributed to these concepts for nursing practice and research considered.
Problems faced by relatives caring for cancer patients at home
Authors: Tsigaroppoulos Thomas , Mazaris Evangelos , Chatzidarellis Eleftherios , Skolarikos Andreas , Varkarakis Ioannis , Deliveliotis Charalambos
Published: January 2009

The care of patients suffering from advanced cancer is not limited in the hospital setting. It continues at home where the burden of care is borne by specific individuals. The aim of the present study was to survey and record the various problems faced by those who care for cancer patients at home. The study was conducted in our hospital during the summer of 2007. All participants completed, during a personal interview, a questionnaire which covered pathologic, social, psychological, spiritual/religious and financial problems. Seventy‐six carers returned fully completed questionnaires. The most frequent problems reported were: anxiety regarding the patient's future (61.8%), troublesome symptoms such as pain (54%), increased economic burden—financial difficulty (51.3%), problems with patient's feeding (50%), unhappiness or depression (48,7%), emotional upset (47.4%), worsening of the patient's behaviour and personality (38.2%), difficulty of establishing a positive attitude regarding their current status (34.2%), transport to hospital (32.9%), assistance from the wider family circle (25%). Taking care of cancer patients at home creates several problems among carers. Many of them remain undetected. The acknowledgement and recognition of these problems by health‐care professionals might contribute to finding solutions in order to assist the difficult task of these individuals.
Systematic review of the effectiveness of primary care nursing
Authors: Keleher Helen , Parker Rhian , Abdulwadud Omar , Francis Karen
Published: January 2009

This paper reports on a systematic review that sought to answer the research question: What is the impact of the primary and community care nurse on patient health outcomes compared with usual doctor‐led care in primary care settings? A range of pertinent text‐words with medical subject headings were combined and electronic databases were searched. Because of the volume of published articles, the search was restricted to studies with high‐level evidence. Overall, 31 relevant studies were identified and included in the review. We found modest international evidence that nurses in primary care settings can provide effective care and achieve positive health outcomes for patients similar to that provided by doctors. Nurses are effective in care management and achieve good patient compliance. Nurses are also effective in a more diverse range of roles including chronic disease management, illness prevention and health promotion. Nevertheless, there is insufficient evidence about primary care nurses' roles and impact on patient health outcomes.
Monitoring nutritional status accurately and reliably in adolescents with anorexia nervosa
Authors: Martin Andrew C , Pascoe Elaine M , Forbes David A
Published: January 2009

Aim:  Accurate assessment of nutritional status is a vital aspect of caring for individuals with anorexia nervosa (AN) and body mass index (BMI) is considered an appropriate and easy to use tool. Because of the intense fear of weight gain, some individuals may attempt to mislead the physician. Mid‐upper arm circumference (MUAC) is a simple, objective method of assessing nutritional status. The setting is an eating disorders clinic in a tertiary paediatric hospital in Western Australia. The aim of this study is to evaluate how well MUAC correlates with BMI in adolescents with AN.

Methods:  Prospective observational study to evaluate nutritional status in adolescents with AN.

Results:  Fifty‐five adolescents aged 12–17 years with AN were assessed between January 1, 2004 and January 1, 2006. MUAC was highly correlated with BMI (r = 0.79, P < 0.001) and individuals with MUAC ≥20 cm rarely required hospitalisation (negative predictive value 93%).

Conclusions:  MUAC reflects nutritional status as defined by BMI in adolescents with AN. Lack of consistency between longitudinal measurements of BMI and MUAC should be viewed suspiciously and prompt a more detailed nutritional assessment.
Vitamin D in infants with cystic fibrosis diagnosed by newborn screening
Authors: Neville Liza A , Ranganathan Sarath C
Published: January 2009

Aims:  Screening enables early nutritional deficiencies to be detected in those with cystic fibrosis (CF). Although vitamin deficiency is considered unlikely in older subjects with normal vitamin E levels, few studies have determined vitamin D status at diagnosis and its relationship to other fat‐soluble vitamins.

Methods:  We reviewed vitamin levels in infants diagnosed with CF by newborn screening over a 5‐year period in Melbourne, Australia. Vitamin D levels were determined using the IDS gamma‐B 25‐OH Vitamin D radio‐immunoassay (Immunodiagnostic Systems Limited, Boldon, UK). Vitamins A and E were evaluated by high‐performance liquid chromatography. We assessed the association between vitamin D level and sex, month of birth, pancreatic status, and vitamin A and E levels.

Results:  Fifty‐eight infants were diagnosed at a median age of 1 month (range: 0–3 months). Initial vitamin D levels were assessed between 0.2 and 3.5 months in 30 (vitamin D) and 45 (vitamins A and E) infants. The number of infants deficient with vitamins D, E and A were 11 (37%), 7 (16%) and 27 (60%), respectively. Vitamin D levels were unrelated to sex, vitamin A or E levels, month of birth or pancreatic status, whereas vitamin A and E levels were significantly lower in those who were pancreatic insufficient. With supplementation, vitamin D increased over time.

Conclusions:  Vitamin D deficiency is common in infants newly diagnosed with CF by newborn screening and is unrelated to pancreatic status or predicted low vitamin E levels. Vitamin D deficiency is less common over time following treatment.
Reverse cholesterol transport in type 2 diabetes mellitus
Authors: Tan K. C. B.
Published: January 2009

High‐density lipoprotein (HDL) plays an important protective role against atherosclerosis, and the anti‐atherogenic properties of HDL include the promotion of cellular cholesterol efflux and reverse cholesterol transport (RCT), as well as antioxidant, anti‐inflammatory and anticoagulant effects. RCT is a complex pathway, which transports cholesterol from peripheral cells and tissues to the liver for its metabolism and biliary excretion. The major steps in the RCT pathway include the efflux of free cholesterol mediated by cholesterol transporters from cells to the main extracellular acceptor HDL, the conversion of free cholesterol to cholesteryl esters and the subsequent removal of cholesteryl ester in HDL by the liver. The efficiency of RCT is influenced by the mobilization of cellular lipids for efflux and the intravascular remodelling and kinetics of HDL metabolism. Despite the increased cardiovascular risk in people with type 2 diabetes, current knowledge on RCT in diabetes is limited. In this article, abnormalities in RCT in type 2 diabetes mellitus and therapeutic strategies targeting HDL and RCT will be reviewed.
Effects of cevoglitazar, a dual PPARα/γ agonist, on ectopic fat deposition in fatty Zucker rats
Authors: Laurent D. , Gounarides J. S. , Gao J. , Boettcher B. R.
Published: January 2009

Aim:  By acting as both insulin sensitizers and lipid‐lowering agents, dual‐acting peroxisome proliferator‐activated receptors α/γ (PPARα/γ) agonists may be used to improve glucose tolerance in type 2 diabetic patients without inducing adiposity and body weight gain. Here, in an animal model of obesity and insulin resistance, the metabolic response to cevoglitazar, a dual PPARα/γ, was characterized using a combination of in vivo and ex vivo magnetic resonance methodologies and compared to treatment effects of fenofibrate, a PPARα agonist, and pioglitazone, a PPARγ agonist.

Methods:  Four groups of fatty Zucker rats: (i) Vehicle; (ii) fenofibrate 150 mg/kg; (iii) pioglitazone 30 mg/kg; and (iv) cevoglitazar 5 mg/kg were investigated before and after treatment. Animals were fed a fat‐enriched (54% kcal fat) diet for 6 weeks, 2 weeks high of fat–exposure alone followed by a 4‐week dosing period.

Results and conclusions:  Cevoglitazar was as effective as pioglitazone at improving glucose tolerance. However, unlike pioglitazone, both fenofibrate and cevoglitazar reduced BW gain and adiposity, independent of food intake. All three treatment regimens normalized intramyocellular lipids. Metabolic profiling showed that in the muscle cevoglitazar improves the lipid profile via both PPARα‐ and PPARγ‐mediated mechanisms. Pioglitazone reduced hepatic lipid accumulation, while cevoglitazar and fenofibrate reduced hepatic lipid concentration below baseline levels (p < 0.05). Metabolic profiling showed that in the liver, cevoglitazar functions largely through PPARα agonism resulting in increased β‐oxidation. Cevoglitazar only induced small changes to the lipid composition of visceral fat. In subcutaneous fat, however, cevoglitazar induced changes similar to those observed with fenofibrate suggesting export of fatty acids from this depot.