Obstructive sleep apnea, hypertension, resistant hypertension and cardiovascular disease

Obstructive sleep apnea (OSA) is one of the most common causes of hypertension (HTN) and cardiovascular disease (CVD). It is also a quite common underlying factor in resistant HTN (RHTN). The main etiological factor of OSA is obesity, which is a rapidly growing global epidemic. To control obesity, patients should be encouraged by health care professionals to lose weight and be educated about weight loss strategies such as lifestyle modifications, which include regular exercise, low-calorie diet, low sodium intake, smoking cessation, and decreased alcohol consumption. This review also emphasizes the importance of screening for OSA as the major underlying cause of essential, and RHTN, which can lead to CVD and can cause end-organ damage. It also stresses the importance of using continuous positive airway pressure (CPAP) and its beneficial effects, along with other antihypertensive regimens, in treating HTN, and RHTN. Treatment with CPAP therapy decreases sympathetic activity, high blood pressure (BP), heart rate, and CVD as well as its associated mortality.

Energy imbalance: obesity, associated comorbidities, prevention, management and public health implications

The prevalence of obesity has been continually increasing, as have its associated comorbidities and health care costs. Effective management of obesity and early intervention measures are necessary to overcome this global issue. The responsibility for preventing and managing this global epidemic does not lie solely on an individual, but also on the entire health care system. Policy makers-nationally and globally-must play their roles to solve the issue. In this review article, we examine methods of controlling and managing obesity through interventions, such as a low caloric diet, physical exercise, pharmacological guidance, and bariatric surgical procedures. While health care professionals should educate patients about all available treatment options for severe obesity, bariatric surgical procedures have increased in popularity and are considered very beneficial with outcomes fruitful in managing severe obesity.

Obstructive sleep apnea and stroke

Obstructive Sleep Apnea (OSA) is a common co-morbid condition in stroke patients. It represents a very important risk factor for stroke in addition to the other established ones such as hypertension, cardiovascular disease (CVD), hyperlipidemia, atrial fibrillation (AF), type 2 diabetes mellitus (T2DM), stress, smoking, and heavy drinking. Although in the United States the prevalence of OSA has somewhat decreased from the previous years, globally its prevalence remains constant, or in some cases, is on the rise. In this review we present the epidemiology for OSA in stroke populations and discuss the risk factors for stroke as well as the underlying pathogenetic mechanisms linking OSA, stroke and CVD. We also emphasize the more thorough evaluation and control of OSA in order to prevent the disabling side effects of a stroke, which not only compromises the physical and mental health of a person and increases the burden on families, but also adds a severe burden to national health economics. OSA should always be considered when assessing a patient with transient ischemic attacks (TIA). Work up and treatment for OSA will not only help prevent stroke with its devastating consequences, but will also help prevent CVD, and ameliorate co-morbid conditions such as diabetes and hypertension in these vulnerable populations.

Sleep health disparity: the putative role of race, ethnicity and socioeconomic status

Sleep plays a pivotal role in both physical and mental health. Sleep quality can be affected by many socio demographic factors, such as race and/or ethnicity, as well as socio economic status (SES). Chronic sleep deprivation is associated with unhealthy behaviors such as alcohol abuse and also places individuals at risk for chronic diseases including obesity, cardiovasculardisease (CVD), depression, and/or anxiety. This review explores the common socio demographic factors and SES that can lead to sleep disturbances. Among these factors are shift work, poor dietary habits, smoking and alcohol abuse. Such factors need to be considered by health care providers in the clinical assessment and management plans of patients with sleep disorders.

Sleep, Melatonin, and the Menopausal Transition: What Are the Links?

The pineal hormone Melatonin plays an important role in the regulation of the circadian sleep/wake cycle, mood, and perhaps immune functions, carcinogensis and reproduction. The human circadian rhythm of melatonin release from the pineal gland is tightly synchronized with the habitual hours of sleep. Peri- and postmenopausal women often complain of difficulties initiating and/or maintaining sleep, with frequent nocturnal and early morning awakenings. In this review we discuss the pathophysiology of melatonin function as it relates to sleep disorders in menopausal women, highlighting the potential use of exogenous melatonin during the menopausal transition and beyond.

Obstructive Sleep Apnea: Women's Perspective

The main characteristics of sleep-disordered breathing (SDB) are airflow limitation, chronic intermittent hypoxia, or apnea; which may lead to tissue hypoperfusion and recurrent arousal from sleep. These episodes of hypoxia or apnea can lead to tissue inflammation, and are causal factors of disturbed sleep in both men and women. Several lines of evidence suggest that sleep patterns differ along the lifespan in both male and female subjects, and this may result from the influence of female gonadotropic hormones on sleep. Compared to men, women have more sleep complaints, as women's sleep is not only influenced by gonadotropins, but also by conditions related to these hormones, such as pregnancy. It is therefore not surprising that sleep disturbances are seen during menopause, too. Factors that may play a role in this type of SDB in women include vasomotor symptoms, changing reproductive hormone levels, circadian rhythm abnormalities, mood disorders, coexistent medical conditions, and lifestyle factors.

Sleep and Premenstrual Syndrome

The etiology of premenstrual syndrome (PMS) is unknown; it may be due to the normal effect of hormones during the menstrual cycle as it occurs in the late luteal phase of the menstrual cycle.PMS affects women of childbearing age and remits with the onset of menstruation. The menstrual phase is known to influence stage 2 and REM sleep in women, irrespective of premenstrual dysphoric disorder (PMDD). Women with PMDD showed a decreased response to melatonin in their luteal phase as compared to the follicular phase of the menstrual cycle. However, melatonin duration or timing of offset in the morning has not been reported to correlate with the mood. Rather, improvement in mood-related symptoms of PMDD has been found to be influenced by sleep deprivation, be it sleep restrictions in early or late night. Sleep disturbance and decreased melatonin secretions due to hormonal fluctuations during the luteal phase of the menstrual cycle could explain the sleep complaints of PMDD.

Anatomical considerations for percutaneous trans ilio-sacroiliac S1 and S2 screw placement

OBJECTIVE

To determine the presence of a consistent osseous corridor through S1 and S2 and fluoroscopic landmarks thereof, which could be used for safe trans ilio-sacroiliac screw fixation of posterior pelvic ring disorders.

STUDY DESIGN

Computed tomography (CT) based anatomical investigation utilising multiplanar image and trajectory reconstruction (Agfa-IMPAX Version 5.2 software). Determination of the presence and dimension of a continuous osseous corridor in the coronal plane of the sacrum at the S1 and S2 vertebral levels.

OUTCOME MEASURES

Determination of: (a) the presence of an osseous corridor in the coronal plane through S1 and S2 in males and females; (b) the dimension of the corridor with regard to diameter and length; (c) the fluoroscopic landmarks of the corridor.

RESULTS

The mean cross-sectional area for S1 corridors in males and females was 2.13 and 1.47 cm(2) , respectively. The mean cross-sectional area for the S2 corridor in males and females was 1.46 and 1.13 cm(2), respectively. The limiting anatomical factor is the sagittal diameter of the sacral ala at the junction to the vertebral body. The centre of the S1 and S2 corridor is located in close proximity to the centre of the S1 and S2 vertebrae on the lateral fluoroscopic view as determined by the adjacent endplates and anterior and posterior vertebral cortices.

CONCLUSION

Two-thirds of males and females have a complete osseous corridor to pass a trans-sacroiliac S1 screw of 8 mm diameter. The S2 corridor was present in all males but only in 87 % of females. Preoperative review of the axial CT slices at the midpoint of the S1 or S2 vertebral body allows the presence of a trans-sacroiliac osseous corridor to be determined by assessing the passage at the narrowest point of the corridor at the junction of the sacral ala to the vertebral body.

Sleep Disorders in Postmenopausal Women

One of the core symptoms of the menopausal transition is sleep disturbance. Peri-menopausal women often complain of difficulties initiating and/or maintaining sleep with frequent nocturnal and early morning awakenings. Factors that may play a role in this type of insomnia include vasomotor symptoms, changing reproductive hormone levels, circadian rhythm abnormalities, mood disorders, coexistent medical conditions, and lifestyle. Other common sleep problems in this age group, such as obstructive sleep apnea and restless leg syndrome, can also worsen the sleep quality. Exogenous melatonin use reportedly induces drowsiness and sleep and may ameliorate sleep disturbances, including the nocturnal awakenings associated with old age and the menopausal transition. Recently, more potent melatonin analogs (selective melatonin-1 (MT1) and melatonin-2 (MT2) receptor agonists) with prolonged effects and slow-release melatonin preparations have been developed. They were found effective in increasing total sleep time and sleep efficiency as well as in reducing sleep latency in insomnia patients. The purpose of this review is to give an overview on the changes in hormonal status to sleep problems among menopausal and postmenopausal women.

Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies

PURPOSE

U-shaped sacral fractures usually result from axial loading of the spine with simultaneous sacral pivoting due to a horizontal fracture which leads to a highly unstable spino-pelvic dissociation. Due to the rarity of these fractures, there is lack of an agreed treatment strategy.

METHODS

A thorough literature search was carried out to identify current treatment concepts. The studies were analysed for mechanism of injury, diagnostic imaging, associated injuries, type of surgery, follow-up times, complications, neurological, clinical and radiological outcome.

RESULTS

Sixty-three cases were found in 12 articles. No Class I, II or III evidence was found in the literature. The most common mechanism of injury was a fall or jump from height. Pre-operative neurological deficit was noted in 50 (94.3%) out of 53 cases (not available in 10 patients). The most used surgical options were spino-pelvic fixation with or without decompression and ilio-sacral screws. Post-operative complications occurred in 24 (38.1%) patients. Average follow-up time was 18.6 months (range 2-34 months). Full neurological recovery was noted in 20 cases, partial recovery in 14 and 9 patients had no neurological recovery (5 patients were lost in follow-up). Fracture healing was mentioned in 7 articles with only 1 case of fracture reduction loss.

CONCLUSION

From the current available data, an evidence based treatment strategy regarding outcome, neurological recovery or fracture healing could not be identified. Limited access and minimal-invasive surgery focussing on sacral reduction and restoration seems to offer comparable results to large spino-pelvic constructs with fewer complications and should be considered as the method of choice. If the fracture is highly unstable and displaced, spino-pelvic fixation might offer better stability.

Posters as a tool for disseminating health related information in a developing country: a pilot experience

OBJECTIVE

To investigate the effectiveness of posters as a tool, for imparting information related to high blood pressure.

METHODS

The intervention involved hanging posters conveying information about blood pressure, in the waiting rooms of 339 health facilities. The impact of this intervention was assessed after 30 days of hanging the posters with the main assessment component of the survey aimed at the target audience at the facilities. 1017 people attending the facilities were interviewed.

RESULTS

Mean age of this population was 40.4 (SD 11.06) years. There were 79% males and 21% females. 80.2% (n=816) of the respondents had noticed the posters. 84.5% of the people were of the opinion that the poster was good. 63.7% of the people understood the overall message of the poster correctly. Regarding change in behaviour, 96.7% (n=789) of the people thought that the poster was asking them to do something; 85.9% (n=501) of these got their blood pressure checked compared to 60.9% (n=14) of those who did not think the poster was asking them to do anything (p=0.004). Of those who said that the poster was asking them to do something, there were varied responses as to what they thought the poster was asking them to do. If the response was that they should have their blood pressure checked, it was taken as a correct response. 87.3% of those who said that the poster was asking them to get their blood pressure checked, actually got their blood pressure checked compared to 83.7% of those who did not understand this message (p=0.241).

CONCLUSIONS

Given the limitations of the study it is difficult to assess the effectiveness of the poster in changing people's behaviour regarding blood pressure check up. This experience will serve as a pilot for a larger prospective study to assess poster as a tool for prompting people to get their blood pressure checked.

Clinical results of the intra cytoplasmic sperm injection (ICSI) at Baqai Institute of Reproduction and Developmental Sciences (BIRDS)

OBJECTIVE

To analyse the results of the new revolutionary technique of Intra Cytoplasmic Sperm Injection (ICSI) for male infertility. Furthermore, to find out the ways of reducing cost of the expensive methods of Assisted Reproductive Techniques.

DESIGN

This is an analytical study of results of 71 patients (86 Cycles) of ICSI performed in first year of its launching in Baqai Institute of Reproduction and Developmental Sciences (BIRDS) from May 1997 to April 1998. Men with semen reports of parameters less than WHO criteria were treated including Azoospermic men.

RESULTS

After ICSI procedure a fertilisation rate of 58.9% was achieved in 86 cycles. A total of 17 clinical pregnancies were had from the transfer of fresh embryos. This includes three pregnancies from Surgical Sperm Collection in azoospermic men. Cost could be reduced by avoiding high dosage of drugs and by cutting out serial serum estrogen levels. Ultrasonic assessment for follicle monitoring is equally satisfactory.

CONCLUSION

ICSI proved to be the only successful treatment for men with poor semen quality. It is giving nearly 20% chances of fatherhood in a man who was labeled infertile previously. Results are promising and will be improving with time. The cost could be reduced to an extent by cutting down drug doses and laboratory investigations without compromising the results.

Characterization of Dictyostelium discoideum cathepsin D

Previous studies using magnetic purification of Dictyostelium discoideum endocytic vesicles led us to the identification of some major vesicle proteins. Using the same purification procedure, we have now focused our interest on a 44 kDa soluble vesicle protein. Microsequencing of internal peptides and subsequent cloning of the corresponding cDNA identified this protein as the Dictyostelium homolog of mammalian cathepsins D. The only glycosylation detected on Dictyostelium cathepsin D (CatD) is common antigen 1, a cluster of mannose 6-sulfate residues on N-linked oligosaccharide chains. CatD intracellular trafficking has been studied, showing the presence of the protein throughout the entire endocytic pathway. During the differentiation process, the catD gene presents a developmental regulation, which is also observed at the protein level. catD gene disruption does not alter significantly the cell behaviour, either in the vegetative form or the differentiation stage. However, modifications in the SDS-PAGE profiles of proteins bearing common antigen 1 were detected, when comparing parental and catD(-) cells. These modifications point to a possible role of CatD in the maturation of a few Dictyostelium lysosomal proteins.

Human alcohol dehydrogenase ADH2 and ADH3 polymorphisms in ethnic Chinese and Indians of West Malaysia

Human alcohol dehydrogenase ADH2 and ADH3 were investigated in liver and stomach specimens of Chinese and Indians from West Malaysia. Eight-nine percent of the Chinese carry the atypical ADH2 type, a proportion very similar to that reported in Japanese. However, among 43 Indian specimens there was not a single case of atypical ADH2. In Indians, the gene frequency of ADH13 is 0.64 and of ADH23 0.36, similar to the frequencies in Caucasians, whereas in Chinese, the gene frequency for ADH13 and ADH23 is 0.91 and 0.09, respectively. We also report some unusual enzymatic characteristics in the course of our study.