Effects of added dead space on sleep disordered breathing at high altitude

Introduction: Sleep disordered breathing with central apnea or hypopnea frequently occurs during sleep at high altitude. The aim of this study was to assess the effects of added dead space (DS) on sleep disordered breathing and transcutaneous CO2 (PtcCO2) level during sleep at high altitude. Methods: Full night sleep recordings were obtained on 12 unacclimatized mountaineers (11 males, 1 female, mean age 39 ± 12 y.o.) during one of the first 4 nights after arrival in Leh, Ladakh (3500 m). In random order, half of the night was spent with a 500 ml increase in dead space through a custom designed full face mask and the other half without it. PtcCO2 was measured in 3 participants. Results: Baseline recordings reveled two clearly distinct groups: one with severe sleep disordered breathing (n = 5) and the other with mild or no disordered breathing (n = 7). Added dead space markedly improved breathing in the first group (baseline vs DS): apnea hypopnea index (AHI) 70.3 ± 25.8 vs 29.4 ± 6.9 (p = 0.013), oxygen desaturation index (ODI): 72.9 ± 24.1/h vs 42.5 ± 14.4 (p = 0.031), whereas it had no significant effect in the second group. Added dead space did not have a significant effect on mean oxygen saturation level. Respiratory events were almost exclusively central apnea or hypopnea except for one subject. Only a minor increase in mean PtcCO2 (n = 3) was observed: 33.6 ± 1.8 mm Hg at baseline and 35.0 ± 2.62 mm Hg with DS. Sleep quality was preserved under dead space condition, since the microarousal rate remained unchanged (16.8 ± 8.7/h vs 19.4 ± 18.6/h (p = 0.51). Conclusion: In mountaineers with severe sleep disordered breathing at high altitude, a 500 ml increase in dead space through a fitted mask significantly improves nocturnal breathing.

The cost-effectiveness and public health benefit of nalmefene added to psychosocial support for the reduction of alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels: a Markov model.

OBJECTIVES: To determine whether nalmefene combined with psychosocial support is cost-effective compared with psychosocial support alone for reducing alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels (DRLs) as defined by the WHO, and to evaluate the public health benefit of reducing harmful alcohol-attributable diseases, injuries and deaths. DESIGN: Decision modelling using Markov chains compared costs and effects over 5 years. SETTING: The analysis was from the perspective of the National Health Service (NHS) in England and Wales. PARTICIPANTS: The model considered the licensed population for nalmefene, specifically adults with both alcohol dependence and high/very high DRLs, who do not require immediate detoxification and who continue to have high/very high DRLs after initial assessment. DATA SOURCES: We modelled treatment effect using data from three clinical trials for nalmefene (ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941)). Baseline characteristics of the model population, treatment resource utilisation and utilities were from these trials. We estimated the number of alcohol-attributable events occurring at different levels of alcohol consumption based on published epidemiological risk-relation studies. Health-related costs were from UK sources. MAIN OUTCOME MEASURES: We measured incremental cost per quality-adjusted life year (QALY) gained and number of alcohol-attributable harmful events avoided. RESULTS: Nalmefene in combination with psychosocial support had an incremental cost-effectiveness ratio (ICER) of £5204 per QALY gained, and was therefore cost-effective at the £20,000 per QALY gained decision threshold. Sensitivity analyses showed that the conclusion was robust. Nalmefene plus psychosocial support led to the avoidance of 7179 alcohol-attributable diseases/injuries and 309 deaths per 100,000 patients compared to psychosocial support alone over the course of 5 years. CONCLUSIONS: Nalmefene can be seen as a cost-effective treatment for alcohol dependence, with substantial public health benefits. TRIAL REGISTRATION NUMBERS: This cost-effectiveness analysis was developed based on data from three randomised clinical trials: ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941).

Valeur ajoutée de la supervision du médecin-assistant par un médecin de famille dans une permanence [Added value of family practitioners' supervision of junior doctors in a walk-in clinic].

The pending workforce crisis in family medicine has triggered various initiatives. This article describes the PMU-FLON walk-in clinic, a project of the Institute of General Medicine University of Lausanne. The working conditions in this clinic are close to that of a family practice. Doctors in training are supervised by family doctors who work part-time in the clinic. The objective is to improve training in the various fields of family medicine, from technical skills (improving optimal use of diagnostic tools), to integrating patients' requests in a more global patient-centered approach. This new educational model allows doctors in training to benefit from the specific approaches of different trainers. It will contribute to promoting quality family medicine in the future.

Added prognostic value of myocardial blood flow quantitation in rubidium-82 positron emission tomography imaging

Les maladies cardiovasculaires restent la cause de mortalité la plus élevée dans le monde occidental. Il s'agit d'un processus long et complexe, dont l'infarctus du myocarde et la mort cardiaque ne sont que la fin d'un spectrum. La perfusion myocardique joue un rôle central dans l'évolution de la maladie et survient chronologiquement en amont de la dysfonction diastolique et systolique, ainsi que de l'infarctus du myocarde. Une meilleure compréhension de la Physiopathologie sous-jacente est cruciale dans le diagnostique et la prise en charge du patient. Dans ce sens, ce travail tente d'évaluer l'apport de l'évaluation de la perfusion myocardique évaluée par la tomographic à émission de positron (PET/CT) quant à la prédiction d'événements cardiovasculaires. De plus, l'apport de l'évaluation quantitative par rapport à l'évaluation qualitative a été démontré dans ce travail. Nous avons utilisé un radiotraceur unique au regard de ses caractéristiques. En effet, Le Rubidium-82 est un traceur qui ne nécessite pas d'un cyclotron pour sa fabrication, dès lors qu'il est produit par un générateur, rendant ainsi sa disponibilité un atout et un avantage potentiel lors de futurs implémentations à plus grande échelle. Ce travail démontre la supériorité de l'analyse de perfusion myocardique quantitative par rapport à l'analyse traditionnelle qualitative, ce qui n'était pas encore confirmé avec le Rubidium-82. Les résultats montrent une démarcation significative entre les différentes valeurs de perfusion quantitative/absolue, permettant de distinguer différentes populations plus ou moins à risque en terme de prédiction d'événements cardiaques futurs. Il est intéressant de noter que dans un modèle combinant l'analyse qualitative et quantitative proposé dans ce travail, l'inclusion des résultats les plus ischémiques obtenus par l'analyse qualitative avec les résultats de perfusion les plus bas en terme de flux myocardique absolu (analyse quantitative) démarque une population à très bas risque d'événements cardiovasculaires majeurs, une prédiction pouvant être observée surplus de 1'000 jours. Ces résultats forment un ajout significatif quant à l'évaluation de la perfusion myocardique par la médecine nucléaire, notamment par ce model intégratif proposé, lequel permet une prédiction précise et contributive dans le cadre de futurs événements cardiovasculaires majeurs.

Development of model observers applied to 3D breast tomosynthesis microcalcifications and masses

The development of model observers for mimicking human detection strategies has followed from symmetric signals in simple noise to increasingly complex backgrounds. In this study we implement different model observers for the complex task of detecting a signal in a 3D image stack. The backgrounds come from real breast tomosynthesis acquisitions and the signals were simulated and reconstructed within the volume. Two different tasks relevant to the early detection of breast cancer were considered: detecting an 8 mm mass and detecting a cluster of microcalcifications. The model observers were calculated using a channelized Hotelling observer (CHO) with dense difference-of-Gaussian channels, and a modified (Partial prewhitening [PPW]) observer which was adapted to realistic signals which are not circularly symmetric. The sustained temporal sensitivity function was used to filter the images before applying the spatial templates. For a frame rate of five frames per second, the only CHO that we calculated performed worse than the humans in a 4-AFC experiment. The other observers were variations of PPW and outperformed human observers in every single case. This initial frame rate was a rather low speed and the temporal filtering did not affect the results compared to a data set with no human temporal effects taken into account. We subsequently investigated two higher speeds at 5, 15 and 30 frames per second. We observed that for large masses, the two types of model observers investigated outperformed the human observers and would be suitable with the appropriate addition of internal noise. However, for microcalcifications both only the PPW observer consistently outperformed the humans. The study demonstrated the possibility of using a model observer which takes into account the temporal effects of scrolling through an image stack while being able to effectively detect a range of mass sizes and distributions.

Hybrid PET/MRI in the assessment of cardiac viability: added value compared to PET/CT

Purpose: We evaluated the potential for hybrid PET/MRI devices to provide integrated metabolic, functional and anatomic characterisation of patients with suspected coronary artery disease.Methods and Materials: Ten patients (5 with suspected hibernating myocardium and 5 healthy volunteers) performed an imaging study using a hybrid PET/MRI (Philips). Viability assessed by 18F-FDG was performed in diseased patients along with MRI anatomic and functional study and reassessed within 30 minutes by conventional PET/CT. Non-contrast right coronary artery (RCA) targeted and whole heart 3D coronary angio-MRI using ECG-gating and respiratory navigator was performed in healthy volunteers with reconstruction performed using MPR and volume rendering. The extent of metabolic defect (MD) using PET/MRI and PET/CT was compared in patients and coronary territories (LAD, CX, RCA). Assessability of coronary lumen was judged as good, sub-optimal or non-assessable using a 16-segments coronary model.Results: Metabolic assessment was successful in all patients with MD being 19.2% vs 18.3% using PET/MRI and PET/CT, respectively (P=ns). The MD was 10.2%, 6 %, and 3 % vs 9.3%, 6 % and 3 % for LAD, CX and RCA territories, respectively (P= ns). Coronary angio-MRI was successful in all volunteers with 66 coronary segments visualised overall. The RCA was fully visualised in 4/5 volunteers and the left coronary arteries in 4/5 volunteers. Assessability in visualised segments was good, sub-optimal and non-assessable in 88 %, 2 % and 10 %, respectively.Conclusion: Hybrid PET/MRI devices may enable metabolic evaluation comparable to PET/CT with additional value owing to accurate functional and anatomical information including coronary assessment.

Permanent Genetic Resources added to Molecular Ecology Resources Database 1 August 2010-30 September 2010

This article documents the addition of 229 microsatellite marker loci to the Molecular Ecology Resources Database. Loci were developed for the following species: Acacia auriculiformis x Acacia mangium hybrid, Alabama argillacea, Anoplopoma fimbria, Aplochiton zebra, Brevicoryne brassicae, Bruguiera gymnorhiza, Bucorvus leadbeateri, Delphacodes detecta, Tumidagena minuta, Dictyostelium giganteum, Echinogammarus berilloni, Epimedium sagittatum, Fraxinus excelsior, Labeo chrysophekadion, Oncorhynchus clarki lewisi, Paratrechina longicornis, Phaeocystis antarctica, Pinus roxburghii and Potamilus capax. These loci were cross-tested on the following species: Acacia peregrinalis, Acacia crassicarpa, Bruguiera cylindrica, Delphacodes detecta, Tumidagena minuta, Dictyostelium macrocephalum, Dictyostelium discoideum, Dictyostelium purpureum, Dictyostelium mucoroides, Dictyostelium rosarium, Polysphondylium pallidum, Epimedium brevicornum, Epimedium koreanum, Epimedium pubescens, Epimedium wushanese and Fraxinus angustifolia.

Quelle attitude face à une masse médiastinale antérieure chez l'adulte [Management of anterior mediastinal masses in adults].

The discovery of an anterior mediastinal mass requires careful management with specific consideration of the pathology. More than 50% of all mediastinal masses seen in adults are in the anterior mediastinum. The most frequent diagnoses are thymoma, lymphoma, teratoma and benign thyroid tumours. 60% of cases are malignant. Often the clinical and radiological findings do not allow a definitive diagnosis and a histological diagnosis is often required to select the optimal treatment modality. The choice of biopsy technique depends on the localization of the lesion, clinical factors, and the availability of special techniques and equipment. Biopsy may be obtained by trans-thoracic puncture under computed tomography or ultrasound guidance, or by a surgical approach (mediastinotomy or thoracoscopy).

Modification de la composition des cigarettes durant te XXe siècle: rôle de l'industrie du tabac et effet sur la dépendance tabagique [Chemicals added to cigarettes and their effects on tobacco dependence]

This paper summarizes data on the factors involved in addiction and dependence to cigarettes. Nicotine has been intensively studied by the tobacco industry, for instance for its addictive effect at the lowest possible rates. The addition of diammonium phosphate and urea produces an alcalinization of the pH of cigarette smoke, and promotes the absorption and the trans-membrane passage of nicotine. The taste, the smell of smoke, and the visual aspect of the pack of cigarettes are also sensory components that promote addiction. Finally, menthol, sugar, cocoa and liquorice added to cigarettes also play a role in dependence and addiction to cigarettes by, for instance, making an anesthetic effect on the airways.

Interpretation of needle biopsies of the kidney for investigation of renal masses.

The development of new therapeutic options for renal tumors has lead to the need of a pretherapeutic diagnosis for an increasing proportion of patients presenting with a renal mass. This need is particularly important for a small, incidentally discovered renal mass (less than 4 cm) as it can be a benign lesion in a significant percentage of cases. Recent studies have shown that needle biopsy is an accurate and safe method allowing for a precise histopathological diagnosis of the mass in most cases. The aims of the biopsy are (1) to assess the benign or malignant nature of the lesion, (2) to assess the primary or secondary nature of the lesion, and (3), in case of a primary malignancy, to determine histological prognostic factors, such as the tumor type. This review, based on the most recent literature and our own experience, is intended to provide a practical approach to the diagnosis, relying on appropriate morphologic assessment and the use of immunohistochemistry.