A 67-year-old woman was hospitalized for progressive dyspnea on exertion. She had undergone orthotopic liver transplantation (OLT) 15 months before admission. Posttransplant therapy consisted of tacrolimus, trimethoprim/sulfamethoxazole, and prednisone (the latter two were discontinued after 1 year). Physical examination revealed fine bibasilar crackles. High-resolution chest CT demonstrated bilateral, diffuse, interstitial infiltrates. Symptoms persisted on i.v. antibiotics and bronchoscopy was performed demonstrating patchy fibroplastic plugs within air spaces consistent with bronchiolitis obliterans organizing pneumonia (BOOP). Prednisone was initiated and the patient had an uneventful recovery. BOOP was initially described as an idiopathic disease process with clinical, radiographic, pathological, and prognostic features distinguishing it from bronchiolitis obliterans and idiopathic pulmonary fibrosis. BOOP has been recognized as a complication of lung and bone marrow transplantation, but the mechanism is unknown. We report a case of BOOP after OLT to highlight the risk in all transplant patients as well as the protective effect of posttransplant prednisone.
Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by episodic decrements in airflow due to upper airway obstruction. Uvulopalatopharyngoplasty (UPPP) is a potential therapy for OSAHS. Nasopharyngeal stenosis is a rare complication of UPPP that worsens OSAHS. We report two patients referred for OSAHS worsened by nasopharyngeal stenosis complicating UPPP. Both patients were treated with carbon dioxide laser release of adhesions and placement of a nasopharyngeal obturator. Follow-up polysomnograms demonstrated resolution of OSAHS correlating with subjective resolution of symptoms. Nasopharyngeal stenosis complicating UPPP can be successfully treated with scar removal and nasopharyngeal stenting. Polysomnographic demonstration of the effectiveness of this therapy has not previously been reported. Future questions include duration of nasopharyngeal stenting and timing of follow-up polysomnography.
Introduction Anemia is a common problem in critically ill patients. The etiology of anemia of critical illness is often determined to be multifactorial in the clinical setting, but the pathophysiology remains to be elucidated. Erythropoietin (EPO) is an endogenous glycoprotein hormone that serves as the primary stimulus for erythropoiesis. Recent evidence has demonstrated a blunted EPO response as a factor contributing to anemia of critical illness in specific subsets of patients. Critically ill patients requiring mechanical ventilation who exhibit anemia have not been the subject of previous studies. Our goal was to evaluate the erythropoietic response to anemia in the critically ill mechanically ventilated patient.
Objectives:The prevalence of depression and insomnia in the military are substantial. Several transcranial magnetic stimulation (TMS) studies have used self-report sleep data as secondary research outcomes; however, there are limited studies using the gold standard of polysomnography (PSG) to ascertain actual sleep changes. Here, we provide data from a pilot and feasibility study using PSG to measure sleep changes after repetitive TMS.Methods: Thirty-eight active duty service members (ADSM) were consented, of which 20 completed the study. The ADSM who met study criteria where sent for an initial PSG and completed baseline self-report measures. They then completed a standard course of TMS, and self-report measures were completed every fifth session. After TMS completion, ADSM underwent final PSG.Results: Comparison of baseline and postintervention PSG sleep parameters highlight that total rapid eye movement sleep improved after a course of TMS, regardless of improvements in depression. Total sleep time also improved, but only in the TMS responders subgroup. The Public Health Questionnaire-9 showed statistically significant improvement as did the Insomnia Severity Index and some components of the RAND Medical Outcomes Short Form 36. Conclusion:Our small study confirms the feasibility of obtaining pre and post PSG for research purposes. We found similar results to previous studies with regard to depression improvement and self-reported sleep. Interestingly, almost all (including electroconvulsive therapy) somatic depression treatments have been shown to decrease REM, whereas our study found an increase in REM. Overall, this study helps further our understanding of TMS effects on sleep and presents new questions for potential larger follow-on studies.
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