In smokers with OSA, increased gas trapping and emphysema as assessed by CT are associated with a decreased AHI. Along with sex and BMI, these measurements may be important in determining the severity of OSA in patients with COPD and may offer a protective mechanism in patients with more advanced disease.

The alveolar bone resorption is a distinctive feature of periodontitis progression and determinant for tooth loss. Regulatory T lymphocytes (Tregs) display immuno-suppressive mechanisms and tissue repairing functions, which are critical to support periodontal health. Tregs may become unstable and dysfunctional under inflammatory conditions, which can even accelerate tissue destruction. In this study, experimental periodontitis was associated with the progressive and increased presence of Th17 and Treg-related mediators in the gingiva (IL-6, IL-17A, IL-17F, RANKL, IL-10, TGF-β and GITR; P < 0.05), and the proliferation of both Treg and Th17 cells in cervical lymph nodes. Tregs from cervical lymph nodes had reduced Foxp3 expression (> 25% MFI loss) and increased IL-17A expression (> 15%), compared with Tregs from spleen and healthy controls. Tregs gene expression analysis showed a differential signature between health and disease, with increased expression of Th17-associated factors in periodontitis-derived Tregs. The ex vivo suppression capacity of Tregs on osteoclastic differentiation was significantly lower in Tregs obtained from periodontally diseased animals compared to controls (P < 0.05), as identified by the increased number of TRAP+ osteoclasts (P < 0.01) in the Tregs/pre-osteoclast co-cultures. Taken together, these results demonstrate that Tregs become phenotypically unstable and lose anti-osteoclastogenic properties during experimental periodontitis; thus, further promoting the Th17-driven bone loss.

A 46-year-old male smoker presented to the emergency room with chest pain and shortness of breath. He was in mild distress with an oxygen saturation of 97% while breathing ambient air. The physical examination revealed hyperresonance and decreased breath sounds on the left. Radiography of the chest showed a large lucency occupying the entire left hemithorax with contralateral mediastinal shift and left lung compressive atelectasis (Panel A). A chest tube was inserted, but follow-up radiography showed that the left lung had not reexpanded. Computed tomography subsequently showed a giant tension bulla occupying the entire left hemithorax and the chest tube in place within the left pleural space, external to the bulla (Panel B, arrow). The patient underwent bullectomy with successful reexpansion of the lung (Panel C). The differentiation between pneumothorax and giant bulla can be difficult. With pneumothorax, the lung collapses toward the ipsilateral hilum unless there are adhesions limiting its motion. A chest tube that is inserted into the pleural space should rapidly evacuate the air. With a tension bulla, the lung is draped around the bulla and the chest tube is held in a peripheral position, external to the bulla, as in this case.

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Purpose Positional obstructive sleep apnea (OSA) is prevalent. We hypothesized that by incorporating positional therapy into a diagnosis-treatment algorithm for OSA it would frequently be prescribed as an appropriate first-line therapy. Methods Fifty-nine members (45 males, 49±9 yrs, BMI 35.2±5.6 kg/m 2 ) of the Law Enforcement Health Benefits (LEHB), Inc. of Philadelphia with clinically suspected OSA were evaluated. Patients completed an Epworth Sleepiness Scale (ESS) questionnaire and a home sleep test (HST). Patients diagnosed with positional OSA (non-supine apnea-hypopnea index [AHI] < 5 events/hr) were offered positional therapy. A cost comparison to continuous positive airway pressure (CPAP) therapy was performed. Results Fifty-four (92%) of the patients (43 males, 49±9 yrs, BMI 35.2±5.3 kg/m 2 ) had OSA on their HST (AHI 24.2±20.1 events/hr). Sixteen (30%) patients had positional OSA. Compared to non-positional patients, patients with positional OSA were less heavy (32.4±5.1 vs. 36.4±5.1 kg/m 2 , respectively [ p =0.009]), less sleepy (ESS 8±5 vs. 12±5, respectively [ p =0.009]), and had less severe OSA (AHI 10.4±4.3 vs. 30.0±21.3 events/hr, respectively [ p <0.001]). Thirteen of the 16 patients with positional OSA agreed to positional therapy and 31 non-positional OSA patients agreed to CPAP therapy. Based on initial costs, incorporating positional therapy ($189.95/device compared to CPAP therapy at $962.49/device) into the treatment algorithm resulted in a 24% cost savings compared to if all the patients were initiated on CPAP therapy. Conclusion With the high prevalence of positional OSA, using a diagnosis-treatment algorithm that incorporates positional therapy allows it to be more frequently considered as a cost effective first-line therapy for OSA.

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