BackgroundObstructive sleep apnea (OSA) is associated with obesity, insulin resistance (IR) and diabetes. Continuous positive airway pressure (CPAP) rapidly mitigates OSA in obese subjects but its metabolic effects are not well-characterized. We postulated that CPAP will decrease IR, ghrelin and resistin and increase adiponectin levels in this setting.MethodsIn a pre- and post-treatment, within-subject design, insulin and appetite-regulating hormones were assayed in 20 obese subjects with OSA before and after 6 months of CPAP use. Primary outcome measures included glucose, insulin, and IR levels. Other measures included ghrelin, leptin, adiponectin and resistin levels. Body weight change were recorded and used to examine the relationship between glucose regulation and appetite-regulating hormones.ResultsCPAP effectively improved hypoxia. However, subjects had increased insulin and IR. Fasting ghrelin decreased significantly while leptin, adiponectin and resistin remained unchanged. Forty percent of patients gained weight significantly. Changes in body weight directly correlated with changes in insulin and IR. Ghrelin changes inversely correlated with changes in IR but did not change as a function of weight.ConclusionsWeight change rather than elimination of hypoxia modulated alterations in IR in obese patients with OSA during the first six months of CPAP therapy.

References 1. Schlesinger AE, Tucker GF, Young SA. Postintubation granuloma of the anterior subglottic larynx. Int J Pediatr Otorhinolaryngol 1985;10:279 -84. 2. Drosnes DL, Zwillenberg DA. Laryngeal granulomatous polyp after short term intubation of child.Often, the anesthesiologist is confronted with the management of a difficult airway outside the operating room setting. This can be quite a challenge and the knowledge of different techniques can prove to be life-saving. At our institution, a case of unexpected difficult airway was managed successfully using a "through the LMA" fiberoptic intubation. The on-call team was called to emergently intubate a patient on the floor. Initial intubation was attempted by the resident after appropriate medication was administered. No visualization of posterior pharyngeal structures was appreciated even after repositioning the head for a second look and a laryngeal mask airway (LMA) #4 (Laryngeal Mask Company Limited, Mahe, Seychelles) was inserted as per the difficult airway algorithm (1). The fiberoptic airway cart was obtained and a 6.0 cuffed endotracheal tube (ETT) (Mallinckrodt Inc., St. Louis, MO) was prepared and fed over a lubricated pediatric bronchoscope. The patient was induced with 20 mg etomidate and longer-acting muscle relaxant, cis-atracurium 10 mg, was administered. The LMA was removed and a direct laryngoscopy was attempted by the attending anesthesiologist yielding the same result. While the LMA was removed, the two plastic bars on the inside were cut away and then reinserted without difficulties (Fig. 1). Correct position was confirmed with auscultation and confirmation of carbon dioxide. The bronchoscope was then inserted through the LMA and into the trachea of the patient without difficulty. The ETT advanced over the bronchoscope and was left in the trachea while the bronchoscope was withdrawn. The distal end of the ETT was verified to be in the trachea of the patient. A COOK airway exchanger catheter, (Bloomington IN), for ETT with internal diameter larger than 4 mm was passed through the ETT. A second ETT of the same diameter was inserted over the tube exchanger and the first ETT was advanced another 3 cm, the LMA was then deflated and removed while the combination of both ETTs and the COOK tube exchanger were held in place (Fig. 2). Once the LMA was removed, the second ETT tube and the COOK connector were removed as well. The connector to the first ETT was inserted and connected to the manual ventilation bag. Carbon dioxide was confirmed and the position of the ETT was fiberoptically reassessed. The patient remained stable throughout.Difficult airway situations can occur at any time and are particularly challenging in the settings outside the operating room because conditions may be suboptimal and there may be limited access to supporting equipment. The difficult airway algorithm (1) requires the availability of an LMA, which is used to bridge the time until a more secure airway, i.e., endotracheal tube, is inserted. Maintaining the airway with an L...

To determine whether alpha-stat or pH-stat strategy should be used, 20 patients undergoing coronary artery bypass grafting during moderate hypothermic hemodilutional cardiopulmonary bypass were studied. The carbon dioxide management during bypass was randomly done according to alpha-stat strategy in 10 patients (i.e., temperature-uncorrected PaCO2 was kept near 40 mm Hg and uncorrected pHa was kept at about 7.4) and according to pH-stat strategy in the other 10 patients (i.e., temperature-corrected PaCO2 was kept near 40 mm Hg and uncorrected pHa was kept at about 7.4). In both groups, when the central venous temperature was stable at 26.5 +/- 2.5 degrees C, the perfusion flow was altered sequentially from 2.4 to 1.8 and 1.2 L.min-1.m-2. The mixed venous oxyhemoglobin saturation at the different perfusion flows was monitored by the Oxy-Stat meter and was correlated with the corresponding mixed venous oxygen tension to construct an oxyhemoglobin dissociation curve. Also, the whole-body oxygen consumption at the different perfusion flows was computed. The whole-body oxygen consumption and the oxyhemoglobin dissociation were not significantly different between the alpha-stat and the pH-stat groups. In both groups, the dissociation curve is shifted to the left, but the oxygen consumption per unit time does not significantly change despite decreasing the perfusion flow from 2.4 to 1.2 L.min-1.m-2. The results suggest that oxygen delivery is not impaired during moderate hypothermic cardiopulmonary bypass independent of whether alpha-stat or pH-stat strategy is used.

Chronic wounds are estimated to affect over 6 million people annually in the United States with an estimated annual cost of $25 billion. Debridement represents a key step in their management and is considered a basic necessity to induce the functional process of tissue repair. However, there is an unmet need for an efficient rapid acting non-surgical debridement agent. Bromelain-based enzymatic debridement has been proven to provide an effective, selective and safe non-surgical debridement in deep burns. EscharEx (MediWound Ltd, Yavne, Israel), is a bromelain-based enzymatic debridement agent currently in development for chronic wounds. The aim of this study was to assess its safety and efficacy in chronic wounds. Seventy-three patients suffering from a lower extremity ulcer of diabetic/venous insufficiency/post-surgical/ traumatic aetiology were enrolled in a multicentre, assessor blinded, randomized controlled trial. Patients were randomized to topical treatment by either EscharEx or its gel vehicle for up to 10 daily 4 hour applications, and then continued follow-up for up to 6 months. The EscharEx arm achieved a significantly higher incidence of complete debridement compared to the gel vehicle arm; 55 versus 29% (p = .047), thus meeting the primary endpoint of this study. The EscharEx and gel vehicle arms

Patients with schizophrenia or schizoaffective disorder have a high prevalence of comorbid cannabis use disorder (CUD). CUD has been associated with poorer outcomes in patients. We compared doses of antipsychotic medications at the time of discharge from hospital among inpatients with schizophrenia or schizoaffective disorder with or without concurrent cannabis use. We reviewed the medical records of patients (N = 8157) with schizophrenia or schizoaffective disorder discharged from the hospital between 2008 and 2012. The patients were divided into two groups; those with urine drug tests positive for cannabis and those negative for cannabis. Doses of antipsychotic medications were converted to chlorpromazine equivalents. Bivariate analyses were done with Student's t test for continuous variables and χ test for categorical variables. Linear regression was carried out to adjust for potential confounders. Unadjusted analysis revealed that the cannabis positive group was discharged on lower doses of antipsychotic medication compared with the cannabis negative group (geometric mean chlorpromazine equivalent doses 431.22 ± 2.20 vs 485.18 ± 2.21; P< 0.001). However, the difference in geometric mean chlorpromazine equivalent doses between the two groups was no longer significant after adjusting for sex, age, race, and length of stay (geometric mean difference 0.99; 95 % CI 0.92-1.10). Though limited by lack of information on duration, amount and severity of cannabis use, as well as inability to control for other non-antipsychotic medications, our study suggests that cannabis use did not significantly impact on doses of antipsychotics required during the periods of acute exacerbation in patients with schizophrenia or schizoaffective disorder.