Salim Surani

A comprehensive review of Vibrio vulnificus: an important cause of severe sepsis and skin and soft-tissue infection.

Vibrio vulnificus is a halophilic Gram-negative bacillus found worldwide in warm coastal waters. The pathogen has the ability to cause primary sepsis in certain high-risk populations, including patients with chronic liver disease, immunodeficiency, iron storage disorders, end-stage renal disease, and diabetes mellitus. Most reported cases of primary sepsis in the USA are associated with the ingestion of raw or undercooked oysters harvested from the Gulf Coast. The mortality rate for patients with severe sepsis is high, exceeding 50% in most reported series. Other clinical presentations include wound infection and gastroenteritis. Mild to moderate wound infection and gastroenteritis may occur in patients without obvious risk factors. Severe wound infection is often characterized by necrotizing skin and soft-tissue infection, including fasciitis and gangrene. V. vulnificus possesses several virulence factors, including the ability to evade destruction by stomach acid, capsular polysaccharide, lipopolysaccharide, cytotoxins, pili, and flagellum. The preferred antimicrobial therapy is doxycycline in combination with ceftazidime and surgery for necrotizing soft-tissue infection.

Gender and ethnic differences in prevalence of self-reported insomnia among patients with obstructive sleep apnea

BackgroundInsomnia and obstructive sleep apnea (OSA) are the two most common sleep disorders. Studies have shown that complaints of insomnia are prevalent among sleep clinic patients evaluated for OSA. Less is known about the gender and ethnic variations in this association.ObjectivesThis paper aims to study the influence of gender and ethnicity in the prevalence of insomnia in patients with OSA and explore the association between these two disorders with an emphasis on psychophysiologic insomnia.Methods and measurementsWe reviewed case files, including self-reported questionnaires and polysomnography studies of 300 OSA patients [apnea–hypopnea index (AHI) of >10] from three ethnic groups—Caucasian, Hispanic, and African American, 50 patients each, male and female, seen at a tertiary care county hospital adult sleep center. Self-reported insomnia was classified as sleep onset insomnia, sleep maintenance insomnia, or insomnia with early morning awakening. Psychophysiologic insomnia was documented if the patient reported two of the following five symptoms: racing thoughts when trying to sleep, increased muscle tension when trying to sleep, fear of being unable to sleep, fear of being unable to fall back to sleep after waking up, and lying in bed worrying. Fischer exact tests for each contingency table were run using SPSS.ResultsAmong OSA patients, women were older, had higher body mass index, and lower AHI at the time of diagnosis, compared to men. Insomnia was more prevalent among patients with OSA (84%) than the reported 30% among general adult population. Sleep onset insomnia was reported more frequently by women (62%) than men (53%) (pu2009=u20090.03). Similarly self-reported psychophysiologic insomnia also showed a female preponderance (53% vs. 45%, pu2009=u20090.03). Caucasian women had the highest rate of self-reported sleep maintenance insomnia (80%). Hispanic women are more likely to complain of symptoms suggestive of psychophysiologic insomnia (58%).ConclusionsThere is a higher prevalence of insomnia in OSA patients. Ethnicity and gender possibly exhibit a complex and significant influence on the reported subtype of insomnia. Further larger studies may help confirm, as well as clarify, mechanisms that underlie the ethnic and gender differences that we have noted.

Sexual dysfunction in women with obstructive sleep apnea.

BackgroundFemale sexual dysfunction is vastly under-recognized but has been previously described in chronic disease states. Sexual dysfunction in male patients with obstructive sleep apnea (OSA) is well described, but not in females.ObjectiveThe objective of this study was to assess the prevalence of sexual dysfunction in women with OSA.MethodsWe studied 21 consecutive pre-menopausal women with OSA, referred to our sleep lab, and who had a positive study for sleep apnea (respiratory disturbance index (RDI)u2009>u20095), and 11 healthy pre-menopausal women were included as the control group. Subjects were administered the Female Sexual Function Index (FSFI) questionnaire and a mood scale—Profile of Mood States.ResultsOf the study group, 11 women (52.4%) had FSFI scores in the poor range (<23) as compared to the control group, in which none of the women (0%) had FSFI scores in the poor range (<23). Negative mood domain scores were not different in patients with poor FSFI compared to patients with normal FSFI scores. There was no correlation between obesity, severity of sleep apnea, or mood disorders on overall scores of sexual dysfunction. Among individual domains, there was a correlation between RDI and arousal scores.ConclusionIn our study, we have found that prevalence of sexual dysfunction is high among women with OSA. Physicians should routinely screen and evaluate women with OSA for sexual dysfunction.

Practice patterns of screening for sleep apnea in physicians treating PCOS patients

Women with polycystic ovarian syndrome (PCOS) have been shown to have a very high prevalence of obstructive sleep apnea (OSA). Screening for OSA is recommended for PCOS patients. How far this is carried out in actual practice is unknown. To study practice patterns with regard to screening for OSA in physicians—both obstetrician/gynecologists (ObGyn) and endocrinologist—who manage PCOS. A secondary aim of this study was to identify practice differences, if any. Two hundred ObGyn and 140 endocrine academic institutions were contacted and mailed with questionnaires, if willing to participate. Responses were obtained from 50 (29.4%) ObGyn physicians and 29 (26.4%) endocrine physicians. The questionnaire was closed-ended. Physicians reported a high occurrence of obesity—36.7% of the physicians reported that 75–100% of their patients had morbid obesity. However, reported prevalence of symptoms was low—86.1% of the physicians felt their patients snored infrequently (<25% of the time) and 74.7% felt that their patients had excess daytime sleepiness (EDS) infrequently. Of the physicians, 92.4% ordered a sleep study <25% of the time. No significant difference in practice between the specialties was identified. Physicians who manage PCOS patients do not believe that these patients have significant symptoms nor warrant frequent testing for OSA. This may reflect lack of knowledge about the link or may imply that PCOS patients remain largely asymptomatic. Educating specialist physicians managing PCOS about OSA and improved tools for OSA screening may improve detection.

Successful urokinase treatment of massive pulmonary embolism in pregnancy

Background Thrombolytic agents have been used successfully to treat patients with massive pulmonary embolism and cardiorespiratory insufficiency, but experience with these drugs in pregnancy is limited. Case A 20-year-old woman at 21 weeks gestation was admitted with a massive pulmonary embolism. She was initially given intravenous heparin therapy but because of worsening clinical condition, urokinase was used. After two 12-hour periods of therapy, the urokinase was discontinued and the heparin restarted. She remained on subcutaneous heparin therapy for the remainder of her pregnancy, which was otherwise uncomplicated. She delivered a healthy male infant at term without complications and was discharged on warfarin therapy. Conclusion Thrombolytic therapy can be life-saving and should be considered in the treatment of hemodynamically significant pulmonary embolism in pregnancy.

Influence of gender on continuous positive airway pressure requirements in patients with obstructive sleep apnea syndrome

IntroductionGender differences have been noted in key aspects of upper airway physiology and pathophysiology of obstructive sleep apnea (OSA). We postulate that these will lead to disparities in pharyngeal collapsibility and, consequently, positive airway pressure requirements of patients with OSA.MethodsA retrospective review of 95 adult patients (56 women, 39 men) with OSA was done. Patients who underwent continuous positive airway pressure (CPAP) titration were included in the study.ResultsThe study groups were similar with regard to the severity of OSA (median apnea–hypopnea index of 34 in men and 24 in women, pu2009=u20090.13). The men were older and less obese than the women (mean age of 46 and 41xa0years, pu2009=u20090.03, BMI of 42 and 49xa0kg/m2, pu2009<u20090.001, in men and women, respectively); Epworth score was similar in the two groups (12 vs.11, pu2009=u20090.91). CPAP requirement was higher in men than in women (12.7 vs. 10.2, pu2009<u20090.0001). The effect of gender on CPAP requirement was found to be significant even when confounding variables were accounted for using linear regression.ConclusionMen with OSA are more likely to require higher levels of CPAP support than women. The effect of gender on CPAP requirement persisted even after correcting for the severity of OSA.

The Relationship between Sleep Disorders and Stroke

Abstract Although sleep appears to be a quiescent, passive state externally, there are a multitude of physiological changes occuring during sleep that can affect cerebral homeostasis and predispose individuals to cerebrovascular disorders. Therefore, it is not surprising that sleep-disordered breathing causes significant nocturnal perturbations, such as obstructive sleep apnea (OSA), that can lead to cerebrovascular disorders. There is evidence to suggest that OSA is a risk factor for stroke, although studies have not been able to clearly discern the absence or presence of OSA before the stroke event. Sleep-disordered breathing, such as OSA and central sleep apnea, can occur as a consequence of stroke. Fortunately, treating OSA appears to decrease morbidity and possibly mortality. Unfortunately, continuous positive airway pressure compliance in this population group is low, and significant efforts and resources may be needed to improve compliance and adherence. Various other sleep disorders, such as insomnia, fatigue, hypersomnia, and parasomnia, can occur following a stroke, and physicians treating patients following a stroke need to be aware of these disorders in order to effectively treat such patients.

Sleepiness in Medical ICU Residents

BACKGROUND AND METHODSnSleepiness in medical residents has crucial implications for the safety of both patients and residents. Measures to improve this have primarily included an Accreditation Council for Graduate Medical Education-mandated reduction in work hours in residency programs. The impact of these work-hour limitations has not been consistent. The purpose of this study was to provide an objective assessment of daytime sleepiness in medical residents working in the medical ICU. Sleep times for 2 days/nights prior to on call and on the day/night of being on call were assessed by actigraphy and sleep diaries. On-call and post-call measurements of residents sleepiness were measured both objectively, by means of a modified multiple sleep latency test (MSLT) [two nap sessions], as well as subjectively, by the Stanford Sleepiness Scale.nnnRESULTSnOur data showed that despite an average sleep time of 7.15 h on nights leading to being on call, the mean sleep latency (MSL) on the on-call day was (+/- SD) 9 +/- 4.4 min, and 4.8 +/- 4.1 min (p < 0.001) on the post-call day. On the post-call day, 14 residents (70%) had an MSL of < 5 min, suggesting severe sleepiness, compared to 6 residents (30%) on the on-call day.nnnCONCLUSIONnOur results demonstrate that residents working in the ICU despite reductions in work hours demonstrate severe degree of sleepiness post-call.

Guidelines for Perioperative Management of the Diabetic Patient

Management of glycemic levels in the perioperative setting is critical, especially in diabetic patients. The effects of surgical stress and anesthesia have unique effects on blood glucose levels, which should be taken into consideration to maintain optimum glycemic control. Each stage of surgery presents unique challenges in keeping glucose levels within target range. Additionally, there are special operative conditions that require distinctive glucose management protocols. Interestingly, the literature still does not report a consensus perioperative glucose management strategy for diabetic patients. We hope to outline the most important factors required in formulating a perioperative diabetic regimen, while still allowing for specific adjustments using prudent clinical judgment. Overall, through careful glycemic management in perioperative patients, we may reduce morbidity and mortality and improve surgical outcomes.

Sleepiness in critical care nurses: Results of a pilot study

BACKGROUNDnSleep deprivation, compounded by circadian disruptions, is a common problem in health care workers. Sleepiness in nurses has important implications for patients as well as nurses own safety.nnnOBJECTIVEnThe objective of the study was to assess comprehensively sleepiness levels in post-night-shift nurses.nnnMETHODSnPost-night-shift nurses in the ICU and on general floors (medicine and surgery) were assessed using subjective (Epworth Sleepiness Scale [ESS]) and objective (Mean Sleep Latency Test [MSLT]) measures.nnnRESULTSnESS was abnormal (>8) in 7 of 10 ICU nurses compared with 2 of 10 floor nurses (P < .005), and mean ESS score was also higher (8.7 +/- 3.9 vs. 5.6 +/- 2.1, respectively; P = 0.042). MSLT values for the first nap period were in the pathologic range in the ICU nurses compared with the floor nurses (4.65 +/- 5.5 vs. 10.85 +/- 7.4 minutes, respectively; P < .05).nnnCONCLUSIONSnPost-night-shift RNs working in the ICU have a pathologic degree of sleepiness.