10/18/2016

Sleep Apnea May Boost Risk for Post-Op Problems

Certain patients should be checked for the disorder before having surgery, researchers say
sleep apnea mask
By 
HealthDay Reporter
MONDAY, Oct. 17, 2016 (HealthDay News) -- Sleep apnea may boost the odds of developing two serious health complications following surgery.
So, finding out if you have the sleep disorder beforehand -- and seeking treatment -- could boost your odds for good recovery from surgery, researchers say.
The two post-op complications are blood clots in the veins and an irregular heartbeat called atrial fibrillation, according to two new studies.
These problems occurred more often among surgical patients who had not yet been diagnosed -- and therefore weren't treated -- with sleep apnea.
Obstructive sleep apnea is characterized by repeated breathing disruptions during sleep. Symptoms include excessive daytime sleepiness, restless sleep and loud snoring -- often with periods of silence followed by gasps. 
More than half of surgery patients who have sleep apnea don't know it, the authors of one new study said. Identifying these patients ahead of time might spare them serious post-op complications, the findings suggest.
Dr. Gregg Fonarow, a professor of cardiology at the University of California, Los Angeles, said the relationship between diagnosed obstructive sleep apnea and post-operative complications is well-documented, with the new research "confirming findings from prior studies."
Sleep apnea appears to expose the heart to "mechanical stress," while also leading to vascular inflammation and an increased risk for blood clots, he explained.
"These physiologic changes could place patients undergoing (open-heart) surgery at higher risk for complications," said Fonarow, who wasn't involved in the study.
Still, this study doesn't establish a direct cause-and-effect relationship between untreated sleep apnea and atrial fibrillation or venous blood clots. And Fonarow isn't sure that treating the sleep disorder would actually prevent these complications.
Both studies are scheduled for presentation Oct. 26 in Los Angeles, at the annual meeting of the American College of Chest Physicians (CHEST). Until the findings are peer-reviewed for publication in a medical journal, they should be considered preliminary.
One study looked at more than 200 patients having open-heart bypass surgery between 2013 and 2015 to see how a high risk for sleep apnea affected the likelihood of developing atrial fibrillation afterward.
Those at high risk of sleep apnea met three of these criteria: being older than 65; snorers; very obese; or having high blood pressure.
Almost 20 percent were considered at high risk for sleep apnea. Two-thirds were at low risk, and nearly 15 percent had already been diagnosed with the sleep disorder, according to the study.
Study senior author Dr. Samir Patel said his team found that high-risk-but-undiagnosed sleep apnea patients do have "more chances of developing [atrial fibrillation] compared to a person who already has sleep apnea, or a person who has a low risk of developing [sleep apnea]."
And when these undiagnosed/untreated sleep apnea patients developed atrial fibrillation after heart surgery, their chances for extended hospitalization and/or death increased as well, added Patel. He's an internal medicine physician with Western Reserve Health Education in Youngstown, Ohio.
Atrial fibrillation occurred among almost 70 percent of high-risk, untreated sleep apnea patients, Patel said. This compared with only about 41 percent of both the low-risk and diagnosed sleep apnea patients.
Patel said patients preparing for open-heart surgery should be tested for sleep apnea in advance, particularly if they seem to be at high risk and/or have telltale symptoms, such as excessive snoring.
The most common treatment for obstructive sleep apnea is called continuous positive airway pressure, or CPAP. CPAP requires wearing a face or nose mask during sleep. The mask is connected to a pump that provides continual airflow in order to keep the airways open. 
The second study found greater risk for other post-surgical complications among 40 patients at high risk for the sleep disorder compared to 50 already being treated for sleep apnea.
Researchers led by Dr. Mohammed Aljasmi of the Henry Ford Hospital in Detroit looked at the post-surgery risk for developing breathing complications, heart problems and medical issues that require hospitalization in an intensive care unit. Surgeries were described as elective, rather than exclusively heart-related.
Those undiagnosed but deemed at high risk of sleep apnea faced significantly greater odds for developing venous thromboembolism, a potentially life-threatening blood clot in the vein, they found.
The findings suggest high-risk sleep apnea patients will fare better after surgery if they first get a sleep apnea diagnosis and begin treatment, the researchers said.
Fonarow, however, isn't convinced that early diagnosis and treatment of sleep apnea would actually lower post-op risks.
He pointed to a large, randomized clinical trial of more than 2,700 patients that found CPAP provided no benefit in lowering cardiovascular events or heart-rhythm disorders in patients with established heart disease.
More information
The U.S. National Institute of Neurological Disorders and Stroke has more about sleep apnea.
SOURCES: Samir Patel, M.D., MPH, internal medicine physician, Western Reserve Health Education, affiliated with Northeast Ohio Medical University, Youngstown, Ohio; Gregg Fonarow, M.D., professor, cardiology, and co-director, Preventative Cardiology Program, University of California, Los Angeles; CHEST meeting, Los Angeles, Oct. 22-26, 2016
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Post Polio Litaff, Association A.C _APPLAC Mexico

The Polio Crusade

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno

video

movie

movie2

A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left

Questions

1
What is that nature of the acute illness in infancy?
2
What is the nature of the subsequent deterioration?
3
What investigations should be performed?
4
What is the differential diagnosis of the cause of the progressive calf hypertrophy?

Answers

QUESTION 1

An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.

QUESTION 2

A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3

QUESTION 3

Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition

QUESTION 4

The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies

    Myositis

    Infiltration

  • tumours

  • amyloidosis

  • cysticercosis

    Link here