Adenotonsillectomy to treat obstructive sleep apnea: Is it enough?

Although adenotonsillectomy is the first line treatment for children with obstructive sleep apnea syndrome (0SAS),1 improvement in objectively documented outcomes is often inadequate and a substantial number of children have residual disease. Early recognition and treatment of children with persistent OSAS is required to prevent long-term morbidity. The management of these children is frequently complex and a multidisciplinary approach is required as most of them have additional risk factors for OSAS and comorbidities. In this paper, we first provide an overview of children at risk for persistent disease following adenotonsillectomy. Thereafter, we discuss different diagnostic modalities to evaluate the sites of persistent upper airway obstruction and the currently available treatment options. Pediatr Pulmonol. 2017;52:699-709. © 2016 Wiley Periodicals, Inc.

Job-Related Stressors of Classical Instrumental Musicians: A Systematic Qualitative Review.

Epidemiological studies among performing artists have found elevated stress levels and health effects, but scarcely the full range of stressors has been reported. We review here the existing literature on job-related stressors of classical instrumental musicians (orchestra musicians). PubMed, Google Scholar and JSTOR databases were screened for relevant papers indexed up to August 2012. A total of 122 papers was initially identified which, after exclusion of duplicates and those not meeting eligibility criteria, yielded 67 articles for final analysis. We identified seven categories of stressors affecting musicians in their everyday working lives: public exposure, personal hazards, repertoire, competition, job context, injury/illness, and criticism, but with interrelated assigned factors. The proposed categories provide a framework for future comprehensive research on the impact and management of musician stressors.

Stress management can facilitate weight loss in Greek overweight and obese women: a pilot study.

BACKGROUND: Stress and negative emotions have been shown to be critical factors in inducing overeating as a form of maladaptive coping in obese people. METHODS: The present study aimed to evaluate the efficacy of an 8-week stress management programme that includes progressive muscle relaxation (PMR) and diaphragmatic breathing on weight loss and eating behaviour in a sample of overweight and obese women who started a weight-loss programme. A total of 34 women with a mean (SD) body mass index of 38.17 (7.19) kg m(-) ² and mean (SD) age 47.35 (11.64) years were recruited from the outpatients Obesity Clinic of a public hospital in Athens. Participants were randomly assigned into a Stress Management (SM) and a control group. Anthropometric measurements were taken before and after the intervention, and the participants completed the following questionnaires: Dutch Eating Behaviour Questionnaire (DEBQ), Eating Attitudes Test (Eat-26), Health Locus of Control (HLC) and Perceived Stress Scale (PSS) before and after the intervention. RESULTS: The findings indicated a significant improvement in weight loss in the SM group [4.44 (0.83) kg] after intervention compared to the control group [1.38 (0.78) kg] (P < 0.05). A higher restrained eating behaviour was observed in the SM group after intervention compared to the control group, although there was no significant difference in perceived stress levels. CONCLUSIONS: The intervention group showed greater weight reduction, possibly because of the stress management programme, and a greater dietary restraint was demonstrated by them compared to the control group. It is likely that stress management could facilitate weight loss in obese women; however, more studies are needed to confirm this hypothesis.

Phospholipase activity after ß-endorphin exposure discriminates Malassezia strains isolated from healthy and seborrhoeic dermatitis skin.

BACKGROUND: Phospholipase activity and its induction by ß-endorphin have been associated with pathogenic Malassezia pachydermatis animal isolates. OBJECTIVE: To evaluate Malassezia phosholipase activity in human isolates from seborrhoeic dermatitis (SD) and healthy controls before and after ß-endorphin exposure. METHODS: Eighty-four volunteers with or without SD (N = 41) were sampled. Isolated Malassezia strains were incubated in Dixon's medium with and without 100 nmol/L ß-endorphin. Subsequently, phospholipase activity was assessed in egg-yolk agar and the results were compared employing Wilcoxon sign test for paired data, chi-squared test and multinomial logistic regression analysis. RESULTS: A total of 64 Malassezia strains were isolated. SD strains tended to have decreased phospholipase activity before (P = 0.057) and increased after exposure to ß-endorphin (P = 0.061) compared to isolates from healthy skin. Phospholipase activity after ß-endorphin exposure related to basal enzyme activity as a measure of per strain phospholipase inducibility by ß-endorphin did not depend on Malassezia species (P = 0.652). However, this latter biochemical trait discriminates strains isolated from SD lesional and healthy skin (P = 0.036). CONCLUSION: ß-endorphin exposure modifies the in vitro phosholipase activity in Malassezia species isolated from SD lesional skin. This is in accordance with emerging evidence that enhanced local lipase activity is involved in the pathogenesis of SD.

A systematic review of randomized controlled interventions for parents' distress in pediatric leukemia.

Objective. This review aims to summarize the existing evidence concerning interventions towards reducing stress in parents with a child with leukemia and their effect in child and family wellbeing. Methods. A systematic review strategy was conducted using MEDLINE covering the period January 1980 to June 2010. Results. Seven randomized controlled trials met the inclusion criteria including in total 1045 parents participants. A variety of cognitive-behavioral interventions problem-solving skills training programs have been used for managing distress in parents and children. Outcome measures are assessed by self-report, observer report, behavioral/psychological, and physiological measures. The most prominent methodological problems were the marked heterogeneity in stress measurement and the relative absence of proper measurement and adjustment of moderating and mediating factors. The largest effect has been obtained by combined cognitive-behavioral interventions with promising but limited evidence for several other psychological interventions. Conclusions. Recommendations for future RCTs are provided, and particular attention to the quality of trial design and reporting is highlighted.

Wide range of point prevalences of healthcare-associated infections in Western Greece.

The purpose of this study was to estimate the prevalence of healthcare-associated infections (HAIs) in the region of Western Greece and its relationship with possible predisposing factors. Two 1-day prevalence studies were performed in all hospitals of the region. The average HAI prevalence was 2·9% (range 0-6·8%) in the hospitals and 0-22·7% between different medical wards. Overall, 90% of HAI patients had predisposing factors. The most frequently isolated microorganism was Escherichia coli (14·3%). The study revealed a relatively low overall point prevalence of HAI, but remarkable discrepancies between the hospitals and wards. This may be due to the presence of confounding medical conditions and/or underreporting of HAIs from certain hospital wards. Local point-prevalence surveys may increase the awareness of HAIs in hospital staff and contribute to the establishment of effective infection control.

Underreporting of communicable diseases in the prefecture of Achaia, western Greece, 1999-2004 - missed opportunities for early intervention.

This study investigates the completeness of the reporting of infectious diseases in the prefecture of Achaia, western Greece in the period of 1999-2004. We collected hospital records relating to infectious diseases retrospectively from three major hospitals in the region and compared the records to corresponding records at the prefectural public health department (PHD). After record-linkage and cross-validation a total of 1,143 notifiable cases were identified in the three hospitals, of which 707 were reported to the PHD of Achaia, resulting in an observed underreporting of infectious diseases of 38% during the study period. At prefecture level, a further 259 cases were notified by other sources, mainly by the fourth hospital of the region not included in our study, resulting in a total of 966 cases reported to the PHD; 73% of these were reported from the three hospitals included in our study, 27% were notified by the fourth hospital not included in our study and less then 0.3% by physicians working in a private practice or health centre. Meningitis (51%), tuberculosis (12%) and salmonellosis (8%) were the most frequently reported diseases followed by hospitalised cases of varicella (7%), brucellosis (6%) and hepatitis (6%). During the study period, clustering of specific diseases like brucellosis, meningitis, mumps, and salmonellosis was observed, indicating possible outbreaks. Our results show that notification system needs to be improved, in order to ensure proper health resources allocation and implementation of focused prevention and control strategies.

Immunocryosurgery for basal cell carcinoma: results of a pilot, prospective, open-label study of cryosurgery during continued imiquimod application.

BACKGROUND/AIM: Theoretical considerations support the combination of cryosurgery and topical imiquimod to treat basal cell carcinomas (BCC). The aim of the present study was to test the feasibility and efficacy of 'cryosurgery during continued imiquimod application' ('immunocryosurgery') to treat 'high-risk-for-recurrence' BCCs. METHODS: Thirteen patients with 21 biopsy-proven tumours (4 of 21 relapses after prior surgery) were included. After 2-5 weeks (median, 3) of daily 5% imiquimod cream application, the tumours were treated by liquid N(2) cryosurgery (spray, two cycles, 10-20 s) and imiquimod was continued for additional 2-12 weeks (median, 4). The outcome after at least 18 months of follow-up (18-24 months) is currently reported. RESULTS: Nineteen of 21 tumours responded promptly to immunocryosurgery; two tumours required additional treatment cycles to clear. Thus, the clinical clearance rate was 100%. Only 1 of 21(5%) tumour relapsed after at least 18 months of follow-up (cumulative efficacy: 95%). CONCLUSIONS: 'Immunocryosurgery' is a promising non-surgical combination modality to treat 'high-risk-for-recurrence BCCs'. Initial evidence is suggestive of an at least additive effect of the two combined modalities. Further studies comparing immunocryosurgery directly with cryosurgery and imiquimod monotherapies will confirm the reported results.

Substantial underreporting of tuberculosis in West Greece: implications for local and national surveillance.

In order to estimate the reliability of the officially reported national tuberculosis (TB) incidence rates we performed a retrospective review of data collected in regional and national public health framework. TB notifications for the period 2000-2003 were obtained from two major hospitals and three relevant Public Health Departments (PHDs) in the region of West Greece, and subsequently compared with the data reported to the Hellenic Centre for Diseases Control (KEELPNO). During the four-year study period a total of 161 cases of TB were reported to the PHDs in West Greece; 70% of these cases were reported to the KEELPNO. Furthermore only 72 (38.7%) out of the 186 cases of TB identified in the two hospitals were notified to the PHDs. Assuming that the degree of undernotification observed for the two hospitals is the same throughout the region, we estimated that the case detection rate was 14 cases per 100,000 persons per year, i.e. 3.7 times higher than the rate officially reported for the period 2000-2003. Male predominance (2.1, male/female ratio) and an increased incidence in the elders (older than 60 years) and adolescents (10-14 years old) were also evident. The study demonstrated a substantial underestimation of TB burden in West Greece. In the face of the massive influx of immigrants and refugees coming from regions with high TB incidence and the increase of the number of drug-resistant cases a reliable and complete notification of TB is crucial in the planning of programs and development of appropriate control policies.

Short communication: dental anxiety levels and outcomes of care: a preliminary report on experiences of a sedation assessment clinic.

AIM: This was twofold: (1) to report on the type of paediatric patient referred to the sedation assessment clinic at the Glasgow Dental Hospital and School, and (2) to report on the level of anxiety. METHODS: This was a two-part study. The first part was a retrospective review of case notes to evaluate referral pathways to and from the sedation assessment clinic with regard to a range of variables. The second part was a prospective clinical report of dental anxiety. RESULTS: It was noted that 31 (67.4%) of patients were initially referred by their general dental practitioner, 7 (15.2%) by community dental surgeons and 8 (17.4%) by hospital dental surgeons. At the initial referral, 4 children (9%) showed symptoms of pain. The majority of patients were from lower social economic areas, as determined by DEPCAT score and exhibiting moderate to high anxiety levels. The children who were referred for general anaesthesia had the highest anxiety scores. Out of a total of 46 patients, five failed to complete treatment within the modality laid out for them at the assessment clinic. CONCLUSIONS: (1) The patients attending the newly established sedation assessment clinic were mainly high caries risk, socially deprived patients and (2) that the majority of patients were dentally anxious, the most anxious appearing to have been referred for treatment under general anaesthesia.

Cyclosporin in idiopathic glomerular disease associated with the nephrotic syndrome : workshop recommendations.

Management of idiopathic glomerular disease associated with nephrotic syndrome (INS) remains controversial and one of the most complex areas relates to utilization of the drug cyclosporin. This is despite its demonstrated effectiveness in several histologic types of the INS in randomized controlled trials. Cyclosporin is effective in inducing remission of proteinuria in approximately 80% of steroid-sensitive cases of minimal change disease (MCD). Cyclosporin is also effective in both the induction of remission and long-term preservation of renal function in steroid-dependent/-resistant MCD and steroid-resistant focal segmental glomerulosclerosis (FSGS). The overall response rate in FSGS is lower than in MCD, and long-term therapy (>12 months) may be required to both achieve remission and sustain it. Cyclosporin therapy is also of benefit in reducing proteinuria in 70-80% of patients with steroid-resistant membranous nephropathy (MGN). In MGN, the maximum benefit is often delayed compared to MCD (>12 weeks). Cyclosporin is generally well tolerated and safe. The major concern remains the nephrotoxicity, but with careful monitoring of the patient's renal function; minimizing the maintenance dose and utilizing repeat renal biopsy in those receiving long-term therapy, this risk can be minimized. The algorithms have been developed derived from the best evidence in the literature in each of the histologic types to help provide a guide to the integration of cyclosporin into the management of INS for the practicing nephrologist.

A report on dental anxiety levels in children undergoing nitrous oxide inhalation sedation and propofol target controlled infusion intravenous sedation.

AIM: To report on two separate child sedation cohorts; one undergoing propofol intravenous sedation (IVS) and the other, nitrous oxide inhalation sedation (IS) in respect to changes in dental anxiety and subject characteristics. STUDY DESIGN: The age, gender, level of social deprivation and amount of treatment performed and observed patient behaviour during treatment, using the Frankl and a VAS scale, were recorded for each subject. Anxiety questionnaires were completed before and after treatment. These were: - Modified Child Dental Anxiety Scale (MCDAS); Children's Fear Survey Schedule- Dental Subscale (CFSS-DS) and two Visual Analogue Scales (VAS). RESULTS AND STATISTICS: Participants (36) attended for treatment under IS and 40 attended for treatment under propofol IVS. The IVS cohort was older (p<0.01), by between 1.9 and 4.1 years and had more treatment [p = 0.015, 95% confidence interval for the difference between the cohort medians was (0, 3) units]. The two cohorts were closely matched in respect to pre-operative anxiety as measured by the MCDAS and CFSS-DS scales. There were significant anxiety reductions within each cohort as measured by three of the scales: - MCDAS, CFSS-DS and VAS (1) (p< or = 0.001) but no significant change in the VAS (2) scores. When the two cohorts were compared, there was no significant difference in the reduction of the self-reported anxiety for any of the four scales (p>0.05). The observed behaviour was good for both cohorts. CONCLUSION: Propofol target-controlled intravenous sedation and nitrous oxide inhalation sedation were similarly efficacious at anxiety reduction in referred dentally anxious children. Subjects undergoing propofol IVS were older than those undergoing IS. Propofol TCI may offer the opportunity for more treatment at each visit. Further propofol TCI conscious sedation studies are required.

Distribution of Malassezia species in pityriasis versicolor and seborrhoeic dermatitis in Greece. Typing of the major pityriasis versicolor isolate M. globosa.

BACKGROUND: The expansion of the genus Malassezia has generated interest in the epidemiological investigation of the distribution of new species in a range of dermatoses, on which variable results have been reported from different geographical regions. No data are thus far available from South-east Europe (Greece). OBJECTIVES: To study the distribution of Malassezia species in pityriasis versicolor (PV) and seborrhoeic dermatitis (SD) and to investigate whether polymorphisms in the internal transcribed spacer (ITS) 1 region facilitate detection of M. globosa and M. sympodialis subtypes. METHODS: In total, 109 patients with PV and SD and positive Malassezia cultures were included in the study. Age, gender, primary/recurrent episode, disease extent and clinical form of PV were recorded. ITS 1 polymorphisms of M. globosa and M. sympodialis type and clinical strains were investigated by polymerase chain reaction (PCR)-single-strand conformational polymorphism (SSCP) analysis. RESULTS: Malassezia globosa was the prevalent species isolated from PV and SD either alone (77% and 39%, respectively) or in combination (13% and 18%, respectively) with other Malassezia species. The pigmented form of PV was strongly correlated with the female gender. PCR-SSCP differentiated five subgroups of M. globosa with one being associated with extensive clinical disease. All M. sympodialis isolates displayed a homogeneous ITS 1 PCR-SSCP profile. CONCLUSIONS: Malassezia species isolation rates were in agreement with those reported from South-west Europe. PCR-SSCP of the ITS 1 is useful for highlighting prospective clinical implications of M. globosa subtypes.

Immunosuppressive therapy and clinical evolution in forty-nine patients with antineutrophil cytoplasmic antibody-associated glomerulonephritis.

Immunosuppressive therapy and clinical evolution were studied in 49 patients (29 females) with antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis. The mean age of patients at presentation was 55 years, and the mean (+/-SD) follow-up was 43 months (+/-33) (range, 3-140). Among the 49 patients, 10 had biopsy-proven Wegener's granulomatosis, 33 microscopic polyangiitis, 2 Churg-Strauss syndrome, and 4 idiopathic crescentic glomerulonephritis. IgG ANCA autoantibodies were detected in all patients. Induction therapy included pulses and oral administration of methylprednisolone (MP) with oral administration of cyclophosphamide (CP) and plasma exchange in patients with alveolar hemorrhage and serum creatinine (SCr) levels >/= 6 mg/dL. CP was converted to azathioprine (AZA) or mycophenolate mofetil (MMF) after 3-6 months of therapy. Low doses of MP with or without AZA or MMF were administered until the end of follow-up. Therapy institution resulted in remission of disease in all patients. The mean SCr levels decreased from 4.9 mg/dL (+/-2.5) at the onset of the disease to 2.8 mg/dL (+/-1.7) (P > 0.0001), and 3.2 mg/dL (+/-2.3) (P > 0.0001) after 3 and 6 months, respectively. At the end of follow-up, 17 (35%) patients progressed to end-stage renal disease after 34 months (+/-29) (range, 3-98), and 30 (61%) patients maintained sufficient renal function. Two patient deaths were attributed to immunosuppression. Patients with high SCr levels at diagnosis and severe interstitial fibrosis found in renal biopsy had poor renal outcome (P > 0.01 and P > 0.02, respectively). Induction therapy with MP and CP seems to be the regimen of choice in patients with ANCA-associated glomerulonephritis. Early diagnosis and therapy institution as well as long-term treatment lead to acceptable renal survival.

Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients.

Presence of a nasogastric tube is a risk factor for the development of ventilator-associated pneumonia (VAP). Alternatively, gastrostomy can be used for administration of enteral feedings. To determine whether early performance of gastrostomy affects frequency of VAP, a randomised, controlled study was carried out in patients mechanically ventilated for stroke or head injury. In the gastrostomy group, patients underwent the procedure within 24 h of intubation. A nasogastric tube was inserted in controls. Individual subjects were studied for 3 weeks. In total, 20 subjects (mean age 48+/-15.2 yrs) were allocated to the gastrostomy group, and 21 to the control group (46.6+/-15.4 yrs). Of these groups, two (10%) and eight (38.1%) developed VAP, respectively. Four patients with gastrostomy and three controls did not complete the study (due to weaning from ventilatory support or death). After excluding these subjects, difference in VAP frequency persisted: two out of 16 subjects with gastrostomy had VAP (12.5%) versus eight out of 18 controls (44.4%). There were no differences in duration of hospitalisation or mortality between the two groups. In conclusion, in patients mechanically ventilated for stroke or head injury early gastrostomy is associated with a lower frequency of ventilator-associated pneumonia compared with a nasogastric tube.

Functional analysis of the classical, alternative, and MBL pathways of the complement system: standardization and validation of a simple ELISA.

Primary defence against invading microorganisms depends on a functional innate immune system and the complement system plays a major role in such immunity. Deficiencies in one of the components of the complement system can cause severe and recurrent infections, systemic diseases, such as systemic lupus erythematosus (SLE) and renal disease. Screening for complement deficiencies in the classical or alternative complement pathways has mainly been performed by haemolytic assays. Here, we describe a simple ELISA-based format for the evaluation of three pathways of complement activation. The assays are based on specific coatings for each pathway in combination with specific buffer systems. We have standardized these assays and defined cut off values to detect complement deficiencies at the different levels of the complement system. The results demonstrate the value of these ELISA-based procedures for the functional assessment of complement deficiencies in clinical practice. The assay is now available commercially in kit form.

Morning levels of fibrinogen in children with sleep-disordered breathing.

Elevated fibrinogen level is a predictor of cardiovascular disease in adults, and it is associated with sleep-disordered breathing. Levels of fibrinogen in adults are affected by other co-existing cardiovascular risk factors, which are not usually present in children. To investigate the association between fibrinogen and sleep-disordered breathing, a case-control study was carried out in children with and without habitual snoring. All snoring children underwent polysomnography. Morning fibrinogen values in 30 children with snoring and an apnoea-hypopnoea index (AHI) > or =5 episodes x h(-1) (median (interquartile range) 318 mg x dL(-1) (290-374)) were similar to values in 61 children with snoring and an AHI <5 episodes x h(-1) (307 (269-346)). Both groups had higher fibrinogen values than those in 23 controls without snoring (271 mg x dL(-1) (244-294)). There was no correlation between fibrinogen values and AHI, respiratory movement/arousal index or haemoglobin desaturation index. In conclusion, fibrinogen values are higher in children with snoring than in controls, but there is no association between these values and polysomnography indices.

Clarithromycin reduces the severity of bronchial hyperresponsiveness in patients with asthma.

A randomised double-blind placebo-controlled study was designed to evaluate the effects of a semisynthetic macrolide antibiotic, clarithromycin, on bronchial hyperresponsiveness to methacholine in patients with a diagnosis of asthma. Adult asthma patients undergoing treatment with budesonide 400 microg b.i.d. and salbutamol 200 microg p.r.n. less than twice weekly were studied. Arm A (16 males/six females, aged 48 +/- 16 yrs) received clarithromycin 250 mg b.i.d. for 8 weeks, arm B (eight males/12 females, aged 42 +/- 12 yrs) clarithromycin 250 mg t.id. and arm C (six males/15 females, aged 41 +/- 16 yrs) placebo dextrose tablets. Bronchial hyperresponsiveness was quantified by measurement of the provocative dose of methacholine causing a 20% fall in forced expiratory volume in one second (PD20). Median (interquartile range) PD20 in the three groups before and after treatment with clarithromycin were: arm A: 0.3 (0.1-1) and 1.3 (0.6-2) mg; arm B: 0.4 (0.1-0.9) and 2 (2-2) mg; and arm C: 0.4 (0.1-0.9) and 0.3 (0.1-0.6) mg, respectively. Serum free cortisol levels were determined and remained unchanged from baseline in the clarithromycin-treated patients. It is concluded that clarithromycin reduces the degree of bronchial hyperresponsiveness in patients with asthma.