Sleep, sleep apnea and atrial fibrillation: Questions and answers.

Sleep apnea (SA) is a common sleep disorder increasingly recognized as a risk for cardiovascular disease. Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with significant morbidity and mortality. An increasing number of investigations in recent years have linked SA to AF. In this review, we aim to provide a critical overview of the existing evidence in a question and answer format by addressing the following: What is the prevalent association between the two conditions (separating nocturnally detected AF episodes from AF as a prevalent condition)? Is SA a risk factor for incident AF? Is SA a risk factor for recurrence of AF following cardioversion/catheter-based ablation? What is the association between SA and AF in patients with heart failure? Are there signature electrocardiographic markers of AF found in patients with SA? Are there electrophysiology-based studies supporting the link between SA and AF? What other sleep characteristics (beyond SA) are found in patients with AF? What is the impact of SA treatment on AF? What is the effect of AF treatment on sleep? Finally, we address unsolved questions and suggest future directions to enhance our understanding of the AF-SA relationship.

Proximal biceps tendon tear in an adolescent tennis player.

The diagnosis of a torn biceps tendon in athletes who use overhead throwing or swinging motions can be difficult to make because there is no one physical examination finding that will confirm the diagnosis, and because magnetic resonance imaging, although sometimes helpful, does not image the length of the biceps tendon adequately. We report a case of an isolated partial biceps tendon tear in an adolescent female athlete who was diagnosed during arthroscopy after the tendon was pulled into the joint. The tendon was cut and a tenodesis was performed. Two years after the surgical procedure, the patient was without pain and returned to playing tennis at her previous level.

To leave or not to leave: survival trade-offs between different migratory strategies in the greater flamingo.

1. The balance between costs and benefits of migration under different environmental, density-dependent and individual conditions may promote a broad range of migratory behaviours. We studied the factors influencing first-year migration and subsequent fidelity or dispersal among wintering areas, and the survival costs of different wintering behaviours in the greater flamingo (Phoenicopterus roseus). 2. We analysed by multievent capture-recapture modelling among-site dispersal/fidelity and site-dependent survival probabilities from 22 671 flamingos ringed in the Camargue (France) between 1977 and 2010 and resighted subsequently in their wintering grounds classified as France, Iberian Peninsula, Italy and North Africa. 3. We found that first- and second-year birds either resident or wintering at medium distances from their birth place, survived better than those wintering further afield. However, under severe winter conditions (extremely cold winter 1984-1985), individuals with the sedentary strategy suffered the highest levels of mortality. From the third winter onwards, the pattern of survival reversed: the long-distance wintering individuals (i.e. North Africa) survived better. 4. The proportion of first-year birds migrating for wintering was highly variable among cohorts and increased with favourable environmental conditions (wet years). After the first winter, birds showed high fidelity (>90%) to their previous wintering area and wintered preferably near their natal colony when they became adults (>2 years). 5. Survival estimates suggest that long-distance migration was costly for young and inexperienced individuals. Nonetheless, for adults, the most southern wintering areas seem to offer the most favourable local conditions for overwinter survival. 6. The higher availability of intermediate stopover sites during wet years may facilitate first-year migration. Then, once they have some wintering experience, flamingos appear to favour the known wintering grounds. As they grow older, dispersing towards the vicinity of the natal colony may provide higher breeding prospects for individuals wintering closer to this high-quality and saturated breeding ground, as predicted by the arrival-time hypothesis.

Fly Fishing-related lesser tuberosity avulsion in an adolescent.

Stress lesions of the shoulder in athletic and active adolescents are most commonly associated with overhead sports. One of the most uncommon stress lesions of the shoulder in adolescents is an avulsion of the lesser tuberosity of the proximal humerus. To our knowledge, only 2 other cases of lesser tuberosity avulsions from repetitive motion have been reported, both of which were secondary to baseball pitching.This article describes a case of an isolated partial avulsion of the lesser tuberosity of the humerus in an adolescent as a result of repetitive stress from fly fishing. The patient had no symptoms in his shoulder until after casting for approximately 10 hours a day for 3 days. He presented with anterior shoulder pain that worsened with abduction and external rotation. On examination, he had tenderness over the lesser tuberosity and pain with subscapularis muscle testing, such as the lift-off test. He had a negative apprehension sign but no signs of a superior labrum tear. Conventional radiography with an axillary view confirmed the diagnosis. He recovered with rest and gradual return to activities. Two years after injury, the patient had no limitations functionally, and his shoulder examination was normal.This case highlights the importance of being aware that (1) this lesion can occur in activities other than baseball, (2) characteristic physical findings exist with this lesion, (3) obtaining an axillary radiograph can confirm diagnosis, and (4) these avulsions can be treated successfully with nonoperative interventions.

Subscapularis strain from swinging a baseball bat in an adolescent with closed physis.

A healthy 16-year-old female baseball player was referred by her pediatrician for evaluation of pain in her right, dominant shoulder. The pain had begun insidiously 4 weeks previously after several sessions of batting practice and had worsened until she could not participate in baseball, even with low doses of ibuprofen. She was not participating in any other sports or weight lifting and had had no previous incidents of shoulder pain, but she did have a history of being able to voluntarily subluxate the right shoulder since she was a child. Her voluntary shoulder subluxation and reduction did not reproduce or worsen her pain. Results from her physical examination and radiographs were normal. Magnetic resonance imaging showed edema in the subscapularis muscle consistent with acute muscle strain. She was treated with 6 weeks of rest, ice, and anti-inflammatory medication as needed. She returned to baseball and hitting during the following 6 weeks with no limitations.

Temporal and spatial variation in dispersal in the greater flamingo (Phoenicopterus ruber roseus).

We studied movements of individually marked greater flamingos (Phoenicopterus ruber roseus) born in the Camargue, southern France, between their two most important breeding colonies in the western Mediterranean (Camargue and Fuente de Piedra, Spain) from 1986 to 1992. The two sites differ in the frequency with which they offer suitable conditions for breeding. Flamingos have bred each year in the Camargue since 1974, but in only 12 of the past 22 years at Fuente de Piedra. Higher colony fidelity is thus expected in the less variable environment (Camargue), but if dispersal occurs competition might be an important factor causing this dispersal. Following years during which breeding birds in the Camrgue were disturbed (1988 and 1990) a higher proportion of adults changed colonies between breeding attempts (= breeding dispersal, 12.4%), while only 0.4% of flamingos breeding in the Camargue dispersed in the other years. As expected, flamingos breeding at Fuente de Piedra showed a higher rate of breeding dispersal (8.14%). No differences were observed between males and females. The importance of breeding failure as a factor causing breeding dispersal in flamingos was also confirmed by the movements of individual birds. The proportion of young flamingos that moved from their natal colony to start breeding at Fuente de Piedra (= natal dispersal) was independent of sex and age, but increased when breeding access to the Camargue colony was more difficult. However, natal dispersal was also higher in 1988 and 1990 (40.5%) than in the remaining years (1.2%), as was breeding dispersal. We discuss possible ways in which the increased natal dispersal among inexperienced birds could be linked with the increased breeding dispersal of adults in the same year.