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Trafficked persons frequently seek healthcare, but many go unrecognized. Most residency programs provide little to no education on the topic. In this pilot study, our objective was to demonstrate t...

Gross hematuria in adults with resultant anemia is highly concerning for genitourinary malignancy. However, in rare instances, malakoplakia can mimic such malignancy. Malakoplakia is a benign granulomatous condition with malfunction of the phagolysosomal activity of macrophages and monocytes.

STUDY OBJECTIVES: To evaluate the utility of a contact-free device in screening for obstructive sleep apnea. METHODS: Three hundred fifty-nine participants (mean age 46 ± 13 years, body mass index 26.1 ± 4.2 kg/m(2), 67.7% male) underwent overnight monitoring using a contact-free device, the OrbSense, and polysomnography (PSG) in the sleep laboratory simultaneously. The OrbSense recordings were analyzed automatically, and PSG was scored based on recommended guidelines. RESULTS: The respiratory event index from the OrbSense was lower than the apnea-hypopnea index (AHI) from PSG (25.5 ± 20.7 vs 27.0 ± 25.2 events/h; P = .007) and was significantly correlated with AHI (Pearson coefficient, 0.92; P < .0001). Bland-Altman analysis showed a mean difference of 1.5 events/h, and the limit of agreement was –18.6 to 21.5 events/h. Use of the OrbSense resulted in larger underestimates of AHI and lower negative predictive values at higher AHI values (especially when AHI ≥ 30 events/h). When we used a PSG diagnostic criterion of AHI > 5 events/h, the optimal diagnostic cutoff value from the OrbSense was 8 events/h, with a sensitivity of 90.4%, a specificity of 77.6%, a 94.6% positive predictive value, and a 65% negative predictive value. For patients with moderate to severe obstructive sleep apnea whose AHI was > 15 events/h, the OrbSense cutoff was 16.6 events/h, with a sensitivity of 87.1% and a specificity of 89.7%. Among the 359 participants, 250 patients (69.6%) had the same obstructive sleep apnea severity division classified by both PSG and the OrbSense. CONCLUSIONS: The contact-free device OrbSense can detect respiratory events during sleep and has close agreement with in-laboratory PSG in screening for obstructive sleep apnea. Further studies are warranted to test its utility in community-based settings and at home. CITATION: Zhao R, Xue JB, Dong XS, et al. Screening for obstructive sleep apnea using a contact-free system compared with polysomnography. J Clin Sleep Med. 2021;17(5):1075–1082.

STUDY OBJECTIVES: Sleep is increasingly recognized to influence a growing array of physiological processes. The relationship between sleep duration and testis size, a marker of male reproductive potential, has not been studied. METHODS: This was a preliminary cross-sectional analysis of the baseline data from 92 healthy men (mean ± standard deviation, age 33 ± 6 years, body mass index [BMI] 24.7 ± 6.1 kg/m(2)), of whom 66 underwent at-home actigraphy and 47 underwent in-laboratory polysomnography. Sleep duration and architecture were measured by actigraphy and polysomnography, testicular volume by Prader orchidometer, total testosterone by liquid chromatography tandem mass spectrometry, free testosterone by equilibrium dialysis, and luteinizing hormone and follicle-stimulating hormone (FSH) by immunochemiluminometric assay. RESULTS: Sleep duration was correlated with testicular volume (r = .31, P = .046) and with FSH (r = −.30, P = .035), and rapid eye movement sleep was correlated with FSH (r = .44, P = .006). The significance of these findings did not change after adjustment for age and BMI, and were confirmed nonparametrically by resampling. A putative inverse U-shaped relationship between testicular volume and sleep duration was observed by polynomial regression (P = .049), but not with resampling (P = .068). CONCLUSIONS: There is a positive linear and a possible inverse U-shaped relationship between sleep duration and testis volume. Longitudinal or interventional studies manipulating sleep are required to better define causality, and ultimately to establish how much sleep is needed to maximize male reproductive potential. CLINICAL TRIAL REGISTRATION: Title: Hormonal Mechanisms of Sleep Restriction, Registry: ClinicalTrials.gov, Identifier: NCT02256865, URL: https://clinicaltrials.gov/ct2/show/NCT02256865 CITATION: Zhang W, Piotrowska K, Chavoshan B, Wallace J, Liu PY. Sleep duration is associated with testis size in healthy young men. J Clin Sleep Med. 2018;14(10):1757–1764.

We present a unique case of a 26 year-old female non-smoker who expired following treatment for presumed pneumonias. At autopsy, lepidic predominant adenocarcinoma with aerogenous spread of mucin without evidence of invasion, a rare diagnosis that previously would have fallen under the umbrella of "bronchioloalveolar carcinoma," was found. Histopathology showed mucin-secreting neoplastic cells lining the alveolar walls, as well as exfoliated and dense aggregates of mucinous debris filling the alveoli. The immediate cause of death was respiratory failure, most likely due to the significant amount of tumor-produced mucin that filled the alveolar spaces, which literally drowned the patient.

Duchenne muscular dystrophy (DMD) is a fatal disease caused by mutation of the gene encoding the cytoskeletal protein dystrophin. Despite a wealth of recent information about the molecular basis of DMD, effective treatment for this disease does not exist because the mechanism by which dystrophin deficiency produces the clinical phenotype is unknown. In both mouse and human skeletal muscle, dystrophin deficiency results in loss of neuronal nitric oxide synthase, which normally is localized to the sarcolemma as part of the dystrophin–glycoprotein complex. Recent studies in mice suggest that skeletal muscle-derived nitric oxide may play a key role in the regulation of blood flow within exercising skeletal muscle by blunting the vasoconstrictor response to α-adrenergic receptor activation. Here we report that this protective mechanism is defective in children with DMD, because the vasoconstrictor response (measured as a decrease in muscle oxygenation) to reflex sympathetic activation was not blunted during exercise of the dystrophic muscles. In contrast, this protective mechanism is intact in healthy children and those with polymyositis or limb-girdle muscular dystrophy, muscle diseases that do not result in loss of neuronal nitric oxide synthase. This clinical investigation suggests that unopposed sympathetic vasoconstriction in exercising human skeletal muscle may constitute a heretofore unappreciated vascular mechanism contributing to the pathogenesis of DMD.

Background —Cocaine is thought to stimulate the cardiovascular system by blocking peripheral norepinephrine reuptake. This study was designed to test the novel hypotheses that cocaine also stimulates the human cardiovascular system by (1) increasing central sympathetic outflow, or (2) decreasing parasympathetic control of heart rate. Methods and Results —In 14 healthy cocaine-naive humans, we measured blood pressure, heart rate, and skin sympathetic nerve activity (SNA) with intraneural microelectrodes before, during, and for 90 minutes after intranasal cocaine (2 mg/kg, n=7) or lidocaine (2 mg/kg, n=7). Intranasal cocaine caused an initial but transient 3.3-fold increase in skin SNA during the period of intranasal administration followed by a sustained 2.4-fold increase lasting for up to 90 minutes after cocaine. Unlike cocaine, intranasal lidocaine caused only a small transient increase in skin SNA due to local nasal irritation. The cocaine-induced increase in SNA was accompanied by decreased skin blood flow, increased skin vascular resistance, and increased heart rate. In 11 additional subjects, we showed that the cocaine-induced increase in heart rate was eliminated by β-adrenergic receptor blockade (propranolol) but unaffected by muscarinic receptor blockade (atropine), indicating sympathetic mediation. Conclusions —These studies provide direct microneurographic evidence in humans that intranasal cocaine stimulates central sympathetic outflow. This central sympathetic activation appears to be targeted not only to the cutaneous circulation promoting peripheral vasoconstriction but also to the heart promoting tachycardia.

Abstract —In experimental animals, systemic administration of nitric oxide synthase (NOS) inhibitors causes large increases in blood pressure that are in part sympathetically mediated. The aim of this study was to determine the extent to which these conclusions can be extrapolated to humans. In healthy normotensive humans, we measured blood pressure in response to two NOS inhibitors, N G -monomethyl- l -arginine ( l -NMMA) and N G -nitro- l -arginine methyl ester ( l -NAME), the latter of which recently became available for use in humans. The major new findings are 3-fold. First, l -NAME produced robust increases in blood pressure that were more than 2 times larger than those previously reported in humans with l -NMMA and approximated those seen in experimental animals. l -NAME (4 mg/kg) raised mean arterial pressure by 24±2 mm Hg (n=27, P l -NMMA (50 mg/kg) raised mean arterial pressure by 15±2 mm Hg (n=4, P l -NAME). Second, the l -NAME–induced increases in blood pressure were caused specifically by NOS inhibition because they were reversed by l -arginine (200 mg/kg, n=12) but not d -arginine (200 mg/kg, n=6) and because N G -nitro- d -arginine methyl ester (4 mg/kg, n=5) had no effect on blood pressure. Third, in humans, there is an important sympathetic component to the blood pressure–raising effect of NOS inhibition. α-Adrenergic blockade with phentolamine (0.2 mg/kg, n=9) attenuated the l -NAME–induced increase in blood pressure by 40% ( P

Cocaine-induced cardiovascular emergencies are mediated by excessive adrenergic stimulation. Animal studies suggest that cocaine not only blocks norepinephrine reuptake peripherally but also inhibits the baroreceptors, thereby reflexively increasing sympathetic nerve discharge. However, the effect of cocaine on sympathetic nerve discharge in humans is unknown. In 12 healthy volunteers, we recorded blood pressure and sympathetic nerve discharge to the skeletal muscle vasculature using intraneural microelectrodes (peroneal nerve) during intranasal cocaine (2 mg/kg, n = 8) or lidocaine (2%, n = 4), an internal local anesthetic control, or intravenous phenylephrine (0.5-2.0 microg/kg, n = 4), an internal sympathomimetic control. Experiments were repeated while minimizing the cocaine-induced rise in blood pressure with intravenous nitroprusside to negate sinoaortic baroreceptor stimulation. After lidocaine, blood pressure and sympathetic nerve discharge were unchanged. After cocaine, blood pressure increased abruptly and remained elevated for 60 min while sympathetic nerve discharge initially was unchanged and then decreased progressively over 60 min to a nadir that was only 2+/-1% of baseline (P < 0.05); however, plasma venous norepinephrine concentrations (n = 5) were unchanged up to 60 min after cocaine. Sympathetic nerve discharge fell more rapidly but to the same nadir when blood pressure was increased similarly with phenylephrine. When the cocaine-induced increase in blood pressure was minimized (nitroprusside), sympathetic nerve discharge did not decrease but rather increased by 2.9 times over baseline (P < 0.05). Baroreflex gain was comparable before and after cocaine. We conclude that in conscious humans the primary effect of intranasal cocaine is to increase sympathetic nerve discharge to the skeletal muscle bed. Furthermore, sinoaortic baroreflexes play a pivotal role in modulating the cocaine-induced sympathetic excitation. The interplay between these excitatory and inhibitory neural influences determines the net effect of cocaine on sympathetic discharge targeted to the human skeletal muscle circulation.

BACKGROUND: The optimal structure of an internal medicine ward team at a teaching hospital is unknown. We hypothesized that increasing the ratio of attendings to housestaff would result in an enhanced perceived educational experience for residents. METHODS: Harbor-UCLA Medical Center (HUMC) is a tertiary care, public hospital in Los Angeles County. Standard ward teams at HUMC, with a housestaff∶attending ratio of 5:1, were split by adding one attending and then dividing the teams into two experimental teams containing ratios of 3:1 and 2:1. Web-based Likert satisfaction surveys were completed by housestaff and attending physicians on the experimental and control teams at the end of their rotations, and objective healthcare outcomes (e.g., length of stay, hospital readmission, mortality) were compared. RESULTS: Nine hundred and ninety patients were admitted to the standard control teams and 184 were admitted to the experimental teams (81 to the one-intern team and 103 to the two-intern team). Patients admitted to the experimental and control teams had similar age and disease severity. Residents and attending physicians consistently indicated that the quality of the educational experience, time spent teaching, time devoted to patient care, and quality of life were superior on the experimental teams. Objective healthcare outcomes did not differ between experimental and control teams. CONCLUSIONS: Altering internal medicine ward team structure to reduce the ratio of housestaff to attending physicians improved the perceived educational experience without altering objective healthcare outcomes.

PURPOSE: Human monoclonal antibody (HuMAb) SK1, a human monoclonal IgM, has previously been shown to react selectively with a wide range of human carcinomas. In this study, the complement-dependent cytotoxicity (CDC) mediated by the HuMAb SK1 was investigated. METHODS: The presence of AgSK1 on the two studied cell lines, HT29 and PANC-1, was evaluated by the immunocytochemical staining. The intracellular and surface locations of the targeting antigen of HuMAb SK1 were further characterized by the study of flow cytometry. The specific lysis of target cells by the HuMAb SK1 in the CDC assay was studied. RESULTS: In the presence of human complement, the HuMAb SK1 was shown to be effective in the lysis of cultured human gastrointestinal cancer cells as well as the fresh colon cancer cells derived from the patient's specimens. In addition, our data suggested that HuMAb SK1 activated the mouse complement in a similar magnitude. CONCLUSIONS: We concluded that HuMAb SK1 showed some promise for future clinical trials. Thein vitroCDC effect of HuMAb SK1 with mouse complement suggested that the antitumor effect of HuMAb SK1 might be successfully studied in the nude mouse model bearing xenografts of human colon cancer as a part of the preclinical evaluation.

Nitric oxide (NO) attenuates alpha-adrenergic vasoconstriction in contracting rodent skeletal muscle, but it is unclear if NO plays a similar role in human muscle. We therefore hypothesized that in humans, NO produced in exercising skeletal muscle blunts the vasoconstrictor response to sympathetic activation. We assessed vasoconstrictor responses in the microcirculation of human forearm muscle using near-infrared spectroscopy to measure decreases in muscle oxygenation during reflex sympathetic activation evoked by lower body negative pressure (LBNP). Experiments were performed before and after NO synthase inhibition produced by systemic infusion of N(G)-nitro-L-arginine methyl ester (L-NAME). Before L-NAME, LBNP at -20 mmHg decreased muscle oxygenation by 20 +/- 2 % in resting forearm and by 2 +/- 3 % in exercising forearm (n = 20), demonstrating metabolic modulation of sympathetic vasoconstriction. As expected, L-NAME increased mean arterial pressure by 17 +/- 3 mmHg, leading to baroreflex-mediated suppression of baseline muscle sympathetic nerve activity (SNA). The increment in muscle SNA in response to LBNP at -20 mmHg also was attenuated after L-NAME (before, +14 +/- 2; after, +8 +/- 1 bursts min(-1); n = 6), but this effect of L-NAME was counteracted by increasing LBNP to -40 mmHg (+19 +/- 2 bursts min(-1)). After L-NAME, LBNP at -20 mmHg decreased muscle oxygenation similarly in resting (-11 +/- 3 %) and exercising (-10 +/- 2 %) forearm (n = 12). Likewise, LBNP at -40 mmHg decreased muscle oxygenation both in resting (-19 +/- 4 %) and exercising (-21 +/- 5 %) forearm (n = 8). These data advance the hypothesis that NO plays an important role in modulating sympathetic vasoconstriction in the microcirculation of exercising muscle, because such modulation is abrogated by NO synthase inhibition with L-NAME.

A large body of clinical investigation implicates an important role for the sympathetic nervous system in linking obesity with hypertension. However, the experimental support for this hypothesis is derived from strictly white cohorts. The goal of this study was to determine whether being overweight begets sympathetic overactivity in black Americans, the ethnic minority at highest risk for hypertension. We recorded postganglionic sympathetic nerve discharge with microelectrodes in muscle nerve fascicles of the peroneal nerve in 92 normotensive young adult black men and women within a wide range of body mass index. The same experiments were performed in a control group of 45 normotensive white men and women of similar ages and body mass indices. The major new findings are 2-fold. First, in young, normotensive, overtly healthy black women, being overweight begets sympathetic overactivity ( r =0.45, P =0.0009), a putative intermediate phenotype for incident hypertension. Second, in black men, sympathetic nerve discharge is dissociated from body mass index ( r =0.03, P =NS). This dissociation is explained in part by a 20% to 40% higher rate of sympathetic nerve discharge in lean black men compared with lean white men and lean black and white women (28±3 versus 18±2, 21±2, and 17±2 bursts/min, respectively; P

many of the cardiovascular and respiratory adjustments to exercise are mediated by activation of the sympathetic nervous system. This sympathetic activation has been attributed both to the central neural drive associated with the volitional component of exercise, termed “central command,” and to

SummaryBackgroundSkeletal muscle dysfunction contributes to exercise limitation in COPD. The role of the nitric oxide synthase (NOS) system in muscle dysfunction is ill defined. Reduced levels of endothelial NOS (eNOS) and elevated levels of inducible NOS (iNOS) in the skeletal muscle of COPD patients have been recently reported. We hypothesized that resistance exercise training (R) and/or testosterone supplementation (T) would alter the transcription and expression of the NOS isoenzymes in COPD skeletal muscle.MethodsVastus lateralis biopsies were obtained before and after a 10-week intervention in 40 men with severe COPD(age 67.7 ± 8.3, FEV1 41.4 ± 12.6% predicted): placebo + no training (P) (n = 11), placebo + resistance training (PR) (n = 8), testosterone + no training (T) (n = 11) and testosterone + resistance training (TR) (n = 10) groups. eNOS, nNOS and iNOS mRNA and protein levels were measured in each sample. mRNA and protein levels were measured using real-time PCR and enzyme-linked immunosorbant assay, respectively.ResultseNOS mRNA increased in the TR group compared to P and T groups (P