Nov-Dec 2014

3

MED

IC M

ENTO

R

Editor’s DeskDear Reader,Greeting from team MEDIC MENTOR

The present era has witnessed Medical field taking a quantum leap. Establishment of new Medical colleges, rapid technological strides and increased awareness levels in the public has created new opportunities. It was often felt that to keep pace with this rapid growth, we need more effective communication channels.

It gives us pleasure to introduce ourselves as the publishers of “MEDIC MENTOR”, India’s only interactive Bi-monthly Journal devoted exclusively to complete Medical Fertility, which is going to launch soon and will circulate free to all Medical students, Private practitioners, and Medical Stores/Labs all over India. Its representatives placed in all major Medical Colleges and centers in India. It is India’s first interactive Medical Professional/Student Friendly Publication on the subject.

As you know that we have approximate 380 Medical Colleges in India and about 1-lac students studying in these colleges. These numbers are increasing every year. More colleges are coming up and more students are entering in Medical profession. Also we have more than 1 Lac Regd. Private Practitioners all over India and most of them are still searching an actual information tool which can guide them about the up gradation of their Clinics. Medic Mentor’s aims at fulfilling such requirements and guide all field of medical professionals about upgrading their practices, the latest breakthroughs in terms of medicines or technology.

Thanking you

One Year Subscription : 500/- Single Copy Cost : 100/-

EditorDr. Zia HashimLayout & Design

Arman DalalPrinted ByAAFREEN NAQVIPublished ByAAFREEN NAQVIOwned ByAAFREEN NAQVI

RNI NO. : DELENG18781Printed AtRolleract Press Services, C-163, GF, Naraina Industrial Area Phase -1, New Delhi-110028

Place of PublicationE-12/18, FF, HAUZ RANI, MALVIYA NAGAR, NEW DELHI-110017

Regd. Office:F-41/B, GF, Barkat Apartment, Shaheen Bagh Abul Fazal Enclave-II Okhla New Delhi-110025,

Tel : +91 11 26941512, +91 9136469979

E-mail : medicmentorjournal@gmail.com

Website : www.medicmentor.in

Dr. Zia HashimM.D. (Internal Medicine, PGI Chandiagrh), D.M. (Pulmonary & Critical Care, PGI Chandigarh), FCCP (USA)

Editor

Nov-Dec 2014

6

MED

IC

MEN

TOR

OBSTRUCTIVE SLEEP APNEA: AN EMERGING EPIDEMIC

Dr. Zia Hashim

We spend one third of our life in sleeping. Sound sleep is essential for sound health. As we entered 21st century the amount of activity kept on decreasing and food intake kept on increasing. This gave rise to a epidemic of obesity. The inverse relation between obesity and sleep is known since the time of Kumbhkaran of Ramayna, it was not until 20 years later that its prevalence and importance as a public health problem was recognized. Obstructive sleep apnea (OSA) is a common disorder that affects one of four men and one of 11 women in the world.1 In India the prevalence of obstructive sleep apnea is about ten percent.2 Syndrome X, which has been recently described is a lethal combination of OSA with metabolic syndrome.3

Sleep related breathing disorders are abnormal respiratory patterns or abnormal reduction in gas exchange(e.g. hypoventilation) during sleep. Abnormal respiratory patterns could be apneas, hypopneas or respiratory effort related arousals (RERAs). Apnea is total cessation or near total cessation of airflow(less than 10% of pre-event flow) for at least 10 seconds. Hypopnea is defined by American Academy of Sleep Medicine (AASM) when all of the following three criteria are met:4 1. Airflow decreases at least 30 percent from pre-

event baseline2. The diminished airflow lasts at least 10 seconds3. The decreased airflow is accompanied by at least

3 percent oxyhemoglobin desaturation from pre-event baseline, or an arousal. Previously definition used a cutoff of 4 percent for oxyhemoglobin desaturation.

RERAs are defined when there is a sequence of breaths that lasts at least 10 seconds, characterized by increasing respiratory effort or flattening of the nasal

pressure waveform followed by an arousal from sleep, which does not meet the criteria for an apnea or hypopnea. Excessive daytime sleepiness with more than 5 RERAs was previously termed upper airway resistance syndrome, which is now considered as OSA. Hypoventilation during sleep is characterized by an increase in the arterial carbon dioxide (PaCO2) to a value >55 mmHg for at least 10 minutes, or a ≥10 mmHg rise in the PaCO2 during sleep (compared with awake supine level) to a value exceeding 50 mmHg for at least 10 minutes. Apnea hypopnea index is the number of apnea or hypopnea per hour of sleep, whereas respiratory disturbance index (RDI) includes RERAs in addition to apnea and hypopnea. OSA in adults is defined as either more than 15 apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI >15 events/hr) in an asymptomatic patient, or more than 5 apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI >5 events per hour) in a patient with symptoms or signs. More than 75 percent of the apneas or hypopneas must have an obstructive pattern. Severity of OSA classified according to AHI is defined as mild if 5–14 events/h, moderate if 15–29 events/h, and severe if 30 events/h5. Management of OSA requires a multidisciplinary approach. Polysomnography should be performed on all patients with history of loud snoring and excessive daytime somnolence. Weight loss and exercise should be offered to all patients. OSA is generally treated when apnea hypopnea index is more than 15 without symptoms or more than 5 with symptoms. Behaviour modification is indicated for all patients who have OSA and a modifiable risk factor. The types of behaviour modification that should be instituted depend upon the characteristics of the patient. Weight loss is recommended for all patients

Nov-Dec 2014

18

MED

IC

MEN

TOR

What soap to use? Bar soap should not be used in any circumstances due to the associated risk of cross contamination. Research has shown that the use of non-antimicrobial soap is more effective than antibacterial alternatives at removing transient organisms. The use of antibacterial l soaps have begun to create concern around the emergence of antibiotic-resistant bacteria and should therefore be avoided. A mild nonantimicrobial liquid soap should be dispensed from a disposable cartridge type container fitted into a closed wall-mounted dispenser unit at each handwash sink area.3

The most commonly used products for surgical hand antisepsis are chlorhexidine or povidone-iodine-containing soaps. The most active agents (in order of decreasing activity) are chlorhexidine gluconate, iodophors, triclosan, and plain soap. Triclosan-containing products have also been tested for surgical hand antisepsis, but triclosan is mainly bacteriostatic, inactive against P. aeruginosa, and has been associated with water pollution in lakes. Hexachlorophene has been banned worldwide because of its high rate of dermal absorption and subsequent toxic effects. Application of chlorhexidine or povidone-iodine result in similar initial reductions of bacterial counts (70–80%), reductions that achieves 99% after repeated application. Rapid regrowth occurs after application of povidone-iodine, but not after use of chlorhexidine. Hexachlorophene and triclosan detergents show a lower immediate reduction, but a good residual effect. These agents are no longer commonly used in operating rooms because other products such as chlorhexidine or povidone-iodine provide similar efficacy at lower levels of toxicity, faster mode of action, or broader spectrum of activity. Despite both in vitro and in vivo studies demonstrating that it is less efficacious than chlorhexidine, povidone-iodine remains one of the widely-used products for surgical hand antisepsis, induces more allergic reactions, and does not show similar residual effects. At the end

of a surgical intervention, iodophor treated hands can have even more microorganisms than before surgical scrubbing. Warm water makes antiseptics and soap work more effectively, while very hot water removes more of the protective fatty acids from the skin. Therefore, washing with hot water should be avoided.5

Surgical hand preparation with alcohol-based hand rubs 5 Several alcohol-based hand rubs have been licensed for the commercial market, frequently with additional, long acting compounds (e.g. chlorhexidine gluconate or quaternary ammonium compounds) limiting regrowth of bacteria on the gloved hand. The antimicrobial efficacy of alcohol based formulations is superior to that of all other currently available methods of preoperative surgical hand preparation.Numerous studies have demonstrated that formulations containing 60–95% alcohol alone, or 50–95% when combined with small amounts of a QAC, hexachlorophene or chlorhexidine gluconate, reduce bacterial counts on the skin immediately post-scrub more effectively than do other agents. Institutions opting to use the WHO-recommended formulations for surgical hand preparation should ensure that a minimum of three applications are used, if not more, for a period of 3 to 5 minutes. For surgical procedures of more than a two hours’ duration, ideally surgeons should practise a second handrub of approximately 1 minute, even though more research is needed on this aspect.

Hand-washing technique 3The correct hand-washing technique is crucial for the effective removal of microorganisms from the hands of dental practitioners. The technique selected by dental professionals should consist of three main stages: preparation, washing

and rinsing, and hand drying. The preparation ritual of wetting hands under warm running water has remained consistent and ensures that there is a more thorough lather of soap over all areas of the hands.