Auto news on Youtube Apr 25 2018

Peutz-Jeghers syndrome, named after Dr. Jan Peutz, who first described it, and Dr. Harold

Joseph Jeghers, who later reported on it, is a rare autosomal dominant condition in

which individuals develop polyps throughout their gastrointestinal tract, as well as dark

spots called melanotic macules in their mouth, lips, genitalia, palms, and soles.

The large intestine is found in the abdominal cavity, which can be thought of as having

two spaces - the intraperitoneal space and the retroperitoneal space.

The intraperitoneal space contains the first part of the duodenum, all of the small intestines,

the transverse colon, sigmoid colon, and the rectum; the retroperitoneal space contains

the distal duodenum, ascending colon, descending colon, and anal canal.

So the large intestines essentially weave back and forth between the intraperitoneal

and retroperitoneal spaces.

Now, the walls of the gastrointestinal tract are composed of four layers.

The outermost layer is the called serosa for the intraperitoneal parts, and the adventitia

for the retroperitoneal parts.

Next is the muscular layer, which contracts to move food through the bowel.

After that is the submucosa, which consists of a dense layer of tissue that contains blood

vessels, lymphatics, and nerves.

And finally, there's the inner lining of the intestine called the mucosa; which surrounds

the lumen of the gastrointestinal tract, and comes into direct contact with digested food.

The mucosa has invaginations called intestinal glands or colonic crypts, and it's lined

with large cells that are specialized in absorption.

Peutz-Jeghers syndrome is caused by a mutation of the STK11 gene, which is a tumor suppressor

gene that codes for a protein called STK11.

So without a functioning STK11 gene, the gastrointestinal cells are more likely to accumulate mutations

and start dividing faster than usual - ultimately giving rise to polyps.

These polyps are benign outgrowths that arise along the gastrointestinal tract, mostly in

the small intestine, but also in the stomach and large intestine as well.

Some polyps then go on to accumulate additional mutations in other tumor suppressor genes

like the K-ras gene and p53 gene, and at that point they might evolve into cancer.

The chance for any single polyp to develop into cancer is generally quite low, but with

people with many polyps, like those suffering from juvenile polyposis syndrome, the risk

for cancer becomes significant.

The STK11 gene is expressed in a number of tissues, so individuals with Peutz-Jeghers

syndrome also have an increased risk of developing extraintestinal cancers without polyps, such

as pancreatic, breast, lung, ovarian, uterine, and testicular cancer.

Polyps can be classified by their gross appearance.

Some are flat, which means that they don't protrude into the lumen from the mucosa.

Some are pedunculated, which means that they do protrude into the lumen and remain attached

to the mucosa by a stalk, just like a mushroom.

And some are sessile, which means that they also protrude into the lumen, but there's

no stalk and the entire tumor is attached to the mucosa.

People with juvenile polyposis syndrome develop hamartomatous polyps, sometimes just called

hamartomas, and these are either sessile or pedunculated.

People with Peutz-Jeghers syndrome also have flat, dark mucocutaneous spots called melanotic

macules, which appear during childhood and often fade as the person gets older.

These macules look a bit like freckles, but arise in different areas, like the mough,

lips, genitalia, palms, and soles.

Individuals with Peutz-Jeghers syndrome often don't have any symptoms; however, if a polyp

becomes big enough to obstruct the intestine, it can cause abdominal pain and constipation.

Some polyps can also ulcerate and cause gastrointestinal bleeding, which can lead to iron deficiency

anemia in the long run.

Diagnosis of Peutz-Jeghers syndrome is usually suspected in individuals with melanotic macules

and typically requires colonoscopy, which is when a camera is inserted retrograde into

the colon and rectum and to take pictures of abnormal looking polyps and a biopsy.

The presence of hamartomas is key in making the diagnosis.

In addition, fecal occult blood testing is often done to look for evidence of gastrointestinal

bleeding.

Ultimately, genetic testing has to be done to look for a mutation in the STK11 gene.

If cancer is suspected, tumor marker screening in blood may be done, especially CEA for colon

cancer, CA19-9 for pancreatic cancer, and CA-125 for ovarian cancer.

It's important for individuals with Peutz-Jeghers syndrome to have frequent endoscopies to screen

for colon cancer.

Some individuals also undergo prophylactic surgery, which means removing the part of

the intestine that has hamartomas before they evolve into carcinomas.

Some individuals also get prophylactic surgery for breasts and gonads, but that can affect

childbearing.

All right, as a quick recap, Peutz-Jeghers syndrome is an autosomal dominant syndrome

caused by a mutation of the STK11 gene.

It is characterized by multiple hamartomas throughout the gastrointestinal tract, along

with melanotic macules in the skin and mucosa, and a high risk of developing malignancy in

various organs, including cancers of the GI tract, pancreas, breasts, lungs, ovaries,

uterus and testicles.

For this reason, people with Peutz-Jeghers syndrome need regular monitoring through endoscopy

and imaging techniques, and sometimes have prophylactic surgery.

For more infomation >> Peutz-Jeghers syndrome - causes, symptoms, diagnosis, treatment, pathology - Duration: 6:45.

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Multiple sclerosis revolutionary treatment, part I - Duration: 11:07.

Paracin, Serbia

I've had multiple sclerosis for 17 years, since 2001.

Before the diagnosis, I lived a healthy life.

I've never smoked or drank alcohol, not even coffee.

I've played football my whole life.

I practised a lot.

My parents worked a lot, in three shifts,

and they couldn't be with me that often when I was a kid.

That's why I grew up mostly with my grandfather.

Then he got sick and died in 2000.

A week or two after his death, my first symptoms appeared.

One morning I woke up with double vision.

After that, my whole life changed.

Belgrade, Serbia

At first, I didn't know what multiple sclerosis was.

They told me that was the reason why I couldn't walk.

I asked the doctors what multiple sclerosis was,

but they just shrugged.

They gave me no explanation.

I was imagining the worst.

I couldn't understand how and why.

I was young, yet confined to bed.

I went to see a GP here, in Paracin.

She told me it was probably due to puberty,

a virus maybe, and I got a lot of different injections.

But my problem persisted.

My double vision went on.

And it would get more blurred the more tired I would get.

For two or three months, the doctors were confused.

I was sent to neurologists in Cuprija, in Paracin,

but my condition remained the same.

My parents were also very confused and worried.

Then we went to the Military Medical Academy in Belgrade.

I had a MRI scan and stayed there for 15 days.

After that, they gave me the MS diagnosis.

I felt the first symptoms after this last war, in 1999.

It started with my right hand shaking,

and then the left one, too.

Then my speech changed.

I started to walk as if I had two buckets full of water

chained to my legs.

That lasted for two years. Then I fell here, in my yard.

I couldn't walk. I was sent to a hospital.

They just put me in bed. They didn't make any tests.

They treated me with misdiagnosis.

I worked for 7 years in a sportswear shop.

We weren't allowed to sit during working hours.

We had to stand up for 8 hours.

During that period, my health condition got worse.

I had walking difficulties, double vision,

as well as urine retention.

For these 17 years, I've had every MS symptom,

at least I think so.

I've thought about suicide.

I had a gun near me while I was lying in bed.

I couldn't move. I wanted to kill myself. But I didn't.

I felt I was a burden to my family.

They had to feed me, change me,

and look after me all the time.

They had to do everything for me, and I felt awful.

In October 2017, I had a relapse,

which means my condition got worse.

I got a pulse therapy, but I was in a really bad state.

I had elevated transaminases, high bilirubin levels,

I felt like I was falling apart.

My condition didn't get any better after the pulse therapy.

I tried everything I thought would help me.

I tried a lot of different things.

But none of all that comes even close to Karnozin Extra.

I started using Karnozin Extra on the 1st of February.

The first day I didn't pay much attention to it,

thinking it would be like with everything else I tried.

But after 2-3 days, I felt a change.

I felt I had more energy.

We, MS patients, we wake up in the morning feeling tired.

And that fatigue gets stronger

during the day, as if we had done some hard work.

But after 2-3 days of taking Karnozin Extra, the fatigue ceased.

Before, going to the toilet for me was the worse part.

Since I couldn't go on my own, someone always had to carry me.

And to be with me in the toilet, as well.

But now, I do everything alone.

I've noticed that my emptying of the bladder is better now.

Now I can see a clear difference.

Now I'm able to function normally through the day

without getting tired, or without feeling

weakness in my legs or numbness in my fingers,

which is great, of course.

When I started using Karnozin Extra my only wish was

to prevent further deterioration

of my health condition.

But now my condition is much better, actually.

My physiotherapists can't recognised me.

They can't believe their eyes when they see me.

They're amazed by my strength.

I'm able to do 40 push-ups in two series.

Before, I could do only 20-25, and now,

since I'm taking Karnozin Extra, I can do 40 of them.

Proper push-ups.

I can lift a bench with one hand.

After I finish with the exercices, I can get up

by myself, and before, the physios had to lift me.

In the beginning, I was a little suspicious.

I mean, before I started taking Karnozin Extra.

But very soon, after only 2-3 days,

I felt a change, and now I believe in it.

I believe that Karnozin Extra is helping me. I'm sure of it.

My only problem now are my legs.

My vision is like an eagle.

When I had a medical check up for a driving licence,

the doctor was stunned I had such a good eyesight with MS.

My driving licence is valid now for the next 2 years.

That's the maximum for MS patients.

Now I have plans. I want to enlarge my family.

Before we couldn't think about a second child,

althought we wanted to have more children.

But now my life is different. I want to have more children.

I have an invalidity pension, which is very small,

only 13,500 dinars, but I don't want to give up.

I want to have a normal life, like other people.

I walk much better now.

My lower limbs circulation improved as well.

Before, my legs were cold and numb.

But now, after two months of taking Karnozin Extra,

I have sensation again.

My child gives me so much strength.

I'm on my way to total recovery.

I know it. I can feel it.

There's no looking back. I just keep on going.

For more infomation >> Multiple sclerosis revolutionary treatment, part I - Duration: 11:07.

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Ulcerative colitis - causes, symptoms, diagnosis, treatment, pathology - Duration: 6:07.

Inflammatory bowel disease can cause inflammation in the small and large intestine, in other

words...inflammation of the bowel.

Colitis refers specifically to inflammation in the colon, or the large intestine.

Ulcerative colitis is a type of inflammatory bowel disease that tends to form ulcers along

the inner-surface or lumen of the large intestine, including both the colon and the rectum.

These ulcers are spots in the mucosa where the tissue has eroded away and left behind

open sores or breaks in the membrane.

Sometimes there is a flare which means that new damage has occurred, and then there are

periods of remission when the tissue starts to heal up.

Ulcerative colitis is actually the most common type of inflammatory bowel disease, not that

there are that many, but this one causes inflammation and ulcers in the mucosa and submucosa of

the large intestine only, which is an important point that sets it apart from Crohn disease,

another inflammatory bowel disease.

Now although certain environmental factors like diet and stress were once thought to

be the culprit behind these ulcers forming in the gut, now it's thought that these

are more secondary, meaning they seem to make symptoms worse, but ulcerative colitis is

now ultimately thought to be autoimmune in origin.

In fact, cytotoxic T cells from the immune system are often found in the epithelium lining

the colon, so the thought is that inflammation and ulceration in the large intestine is caused

by T cells destroying the cells lining the walls of the large intestine, leaving behind

these eroded areas or ulcers.

It's unclear what exactly these T cells are meant to be targeting though.

Some patients have p-ANCAs in their blood, or perinuclear antineutrophilic cytoplasmic

antibodies, which are a kind of antibodies that target antigens in the body's own neutrophils.

Although not completely understood, some theories suggest this may be partly due to an immune

reaction to gut bacteria that have some structural similarity to our own cells, allowing antibodies

to those gut bacteria, or p-ANCAs, to "cross-react" with neutrophils.

Patients also seem to have a higher proportion of gut bacteria that produce sulfides, and

often high sulfide production is correlated with periods of active inflammation as opposed

to remission.

Ultimately, though, these are mostly correlations and theories, and we've yet to nail down

the precise mechanism behind mucosal destruction; the cause is ultimately some combination of

environmental stimuli, perhaps the sulfide-producing bacteria, mixed with a genetic predisposition,

because patients with a family history of ulcerative colitis are more likely to develop

the disease themselves.

It also seems to be more common in young women from the teens to 30s, with more prevalence

among caucasians and eastern european jews.

With ulcerative colitis, the pattern for ulceration seems to be circumferential and continuous,

meaning that the inflammation goes around the whole lumen and starts in the rectum and

continues along the large intestine without any apparent breaks of "normal" or unaffected

tissue, like it's working it's way from one end to the other.

As more damage is done to the tissue, patients experience pain in the left lower quadrant

which corresponds to the rectum, and more severe and frequent bouts of diarrhea, sometimes

with blood in the stool as well.

As the mucosa and epithelium are destroyed, blood and serum may be released into the lumen,

which contributes to the blood seen in the stools, but also, what's one of the main

jobs of the large intestine?

Absorbing water.

As these cells are destroyed, the large intestine can't perform this function as efficiently

and ends up letting too much water through, contributing to diarrhea.

Diagnosis of ulcerative colitis typically requires colonoscopy, which is when a long

tube with a camera at the end, is inserted retrograde through the anus, and into the

rectum and colon to see the ulcers, and take a biopsy.

In addition, radiological imaging maybe done with the help of CT scan, MRI, a barium enema,

which is where a liquid is injected into the rectum through a small tube, and an X ray

is taken to look for abnormalities in the large intestines.

Treatment for ulcerative colitis depends on the severity of symptoms, often anti-inflammatory

medications like sulfasalazine or mesalamine are given; in more severe cases, drugs that

suppress the immune system, like corticosteroids, azathioprine, or cyclosporine might be prescribed.

If those fail, biologic treatments, such as infliximab, a TNF inhibitor, adalimumab and

golimumab can be used.

Finally, if these treatment options fail, sometimes patients will have a colectomy which

is a surgical removal of the colon.

Since the disease only affects the large intestine, removal of the colon generally cures the disease,

but you have to weigh the benefits of curing the disease against the total loss of of the

large intestine!

Alright, as a quick recap… ulcerative colitis is the most common type of inflammatory bowel

disease, where ulcers form along the inner-surface or lumen of the large intestine, including

both the colon and the rectum.

Ulcerative colitis is diagnosed with the help of colonoscopy, and barium enema, and treatment

involves anti-inflammatory medications, immunosuppressant, or colectomy to remove diseased parts of the

colon in severe cases.

For more infomation >> Ulcerative colitis - causes, symptoms, diagnosis, treatment, pathology - Duration: 6:07.

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How to Get Rid Of a Painful Earache Treatment and Home Remedies - Duration: 3:28.

For more infomation >> How to Get Rid Of a Painful Earache Treatment and Home Remedies - Duration: 3:28.

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Ultrasound Treatment for Essential Tremor - Duration: 1:40.

For more infomation >> Ultrasound Treatment for Essential Tremor - Duration: 1:40.

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The Answers: What Is Motivational Interviewing (MI) In Addiction Treatment? - Duration: 0:57.

Motivational interviewing or MI is a type of treatment modality that can be used to help address addiction and facilitate change.

The purpose of MI is to strengthen the clients motivation for and commitment to change.

A session of motivational interviewing may include open-ended questions,

Affirmations, reflective listening, and change-talk including: How to prepare for change and how to implement it

MI has been

Extensively studied and is proven to help people reduce their drinking or drug use - and it may be combined with other treatment modalities

through the recovery process.

For more infomation >> The Answers: What Is Motivational Interviewing (MI) In Addiction Treatment? - Duration: 0:57.

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How to Treat Wrinkles Under and Around the Eyes - Duration: 10:14.

Wrinkles under and around the eyes inspire people to spend a lot of money on solutions

from miracle creams to medically based procedures.

The specific reasons for different types of wrinkles determine how the wrinkles are treated.

I'll discuss the way I help my patients who come in concerned about wrinkles under

and around the eyes.

I'm Dr Amiya Prasad.

I'm a Board Certified Cosmetic Surgeon and Fellowship Trained Oculoplastic Surgeon.

I've been in practice in Manhattan and Long Island for over 20 years.

I specialize in cosmetic procedures of the eyes and eyelids, and treating the signs of

facial aging, ranging from advanced techniques such as upper and lower eyelid surgery; injectable

treatments around the eyes such as cosmetic fillers, platelet-rich plasma, and Botox;

as well as laser and radiofrequency treatments for eyelid skin.

Many people first recognize signs of aging around their eyes.

This includes wrinkles just below the eyes, to crow's feet that appear when smiling

or squinting.

We face people every day with our eyes, and the eyes are the first thing we see in the

mirror.

The appearance of your eyes can project an impression to another person in a fraction

of second that you're tired (even if you're not) or older than you really are.

So, it's natural to want to refresh the appearance of your eyes and diminish the signs

of aging, and tired looking eyes.

There are two basic types of wrinkles around the eyes: static wrinkles which appear when

the face is at rest, or with no expression; and dynamic wrinkles that appear when smiling

or other facial expressions.

Treating these two different types of wrinkles need separate approaches

Wrinkles are one of the most noticeable aspects of an aged appearance.

While there are more significant causes of facial aging such as loss of facial volume

from bone loss and sagging as skin and underlying support gets weak, wrinkles are what most

people see when they look at themselves and conclude that they are aging.

There is a common misconception that under eye wrinkles are caused by excess eyelid skin.

Patients will sit in front of me and pull on their lower eyelid skin and believe there

is excess.

In actuality, this stretchy characteristic is more the result of decrease in skin quality

and facial volume loss.

Nonetheless, well-meaning doctors often try do address under eye wrinkles during lower

eyelid surgery by removing skin.

In my opinion, this is not the best treatment for wrinkles under the eyes, as skin shortage

can make pull the eyelids down, making the eyes look rounded and hollow.

Under eye wrinkles are most commonly caused by collagen loss, not excess skin quantity,

so treatment should be about improving the eyelid skin, rather than removing it.

Lines that appear around the eyes with facial movement expression, such as those commonly

known as crow's feet, appear due to muscle activity.

Collagen loss and breakdown as well as constant creasing of the skin make these lines appear

prominently, even at rest.

Since movement causes the these lines to deepen, limiting movement can help diminish these

lines.

Wrinkles under the eyes are treated by improving lower eyelid skin quality.

This may involve heating devices such as lasers or radiofrequency technology applied with

precision to stimulate the body's collagen production.

The body produces collagen as a response to injury, so applying heat as well as removing

part of the upper layers of skin as in the case of ablation is a controlled injury.

Increased collagen in the lower eyelid skin makes the skin thicker, and healthier.

In addition, removal of the top layer of skin cells, allows new and fresh layers of skin

cells to emerge.

It is important that heating and ablative devices are not overused as too much heat

energy or overaggressive ablation can cause the skin to become thinner.

Collagen stimulation is not limited to the application of thermal energy and laser devices.

Collagen production and increased blood supply in the lower eyelid skin can be stimulated

with a regenerative treatment called platelet-rich plasma, or PRP.

Platelet-rich plasma is a concentration of the platelet component of the blood, which

is responsible for healing when you have a cut.

PRP is concentration of the wound healing growth factors that can also stimulate a collagen

and also stimulate more blood supply the under eye skin.

PRP can also be used to help help with skin discoloration under the eyes commonly known

as dark circles.

To reduce wrinkles around the eyes that appear with movement, the treatment approach would

be to reduce the movement that cause these wrinkles.

This movement can be reduced by limiting muscle activity with a neurotoxin such as Botox,

Dysport, or Xeomin.

Reduced movement makes the lines appear less deep.

An artistic and experienced touch with injectable neurotoxins is important so that natural movement

and facial expressions are not affected.

With time and regular treatment, lines and depressions in the skin caused by constant

muscle contraction improve.

It is important to understand that wrinkles around the eyes cannot be completely eliminated.

The goal here is to improve or to reduce the wrinkles.

As is often seen on some well known people, attempting to completely erase lines and wrinkles

could result in frozen, expressionless faces that don't look natural.

When can you go back to work: Laser and radiofrequency may take a day to a week before returning

to work.

The healing process which going on below the surface is characterized continued collagen

production and remodeling.

PRP can be placed below the skin as well as in the upper layers of skin and can have anywhere

from no downtime to a day or two . Neurotoxins like Botox and Dysport take about 3 days for

effect and 2 weeks for full effect.

It is routine for our patients to go back to work right after treatment.

When it comes to lines and wrinkles under and around the eyes, I always discuss aspects

of lifestyle with my patients.

Simply said, anything that's not good for your health is not good for your skin.

Poor diet, smoking and excess sun exposure of indoor tanning with ultraviolet light accelerated

loss of collagen.

I also discuss strategies for keeping the skin looking good for the long term through

regularly scheduled treatments and skin products such as sunblock and cosmeceutical products.

In the modern world, people are being constantly bombarded by irresponsible messaging from

the internet and television.

Hype for products and procedures result all too often in people having poor outcomes and

permanent skin damage.

A lot of people make the mistake of having procedures based on coupon offers to save

money or from inexperienced practitioners only to spend more money and time trying to

repair their overtreated or damaged skin.

I recommend to find a doctor who you can trust to have your best interest in mind and be

your guide to navigate through all the messaging before you undergo a procedure.

In my practice, I provide my patients with a treatment plan with an understanding of

what to expect with the procedures I've recommended.

I hope you found this information helpful...thank you for your question

For more infomation >> How to Treat Wrinkles Under and Around the Eyes - Duration: 10:14.

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Top Hillary Fundraiser in Disgrace as Video of Sickening Treatment of Cops Goes Viral - Duration: 3:18.

For more infomation >> Top Hillary Fundraiser in Disgrace as Video of Sickening Treatment of Cops Goes Viral - Duration: 3:18.

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Nail Psoriasis Treatment Naturally at Home - Home Remedies for Psoriasis on Nail - Duration: 1:57.

Nail Psoriasis Treatment Naturally at Home

Nail Psoriasis Treatment Naturally at Home

Nail Psoriasis Treatment Naturally at Home

For more infomation >> Nail Psoriasis Treatment Naturally at Home - Home Remedies for Psoriasis on Nail - Duration: 1:57.

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ABNS Ep 7 Treatment for Sleep Apneas - Duration: 17:56.

[Dr. Julie Kinn] This is A Better Night's Sleep, a podcast about sleep, sleep disorders,

and evidence-based treatments.

From Military Health Sleep Experts, I'm Dr. Julie Kinn, with the Defense Health Agency.

[Dr. Jon Olin] And I'm Dr. Jonathan Olin, sleep physician and medical director of the

Evans Army Community Hospital Sleep Lab.

[Dr. Julie Kinn] Jon, in our last episode, you taught us about sleep apneas and how you

diagnose them with in-lab studies and studies at home.

Today, we're going to talk about treatment.

But before we get into that, can you please remind us about the different kinds of sleep

apneas?

[Dr. Jon Olin] Sure.

So obstructive is more common.

And think of it as frankly an obstruction, kind of like a cork blocking a bottle.

So there's actually a problem with a blockage leading to the person-- obstructive sleep

apnea, when the person is asleep, they're obstructed and they're not able to move air.

Generally, their tongue, their soft palate, their upper airway is collapsing and then

blocking and interfering with air flow.

So again, we earlier described that we don't demand perfection in the field.

They don't have to be open 100% of the time throughout all sleep time when studied.

But if that's occurring 15 or 30 times an hour, we'd call that, for more 15 to 30, moderate

obstructive sleep apnea.

If it's more than 30, we call it severe obstructive sleep apnea by frequency of events.

[Dr. Jon Olin] Central sleep apnea is again asleep, not moving air, but not an effort

to breathe.

And that's the brain not giving input to go ahead and breathe.

That's common in some conditions.

The conditions that are associated with central sleep apnea are broad.

Like obstructive sleep apnea is generally a blockage or is a blockage.

Central sleep apnea, all of us here in the Northwest, I'm in Colorado.

If you take me to the top of Mount Rainier or I take you to the top of Pikes Peak, both

of us are going to have central sleep apneas, where we're going to hyperventilate because

of the altitude and elevation.

We're going to hyperventilate and then our brains are going to go, "Oh good, I got a

good oxygen level."

And as we drift off to sleep, we're not going to breathe.

And then our brains are going to, "Oh, there's a problem."

[Dr. Jon Olin] So, that can be seen, for example, with elevation.

It can be seen with medications, including for example narcotics or respiratory depressants.

Medications that decrease brain input to sleep.

It can be seen with cardiac conditions, like congestive heart failure.

It can be seen with pulmonary conditions.

It could be seen with neuromuscular conditions, for example polio.

I know that's relatively rare in the US now.

So the causes for why someone is not breathing can be more complex than usually the causes

with an obstructive sleep apnea, which generally is an obstruction of the upper airway.

[Dr. Julie Kinn] And it sounds like you might not even know that you're prone to this until

you're deployed or having a permanent change of station to a place with a different elevation.

[Dr. Jon Olin] I mean realistically, I think a substantial portion of us are going to have

these central apneas at over 10,000 feet elevation.

Certainly, more people have them at Fort Carson, which is ballpark 6,000 feet, than say, Tacoma

area, basically sea level.

Is 6,000 feet absolutely where everyone has them?

No.

But they're way more common here.

And there is a sleep lab at the Air Force Academy here in Colorado Springs that's another

1,000 feet and they're more common just additional 1,000 feet.

So we're kind of teeter-tottering here at this elevation, at 6,000 feet, with more common,

but not way, way common.

And then think, at 14,000 feet, basically, everyone's going to have them.

[Dr. Julie Kinn] I'm assuming the treatments differ for obstructive sleep apnea and central

sleep apnea?

[Dr. Jon Olin] Sure.

So central sleep apnea, you figure out what the cause is and then address that.

[Dr. Julie Kinn] Okay.

[Dr. Jon Olin] If it's elevation, then they may need time to adjust.

We try to avoid studying someone that just got off a plane and just arrived here 12 hours

ago.

So we're going to give them time to adjust.

If they're on narcotics or medications, just had surgery, had a procedure, we're going

to try to study them off of the narcotics or respiratory-depressant medications.

And then if they have ongoing central events, we can look at PAP, which is positive airway

pressure, which can be useful.

Sometimes for people, [bleeding?] in oxygen can be useful, where they're getting some

extra oxygen.

And then there are special PAP-type machines that are useful for treating central apneas

called ASV, for example, is one type.

They're specific treatments for central apnea, but in general, looking at why they're having

the central apneas and trying to address that is useful and appropriate.

[Dr. Jon Olin] But we should really talk about the more common condition which is obstructive

sleep apnea.

So in general, you're going to try to somehow hold the airway open that's collapsing.

So one way to do that is weight loss or weight control, if that's relevant and appropriate.

So someone who is overweight by 10 or 20 pounds, or 10 or 15 percent, if they lose weight, that may

be helpful, especially lose some weight around their neck.

There's obviously no way to specifically only lose weight around their neck or in their

oral area.

But avoiding gaining weight is going to be important.

So weight loss, weight control is relevant for some, for some, not relevant.

They're normal weight or underweight and they still have severe apnea.

[Dr. Jon Olin] PAP, positive airway pressure, where you're holding open a collapsing airway

with air pressure.

So if I break my finger-- I know Julie we're doing this podcast not nearby, but if you

were nearby, you could grab a pencil or pen and some duct tape or something and splint

it up.

And we could go over to the ER and they'd look at it, but we could somehow splint or

control it so it's not flopping around my broken finger.

So airway, obviously, much trickier area to splint.

We can't tell people, "Hey, reach in the back of your mouth, pull your tongue forward, push

your tonsils out of the way, now fall asleep."

They're going to say, "I'm going to throw up, never mind try to fall asleep."

So one way to splint it, to hold it open, is actually with air and air pressure.

So these are machines that pump air and they'll get many different types of masks.

And they're connected with a tube, from the machine through the tube, to the mask.

And some of the masks go over just nose and some of them just barely touch or kind of

touch the nostrils, the opening and will push in air.

So holding open this airway that was collapsing.

[Dr. Julie Kinn] So is it pushing oxygen in to replace oxygen from breathing less?

[Dr. Jon Olin] It's actually room air.

So we're not pumping in that, oxygen only, it's room air that's being pumped in or--

that's using the room air pressure to hold open the airway.

That's actually a common thought is like, "Well, why can't I just put in a little oxygen?"

Like the nasal cannulas, you see those in medical movies or TV shows of like, "I could

just have some oxygen.

That'll help my obstructive apnea."

And it may help it very, very slightly, in the sense that your oxygen levels are slightly

higher, but it's not doing anything to open the obstruction.

It's just waving around a higher concentration of air in front of the obstruction, not going

to do anything to open the obstruction.

So we need to do something to open the obstruction.

[Dr. Jon Olin] So PAP sure can and that's considered the gold standard.

And for severe, that's going to be generally the treatment that's recommended.

There will be some people in a sleep study, either home or in lab, that have documented,

say, severe or moderate sleep apnea when they're on their back, supine, and none or good breathing

when they're on their side, lateral.

If there's significant data for that, then positional therapy could be considered.

And this is a person doing something in an organized way, not just saying, "Oh, my sleep

study said I'm severe on my back," but they're going to do something in an organized way

to make sure that they're not sleeping on their back.

So, that's going to be like body pillows, could be tennis balls sewn.

This will sound a little weird, but tennis balls, pockets for tennis balls sewn in the

back of their pajama top and you put those in an X or a T and you can sleep.

[Dr. Julie Kinn] So that if you roll onto it, it's uncomfortable?

[Dr. Jon Olin] Exactly.

So you train yourself to sleep on your side.

Exactly.

So why are people worse on their back?

Because their tongue is generally flopping back and then blocking or closing the airway.

So they do something in an organized way to make sure that they're not on their back.

Surgery can be considered.

There are multiple surgeries.

The most common one is removing tonsils and some of the soft palate and the adenoids,

the little dangly thing back there called the uvula.

The statistics for that are not very, very encouraging and that under 50% of people get

50% improvement is what I've seen and so it's generally not a first-line treatment.

It could be something that is considered for people in the mild range for severe obstructive

sleep apnea.

Some of these surgeries are not first-line treatments.

There are other surgeries that are more aggressive, but people need to be thoughtful and discuss

those on my opinion with an experienced eye, ear, nose, and throat surgeon before they

do that.

[Dr. Jon Olin] Generally, PAP is as I said the mainstay gold standard of treatment for

severe.

There are also, for mild obstructive sleep apnea, things called oral appliances or mandibular

advancement devices.

So it'll sound a little weird, but tongue, believe it or not, is attached to jaw and

if you do something with like a double retainer to advance jaw even millimeters, you're pulling

tongue forward millimeters and opening airway possibly millimeters.

So again, for someone very severe and not a first-line treatment, but for someone with

mild, the millimeters may be enough to then have effective treatment.

I like getting follow-up sleep studies to prove that treatments are effective.

If they had an in-lab study and we know they're good in various stages, including REM on their

side, then that's your data, but I like getting follow-up study with an oral appliance to

show that it's effective and achieving good results.

[Dr. Julie Kinn] Now what about nose strips and devices for the nose?

[Dr. Jon Olin] Nose strips can be useful for snoring.

There's not really good data that they're useful for obstructive sleep apnea.

So it can improve airflow through the nose, so then there's less fluttering or less snoring

as it's going by the soft palate.

But in general, the obstructions are an upper airway and so improving some airflow from

nose does not open the airway.

[Dr. Julie Kinn] Okay.

Good to know.

Sounds like there's a lot of different treatment options and that surgery is definitely not

the first step.

[Dr. Jon Olin] Yeah, there are many treatments.

I should say also with PAP, again for moderate is generally considered the gold standard.

For PAP, the machines now, they're increasingly modern.

They're quiet, they're quieter than your household's fan in general.

They're relatively small, they are little bigger than-- they're like a small shoe box

and they have modems in them.

So they track actually hours of use that the person is using it and advance per hour.

So it's I think interesting and fun for patients to be able to look at that data so they can

track their hours of use, their advance per hour.

Is it as accurate as a full in-lab attended study?

No.

Because it was not a tech nearby, there was not all the wires, but we can look at how

they're using it.

The army, I think of the military and the field, in general, consider adequate treatment

more than four hours a night, more than 70 percent of the time.

So in other words, 21 out of 30 days for more than four hours.

[Dr. Jon Olin] And in general, we'd like to see events per hour at less than five, especially

if they're moderate or severe.

Sometimes, if they have 100 events an hour in their eight-- with the PAP, they reduce

to 6.0 events per hour and might view that as pretty darn good, they're 94% improved.

But in generally like events, at less than five per hour.

So there aren't that many treatments we can see how people are doing over a 30-day period,

over a 60-day period.

But this is one and then hopefully we get patients and service members buying it and

going, "Oh wow.

Actually, I'm starting to feel a little better.

Does takes weeks off and I'm starting to feel a little better.

My memory is a little better, my concentration is a little better.

I've noticed my blood pressure might be a teeny bit better."

People can get a lot of improvement with quality life with improved sleep.

[Dr. Julie Kinn] So can you take the PAP machine with you on deployment?

Would having this kind of diagnosis and treatment make one unable to deploy?

[Dr. Jon Olin] No.

That's a good question.

So years and years ago, yes, you could not take it with you to deploy.

Now you can.

And in fact, it's encouraged.

If someone has a knee condition and need a brace, then we're going to say, "Yes, deploy

with a knee brace."

We're not going to ask you to rock or to deploy and do significant time on your feet without

your knee brace and the same thing for sleep.

So they do need access to electricity.

They may deploy with the battery pack, which is eight-hour one-night backup.

It's not a one month supply of ongoing battery.

They'd have to recharge it.

So they do need access to electricity.

I like people to have filtered air.

What does filtered air mean?

It means a room or some kind of enclosed container with a floor, four walls, and a ceiling.

In other words, I don't like PAP just being sat down, the machine being sat down in a

pile of mud.

[Dr. Jon Olin] Even if they have a generator nearby, yeah, it's not going to do well for

them or for the machine to be doing that.

Yes, it'll keep your airway open for some of the hours, but it's going to break the

machine impact on the filter.

But [inaudible] people deploy and the machines themselves will again track their use, track

their data.

But if someone has severe obstructive sleep apnea and then deploys, and then is not with

their machine, and then is bound to falling asleep, that's dangerous.

That's a problem.

So the dangerous significance and consequences of untreated apnea are not just civilian,

they can be military obviously also when deployed.

So the army would like people to, especially the people with symptoms, meaning daytime

sleepiness, to be deploying with their PAP because we want them to be treated, want them

to have a better quality of life, better concentration, better attention, better focus.

[Dr. Julie Kinn] I'm hearing that there's a lot of treatment options and that any sleep

physician will be able to walk our listeners through them to figure out the best

place to start.

[Dr. Jon Olin] Right.

And it doesn't have to be a Board-certified sleep physician, there are many of the PCMs

are increasingly knowledgeable about sleep apnea, abstractive sleep apnea, and treatment

options.

So review this with a provider.

They may consult or the person may choose to be seen by a sleep physician.

But treatment is better than the no treatment.

And there are many primary care managers that are familiar with many of the sleep conditions

and treatment options.

Untreated sleep apnea is associated with high blood pressure, strokes, diabetes, and car

accidents.

And these, again, things tend to, again, normalize with treatment.

Is it an emergency if someone misses their PAP for one night?

No.

But ongoing no treatment or non-treatment is a significant health concern and safety

concern.

So we do encourage people to follow up and get treatment for their sleep disorders.

[Dr. Julie Kinn] That's a great reminder about the importance of this topic for our listeners

and our loved ones.

Thank you Jon.

Thank you listeners for tuning in.

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