Obstructive sleep apnoea

This chapter covers the causes, signs, and symptoms of obstructive sleep apnoea (OSA). It explains the process of diagnosis, from a history, medications, family, and psychosocial history, occupation, and diagnostic procedures. Differential diagnoses that should be excluded are listed. The prevalence of OSA is estimated to be around 4% of the population. It is quite a common disorder, although this figure may be an underestimate as many people may not seek treatment. Prevalence figures also vary according to the chosen threshold for defining a significant sleep abnormality and symptoms. Treatment options are also outlined, and the specific aspects of nursing care are listed.

Abstract P108: The Cause and Treatment of Paroxysmal Hypertension

Introduction: The cause and treatment of paroxysmal hypertension (PH) (“pseudopheochromocytoma”) in the 98-99% of patients who do not have a pheochromocytoma has long been a mystery. It has been linked to a psychosomatic origin based on the finding in nearly all patients of repression of emotions associated with either a past history of overwhelming stress or trauma or a repressive coping style. The purpose of this study is to convey further experience in understanding and treating PH. Methods: We reviewed the medical records of patients with a diagnosis of PH. Patients were considered to have PH if episodes were sudden in onset, were unprovoked (not precipitated by stress or anxiety) and were symptomatic (e.g., headache, flushing, tachycardia and/or others). Patient characteristics, psychosocial history and response to treatment were assessed. Based on the previous study, the psychosocial characteristics examined most closely were the presence of a past history of trauma or overwhelming stress, the emotional response to that trauma, the presence or absence of a history of depression or anxiety, and the presence or absence of a repressive coping style. Results: Sixty-eight percent of patients (24 of 35) reported a history of trauma with repression of related emotions; a repressive coping style was evident in 26% (9 of 35). Neither characteristic was evident in only 2 patients (6%). Most patients were prescribed clonidine and/or alprazolam for acute management of paroxysms; this intervention was considered sufficient by 10 (28%). Twenty-three of the remaining 25 were offered treatment with an antidepressant. Two refused and two could not tolerate an effective dose. Of the remaining 19, 17 (89%) responded, including 10 (53%) with complete cessation and 7 (37%) with reduction in frequency of paroxysms. The disorder resolved promptly without medication in 2 patients who gained awareness of emotions long held from awareness. Conclusions: The psychosocial history, the marked efficacy of antidepressant agents, and the rapid cure associated with gaining of awareness of previously repressed emotions strongly support the origin of PH in repressed emotions. To date, no other cause or effective treatment has been reported.

Social and Cultural Factors Leading to Suicide Attempt via Organophosphate Poisoning in Nepal

Organophosphates are commonly used in rural, agricultural communities worldwide. Poisoning in Nepal is commonly a result of suicide attempt via ingestion with a mortality rate of 41 times higher than in the United States even after appropriate treatment. The patient discussed in this case is a 46-year-old Nepalese female with a complicated psychosocial history that presented with a suicide attempt via organophosphate ingestion. She required higher doses and greater lengths of treatment of atropine and pralidoxime to resolve symptoms of toxicity that resulted in atropine-induced psychosis, a side effect rarely cited in the literature. This patient was one of many who attempt suicide in Nepal, where suicide is the leading cause of death for young to middle aged women in the country.

DEVELOPMENT OF A STANDARDIZED APPROACH FOR THE ASSESSMENT OF BOWEL AND BLADDER DYSFUNCTION IN COMMUNITY PAEDIATRICS

BACKGROUND Bowel and bladder dysfunction (BBD) is a common yet underdiagnosed paediatric condition that describes a constellation of lower urinary tract symptoms (LUTS) associated with constipation and/or encopresis. Many children with BBD have co-morbid neuropsychiatric symptoms (e.g., inattention, anxiety) and psychosocial stressors. Thus, clinical assessment of behavioural symptoms and social risk factors in this population is essential. However, there is no standardized approach for a comprehensive assessment of BBD. OBJECTIVES We aim to develop and evaluate physician and parent perceptions with 1) a standardized BBD history and physical intake form for physicians, and 2) a parent-reported intake form. DESIGN/METHODS From June to Oct 2017, a quality improvement study was conducted in the BBD network, an existing paediatric collaborative initiative consisting of 7 community sites with support of the paediatric urology division in a tertiary hospital. Based on literature review and expert opinions, a standardized intake form was developed for BBD assessment with targeted questions for LUTS, constipation, behavioural, dietary, and psychosocial history, along with a physical exam checklist for neurological red flags. Further, a shorter parent-reported intake questionnaire was developed to clarify patterns of dysfunctional voiding symptoms, dietary recall and stool history. Both forms underwent usability testing and iterative refinement. Prior to clinic, families of children referred for BBD were mailed an intake package for completion. During the clinic, physicians were asked to use the standardized intake form for new referrals. Afterwards, both physicians and parents were given anonymous surveys to evaluate their perceptions of the intake process. RESULTS A total of 8 physicians and 20 parents responded, with 60% of patients being between ages 4–10 and 55% male. Physicians found the standardized intake form to be a useful guide that reminded them to ask about specific urinary symptoms (88% of the time), constipation (75%), and psychosocial history (76%). The majority of physicians (75%) agreed they would use the intake form again and recommended its implementation. Further, parents responded positively by agreeing that the intake package was easy to complete (65%), felt included in care decisions (95%), and had questions answered appropriately (100%). CONCLUSION In assessment of BBD, a standardized intake form can help guide physicians to efficiently gather a comprehensive history, rule out red flags, and screen for psychosocial risk factors. With refinements, it can potentially help create a common clinical experience and empower more community paediatricians to manage BBD in the future.