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Clinical Briefings: Clinical Reports from Penn Medicine™

Distraction Osteogenesis
noreply@blogger.com (Penn Medicine) Wed, 23 Jun 2010 05:43:00 -0700
Oral and maxillofacial surgeons at Penn were among the first to apply distraction osteogenesis to the treatment of surgical, genetic, age-related and traumatic defects of the jaws.1 Originally developed to treat patients with orthopaedic trauma or disease, distraction osteogenesis involves the use of a distraction device to gradually (1 mm per day) separate existing bone segments, creating gaps where new bone forms.This process continues until the desired bone height or length is achieved, at which point a final consolidation, or healing, phase occurs. During this time, the immature osteoid matrix matures into bone. One advantage of distraction osteogenesis is that it precludes harvest bone grafting, a procedure with many potential complications.At Penn, distraction osteogenesis is used to produce bone growth in a wide range of conditions including alveolar atrophy of edentulous areas requiring endosseous implant-supported dental restoration; reconstruction following segmental resection of the jaw; alveolar defects due to traumatic injury and congenital alveolar deformity.Case StudyRW was referred to Penn Oral and Maxillofacial Surgery at age 13, when a lump was discovered in his left jaw. On examination, RW was noted to have a painless expansion of the left buccal cortex of the mandible and decreased light touch sensation of the left lower lip.Panorex and CT evaluation revealed a radiolucent lesion of the left mandible extending from the first premolar to the angle of the mandible. Histologic examination of an incisional biopsy of the lesion was consistent with desmoplastic fibroma. Rather than surgical management of the lesion, RW and his family opted for a course of chemotherapy at this time.When the lesion began to enlarge a year later despite this treatment, RW had a mandibular resection with free fibular bone graft reconstruction (Figure 1), a treatment judged successful.A year later, the neomandible was evaluated for possible dental rehabilitation. Because RW’s ridge height would not support endosseous implants and his bone graft was poorly positioned in relation to the adjacent dentition, augmentation of the neo-mandible was deemed necessary.RW had distraction osteogenesis to improvehis alveolar height. Following removal of the reconstructionbone plate, the fibula graft was osteotomized to create a mobile segment at the superior aspect. Two alveolar distraction devices were then placed in parallel (Figure 2).Five days later, RW began activating the distraction devices at a rate of 1mm per day. After the device maximum of 1.5cm was achieved (Figure 3), RW entered the three-to-four month consolidation phase, then returned for removal of the distractors. Examination at this time revealed adequate height of bone to support dental implants. Subsequently, RW underwent placement of eight dental implants (Figure 4) followed by fabrication of an implant-supported dental restoration. His appearance restored, RW has returned to school and has had no complications.1. Havlik RJ, Bartlett SP. J Craniofac Surg. 1994;5:305-310.Our Team of FacultyThe Department of Oral and Maxillofacial Surgery at Penn is composed of a multidisciplinary team of dental/ medical specialists whose expertise encompasses non-surgical and surgical treatment of oral and maxillofacial disorders, traumatic injuries, congenital defects, oral lesions and temporomandibular joint dysfunction.Lawrence M. Levin, DMD, MDChair, Department of Oral and Maxillofacial SurgeryLee R. Carrasco, DDS, MDAssistant Professor of Oral and Maxillofacial SurgeryJoli C. Chou, DMD, MDInstructor, Oral and Maxillofacial SurgeryHelen Giannakopoulos, DDS, MDAssistant Professor of Oral and Maxillofacial SurgeryBarry H. Handler, DDS, MDAssociate Professor of Oral and Maxillofacial SurgeryPeter D. Quinn, DMD, MDProfessor of Oral and Maxillofacial Surgery and Pharmacology-Clinician EducatorDavid C. Stanton, DMD, MD, FACSAssociate Professor of Oral and Maxillofacial SurgeryAccessPatient appointments are available at:Department of Oral and Maxillofacial SurgeryHospital of the University of Pennsylvania5 White3400 Spruce StreetPhiladelphia, PA 19104Penn Presbyterian Medical Center38th and Market Streets235 Myrin PavilionPhiladelphia, PA 19104Penn Medicine at Radnor250 King of Prussia RoadRadnor, PA 19087To refer a patient and/or consult with a physician: Call 800.789.PENN (7366) or visit PennMedicine.org/referral.
Surgical Management of Severe Glenohumeral Chondrolysis in Younger Patients
noreply@blogger.com (Penn Medicine) Mon, 21 Jun 2010 06:51:00 -0700
Surgeons at the Penn Shoulder and Elbow Service are repairing advanced chondrolysis of the shoulder in patients younger than 40 years of age by combining a regenerative tissue matrix with an unstemmed, resurfacing humeral prosthesis. The combined therapy effectively addresses the progressive and destructive effects associated with chondrolysis, including damage to the articular cartilage of the humeral and glenoid bearing surfaces.The etiology of chondrolysis in the shoulders of young patients is thought to include postsurgical chondral apoptosis, postoperative trauma, avascular necrosis, focal defects and idiopathic autoimmune resorption.Treatment centers upon long-term resolution of pain and the return of normal or near-normal range of movement in the affected joint. In older patients, traditional total shoulder arthroplasty is the treatment of choice. However, with concerns over glenoid component wear in younger patients, traditional arthroplasty is not ideal for younger patients.Orthopaedic surgeons at Penn have the advantages of a dedicated research facility and access to the latest developments in orthopaedic devices and technologies. Thus, their approach to severe chondrolysis has evolved to include two sympathetic components: an unstemmed humeral resurfacing component and a recombinant tissue matrix placed at the glenoid cavity.Resurfacing of the humeral head is initially performed through a standard deltopectoral incision (Figure 1).With a trial humeral component in place, the glenoid surface is prepared and a tissue matrix is grafted onto the damaged glenoid surface. The matrix is composed of 1 mm to 2 mm thick dermis processed to remove cellular components. Interposed between the glenoid and the resurfaced humeral head, the matrix restores protection to the exposed bone to further alleviate glenoid­sided pain and restore function to the joint.Case StudyAF, a 22-year-old NCAA Division I female gymnast, was referred to Penn Sports Medicine a year after developing postsurgical chondrolysis in her right shoulder. She had initially sustained a glenoid labrum tear treated arthroscopically.Her postoperative course was marked by diminished glenohumeral motion and severe pain. During this time, she experienced significant pain at rest, for which conservative treatment with nonsteroidal agents and narcotic pain medications were ineffective. A magnetic resonance imaging scan of the shoulder found significant chondrolysis of right humeral head and glenoid articular surfaces. Arthroscopic evaluation confirmed diffuse chondrolysis.After considering further nonoperative therapy and total shoulder replacement, the patient chose to have humeral surface replacement arthroplasty using a graft jacket regenerative tissue matrix and unstemmed prosthesis (Figure 2).Postoperatively,she has had near complete resolution of her pain, restoration of her motion and has returned to non-weight bearing activities in competitive NCAA Division I gymnastics.Our Team of FacultyThe Penn Shoulder and Elbow Service is comprised of a team of orthopaedic surgeons, rehabilitation and family practice physicians, nurses and physical therapists dedicated to patient care. To enhance the mobility, independence, and quality of life of orthopaedic patients, Penn Shoulder and Elbow Service physicians create and utilize the latest advances in shoulder and elbow diagnosis, treatment and rehabilitation.Penn Shoulder and Elbow ServiceDavid L. Glaser, MDChief, Shoulder and Elbow ServiceDirector, Shoulder and Elbow Fellowship ProgramAssistant Professor of Orthopaedic SurgeryA graduate of Cornell University Medical College, Dr. Glaser completed his residency and fellowship training at the Hospital of the University of Pennsylvania. Dr. Glaser’s specialties encompass the treatment of shoulder and elbow disorders, including complex revision surgeries, fracture repairs, sports injuries and shoulder replacement surgery.Performing Surgery for Severe Glenohumeral Chondrolysisat PennG. Russell Huffman, MD, MPHAssistant Professor of Orthopaedic SurgeryDr. Huffman attended Duke University School of Medicine and completed his internship and residency at the University of California at San Francisco. He subsequently completed a shoulder and elbow fellowship at the University of Southern California, and pursued further subspecialty training in elbow surgery at the Mayo Clinic. Dr. Huffman specializes in the arthroscopic treatment of athletic shoulder and elbow disorders, as well as joint replacement and fracture repair surgery of the shoulder and elbow.AccessPatient appointments are available at:Penn Orthopaedic InstitutePenn Presbyterian Medical Center1 Cupp Pavilion38th and Market StreetsPhiladelphia, PA 19104Penn Orthopaedic InstitutePenn Medicine at Radnor250 King of Prussia RoadRadnor, PA 19087Penn Sports Medicine Center235 S. 33rd Street, 1st FloorWeightman HallPhiladelphia, PA 19104To refer a patient and/or consult with a physician:Call 800.789.PENN (7366)or visitPennMedicine.org/referral.
Reverse Shoulder Replacement Surgery
noreply@blogger.com (Penn Medicine) Mon, 21 Jun 2010 06:25:00 -0700
Surgeons at the Shoulder and Elbow Service at Penn are performing reverse shoulder replacement surgery to treat intractable shoulder pain and dysfunction. An innovative procedure, reverse shoulder replacement surgery employs a prosthesis (Figure 1) to reverse the anatomy of the normal shoulder. This configuration avoids the displacement, instability and limitation of motion that frequently occurs when conventional arthroplasty is used to treat certain types of shoulder problems.Reverse shoulder surgery is often used for patients with chronic, long-standing rotator cuff tears and arthritis, or to treat the sequelae of shoulder fractures previously treated with replacement surgery. Patients who receive the prosthesis typically report significant reductions in pain within three months of surgery, as well as improved function, flexibility and range of movement.Case StudyMr. M, a 66-year-old man with a year long history of shoulder pain was referred to the Penn Shoulder and Elbow Service for evaluation of progressive weakness, chronic pain and limitation of movement in his right shoulder. At Penn, an X-ray and subsequent MRI of the shoulder demonstrated deterioration of the glenohumeral joint with superior migration of the humeral head and a retracted irreparable rotator cuff tear (Figures 1 & 2). After a discussion of his options, Mr. M chose to have reverse shoulder surgery.Prior to surgery, additional anteroposterior and lateral radiographs were taken to determine the optimum implant position of both the glenosphere and the humeral component. The glenohumeral joint was opened and dissected to allow removal of abnormal tissue resulting from arthritis and chronic rotator cuff injury.After the deformed humeral head was removed, the humeral medullary canal was prepared, and the stem support for the socket inserted and pressfit into the humerus for subsequent bony ingrowth. Next, the glenoid was prepared for placement of a baseplate into which bone grows, and the glenosphere was locked into this.Trials were then performed to ensure proper range of motion, soft tissue balance and implant stability, after which the final polyethylene socket was attached to the humerus. The repairable portion of the rotator cuff was reattached and the skin closed in layers, concluding the surgery (Figure 3).Mr. M’s post-operative recovery was uneventful. At his two-week follow-up visit, he reported a substantial reduction in pain and discomfort. Now more than three months out from his surgery, he has no pain and uses his arm for functions of daily living. He is currently preparing for replacement of his left shoulder.Our Team of FacultyThe Penn Shoulder and Elbow Service is comprised of a team of orthopaedic surgeons, rehabilitation and family practice physicians, nurses and physical therapists dedicated to patient care. To enhance the mobility, independence, and quality of life of orthopaedic patients, Penn Shoulder and Elbow Service physicians create and use the latest advances in shoulder and elbow diagnosis, treatment and rehabilitation. DEPARTMENT OF ORTHOPAEDIC SURGERYDavid L. Glaser, MDChief, Shoulder and Elbow ServiceDirector, Shoulder and Elbow Fellowship ProgramAssistant Professor of Orthopaedic SurgeryA graduate of Cornell University Medical College, Dr. Glaser completed his residency and fellowship training at the Hospital of the University of Pennsylvania. Dr. Glaser’s specialties encompass the treatment of shoulder and elbow disorders, including complex revision surgeries, fracture repairs, sports injuries and shoulder replacement surgery.G. Russell Huffman, MD, MPHAssistant Professor of Orthopaedic SurgeryDr. Huffman attended Duke University School of Medicine and completed his internship and residency at the University of California at San Francisco. He subsequently completed a shoulder and elbow fellowship at the University of Southern California, and pursued further subspecialty training in elbow surgery at the Mayo Clinic. Dr. Huffman specializes in the arthroscopic treatment of athletic shoulder and elbow disorders, as well as joint replacement and fracture repair surgery of the shoulder and elbow.AccessPatient appointments are available at:Penn Orthopaedic InstitutePenn Presbyterian Medical Center1 Cupp Pavilion38th and Market StreetsPhiladelphia, PA 19104Penn Orthopaedic InstitutePenn Medicine at Radnor250 King of Prussia RoadRadnor, PA 19087Penn Sports Medicine Center235 S. 33rd Street, 1st FloorWeightman HallPhiladelphia, PA 19104To refer a patient and/or consult with a physician:Call 800.789.PENN (7366) or visitPennMedicine.org/referral.
Repair and Reconstruction of Type IIIB Open Tibial Fractures
noreply@blogger.com (Penn Medicine) Mon, 21 Jun 2010 06:04:00 -0700
The prevailing objectives for the management of high-energy type IIIB open tibial fractures at the Hospital of the University of Pennsylvania (HUP) include emergent debridement, irrigation, and temporizing fixation, followed by early soft tissue and bony reconstruction of the limb, return to function after healing and long-term limb survival.To optimize the treatment of these debilitating injuries and minimize their postoperative complications, HUP has assembled an interdiscipli­nary team of specialists in orthopaedic trauma surgery, plastic surgery and trauma/critical care.At Penn, patients sustaining high energy type IIIB open tibial fractures are usually aggressively resuscitated at presentation to maintain perfusion of their at-risk limb. After appropriate emergent management, which might include debride­ment and irrigation, temporizing orthopaedic stabilization, advanced radiographic imaging and evaluation of vascular patency in the affected limb, pre-operative planning for definitive management is initiated through cross-disciplinary communication between Orthopaedic Surgery, Plastic Surgery and the Division of Traumatology and Surgical Critical Care.Definitive management includes reconstruction and stabilization of the tibia using optimal implant technology to restore length, alignment and rotation of the limb. After definitive fixation, the plastic surgeons provide adequate soft tissue coverage with free flaps.If the patient’s injuries allow, definitive stabilization and soft coverage is usually performed within seven days to optimize outcomes. In the immediate postoperative period, a variety of techniques are incorporated to avoid and prevent deep infection, wound contamination, osteomyelitis, non-union, and tissue necrosis.Case StudyFollowing a bicycle accident, Ms. A, a 23-year-old woman, was transferred to the Penn Orthopaedic Trauma Service with a type IIIB fracture involving the articular surface of the distal tibia. The wound spanned a six-inch diameter of the left anteromedial surface of the tibia with gross contamination. At Penn, Ms. A was taken immediately to the OR, where her wound was aggressively debrided of devitalized tissue and copiously irrigated. Her tibia was temporarily stabilized via external fixation and an antibiotic bead pouch was applied.Three days later, Ms. A’s wound received a repeat debridement and irrigation. At this time, Penn Plastic Surgery performed an intraoperative consultation for her leg to determine the best course for soft tissue coverage.On day six, an open reduction and internal fixation of the open tibia fracture took place with removal of the external fixator. Concomitant to this definitive fixation, a free flap procedure was performed to provide soft tissue coverage.Once the flap healed, Ms. A began aggressive rehabili­tation to regain range of motion in the limb; transition to weight-bearing occurred as tolerated. At this time, her free flap has healed and she is fully weight-bearing. No further surgery is required.Our Team of FacultyThe management of type IIIB open tibial fractures at the Hospital of the University of Pennsylvania involves a multidisciplinary effort including the Orthopaedic Trauma Service, Penn Plastic Surgery, and the Division of Traumatology and Surgical Critical Care.ORTHOPAEDIC TRAUMA SURGERYComprised of an integrated team of surgeons, nurse practitioners, nurses, social workers, therapists, interventional radiologists, plastic surgeons, critical care specialists, vascular surgeons, and rehabilitation specialists, the Penn Orthopaedic Trauma Service is committed to pre-eminent orthopaedic surgery and clinical research and excellence in the education of orthopaedic trauma surgeons.DEPARTMENT OF ORTHOPAEDIC SURGERYSamir Mehta, MDChief, Orthopaedic Trauma ServiceAssistant Professor of Orthopaedic SurgeryDavid J. Bozentka, MDChief, Hand SurgeryAssociate Professor of Orthopaedic SurgeryJohn L. Esterhai Jr., MDProfessor of Orthopaedic SurgeryR. Bruce Heppenstall, MDProfessor of Orthopaedic SurgeryDavid R. Steinberg, MDAssociate Professor of Orthopaedic SurgeryORTHOPAEDIC TRAUMA NURSE PRACTITIONERAdele Hamilton, CRNPPLASTIC SURGERYThe Penn Plastic Surgery Service provides a complete range of reconstructive and cosmetic surgery options, as well as medical services dedicated to the restoration of function and treatment of appearance. Specialty areas include reconstruction following tumor resection or trauma, reconstructive microsurgery, breast reconstruction, craniofacial reconstruction, and the full range of cosmetic surgery and services.Joseph M. Serletti, MD, FACS Chief, Division of Plastic Surgery Henry Royster-William Maul Measey Professor in Plastic and Reconstructive SurgeryStephen J. Kovach III, MD Assistant Professor of SurgeryDavid W. Low, MD Associate Professor of SurgeryLiza C. Wu, MD Assistant Professor of SurgeryTRAUMATOLOGY & SURGICAL CRITICAL CAREThe trauma surgeons of the Division of Traumatology and Surgical Critical Care participate in the evaluation and resuscitation of all patients with severe orthopaedic injuries, including open tibial fractures.C. William Schwab, MDChief, Division of Traumatology & Surgical Critical CareProfessor of SurgeryPatrick M. Reilly, MDAssociate Professor of SurgeryAccessPatient appointments are available at:Penn Orthopaedic InstituteHospital of the University of Pennsylvania2 Silverstein3400 Spruce StreetPhiladelphia, PA 19104Penn Orthopaedic InstitutePenn Presbyterian Medical Center1 Cupp Pavilion38th and Market StreetsPhiladelphia, PA 19104Penn Plastic Surgery and theCenter for Human AppearancePerelman Center for Advanced MedicineEast Pavilion, 1st Floor3400 Civic Center BoulevardPhiladelphia, PA 19104To refer a patient and/or consult with a physician:Call 800.789.PENN (7366)or visitPennMedicine.org/referral.
Orthopaedic Trauma Surgery
noreply@blogger.com (Penn Medicine) Mon, 21 Jun 2010 05:17:00 -0700
The development of the Orthopaedic Trauma Service at Penn reflects the coming of age of the emerging subspecialty of orthopaedic traumatology. Trained to treat patients with complex polytrauma or abnormal healing processes, the surgeons of the Penn Orthopaedic Trauma Service specialize in surgery for sudden, severe musculoskeletal trauma, reconstruction for periarticular fractures, long­term rehabilitation for debilitating post­traumatic sequelae (including fracture non­union and chronic osteomyelitis), and the treatment of complex pelvic and acetabular fractures.Patient care at Penn is optimized through the coordination of a multidisciplinary team of specialists and subspecialists within the departments of Orthopaedic Surgery, Trauma and Surgical Critical Care, the Trauma Center at Penn, Plastic Surgery and Neurosurgery. Hand and upper extremity services (including microvascular and reconstructive surgery) are offered in partnership with the Penn Orthopaedic Institute.In addition to medical and surgical services, the Penn Orthopaedic Trauma Service embraces resident education for orthopaedic trauma, and is among the few orthopaedic trauma departments in the nation engaging in active research of the biomechanical and orthobiological aspects of healing.Case StudyAfter being struck by an automobile, Mrs. R, a 39-­year-­old female, was brought to the Penn Orthopaedic Trauma Service at the Hospital of the University of Pennsylvania by PennSTAR. The Trauma System was activated upon her arrival at HUP.A primary survey at this time indicated hemodynamic instability, multiple rib fractures to the right rib cage and a vertical shear pelvic ring injury. A subsequent CT scan of the pelvis found a right sacroiliac joint fracture dislocation and bilateral inferior and superior pubic ramus fractures. Mrs. R was intubated and resuscitated and circumferential pelvic compression was applied emergently.When her hemodynamic status failed to improve, Mrs. R was sent to intervention­al radiology for an emergent embolization of the right superior gluteal artery. She was admitted to the Trauma Intensive Care Unit, where her right lower extremity was placed in distal femoral traction and she was stabilized and cleared for an orthopaedic surgical intervention. In the operating room, an open right sacroiliac joint reduction was performed employing the iliac window of the ilioinguinal approach.Two plates were applied along the anterior sacroiliac joint and a percutaneous upper sacral segment screw was placed to stabilize the posterior ring. To address continued instabil­ity of the anterior ring, a supra­acetabular external fixator was applied. Intra­operative blood loss was minimal. Mrs. R was extubated and neurologically intact.Post­operatively, Mrs. R was allowed to weight bear fully on the left and to be 10% weight bearing on the right. At six weeks, Mrs. R’s external fixator was removed and her weight­bearing was advanced. Today, Mrs. R is at home recovering from her injury. She is starting to put some weight on her right leg and is walking with crutches.Our Team of Faculty The Penn Orthopaedic Trauma Service is comprised of an integrated, multi­disciplinary team of surgeons, nurses, social workers, therapists, interventional radiologists and rehabilitation specialists committed to pre­eminent orthopaedic surgery and clinical research and excellence in the education of orthopaedic trauma surgeons. Subspecialties within the Penn Orthopaedic Trauma Service provide a comprehensive array of surgical and rehabilitative services for the hand, foot, ankle, spine and joints.DEPARTMENT OF ORTHOPAEDIC SURGERYSamir Mehta, MDChief, Orthopaedic Trauma Service AssistantProfessor of Orthopaedic SurgeryDavid J. Bozentka, MDAssociate Professor of Orthopaedic SurgeryJohn L. Esterhai Jr., MDProfessor of Orthopaedic SurgeryDavid L. Glaser, MDAssistant Professor of Orthopaedic SurgeryJonathan P. Garino, MDAssociate Professor of Orthopaedic SurgeryNader M. Hebela, MDAssistant Professor of Orthopaedic SurgeryR. Bruce Heppenstall, MDProfessor of Orthopaedic SurgeryG. Russell Huffman, MD, MPHAssistant Professor of Orthopaedic SurgeryCraig Israelite, MDAssistant Professor of Orthopaedic SurgeryGwo-Chin Lee, MDAssistant Professor of Orthopaedic SurgeryDavid R. Steinberg, MDAssociate Professor of Orthopaedic SurgeryORTHOPAEDIC TRAUMA NURSE PRACTITIONERAdele Hamilton, CRNPDIVISION OF TRAUMA & SURGICAL CRITICAL CARE THE TRAUMA CENTER AT PENNC. William Schwab, MDChief, Division of Traumatology & Surgical Critical CareProfessor of SurgeryBenjamin Braslow, MDAssistant Professor of SurgeryForrest Fernandez, MDAssistant Professor of SurgeryPatrick Kim, MD, FACSAssistant Professor of SurgeryJose L. Pascual, MDAssistant Professor of SurgeryPatrick M. Reilly, MDAssociate Professor of SurgeryBabak Sarani, MDAssistant Professor of SurgeryCarrie A. Sims, MDAssistant Professor of SurgeryAccessPatient appointments are available at:Penn Orthopaedic InstituteHospital of the University of Pennsylvania2 Silverstein3400 Spruce StreetPhiladelphia, PA 19104Penn Orthopaedic InstitutePenn Presbyterian Medical Center1 Cupp Pavilion38th and Market StreetsPhiladelphia, PA 19104Penn Orthopaedic InstitutePenn Medicine at Radnor250 King of Prussia RoadRadnor, PA 19087For urgent access, call: 800.543.STAR(7827)The PennSTAR Communications Center will facilitate any and all requests.To refer a patient and/or consult with a physician:Call 800.789.PENN (7366)or visitPennMedicine.org/referral.
Importance of Evaluation for Obstructive Sleep Apnea in Obese Patients with Type 2 Diabetes
noreply@blogger.com (Penn Medicine) Thu, 17 Jun 2010 07:51:00 -0700
Specialists at the Penn Sleep Centers are encouraging physicians treating obese patients with diabetes, particularly those with higher waist circumferences (truncal obesity), to be evaluated for obstructive sleep apnea (OSA). Data from epidemiologic and clinical studies now suggests that OSA places patients at increased risk for the development of altered glucose metabolism, and could thus be a contributing cause of type 2 diabetes.1 In studies comparing obese OSA patients with weight matched non-OSA controls, the combination of OSA and obesity was found to increase insulin resistance.2According to a recent report,3 the prevalence of undiagnosed OSA among obese patients with type 2 diabetes is greater than 85% (Figure 1). Importantly, many of the patients in the study had no symptoms of sleepiness or snoring, and reported symptoms (such as sleepiness and snoring) did not predict which patients were likely to have sleep apnea. More than half of the patients with OSA had moderate or severe sleep apnea, a factor shown in recent population-basedand longitudinal studies to be an independent risk factor for all cause mortality.Some studies 4,5 have shown that diabetic patients with OSA who receive sustained, regular treatment with continuous positive airway pressure (CPAP) can improve insulin sensitivity and glycaemic control. CPAP treatment has been demonstrated to reduce systolic blood pressure and heart rate and to improve left ventricular ejection fraction in patients with OSA.Case StudyMr. E, a 35-year-­old man, presented to his primary care physician for routine follow up care. His medical history was significant for type 2 diabetes, hypertension and obesity. Outpatient medications included metformin 1000mg twice daily, lisinopril 10mg once daily and amlodipine 10mg once daily.The patient had no specific complaints during the visit but, when asked by his physician, admitted that his wife had urged him to visit because she could no longer tolerate his snoring. He denied excessive daytime sleepiness. Clinical examination was significant only for obesity (body mass index = 37.2kg/m2) and an elevated blood pressure of 145/94, despite antihypertensive medications. An outpatient sleep study was ordered to investigate for obstructive sleep apnea (OSA).The polysomnogram revealed severe obstructive sleep apnea with an apnea hypopnea index of 42 events per hour and an oxyhemoglobin nadir of 80%. The patient was referred for a titration polysomnogram, which established a CPAP pressure of 10 cm of water as the optimal pressure needed to treat Mr. E’s severe OSA. CPAP therapy was initiated using a nasal mask interface.Mr. E returned to his primary care provider three months later. His blood pressure was within optimal range (128/74) without change in his antihypertensive regimen. His wife reported his snoring had been abolished with the use of his CPAP unit. In addition, Mr. E noted that he now feels more energized and rested on waking in the morning."Given that OSA may complicate diabetes in the obese, it’s important that physicians treating obese patients with type 2 diabetes consider the possibility of OSA, even in the absence of symptoms. This is especially true of those with higher waist circumference and higher BMI levels."-Allan I. Pack, MB, ChB, PhD Chief, Division of Sleep Medicine Professor of MedicineReferences1. Tasali E, Mokhlesi B, Van Cauter E. Chest. 2008;133:496­506.2. Tassone F, Lanfranco F, Gianotti L, et al. Clin Endocrinol (Oxf). 2003;59:374­379.3. Foster GD, Sanders MH, Millman R, et al. In press. Diabetes Care. 2009.4. Schachin SP, Nechanitzky T, Dittel C, et al. Med Sci Monit. 2008;14:CR117­CR121.5. Harsch IA, Schahin SP, Radespiel­Tröger M, et al. Am J Resp Crit Care Med. 2004;169:156­162.Team of FacultyThe Penn Sleep Center is comprised of a multidisciplinary team of clinicians from the departments of medicine, neurology, psychiatry, otorhinolaryngology and oral and maxillofacial surgery—a concentration of expertise that permits a comprehensive approach to the diagnosis and treatment of sleep disorders and their comorbidities. One of only three sleep centers in the United States designated by the National Institutes of Health as a specialized center for research in sleep, the Penn Sleep Center is fully accredited by the American Academy of Sleep Medicine. With seven locations in the Philadelphia area, the Sleep Center currently performs more than 5,000 sleep studies each year.Allan I. Pack, MD, PhdAssistant Professor of Urology in SurgeryCharles R. Cantor, MD, DABSMMedical Director, Penn Sleep CentersClinical Associate Professor of NeurologyMaria Antoniou, MD, DABSMAssistant Professor of Clinical Medicine Eliot Friedman, MDInstructor in MedicinePhilip R. Gehrman, PhD, CBSMAssistant Professor of PsychiatryNalaka S. Gooneratne, MD, DABSMAssistant Professor of MedicineIndira Gurubhagavatula, MD, MPHAssistant Professor of MedicineGrace W. Pien, MD, MSCE, DABSMAssistant Professor of MedicineDavid M. Raizen, MD, PhD, DABSMAssistant Professor of NeurologyIlene M. Rosen, MD, DABSMAssistant Professor of Clinical MedicineSharon L. Schutte-Rodin, MD, DASBSM, CBSMClinical Associate Professor of MedicineRichard J. Schwab, MD, DABSMProfessor of MedicineSigrid C. Veasey, MD, DABSMAssociate Professor of MedicineAccessPatient appointments are available at:Penn Sleep CentersHospital of the University of Pennsylvania*†3624 Market StreetSuite 201Philadelphia, PA 19104Penn Sleep Center**†3624 Market Street, Suite 201Philadelphia, PAPennsylvania Hospital**800 Spruce StreetPhiladelphia, PA 19107Penn Medicine at Radnor ***†250 King of Prussia Road2nd FloorRadnor, PA 19087Penn Sleep Center at theSheraton University City Hotel*†36th and Chestnut StreetsPhiladelphia, PA 19104Penn Sleep Center at thePavilion at Doylestown Hospital*599 West State StreetSuite 101Doylestown, PA 18901Penn Sleep Center at AudubonHomewood Suites Hotel*†681 Shannondell BlvdAudubon, PA 19403† Indicates a facility of the Hospital of the University of Pennsylvania* Indicates overnight sleep study site ** Indicates overnight sleep study site and sleep specialist site*** Indicates sleep specialist siteTo refer a patient and/or consult with a physician:Call 800.789.PENN (7366) or visitPennMedicine.org/referral.

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When a biopsy cannot completely rule out cancer
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