Brainstem infarction and sleep-disordered breathing in the BASIC sleep apnea study

BackgroundAssociation between cerebral infarction site and poststroke sleep-disordered breathing (SDB) has important implications for SDB screening and the pathophysiology of poststroke SDB. Within a large, population-based study, we assessed whether brainstem infarction location is associated with SDB presence and severity.MethodsCross-sectional study was conducted on ischemic stroke patients in the Brain Attack Surveillance in Corpus Christi (BASIC) project. Subjects underwent SDB screening (median 13 days after stroke) with a well-validated cardiopulmonary sleep apnea-testing device (n = 355). Acute infarction location was determined based on review of radiology reports and dichotomized into brainstem involvement or none. Logistic and linear regression models were used to test the associations between brainstem involvement and SDB or apnea/hypopnea index (AHI) in unadjusted and adjusted models.ResultsA total of 38 participants (11%) had acute infarction involving the brainstem. Of those without brainstem infarction, 59% had significant SDB (AHI ⩾ 10); the median AHI was 13 (interquartile range (IQR) 6, 26). Of those with brainstem infarction, 84% had SDB; median AHI was 20 (IQR 11, 38). In unadjusted analysis, brainstem involvement was associated with over three times the odds of SDB (odds ratio (OR) 3.71 (95% confidence interval (CI): 1.52, 9.13)). In a multivariable model, adjusted for demographics, body mass index (BMI), hypertension, diabetes, coronary artery disease, atrial fibrillation, prior stroke/transient ischemic attack (TIA), and stroke severity, results were similar (OR 3.76 (95% CI: 1.44, 9.81)). Brainstem infarction was also associated with AHI (continuous) in unadjusted (p = 0.004) and adjusted models (p = 0.004).ConclusionsData from this population-based stroke study show that acute infarction involving the brainstem is associated with both presence and severity of SDB.     

Sleep-disordered breathing and cardiac autonomic modulation in children

ObjectivesTo investigate the adverse cardiac autonomic effects of sleep-disordered breathing (SDB) in a large population-based sample and a clinical sample of children.MethodsSubjects included a population-based sample of 700 and a clinically diagnosed sample of 43 SDB children. SDB was defined based on an apnea hypopnea index (AHI) ? 1 during one night of polysomnography. Cardiac autonomic modulation was measured by heart rate variability (HRV) analysis of the beat-to-beat RR interval data collected during polysomnography.ResultsThe mean (SD) age was 112 (21) months, with 49% male and 25% non-white. About 73.0% had AHI < 1 (no SDB), 25.8% had 1–5 AHI (mild SDB), and 1.2% had ?5 AHI (moderate SDB). Among individuals with moderate SDB in the population-based sample and the clinically diagnosed SDB patients, the mean (SE) of HRV-high frequency power (HF) was significantly lower compared to children without SDB [6.00 (0.32) and 6.24 (0.14), respectively, vs. 6.68 (0.04) ms², p < 0.05 and p < 0.01, respectively], whereas the low frequency power to high frequency power ratio (LF/HF) was significantly higher [1.62 (0.20) and 1.74 (0.09), respectively, vs. 0.99 (0.02), both p < 0.01)].ConclusionsSDB in healthy young children and in clinical patients is significantly associated with impaired cardiac autonomic modulation, i.e., sympathetic overflow and weaker parasympathetic modulation, which may contribute to increased risk of acute cardiac events in persons with SDB, even before reaching the “high risk age.”     

High glycemic variability: An underestimated determinant of stroke functional outcome following large vessel occlusion

Background and purposeEarly glycemic variability (GV) in diabetic patients is a poor prognosis factor following cardiovascular events. However, its influence on the course of acute ischemic stroke (AIS) with large vessel occlusion remains unclear. We investigated the relationship between high GV during acute stroke and three-month functional outcome among patients treated with combined intravenous thrombolysis and endovascular therapy for large vessel occlusion.MethodsA single-center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent thrombolysis and mechanical thrombectomy between January 2015 and May 2017. Early GV was assessed using standard deviation (SD) of blood glucose levels for the first 24 hours. The main outcome was functional status at three months as defined by the modified Rankin scale (mRS). Secondary outcomes were change in NIHSS score from baseline to 24 hours and occurrence of severe hemorrhagic transformation. Multivariate logistic regression analyses including GV, admission glycemia and mean glycemia were performed.ResultsAmong the 93 patients evaluated, 26 had early high GV (≥ 20.9 mg/dl). High GV was associated with poor functional outcome (OR = 8.00; 95%CI [1.34–47.89]; P = 0.02) unlike admission glycemia and mean glycemia (OR = 2.92; 95%CI [0.51–16.60]; P = 0.23 and OR = 0.36; 95%CI [0.05-2.6]; p = 0.31, respectively). High GV was not associated with NIHSS at 24 hours or hemorrhagic transformation.ConclusionAcute high GV contributes to poorer functional outcome following AIS related to large vessel occlusion and should be considered as a new target in acute stroke management.     

General anesthesia or conscious sedation for endovascular therapy of basilar artery occlusions: ETIS registry results

Background and purposeAcute basilar artery occlusions (BAO) are associated with poor outcome despite modern endovascular treatment (EVT). The best anesthetic management during EVT is not known and may affect the procedure and clinical outcome. We compared the efficacy and safety of general anesthesia (GA) and conscious sedation/local anesthesia (CS/LA) in a large cohort of stroke patients with BAO treated with EVT in current clinical practice.MethodsData from the ongoing prospective multicenter Endovascular Treatment In Ischemic Stroke Registry of consecutive acute BAO patients who had EVT indication from January 1st, 2015, to December 31st, 2021, were retrospectively analyzed. Two groups were compared: patients treated with CS/LA versus GA (both types of anesthesia being performed in the angiosuite). Good outcome was defined as modified Rankin Scale (mRS) score 0–3 at 90 days.ResultsAmong the 524 included patients, 266 had GA and 246 had CS/LA (67 LA). Fifty-three patients finally did not undergo EVT: 15 patients (5.9%) in the GA group and 38 patients (16.1%) in the CS/LA group (P < 0.001). After matching, two groups of 129 patients each were retained for primary analysis. The two groups were well balanced in terms of baseline characteristics. After adjustment, CS/LA compared to GA was not associated with good outcome (OR = 0.90 [95%CI 0.46–1.77] P = 0.769) or mortality (OR = 0.75 [0.37–1.49] P = 0.420) or modified thrombolysis in cerebral infarction score 2b-3 (OR = 0.43 [0.16–1.16] P = 0.098). On mixed ordinal logistic regression, the modality of anesthesia was not associated with any significant change in the overall distribution of the 90-day mRS (adjusted OR = 1.08 [0.62–1.88] P = 0.767).ConclusionsSafety, outcome and quality of EVT under either CS/LA or GA for stroke due to acute BAO appear similar. Further randomized trials are warranted.     

IV t-PA therapy in acute stroke patients with atrial fibrillation

Background and purposeAtrial fibrillation (AF) is a predictor for severe stroke. Intravenous administration of tissue plasminogen activator (t-PA) can improve clinical outcomes in patients with acute ischemic stroke. We investigated clinical characteristics and patient outcome in patients with and without AF after t-PA therapy.MethodsConsecutive ischemic stroke patients treated with t-PA within 3 h of stroke onset were studied prospectively. MRI examinations, including diffusion weighted imaging and MRA, were performed before t-PA thrombolysis. NIHSS scores were obtained before and 7 days after t-PA infusion. The patients were divided into two groups (AF group and Non-AF group). Their clinical characteristics and outcome 7 days and 3 months after t-PA therapy were compared.Results85 patients (56 males, mean age, 73.4 ± 11.5 years) were enrolled in the present study. The AF-group had 44 patients, and the Non-AF group had 41 patients. Fewer patients with AF had dramatic improvement at 7 days and favorable outcome (mRS 0–1) at 3 months after t-PA therapy than patients without AF (31.8% vs. 61.0%, P = 0.007, and 15.9% vs. 46.3%, P = 0.002). On the other hand, worsening at 7 days and poor outcome (mRS > 3 and death) at 3 months after t-PA therapy were more frequently observed in AF group than Non-AF group (22.7% vs. 9.8%, P = 0.107, and 70.5% vs. 41.5%, P = 0.007). After adjusting age and gender, patients with AF more frequently had worsening and poor outcome than those without AF (adjusted OR; 4.54, 95% CI 1.04–19.75, P = 0.044, and adjusted OR; 2.8, 95% CI 1.10–7.28, P = 0.032).ConclusionThe present study found that acute ischemic stroke patients with AF more frequently had poor outcome after IV-t-PA therapy compared with those without AF.     

Increased risk of snoring and adenotonsillectomy in children referred for tympanostomy tube insertion

ObjectiveEustachian tube dysfunction and sleep-disordered breathing (SDB) share common pathophysiologic mechanisms. Our objective was to investigate whether children referred for isolated TTI (tympanostomy tube insertion) are at increased risk for snoring and upper airway procedures.MethodsTelephone interviews to parents of children who underwent isolated TTI and to age- and gender-matched controls were conducted.ResultsFour hundred fifty-seven children were included in the study; 352 had isolated TTI (study group) and 105 children were controls. Twenty-two percent of children in the study group were reported to snore compared with 7.6% in the controls (p = 0.001). Eighteen percent of children in the study group were reported to have undergone adenotonsillectomy compared with 4.8% in the controls (p = 0.0005). Future SDB, i.e., either snoring or adenotonsillectomy following TTI, was found in 34% of children in the study group compared with 11% in the controls (p = 0.0004). Children who underwent isolated TTI were at increased risk for future snoring (OR = 3.4, CI: 1.6–7.2) and future adenotonsillectomy (OR = 4.4, CI: 1.7–11.2).ConclusionsChildren who undergo isolated TTI are at increased risk for snoring and for adenotonsillectomy. We suggest that these children be followed for symptoms of SDB on a scheduled basis to allow for early diagnosis and intervention.     

Study of association of severity of sleep disordered breathing and functional outcome in stroke patients

ObjectiveSleep disordered breathing (SDB) is a prevalent yet underrecognized condition that may have major adverse consequences for those affected by it. We performed a prospective observational study to seek a correlation of severity of SDB with the severity of stroke and its functional outcome.MethodsPatients with history of recent-onset stroke were recruited and underwent overnight polysomnography (PSG) after the acute phase of the stroke was over; for defining hypopneas, 3% and 4% desaturation limits were used, and the apnea−hypopnea index was respectively calculated as AHI_3% and AHI_4%. Stroke severity was graded using the Scandinavian Stroke Scale. Functional disability and neurological impairment was evaluated six weeks after the PSG using the Barthel Index (<80 = functional dependence; ≥80 = functional independence) and modified Rankins Scale (>2 = poor outcome; ≤2 = good outcome).ResultsA total of 50 patients were enrolled, 30 (60%) with ischemic stroke and 20 (40%) with hemorrhagic strokes. Of the patients, 39 (78%) had an AHI_4% of >5/h, 23 (46%) had an AHI_4% of >15/h, and 9 (18%) had an AHI_4% of >30/h. Multivariate analysis showed that body mass index (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.04–1.54, p = 0.019) and Scandinavian Stroke Scale score (stroke severity) (OR = 0.86; 95% CI = 0.76–0.96, p = 0.009) were significant risk factors for predicting SDB (AHI_4% > 15) in patients of stroke. When we looked for factors predicting outcomes, only AHI_4% (OR = 1.20; 95% CI 1.01–1.43, p value 0.041) was predictive of the functional dependence (based on Barthel Index) of the patient and AHI_4% (OR = 1.14; 95% CI 1.03–1.25, p = 0.008) and body mass index (OR = 0.75; 95% CI 0.59–0.96, p = 0.024) were found to be predictive of poor outcome (based on modified Rankins Scale). We obtained similar results, regardless of the hypopnea definition used.ConclusionIn conclusion, given the high frequency of SDB in stroke patients and its correlation with poor outcome, screening for obstructive sleep apnea in all stroke and transient ischemic attack patients may be warranted.     

Carotid artery atherosclerosis and sleep disordered breathing in healthy elderly subjects: The Synapse cohort

BackgroundSleep-disordered breathing (SDB) has emerged as an independent risk factor for carotid atherosclerosis (CA) and cerebrovascular disease in middle-aged subjects. Currently, there is no study providing a causal relationship between SDB and cerebrovascular lesions in elderly.ObjectiveTo assess the impact of SDB on CA in a cohort of healthy elderly subjects.MethodsSeven hundred and fifty-five participants of a cross-sectional study on the association between SDB and cardiovascular morbidity, aged 68 yr at study entry, were examined. All subjects underwent carotid ultrasonography and risk factors for atherosclerosis including smoking, metabolic syndrome and hypertension were examined. An apnea + hypopnea index (AHI) > 15 was considered indicative of SDB.ResultsPresence of carotid lesion was found in 35% of the sample, predominantly in men and in overweight subjects. The most frequent alteration was arteriosclerosis present in 74% of cases, with stenosis >50% found in only 9% of subjects. No significant difference in the prevalence of carotid lesion was found between subjects with and without SDB, subjects with an AHI > 30, even though, having a slight increase in CA. At the logistic regression analysis, male gender (p < 0.001), systolic and diastolic blood pressure (p < 0.001), dyslipidemia (p = 0.003) and hypertension (p = 0.009) were the variables independently associated with carotid lesions even in severe cases.ConclusionThe incidence of CA in healthy elderly subjects is mediated more by gender, metabolic factors and hypertension than by presence of SDB. Further clinical studies including extensive evaluation of all atherosclerotic factors are needed to elucidate the predisposing role of SDB for cerebrovascular risk.     

Poststroke fatigue is associated with caudate infarcts

ObjectiveThe caudate nucleus may be involved in the pathogenesis of the fatigue observed in neurological disorders. However, the significance of caudate lesions in poststroke fatigue (PSF) is unknown. This study examined the association between caudate infarcts and PSF.MethodsFive hundred Chinese patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong participated in the study. All participants were assessed for PSF with the Fatigue Severity Scale (FSS) three months after their index stroke. PSF was defined as a mean FSS score of 4.0 or more. Physical functioning and depressive symptoms were measured by the Barthel Index (BI) and the Geriatric Depression Scale (GDS).ResultsOne hundred and twenty-five (25.0%) of the patients had PSF. Compared to the non-fatigue group, the PSF patients were more likely to be women and had hyperlipidemia, lower BI and higher GDS scores. Caudate (8.0% versus 1.3%, p = 0.001) and putamen (19.2% versus 12.0%, p = 0.043) acute infarcts were more common in the PSF group, whereas pons infarcts (13.6% versus 22.2%, p = 0.038) were less common. Acute caudate infarcts remained an independent predictor of PSF in the multivariate analysis, with an odds ratio of 6.4.ConclusionsThe results suggest that patients with PSF are more likely to have caudate infarcts.     

A cohort study of patients with anemia on admission and fatality after acute ischemic stroke

Reduced blood hemoglobin levels may impair oxygen delivery to the brain and hinder neurological improvement. We prospectively registered consecutively hospitalized Chinese patients with acute ischemic stroke within 24 hours of symptom onset to investigate whether anemia on admission influences case fatality and functional outcome of acute ischemic stroke at 12 months. Anemia was defined as a blood hemoglobin level of < 120 g/L for women, and < 130 g/L for men. We also performed a meta-analysis of the current cohort and previously published studies. We included 1176 patients, of whom 351 patients (29.8%) had anemia. Age (odds ratio [OR] = 1.02, 95% confidence interval [CI]: 1.01–1.03), history of hemorrhagic stroke (OR = 3.34, 95% CI: 1.17–9.56), alcohol consumption (OR = 0.59, 95% CI: 0.38–0.92), and estimated glomerular filtration rate < 60 mL/minute per 1.73 m² (OR = 1.34, 95% CI: 1.00–1.80) were the independent predictors of anemia. After adjustment for potential confounders, anemia on admission was shown to be an independent predictor of death at discharge and at 12 months (OR = 1.66, 95% CI, 1.08–2.56; OR = 1.56, 95% CI, 1.05–2.31). A meta-analysis of six included studies involving 3810 participants confirmed that anemia on admission was an independent predictor of death at the end of follow-up (OR = 1.67, 95% CI, 1.25–2.08). Further studies are required to confirm these findings.     

Risk of stroke in imaging-proven subclavian steal syndrome

To determine the risk of stroke in patients with subclavian steal syndrome (SSS). We identified 165 patients with imaging-proven SSS from two hospitals. Demographic, clinical and imaging data were retrospectively collected. Patients were followed up for stroke events. Stroke occurred in 43 patients with a median follow-up of 28 months. Seven of these cases were identified prospectively and 36 cases retrospectively. On multivariate analysis, presence of symptoms at presentation (p = 0.029) was a significant predictor of stroke. Presence of symptoms at presentation predicted stroke in imaging-proven SSS.     

Comparison of magnetic resonance angiography techniques to brain digital subtraction arteriography in the setting of mechanical thrombectomy: A non-inferiority study

IntroductionWe performed a non-inferiority study comparing magnetic resonance angiography (MRA) techniques including contrast-enhanced (CE) and time-of-flight (TOF) with brain digital subtraction arteriography (DSA) in localizing occlusion sites in acute ischemic stroke (AIS) with a prespecified inferiority margin taking into account thrombus migration.Materials and methodsHIBISCUS-STROKE (CoHort of Patients to Identify Biological and Imaging markerS of CardiovascUlar Outcomes in Stroke) includes large-vessel-occlusion (LVO) AIS treated with mechanical thrombectomy (MT) following brain magnetic resonance imaging (MRI) including both CE-MRA and TOF-MRA. Locations of arterial occlusions were assessed independently for both MRA techniques and compared to brain DSA findings. Number of patients needed was 48 patients to exclude a difference of more than 20%. Discrepancy factors were assessed using univariate general linear models analysis.ResultsThe study included 151 patients with a mean age of 67.6 ± 15.9 years. In all included patients, TOF-MRA and CE-MRA detected arterial occlusions, which were confirmed by brain DSA. For CE-MRA, 38 (25.17%) patients had discordant findings compared with brain DSA and 50 patients (33.11%) with TOF-MRA. The discordance factors were identical for both MRA techniques namely, tandem occlusions (OR = 1.29, P = 0.004 for CE-MRA and OR = 1.61, P < 0.001 for TOF-MRA), proximal internal carotid artery occlusions (OR = 1.30, P = 0.002 for CE-MRA and OR = 1.47, P < 0.001 for TOF-MRA) and time from MRI to MT (OR = 1.01, P = 0.01 for CE-MRA and OR = 1.01, P = 0.02 for TOF-MRA).ConclusionBoth MRA techniques are inferior to brain DSA in localizing arterial occlusions in LVO-AIS patients despite addressing the migratory nature of the thrombus.     

Prevalence and factors associated with snoring in 3-year olds: Early links with behavioral adjustment

ObjectiveIdentify the prevalence of sleep disordered breathing (SDB) symptoms in a community sample of New Zealand 3-year olds. To examine sleep, demographic, health, environmental, familial, perinatal, and behavioral adjustment factors associated with habitual snoring.MethodsA cross sectional study, in which parents of 823 children aged 3 years 0 months to 3 years 12 months (M:F = 1:0.9) were recruited from the community. Participants completed questionnaires designed to assess information relevant to their children’s sleep, with a particular focus on snoring.ResultsParents reported snoring at least once a week in 36.9% of children, and habitual snoring (more than four nights per week) in 11.3% of children. Univariate analysis showed habitual snoring was more common amongst Māori (indigenous New Zealanders) (P = 0.04) and males (P = 0.05), and that habitual snorers came from more socio-economically deprived neighborhoods (P < 0.01). Several other SDB-related symptoms were significantly associated with habitual snoring: mouth breathing, sweating profusely, waking during the night, sleeping with neck extended, constant runny nose, and suffering from tonsillitis. Mouth breathing was the most strongly associated. Multivariate analyzes revealed a strong positive relationship between snoring and some health and familial factors, as well as parent reported child irritability (OR = 2.83; 95% CI 1.4–5.6) and hyperactivity (OR = 1.6; 95% CI 1.0–2.7).ConclusionsThe prevalence of habitual snoring amongst New Zealand pre-schoolers is similar to that reported elsewhere. Factors associated with habitual snoring include male gender, Māori ethnicity, and poorer deprivation neighborhood, as well as a variety of other environmental and health factors. The data provide evidence that habitual snoring associated with irritable and hyperactive behavior is evident in children as young as three.     

El insomnio y la pobre calidad de sueño se asocian a un mal control de crisis en pacientes con epilepsia

ObjectivesThis study aimed to assess the presence of sleep disorders in patients with epilepsy and to analyse their association with seizure control.MethodsWe performed a cross-sectional study of patients with epilepsy, recruited consecutively between September 2017 and December 2018. Patients were classified as having good seizure control (no seizures in the last 4 weeks) or poor seizure control (at least one seizure in the last 4 weeks). We performed intergroup comparisons for demographic and clinical data, insomnia (Insomnia Severity Index [ISI]), excessive daytime sleepiness (Epworth Sleepiness Scale [ESS]), sleep quality (Pittsburgh Sleep Quality Index [PSQI]), depression (Beck Depression Inventory-II [BDI-II]), and quality of life (Quality of Life in Epilepsy Inventory-10 [QOLIE-10]).ResultsThe sample included a total of 123 patients, of whom 31.7% had excessive daytime sleepiness (ESS ≥ 10), 50.4% had insomnia (ISI ≥ 10), and 53.6% had poor sleep quality (PSQI ≥ 5). According to our multivariate analysis, presence of seizures was associated with unemployment (odds ratio [OR] = 4.7; 95% confidence interval [CI], 1.36-19.2; P = .02), a higher number of antiepileptic drugs (OR = 5.87; 95% CI, 1.81-27.1; P < .001), insomnia (OR = 1.9; 95% CI, 1.1-9.3; P = .04), and poor sleep quality (OR = 2.8; 95% CI, 1.9-10.32; P = .01).ConclusionsSleep disorders are common in patients with epilepsy. Insomnia and poor sleep quality were associated with poor seizure control. These findings support the hypothesis that sleep disorders constitute a significant comorbidity of epilepsy, especially in patients with poor seizure control.     

Risk factors associated with short sleep duration among Chinese school-aged children

ObjectivesTo examine risk factors regarding short sleep duration among Chinese school-aged children.MethodsA random sample of 20,778 children aged around 5–11 years participated in a cross-sectional survey, which was conducted in eight cities of China in 2005. A parent-administered questionnaire was used to collect information on children’s sleep duration and possible related factors from eight domains. Short sleep duration was defined as total sleep duration <9 h per day.ResultsIn all, 28.3% of the sampled children slept <9 h per day. The multivariate logistic regression identified, after adjusting for demographic and socioeconomic variables, factors associated with short sleep duration: more television viewing during weekdays (OR = 1.21, p = 0.004), more frequent computer/internet using (OR = 1.17, p = 0.006), earlier school starting time (OR = 1.10, p = 0.020), more time on homework during weekdays (OR = 1.66, p < 0.001) and weekends (OR = 1.14, p = 0.001), poor bedtime hygiene (e.g., having drinks with caffeine after 6:00PM [OR = 1.22, p < 0.001], doing exciting activities during bedtime [OR = 1.16, p < 0.001], and irregular bedtime [OR = 1.55, p < 0.001]), and shorter sleep duration of parents (mother: OR = 1.31, p < 0.001 for sleep duration <6 h and OR = 1.24, p = 0.006 for 6–8 h; father: OR = 1.52, p < 0.001 for <6 h and OR = 1.19, p < 0.001 for 6–8 h).ConclusionsFactors associated with sleep duration covered multidimensional domains among school-aged children. Compared to sleep environments and chronic health problems, school schedules, lifestyle patterns, and parents’ sleep habits had greater impact on children’s sleep duration, indicating the existing chronic sleep loss in school children could be, at least partly, intervened by reducing the use of visual technologies, by changing the school schedules, by improving the sleep hygiene routine, and by regulating parents’ sleep habits.     

Suicide attempt in first-episode psychosis: A 7.4 year follow-up study

BackgroundIndividuals with first-episode psychosis demonstrate high rates of suicide attempt (SA).Aims1) To examine the prevalence of, and risk factors for, SA in a first-episode psychosis (FEP) cohort over a 7.4 year follow-up period. 2) To investigate differences between single versus multiple suicide attempters.MethodsThis study reports baseline and follow-up data from a naturalistic, prospective follow-up of 413 FEP patients treated at a specialist early psychosis centre. Assessments were conducted at treatment entry, initial symptom remission or stabilization, and long term follow-up. Binary logistic regression models were used to assess unadjusted and adjusted associations between early illness and sociodemographic characteristics and two outcome measures: any SA during follow-up; and multiple SAs.ResultsFollow-up data were available for 282 participants. Sixty-one (21.6%) made a suicide attempt over the follow-up period, including 12 successful suicides. The following baseline risk factors increased the risk of any SA: history of self-harm (OR = 4.27; p < 0.001), suicidal tendencies (OR = 2.30; p = 0.022), being depressed for > 50% of the initial psychotic episode (OR = 2.49; p = 0.045), and hopelessness (OR = 2.03; p = 0.030). History of problem alcohol use increased the risk of multiple SAs (OR = 4.43; 95% CI (1.05–18.7); p = 0.043).DiscussionThe prevalence of suicide attempt in this study exceeds reports from short-term FEP studies but is comparable to longer term follow-up studies, indicating that risk remains elevated for at least 7 years following commencement of treatment. The key predictor of future suicide attempt was previous self-harm, indicating that interventions for self-harm are required.     

Endoscopic endonasal approach to pituitary adenomas: Impact on adenohypophyseal function. Study of 231 cases

PurposeTo identify presurgical and surgical factors associated with the development of hypopituitarism and its recovery after endoscopic endonasal transsphenoidal (EET) resection of pituitary adenomas (PAs).MethodsRetrospective study of patients with PAs operated by the same neurosurgeon through an EET approach in two Spanish tertiary hospitals in ten years.Results242 pituitary surgeries performed in 231 patients were analyzed. In the 154 surgeries performed in 146 patients with non-functioning PAs (NFPAs), 46.8% (n = 72) presented presurgical hypopituitarism. After PAs resection, 41 of these (56.9%) normalized pituitary function and 11 of 82 patients with preoperative normal function (13.4%) developed new pituitary deficits. Patients with preoperative visual impairment (OR = 3.9, p = 0.046) and operated in the first four years of the neurosurgeon's learning curve (OR = 5.7, p = 0.016) presented a higher risk of developing postoperative hypopituitarism.Of the 88 surgeries in 85 patients with functioning PAs (FPAs), 23.9% presented presurgical hypopituitarism, and 47.6% of those recovered after surgery. 9% of the cases with preoperative normal function developed new pituitary deficit/s. Diabetic patients presented a higher risk of persistence of hypopituitarism (OR = 10.5, p = 0.024). Patients with presurgical visual impairment (OR = 30.0, p = 0.010) and PAs >3 cm (OR = 14.0, p = 0.027) had higher risk of developing new pituitary deficits.ConclusionApproximately 50% of patients with PAs and preoperative hypopituitarism recover pituitary function after EET surgery. 10% of patients with normal function develop new deficits. Patients with NFPAs with visual involvement and operated in the first four years of neurosurgeon's learning curve, and FPAs patients with presurgical visual impairment and tumor size >3 cm have a higher risk of postoperative hypopituitarism.     

Sudden unexpected death in epilepsy: Knowledge and experience among U.S. and Canadian neurologists

ImportanceSudden unexpected death in epilepsy (SUDEP) is a common cause of mortality in patients with the disease, but it is unknown how neurologists disclose this risk when counseling patients.ObjectiveThis study aimed at examining SUDEP discussion practices of neurologists in the U.S. and Canada.DesignAn electronic, web-based survey was sent to 17,558 neurologists in the U.S. and Canada. Survey questions included frequency of SUDEP discussion, reasons for discussing/not discussing SUDEP, timing of SUDEP discussions, and perceived patient reactions. We examined factors that influence the frequency of SUDEP discussion and perceived patient response using multivariate logistic regression.ParticipantsThe participants of this study were neurologists who completed postgraduate training and devoted > 5% of their time to patient care.ResultsThere was a response rate of 9.3%; 1200 respondents met eligibility criteria and completed surveys. Only 6.8% of the respondents discussed SUDEP with nearly all (> 90% of the time) of their patients with epilepsy/caregivers, while 11.6% never discussed it. Factors that independently predicted whether SUDEP was discussed nearly all of the time were the following: number of patients with epilepsy seen annually (OR = 2.01, 95% CI = 1.20–3.37, p < 0.01) and if the respondent had a SUDEP case in the past 24 months (OR = 2.27, 95% CI = 1.37–3.66, p < 0.01). A majority of respondents (59.5%) reported that negative reactions were the most common response to a discussion of SUDEP. Having additional epilepsy/neurophysiology training was associated with an increased risk of a perceived negative response (OR = 1.36, 95% CI = 1.02–1.82, p = 0.038), while years in practice (OR = 0.85, 95% CI = 0.77–0.95, p < 0.005) and seeing both adults and children were associated with a decreased likelihood of negative response (OR = 0.15, 95% CI = 0.032–0.74, p = 0.02).ConclusionsU.S. and Canadian neurologists rarely discuss SUDEP with all patients with epilepsy/caregivers though discussions are more likely among neurologists who frequently see patients with epilepsy or had a recent SUDEP in their practice. Perceived negative reactions to SUDEP discussions are common but not universal; more experienced neurologists may be less likely to encounter negative reactions, suggesting that there may be ways to frame the discussion that minimizes patient/caregiver distress.     

Reciprocal interactions of obstructive sleep apnea and hypertension associated with ACE I/D polymorphism in males

BackgroundThe angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism gene contributes to the genesis of hypertension (HTN) and may help explain the relationship between obstructive sleep apnea (OSA) and HTN. However, ACE is a pleiotropic gene that has several influences, including skeletal muscle and control of ventilation. We therefore tested the hypothesis that ACE polymorphism influences OSA severity.MethodsMale OSA patients (apnea-hypopnea index [AHI] > 5 events/h) from 2 university sleep centers were evaluated by polysomnography and ACE I/D polymorphism genotyping.ResultsWe studied 266 males with OSA (age = 48 ± 13y, body mass index = 29 ± 5kg/m², AHI = 34 ± 25events/h). HTN was present in 114 patients (43%) who were older (p < 0.01), heavier (p < 0.05) and had more severe OSA (p < 0.01). The I allele was associated with HTN in patients with mild to moderate OSA (p < 0.01), but not in those with severe OSA. ACE I/D polymorphism was not associated with apnea severity among normotensive patients. In contrast, the only variables independently associated with OSA severity among patients with hypertension in multivariate analysis were BMI (OR = 1.12) and II genotype (OR = 0.27).ConclusionsOur results indicate reciprocal interactions between OSA and HTN with ACE I/D polymorphism, suggesting that among hypertensive OSA males, the homozygous ACE I allele protects from severe OSA.