Efecto a largo plazo de la presión positiva automática en la vía aérea sobre la proteína C reactiva y la interleucina-6 en varones con síndrome de apnea obstructiva del sueño

Background and objectives

Obstructive sleep apnoea (OSA) has been increasingly linked to cardiovascular disease. Inflammatory processes associated with OSA may contribute to this morbidity. Some studies have reported serum levels of high sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6) to be increased in these patients. Primary objective: investigate the impact of short and long-term autoadjusting positive airway pressure (APAP) therapy on IL-6 and hs-CRP serum levels in patients with moderate to severe obstructive sleep apnoea. Secundary Objective: evaluate the basal hs-CRP and IL-6 levels in OSA patients and its possible relation to OSA severity, independently of confounders and compare the hs-CRP levels in OSA patients with those in community controls.

Patients and methods

This is a prospective study including 98 male patients with moderate to severe OSA confirmed by domiciliary sleep study. Malignancy and chronic inflammatory diseases were exclusion criteria. hs-CRP and IL-6 serum levels were evaluated before APAP, 9 days and 6 months after therapy. Community controls (n=103) were selected using random digit dialling, and matched by age and body mass index (BMI) for comparison of hs-CRP levels at baseline.

Results

The studied population had a mean age of 55.3±10.7 years, mean BMI 33.2±5.0 kg/m², mean apnoea-hypopnoea index 51.7±21.3/h and mean desaturation index 86.3±5.3/h. The APAP compliance was good: 91.27%±20.45 days usage and 5.76±1.59 h/night of usage.Mean basal hs-CRP and IL-6 serum values were 0.52±0.53 μg/l and 17.7±22.5 μg/l, respectively. CRP levels at baseline correlated significantly with apnoea-hypopnoea index, desaturation index and minimum nocturnal oxygen saturation. IL-6 levels at baseline correlated significantly and negatively with minimum nocturnal oxygen saturation. When adjusting for confounding factors found in this study, all these relations lost significance.CRP is significantly increased in patients when compared to controls (p=0.002) and when considering hs-CRP cardiovascular risk stratified categories, cases had significantly more patients at high risk of cardiovascular events than controls (p=0.002).After adjustment for BMI and arterial hypertension, cases had an almost twofold moderate risk of cardiovascular events and more than a twofold severe risk of cardiovascular events when compared to controls.We found no significant difference between hs-CRP and IL-6 concentrations pre-treatment and in two moments post-treatment (9 days and 6 months) (CRP: p=0.720 and p=0.387, respectively; IL-6: p=0.266 and p=0.238, respectively).

Conclusions

OSA is associated with a low-grade inflammatory process; hs-CRP serum levels are elevated in OSA patients when comparing to community controls, independently of age and BMI and the former have a significantly higher risk of cardiovascular events when compared to the latter. There was no significant decrease of both inflamatory mediators (hs-CRP, IL-6) after short and long-term APAP therapy.     

Variabilidad de la señal de frecuencia de pulso obtenida mediante pulsioximetría nocturna en pacientes con síndrome de apnea hipopnea del sueño

Introduction

The measurement of central tendency (MCT) is a non-linear analysis technique which applied to second order differences diagrams enables the degree of variability to be quantified in a data series. In the present study an attempt is made to quantify and characterise the changes in heart rate obtained by pulse oximetry in patients with a clinical suspicion of sleep apnoea/hypoapnoea syndrome (SAHS) using the MCT and to evaluate its diagnostic use.

Patients and Methods

A total of 187 patients were included in the study, on whom a nocturnal polysomnographic and pulse oximetry study was performed. To evaluate the variability of the heart rate the MCT applied to graphs of second order differences obtained from the heart rate record.

Result

Patients with SAHS had a higher heart rate variablity than patients without SAHS (0.449 vs. 0.666, P<0.001. In the multivariate analysis, the heart rate, the minimum saturation and the desaturation index of 4% were independently associated with the heart rate variability. As a diagnostic method, the MCT of the heart rate gives a sensitivity of 69.3%, a specificity of 77.6% and a diagnostic precision of 72.7%

Conclusions

Patients with SAHS have a greater variabilityin heart rate during the night, evaluated by applying the MCT of the heart rate to diagrams of second order differences. As a screening method, the MCT applied to the heart rate has a moderate sensitivity and specificity.     

Características clínicas y polisomnográficas del síndrome de apneas durante el sueño localizado en la fase REM

Objective

The aim of this study was to analyze the clinical and polysomnographic features of rapid eye movement (REM)–specific sleep disordered-breathing (SDB).

Patients and methods

All cases of sleep apnea-hypopnea syndrome (SAHS) (apnea-hypopnea index [AHI]?>10/h) diagnosed using overnight polysomnography during the period 2004 to 2006 were analyzed retrospectively. Those cases in which the ratio of AHI during REM sleep to AHI during non-REM sleep was more than 2 were classified as REM-specific SDB. We recorded the following data: clinical signs and symptoms related to SAHS, PSG results, cardiovascular risk factors, and previous cardiovascular events. Logistic regression analysis was used to identify predictors of REM-specific SDB and to analyze the possible interactions between variables.

Results

A total of 419 patients were analyzed, of whom 138 (32.9%) presented REM-specific SDB. This condition was more common in patients with mild to moderate SAHS than in those with more severe cases (odds ratio, 8.21; 95% confidence interval, 4.83–14.03). The variables independently associated with REM-specific SDB in the logistic regression analysis were female sex, lower AHI, and higher body mass index. No interactions between the main variables studied were found. There were no differences between patients with REM-specific SDB and those with non-REM-specific SDB with regard to signs and symptoms related to SAHS, excessive daytime sleepiness, sleep architecture, cardiovascular risk factors, or history of cardiovascular episodes.

Conclusions

REM-specific SDB could be considered an initial stage of SAHS that mainly affects obese women with mild to moderate sleep disorders, and that does not differ from non-REM-specific SDB in terms of clinical presentation, sleep architecture, or cardiovascular comorbidity.     

Variación de la expresión proteica en función de la gravedad del síndrome de apnea-hipopnea del sueño

Objective

A prospective study with a consecutive sample and a control group to determine whether protein expression in patients with sleep apnoea-hypopnoea syndrome (SAHS) is different from that of the control group (IAH ≤5).

Patients and methods

A total of 32 patients aged between 35 and 60 years who had a polysomnograph performed were included. Patients with an acute or chronic were excluded. The first dimension of the proteomic study was carried out on IPG strips (18 cm, pH 4–7) and the second on SDS-PAGE gels in triplicate for each group. The gels were stained with SYPRO-Ruby (Bio-Rad^®), the images obtained with an FX-Imager laser scanner and the spots were analysed using ProteomWeaver v. 4.0 (Bio-Rad^®) software. Significant changes between the gels were analysed by replicates and separately, being considered a significant change if the relative intensity of the spots was three times higher or lower than that of the control and if it was observed in 2 of the 3 replicates of each group, with a coefficient of variation of <20%.

Results

The patients were divided into 8 subjects per group (control, mild, moderate and severe). The comparison of the gels showed significant differences between the control group and the 3 clinical groups, with significant over-expression being observed in 3 spots, and under-expression in 7 spots in the control group.

Conclusion

There are significant changes in protein expression between a control group and patients in different stages of disease. The proteomic study can identify biomarkers associated with the diagnosis and severity of the SAHS.     

Insuficiencia respiratoria hipercápnica aguda en pacientes con apneas del sueño

Introduction

Acute hypercapnic respiratory failure (AHRF) is a serious condition observed in some patients with sleep apnea-hypopnea syndrome (SAHS). The objective of the present study was to study the clinical characteristics of SAHS patients who develop AHRF and their prognosis.

Patients and method

A total of 70 consecutive SAHS patients who survived an AHRF episode and 70 SAHS patients paired by age with no previous history of AHRF were prospectively studied and followed up for 3 years.

Results

The deterioration of lung function due to obesity or concomitant chronic obstructive pulmonary diseases (COPD) was common in SAHS patients with AHRF. In the multivariate analysis, the risk factors associated with AHRF were baseline PaO_2, the theoretical percentage value of the forced vital capacity, alcohol consumption, and benzodiazepines. The mortality during follow up was higher among patients who had AHRF than in the control group. The main cause of death was respiratory, and the coexistence of COPD was identified as a mortality risk factor.

Conclusions

The development of AHRF in SAHS patients is associated with a deterioration in lung function and with alcohol and benzodiazepine consumption. The patients had a higher mortality after the AHRF episode, mainly a respiratory cause. New studies are required that evaluate the different available therapeutic options in these patients.     

Síndrome de apnea-hipopnea del sueño en pacientes normopeso: características y comparación con pacientes con sobrepeso y obesidad

Objective

To determine the frequency of obstructive sleep apnoea (OSA) and metabolic syndrome (MS) in normal weight patients and their characteristics, and to compare these with overweight and obese patients.

Methods

We studied all patients with suspected OSA referred to the sleep laboratory from January to December 2009. OSA was diagnosed when the apnoea-hypopnoea index (AHI) was > 5 and symptoms were present. MS was diagnosed according to International Diabetes Federation (IDF) criteria. The patients were distributed into 3 groups according to body mass index (BMI): normal weight (< 25 kg/m²), overweight (25-29.9 kg/m²) and obese (≥ 30 kg/m²).

Results

We studied 475 patients: 7.60% normal weight and 56.4% obese. Most patients in the normal weight group were women, snorers, non-smokers, non-drinkers and were significantly younger and with a smaller neck and waist circumference than obese and overweight patients. OSA was diagnosed in 90.10%: 77.70% normal weight. OSA in these patients was mostly mild, and there were differences between the diagnosis of OSA and the BMI classified. MS was diagnosed in 64.40%: 33.33% normal weight. There was a higher probability of MS as the BMI increased. OSA and MS frequency in normal weight patients was 22% and in obese patients was 70.52%. OSA in normal weight patients was related with gender and age. There was no relationship between OSA and MS, or between otorhinolaryngological malformations and OSA in normal weight patients. Eight normal weight patients with OSA were treated with continuous positive airway pressure (CPAP) therapy.

Conclusions

The frequency of OSA in normal weight patients was lower than in overweight and obese patients. The frequency of concomitant OSA and MS was lower in normal weight patients than in obese subjects. Normal weight patients were mostly women, younger and had no toxic habits. In normal weight patients, age and gender were predictive factors for OSA, but OSA and MS were not related.     

Síndrome de apneas-hipopneas durante el sueño sin somnolencia

Nowadays, sleepiness in patients with sleep apnea-hypopnea syndrome (SAHS) is understandable. It is somewhat more difficult to explain why most patients with SAHS enrolled in epidemiologic studies, even those with a high apnea-hypopnea index, do not experience excessive daytime sleepiness. The reasons for this discrepancy lie beyond mere polysomnographic events.     

Efecto de la presión positiva continua en las vías aéreas y de la cirugía de las vías aéreas superiores sobre los biomarcadores en condensado de aire exhalado y en suero en pacientes con apnea del sueño

Introduction

Studies on inflammation biomarkers in serum and in exhaled breath condensate (EBC) in obstructive sleep apnea (OSA) have shown conflicting results. The objective of this study is to assess EBC and serum biomarkers in OSA patients at baseline and after continuous positive airway pressure (CPAP) or upper airway surgery (UAS).

Patients and methods

Nine OSA patients referred for UAS were matched for anthropometric characteristics and apnea-hypopnea index with 20 patients receiving CPAP. pH, nitrite (NO₂⁻), nitrate and interleukin 6 in EBC and NO₂⁻, nitrate, leukotriene B₄ and interleukin 6 in serum were determined. EBC and serum samples were collected at baseline and 3 months after CPAP or UAS.

Results

Patients’ mean body mass index was 30 (range 24.9-40) kg/m². EBC biomarker levels at baseline were within normal range and did not differ significantly after CPAP or UAS. No significant changes were observed in the serum concentration of the biomarkers determined after CPAP but the serum concentration of NO₂⁻ increased significantly at 3 months after UAS (P = .0078).

Conclusion

In mildly obese OSA patients, EBC biomarkers of inflammation or oxidative stress were normal at baseline and remained unchanged 3 months after UAS or CPAP. Although UAS was not effective in terms of reducing OSA severity, it was associated with an increase in serum NO₂⁻.     

El síndrome de apneas-hipopneas durante el sueño en edades avanzadas

The population pyramid is changing due to the increasing longevity of the population, making it a priority to have better knowledge of those diseases that have an increasingly major impact in advanced age. Sleep apnea-hypopnea syndrome (SAHS) affects 15–20% of individuals over 65 years. However, despite this high prevalence and that one in four sleep studies are conducted on the elderly in this country and that more 60% of these were treated with CPAP, there are few specific studies in this age group on the diagnosis and management of this syndrome. The physiological increase of the number of sleep respiratory disorders with the passing of time may be the biggest obstacle when defining, diagnosing and treating SAHS in the elderly. In any case and while more solid scientific evidence is obtained, the National SAHS Consensus, as well as the Guidelines on the diagnosis and treatment of SAHS, recommend that, within logical limits, age itself should not be an obstacle to offering the elderly diagnostic help and treatment similar to that offered to the rest of the population.     

Consistencia interna y validez de la versión española del cuestionario de calidad de vida específico para el síndrome de apnea del sueño: Sleep Apnoea Quality of Life Index

Introduction

The objective of the present study was to validate the Spanish version of the SAQLI, which is a health-related quality of life (HRQL) questionnaire specific for sleep apnea-hypopnea syndrome (SAHS), and to assess its sensitivity to change.

Material and methods

A multicenter study performed in a group of patients with SAHS (apnea-hypopnea index [AHI] ≥5) who had been referred to the centers’ Sleep Units. All patients completed the following questionnaires: SF-36, FOSQ, SAQLI and Epworth scale. The psychometric properties (internal consistency, construct validity, concurrent validity, predictive value, repeatability and responsiveness to change) of the SAQLI were assessed (four domains: daily function, social interactions, emotional function and symptoms; an optional fifth domain is treatment-related symptoms).

Results

One hundred sixty-two patients were included for study (mean age: 58 ± 12; Epworth: 10 ± 4; BMI: 33 ± 5.9 kg m⁻²; AHI: 37 ± 15 hour⁻¹). The factorial analysis showed a construct of four factors with similar distribution to the original questionnaire domains. Internal consistency (Cronbach's alpha between 0.78 and 0.82 for the different domains), concurrent validity for SF-36, Epworth scale and FOSQ, and test-retest reliability were appropriate. The predictive validity of the questionnaire showed no significant correlations with the severity of SAHS. SAQLI showed good sensitivity to change in all the domains of the questionnaire (p < 0,01).

Conclusions

The Spanish version of the SAQLI is a valid HRQL measurement with appropriate psychometric properties for use in patients with SAHS and it is sensitive to change.     

Efecto del tratamiento optimizado con insulina en la reactividad plaquetaria tras el alta de pacientes hiperglucémicos con síndrome coronario agudo

Introduction and objectives

Intensive glucose control with insulin in patients with an acute coronary syndrome reduces platelet reactivity during hospitalization, compared to conventional control. However, the effect of strict, long-term glucose control on platelet reactivity in these patients remains uncertain.

Methods

This is a prospective, randomized trial evaluating the effects of optimized glucose control (target glucose, 80-120 mg/dL) with insulin, compared with conventional control (target glucose, <180 mg/dL), on platelet reactivity after hospital discharge in patients with an acute coronary syndrome and hyperglycemia. The primary endpoint was assessment of platelet aggregation after stimulation with adenosine diphosphate 20 μM at 12-month follow-up.

Results

One hundred four patients were randomized to optimized management (n=53) or conventional management (n=51). There were no differences between groups in baseline characteristics or platelet function. After 12 months of follow-up, blood glucose levels were significantly lower in the optimized treatment group (104 vs 119 mg/dL; P<.001). However, platelet aggregation following adenosine diphosphate 20 μM stimulation showed no differences between the groups (54.2% [14.3%] vs 55.1% [18.3%] respectively; P=.81). There were no significant differences for other platelet function tests.

Conclusions

Long-term optimized glucose control with insulin in patients with an acute coronary syndrome did not result in a reduction in platelet reactivity compared to conventional control.Full English text available from:www.revespcardiol.org/en     

Importancia de la dieta en el síndrome del intestino irritable

About two-thirds of irritable bowel syndrome (IBS) patients associate their symptoms with certain foods. We reviewed food-related factors putatively associated with manifestations of IBS. Soluble fiber may improve constipation but frequently increases bloating and abdominal pain. Carbohydrate malabsorption seems to be more frequent in IBS. A low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet significantly reduces IBS symptoms and has been suggested as a therapeutic option. Serological screening for celiac disease should be done in patients without constipation. Moreover, non-celiac disease gluten sensitivity, defined as gluten intolerance once celiac disease and wheat allergy have been ruled out, should be considered in these patients. There is no specific diet for IBS patients but small and frequent meals, avoiding greasy foods, dairy products, many carbohydrates, caffeine and alcohol, is recommended.     

Utilidad de la detección del virus del papiloma humano en el cribado de neoplasia intraepitelial anal en pacientes con conductas de riesgo

Introduction

The incidence of intraepithelial anal neoplasia is increasing in certain risk behaviour groups, and human papillomavirus (HPV) infection is involved in its pathogenesis. The systematic use of anal cytology, and more recently HPV detection by hybrid capture and genotyping, have been introduced into screening programs in recent decades.

Material and methods

A retrospective cohort study was carried out on individuals with risk behaviours of developing intraepithelial anal neoplasia and who attended Sexually Transmitted Infections clinics in the Dermatology area of the Hospital Costa del Sol from January 2010 to December 2012. The intraepithelial anal neoplasia screening was performed using anal cytology and HPV genotyping.

Results

Half (50%) of the study population were HIV positive. A high frequency of anal dysplasia and presence of HPV in cytology (82.1%) and genotype (79%) was found. A statistically significant association (P < .005) was obtained between the presence of high-risk HPV genotypes and the presence of high-grade dysplasia in the second directed cytology. HPV genotyping enabled 17 cases (22%) of severe dysplasia to be identified that were under-diagnosed in the first cytology.

Conclusion

Cases of high-grade dysplasia can be under-diagnosed by a first anal cytology. Detection of HPV can supplement this procedure, leading to the identification of those patients most at risk of developing high-grade anal dysplasia.     

Recomendaciones para el diagnóstico,seguimiento y tratamiento de la embarazada y del niño con enfermedad de Chagas

Congenital transmission of Chagas disease now occurs in areas where the disease is non-endemic, and also from one generation to another. According to epidemiological data from Latin America, the prevalence of the disease in pregnant women is 0.7%-54%, and the prevalence of vertical transmission is around 5%-6%. Congenital T. cruzi infection is an acute infection in newborns that should be treated with anti-parasitic therapy. The treatment of pregnant women could also have an impact on the control of the disease. This article has been prepared following the recommendations suggested by a group of experts in Infectious Diseases, Microbiology, Gynaecology and Paediatrics.     

Patrón de inicio del seguimiento clínico en los pacientes con infección por el virus de la inmunodeficiencia humana en España

Objetive

To describe linkage to care among new HIV diagnoses in Spain; and to estimate factors associated to linkage to care within three months after diagnosis.

Methods

The distribution of the time elapsing between the date of HIV diagnosis and the date of first determination of CD4 (considered to be the date of linkage to care) was calculated among new HIV diagnoses in 2010 in the seven Autonomous Regions participating, where data on date of CD4 count was available. Linkage to care was considered «correct» if done within three months after diagnosis. Factors associated to correct linkage to care were estimated using logistic regression.

Results

A total of 1769 new HIV diagnoses were included. Of them, 83.1% had evidence of linkage to care within a year, and 75.7% were linked within three months after diagnosis. Being an injectable drug user (IDU) was the only factor inversely associated with linkage to care within 3 months (OR = 0.3; 95% CI: 0.2-0.6).

Conclusion

In Spain linkage to care after HIV diagnosis is good, but there is still room for improvement, especially among IDUs.