Obstructive Sleep Apnea and Optic Neuropathy: Is There a Link?

Over the last decade, there has been an emerging interest in the link between obstructive sleep apnea (OSA) and ocular health. Though the evidence for OSA playing a role in cerebrovascular disease risk seems clear, the same cannot be said for optic neuropathies. The association between OSA and glaucoma or non-arteritic anterior ischemic optic neuropathy (NAION) has been postulated to be secondary to direct hypoxia or mechanisms of optic nerve head vascular dysregulation. Papilledema and increased intracranial pressure have also been reported in OSA and are thought to be due to increased cerebral perfusion pressure and cerebral venous dilation secondary to hypoxia and hypercapnia. This article reviews the evidence for possible pathophysiological links between OSA and optic nerve pathology. The epidemiologic and clinical evidence for an association, direct or indirect, between OSA and glaucoma, non-arteritic anterior ischemic optic neuropathy (NAION), and papilledema or idiopathic intracranial hypertension is presented.     

Recurrent Ischemic Stroke – A Systematic Review and Meta-Analysis

ObjectivesRecurrent stroke remains a challenge though secondary prevention is initiated immediately post-stroke. Stroke subtype may determine the risk of recurrent stroke and require specific preventive measures. We aimed to identify subtype-specific stroke recurrence and associated risk factors over time.Methods and materialsA systematic review was performed using PubMed and Embase for studies including adults >18 years, first-ever ischemic stroke in population-based observational studies or registries, documented TOAST-criteria and minimum 1-year follow-up. Meta-analysis on stroke recurrence rate was performed. Final search: November 2019.ResultsThe search retrieved 26 studies (between 1997 and 2019). Stroke recurrence rate ranged from 5.7% to 51.3%. Recurrent stroke was most frequent in large artery atherosclerosis (LAA) and cardioembolic (CE) stroke with recurrent stroke similar to index stroke subtype. We identified a lower recurrence rate for small vessel occlusion (SVO) stroke with recurrence frequently of another stroke subtype. Based on a meta-analysis the summary proportion recurrence rate of recurrent stroke in studies using TOAST-criteria = 0.12 and = 0.14 in studies using TOAST-like criteria. Hypertension, diabetes mellitus, atrial fibrillation previous transient ischemic attack, and high stroke severity were independent risk factors for recurrence.ConclusionStroke recurrence rates seem unchanged over time despite the use of secondary prevention. The highest recurrence rate is in LAA and CE stroke eliciting same subtype recurrent stroke. A lower recurrence rate is seen with SVO stroke with a more diverse recurrence pattern. Extensive workup is important in all stroke subtypes - including SVO stroke. Future research needs to identify better preventive treatment and improve compliance to risk factor prevention to reduce stroke recurrence.     

The HOPES Registry – Houston Methodist Hospital Outcomes-based Prospective Endpoints in Stroke

Background

We present a single institution registry with the novel feature of 90-day outcome assessments on all hospitalized acute stroke patients, inclusive of every patient with a primary discharge diagnosis of transient ischemic attack (TIA), acute ischemic stroke (AIS), nontraumatic subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH).

Development of the Usability of Sleep Apnea Equipment – Positive Airway Pressure (USE-PAP) questionnaire

BackgroundA growing number of positive airway pressure (PAP) device users will develop physical/sensory impairments such as arthritis. For these individuals, the usability of their PAP devices (eg, efficiency and satisfaction) may impact the frequency and safety of device usage. Questionnaires to assess PAP usability are unavailable; therefore, we developed the Usability of Sleep Apnea Equipment – Positive Airway Pressure (USE-PAP) questionnaire.MethodsQuestionnaire development included in-depth interviews to identify relevant content areas, a technical advisory panel to review/edit items, cognitive interviews to refine items, and a cross-sectional survey of Veterans Affairs sleep clinic patients assessing PAP device usability overall (one multi-item scale), usability of PAP components (multi-item scales for machine controls, mask/headgear, tubing, and humidifier), frequency of usability-related issues (one multi-item scale), PAP device characteristics, and demographics.ResultsAfter conducting 19 in-depth interviews, a panel meeting, and 10 cognitive interviews, we administered the survey to 100 PAP device users (67% ≥60 years; 90% male). The items assessing machine control usability received the least favorable ratings. Twenty percent of respondents reported difficulty getting equipment ready for use, and 33 percent had difficulty cleaning equipment. The six multi-item scales had excellent internal consistency reliability (alpha ≥0.84) and item–rest correlations (≥0.39).ConclusionsThis study provides initial support for the USE-PAP for measuring PAP device usability. Studies that include large samples are needed to further evaluate the psychometric properties of the USE-PAP. In addition, comparisons of USE-PAP responses with direct observations of PAP-related tasks and objectively measured PAP adherence are needed to fully evaluate the questionnaire.     

Association of Early Oxygenation Levels with Mortality in Acute Ischemic Stroke – A Retrospective Cohort Study

BackgroundIschemic stroke is an emergency with elevated risk for morbidity and mortality. Hypoxia is harmful in acute ischemic stroke. Recent evidence raises concerns regarding hyperoxia as well in acute illness, and for supplemental oxygen therapy when SpO₂greater than 92%. Current AHA/ASA guidelines recommend maintaining SpO₂greater than 94%. In this study, we aimed to assess the relationship between the oxygenation levels within the first 6-hour of ischemic stroke admission and mortality.MethodsWith the approval of the Human Studies Committee (IRB #: 13.0396), we performed a retrospective cohort study of ischemic stroke patients consecutively admitted to our hospital in the years 2013-14 and 2017-18 (n = 1479). Relationship between the first 6 hours oxygenation status and in-house mortality was assessed. SpO₂/FiO₂ ratio was used as the oxygenation outcome parameter. Patients who were intubated at admission were excluded. Additionally, demographics, baseline confounding factors, neurological status, and laboratory values on admission were examined for their association with mortality in a multivariate logistic regression analysis.ResultsMean age of patients was 64 ± 15 years. Time interval from last seen normal to hospital admission was 7 ± 5 hours (mean ± standard deviation). NIHSS on arrival was 41, 2, 3, 4, 5, 6, 7, 8, 9 (median-IQR). Fourteen percent of patients received IV alteplase and 6% were treated with mechanical thrombectomy. Baseline SpO₂ was 97 ± 2%, and 47% of the patients required supplemental oxygen treatment per AHA/ASA guidelines. In hospital mortality rate of this cohort was 5.7%. Lower mean SpO₂ /FiO₂ levels were strongly correlated with increasing mortality rates (R² = .973). Age (1.048 [1.028-1.068]), NIHSS (1.120 [1.088-1.154]), WBC (1.116 [1.061-1.175]) and Mean SpO₂/FiO₂ (.995 [.992-.999]) independently risk associated with mortality.ConclusionsBaseline oxygenation varies within the acute ischemic stroke patient population. In this retrospective cohort study, we are reporting a strong association between lower SpO₂/FiO₂ levels in the first few hours of admission and mortality. In the light of these results, we plan to prospectively assess the role of oxygenation further in the context of recanalization status of stroke.     

A Case–Control Study of Stroke Risk Factors and Outcomes in African American Stroke Patients With and Without Crack–Cocaine Abuse

Background  

Stroke in crack–cocaine abusers is increasingly recognized. We aimed to identify significant differences in stroke risk factors, characteristics, and outcomes between hospitalized stroke patients with and without crack–cocaine abuse.     

MMSE Changes During and After ECT in Late-Life Depression: A Prospective Study

ObjectiveThere is ongoing concern about the impact of electroconvulsive therapy (ECT) on cognition in patients with late-life depression (LLD), especially in patients for whom pretreatment Mini-Mental State Exam (MMSE) scores are low. Our aim was to examine the evolution of cognitive effects of ECT, using the MMSE in a large group of patients with LLD.MethodsOne hundred nine patients aged 55 years and older with unipolar depression, referred for ECT, were included in our study. The MMSE was assessed before, during, immediately after, and 6 months after ECT.ResultsMMSE scores improved significantly during the course of ECT and remained stable during the 6-month period after ending ECT for the total group. In the group of patients with a low MMSE score (<24) at baseline, the MMSE score improved significantly during ECT, whereas in the group of patients with a normal MMSE score (≥24) at baseline, the score did not change significantly during ECT. In both groups, MMSE scores still increased slightly after ECT was discontinued.ConclusionECT does not cause deleterious cognitive effects, as measured with the MMSE, during and for 6 months after the ECT course in patients with LLD. In the event of a baseline cognitive impairment, MMSE scores tend to improve significantly during and for 6 months after the ECT course. The presence of pretreatment cognitive impairment should not lead clinicians to withhold ECT in older patients with severe depression.     

Mastering Health Following Minor Stroke—A Qualitative Explorative Study

BackgroundPatients with minor stroke or transient ischemic attack are encouraged to adopt a healthy lifestyle to prevent recurrent stroke. After discharge health behaviour is performed in an individual everyday context and must be properly understood within this context, including which aspects act as facilitators or barriers for healthy behaviour.ObjectivesTo explore the experience of daily life in patients discharged home after minor stroke or transient ischemic attack, focusing on perceived health and reflection on health behaviour, and how this is associated with their overall experience of returning to their everyday context in relation to potential sequelae of stroke.MethodsSemi-structured qualitative interviews were conducted 3 - 13 months after discharge with sixteen patients discharged home after minor stroke or transient ischemic attack. Inductive thematic analysis was performed to analyse the interviews.ResultsParticipants associated their health and behaviour within a lens of worrying for future life prospect and triggered by perceived intrusive changes in their life condition. Even though some found it possible to resume participation in everyday life within weeks, they became increasingly aware that minor cognitive deficits, difficulties with planning, multi-tasking, memory, and fatigue influenced their health believes and behavioural patterns. The need for social and professional support had to be balanced against a wish for independence.ConclusionPatients with minor stroke or transient ischemic attacks experience changes as both being concrete in the form of persisting symptoms and abstract in the form of worries and uncertainty about the future. Perceived health was associated with a new sense of vulnerability due to realisations about the risk of recurrent stroke. Worries were anchored within the individual to handle, but for some they serve as a motivator to regulate their behaviour in order to master health.     

Location and Restoration of Function after Cerebellar Tumor Removal—A Longitudinal Study of Children and Adolescents

Sequelae in children following cerebellar tumor removal surgery are well defined, and predictors for poor recovery include lesions of the cerebellar nuclei and the inferior vermis. Dynamic reorganization is thought to promote functional recovery in particular within the first year after surgery. Yet, the time course and mechanisms of recovery within this critical time frame are elusive and longitudinal studies are missing. Thus, a group of children and adolescents (n?=?12, range 6–17 years) were followed longitudinally after cerebellar surgery and compared to age- and gender-matched controls (n?=?11). Patients were examined (1) within the first days, (2) 3 months, and (3) 1 year after surgery. Each time behavioral tests of balance and upper limb motor function, ataxia rating, and a MRI scan were performed. Data were used for subsequent lesion–symptom mapping of cerebellar function. Behavioral improvements continued beyond 3 months, but were not complete in all patients after 1 year. At that time, remaining deficits were mild. Within the first 3 months, cerebellar lesion volumes were notably reduced by vanishing edema. Reduction in edema affecting the deep cerebellar nuclei but not reduction of total cerebellar lesion volume was a major predictor of early functional recovery. Persistent impairment in balance and upper limb function was linked to permanent lesions of the inferior vermis and the deep cerebellar nuclei.     

Markers of glycemic control and insulin resistance in non-diabetic patients with Obstructive Sleep Apnea Hypopnea Syndrome: Does adherence to CPAP treatment improve glycemic control?

Background and AimObstructive Sleep Apnea Hypopnea Syndrome (OSAHS) is associated with glucose dysmetabolism and insulin resistance, therefore the amelioration of breathing disturbances during sleep can allegedly modify the levels of markers of glucose regulation and insulin resistance, such as glycated hemoglobin, fasting glucose, insulin and HOMA_IR. The aim of this study was to explore the association between these parameters and sleep characteristics in non-diabetic OSAHS patients, as well as the effect of 6 months CPAP therapy on these markers, according to adherence to CPAP treatment.MethodsEuglycemic patients (n = 56; mean age ± SD: 46.07 ± 10.67 years) with newly diagnosed OSAHS were included. Glycated hemoglobin, fasting glucose, insulin levels and HOMA_IR were estimated at baseline and 6 months after CPAP application. According to CPAP adherence, patients were classified as follows: group 1 (mean CPAP use ? 4 h/night), group 2 (mean CPAP use < 4 h/night) and group 3 (refused CPAP treatment), and comparisons of levels of the examined parameters were performed.ResultsAt baseline, average SpO₂ during sleep was negatively correlated with insulin levels and HOMA_IR while minimum SpO₂ during sleep was also negatively correlated with insulin levels. After 6 months, only group 1 patients demonstrated a significant decrease in glycated hemoglobin (p = 0.004) accompanied by a decrease in hs-CRP levels (p = 0.002). No other statistically significant change was observed.ConclusionsNighttime hypoxia can affect fasting insulin levels in non-diabetic OSAHS patients. Good adherence to long-term CPAP treatment can significantly reduce HbA_1C levels, but has no effect on markers of insulin resistance.