Elisabet Martínez-Cerón

Effect of Continuous Positive Airway Pressure on Glycemic Control in Patients with Obstructive Sleep Apnea and Type 2 Diabetes. A Randomized Clinical Trial

RATIONALE Obstructive sleep apnea (OSA) is a risk factor for type 2 diabetes that adversely impacts glycemic control. However, there is little evidence about the effect of continuous positive airway pressure (CPAP) on glycemic control in patients with diabetes. OBJECTIVES To assess the effect of CPAP on glycated hemoglobin (HbA1c) levels in patients with suboptimally controlled type 2 diabetes and OSA, and to identify its determinants. METHODS In a 6-month, open-label, parallel, and randomized clinical trial, 50 patients with OSA and type 2 diabetes and two HbA1c levels equal to or exceeding 6.5% were randomized to CPAP (n = 26) or no CPAP (control; n = 24), while their usual medication for diabetes remained unchanged. MEASUREMENTS AND MAIN RESULTS HbA1c levels, Homeostasis Model Assessment and Qualitative Insulin Sensitivity Check Index scores, systemic biomarkers, and health-related quality of life were measured at 3 and 6 months. After 6 months, the CPAP group achieved a greater decrease in HbA1c levels compared with the control group. Insulin resistance and sensitivity measurements (in noninsulin users) and serum levels of IL-1β, IL-6, and adiponectin also improved in the CPAP group compared with the control group after 6 months. In patients treated with CPAP, mean nocturnal oxygen saturation and baseline IL-1β were independently related to the 6-month change in HbA1c levels (r(2) = 0.510, P = 0.002). CONCLUSIONS Among patients with suboptimally controlled type 2 diabetes and OSA, CPAP treatment for 6 months resulted in improved glycemic control and insulin resistance compared with results for a control group. Clinical trial registered with www.clinicaltrials.gov (NCT01801150).

Effects of continuous positive airway pressure treatment on glucose metabolism in patients with obstructive sleep apnea.

A possible association between obstructive sleep apnea (OSA) and type 2 diabetes (T2DM) has been suggested. OSA could alter glucose metabolism, generating insulin resistance and favoring the development of T2DM. In addition, our greater understanding of intermediate disorders produced by intermittent hypoxia and sleep fragmentation, such as sympathetic activation, oxidative stress, systemic inflammation and alterations in appetite-regulating hormones, provides biological plausibility to this possible association. Nevertheless, there are still few data available about the consequences of suppressing apnea. Therefore, the objective of this review was to analyze current knowledge about the effect of continuous positive airway pressure (CPAP) on glucose metabolism. A global interpretation of the studies evaluated shows that CPAP could improve insulin resistance, and perhaps also glycemic control, in OSA patients who still have not developed diabetes. In addition, it seems possible that the effect of CPAP is still greater in patients with OSA and T2DM, particularly in those patients with more severe and symptomatic OSA, in those with poorer baseline glycemic control and with greater compliance and duration of CPAP treatment. In conclusion, although the current information available is limited, it suggests that apnea reversion by means of CPAP could improve the control of glucose metabolism.

Classification of Airflow Limitation Based on z-Score Underestimates Mortality in Patients with Chronic Obstructive Pulmonary Disease

&NA; Rationale: Global Lung Function Initiative recommends reporting lung function measures as z‐score, and a classification of airflow limitation (AL) based on this parameter has recently been proposed. Objectives: To evaluate the prognostic capacity of the AL classifications based on z‐score or percentage predicted of FEV1 in patients with chronic obstructive pulmonary disease (COPD). Methods: A cohort of 2,614 patients with COPD recruited outside the hospital setting was examined after a mean (± SD) of 57 ± 13 months of follow‐up, totaling 10,322 person‐years. All‐cause mortality was analyzed, evaluating the predictive capacity of several AL staging systems. Measurements and Main Results: Based on Global Initiative for Chronic Obstructive Lung Disease guidelines, 461 patients (17.6%) had mild, 1,452 (55.5%) moderate, 590 (22.6%) severe, and 111 (4.2%) very severe AL. According to z‐score classification, 66.3% of patients remained with the same severity, whereas 23.7% worsened and 10.0% improved. Unlike other staging systems, patients with severe AL according to z‐score had higher mortality than those with very severe AL (increase of risk by 5.2 and 3.9 times compared with mild AL, respectively). The predictive capacity for 5‐year survival was slightly higher for FEV1 expressed as percentage of predicted than as z‐score (area under the curve: 0.714‐0.760 vs. 0.649‐0.708, respectively). A severity‐dependent relationship between AL grades by z‐score and mortality was only detected in patients younger than age 60 years. Conclusions: In patients with COPD, the AL classification based on z‐score predicts worse mortality than those based on percentage of predicted. It is possible that the z‐score underestimates AL severity in patients older than 60 years of age with severe functional impairment.

Does airway hyperresponsiveness monitoring lead to improved asthma control

The current guidelines recommend an approach to asthma management based on asthma control, rather than asthma severity. Although several specific questionnaires have been developed and control criteria have been established based on clinical guidelines, the evaluation of asthma control is still not optimal. In general, these indicators provide adequate assessment of current control, but they are more limited when estimating future risk. There is much evidence demonstrating the persistence of airway inflammation and airway hyperresponsiveness (AHR) in patients with total control. Therefore, the objective of this review was to analyse the possible role of AHR monitoring as an instrument for assessing asthma control. We will evaluate its capacity as an indicator for future risk, both for estimating the possibility of clinical deterioration and loss of lung function or exacerbations. Furthermore, its relationship with inhaled corticosteroid treatment will be analysed, while emphasizing its capacity for predicting response and adjusting dosage, as well as information about the capability of AHR for monitoring treatment. Last of all, we will discuss the main limitations and emerging opportunities of AHR as an assessment instrument for asthma control.

Chronic Obstructive Pulmonary Disease and Diabetes Mellitus

The progressive increase in the average age of the population leads to chronic diseases that are increasingly important. Chronic conditions are large in number, the prevalence of each one is high and so does the annual cost of their care. Moreover, clinicians alert about the impact of one disease on the development and severity of others. Among chronic morbidities the most prevalent are cardiovascular disease (CV), cancer, diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD) (Chillon et al., 2009). Noticeably, a 25% of patients older than 65 years have two chronic conditions and this figure rises to 40% in population over 75 years old (Chatila et al., 2008).

Inflamación sistémica como nexo de unión entre la enfermedad pulmonar obstructiva crónica y sus comorbilidades

Las enfermedades crónicas suponen un reto importante de la medicina actual, tanto por el aumento progresivo de la edad media poblacional, como por el coste anual dedicado a ellas. Se estima que el 25% de los pacientes mayores de 65 años presentan 2 procesos crónicos, cifra que aumenta hasta un 40% en los que superan los 75 años de edad. Los procesos crónicos más frecuentes a los que nos referimos son la enfermedad cardiovascular, el cáncer, la diabetes mellitus y la enfermedad pulmonar obstructiva crónica (EPOC). La EPOC es una afectación prevenible y tratable cuya causa principal es el humo de tabaco, que produce una obstrucción progresiva poco reversible al flujo aéreo y que se asocia a una inflamación sistémica. Debido al carácter sistémico de la inflamación asociada, se han propuesto nuevas definiciones para la EPOC, como «sı́ndrome inflamatorio sistémico», enfatizando la no exclusividad de la afectación pulmonar y la asociación habitual secundaria con otras comorbilidades. Las enfermedades más frecuentes en los pacientes con EPOC son las afectaciones cardiovasculares, el cáncer pulmonar, las alteraciones nutricionales, las disfunciones musculoesqueléticas, la anemia y la depresión. Además, todas ellas tienen un efecto negativo sobre el pronóstico global y sobre la calidad de vida de los pacientes. Cada vez más autores afirman que la inflamación sistémica es el punto de partida para explicar la relación de la EPOC con otras enfermedades crónicas. El cı́rculo patológico de hipoxia-inflamación-estrés oxidativo es el más aceptado por la comunidad cientı́fica a la hora de explicar esta asociación. La inflamación pulmonar, que principalmente se debe al humo de tabaco, origina a nivel local un aumento de citocinas inflamatorias, neutrófilos, macrófagos y linfocitos T. Esta activación provoca un daño celular y tisular que da lugar a una respuesta inmune, y desestabiliza los compuestos de la matriz extracelular pulmonar con la consecuente ruptura y liberación de diversos

Small airway dysfunction in smokers with stable ischemic heart disease

Background A higher prevalence of airflow limitation (AL) has been described in patients with ischemic heart disease (IHD). Although small airway dysfunction (SAD) is an early feature of AL, there is little information about its occurrence in IHD patients. Our objective was to describe the prevalence of SAD in IHD patients, while comparing patient-related outcomes and future health risk among IHD patients with AL, SAD and normal lung function. Methods In 118 consecutive smoking patients with stable IHD, comorbidities, utilization of healthcare resources, current treatment, blood biochemistry and health status were recorded. SAD was evaluated by impulse oscillometry, and pre- and post-bronchodilator spirometry was performed. Results The prevalence of AL and SAD were 20.3 (95% CI, 13.1–27.6%) and 26.3% (95% CI, 18.3–34.2%), respectively. Compared to the normal lung function group, patients with SAD and without AL had lower spirometric values, poorer quality of life and higher levels of C-reactive protein (CRP), as well as increased cardiovascular risk and more vascular age. In patients with normal spirometry, the presence of SAD was independently associated with pack-years, HDL-cholesterol and CRP levels. Conclusion In patients with IHD, the presence of SAD is common and that it is associated with reduced health status and increased future cardiac risk.

The effect of treatment for sleep apnoea on determinants of blood pressure control

Our aim was to assess the effect of continuous positive airway pressure (CPAP) on the nocturnal evolution of peripheral chemosensitivity, renin–angiotensin–aldosterone system activity, sympathetic tone and endothelial biomarkers in obstructive sleep apnoea (OSA) patients with isolated nocturnal hypertension (INH) or day–night sustained hypertension (D-NSH). In a crossover randomised trial, 32 OSA patients newly diagnosed with hypertension and without antihypertensive treatment were randomly assigned to 12 weeks of CPAP or sham CPAP. Peripheral chemosensitivity was evaluated before and after sleep using the hypoxic withdrawal test (%ΔVI). At baseline, D-NSH patients showed higher %ΔVI before sleep and higher levels of aldosterone and diurnal catecholamines. CPAP only reduced the nocturnal increase of %ΔVI in INH patients (6.9%, 95% CI 1.0–12.8%; p=0.026). CPAP-induced change from baseline in %ΔVI after sleep was 7.5% (95% CI 2.6–12.2%, p=0.005) in the INH group and 5.7% (95% CI 2.2–9.3%, p=0.004) in the D-NSH group. In contrast, %ΔVI before sleep only decreased with CPAP in the D-NSH patients (3.0%, 95% CI 0.5–5.6%; p=0.023). In conclusion, CPAP reduces the nocturnal increase of peripheral chemosensitivity experienced by INH patients and corrects the high daytime sensitivity of patients with D-NSH. Differences in response to CPAP between these patients can help better understand the mechanisms of perpetuation of hypertension in sleep apnoea. Peripheral chemosensitivity justifies differences in nocturnal–diurnal blood pressure in patients with sleep apnoea http://ow.ly/ntYr30eFU0b

Discussion and Shared Decision-Making in a ‘State of Permanent Distress’:

It is the case of a 66-year-old man in a permanent vegetative state which his family is blocked due to suffering. A process and a document of a shared decision-making between the family and the professional team allowed giving emotional support, unlocking the situation and preventing complicated grief.