Mario Francesco Damiani

Correlation between Inflammatory Markers of Atherosclerosis and Carotid Intima-Media Thickness in Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is a sleep-related breathing disorder associated with the development of cardiovascular diseases and atherosclerosis. Systemic inflammation plays an important role in the development of cardiovascular complications in OSA patients. The aim of the study was to evaluate the relationship between carotid intima-media thickness (cIMT) and inflammatory markers plasma levels in OSA patients. We enrolled 80 OSA patients and 40 controls matched for age and body mass index (BMI). The presence and severity of sleep apnea was determined by in-laboratory portable monitoring (PM). Demographic data, blood pressure, heart rate, and cIMT were measured. High-sensitive C-Reactive Protein (hsCRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α and pentraxin (PTX)-3 serum concentrations were detected. cIMT was higher in OSA patients than controls (0.89 ± 0.13 mm vs. 0.65 ± 0.1 mm, p < 0.01). Moderate-severe OSA patients (0.95 ± 0.09 mm) had significantly increased cIMT than mild OSA (0.76 ± 0.1 mm; p < 0.01) and control (0.65 ± 0.1 mm; p < 0.01). hsCRP, IL-6, TNF-α, and PTX-3 in patients with OSA (1.67 ± 0.66 mg/L, 2.86 ± 1.39 pg/mL, 20.09 ± 5.39 pg/mL, 2.1 ± 0.59 ng/mL, respectively) were significantly higher than in controls (1.08 ± 0.53 mg/L, p < 0.01; 1.5 ± 0.67 pg/mL, p < 0.01; 12.53 ± 3.48 pg/mL, p < 0.01; 1.45 ± 0.41 ng/mL, p < 0.01, respectively). Carotid IMT was significantly correlated to CRP (r = 0.44; p < 0.01), IL-6 (r = 0.42; p < 0.01), TNF-α (r = 0.53; p < 0.01), and PTX-3 (r = 0.49; p < 0.01). OSA patients showed increased cIMT, CRP, IL-6, TNF-α, and PTX-3 levels. Inflammatory markers levels are correlated to cIMT in OSA patients.

Obstructive Sleep Apnea, Hypertension, and Their Additive Effects on Atherosclerosis

Background and Aims. It is widely accepted that obstructive sleep apnea (OSA) is independently associated with atherosclerosis. Similar to OSA, hypertension (HTN) is a condition associated with atherosclerosis. However, to date, the impact of the simultaneous presence of OSA and HTN on the risk of atherosclerosis has not been extensively studied. The aim of this study was to evaluate the consequences of the coexistence of OSA and HTN on carotid intima-media thickness (IMT) and on inflammatory markers of atherosclerosis (such as interleukin- [IL-] 6 and pentraxin- [PTX-] 3). Methods. The study design allowed us to define 4 groups: (1) controls (n = 30); (2) OSA patients without HTN (n = 30); (3) HTN patients without OSA (n = 30); (4) patients with OSA and HTN (n = 30). In the morning after portable monitoring (between 7 am and 8 am), blood samples were collected, and carotid IMT was measured. Results. Carotid IMT, IL-6, and PTX-3 in OSA normotensive patients and in non-OSA HTN subjects were significantly higher compared to control subjects; in addition, in OSA hypertensive patients they were significantly increased compared to OSA normotensive, non-OSA HTN, or control subjects. Conclusions. OSA and HTN have an additive role in the progression of carotid atherosclerosis and in blood levels of inflammatory markers for atherosclerosis, such as interleukin-6 and pentraxin-3.

The Epworth Sleepiness Scale: conventional self vs physician administration.

Abstract ABSTRACT BACKGROUND AND AIMS: the Epworth Sleepiness Scale (ESS) is a simple self-administered questionnaire which provides a measurement of the subjects level of daytime sleepiness, and is widely used for patients with obstructive sleep apnea (OSA). Some recent works undermined its accuracy. The aim of this study was to compare self-administered ESS scores to physician-administered scores, in a sample of patients with suspicion of OSA. METHODS: patients were randomly divided into 2 groups: group I or the self-administered group (n=113), and group II or the physician-administered group (n=112). Patients in group I were asked to complete the ESS in the traditional way; in group II, the ESS was administered by a sleep medicine physician. Subjects in both groups underwent diagnostic in-laboratory portable monitoring (PM) within a weeks time. RESULTS: the percentage of questionnaires properly completed was significantly different between groups: 77% (87/113) in the group I vs 100% (112/112) in the group II (p=0.00). Scores obtained by the physician-administered questionnaire were higher than those derived by the self-administered ESS (ESSp:12.09 ± 4.1 vs ESSs:10.37 ± 5.49; p=0.01). The ESSp was more highly correlated with apnea-hypopnea index, and oxygen desaturation index than the ESSs. CONCLUSIONS: our results lead to consider the physician-administered ESS to be more accurate than the traditional ESS; thus, our suggestion is to validate this new method of administration.BACKGROUND The Epworth Sleepiness Scale (ESS) is a simple, self-administered questionnaire that provides a measurement of the subjects level of daytime sleepiness, and is widely used for patients with obstructive sleep apnea (OSA). Some works undermined its accuracy. The aim of this study was to compare self-administered ESS scores to physician-administered scores in a sample of patients with suspicion of OSA. METHODS Patients were randomly divided into two groups: group 1, or the self-administered group (n = 113); and group 2, or the physician-administered group (n = 112). Patients in group 1 were asked to complete the ESS in the traditional way; in group 2, the ESS was administered by a sleep-medicine physician. Subjects in both groups underwent diagnostic in-laboratory portable monitoring (PM) within 1 weeks time. RESULTS The percentage of questionnaires properly completed was significantly different between groups: 77% (87 of 113) in the group 1 vs 100% (112 of 112) in the group 2 (P = .00). Scores obtained when a physician administered the questionnaire (ESSp) were higher than those when the ESS was self administered (ESSs) (ESSp:12.09 ± 4.1 vs ESSs:10.37 ± 5.49; P = .01). The ESSp was more highly correlated with apnea-hypopnea index and oxygen desaturation index than the ESSs. CONCLUSIONS Our results lead us to consider the physician-administered ESS to be more accurate than the traditional ESS; thus, our suggestion is to validate this new method of administration.

Polysomnograph Chart View by Patients: A New Educational Strategy to Improve CPAP Adherence in Sleep Apnea Therapy

BACKGROUND: CPAP is currently the treatment of choice for obstructive sleep apnea syndrome, but therapy adherence is poor. Many educational trials have been proposed to increase CPAP adherence. We tested the hypothesis that polysomnograph chart viewing by patients would improve CPAP adherence. METHODS: A controlled parallel group study was performed with 206 newly diagnosed obstructive sleep apnea syndrome patients, randomized into 2 groups (n = 103 each): standard support group, and educational support group. Each educational support group subject viewed 2 consecutive polysomnograms on the computer screen: the first recorded during a standard diagnostic overnight polysomnography, and the second during a full-night polysomnography with nasal CPAP. The subjects attention was drawn only to the flow and oxyhemoglobin saturation curves. Clinical outcomes were assessed via polysomnography at CPAP initiation and after 1, 3, and 12 months. RESULTS: After 12 months of CPAP, 76% of the educational support group and 52% of the standard support group returned for a follow-up visit (P < .001). Statistical significance had already been reached after 1 and 3 months. Moreover, CPAP use (measured as hours of use per night) was higher in the educational support group at each control visit. CONCLUSIONS: Polysomnograph chart viewing by obstructive sleep apnea patients can increase CPAP adherence, as evaluated by rate of return for the follow-up visit and mean nightly CPAP use.

Titration effectiveness of two autoadjustable continuous positive airway pressure devices driven by different algorithms in patients with obstructive sleep apnoea

Nocturnal application of continuous positive airway pressure (CPAP) is the standard treatment for patients with obstructive sleep apnoea (OSA). Determination of the therapeutic pressure (CPAP titration) is usually performed by a technician in the sleep laboratory during attended polysomnography. One possible alternative to manual titration is automated titration. Indeed, during the last 15 years, devices have been developed that deliver autoadjustable CPAP (A‐CPAP). The aim of the present study was to compare the titration effectiveness of two A‐CPAP devices using different flow‐based algorithms in patients with OSA.

Home unattended portable monitoring and automatic CPAP titration in patients with high risk for moderate to severe obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea is a disorder characterized by recurrent obstruction of the upper airways during sleep. The high prevalence of this disease led to proposed new strategies based on the home evaluation and management of patients. OBJECTIVE: To compare home unattended portable monitoring and automatic CPAP titration with attended in-laboratory analysis, in a sample of patients with high risk for moderate to severe obstructive sleep apnea. METHODS: We enrolled 131 subjects, who were randomly divided into 2 groups: the home group (n = 66) was diagnosed and titrated at home; the laboratory group (n = 65) was analyzed in the sleep laboratory of our hospital. Diagnostic evaluations were carried out with portable monitoring at home, and with polysomnography in the sleep laboratory. Titration of CPAP was performed with the same automatic CPAP device in both groups. RESULTS: At the end of the study, 13 (19%) subjects had dropped out of the home group, and 9 (14%) of the laboratory group (P = .50). There were no significant differences among groups in both baseline and with-CPAP values of apnea-hypopnea index, oxygen desaturation index, and total sleep time with SpO2 below 90%. In the home group, the therapeutic pressure values reached at the end of each unattended home titration night were similar. CONCLUSIONS: A home diagnosis and titration approach should be considered in a subset of patients with obstructive sleep apnea. A single unattended titration night is sufficient to determine the therapeutic pressure.

Influence of obstructive sleep apnea on endothelial function in obese patients.

www.chestpubs.org (Mr Day), Kingston General Hospital, and Department of Community Health and Epidemiology (Mr Day), Queen’s University. Financial/nonfi nancial disclosures: The authors have reported to CHEST that no potential confl icts of interest exist with any companies/organizations whose products or services may be discussed in this article . Correspondence to: Renee D. Stapleton, MD, PhD, FCCP, Department of Medicine, University of Vermont College of Medicine, 149 Beaumont Ave, HSRF 222, Burlington, VT 05405; e-mail: renee.stapleton@uvm.edu

The Prognostic Role of Obstructive Sleep Apnea at the Onset of Amyotrophic Lateral Sclerosis

Background/Objective: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by the progressive loss of central and peripheral motor neurons. Some studies have found discordant data in the presence of sleep apnea in ALS patients. An obstructive component also occurs with upper airways hypotonia and muscle weakness that may result in an excessive reduction of airway lumen, leading to obstructive sleep apnea (OSA). The aim of this study was to assess the role of obstructive apneic events at disease onset in the ALS prognosis. Methods: A longitudinal retrospective study was conducted on 42 clinically diagnosed ALS patients. The study population was divided into 2 groups according to their obstructive apnea/hypopnea index (AHIo): group 1 consisted of 20 patients with an AHIo ≥5 and group 2 consisted of 22 patients with an AHIo <5. Both groups were compared with regard to demographic, polygraphic, and respiratory function parameters as well as ALS characteristics (bulbar onset, time between onset and first check-up, time between diagnosis and first check-up, time between first check-up and death or tracheostomy). Results: The mean survival in ALS patients with an AHIo ≥5 was significantly shorter than in ALS without OSA (p = 0.0237). The sniff nasal inspiratory pressure test was significantly correlated with AHIo, time of oxyhemoglobin saturation below 90% and the oxyhemoglobin desaturation index (p < 0.0001). Conclusions: Our study highlights the importance of an early diagnosis of OSA in ALS patients, allowing the identification of ALS patients with an OSA phenotype (AHIo ≥5), who are characterized by a worse prognosis.

Influence of obstructive sleep apnea on cognitive impairment in patients with COPD.

We read with great interest the recent article in CHEST (December 2012) by Villeneuve et al 1 entitled “Mild Cognitive Impairment in Moderate to Severe COPD: A Preliminary Study.” In their article, Villeneuve et al 1 demonstrated that 36% of patients with COPD had mild cognitive impairment (MCI), compared with 12% of healthy subjects. The authors took great care to exclude from the study all patients who presented comorbidities that could affect cognitive function. With regard to the comorbidities associated with COPD, we would like to highlight the important role of obstructive sleep apnea (OSA). Indeed, it was appreciated by several well-controlled epidemiologic studies that about 20% of subjects with OSA will have COPD, 2 and about 10% of OSA is disclosed among patients with COPD independently of the degree of functional status. 3 There is evidence that OSA has an active role in the development of cognitive impairment. 4 In this regard, in the study of Villeneuve et al, 1 an intriguing fi nding is the slight (although not significant) increase in the Epworth Sleepiness Scale among patients with COPD and MCI compared with patients with COPD but without MCI, which may lead one to hypothesize the presence of a proportion of patients with OSA among subjects with COPD and MCI. The primary mechanisms underlying cognitive impairment in OSA are represented by nocturnal hypoxemia, sleep fragmentation, and daytime sleepiness 4 ; large studies suggest that hypoxemia is responsible for frontal impairment and executive dysfunction, while sleep fragmentation and daytime sleepiness infl uence attention. 4 In patients with COPD, hypoxemia, hypercapnia, and vascular comorbidities may be a cause of cognitive alterations. 1 Therefore, in patients with COPD and OSA (overlap syndrome), there is the possibility that all the aforesaid mechanisms operate simultaneously and/or synergistically. In this regard, it is widely accepted that patients with overlap syndrome develop more pronounced, nocturnal, oxygen desaturation than those with COPD or OSA alone. 3 Furthermore, there is evidence that subjects with overlap syn drome show more severe diurnal hypoxemia compared with patients with OSA. 5 For all these reasons, we would like to stimulate discussion about the need to consider the presence of OSA among patients with COPD who have cognitive impairment.

Recurrent pulmonary embolism due to echinococcosis secondary to hepatic surgery for hydatid cysts.

Abstract We describe the case of a 53-year-old man with recurrent pulmonary embolism due to intra-arterial cysts from Echinococcus. Both the patient’s medical history and the computed tomographic (CT) scan abnormalities led to the diagnosis. The CT scan, performed during hospitalization in our ward, showed cystic masses in the left main pulmonary artery and in the descending branch of the right pulmonary artery. Within cystic masses, thin septa were visible, giving a chambered appearance, which was suggestive of a group of daughter cysts. In the past, our patient underwent multiple operations for recurring echinococcal cysts of the liver. After the last intervention, 4 years earlier, his postoperative course was complicated by pulmonary embolism: a CT scan showed a filling defect in the descending branch of the right pulmonary artery, which was caused by the same cystic mass as 4 years later, although smaller. This mass, not properly treated, increased in diameter. Moreover, after 4 years, there has been a new episode of embolism, which involved the left main pulmonary artery. This is the first case in which there are repeated episodes of pulmonary embolism echinococcosis after hepatic surgery for removal of hydatid cysts.