Olga Parra

Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial

The aim of the present study was to assess the impact of nasal continuous positive airway pressure (nCPAP) in ischaemic stroke patients followed for 2 yrs. Stroke patients with an apnoea–hypopnoea index ≥20 events·h−1 were randomised to early nCPAP (n = 71; 3–6 days after stroke onset) or conventional treatment (n = 69). The Barthel Index, Canadian Scale, Rankin Scale and Short Form-36 were measured at baseline, and at 1, 3, 12 and 24 months. The percentage of patients with neurological improvement 1 month after stroke was significantly higher in the nCPAP group (Rankin scale 90.9 versus 56.3% (p<0.01); Canadian scale 88.2 versus 72.7% (p<0.05)). The mean time until the appearance of cardiovascular events was longer in the nCPAP group (14.9 versus 7.9 months; p = 0.044), although cardiovascular event-free survival after 24 months was similar in both groups. The cardiovascular mortality rate was 0% in the nCPAP group and 4.3% in the control group (p = 0.161). Early use of nCPAP seems to accelerate neurological recovery and to delay the appearance of cardiovascular events, although an improvement in patients’ survival or quality of life was not shown.

Diagnosis and treatment of sleep apnea-hypopnea syndrome

a Unidad del Sueno, Servicio de Neumologia, Hospital Vall d’Hebron, Barcelona, Spain, (Ciberes) b Unidad Multidisciplinar de Trastornos del Sueno, Hospital Txagorritxu, Vitoria, Spain, (Ciberes) c Unidad de Neumologia, Hospital de Requena, Valencia, Spain, (Ciberes) d Servicio de Neumologia, Hospital Universitario Miguel Servet, IACS, Zaragoza, Spain, (Ciberes) e Servei de Pneumologia, Hospital del Mar-IMIM, Hospital de Sabadell, UPF, UAB, Barcelona, Spain, (Ciberes) f Servicio de Neumologia, Hospital San Pedro de Alcantara, Caceres, Spain, (Ciberes) g Servei de Pneumologia, Hospital Universitari Sagrat Cor, UB, Barcelona, Spain, (Ciberes) h Unidad de Sueno, Hospital Universitario Complejo Asistencial de Burgos, Spain, (Ciberes) i Servicio de Neumologia, Hospital Universitario Complejo Asistencial de Burgos, Spain, (Ciberes)

Efficacy of continuous positive airway pressure treatment on 5-year survival in patients with ischaemic stroke and obstructive sleep apnea: a randomized controlled trial

The main purpose of the present analysis is to assess the influence of introducing early nasal continuous positive airway pressure (nCPAP) treatment on cardiovascular recurrences and mortality in patients with a first‐ever ischaemic stroke and moderate–severe obstructive sleep apnea (OSA) with an apnea–hypopnea index (AHI) ≥20 events h−1 during a 5‐year follow‐up. Patients received conventional treatment for stroke and were assigned randomly to the nCPAP group (n = 71) or the control group (n = 69). Cardiovascular events and mortality were registered for all patients. Survival and cardiovascular event‐free survival analysis were performed after 5‐year follow‐up using the Kaplan–Meier test. Patients in the nCPAP group had significantly higher cardiovascular survival than the control group (100 versus 89.9%, log‐rank test 5.887; P = 0.015) However, and also despite a positive tendency, there were no significant differences in the cardiovascular event‐free survival at 68 months between the nCPAP and control groups (89.5 versus 75.4%, log‐rank test 3.565; P = 0.059). Early nCPAP therapy has a positive effect on long‐term survival in ischaemic stroke patients and moderate–severe OSA.

A Bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: a multicentre randomised controlled trial

Background Compliance with continuous positive airway pressure (CPAP) therapy is essential in patients with obstructive sleep apnoea (OSA), but adequate control is not always possible. This is clinically important because CPAP can reverse the morbidity and mortality associated with OSA. Telemedicine, with support provided via a web platform and video conferences, could represent a cost-effective alternative to standard care management. Aim To assess the telemedicine impact on treatment compliance, cost-effectiveness and improvement in quality of life (QoL) when compared with traditional face-to-face follow-up. Methods A randomised controlled trial was performed to compare a telemedicine-based CPAP follow-up strategy with standard face-to-face management. Consecutive OSA patients requiring CPAP treatment, with sufficient internet skills and who agreed to participate, were enrolled. They were followed-up at 1, 3 and 6 months and answered surveys about sleep, CPAP side effects and lifestyle. We compared CPAP compliance, cost-effectiveness and QoL between the beginning and the end of the study. A Bayesian cost-effectiveness analysis with non-informative priors was performed. Results We randomised 139 patients. At 6 months, we found similar levels of CPAP compliance, and improved daytime sleepiness, QoL, side effects and degree of satisfaction in both groups. Despite requiring more visits, the telemedicine group was more cost-effective: costs were lower and differences in effectiveness were not relevant. Conclusions A telemedicine-based strategy for the follow-up of CPAP treatment in patients with OSA was as effective as standard hospital-based care in terms of CPAP compliance and symptom improvement, with comparable side effects and satisfaction rates. The telemedicine-based strategy had lower total costs due to savings on transport and less lost productivity (indirect costs). Trial register number NCT01716676.

Cheyne-stokes respiration in patients with first-ever lacunar stroke.

The aim of this single-center prospective study was to assess the presence of Cheyne-Stokes respiration (CSR) and CSR-related variables in 68 consecutive patients with radiologically proven first-ever lacunar stroke undergoing a respiratory sleep study using a portable respiratory polygraph within the first 48 hours of stroke onset. CSR was diagnosed in 14 patients (20.6%). Patients with CSR as compared with those without CSR showed a significantly higher mean (standard deviation, SD) apnea-hypopnea index (AHI) (34.9 (21.7) versus 18.5 (14.4), P = 0.001) and central apnea index (13.1 (13.8) versus 1.8 (3.4), P = 0.0001) as well as higher scores of the Barthel index and the Canadian Neurological scale as a measure of stroke severity, and longer hospital stay. CSR was present in one of each five patients with lacunar stroke. The presence of CSR was associated with a trend towards a higher functional stroke severity and worse prognosis.

Gender differences and woman-specific trends in acute stroke: Results from a hospital-based registry (1986–2009)

OBJECTIVE We assessed gender differences and women-specific secular trends in stroke. METHODS Data from 2318 women and 2274 men with first-ever stroke collected from the Sagrat Cor Hospital Stroke Registry of Barcelona between 1986 and 2009 were analyzed. RESULTS Patients age increased significantly from a mean of 74.5 years in 1986-1992 to 81.2 years in 2004-2009 (P < 0.001). Patients aged ≥ 85 years increased from 18.5% to 38.5% (P = 0.0001) as were patients with hypertension, atrial fibrillation, and cardioembolic stroke. The in-hospital death decreased from 17.6% to 11% (P = 0.02), median length of hospital from 14 to 9 days (P = 0.0001) and prolonged hospital stay (> 12 days) from 59.7% to 33.7% (P = 0.0001). Lacunar infarction was more frequent in men (21.5% vs. 16.2%, P = 0.0003) and cardioembolic infarction in women (26% vs. 15.6%, P = 0.0001). Acute stroke in women continues to be a severe disease with high risk of death in the immediate post-stroke phase (13.5%) and low probability of early full neurological recovery (13.9% vs. 11.8%, P = 0.029). CONCLUSION Women differ from men in the distribution of risk factors and stroke subtype, stroke severity, and outcome. An increase in the patients age, hypertension, atrial fibrillation and cardioembolic infarction, as well as a decrease mortality and length of hospitalization over a 24-year period was recorded.

Determinants of early outcome in spontaneous lobar cerebral hemorrhage

Objective –  To identify determinants of early outcome in spontaneous lobar hemorrhage.

Nineteen-year trends in risk factors, clinical characteristics and prognosis in lacunar infarcts.

Background: Cardiovascular risk factors, clinical features and early outcome of first-ever cerebral lacunar infarcts from 1986 to 2004, using the Sagrat Cor Hospital of Barcelona Stroke Registry, were assessed and compared with data from patients with nonlacunar infarction. Methods: The study population consisted of 566 patients with lacunar infarct and 1,516 patients with nonlacunar infarct. Secular trends for the periods 1986–1992, 1993–1998 and 1999–2004 were analyzed. Results: Age and the percentage of very old patients (≧85 years old) increased significantly (p < 0.001) throughout the time period. There was a significant decrease in the percentage of patients with hypertension, but the percentage of patients with chronic obstructive pulmonary disease increased. The use of brain magnetic resonance imaging (MRI) also increased significantly. The median length of hospital stay decreased significantly. Conclusions: Significant changes over a 19-year period included an increase in the patients’ age, frequency of very old patients (≧85 years old) and use of MRI studies, whereas the frequency of hypertension and length of hospital stay decreased.

Hematological disorders: a commonly unrecognized cause of acute stroke

ABSTRACT Introduction: Hematological disorders account for about 1.3% of all causes of acute stroke. This systematized review presents updated information on the implications of this category of heterogeneous diseases as a cause of stroke. Areas covered: The most relevant aspects of the relationship between stroke and hematological disorders are reported. A high index of suspicion is needed in young stroke patients, patients with recurrent stroke of undetermined cause, and in patients with prior history of venous thrombosis to identify a potential hematological disorder as the definitive etiology of stroke Expert commentary: Stroke can be the presenting manifestation of a specific hematological disease or may appear as a complication in the course of hematological disorders. It is important to make a correct diagnosis of the underlying hematological disorder in order to treat stroke patients promptly and appropriately as well as to establish the optimal secondary prevention strategy for recurrent vascular cerebral disease.

Relación de las profesiones y las condiciones laborales con la neumonía adquirida en la comunidad

INTRODUCTION Community-acquired pneumonia (CAP) is not considered a professional disease, and the effect of different occupations and working conditions on susceptibility to CAP is unknown. The aim of this study is to determine whether different jobs and certain working conditions are risk factors for CAP. METHODOLOGY Over a 1-year period, all radiologically confirmed cases of CAP (n=1,336) and age- and sex-matched controls (n=1,326) were enrolled in a population-based case-control study. A questionnaire on CAP risk factors, including work-related questions, was administered to all participants during an in-person interview. RESULTS The bivariate analysis showed that office work is a protective factor against CAP, while building work, contact with dust and sudden changes of temperature in the workplace were risk factors for CAP. The occupational factor disappeared when the multivariate analysis was adjusted for working conditions. Contact with dust (previous month) and sudden changes of temperature (previous 3 months) were risk factors for CAP, irrespective of the number of years spent working in these conditions, suggesting reversibility. CONCLUSION Some recent working conditions such as exposure to dust and sudden changes of temperature in the workplace are risk factors for CAP. Both factors are reversible and preventable.