Cost-effectiveness analysis of robot-assisted gait training in patients with bilateral spastic cerebral palsy.

BACKGROUND: To date, there have been no published studies evaluating the cost-effectiveness of robot-assisted gait training (RAGT) in adolescent and adult patients with cerebral palsy (CP). The study´s aim was to analyse the cost-effectiveness of RAGT versus conventional kinesiotherapy (CON) from the health care provider's perspective. METHODS: We expressed the cost-effectiveness of RAGT in the Lokomat® system after analysing the costs and effects of RAGT and conventional therapy through the Incremental Cost-Effectiveness Ratio (ICER) based on a bicentric randomized controlled study, in which we demonstrated that the intensive RAGT regimen is more effective than conventional therapy in terms of improvements in gross motor functions in adolescent and adult patients with bilateral spastic CP. RESULTS: According to the calculated ICER ratio for Lokomat®, an additional improvement per unit of effect (1% in GMFM), compared to conventional therapy, results in an average cost increase of EUR70.38 per patient in a therapeutic block consisting of 20 TUs (Therapeutic Units). CONCLUSION: However, from the comprehensive analysis of the results and evaluation of the long-term effects, it follows that RAGT applied in adolescent and adult patients with bilateral spastic CP is not only more effective in terms of evaluation of monitored clinical parameters, but in the long term it is also more cost-effective compared to conventional therapy.

Adherence to positive airway pressure therapy initiated in the early subacute phase of ischemic stroke: a PRESS study follow-up.

BACKGROUND: Sleep-disordered breathing (SDB) is frequent in stroke patients and negatively affects stroke outcomes. Positive airway pressure (PAP) is the standard first-line treatment for patients with moderate-to-severe SDB. Despite a strong link between PAP adherence and therapeutic response, rates of post-stroke PAP adherence remain underexplored. Our study aimed to determine PAP adherence in patients undergoing comprehensive sleep apnea assessment and in-lab PAP titration in the early subacute phase of stroke. METHODS: In-hospital screening pulse oximetry was performed in consecutive patients with imaging-confirmed acute ischemic stroke. Subjects with desaturation index ≥ 15.3/h were selected as PAP candidates, and polysomnography was recommended. In a sleep laboratory setting, subjects underwent a diagnostic night followed by a titration night, and PAP therapy was initiated in subjects with apnea-hypopnea index ≥ 15/h. Adherence to PAP therapy was assessed at a 6-month follow-up visit. RESULTS: Of 225 consecutive patients with acute ischemic stroke, 116 were PAP candidates and 52 were able to undergo polysomnography. PAP therapy was initiated in 35 subjects. At a 6-month follow-up visit, out of 34 stroke survivors, PAP adherence (PAP use of > 4 h per night) was present in 47%. Except for the significantly lower minimal nocturnal O2 saturation determined from the polysomnography (74.6 ± 11.7% vs. 81.8 ± 5.2%, p = 0.025), no other significant difference in characteristics of the groups with PAP adherence and PAP non-adherence was found. CONCLUSIONS: Less than half of the stroke subjects remained adherent to PAP therapy at 6 months post-PAP initiation. Special attention to support adaptation and adherence to PAP treatment is needed in this group of patients.

No Difference in Sleep Desaturations Severity between Patients with Wake-Up and Non-Wake-Up Stroke: A PRESS Study Results.

BACKGROUND: Wake-up stroke (WUS) is a certain type of ischemic stroke in which a patient wakes up with a new neurological deficit due to cerebral ischemia. Sleep-disordered breathing is an independent risk factor for stroke, but the role of nocturnal oxygen desaturation in the pathophysiology of WUS is still insufficiently explored. According to several studies, patients with WUS have a significantly more severe sleep apnea syndrome and lower mean blood oxygen saturation. This study aimed to assess the severity of nocturnal desaturations in acute WUS and non-WUS patients using nocturnal pulse oximetry. MATERIAL AND METHODS: The cohort of 225 consecutive patients with neuroimaging-verified acute cerebral ischemia was prospectively enrolled. For further analyses, 213 subjects with known WUS/non-WUS status were selected (111 males and 102 females, average age 70.4 ±12.9, median baseline NIHSS = 5, median baseline mRS = 3). Patients were divided into the WUS group (n = 45) and the non-WUS group (n = 168). Overnight pulse oximetry was performed within 7 days of the stroke onset and data of both of the studied groups were compared. RESULTS: We found oxygen desaturation index (ODI) in the WUS group was 14.5 vs. 16.6 (p = 0.728) in the non-WUS group, basal O2 saturation was 92.2% vs. 92.5% (p = 0.475), average low O2 saturation was 90.3% vs. 89.6% (p = 0.375), minimal O2 saturation was 79.5% vs. 80.6% (p = 0.563), and time with O2 saturation <90% (T90) was 4.4% vs. 4.7% (p = 0.729). CONCLUSIONS: In the studied sample, monitored respiratory parameters including ODI, basal O2 saturation, average low O2 saturation, minimal O2 saturation, and T90 did not significantly differ between groups of WUS and non-WUS patients.

Impairment of endothelial function in Parkinson's disease.

OBJECTIVE: There are conflicting data regarding the relationship between Parkinson's disease (PD) and the atherosclerotic process. This study aimed to compare endothelial function in patients with PD and matched controls. In PD subjects, we searched for factors contributing to endothelial dysfunction as well. Traditional vascular risk factors, PD characteristics, and PD medication were considered. RESULTS: We prospectively enrolled 41 patients with PD and 41 controls matched for age, sex, body mass index, and vascular risk factors. Endothelial function (EF) was assessed using peripheral arterial tonometry (EndoPAT 2000 device) and expressed as reperfusion hyperemia index (RHI). Clinical characteristics including PD medication were recorded. RHI was non-significantly lower in the PD group than in controls (1.8 ± 0.5 vs. 1.9 ± 0.5, p = 0.478). In PD patients, in linear regression analysis, smoking (beta = -0.453, p = 0.008) and use of dopamine agonists (beta = -0.365, p = 0.030) were significant contributors in a model predicting RHI. Despite non-significant differences in endothelial dysfunction between PD patients and controls, our results suggest an association between smoking, dopamine agonists, and impaired EF in PD patients. The small sample size, as well as the absence of an extended search for traditional and non-traditional vascular risk factors, are the most important factors limiting the interpretation of the current results.

Mood disorders in patients with hypersomnia: comparison of sleep-related breathing disorders versus narcolepsy.

BACKGROUND: Anxiety and depression are common comorbidities of excessive daytime sleepiness (EDS). Sleep-related breathing disorders (SBD) and central disorders of hypersomnolence (like narcolepsy [NA]) are the most frequent causes of EDS. This study aimed to evaluate mood disorders in NA patients compared to the subjects with EDS due to SBD (SBD-EDS). METHODS: In a retrospective analysis, subjects with NA and SBD-EDS were compared. All subjects underwent overnight polysomnography. NA patients underwent also multiple sleep latency test. Epworth sleepiness scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Becks questionnaire, and Zung depression scale were used to assess EDS, sleep quality, anxiety, and depression, respectively. RESULTS: We enrolled 24 NA and 41 SBD-EDS subjects. Values of PSQI and Zung scale were significantly worse in the SBD-EDS group than in NA patients (8.34±3.84 vs. 6.83±2.25, p=0.04; 46.86±12.69 vs. 40.81±11.27, p=0.03, respectively). Anxiety was significantly more frequent in SBD-EDS subjects compared to NA (63.4% vs. 37.5%, p=0.04). Out of all observed sleep-related indices, PSQI was the only factor, that significantly correlated with the measures of anxiety in both groups (NA: r=0.65, p=0.001; SBD-EDS: r=0.45, p=0.003) and with the measures of depression in NA subjects (r=0.51, p=0.01). In SBD-EDS group, measures of depression significantly correlated with PSQI (r=0.46, p=0.002), oxygen desaturation index (r=0.35, p=0.03), and ESS (r=0.5, p=0.001). CONCLUSION: Compared to NA, our results suggest significantly worse measures of depression and a significantly higher frequency of anxiety in the SBD-EDS population. Measures of anxiety and depression significantly correlated with quality of sleep in both groups.

Cerebral blood flow in stroke patients with sleep apnea: any role of single-night positive airway pressure therapy?

BACKGROUND AND OBJECTIVE: Sleep-disordered breathing (SDB) is more prevalent in patients with stroke than in the population without a history of stroke. SDB is an independent risk factor for stroke. SDB impairs cerebral circulation by several mechanisms, and therefore possibly contributes to wake-up stroke. Ultrasound-tagged near-infrared spectroscopy (UT-NIRS) is a novel technology able to detect cerebral blood flow noninvasively and in real-time, displaying cerebral flow as cerebral flow index (CFI). Positive airway pressure (PAP) is the most effective approach in the treatment of SDB. We aimed to assess if single-night PAP impacts cerebral blood flow in sleep apnea patients after stroke and without a history of stroke. MATERIALS AND METHODS: 11 stroke patients and six controls with sleep apnea were enrolled. Stroke patients underwent overnight pulse oximetry within seven days after stroke. Desaturation index ≥ 15/hour was considered a positive screening. Six weeks after stroke, patients with positive screening underwent overnight polysomnography together with cerebral blood flow monitoring using UT-NIRS (diagnostic night) and also with additional PAP therapy (therapeutic night). RESULTS: The number of respiratory events decreased significantly in the group of stroke patients (apnea-hypopnea index [AHI] from 22.6±9.0 to 9.9±9.9) and controls (AHI from 58.1±14.9 to 7.0±9.7). CFI showed no significant changes between a diagnostic and therapeutic night in both groups. CONCLUSION: Despite the significant reduction of respiratory events, single-night PAP therapy does not improve overall cerebral blood flow, as defined by CFI.