Seizure symptoms and ambulatory EEG findings: incidence of epileptiform discharges.

AIMS: Ambulatory video-EEG monitoring has been utilized as a cost-effective alternative to inpatient video-EEG monitoring for non-surgical diagnostic evaluation of symptoms suggestive of epileptic seizures. We aimed to assess incidence of epileptiform discharges in ambulatory video-EEG recordings according to seizure symptom history obtained during clinical evaluation. METHODS: This was a retrospective cohort study. We queried seizure symptoms from 9,221 consecutive ambulatory video-EEG studies in 35 states over one calendar year. We assessed incidence of epileptiform discharges for each symptom, including symptoms that conformed to a category heading, even if not included in the ILAE 2017 symptom list. We report incidences, odds ratios, and corresponding p values using Fisher's exact test and univariate logistic regression. We applied multivariable logistic regression to generate odds ratios for the six symptom categories that are controlled for the presence of other symptoms. RESULTS: History that included motor symptoms (OR=1.53) or automatisms (OR=1.42) was associated with increased occurrence of epileptiform discharges, whereas history of sensory symptoms (OR=0.76) predicted lack of epileptiform discharges. Patient-reported symptoms that were associated with increased occurrence of epileptiform discharges included lip-smacking, moaning, verbal automatism, aggression, eye-blinking, déjà vu, muscle pain, urinary incontinence, choking and jerking. On the other hand, auditory hallucination memory deficits, lightheadedness, syncope, giddiness, fibromyalgia and chronic pain predicted absence of epileptiform discharges. The majority of epileptiform discharges consisted only of interictal sharp waves or spikes. CONCLUSIONS: Our study shows that the use of ILAE 2017 symptom categories may help guide ambulatory video-EEG studies.

Missing value imputation for physical activity data measured by accelerometer.

An accelerometer, a wearable motion sensor on the hip or wrist, is becoming a popular tool in clinical and epidemiological studies for measuring the physical activity. Such data provide a series of activity counts at every minute or even more often and displays a person's activity pattern throughout a day. Unfortunately, the collected data can include irregular missing intervals because of noncompliance of participants and therefore make the statistical analysis more challenging. The purpose of this study is to develop a novel imputation method to handle the multivariate count data, motivated by the accelerometer data structure. We specify the predictive distribution of the missing data with a mixture of zero-inflated Poisson and Log-normal distribution, which is shown to be effective to deal with the minute-by-minute autocorrelation as well as under- and over-dispersion of count data. The imputation is performed at the minute level and follows the principles of multiple imputation using a fully conditional specification with the chained algorithm. To facilitate the practical use of this method, we provide an R package accelmissing. Our method is demonstrated using 2003-2004 National Health and Nutrition Examination Survey data.

Objective Measurement of Adherence to Out-Patient Airway Clearance Therapy by High-Frequency Chest Wall Compression in Cystic Fibrosis.

BACKGROUND: Objective measures of adherence to high-frequency chest wall compression (HFCWC), a form of airway clearance therapy for patients with cystic fibrosis, are lacking. We used a novel electronic monitoring device integrated into an HFCWC vest to measure adherence compared with self-reported adherence. We determined factors that influenced adherence and how adherence correlated with baseline pulmonary function and pulmonary exacerbations. METHODS: Data were collected by direct measurement of date, time of day, and duration of HFCWC use to determine the number of daily treatments and daily duration of treatments. Chart review provided prescribed airway clearance therapy treatment and demographic and clinical information. Subject and caregiver report of the daily number of airway clearance therapy treatments was obtained by telephone interviews. Analysis used 2-sample and paired t test, analysis of variance, and linear regression. RESULTS: Average adherence was 69%. Adherence was highest in children (82%, P = .02) and those receiving assistance with treatment (82%, P < .001). Subjects overestimated therapy duration from a mean ± SD of 127 ± 169% by adults to 19.2 ± 26.3% by parents or guardians of children. Average adherence decreased with increasing prescribed therapy time (P = .02). Average daily therapy time and adherence had significant positive associations with baseline FEV1 percent of predicted (P = .02 and P = .02, respectively) and negative associations with pulmonary exacerbations during the pre-study period and at baseline (P = .044 and P = .02, respectively). CONCLUSIONS: Greater adherence to HFCWC measured directly by a novel recorder was associated with better baseline pulmonary function and fewer exacerbations in the pre-study and baseline period. Adherence decreased with age and prescribed therapy time and increased with therapy assistance. Self-report overestimation is large and thus not an accurate measure of adherence.

Daily step count and the need for hospital care in subsequent years in a community-based sample of older Australians.

OBJECTIVES: To determine the extent to which physical activity reduces the number of hospital bed-days for Australians over 55, using an objective measure of activity. DESIGN, SETTING AND PARTICIPANTS: 9784 Newcastle residents aged 55 years or more were invited to participate. 3253 responders were eligible and wore pedometers for one week during 2005-2007; their hospital data from recruitment to 31 March 2015 were analysed (mean follow-up time: 8.2 years). Complete data for 2110 people were available for analysis. MAIN OUTCOME MEASURES: Mean annual hospital bed-days, according to individual step count. RESULTS: There was a statistically significant reduction in the number of hospital bed-days associated with higher step counts; the incidence rate ratio per extra 1000 steps per day at baseline was 0.91 (95% CI, 0.90-0.94). The disease-specific reductions were significant for admissions for cancer and diabetes, but not for cardiovascular disease. The difference between 4500 and 8800 steps per day (the upper and lower quartile boundaries for step count) was 0.36 bed-days per person per year, after adjusting for age, sex, number of medications, number of comorbidities, smoking and alcohol status, and education. When analysis was restricted to hospital admissions after the first 2 years of follow-up, the difference was 0.29 bed-days per person per year. CONCLUSIONS: More active people require less hospital care, and an achievable extra 4300 steps per day would result in an average of one less day in hospital for each 3 years of life.

Manejo ambulatorio de la enfermedad pulmonar obstructiva crónica / Outpatient Management of Chronic Obstructive Pulmonary Disease

La Organización Mundial para la Salud (OMS) estima que actualmente en el mundo existen 210 millones de personas que padecen EPOC; asimismo estima que en el año 2030 esta enfermedad será la tercera causa de muerte a nivel mundial. El 90% de las muertes se producen en países de ingresos medios a bajos. De las dos presentaciones de EPOC la más frecuente es a nivel mundial bronquitis crónica...(AU)

Proposed comprehensive ototoxicity monitoring program for VA healthcare (COMP-VA).

Prevention and rehabilitation of hearing loss and tinnitus, the two most commonly awarded service-connected disabilities, are high priority initiatives in the Department of Veterans Affairs (VA). At least 4,000 Veterans, most with significant hearing loss, will receive cisplatin this year, with more than half sustaining permanent hearing shift and nearly 40% developing new tinnitus. With improved survivability following cancer treatment, Veterans treated with cisplatin are approached with the dual goals of effective treatment and preserved quality of life. This article describes COMP-VA, a comprehensive ototoxicity monitoring program developed for VA patients receiving cisplatin. The program includes an individualized pretreatment prediction model that identifies the likelihood of hearing shift given cisplatin dose and patient factors. It supports both manual and automated hearing testing with a newly developed portable audiometer capable of performing the recommended procedures on the chemotherapy unit during treatment. It also includes objective methods for identifying outer hair cell changes and predicting audiogram changes using distortion-product otoacoustic emissions. We describe this program of evidence-based ototoxicity monitoring protocols using a case example to give the reader an understanding of how this program would be applied, along with a plan for future work to accomplish the final stages of program development.

Clinical usefulness of watch-PAT for assessing the surgical results of obstructive sleep apnea syndrome.

OBJECTIVE: This study aimed to assess the accuracy and clinical efficacy of a wrist-worn device that is based on peripheral arterial tonometry (watch-PAT) to evaluate the surgical results of obstructive sleep apnea (OSA) syndrome subjects. STUDY DESIGN AND METHOD: Thirty-five subjects who were diagnosed with OSA and underwent sleep surgeries such as septoplasty, tonsillectomy, or uvuloplasty to correct their airway collapse, participated in this study; the watch-PAT-derived respiratory disturbance index (RDI), apnea and hypopnea index (AHI), lowest oxygen saturation, and valid sleep time were measured after the sleep surgery. RESULTS: The present study showed that RDI (32.8 ± 10.7 vs. 14.8 ± 7.5), AHI (30.3 ± 8.6 vs. 13.4 ± 8.2 events/h), lowest oxygen saturation (78.2% ± 8.4% vs. 90.5% ± 7.1%), and valid sleep time (329.1 ± 47.2 min and a postoperative value of 389.1 ± 50.1 min) recovered to within a normal range after surgery in 28 subjects. In addition, good agreement was found between watch-PAT-derived factors and visual analogue scales for changes in subjective symptoms, such as snoring, apnea, and daytime somnolence. Seven of the 35 subjects showed no improvement for their subjective symptoms and complained of snoring and apnea after surgery. We found that the RDI and AHI of those 7 subjects were not reduced, and the changes between pre- and postoperative values which were measured with watch-PAT were minimal. Their postoperative lowest oxygen saturation and valid sleep time were not elevated per the watch-PAT. The results support a strong correlation between the findings from watch-PAT and improved symptoms after surgical correction of an airway collapse. CONCLUSIONS: Our study provides evidence that the factors measured by the watch-PAT might be reliable indicators of symptomatic changes in OSA subjects after sleep surgery and also shows that the watch-PAT is a highly sensitive portable device for estimating treatment results in OSA.

The ambulatory arterial stiffness index and target-organ damage in Chinese patients with chronic kidney disease.

BACKGROUND: The ambulatory arterial stiffness index (AASI) can be used to predict cardiovascular morbidity and mortality in hypertensive patients. However, data on AASI in Chinese patients with chronic kidney disease (CKD) is not available. METHODS: This cross-sectional study enrolled 583 CKD patients. Univariate and multivariate analyses were used to evaluate the relationship between AASI and renal function and parameters of cardiovascular injury. RESULTS: Patients with a higher AASI had a higher systolic blood pressure, a lower estimated glomerular filtration rate (eGFR), a higher serum cystatin C, a higher left ventricular mass index (LVMI) and carotid intima-media thickness (cIMT). Univariate analyses showed that AASI was positively correlated with serum cystatin C (r=0.296, P < 0.001), serum creatinine (r=0.182, P < 0.001), and LVMI (r = 0.205, P < 0.001) and negatively correlated with the eGFR (r = -0.200, P < 0.001). Multivariate analyses revealed that serum cystatin C, eGFR, serum creatinine and LVMI were independently correlated with AASI. CONCLUSIONS: These data suggest that AASI was closely correlated with renal function and parameters of cardiovascular injury in Chinese CKD patients. Good quality, long-term, large longitudinal trials to validate the role of AASI in clinical practice for Chinese CKD patients.

Factors associated with participant compliance in studies using accelerometers.

Participant compliance is an important issue in studies using accelerometers. Some participants wear the accelerometer for the duration specified by the researchers but many do not. We investigated a range of demographic factors associated with participant compliance in obtaining analyzable accelerometer data. A total of 3601 participants (aged 47.6±13.1 years, 44.6% male) were included. They were asked to wear an accelerometer (ActiGraph) for four consecutive days after completing a household survey during March 2009-January 2011 in Hong Kong. Participants wore the accelerometer on average for 13.9h in a 24-h day. No significant difference was found between males and females (p=0.38). Using log-linear regression, it was found that older participants (0.5% more wearing hours for each year of age, p<0.001), those with full-time job (p<0.01), with tertiary education (p<0.01), non-smokers (p<0.01) and with high self-reported health (p<0.05) wore the accelerometer for more hours. These results provide details for estimating compliance rates for samples with different characteristics and thus sample size calculation to account for participant compliance.

Validation of activity questionnaires in patients with cystic fibrosis by accelerometry and cycle ergometry.

BACKGROUND: The objective of this study was to validate physical activity questionnaires for cystic fibrosis (CF) against accelerometry and cycle ergometry. METHODS: 41 patients with CF (12-42 years) completed the Habitual Activity Estimation Scale (HAES), the 7-Day Physical Activity Recall questionnaire (7D-PAR) and the Lipid Research Clinics questionnaire (LRC) and performed an incremental exercise test according to the Godfrey protocol up to volitional fatigue. Time spent in moderate and vigorous physical activity (MVPA) assessed objectively by accelerometry was related to the time spent in the respective activity categories by correlation analyses and calculating intraclass correlation coefficients (ICC). Furthermore, the results of the exercise test were correlated with the results of the questionnaires. RESULTS: Time spent in the categories 'hard','very hard' and 'hard & very hard' of the 7D-PAR (0.41 < r < 0.56) and 'active' (r = 0.33) of the HAES correlated significantly with MVPA. The activity levels of the LRC were not related to objectively determined physical activity. Significant ICCs were only observed between the 7D-PAR activitiy categories and MVPA (ICC = 0.40-0.44). Only the LRC showed moderate correlations with the exercise test (Wmax: r = 0.46, p = 0.002; VO2peak: r = 0.32, p = 0.041). CONCLUSIONS: In conclusion, the activity categories 'hard' and 'very hard' of the 7D-PAR best reflected objectively measured MVPA. Since the association was at most moderate, the 7D-PAR may be selected to describe physical activity within a population. None of the evaluated questionnaires was able to generate valid physical activity data exercise performance data at the individual level. Neither did any of the questionnaires provide a valid assessment of aerobic fitness on an invidual level.

Step-based translation of physical activity guidelines in the Lower Mississippi Delta.

To determine how many steps·day(-1) equate to current moderate-to-vigorous physical activity (MVPA) guidelines in a population from the Lower Mississippi Delta (LMD) of the United States, 58 overweight adults wore an Actigraph accelerometer (GT3X) for up to 2 weeks. Min·day(-1) in MVPA was a good predictor of steps·day(-1) (r(2) = 0.62; p < 0.001; linear regression), such that 30 min of daily MVPA equated to 9154 steps·day(-1) (mixed-model approach). Using receiver operating characteristic analysis, sensitivity and specificity were optimized at 8357 steps·day(-1). Results indicate that overweight residents of the LMD should be accumulating at least 8300-9100 steps·day(-1) to meet the recommendation of 30 min·day(-1) MVPA.

Telemonitoring in chronic obstructive airway disease and adult patients with cystic fibrosis.

We compared the use of telemonitoring in patients with chronic obstructive pulmonary disease (COPD) and adult patients with cystic fibrosis (CF). Seventy patients (51 CF and 19 COPD) were enrolled in two studies of six months' duration. Patients used a personal data assistant (PDA) attached to a spirometer to score symptoms and to perform daily spirometry. Criteria for diagnosis of exacerbations of COPD and CF were pre-defined. When exacerbations were detected, patients were offered treatment according to a pre-designed protocol. Thirty-two (63%) CF patients and one (5%) COPD patient withdrew from the studies due to lack of adherence to daily recording. For those who remained in the study, COPD patients recorded more study days (139) than CF patients (113), P = 0.03. The median number of exacerbations detected during the study was greater in COPD than in CF patients, although this was not significant. The median number of device-detected exacerbations in the COPD group was significantly greater than in the CF group, P = 0.024. When compared to a parallel period in the previous year, the number of hospitalisations for COPD exacerbations was reduced, whereas the number of intravenous antibiotics in CF patients did not differ. Adherence to telemonitoring was much greater for COPD than CF patients and the results appear to be more favourable for COPD patients than for CF patients.

Reliability and validity of the habitual activity estimation scale (HAES) in patients with cystic fibrosis.

PURPOSE: To understand potential benefits of exercise in the cystic fibrosis (CF) population, there needs to be accurate methods to quantify it. The Habitual Activity Estimation Scale (HAES) questionnaire has been shown to be a feasible tool to measure physical activity however the reliability and validity have yet to be determined in the CF population. METHODS: Fourteen (seven male, seven female) patients aged 16.2 +/- 4.2 years with CF participated in this study. Participants were clinically stable at the time of the study and participating in their habitual physical activity. To assess reliability, patients completed the HAES and a validated 3-day activity diary, and wore an ActiGraph Accelerometer for two consecutive weeks. Validity was assessed by comparing the activity results of each of the three instruments over a single week time period. RESULTS: ICC estimates of reliability for the HAES, diary, and accelerometer were 0.72 (P < 0.0001), 0.76 (P < 0.0001), 0.63 (P < 0.0001), respectively. Validity analysis indicated that there were significant relationships between the participants' activity results as estimated by the HAES, diary and accelerometer. Further, significant relationships were detected between activity measures when broken into morning, afternoon, or evening periods, and between measures from weekday or weekend days. There were also significant relationships among the three instruments when recording different activity levels (somewhat inactive, somewhat active, and very active). CONCLUSION: The findings of this study suggest that the HAES questionnaire is a reliable and valid instrument that can be used to assess activities of varying intensity in patients with CF.

Prevalence and clinical significance of isolated ambulatory hypertension in young subjects screened for stage 1 hypertension.

Little is known about the clinical significance of isolated ambulatory hypertension, a condition characterized by low office but elevated ambulatory blood pressure. This study aimed to investigate the prevalence and the predictive value of isolated ambulatory hypertension diagnosed after 3 months of observation for the development of sustained hypertension within a cohort of 871 never-treated stage-1 hypertensive subjects. The study end point was progression to more severe hypertension and need of antihypertensive medication. In 244 subjects (28%), clinic blood pressure declined to <140/90 mm Hg after 3 months. Of these, 124 (14.2% of total) had low clinic and ambulatory blood pressures after 3 months (nonhypertensive subjects), whereas 120 subjects (13.8% of total) showed low clinic but elevated ambulatory blood pressure (isolated ambulatory hypertension). During the 6 years of observation, the number of end points based on multiple clinic blood pressure readings progressively increased from the nonhypertensive subjects (19%) to the subjects with isolated ambulatory hypertension (35%) and to the subjects with high clinic and high ambulatory blood pressures (65%, P<0.0001). In an adjusted proportional hazard model, isolated ambulatory hypertension status was associated with a 2.2 (P=0.02) increase in the risk of reaching the end point in comparison with the nonhypertensive subjects. Final ambulatory systolic blood pressure was also higher in the former than the latter (P=0.03). Our results indicate that among subjects screened for stage 1 hypertension, individuals with isolated ambulatory hypertension after 3 months of observation have increased risk of developing sustained hypertension in later life compared with subjects in whom both clinic and ambulatory blood pressures are normal.

[Apnea states in infants, anxiety of parents and pediatricians, and home monitoring of respiration in children]. / Stany bezdechu u niemowlat, obawy rodziców i pediatrów a domowe monitorowanie oddechu u dzieci.

In order to determine parental reasons of the use of home apnea/respiration monitors and to estimate the grounds of these decisions correspondence contact was achieved with the parents of 71 infants monitored by means of the APNEAL-1 device. Filled up questionnaires were the source of data regarding the families (structure, health practices, mothers' age and education, course of pregnancy and delivery), monitored infants (birth weight, Apgar score, apnea events) and the reasons of monitoring. Also opinions concerning monitor usefulness and performance were gathered. The majority of our families (> 97%) consisted of both parents, their socio-economic status was medium (52.11%) or good (46.48%) and they were residents of cities (88.73%). Cigarette smoking was present in 22 families (31%) with 13 smoking mothers (18.31%). Mothers' mean age was 29.11 years (SD 4.84), 45% of them had high school education and 36.62%-university education. As many as 45% of the pregnancies had a pathological course and 34.3% were terminated by a preterm delivery. Mean birth weight of monitored children was 2914.93 g (SD 971.4), mean Apgar score was 8.31 (SD 2.46). More than 60% of children were breast fed during the first six months of life, and 30% of them--during first year of life. Bed sharing was reported in only 8% of children. Apnea episodes were observed in 30 infants (42.25 of whole group), in 20 of them only during the neonatal period. More apnea episodes were present in premature infants (48% of premature versus 30% of full term infants). Only 12 children (16.9% of whole group) manifested apnea events during the monitoring period. However, almost all the parents (97%) had a high opinion of the role played by the monitor (mean monitoring time 7.12 months, SD 4.44). In 27 families (38%) a cause of monitoring was a preceeding apnea event. The decision of remaining parents was based exclusively on fear. This fear was justified only in a small number of families (previous SIDS victim, GER). Numerous children were monitored solely on the basis of information of apnea existence in children. Such a difficult to accept monitoring reason probably has its source in inappropriate family health education.

[SIDS prevention program in Tyrol]. / Das SIDS-Vorsorgeprogramm Tirol.

In April 1994, an intervention campaign to reduce the incidence of sudden infant death syndrome (SIDS) was established in the Tyrol. The campaign was intended to increase knowledge concerning risk factors for SIDS in the general community and to improve individual care for infants at risk. In contrast to interventional programmes in other federal states of Austria (i.e. Vorarlberg, Styria), this programme did not utilise polysomnography for identifying infants at risk. A part of the intervention programme was the "Styrian risk questionnaire", a standardised questionnaire concerning risk factors for SIDS. Individual instructions for health care of children at risk (risk score > or = 7) were provided and, if necessary, subscription of home monitoring was performed at the out-patient department (SIDS out-patient service) of the Department of Paediatrics in Innsbruck and other paediatric departments throughout the Tyrol. The educational programme also included information concerning basic life support. Psychological support was offered to parents of SIDS infants. Risk factors for SIDS in the Tyrol before the campaign were assessed in a retrospective case-control study (time period 1984-1994; 99 SIDS infants, 136 controls). The risk of SIDS was markedly reduced when parents had detailed knowledge of the risk factors of SIDS (odds ratio (OR) 0.03; p < 0.001), which emphasises the importance of information and educational programmes. The incidence of SIDS declined after the beginning of the intervention campaign from 1.83/1000 live births (average incidence from 1984-1994) to 0.4/1000 live births and remained at this level thereafter. Post-neonatal mortality also declined from 3.9 to 1.3/1000 live births. The prevalence of the prone sleeping position declined immediately after the campaign (53.7% vs. 5.4%, p < 0.001), as did the frequency of maternal smoking during pregnancy (22.9% vs. 14.5%, p < 0.01). Breast feeding became more popular. In all, the low-cost intervention programme in the Tyrol proved to be highly efficient in reducing the risk of SIDS and in maintaining this effect for several years.

Relationship between endoscopic esophagitis and patterns of gastroesophageal reflux in ambulatory pHmetry.

AIM: to evaluate the possible relationship between the various grades of endoscopic esophagitis and the different patterns of reflux determined by 24-hour ambulatory pH-metry. PATIENTS AND METHODS: we selected 80 patients with symptoms of gastroesophageal reflux disease in whom upper digestive tract endoscopy revealed some degree of mucosal lesion. These patients subsequently underwent 24-hour ambulatory pH-metry. The lesions of the mucosa were classified into 4 grades according to the criteria of Savary and Miller. The patterns of reflux were determined by 24-hour pH-metry and classified according to the severity of reflux (slight, moderate or severe, using DeMeester's table) and the type of reflux (in bipedestation, supine or mixed) according to the percentage of time at pH < 4 in bipedestation, in decubitus or in both positions. RESULTS: patients with grades I and II esophagitis showed variable patterns of reflux, although the most frequent seemed to be slight in bipedestation, which we observed in 34% of the patients. Most (76. 2%) of the patients with grades III or IV (p < 0.05) showed a clearly defined pattern of severe type in the supine position or in both positions. CONCLUSIONS: the presence of a reflux pattern of predominantly supine or mixed type in 24-hour pH-metry may help to identify patients at higher risk for developing severe esophagitis or other complications.

[Outpatient urodynamic monitoring in the diagnosis of subclinical forms of a urination disorder in women]. / Ambulatornyi monitoring urodinamiki v diagnostike subklinicheskikh form narusheniia mocheispuskaniia u zhenshchin.

The authors studied potentialities of outpatient urodynamic monitoring in diagnosis of subclinical urination defects in females. The examination was made of 31 females aged 25-55 years (mean age 43.8 years) with complaints of pollakiuria, precipitant urination. Laboratory urodynamic investigation combined retrograde cystometry, profilometry and uroflowmetry (Jupiter 8000 Video produced by WIEST) and was followed by urodynamic monitoring (CAMSYS 6300 by WIEST). Standard combined urodynamic evaluation registered normal urodynamic parameters in 17 females, unstable urethra in 4, unstable detrusor in 7, unstable urethra and detrusor in 3 patients. The curves devised on the basis of the outpatient urodynamic monitoring data indicated that; normal urodynamics, unstable urethra, unstable detrusor, detrusor-sphincter dyssynergia, combined instability of urethra and detrusor, unstable detrusor plus detrusor-sphincter dyssynergia in 4, 10, 7, 3, 2, 2 females, respectively. 3 cases were ineligible. The above investigation promoted accurate diagnosis in 41.9% of cases. Outpatient monitoring is a method of choice in diagnosis of subclinical urination disorders.