Increased incidence of nonfatal cardiovascular events in stroke patients with sleep apnoea: effect of CPAP treatment.

Obstructive sleep apnoea (OSA) is a risk factor for stroke, but little is known about the effect of OSA and continuous positive airway pressure (CPAP) on the incidence of long-term, nonfatal cardiovascular events (CVE) in stroke patients. A prospective observational study was made in 223 patients consecutively admitted for stroke. A sleep study was performed on 166 of them. 31 had an apnoea/hypopnoea index (AHI) <10 events · h(-1); 39 had an AHI between 10 and 19 events · h(-1) and 96 had an AHI ≥ 20 events · h(-1). CPAP treatment was offered when AHI was ≥ 20 events · h(-1). Patients were followed up for 7 yrs and incident CVE data were recorded. The mean ± SD age of the subjects was 73.3 ± 11 yrs; mean AHI was 26 ± 16.7 events · h(-1). Patients with moderate-to-severe OSA who could not tolerate CPAP (AHI ≥ 20 events · h(-1); n = 68) showed an increased adjusted incidence of nonfatal CVE, especially new ischaemic strokes (hazard ratio 2.87, 95% CI 1.11-7.71; p = 0.03), compared with patients with moderate-to-severe OSA who tolerated CPAP (n = 28), patients with mild disease (AHI 10-19 events · h(-1); n = 36) and patients without OSA (AHI <10 events · h(-1); n = 31). Our results suggest that the presence of moderate-to-severe OSA is associated with an increased long-term incidence of nonfatal CVE in stroke patients and that CPAP reduces the excess of incidence seen in these patients.

[News on venous thromboembolic disease]. / Novedades en la enfermedad tromboembólica venosa.

This paper brings together the latest developments that have occurred in different aspects of venous thromboembolism (VTE): VTE prophylaxis in high-risk orthopedic surgery and acutely ill hospitalized medical patients; therapeutic advances in pulmonary embolism and superficial vein thrombosis and VTE future prospects. It summarizes the reviews that five speakers made in-depth for the Second Day in New Anticoagulant Treatment, held in Madrid on November 18, 2011, organized by the Foundation for the Study of Thromboembolic Disease in Spain and endorsed by the Spanish Society of Internal Medicine, Spanish Society of Pneumology and Thoracic Surgery, Spanish Society of Cardiology, Spanish Society of Thrombosis and Haemostasis and the Spanish Society of Angiology and Vascular Surgery.

[Impact of exacerbations on the clinical course of chronic obstructive pulmonary disease]. / Impacto de las exacerbaciones en la evolución de la EPOC.

The clinical course of chronic obstructive pulmonary disease (COPD) is marked by frequent exacerbations. Not all patients suffer exacerbations and not all decompensations have the same consequences; however, in the last few years, these episodes of clinical instability - especially if recurrent - have come to be viewed as a major element in the natural history of the disease insofar as they generate heavy workload and high costs, síntonegatively affect patients' quality of life, contribute to the multidimensional progression of the disease and, finally, affect its prognosis. The present article reviews the current scientific evidence on the impact of exacerbations on the clinical course of COPD and analyzes this impact from a multidimensional perspective. The need to base the management of COPD on clinical phenotypes is discussed, emphasizing the importance of the exacerbation phenotype, a clinical phenotype characterized by frequent exacerbations. This phenotype is often associated with the presence of cough and chronic expectoration, latent bronchial infection and bronchiectasis and leads to higher morbidity and mortality.

[Morbidity from patients admitted for heart failure in the departments of internal medicine]. / Comorbilidad de los pacientes ingresados por insuficiencia cardiaca en los servicios de medicina interna.

BACKGROUND AND OBJECTIVES: Heart Failure (HF) patients present frequently comorbidities. Little is known about the impact of these comorbidities in morbimortality. We analyzed the comorbidities of HF patients admitted in Spanish internal medicine units and its relation with different socio-demographics and clinical variables. PATIENTS AND METHODS: We studied prospectively 2127 patients (admitted from 01.10.2000-28.02.2001) with HF in 51 Hospitals of different categories (from local hospitals to university hospitals) in which an internist was available to collaborate in the study. Comorbidities were estimated by the Charlson index. RESULTS: Mean age was 77 years (women 57%). 45% of patients have had a previous admission in the last year. 41% had a functional stage NYHA iii/iv. Eyection fraction was preserved in 53% of patients. Comorbidities were identified in 60% of patients (diabetes mellitus, 39%; chronic lung disease 31%). The average Charlson index was 5.4 points (range 2-11 points). Global inhospital mortality was 6.1%. During the admission more patients died in the Group with higher comorbidities (Charlson, >3 points; 8.4%) than in the Group with low Charlson index (1-2, 5.2%; p<0.01). Treatments prescribed were similar in both groups. In a multivariant analysis comorbidities was associated independently with masculine gender, age superior to 75 years, functional status NYHA iii/iv and dysfunctional physical capacity. CONCLUSIONS: Comorbidities determined by Charlson index were associated with more frequent admission, longer stay in hospital, higher discapacity and higher mortality. These results enhance the importance of comorbidities in prognosis of heart failure patients admitted in internal medicine units in Spain.

Obstructive sleep apnea has little impact on quality of life in the elderly.

STUDY OBJECTIVE: To analyze the impact of the number of respiratory sleep disorders or clinically related conditions (especially excessive daytime sleepiness [EDS]), on health related quality of life (HRQoL) in subjects over 65 years of age, as compared to younger subjects and the general population. METHODS: Two hundred and twelve adult patients with obstructive sleep apnea (OSA, AHI> or =10) divided into two age groups, over 65 (n=109, mean age 74.6 [6,8] years, and 65 or under (n=103, mean age 51.7, [6,5] years). General, anthropometric and clinical data related to OSA (epworth sleepiness score [ESS]), comorbidities (Charlson comorbidity index [CCI]), HRQoL (SF-36 questionnaire), use of psychotropic medications and habitual polygraphic/polysomnographic parameters were recorded and compared between the two age groups. The HRQoL values in each age group were compared with the values in the general population, adjusted for age and gender. RESULTS: In patients 65 and under, both the presence of OSA as well as the presence of EDS (ESS>11) were associated with an important deterioration in HRQoL as compared to normal reference values. The principal determinants of HRQoL were the presence of EDS (p<0.04), body mass index (p<0.03) and the apnea-hypopnea index (AHI) (p<0.04). Nevertheless, in subjects over 65 years of age, the presence of OSA or EDS had only a slight impact on HRQoL, relative to normal values. In this age group, the principal determinants of HRQoL were the presence of comorbidities (CCI, p<0.01), age (p<0.01), oxygen desaturation parameters (p<0.04) and the use of psychotropic medications (p<0.04). CONCLUSION: In elders, the presence of OSA with or without EDS has little impact on HRQoL measures.

Dissociation of lung function, dyspnea ratings and pulmonary extension in bronchiectasis.

UNLABELLED: Bronchiectasis is a heterogeneous disease in terms of its clinical and functional presentation. Some isolated parameters have been used to assess the severity of bronchiectasis or its response to treatment. A study was undertaken to evaluate whether lung function, dyspnea and extension of the disease are separate entities in the impact of bronchiectasis upon patients using factor analysis. Patients with bronchiectasis diagnosed by high-resolution computed tomography (HRCT) and airflow obstruction defined by FEV1/FVC<70% were included. Data were collected relating to clinical history, three different clinical ratings of dyspnea (Medical Research Council (MRC), Borg scale and Basal Dyspnea Index), the extent of bronchiectasis and functional variables. A total of 81 patients (mean age (SD): 69.5 (8.7)) years were included. The degree of dyspnea (MRC) was 1.9 (0.8). Mean FEV1 was 1301 ml (56.9% pred.). Four factors were found that accounted for 84.1% of the total data variance. Factor 1 (45.6% of the data variance) included the three measurements of dyspnea. Factor 2 (16% variance) comprised airflow obstruction parameters (FEV1, FEV1/FVC and PEF). Factor 3 (13.8% variance) included RV/TLC and RV (lung hyperinflation). Factor 4 (8.6% variance) included bronchiectasis extent. Dyspnea was more closely correlated with lung hyperinflation (r:0.33-0.54) than with airflow obstruction parameters (r:0.17-0.26). CONCLUSIONS: Airflow obstruction, dyspnea, lung hyperinflation and the lung extent of the bronchiectasis are four independent entities in the impact of bronchiectasis upon patients.

[Sleep-disordered breathing in patients with difficult-to-control hypertension]. / Trastornos respiratorios durante el sueño en pacientes con hipertensión arterial de difícil control.

OBJECTIVE: To analyze the relationship between sleep-disordered breathing and difficult-to-control arterial hyper-tension. PATIENTS AND METHODS: Patients were considered to have difficult-to-control hypertension when mean systolic blood pressure was 125 mm Hg or higher and/or mean diastolic blood pressure was more than or equal to 80 mm Hg (as recorded during 2 24-hour ambulatory monitoring studies) despite the use of 3 or more antihypertensive drugs. Respiratory polygraphy using the AutoSet device (ResMed Corp, Sydney, Australia) was then performed to study sleep-disordered breathing in all patients. RESULTS: Forty-nine patients with a mean (SD) age of 68.1 (9.1) years, mean systolic and diastolic pressures of 152.5 (13)/89.2 (8.5) mm Hg, and an average of 3.5 prescribed drugs were included in the study. The mean apnea-hypopnea index (AHI) was 26.2 (19.5) and events were predominantly obstructive. Patients with severe sleep apnea-hypopnea syndrome (SAHS) (AHI > or = 30; 40.8%) showed more uncontrolled daytime (P = .017) and nighttime (P = .033) systolic pressure than the rest, as well as higher daytime diastolic pressure (P = .035) and a greater consumption of drugs than those without severe SAHS (AHI < 10; 28.6%) (P = .041). The study population as a whole showed a significant correlation between blood pressure and obesity. There was a significant correlation (adjusted for age and sex) with AHI only in patients with SAHS. AHI was found to be the independent predictor with the greatest effect on blood pressure in these patients. CONCLUSIONS: Prevalence of SAHS was very high in patients with difficult-to-control hypertension. In patients with SAHS, AHI was found to be the independent predictor with the greatest affect on arterial blood pressure.

[RECALMIN. Patient care in the internal medicine units of the Spanish national health system]. / RECALMIN. La atención al paciente en las unidades de Medicina Interna del Sistema Nacional de Salud.

OBJECTIVES: To perform a situation analysis of the care provided by internal medicine units (IMUs) in Spain and to develop, based on this analysis, proposals for improving the quality of care in these units. MATERIAL AND METHODS: A descriptive, cross-sectional study of the IMUs of general acute care hospitals of the Spanish National Health System (SNHS), with data referring to 2013. The study variables were collected via an ad hoc questionnaire. RESULTS: Of the total 260hospitals identified in the SNHS, 142responses were obtained from 139hospitals throughout Spain, which represents 53.5% of the IMUs in the SNHS. The mean number of internists per IMU was 14±8, with a mean rate of 7.2±3.3 internists per 100,000 inhabitants. In 2013, the average number of hospital discharges from the IMU was 2,987±2,066, and those discharged by internists was 232±107. Sixty-one percent of the IMUs had implemented an interconsultation unit, and 41% had implemented a systematic care program for complex chronic patients. Thirty-three percent of the IMUs conducted multidisciplinary rounds, and 60% of these IMUs planned the discharge. CONCLUSIONS: The 2013 RECALMIN survey revealed a number of important aspects of the organisation, structure and management of IMUs. The remarkable variability in the indicators of structure, activity and management probably reflect significant differences in efficiency and productivity, which therefore provide significant room for improvement.

Factors influencing medical treatment of heart failure patients in Spanish internal medicine departments: a national survey.

BACKGROUND: The medical management of heart failure (HF) in clinical practice varies considerably by country and by medical specialty. AIM: To assess the treatment of HF patients admitted to Internal Medicine departments, and to evaluate out-patient management prior to admission, by specialty. DESIGN: Prospective cross-sectional multi-centre survey. METHODS: Of 55 randomly selected Spanish hospitals, 51 agreed to participate. All patients (n = 2145) consecutively admitted for decompensated HF to the Departments of Internal Medicine of these hospitals, over 5 months, were included. Twenty variables were analysed, including aspects relating to out-patient management prior to admission. RESULTS: Mean +/- SD age was 77.2 +/- 10.5 years, 57.3% were female, 47% had systolic dysfunction. Prescriptions at discharge: loop diuretics 85.6%, spironolactone 29.8%, ACEIs 65.8%, beta-blockers 8.7%, cardiac glycosides 39%. At admission, 86% already had a diagnosis of HF. Of these, 53% (older patients and more women) were being treated on an out-patient basis by primary care physicians. Primary care physicians requested fewer echocardiograms than internists (38% vs. 69%, p<0.001) and prescribed fewer drugs (ACEIs 40% vs. 54%, p<0.001; spironolactone 15% vs. 23%, p<0.05; beta-blockers 6% vs. 13%, p<0.01). The internists treated more incapacitated patients than the cardiologists (p<0.001), prescribed more high-dose ACEIs (20% vs. 13%, p<0.01) and spironolactone (26% vs. 20%, p<0.05), and fewer anticoagulants (32% vs. 39%, p<0.05). DISCUSSION: Patients admitted to medical departments with HF are different to those found in clinical trials. Their management is currently suboptimal. Differences in treatment between internists and cardiologists appear to be accounted for by differences in the patients they treat.

[Internal consistency and validity of the Spanish version of the St. George's respiratory questionnaire for use in patients with clinically stable bronchiectasis]. / Consistencia interna y validez de la versión española del St. George's Respiratory Questionnaire para su uso en pacientes afectados de bronquiectasias clínicamente estables.

OBJECTIVE: To analyze the reliability and validity of the St. George's Respiratory Questionnaire (SGRQ) for use in patients with clinically stable bronchiectasis. MATERIAL AND METHODS: The SGRQ (50 items on 3 scales--symptoms, activity, and impact) was administered to 102 patients (mean [SD] age, 69.5 [8.7] years; 63% men) with clinically stable bronchiectasis. Disease severity was classified according parameters such as airflow obstruction (forced expiratory volume in 1 second), colonization by Pseudomonas aeruginosa, extent of bronchiectasis, symptoms, daily quantity of sputum, and number of exacerbations. Internal consistency (Cronbach's alpha and correlation between items and between item and scale), concurrent validity (correlation between items and clinical variables), predictive validity (correlation between items and severity), and construct validity (factorial analysis of main components) were assessed. RESULTS: The internal consistency of the SGRQ was excellent (Cronbach's alpha between 0.81 and 0.87 for the different scales, and 0.90 for the overall score). Concurrent validity was high, as correlations between items and clinical variables were significant and followed the expected distribution. The SGRQ differentiated between degrees of disease severity, regardless of the clinical variable used. The factorial analysis showed a construct of 4 factors that were only moderately similar to the original structure of the questionnaire, due mainly to inclusion of a small number of questions with conditioned response and others with low discriminatory capacity. CONCLUSIONS: The SGRQ shows excellent concurrent and predictive internal consistency and validity, though restructuring of the original construct would be advisable before use in patients with stable bronchiectasis.

High prevalence of Strongyloides stercoralis among farm workers on the Mediterranean coast of Spain: analysis of the predictive factors of infection in developed countries.

Strongyloidiasis is a parasitosis characterized by persistent infection before dissemination and the development of potentially fatal disease. Since diagnosis is difficult, knowledge of the prevalence and geographic distribution of the disease is of practical importance. A study was made of Strongyloides stercoralis infection in a random and representative sample of farm workers in a tourist region in Spain based on the detection of larvae of triple stool samples. The prevalence of infection was 12.4% (95% confidence interval [CI] = 8.4-16.4). None of the 26 clinical or epidemiologic variables analyzed were found to be predictive of infection. Only eosinophilia (> 400 eosinophils/mm3) was significantly greater among the infected individuals (odds ratio = 73.4, 95% CI = 16.3-327.0), with a sensitivity of 93.5% and a specificity of 93.1%. A screening program is proposed to detect eosinophilia, to provide treatment without stool examinations, and thus afford a cost-effective policy for preventing the development of severe forms of the disease among specific risk groups where the prevalence of other parasitoses is low.

[Sequential use of nocturnal pulse oximetry and respiratory polygraphy (AutoSet) for diagnosing sleep apnea/hypopnea syndrome in high risk patients]. / Uso secuencial de la pulsioximetría nocturna y la poligrafía respiratoria (AutoSet) para el diagnóstico del síndrome de apneas-hipopneas durante el sueño en pacientes con alta sospecha clínica.

OBJECTIVE: To construct an algorithm for the diagnosis of sleep apnea/hypopnea syndrome (SAHS) based on the optimized sequential use of nocturnal pulse oximetry and respiratory polygraphy (AutoSet, AS) in patients suspected of SAHS. METHODS: Simultaneous performance of pulse oximetry and AS in 145 patients highly suspected of SAHS (at least two of the following signs or symptoms: chronic snoring, observations of repeated apneic events, and abnormal daytime drowsiness). SAHS was diagnosed when the apnea/hypopnea index (AHI) was greater than or equal to 10, based on AS findings. The diagnostic algorithm was obtained by calculating the prevalence of SAHS, calculating the best diagnostic cutoff point for a desaturation index greater than or equal to 4% (ID4%) based on the AHI; analyzing the positive predictive value (PPV) and negative predictive value (NPV) for the cutoff and the correlation and agreement between ID4% and the AHI depending on the presence and severity of SAHS. RESULTS: The overall prevalence of SAHS was 83.4%. The best cutoff point was obtained using ID4% greater than or equal to 10 (sensitivity 82%; specificity 83%). The PPV and NPV for the prevalence calculated were 0.95 and 0.29, respectively. The correlation between ID4% and AHI was 0.84; overall agreement was 0.93. For patients who did not have SAHS, the PPV was 0.49, and the NPV was 0.35; both gradually increased in cases of mild, moderate and severe SAHS (to 0.90 and 0.95, respectively, for severe SAHS). Using these data we created a diagnostic algorithm according to which an ID4% greater than or equal to 30 for nocturnal pulse oximetry (sensitivity 72%, specificity 100%) would indicate that AS testing would be unnecessary. An ID4% less than 30, on the other hand, would lead to further testing (AS, or polysomnography in the event of a negative AS), based on the high prevalence of SAHS in our series. CONCLUSIONS: The sequential use of nocturnal pulse oximetry and AS allows substantial savings of polysomnographic testing in groups at high risk of SAHS.

[Prevalence of sleep-disordered breathing in patients with acute ischemic stroke: influence of onset time of stroke]. / Prevalencia de trastornos respiratorios durante el sueño en paciente con ictus isquémico agudo. Influencia del momento de aparición del ictus.

OBJECTIVE: To analyze the prevalence of sleep-disordered breathing in patients with acute ischemic stroke and the influence of the characteristics of the stroke and time of onset. PATIENTS AND METHODS: Polysomnography was performed with an Autoset Portable Plus II in 139 patients within 72 hours of the onset of symptoms. Standard polysomnographic data, signs and symptoms related with sleep apnea-hypopnea syndrome (SAHS) prior to ischemic stroke, vascular risk factors, and characteristics and onset time (day/night) of ischemic stroke were recorded. The polysomnographic data were compared with results published for subjects of a similar age in the general population. RESULTS: The mean age was 73.6 (SD 11.1) years (59% of the patients were men). Prior to the stroke, 64.7% of the patients snored, 21.6% presented repetitive sleep apneas, and 35.6% had daytime sleepiness. The mean apnea-hypopnea index (AHI) was 29.1 (17.9) episodes/hour, the obstructive component of which was 20.1 (15.7) episodes/hour. Five patients presented Cheyne-Stokes breathing. The AHI (for all cut-points from 5 to 50), chronic snoring, and daytime sleepiness were significantly greater than those published for the general population. The stroke characteristics showed no significant differences between daytime and nighttime onset. Nighttime stroke (60.4%) was associated with a significantly higher AHI (33.3 compared to 24.7 episodes/ hour) mainly because of obstructive apneas. Nighttime stroke was also associated with a greater nighttime desaturation and a greater probability of SAHS symptoms prior to stroke (odds ratio, 2.62). In contrast, there were no differences in vascular risk factors between daytime and nighttime stroke onset. CONCLUSION: The prevalences of sleep-disordered breath- ing with clinical signs and symptoms of SAHS were high in this population of patients with acute ischemic stroke. Patients with nighttime stroke had more obstructive sleep-disordered breathing and a higher clinical probability of obstructive SAHS before stroke. These findings support the hypothesis that obstructive SAHS is a risk factor for ischemic stroke, particularly for strokes presenting at night.

[Pasteurella multocida infection of cavitated lung squamous carcinoma]. / Infección por Pasteurella multocida de un carcinoma escamoso de pulmón cavitado.

Pasteurella multocida has rarely been reported to cause lung disease in humans. Infection usually arises from bites or scratches from animal carriers of the pathogen. Cases of pneumonia, lung abscess, airway infection or infection of pre-existing bronchiectasis have been described, usually in individuals who are in direct contact with carrier animals and who have a chronic debilitating disease. It is unusual for P. multocida to be ingested and appear among oropharyngeal flora in humans. We report the first case published (Medline search 1966-2002) of a cavitated lung with squamous carcinoma that became infected by P. multocida in an elderly patient who denied contact with potential carrier animals. We believe that the P. multocida infection in humans is underdiagnosed because clinical suspicion is low and the bacterium is highly susceptible to common antibiotics.

[Clinical predictors of sleep apnea-hypopnea syndrome susceptible to treatment with continuous positive airway pressure]. / Valor predictivo de la clínica para la identificación de los pacientes don síndrome de apneas-hipopneas durante el sueño susceptibles de tratamiento con presión positiva continua de la vía aérea (CPAP).

OBJECTIVE: To analyze the predictive value of clinical data for identifying patients suspected of sleep apnea-hypopnea syndrome with an apnea-hypopnea index (AHI)> or = 30. MATERIAL AND METHODS: Patient characteristics, cardiorespiratory medical history, and clinical signs and symptoms were recorded for all patients. Exclusion criteria were daytime respiratory insufficiency or heart failure. All patients underwent polysomnographic testing (AutoSet Portable Plus II, ResMed Corp, Sydney, Australia) for automatic AHI calculation and manual determination of central and obstructive apneas. A logistic regression model was constructed to calculate the likelihood of an individual's presenting an AHI> or = 30 as well as the predictive value of each variable and of the final model. RESULTS: Three hundred twenty-nine patients with a mean +/- SD age of 58 +/- 13.45 years were studied; 76.4% were men. Data for 207 patients were used to construct the logistic regression model: logit (P) = 2.5 blood pressure + 1.5 Epworth test + body mass index + 0.6 repeated observed episodes of apnea 2.1. Logit(P) was loge (1-P)/P and variables were dichotomized with cut points of 11 for the Epworth test and of 30 kg/m2 for body mass index. The diagnostic sensitivity of the model was 80.2% (75%-86%), specificity was 93.4% (89%-95%), positive predictive value was 89.6% (84%-93%) and negative predictive value was 86.9% (81%-90%), such that 89.6% of the patients were correctly classified. The variable with the greatest predictive value was high blood pressure. The model was validated prospectively in the remaining 102 patients. CONCLUSIONS: Prior to diagnostic tests for SAHS, clinical data can be useful for identifying patients suspected to have a AHI> or = 30.

[Hepatic granulocytic sarcoma: an unusual presentation]. / Sarcoma granulocítico hepático: una presentación inusual.

A case of granulocytic sarcoma (chloroma) of hepatic localization is presented. It is a extramedullary strange tumour, composed of immature precursors of myeloid cells. Clinically it can show, before, during or after a acute myeloid leukemia, chronic myeloproliferative disorders or myelodysplastic syndromes. Our patient, 81 year-old male, presented a process of important acute jaundice, with negative image technics, what indicated us the intrahepatic origin, negative tumorals markers, negative serology and hepatic biopsy (the piece of greenish coloration is described) what showed a hepatic sinusoides diffuse infiltration by indifferentiation cellularity, with study immuno-histochemical that was positive for the myeloperoxydase, giving a diagnose compatible with hepatic infiltration for acute myeloid leukemia. The patient doesn't present affectation of peripheral blood, and he died for acute hepatic and renal failure after 8 days of entrance.

[Bilateral primary adrenal lymphoma: an unusual presentation]. / Linfoma suprarrenal primario bilateral: una presentación inusual.

A case of primary adrenal bilateral non-Hodgking lymphoma, with depressed adrenal reserve is presented. This rare neoplasm causes rapid evolution and fatal outcome in most cases. In our patient, lethal outcome was associated with severe hypercalcemia and refractary hypotension. Many other complications are due to tumoral lysis syndrome associated with high steroid doses in adrenal insufficiency. This rare entity must be included in the differencial diagnosis of adrenal masses, uni or bilateral, because early diagnostic is important for preventing complications, potentially lethals and for improving survival. Image thecnics and ultrasound-guided or computed-tomography-guided FNA, are best diagnostic methods, but in many cases, definitive diagnostic is obtained by necropsy.

Positive effect of CPAP treatment on the control of difficult-to-treat hypertension.

The aim of the present study was to analyse the role of continuous positive airway pressure (CPAP) treatment in patients with difficult-to-control hypertension (DC-HT) and sleep apnoea. An Autoset (ResMed, Sydney, Australia) study was performed in 60 patients diagnosed with DC-HT based on two 24-h ambulatory blood pressure monitorisation (ABPM) studies. CPAP was offered to patients with an apnoea/hypopnoea index (AHI) > or =15 events.h(-1). After 3 months of treatment, repeat ABPM was performed to evaluate the effect of CPAP upon the blood pressure values. A total of 39 (65%) patients received CPAP treatment, but only 33 completed the study. The mean+/-sd systolic and diastolic blood pressures (SBP and DBP, respectively) were 154.8+/-14 and 90+/-8.8 mmHg. Patients had a mean+/-sd AHI of 37.7+/-18.2 events.h(-1). Only three patients presented a dipper nocturnal pressure pattern. CPAP treatment significantly reduced SBP (-5.2 mmHg), and particularly the nocturnal values (-6.1 mmHg), but not DBP. Considering only those patients who tolerated CPAP, the decrease in SBP was greater (-7.3 mmHg). Furthermore, CPAP treatment significantly increased the percentage of patients who recovered the dipper pattern (three (9.1%) out of 33 versus 12 (36.4%) out of 33). Continuous positive airway pressure treatment significantly reduces systolic blood pressure, particularly at night, and normalises the nocturnal pressure pattern in patients with difficult-to-control hypertension and sleep apnoea.

Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) often present with severe acute exacerbations requiring hospital treatment. However, little is known about the prognostic consequences of these exacerbations. A study was undertaken to investigate whether severe acute exacerbations of COPD exert a direct effect on mortality. METHODS: Multivariate techniques were used to analyse the prognostic influence of acute exacerbations of COPD treated in hospital (visits to the emergency service and admissions), patient age, smoking, body mass index, co-morbidity, long term oxygen therapy, forced spirometric parameters, and arterial blood gas tensions in a prospective cohort of 304 men with COPD followed up for 5 years. The mean (SD) age of the patients was 71 (9) years and forced expiratory volume in 1 second was 46 (17)%. RESULTS: Only older age (hazard ratio (HR) 5.28, 95% CI 1.75 to 15.93), arterial carbon dioxide tension (HR 1.07, 95% CI 1.02 to 1.12), and acute exacerbations of COPD were found to be independent indicators of a poor prognosis. The patients with the greatest mortality risk were those with three or more acute COPD exacerbations (HR 4.13, 95% CI 1.80 to 9.41). CONCLUSIONS: This study shows for the first time that severe acute exacerbations of COPD have an independent negative impact on patient prognosis. Mortality increases with the frequency of severe exacerbations, particularly if these require admission to hospital.

[Ischemic stroke and sleep apnea. Relationship between sleep breathing disorders and carotid stenosis]. / Ictus isquémico y apnea del sueño. Relación entre trastornos respiratorios durante el sueño y estenosis carotídea.

OBJECTIVE: To investigate the possible relation between the number of sleep breathing disorders (SBD) and significant extracranial carotid stenosis (ECS) in patients suffering ischemic stroke or transient ischemic attack (TIA). PATIENTS AND METHODS: Sixty-eight patients (72.2 years; 68 % males) surviving two months after ischemic stroke or TIA were studied, with the collection of general and anthropometric variables, the characteristics and repercussions of stroke, and the clinical manifestations related to sleep apnea-hypopnea syndrome (SAHS). Neurovascular status was evaluated by carotid continuous doppler flowmetry and transcraneal doppler, with cerebral MR-angio and/or arteriography when suspecting stenosis > 50 %, and respiratory polygraphy after the acute phase to assess the number and type of SBD. RESULTS: Fifteen patients (22.1 %) presented ECS. Of these, 80 % had an apnea-hypopnea index (AHI) > 30. The patients with ECS presented increased drowsiness (p = 0.01), greater AHI (36.2 vs 21.9; p = 0.003), and increased nocturnal oxygen desaturation (p = 0.01). Arterial hypertension (AHT) was also significantly more prevalent in this group of patients (p = 0.003), as was diabetes mellitus (p = 0.01) and hypercholesterolemia (p = 0.02) though logistic regression analysis only showed AHT (odds ratio [OR]: 12,7) and AHI > 30 (OR: 13,6) to exhibit independent ECS predictive capacity. CONCLUSIONS: The presence of numerous SBD is predictive of ECS, independently of the presence of AHT. Patients with ECS have more SAHS related clinical manifestations prior to stroke; as a result, SAHS could be anterior to the neurological event and act as a risk factor for the latter in this group of patients.