Sleep disorders and their impacts on healthy, dependent, and frail older adults.

BACKGROUND: Sleep disorders differ widely in the heterogeneous older adult population. Older adults can be classified into three groups based upon their overall level of disability: healthy, dependent, and frail. Frailty is an emerging concept that denotes older persons at increased risk for poor outcomes. OBJECTIVE: The aim of this consensus review is to describe the sleep disorders observed in healthy and dependent older adults and to discuss the potential sleep disorders associated with frailty as well as their potential consequences on this weakened population. METHODS: A review task force was created including neurologists, geriatricians, sleep specialists and geriatric psychiatrists to discuss age related sleep disorders depending on the three categories of older adults. All published studies on sleep in older adults on Ovid Medline were reviewed and 106 articles were selected for the purpose of this consensus. RESULTS: Many healthy older adults have complains about their sleep such as waking not rested and too early, trouble falling asleep, daytime napping, and multiple nocturnal awakenings. Sleep architecture is modified by age with an increased percentage of time spent in stage one and a decreased percentage spent in stages three and four. Insomnia is frequent and its mechanisms include painful medical conditions, psychological distress, loss of physical activity and iatrogenic influences. Treatments are also involved in older adults' somnolence. The prevalence of primary sleep disorders such as restless legs syndrome, periodic limb movements and sleep disordered breathing increases with age. Potential outcomes relevant to these sleep disorders in old age include mortality, cardiovascular and neurobehavioral co-morbidities. Sleep in dependent older adults such as patients with Alzheimer Disease (AD) is disturbed. The sleep patterns observed in these patients are often similar to those observed in non-demented elderly but alterations are more severe. Nocturnal sleep disruption and daytime sleepiness are the main problems. They are the results of Sleep/wake circadian rhythm disorders, environmental, psychological and iatrogenic factors. They are worsened by other sleep disorders such as sleep disordered breathing. Sleep in frail older adults per se has not yet been formally studied but four axes of investigation should be considered: i) sleep architecture abnormalities, ii) insomnia iii) restless legs syndrome (RLS), iv) sleep disordered breathing. CONCLUSION: Our knowledge in the field of sleep disorders in older adults has increased in recent years, yet some groups within this heterogeneous population, such as frail older adults, remain to be more thoroughly studied and characterized.

[Mandibular advancement surgery in patients with severe obstructive sleep apnea uncontrolled by continuous positive airway pressure. A retrospective review of 25 patients between 1998 and 2004]. / Prise en charge par chirurgie d'avancée des maxillaires des patients porteurs d'un syndrome d'apnées du sommeil sévère en échec d'un traitement par pression positive continue: étude rétrospective de 25 patients entre 1998 et 2004.

INTRODUCTION: Continuous positive airway pressure (CPAP) is ineffective in some patients with obstructive sleep apnoea syndrome (OSAS) and some patients do not tolerate it. This study evaluated the outcomes of maxillo-mandibular advancement in OSAS patients without morbid obesity or severe maxillo-mandibular deformity who had first been treated with CPAP for at least 6 months. METHODS: A retrospective study reporting on the experience of the CHU Toulouse Rangueil sleep disorder centre between 1998 and 2004. We performed polysomnography and cephalometry before and 3 months after surgery. RESULTS: 25 male patients with mean apnoea hypopnoea index at 45/hour (+/-15) were treated by maxillo-mandibular advancement. The mean age of participants was 48 years (+/-7), and the mean body mass index was 28 kg/m2 (+/-3.4). Cephalometry demonstrated a retroposition of the mandible (SNB < 80 degrees +/-5) and narrow linguopharyngeal space (ELP = 8 mm+/-3). 3 months after surgery the apnoea hypopnoea index (AHI) had decreased from 45+/-15 to 7+/-7 (p < 0.0001), the Epworth sleepiness scale decreased from 11+/-5 to 6+/-4 (p < 0.01). The linguopharyngeal space was larger (ELP = 14 mm). Success rate defined as an AHI < 15/hour was 89%, and 74% for an AHI < 10/hour. 16 patients underwent polysomnography one year after surgery. The results were the same. There were no post surgical complications, except for one patient who developed permanent labial hypoesthesia. CONCLUSIONS: Maxillo-mandibular advancement seems to be an effective 2nd line therapy for the treatment of severe OSAS.

Shuttle versus six-minute walk test in the prediction of outcome in chronic heart failure.

We prospectively analysed the potential usefulness of a symptom-limited walk test, the shuttle walk test (SWT), in the prediction of major cardiac events in 46 consecutive patients with chronic heart failure (NYHA class II-IV, ejection fraction <0.40) and compared it with that of a time-limited walk test, the six-minute walk test (6-MT). After a mean follow-up of 17 months (range, 8-28 months), 15 of 46 patients (33%) experienced a major cardiac event, defined as a cardiac death, urgent transplantation, or hospital admission for continuous inotropic or mechanical support. Distance walked in the SWT was shown to be a predictor of outcome at one year of follow-up (P=0.03), but distance ambulated in the 6-MT was not (P=0.07). In multivariate analysis, percentage of age-gender predicted peak oxygen uptake was the best predictor of major cardiac events. When patients were divided into tertiles according to performance in both walk tests, there was an overall difference in event-free survival at 12 months among SWT tertiles (P=0.004), but not among 6-MT tertiles (P=0.09). A low performance in the SWT (distance ambulated <450 m) allowed identification of a subgroup of patients with a high risk for major cardiac events at short-term. We conclude that, in patients with chronic heart failure, distance ambulated in the SWT predicts event-free survival at one year better than that in the 6-MT.

[Efficacy of a program for tobacco use cessation with a combined substitution treatment of nicotine (patches plus chewing gum) at 6 months of follow-up]. / Eficacia de un programa de deshabituación al tabaco con tratamiento sustitutivo combinado de nicotina (parches más chicles) a los 6 meses de seguimiento.

Our aim was to assess the efficacy after 6 months of combined smoking cessation therapy using nicotine substitution with both chewing gum and patches. Sixty-six (25 women, 41 men) heavy smokers (38.04 packs/year and 8.42 mean score on Fagerström test) were followed between September 1995 and March 1997. Most patients were referred by respiratory, cardiology or ear-nose-and-throat outpatient clinics. The patients were prescribed 24-hour nicotine substitution therapy with 21 mg patches, plus chewing gum providing 2 mg of nicotine (3 to 10 per day) for a minimum of 8 weeks and a maximum of 12, with gradually decreasing doses. The patients were checked 1, 2, 4, 8, 12 and 24 weeks after enrollment. Expired air carbon monoxide was measured to confirm abstinence at each checkup and a simple questionnaire was filled in to assess abstinence syndrome and detect the presence of treatment side effects. Rate of abstinence achieved with this protocol after six months of follow-up was 37.9%. The failure rate was highest in the first week (33%) but gradually decreased until week 12. No patients had to abandon treatment due to side effects.

[Peripheral muscle strength in stable COPD patients: correlation with respiratory function variables and quality of life]. / Fuerza de los músculos periféricos en pacientes con EPOC estable: correlación con parámetros funcionales respiratorios y de calidad de vida.

The aim of this study was to assess peripheral muscle strength in patients with chronic obstructive pulmonary disease (COPD) using a simple test and to look for correlation with function variables, physiological strength variables and quality of life parameters. Twenty-three COPD patients with moderate to severe air-flow limitation (FEV1 = 39 +/- 12%) in stable phase but displaying inability to carry out daily tasks were enrolled. Peripheral muscle strength was assessed in all patients by measuring the maximum load in a single repetition of five simple upper and lower extremity exercises performed at a multi-gymnastics station. Results were compared to respiratory function variables (FVC, FEV1, FEV1/FVC and gasometry), to results of an exercise test on a cycle ergometer with monitoring of respiratory gases (VEmax, VO2max and Wmax), to endurance (minutes) to dyspnea (Mahler's scale) and to quality of life (Chronic Respiratory Disease Questionnaire-CRDQ). No relation between functional parameters and endurance in minutes was found. Minute ventilation (VE) proved to be significantly related to oxygen intake (VO) and maximum work in the stress test. Dyspnea on Mahler's scale was unrelated, but fatigue variables and emotional function variables on the CRDQ were related. We conclude that peripheral muscle strength is unrelated to level of flow limitation or exercise tolerance in COPD patients. Peripheral muscle strength is related, however, to maximum work load and some aspects of quality of life.

[Prediction of maximal ventilation during exercise in patients with chronic obstructive pulmonary disease]. / Predicción de la ventilación máxima alcanzada en el esfuerzo en pacientes con enfermedad pulmonar obstructiva crónica.

To analyze the validity of baseline lung function parameters as predictors of maximal exercise ventilation (VEmax) in patients with chronic obstructive pulmonary disease (COPD), we studied 33 stable patients (FEV1 43.6 +/- 16.8%, FEV1/FVC% 48.4 +/- 9.2, FRC 156.8 +/- 32.7% and RV 212 +/- 53.9%). The sample was later divided into 3 groups based on severity of disease (severe, moderate or mild) in order to determine whether ability to predict VEmax increased with airways obstruction (FEV1 26.9 +/- 4.9%, 40.2 +/- 3.5% and 63.9 +/- 10%, respectively). The patients underwent lung function testing at rest and after a progressive stress test, with the maximal reading taken with the subject on a tread mill. We found greater correlation between VEmax and RV, FEV1 and FRC (r = -0.77, 0.75 and -0.74, respectively); the correlation was stronger in patients with severe COPD, in whom FEV1 was under 35% of the predicted value (r = -0.88, 0.753 and -0.83, respectively). Correlation decreased or disappeared with less functional impairment. Prediction of VEmax was more reliable with equations that employed FEV1 accompanied by data reflecting degree of insufflation, RV or FRC (VEmax = 45.2 +/- 8.98 x FEV1 - 5.07 x RV; r2 = 0.72) than with equations based on FEV1 alone (VEmax = 14.79 + 15.03 x FEV1; r2 = 0.56). We therefore conclude that ventilatory limitation during exercise in patients with COPD is better defined by considering parameters related to lung insufflation along with those reflecting degree of expiratory obstruction, given that the former affect the greater or lesser efficacy of muscles under stress.(ABSTRACT TRUNCATED AT 250 WORDS)

[The use of cardiopulmonary exercise test in patients with mitochondrial myopathies]. / Utilidad de la prueba de ejercicio cardiopulmonar en pacientes con miopatía mitocondrial.

BACKGROUND: Exercise tests has been used in the diagnosis of metabolic myopathies. If there is an abnormal response pattern in mild mitochondrial myopathy (MM) and her role in the initial suspect diagnostic is unknown. SUBJECTS AND METHODS: Prospective study of 26 patients with mitochondrial myopathy (15 men, 11 women) and a control group of 14 sedentary volunteers (9 men, 5 woman) with similar antropometric characteristics. We have made pulmonary function tests and treadmill exercise with serial venous sampling of blood lactate, piruvate, ketone bodies, free fatty acids and creatinkinase. RESULTS: Patients with MM showed exercise limitation with lower maximal power (MM = 143 [47] vatts, C = 187 [40] vatts, p = 0.006), maximal oxygen uptake (MM = 27 [8] ml/min/kg, C = 40 [7] ml/min/kg, p = 0.001) and maximal oxygen pulse (MM = 11 [3] ml/beat, C = 14 [3] ml/beat, p = 0.006). For the same oxygen uptake the heart rate was higher and the anaerobic threshold was earlier in MM patients (MM = 48% [14], C = 62% [12], p = 0.01). We found a considerable slower maximal oxygen uptake in patients with lipid increase in muscle biopsy (n = 15). Acetoacetate curves, beta-hydroxybutyrate, free fatty acids and creatinkinase were similar in both groups. The exercise test was pathologic in 17/26 of the patients. The sensitivity of the exercise test for maximal oxygen uptake was 0.65. CONCLUSIONS: The cardiopulmonary exercise test is a useful test in the suspect initial diagnostic of patients with mild mitochondrial myopathy because the majority of patients show a pathologic test.

Expresión de E-Cadherina y Syndecan-1 en Liquen Plano de Piel y de Mucosa Oral / Expression of E-Cadherin and Syndecan-1 in Oral and Skin Lichen Planus

El liquen plano es una lesión inmunológica que se caracteriza por presentar apoptosis de los queratinocitos basales, licuefacción de la membrana basal e infiltrado linfoplasmocitario en banda, estas características pudieran estar asociadas con la pérdida de adhesiones celulares y riesgo de transformación maligna. Para identificar el potencial regulatorio asociado a la adhesión celular de los queratinocitos basales y la posible capacidad de transformación maligna, se investigó la expresión "in situ" de E-cadherina y Syndecan-1 el liquen plano de piel y de mucosa oral. En un total de 37 casos de liquen plano de piel y 5 casos de liquen plano oral, se realizaron estudios de inmunohistoquímica para la detección de E-cadherina y Syndecan-1. En las áreas de enfermedad activa del liquen plano de piel los queratinocitos basales no expresaron E-cadherina y la expresión de Syndecan-1 fue focal, en las áreas de tejido epitelial libre de enfermedad la expresión de ambas proteínas fue muy similar. Los cambios de expresión de las proteínas E-cadherina y Syndecan-1 sugieren una posible asociación de las mismas a la patogénesis de Liquen plano de piel y de mucosa oral.

Lichen planus is an immunological lesion is characterized by basal keratinocytes apoptosis, liquefaction of the basal membrane and linphoplasmocitary infiltration, these features may be associated with loss of cellular adhesion and risk of malignant transformation. To identify the regulatory potential associated with cell adhesion of basal keratinocytes and the malignant transformation potential, the "in situ" expression of E-cadherin and Syndecan-1 proteins in skin and oral lichen planus were investigated. A total of 37 cases of skin lichen planus and 5 cases of oral lichen planus we reevaluated by immunohistochemical approach, using E-cadherin and Syndecan-1antibodies. In areas of active disease in skin lichen planus the basal keratinocytes did not express E-cadherin and Syndecan-1 expression was focal, in the of epithelial tissue areas of free lesion the expression of both proteins were similar. Changes in E-cadherin and Syndecan-1 expression suggest a possible association of this proteins with the pathogenesis of skin and oral lichen planus.

Role of cardiopulmonary exercise testing and the criteria used to determine disability in patients with severe chronic obstructive pulmonary disease.

The aim of this study was to evaluate the precision and variability with which resting pulmonary function tests (resting PFTs) can be used to predict the capacity in exercise, and the usefulness of the different measurements of pulmonary function in the evaluation of impairment/disability in patients with chronic obstructive pulmonary disease (COPD). We studied 78 patients with stabilized COPD (FEV1 45.1 +/- 17.1%). Of these, 39 suffered severe impairment according to the resting PFTs. Both the group with severe impairment (maximal oxygen consumption [VO2,max]: 16.22 +/- 5 ml/kg/min; maximal minute ventilation [VEmax]: 31.87 +/- 7.1 L/min; maximal heart rate [HRmax]: 133.8 +/- 10.9 beats/min) and the group with nonsevere impairment according to the resting PFTs (VO2max: 22.55 +/- 7.9 ml/kg/min; VEmax: 42.11 +/- 10.9 L/min; HRmax: 138 +/- 13.7 beats/min) showed ventilatory limitation during exercise. FEV1 was the most prevalent criterion for the determination of severe impairment (FEV1 < 40%), and was the variable best correlated to VO2max (r = 0.52 with VO2max as absolute value and r = 0.54 with VO2max expressed as a percentage of the reference value), but the resting PFTs were not predictive of exercise performance including patients with severe COPD. Evaluation of working capacity (based on VO2max) revealed a significant number of inaccurate predictions among the results of the resting PFTs. Sensitivity and specificity analysis were used to compare the different criteria used to evaluate the severity of disability. They reveal that the classification will be different according to the criteria used.(ABSTRACT TRUNCATED AT 250 WORDS)

[Inflammatory pseudotumor of the lung: presentation of 2 cases, one of them endobronchial]. / Pseudotumor inflamatorio de pulmón: presentación de dos casos, uno de ellos endobronquial.

Inflammatory pseudotumor (IP) is a rare pathological entity. Although, the pulmonary affection is the most frequent, any other organ can be involved. Its etiopathology is unknown. The disease is considered as a reactive process constituted by chronic inflammatory elements and a benign behavior. The lack of a specific clinical setting and the low profitability of the bloodless techniques makes mandatory the thoracostomy for a definitive diagnosis. We report two cases of pulmonary IP. One of them with an endobronchial localization which is a infrequent variety, scantily reported in the medical literature. We discuss the clinical and etiopathologic aspects of this rare pathological entity.

A shuttle walk test for assessment of functional capacity in chronic heart failure.

BACKGROUND: Peak oxygen uptake (peak VO(2)) is a reference parameter in the assessment of functional capacity of patients with chronic heart failure, but the procedure for cardiopulmonary exercise testing with expired gas analysis is complex and expensive, so more simple and available methods are desirable. METHODS: We compared the usefulness of a time-limited walk test, the 6-minute walk test (6-MT), with that of a symptom-limited walk test, the shuttle walk test (SWT), in the evaluation of patients with moderate to severe chronic heart failure. We prospectively studied 46 clinically stable patients in New York Heart Association class II to IV heart failure with left ventricular ejection fraction <40% (aged 53 +/- 10 years, ejection fraction 23% +/- 8%, New York Heart Association functional class 2.8 +/- 0.7). Each patient performed two 6-MT, two SWT and a cardiopulmonary exercise testing within 2 weeks. RESULTS: We found a close correlation between distance walked in SWT and peak VO(2 ) (r = 0.83, P <.001) and a moderate correlation between distance in 6-MT and peak VO(2) (r = 0.69, P <.001). Both walk tests showed to be reproducible after just one practice walk. All patients who walked > 450 m in SWT had a peak VO(2) >14 mL/kg/min. The overall discriminatory accuracy for SWT distance was greater than that for 6-MT distance for predicting a peak VO(2 ) <14 mL/kg/min (area under receiver operator characteristic curves 0.97 and 0.83 respectively, P =.02). Stepwise multivariate regression analysis, including clinical, exercise testing, echocardiographic, radionuclide-angiographic, and rest hemodynamic data, showed that distance walked in SWT was the only independent predictor of peak VO(2) (P <.001) and the strongest predictor of percent achieved of age- and sex-predicted peak VO(2) (%PVO(2)) (P <.001), with only age offering additional information (P =.02). CONCLUSIONS: The SWT shows to be a feasible and safe method to evaluate patients with chronic heart failure that strongly and independently predicts peak VO(2) and %PVO(2.) This symptom-limited walk test seems to be more useful than 6-MT in the assessment of functional capacity in these patients.

Isolation and characterization of Melanoplus sanguinipes adipokinetic hormone: a new member of the AKH/RPCH family.

A neuropeptide hormone isolated from corpora cardiaca of Melanoplus sanguinipes was purified by HPLC. The HPLC fractions were examined for adipokinetic activity with an in vivo bioassay. A single large UV absorbent peak was active in the mobilization of lipid while the other HPLC fractions showed no detectable activity. This large peak had a retention time and amino acid composition identical to synthetic Lom-AKH-I which was analyzed in a parallel manner. The primary sequence structure, pGlu-Leu-Asn-Phe-Thr-Pro-Asn-Trp-Gly-Thr-NH2, was determined by automated gas-phase Edman degradation. The peptide was deblocked prior to sequencing using pyroglutamate aminopeptidase and the sequence was confirmed with mass spectrometry. The C-terminus of the peptide was determined to be blocked, as indicated by the lack of digestion with carboxypeptidase A. The knowledge of the primary sequence of Mes-AKH allows the use of a commercially available synthetic peptide and its antibodies for use in future research with Melanoplus sanguinipes.

Estrategias de entrenamiento muscular en la enfermedad pulmonar obstructiva crónica. ¿Entrenamiento de resistencia, de fuerza o combinado? / Muscle training strategies in chronic obstructive pulmonary disease

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Valoración de la capacidad laboral e incapacidad/invalidez en las enfermedades respiratorias / No disponible

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Guía clínica para el diagnóstico y el tratamiento de la enfermedad pulmonar obstructiva crónica / Clinical guidelines for diagnosing and treating chronic obstructive pulmonary disease

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