Changes in plasma concentrations of novel vascular and inflammatory biomarkers in obstructive sleep apnea patients pre- and post-stroke.

BACKGROUND: Obstructive sleep apnea (OSA) is increasingly recognized as a common condition in the general population and causes significant OSA-associated morbidities including cardiovascular and cerebrovascular events such as cerebral small vessel disease (CSVD) and stroke. METHODS: In this study, using sensitive ELISA immunoassays, we measured subset of endothelial/vascular and inflammatory biomarkers as well as neurofilament light chain (NfL), a sensitive marker for neuroaxonal injury, using plasma from OSA patients post-stroke (Acute Cerebral Infarction (ACI), N = 26) to determine their usefulness as potential prognostic markers in disease progression. RESULTS: Our results showed significantly increased plasma TNFα and NfL concentrations and decreased concentrations of platelet derived growth factor (PDGF-AA) in post-stroke OSA patients with more severe white matter hyperintensities (WMHs). And after separating the patients based on sex, compared to females, male post-stroke OSA patients with severe WMHs have increased circulating levels of inflammatory chemokine CXCL10 and cytokine Interleukin-10 (IL-10) and significantly decreased levels of Angiopoietin-1 (Ang-1) an important protein responsible for endothelial/vascular integrity functions. Importantly, in a subset of newly diagnosed OSA patients (without prior history of stroke), significantly increased plasma CXCL10 levels and decreased plasma Ang-1 levels were also readily observed when compared to healthy controls, indicating possible altered endothelial integrity and ongoing vascular inflammation in these newly diagnosed OSA patients. CONCLUSIONS: In summary, our study has identified a novel set of plasma biomarkers including PDGF-AA, CXCL10 and Ang-1 for their potential prognostic value for disease outcomes pre- and post-stroke in OSA patients and use as surrogate markers to measure efficacy of treatment modalities.

Sleep and Perivascular Spaces.

PURPOSE OF REVIEW: The glymphatic system is hypothesized to act as the brain's filtration system to remove toxic solutes that accumulate throughout the day. Perivascular spaces (PVSs) play a fundamental role in the ability of the glymphatic system to function, and sleep influences the effectiveness of this system. This article reviews the complexity of the interplay between sleep, the glymphatic system, and PVS. RECENT FINDINGS: New imaging techniques have illuminated the structure of PVS and their associations with differing disease states. Research has shown that sleep may play a key role in the function of PVS and the influence of adenosine, astrocyte, and aquaporin-4 channel in the function of the glymphatic system. Emerging data suggest that differing pathological states such as neuroinflammatory conditions, neurodegenerative diseases, and cognitive dysfunction may be associated with underlying glymphatic system dysfunction, and sleep disorders could be a potential intervention target.

Out of the Laboratory and into the Home: Home Testing for Sleep Apnea and Other Sleep Disorders.

SUMMARY: Home sleep testing has emerged over the past decade and become an intriguing option for patients and providers because it can be conducted in the home environment. However, appropriate application of this technology is key to ensure accurate and validated results to provide appropriate patient care. In this review, we will cover the current guidelines for the use of home sleep apnea tests, the types of testing available, and future directions of home testing.

The temporal onset of the core features in dementia with Lewy bodies.

INTRODUCTION: We examined the temporal sequence of the core features in probable dementia with Lewy bodies (DLB). METHODS: In 488 patients with probable DLB, the onset of each core feature and time to diagnosis was determined for men and women, and a pathologic subgroup (n = 209). RESULTS: REM sleep behavior disorder (RBD) developed before the other core features in men and women. Men were more likely to have RBD and were diagnosed with probable DLB earlier than women. Visual hallucinations developed after the other core features in men, but in women, they appeared earlier and concurrently with fluctuations and parkinsonism. Women were older and more cognitively impaired at first visit, were less likely to have RBD, more likely to be diagnosed with probable DLB later than men, and more likely to have neocortical tangles. DISCUSSION: An earlier latency to probable DLB was associated with men, RBD, and Lewy body disease without neocortical tangles.

Sleep Medicine Milestones 2.0: designed for our field.

NONE: The Accreditation Council for Graduate Medical Education published the first sleep medicine milestones in 2015. However, these milestones were the same among all internal medicine fellowship programs; they were not specific to the specialty. Based on stakeholder feedback, the Accreditation Council for Graduate Medical Education called for the creation of specialty-specific milestones. Herein, we outline the history of Accreditation Council for Graduate Medical Education reporting milestones; the identification of knowledge, skills, and attitudes that define the practice of sleep medicine; and the creation of the supplemental guide and sleep medicine-specific milestones (Sleep Medicine Milestones 2.0) to assess developmental progression during fellowship training.

Cardiovascular Consequences of Obstructive Sleep Apnea.

PURPOSE OF REVIEW: To review the clinical evidence for a relationship between obstructive sleep apnea and hypertension, arrhythmias, coronary artery disease, and congestive heart failure. RECENT FINDINGS: Current data show that obstructive sleep apnea is a risk for cardiovascular disease. Studies have linked untreated moderate to severe obstructive sleep apnea to hypertension, cardiac arrhythmias, coronary artery disease, and congestive heart failure. However, uncertainty regarding benefits of treatment of obstructive sleep apnea to reduce the risk of cardiovascular disease still exists. The issue of poor compliance has been an on-going limitation of CPAP trials. Evidence shows obstructive sleep apnea is a risk factor for cardiovascular disease but trials have yet to clarify if cardiovascular disease morbidity and mortality decreases with treatment of the apnea. Future treatment trials are needed to address the question of whether treatment decreases cardiovascular risk in patients with obstructive sleep apnea.

Ehrlichia Meningitis Mimicking Aneurysmal Subarachnoid Hemorrhage: A Case Study for Medical Decision-Making Heuristics.

Thunderclap headache is a sudden and severe headache that can occur after an aneurysmal subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage is a medical emergency that requires prompt attention and hospitalization. Patients with thunderclap headache often undergo a noncontrast head computed tomography (CT) scan to ascertain SAH bleeding and, if the scan is negative, then undergo a lumbar puncture to look for cerebrospinal fluid (CSF) red blood cells (RBCs), which would be consistent with an aneurysmal leak. If the initial CT is negative and CSF is positive for RBCs, patients are usually admitted to the hospital for evaluation of intracranial aneurysm. We encountered a patient with thunderclap headache whose initial head CT was negative for SAH and whose CSF tested positive for RBCs. The patient was referred to our center for evaluation and management of aneurysmal SAH. However, on careful review of the patient's medical history, serum laboratory values, and spinal fluid values, the patient was diagnosed with Ehrlichia chaffeensis meningitis. While Ehrlichia meningitis is rare, it is important to recognize the clinical clues that could help avoid formal cerebral angiography, a costly and potentially unnecessary procedure. We present how this case represented a cognitive framing bias and anchoring heuristic as well as steps that medical providers can use to prevent such cognitive errors in diagnosis.

Neurocognitive outcome following stereotactic laser ablation in two patients with MRI-/PET+ mTLE.

The most effective treatment for drug-resistant seizures associated with mesial temporal lobe epilepsy (mTLE) is surgical resection. Neurocognitive sequelae may occur and are especially likely to occur after left temporal lobectomy. Smaller resections observed with selective amygdalohippocampectomy have resulted in a more favorable neurocognitive outcome in some cases when compared to standard anterior temporal lobectomy. Specifically, MRI-guided interstitial laser thermal ablation (MRgLITT) uses a superselective stereotactic amygdalohippocampotomy that has been reported to preserve object recognition and naming abilities compared with standard temporal lobe resection. We report two patients with drug-resistant mTLE and a normal high-resolution 3-T brain MRI who underwent neuropsychological assessment pre- and postleft temporal MRgLITT. Both patients demonstrated preserved visual naming ability following surgery. Semantic verbal fluency declined after surgery, but the magnitude of decline did not reach the statistical threshold for reliable change. Both patients demonstrated statistically significant and clinically meaningful declines in memory, but abilities across other nonmemory neurocognitive domains (i.e., visuospatial ability, attention) were preserved.

Willis-Ekbom disease is not associated with poor cardiovascular health in adults.

BACKGROUND: Willis-Ekbom disease (WED), also called restless legs syndrome (RLS), is a neurologic sensorimotor disease that may be associated with cardiovascular disease. Given high morbidity and mortality rates of cardiovascular disease worldwide, we assessed the relation between WED/RLS and cardiovascular health risks in a native South American population. We prospectively analyzed data from The Atahualpa Project of Ecuadorian adults aged 40 years and older. Physicians interviewed consented persons on the health behavior and health factors of the American Heart Association (AHA) for ideal cardiovascular health in adults and underwent fasting laboratory blood collection and blood pressure evaluation. Certified neurologists conducted face-to-face interviews using the International Restless Legs Syndrome Study Group (IRLSSG) field instrument. Persons testing positive for WED/RLS and age-and sex-matched controls underwent confirmatory physical examinations conducted by a neurologist and a sleep specialist to whom IRLSSG designation was blinded. FINDINGS: Of 665 persons, 94 (14 %) tested positive in IRLSSG; 40 (6 %) had a diagnosis of WED/RLS after neurologic examination and interview. Patients with WED/RLS were younger (53.5 vs 59.9 years, P = .001), without significant differences in sex ratios. Among AHA risk factors, only obesity was significantly more prevalent among patients with WED/RLS (42.5 % vs 23.5 %, P = .01). However, after adjustment for confounders, body mass index was not significantly associated with WED/RLS. CONCLUSIONS: In adult Amerindians, although obesity and body mass index were associated with WED/RLS on univariate analyses, the association was not present after adjustment for confounders. No other significant associations were found between WED/RLS and AHA cardiovascular metrics.