European guideline for the diagnosis and treatment of insomnia.

This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).

Romanian Guidelines for the Diagnosis and Treatment of GERD-induced Respiratory Manifestations.

BACKGROUND AND AIMS: Gastroesophageal reflux disease (GERD) is a common condition present in daily practice with a wide range of clinical phenotypes. In this line, respiratory conditions may be associated with GERD. The Romanian Societies of Gastroenterology and Neurogastroenterology, in association with the Romanian Society of Pneumology, aimed to create a guideline regarding the epidemiology, diagnosis and treatment of respiratory conditions associated with GERD. METHODS: Delphi methodology was used and eleven common working groups of experts were created. The experts reviewed the literature according to GRADE criteria and formulated 34 statements and recommendations. Consensus (>80% agreement) was reached for some of the statements after all participants voted. RESULTS: All the statements and the literature review are presented in the paper, together with their correspondent grade of evidence and the voting results. Based on >80% voting agreement, a number of 22 recommendations were postulated regarding the diagnosis and treatment of GERD-induced respiratory symptoms. The experts considered that GERD may cause bronchial asthma and chronic cough in an important number of patients through micro-aspiration and vagal-mediated tracheobronchial reflex. GERD should be suspected in patients with asthma with suboptimal controlled or after exclusion of other causes, also in nocturnal refractory cough which needs gastroenterological investigations to confirm the diagnosis. Therapeutic test with double dose proton pump inhibitors (PPI) for 3 months is also useful. GERD induced respiratory conditions are difficult to treat; however,proton pump inhibitors and laparoscopic Nissen fundoplication are endorsed for therapy. CONCLUSIONS: This guideline could be useful for the multidisciplinary management of GERD with respiratory symptoms in current practice.

Basal cell carcinoma-not always the 'good guy': Case report of a life-threatening basosquamous carcinoma and review of the literature.

Cutaneous basosquamous carcinoma is a variant of basal cell carcinoma that is characterized by histopathological features of both basal and squamous cell carcinoma. Due to its local invasiveness, high frequency of recurrence, and its metastatic potential, it is considered to be one of the most aggressive subtypes of basal cell carcinoma. We present the case of an 81-year-old male who was admitted to the hospital with incessant hemorrhage arising from a cutaneous tumor that later proved to be a basosquamous carcinoma. Due to the COVID-19 pandemic at the time, the patient did not seek medical attention as soon as the bleeding was observed, although he did present when the symptom increased in intensity and became incessant. To our knowledge, this is the first case report of a cutaneous basosquamous carcinoma that presents with a massive life-threatening hemorrhage tumor, thus endangering the patient's life. The clinical and histopathological features, the behavior and the treatment of cutaneous basosquamous carcinoma are further reviewed in this article.

Stem/progenitor cells and obstructive sleep apnea syndrome - new insights for clinical applications.

Obstructive sleep apnea syndrome (OSAS) is a widespread disorder, characterized by recurrent upper airway obstruction during sleep, mostly as a result of complete or partial pharyngeal obstruction. Due to the occurrence of frequent and regular hypoxic events, patients with OSAS are at increased risk of cardiovascular disease, stroke, metabolic disorders, occupational errors, motor vehicle accidents and even death. Thus, OSAS has severe consequences and represents a significant economic burden. However, some of the consequences, as well as their costs can be reduced with appropriate detection and treatment. In this context, the recent advances that were made in stem cell biology knowledge and stem cell - based technologies hold a great promise for various medical conditions, including respiratory diseases. However, the investigation of the role of stem cells in OSAS is still recent and rather limited, requiring further studies, both in animal models and humans. The goal of this review is to summarize the current state of knowledge regarding both lung resident as well as circulating stem/progenitor cells and discuss existing controversies in the field in order to identify future research directions for clinical applications in OSAS. Also, the paper highlights the requisite for inter-institutional, multi-disciplinary research collaborations in order to achieve breakthrough results in the field.

The Role of Obstructive Sleep Apnea in Developing Gestational Hypertension and Preeclampsia.

Gestational hypertension and preeclampsia are the most frequent medical complications in pregnancy and major causes of maternal and fetal morbidity and mortality. It is also known that these conditions are associated with a long term increased cardiovascular global risk for these young women. Obstructive sleep apnea (OSA) seems to be not only a frequent pathology associated with pregnancy but also an independent factor for developing gestational hypertension. It is well known the relationship between gestational hypertension, preeclampsia and intrauterine growth restriction of the foetus so the outcomes of this pathologies are important for both mother and child. Increasing awareness of OSA among pregnant women with gestational hypertension and preeclampsia is important given the potential benefits of the treatment with continuous positive airway pressure (CPAP) on these patients.

Influence of smoking on sleep and obstructive sleep apnea syndrome.

The various ill effects that tobacco smoking has on health have been largely studied, particularly on vascular, neoplastic, and respiratory diseases. Lately, the discussion about the negative impact of cigarette smoking moved towards sleep medicine. Tobacco consumption has been associated with sleep disordered architecture, both during regular intake and after withdrawal. Its effects on sleep disordered breathing (SDB) and especially obstructive sleep apnea syndrome (OSAS) still remain a matter of debate. It is unclear whether smoking represents a risk factor for OSAS or whether smoking cessation has any beneficial effects on OSAS and its therapy. There seems to be a synergistic effect between smoking and OSAS, both causing an increase in cardiovascular morbidity. Future studies are needed in order to establish the strength of this association. We aim to review the literature regarding the consequences of smoking on sleep architecture and SDB, adding emphasis on OSAS clinical implications and treatment.

Analysis of bronchoalveolar lavage fluid in a first Romanian pulmonary alveolar proteinosis cohort.

The features of bronchoalveolar lavage fluid (BALF) components and the severity of pulmonary alveolar proteinosis (PAP) were analyzed in the first Romanian cohort of patients admitted to "Marius Nasta" Institute of Pneumophtisiology, Bucharest, Romania. A six-year follow-up study based on bronchoalveolar lavage (BAL) data was performed between January 2007 to December 2012. Study cohort consisted in 20 inpatients diagnosed with PAP, based on BALF cytological findings and÷or on histopathological findings. Demographic, medical history, tobacco use, clinical and radiological features, disease progression with or without whole lung lavage (WLL) therapy were collected. Disease severity was evaluated by pulmonary function testing including spirometry, blood gas analysis, plethysmography, and diffusing capacity of the lung for carbon monoxide (DLCO), also known as transfer factor (TLCO). The cellular profile of all BALF specimens was analyzed. Statistical analysis made by SPSS version 17.0 included Student's t-test, chi-square test and ANOVA. Mean age of the subjects was 43±16.59 years, with male predominance (n=12; 60%). Diagnosis of PAP was facilitated by fiberbronchoscopy (FBS) with BAL in 90% of cases. Cytological findings of BALF revealed lower macrophages (57.26±18.19%), with a preponderance of neutrophils (17.75±19.44%) and lymphocytes (21.8±16.12%). Lower oxygen partial pressure was identified in elders, comparing to younger patients (p=0.038). Patients treated by WLL had a lower total lung capacity (TLC) and DLCO versus those who did not required WLL (p=0.009, respectively p=0.056). The severity of pulmonary abnormalities provided WLL indication was not influenced by BALF cellularity.

Long-term gender-specific evolution of blood pressure under CPAP therapy in hypertensive patients with obstructive sleep apnea syndrome.

INTRODUCTION: Reduction of blood pressure (BP) under CPAP treatment in patients with obstructive sleep apnea syndrome (OSAS) associating hypertension (HT) is controversial and short-term evolution is often measured using the sphygmomanometer. PURPOSE: To study the variation in BP (sphygmomanometer and Holter) after 3 and 6 months of CPAP in OSAS patients associating hypertension. METHODS: We applied the exclusion criteria (hypoventilation, respiratory diseases, secondary hypertension, antihypertensive treatment modification during study, non-compliance) on 96 consecutive patients (SPSS 17.0: Chi test, T-test). RESULTS: 15 hypertensive patients (8.53 years from diagnosis) with OSAS succeeded six months of following: 3 women (20%), 12 men (80%) were comparable as age, body mass index and Epworth score; women had more severe OSAS. Sphygmomanometer measuring in men showed a decrease in systolic BP (SBP) (142 ± 8.9 to 128.7 ± 11.7 mmHg, p = 0.005) and diastolic BP (DBP) (82 ± 17.19 to 69.1 ± 6.6 mmHg, p = 0.040) at three months of treatment. Women had no changes at 3 and 6 months of assessment using the sphygmomanometer. BP Holter showed no significant changes in men; women exhibit a significant increase in maximum DBP/24 hours (104 ± 13.4 to 169.5 ± 27.5 mmHg, p = 0.034) and mean daytime DBP/24 hours (100 ± 14.1 to 166 ± 32.5 mmHg, p = 0.046) from 3 to 6 months. No group presents dipper status change to 3 or 6 months. CONCLUSIONS: The trend in both groups of increase in BP for 3 to 6 months is explained by the natural evolution of an old HT history. Long time monitoring using Holter device is more accurate in assessing cardiovascular risk.

Alpha-1 antitrypsin deficiency, SZ phenotype: a rare type of a rare disease. Case report.

Alpha-1 antitrypsin deficiency is one of the genetic diseases with a clear impact on the structure and function of the lung, rarely diagnosed and treated. We present the case of a 51-year-old female patient, heavy smoker, known with chronic obstructive pulmonary disease (COPD) for 12 years, untreated, who was hospitalized for the first time in our clinic having symptoms of a severe COPD exacerbation. She has significant cardiac disease (rheumatic mitral disease, with previous episodes of pulmonary edema and cardiac arrest) and hepatitis B. The patient is hypoxic, with severe mixed ventilatory dysfunction. During the hospitalisation she received treatment of the exacerbation and after that she received recommendation of chronic inhaled bronchodilator and corticosteroid treatment. The test for alpha-1 antitrypsin deficiency has detected a plasma of 63 mg/dl, SZ phenotype. The patient returns for a second evaluation. Functional tests are significantly improved (despite inconsistent treatment) with the impressive improvement of FEV7 values and identification by plethysmography of a restrictive syndrome. Echocardiography identifies mitral valve changes likely rheumatic, severe pulmonary hypertension. Computer tomography was performed, highlighting discrete interstitial changes and denying the existence of emphysema. Marked increase in FEV1 values supported adding bronchial asthma to the list of diagnosis and recommendation to continue inhaled corticosteroid combination bronchodilator as treatment. The particularity of the case is the rare phenotype, association of asthma and COPD as the clinical manifestation and the presence of comorbidities, which complicates the diagnosis and prognosis.

Obstructive sleep apnea syndrome and arterial hypertension--a complicated relationship? The role of controlling blood pressure values in patients with OSAS.

BACKGROUND: Arterial hypertension (HT) and obstructive sleep apnea syndrome (OSAS) are associated through cause-effect relationship. We aimed to study the effect of medication controlled hypertension on OSAS patients. METHODS: From 483 followed patients with OSAS, 252 associating HT; 142 patients of them (56.34%) received antihypertensive medication, 59 patients (41.54%) had controlled HT, 83 patients (58.46%) had uncontrolled HT. Demographic and anthropometric data, OSAS symptoms, comorbidities, apnea index (IA), apnea-hypopnea index (IAH), desaturation index, CPAP titration, CPAP failure rate were studiated regarding differences between patients with controlled and uncontrolled HT. RESULTS: Fifty nine patients with controlled HT were: 20 women (33.9%), 39 men (66.1%), with mean age of 56.08 years +/- 11.33, with an average AHI of 53.61 +/- 34.42/hour, an average of CPAP pressure prediction of 10.15 +/- 243 cm H2O. Eighty three patients with uncontrolled HT were: 18 women (21.7%), 65 men (78.3%), with mean age 55 +/- 9.06 years, with an average AHl of 61.91 +/- 43.61/hour, an average of CPAP pressure prediction of 10.47 +/- 2cm H2O. Comparing with the controlled HT group, patients with uncontrolled HT reported morning headaches, morning fatigue and impotency in a higher rate (p = 0.020, 0.018, 0.011 respectively); Epworth Sleepiness Scale was under 10 (cut-off for daytime sleepiness) in patients with controlled HT(p = 0.001) and higher in those with uncontrolled HT. Patients with uncontrolled HT were diagnosed with HT for a longer period (p = 0.006), had higher values of systolic and diastolic blood pressure at the time of the presentation. Statistically significant differences were found only for AHI post-CPAP (11.89/h vs. 22.30/h, p = 0.013) and nocturnal desaturation index post-CPAP (6.03/h vs. 16.55/h, p = 0.017), both higher in patients with uncontrolled HT. The hypothesis regarding existing differences related to the cardiovascular comorbidities was not supported. CONCLUSIONS: Controlled blood pressure deletes sleepiness, a defining symptom for OSAS and reduces remaining symptoms (headaches, impotency and morning fatigue). Presence of OSAS symptoms is less common in the controlled HT group, making the OSAS more difficult to suspect. These patients may have a grater benefit from CPAP therapy--they have AHI post-CPAP and desaturations post-CPAP significantly lower than patients with uncontrolled HT.

[What is new in the interpretation of polysomnography according to the revised manual for sleep staging in adults? A comparative analysis]. / Ce aduce nou interpretarea polisomnografiei dupa manualul revizuit de stadializare a somnului la adult? Analiza comparativa.

Aim of this paper is to compare the new polysomnography staging manual according to American Academy of Sleep Medicine with Rechtschaffen & Kales rules, underlying the newly introduced aspects and illustrated with polysomnographic images. The new rules simplify the staging but increase the time of electrodes application. They were established on the base of low levels of evidence, without being included in the multicenter statistical validation. For the first time in literature are given details about the criteria for the interpretation of sleep in children, but there are problems still remain unanswered, such as those regarding the scoring of hypopnea. In Romania, the main problem is primarily limited access to investigation and the deficit of health professionals.