Sleep apnea syndrome associated with gonadal hormone imbalance (Review).

Patients with obstructive sleep apnea exhibit an increased risk of developing gonadal disorders. Because a notable number of people worldwide have sleep respiratory and reproductive disorders, it is essential to recognize the association between local upper airway dysfunction and its gonadal effects. Repeated breathing pauses cause sleep fragmentation, disorganization of sleep cycles and stages, sympathetic activation, intermittent hypoxemia and systemic inflammation. Nocturnal intermittent hypoxemia has a direct central effect on neurotransmitters, with disturbances in the normal production of hypothalamic-pituitary hormones. Awakenings and micro-awakenings at the end of apneic episodes produce a central stress responsible for hormonal changes and subsequent endocrine imbalances. The aim of the present study was to investigate the impact of obstructive sleep apnea syndrome (OSAS) on gonadal hormonal homeostasis and its consequences. Recognizing and understanding how local upper airway dysfunction causes gonadal imbalance may facilitate better care for patients with OSAS. Although there may be a direct relationship between sleep-disordered breathing and gonadal function mediated by hormones via the hypothalamic-pituitary-gonadal axis, to date, current therapies have not been effective.

Predictors of negative outcomes in hospitalized patients with SARS­CoV­2 pneumonia: A retrospective study.

The coronavirus disease 2019 (COVID-19) pandemic posed a serious threat to human health worldwide after the first case was identified in December 2019. Specific therapeutic options for COVID-19 are lacking; thus, the treatment of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is complex in clinical practice. Despite the development of treatment options and methods to limit the spread of SARS-CoV-2, certain patients experience critical illness and numerous deaths have occurred. Notably, treatment of this disease is complex due to the evolution of viral mutations and variants with different rates of infection. Moreover, specific patient characteristics may be associated with rapid disease progression and poor outcomes. Thus, the present study aimed to identify the specific characteristics of patients who developed poor outcomes, including clinical manifestations, blood samples (blood cell count and coagulation tests) at hospital admission and comorbidities. The present study included a total of 1,813 patients hospitalized with pneumonia and SARS-CoV-2 infection, and mortality rates associated with each patient characteristic were calculated. The characteristics associated with the highest risk of mortality were as follows: Age >90 years (OR, 105; 95% CI, 17.70-2,023.00); oxygen saturation at the time of hospital admission <89% in room air (OR, 14.3; 95% CI, 7.54-30.7), admission to the Intensive Care Unit (OR, 39.4; 95% CI, 27.7-57.0); and a neutrophil/lymphocyte ratio of 8.76-54.2 (OR, 14; 95% CI, 7.62-29.0). Treatment of patients with SARS-CoV-2 pneumonia represents a challenge for the healthcare system, but there are a number of predictors for poor patient outcomes that could be identified at the time of hospital admission.

Pathological Presence of Free Air in the Thorax: Pneumothorax and Pneumomediastinum as a Complication of COVID-19.

INTRODUCTION: The abnormal presence of free air in the thorax, pneumothorax, and pneumomediastinum are complications for critically ill patients suffering from coronavirus disease 2019 (COVID-19). The development of these events may lead to a poor prognosis and make the management of this category of patients more difficult. STUDY DESIGN: We performed an observational retrospective study, including patients with SARS-CoV-2 infection and pneumonia who were hospitalized, to analyze the cases that developed pneumothorax or pneumomediastinum as a complication. RESULTS: A total of 28 cases (1.51%) from 1844 patients with SARS-CoV-2 pneumonia developed pneumothorax or pneumomediastinum during hospitalization. Of them, 21 (75%) needed intensive care unit admission and ventilation, and 10 (35.71) were cured. CONCLUSION: The male gender is more probable to be involved in the development of pneumothorax or pneumomediastinum in patients with SARS-CoV-2 pneumonia. The incidence of these events is low, and conservative treatment could provide a better outcome.

Skin, ear and testis--unusual sites of tuberculosis.

Pulmonary localization is the most common site of tuberculosis (TB)and the most contagious form. Extrapulmonary tuberculosis with the rarest and most unexpected localizations represents a significant proportion of all cases of tuberculosis and remains an important public health problem. We report three unusual TB locations: skin, ear and testis occurred in three immunocompetent patients. In the case of skin and testicular lesions, diagnosis was based on pathological confirmation of granulomas with caseous necrosis. In the third case the diagnosis was made possible by identification of positive Acid-Fast Bacilli smear and positive culture from othic drainage fluid. The outcome at all three patients was good with antituberculous treatment. These unusual localization of tuberculosis also highlight the possibility of extrapulmonary tuberculosis as a differential diagnosis in many common diseases.

Treatment options in stage III non-small cell lung cancer.

Lung cancer is responsible for over 1 million deaths annually, worldwide. The disease becomes symptomatic in advanced stages, so the diagnosis is delayed and 90% of cases cannot benefit from a curative treatment. In NSCLC surgical resection represents the best option for long term survival in resectable stage III and in clinical stage I/II. Patients with stage IIIB or IV usually receive chemotherapy or palliative treatment. For patients with no driver mutation detected platinum based combination chemotherapy is the first choice. Definitive radiotherapy is considered an lternative for patients who are not candidates for combined modality treatment. When a stage IV cancer is diagnosed based on an isolated metastasis, the patient's benefit from the removal of the etastasis and of the primary tumor if it is resectable. The prognosis in NSLC is mainly influenced by the TNM stage at diagnosis. The rate of survival decreases in opposing correlation with the stage of the cancer. Poor performance status, reduced lung capacity, weight loss, vascular invasion are indicators for a poor prognosis

Positive pressure therapy in patients with cardiac arrhythmias and obstructive sleep apnea.

BACKGROUND: Positive pressure therapy (CPAP) in patients with cardiac arrhythmias and obstructive sleep apnea (OSAS) may have favorable effects by correcting intermittent hypoxemia and sympathetic activation. OBJECTIVE: To assess the effect of CPAP added to pharmacological treatment in the rate control and prevention of arrhythmias recurrence in patients with OSA. MATERIALS AND METHODS: Prospective, interventional study study which included patients diagnosed with OSAS (cardiorespiratorypolygraphy, AHI>5/hour), and arrhythmias (ECG, Holter ECG), divided in two groups: group A (pharmacological therapy only) and group B (pharmacological therapy and CPAP). The patients were evaluated at enrollment (T0), at 3 and 6 months (T3 and T6) regarding the type, severity and recurrence of cardiac arrhythmias. RESULTS: 36 patients (31 men), mean age: 63.2 ± 12 years were enroled. In group A: 7 patients with ventricular extrasystoles, 8 with permanent atrial fibrillation, 1 patient with atrial flutter and 2 patients with paroxystic supraventricular tachycardia. In group B: 8 patients with ventricular extrasystoles, 5 with permanent atrial fibrillation, 2 patients with recurrent episodes of atrial fibrillation and 3 with paroxystic supraventricular tachycardia. A positive correlation (r: 0.74, p < 0.001) between Oxygen Desaturation Index and AHI was found. At T6, 12 patients from group B, and 18 from group A were evaluated. In group B, the mean heart rate in patients with atrial fibrillation was 69/min., lower than in group A (82/min.), no cases with recurrent atrial fibrillation were found, and more patients with class II Lown ventricular extrasystoles passed in class I Lown, compared to group A. In group B, heart rate statistically correlated with AHI (r: 0.53, p < 0.005). CONCLUSION: In patients with OSAS, adding CPAP to pharmacological therapy has favorable effects on preventing recurrences, heart rate control in patients with atrial fibrillation and in reducing frequency and/or severity of ventricular extrasystoles.

The efficiency of continuous positive airway pressure therapy in reducing cardiovascular dysfunction in a patient with arterial hypertension and obstructive sleep apnea.

Obstructive sleep apnea (OSA) has been included by European and American hypertension therapy guidelines as a common cause of high blood pressure. Recent studies have demonstrated a strong link between OSA and HBP and the treatment thereof should consist of combination therapy, especially in patients with refractory AHT and a non-dipping profile. We present the case of a patient with high grade hypertension, with secondary organ damage and severe OSA. The ultimate method for controlling blood pressure and reversing subclinical cardiac and cerebrovascular dysfunction of this patient was the specific therapy with continuous positive airway pressure (cPAP).

[Metabolic profile in obese patients with obstructive sleep apnea. A comparison between patients with insulin resistance and with insulin sensitivity]. / Profilul metabolic al pacientilor cu sindrom de apnee obstructiva în somn si obezitate. Comparatie între pacienti cu insulinorezistenta si pacienti cu insulinosensibilitate.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) may induce metabolic abnormalities through intermittent hypoxemia and simpathetic activation. It is difficult to demonstrate an independent role of OSAS in the occurrence of metabolic abnormalities, as obesity represents an important risk factor for both OSAS and metabolic abnormalities. AIM: to assess the relations between insulin resistance (IR), insulin sensitivity (IS), OSAS severity and nocturnal oxyhaemoglobin levels in obese, nondiabetic patients with daytime sleepiness. MATERIAL AND METHODS: We evaluated 99 consecutive, obese, nondiabetic patients (fasting glycemia < 126 mg/dL, no hypoglycemic or hypolipemiant medication) diagnosed with OSAS (AHI > 5/hour and daytime sleepiness) by an ambulatory six channel cardio-respiratory polygraphy. Hight, weight serum triglycerides (TG), high density lipoprotein-cholesterol (HDL-C) levels were evaluated. Correlations between Apneea Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), average and lowest oxyhaemoglobin saturation (SaO), body mass index (BMI) and insulin resistance or sensitivity were assesed. IR was defined as a TG/ HDL-Cratio > 3, and insulin sensitivity (IS) as a TG/HDL-C ratio < 2. RESULTS: 64 patients (out of 99) had lR and 18 IS. In the IR group (44 men and 20 women), the mean age was 52 +/- 10.6 years, mean BMI: 38.54 +/- 6.67 Kg/m2 (30-60), TG/HDL-C:5, 27 +/- 2.03 (3.02-11.1), mean AHI: 49.65 +/- 25.55/hour (7-110), mean ODI: 4769 +/- 24.95/hour (4-98), mean average SaO2 89.42 +/- 4.6 and mean lowest SaO2 68.4% +/- 13.8% (32-88%). 48 patients had severe, 7 moderate and 9 mild OSAS. In the IS group (10 men and 8 women), the mean age was 58.4 +/- 8.2years, mean BMI: 35.4 +/- 4.29 Kg/m2 (30-46), TG/ HDL-C: 1.64 +/- 0.29 (1.13-1.95), mean AHI: 45.8 +/- 30.3/hour (9-131), mean ODI: 39.9 +/- 32.2/hour (2-133), mean average SaO2 90.8 +/- 8.2 (81-95) and mean lowest SaO2: 74% +/- 10.8% (52-87%). 12 patients had severe, 3 moderate and 3 mild OSAS. Insulin sensitivity positively correlated with mean average SaO2 (r: 0.49; p: 0.037) and negatively with ODI (r: - 0,56; p: 0.014). Insulin resistance negatively correlated with mean lowest SaO2 (r: -0,25; p: 0.045). Mean lowest SaO2 values were significant lower in patients with IR than in those with IS (p: 0.042). No statistically significant difference was found for BMI, AHI or ODI between IR and IS patients. CONCLUSIONS: nocturnal oxyhaemoglobin levels rather than OSAS severity (expressed as AHI or ODI) may be involved in the occurrence of metabolic abnormalities in obese nondiabetic patients. Preserving insulin sensitivity is more likely when oxyhaemoglobin levels are higher and ODI is lower. Mean lowest nocturnal SaO2 levels seems to be independently involved in the development of insulin resistance as no statistically significant differences were found for BMI between the two groups.

The role of overnight pulse-oximetry in recognition of obstructive sleep apnea syndrome in morbidly obese and non obese patients.

MATERIAL AND METHODS: We prospectively evaluated 199 individuals with high pre-test clinical suspicion of OSAS. Of these, 123 patients were morbidly obese (Group A) and 76 were non-obese (Group B). We performed six channel cardio-respiratory polygraphy and assessed the correlation between the Desaturation Index (DI) and the Apnea Hypopnea Index (AHI) for both groups. RESULTS: In group A: 116 patients (94.3%) were diagnosed with OSAS (AHI>5/hour); mean age: 59.4±10.9 years; mean BMI: 44.8±4.9 kg/m(2). The mean DI was 47.2±27.6/hour and the mean AHI: 46.5±27.6/hour. Mean average SaO2 was 88.5±6.3 %. In group B, 65 patients (85.52%) were diagnosed with SAS; mean age: 51.2 ± 12.7 years; mean BMI: 27.24±2.2 kg/m(2).The mean DI was 23.12 ± 18.35/hour and the mean AHI: 28.8 ± 18.5/hour. Mean average SaO2 was 93.7±2.07 %.A significant positive correlation (correlation index rA = 0.863 and rB= 0.877) was found between DI and AHI in both groups (p<0.001). CONCLUSION: Assessment of the Desaturation Index by nocturnal pulse-oximetry maintains its utility as a screening method for OSAS in both obese and non-obese patients with high clinical pre-test suspicion, despite the fact that the basal nocturnal saturation was found to be lower in group A.

Unilateral pulmonary hilar tumor mass: is it always lung cancer?

Sarcoidosis is a multisystem inflammatory disease of unknown etiology, characterized by noncaseating epithelioid cell granulomas. In sarcoidosis, the most common radiological findings are mediastinal and bilateral hilar lymph node enlargement. We present a case of sarcoidosis with a rare radiological aspect of pulmonary hilar tumor mass.A 54-year-old female patient, active smoker (40 packs/year), with a history of cutaneous lupus, was admitted in our institute for progressive dyspnea and dry cough. At admission physical examination and laboratory tests were normal. Pulmonary function tests diagnosed an obstructive syndrome. Chest X-ray showed a tumor mass of the right pulmonary hilum. Transbronchial biopsy was nondiagnostic. HRCT-scan showed a tumor mass in the right hilum, which raised the suspicion of a lung cancer. PET-CT scan revealed a high metabolic activity of the tumor mass and of a paratracheal right lymphadenopathy. Lymph node biopsy by mediastinoscopy showed noncaseating epithelioid-cell granulomas, sustaining the diagnosis of sarcoidosis. The outcome was favorable, with spontaneous remission without treatment, but with a relapse that responded after systemic corticotherapy.In conclusion, even if a tumor mass in the pulmonary hilum is highly suggestive of lung cancer, a positive diagnosis should be made only after histological examination, because other benign conditions, like sarcoidosis, could have such an aspect.

[Devices used in non-invasive ventilation for obstructive sleep apnea associating COPD and/or morbid obesity]. / Dispozitive utilizate în ventilatia non-invaziva in Sindromul de Apnee în Somn, care asociaza BPOC si/sau obezitate morbida.

Obstructive Sleep Apnea (OSA), COPD and morbid obesity are three medical conditions with increasing prevalence, and their association is not rare in clinical practice. Whereas CPAP remains the gold standard therapy of severe symptomatic OSA, non-invasive ventilation, often requiring additional oxygen therapy, could be necessary to achieve a satisfactory arterial oxyhaemoglobin saturation and carbon dioxide level, and is used on a long term basis for patients with OSA and COPD/morbid obesity. Thus, non-invasive ventilation is intended to increase the minute ventilation, and the devices used could achieve this either by providing a targeted volume as a result ofa pressure (barometric devices), or an actual volume (volumetric devices). In this paper are described the basic mechanisms, operating principle, the advantages and limitations of the most used devices for this kind of patients, in ambulatory settings.

A rare case of lung tumor -- pulmonary inflammatory pseudotumor.

Pulmonary inflammatory pseudotumor (PIP) is a rare condition of unknown etiology. It is still a matter of debate if it represents an inflammatory lesion characterized by uncontrolled cell growth or a true neoplasm. Although mostly benign, these tumors are diagnosis and therapeutic challenges. Preoperative diagnosis can rarely be established. The treatment of choice is surgical resection which has both diagnostic and therapeutic value. We report the case of a 63-year-old male presented with clinical and imagistic picture suggestive of malignancy in the thorax. Lobectomy was performed with histological diagnosis of PIP. No evidence of tumor recurrence.

[Therapeutical approach in severe exacerbation of COPD associating obstructive sleep apnoea and obesity]. / Atitudine terapeutica în exacerbarea severa a BPOC care asociaza sindrom de apnee în somn si obezitate.

COPD exacerbations with respiratory acidosis are difficult to manage, especially when OSA and obesity are associated. The solution is the use of noninvasive ventilation associated with oxygenotherapy in order to correct the hypercapnia, hypoxemia and respiratory acidosis and to prevent the invasive mechanical ventilation. Early respiratory rehabilitation and the use of a domiciliary ventilatory support after the acute episode could be a part of the management for these patients. We present a modality of therapeutical approach through a clinical case.

Sildenafil Reduces Inflammation and Prevents Pulmonary Arterial Remodeling of the Monocrotaline - induced Disease in the Wistar Rats.

OBJECTIVES: Pulmonary arterial hypertension (PAH) is a rare and severe disease with incompletely under stood pathogenesis. PAH is associated with pulmonary arterial remodeling and inflammation. We evaluated the effects of Sildenafil on the Monocrotaline (MCT) -induced disease in Wistar rats, for potential benefit in the early phases of inflammation and vascular remodeling. MATERIAL AND METHODS: MCT-injected rats, MCT-injected sildenafil-treated rats (starting day 1 with 2 x 0.2 mg/day; total of 2 mg/kgc/day) and saline-injected control rats were evaluated at day 14 and day 28 following MCT for pulmonary morphological changes - lesions, inflammation (inflammator y index), arterial morphometry (hypertrophy index), immunohistochemistry for smooth muscle cell marker. OUTCOMES: The administration of sildenafil following MCT significantly reduced the severity of inflammation in the acute stage of the disease (reduction of the inflammatory index by 6.038% (p <0.05)) and prevented pulmonary arterial remodeling (reduction of the hypertrophy index by 7.306% (p<0.001)). It also improved survival in the early phase with a mortality rate during the first 14 days of 4 in the MCT- exposed rats vs 1 in the MCT-exposed sildenafil-treated rate. CONCLUSIONS: Early administration of sildenafil in the MCT experimental PAH improves inflammation and survival, and prevents pulmonary vascular remodeling. Our study suggests that one of the mechanisms involved, besides vasodilatation and anti-proliferative effect, could be a direct anti-inflammatory effect of sildenafil.