Identifying obstructive sleep apnea in patients with epilepsy: A cross-sectional multicenter study.

OBJECTIVE: Several screening questionnaires for obstructive sleep apnea (OSA) have been introduced. No study has compared the performance of different questionnaire in the same patients with epilepsy. Herein, we compare the performance characteristics of four common questionnaires for assessing the probability of OSA in patients with epilepsy. METHODS: This cross-sectional multicenter study was conducted among adult epilepsy patients attending neurology and general medical clinics in Thailand. Before performing full polysomnography (PSG), all participants completed the STOP-BANG, STOP-BAG, SA-SDQ, and NoSAS questionnaires. OSA was defined by apnea/ hypopnea index (AHI) criteria of AHI: ≥ 5, ≥ 15, and ≥ 30. Discriminatory ability was assessed by area under the receiver operating characteristics (ROC) curve (AUC) and likelihood ratio. To improve discriminative ability, we created 3 ranges of the score to predict lower, middle, and higher probability of OSA as defined by each diagnostic criterion. RESULTS: A total 166 patients with epilepsy were included. OSA prevalence was 38%. Overall, NoSAS had higher AUC at all AHI criteria but not significantly higher than that of other scales. Using prediction cut-points for NoSAS of ≥ 4 and ≥ 8 to predict OSA defined by AHI ≥ 5, the likelihood ratios for the 3 ranges were 0.37, 2.22 and 9.81 respectively. CONCLUSION: Among the 4 scales, the 2-cut-point NoSAS score had the highest discriminatory ability at each AHI cutoff.

Obstructive sleep apnea and sudden unexpected death in epilepsy in unselected patients with epilepsy: are they associated?

PURPOSE: We aimed to determine (1) the frequency of high-risk sudden unexpected death in epilepsy (SUDEP) in patients with epilepsy who have had obstructive sleep apnea (OSA) in different stages of sleep using the revised SUDEP risk inventory (rSUDEP-7) score instrument and (2) the factors associated with high risk SUDEP in patients with epilepsy who have had OSA. METHODS: We conducted a cross-sectional study of consecutive subjects who are more than 15 years old without known sleep disorders, recruited from a single epilepsy clinic in a tertiary care facility. Participants underwent polysomnography. Scoring was performed by two blinded board-certified sleep physicians. The relationships between rSUDEP-7 scores and OSA measures were evaluated using Wilcoxon rank-sum test, chi-squared test, and quantile regression. RESULTS: Our study population consisted of 95 participants. Overall median (IQR) apnea-hypopnea index (AHI) of our populations was 2.3 (0.7,7.5) events rate per hour; 12 (75%) patients had moderate OSA and 4 (25%) patients had severe OSA. Nine patients had a rSUDEP-7 score of 5 to 7. There was no significant difference between total rSUDEP-7 score or rSUDEP-7 score of > 5 or < 5 and total AHI, supine AHI, non-supine AHI, NREM AHI, or REM AHI; similarly, (2) there was no significant difference in total rSUDEP-7 score between AHI of < 15 or > 15. CONCLUSION: Our study reveals no association between AHI score, OSA, and total rSUDEP-7 score or rSUDEP-7 score of > 5. The pathophysiology underlying SUDEP appears complex. We need further studies on SUDEP to help elucidate the cardiorespiratory mechanisms and predisposing factors.

Comparison of the clinical outcomes between unattended home APAP and polysomnography manual titration in obstructive sleep apnea patients.

OBJECTIVE: To compare the clinical outcomes and determine the difference in therapeutic pressure between Automatic positive airway pressure (APAP) and polysomnography manual titration. MATERIAL AND METHOD: Fifty patients of obstructive sleep apnea (OSA), moderate to severe cases, were randomized into two groups of intervention: 95-percentile pressure derived from APAP titration and an optimal pressure derived from manual titration. Clinical outcomes were assessed before and after four weeks. RESULTS: The average 95-percentile pressure derived from APAP titration was 11.7 +/- 0.3 cmH2O with median mask leak 1.3 L/min. The average optimal pressure derived from manual titration was 8.2 +/- 0.3 cmH2O. Pearson correlation analysis showed weak positive correlation (r = 0.336, p = 0.017). The Epworth Sleepiness Score (ESS), Quality of life tests: PSQI (Pittsburg Sleep Quality Index), and SF-36 (Medical Outcomes Study 36-Item Short-Form Health Survey) were improved significantly in both groups, but there were no statistical significant differences between groups. CONCLUSION: An APAP titration is an effective method of pressure determination for conventional CPAP therapy and shows no difference in clinical outcomes comparing the standard titration.

Does oral prednisolone increase the efficacy of subsequent nasal steroids in treating nasal polyposis?

BACKGROUND: Although combined oral and nasal steroid therapy is widely used in nasal polyposis, a subset of patients show an unfavorable therapeutic outcome. This study aimed to evaluate whether oral prednisolone produces any additive effects on subsequent nasal steroid therapy and to evaluate if any clinical variables can predict therapeutic outcome. METHODS: Using a 3:2 randomization ratio, 67 patients with nasal polyposis received 50 mg of prednisolone and 47 patients received placebo daily for 2 weeks, followed by mometasone furoate nasal spray (MFNS) at 200 micrograms twice daily for 10 weeks. Clinical response was evaluated by nasal symptom score (NSS), peak expiratory flow index (PEFI), and total nasal polyps score (TNPS). Potential predictor variables were assessed by clinical history, nasal endoscopy, allergy skin test, and sinus radiography. RESULTS: At the end of the 2-week oral steroid phase, the prednisolone group showed significantly greater improvements in all nasal symptoms, nasal airflow, and polyp size than the placebo group. In the nasal steroid phase, while the MFNS maintained the outcome improvements in the prednisolone group, all outcome variables in the placebo group showed continuing improvements. At the end of the nasal steroid phase, there were no significant differences of most outcome improvements between the two groups, except in hyposmia, PEFI, and TNPS (p = 0.049, p = 0.029, and p = 0.005, respectively). In the prednisolone group, patients with polyps grade 3 and endoscopic signs of meatal discharge showed significantly less improvement in total NSS, PEFI, and TNPS than patients with grade 1-2 size and negative metal discharge. CONCLUSION: In the 12-week treatment evaluation of nasal polyposis, pretreatment with oral steroids had no significant advantage for most nasal symptoms other than earlier relief; however, combined oral and nasal steroid therapy more effectively improved hyposmia, polyps size, and nasal airflow. Polyps size grade 3 and/or endoscopic signs of meatal discharge predisposed to a poorer treatment outcome.

Clinical outcomes of cervical node metastasis from an unknown primary in Songklanagarind Hospital.

OBJECTIVE: To study the clinical outcomes of cervical lymph node metastases from an unknown primary site. MATERIAL AND METHOD: A retrospective review of 139 patients diagnosed with cervical neck node metastases from an unknown primary site in Songklanagarind Hospital between 2000 and 2010 was included. The data of patient and tumor characteristics, diagnostic procedures, and treatment outcomes were recorded. The disease-free and overall survival rates were calculated RESULTS: Age ranged from 33 to 95 years with male predominance in 121 patients (87%). The majority of histological finding was squamous cell carcinoma and poorly differentiated grading was predominant. The 3- and 5-year disease-free/overall survival rates were 55.5/33.9% and 48.6/27.8%, respectively. The survival rate was lower significantly in level IV, N3 stage, extracapsular spread, and distant metastasis. The surgery followed by radiation seemed to improve the overall survival of 32.6% at five years. By the average follow-up time of 29.8 months, the emerging primary tumor was found in 12 patients (8.6%). CONCLUSION: The important prognostic factors are nodal status, metastasis, and extracapsular extension. Panendoscopy is recommended for routine diagnostic work-up, as well as the treatment with surgery followed by radiation is useful for improving the survival outcome.

Clinical efficacy of a short course of systemic steroids in nasal polyposis.

BACKGROUND: Although oral steroids are widely used for the treatment of nasal polyposis, a subset of patients shows an unfavorable therapeutic outcome. The aim of this study was to evaluate the efficacy of a short course of oral prednisolone in nasal polyposis and to evaluate which, if any, clinical variables can predict treatment outcome in these patients. METHODOLOGY/PRINCIPAL: Using a 3:2 randomization ratio, 63 patients with nasal polyposis received 50 mg of prednisolone and 46 patients received placebo daily for 14 days. Clinical response was evaluated by total nasal symptoms score (TNSS), peak expiratory flow index (PEFI) and total nasal polyps score (TNPS). Potential predictor variables were assessed by clinical history, nasal endoscopy, allergy skin test and sinus radiography. RESULTS: The prednisolone-treated group showed significantly greater improvements in all nasal symptoms, nasal flow and polyp size than the placebo-treated group (p < 0.001, all). In the prednisolone-treated group, patients with grade 3 polyps and positive nasal endoscopy showed significantly less improvement in TNSS, PEFI and TNPS than patients with grades 1-2 size and with negative nasal endoscopy. CONCLUSIONS: A short course of oral steroids showed good clinical efficacy in the treatment of nasal polyposis, however, polyps size grade 3 and/or positive nasal endoscopy predispose to a poorer treatment outcome.