Health Preference Measures in Patients with Obstructive Sleep Apnea Syndrome Undergoing Continuous Positive Airway Pressure Therapy: Data from a Randomized Trial.

BACKGROUND: In patients with obstructive sleep apnea syndrome (OSAS), the preference-based, health-related quality of life in terms of utility has not been extensively studied. OBJECTIVE: To address this point, we compared the performance of different instruments assessing utility in patients with OSAS undergoing continuous positive airway pressure (CPAP) therapy. MATERIALS AND METHODS: Data of 208 patients with OSAS (28 women, mean ± SE age 54.4 ± 0.7 years, apnea-hypopnea index (AHI) 51.9 ± 1.8/h, Epworth sleepiness score 13.4 ± 0.2) participating in a randomized trial of different CPAP modalities over 2 years were analyzed. Evaluations included sleep studies, Epworth sleepiness scale, and several utility instruments that measure subjective health preference on a scale ranging from 1 (most preferred and perfect health) to 0 (least preferred and very poor health). RESULTS: After 2 years of CPAP therapy, the mean ± SE AHI was 6.7 ± 1.5/h and Epworth score 7.9 ± 0.4, both p < 0.001 versus baseline. Baseline utilities and changes (95% confidence interval) after 2 years of CPAP therapy were EuroQol 5-dimensions 0.79 ± 0.01, 0.02 (0.00-0.05, p = 0.064); short-form 6-dimension medical outcome questionnaire 0.72 ± 0.01, 0.06 (0.04-0.08, p < 0.001); Euro-thermometer visual analog scale 0.70 ± 0.01, 0.09 (0.07-0.12, p < 0.001); time trade-off 0.82 ± 0.01, 0.03 (0.01-0.06, p = 0.002); and standard gamble 0.82 ± 0.01, -0.01 (-0.03 to 0.02, p = 0.712). CONCLUSION: The short-form 6-dimensions questionnaire, the Euro-thermometer, and the time trade-off instruments reflected the major clinical improvements in OSAS, while the EuroQoL 5-dimensions and standard gamble tests were not sensitive to CPAP effects. These results indicate that the evaluation of utility of a treatment for OSAS depends critically on the instrument used, which is important from an individual and societal perspective.

[Pulmonary Infiltrate - Not Always Due to Bacterial Infection]. / Pneumonisches Infiltrat ­ nicht immer eine bakterielle Infektion.

Pulmonary Infiltrate - Not Always Due to Bacterial Infection Abstract. A 65-year-old female patient with a history of controlled asthma was diagnosed with community-acquired pneumonia (CAP). After two weeks of treatment on co-amoxicillin, she failed to respond and was referred for further investigations. Clinical symptoms and laboratory results were suggestive for eosinophilic granulomatosis with polyangiitis (EGPA). Diagnosis and treatment of this disease are still challenging, especially in cases with vital organ involvement.

Jo1-antisynthetase syndrome and severe interstitial lung disease with organising pneumonia on histopathology with favourable outcome on early combined treatment with corticosteroids, mycophenolate mofetil and rituximab.

Antisynthetase syndrome is a rare autoimmune disease and represents a distinct entity within the idiopathic inflammatory myopathies. Its variable systemic manifestations are composed of myositis, interstitial lung disease, non-erosive arthritis, fever, Raynaud's phenomenon, hyperkeratotic skin changes and the presence of antibodies against aminoacyl-transfer-RNA-synthetases. Interstitial lung disease is the major determinant of morbidity and mortality. The role of lung biopsy remains controversial but it might be considered on an individual basis and may provide information regarding prognosis and treatment response. An integrated clinical, radiological and pathological approach to interstitial lung disease has to be emphasised. Due to the rarity of the disease, no standardised treatment guidelines for antisynthetase syndrome exist. We discuss a patient with anti-Jo1-autoantibody antisynthetase syndrome with proximal myositis and severe, rapid onset, interstitial lung disease with a histopathological pattern of organising pneumonia on surgical lung biopsy and good response to early combined immunosuppressive treatment with corticosteroids, mycophenolate mofetil and rituximab.

Autoadjusted versus fixed CPAP for obstructive sleep apnoea: a multicentre, randomised equivalence trial.

BACKGROUND: The obstructive sleep apnoea syndrome (OSAS) is conventionally treated by continuous positive airway pressure set at a fixed level (fCPAP). Automatic mask pressure adjustment (autoCPAP) is increasingly used during home therapy. We investigated whether autoCPAP is equivalent to fCPAP in improving sleepiness in patients with OSAS in the long-term. METHODS: In this multicentre equivalence trial, 208 patients with OSAS, with median Epworth sleepiness score (ESS) 13, apnoea/hypopnoea index 48.4/hour, were randomised to treatment with autoCPAP (5-15 mbar) or fCPAP (pressure set at the 90th percentile applied by autoCPAP during 2-4 weeks adaptation). Coprimary outcomes were changes in subjective and objective sleepiness from baseline to 2 years after treatment. Equivalence ranges were ±2 points in ESS and ±3 min sleep resistance time evaluated by recording responses to light signals. RESULTS: At 2 years, in the intention to treat analysis, the reduction in sleepiness versus pretreatment baseline was similar in patients using autoCPAP (n=113, mean ESS-change -6.3, 95% CI -7.1 to -5.5; sleep resistance time +8.3 min, +6.9 to +9.7) and fCPAP (n=95, mean ESS-change -6.2, 95% CI -7.0 to -5.3; sleep resistance time +6.3 min, +4.7 to +7.8). The 95% CI of difference in ESS-reduction between autoCPAP and fCPAP was -0.9 to +1.4 and the 95% CI of difference in increase in sleep resistance time was -2.6 to +1.0 min. Blood pressure reduction and OSAS-related costs were similar between groups. CONCLUSIONS: AutoCPAP and fCPAP are equivalent within prespecified ranges in improving subjective and objective sleepiness in patients with OSAS over the course of 2 years. Costs of these treatments are similar. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT00280800.

Obstructive sleep apnea in patients with central serous chorioretinopathy.

BACKGROUND: Patients with central serous chorioretinopathy (CSC) show an increased sympathetic activity compared to controls. Additionally, there are several reports of increased corticosteroid and catecholamine levels in these patients. Obstructive sleep apnea syndrome (OSAS) has been shown to enhance sympathetic activity depending on severity. Respiratory disturbance increases urinary catecholamine secretion and is associated with the occurence of hypertension in a dose dependent manner. Therefore we hypothesize that OSAS may act as a risk factor for the development of CSC. METHODS: Patients with active CSC or with pigment epithelial disturbances after CSC were contacted to answer a questionnaire about general health, drugs and sleeping habits and to complete the Epworth Sleepiness Scale (ESS) score, a widely used subjective measure of daytime sleepiness. Patients with an ESS score of >10 were referred to our department of pulmonary medicine for evaluating of respiratory disturbance in sleep. RESULTS: We identified 56 consecutive patients with angiographic criteria for acute CSC or pigment epithelial defects after CSC, seven (12.5%) of whom were excluded because of a history of systemic or topic corticosteroid use. Thirty-six (73.5%) of the remaining 49 patients returned the questionnaire. Fourteen (38.8%) had an ESS score of >10. They were referred to the Department of Pulmonary Medicine. In eight (22.2%) of these patients, a diagnosis of obstructive sleep apnea syndrome was confirmed. CONCLUSIONS: We found that 22% of the patients with acute or chronic CSC in this case series also suffered from OSAS, whereas in the general population OSAS is considerably less frequently reported (2-4%). OSAS therefore may act as a risk factor for the development of CSC. However, prospective controlled data is needed to definitely evaluate the possible association between CSC and OSAS. Also the clinical course of CSC during treatment of OSAS would be of particular interest.

Respiratory polygraphy in sleep apnoea diagnosis. Report of the Swiss respiratory polygraphy registry and systematic review of the literature.

BACKGROUND: Sleep related breathing disorders (SBD) are common and associated with morbidity and mortality. Since polysomnography, the conventional diagnostic gold standard is costly and not generally available, ambulatory respiratory polygraphic sleep studies (RP) are used. To evaluate whether RP reimbursement by health insurance companies was justified, the Swiss Federal Office of Public Health (FOPH) requested registration of RP during 36 months and a literature review on RP. The results are reported here. METHODS: RP reimbursed from July 2002 to December 2005 by Swiss health insurance companies were analysed. A review of the literature from 2003 comparing RP with PSG was updated. The outcome of interest was the apnoea/hypopnoea index. RESULTS: Datasets on 11,485 RP were evaluated, 8179 were performed to evaluate suspected obstructive sleep apnoea syndrome (OSAS). In patients with snoring, witnessed apnoea and hypersomnia (n = 4180), 80.2% of RP confirmed OSAS, 3.5% of RP were inconclusive prompting polysomnography. Six studies published between 2003 and 2005 were pooled with a former review of 12 studies. With a mean pre-test probability of 64% for OSAS, the post-test probability after a negative result ranged from 8% (negative likelihood ratio of 0.05) to 23% (negative likelihood ratio of 0.20). The post-test probability after a positive result was within a range of 98% (positive likelihood ratio of 23.8) to 90% (positive likelihood ratio of 5.7). CONCLUSIONS: In selected patients with clinically suspected OSAS RP allows accurate and simple diagnosis of OSAS. According to the practice in Switzerland as reflected by the registry additional PSG are rarely required, suggesting relevant cost savings by RP. Granting reimbursement for RP as introduced in the meantime by the FOPH seems justified.

Effects of sinus surgery in patients with cystic fibrosis after lung transplantation: a 10-year experience.

Chronic infectious rhinosinusitis with Pseudomonas aeruginosa is common in cystic fibrosis and may result in allograft infection after lung transplantation. Sinus surgery followed by nasal care may reduce these adverse effects. Sinus surgery was performed in 37 patients with cystic fibrosis after transplantation. Bacteriology of sinus aspirates (n=771) and bronchoalveolar lavage (BAL) (n=256) was correlated with clinical data. Sinus surgery was successful in 54% and partially successful in 27% of patients. A significant correlation between negative sinus aspirates and negative BAL and between positive sinus aspirates and positive BAL (P<0.0001) was found. Successful sinus management led to a lower incidence of tracheobronchitis and pneumonia (P=0.009) and a trend toward a lower incidence of bronchiolitis obliterans syndrome (P=0.23). Sinus surgery followed by daily nasal douching may control posttransplant lower airway colonization and infection. In the long term, this concept may lead to less bronchiolitis obliterans syndrome by decreasing bronchiolar inflammation.