Frequency and evolution of sleep-wake disturbances after ischemic stroke: A 2-year prospective study of 437 patients.

OBJECTIVE: In the absence of systematic and longitudinal data, this study prospectively assessed both frequency and evolution of sleep-wake disturbances (SWD) after stroke. METHODS: In 437 consecutively recruited patients with ischemic stroke or transient ischemic attack (TIA), stroke characteristics and outcome were assessed within the 1st week and 3.2 ± 0.3 years (M±SD) after the acute event. SWD were assessed by interview and questionnaires at 1 and 3 months as well as 1 and 2 years after the acute event. Sleep disordered breathing (SDB) was assessed by respirography in the acute phase and repeated in one fifth of the participants 3 months and 1 year later. RESULTS: Patients (63.8% male, 87% ischemic stroke and mean age 65.1 ± 13.0 years) presented with mean NIHSS-score of 3.5 ± 4.5 at admission. In the acute phase, respiratory event index was >15/h in 34% and >30/h in 15% of patients. Over the entire observation period, the frequencies of excessive daytime sleepiness (EDS), fatigue and insomnia varied between 10-14%, 22-28% and 20-28%, respectively. Mean insomnia and EDS scores decreased from acute to chronic stroke, whereas restless legs syndrome (RLS) percentages (6-9%) and mean fatigue scores remained similar. Mean self-reported sleep duration was enhanced at acute stroke (month 1: 07:54 ± 01:27h) and decreased at chronic stage (year 2: 07:43 ± 01:20h). CONCLUSIONS: This study documents a high frequency of SDB, insomnia, fatigue and a prolonged sleep duration after stroke/TIA, which can persist for years. Considering the negative effects of SWD on physical, brain and mental health these data suggest the need for a systematic assessment and management of post-stroke SWD.

Pulmonary Recovery 12 Months after Non-Severe and Severe COVID-19: The Prospective Swiss COVID-19 Lung Study.

BACKGROUND: Lung function impairment persists in some patients for months after acute coronavirus disease 2019 (COVID-19). Long-term lung function, radiological features, and their association remain to be clarified. OBJECTIVES: We aimed to prospectively investigate lung function and radiological abnormalities over 12 months after severe and non-severe COVID-19. METHODS: 584 patients were included in the Swiss COVID-19 lung study. We assessed lung function at 3, 6, and 12 months after acute COVID-19 and compared chest computed tomography (CT) imaging to lung functional abnormalities. RESULTS: At 12 months, diffusion capacity for carbon monoxide (DLCOcorr) was lower after severe COVID-19 compared to non-severe COVID-19 (74.9% vs. 85.2% predicted, p < 0.001). Similarly, minimal oxygen saturation on 6-min walk test and total lung capacity were lower after severe COVID-19 (89.6% vs. 92.2%, p = 0.004, respectively, 88.2% vs. 95.1% predicted, p = 0.011). The difference for forced vital capacity (91.6% vs. 96.3% predicted, p = 0.082) was not statistically significant. Between 3 and 12 months, lung function improved in both groups and differences in DLCO between non-severe and severe COVID-19 patients decreased. In patients with chest CT scans at 12 months, we observed a correlation between radiological abnormalities and reduced lung function. While the overall extent of radiological abnormalities diminished over time, the frequency of mosaic attenuation and curvilinear patterns increased. CONCLUSIONS: In this prospective cohort study, patients who had severe COVID-19 had diminished lung function over the first year compared to those after non-severe COVID-19, albeit with a greater extent of recovery in the severe disease group.

Effect of early sleep apnoea treatment with adaptive servo-ventilation in acute stroke patients on cerebral lesion evolution and neurological outcomes: study protocol for a multicentre, randomized controlled, rater-blinded, clinical trial (eSATIS: early Sleep Apnoea Treatment in Stroke).

BACKGROUND: Sleep-disordered breathing (SDB) is highly prevalent in acute ischaemic stroke and is associated with worse functional outcome and increased risk of recurrence. Recent meta-analyses suggest the possibility of beneficial effects of nocturnal ventilatory treatments (continuous positive airway pressure (CPAP) or adaptive servo-ventilation (ASV)) in stroke patients with SDB. The evidence for a favourable effect of early SDB treatment in acute stroke patients remains, however, uncertain. METHODS: eSATIS is an open-label, multicentre (6 centres in 4 countries), interventional, randomized controlled trial in patients with acute ischaemic stroke and significant SDB. Primary outcome of the study is the impact of immediate SDB treatment with non-invasive ASV on infarct progression measured with magnetic resonance imaging in the first 3 months after stroke. Secondary outcomes are the effects of immediate SDB treatment vs non-treatment on clinical outcome (independence in daily functioning, new cardio-/cerebrovascular events including death, cognition) and physiological parameters (blood pressure, endothelial functioning/arterial stiffness). After respiratory polygraphy in the first night after stroke, patients are classified as having significant SDB (apnoea-hypopnoea index (AHI) > 20/h) or no SDB (AHI < 5/h). Patients with significant SDB are randomized to treatment (ASV+ group) or no treatment (ASV- group) from the second night after stroke. In all patients, clinical, physiological and magnetic resonance imaging studies are performed between day 1 (visit 1) and days 4-7 (visit 4) and repeated at day 90 ± 7 (visit 6) after stroke. DISCUSSION: The trial will give information on the feasibility and efficacy of ASV treatment in patients with acute stroke and SDB and allows assessing the impact of SDB on stroke outcome. Diagnosing and treating SDB during the acute phase of stroke is not yet current medical practice. Evidence in favour of ASV treatment from a randomized multicentre trial may lead to a change in stroke care and to improved outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02554487 , retrospectively registered on 16 September 2015 (actual study start date, 13 August 2015), and www.kofam.ch (SNCTP000001521).

Pulmonary function and radiological features 4 months after COVID-19: first results from the national prospective observational Swiss COVID-19 lung study.

BACKGROUND: The infectious coronavirus disease 2019 (COVID-19) pandemic is an ongoing global healthcare challenge. Up to one-third of hospitalised patients develop severe pulmonary complications and acute respiratory distress syndrome. Pulmonary outcomes following COVID-19 are unknown. METHODS: The Swiss COVID-19 lung study is a multicentre prospective cohort investigating pulmonary sequelae of COVID-19. We report on initial follow-up 4 months after mild/moderate or severe/critical COVID-19 according to the World Health Organization severity classification. RESULTS: 113 COVID-19 survivors were included (mild/moderate n=47, severe/critical n=66). We confirmed several comorbidities as risk factors for severe/critical disease. Severe/critical disease was associated with impaired pulmonary function, i.e. diffusing capacity of the lung for carbon monoxide (D LCO) % predicted, reduced 6-min walk distance (6MWD) and exercise-induced oxygen desaturation. After adjustment for potential confounding by age, sex and body mass index (BMI), patients after severe/critical COVID-19 had a D LCO 20.9% pred (95% CI 12.4-29.4% pred, p=0.01) lower at follow-up. D LCO % pred was the strongest independent factor associated with previous severe/critical disease when age, sex, BMI, 6MWD and minimal peripheral oxygen saturation at exercise were included in the multivariable model (adjusted odds ratio per 10% predicted 0.59, 95% CI 0. 37-0.87; p=0.01). Mosaic hypoattenuation on chest computed tomography at follow-up was significantly associated with previous severe/critical COVID-19 including adjustment for age and sex (adjusted OR 11.7, 95% CI 1.7-239; p=0.03). CONCLUSIONS: 4 months after severe acute respiratory syndrome coronavirus 2 infection, severe/critical COVID-19 was associated with significant functional and radiological abnormalities, potentially due to small-airway and lung parenchymal disease. A systematic follow-up for survivors needs to be evaluated to optimise care for patients recovering from COVID-19.

Pulse Oximetry at the Wrist During Sleep: Performance, Challenges and Perspectives.

The state-of-the-art non-invasive measurement of peripheral oxygen saturation (SpO2) during sleep is mainly based on pulse oximetry at the fingertip. Although this approach is noninvasive, it can still be obtrusive and cumbersome to apply, in particular for ambulatory monitoring over several nights.We developed a wrist-worn reflectance pulse oximetry device which can be embedded in a watch, making it less obtrusive and easy to apply. This device was tested in an ongoing clinical study on 57 subjects (33 patients and 24 healthy volunteers) undergoing a full overnight polysomnography recording. The accuracy was evaluated against state-of-the-art fingertip SpO2 measurements.In the 54 subjects available for analysis we obtained an SpO2 accuracy (ARMS) of 3.4 % when automatically rejecting 17.7 % of signals due to low quality. When further excluding measurements suffering from insufficient contact of the watch with the skin an ARMS of 2.7 % was obtained while rejecting a total of 23.2 % measurements. These accuracies comply with the ISO standard and the FDA guidance for pulse oximeters.The present results are promising and pave the way for unobtrusive and continuous monitoring of SpO2 to screen for sleep disordered breathing. Nonetheless, contact pressure and venous blood have shown to adversely affect the SpO2 estimation and remain a challenge for wrist-based reflectance pulse oximetry.

SAS Care 1: sleep-disordered breathing in acute stroke an transient ischaemic attack - prevalence, evolution and association with functional outcome at 3 months, a prospective observational polysomnography study.

Sleep-disordered breathing (SDB) is frequent in patients with acute stroke. Little is known, however about the evolution of SDB after stroke. Most of our knowledge stems from smaller cohort studies applying limited cardiopulmonary sleep recordings or from cross-sectional data collected in different populations. This study aims to determine prevalence, type and intra-individual evolution of SDB based on full-night polysomnography (PSG) in acute stroke and 3 months thereafter. Furthermore, we aimed to identify predictors of SDB in the acute and chronic phase and to evaluate associations between SDB and functional outcome at 3 months (M3). A total of 166 patients with acute cerebrovascular events were evaluated by full PSG at baseline and 105 again at M3. The baseline prevalence of SDB (apnoea-hypopnoea index (AHI)>5·h-1) was 80.5% and 25.4% of the patients had severe SDB (AHI>30·h-1). Obstructive sleep apnoea was more prevalent than central sleep apnoea (83.8% versus 13%). Mean±SD AHI was 21.4±17.6·h-1and decreased significantly at M3 (18±16.4·h-1; p=0.018). At M3, 91% of all patients with baseline SDB still had an AHI>5·h-1 and in 68.1% the predominant type of SDB remained unchanged (78.9% in obstructive sleep apnoea and 44.4% in central sleep apnoea). The only predictors of SDB at baseline were higher age and body mass index and in the chronic phase additionally baseline AHI. Baseline AHI was associated with functional outcome (modified Rankin score >3) at M3. The high prevalence of SDB in acute stroke, its persistence after 3 months, and the association with functional outcome supports the recommendation for a rapid SDB screening in stroke patients.

Calculated parenteral initial treatment of bacterial infections: Respiratory infections.

This is the fifth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. It provides recommendations for the empirical and targeted antimicrobial treatment of lower respiratory tract infections, with a special emphasis on the treatment of acute exacerbation of COPD, community-acquired pneumonia and hospital-acquired pneumonia.

Pulmonary nocardiosis in Western Europe-Clinical evaluation of 43 patients and population-based estimates of hospitalization rates.

BACKGROUND: Pulmonary nocardiosis (PN) is an uncommon but potentially life-threatening infection. Most of our knowledge on PN is derived from case reports and small case series. Increasing incidence rates of PN have been reported recently. The aim of this study was to describe the clinical course of and risk factors for PN in four Western European countries and to estimate population-based annual hospitalization rates. METHODS: This was a retrospective evaluation (1995-2011) of the clinical course of and risk factors for PN in patients at 11 hospitals in four European countries (Germany, Austria, Switzerland, and the Netherlands). Population-based estimates of hospitalization rates for PN in Germany (2005 to 2011) were calculated using official German nationwide diagnosis-related groups (DRG) hospital statistics. RESULTS: Forty-three patients fulfilled stringent criteria for proven (n=8) and probable (n=35) PN; seven had extrapulmonary dissemination. For these 43 patients, the major risk factors for PN were immunocompromising (83.7%) and/or pulmonary (58.1%; as only comorbidity in 27.9%) comorbidities. The median duration of PN targeted therapy was 12 weeks. Distinctive patterns of resistance were observed (imipenem susceptibility: Nocardia farcinica 33.3%; Nocardia asteroides 66.7%). The overall mortality rate was 18.9% (50% in disseminated PN). Over time, annual PN hospitalization rates remained unchanged at around 0.04/100000, with the highest rate among men aged 75-84 years (0.24/100000). CONCLUSIONS: PN is a rare, but potentially life-threatening disease, and mainly affects immunocompromised elderly males. Overall, annual hospitalization rates remained stable between 2005 and 2011.

Microbial and host immune factors as drivers of COPD.

Compartmentalisation of the respiratory tract microbiota in patients with different chronic obstructive pulmonary disease (COPD) severity degrees needs to be systematically investigated. In addition, it is unknown if the inflammatory and emphysematous milieux in patients with COPD are associated with changes in the respiratory tract microbiota and host macrophage gene expression. We performed a cross-sectional study to compare non-COPD controls (n=10) to COPD patients (n=32) with different disease severity degrees. Samples (n=187) were obtained from different sites of the upper and lower respiratory tract. Microbiota analyses were performed by 16S ribosomal RNA gene sequencing and host gene expression analyses by quantitative real-time PCR of distinct markers of bronchoalveolar lavage cells. Overall, the microbial communities of severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade 3/4) patients clustered significantly differently to controls and less severe COPD (GOLD 1/2) patients (permutational multivariate ANOVA (MANOVA), p=0.001). However, we could not detect significant associations between the different sampling sites in the lower airways. In addition, the chosen set of host gene expression markers significantly separated COPD GOLD 3/4 patients, and we found correlations between the composition of the microbiota and the host data. In conclusion, this study demonstrates associations between host gene expression and microbiota profiles that may influence the course of COPD.

Prevalence and Prediction of Obstructive Sleep Apnea Prior to Bariatric Surgery-Gender-Specific Performance of Four Sleep Questionnaires.

PURPOSE: Bariatric surgery (BS) is a treatment option for morbid obesity leading to substantial and sustained weight loss in adults. As obstructive sleep apnea (OSA) is highly prevalent in obese subjects and may increase the perioperative risk, screening for OSA is recommended prior to BS. In clinical routine, BS is performed more frequently in women. Therefore, we sought to assess the gender-specific performance of four sleep questionnaires (Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), STOPBang, and NoSAS) to predict moderate to severe OSA in the morbidly obese population. MATERIAL AND METHODS: We applied all four questionnaires to patients scheduled for BS with polygraphic OSA screening at our institution between 2012 and 2015 and performed gender-specific sensitivity analyses. RESULTS: We included 251 bariatric patients (76% female, median age 39 years, median BMI 42.0 kg/m2). OSA (AHI > 5/h; AHI > 15/h) was present in 43% (females 35%, males 68%; p < 0.001) and 21% (females 13%, males 45%; p < 0.001). STOPBang and NoSAS performed markedly better than ESS and FSS. With the exception of the ESS, all sleep questionnaires allowed better OSA prediction in women than in men. CONCLUSION: In obese patients scheduled for BS, a gender-specific difference was observed in the performance of the evaluated OSA screening questionnaires. This needs to be considered when these questionnaires are used. Our results underline the need for better gender-specific OSA screening algorithms in morbidly obese patients.

Periodic limb movements during sleep in stroke/TIA: Prevalence, course, and cardiovascular burden.

OBJECTIVE: To define the prevalence, time course, and associated factors of periodic limb movements during sleep (PLMS) in patients with ischemic stroke or TIA. METHODS: Patients enrolled in the prospective Sleep-Disordered Breathing in Transient Ischemia Attack (TIA)/Ischemic Stroke and Continuous Positive Airway Pressure (CPAP) Treatment Efficacy (SAS-CARE) study underwent a double polysomnographic investigation in the acute and chronic phases after stroke/TIA, together with a MRI brain scan and a 24-hour blood pressure evaluation. The prevalence of PLMS in patients was compared with that in a matched sample of randomly selected healthy controls from the HypnoLaus cohort. One hundred sixty-nine recordings were performed in the acute phase and 191 after 3 months (210 recordings were obtained from the same 105 patients in both phases) and were compared to those of 162 controls. RESULTS: The mean number of PLMS per hour and the percentage of participants with a PLMS index >10 and >15 per hour were similar between patients and controls. PLMS remained stable from the acute to the chronic phase after stroke. Factors positively associated with PLMS were age, body mass index, and history of hypertension. Blood pressure over 24 hours and the burden of cerebrovascular damage were similar between the groups with PLMS and without PLMS. CONCLUSIONS: PLMS are equally frequent in patients with stroke/TIA and the general population. The absence of higher blood pressure values and of a greater vascular brain damage found in patients with PLMS compared to those without PLMS might be due to a greater use of antihypertensive medication among patients with PLMS, which corresponds to a higher prevalence of previous diagnosis of hypertension in these patients.

CPAP as treatment of sleep apnea after stroke: A meta-analysis of randomized trials.

OBJECTIVE: To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) examining the effectiveness of continuous positive airway pressure (CPAP) in stroke patients with sleep disordered breathing (SDB). METHODS: In a systematic literature search of electronic databases (MEDLINE, Embase, and the Cochrane Library) from 1980 to November 2016, we identified RCTs that assessed CPAP compared to standard care or sham CPAP in adult patients with stroke or TIA with SDB. Mean CPAP use, odds ratios (ORs), and standardized mean differences (SMDs) were calculated. The prespecified outcomes were adherence to CPAP, neurologic improvement, adverse events, new vascular events, and death. RESULTS: Ten RCTs (564 participants) with CPAP as intervention were included. Two studies compared CPAP with sham CPAP; 8 compared CPAP with usual care. Mean CPAP use across the trials was 4.53 hours per night (95% confidence interval [CI] 3.97-5.08). The OR of dropping out with CPAP was 1.83 (95% CI 1.05-3.21, p = 0.033). The combined analysis of the neurofunctional scales (NIH Stroke Scale and Canadian Neurological Scale) showed an overall neurofunctional improvement with CPAP (SMD 0.5406, 95% CI 0.0263-1.0548) but with a considerable heterogeneity (I2 = 78.9%, p = 0.0394) across the studies. Long-term survival was improved with CPAP in 1 trial. CONCLUSION: CPAP use after stroke is acceptable once the treatment is tolerated. The data indicate that CPAP might be beneficial for neurologic recovery, which justifies larger RCTs.

Sleep-disordered breathing and stroke: chicken or egg?

The bidirectional interaction between sleep-disordered breathing (SDB) and stroke has been the subject of many studies. On the one hand, different forms of SDB, and especially obstructive sleep apnea, increase the risk of stroke either directly or indirectly by influencing other known cardiovascular risk factors such as arterial hypertension and arrhythmias. On the other hand, stroke itself can cause either de novo appearance of SDB, aggravate a pre-existing SDB, or trigger a transition from one type of pathological SDB pattern into another. In this review, we discuss some aspects of this "chicken or egg" relationship.

Perioperative Lung Function Monitoring for Anatomic Lung Resections.

BACKGROUND: The aim of this study was to prospectively investigate the correlation between postoperative spirometry values and pulmonary complications after anatomic lung resections. In addition, we compared postoperative pulmonary function changes between open and minimally invasive approaches. METHODS: Three hundred eighty-four patients who underwent an anatomic lung resection at our institution between June 2013 and June 2016 were enrolled in this prospective observational trial. Bedside spirometry was performed before surgery and postoperatively every second day until discharge. For the 250 patients who completed the trial, the following data were collected and analyzed: spirometry findings, pain management, surgical procedure, and postoperative complications. A propensity score matched analysis was performed to compare open and minimally invasive approaches. RESULTS: Postoperative pneumonia was significantly more frequent after open surgery (13.2% versus 4.4%, p = 0.016); furthermore, these patients showed significantly greater losses of forced expiratory volume in 1 second on postoperative day 4 compared with patients without pneumonia (loss in percent from preoperative absolute values: 43.2% versus 32,2%, p = 0.013). When focusing on patients without pneumonia, propensity matched analysis revealed a significantly faster recovery of forced expiratory volume in 1 second on postoperative day 4 in the minimally invasive group compared with the open group (p = 0.011). CONCLUSIONS: Daily bedside spirometry might be a helpful diagnostic adjunct for early recognition, and hence, timely treatment, of pulmonary infection after open anatomic lung resections. In addition, minimally invasive techniques not only resulted in a lower rate of pulmonary infections but also resulted in faster postoperative recovery of pulmonary function and shorter hospital stay.

The SERVE-HF safety notice in clinical practice - experiences of a tertiary sleep center.

BACKGROUND: In May 2015, the results of the SERVE-HF trial - addressing adaptive servoventilation (ASV) in chronic congestive heart failure (CHF) patients with central sleep apnea (CSA) - prompted a field safety notice. It was recommended to identify CHF patients treated with ASV and to advise the discontinuation of the treatment. We aimed to analyze the identification process and effect of ASV discontinuation on affected patients. METHODS: 126 patients treated with ASV on May 13th, 2015 at our institution were retrospectively analyzed. Treatment decisions, effect of ASV discontinuation and clinical course were followed for a year. Patients on ASV with CHF were compared to those without CHF. RESULTS: The risk criteria of the safety notice were fulfilled by 10.3% of patients (13/126). Additional echocardiographies were performed in 38%. ASV was discontinued in 93% of patients without adverse events (emergency hospitalization in n = 1). CSA reappeared immediately. Day- or nighttime symptoms were reported by 61%. Symptomatic patients were started on alternative treatments. CHF and non-CHF patients differed in cardiac function and type of SDB. CHF patients had shorter overall treatment duration. Compliance to ASV was similar in both groups with a median usage of 412 min (269; 495)/night in the CHF group and 414.5 min (347; 480) in the non-CHF group. CONCLUSION: Identification of patients "at risk" is feasible but outcome of discontinuation of ASV cannot be evaluated based on these data. ASV withdrawal in patients with stable chronic CHF and CSA leads to an immediate return of sleep disordered breathing. Symptomatic patients may ask for alternative treatment options.

Bone subtraction radiography in adult patients with cystic fibrosis.

Background Bone subtraction radiography allows reading pulmonary changes of chest radiographs more accurately without superimposition of bones. Purpose To evaluate the value of bone subtraction chest radiography using dual energy (DE) bone subtracted lung images compared to conventional radiographs (CR) in adult patients with cystic fibrosis (CF). Material and Methods Forty-nine DE radiographs of 24 patients (16 men) with CF (mean age, 32 years; age range, 18-71 years) were included. Lung function tests were performed within 10 days of the radiographs. Two radiologists evaluated all CR, DE, and CR + DE radiographs using the modified Chrispin-Norman score (CNS) and a five-point score for the confidence. Findings were statistically evaluated by Friedman ANOVA and Wilcoxon matched-pairs test. Results There was significant difference of CNS between CR and DE ( P = 0.044) as well as CR and CR + DE ( P < 0.001). CNS of CR images showed moderate correlation with FEV1% (R = 0.287, P = 0.046) while DE and CR + DE correlated poorly with FEV1% (R = 0.023, P = 0.874 and R = 0.04, P = 0.785). A higher confidence was achieved with bone-subtracted radiographs compared to radiographs alone (median, CR 3.3, DE 3.9, CR + DE 4.1, for both P < 0.001). Conclusion DE radiographs are reliable for the evaluation of adult patients with CF in acute exacerbation. For yearly surveillance, CR and DE radiographs may play a limited role. However, in clinical routine, DE radiographs are useful for adult CF patients and may depict more accurately inflammatory changes than CR.

A 43-Year-Old Man With Daytime Sleepiness and a Heart Murmur.

A 43-year-old man was referred to our tertiary sleep center for the initiation of sleep apnea treatment. A prior diagnostic overnight polysomnography (Fig 1) had revealed an apnea-hypopnea index (AHI) of 22/h of sleep. The apneas were predominantly central (central AHI, 18.2/h; obstructive AHI, 3.8/h), more pronounced in the supine position (AHI supine, 36.6/h; AHI nonsupine, 11/h) and during non-rapid eye movement (non-REM) sleep (REM, 15.8/h; non-REM, 23.5/h). A continuous positive airway pressure (CPAP) trial in an outpatient setting had failed, as the fixed CPAP of 11 cm H2O was not tolerated by the patient because of a feeling of lightheadedness when wearing the mask. At referral, the patient complained about falling asleep in front of the computer in the afternoons despite regular bedtimes and 7 to 8 h of sleep per night. His Epworth Sleepiness Scale score was 11. He had no significant past history including cardiopulmonary disease. He was not taking any medication but had noticed a slow decline in general physical performance in the last year, with dyspnea (New York Heart Association class I) after running distances of 1 to 2 km. He had never experienced syncope. His family history was unremarkable.

Community-acquired Haemophilus influenzae pneumonia--New insights from the CAPNETZ study.

OBJECTIVES: We aimed to identify clinical characteristics and to assess effectiveness of different initial antibiotic regimens in adult patients with community-acquired pneumonia (CAP) caused by Haemophilus influenzae. METHODS: Characteristics were compared between patients with H. influenzae monoinfection versus CAP of other and unknown aetiology enrolled by the German prospective cohort study CAPNETZ. Impact of initial antibiotic treatment on "early clinical response" according to FDA criteria and overall clinical cure were analysed. RESULTS: H. influenzae was found in 176 out of 2790 patients with pathogen detection (6.3%). Characteristics significantly associated with a H. influenzae CAP (p < 0.017) included purulent sputum, prior pneumococcal vaccination and respiratory co-morbidities. Early clinical response rates on day 4 did not differ between patients receiving any mono- versus combination therapy (85.9% versus 88%), but were numerically higher for regimens including any fluoroquinolone (96.7%) and lower under macrolide monotherapy (70%). Initial CURB-65 score and chronic liver disease were identified as negative predictors for "early clinical response". At day 14, overall clinical cure was 91.9%. CONCLUSIONS: H. influenzae was a common CAP pathogen, particularly in patients with previous pneumococcal vaccination and respiratory co-morbidities. Severity of illness and chronic liver disease were associated with a lower rate of "early clinical response".