The association between migraine and dementia - a national register-based matched cohort study.

OBJECTIVES: Migraine and dementia, two major public health challenges, are associated, but more knowledge is needed to understand their relationship. Objectives of this study were to investigate 1) the association between non-self-reported measures of migraine and dementia, and whether dementia was associated with 2) migraine without aura (MO) and with aura (MA) in combination with migraine medication use, and 3) migraine severity operationalized as the number of migraine prescriptions. STUDY DESIGN: Matched cohort study. METHODS: National register data were obtained from individuals born between 1934 and 1958. Migraine cases (aged 25-58 years) were identified by migraine diagnoses and redeemed migraine medication. Migraine cases were matched with non-cases (N = 340,850) and date of diagnosis or medication redemption was defined as index year. Dementia was identified by dementia diagnoses and redeemed dementia medication. RESULTS: We observed a 1.46 (95% CI: 1.26-1.69) times higher dementia rate in individuals with a migraine diagnosis and a 0.86 (95% CI: 0.76-0.97) times lower rate when using migraine medication. We found the highest dementia rate among individuals with MA, who also used migraine medication (HR = 2.23; 95% CI: 1.19-4.17), and the lowest rate among individuals with MO, who also used medication (HR = 1.25; 95% CI: 0.75-2.10). The number of migraine medication prescriptions was not associated with dementia. CONCLUSIONS: Being registered with a migraine diagnosis was associated with a higher dementia rate, while use of prescribed migraine medication was not. The differences in the dementia rate among migraine cases identified via diagnoses versus medications warrants further investigation.

Factores pronósticos precoces de morbimortalidad en el traumatismo craneoencefálico grave en niños. Experiencia en una unidad de politraumatismo infantil / Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit

Objetivo Identificar factores pronósticos precoces que conduzcan a un mayor riesgo de pronóstico desfavorable. Diseño Estudio de cohortes observacional de octubre 2002 a octubre 2017. Pacientes y ámbito Se incluyeron pacientes menores de 18 años con TCE grave ingresados en cuidados intensivos (UCIP). Variables e intervenciones Se recogieron variables epidemiológicas, clínico-analíticas y terapéuticas. Se valoró la capacidad funcional del paciente a los 6 meses mediante la Glasgow Outcome Scale (GOS). Se consideró pronóstico desfavorable un GOS menor o igual a 3. Se realizó un análisis univariante para comparar grupos de buen y mal pronóstico y su relación con las diferentes variables. Se realizó un análisis multivariante para predecir el pronóstico del paciente. Resultados 98 pacientes, 61,2% varones, mediana de edad 6,4 años (RIQ 2.49–11.23). El 84,7% fueron atendidos por los servicios de emergencias extrahospitalarios. A los 6 meses, el 51% presentaba recuperación satisfactoria, 26,5% secuelas moderadas, 6,1% secuelas graves y 2% estado vegetativo. Fallecieron el 14,3%. Hubo significación estadística entre la puntuación en la escala de coma de Glasgow (ECG) prehospitalaria, reactividad pupilar, hipotensión arterial, hipoxia, ciertas alteraciones analíticas y radiológicas (compresión de las cisternas basales), con pronóstico desfavorable. El análisis multivariante demostró que es posible realizar modelos predictores de la evolución de los pacientes. Conclusiones Es posible identificar factores pronósticos de mala evolución en las primeras 24 horas postraumatismo. Su conocimiento puede ayudar a la toma de decisiones clínicas y ofrecer una mejor información a las familias (AU)

Objective To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. Design Observational cohort study from October 2002 to October 2017. Setting and patients Patients with severe TBI admitted to intensive care were included. Variables and interventions Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. Results 98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49–11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. Conclusions it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families (AU)

Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit.

OBJECTIVE: To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. DESIGN: Observational cohort study from October 2002 to October 2017. SETTING AND PATIENTS: Patients with severe TBI admitted to intensive care were included. VARIABLES AND INTERVENTIONS: Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. RESULTS: 98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49-11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. CONCLUSIONS: it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.

Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit. / Factores pronósticos precoces de morbimortalidad en el traumatismo craneoencefálico grave en niños. Experiencia en una unidad de politraumatismo infantil.

OBJECTIVE: To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. DESIGN: Observational cohort study from October 2002 to October 2017. SETTING AND PATIENTS: Patients with severe TBI admitted to intensive care were included. VARIABLES AND INTERVENTIONS: Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS ≤3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. RESULTS: A total of 98 patients were included, 61.2% males, median age 6.4years (IQR 2.49-11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. CONCLUSIONS: It is possible to identify prognostic factors of poor evolution in the first 24hours after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.

Respiratory and pharmacological management in severe acute bronchiolitis: Were clinical guidelines not written for critical care?

PURPOSE: The treatment applied for children admitted to the pediatric intensive care unit (PICU) for severe acute bronchiolitis may differ from general recommendations. The first objective of our study was to describe the treatments offered to these children in a Spanish tertiary PICU. The second objective was to analyse the changes in management derived from the publication of the American Academy of Pediatrics (AAP) bronchiolitis guideline in 2014. METHODS: This was a retrospective-prospective observational study conducted during two epidemic waves (2014-2015 and 2015-2016). The AAP guidelines were distributed and taught to PICU staff between both epidemic waves. RESULTS: A total of 138 children were enrolled (78 male). In the first period, 78 children were enrolled. The median age was 1.8 months (IQR 1.1-3.6). There were no differences between the management in the two periods, except for the use of high-flow oxygen therapy (HFOT); its use increased in the second period. Overall, 83% of patients received non-invasive ventilation or HFOT. Children older than 12 months received HFOT exclusively. In comparison, continuous positive airway pressure and bi-level positive airway pressure were used less during the period 2015-2016 (P=0.036). Regarding pharmacological therapy, 70% of patients received antibiotics, 23% steroids, 33% salbutamol, 31% adrenaline, and 7% hypertonic saline. The mortality rate was zero. CONCLUSIONS: Our PICU did not follow the AAP recommendations. There were no differences between the two periods, except in the use of HFOT. All children older than 12 months received HFOT exclusively. The rate of using invasive mechanical ventilation was also low.

A smartphone oximeter with a fingertip probe for use during exercise training: usability, validity and reliability in individuals with chronic lung disease and healthy controls.

BACKGROUND AND AIM: Telehealth is a strategy to expand the reach of pulmonary rehabilitation (PR). Smartphones can monitor and transmit oxygen saturation (SpO2) and heart rate (HR) data to ensure patient safety during home-based or other exercise. The purpose of this study was to evaluate the usability, validity and reliability of a Kenek O2 pulse oximeter and custom prototype smartphone application (smartphone oximeter) during rest and exercise in healthy participants and those with chronic lung disease. METHODS: Fifteen individuals with chronic lung disease and 15 healthy controls were recruited. SpO2 and HR were evaluated at rest and during cycling and walking. SpO2 was valid if the mean bias was within +±2%, the level of agreement (LoA) was within ±4%; HR was valid if the mean bias was within ±5 beats per min (bpm), LoA was within ±10bpm. Usability was assessed with a questionnaire and direct observation. RESULTS: The smartphone oximeter was deemed easy to use. At rest, SpO2 measures were valid in both groups (bias <2%, lower bound LoA -2 to 3%). During exercise, SpO2 measurement did not meet validity and reliability thresholds in the patients with chronic lung disease, but was accurate for the healthy controls. HR recording during exercise or rest was not valid (LoA>10bpm) in either group. CONCLUSIONS: The smartphone oximeter did not record HR or SpO2 accurately in patients with chronic lung disease during exercise, although SpO2 was valid at rest. During exercise, patients with chronic lung disease should pause to ensure greatest accuracy of SpO2 and HR measurement.

Accuracy of CD64 expression on neutrophils and monocytes in bacterial infection diagnosis at pediatric intensive care admission.

The CD64 receptor has been described as an interesting bacterial infection biomarker. Its expression has not been studied in previously healthy children admitted to pediatric critical care unit (PICU). Our objective was firstly to describe the CD64 expression and secondly study its diagnostic accuracy to discriminate bacterial versus viral infection in this children. We made a prospective double-blind observational study (March 2016-February 2018). A flow cytometry (FC) was done from peripheral blood at PICU admission. We studied the percentage of CD64+ neutrophils and the CD64 mean fluorescence intensity (MFI) on neutrophils (nCD64) and monocytes (mCD64). Statistical analyses were performed with non-parametric tests (p < 0.05). Twenty children in the bacterial infection group (BIG) and 25 in the viral infection group (VIG). Children in BIG showed higher values of CD64+ neutrophils (p = 0.000), nCD64 (p = 0.001), and mCD64 (p = 0.003). In addition, CD64+ neutrophils and nCD64 expression have positive correlation with procalcitonin and C reactive protein. The nCD64 area under the curve (AUC) was 0.83 (p = 0.000). The %CD64+ neutrophils showed an AUC of 0.828 (p = 0.000). The mCD64 AUC was 0.83 (p = 0.003). The nCD64 and %CD64+ neutrophils also showed higher combined values of sensitivity (74%) and specificity (90%) than all classical biomarkers.In our series CD64 expression allows to discriminate between bacterial and viral infection at PICU admission. Future studies should confirm this and be focused in the study of CD64 correlation with clinical data and its utility as an evolution biomarker in critical care children.

Airflow from nasal pulse oximetry in the screening of obstructive sleep apnea.

Obstructive Sleep Apnea (OSA) is recognized as an increasing health risk, leading to daytime sleepiness and various medical conditions, such as hypertension and heart failure. Polysomnography (PSG), the gold standard to diagnose OSA, is a resource-intensive and expensive investigation confined to the hospital.Portable home monitoring, i.e. pulse oximetry, may become an acceptable OSA screening method. The novel nasal pulse oximeter sensor (Xhale Alar) adds the possibility of combining pulse oximetry (SpO2) with airflow analysis by an integrated thermistor, which might increase the diagnostic accuracy.In the Alar pilot study, 39 adults were measured during an overnight PSG recording together with the Alar sensor. This study aims to investigate the additional value of an airflow signal compared to SpO2 analysis in OSA screening. Both time and spectral features were extracted from SpO2 and airflow signals recorded with the Alar sensor. Leave one out cross-validation was used to develop Random Forest models in screening for apnea-hypopnea index (AHI) thresholds 5 and 10. Using both AHI ≥ 5 and AHI ≥ 10 as the diagnostic cutoff, the airflow signal shows respectively an AUC of 89% and 80% compared to 78% and 77% with SpO2 analysis, showing a higher performance using an airflow signal in screening adults for OSA.

Patient and health care professional perspectives on using telehealth to deliver pulmonary rehabilitation.

The objective of this study was to identify the necessary features of pulmonary telerehabilitation (P-TR) from the perspectives of individuals living with chronic lung disease and health care professionals (HCPs) who deliver pulmonary rehabilitation (PR). Focus groups were carried out with patients ( n = 26) and HCPs ( n = 26) to elicit and explore their opinions about the critical elements of in-person PR and ideas for how these elements could be supported using technology. A questionnaire was used to assess technology use, PR experience, and general health status. Four key elements of PR were identified as critical to P-TR: the social aspect of PR; communicating with HCPs for education and support; using biosensors for monitoring and promoting self-knowledge; and the evolution of support with progress over time. A range of technology-enabled devices and programs were suggested as means to recreate aspects of these integral elements. Consultations with patients and HCPs suggest that users are interested in technology and want to ensure it recreates the important aspects of PR. Patients and HCPs identified similar key elements for P-TR. The opinions and suggestions of patients and HCPs should be the driving force of innovation if P-TR is to succeed in improving health outcomes.

Time-varying signal analysis to detect high-altitude periodic breathing in climbers ascending to extreme altitude.

This work investigates the performance of cardiorespiratory analysis detecting periodic breathing (PB) in chest wall recordings in mountaineers climbing to extreme altitude. The breathing patterns of 34 mountaineers were monitored unobtrusively by inductance plethysmography, ECG and pulse oximetry using a portable recorder during climbs at altitudes between 4497 and 7546 m on Mt. Muztagh Ata. The minute ventilation (VE) and heart rate (HR) signals were studied, to identify visually scored PB, applying time-varying spectral, coherence and entropy analysis. In 411 climbing periods, 30-120 min in duration, high values of mean power (MP(VE)) and slope (MSlope(VE)) of the modulation frequency band of VE, accurately identified PB, with an area under the ROC curve of 88 and 89%, respectively. Prolonged stay at altitude was associated with an increase in PB. During PB episodes, higher peak power of ventilatory (MP(VE)) and cardiac (MP(LF)(HR) ) oscillations and cardiorespiratory coherence (MP(LF)(Coher)), but reduced ventilation entropy (SampEn(VE)), was observed. Therefore, the characterization of cardiorespiratory dynamics by the analysis of VE and HR signals accurately identifies PB and effects of altitude acclimatization, providing promising tools for investigating physiologic effects of environmental exposures and diseases.

External ophthalmomyiasis: a case series.

Oestrus ovis or 'sheep botfly' causes common ophthalmomyiasis in warm climates. It is a self-limited infestation with symptoms such as foreign body sensation and/or tearing. The larvae can be observed in the conjunctiva and should be extracted with forceps. The development of larvae beyond the first stage does not occur in healthy humans, although they may penetrate the ocular globe, causing so-called internal myiasis. External ophthalmomyiasis is typical of rural areas, but it may be observed occasionally in urban environments.

Periodic breathing during ascent to extreme altitude quantified by spectral analysis of the respiratory volume signal.

High altitude periodic breathing (PB) shares some common pathophysiologic aspects with sleep apnea, Cheyne-Stokes respiration and PB in heart failure patients. Methods that allow quantifying instabilities of respiratory control provide valuable insights in physiologic mechanisms and help to identify therapeutic targets. Under the hypothesis that high altitude PB appears even during physical activity and can be identified in comparison to visual analysis in conditions of low SNR, this study aims to identify PB by characterizing the respiratory pattern through the respiratory volume signal. A number of spectral parameters are extracted from the power spectral density (PSD) of the volume signal, derived from respiratory inductive plethysmography and evaluated through a linear discriminant analysis. A dataset of 34 healthy mountaineers ascending to Mt. Muztagh Ata, China (7,546 m) visually labeled as PB and non periodic breathing (nPB) is analyzed. All climbing periods within all the ascents are considered (total climbing periods: 371 nPB and 40 PB). The best crossvalidated result classifying PB and nPB is obtained with Pm (power of the modulation frequency band) and R (ratio between modulation and respiration power) with an accuracy of 80.3% and area under the receiver operating characteristic curve of 84.5%. Comparing the subjects from 1(st) and 2(nd) ascents (at the same altitudes but the latter more acclimatized) the effect of acclimatization is evaluated. SaO(2) and periodic breathing cycles significantly increased with acclimatization (p-value < 0.05). Higher Pm and higher respiratory frequencies are observed at lower SaO(2), through a significant negative correlation (p-value < 0.01). Higher Pm is observed at climbing periods visually labeled as PB with > 5 periodic breathing cycles through a significant positive correlation (p-value < 0.01). Our data demonstrate that quantification of the respiratory volume signal using spectral analysis is suitable to identify effects of hypobaric hypoxia on control of breathing.

Breathing pattern characterization in chronic heart failure patients using the respiratory flow signal.

This study proposes a method for the characterization of respiratory patterns in chronic heart failure (CHF) patients with periodic breathing (PB) and nonperiodic breathing (nPB), using the flow signal. Autoregressive modeling of the envelope of the respiratory flow signal is the starting point for the pattern characterization. Spectral parameters extracted from the discriminant frequency band (DB) are used to characterize the respiratory patterns. For each classification problem, the most discriminant parameter subset is selected using the leave-one-out cross-validation technique. The power in the right DB provides an accuracy of 84.6% when classifying PB vs. nPB patterns in CHF patients, whereas the power of the DB provides an accuracy of 85.5% when classifying the whole group of CHF patients vs. healthy subjects, and 85.2% when classifying nPB patients vs. healthy subjects.