Relación entre la apnea obstructiva del sueño y la diabetes mellitus tipo 2 / Relationship between obstructive sleep apnea and type 2 diabetes mellitus

Introducción: La asociación entre la apnea obstructiva del sueño (AOS) y el metabolismo de la glucosa sigue siendo controvertida. Este estudio investiga la relación entre la AOS y la diabetes mellitus tipo 2 (DM) y prediabetes (preDM) incidentes, así como el efecto del tratamiento con presión positiva continua en la vía aérea (CPAP) a largo plazo. Métodos: Estudio de seguimiento en cohorte retrospectiva clínica de pacientes con AOS y controles seleccionados de manera aleatoria. Los datos sobre DM incidente y preDM, así como de la CPAP se obtuvieron de los registros hospitalarios. La relación entre AOS basal y la DM incidente se examinó con modelos de regresión de Cox. Resultados: De un total de 356 pacientes, 169 con AOS y 187 controles fueron seguidos por una mediana de 98 meses; 47 enfermos (13,2%) desarrollaron DM y 43 (12,1%) preDM. La incidencia acumulada a los cinco años de DM fue de 10,7% (6,5-13,9%). De los sujetos con preDM en la muestra basal, 87% evolucionaron a DM incidente. Se demuestra que el índice de masa corporal (IMC), la hipoxia nocturna y el índice de apnea hipopnea (IAH) son factores de riesgo para el desarrollo de DM, y que la CPAP los disminuye. Conclusiones: Los pacientes con AOS tienen mayor probabilidad de desarrollar DM. Los factores de riesgo implicados son el IMC, la hipoxia nocturna y el IAH. El uso regular de CPAP a largo plazo se asoció con una disminución de estos. (AU)

Introduction: The association between obstructive sleep apnea (OSA) and glucose metabolism remains controversial. This study investigates the relationship between OSA and incident type 2 diabetes (DM) and prediabetes (preDM), as well as the effect of long-term CPAP (continuous positive airway pressure) treatment. Methods: Follow-up study in a retrospective clinical cohort of patients with OSA and randomly selected controls. Data on incident DM and preDM as well as CPAP were obtained from hospital records. The relationship between baseline OSA and incident DM was examined using COX regression models. Results: Three hundred and fifty-six patients, 169 with OSA and 187 controls were followed for a median of 98 months; 47 patients (13.2%) developed DM and 43 (12.1%) developed preDM. The 5-year cumulative incidence of DM was 10.7% (6.5–13.9%). 87% of subjects with preDM in the baseline sample progressed to incident DM. It is shown that body mass index (BMI), nocturnal hypoxia and apnea hypopnea index (AHI) are risk factors for the development of DM and that CPAP reduces this risk. Conclusions: Patients with OSA have a higher risk of developing DM. The risk factors involved are BMI, nocturnal hypoxia and AHI. Regular long-term CPAP use was associated with a decreased risk. (AU)

Relationship between obstructive sleep apnea and type 2 diabetes mellitus. / Relación entre la apnea obstructiva del sueño y la diabetes mellitus tipo 2.

INTRODUCTION: The association between obstructive sleep apnea (OSA) and glucose metabolism remains controversial. This study investigates the relationship between OSA and incident type 2 diabetes (DM) and prediabetes (preDM), as well as the effect of long-term CPAP (continuous positive airway pressure) treatment. METHODS: Follow-up study in a retrospective clinical cohort of patients with OSA and randomly selected controls. Data on incident DM and preDM as well as CPAP were obtained from hospital records. The relationship between baseline OSA and incident DM was examined using COX regression models. RESULTS: Three hundred and fifty-six patients, 169 with OSA and 187 controls were followed for a median of 98 months; 47 patients (13.2%) developed DM and 43 (12.1%) developed preDM. The 5-year cumulative incidence of DM was 10.7% (6.5-13.9%). 87% of subjects with preDM in the baseline sample progressed to incident DM. It is shown that body mass index (BMI), nocturnal hypoxia and apnea hypopnea index (AHI) are risk factors for the development of DM and that CPAP reduces this risk. CONCLUSIONS: Patients with OSA have a higher risk of developing DM. The risk factors involved are BMI, nocturnal hypoxia and AHI. Regular long-term CPAP use was associated with a decreased risk.

Diabetes y apnea obstructiva del sueño. Un estudio de casos y controles / Diabetes and obstructive sleep apnoea: A case-control study

Introducción La apnea obstructiva del sueño (AOS) y la diabetes mellitus (DM) son enfermedades muy prevalentes frecuentemente asociadas. Su coexistencia se asocia de forma independiente con un aumento de la prevalencia de comorbilidades cardiovasculares. Al existir un infradiagnóstico de esta asociación, es necesario optimizar la sospecha clínica mediante el estudio de predictores independientes de DM o de prediabetes (preDM) en pacientes con AOS. Método Estudio de casos y controles, seleccionados de manera aleatoria simple y emparejados por sexo, índice de masa corporal (IMC) y edad, que pretende estudiar la asociación de la AOS con la DM y la preDM e identificar factores predictores independientes para ambas enfermedades, en las personas con AOS. Resultados Incluimos 208 casos con AOS y 208 controles, sin AOS. En los primeros, el 18,8% tenían DM, por solo el 10,1% en los segundos (p=0,00). La prevalencia de preDM fue del 41,8% vs el 10,6%, respectivamente (p=0,00). Ciento veinticuatro casos (59,6%) refirieron excesiva somnolencia diurna (ESD) (escala Epworth, 10,5±3,1) vs el 24,5% del grupo control (escala Epworth, 6,6±2,9). El índice de apnea-hipopnea (IAH) y los índices de desaturación de O2 (IDO, CT90 y CT80) fueron significativamente mayores en el grupo de casos. El riesgo de presentar DM se relacionó con la edad, la hipoxemia nocturna y la ESD. El riesgo de presentar preDM, con el IMC y con el IAH. Conclusiones La AOS se asocia a la DM y a la preDM. La edad, la hipoxemia nocturna y la ESD son predictores de DM. El IMC y el IAH lo son de la preDM. (AU)

Introduction Obstructive sleep apnoea (OSA) and diabetes mellitus (DM) are very prevalent diseases frequently associated. Their coexistence is independently associated with an increased prevalence of cardiovascular comorbidities. As this association is underdiagnosed, it is necessary to optimise clinical suspicion by studying independent predictors of DM or prediabetes (preDM) in patients with OSA. Method A simple randomised case-control study, matched for sex, body mass index (BMI) and age, aimed to study the association of OSA with DM and preDM and to identify independent predictors for both diseases in people with OSA. Results We included 208 cases with OSA and 208 controls without OSA. In the former, 18.8% had DM compared to only 10.1% in the latter (P=.00). Prevalence of preDM was 41.8% vs. 10.6%, respectively (P=.00). One hundred and twenty-four cases (59.6%) reported excessive daytime sleepiness (EDS) (Epworth scale, 10.5±3.1) vs. 24.5% of the control group (Epworth scale, 6.6±2.9). Apnoea-hypopnoea index (AHI) and O2 desaturation indices (IDO, CT90 and CT80) were significantly higher in the case group. The risk of MD was related to age, nocturnal hypoxaemia and EDS. The risk of pre-MD was related to BMI and AHI. Conclusions OSA is associated with DM and preDM. Age, nocturnal hypoxaemia and EDS are predictors of DM. BMI and AHI are predictors of pre-MD. (AU)

Diabetes y apnea obstructiva del sueño. Un estudio de casos y controles / Diabetes and obstructive sleep apnoea: A case-control study

Introducción La apnea obstructiva del sueño (AOS) y la diabetes mellitus (DM) son enfermedades muy prevalentes frecuentemente asociadas. Su coexistencia se asocia de forma independiente con un aumento de la prevalencia de comorbilidades cardiovasculares. Al existir un infradiagnóstico de esta asociación, es necesario optimizar la sospecha clínica mediante el estudio de predictores independientes de DM o de prediabetes (preDM) en pacientes con AOS. Método Estudio de casos y controles, seleccionados de manera aleatoria simple y emparejados por sexo, índice de masa corporal (IMC) y edad, que pretende estudiar la asociación de la AOS con la DM y la preDM e identificar factores predictores independientes para ambas enfermedades, en las personas con AOS. Resultados Incluimos 208 casos con AOS y 208 controles, sin AOS. En los primeros, el 18,8% tenían DM, por solo el 10,1% en los segundos (p=0,00). La prevalencia de preDM fue del 41,8% vs el 10,6%, respectivamente (p=0,00). Ciento veinticuatro casos (59,6%) refirieron excesiva somnolencia diurna (ESD) (escala Epworth, 10,5±3,1) vs el 24,5% del grupo control (escala Epworth, 6,6±2,9). El índice de apnea-hipopnea (IAH) y los índices de desaturación de O2 (IDO, CT90 y CT80) fueron significativamente mayores en el grupo de casos. El riesgo de presentar DM se relacionó con la edad, la hipoxemia nocturna y la ESD. El riesgo de presentar preDM, con el IMC y con el IAH. Conclusiones La AOS se asocia a la DM y a la preDM. La edad, la hipoxemia nocturna y la ESD son predictores de DM. El IMC y el IAH lo son de la preDM. (AU)

Introduction Obstructive sleep apnoea (OSA) and diabetes mellitus (DM) are very prevalent diseases frequently associated. Their coexistence is independently associated with an increased prevalence of cardiovascular comorbidities. As this association is underdiagnosed, it is necessary to optimise clinical suspicion by studying independent predictors of DM or prediabetes (preDM) in patients with OSA. Method A simple randomised case-control study, matched for sex, body mass index (BMI) and age, aimed to study the association of OSA with DM and preDM and to identify independent predictors for both diseases in people with OSA. Results We included 208 cases with OSA and 208 controls without OSA. In the former, 18.8% had DM compared to only 10.1% in the latter (P=.00). Prevalence of preDM was 41.8% vs. 10.6%, respectively (P=.00). One hundred and twenty-four cases (59.6%) reported excessive daytime sleepiness (EDS) (Epworth scale, 10.5±3.1) vs. 24.5% of the control group (Epworth scale, 6.6±2.9). Apnoea-hypopnoea index (AHI) and O2 desaturation indices (IDO, CT90 and CT80) were significantly higher in the case group. The risk of MD was related to age, nocturnal hypoxaemia and EDS. The risk of pre-MD was related to BMI and AHI. Conclusions OSA is associated with DM and preDM. Age, nocturnal hypoxaemia and EDS are predictors of DM. BMI and AHI are predictors of pre-MD. (AU)

Analysis of the quality of e-Consultations in chronic obstructive pulmonary disease.

INTRODUCTION: The quality of e-Consultations in the COPD is unknown. The objectives of this study were (i) to evaluate the quality of referrals; (ii) to define the characteristics of patients referred from Primary Care (PC) to the Unit of Pulmonology; and (iii) to describe differences between accepted and rejected patients. METHODS: A retrospective, observational study of e-Consultations requested by PC for suspected COPD throughout 2022. To quantify the quality of the e-Consultations, an arbitrary scale of 12 variables (score 0-10) was created. RESULTS: In total, 384 e-Consultations were reviewed, of which 167 (43.5 %) resulted in a face-to-face visit, and 217 (56.5 %) were rejected. No differences were observed between the two types of patients, except for confirmations of diagnostic suspicion of COPD [significantly higher in accepted patients (p = 0.042)]; physical examination data of rejected patients (more data provided; p = 0.015); and lung function (significantly better in rejected patients). The mean quality of referrals was acceptable (5.6 ± 2.1 score): 121 (31.3 %) had insufficient quality; 118 (30.5 %) acceptable; 75 (19.4 %) good, and 30 (7.8 %) excellent. Quality was low in half of the variables analyzed (6/12); acceptable in 3, and good in another 3. The capacity of resolution of referrals was good (one e-Consultation) in 199 requests (66.1 %); deficient (two e-Consultations) in 72 (23.9 %), and poor (≥3 e-Consultations) in 30 (10 %). Overdiagnosis was 40.2 % (86/214 e-Consultations). The risk could be classified in 247 patients (64.3 %; 135 low-risk; 90 high-risk). CONCLUSIONS: When adequate information is provided, e-Consultations help identify different levels of severity. However, the quality and capacity of resolution of referrals were suboptimal, with a high percentage of overdiagnoses.

[Diabetes and obstructive sleep apnoea: A case-control study]. / Diabetes y apnea obstructiva del sueño. Un estudio de casos y controles.

INTRODUCTION: Obstructive sleep apnoea (OSA) and diabetes mellitus (DM) are very prevalent diseases frequently associated. Their coexistence is independently associated with an increased prevalence of cardiovascular comorbidities. As this association is underdiagnosed, it is necessary to optimise clinical suspicion by studying independent predictors of DM or prediabetes (preDM) in patients with OSA. METHOD: A simple randomised case-control study, matched for sex, body mass index (BMI) and age, aimed to study the association of OSA with DM and preDM and to identify independent predictors for both diseases in people with OSA. RESULTS: We included 208 cases with OSA and 208 controls without OSA. In the former, 18.8% had DM compared to only 10.1% in the latter (P=.00). Prevalence of preDM was 41.8% vs. 10.6%, respectively (P=.00). One hundred and twenty-four cases (59.6%) reported excessive daytime sleepiness (EDS) (Epworth scale, 10.5±3.1) vs. 24.5% of the control group (Epworth scale, 6.6±2.9). Apnoea-hypopnoea index (AHI) and O2 desaturation indices (IDO, CT90 and CT80) were significantly higher in the case group. The risk of MD was related to age, nocturnal hypoxaemia and EDS. The risk of pre-MD was related to BMI and AHI. CONCLUSIONS: OSA is associated with DM and preDM. Age, nocturnal hypoxaemia and EDS are predictors of DM. BMI and AHI are predictors of pre-MD.

Cost-Effectiveness of a New Outpatient Pulmonology Care Model Based on Physician-to-Physician Electronic Consultation.

Introduction: This study assesses the impact of an electronic physician-to-physician consultation program on the waiting list and the costs of a Pulmonology Unit. Materials and Methods: A prepost intervention study was conducted after a new ambulatory pulmonary care protocol was implemented and the capacity of the unit was adopted. In the new model, physicians at all levels of healthcare send electronic consultations to specialists. Results: In the preintervention year (2019), the Unit of Pulmonology attended 7,055 consultations (466 e-consultations and 6,589 first face-to-face visits), which decreased to 6,157 (3,934 e-consultations and 2,223 first face-to-face visits; 12.7% reduction) in the postintervention year (all were e-consultations). The mean wait time for the first appointment was 25.7 days in 2019 versus 3.2 days in 2021 (p < 0.001). In total, 43.5% of cases were solved via physician-to-physiciane-consultation. A total of 2,223 patients needed a face-to-face visit, with a mean wait time of 7.5 days. The mean of patients in the waiting listing decreased from 450.8 in 2019 to 44.8 in 2021 (90% reduction). The annual time devoted to e-consultations and first face-to-face visits following an e-consultation diminished significantly after the intervention (1,724 hours versus 2,312.8; 25.4% reduction). Each query solved via e-consultation represented a saving of €652.8, resulting in a total annual saving of €827,062. Conclusions: Physician-to-physiciane-consultations reduce waiting times, improve access of complex patients to specialty care, and ensure that cases are managed at the appropriate level. E-consultation reduces costs, which benefits both, society and the healthcare system.

Diagnosis of Obstructive Sleep Apnea in Patients with Associated Comorbidity.

Obstructive sleep apnea (OSA) is a heterogeneous disease with many physiological implications. OSA is associated with a great diversity of diseases, with which it shares common and very often bidirectional pathophysiological mechanisms, leading to significantly negative implications on morbidity and mortality. In these patients, underdiagnosis of OSA is high. Concerning cardiorespiratory comorbidities, several studies have assessed the usefulness of simplified screening tests for OSA in patients with hypertension, COPD, heart failure, atrial fibrillation, stroke, morbid obesity, and in hospitalized elders.The key question is whether there is any benefit in the screening for the existence of OSA in patients with comorbidities. In this regard, there are few studies evaluating the performance of the various diagnostic procedures in patients at high risk for OSA. The purpose of this chapter is to review the existing literature about diagnosis in those diseases with a high risk for OSA, with special reference to artificial intelligence-related methods.

Sarcoidosis. Disease progression based on radiological and functional course: Predictive factors.

BACKGROUND: Sarcoidosis is a multiorgan granulomatous disease with a variable course. OOBJECTIVES: The purpose of this study is to identify the patients that are more likely to experience disease progression. METHODS: A retrospective study in patients ≥18 years. Pulmonary function and radiological stage (Scadding criteria) were assessed at diagnosis, and at 1, 3 and 5 years. Sarcoidosis progression was established based on deterioration of radiological or pulmonary function (decrease ≥10% of FVC and/or ≥15% of diffusing capacity of the lung (DLCO). RESULTS: The sample included 277 caucasian patients [mean age, 50±13.6; 69.7% between 31-60 years; 56.3% men]. In total, 65% had stage II sarcoidosis, whereas only 8.3% had stage III/IV disease. Mean pulmonary function (FVC, FEV1, FEV1/FVC and DLCO) at diagnosis was 103±21.8, 96±22.2, 76.2±8 and 81.7±21.7, respectively. The percentage of patients with normal FVC and DLCO was 72.2% and 51.8%, respectively. Radiological stage did not change significantly during follow-up (5 years; p=0.080) and only progressed in 13 patients (5.7%). At 3 years, FVC improved, whereas DLCO exacerbated significantly (p<0.001 for the two). Disease progressed in 34.5% of the patients (57/165) whose pulmonary function and radiological stage were available (both baseline and at 3 years). Age was associated with disease progression [OR=1.04 (95%CI=1.01, 1.06)]. Risk increased by 4% for each year older a patient was at diagnosis. CONCLUSIONS: At 3 years, a third of patients experienced sarcoidosis progression. Age was the only factor associated with disease prognosis.

Health outcomes: Towards the accreditation of respiratory medicine departments / Resultados de salud: hacia la acreditación de los servicios de neumología

National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care. (AU)

Los sistemas nacionales de salud deben garantizar a los ciudadanos el cumplimiento de unas condiciones básicas como la equidad, la eficiencia, la calidad y la transparencia. En aras del derecho que tiene la sociedad a conocer los resultados de salud de su área sanitaria, el objetivo de este artículo es elaborar una propuesta de acreditación de los servicios de neumología desde el punto de vista asistencial, docente e investigador, midiendo sus resultados de salud a través de indicadores de calidad en la atención. Para mejorar estos, deberíamos utilizar unas herramientas de gestión (que se desarrollan en el artículo) y que, sin duda, nos ayudarían a conseguir los objetivos propuestos. La mejora del nivel de acreditación puede servir como estímulo para perfeccionar la gestión clínica y para que los profesionales ejerzan una capacidad de dirección cada vez mayor y adopten medidas para reforzar los resultados en la atención a sus pacientes. (AU)

Impacto del síndrome de apnea-hipopnea del sueño en la neuropatía diabética. Revisión sistemática / Impact of sleep apnoea-hypopnoea syndrome on diabetic neuropathy. A systematic review

Introducción: La diabetes mellitus y el síndrome de apnea-hipopnea del sueño parecen estar relacionados, pero no está bien definido si en los pacientes con ambas enfermedades existe un mayor riesgo de neuropatía periférica. Para ello, realizamos una revisión sistemática.MétodosBúsqueda bibliográfica en 3 bases de datos electrónicas usando una estrategia predefinida y la metodología PRISMA. Solamente se incluyeron estudios originales (cualquier tipo de diseño) y publicados a partir del año 2000 en inglés, francés, portugués o español. Se estableció una escala de calidad de los estudios.ResultadosSe seleccionaron 12 artículos, de los que 6 estudiaban pacientes diabéticos tipo 2. La prevalencia global de síndrome de apnea-hipopnea del sueño fue del 43,7% (1.559/3.564 pacientes). La neuropatía diabética fue más frecuente en los pacientes con síndrome de apnea-hipopnea del sueño en 9 estudios, aunque solo en 4 de manera significativa (60 vs. 27%, p<0,001; 64,5 vs. 36%, p=0,03; 37 vs. 23,4%, p<0,02; 66,6 vs. 0%, p=0,007). En un estudio, la neuropatía diabética fue más frecuente en los pacientes sin síndrome de apnea-hipopnea del sueño (aunque sin significación estadística) y en 2 no se hizo la comparación entre pacientes con/sin síndrome de apnea-hipopnea del sueño.ConclusionesLos resultados observados indican una relación entre diabetes mellitus y síndrome de apnea-hipopnea del sueño en la aparición de neuropatía diabética.

Introduction: Diabetes mellitus and sleep apnoea-hypopnoea syndrome appear to be related, but it is not well defined whether there is an increased risk of peripheral neuropathy in patients with both diseases. For this reason, we conducted a systematic review.MethodsBibliographic search in 3 electronic databases using a predefined strategy and the PRISMA methodology. Only original studies (any type of design) published from 2000 onwards in English, French, Portuguese or Spanish were included. A study quality scale was established.ResultsTwelve articles were selected, of which six studied type 2 diabetic patients. The overall prevalence of sleep apnoea-hypopnoea syndrome was 43.7% (1,559/3,564 patients). Diabetic neuropathy was more frequent in patients with sleep apnoea-hypopnoea syndrome in nine studies, although significantly only in four (60% vs 27%, P<.001; 64.5% vs 36%, P=.03; 37% vs 23.4%, P<.02; 66.6% vs 0%, P=.007). In one study, diabetic neuropathy was more frequent in patients without sleep apnoea-hypopnoea syndrome (although not statistically significant) and in 2 no comparison was made between patients with/without sleep apnoea/hypopnoea syndrome.ConclusionsThe observed results suggest a relationship between diabetes mellitus and sleep apnoea-hypopnoea syndrome in the occurrence of diabetic neuropathy. (AU)

Health Outcomes: Towards the Accreditation of Respiratory Medicine Departments. / Resultados de salud: hacia la acreditación de los servicios de neumología.

National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

Health outcomes: Towards the accreditation of respiratory medicine departments.

National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

Impact of sleep apnoea-hypopnoea syndrome on diabetic neuropathy. A systematic review. / Impacto del síndrome de apnea-hipopnea del sueño en la neuropatía diabética. Revisión sistemática.

INTRODUCTION: Diabetes mellitus and sleep apnoea-hypopnoea syndrome appear to be related, but it is not well defined whether there is an increased risk of peripheral neuropathy in patients with both diseases. For this reason, we conducted a systematic review. METHODS: Bibliographic search in 3 electronic databases using a predefined strategy and the PRISMA methodology. Only original studies (any type of design) published from 2000 onwards in English, French, Portuguese or Spanish were included. A study quality scale was established. RESULTS: Twelve articles were selected, of which six studied type 2 diabetic patients. The overall prevalence of sleep apnoea-hypopnoea syndrome was 43.7% (1,559/3,564 patients). Diabetic neuropathy was more frequent in patients with sleep apnoea-hypopnoea syndrome in nine studies, although significantly only in four (60% vs 27%, P<.001; 64.5% vs 36%, P=.03; 37% vs 23.4%, P<.02; 66.6% vs 0%, P=.007). In one study, diabetic neuropathy was more frequent in patients without sleep apnoea-hypopnoea syndrome (although not statistically significant) and in 2 no comparison was made between patients with/without sleep apnoea/hypopnoea syndrome. CONCLUSIONS: The observed results suggest a relationship between diabetes mellitus and sleep apnoea-hypopnoea syndrome in the occurrence of diabetic neuropathy.

Telemedicine system for the care of patients with neuromuscular disease and chronic respiratory failure.

INTRODUCTION: Neuromuscular diseases cause a number of limitations which may be improved by using a telemedicine system. These include functional impairment and dependence associated with muscle weakness, the insidious development of respiratory failure and episodes of exacerbation. MATERIAL AND METHODS: The present study involved three patients with severe neuromuscular disease, chronic respiratory failure and long-term mechanical ventilation, who were followed up using a telemedicine platform. The telemedicine system is based on videoconferencing and telemonitoring of cardiorespiratory variables (oxygen saturation, heart rate, blood pressure and electrocardiogram). Two different protocols were followed depending on whether the patient condition was stable or unstable. RESULTS: Over a period of 5 years, we analyzed a series of variables including use of the system, patient satisfaction and clinical impact. Overall we performed 290 videoconference sessions, 269 short monitoring oximetry measurements and 110 blood pressure measurements. With respect to the clinical impact, after enrolment in the telemedicine program, the total number of hospital admissions fell from 18 to 3. CONCLUSIONS: Our findings indicate that the system was user friendly for patients and care givers. Patient satisfaction scores were acceptable. The telemedicine system was effective for the home treatment of three patients with severe neuromuscular diseases and reduced the need for hospital admissions.

Heart rate variability in patients with severe chronic obstructive pulmonary disease in a home care program.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients present functional and structural changes of the respiratory system that have a profound influence on cardiac autonomic dysfunction. OBJETIVE: To analyse heart rate variability in COPD patients under stable condition and during acute exacerbation episodes (AECOPD). METHODS: Twenty three severe COPD male patients, 69.6 ± 7.3 years, in stable condition were followed up for two years. Home visits were carried out by a nurse every month, and home or hospital visits were arranged on demand. Every three months an ECG, oxygen saturation and spirometric recording was obtained for each patient. If the patient presented AECOPD compatible clinical data the same measurements were performed before any change of treatment. Spectral parameters of heart rate variability in time and frequency domains were obtained from ECG. The time evolution of power in low frequency (LF) and high frequency (HF) bands were obtained from the spectrogram. In addition, we calculated the LF/HF ratio and total heart rate variability power (POW). RESULTS: We analysed 154 patient-visit records during the follow up, pertaining to 23 patients and 8 controls; 19 of the patients had experienced at least one AECOPD. Stable COPD patients had higher HF values than control subjects. No significant differences were found in LF, LF/HF ratio or POW variables. AECOPD patients had higher LF, HF and POW than the stable COPD and control groups. CONCLUSION: AECOPD patients exhibited signs of increased autonomic activity compared with stable COPD.

Pathophysiologic mechanisms of cardiovascular disease in obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep disorder, characterized by repeated disruptions of breathing during sleep. This disease has many potential consequences including excessive daytime sleepiness, neurocognitive deterioration, endocrinologic and metabolic effects, and decreased quality of life. Patients with OSAS experience repetitive episodes of hypoxia and reoxygenation during transient cessation of breathing that provoke systemic effects. Furthermore, there may be increased levels of biomarkers linked to endocrine-metabolic and cardiovascular alterations. Epidemiological studies have identified OSAS as an independent comorbid factor in cardiovascular and cerebrovascular diseases, and physiopathological links may exist with onset and progression of heart failure. In addition, OSAS is associated with other disorders and comorbidities which worsen cardiovascular consequences, such as obesity, diabetes, and metabolic syndrome. Metabolic syndrome is an emerging public health problem that represents a constellation of cardiovascular risk factors. Both OSAS and metabolic syndrome may exert negative synergistic effects on the cardiovascular system through multiple mechanisms (e.g., hypoxemia, sleep disruption, activation of the sympathetic nervous system, and inflammatory activation). It has been found that CPAP therapy for OSAS provides an objective improvement in symptoms and cardiac function, decreases cardiovascular risk, improves insulin sensitivity, and normalises biomarkers. OSAS contributes to the pathogenesis of cardiovascular disease independently and by interaction with comorbidities. The present review focuses on indirect and direct evidence regarding mechanisms implicated in cardiovascular disease among OSAS patients.

Metastases of renal cell carcinoma to the thyroid gland with synchronous benign and malignant follicular cell-derived neoplasms.

Clear cell renal cell carcinoma (CCRCC) is the most common origin for metastasis in the thyroid. A 51-year-old woman was referred to our hospital for a subcarinal lesion. Ten years before, the patient had undergone a nephrectomy for CCRCC. Whole-body fluorodeoxyglucose positron emission tomography revealed elevated values in the thyroid gland, while the mediastinum was normal. An endoscopic ultrasonography-guided fine-needle aspiration biopsy of the mediastinal mass was consistent with CCRCC, and this was confirmed after resection. The thyroidectomy specimen also revealed lymphocytic thyroiditis, nodular hyperplasia, one follicular adenoma, two papillary microcarcinomas, and six foci of metastatic CCRCC involving both thyroid lobes. Curiously two of the six metastatic foci were located inside two adenomatoid nodules (tumor-in-tumor). The metastatic cells were positive for cytokeratins, CD10, epidermal growth factor receptor, and vascular endothelial growth factor receptor 2. No BRAF gene mutations were found in any of the primary and metastatic lesions. The patient was treated with sunitinib and finally died due to CCRCC distant metastases 6 years after the thyroidectomy. In CCRCC patients, a particularly prolonged survival rate may be achieved with the appropriate therapy, in contrast to the ominous prognosis typically found in patients with thyroid metastases from other origins.

Aplicaciones clínicas de las redes neuronales en el síndrome de apnea hipopnea del sueño / No disponible

Existe en la actualidad un gran interés en la utilización de procedimientos basados en la inteligencia artificial y en el análisis de las señales biomédicas como métodos de ayuda en la toma de decisiones clínicas, fundamentalmente en el área diagnóstica y terapéutica. Dentro de estos sistemas expertos, se incluye la utilización de regresión logística, árboles genealógicos, análisis discriminante y las redes neuronales. Las redes neuronales presentan grandes posibilidades de aplicación en el campo de la predicción. Su limitación principal es su complejidad en el momento de su diseño. En el campo de los trastornos respiratorios del sueño han sido ampliamente utilizadas tanto en el diagnóstico como en en el reconocimiento de señales, y destaca su gran aporte a los importantes avances tecnológicos acaecidos en el diseño de las CPAP (AU)

There is currently a great interest in the use of procedures based on artificial intelligence and in biomedical signal processing as helpful methods for clinical choice making, mainly in the diagnosis and therapeutical field. Some of these expert systems are logistic regression, family trees, linear discriminant analysis and neural networks. Neural networks show great application options in the prediction field. Their main limitation is their complexity when being designed. They have been widely used in the sleep respiratory disorders field, both for diagnosis and for signal recognition, and they greatly contribute to key technological progress achieved in CPAP design (AU)