Sex differences in patients with systemic lupus erythematosus from Northwest Spain.

To further establish potential differences according to sex in systemic lupus erythematosus (SLE) patients from Southern Europe. We assessed clinical and epidemiological data of patients diagnosed with SLE according to the 1982 American College of Rheumatology classification criteria at the single hospital for a well-defined population of Northwest Spain, between 1987 and 2006. Prevalence in December 2006 and age-standardized incidence rates in the whole period were estimated. Kaplan-Meier method was used in order to estimate the probability of survivorship. Women outnumbered men [127 (84.7%) vs. 23 (15.3%)]. The median age at the time of disease diagnosis in men was 54 years versus 43 in women (p < 0.001). Annual incidence rates were higher in women [5.9 (95% confidence interval--CI 4.9-7.0) per 100,000 population] than in men [1.1 (95% CI 0.7-1.7) per 100,000 population; p < 0.001]. Raynaud's phenomenon was more common in women (40.9 vs. 3.0%; p = 0.01). While the frequency of secondary Sjögren's syndrome was increased in women (p = 0.02), renal disease at the time of diagnosis (39.1 vs. 15.0%; p < 0.01) and over the course of the disease was more common in men (43.5 vs. 24.4%; p = 0.06). Higher frequency of thrombocytopenia (39.1 vs. 16.5%; p = 0.01) and lower frequency of anti-SSA (13.0 vs. 31.5%; p = 0.08) and anti-SSB (0 vs. 17.7%; p = 0.03) were observed in men. The 5- and 10-year survival probabilities were nonsignificantly reduced in men (91.3 and 78.3 3% vs. 94.6 and 89.2% in women). The frequency of some clinical manifestations is different in men and women with SLE. Higher awareness of these peculiarities may help to establish appropriate diagnosis and management of SLE in men.

The pathogenesis of OSA-related hypertension: what are the determining factors?

Sleep-disordered breathing has a relatively high prevalence, which varies from 3-7% in males and from 2-5% in females in the adult population. Studies published in the literature have shown that sleep apnea is closely related to an increased risk of developing various pathologies, among which arterial hypertension stands out. The prevalence of hypertension in patients suffering from obstructive sleep apnea (OSA) ranges from 35-80% and appears to be related to OSA severity. Approximately 40-50% of patients affected by hypertension are also affected by OSA and this association seems to be stronger in young and middle-aged adults (<50 years of age). The primary objective of this narrative review is to provide an update on what are the main contributing comorbidities to the development of a hypertensive state in patients suffering from OSA, an independent risk factor for diurnal hypertension, implicated as a risk factor for the first stroke, recurrent stroke, and post-stroke mortality. There are a lot of factors that contribute to developing a hypertensive state in OSA patients, some more decisive, others less. More evidence from longitudinal studies is needed on the impact of OSA on cardiovascular risk in females, on the causal link between OSA and arterial hypertension or metabolic diseases, like diabetes and glucose intolerance, and the effect of different kinds of OSA treatment.

Effectiveness of a new "focused pulse" high-frequency chest wall oscillation in patients with moderate to severe COPD.

BACKGROUND: Chest physiotherapy plays a crucial role in the treatment of COPD, although the optimal techniques for airway clearance have not been definitively established. Among the different techniques, high-frequency chest wall oscillation (HFCWO) has gained attention for its potential to create a widespread lung percussion, facilitating the removal of secretions and potentially clearing the peripheral bronchial tree. This study aims to assess the effectiveness of a novel "focused pulse" HFCWO in patients with moderate to severe COPD. METHODS: Sixty patients were randomized to three groups: a group treated with the PEP technique, a group with "focused pulse "HFCWO" and a group with pharmacological therapy alone (control group). The primary outcomes were changes in respiratory function parameters, changes in dyspnea and quality of life scores as well as daily life activity and health status assessment. The secondary outcomes were the number of exacerbations and the number of practitioner or emergency department (ED) visits after 1, 3, and 6 months. RESULTS: Sixty patients concluded the study with 20 patients allocated to each group. The two devices improved respiratory function tests, quality of life and health scores and dyspnea compared to the control group. Maximal expiratory pressure and diffusing lung carbon oxide were significantly improved in the focused pulse HFCWO group compared to the PEP group. Only pulse-focused HFCWO showed a statistically significant lower number of exacerbations and visits to ED or practitioner compared to the control group. CONCLUSIONS: The focused pulse HFCWO technique improves daily life activities and lung function in patients with stable COPD. The device demonstrated significantly greater effectiveness in lowering COPD exacerbations as well as visits to ED or practitioner.

Adiponectin and resistin serum levels in non-diabetic ankylosing spondylitis patients undergoing TNF-α antagonist therapy.

OBJECTIVES: The objective of this paper is to assess if disease activity, systemic inflammation and metabolic syndrome are potential determinants of circulating adiponectin and resistin levels in ankylosing spondylitis (AS) patients undergoing TNF-α antagonist therapy. METHODS: We investigated adiponectin and resistin serum concentrations in a series of 29 non-diabetic AS patients without history of cardiovascular (CV) events that were treated with the TNF-α antagonist infliximab, immediately prior to an infliximab infusion. Adipokine levels were also determined immediately after administration of an infliximab dose. RESULTS: A significant correlation between adiponectin concentrations and insulin sensitivity (QUICKI at the time of the study) was seen (r=0.384; p=0.05). Also, a marginally significant negative correlation between adiponectin serum levels and the body mass index was observed (r=-0.367; p=0.07). Circulating adiponectin and resistin concentrations did not correlate with disease duration, erythrocyte sedimentation rate, C-reactive protein, BASDAI or VAS at the time of the study. However, AS patients with hip involvement or synovitis and/or enthesitis in other peripheral joints had higher adiponectin concentrations than those who did not have these complications (p-value for both comparisons =0.01). Adiponectin and resistin levels did not change upon infliximab administration. CONCLUSIONS: The present study shows that in non-diabetic patients with AS on treatment with infliximab adiponectin and resistin serum levels do not correlate with disease activity. Nevertheless, adiponectin concentration correlates with insulin sensitivity. This finding raises the possibility that low circulating adiponectin concentrations may be involved in the pathogenesis of the CV disease in AS.

Leptin and visfatin serum levels in non-diabetic ankylosing spondylitis patients undergoing TNF-α antagonist therapy.

OBJECTIVES: This paper aims to determine whether disease activity, systemic inflammation and metabolic syndrome are potential determinants of circulating leptin and visfatin levels in ankylosing spondylitis (AS) patients undergoing TNF-α antagonist therapy. We also assessed whether the infusion of infliximab may alter circulating leptin and visfatin concentrations in these patients. METHODS: We investigated leptin and visfatin serum concentrations in a series of 30 non-diabetic AS patients without history of cardiovascular (CV) events that were treated with the TNF-α antagonist infliximab, immediately prior to an infliximab infusion. Leptin and visfatin levels were also determined immediately after administration of an infliximab dose. RESULTS: Significant differences in leptin concentrations between men (8.85±5.31 ng/ml) and women (18.96±9.72 ng/ml) were observed (p=0.001). A significant correlation between visfatin concentrations and insulin resistance (HOMA at the time of the study) was found (r= 0.493; p=0.009). Circulating leptin and visfatin concentrations did not correlate with disease duration, erythrocyte sedimentation rate, C-reactive protein, BASDAI and VAS at the time of the study and adiponectin and resistin levels prior to infliximab infusion. Likewise, no differences in leptin and visfatin concentrations were observed when patients with a history of anterior uveitis or presence of syndesmophytes were compared with the remaining patients who did not exhibit these features. Leptin and visfatin levels did not change upon infliximab administration. CONCLUSIONS: The present study indicates that in non-diabetic patients with AS on treatment with infliximab leptin and visfatin serum levels do not correlate with disease activity or systemic inflammation. Nevertheless, visfatin concentration correlates with insulin resistance.

Gender differences in obesity hypoventilation syndrome.

Sleep-disordered breathing (SDB) is a group of sleep-related breathing disorders which includes obstructive sleep apnea (OSA), central sleep apnea (CSA), and obesity hypoventilation syndrome (OHS). OHS is characterized by a combination of obesity, daytime hypercapnia and hypoxemia, and sleep-disordered breathing without other known hypoventilation causes, such as severe obstructive or restrictive parenchymal lung disease, kyphoscoliosis, severe hypothyroidism, neuromuscular disease, or congenital central hypoventilation syndrome. Four hundred ninety potentially eligible references were identified; of these, 462 abstracts or full texts were excluded because they did not fulfil inclusion criteria. We reviewed the full text of the remaining 38 papers which fulfilled the inclusion criteria. The role of gender in SDB and particularly in OHS is not well known. In general, the diseases are under-recognized in women and only a few studies have reported the impact of gender on clinical presentation and treatment outcome. On the other hand, there is often a delay in diagnosing these diseases in women as compared to men; therefore, they are often more advanced when diagnosed in women. Better understanding and clinical awareness of the higher OHS prevalence in postmenopausal women may lead to earlier diagnosis and a more timely and appropriate treatment. Further studies are needed to assess the prevalence of OHS in women, the effect of menopause on OHS, and the increased risk of OHS, which will hopefully lead to optimizing OHS patient care.

Risk factors in developing retinal vein occlusion in subject with obstructive sleep apnea.

BACKGROUND: Patients with obstructive sleep apnoea (OSA) have a higher risk of developing vascular diseases. In this study, we evaluated the clinical profile of patients with OSA who develop Retinal Vein Occlusion (RVO) compared with a population of OSA patients without RVO. METHODS: We analysed patients with OSA diagnosed with RVO (21 cases; mean of age 61 (12) yrs. range 44-87 yrs. 67% men), belonging to a large cohort of people with long-term follow-up for RVO (up to 12 years). We compared them with 21 patients with OSA, without RVO, matched by age and gender, selected from the Sleep Unit Registry (control group). RESULTS: There were no differences in the prevalence of arterial hypertension (AHT) or Diabetes mellitus (DM), but the RVO patients presented a higher diastolic blood pressure compared to controls (87.6±12.6 mmHg vs. 77.9±10.1 mm Hg respectively). The polygraphic parameters were similar in both groups. The Apnoea-Hypopnoea Index (IHA) similar in both groups (30.4 ±20.9 RVO vs. 33.7 ± 22.1 controls). In addition, RVO patients had a less favourable lipid profile, with higher total cholesterol (218±52 mg/dL vs. 179±41 mg/dL), higher LDL cholesterol (139±47 mg/dL vs. 107±32 mg/dL) and higher atherogenic indices: LDL/HDL (2.78 ± 0.95 RVO vs. 2.03±0.67 controls) and total cholesterol / HDL (4.37± 1.08 vs. 3.45 ± 0.84). Among the cases, 81% had peripheral RVO (superior temporal branch in 20 out of 21 cases) and 19% had central RVO. 62% of the cases received intravitreal antiangiogenic therapy and dexamethasone implants and 33% received argon laser photocoagulation. CONCLUSIONS: Poor control of cardiovascular risk factors, particularly dyslipidaemias, in patients with OSA may lead to the development of this ocular complication.

Mandibular Torus as a New Index of Success for Mandibular Advancement Devices.

BACKGROUND: In obstructive sleep apnoea (OSA), treatment with mandibular advancement devices (MADs) reduces patients' Apnoea-Hypopnoea index (AHI) scores and improves their sleepiness and quality of life. MADs are non-invasive alternatives for patients who cannot tolerate traditional continuous positive airway pressure (CPAP) therapy. The variability of responses to these devices makes it necessary to search for predictors of success. The aim of our study was to evaluate the presence of mandibular torus as a predictor of MAD efficacy in OSA and to identify other potential cephalometric factors that could influence the response to treatment. METHODS: This was a retrospective cohort study. The study included 103 patients diagnosed of OSA who met the criteria for initiation of treatment with MAD. Structural variables were collected (cephalometric and the presence or absence of mandibular torus). Statistical analysis was performed to evaluate the existence of predictive factors for the efficacy of MADs. RESULTS: A total of 103 patients who were consecutively referred for treatment with MAD were included (89.3% men); the mean age of the participants was 46.3 years, and the mean AHI before MAD was 31.4 (SD 16.2) and post- MAD 11.3 (SD 9.2). Thirty-three percent of patients had mandibular torus. Torus was associated with a better response (odds ratio (OR) = 2.854 (p = 0.035)) after adjustment for sex, age, body mass index (BMI; kg/m2), the angle formed by the occlusal plane to the sella-nasion plane (OCC plane to SN), overinjection, and smoking. No cephalometric predictors of efficacy were found that were predictive of MAD treatment success. CONCLUSIONS: The presence of a mandibular torus practically triples the probability of MAD success. This is the simplest examination with the greatest benefits in terms of the efficacy of MAD treatment for OSA.

Differences between sexes concerning COVID-19-related pneumonia.

BACKGROUND: Pneumonia is both the most common type of lower respiratory tract infection and a major cause of morbidity and mortality worldwide. The COVID-19 pandemic caused by the SARS-CoV-2 raised an extremely serious concern, because its most frequent clinical presentation was pneumonia. Features such as sex play an active role in the incidence and outcomes of pneumonia. This study aimed to evaluate differences between sexes concerning COVID-19-related pneumonia. METHODS: This was a retrospective, multicenter study that enrolled 340 consecutive adult patients admitted to hospital for COVID-19-related pneumonia. Of these patients, 219 were males (64.4%) and 121, females (35.6%). Primary endpoints were differences between both sexes as per clinical features, laboratory and radiologic results, and in-hospital and 30-day mortality. Secondary outcomes included differences between both sexes and factors associated with mortality. RESULTS: Males admitted to the COVID-19 Unit were older than females (74.5±15.7 vs. 64.5±11.9). Cardiovascular disorders were more frequent in males (19.17% vs. 13.25%), whereas obesity was more common in females (54.5% vs. 37.45%). In-hospital and 30-day mortality were higher in males than in females (23.3% vs. 15.7%; 24.6% vs. 19.8%, respectively). No differences were observed in hospital stay; however, males had a longer ICU stay when compared with females (11.04±5.4 vs. 7.05±3.4). Variables associated with a higher mortality rate included older age, a lower number of lymphocytes upon admission and higher levels of ferritin and troponin upon admission. CONCLUSIONS: Males had significantly higher mortality and longer ICU stay than females. More comorbidities in males than in females could explain the difference in mortality rates. The protective role of genetic factors can partially explain the better outcomes observed in female patients with COVID-19.

Management of patients with severe acute respiratory failure due to SARS-CoV-2 pneumonia with noninvasive ventilatory support outside Intensive Care Unit.

BACKGROUND: COVID-19 has high mortality rate mainly stemming from acute respiratory distress leading to respiratory failure (ARF). Aim of the study was to evaluate the management of severe ARF due to COVID-19 pneumonia using noninvasive ventilatory support (NIVS), studying safety and effectiveness of NIVS. METHODS: This is a retrospective, multicenter study. Primary outcomes were NIVS failure with intubation rate and hospital mortality. Secondary outcomes were hospital stay and factors related to NIVS failure and mortality. These outcomes were compared with patients intubated and admitted to ICU. RESULTS: One hundred sixty-two patients were hospitalized because of severe respiratory failure (PaO2/FiO2 ratio <250). One hundred thirty-eight patients were admitted to Respiratory Intermediate Care Unit (RICU) for a NIVS trial. One hundred patients were treated successfully with NIVS (74.5%); 38 failed NIVS trial (27.5%). In-hospital mortality was 23.18% in RICU group and 30.55% in ICU group. Patients with NIVS failure were older, had a lower number of lymphocytes, a higher IL-6, lower PaO2, PaC O2, PaO2/FiO2 ratio, higher respiratory rate (RR) and heart rate at admission and lower PaO2, and PaO2/FiO2 ratio and higher RR after 1-6 hours. Multivariate analysis identified higher age, C-reactive protein as well as RR after 1-6 hours and PaO2/FiO2 ratio after 1-6 hours as an independent predictor mortality. CONCLUSIONS: NIVS is a safe and effective strategy in the treatment of severe ARF due to COVID-19 related pneumonia, that reduces mortality and length of hospital stay in the carefully selected patients.

Non-invasive ventilation in palliative care: a systematic review.

INTRODUCTION: An ageing population and steady increase in the rates of neoplasms and chronic degenerative diseases poses a challenge for societies and their healthcare systems. Because of the recent and continued advances in therapies, such as the development and widespread use of non-invasive ventilation (NIV), survival rates have increased for these pathologies. For patients with end-stage chronic respiratory diseases, the use of NIV following the onset of acute or severe chronic respiratory failure is a valid option when intubation has been excluded. EVIDENCE ACQUISITION: The following electronic databases were searched from their inception to January 2000 to December 2017: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), the Cochrane Database of Systematic Reviews, ACP Journal Club database. EVIDENCE SYNTHESIS: The available evidence strongly supports the use of NIV in patients presenting with an exacerbation of chronic obstructive pulmonary disease, as well end-stage neuromuscular disease. Few studies support the use of NIV in end-stage interstitial lung disease and in morbid obesity patients. In patients with cancer has been recommend offering NIV as palliative care to improve dyspnea. CONCLUSIONS: The decision regarding the treatment should be made by the patient, ideally before reaching the terminal stage and after having a frank dialogue with healthcare professionals and family members.

Audiovestibular manifestations in patients with ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic inflammatory disease of unknown origin affecting up to 1% of the population. Little is known about audiovestibular impairment in patients with AS, especially the presence of cochleovestibular dysfunction in these patients. To investigate audiovestibular manifestations in AS, we studied a series of 50 consecutive patients who fulfilled the modified New York diagnostic criteria for AS and 44 matched controls. Individuals with history of cardiovascular disease, cerebrovascular complications, peripheral artery disease, renal insufficiency, syphilis, Meniere and other vestibular syndromes, infections involving the inner ear, barotrauma, or in treatment with ototoxic drugs were excluded. Most patients with AS were men (80%). The mean age at the time of study was 52.5 years, and mean age at the onset of symptoms was 34.4 years. Twenty-nine (58%) patients showed abnormal hearing loss in the audiogram compared to only 8 (18%) controls (p < 0.001). Values of audiometric tests (pure-tone average and speech reception threshold) yielded significant differences between patients and controls (p < 0.001). It is noteworthy that the audiogram shape disclosed a predominant pattern of high-frequency sensorineural hearing loss in AS patients (50%) compared to controls (18%) (p = 0.002). Also, AS patients exhibited abnormal vestibular tests more commonly than controls. AS patients had an increased frequency of head-shaking nystagmus (20%) compared to controls (0%) (p < 0.001). Moreover, patients (26%) showed a significantly increased frequency of abnormal caloric test compared to controls (0%) (p < 0.001). Finally, a significantly increased frequency of abnormal clinical test of sensory integration and balance with a predominant vestibular loss pattern was observed in patients (36%) compared to controls (5%) (p < 0.001). In conclusion, the current study demonstrates strong evidence for inner ear compromise in patients with AS.

Systemic lupus erythematosus in northwestern Spain: a 20-year epidemiologic study.

To further investigate the epidemiology of systemic lupus erythematosus (SLE) in southern Europe, we assessed the incidence, prevalence, clinical spectrum of the disease, flares, and survival of patients diagnosed with SLE in the Lugo region of northwestern Spain. Between January 1987 and December 2006, 150 Lugo residents were diagnosed as having SLE according to the 1982 American College of Rheumatology criteria for the classification of SLE. Women outnumbered men (127 [84.7%] vs. 23 [15.3%]). The mean age at the time of disease diagnosis was 46.1 ± 19.6 years. The mean follow-up from the time of disease diagnosis was 7.8 ± 4.5 years. The age- and sex-adjusted annual incidence rate over the 20-year study period was 3.6 (95% confidence interval [CI], 3.0-4.2) per 100,000 population aged 15 years and older. The overall annual incidence rate over the 20-year study period in women (5.9/100,000 population aged ≥ 15 yr; 95% CI, 4.9-7.0) was higher than in men (1.1/100,000 population aged ≥ 15 yr; 95% CI, 0.7-1.7) (p < 0.001). By December 31, 2006, the overall age-adjusted SLE prevalence in the Lugo region for patients who fulfilled at least 4 of 1982 American College of Rheumatology criteria was 17.5 per 100,000 population aged 15 years and older (95% CI, 12.6-24.1). Prevalence in women (29.2/100,000 population aged ≥ 15 yr; 95% CI, 20.0-40.7) was higher than in men (5.8/100,000 population aged ≥ 15 yr; 95% CI, 2.0-12.0). The most frequent clinical manifestation was arthritis. As reported in population-based studies on SLE patients of European descent, renal disease was observed in only 27.3% of the patients. The rate of flares was 0.084/year. A younger age and the presence of nephritis at the time of disease diagnosis were associated with the development of flares during the follow-up of Lugo patients. Compared with the general population the probability of survival in patients with SLE was significantly reduced (p = 0.04). In conclusion, the present study establishes a baseline estimate of the incidence and clinical spectrum of SLE in northwestern Spain. According to our results, the incidence of SLE in northwestern Spain is slightly higher than that reported in most European regions. Patients with SLE from northwestern Spain have a later average age onset and a lower frequency of nephritis than in the African-American population. However, our data show a reduced probability of survival in Spanish patients with SLE.