Pulse Wave Amplitude Drops Index: A Biomarker of Cardiovascular Risk in Obstructive Sleep Apnea.

Rationale: It is currently unclear which patients with obstructive sleep apnea (OSA) are at increased cardiovascular risk. Objective: To investigate the value of pulse wave amplitude drops (PWADs), reflecting sympathetic activations and vasoreactivity, as a biomarker of cardiovascular risk in OSA. Methods: PWADs were derived from pulse oximetry-based photoplethysmography signals in three prospective cohorts: HypnoLaus (N = 1,941), the Pays-de-la-Loire Sleep Cohort (PLSC; N = 6,367), and "Impact of Sleep Apnea syndrome in the evolution of Acute Coronary syndrome. Effect of intervention with CPAP" (ISAACC) (N = 692). The PWAD index was the number of PWADs (>30%) per hour during sleep. All participants were divided into subgroups according to the presence or absence of OSA (defined as ⩾15 or more events per hour or <15/h, respectively, on the apnea-hypopnea index) and the median PWAD index. Primary outcome was the incidence of composite cardiovascular events. Measurements and Main Results: Using Cox models adjusted for cardiovascular risk factors (hazard ratio; HR [95% confidence interval]), patients with a low PWAD index and OSA had a higher incidence of cardiovascular events compared with the high-PWAD and OSA group and those without OSA in the HypnoLaus cohort (HR, 2.16 [1.07-4.34], P = 0.031; and 2.35 [1.12-4.93], P = 0.024) and in the PLSC (1.36 [1.13-1.63], P = 0.001; and 1.44 [1.06-1.94], P = 0.019), respectively. In the ISAACC cohort, the low-PWAD and OSA untreated group had a higher cardiovascular event recurrence rate than that of the no-OSA group (2.03 [1.08-3.81], P = 0.028). In the PLSC and HypnoLaus cohorts, every increase of 10 events per hour in the continuous PWAD index was negatively associated with incident cardiovascular events exclusively in patients with OSA (HR, 0.85 [0.73-0.99], P = 0.031; and HR, 0.91 [0.86-0.96], P < 0.001, respectively). This association was not significant in the no-OSA group and the ISAACC cohort. Conclusions: In patients with OSA, a low PWAD index reflecting poor autonomic and vascular reactivity was independently associated with a higher cardiovascular risk.

Effect of oxybutynin and reboxetine on obstructive sleep apnea: a randomized, placebo-controlled, double-blind, crossover trial.

STUDY OBJECTIVES: Although recent investigations combining noradrenergic and antimuscarinic drugs have shown promising short-term results to treat obstructive sleep apnea (OSA), the mid-term effect and optimal dosage remain uncertain. The present study aimed to evaluate the effect of 1 week of 5 mg oxybutynin and 6 mg reboxetine (oxy-reb) on OSA versus placebo. METHODS: We performed a randomized, placebo-controlled, double-blind, crossover trial comparing the effect of 1 week of oxy-reb versus 1 week of placebo on OSA severity. At-home polysomnography was performed at baseline and after each week of intervention. RESULTS: Fifteen participants (male 66.7%) aged 59 [44-62] years (median [interquartile range]) with a mean body mass index of 33.1 ± 6.6 kg/m2 were included. No significant difference in apnea-hypopnea index (AHI) was observed between conditions (estimated marginal means [95% confidence interval] at baseline: 39.7 [28.5-55.3]; oxy-reb: 34.5 [22.7-52.3]; placebo: 37.9 [27.1-52.9]; p = 0.652), but oxy-reb improved average oxygen desaturation (p = 0.016) and hypoxic burden (p = 0.011) and lowered sleep efficiency (p = 0.019) and rapid eye movement sleep (p = 0.002). Moreover, participants reported reduced sleep quality during the week of oxy-reb compared to the week of placebo (4.7 [3.5; 5.9] vs. 6.5 [5.5; 7.5] on a 0-10 visual analogic scale, respectively; p = 0.001). No significant differences in sleepiness, vigilance, and fatigue were observed. No serious adverse events occurred. CONCLUSIONS: Administration of oxybutynin 5 mg and reboxetine 6 mg did not improve OSA severity assessed by AHI, but did alter sleep architecture and sleep quality. Reduced average oxygen desaturation and hypoxic burden were also observed. CLINICAL TRIAL: ClinicalTrials.gov, https://clinicaltrials.gov, NCT04394143.

[Place of the respiratory physiotherapist in the Covid-19 crisis: Neuchâtel experience]. / Place du physiothérapeute respiratoire dans la crise Covid-19 : expérience neuchâteloise.

The physiotherapy service became an important player in the care of patients with COVID-19 at Pourtalès hospital (Neuchâtel, Switzerland), illustrating its important role in the organization of acute care units. The workforce was increased, and the diaries extended (7/7d, 24/24h). Respiratory physiotherapists were largely involved in the initiation and the adaptation of the respiratory therapy in the units dedicated to Covid-19 patients (emergency, intensive care and pulmonology units), such as oxygen therapy and both invasive and non-invasive ventilation. Rehabilitation was also early initiated in order to limit the risk of intensive care unit-acquired polyneuromyopathy and to prevent physical deconditioning.

Le Service de physiothérapie s'est inscrit comme un acteur important dans la prise en charge des patients Covid-19 à l'Hôpital Pourtalès (Neuchâtel, Suisse), illustrant son rôle important dans l'organigramme des unités de soins aigus. L'effectif a été augmenté et les horaires étendus (7 j/7, 24 h/24). Les physiothérapeutes spécialisés dans le domaine respiratoire ont activement participé à la mise en route des traitements respiratoires et à leur adaptation dans les unités dédiées aux patients Covid-19 (urgences, soins intensifs et pneumologie), tels que l'oxygénothérapie et l'assistance ventilatoire invasive et non invasive. Une réhabilitation a par ailleurs été initiée précocement afin de limiter le risque de polyneuromyopathie acquise aux soins intensifs et de prévenir le déconditionnement physique.

[Circadian rhythm sleep disorders: clinical picture, diagnosis and treatment]. / Troubles du rythme circadien veille-sommeil†: tableau clinique, diagnostic et prise en charge.

Circadian rhythm sleep disorders (CRSD) represent sleep-wake disturbances due to a disruption of endogenous circadian system or to a desynchronization between internal sleep-wake rhythms and the external environment. They comprise seven diagnostic entities grouped in two main categories: endogenous and exogenous. The patients typically describe chronic excessive daytime sleepiness and/or insomnia symptoms, impacting their daytime functioning. The exact prevalence of CRSD is probably underestimated. The diagnosis is based on sleep diary coupled with actigraphy. Several therapeutic options are validated to allow the realignment between endogenous circadian rhythm and the external environment. The correct diagnostic of CRSD is important to improve the patient's quality of life and to propose them appropriate treatment.

Les troubles du rythme circadien veille-sommeil (TRCVS) résultent d'un dysfonctionnement du rythme circadien endogène ou d'une désynchronisation entre ce dernier et l'environnement extérieur. Ce groupe de pathologies du sommeil comprend 7 sous-entités réparties en 2 catégories : des troubles exogènes et des troubles endogènes. La symptomatologie commune sont des plaintes chroniques de somnolence diurne et/ou d'insomnie, ayant des répercussions sur le fonctionnement quotidien. Leur prévalence exacte est inconnue et les TRCVS sont potentiellement sous-diagnostiqués. Le diagnostic repose sur l'utilisation de l'agenda de sommeil et de l'actigraphie. Diverses approches thérapeutiques existent pour permettre une resynchronisation entre le rythme circadien endogène et l'environnement extérieur.

Improvement of sleep architecture parameters in cirrhotic patients with recurrent hepatic encephalopathy with the use of rifaximin.

BACKGROUND AND AIM: Sleep disorders are frequently reported in patients with cirrhosis and hepatic encephalopathy (HE). This study assessed the effect of rifaximin on sleep architecture parameters in patients with recurrent HE. PATIENTS AND METHODS: This sequential, prospective, and exploratory study involved all patients with cirrhosis and recurrent HE admitted between June 2014 and September 2015. HE was assessed according to the West-Haven Classification. Patients underwent 24-h polysomnography (PSG) and 7-day actigraphy. Rapid eye movement (REM) sleep was considered to be an indicator of good sleep quality. Patients completed questionnaires assessing the quality of sleep and sleepiness. After a 28-day course of rifaximin, the same assessment was repeated. RESULTS: Fifteen patients were included (nine men, mean age: 57±11 years). Child-Pugh scores ranged from B7 to C15. Before rifaximin, the mean HE score was 2.7±0.7. Data from PSG analysis indicated long total sleep time (TST): 571±288 min, and limited REM sleep: 2.5% TST (0-19). Seven-day actigraphy showed an impaired number of steps: 1690/24 h (176-6945). Questionnaires indicated that patients experienced impaired sleep quality and excessive daytime sleepiness. After rifaximin, HE scores decreased to 1.7±0.6 (P<0.001). REM sleep increased to 8.5% TST (0-25) (P=0.003). No changes were observed for TST, number of steps, and on questionnaires. CONCLUSION: Patients with recurrent HE suffer from poor sleep quality and excessive daytime sleepiness. On 24-h PSG, rifaximin improves objective sleep architecture parameters with no changes in the subjective quality of sleep and sleepiness.

Driver oncogenes in Sub-Saharan African patients with non-small cell lung cancer.

Non-small cell lung cancer can exhibit driver oncogenes, including epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK), that are possible targets for therapy. The prevalence of these rearranged driver oncogenes is influenced by race, smoking habits, and gender. Most data come from Caucasian and Asian populations. To our knowledge, there is no literature available about the prevalence of driver oncogenes in Sub-Saharan Africa, where the tobacco epidemic is still in the early stage. In this small case series, 6 patients of Sub-Saharan African ethnicity with stage IV lung adenocarcinoma are described. EGFR mutation was present in 3/6 patients and ALK rearrangement in 1/6 patients. This incidence seems high but interestingly, all patients were non-smokers or light smokers. In this series, the high prevalence of driver oncogene was probably related to low smoking habits and these initial data in Sub-Saharan Africans suggest high prevalence of driver mutations for this reason.

Very early screening for sleep-disordered breathing in acute coronary syndrome in patients without acute heart failure.

BACKGROUND: Obstructive sleep apnea (OSA) is frequently associated with acute coronary syndrome (ACS). Screening of sleep-disordered breathing (SDB) has not been previously evaluated in ACS within 72 h in intensive care settings and its management could potentially enhance patients' prognosis. This pilot study assessed the feasibility of SDB screening at the early phase of ACS. METHODS: All consecutive patients admitted to the coronary care unit (CCU) for ACS without acute heart failure underwent one overnight-attended polysomnography (PSG) within 72 h after admission. A telemonitoring (TM) system was set up to remotely monitor the signals and repair faulty sensors. The 27 recordings were analyzed as respiratory polygraphy (RP) and as PSG, and the results were compared. RESULTS: The TM system allowed successful intervention in 48% of recordings, resulting in excellent quality PSG for 89% of cases. The prevalence of SDB [apnea-hypopnea index (AHI) ≥ 15/h] was 82% and mainly consisted of central SDB and periodic breathing, except three patients with OSA. Compared with PSG, RP underestimated AHI, probably due to the poor sleep efficiency, reduction of slow-wave sleep, and alteration of rapid eye movement sleep. CONCLUSION: An early SDB screening by remote-attended PSG is feasible in ACS patients shortly after admission to CCU. The TM enhanced the quality of PSG. A high prevalence of central SDB was noticed, for which the etiology remains unknown. Further large-scale studies are needed to determine whether central SDB is an incidental finding in early ACS and whether the presence and severity of SDB have a prognostic impact.

Real-time attended home-polysomnography with telematic data transmission.

PURPOSE: Home-polysomnography (HPSG) has been proposed as a cost-effective alternative for obstructive sleep apnea (OSA) diagnosis. We assessed, in a feasibility study, whether telematic transmission using the Dream® and Sleepbox® technologies was associated with low HPSG failure rate. METHODS: Patients referred by chest physicians for clinical suspicion of OSA underwent one HPSG, using Dream® and Sleepbox® (Medatec, Belgium), which is a wireless system able to communicate with Dream®, and with Internet through a wi-fi/3G interface. It is equipped with a digital infrared camera, and with a speaker/microphone system for bidirectional audio/video communication via Skype®. The Sleep Lab nurse performed a remote discontinuous monitoring of the PSG. In case of sensor loss, she called the patient who had been previously educated to replace the sensors. RESULTS: Twenty-one patients have been studied. 90% of the recordings were of excellent quality. We observed a 10% PSG failure rate: one failure of the Dream®, and one recording of poor quality. There were 2 successful Skype® interventions resulting in readjustment of the defective probes (nasal cannula and EEG). PSG signal visualization was possible in 90% of cases but Skype® connection was problematic in 19% of cases. However, patients could be reached by phone to solve the problem. CONCLUSIONS: Real-time attended HPSG through telematic data transmission is feasible and could be an interesting perspective to decrease the failure rate of home sleep studies, even if some technical aspects need to be improved.