Ultrasound-Guided Ethanol Percutaneous Ablation Versus Rescue Surgery in Patients With Locoregional Recurrence of Papillary Thyroid Cancer

OBJECTIVES

Neck recurrence of papillary thyroid cancer (PTC) is frequently detected after initial surgery. The management of these lesions may include rescue surgery (RS) or minimally invasive techniques in selected patients, but comparative studies evaluating the effectiveness and safety of these techniques are lacking. In this paper, we compared ultrasound-guided ethanol ablation (EA) in selected patients to RS in a matched cohort.

METHODS

We retrospectively compared 41 patients and 41 matched PTC patients without known distant metastases, who underwent ultrasound-guided EA or RS (matched reference group), who had 63 and 75 thyroid bed and/or lymph node confirmed PTC recurrences during a median follow-up of 72.8 and 89.6 months, respectively. The primary outcome was time until structural recurrence, compared using Kaplan-Meier survival curves. The secondary outcomes included time until biochemical recurrence, plasma thyroglobulin (Tg) levels, American Thyroid Association (ATA) response-to-therapy categories by the last available observation, and treatment-derived complications in each group.

RESULTS

No significant differences were found between the EA and RS groups for time until structural recurrence (log-rank test, P=0.94). The time until biochemical recurrence was also similar (P=0.51); and the plasma Tg concentration reduction and proportions of patients in the ATA reclassification categories were also similar. A significantly higher proportion of patients in the RS group presented treatment-derived complications (29.27% vs. 9.75%, P<0.05).

CONCLUSION

In this retrospective analysis, the treatment of PTC neck recurrence with EA in selected patients was comparable to RS in a matched reference group for the long-term risk of structural or biochemical relapse, but with a lower risk of treatment-derived complications. These.

RESULTS

support the effectiveness and safety of this minimally invasive technique in the management of selected patients with recurrent PTC.

Age-standardized incidence, mortality rate and trend changes of thyroid cancer in the Balearic Islands during the 2000-2020 period: a population-based study

OBJECTIVE

Global thyroid cancer (TC) incidence is growing worldwide, but great heterogenicity exists among published studies and thus, population-specific epidemiological studies are needed to adequate health resources and evaluate impact of overdiagnosis.

METHODS

We conducted a Public Health System database retrospective review of TC incident cases from 2000 to 2020 in the Balearic Islands region and evaluated age-standardized incidence (ASIR), age at diagnosis, gender distribution, tumor size and histological subtype, mortality rate (MR) and cause of death. Estimated annual percent changes (EAPCs) were also evaluated and data from the 2000-2009 period was compared to the 2010-2020, when neck ultrasound (US) was routinely performed by clinicians at Endocrinology Departments.

RESULTS

A total of 1,387 incident cases of TC were detected. Overall, ASIR (x105) was 5.01 with a 7.82% increment in EAPC. A significant increase in the 2010-2020 period was seen for ASIR (6.99 vs. 2.82, p<0.001) and age at diagnosis (52.11 vs. 47.32, p<0.001) compared to the 2000-2009 period. A reduction in tumor size (2.00 vs 2.78 cm, p<0,001) and a 6.31% increase in Micropapillary TC (p<0.05) were also seen. Disease-specific MR remained stable at 0.21 (x105). Mean age at diagnosis for all mortality groups was older than survivors (p<0.001).

CONCLUSION

Incidence of TC has grown in the 2000-2020 period in the Balearic Islands, but mortality rate has not changed. Beyond other factors, a significant contribution of overdiagnosis to this increased incidence is likely, due to changes in the routine management of thyroid nodular disease and increased availability of neck US.

Vitamin D as a biomarker of health in snoring children: a familial aggregation study

BACKGROUND

Hypovitaminosis D is a common health problem. The purpose of this study was to investigate the inter-relationship between serum 25(OH)D levels and paternal and maternal vitamin D status in a sample of snoring children.

METHODS

We selected 137 participants for whom serum 25(OH)D had been measured and underwent overnight polysomnography evaluation. Serum glucose, lipids, liver enzymes, parathyroid hormone, insulin, and glycated hemoglobin were also measured. Glucose and insulin levels were used to estimate insulin resistance with the homeostasis model assessment (HOMA-IR).

RESULTS

Vitamin D insufficiency (<30 ng/mL) and deficiency (<20 ng/mL) were found in 40.9 and 17.5% of children, respectively. After adjustments for age, BMI z-score and seasonality, the odds ratio for risk of vitamin D insufficiency according to the vitamin D status of parents were: OR (95% CI): paternal insufficiency 15.1 (2.7-35.7), p = 0.002; maternal insufficiency 7.2 (2.4-22), p = 0.001. When children with vitamin D deficiency were analyzed separately, serum 25(OH)D concentration was found to be associated with the apnea-hypopnea index (r = -0.647, p = 0.009) and respiratory arousal index (r = -0.669, p = 0.034).

CONCLUSIONS

Family patterns of vitamin D could be helpful for the early identification of children at risk of metabolic and/or sleep disturbances and when considering strategies to improve vitamin D status.

IMPACT

Family patterns of vitamin D could be helpful for the early identification of snoring children at risk of metabolic and/or sleep disturbances. Significant associations were found between serum 25-hydroxyvitamin D (25(OH)D) concentrations in children and their parents. An inverse association between 25(OH)D levels and OSA severity was detected in deficient vitamin D children. Children with insufficient and deficient vitamin D status tended to have a worse metabolic profile, so strategies are needed to improve vitamin D status.

Surfactant protein D concentration in a pediatric population with suspected sleep disorder

Obstructive sleep apnea (OSA) affects between 2% and 4% in children and there is a search for new biomarkers that can be useful both in the diagnosis and in the evolution of the disease. The surfactant protein D (SP-D) is a collection that is part of the innate immune system exerting an anti-inflammatory and antimicrobial effect. Thus, the objective of this study was to evaluate the concentration of SP-D in the suspect OSA pediatric population. A total of 178 children were recruited in this prospective study. Blood samples, sleep parameters, feeding habits, anthropometric, sociodemographic, and family data were collected. Specific biochemical determinations were made, and the plasmatic concentrations of SP-D were measured by enzyme-linked immunosorbent assay. We found no statistical correlation between the SP-D concentration and the apnea-hypopnea index (AHI) from the data. Nevertheless, the changes in SP-D levels could be correlated to a large extent by the arousals that often go along with hypopneas (r = -0.258, p = 0.011 unadjusted; r = -0.258, p = 0.014 adjusted by age and body mass inded [BMI] Z-score). Intermittent hypoxia was correlated with C-reactive protein levels (r = 0.547, p < 0.001 unadjusted; r = 0.542, p < 0.001 adjusted by age and BMI Z-score). Although AHI and SP-D did not appear to correlate, a secondary analysis suggests that sleep fragmentation, which is produced by arousals, may do, and further research is needed to determine the mechanisms by which changes in SP-D occur in OSA.

Thyroid Disfunction in Critically Ill COVID-19 Patients. Relationship with In-Hospital Mortality

The incidence of thyroid disfunction has not been analyzed in critically ill COVID-19 patients. Our objective was to analyze the relationship of the thyroid profile and in-hospital mortality in critically ill COVID-19 patients. This was a prospective single-center study involving critically ill COVID-19 patients admitted to the ICU of a tertiary University Hospital. Thyroid hormones were measured through drawing blood samples from a central venous catheter at ICU admission and on the fifth day. A multiple logistic regression analysis was performed to analyze the variables associated with mortality. The ability of the different thyroid hormones to predict in-hospital mortality was evaluated by calculating the receiver operating characteristics (ROCs) and the area under the curve (AUC). A total of 78 patients were included in the study at ICU admission; 72 had their thyroid profile measured at day 5. In-hospital mortality reached 29.5%. Multiple logistic regression analysis showed that variables associated with mortality were age and prior beta-blocker therapy at ICU admission and age fT4 at day 5. The AUC for in-hospital mortality predictions of fT4 at day 5 was 0.69. Thyroid responses are commonly observed in critically ill COVID-19 patients. fT4 at day 5 after ICU admission was associated with mortality.

Polysomnographic Characteristics of Snoring Children: A Familial Study of Obstructive Sleep Apnea Syndrome

BACKGROUND AND OBJECTIVES

Available evidence suggests a familial basis for OSA. The aim of the present study was to assess the potential influences of parental OSA in predicting the diagnosis and severity of OSA in snoring children.

METHODS

Observational study, we prospectively enrolled 84 children and their parents. A complete nocturnal polysomnography was performed. Children were categorized into 3 severity groups according to the apnea-hypopnea index (AHI<1h^-1, AHI≥1h^-1 to AHI<5h^-1, and AHI≥5h^-1). Adults were grouped according two criteria (AHI≥5h^-1 and ≥10h^-1).

RESULTS

There were no significant differences in age, gender, BMI and BMI z-score among groups. Among the children, 54.7% had an AHI≥1h^-1 and 21.4% had an AHI≥5h^-1. Overall, we observed that 60.7% of fathers and 23.8% of mothers of our population had OSA (AHI≥5h^-1). The prevalence of fathers with OSA increases with the children's severity (83% in the group of children with moderate-severe OSA, p=0.035). The odds of having moderate-severe pediatric OSA (AHI≥5h^-1) were more than 4 times higher among children with a father with AHI≥5h^-1 (OR: 4.92, 95% CI: 1.27-19.06; p=0.021). There was no evidence of any maternal influence on OSA severity among the children studied.

CONCLUSIONS

Our findings suggest a high prevalence of OSA among the family members studied with an increased association of childhood OSA with paternal OSA. Prediction of OSA risk among children can be significantly improved by adding data on paternal OSA status.

Impact of Obstructive Sleep Apnea on Gestational Diabetes Mellitus

INTRODUCTION

Obstructive sleep apnea (OSA) increases the risk of type 2 diabetes, and hyperinsulinemia. Pregnancy increases the risk of OSA; however, the relationship between OSA and gestational diabetes mellitus (GDM) is unclear. We aimed (1) to evaluate OSA prevalence in GDM patients; (2) to assess the association between OSA and GDM; and (3) to determine the relationships between sleep parameters with insulin resistance (IR).

METHODS

A total of 177 consecutive women (89 with GDM, 88 controls) in the third trimester of pregnancy underwent a hospital polysomnography. OSA was defined when the apnea-hypopnea index (AHI) was ≥5h-1.

RESULTS

Patients with GDM had higher pregestational body mass index (BMI) and neck circumference than controls, but no differences in snoring or OSA-symptoms, or AHI (3.2±6.0 vs. 1.9±2.7h-1, p=.069). OSA prevalence was not significantly different in both groups. We did not identify OSA as a GDM risk factor in the crude analysis 1.65 (95%CI: 0.73-3.77; p=.232). Multiple regression showed that total sleep time (TST), TST spent with oxygen saturation<90% (T90), and maximum duration of respiratory events as independent factors related with homeostasis model assessment of IR, while T90 was the only independent determinant of quantitative insulin sensitivity check index.

CONCLUSION

OSA prevalence during the third trimester of pregnancy was not significantly different in patients with GDM than without GDM, and no associations between OSA and GDM determinants were found. We identified T90 and obstructive respiratory events length positive-related to IR, while TST showed an inverse relationship with IR in pregnant women.

Bilateral microphthalmos with bilateral orbital cysts: individualising the treatment according to the visual potential. A case report

The case is presented of a 3-month-old infant diagnosed with microphthalmos and orbital cysts. Magnetic Resonance Imaging revealed a bilateral microphthalmia with a moderate right cyst and a severe left cyst. Visual potential of the right eye was uncertain. Non-surgical treatment was decided. At the age of 2 years old, physical examination showed a significant decrease of the cysts and visual acuity of hand movements due to the residual vision of his right eye. Microphthalmos with orbital cyst is a rare congenital anomaly. Cysts tend to enlarge with time. At the moment, no standard protocol for the management of this pathology has been described. Unlike in our patient, visual acuity in these patients is usually of no-light perception. The observation could be an alternative in severe cases, since there is a possibility of spontaneous reduction, displacement, or regression of the cysts.

Post-mortem toxicology in the diagnosis of sudden death in young and middle-aged victims

OBJECTIVE

We aimed to investigate the impact of the toxicological results found in cases of sudden death (SD) and to correlate the clinical, autopsy and genetic findings with the toxicology results.

MATERIALS AND METHODS

Consecutive SD in people aged between 16 and 50 years with medico-legal autopsies and toxicology studies were included over a 3-year period. The comparison between the toxicological data and demographic characteristics, clinical circumstances, autopsy, and genetic results were taken into account.

RESULTS

101 cases were finally included. They were predominately males (84%) and the mean age was 39.8 years. 52 (51.5%) cases had positive toxicological findings and in 25 cases (24.8%), toxic compounds were considered the first cause of death. Ethanol was the most frequently identified agent (69%), following by licit drugs (56%) and drugs of abuse (39%). Cases with positive toxicology were younger than those with negative results (37.9±9.1 vs. 41.9±7.8; p=0.02). Patients with more than 3 comorbidities showed an association with positive toxicological results (n=14 vs. n=3; p=0.017). The genetic study was performed in 70 (69.3%) SD cases. We identified pathogenic or likely pathogenic variants in 17.1% cases and uncertain significance variants in 42.8% cases. 58% of these variants were probably related to the cause of death.

CONCLUSIONS

A large fraction of SD victims had positive toxicological findings and a quarter of deaths were directly caused by toxic substances. The identification of the factors that trigger SD provides a good approach to contribute in avoiding future episodes.

Prothrombotic state in children with obstructive sleep apnea

OBJECTIVE

Increased blood coagulation might be one important mechanism linking obstructive sleep apnea (OSA) with cardiovascular diseases. We tested the association between several hemostatic parameters and sleep breathing-related variables in a representative pediatric population with a clinical suspicion of OSA.

METHODS

Polysomnography was performed in 152 snoring children to diagnose OSA. Anthropometric and clinical data were registered and venous blood samples were collected for the measurement of platelet count, plateletcrit, platelet distribution width (PDW), mean platelet volume (MPV), prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and C-reactive protein.

RESULTS

Children with OSA had significantly higher platelet count, plateletcrit and PDW compared with those without OSA. After controlling for the anthropometric characteristics (age, gender, body mass index (BMI) z-score), platelet count negatively correlated with minimum SaO₂ while the plateletcrit correlated with time with SaO₂ <90% and MPV correlated with apnea-hypopnea index. PT and PT international normalized ratio correlated with mean SaO₂ and aPTT correlated with the oxygen desaturation index.

CONCLUSION

Our findings suggest that different OSA-related effects may be factors contributing to an enhanced coagulability in pediatric OSA. Measures reflecting apnea severity and disrupted sleep were associated with clotting factor changes independent of covariates affecting hemostatic function.

Circulating branched-chain amino acids in children with obstructive sleep apnea

INTRODUCTION

The effects of obstructive sleep apnea (OSA) on the metabolic system are not well understood, especially in children. Recent studies have provided evidence of the modulation of insulin action by branched-chain amino acids (BCAAs) and suggested novel mechanistic relationships between glucose and amino acid metabolic pathways. We hypothesized that plasma BCAA levels may serve as biomarkers of insulin resistance and metabolic dysfunction in children with OSA.

METHODS

A polysomnography was conducted for the diagnosis of OSA in 90 snoring children, in a tertiary hospital. Anthropometric and clinical data were measured and venous blood samples were collected for the measurement of plasma glucose, insulin, HbA1c, and amino acids.

RESULTS

Children with OSA had significantly higher levels of BCAAs (leucine, isoleucine, and total BCAAs) compared with those without OSA (P = 0.024). A positive significant correlation was observed between insulin levels and both leucine and isoleucine (r = 0.232; P < 0.05). On multivariate regression analyses, the presence of OSA was significantly associated with leucine, isoleucine, and total BCAA concentrations (P = 0.028), whereas the arousal index was associated with leucine, valine, and total BCAA levels (P = 0.037).

CONCLUSIONS

The presence of OSA and sleep fragmentation may induce changes in branched-chain amino acid metabolism in snoring children, independently of obesity. These data may suggest a new mechanism linking OSA and glucose homeostasis.

Glycated hemoglobin and sleep apnea syndrome in children: beyond the apnea-hypopnea index

PURPOSE

Snoring and obstructive sleep apnea syndrome (OSA) are frequent conditions in pediatrics. Glycated hemoglobin (Hb_A1C) is a useful homeostatic biomarker of glycemia and may reflect alterations deriving from sleep breathing disorders. The aim of this study was to relate the severity of OSA with blood Hb_A1C levels in children.

METHODS

A descriptive observational study in snoring patients was performed. All patients underwent a sleep study and classified either as simple snorers (apnea-hypopnea index; AHI ≤ 1 episodies/h) or as OSA patients (AHI > 1 episodes/h). In the following morning, a blood glycemic profile (fasting glucose, insulin, Hb_A1C, and the HOMA index) was performed to every individual.

RESULTS

A total of 48 patients were included. Hb_A1C levels were shown to be increased in the moderate OSA (AHI > 5 episodes/h) group (5.05 ± 0.25 vs. 5.24 ± 0.29%; p = 0.019). Significant correlations were found between Hb_A1C values and AHI (r = 0.345; p = 0.016) and also with oxygen desaturation index (r = 0.40; p = 0.005). Correlations remained significant after adjusting by age and body mass index. The AHI-associated change in Hb_A1C was 13.4% (p = 0.011).

CONCLUSIONS

In the pediatric population, Hb_A1C is a biomarker associated with OSA severity, and this relationship is age- and obesity-independent. The fact that this association was observed in snoring patients could help the physician in the distinction between those patients affected with OSA and those with simple snoring. Therefore, Hb_A1C measurement could play a major role in the diagnosis and the management of the syndrome.

A randomized controlled trial: branched-chain amino acid levels and glucose metabolism in patients with obesity and sleep apnea

There is evidence that changes in branched-chain amino acid (BCAA) levels may correlate with the efficacy of therapeutic interventions for affecting improvement in metabolic control. The objective of this study was to evaluate whether serum concentrations of BCAAs (leucine, isoleucine, valine) could mediate in insulin sensitivity and glucose tolerance after continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). A prospective randomized controlled trial of OSA patients with morbid obesity was conducted. Eighty patients were randomized into two groups: 38 received conservative treatment and 42 received CPAP treatment for 12 weeks. Plasma levels of BCAA, glucose tolerance and insulin resistance were evaluated at baseline and after treatment. After treatment, significant decreases of leucine levels were observed in both groups when compared with baseline levels (P < 0.005). With respect to patients with normal glucose tolerance (NGT), patients with impaired glucose tolerance (IGT) had higher baseline levels of isoleucine (78 ± 16 versus 70 ± 13 μmol L^-1 , P = 0.014) and valine (286 ± 36 versus 268 ± 41 μmol L^-1 , P = 0.049), respectively. Changes in levels of leucine and isoleucine after treatment were related negatively to changes in fasting plasma glucose and glycosylated haemoglobin values only in the conservative group (P < 0.05). In summary, we found that the treatment with CPAP for 12 weeks caused similar changes in circulating BCAAs concentrations to conservative treatment and a differential metabolic response of CPAP and conservative treatment was observed between the relationship of BCAAs and glucose homeostasis. Additional studies are needed to determine the interplay between branched-chain amino acids and glucose metabolism in patients with sleep apnea.

Quantifying endogenous androgens, estrogens, pregnenolone and progesterone metabolites in human urine by gas chromatography tandem mass spectrometry

A method for the quantitation of 22 urinary steroids (androgens, estrogens and the main pregnenolone and progesterone metabolites) by means of gas chromatography tandem mass spectrometry using a triple quadrupole analyzer has been developed. Two different enzymatic hydrolysis protocols were investigated; one capable of releasing steroids present as both sulfates and glucuronides (total fraction), and another with β-glucuronidase activity only. After selecting adequate internal standards and choosing the optimal instrumental parameters, i.e. chromatographic separation and ion transition conditions, the method was fully validated using both hydrolysis protocols. The method was shown to be linear (r >0.99) in the range of endogenous concentrations for all studied steroids with extraction recoveries higher than 80%. The use of labeled internal standards allowed for both a correct quantification and the evaluation of the rate of deconjugation for sulfates and glucuronides in every sample. In general, the sensitivity of the method was suitable for the detection of the endogenous levels, with limits of quantification ranging from 0.1 to 20ng/mL. Accuracies ranging from 80% to 120%, and relative standard deviations below 25% in intra- and inter- assay experiments were found for most of the analytes. The applicability of the validated method was tested by quantifying twenty-two metabolites in 24-h urine samples collected from healthy individuals. The ranges for the excretion of steroids in the total and glucuronide fractions obtained with the new method were compared with those available in the literature. By comparing the figures in both fractions, an estimation of the percentage that the sulfation represents for each steroid was also calculated. The presence of side enzymatic activities and the utility of the method for clinical studies as well as for doping control analysis is discussed.

Gut epithelial barrier markers in patients with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is now being recognized as an additional contributing factor to the pathogenesis of obesity-related comorbidities. At the same time, there is now increasing evidence to suggest that intestinal wall permeability plays a role in the development of metabolic syndrome. In the present study, circulating zonulin and fatty acid binding protein (I-FABP) were measured in association with metabolic, hepatic, and inflammatory parameters.

RESULTS

Compared with controls, plasma I-FABP levels were significantly higher in patients with OSA (571 pg/mL [IQR 290-950] vs 396 pg/mL [IQR 234-559], p = 0.04). Zonulin levels were similar between groups. Significant relationships were observed between zonulin levels and waist circumference (p < 0.05), glucose (p < 0.05), and insulin (p < 0.05). In addition, in the OSA group, zonulin levels correlated negatively with the mean nocturnal oxygenation saturation (p < 0.05) and positively with total cholesterol (p < 0.05), alanine aminotransferase (ALT) (p < 0.005), aminotransferase (AST) (p < 0.01), gamma glutamyltransferase (GGT) (p < 0.005), and high-sensitivity C-reactive protein (hs-CRP) (p < 0.05). Multivariate analysis showed that associations between zonulin and ALT, AST, and hs-CRP were attenuated, but not eliminated, after adjustment for other variables.

CONCLUSIONS

The results of this study suggest that OSA is a risk factor for intestinal damage, regardless of metabolic profile, and that intestinal permeability might be a possible contributor to nonalcoholic fatty liver disease in patients with OSA.

Evaluation of emerging contaminants in a drinking water treatment plant using electrodialysis reversal technology

Emerging contaminants (EC) have gained much attention with globally increasing consumption and detection in aquatic ecosystems during the last two decades from ng/L to lower ug/L. The aim of this study was to evaluate the occurrence and removal of pharmaceutically active compounds (PhACs), endocrine disrupting chemicals (EDCs) and related compounds in a Drinking Water Treatment Plant (DWTP) treating raw water from the Mediterranean Llobregat River. The DWTP combined conventional treatment steps with the world's largest electrodialysis reversal (EDR) facility. 49 different PhACs, EDCs and related compounds were found above their limit of quantification in the influent of the DWTP, summing up to a total concentration of ECs between 1600-4200 ng/L. As expected, oxidation using chlorine dioxide and granular activated carbon filters were the most efficient technologies for EC removal. However, despite the low concentration detected in the influent of the EDR process, it was also possible to demonstrate that this process partially removed ionized compounds, thereby constituting an additional barrier against EC pollution in the product. In the product of the EDR system, only 18 out of 49 compounds were quantifiable in at least one of the four experimental campaigns, showing in all cases removals higher than 65% and often beyond 90% for the overall DWTP process.

Nondestructive Detection of White Root Rot Disease in Avocado Rootstocks by Leaf Chlorophyll Fluorescence

White root rot (WRR) disease caused by Rosellinia necatrix is one of the most important threats affecting avocado orchards in temperate regions. In this study, we monitored the progression of WRR disease at the leaf and root levels by the combination of nondestructive chlorophyll fluorescence measurements and confocal laser-scanning microscopy on avocado genotypes susceptible to R. necatrix. Leaf photochemistry was affected at early stages of disease development prior to the appearance of aboveground symptoms, made evident as significant decreases in the trapping efficiency of photosystem-II (F_v'/F_m') and in the steady-state of chlorophyll fluorescence yield (F_s) normalized to the minimal fluorescence yield (F₀) (F_s/F₀). Decreases in F_v'/F_m' and F_s/F₀ were associated with different degrees of fungal penetration, primarily in the lateral roots but not in areas next to the main root collar. Aboveground symptoms were observed only when the fungus reached the root collar. Leaf physiology was also tracked in a tolerant genotype where no changes were observed during disease progression despite the presence of the fungus in the root system. These results highlight the usefulness of this technique for the early detection of fungal infection and the rapid removal of highly susceptible genotypes in rootstock avocado-breeding programs.

Total adult cardiovascular risk in Central America

OBJECTIVE

To evaluate prevalence of cardiovascular risk among adults 40 years and older using population-based samples from six Central American countries.

METHODS

Risk factors were derived from a multi-national cross-sectional survey implemented in 2003-2006, which included a sample of 4 202 participants aged 40 years and older. Charts produced by the World Health Organization and the International Society of Hypertension for the Region of the Americas sub-region B were used to predict risk on the basis of factors including age, sex, blood pressure, total serum cholesterol, smoking status, and diabetes status.

RESULTS

Overall, 85.9% of the population was classified as having < 10% risk for cardiovascular events during the following ten years. The likelihood of being in this risk group decreased with age in both males and females. Four percent of respondents were identified as having > 20% risk. More than 75% of those with a 30-40% risk had previously been identified by health services, and an additional 23% were identified during the study, suggesting they could be diagnosed by opportunistic screening for diabetes, hypertension and hypercholesterolemia. Results of bivariate analysis showed that respondents who were male, older, obese and/or less educated had higher risk for cardiovascular events, but a multivariate analysis including education indicated highest risks for older, obese, and less educated females.

CONCLUSIONS

Measuring cardiovascular disease risk identifies most cases of (or at risk for) diabetes, hypertension and hypercholesterolemia among adults 40 years and older. This strategy can facilitate implementation of control programs and decrease disabilities and premature mortality.

Precision Medicine in Patients With Resistant Hypertension and Obstructive Sleep Apnea: Blood Pressure Response to Continuous Positive Airway Pressure Treatment

BACKGROUND

In patients with resistant hypertension (RH) and obstructive sleep apnea (OSA), the blood pressure response to continuous positive airway pressure (CPAP) treatment is highly variable and could be associated with differential micro-ribonucleic acid (miRNA) profiles. Currently, no available methods exist to identify patients who will respond favorably to CPAP treatment.

OBJECTIVES

The aim of this study was to identify plasma miRNA profiles that predict blood pressure responses to CPAP treatment.

METHODS

Cardiovascular system-focused circulating miRNA expression was evaluated in plasma samples using an 84-miRNA array among patients with RH and OSA at baseline and after 3 months of adherent CPAP use. Pathway analysis and miRNA target gene enrichment were performed in silico. Plasma levels of peptides and hormones related to cardiovascular function were also measured.

RESULTS

The OSA responder group exhibited blood pressure decreases exceeding the observed median (>4.5 mm Hg) after CPAP, which were not present in the nonresponder group (≤4.5 mm Hg) (p < 0.01). Three miRNAs provided a discriminatory predictive model for such a favorable blood pressure response to CPAP (area under the curve: 0.92; p = 0.01). Additionally, CPAP treatment significantly altered a total of 47 plasma miRNAs and decreased aldosterone-to-renin ratios in the responder group (p = 0.016) but not in the nonresponder group.

CONCLUSIONS

A singular pre-CPAP treatment cluster of 3 plasma miRNAs predicts blood pressure responses to CPAP treatment in patients with RH and OSA. CPAP treatment is accompanied by changes in cardiovascular system-related miRNAs that may potentially influence the risk for cardiovascular disease among patients with OSA and RH. (Effect of Continuous Positive Airway Pressure [CPAP] Treatment in the Control of Refractory Hypertension; NCT00616265).

Urinary cysteinyl progestogens: Occurrence and origin

The presence of two cysteinyl progestogens, 16-cysteinyl-progesterone (16-Cys-Prog) and 16-cysteinyl-pregnenolone (16-Cys-Preg), in human urine is described for the first time. Their occurrence was unequivocally confirmed by comparison with synthesized material by using mass spectrometric detectors. Several experiments were performed in order to clarify their origin. The adrenal origin of both 16-Cys-Prog and 16-Cys-Preg can be inferred from the increase in their concentrations after ACTH stimulatory test, together with their circadian variation similar to the one observed for cortisol. Moreover, the notable increase in excretions of 16-Cys-Prog during the luteal phase of the menstrual cycle points towards an ovarian production for this progestogen. However, the analysis of samples during the course of two pregnancies revealed that, in spite of the large amounts of progesterone produced during gestation, the human placenta lacks the capacity to make 16-Cys-Prog. The adrenal and ovarian origin has been further indicated by the absence of both metabolites in samples collected from a subject with bilateral adrenalectomy and hypogonadotrophyic hypogonadism. Regarding liver action, in vitro studies with hepatocytes and progesterone indicate that, although the liver is able to metabolize progesterone to 6-dehydroprogesterone, it has not the enzymatic machinery for the generation of 16-dehydroprogesterone. Taken together, these results open the possibility for a noninvasive test for the simultaneous evaluation of progesterone biosynthesis in different organs.

High D-dimer levels after stopping anticoagulants in pulmonary embolism with sleep apnoea

Obstructive sleep apnoea is a risk factor for pulmonary embolism. Elevated D-dimer levels and other biomarkers are associated with recurrent pulmonary embolism. The objectives were to compare the frequency of elevated D-dimer levels (>500 ng·mL−1) and further coagulation biomarkers after oral anticoagulation withdrawal in pulmonary embolism patients, with and without obstructive sleep apnoea, including two control groups without pulmonary embolism.

We performed home respiratory polygraphy. We also measured basic biochemical profile and haemogram, and coagulation biomarkers (D-dimer, prothrombin fragment 1+2, thrombin-antithrombin complex, plasminogen activator inhibitor 1, and soluble P-selectin).

64 (74.4%) of the pulmonary embolism cases and 41 (46.11%) of the controls without pulmonary embolism had obstructive sleep apnoea. Plasmatic D-dimer was higher in PE patients with OSA than in those without obstructive sleep apnoea. D-dimer levels were significantly correlated with apnoea–hypopnoea index, and nocturnal hypoxia. There were more patients with high D-dimer after stopping anticoagulants in those with pulmonary embolism and obstructive sleep apnoea compared with PE without obstructive sleep apnoea (35.4% versus 19.0%, p=0.003). Apnoea–hypopnoea index was independently associated with high D-dimer.

Pulmonary embolism patients with obstructive sleep apnoea had higher rates of elevated D-dimer levels after anticoagulation discontinuation for pulmonary embolism than in patients without obstructive sleep apnoea and, therefore, higher procoagulant state that might increase the risk of pulmonary embolism recurrence.

Effect of obstructive sleep apnoea on severity and short-term prognosis of acute coronary syndrome

The goal of this study was to evaluate the influence of obstructive sleep apnoea on the severity and short-term prognosis of patients admitted for acute coronary syndrome. Obstructive sleep apnoea was defined as an apnoea-hypopnoea index (AHI) >15 h(-1). We evaluated the acute coronary syndrome severity (ejection fraction, Killip class, number of diseased vessels, and plasma peak troponin) and short-term prognosis (length of hospitalisation, complications and mortality). We included 213 patients with obstructive sleep apnoea (mean±sd AHI 30±14 h(-1), 61±10 years, 80% males) and 218 controls (AHI 6±4 h(-1), 57±12 years, 82% males). Patients with obstructive sleep apnoea exhibited a higher prevalence of systemic hypertension (55% versus 37%, p<0.001), higher body mass index (29±4 kg·m(-2) versus 26±4 kg·m(-2), p<0.001), and lower percentage of smokers (61% versus 71%, p=0.04). After adjusting for smoking, age, body mass index and hypertension, the plasma peak troponin levels were significantly elevated in the obstructive sleep apnoea group (831±908 ng·L(-1) versus 987±884 ng·L(-1), p=0.03) and higher AHI severity was associated with an increased number of diseased vessels (p=0.04). The mean length of stay in the coronary care unit was higher in the obstructive sleep apnoea group (p=0.03). This study indicates that obstructive sleep apnoea is related to an increase in the peak plasma troponin levels, number of diseased vessels, and length of stay in the coronary care unit.

Effect of CPAP treatment on plasma high sensitivity troponin levels in patients with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is associated with an increased prevalence of cardiovascular diseases. New generations of highly sensitive assays for cardiac troponin (hs-cTnT) have been introduced recently, and a number of clinical observations have challenged the notion that troponins are only increased in blood following irreversible necrosis.

OBJECTIVE

The aims of this study were to compare the levels of hs-cTnT between a group of healthy controls and a group of patients with OSA without co-existent coronary artery disease, and to assess the possible influence of the treatment with Continuous positive airway pressure (CPAP) on these levels.

METHODS

The study population included 200 male participants. The case (n = 133) or control (n = 67) status was defined by an apnea-hypopnea index of 10 or greater. The hs-cTnT assay was validated as reported previously, with a limit of detection of 3 ng/L and an upper reference limit (99th percentile) of 14 ng/L.

RESULTS

The proportion of subjects with detectable plasma hs-cTnT was higher in patients with OSA than in controls (61 vs 75%, p = 0.04). In patients, a significant increase in hs-cTnT levels was observed after an effective treatment with CPAP (7.3 ± 3.4 vs 10.1 ± 4.9 ng/L; p < 0.01).

CONCLUSION

This study shows that the percentage of subjects with detectable hs-cTnT is associated with the presence of OSA. It also evidences that treatment with CPAP is followed by a rise in hs-cTnT concentrations. It is reasonable to suggest that CPAP therapy might induce a potential degree of cardiac stress, resulting in deleterious consequences for the heart.

Impact of OSA on biological markers in morbid obesity and metabolic syndrome

BACKGROUND AND OBJECTIVE

There is compelling evidence that obstructive sleep apnoea (OSA) can affect metabolic syndrome (MetS) and cardiovascular risk, but the intermediate mechanisms through which it occurs have not been well defined. We explored the impact of OSA in morbidly obese patients with MetS on adipokines, pro-inflammatory markers, endothelial dysfunction, and atherosclerosis markers.

METHODS

We included 52 morbidly obese patients in an observational study matched for age, gender and central obesity in 3 groups (OSA-MetS, Non-OSA-MetS, and Non OSA-non-MetS). Anthropometrical, blood pressure, and fasting blood measurements were obtained the morning after an overnight polysomnography. VEGF, soluble CD40 ligand (sCD40L), TNF-α, IL-6, leptin, adiponectin, and chemerin were determined in serum by ELISA. OSA was defined as apnea/ hypopnea index ≥ 15 and MetS by NCEP-ATP III.

RESULTS

Cases and control subjects did not differ in age, BMI, waist circumference, and gender (43 ± 10 years, 46 ± 5 kg/m(2), 128 ± 10 cm, 71% females). The cases had severe OSA with 47 (32-66) events/h, time spent < 90% SpO2 7% (5%-31%). All groups presented similar serum cytokines, adipokines, VEGF, and sCD40L levels.

CONCLUSIONS

In a morbidly obese population with established MetS, the presence of OSA did not determine any differences in the studied mediators when matched by central obesity. Morbidly obese NonOSA-NonMetS had a similar inflammatory, adipokine VEGF, and sCD40L profile as those with established MetS, with or without OSA. Obesity itself could overwhelm the effect of sleep apnea and MetS in the studied biomarkers.

CITATION

Salord N; Gasa M; Mayos M; Fortuna-Gutierrez AM; Montserrat JM; Sánchez-de-la-Torre M; Barceló A; Barbé F; Vilarrasa N; Monasterio C. Impact of OSA on biological markers in morbid obesity and metabolic syndrome.

Usefulness of Benedict's test for the screening of galactosemia

BACKGROUND

Benedict's test for the screening of galactosemia presents a high false-positive rate, which puts into question its usefulness.

METHODS

We evaluated the results of Benedict's test as screening strategy for galactosemia, and the patients' definite diagnosis in our hospital in the last 25 years. We also assessed the most prevalent clinical conditions among the false-positive cases.

RESULTS

Apart from glycosuria, many non-galactosemic newborns with heart alterations, prematurity, icterus and sepsis usually lead to false-positive results using Benedict's. No false-negative case for Benedict's test was reported in our hospital.

CONCLUSIONS

A better approach in terms of cost-effectiveness, sensitivity and specificity is needed for an effective screening of galactosemia.

Relationship between aldosterone and the metabolic syndrome in patients with obstructive sleep apnea hypopnea syndrome: effect of continuous positive airway pressure treatment

Background

Metabolic syndrome (MS) occurs frequently in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). We hypothesized that aldosterone levels are elevated in OSAHS and associated with the presence of MS.

Methods

We studied 66 patients with OSAHS (33 with MS and 33 without MS) and 35 controls. The occurrence of the MS was analyzed according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) clinical criteria. Measurements of plasma renin activity (PRA), aldosterone, aldosterone:PRA ratio, creatinine, glucose, triglycerides, cholesterol and HDL cholesterol were obtained at baseline and after CPAP treatment.

Results

Aldosterone levels were associated with the severity of OSAHS and higher than controls (p = 0.046). Significant differences in aldosterone levels were detected between OSAHS patients with and without MS (p = 0.041). A significant reduction was observed in the aldosterone levels in patients under CPAP treatment (p = 0.012).

Conclusion

This study shows that aldosterone levels are elevated in OSAHS in comparison to controls, and that CPAP therapy reduces aldosterone levels. It also shows that aldosterone levels are associated with the presence of metabolic syndrome, suggesting that aldosterone excess might predispose or aggravate the metabolic and cardiovascular complications of OSAHS.

Trial registration

The study is not a randomized controlled trial and was not registered.

Rationale and methodology of the impact of continuous positive airway pressure on patients with ACS and nonsleepy OSA: the ISAACC Trial

BACKGROUND

Obstructive sleep apnea (OSA) is common in acute coronary syndrome (ACS) and a possible cause of increased morbidity and mortality.

OBJECTIVES

The main objective is to determine in patients with ACS and OSA if CPAP treatment reduces the incidence of cardiovascular events (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, and hospitalization for unstable angina or transient ischemic attack). The secondary objectives are to determine the prevalence of nonsleepy OSA in patients with ACS; assess the effect of CPAP on the incidence of newly diagnosed diabetes mellitus, symptoms, and quality of life; identify biomarkers of risk involved in cardiovascular complications in these patients; and conduct a cost-effectiveness analysis of diagnosis and treatment.

POPULATION AND METHODOLOGY

Multicenter, prospective, randomized and controlled study. Patients are admitted to the coronary care unit with diagnosis of ACS and without daytime sleepiness (Epworth Sleepiness Scale ≤10) at 15 teaching hospitals in Spain. All patients undergo a sleep study by cardiorespiratory polygraphy. Patients with an apnea-hypopnea index ≥15/hour will be randomized to treatment with CPAP (group 1, 632 patients) or conservative treatment (group 2, 632 patients). Patients with an apnea-hypopnea index <15/hour (group 3, 600 patients) will be followed as a reference group. Patients will be monitored at baseline (T0), 1 month (T1), 3 months (T2), 6 months (T3), 12 months (T4), and every 6 months thereafter (where applicable) during the follow-up period.

CONCLUSIONS

The ISAACC trial will contribute to evaluating the effect of CPAP treatment on cardiovascular events in patients with ACS and OSA.

Association between obstructive sleep apnea and pulmonary embolism

OBJECTIVES

To compare the prevalence of obstructive sleep apnea (OSA) in patients with pulmonary embolism (PE) with a sex-, age-, and body mass index (BMI)-matched, population-based control group and to assess the association between OSA and PE.

METHODS

We performed a case-control study from October 1, 2006, through November 30, 2009. We included 107 patients with PE and a control group (n=102) without PE in University Hospitals Son Espases and La Paz in Spain. Variables included in the analysis were medical history, anthropometric variables (weight, height, BMI, and neck circumference), Epworth Sleepiness Scale score, home respiratory polygraphy, basic biochemical profile and hemogram, spirometry, and physical activity.

RESULTS

The mean ± SD apnea-hypopnea index (AHI) was significantly higher in patients with PE than population controls (21.2±20.6 vs 11.5±15.9 h(-1); P<.001). The presence of an AHI greater than 5 h(-1) and hypersomnolence (Epworth Sleepiness Scale score ≥11) was more frequent in PE patients than in controls (14.0% vs 4.9%; P=.0002). A crude model analysis by several cutoffs revealed that the AHI was significantly associated with PE. After adjustment for age, sex, smoking, BMI, lung function, and all known PE risk factors, the odds ratio for PE was 3.7 (95% CI, 1.3-10.5; P=.01).

CONCLUSION

A higher prevalence of OSA was detected in patients diagnosed as having acute PE than controls. This study identified a significant and independent association between OSA and PE.

Stress hyperglycaemia in critically ill patients: potential role of incretin hormones; a preliminary study

BACKGROUND

Stress hyperglycaemia is common in the intensive care unit (ICU) setting and has been related to a worst outcome.

OBJECTIVE

The objective was to characterize the association of glucoregulatory hormones, mainly incretins, with the levels of glycaemia, and its relationship with outcome in ICU patients.

METHODS

We prospectively studied 60 patients. Stress hyperglycaemia was diagnosed when glycaemia was < 115 mg/dL. At ICU admission we determined glycaemia, insulin, glucagon, cortisol, glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) plasma levels. Groups were compared using Kruskal-Wallis test. The association between glycaemia levels and glucoregulatory hormones was evaluated using linear regression.

RESULTS

Forty-five patients (75%) had hyperglycaemia. We observed no differences in glucoregulatory hormones levels between normo- and hyper- glycaemia groups. Glycaemia levels were not significantly correlated with insulin, glucagon, cortisol or GIP levels, but were correlated with GLP-1 (p = 0.04). GLP-1 was also correlated with cortisol (p = 0.01), but failed to show a significant correlation with insulin, glucagon or GIP levels. Lower levels of plasma GLP-1 were found in patients with stress hyperglycaemia requiring vasoactive support (p = 0.02).

CONCLUSIONS

Glycaemia levels were correlated with GLP-1 levels in ICU patients. GLP-1 levels were also associated with cortisol. Patients with stress hyperglycaemia who required vasoactive support had lower incretin levels compared with those patients with stress hyperglycaemia who were hemodynamically stables. (ClinicalTrials.gov Identifier: NCT01087372).

Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial

CONTEXT

Continuous positive airway pressure (CPAP) is the first-line treatment for patients with symptomatic obstructive sleep apnea (OSA). However, its indication for all patients with sleep-disordered breathing, regardless of daytime symptoms, is unclear.

OBJECTIVE

To evaluate the effect of CPAP treatment on the incidence of hypertension or cardiovascular events in a cohort of nonsleepy patients with OSA.

DESIGN, SETTING, AND PATIENTS

Multicenter, parallel-group, randomized controlled trial in 14 teaching hospitals in Spain. Between May 2004 and May 2006, 725 consecutive patients were enrolled who had an apnea-hypopnea index of 20 h(-1) or greater and an Epworth Sleepiness Scale score of 10 or less (scores range from 0-24, with values <10 suggesting no daytime sleepiness). Exclusion criteria were previous cardiovascular event, physical or psychological incapacity, chronic disease, or drug or alcohol addiction. Follow-up ended in May 2009.

INTERVENTION

Patients were allocated to receive CPAP treatment or no active intervention. All participants received dietary counseling and sleep hygiene advice.

MAIN OUTCOME MEASURES

Incidence of either systemic hypertension (taking antihypertensive medication or blood pressure greater than 140/90 mm Hg) or cardiovascular event (nonfatal myocardial infarction, nonfatal stroke, transient ischemic attack, hospitalization for unstable angina or arrhythmia, heart failure, or cardiovascular death).

RESULTS

Seven hundred twenty-three patients underwent follow-up for a median of 4 (interquartile range, 2.7-4.4) years (1 patient from each group did not receive allocated treatment); 357 in the CPAP group and 366 in the control group were included in the analysis. In the CPAP group there were 68 patients with new hypertension and 28 cardiovascular events (17 unstable angina or arrhythmia, 3 nonfatal stroke, 3 heart failure, 2 nonfatal myocardial infarction, 2 transient ischemic attack, 1 cardiovascular death). In the control group there were 79 patients with new hypertension and 31 cardiovascular events (11 unstable angina or arrhythmia, 8 nonfatal myocardial infarction, 5 transient ischemic attack, 5 heart failure, 2 nonfatal stroke). The hypertension or cardiovascular event incidence density rate was 9.20 per 100 person-years (95% CI, 7.36-11.04) in the CPAP group and 11.02 per 100 person-years (95% CI, 8.96-13.08) in the control group. The incidence density ratio was 0.83 (95% CI, 0.63-1.1; P = .20).

CONCLUSIONS

In patients with OSA without daytime sleepiness, the prescription of CPAP compared with usual care did not result in a statistically significant reduction in the incidence of hypertension or cardiovascular events. However, the study may have had limited power to detect a significant difference.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00127348.

Development of robust discriminant equations for assessing subtypes of glioblastoma biopsies

Background:

In the preceding decade, various studies on glioblastoma (Gb) demonstrated that signatures obtained from gene expression microarrays correlate better with survival than with histopathological classification. However, there is not a universal consensus formula to predict patient survival.

Methods:

We developed a gene signature using the expression profile of 47 Gbs through an unsupervised procedure and two groups were obtained. Subsequent to a training procedure through leave-one-out cross-validation, we fitted a discriminant (linear discriminant analysis (LDA)) equation using the four most discriminant probesets. This was repeated for two other published signatures and the performance of LDA equations was evaluated on an independent test set, which contained status of IDH1 mutation, EGFR amplification, MGMT methylation and gene VEGF expression, among other clinical and molecular information.

Results:

The unsupervised local signature was composed of 69 probesets and clearly defined two Gb groups, which would agree with primary and secondary Gbs. This hypothesis was confirmed by predicting cases from the independent data set using the equations developed by us. The high survival group predicted by equations based on our local and one of the published signatures contained a significantly higher percentage of cases displaying IDH1 mutation and non-amplification of EGFR. In contrast, only the equation based on the published signature showed in the poor survival group a significant high percentage of cases displaying a hypothesised methylation of MGMT gene promoter and overexpression of gene VEGF.

Conclusion:

We have produced a robust equation to confidently discriminate Gb subtypes based in the normalised expression level of only four genes.

Metabolic syndrome, insulin resistance and sleepiness in real-life obstructive sleep apnoea

The metabolic syndrome shows a variable prevalence in obstructive sleep apnoea (OSA), and its association with insulin resistance or excessive daytime sleepiness in OSA is unclear. This study assessed the following in consecutive patients with newly diagnosed OSA: 1) the prevalence of metabolic syndrome; and 2) its association with insulin resistance and daytime sleepiness. Metabolic syndrome (National Cholesterol Education Program Adult Treatment Panel (NCEP-ATP) III criteria), insulin resistance (Homeostatic Model Assessment (HOMA) index, n = 288) and daytime sleepiness (Epworth Sleepiness Scale) were assessed in 529 OSA patients. The prevalence of metabolic syndrome was 51.2%, which increased with OSA severity. Each metabolic syndrome component correlated with apnoea/hypopnoea index, but only blood pressure retained significance after correction for confounders. Both obesity and OSA contributed to metabolic abnormalities, with different sex-related patterns, since diagnosis of metabolic syndrome was significantly associated with neck circumference, age, body mass index and lowest arterial oxygen saturation in males, and with age and arousal index in females. The number of metabolic syndrome components increased with HOMA index (p<0.001). Prevalence of sleepiness was the same in patients with and without metabolic syndrome. The metabolic syndrome occurs in about half of "real-life" OSA patients, irrespective of daytime sleepiness, and is a reliable marker of insulin resistance.

The influence of obesity and obstructive sleep apnea on metabolic hormones

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is a common disorder characterized by excessive daytime sleepiness and repetitive upper airway obstruction episodes during sleep. Clinically, obesity is a major risk factor for developing OSAS. However, OSAS has been associated with hormonal and metabolic alterations that could predispose patients to obesity. The aim of this study was to investigate the independent role of apneas and obesity on plasma levels of metabolic hormones (adiponectin, ghrelin, and leptin) in patients with OSAS.

METHODS

We have studied patients with OSAS and controls with and without obesity. All patients were male, had an apnea-hypopnea index of 20/h or greater, and were eligible for nasal continuous positive airway pressure (nCPAP) treatment. Patients were considered obese (n = 28) when their BMI was higher than 30 kg/m(2) and non-obese (n = 21) when it was lower than 27 kg/m(2). Non-obese control subjects (n = 20) were non-snorers with a normal cardiorespiratory sleep study, while obese control subjects (n = 10) were recruited from those obese subjects who were visited in our sleep unit and for whom OSAS was excluded by full polysomnography. A single blood sample was obtained from an antecubital vein in all participants after the completion of the nocturnal sleep laboratory recording. Plasma leptin, adiponectin, and ghrelin levels were determined by radioimmunoassay.

RESULTS

The adiponectin, ghrelin, and leptin plasma levels were similar in both patients and controls. There were differences in leptin and adiponectin plasma levels between the obese and non-obese in both patient and control groups. In the case of ghrelin, differences between obese and non-obese subjects were only seen in patients. There were no significant differences in hormone levels between the obese controls and obese patients or between non-obese controls and non-obese patients. After 3 months of nCPAP treatment, adiponectin levels decreased significantly both in obese and non-obese patients, and leptin levels decreased in obese patients. Finally, nCPAP did not reduce ghrelin in either obese or non-obese patients.

CONCLUSIONS

The basal levels of leptin, adiponectin, and ghrelin were mostly associated with obesity. We found that sleep apnea was not a determinant factor in leptin, adiponectin, and ghrelin hormonal levels. Interestingly, nCPAP treatment diminishes leptin in obese OSA patients and adiponectin levels in obese and non-obese patients with OSAS.

NADPH oxidase p22phox polymorphisms and oxidative stress in patients with obstructive sleep apnoea

BACKGROUND

Obstructive Sleep Apnoea (OSA) is associated with increased oxidative stress. NADPH oxidases are the main source of Reactive Oxygen Species (ROS) in the vasculature. Several polymorphisms related to NADPH oxidase expression or activity have been identified. We compared the distribution of the allelic frequencies of A-930G and C242T polymorphisms and their possible relationship with the levels of 8-isoprostanes as a marker of oxidative stress in patients with OSA and in a control group without OSA.

METHODS

This is a case-control study. We determined the A-930G and C242T p22phox genotypes in 427 patients with OSA and in 139 healthy subjects recruited from the Sleep Unit of Son Dureta University Hospital, (Palma de Mallorca, Spain). 8-Isoprostane was measured as an oxidative stress marker.

RESULTS

The distribution of the p22phox genotypes in OSA and in control subjects was different. The risk of OSA was associated with the presence of the G allele in the A-930G p22phox independently of age, gender, Body Mass Index (BMI), hypertension, dyslipemia and diabetes, but no association was found with the C242T polymorphism. The median level of 8-isoprostane was significantly higher in OSA patients. Synergic effect in 8-Isoprostane levels was observed when these two polymorphisms were analysed together.

CONCLUSION

the A-930G polymorphism of the p22phox gene may play an important role in genetic susceptibility to OSA. Furthermore, the C242T and A-930G polymorphisms of the p22phox gene have a synergic effect on the 8-isoprostane levels, suggesting that they may be involved in the development of oxidative stress in these patients.

Day-night variations in endothelial dysfunction markers and haemostatic factors in sleep apnoea

Patients with sleep apnoea have a significant alteration in the day-night pattern of myocardial infarction and sudden cardiac death observed in the general population. The aim of this study was to investigate the influence of sleep apnoea on the diurnal variations in various haemostatic parameters (factor VII, von Willebrand factor and plasminogen activator inhibitor (PAI)-1) and markers of endothelial dysfunction (asymmetric dimethylarginine (ADMA) and soluble CD40 ligand (sCD40L)). We studied 26 male patients with obstructive sleep apnoea syndrome (OSAS; 13 patients with severe OSAS (apnoea/hypopnoea index (AHI) >30 events · h(-1)) and 13 patients with mild-to-moderate OSAS (AHI <30 events · h(-1))) and 12 controls of similar body mass index (BMI) and waist circumference. In each subject, six different samples were obtained over 24 h. Although all the markers values tended to be higher in patients with severe OSAS, differences did not reach statistical significance at any time. PAI-1 levels were significantly related to BMI (p<0.001), mean (p<0.001) and minimal (p = 0.047) nocturnal oxygenation saturation. ADMA levels were significantly related to arousal index (p = 0.046). The results of this study suggest that day-night variations in factor VII:antigen (Ag), von Willebrand factor:Ag, PAI-1, sCD40L and ADMA levels may be dependent on either the obesity index or metabolic dysfunction rather than on sleep apnoea alone.

Free fatty acids and the metabolic syndrome in patients with obstructive sleep apnoea

Obesity and metabolic syndrome (MS) occur frequently in patients with obstructive sleep apnoea syndrome (OSAS). We hypothesised that circulating free fatty acids (FFAs) are elevated in OSAS patients independently of obesity. This elevation may contribute to the development of MS in these patients. We studied 119 OSAS patients and 119 controls. Participants were recruited and studied at sleep unit of our institution (Hospital Universitari Son Dureta, Palma de Mallorca, Spain) and were matched for sex, age and body mass index (BMI). The occurrence of MS was analysed by clinical criteria. Serum levels of FFAs, glucose, triglycerides, cholesterol, high-density lipoprotein-cholesterol, aspartate aminotransferase, alanine aminotransferase, γ-glutamyltransferase, C-reactive protein and 8-isoprostanes were determined. Prevalence of MS was higher in OSAS than in the control group (38 versus 21%; p=0.006). OSAS patients had higher FFAs levels than controls (mean±sd 12.2±4.9 versus 10.5±5.0 mg·dL(-1); p=0.015). Among subjects without MS, OSAS patients (OSAS+ MS-) showed higher levels of FFAs than controls (OSAS- MS-) (11.6±4.7 versus 10.0±4.4 mg·dL(-1); p=0.04). In a multiple regression model, after adjustment for age, sex, BMI and the presence of MS, FFAs were significantly associated with apnoea/hypopnoea index (p=0.04). This study shows that FFAs are elevated in OSAS and could be one of the mechanisms involved in the metabolic complications of OSAS.

Telomere shortening in sleep apnea syndrome

BACKGROUND

Telomere length (TL) in circulating leukocytes relates to the chronological age of the individual but it is believed to reflect also the cumulative burden of oxidative stress and inflammation over the life-time. Shortening of TL has been reported in several chronic conditions characterized by oxidative stress and inflammation, such as diabetes and atherosclerosis. Because these conditions also occur in patients with Obstructive Sleep Apnea Syndrome (OSAS), we hypothesized that TL would be reduced in patients with OSAS.

METHODS

We compared TL in 256 patients with OSAS and 148 controls without OSAS. We also investigated if TL was related to the severity of OSAS, the presence of metabolic disorders and/or cardiovascular risk factors in these patients.

RESULTS

TL was significantly shorter in patients with OSAS than in controls (p<0.001). This difference persisted after adjustment for age, body mass index, cholesterol, triglycerides, glucose, and uric acid levels, smoking status and the presence of arterial hypertension (p=0.018). TL was not related to the severity of OSAS as assessed by the apnea-hypopnea index, nocturnal oxygen saturation and daytime sleepiness.

CONCLUSIONS

TL in circulating leukocytes is shorter in patients with OSAS than subjects without OSAS. The mechanism of this observation is unresolved since it appears independent of chronological age, the severity of OSAS and/or the presence of cardiovascular or metabolic alterations but the potential utility of TL as a biomarker of increased cardiovascular risk in these patients justifies further studies.

Non-synonymous polymorphism in the neuropeptide S precursor gene and sleep apnea

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is a complex disease with a strong genetic basis. One of the primary molecular domains affected by OSAS is sympathetic activity. Neuropeptide S (NPS) plays an important role in the regulation of the sleep-wakefulness cycle, anxiety states, and daytime sleepiness. It is important to study neuropeptides related to sympathetic activity regulation and how their function could be modified by genetic variants affecting the expression of these molecules.

OBJECTIVES

We investigated the association of the non-synonymous polymorphism rs4751440 in the NPS precursor gene with OSAS and certain variables related to OSAS (daytime sleepiness, body mass index (BMI), insulin resistance, and blood pressure). This polymorphism causes an amino acid substitution in exon 3 of the human NPS precursor gene.

PATIENTS AND METHODS

We included 253 OSAS patients and 70 healthy subjects. Genotyping was done by polymerase chain reaction using specific flanking primers and agarose gel electrophoresis. Daytime sleepiness, BMI, plasma levels of high-density lipoprotein, glucose, total cholesterol, insulin, triglycerides, and the homeostasis model assessment index were also determined.

RESULTS

A similar genotypic and allelic distribution was found in OSAS patients and controls. The risk of OSAS was not associated with the rs4751440 polymorphism. There was no significant interaction between daytime sleepiness or metabolic variables and the rs4751440 polymorphism.

CONCLUSION

Genotypic and allelic frequency distribution of the rs4751440 polymorphism was similar in OSAS patients and controls. In this population-based study, we could not show a significant association between rs4751440 polymorphism and susceptibility to OSAS or certain phenotypes related to OSAS (daytime sleepiness, BMI, systolic blood pressure, and insulin resistance) with the exception of diastolic blood pressure.

Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon

BACKGROUND

Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health.

METHODS

Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought.

RESULTS

Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation.

CONCLUSION

Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

Insulin resistance and daytime sleepiness in patients with sleep apnoea

BACKGROUND

Excessive daytime sleepiness (EDS), obesity and insulin resistance (IR) occur frequently in patients with obstructive sleep apnoea syndrome (OSAS). We hypothesised that in these patients, EDS is a marker of IR, independent of obesity.

METHODS

We studied 44 patients with OSAS (22 with and 22 without EDS) matched for age (+/-5 years), body mass index (BMI +/-3 kg/m(2)) and severity of OSAS (as determined by the apnoea-hypopnoea index (AHI)), and 23 healthy controls. Patients (n = 35) were re-examined after 3 months of effective therapy with continuous positive airway pressure (CPAP). EDS was assessed by both subjective (Epworth Sleepiness Scale) and objective (Multiple Sleep Latency Test) methods. IR was determined by the HOMA index. Serum levels of glucose, triglycerides, cholesterol, cortisol, insulin, thyrotropin, growth hormone and insulin-like growth factor I (IGF-I) were also determined.

RESULTS

Despite the fact that age, BMI and AHI were similar, patients with EDS had higher plasma levels of glucose (p<0.05) and insulin (p<0.01), as well as evidence of IR (p<0.01) compared with patients without EDS or healthy controls. CPAP treatment reduced cholesterol, insulin and the HOMA index and increased IGF-1 levels in patients with EDS, but did not modify any of these variables in patients without EDS.

CONCLUSION

EDS in OSAS is associated with IR, independent of obesity. Hence EDS may be a useful clinical marker to identify patients with OSAS at risk of metabolic syndrome.