Autonomic nervous system (ANS) has been extensively explored in obstructive sleep apnea (OSA).
Autonomic alterations in these patients have been described by means of several methods, evaluating ANS ...function both directly with microneurography and indirectly through baroreflex sensitivity (BRS, by the sequence method or the cross-spectral approach), heart rate variability analysis (HRV, both in the time and frequency domain) during sleep and wake, or conventional laboratory tests, including cold pressor test, hand grip test or measurement of urinary cathecolamine excretion.
Several studies in OSA patients have shown ANS alterations, in particular sympathetic overactivity, both acutely during apnea events and chronically during the daytime, being both also involved in cardiovascular consequences of sleep disordered breathing.
The association between OSA and sympathetic dysregulation suggests a dose response relationship between OSA severity and the degree of sympathetic overactivity and this association seems to be reversible as the treatment of OSA is implemented.
Additionally ANS is involved in regulating visceral and humoral functions to maintain the body homeostasis and in reaction and adaptation to external and internal stressor stimuli.
However, the vast majority of studies have focussed on cardiovascular alterations, which are easier to measure, somewhat neglecting the other functions regulated by ANS.
More evidence is therefore needed to better characterize the impact that sleep disorder breathing may have on ANS both in the short and long term.
Background
Air pollution and obstructive sleep apnea (OSA) are both linked with cardiovascular co-morbidities and share similar pathophysiological mechanisms. A causal association between the two has ...been postulated. However, the results of the studies on this topic are conflicting mainly because of the lack of adjustment for important confounders such as seasonality and temperature. We aimed to evaluate if such an association exists in a highly polluted area like Lombardy region (Italy) when accounting for all confounders.
Methods
Data of adult patients seen at the Sleep Disorder Centre in Milan from 2010 to 2020 were analysed and the main polygraphic data were retrieved. Air pollutant concentrations of the following pollutants NO
2
, O
3
, PM
2.5
, and PM
10
were collected through monitoring stations.
Results
A total of 3493 patients were included: males (2358, 67.5%) mean age 60.1 (SD = 14.3) years, BMI 29.2 (6.2) kg/m
2
, mean AHI 16.5 (18.1) events/h. After adjusting for all confounders, in the multivariable analysis, the only associations that remained significant were long-term exposure to O
3
with indexes of OSA severity (AHI and ODI) but only in spring. Furthermore, a positive association was seen between long-term exposure to PM
10
and ODI but in springtime only.
Conclusion
The findings of the current study does not support an association between fine particulate matter and OSA severity.
Aims
To assess the prevalence of risk factors for obstructive sleep apnoea in people with diabetic foot ulcers and to determine whether this risk predicts diabetic foot ulcer healing.
Methods
We ...studied 94 consecutive people (69% men) with diabetic foot ulcers (Type 2 diabetes, n=66, Type 1 diabetes, n=28) attending a university hospital foot unit. All participants were screened for obstructive sleep apnoea using the STOP‐BANG questionnaire, with a score ≥4 identifying high risk of obstructive sleep apnoea. The primary outcome was poor diabetic foot ulcer healing, defined as diabetic foot ulcer recurrence (diabetic foot ulcers which healed and re‐ulcerated in same anatomical position) and/or diabetic foot ulcer persistence (no evidence of healing on clinical examination). All participants were evaluated at 12 months.
Results
Of the 94 participants, 60 (64%) had a STOP‐BANG score ≥4. Over 12 months, 27 participants with a score ≥4 had poor diabetic foot ulcer healing as compared to seven with a score <4 (45% vs 20.5%; P=0.025). A STOP‐BANG score ≥4 significantly increased the relative risk of poor healing more than twofold, independently of other risk factors in multivariable analyses.
Conclusions
There is a high prevalence of features and risk of obstructive sleep apnoea in people with diabetic foot ulcers. A STOP‐BANG score ≥4 predicts poor diabetic foot ulcer healing. Obstructive sleep apnoea may be a potential, modifiable risk factor/treatment target to improve diabetic foot ulcer outcomes.
What's new?
The impact of risk factors for obstructive sleep apnoea (OSA) on diabetic foot ulcer healing is unknown.
We describe for the first time a high prevalence (60%) of risk factors for OSA in patients with diabetic foot ulcers.
We also report in this prospective study the novel finding that a high risk of OSA predicts, independently of traditional risk factors, a more than twofold increased risk of poor diabetic foot ulcer healing.
Our results support the hypothesis that OSA is a potential, modifiable risk factor/treatment target to improve diabetic foot ulcer outcomes.
Highlights • Postural orthostatic tachycardia syndrome is associated with sleep disturbances. • As objective data are lacking, 37 patients were assessed by polysomnography. • Our data did not confirm ...relevant sleep pathologies. • Patients without daytime sleepiness had reduced parasympathetic activation at night.
•State of art of management and treatment of hypertension emergency/urgency in Italy.•Good knowledge of definition and treatment.•Fair quality of blood pressure measurement technique.•Lack of ...protocol or fast track for this problem.•Differences in terms of treatment and diagnosis across macro-areas.
Hypertensive emergencies (HE) and urgencies (HU) are frequent causes of patients referral to Emergency Department (ED) and the approach may be different according to local clinical practice. Our aim was to explore awareness, management, treatment and counselling after discharge of HE and HU in Italy, by mean of an on-line survey. The young investigator research group of the Italian Society of Hypertension developed a 23-item questionnaire spread by e-mail invitation to the members of Italian Scientific societies in the field of Hypertension. 665 questionnaires were collected from EDs, Emergency and Urgency Medicine, Cardiology or Coronary Units, Internal Medicines, Intensive care, Stroke units. Symptoms considered suspicious of acute organ damage were: chest pain (89.0%), visual disturbances (89.8%), dyspnoea (82.7%), headache (82.1%), dizziness (52.0%), conjunctival haemorrhages (41.5%), tinnitus (38.2%) and epistaxis (34.4%). Exams more frequent prescribed were: electrocardiogram (97.2%), serum creatinine (91.4%), markers of cardiomyocyte necrosis (66.2%), echocardiography (65.1%). The use of intravenous or oral medications to treat HEs was 94.7% and 3.5%, while for HUs 24.4% and 70.8% respectively. Of note, a surprisingly high percentage of physicians (22 % overall, 24.5% in North Italy) used to prescribe sublingual nifedipine. After discharge, home blood pressure monitoring and general practitioner re-evaluation were more frequently suggested, while ambulatory blood pressure monitoring and hypertension specialist examination were less prescribed. The differences observed across the different macro-areas, regarded prescription of diagnostic test and drug administration. This survey depicts a complex situation of shades and lights in the real-life management of HE and HU in Italy.
OBJECTIVE:Hypertensive emergencies (HE) and urgencies (HU) are frequent causes of patients referral to Italian Emergency Department (ED), however the diagnostic and therapeutic approach may differ ...across the Italian country. The aim of the study GEAR (Gestione delle Emergenze e urgenze in ARea critica) was to explore awareness, management, treatment and counselling after discharge of HE and HU in Italy, by mean of on-line survey.
DESIGN AND METHOD:The young investigator research group of the Italian Society of Hypertension developed a 23-items questionnaire spread by e-mail invitation to the members of Italian Scientific societies involved in the field of Emergency Medicine and Hypertension.
RESULTS:665 questionnaires were collected59.7% from EDs, 22% from Emergency and Urgency Medicine wards, 8.7% from Cardiology or Coronary Units, 5.7% from Internal Medicines and 3.9% from Intensive care or Stroke units. The definition of HE and HU was correctly identified by 81.2% and 89.3% of the responders respectively. The symptoms considered suspicious of acute organ damage werechest pain (89.0%), visual disturbances (89.8%), dyspnoea (82.7%), headache (82.1%), dizziness (52.0%), conjunctival haemorrhages (41.5%), tinnitus (38.2%), epistaxis (34.4%). Appropriate cuffs, for different arm sizes, were not widely available in all units94% had standard cuffs, 57% small and 75.6 % large cuffs, extra-large only 38.5%. The exams more frequent prescribed to evaluate target organ damage were electrocardiogram (97.2%), serum creatinine (91.4%), markers of cardiomyocyte necrosis (66.2%), echocardiography (65.1%). HEs were treated by 94.7% of the physicians by intravenous medications and by 3.5% by oral drugs, while HUs were treated by intravenous drugs in 24.4% of the cases and by oral drugs in 70.8%. When patients were discharged from ED, 87.5 % of the responders recommended home blood pressure monitoring, 87.5% general practitioner re-evaluation, while ambulatory blood pressure monitoring and hypertension specialist examination were less frequently recommended.
CONCLUSIONS:This survey depicts a complex situation of shades and lights in the real-life management of HE and HU in Italy. Strong unmet needs clearly emerged, especially for educational initiatives, standardized treatment protocols and interrelationship with the chronic care system.
Obstructive Sleep Apnoea (OSA) is a breathing disorder characterized by narrowing of the upper airway that impairs normal ventilation during sleep. OSA is a highly prevalent condition which is ...associated with several Cardiovascular (CV) risk factors and CV diseases. Despite this clear association, Randomized Controlled Trials (RCTs) have provided equivocal data that treatment of sleep apnoea can improve CV outcomes regardless of its ability to reduce blood pressure. Here, we critically review the evidence that supports role of OSA as a risk factor for increased arterial stiffness which represents an early manifestation of vascular damage often preceding major CV events. Additionally, we examined evidence from interventional RCTs to assess if treatment of OSA by continuous positive airway pressure can affect arterial stiffness measured as carotid-femoral pulse wave velocity. Overall, a large body of evidence supports the role of OSA as a risk factor for increased arterial stiffness and several pathophysiological mechanisms, including activation of the autonomic nervous system, may help to explain the link between breathing disorders and vascular alterations (here mainly examined as functional properties). Whether the causal relationship between OSA and vascular damage exists or is mostly explained by confounders and whether OSA treatment can improve vascular stiffening is still debated.
OBJECTIVE:Treatment of obstructive sleep apnoea (OSA) has been shown to reduce blood pressure (BP). However, the effect size is modest and treatment of OSA is not recommended as the only treatment ...target when treating hypertension. Despite the limited effect of continuous positive airway pressure (CPAP) therapy on BP, it is likely that certain phenotypes of OSA patients respond better to CPAP than others. The aim of the present systematic review and meta-analysis was to identify potential predictors for BP response in patients with OSA undergoing CPAP treatment.(Figure is included in full-text article.)
DESIGN AND METHOD:A systematic search was conducted in three databases (MEDLINE, Embase and Web of Science) using terms exploring three domains (obstructive sleep apnoea, CPAP, clinical trial) based on the following inclusion criteriai) randomised controlled clinical trials published between January 1st 1960 to December 31st 2017 including a reasonable control group; iii) OSA diagnosis using polysomnography; iv) age >18 years; v) OSA severity of at least 5 AHI/h. The random effect model was fitted to estimate the pooled BP reductions calculated as the difference between the BP change (end-treatment minus baseline) in the CPAP and control group. Moreover, the original estimates have been stratified according to selected patient characteristics.
RESULTS:Out of 2445 articles, 59 RCTs were included (n = 7,329 subjects) comparing CPAP with control groups. CPAP was associated with a net reduction in systolic BP of −2.12 (95% CI −2.82 to −1.42) mmHg and in diastolic BP of −1.97 (95% CI −2.46 to −1.48) mmHg, favouring treatment of OSA using CPAP (both p-values < 0.001). The subgroup analysis showed that systolic BP reduction was greater in subjects younger than 60 years (−2.88 fro age 40–50, −2.78 for age 50–60 and −0.61 for age more than 60 years, p = 0.007) and in patients with controlled BP at baseline versus uncontrolled BP (−1.45 vs −4.14, p = 0.002) (Figure 1).
CONCLUSIONS:Younger patients (< 60 years) with uncontrolled blood pressure at baseline are more likely to experience significant BP reductions with CPAP therapy. Phenotypisation of specific cohorts of patients can guide clinicians to target OSA treatment and help to optimise patients’ cardiovascular risk.
Summary
In the last years, follice‐stimulating hormone (FSH) receptor (FSHR) gene polymorphisms have been studied as potential risk factors for spermatogenetic failure. In this study, we have ...evaluated the response of FSH treatment in terms of sperm production on the basis of Ala307Thr‐Asn680Ser polymorphisms in the FSHR gene in a group of oligozoospermic subjects with hypospermatogenesis and normal FSH levels. Patients were randomized into two groups: 70 treated with recombinant FSH (150 IU thrice per week for 3 months) and 35 without treatment. After 3 months of treatment, we observed significant increase in total sperm count, sperm concentration, forward motility, percentage of normal morphology forms and total motile sperm. When 70 treated subjects were subdivided based on FSHR genotype, only subjects with at least one serine in position 680 showed a statistically significant increase in these sperm parameters, whereas subjects with homozygote Thr307‐Asn680 showed no difference in any seminal parameters evaluated. Non‐treated subjects showed no differences in any parameter evaluated. This study suggests that the analysis of this gene represents a valid pharmacogenetic approach to the treatment of male infertility, confirming also the importance of strict criteria for the selection of patients to be treated with FSH.
The ALPI linac at INFN-LNL was substantially refurbished in 2018, especially in view of its use as secondary accelerator for exotic species in the framework of the SPES project. In particular: 10 ...magnetic triplets were replaced with higher gradient ones; two cryomodules with quarter wave resonator were moved from the PIAVE injector to ALPI, so as to make them available both for exotic and stable beams; the cryogenic plant was renovated; the whole linac, its injector and its beam lines were eventually realigned via LASER tracking (LT). The expected outcome of the refurbishment project is a larger beam transmission (crucial for the efficient transport of the unavoidably low current exotic beams) and improved overall reliability so as to further extend the lifetime of an already 25 years old machine. The hardware commissioning of this new configuration will be reported.
PDF
