Background
Several studies have presented evidence that blocking peripheral nerves is effective for the treatment of some headaches and cranial neuralgias, resulting in reduction of the frequency, ...intensity, and duration of pain.
Objectives
In this article we describe the role of nerve block in the treatment of headaches and cranial neuralgias, and the experience of a tertiary headache center regarding this issue. We also report the anatomical landmarks, techniques, materials used, contraindications, and side effects of peripheral nerve block, as well as the mechanisms of action of lidocaine and dexamethasone.
Conclusions
The nerve block can be used in primary (migraine, cluster headache, and nummular headache) and secondary headaches (cervicogenic headache and headache attributed to craniotomy), as well in cranial neuralgias (trigeminal neuropathies, glossopharyngeal and occipital neuralgias). In some of them this procedure is necessary for both diagnosis and treatment, while in others it is an adjuvant treatment. The block of the greater occipital nerve with an anesthetic and corticosteroid compound has proved to be effective in the treatment of cluster headache. Regarding the treatment of other headaches and cranial neuralgias, controlled studies are still necessary to clarify the real role of peripheral nerve block.
Background
Exposure to light plays a crucial role in biological processes, influencing mood and alertness. Daytime workers may be exposed to insufficient or inappropriate light during daytime, ...leading to mood disturbances and decreases in levels of alertness.
Objectives
To assess the effectiveness and safety of lighting interventions to improve alertness and mood in daytime workers.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, seven other databases; ClinicalTrials.gov and the World Health Organization trials portal up to January 2018.
Selection criteria
We included randomised controlled trials (RCTs), and non‐randomised controlled before‐after trials (CBAs) that employed a cross‐over or parallel‐group design, focusing on any type of lighting interventions applied for daytime workers.
Data collection and analysis
Two review authors independently screened references in two stages, extracted outcome data and assessed risk of bias. We used standardised mean differences (SMDs) and 95% confidence intervals (CI) to pool data from different questionnaires and scales assessing the same outcome across different studies. We combined clinically homogeneous studies in a meta‐analysis. We used the GRADE system to rate quality of evidence.
Main results
The search yielded 2844 references. After screening titles and s, we considered 34 full text articles for inclusion. We scrutinised reports against the eligibility criteria, resulting in the inclusion of five studies (three RCTs and two CBAs) with 282 participants altogether. These studies evaluated four types of comparisons: cool‐white light, technically known as high correlated colour temperature (CCT) light versus standard illumination; different proportions of indirect and direct light; individually applied blue‐enriched light versus no treatment; and individually applied morning bright light versus afternoon bright light for subsyndromal seasonal affective disorder.
We found no studies comparing one level of illuminance versus another.
We found two CBA studies (163 participants) comparing high CCT light with standard illumination. By pooling their results via meta‐analysis we found that high CCT light may improve alertness (SMD −0.69, 95% CI −1.28 to −0.10; Columbia Jet Lag Scale and the Karolinska Sleepiness Scale) when compared to standard illumination. In one of the two CBA studies with 94 participants there was no difference in positive mood (mean difference (MD) 2.08, 95% CI −0.1 to 4.26) or negative mood (MD −0.45, 95% CI −1.84 to 0.94) assessed using the Positive and Negative Affect Schedule (PANAS) scale. High CCT light may have fewer adverse events than standard lighting (one CBA; 94 participants). Both studies were sponsored by the industry. We graded the quality of evidence as very low.
We found no studies comparing light of a particular illuminance and light spectrum or CCT versus another combination of illuminance and light spectrum or CCT.
We found no studies comparing daylight versus artificial light.
We found one RCT (64 participants) comparing the effects of different proportions of direct and indirect light: 100% direct lighting, 70% direct lighting plus 30% indirect lighting, 30% direct lighting plus 70% indirect lighting and 100% indirect lighting. There was no substantial difference in mood, as assessed by the Beck Depression Inventory, or in adverse events, such as ocular, reading or concentration problems, in the short or medium term. We graded the quality of evidence as low.
We found two RCTs comparing individually administered light versus no treatment. According to one RCT with 25 participants, blue‐enriched light individually applied for 30 minutes a day may enhance alertness (MD −3.30, 95% CI −6.28 to −0.32; Epworth Sleepiness Scale) and may improve mood (MD −4.8, 95% CI −9.46 to −0.14; Beck Depression Inventory). We graded the quality of evidence as very low. One RCT with 30 participants compared individually applied morning bright light versus afternoon bright light for subsyndromal seasonal affective disorder. There was no substantial difference in alertness levels (MD 7.00, 95% CI −10.18 to 24.18), seasonal affective disorder symptoms (RR 1.60, 95% CI 0.81, 3.20; number of participants presenting with a decrease of at least 50% in SIGH‐SAD scores) or frequency of adverse events (RR 0.53, 95% CI 0.26 to 1.07). Among all participants, 57% had a reduction of at least 50% in their SIGH‐SAD score. We graded the quality of evidence as low.
Publication bias could not be assessed for any of these comparisons.
Authors' conclusions
There is very low‐quality evidence based on two CBA studies that high CCT light may improve alertness, but not mood, in daytime workers. There is very low‐quality evidence based on one CBA study that high CCT light may also cause less irritability, eye discomfort and headache than standard illumination. There is low‐quality evidence based on one RCT that different proportions of direct and indirect light in the workplace do not affect alertness or mood. There is very low‐quality evidence based on one RCT that individually applied blue‐enriched light improves both alertness and mood. There is low‐quality evidence based on one RCT that individually administered bright light during the afternoon is as effective as morning exposure for improving alertness and mood in subsyndromal seasonal affective disorder.
Obstructive sleep apnea (OSA) is one of the most common sleep disorders and affects nearly a billion people worldwide. Furthermore, it is estimated that many patients with OSA are underdiagnosed, ...which contributes to the development of comorbidities, such as cardiac autonomic imbalance, leading to high cardiac risk. Heart rate variability (HRV) is a non‐invasive, widely used approach to evaluate neural control of the heart. This study aims to seek the relationship between HRV indices and the presence and severity of OSA. Polysomnography (PSG) exams of 157 patients were classified into four groups: OSA‐free (N=26), mild (N=39), moderate (N=37), and severe OSA (N=55). The electrocardiogram was extracted from the PSG, and a 15‐min beat‐by‐beat series of RR intervals was generated every hour during the first 6 h of sleep. Linear and nonlinear HRV approaches were employed to calculate a variety of indices of HRV. Specifically, time‐ and frequency‐domain, symbolic analysis, entropy measures, heart rate fragmentation, acceleration and deceleration capacities, asymmetry measures, and fractal analysis (detrended fluctuation analysis). Results with indices of sympathovagal balance reinforced previous findings that patients with OSA have sympathetic overactivity. Nonlinear indices showed that these patients suffer from a loss of physiologic complexity, contributing to their higher risk of development of cardiovascular disease. Moreover, as shown in the table below, many HRV indices presented statistically significant correlation with PSG's clinical scores: apnea/hypopnea index (AHI), microarousal index (MI), percentage of the total sleep time that the patient was with oxygen saturation below 90% (T90), and oxygen saturation nadir during sleep (SatMin). Therefore, a complete set of HRV indices, especially the nonlinear ones, can bring valuable information about the presence and severity of OSA, suggesting that HRV can be helpful in a quick diagnosis of OSA, potentially reducing the development of comorbidities.
Obstructive sleep apnea (OSA) is highly prevalent, and positive airway pressure (PAP) therapy is the primary treatment. This study aimed to assess the diagnostic and PAP treatment resources for OSA ...within Brazil's Unified Health System and to identify potential inequalities and gaps.
A structured survey was sent to members of the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine to identify sleep laboratories providing OSA diagnosis and/or treatment within Brazil's Unified Health System. The numbers of centers, care team structure, sleep studies availability, PAP accessibility, and follow-up services were characterized in all 5 Brazilian regions.
Forty-seven centers were identified: Midwest (n = 4), Northeast (n = 10), North (n = 3), Southeast (n = 22), and South (n = 8). Most centers (70%) provided both OSA diagnosis and treatment, mainly in capitals and/or metropolises (87%). Ten out of 27 Brazilian Federal Units lacked sleep services for OSA management, with the North having the highest proportion of states without a sleep service (71%). The annual number of diagnostic exams for OSA was 14,932, with significant heterogeneity across regions (Midwest: 240; North: 400; Northeast: 3,564; South: 4,380; Southeast: 6,348). Mean waiting times for diagnosis and treatment were 11 and 8 months, respectively. Only 46% of PAP treatments were publicly funded, making legal injunctions and out-of-pocket expenditure common practices.
This study revealed significant disparities in OSA diagnosis and treatment resources across Brazil, with the North region being particularly underserved. The findings underscore an urgent need for strategies to improve sleep care nationwide.
Drager LF, Santos RB, Pachito D, Albertini CS, Sert Kuniyoshi FH, Eckeli AL. Inequalities in the access to diagnosis and treatment of obstructive sleep apnea in Brazil: a cross-sectional study.
. 2024;20(5):735-742.
This study aimed to conduct a cost-utility analysis of continuous positive airway pressure (CPAP) therapy compared with usual care as treatment of moderate to severe cases of obstructive sleep apnea ...(OSA) in Brazil, where decentralized policies of CPAP provision are in place.
Markov cohort model comparing CPAP therapy with usual care, that is, no specific treatment for OSA, for moderate to severe cases was used. The payer perspective from the Unified Health System, Brazil, was adopted. Effectiveness parameters and costs related to health states were informed by literature review. Resource use related to CPAP therapy was defined by specialists and costs informed by recent purchase and leasing contracts. Incremental cost-effectiveness ratios were generated for purchase and leasing contracts to reflect current practices. A conservative willingness-to-pay threshold was set at 1 gross domestic product per capita per quality-adjusted life-year (QALY) (Brazilian reais BRL 40 712/QALY). Uncertainties were explored in deterministic and probabilistic sensitivity analyses.
Incremental cost-effectiveness ratio for the purchase modality was 8303 BRL/QALY and for leasing 45 192 BRL/QALY. Considering the adopted willingness-to-pay threshold, provision of CPAP by the purchase modality was considered cost-effective but not the leasing modality. The parameter related to the greatest uncertainty was the reduction in the risk of having a stroke attributable to CPAP. Probabilistic analysis confirmed the robustness of results.
CPAP therapy is a cost-effective alternative compared with usual care for moderate to severe OSA for the purchase modality. These results should help underpinning the decision making related to a uniform policy of CPAP provision across the country.
•In Brazil, the lack of a national guideline to orientate the lines of care of obstructive sleep apnea promotes inequity and inefficiency.•This present cost-utility analysis demonstrates that continuous positive airway pressure (CPAP) therapy for moderate to severe obstructive sleep apnea is cost-effective in the public health system, if the modality for CPAP obtention is purchase, but not for the leasing modality.•Our findings should underpin the decision making related to the design of programs for the provision of CPAP therapy in the public health system in Brazil, to expand access to treatment in a more efficient way.
Purpose
To synthesize findings of economic evaluations investigating cost-effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) and of strategies of ...organization of care related to CPAP therapy.
Methods
Scoping review with searches conducted in MEDLINE, CRD, LILACS, and Embase in August 2020. Eligible studies were economic evaluations comparing CPAP to other alternative or assessing strategies of care for CPAP therapy. Results were presented narratively, and incremental cost-effectiveness ratios (ICER) were presented in evidence maps.
Results
Of 34 studies, 3 concluded that CPAP is less costly and more effective when compared to usual care. Most studies indicated that CPAP is associated with better health outcomes, but at higher prices. ICER ranged from USD 316 to 98,793 per quality-adjusted life years (QALY) gained (median 16,499; IQR 8267 to 33,119). One study concluded that CPAP is more costly and less effective, when treatment is applied to all patients, regardless of disease severity. Variability of ICER was mainly due to definition of population and applied time horizons. When CPAP was compared to mandibular advancement device, ICER ranged from USD 21,153 to 361,028 (median 89,671; IQR 26,829 to 295,983), which represents the investment in CPAP therapy required to obtain one extra QALY. Three studies assessed the effects of organizing CPAP therapy in primary care, which was cost-effective or cost-saving.
Conclusions
Compared to usual care, CPAP is cost-effective after the second year of treatment, when indicated for moderate-to-severe OSA. CPAP therapy may be even more cost-effective by using different strategies of organization of care. These findings may inform decision making related to CPAP reimbursement in health systems.
Clinical Trial Registration number
Not applicable
Aim
Sleep disorders can be associated with an increased risk for cognitive decline in patients with Parkinson's disease (PD). The aim of this study was to examine the association between cognitive ...status and presence of sleep symptoms and sleep disorders in PD patients.
Methods
We evaluated excessive sleepiness, other sleep symptoms, and performed polysomnography and neuropsychological evaluation in 79 patients. They were classified as having normal cognition (PDNC), mild cognitive impairment (PDMCI), or dementia (PDD).
Results
There were 29 PDNC, 39 PDMCI, and 11 PDD patients. PDD patients were older, had higher scores on the Unified Parkinson's Disease Rating Scale, and lower Schwab and England Activities of Daily Living scores than PDNC patients. After analysis of the polysomnographic variables, it was also found that PDD patients had a lower sleep efficiency, lower total sleep time, and lower number of sleep state changes than PDNC patients. In a stepwise analysis, defining Mattis Dementia Rating Scale scores as the dependent variable, the results were a model that selected three variables that accounted for 59% of the variation in the Mattis Dementia Rating Scale score: wake time after sleep onset, number of state changes, and schooling.
Conclusion
We found a significant association between global cognitive performance and wake time after sleep onset and the number of state changes during sleep measured in the polysomnography of PD patients. However, we did not find any other association between sleep disorders or symptoms and cognitive status or cognitive performance of PD patients.
Purpose
Drug-induced sleep endoscopy (DISE) has been poorly explored as an examination to assess positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA). The present ...study aimed to identify by DISE possible characteristics related to low compliance with PAP therapy due to respiratory complaints.
Methods
Patients using PAP for OSA underwent DISE in two conditions: (1) baseline (without PAP) and (2) PAP (with the same mask and airway pressure used at home). We compared patients reporting low compliance to PAP due to respiratory complaints to those well-adapted to therapy. VOTE classification (assessment of velopharynx, oropharynx, tongue base, and epiglottis) and TOTAL VOTE score (the sum of VOTE scores at each anatomical site) were assessed. ROC curve analyzed the accuracy of TOTAL VOTE to predict low compliance due to persistent pharyngeal obstruction in both conditions.
Results
Of 19 patients enrolled, all presented multilevel pharyngeal obstruction at baseline condition, with no difference between groups at this study point. When PAP was added, the median VOTE value was higher in the epiglottis (
P
value=0.02) and tended to be higher at the velum and tongue base in the poorly adapted group; TOTAL VOTE score was also significantly increased in patients with low compliance (
P
value<0.001). ROC curve demonstrated that patients with TOTAL VOTE scored 2.5 or more during DISE with PAP presented a 4.6-fold higher risk for low compliance with PAP therapy due to pharyngeal obstruction (AUC: 0.88±0.07;
P
value<0.01; sensitivity: 77%; specificity: 83%).
Conclusions
Adding PAP during a DISE examination may help to predict persistent pharyngeal obstruction during PAP therapy.
Highlights • Obstructive sleep apnea (OSA) is very frequent in Brazilian patients with acute stroke. • Severe OSA was associated with a poor long-term functional outcome following stroke. • OSA is a ...treatable condition and therefore its treatment seems to be a potential target to improve outcome of acute stroke patients.
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