Post-stroke sleep-disordered breathing - pathophysiology and therapy options

Note: This article was submitted to Otorhinolaryngology - Head and Neck Surgery, a section of the journal Frontiers in Surgery. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.Sleep-disordered breathing (SDB), encompassing both obstructive and central sleep apnea, is prevalent in at least 50% of stroke patients. Small studies have shown vast improvements in post-stroke functional recovery outcomes after the treatment of SDB by continuous positive airway pressure. However, compliance to this therapy is very poor in this complex patient group. There are alternative therapy options for SDB that may be more amenable for use in at least some post-stroke patients, including mandibular advancement, supine avoidance, and oxygen therapy. There are few studies, however, that demonstrate efficacy and compliance with these alternative therapies currently. Furthermore, novel SDB-phenotyping approaches may help to provide important clinical information to direct therapy selection in individual patients. Prior to realizing individualized therapy, we need a better understanding of the pathophysiology of SDB in post-stroke patients, including the role of inherent phenotypic traits, as well as the contribution of stroke size and location. This review summarizes the available literature on SDB pathophysiology and treatment in post-stroke patients, identifies gaps in the literature, and sets out areas for further research

Stormwater detention reservoirs : an opportunity for monitoring and a potential site to prevent the spread of urban microplastics

Stormwater runoff carries pollutants from urban areas to rivers and has the potential to be a main contributing source of microplastics (MPs) to the ecosystem. Stormwater detention reservoirs (SDRs) differ from ponds and lakes in that SDRs retain most particulate matter and they are emptied after storm events. This paper investigates the occurrence of MPs in the SDR of the Alto-Tietê catchment area, Itaim stream in Poá city, São Paulo, Brazil. The MPs found were classified in different categories: shapes (fragment, line/fibre, film/sheet and pellet); size (0.5 mm, between 0.5 mm and 1 mm and >1 mm); and polymer composition. Results have shown that most of the MPs found in the samples are fragments (57%), followed by pellets (27%), fibres/lines (9%), and then films/sheets (6%). Small particles (0.5 mm) represented 89% of the total MPs, and this category mainly included fragments (62%) and pellets (30%). MPs were found in a vast variety of shapes and colours, which shows a likely variety of sources. Besides the occurrence of MPs in the stormwater samples, the potential of SDRs as a first sanitary barrier to retain MPs before they reach the ecosystem has been speculated

Limitations of Electromyography in the Assessment of Abdominal Wall Muscle Contractility Following Botulinum Toxin A Injection

Purpose: Pre-operative botulinum toxin A (BTA) injection of the lateral obliques aims to facilitate the closure of large ventral hernia defects and decrease the risk of repair breakdown during the critical healing phase. The exact duration of post-operative BTA effect and top-up timing in cases at high risk of recurrence remains uncertain. This study was designed to assess the value of electromyography (EMG) in determining the appropriate time for BTA top-up.Methods: 56 patients underwent ventral hernia repair with pre-operative BTA infiltration of the lateral obliques. Eleven patients at high risk of recurrence considered suitable for BTA top-up were assessed post-operatively with both functional computed tomography (CT) and EMG. CT assessed segmental contractility of each muscle layer. Single-point EMG assessed the activity of individual muscle layers bilaterally in the anterior axillary line.Results: CT showed (i) variable contractility of anterior and posterior muscle segments prior to BTA injection; (ii) absent or incomplete muscle paralysis in over half of all segments; (iii) increased BTA effect on progress scans; and (iv) non-uniform pattern of change in BTA effect between the anterior and posterior muscle. EMG demonstrated modest voluntary activity in most muscle layers. Compared to standard of reference (CT), EMG showed moderate sensitivity (0.62), poor specificity (0.48), poor accuracy (0.57), and incorrect grading in 71% of true positive results.Conclusions: As BTA effect wanes, single-point EMG cannot reliably determine functional muscle status. A novel finding is that BTA-induced paralysis of the abdominal muscles may be remarkably non-uniform in degree, distribution and duration

Abordagens terapêuticas inovadoras na gestão da dor crônica: uma síntese de evidências

Inovações terapêuticas, como o uso de células-tronco mesenquimais e plasma rico em plaquetas, oferecem avanços promissores na gestão da dor crônica, proporcionando não apenas alívio imediato, mas também abordando as causas subjacentes para melhorar a qualidade de vida dos pacientes. Este estudo teve como objetivo desenvolver uma síntese de evidências sobre abordagens terapêuticas inovadoras na gestão da dor crônica. Nesse sentido, foi desenvolvida uma revisão sistemática da literatura, utilizando Scielo, Lilacs e Medline como bases de dados. A partir da análise qualitativa dos resultados, concluiu-se que abordagens terapêuticas inovadoras, como fisioterapia, terapias cognitivo-comportamentais e intervenções farmacológicas específicas, são eficazes na gestão da dor crônica. A ênfase na personalização do tratamento, considerando a diversidade da condição, destaca-se como crucial para otimizar resultados

The effects of Morphine on upper airway and respiratory physiology: implications for sleep and respiratory disease

Opioids are used routinely for acute and chronic pain management, as an adjunct to anaesthesia and to manage opioid dependence. Low-dose morphine is the only evidence-based therapy (from randomised trials) that reduces breathlessness accompanying chronic cardiorespiratory disorders. However, the mechanisms by which low-dose morphine (<40mg extended release) reduces breathlessness remain unclear. Similar to the bidirectional relationship between sleep and pain, relief of nocturnal breathlessness may improve sleep quality and contribute to the therapeutic benefit of low-dose morphine on daytime breathlessness. Thus, in Study 1 Likert scale questionnaires were used to assess subjective sleep quality from a previously conducted double-blind, randomised, cross-over study in which 38 chronic refractory breathlessness patients received 20mg of Kapanol for 4 consecutive days followed by placebo or vice-versa. Low-dose oral morphine reduced perceived sleep disruption due to breathlessness in a time-dependent manner and improved perceived sleep quality. Patients who experienced the greatest improvement in breathlessness also had larger perceived improvements in sleep quality. While opioids clearly yield therapeutic benefit for many health conditions there is risk of harm. In recent years opioid prescription rates have increased markedly. This has been coupled with a substantial escalation in prescription opioid deaths. Deaths routinely occur due to respiratory arrest during sleep when wakefulness protective mechanisms are absent and respiratory chemoreceptor responses (PCO2 and PO2) are lowest. Given that obstructive sleep apnoea (OSA) is a common condition characterised by repetitive pharyngeal collapse during sleep and unstable respiratory control, there is concern that morphine may worsen OSA and that these patients may be particularly vulnerable to harm. OSA is also associated with reduced respiratory sensation awake and many OSA patients have co-morbid disease. The extent to which morphine alters wake respiratory sensation in people with OSA is unknown.Thus, to investigate how morphine affects respiratory and tactile sensation and key pathophysiological causes of OSA, 21 men with OSA were studied on 2 occasions after receiving 40mg of morphine (MS Contin) or placebo according to a double-blind, randomised, cross-over study design. For the wakefulness component (Study 2), Von Frey filaments were used to determine peripheral and upper airway tactile thresholds. Respiratory load detection and magnitude estimation tests were also performed. MS Contin did not alter tactile thresholds, respiratory load detection or magnitude estimation compared to placebo. For the sleep component (Study 3), the effects of 40mg of MS Contin on 4-key pathophysiological causes of OSA (pharyngeal critical closure pressure, genioglossus muscle responsiveness, respiratory arousal threshold and respiratory control response to CO2 and loop gain) were determined using detailed respiratory phenotyping methodology. Ventilatory responses to high CO2 and loop gain were reduced with morphine. However, the other phenotypic traits were not different compared to placebo. In summary, improved sleep quality may contribute to reductions in breathlessness with low-dose morphine in people with refractory dyspnoea. 40mg of MS Contin does not reduce tactile or respiratory sensation in men with untreated OSA nor does it systematically reduce pharyngeal muscle activity, increase airway collapsibility or alter the arousal threshold. However, respiratory control and ventilatory responses to elevated CO2 are impaired. These findings have important implications for acute morphine use in OSA

Post-Stroke Sleep-Disordered Breathing—Pathophysiology and Therapy Options

Sleep-disordered breathing (SDB), encompassing both obstructive and central sleep apnea, is prevalent in at least 50% of stroke patients. Small studies have shown vast improvements in post-stroke functional recovery outcomes after the treatment of SDB by continuous positive airway pressure. However, compliance to this therapy is very poor in this complex patient group. There are alternative therapy options for SDB that may be more amenable for use in at least some post-stroke patients, including mandibular advancement, supine avoidance, and oxygen therapy. There are few studies, however, that demonstrate efficacy and compliance with these alternative therapies currently. Furthermore, novel SDB-phenotyping approaches may help to provide important clinical information to direct therapy selection in individual patients. Prior to realizing individualized therapy, we need a better understanding of the pathophysiology of SDB in post-stroke patients, including the role of inherent phenotypic traits, as well as the contribution of stroke size and location. This review summarizes the available literature on SDB pathophysiology and treatment in post-stroke patients, identifies gaps in the literature, and sets out areas for further research

Chronic unremitting headache associated with Lyme disease-like illness

The Brazilian Lyme-disease-like illness (BLDLI) or Baggio-Yoshinari syndrome is a unique zoonosis found in Brazil. It reproduces all the clinical symptoms of Lyme disease except for the high frequencies of relapse and the presence of autoimmune manifestations. Two cases of borreliosis manifesting with unremitting headache, which is a symptom associated with late-stage BLDLI, were presented. Clinical, therapeutic, and prognostic aspects of the BLDLI and its associated headaches were showed and discussed in this article. BLDLI diagnosis requires additional attention by physicians, since the disease has a tendency to progress to the late, recurrent stage or the chronic form, and the associated headache can be confused with chronic primary headache or with analgesic-overuse one. Special attention should be paid to patients with headaches who have traveled to endemic areas

Gait in normal pressure hydrocephalus: characteristics and effects of the CSF tap test

ABSTRACT Normal pressure hydrocephalus (NPH), described by Hakim and Adams in 1965, is characterized by gait apraxia, urinary incontinence, and dementia. It is associated with normal cerebrospinal fluid (CSF) pressure and ventricular dilation that cannot be attributed to cerebral atrophy. Objectives: To evaluate gait characteristics in patients with idiopathic NPH and investigate the effect of the CSF tap test (CSF-TT) on gait. Methods: Twenty-five patients diagnosed with probable idiopathic NPH were submitted to the CSF-TT. The procedure aimed to achieve changes in gait parameters. Results: Fifteen gait parameters were assessed before and after the CSF-TT. Five showed a statistically significant improvement (p < 0.05): walking speed (p < 0.001), cadence (p < 0.001), step length (p < 0.001), en bloc turning (p = 0.001), and step height (p = 0.004). Conclusion: This study demonstrated that gait speed was the most responsive parameter to the CSF-TT, followed by cadence, step length, en bloc turning, and step height