[Residual excessive daytime sleepiness in CPAP-treated obstructive sleep apnea]

Obstructive sleep apnea (OSA) is a common condition most often characterized by daytime sleepiness. cPAP therapy is very effective in reversing symptoms. However, some patients still complain of excessive daytime sleepiness despite treatment, It is essential to document sufficient use of CPAP and to rule out the presence of residual respiratory events. Search for other underlying causes of sleepiness are then to be investigated by a detailed history together with a sleep night recording. The purpose of this article is to guide the clinician in providing comprehensive medical care for those patients.

Gait abnormalities in obstructive sleep apnea and impact of continuous positive airway pressure

We aimed to determine the effect of continuous positive airway pressure (CPAP) on gait in obstructive sleep apnea (OSA) patients. Gait during single and dual tasks was recorded in 15 OSA patients at baseline and after 8 weeks of CPAP therapy. Step and stance time improved after CPAP. We showed a specific dual-task effect in the condition of verbal fluency. Eight weeks of CPAP seems to improve gait of OSA patients that are specifically disturbed by the dual task of verbal fluency.

[Pulmonary medicine 2012: news for the general practitioner]

This review reports on papers published in 2012 that will most likely impact on daily medical practice in four different areas of pulmonary medicine. How should treatment of asthma with inhaled corticosteroids be adjusted on the long run? Should idiopathic pulmonary fibrosis receive treatment with immunosuppressive drugs? Is a long-term treatment with azithromycine for bronchiectasis supported by evidence, apart from patients with cystic fibrosis? And finally, can treatment of obstructive sleep apnea with continuous positive pressure (CPAP) prevent the occurrence of new, systemic hypertension?

[Chronic obstructive pulmonary disease: risk and benefit of testosterone therapy]

Muscular wasting is frequently encountered in COPD patients and is related to a decrease in exercise tolerance, a higher morbidity and mortality. One of the potential causes isa low serum testosterone, which is frequent in COPD. Various studies have explored the effect of testosterone administration alone or as part of combined pulmonary rehabilitation and nutrition protocols. Testosterone had a positive impact on muscle mass and force, and to a lesser extent on physical endurance and respiratory parameters. Future studies should better define appropriate dosage and treatment duration. In the meantime, testosterone should be administered to COPD patients with overt hypogonadism, or in multidisciplinary specialized programmes.

Is atrial fibrillation associated with pulmonary embolism?

BACKGROUND

A pulmonary embolism (PE) is thought to be associated with atrial fibrillation (AF). Nevertheless, this association is based on weak data.

OBJECTIVES

To assess whether the presence of AF influences the clinical probability of PE in a cohort of patients with suspected PE and to confirm the association between PE and AF.

PATIENTS/METHODS

We retrospectively analyzed the data from two trials that included 2449 consecutive patients admitted for a clinically suspected PE. An electrocardiography (ECG) was systematically performed and a PE was diagnosed by computer tomography (CT). The prevalence of AF among patients with or without a PE was compared in a multivariate logistic regression model.

RESULTS

The prevalence of PE was 22.8% (519/2272) in patients without AF and 18.8% (25/133) in patients with AF (P = 0.28). After adjustment for confounding factors, AF did not significantly modify the probability of PE (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.42-1.11). However, when PE suspicion was based on new-onset dyspnea, AF significantly decreased the probability of PE (OR 0.47, 95% CI 0.26-0.84). If isolated chest pain without dyspnea was the presenting complaint, AF tended to increase the probability of PE (OR 2.42, 95% CI 0.97-6.07).

CONCLUSIONS

Overall, the presence of AF does not increase the probability of PE when this diagnosis is suspected. Nevertheless, when PE suspicion is based on new-onset dyspnea, AF significantly decreases the probability of PE, as AF may mimic its clinical presentation. However, in patients with chest pain alone, AF tends to increase PE probability.

[Leukotriene-modifiers in asthma treatment]

This review aims to evaluate the efficacy of the leukotriene modifiers in the different stages and subgroups of asthma. In mild asthma, they bring some improvement as monotherapy, but less than inhaled steroids. In moderate asthma, leukotriene modifiers associated with inhaled steroids seem to offer a slight advantage over placebo. No evidence of additional effect has been published in severe asthma. Exercice- and aspirin-induced asthma are particulary responsive to leukotriene modifiers. This treatment may also play a role in acute asthma. In practice, it is possible to select patients who benefit from those molecules. If only these "responders" are treated, leukotriene modifiers are an adequate treatment, easy to use and well tolerated.

New autosomal recessive mutation of the TSH-beta subunit gene causing central isolated hypothyroidism

We identified a new nonsense mutation of the TSH-beta subunit gene responsible for a severe isolated TSH deficiency in two children from the same consanguineous kindred. These affected children are homozygous for a C-to-T transition at nucleotide 654 of the TSH-beta subunit gene, leading to the conversion of a glutamine (CAG) to a premature stop codon (TAG) in the codon 49 (Q49X). The resulting nascent peptide does not contain the seat belt region (amino acid residues 88-105), a TSH-beta subunit region crucial for the dimerization with the alpha-subunit, and, hence, the correct secretion of the mature TSH heterodimer is hampered. Free T(3), free T(4) as well as basal TSH levels were extremely low in both affected individuals and, importantly, TRH stimulations failed to increase serum TSH, but not PRL, confirming isolated TSH deficiency. Using the new StyI endonuclease restriction site generated by the mutation, we confirmed that the affected children were homozygous for the Q49X TSH-beta mutation whereas their unaffected parents as well as their unaffected brother were heterozygous. Consequently, this isolated TSH deficiency follows an autosomal recessive mode of inheritance.