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The case for improving the detection and treatment of obstructive sleep apnea following stroke

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KEY POINTS

  • Obstructive sleep apnea (OSA) is prevalent and harmful after stroke.

  • Investigation of sleep disorders, particularly OSA, should be strongly considered for patients who have had a stroke, with the goal of improving nonvascular outcomes.

  • Obstructive sleep apnea should be treated like a vascular risk factor.

  • Future trials will assess whether treatment for OSA initiated early after stroke reduces stroke recurrence.

Stroke is a leading cause of death and disability for people in Canada. Beyond the initial brain injury, the sequelae of stroke may also include several comorbidities, with sleep disorders being among the most important. Obstructive sleep apnea (OSA) and sleep–wake disturbances are highly prevalent among patients who have had a stroke; they may be both a risk factor for and a consequence of stroke, and can substantially affect stroke recovery and functional outcomes.1 Moreover, post-stroke fatigue is a top research priority for patients who have had a stroke.2

In related research, Jeffers and colleagues3 used cross-sectional data from the Canadian Community Health Survey to study relative rates of 4 self-reported sleep disturbances, namely having trouble staying awake, either short (< 5 h) or long (> 9 h) nightly sleep duration, having trouble going to or staying asleep, and having unrefreshing sleep. Almost two-thirds of respondents who reported a history of stroke also reported sleep difficulties; those with a history of stroke also reported each form of sleep disturbance significantly more frequently than those without a history a stroke.

Although the authors of the related research did not specifically examine OSA, many of the sleep concerns among those who reported a history of stroke were likely driven by OSA, the most common post-stroke sleep disorder, which has been reported to occur in as many as 72% of patients who have had a stroke or transient ischemic attack (TIA), depending on OSA severity.4 Patients with pre-existing OSA have poorer functional outcomes and spend more time in rehabilitation after a stroke.5 Randomized controlled trials have shown that treatment of post-stroke OSA using continuous positive airway pressure (CPAP) improves neurologic recovery and quality of life, and reduces daytime sleepiness and depressive symptoms.6,7

Given that OSA is a well-established risk factor for stroke, with a greater adjusted relative risk for stroke similar to or higher than traditional modifiable vascular risk factors that are commonly managed after stroke,8 it would make sense that OSA be routinely screened for and treated after stroke. However, a 2019 study suggested otherwise.9

Lack of screening for OSA after stroke may be explained by several barriers. Obstructive sleep apnea often presents atypically after stroke, and many patients with OSA who have had a stroke do not have the typical clinical features of OSA, such as obesity and daytime sleepiness.10 Many clinicians may be unaware of the importance of managing OSA and any associated symptoms after stroke. Moreover, testing for sleep disorders requires a multidisciplinary approach, and stroke rehabilitation centres may not have the necessary expertise to conduct sleep testing. Furthermore, the current gold standard for diagnosing OSA, in-laboratory sleep testing or polysomnography, is inconvenient for patients who are vulnerable and those with disabilities, and access to such testing in some Canadian centres may be limited. In a randomized controlled trial that assigned 250 consecutively recruited patients with a history of stroke or TIA to either ambulatory or in-laboratory sleep testing, rates of OSA diagnosis and treatment, as well as functional outcomes and daytime sleepiness, were significantly improved in the ambulatory testing arm.11 These results suggest that removing the barriers associated with in-laboratory sleep testing (through the use of ambulatory testing for OSA) may enhance outcomes among patients who have had a stroke or TIA.

Finally, screening for and management of OSA after stroke is underemphasized in stroke guidelines. For example, the 2014 and 2018 guidelines from the American Heart Association and the American Stroke Association for the secondary prevention of stroke stated that evaluation for OSA “may be considered” for patients with stroke or TIA.12 The most recent version of the Canadian Stroke Best Practice Recommendations removed recommendations on management of sleep apnea,13 although earlier versions did comment on OSA.

Fundamental to the question of whether clinicians should screen for and manage OSA after TIA or stroke is whether treatment of OSA after stroke or TIA reduces incident vascular events or mortality. Although studies assessing the impact of CPAP on nonvascular outcomes among patients with post-stroke OSA have shown positive outcomes, trials evaluating whether CPAP can reduce the risk of incident stroke or death have been largely negative.6 The largest of these trials, the Sleep Apnea Cardiovascular Endpoints (SAVE) trial,7 randomized 2717 patients with coronary or cerebrovascular disease (including 1432 with ischemic stroke or intracerebral hemorrhage) to receive CPAP or usual care. Although the overall findings showed no significant reduction in risk of vascular events or death, a preplanned post hoc subgroup analysis showed that patients who had good adherence to CPAP had a significantly lower risk of cerebrovascular events than those in the usual care group. This was consistent with the findings of earlier, smaller trials that also showed that significant reductions in incident vascular events occurred in subgroups with good CPAP adherence. 14,15 Since randomization was not respected in these subgroup analyses, the findings should be interpreted with caution.

It is important to note that the evidence for various interventions in stroke care has varied over time. Evidence related to OSA is rapidly evolving, and future trials that look at outcomes related to OSA after stroke will need to reconsider how OSA is defined and consider selecting patients on the basis of distinct clinical phenotypes. 16,17 For patients who cannot tolerate CPAP, many new treatment alternatives — including use of pharmacological agents, hypoglossal nerve stimulation, oropharyngeal exercises and dental appliances — have been shown to be effective outside of the stroke population; these need to be evaluated for patients who have had a stroke or TIA.18 Reflecting what has been seen in other studies evaluating secondary stroke prevention strategies (e.g., antiplatelet trials), interventions for OSA will need to be administered in the hours and days after stroke and not in a delayed fashion, as was done in the SAVE trial. Furthermore, in future trials, sample sizes and follow-up periods need to be carefully calculated to assure adequate power and outcome assessment.6

Investigation of sleep disorders, particularly OSA, should be strongly considered for patients who have had a stroke, with the goal of improving nonvascular outcomes, such as daytime sleepiness, mood and functional outcomes. A good argument can be made for treating OSA like any other vascular risk factor.8 Future trials, such as the ongoing Sleep for Stroke Management and Recovery Trial (Sleep SMART Trial; NCT03812653), will assess whether CPAP treatment for OSA that is started early after stroke reduces stroke recurrence.

Footnotes

  • Competing interests: Mark Boulos reports funding from the Canadian Institutes of Health Research, Canadian Partnership for Stroke Recovery, Alternative Funding Plan from the Academic Health Sciences Centres of Ontario, Ontario Genomics and McLaughlin Centre for Molecular Medicine. He also reports consulting fees and honoraria from Jazz Pharmaceuticals, Paladin Labs, Eisai and the OntarioMD Peer Leader Program; travel support from McGill University; and receipt of sleep equipment or research support from Braebon Medical Corporation, The Mahaffy Family Research Fund and Green Mountain.

  • This article was solicited and has not been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

 

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What’s the greatest holiday gift: lips, hair, skin? Give the gift of great skin this holiday season

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Give the gift of great skin this holiday season

Skinstitut Holiday Gift Kits take the stress out of gifting

Toronto, October 31, 2024 – Beauty gifts are at the top of holiday wish lists this year, and Laser Clinics Canada, a leader in advanced beauty treatments and skincare, is taking the pressure out of seasonal shopping. Today, Laser Clincs Canada announces the arrival of its 2024 Holiday Gift Kits, courtesy of Skinstitut, the exclusive skincare line of Laser Clinics Group.

In time for the busy shopping season, the limited-edition Holiday Gifts Kits are available in Laser Clinics locations in the GTA and Ottawa. Clinics are conveniently located in popular shopping centers, including Hillcrest Mall, Square One, CF Sherway Gardens, Scarborough Town Centre, Rideau Centre, Union Station and CF Markville. These limited-edition Kits are available on a first come, first served basis.

“These kits combine our best-selling products, bundled to address the most relevant skin concerns we’re seeing among our clients,” says Christina Ho, Senior Brand & LAM Manager at Laser Clinics Canada. “With several price points available, the kits offer excellent value and suit a variety of gift-giving needs, from those new to cosmeceuticals to those looking to level up their skincare routine. What’s more, these kits are priced with a savings of up to 33 per cent so gift givers can save during the holiday season.

There are two kits to select from, each designed to address key skin concerns and each with a unique theme — Brightening Basics and Hydration Heroes.

Brightening Basics is a mix of everyday essentials for glowing skin for all skin types. The bundle comes in a sleek pink, reusable case and includes three full-sized products: 200ml gentle cleanser, 50ml Moisture Defence (normal skin) and 30ml1% Hyaluronic Complex Serum. The Brightening Basics kit is available at $129, a saving of 33 per cent.

Hydration Heroes is a mix of hydration essentials and active heroes that cater to a wide variety of clients. A perfect stocking stuffer, this bundle includes four deluxe products: Moisture 15 15 ml Defence for normal skin, 10 ml 1% Hyaluronic Complex Serum, 10 ml Retinol Serum and 50 ml Expert Squalane Cleansing Oil. The kit retails at $59.

In addition to the 2024 Holiday Gifts Kits, gift givers can easily add a Laser Clinic Canada gift card to the mix. Offering flexibility, recipients can choose from a wide range of treatments offered by Laser Clinics Canada, or they can expand their collection of exclusive Skinstitut products.

 

Brightening Basics 2024 Holiday Gift Kit by Skinstitut, available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

Hydration Heroes 2024 Holiday Gift Kit by Skinstitut – available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

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Here is how to prepare your online accounts for when you die

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LONDON (AP) — Most people have accumulated a pile of data — selfies, emails, videos and more — on their social media and digital accounts over their lifetimes. What happens to it when we die?

It’s wise to draft a will spelling out who inherits your physical assets after you’re gone, but don’t forget to take care of your digital estate too. Friends and family might treasure files and posts you’ve left behind, but they could get lost in digital purgatory after you pass away unless you take some simple steps.

Here’s how you can prepare your digital life for your survivors:

Apple

The iPhone maker lets you nominate a “ legacy contact ” who can access your Apple account’s data after you die. The company says it’s a secure way to give trusted people access to photos, files and messages. To set it up you’ll need an Apple device with a fairly recent operating system — iPhones and iPads need iOS or iPadOS 15.2 and MacBooks needs macOS Monterey 12.1.

For iPhones, go to settings, tap Sign-in & Security and then Legacy Contact. You can name one or more people, and they don’t need an Apple ID or device.

You’ll have to share an access key with your contact. It can be a digital version sent electronically, or you can print a copy or save it as a screenshot or PDF.

Take note that there are some types of files you won’t be able to pass on — including digital rights-protected music, movies and passwords stored in Apple’s password manager. Legacy contacts can only access a deceased user’s account for three years before Apple deletes the account.

Google

Google takes a different approach with its Inactive Account Manager, which allows you to share your data with someone if it notices that you’ve stopped using your account.

When setting it up, you need to decide how long Google should wait — from three to 18 months — before considering your account inactive. Once that time is up, Google can notify up to 10 people.

You can write a message informing them you’ve stopped using the account, and, optionally, include a link to download your data. You can choose what types of data they can access — including emails, photos, calendar entries and YouTube videos.

There’s also an option to automatically delete your account after three months of inactivity, so your contacts will have to download any data before that deadline.

Facebook and Instagram

Some social media platforms can preserve accounts for people who have died so that friends and family can honor their memories.

When users of Facebook or Instagram die, parent company Meta says it can memorialize the account if it gets a “valid request” from a friend or family member. Requests can be submitted through an online form.

The social media company strongly recommends Facebook users add a legacy contact to look after their memorial accounts. Legacy contacts can do things like respond to new friend requests and update pinned posts, but they can’t read private messages or remove or alter previous posts. You can only choose one person, who also has to have a Facebook account.

You can also ask Facebook or Instagram to delete a deceased user’s account if you’re a close family member or an executor. You’ll need to send in documents like a death certificate.

TikTok

The video-sharing platform says that if a user has died, people can submit a request to memorialize the account through the settings menu. Go to the Report a Problem section, then Account and profile, then Manage account, where you can report a deceased user.

Once an account has been memorialized, it will be labeled “Remembering.” No one will be able to log into the account, which prevents anyone from editing the profile or using the account to post new content or send messages.

X

It’s not possible to nominate a legacy contact on Elon Musk’s social media site. But family members or an authorized person can submit a request to deactivate a deceased user’s account.

Passwords

Besides the major online services, you’ll probably have dozens if not hundreds of other digital accounts that your survivors might need to access. You could just write all your login credentials down in a notebook and put it somewhere safe. But making a physical copy presents its own vulnerabilities. What if you lose track of it? What if someone finds it?

Instead, consider a password manager that has an emergency access feature. Password managers are digital vaults that you can use to store all your credentials. Some, like Keeper,Bitwarden and NordPass, allow users to nominate one or more trusted contacts who can access their keys in case of an emergency such as a death.

But there are a few catches: Those contacts also need to use the same password manager and you might have to pay for the service.

___

Is there a tech challenge you need help figuring out? Write to us at onetechtip@ap.org with your questions.

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Pediatric group says doctors should regularly screen kids for reading difficulties

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The Canadian Paediatric Society says doctors should regularly screen children for reading difficulties and dyslexia, calling low literacy a “serious public health concern” that can increase the risk of other problems including anxiety, low self-esteem and behavioural issues, with lifelong consequences.

New guidance issued Wednesday says family doctors, nurses, pediatricians and other medical professionals who care for school-aged kids are in a unique position to help struggling readers access educational and specialty supports, noting that identifying problems early couldhelp kids sooner — when it’s more effective — as well as reveal other possible learning or developmental issues.

The 10 recommendations include regular screening for kids aged four to seven, especially if they belong to groups at higher risk of low literacy, including newcomers to Canada, racialized Canadians and Indigenous Peoples. The society says this can be done in a two-to-three-minute office-based assessment.

Other tips encourage doctors to look for conditions often seen among poor readers such as attention-deficit hyperactivity disorder; to advocate for early literacy training for pediatric and family medicine residents; to liaise with schools on behalf of families seeking help; and to push provincial and territorial education ministries to integrate evidence-based phonics instruction into curriculums, starting in kindergarten.

Dr. Scott McLeod, one of the authors and chair of the society’s mental health and developmental disabilities committee, said a key goal is to catch kids who may be falling through the cracks and to better connect families to resources, including quicker targeted help from schools.

“Collaboration in this area is so key because we need to move away from the silos of: everything educational must exist within the educational portfolio,” McLeod said in an interview from Calgary, where he is a developmental pediatrician at Alberta Children’s Hospital.

“Reading, yes, it’s education, but it’s also health because we know that literacy impacts health. So I think that a statement like this opens the window to say: Yes, parents can come to their health-care provider to get advice, get recommendations, hopefully start a collaboration with school teachers.”

McLeod noted that pediatricians already look for signs of low literacy in young children by way of a commonly used tool known as the Rourke Baby Record, which offers a checklist of key topics, such as nutrition and developmental benchmarks, to cover in a well-child appointment.

But he said questions about reading could be “a standing item” in checkups and he hoped the society’s statement to medical professionals who care for children “enhances their confidence in being a strong advocate for the child” while spurring partnerships with others involved in a child’s life such as teachers and psychologists.

The guidance said pediatricians also play a key role in detecting and monitoring conditions that often coexist with difficulty reading such as attention-deficit hyperactivity disorder, but McLeod noted that getting such specific diagnoses typically involves a referral to a specialist, during which time a child continues to struggle.

He also acknowledged that some schools can be slow to act without a specific diagnosis from a specialist, and even then a child may end up on a wait list for school interventions.

“Evidence-based reading instruction shouldn’t have to wait for some of that access to specialized assessments to occur,” he said.

“My hope is that (by) having an existing statement or document written by the Canadian Paediatric Society … we’re able to skip a few steps or have some of the early interventions present,” he said.

McLeod added that obtaining specific assessments from medical specialists is “definitely beneficial and advantageous” to know where a child is at, “but having that sort of clear, thorough assessment shouldn’t be a barrier to intervention starting.”

McLeod said the society was partly spurred to act by 2022’s “Right to Read Inquiry Report” from the Ontario Human Rights Commission, which made 157 recommendations to address inequities related to reading instruction in that province.

He called the new guidelines “a big reminder” to pediatric providers, family doctors, school teachers and psychologists of the importance of literacy.

“Early identification of reading difficulty can truly change the trajectory of a child’s life.”

This report by The Canadian Press was first published Oct. 23, 2024.

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