The effect of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea and uncontrolled hypertension - Study design and challenges during the COVID-19 pandemic

OBJECTIVES: To describe the MORPHEOS (Morbidity in patients with uncontrolled HTN and OSA) trial, and describe the challenges imposed by the COVID-19 pandemic. METHODS: MORPHEOS is a multicenter (n=6) randomized controlled trial designed to evaluate the blood pressure (BP) lowering effects of treatment with continuous positive airway pressure (CPAP) or placebo (nasal strips) for 6 months in adult patients with uncontrolled hypertension (HTN) and moderate-to-severe obstructive sleep apnea (OSA). Patients using at least one antihypertensive medication were included. Uncontrolled HTN was confirmed by at least one abnormal parameter in the 24-hour ABPM and ≥80% medication adherence evaluated by pill counting after the run-in period. OSA was defined by an apnea-hypopnea index ≥15 events/hours. The co-primary endpoints are brachial BP (office and ambulatory BP monitoring, ABPM) and central BP. Secondary outcomes include hypertension-mediated organ damage (HMOD) to heart, aorta, eye, and kidney. We pre-specified several sub-studies from this investigation. Visits occur once a week in the first month and once a month thereafter. The programmed sample size was 176 patients but the pandemic prevented this final target. A post-hoc power analysis will be calculated from the final sample. ClinicalTrials.gov: NCT02270658. RESULTS: The first 100 patients are predominantly males (n=69), age: 52±10 years, body mass index: 32.7±3.9 kg/m2 with frequent co-morbidities. CONCLUSIONS: The MORPHEOS trial has a unique study design including a run-in period; pill counting, and detailed analysis of hypertension-mediated organ damage in patients with uncontrolled HTN that will allow clarification of the impact of OSA treatment with CPAP.

Diagnostic accuracy of oximetry for obstructive sleep apnea: a study on older adults in a home setting

OBJECTIVES: Owing to the fact that obstructive sleep apnea (OSA) is an underreported disease, the strategy used for the diagnosis of OSA has been extensively dissected to devise a simplified process that can be accessed by the public health services. Polysomnography (PSG) type I, the gold standard for the diagnosis of OSA, is expensive and difficult to access by low-income populations. In this study, we aimed to verify the accuracy of the oxyhemoglobin desaturation index (ODI) in comparison to the apnea-hypopnea index (AHI) using a portable monitor. METHODS: We evaluated 94 type III PSG home test results of 65 elderly patients (69.21±6.94 years old), along with information, such as the body mass index (BMI) and sex, using data obtained from a clinical trial database. RESULTS: A significant linear positive correlation (r=0.93, p<0.05) was observed between ODI and AHI, without any interference from sex, BMI, and positional component. The sensitivity of ODI compared to that of AHI increased with an increase in the severity of OSA, while the specificity of ODI in comparison to that of AHI was high for all degrees of severity. The accuracy of ODI was 80.7% for distinguishing between patients with mild and moderate apnea and 84.4% for distinguishing between patients with moderate and severe apnea. CONCLUSION: The ODI values obtained in uncontrolled conditions exhibited high sensitivity for identifying severe apnea compared to the AHI values, and correctly identified the severity of OSA in more than 80% of the cases. Thus, oximetry is promising strategy for diagnosing OSA.

Effects of exercise on sleep symptoms in patients with severe obstructive sleep apnea / Efeitos do exercício nos sintomas do sono em pacientes com apneia obstrutiva do sono

ABSTRACT Objective: To investigate the extent to which exercise is associated with symptoms in patients with severe obstructive sleep apnea (OSA). Methods: We included subjects with an apnea-hypopnea index (AHI) > 30 events/h who completed validated sleep and exercise questionnaires. We compared symptom frequency/scores between exercisers and nonexercisers, adjusting for the usual confounders. Results: The sample included 907 nonexercisers and 488 exercisers (mean age, 49 ± 14 years; mean AHI, 53 ± 20 events/h; 81% men). Nonexercisers and exercisers differed significantly in terms of obesity (72% vs. 54%), the mean proportion of sleep in non-rapid eye movement stage 3 sleep (9 ± 8% vs. 11 ± 6%), and tiredness (78% vs. 68%). Nonexercisers had a higher symptom frequency/scores and poorer sleep quality. Adjustment for exercise weakened the associations between individual symptoms and the AHI, indicating that exercise has a mitigating effect. In binary logistic models, exercise was associated with approximately 30% lower adjusted questionnaire1 score > 2, tiredness; poor-quality sleep, unrefreshing sleep, and negative mood on awakening. Although the odds of an Epworth Sleepiness Scale score > 10 were lower in exercisers, that association did not withstand adjustment for confounders. Conclusions: Exercise is associated with lower frequency/intensity of symptoms in patients with severe OSA. Because up to one third of patients with severe OSA might exercise regularly and therefore be mildly symptomatic, it is important not to rule out a diagnosis of OSA in such patients.

RESUMO Objetivo: Investigar até que ponto o exercício está associado a sintomas em pacientes com apneia obstrutiva do sono (AOS) grave. Métodos: Foram incluídos indivíduos com um índice de apneia-hipopneia (IAH) > 30 eventos/h que completaram questionários de sono e exercício validados. Comparamos a frequência/pontuação de sintomas entre praticantes e não praticantes de exercícios, ajustados para os fatores de confusão habituais. Resultados: A amostra incluiu 907 não praticantes e 488 praticantes (idade média de 49 ± 14 anos; IAH médio, 53±20 eventos/h; 81% homens). Não praticantes e praticantes diferiram significativamente em termos de obesidade (72% vs. 54%), proporção média de sono em estágio de sono 3 com non-rapid eye movement (9 ± 8% vs. 11 ± 6%) e cansaço (78% vs. 68%). Os não praticantes tiveram uma maior frequência/pontuação de sintomas e uma pior qualidade do sono. O ajuste para exercício enfraqueceu as associações entre sintomas individuais e o IAH, indicando que o exercício tem um efeito atenuante. Nos modelos logísticos binários, o exercício foi associado a uma redução de aproximadamente 30% no escore > 2 no questionário ajustado1 para cansaço; sono de má qualidade, sono não reparador e humor negativo ao despertar. Embora as chances de um escore >10 na Escala de Sonolência de Epworth ter sido menor nos praticantes, essa associação não resistiu ao ajuste para fatores de confusão. Conclusões: O exercício está associado a uma menor frequência/intensidade de sintomas em pacientes com AOS grave. Como até um terço dos pacientes com AOS grave pode se exercitar regularmente e, portanto, ser levemente sintomático, é importante não descartar um diagnóstico de AOS nesses pacientes.

Intermittent hypoxia, brain glyoxalase-1 and glutathione reductase-1, and anxiety-like behavior in mice

Objective: Sleep apnea has been associated with anxiety, but the mechanisms of the sleep apnea-anxiety relationship are unresolved. Sleep apnea causes oxidative stress, which might enhance anxiety-like behavior in rodents. To clarify the apnea-anxiety connection, we tested the effect of intermittent hypoxia, a model of sleep apnea, on the anxiety behavior of mice. Methods: The rodents were exposed daily to 480 one-minute cycles of intermittent hypoxia to a nadir of 7±1% inspiratory oxygen fraction or to a sham procedure with room air. After 7 days, the mice from both groups were placed in an elevated plus maze and were video recorded for 10 min to allow analysis of latency, frequency, and duration in open and closed arms. Glyoxalase-1 (Glo1) and glutathione reductase-1 (GR1) were measured in the cerebral cortex, hippocampus, and striatum by Western blotting. Results: Compared to controls, the intermittent hypoxia group displayed less anxiety-like behavior, perceived by a statistically significant increase in the number of entries and total time spent in open arms. A higher expression of GR1 in the cortex was also observed. Conclusion: The lack of a clear anxiety response as an outcome of intermittent hypoxia exposure suggests the existence of additional layers in the anxiety mechanism in sleep apnea, possibly represented by sleepiness and irreversible neuronal damage.

Clínica virtual docente: un espacio formativo para la enseñanza de las ciencias médicas / Teaching virtual clinic: a training space for teaching medical sciences

La Clínica virtual es un espacio con fines docentes en las ciencias médicas, donde predomina la aplicación del método científico en los aspectos clínico, epidemiológico y diagnóstico; sin embargo, se han evidenciado insuficiencias en el empleo de esta herramienta tecnológica para abordar y solucionar situaciones profesionales en los procesos formativos de pregrado y posgrado. Por ello, se decidió elaborar una estrategia didáctica que propiciara el desarrollo de actividades formativas en las carreras y especialidades de las ciencias médicas mediante el apoyo de la Clínica virtual como expresión de la telemedicina, y que puede ser adaptada según las características particulares del grupo de estudiantes, de las asignaturas y las especificidades de cada tema en cuestión.

Virtual Clinic is a space with teaching aims in medical sciences, where the implementation of the scientific method prevails in the clinical, epidemiological and diagnostic aspects; however, inadequacies in the use of this technological tool to approach and solve professional situations in predegree and postdegree training processes have been evidenced. That is why, it was decided to elaborate a didactic strategy that propitiated the development of training activities in the careers and specialties of medical sciences with the support of virtual Clinic as expression of Telemedicine, and that can be adapted according to the peculiar characteristics of the group of students, subjects and specificities of each topic.

The effect of caffeine supplementation on exercise performance evaluated by a novel animal model

Introduction: Caffeinated drinks are used for improve performance. Animal models represent investigational strategy that circumvents most of the drawbacks of research in humans, including motivational factors and the placebo effect. No animal model that could test whether different forms of administering caffeine affect exercise propensity was found in the literature. Methods: An animal model of grouped voluntary exercise was tested. Two-month-old male C57/bl mice were housed in a cage fitted with one running wheel and a monitoring system. Six animals per cage were introduced individually. To assess the sensitivity of the model, the effect of different caffeinated drinks was observed in mice exercising ad libitum. During 2 days, the mice received: 1) pure anhydrous caffeine 0.125 mg/mL (PC), 2) cola drink (CC), and 3) caffeine-taurine-glucuronolactone drink (CTG), intercalating wash-out periods of 2 days, receiving pure water. Results: The distance run during the periods of water ingestion was significantly lower than during the periods of stimulant drinks ingestion: PC (5.6 ± 1.3 km; p = 0.02), of CC ingestion (7.6 ± 0.6 km; p = 0.001), and of CTG ingestion (8.3 ± 1.6 km; p = 0.009). The performances when ingesting the three caffeinated drinks do not follow a dose-response curve. Conclusions: The model described here was able to measure the effect of caffeine intake on voluntary exercise of mice. The sensitivity of the model to the effect of caffeine needs to be further validated. The action of each component of the drinks on exercise performance needs to be clarified in future research. The present model is adequate for such investigation (AU)

Importancia de los repositorios para preservar y recuperar la información / Importance of repositories for preserving and recovering information

Los repositorios constituyen sistemas de información que tienen como finalidad organizar, preservar y difundir en el modo acceso abierto (Open Access) recursos científicos y académicos de las instituciones. En Cuba, y particularmente la red de Infomed, ha propiciado la elaboración de estos sistemas con el objetivo de garantizar un acceso fácil, controlado y estandarizado de determinados recursos informativos. Este trabajo tiene como propósito profundizar en la importancia de los repositorios en el Sistema Nacional de Salud. A tales efectos se analizaron algunos elementos relacionados con el acceso abierto y las plataformas más utilizadas para la creación de los repositorios como el CWIS (Campus Wide Information System), así como las ventajas y desventajas de esta herramienta.

Repositories constitute information systems which have as purpose to organize, preserve and diffuse the scientific and academic resources of the institutions in Open Access. In Cuba, and particularly Infomed network, has propitiated the implementation of these systems with the objective of guaranteeing an easy, controlled and standardized access of certain informative resources. The purpose of this work is to deepen in the importance of repositories in the National Health System. To achieve this, some elements related to the open access and the most used platforms for the implementation of repositories such as CWIS (Campus Wide Information System), as well as the advantages and disadvantages of this tool were analyzed.

Sleep-disordered breathing in patients with cystic fibrosis / Distúrbios respiratórios do sono em pacientes com fibrose cística

AbstractObjective: To test the hypothesis that disease severity in patients with cystic fibrosis (CF) is correlated with an increased risk of sleep apnea.Methods: A total of 34 CF patients underwent clinical and functional evaluation, as well as portable polysomnography, spirometry, and determination of IL-1β levels.Results: Mean apnea-hypopnea index (AHI), SpO2 on room air, and Epworth Sleepiness Scale score were 4.8 ± 2.6, 95.9 ± 1.9%, and 7.6 ± 3.8 points, respectively. Of the 34 patients, 19 were well-nourished, 6 were at nutritional risk, and 9 were malnourished. In the multivariate model to predict the AHI, the following variables remained significant: nutritional status (β = −0.386; p = 0.014); SpO2 (β = −0.453; p = 0.005), and the Epworth Sleepiness Scale score (β = 0.429; p = 0.006). The model explained 51% of the variation in the AHI.Conclusions: The major determinants of sleep apnea were nutritional status, SpO2, and daytime sleepiness. This knowledge not only provides an opportunity to define the clinical risk of having sleep apnea but also creates an avenue for the treatment and prevention of the disease.

ResumoObjetivo: Testar a hipótese de que a gravidade da doença em pacientes com fibrose cística (FC) correlaciona-se com maior risco de apneia do sono.Métodos: Um total de 34 pacientes com FC foram submetidos a avaliação clínica e funcional, polissonografia portátil, espirometria e dosagem de IL-1β.Resultados: As médias do índice de apneia e hipopneia (IAH), da SpO2 em ar ambiente e da pontuação na Escala de Sonolência de Epworth foram de 4,8 ± 2,6, 95,9 ± 1,9% e 7,6 ± 3,8, respectivamente. Dos 34 pacientes, 19 eram eutróficos, 6 apresentavam risco nutricional e 9 apresentavam desnutrição. No modelo multivariado para prever o IAH, permaneceram significativos o estado nutricional (β = −0,386; p = 0,014), a SpO2 (β = −0,453; p = 0,005) e a pontuação na Escala de Sonolência de Epworth (β = 0,429; p = 0,006). O modelo explicou 51% da variação do IAH.Conclusões: Os maiores determinantes de apneia do sono foram o estado nutricional, a SpO2 e a sonolência diurna. Esse conhecimento representa não somente uma oportunidade de definir o risco clínico de apresentar apneia do sono, mas também de atuar na prevenção e tratamento da doença.

Uncoupling protein-2 mRNA expression in mice subjected to intermittent hypoxia / Expressão do mRNA da uncoupling protein-2 em camundongos submetidos à hipóxia intermitente

Objective: To investigate the effect of intermittent hypoxia-a model of obstructive sleep apnea (OSA)-on pancreatic expression of uncoupling protein-2 (UCP2), as well as on glycemic and lipid profiles, in C57BL mice. Methods: For 8 h/day over a 35-day period, male C57BL mice were exposed to intermittent hypoxia (hypoxia group) or to a sham procedure (normoxia group). The intermittent hypoxia condition involved exposing mice to an atmosphere of 92% N and 8% CO2 for 30 s, progressively reducing the fraction of inspired oxygen to 8 ± 1%, after which they were exposed to room air for 30 s and the cycle was repeated (480 cycles over the 8-h experimental period). Pancreases were dissected to isolate the islets. Real-time PCR was performed with TaqMan assays. Results: Expression of UCP2 mRNA in pancreatic islets was 20% higher in the normoxia group than in the hypoxia group (p = 0.11). Fasting serum insulin was higher in the hypoxia group than in the normoxia group (p = 0.01). The homeostasis model assessment of insulin resistance indicated that, in comparison with the control mice, the mice exposed to intermittent hypoxia showed 15% lower insulin resistance (p = 0.09) and 21% higher pancreatic β-cell function (p = 0.01). Immunohistochemical staining of the islets showed no significant differences between the two groups in terms of the area or intensity of α- and β-cell staining for insulin and glucagon. Conclusions: To our knowledge, this is the first report of the effect of intermittent hypoxia on UCP2 expression. Our findings suggest that UCP2 regulates insulin production in OSA. Further study of the role that UCP2 plays in the glycemic control of OSA patients is warranted. .

Objetivo: Investigar o efeito da hipóxia intermitente com um modelo de apneia obstrutiva do sono (AOS) sobre a expressão de uncoupling protein-2 (UCP2), assim como sobre perfis glicêmicos e lipídicos, em camundongos C57BL. Métodos: Camundongos C57BL machos foram expostos a hipóxia intermitente ou hipóxia simulada (grupo controle) 8 h/dia durante 35 dias. A condição de hipóxia intermitente envolveu a exposição dos camundongos a uma atmosfera de 92% de N e 8% de CO2 por 30 s, com redução progressiva de fração de O2 inspirado até 8 ± 1%, seguida por exposição a ar ambiente por 30 s e repetições do ciclo (480 ciclos no período experimental de 8 h). Os pâncreas foram dissecados para isolar as ilhotas. Foi realizada PCR em tempo real utilizando o método TaqMan. Resultados: A expressão do mRNA da UCP2 nas ilhotas pancreáticas foi 20% maior no grupo controle que no grupo hipóxia (p = 0,11). A insulina sérica de jejum foi maior no grupo hipóxia do que no grupo controle (p = 0,01). O modelo de avaliação da homeostase de resistência à insulina indicou que, em comparação com os camundongos controle, aqueles expostos à hipóxia intermitente apresentaram 15% menor resistência à insulina (p = 0,09) e 21% maior função das células beta (p = 0,01). A coloração das ilhotas pancreáticas por imuno-histoquímica não mostrou diferenças significativas entre os grupos em termos da área ou da intensidade das células alfa e beta, marcadas por insulina e glucagon. Conclusões: Segundo nosso conhecimento, esta é a primeira descrição do efeito da hipóxia intermitente sobre a expressão da UCP2. Nossos achados sugerem que UCP2 regula a produção de insulina na AOS. Futuras investigações sobre o papel da UCP2 no controle glicêmico em pacientes com AOS são justificadas. .

Melatonin prevents hyperglycemia in a model of sleep apnea

Objective Obstructive sleep apnea is a common disorder associated with aging and obesity. Apneas cause repeated arousals, intermittent hypoxia, and oxidative stress. Changes in glucolipidic profile occur in apnea patients, independently of obesity. Animal models of sleep apnea induce hyperglycemia. This study aims to evaluate the effect of the antioxidants melatonin and N-acetylcysteine on glucose, triglyceride, and cholesterol levels in animals exposed to intermittent hypoxia. Materials and methods Two groups of Balb/c mice were exposed to intermittent hypoxia (n = 36) or sham intermittent hypoxia (n = 36) for 35 days. The intermittent hypoxia group underwent a total of 480 cycles of 30 seconds reducing the inspired oxygen fraction from 21% to 7 ± 1% followed by 30 seconds of normoxia, during 8 hours daily. Melatonin or N-acetylcysteine were injected intraperitonially daily from day 21 on. Results At day 35, glucose levels were significantly higher in the intermittent hypoxia group than in the control group. The intermittent hypoxia groups receiving N-acetylcysteine and vehicle showed higher glucose levels than the group receiving melatonin. The lipid profile was not affected by intermittent hypoxia or antioxidant administration. Conclusions The present results suggest that melatonin prevents the well-recognized increase in glucose levels that usually follows exposure to intermittent hypoxia. Further exploration of the role of melatonin in sleep apnea is warranted. Arch Endocrinol Metab. 2015;59(1):66-70 .

Ecocardiografia em pacientes com apneia do sono grave com e sem pressão arterial controlada: estudo transversal / Echocardiography in patients with severe sleep apnea with and without controlled blood pressure: cross sectional study

A apneia obstrutiva do sono (AOS) afeta a anatomia e função do coração. Ocorre hipertensão arterial em metade dos casos de AOS, dificultando atribuir a etiologia dessas alterações separadamente à hipertensão arterial ou à apneia do sono. Métodos: Estudo transversal de pacientes com índice de apneia-hipopneia maior que 50 eventos por hora. As variáveis ecocardiográficas comparadas em indivíduos com hipertensão arterial controlada e não controlada foram: 1) fração de ejeção, 2) diâmetro da aorta, 3) diâmetro do átrio esquerdo, 4) diâmetro de ventrículo direito, 5) diâmetros do ventrículo esquerdo diastólico e sistólico, 6) percentagem delta, 7) espessura do septo, 8) espessura da parede posterior. Resultados: Foram incluídos 83 voluntários, 50 com pressão arterial não controlada. Em média, a idade era 47 ± 9,5 anos, o índice de massa corporal 34 ± 5,4 Kg/m2 , o índice de apneia-hipopneia 86 ± 18 eventos/hora. Sessenta pacientes apresentaram anormalidade no ecocardiograma. A hipertrofia de ventrículo esquerdo foi o achado mais comum, sem diferença de frequência em controles (39%) e em hipertensos (48%), seguida por disfunção diastólica em controles (27%) e em hipertensos (32%). Conclusões: Indivíduos com apneia do sono grave e pressão arterial controlada apresentam alterações no ecocardiograma de tipo e frequência semelhantes aos com hipertensão não controlada. Isso sugere que a apneia do sono pode causar dano cardíaco independentemente de hipertensão. Quando não explicáveis por hipertensão arterial, achados como hipertrofia de ventrículo esquerdo podem ser provocados por apneia do sono...

Obstructive sleep apnea (OSA) affects the cardiac anatomy and function. Hypertension occurs in half the OSA cases, making it difficult to attribute the cause of these changes separately to arterial hypertension or sleep apnea. Methods: Prospective cross-sectional study of volunteers with apnea-hypopnea index >50 events per hour. The echocardiographic variables were analyzed: 1) ejection fraction, 2) aortic diameter, 3) left atrial diameter, 4) right ventricular diameter, 5) diastolic and systolic diameters of the left ventricle, 6) delta percentage, 7) septum thickness, 8) posterior wall thickness. Results: There were 83 participants, 74 men, 50 with hypertension. The average age was 47 ± 9.5 years, body mass index of 34 ± 5.4 kg/m2 , apnea-hypopnea index of 86±18 events/hour, and minimum oxygen saturation of 55 ± 17%. Left ventricular hypertrophy was the most common echocardiographic abnormality in subjects without hypertension (39%) and with hypertension (48%), followed by diastolic dysfunction in subjects with normal blood pressure (27%) and with high blood pressure (32%). There was no statistically significant difference in echocardiographic characteristics between hypertensive subjects with those with normal pressure. Conclusions: Individuals with normal blood pressure and severe sleep apnea show abnormalities in the echocardiogram with frequency similar to that observed in patients with high blood pressure. This suggests that sleep apnea can cause ventricular overload independently of hypertension. When not explained by high blood pressure, left ventricular hypertrophy can be caused by sleep apnea...

Scores of a web-based version of the Seasonal Pattern Assessment Questionnaire in Brazil

Seasonal affective disorder (SAD) is a proposed mental disorder still controversial. This condition is prevalent in northern latitudes, but few studies have been conducted at locations in the southern hemisphere. It is usually assessed by the Seasonal Pattern Assessment Questionnaire (SPAQ). This study aimed to evaluate, through on-line questionnaire, the hypothesis that, in the Brazilian population, latitude and longitude influence SPAQ scores. Methods: An advertisement was posted on a sleep medicine website inviting visitors to investigate seasonal patterns of behavior and mood, using a Brazilian Portuguese version of the SPAQ. The geographic coordinates of the place of residence of each respondent were analyzed as a continuous variable or distributed in quartiles of latitude and longitude. The psychometric properties of the SPAQ were assessed by reliability and factor analyses. Results: Answers from 1001 respondents out of 1045 were considered eligible. High SPAQ scores were observed in 287 respondents, equally distributed among all latitude and longitude quartiles. Data collected in different seasons and during daylight saving time did not differ significantly in any of the scores for SPAQ dimensions. No correlations between SPAQ scores and latitude or longitude were observed. Psychometric properties of the SPAQ were preserved in all geographic locations. Conclusion: The finding of similar SPAQ scores at a wide latitude range defies the concept of SAD symptoms as latitude or longitude-dependent phenomena...

Otitis media crónica complicada en un adolescente con malformación auditiva / Complicated chronic otitis media in an adolescent with auditory malformation

Se describe el caso clínico de un adolescente de 17 años de edad, multimalformado, con agenesia del pabellón auricular, así como en el oído externo y medio, quien presentó otitis media crónica complicada. Fue ingresado en el Servicio de Otorrinolaringología del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" y se le indicó antibioticoterapia triple. Posteriormente se realizó una incisión en la región mastoidea del lado izquierdo, se drenó abundante pus, se colocó drenaje y se mantuvo la medicación con antibióticos. El paciente evolucionó favorablemente y egresó a los 10 días. Se concluyó el caso como una otitis media crónica con mastoiditis aguda.

The case report of a 17 year-old adolescent, with multiple malformations, agenesia of pinna as well as of the external and middle ear who presented with complicated chronic otitis media is described. He was admitted to the Otorhinolaryngology Service of "Saturnino Lora Torres" Clinical Surgical Teaching Provincial Hospital and he was indicated triple antibiotic therapy. Later an incision in the mastoid region of his left side was carried out, abundant pus was drained, drainage was placed and the medication with antibiotics was maintained. The patient had a favorable clinical course and he was discharged 10 days later. It was concluded that the case was a chronic otitis media with acute mastoiditis.

Obstructive sleep apnea, detected by the Berlin Questionnaire: an associated risk factor for coronary artery disease / Risco de apneia obstrutiva do sono detectado pelo Questionário de Berlim está associado com doença arterial coronariana

Obstructive sleep apnea (OSA), a risk factor for coronary artery disease, remains under diagnosed. We investigated if OSA identified by the Berlin Questionnaire (BQ) is associated with the risk of coronary artery disease. Cases were patients referred for elective coronariography. The cases were classified with significant coronary lesions (stenosis > 50% in an epicardial coronary) or without significant coronary lesions. Controls were selected from a population-based sample. Positive BQ results were identified in 135 (41.2%) of 328 cases, in contrast with 151 (34.4%) of 439 control subjects (p = 0.03). In a multinomial logistic analysis, the risk for OSA identified by the BQ was independently associated with coronary artery disease in cases with lesions of at least 50% (OR = 1.53; 95%CI: 1.02-2.30; p = 0.04). The risk from OSA identified by the BQ was higher in younger subjects (40-59 years) (OR = 1.76; 95%CI: 1.05-2.97; p = 0.03) and in women (OR = 3.56; 95%CI: 1.64-7.72; p = 0.001). In conclusion, OSA identified by the BQ greatly increases the risks of coronary artery disease in patients having significant coronary artery lesions indicated by anangiogram, particularly in younger individuals and in women.

Síndrome da apneia obstrutiva do sono (SAOS), fator de risco para doença arterial coronariana, permanece subdiagnosticada. Investigou-se se o risco de SAOS pelo Questionário de Berlim (QB) associa-se com doença arterial coronariana. Casos foram pacientes encaminhados para coronariografia eletiva, classificados em casos com lesão significativa (estenose > 50%) ou sem lesões significativas. Controles foram selecionados em amostra populacional. QB foi positivo em 135 (41,2%) de 328 casos, em contraste com 151 (34,4%) de 439 controles (p = 0,03). Em análise logística multinomial, o risco de SAOS identificado pelo QB associou-se com doença arterial coronariana exclusivamente nos casos com lesões de pelo menos 50% (OR: 1,53; IC95%: 1,02-2,30; p = 0,04). Em indivíduos com lesões significativas, o risco de SAOS pela QB foi maior entre os que têm 40-59 anos (OR: 1,76; IC95%: 1,05-2,97; p = 0,03) e em mulheres (OR: 3,56; IC95%: 1,64-7,72; p = 0,001). Em conclusão, alto risco para a SAOS identificados pela QB associa-se a risco de lesões coronarianas significativas na angiografia, particularmente em indivíduos mais jovens e em mulheres.

Apneia obstrutiva do sono e hipertensão arterial / Obstructive sleep apnea and hypertension

A apneia obstrutiva do sono é fator causal de hipertensão arterial sistêmica. A evidência dessa relação de casualidade provém de resultados de pesquisa em pelo menos três campos: 1) estudos observacionais transversais e de coorte que identificaram maior prevalência e incidência de hipertensão em pacientes com apneia do sono; 2) estudos de coorte que observaram efeito dose-resposta (quanto mais grave o distúrbio do sono maior a probabilidade de hipertensão; e 3) ensaios clínicos randomizados e meta análises que demonstraram que o tratamento da apneia do sono utilizando pressão positiva contínua nas vias aéreas (CPAP) reduz a pressão arterial, sobretudo quando esta estiver mais elevada. Esforços vêm sendo empreendidos para identificar apneia do sono em hipertensos. Embora o mecanismo fisiopatológico seja ainda apenas parcialmente compreendido, a hipóxia intermitente parece ser a principal causa de aumento da pressão arterial sistêmica. Hipertensão arterial sistêmica per se não é indicação para avaliação diagnóstica de apneia obstrutiva do sono: entretanto, nos casos de hipertensão de difícil controle, a apneia obstrutiva do sono é particularmente comum e a investigação diagnóstica torna-se obrigatória.

Consequências cardiovasculares na SAOS / Cardiovascular consequences of obstructive sleep apnea syndrome

Uma condição clínica muito comum é SAOS, que está associada a várias doenças cardiovasculares, incluindo hipertensão arterial sistêmica, fibrilação atrial e aterosclerose. A associação entre SAOS e doença cardiovascular não é somente uma consequência da sobreposição de fatores de risco, incluindo obesidade, sedentarismo, ser do sexo masculino e ter idade maior. Existem evidências crescentes de que SAOS contribui de forma independente para o aparecimento e a progressão de várias doenças cardiovasculares. Os mecanismos pelos quais SAOS pode afetar o sistema cardiovascular são múltiplos e incluem a ativação do sistema nervoso simpático, inflamação sistêmica, resistência a insulina e geração de estresse oxidativo. Existem evidências que o tratamento de SAOS com CPAP pode reduzir a pressão arterial, sinais precoces de aterosclerose, risco de recorrência de fibrilação atrial e mortalidade, principalmente por acidente vascular cerebral e infarto agudo do miocárdio, em pacientes com SAOS grave.

Obstructive sleep apnea syndrome (OSAS) is a common condition associated with various cardiovascular diseases, including systemic arterial hypertension, atrial fibrillation, and atherosclerosis. The association between OSAS and cardiovascular disease has been related to the overlapping of risk factors, including obesity, having a sedentary lifestyle, being male, and being older. However, there is mounting evidence that OSAS can also independently contribute to the development and progression of various cardiovascular diseases. The mechanisms by which OSAS can affect the cardiovascular system are multiple, including the activation of the sympathetic nervous system, systemic inflammation, insulin resistance, and oxidative stress. There is also evidence that the treatment of OSAS with CPAP can reduce arterial blood pressure, early signs of atherosclerosis, the risk of atrial fibrillation recurrence, and mortality (principally mortality due to stroke or acute myocardial infarction) in patients with severe OSAS.

Circadian rhythm sleep disorders.

Circadian rhythm sleep disorders are common conditions manifested as misalignment between the sleep period and the physical/social 24-h environmental cycle. Delayed sleep phase (typical in adolescents) and advanced sleep phase (frequent in the elderly), situations in which the sleep period is displaced to a later or earlier time, respectively, are the two most prevalent circadian rhythm sleep disorders. There are, however, nine possible diagnoses of clinical interest. Since light is the main cue used in synchronizing the biological clock, blind individuals and night-shift/rotating-shift workers are more prone to develop circadian rhythm sleep disorders. In this article, the circadian rhythm syndromes included in the new International Classification of Sleep Disorders are reviewed as well as the most recent guidelines for diagnosis and treatment.

Hipertensão arterial resistente e apneia do sono / Resistant hypertension and sleep apnea

A associação entre apneia obstrutiva do sono (AOS) e hipertensão arterial sistêmica (HAS) resistente está bem estabelecida, conferindo risco relativo próximo a 4,0. O relatório do Joint National Committee (JNC-VII) propôs novo paradigma de investigação da HAS ao introduzir a AOS entre as nove causas identificáveis de HAS. Assim, a investigação de AOS deve ser parte integral da avaliação de qualquer paciente com HAS resistente. O estudo pioneiro de casos e controles em hipertensos controlados e hipertensos resistentes, pareados para os principais fatores de confusão, encontrou prevalência de AOS de 38% nos hipertensos controlados contra 71% nos hipertensos resistentes (p < 0,001). O tratamento da AOS, principalmente o uso de pressão positiva contínua em via aérea (CPAP), promove a melhora dos sintomas e da qualidadede vida dos pacientes e pode auxiliar no controle dos níveis pressóricos. Há indícios de que o tratamento da AOS possa reverter HAS resistente. Os recursos instalados para realizar polissonografia são insuficientes para avaliar todos os casos de HAS, até mesmo apenas os casos resistentes. Evidência da possibilidade de se diagnosticar AOS, em larga escala, com métodos mais facilmente utilizáveis como polissonografia portátil e questionários, cria possibilidades para pesquisa e melhor cuidado clínico.

The association between obstructive sleep apnea (OSA) and systemic hypertension (HTN) is well documented, with a relative risk of 4.0. The Seventh Report of the Joint National Committee (JNC-VII) introduced OSA among the nine identifiable causes of HTN, creating a new paradigm for the evaluation of HTN. It is recommended that OSA should be investigated in any patient with resistant hypertension. The pioneering case-control study assessing OSA in patients with resistant HTN and matched controls with well controlled HTN, reported an OSA prevalence of 71% and 38% respectively (p < 0.001). The treatment for OSA, chiefly with continuous positive airway pressure (CPAP) improves symptoms and the quality of life of patients and possibly helps to control blood pressure levels. There is no strong evidence that OSA treatment could restore normal blood pressure in resistant HTN. Polysomnography resources are insufficient to evaluate every patient with HTN, even if only resistant HTN patients were assessed. Recent evidence that OSA can be investigated with tools such as questionnaires and portable polysomnographyadds opportunities for research and better clinical management.

Dimensions of sleepiness and their correlations with sleep-disordered breathing in mild sleep apnea / Dimensões da sonolência e suas correlações com os transtornos respiratórios do sono na apneia do sono leve

OBJECTIVE: There are many ways of assessing sleepiness, which has many dimensions. In patients presenting a borderline apnea-hypopnea index (AHI, expressed as events/hour of sleep), the mechanisms of excessive daytime sleepiness (EDS) remain only partially understood. In the initial stages of sleep-disordered breathing, the AHI might be related to as-yet-unexplored EDS dimensions. METHODS: We reviewed the polysomnography results of 331 patients (52 percent males). The mean age was 40 ± 13 years, and the mean AHI was 4 ± 2 (range, 0-9). We assessed ten potential dimensions of sleepiness based on polysomnography results and medical histories. RESULTS: The AHI in non-rapid eye movement (NREM) stage 1 sleep (AHI-N1), in NREM stage 2 sleep (AHI-N2), and in REM sleep (AHI-REM) were, respectively, 6 ± 7, 3 ± 3 and 10 ± 4. The AHI-N2 correlated significantly with the greatest number of EDS dimensions (5/10), including the Epworth sleepiness scale score (r = 0.216, p < 0.001). Factor analysis, using Cronbach's alpha, reduced the variables to three relevant factors: QUESTIONNAIRE (α = 0.7); POLYSOMNOGRAPHY (α = 0.68); and COMPLAINTS (α = 0.55). We used these factors as dependent variables in a stepwise multiple regression analysis, adjusting for age, gender, and body mass index. The AHI-N1 correlated significantly with POLYSOMNOGRAPHY (β = -0.173, p = 0.003), and the AHI-N2 correlated significantly with COMPLAINTS (β = -0.152, p = 0.017). The AHI-REM did not correlate with any factor. CONCLUSIONS: Our results underscore the multidimensionality of EDS in mild sleep apnea.

OBJETIVO: Há muitas formas de avaliação da sonolência, a qual possui diversas dimensões. Em pacientes com um índice de apneia-hipopneia (IAH, expresso em eventos/hora de sono) limítrofe, os mecanismos da sonolência excessiva diurna (SED) permanecem apenas parcialmente esclarecidos. Nos estágios iniciais do transtorno respiratório do sono, o IAH pode estar relacionado a outras dimensões da SED ainda não exploradas. MÉTODOS: Revisamos os resultados de polissonografia de 331 pacientes (52 por cento do sexo masculino). A idade média foi de 40 ± 13 anos e o IAH médio de 4 ± 2 (variação, 0-9). Avaliamos dez dimensões potenciais de sonolência com base nos resultados da polissonografia e da história médica. RESULTADOS: O IAH em sono non-rapid eye movement (NREM) estágio 1 (IAH-N1), em sono NREM estágio 2 (IAH-N2), e em sono REM (IAH-REM) foram, respectivamente, 6 ± 7, 3 ± 3 e 10 ± 4. O IAH-N2 se correlacionou significantemente com o maior número de dimensões de SED (5/10), incluindo o escore da escala de sonolência de Epworth (r = 0,216, p < 0,001). Análise de fatores, utilizando-se o alfa de Cronbach, reduziu as variáveis a três fatores relevantes: QUESTIONÁRIO (α = 0,7); POLISSONOGRAFIA (α = 0,68); e QUEIXAS (α = 0,55). Usando esses fatores como variáveis dependentes na regressão múltipla, ajustando para idade, gênero e índice de massa corporal, o IAH-N1 se correlacionou significantemente com POLISSONOGRAFIA (β = -0,173, p = 0,003) e o IAH-N2, com QUEIXAS (β = -0,152, p = 0,017). O IAH-REM não se correlacionou com nenhum fator. CONCLUSÕES: Nossos resultados confirmam a multidimensionalidade da SED na apneia do sono leve.

Síndrome das apnéias-hipopnéias obstrutivas do sono: associação com gênero e obesidade e fatores relacionados à sonolência / Obstructive sleep apnea-hypopnea syndrome: association with gender, obesity and sleepiness-related factors

OBJETIVO: Estudar os efeitos de gênero e obesidade e identificar fatores relacionados à sonolência diurna excessiva (SDE) em indivíduos com síndrome das apnéias-hipopnéias obstrutivas do sono (SAHOS). MÉTODOS: Foram selecionados para inclusão no estudo 300 pacientes consecutivos, atendidos em clínica do sono, com índice de apnéia/hipopnéia (IAH) > 10 eventos/hora de sono, que completaram adequadamente a avaliação clínica. RESULTADOS: A média de idade foi de 47 ± 11 anos e o IAH médio foi de 52,1 ± 29,2 eventos/hora de sono. As mulheres apresentaram maior média de idade, menos sonolência e menos tempo em apnéia. O escore médio de SDE foi de 14,7 ± 7,2. O escore de SDE correlacionou-se melhor com movimentos corpóreos (r = 0,43; p < 0,01), eventos respiratórios durante o sono (r = 0,40; p < 0,01), tempo em apnéia (r = 0,40; p < 0,01), valores mínimos da saturação periférica de oxigênio (SpO2; r = -0,38; p < 0,01) e IAH (r = 0,37; p < 0,01). O índice de massa corpórea (IMC) médio foi de 30,2 ± 5,3 kg/m². Sobrepeso, obesidade e obesidade mórbida foram observados em, respectivamente, 41, 44 e 5,3 por cento dos casos. A gravidade da doença correlacionou-se melhor com IMC (r = 0,51; p < 0,01). CONCLUSÕES: Maior média de idade, menor escore de SDE e menor tempo em apnéia foram associados ao gênero feminino. Fragmentação do sono, número e duração de eventos respiratórios durante o sono, níveis de SpO2 e obesidade se associaram à sonolência. O IMC teve efeito significativo na gravidade da SAHOS.

OBJECTIVE: To study the effects that gender and obesity have on excessive daytime sleepiness (EDS) in individuals with obstructive sleep apnea-hypopnea syndrome (OSAHS), as well as to identify factors associated with EDS in such individuals. METHODS: A total of 300 consecutive patients who completed the clinical evaluation satisfactorily and whose polysomnography showed an apnea-hypopnea index (AHI) > 10 events/hour of sleep were selected from a sleep clinic population for inclusion in the study. RESULTS: Mean age was 47 ± 11 years, and mean AHI was 52.1 ± 29.2 events/hour of sleep. Females presented higher mean age, lower EDS scores and less time in apnea. Mean EDS score was 14.7 ± 7.2. The EDS score correlated better with body movements (r = 0.43; p < 0.01), respiratory events during sleep (r = 0.40; p < 0.01), duration of apnea (r = 0.40; p < 0.01), peripheral oxygen saturation (SpO2; r = -0.38; p < 0.01) and AHI (r = 0.37; p < 0.01). Mean body mass index (BMI) was 30.2 ± 5.3 kg/m². Overweight, obesity and morbid obesity were observed in 41, 44 and 5.3 percent of cases, respectively. Disease severity correlated most strongly with BMI (r = 0.51; p < 0.01). CONCLUSIONS: Higher mean age, lower EDS scores and less time spent in sleep apnea time in apnea were associated with being female. Fragmented sleep, number/duration of respiratory events during sleep, SpO2 levels and obesity were associated with sleepiness. The BMI had a significant effect on OSAHS severity.