Síndrome de apneas del sueño: revisión de 25 años de experiencia / Sleep apnea syndrome: review of 25 years of experience / Síndrome da apnéia do sono: revisão de 25 anos de experiência

El conocimiento científico y clínico sobre los trastornos respiratorios del sueño se ha desarrollado de manera acelerada en las últimas décadas. El objetivo de este estudio es presentar la experiencia adquirida en nuestro país, en el diagnóstico y tratamiento del síndrome de apneas del sueño de tipo obstructivo, durante el desarrollo de una nueva disciplina en el ámbito de la neumología. Se revisaron los registros de 3109 pacientes; 447 con historias clínicas electrónicas y cuestionarios para cuantificación de síntomas y 1779 polisomnografías de pacientes con apneas de tipo obstructivo. Se presenta la evolución de la referencia de pacientes, las características demográficas (en especial el aumento de la prevalencia en jóvenes) y los hallazgos clínicos más frecuentes. Se destacan los factores de riesgo relevantes: obesidad y su relación con la severidad, enfermedades endocrinas y desplazamiento cefálico de fluidos. Se destaca el modo de acceso y la adherencia al tratamiento. La implementación de unidades clínicas de sueño permitió la referencia de pacientes para el diagnóstico y el tratamiento, dando lugar a una nueva disciplina de la neumología. La prevalencia de las apneas obstructivas del sueño es muy elevada, con progresivo y sostenido incremento. El tratamiento con aplicación de presión nasal no invasiva es factible. Aunque con distintos grados de accesibilidad y adherencia, ha permitido la corrección del trastorno respiratorio del sueño más relevante.

Scientific and clinical knowledge on sleep-disordered breathing has developed at an accelerated pace in the last decades. The objective of this study is to present the experience gained in our country in the diagnosis and treatment of obstructive sleep apnea syndrome during the development of a new discipline in the field of pneumology. Clinical records of 3109 patients were reviewed; 447 with electronic medical records and questionnaires for quantification of symptoms and 1779 polysomnographies of patients with obstructive apneas. The time evolution of the patient referral, the demographic characteristics (especially the increase in the prevalence in young people) and the most frequent clinical findings are presented. We highlight the relevant risk factors: obesity and its relationship with severity, endocrine diseases and cephalic fluid displacement. Access mode and adherence to treatment are highlighted. The implementation of sleep clinics allowed the referral of patients for diagnosis and treatment, giving rise to a new discipline of pneumology. The prevalence of obstructive sleep apnea is high, with progressive and sustained increase. Treatment with non-invasive nasal pressure application is feasible. Although with different degrees of accessibility and adherence, it has allowed the correction of the most relevant respiratory sleep disorder

O conhecimento científico e clínico sobre os transtornos respiratórios do sono desenvolveu-se rapidamente nas últimas décadas. O objetivo deste estudo é apresentar a experiência adquirida em nosso país no diagnóstico e tratamento da síndrome da apneia obstrutiva do sono durante o desenvolvimento de uma nova disciplina no campo da pneumologia. Os registros de 3109 pacientes foram revisados; 447 com registros médicos eletrônicos e questionários para quantificação de sintomas e 1779 polissonografias de pacientes com apnéia obstrutiva. Apresentamos a evolução da referência do paciente, as características demográficas (especialmente o aumento da prevalência em jovens) e os achados clínicos mais freqüentes. Destacamos os fatores de risco relevantes: obesidade e sua relação com severidade, doenças endócrinas e deslocamento do cefálico de fluídos. O modo de acesso e a adesão ao tratamento são destacados. A implementação de unidades de sono clínicas permitiu a referência de pacientes para diagnóstico e tratamento, dando origem a uma nova disciplina de pneumologia. A prevalência da apneia obstrutiva do sono é muito alta, com aumento progressivo e sustentado. O tratamento com pressão nasal não invasiva é viável. Embora com diferentes graus de acessibilidade e adesão, permitiu a correção do transtorno do sono respiratório mais relevante.

Impacts of albumin synergized with hydroxyethyl starch on early microvascular albumin leakage after major abdominal surgery in rabbits

Abstract Purpose: To investigate the impacts of albumin synergized with hydroxyethyl starch (HES) on early microvascular albumin leakage after major abdominal surgery in rabbits. Methods: Forty male Japanese rabbits were randomly divided into four groups: the control group, the saline group, the albumin group, and the Syn group (hydroxyethyl starch+albumin). The latter three groups were performed gastrectomy plus resection of pancreatic body and tail and splenectomy. The serum albumin concentration was detected before and 48h after surgery, and the conditions of mesenteric microvascular leakage in these 4 groups were observed under microscope 48 h after surgery to calculate the leakage rate. Results: Compared with the saline group, the albumin group and the Syn group exhibited significantly increased serum albumin concentrations 48h after surgery (P<0.05). The albumin leakage rate was the most obvious in the albumin group, followed by the saline group, while that in the Syn group was the minimal, and there existed significant differences among these groups (P<0.05) . Conclusion: Simple administration of albumin in the early stage after major abdominal surgery could increase the albumin leakage, while the synergization of albumin and hydroxyethyl starch could reduce the albumin leakage.

Fluid distribution kinetics during cardiopulmonary bypass

OBJECTIVE: The purpose of this study was to examine the isovolumetric distribution kinetics of crystalloid fluid during cardiopulmonary bypass. METHODS: Ten patients undergoing coronary artery bypass grafting participated in this prospective observational study. The blood hemoglobin and the serum albumin and sodium concentrations were measured repeatedly during the distribution of priming solution (Ringer's acetate 1470 ml and mannitol 15% 200 ml) and initial cardioplegia. The rate of crystalloid fluid distribution was calculated based on 3-min Hb changes. The preoperative blood volume was extrapolated from the marked hemodilution occurring during the onset of cardiopulmonary bypass. Clinicaltrials.gov: NCT01115166. RESULTS: The distribution half-time of Ringer's acetate averaged 8 minutes, corresponding to a transcapillary escape rate of 0.38 ml/kg/min. The intravascular albumin mass increased by 5.4% according to mass balance calculations. The preoperative blood volume, as extrapolated from the drop in hemoglobin concentration by 32% (mean) at the beginning of cardiopulmonary bypass, was 0.6-1.2 L less than that estimated by anthropometric methods (p<0.02). The mass balance of sodium indicated a translocation from the intracellular to the extracellular fluid space in 8 of the 10 patients, with a median volume of 236 ml. CONCLUSIONS: The distribution half-time of Ringer's solution during isovolumetric cardiopulmonary bypass was 8 minutes, which is the same as for crystalloid fluid infusions in healthy subjects. The intravascular albumin mass increased. Most patients were hypovolemic prior to the start of anesthesia. Intracellular edema did not occur. .

Docetaxel-induced Severe Fluid Retention in a Breast Cancer Patient: A Case Report / 한국유방암학회지

Among many adverse effects of docetaxel, fluid retention is a well recognized, cumulative side effect, but severe fluid retention is rare. We report here on a case of docetaxel-induced severe fluid retention with peripheral edema, pleural effusion, severe ascites and pericardial effusion in a 41-year-old woman. She had been treated with 3 cycles of docetaxel 9 days previously and she was admitted to our hospital due to abdominal distention and mild dyspnea. Radiologic studies revealed pleural effusion, severe ascites and a small pericardial effusion. Diuretics were given for 21 days. The pleural effusion was resolved after treatment with diuretics for 2 days, but the ascites wasn't resolved until 14 days of diuretics. After treatment with diuretics for 21 days, all the symptoms of the patient were completely resolved. Early detection is mandatory and diuretics are very effective for patient suffering with docetaxel-induced severe fluid retention.

Accidentabilidad por exposición muco cutánea a fluidos biológicos en profesionales de laboratorios clínicos / Accidentality from mucocutaneous exposure to biological fluids among clinical laboratory professionals

Se determinó la exposición laboral accidental a fluidos biológicos por contacto muco-cutáneo y factores asociados, mediante un estudio descriptivo dirigido a una muestra de 156 bioanalistas adscritos a laboratorios clínicos públicos del área metropolitana del estado Zulia. Para la recolección de datos se diseñó un instrumento que explora la exposición y factores vinculados así como el cumplimiento de medidas post exposición biológica. El promedio de edad de los Bioanalistas fue de 41.9 ± 9.7 años con predominio del sexo femenino 87,2 por ciento. Se evidencia exposición por accidentes muco-cutáneos con una tasa de prevalencia de 176,2 accidentes por cada 100 trabajadores, representados principalmente por salpicaduras 44,3 por ciento y spray 32,7 por ciento detectados en razón de su ocurrencia en un nivel de exposición moderado, en las edades , 54-60 y 26-32 años, en sexo femenino, entre 1-8 años de antigüedad, durante la jornada diurna. La accidentabilidad en relación a los factores asociados, se registra en un nivel de exposición moderado, con todos los fluidos biológicos indagados, en pequeño volumen, a nivel de mucosa ocular, en áreas de procesamiento de muestras y disposición de desechos en el laboratorio. Un nivel de mediano cumplimiento se obtuvo para el manejo post exposición identificándose diferencia estadísticamente significativa entre las medidas indagadas (p> 0.01). La magnitud y características de la exposición a fluidos biológicos revisten una problemática que puede impactar en la salud del personal y debe ser abordada institucionalmente para una efectiva gestión de prevención y control de riesgo.

Occupational exposure to biological fluids through mucocutaneous contact and related factors was determined through a descriptive study using a sample of 156 medical technicians working in public clinical laboratories in the metropolitan area of Zulia. A survey for data collection was designed which explored exposure and related factors such as compliance with post biological exposure measures. The age average of the bioanalysts was 41.9± 9.7; 87.2 percent were female. Results evidenced occupational exposure through mucocutaneous accidents, with a prevalence rate of 172.6 accidents for every 100 workers, represented primarily by splashes 44.3 percent and spray 32.7 percent, detected at a moderate level involving female workers with age ranges 54-60 and 26-32, 1-8 years on the job, during day shifts. Biological accidentality according to associate factors showed moderate exposure levels for all the biological fluids investigated in small volumes, at the level of the ocular mucosa, in sample processing and waste disposal areas. A medium compliance level was recorded for post-exposure handling, with a statistically significant difference (p>0.01) among the measures investigated. The magnitude and characteristics of exposure to biological fluids poses a problem that could impact personnel health, and it should be addressed institutionally to achieve effective prevention and risk control management.

Estudio de los mecanismos de transporte iónico involucrados en la secreción en túbulos de malpighi de chipo (Rhodnius prolixus) / Study of the mechanism of ionic transport involved on the secretion of malpighian tubes of chipos (Rhodnius prolixus)

Se midió la tasa de secreción y los cambios en la concentración interna de sodio y protones de los túbulos demalpighi (UMT) en Rhodnius prolixus bajo estimulación con 5-OH-Triptamina. Para medir secreción utilizamos un sistema de doble perfusión para tener acceso por separado a las membranas basolateral y/o apical de la célula. Los flujos iónicos se midieron por microfluorometría. Se aplicaron hasta trece agentes farmacológicos: Ouabaina, Bafilomicina A1, Furosamida, Bumetanida, DIOA, Probenecina, SITS, Acetazolamida, Amilorida, DPC, BaCl2, pCMBS y DTT. Estos agentes son bloqueadores conocidos de diferentes funciones de transporte de iones, conocidos como ATPasas, co- y/o contratransportadores asi como de canales iónicos y de agua. La asunción básica es que los cambios en los movimientos de agua reflejan los cambios en los mecanismos del transporte de iones que se localizan de la siguiente manera: (i) en la membrana basolateral de la célula, los principales son un cotransportador de Na+-K+-2Cl– y el intercambiador de Cl--HCO- 3; la ATPasa de Na+- K+ y la ATPasa de Na+ y los canales de Cl- y de agua (Rp-MIP) son de importancia intermedia, mientras que los canales de K+ son menos importantes: (ii) en la membrana celular apical, la mayor importancia la tiene un cotransportador de K+-Cl-, que ha sido localizado por primera vez, una ATPasa de H+ tipo V, y un intercambiador de Na+-H+; el intercambiador urato-anión y los canales de K+ son importantes mientras que los canales de Clno lo son. En este trabajo presentamos un modelo actualizado que explica la secreción del UMT.

We have measured fluid secretion rate and intracelular concentration of sodium and protons, in Rhodnius prolixusUMT stimulated to secrete with 5-OH-tryptamine. We used double perfusions in order to have access separately to the basolateral and to the apical cell membranes. The ionic fluxes has been measured using microfluorimetry. 13 pharmacological agents were applied: Ouabain, Bafilomycin A1, Furosemide, Bumetanide, DIOA, Probenecid, SITS, Acetazolamide, Amiloride, DPC, BaCl2, pCMBS and DTT. These agents are known to block different ion transport functions, namely ATPases, co- and/or counter- transporters and ionic and water channels. The basic assumption is that water movement changes reflect changes on ion transport mechanisms which we localize as follows: (i) At the basolateral cell membrane: a Na+ - K+ - 2Cl- cotransport; a Cl- - HCO3 - exchange; the Na+ - K+ - ATPase, Cl- channels and Rp-MIP water channels are fundamental; K+ channels play a lesser role. (ii) At the apical cell membrane, a K+ - Cl- cotransport that is located for the first time; a V - H+ - ATPase; an Na+– H+ exchange; an urate - anion exchange and K+ channels are important, while Cl- channels are not. The present experiments allow us to build a tentative model for the function of the UMT cell, which includes a paracellular pathway for fluid flow. In this work we propose a new actualized model to explain the UMT secretion.

Severe hyponatraemia: current concepts on pathogenesis and treatment.

Severe hyponatraemia (serum sodium <120 mEq/L) is a serious electrolyte disorder associated with life-threatening neurological complications. It develops most often when the ability of the kidney to excrete free water is impaired. The initial adaptation of the brain to hyponatraemia includes loss of water, sodium, potassium and chloride into the cerebrospinal fluid and the late adaptation consists of the loss of organic osmolytes. Adaptation of the brain to hyponatraemia causes potential problems during therapy, as re-adaptation requires a considerably longer time. Rapid correction of hyponatraemia may lead to the development of the osmotic demyelination syndrome. Though the ideal treatment for severe hyponatraemia remains controversial, a consensus regarding therapeutic guidelines has emerged. The rate of correction and the type of infusate depend on the duration and cause of the hyponatraemia, clinical presentation, volume status, renal function and the serum potassium level. The prognosis of the osmotic demyelination syndrome is rather dismal although several therapeutic modalities have been tried.

Hiponatremia / Hyponatremia

Se define a la hiponatremia como la concentración de sodio plasmático menor de 130 mmol/L. Se puede presentar en las siguientes situaciones: trastornos en la eliminación renal de agua (pérdidas en aparato digestivo, pérdidas renales por hipoaldosteronismo, enfermedades renales perdedoras de sal, pérdidas por piel, estados edematosos, depleción de potasio), insuficiencia renal y por uso de diuréticos, hipotiroidismo o en la pseudohiponatremia. Existen 3 posibles estados del organismo con respecto al contenido de sodio: a) disminución del contenido total de sodio, b) normalidad en el contenido total de sodio y c) aumento en el contenido total de sodio. Estos 3 estados pueden acompañarse de otras 3 situaciones cada uno: disminución, normalidad y aumento en el contenido total del agua. La hiponatremia puede ser aguda o crónica. El tratamiento de los síndromes que producen hiponatremia se basa en 3 principios que pueden aplicarse por separado o juntos: la administración de soluciones de NaCl para elevar la concentración del sodio sérico, aplicable en los pacientes con depleción del sodio total; restricción de la ingesta de agua en los pacientes normovolémicos o edematosos; y tratamiento de la causa subyacente

Changes of Left Ventricular Function in Chronic Renal Failure Before and After Hemodialysis / 대한신장학회잡지

The cardiac function of the patients with chronic renal failure, who have had routine hemodialysis for long period is influenced by many factors including hypertension, anemia, artherosclerosis, interdialytic fluid collection and acidosis. Also the fluid shifts that occur during dialysis can alter left ventricular loading conditions. Hemodialysis may also influence left ventricular contractility by virture of its ability to correct electrolyte imbalances, BUN, hematocrit and concentration of inotrophics. Ten patients with chronic renal failure, who have hemodialysis during more than 6 months were studied for the effect of hemodialysis on left ventricular function through echocardiography. 1) Body weight and systolic blood pressure were decreased(P<0.05) and diastolic blood pressure mean arterial blood pressure and heart rate did not increased significantly. 2) Serum calcium increased and BUN and serum potassium decreased significantly(P<0.05). 3) The prolonged preejection period, decreased left ventricular ejection time, stroke volume, endsystolic wall stress and increased rate corrected velocity of circumferential fiber shortening, shortening fraction had statistical significance. In conclusion, hemodialysis can improve cardiac function as decreased preload and increased left ventricular contractility from the patients with chronic renal failure.