Prevalencia del síndrome de apnea obstructiva del sueño en adultos que acuden a la consulta externa de medicina familiar, en Monterrey, México (el SAOS sigue siendo una entidad subdiagnosticada en Latinoamérica) / Prevalence of the syndrome of obstructive sleep apnea in adults who consulting family medicine in Monterrey, Mexico (SAOS continues to be underdiagnosed in Latin America)

El síndrome de apnea obstructiva del sueño (SAOS) es una enfermedad común, caracterizada por episodios recurrentes de obstrucción de la vía aérea superior que ocurren durante el sueño, con descensos en la saturación de oxígeno de la hemoglobina, sueño intranquilo y despertares nocturnos, que se ha asociado a un incremento de morbimortalidad fundamentalmente de origen cardiovascular. Afecta al 2-4% de las mujeres y al 4-6% de los hombres de la población general en edad media de la vida. Objetivo: Determinar la prevalencia del síndrome de apnea obstructiva del sueño en adultos que acuden a la consulta externa de la Clínica Hospital Constitución ISSSTE, Nuevo León. Resultados: La distribución por género fue: 47 hombres (51,1%) y 45 mujeres (48,9%). El índice de masa corporal (IMC) promedio fue de 31,2 (IC 95% 30-32,34). Solo diez personas (11%) presentaron IMC normal (< 25), 35 pacientes (38%) evidenciaron sobrepeso (IMC de 25 a 29) y 47 (51%) demostraron obesidad (IMC mayor de 30). Se analizaron 92 poligrafías respiratorias, y mediante un índice de apneahipopnea (IAH) > 5 se encontró una prevalencia del 77%, de los cuales 42% eran mujeres y 58% hombres, con una edad promedio de 52 años. 41% con grado leve (es decir, IAH 5 a 14), 27% con grado moderado (IAH 15 a 29) y 32% con grado severo (IAH igual o mayor de 30). Las patologías señaladas en el total de las encuestas (n = 92) fueron: ansiedad, 39 pacientes (42,4%); depresión, 22 (24,5%); enfermedades renales, 10 (11%); hipertensión arterial, 32 (35%); diabetes, 17 (18,5%); enfermedades reumáticas, 16 (17,4%); convulsiones, 7 (7,6%); alergias, 24 (26%). Conclusiones: En nuestro estudio encontramos que la prevalencia del síndrome de apnea del sueño es alta, con más frecuencia en el género masculino, que aumenta en mayores de 50 años de edad, y la mayoría de pacientes presentan sobrepeso u obesidad. También se comprobó que hasta el 35% de los hipertensos padecen apnea del sueño. Otro dato importante es la frecuencia de pacientes con apnea del sueño que refirieron ansiedad (42,2%)…

Obstructive Sleep Apnea Syndrome (OSAS) is a common disease characterized by recurrent episodes of obstruction of the upper airway during sleep that occur with decreases in oxygen saturation of hemoglobin, restless sleep and nocturnal awakenings, has been associated with increased cardiovascular morbidity and mortality primarily. It affects 2-4% of women and 4-6% of men in the general population in middle age of life Objective: To determine the prevalence of Obstructive Sleep Apnea Syndrome in adults attending the outpatient clinic of the hospital establishment, ISSSTE, Nuevo Le¨®n. Results: The gender distribution was 47 males (51.1%) and 45 women (48.9%). The average BMI of 31.2 (95% CI 30-32.34). Only 10 people (11%) with normal BMI (BMI <25), overweight (BMI 25 to 29) 35 patients (38%), obese (BMI greater than 30) 47 patients (51%). 92 We analyzed respiratory polygraphs, and employing an apnea hypopnea index (AHI) > 5 found a prevalence of 77%, of which 42% are women and 58% men, with an average age of 52 years old. 41% with mild (ie AHI 5-14), 27% with moderate (AHI 15-29) and 32% with severe (AHI ¡Ý 30). The pathologies identified in the total survey (n = 92) are: anxiety 39 patients (42.4%), depression 22 (24.5%), kidney disease 10 (11%), hypertension 32 (35%), diabetes 17 (18.5%), rheumatic diseases 16 (17.4%), seizures 7 (7.6%), allergy 24 (26%). Conclusions: In our study we found that the prevalence of Obstructive Sleep Apnea Syndrome is high, it is more common in the male gender, increased frequency in patients over 50 years of age, the majorities are overweight or obese. We also found that up to 35% of hypertensive patients with sleep apnea. Another important fact is the frequency of patients with sleep apnea who reported anxiety (42.2%)...

Fatores de risco para raquianestesia em recém-nascidos pré-termo submetidos a herniorrafia inguinal / Risk factors for spinal anesthesia in preterm infants undergoing inguinal hernia repair

OBJETIVOS: Investigar os fatores de risco e a incidência de efeitos adversos perioperatórios advindos da raquianestesia não suplementada em recém-nascidos pré-termo. Também foi avaliado o tempo decorrido até o reinício da alimentação oral e até a alta hospitalar. MÉTODOS: Foram coletados prospectivamente os dados perioperatórios de todos os recém-nascidos prematuros e ex-prematuros submetidos a herniorrafia inguinal com raquianestesia em um centro médico terciário. RESULTADOS: O grupo de estudo consistiu em 144 recém-nascidos com uma idade gestacional mediana de 30 semanas, idade concepcional de 37 semanas, peso de nascimento de 1.420 g, e peso de 2.140 g no momento da cirurgia. No total, seis (4,2%) recém-nascidos apresentaram complicações intraoperatórias, que incluíram apneia (2/1,4%), bradicardia (2/1,4%) e hipoxemia (4/2,8%). Complicações pós-operatórias ocorreram em 15 (10,4%) recém-nascidos, principalmente hipoxemia (3/2,1%), bradicardia (8/5,5%) e apneia (6/4,1%). Os fatores preditivos de desfecho desfavorável (apneia, alimentação oral > 6 h de pós-operatório, ou alta > 30 h de pós-operatório) foram displasia broncopulmonar [razão de chances (OR) = 3,2, intervalo de confiança de 95% (IC95%) 2,8-5,3; p = 0,01] e leucomalácia periventricular (OR = 2,8, IC95% 2,1-4,9; p = 0,03). CONCLUSÕES: A raquianestesia é segura e eficaz na herniorrafia inguinal em recém-nascidos pré-termo, levando a um reinício precoce da alimentação oral e a um menor período de hospitalização. Displasia broncopulmonar e leucomalácia periventricular podem acarretar risco de desfecho desfavorável.

OBJECTIVES: To investigate the risk factors and incidence of perioperative adverse effects from unsupplemented spinal anesthesia in preterm infants. Times to resumption of oral feeding and to home discharge were also evaluated. METHODS: Perioperative data were collected prospectively for all preterm and former preterm infants who underwent inguinal hernia repair with spinal anesthesia at a tertiary medical center. RESULTS: The study group consisted of 144 infants with a median gestational age of 30 weeks, postmenstrual age of 37 weeks, birth weight of 1,420 g, and weight at surgery of 2,140 g. Overall, six (4.2%) infants had intraoperative complications, which included apnea (2/1.4%), bradycardia (2/1.4%), and hypoxemia (4/2.8%). Postoperative complications occurred in 15 (10.4%) infants, mainly hypoxemia (3/2.1%), bradycardia (8/5.5%), and apnea (6/4.1%). Predictive factors of an unfavorable outcome (apnea, resumption of oral feeding > 6 h postoperatively, or discharge > 30 h postoperatively) were bronchopulmonary dysplasia (odds ratio [OR] = 3.2, 95% confidence interval [95%CI] 2.8-5.3; p = 0.01) and periventricular leukomalacia (OR = 2.8, 95%CI 2.1-4.9; p = 0.03). CONCLUSIONS: Spinal anesthesia is safe and effective for inguinal hernia repair in preterm infants, with early resumption of oral feeding and short hospitalization. Bronchopulmonary dysplasia and periventricular leukomalacia may pose risks for an unfavorable outcome.

Apneas e infecciones en lactantes / Apnea and infections in infants

Infections are a frequent cause of apnea in infants, involving both respiratory and extrarrespiratory systems. In the first group we find upper respiratory infections and lower respiratory infections caused by virus or bacteria such as Respiratory Syncytial Virus, Parainfluenza and Bordetella pertussis; in the second group urinary tract infections and severe infections such as meningitis and sepsis are of importance. In this article we analyze different causes of infections attributed to apnea, taking into account existing literature at the time.

Las infecciones son una frecuente causa de apneas en lactantes, pudiendo involucrar tanto el sistema respiratorio como extrarrespiratorio. En el primero encontramos las infecciones respiratorias altas y/o bajas producidas tanto por virus como bacterias, donde destacan Virus Respiratorio Sincicial, Parainfluenza y Bordetella Pertussis; en el segundo grupo son de importancia la infección urinaria e infecciones graves como meningitis y sepsis. En este artículo se analizan estas distintas causas infecciosas atribuidas a eventos de apneas en lactantes, en consideración a la literatura actualmente existente.

A Case Report on 30-Week Premature Twin Babies with Congenital Myotonic Dystrophy Conceived by In Vitro Fertilization

Congenital myotonic dystrophy type 1 (DM1) presents severe generalized weakness, hypotonia, and respiratory compromise after delivery with high mortality and poor prognosis. We presented a congenital DM1 of premature twins in the 30th week of gestation. These twins were conceived by in vitro fertilization (IVF). Both babies presented apnea and hypotonia and had characteristic facial appearance. They were diagnosed DM1 by genetic method. They were complicated by chylothorax and expired at 100 and 215 days of age, respectively. Mother was diagnosed DM1 during the evaluation of babies. This is the first report on congenital DM1 which accompanied the chylothorax. More investigation on the association with chylothorax and congenital DM1 is recommended. With a case of severe neonatal hypotonia, congenital DM1 should be differentiated in any gestational age. Finally, since DM1 is a cause of infertility, we should consider DM1 in infertility clinic with detailed history and physical examination.

Computed tomography assessment of lung structure in patients undergoing cardiac surgery with cardiopulmonary bypass

Hypoxemia is a frequent complication after coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB), usually attributed to atelectasis. Using computed tomography (CT), we investigated postoperative pulmonary alterations and their impact on blood oxygenation. Eighteen non-hypoxemic patients (15 men and 3 women) with normal cardiac function scheduled for CABG under CPB were studied. Hemodynamic measurements and blood samples were obtained before surgery, after intubation, after CPB, at admission to the intensive care unit, and 12, 24, and 48 h after surgery. Pre- and postoperative volumetric thoracic CT scans were acquired under apnea conditions after a spontaneous expiration. Data were analyzed by the paired Student t-test and one-way repeated measures analysis of variance. Mean age was 63 ± 9 years. The PaO2/FiO2 ratio was significantly reduced after anesthesia induction, reaching its nadir after CPB and partially improving 12 h after surgery. Compared to preoperative CT, there was a 31 percent postoperative reduction in pulmonary gas volume (P < 0.001) while tissue volume increased by 19 percent (P < 0.001). Non-aerated lung increased by 253 ± 97 g (P < 0.001), from 3 to 27 percent, after surgery and poorly aerated lung by 72 ± 68 g (P < 0.001), from 24 to 27 percent, while normally aerated lung was reduced by 147 ± 119 g (P < 0.001), from 72 to 46 percent. No correlations (Pearson) were observed between PaO2/FiO2 ratio or shunt fraction at 24 h postoperatively and postoperative lung alterations. The data show that lung structure is profoundly modified after CABG with CPB. Taken together, multiple changes occurring in the lungs contribute to postoperative hypoxemia rather than atelectasis alone.

Mulheres e esporte de risco: um mergulho no universo das apneístas / Women and risk sports: diving into the universe of apneístas

Este estudo, de natureza qualitativa propõe-se investigar, sob a ótica do Imaginário Social, os sentidos de limite, risco e corpo para mulheres praticantes de mergulho em apneia, no qual a vivência de uma prática de risco extremo é deliberadamente escolhida pelas informantes. Nossa amostra, intencional, foi composta por oito mulheres que praticam o esporte. O procedimento metodológico utilizado para a interpretação das falas foi a Análise do Discurso proposta por Orlandi (1987, 1993, 1999). Também trabalhamos com a interpretação das palavras que emergem na realização da técnica da Associação de Ideias (ABRIC, 1994). Nove grupos semânticos organizaram-se em torno de um grupo de associações comuns e outro de associações não comuns. As mergulhadoras das grandes profundidades sabem que ao praticarem um esporte de risco extremo desafiam seus limites corporais, e precisam tomar cuidado para não extrapolar esses limites. É preciso estendê-los. A preocupação parece estar presente na vivência deste limiar entre a vida e a morte.

This study of qualitative nature aims at investigating, from a Social Imaginary perspective, the senses of limit, risk and body are for the women who practice apneic diving. The experience of this extreme risk practice is deliberately chosen by informants. Our intentionally selected sample was made up of eight women who practice the sports. The method applied for the interpretation of those speeches was Orlandi's Discourse Analysis (1987, 1993, 1999). We have worked with the interpretation of words that emerge from the Idea Association (ABRIC, 1994) technique. Nine semantic groups were organized around a group of common associations and another group of uncommon associations. The divers who go down great depths know that the practice of that sport of high risks challenges their body limits, and they must be careful not to go beyond those limits. They must extend them. That concern seems to be present in the experience of that boundary between life and death.

Non-rotavirus infection causing apnea in a neonate.

Apnea in a premature infant is not always due to immaturity and caffeine is not always the answer. We report a case of apnea in a preterm infant who presented at two weeks of life with increase in frequency of apnea that did not respond to caffeine. Family history was significant for diarrhea in a sibling. Stool PCR was positive for Norovirus Genogroup II. Enteric isolation was instituted and the apnea resolved spontaneously with conservative management. Re-emergence of apnea or persistent apnea necessitates further investigation to elucidate the etiology.

Relación causal entre apnea y reflujo gastroesofágico / Causal relationships between apnea and gastro-esophageal reflux

Los vómitos, el reflujo gastroesofágico y los episodios de apnea en lactantes son problemas que asustan a los padres y de los cuales deben sier bien informados. En los últimos años se ha logrado estudiar y acotar mejor el diagnóstico de Apparent Life Threatening Event (ALTE) y su escasa relación con el reflujo gastroesofágico.

Eventos de aparente amenaza a la vida (ALTE): conceptos, etiología y manejo / Apparent life-threatening event (ALTE): concepts of etiology and management

Los Eventos de Aparente Amenaza a la Vida (ALTE) son un desafió para el médico por su diversidad etiológica y el estrés que experimentan los familiares al observar un episodio de muerte inminente. En este artículo se analizan las causas relacionadas con ALTE, se plantean estrategias de estudio y de seguimiento.

Breath holding spells: evaluation of autonomic nervous system function.

This study attempted to determine noninvasively whether a dysregulation of autonomic reflexes exists in children with breath holding spells (BHS).Fifty children between 13 to 47 months of age who had experienced BHS were evaluated at a time when they stopped having spells, for autonomic nervous system (ANS) dysfunction. The results were compared with the test results of control group of 100 normal children (age and sex matched). Breath holding children displayed significantly high resting heart rate and resting diastolic BP significantly abnormal; 30: 15 RR ratio after rising from supine to standing position; showed significant hypersensitivity of pupil on instillation of 0.125 percent pilocarpine into conjunctival sac and positive Orthostatic signs when compared to control group. This study correlates with the hypothesis that a subtle underlying generalized autonomic dysfunction exists in children with BHS.

Eventos com aparente risco de vida: incidência, etiologia e investigação clínica / Apparent life-threatening events: incidence, etiology and investigation

O presente estudo tem por objetivo avaliar a incidência, fatores etiológicos e investigação clínica de pacientes com Evento com Aparente Risco de vida (Apparent life-threatening event – ALTE). O método utilizado foi à revisão da literatura através de pesquisa no banco de dados Medline e Lilacs entre 1986-2006 e publicações da Associação Latinoamericana de Pediatria, selecionados a partir de autores com experiência reconhecida em ALTE. Foram revisados 13 artigos de autores renomados além de 3 consensos: americano sobre apnéia infantil e monitorização domiciliar, consenso latinoamericano sobre ALTE e consenso da sociedade européia para estudo e prevenção de morte infantil. A incidência de ALTE descrita foi de 0,6 a 2,27 nos casos revisados. Quanto a etiologia aproximadamente 50 dos casos de ALTE são sintomáticos, sendo mais freqüente doenças do trato gastrointestinal e neurológicas. A investigação deve ser realizada seguindo protocolo padrão e estar direcionada para o diagnóstico da doença de base que definirá o prognóstico do ALTE. Casos recorrentes sem etiologia definida na investigação inicial necessitam de exames complementares, devendo ser considerado o abuso infantil e Munchausen por procuração como diagnóstico diferencial. Concluiu-se que como o episódio de ALTE pode ser a manifestação inicial de entidades nosológicas diversas recomenda-se sua investigação diagnóstica direcionada para doença de base.

Slow versus fast enteral feed advancement in very low birth weight infants: a randomized control trial.

OBJECTIVE: To evaluate the tolerance of rapid advancement of enteral feeds in VLBW babies. SETTING: Tertiary teaching hospital. DESIGN: Randomized controlled trial. METHODS: All stable neonates with birth weight less than 1250 grams were included in the study. The primary outcome variable was the time taken to achieve full enteral feeds (defined as 180 ml/kg/day). The secondary outcome variables were incidence of Necrotizing enterocolitis (NNEC) and incidence of apnea. At 48 hours, the infants were randomized into the slow advancement group (enteral feeds advanced by increments of 15 ml/kg/day) or fast advancement group (enteral feeds advanced by increments of 30 ml/kg/day). The monitoring during feeding included daily weight record, two hourly abdominal girth charting, gastric aspirates, apnea, time taken to reach full enteral feedings and for NNEC. RESULTS: There were 53 infants who were enrolled for the study (27 in the fast advancement group and 26 in the slow advancement group). In the fast advancement group, 20 percent completed the trial; whereas 14 (53.8 percent;) in the slow advancement group completed the study. The two groups were comparable for birth weights, gestational age, sex, intrauterine growth status, Apgar and CRIB scores. The infants in the fast group reached full enteral intake of 180 ml/kg/day significantly earlier (10 +/- 1.8 days) than in the slow group (14.8 +/- 1.5 days). The two groups were comparable for episodes of feed intolerance, apnea, NNEC. Infants in the fast group regained birth weight significantly earlier (median 18 days) than in the slow advancement group (median 23 days). CONCLUSIONS: Stable VLBW neonates can tolerate rapid advancements of enteral feeding without increased risk of adverse effects.

Alteraciones polisomnográficas en lactantes con reflujo gastroesofágico / Polysomnographic abnormalities in infants with gastroesophageal reflux

BACKGROUND: Infant apnea is a common problem that conveys significant burden to families and physicians. Its temporal relationship with gastroesophageal reflux (GER) is controversial. AIM: To establish whether infants with GER of different magnitude have a higher incidence of respiratory events than children without GER. PATIENTS AND METHODS: 146 consecutive patients were evaluated with polisomnography (PSG) and with an esophageal pH probe. Those infants without GER episodes or with an esophageal pH below 4.0 in less than 5 per cent of total sleep time were considered as physiologic GER (Group I), between 5-10 per cent as mild GER (Group II), and over 10 per cent as severe GER (Group III). These groups were evaluated for demographic and polysomnographic characteristics. RESULTS: There were no differences in the demographic and global PSG characteristics neither in oxymetry, heart rate or electroencephalographic abnormalities. Group III infants had a higher percentage of active sleep compared to infants of Group I (p < 0.05) and higher incidence of central pauses and apneas compared to infants of Group I (p < 0.05). CONCLUSIONS: The presence of severe GER may modify the sleep pattern in infants, increasing the percentage of active sleep. The presence of central pauses and apneas in infants with severe GER suggest an association between the inmaturity of the respiratory centers and the adaptation of the anti-reflux mechanisms.

An infant with "dying spells".

A 45-day-old infant presented with the unusual and intriguing symptom of episodic crying and loss of consciousness. The infant was discovered to have a vascular compression of the trachea by the innominate artery, almost serendipitously. He was cured of his symptoms by anterior suspension of the innominate artery.

Apnea in the newborn.

Apnea, defined as cessation of breathing resulting in pathological changes in heart rate and oxygen saturation, is a common occurrence in sick neonates. Apnea is a common manifestation of various etiologies in sick neonates. In preterm children it may be related to the immaturity of the central nervous system. Secondary causes of apnea should be excluded before a diagnosis of apnea of prematurity is made. Methylaxanthines and Continuous Positive Airway Pressure form the mainstay of treatment of apnea in neonates. Mechanical ventilation is reserved for apnea resistant to above therapy. An approach to the management of apnea in neonates has been described.

Estudo comparativo da anestesia com propofol ou thionembutal em cães / Comparative study of the anesthesia with propofol or thionembutal in dogs

Os autores compararam o uso de propofol e thionembutal observando as freqüências cardíaca e respiratória e a presença das seguintes intercorrências: apnéia, tremor, bradicardia, taquicardia, taquipnéia e parada cardíaca. Foram randomizados 100 cães para serem anestesiados com propofol ou thionembutal, sendo monitorizados os parâmetros de interesse ao estudo. Foi constatado que existe importância significantemente maior em relação a ocorrência de apnéia e tremor em ambos os grupos, sendo menores com o uso de propofol. O propofol mostrou-se uma droga mais segura para a anestesia em cães do que o thionembutal.

Ventilación mecánica en recién nacidos con infección respiratoria aguda baja por virus respiratorio sincicial / Mechanical ventilation in newborns with lower respiratory tract infection with respiratory syncytial virus

El objetivo de la presente comunicación breve fue determinar la incidencia de recién nacidos (RN) con infección respiratoria aguda baja (IRAB) por virus respiratorio sincicial (VRS) que requirieron ventilación mecánica, las causas que motivaron la VM y algunas características clínicas y epidemiológicas del grupo. De los 150 RN hospitalizados por IRAB por VRS, 11 (7,3 por ciento) requirieron VM, en 10 de la causa de la VM fue apneas a repetición y en 1 insuficiencia respiratoria global más apnea. En promedio la edad de ingreso fue de 18,1 días, siendo los signos más frecuentes: tos (81,8 por ciento) y dificultad respiratoria (54,5 por ciento). Solo un paciente requirió PIM mayor de 35 cm H2O y solo dos requirieron FiO2 mayor de 0,4; el índice de oxigenación promedio fue de 5,5 y la duración de la VM fue de 3,5 ñ 2,8 días (1 a 11 días). La mediana de la duración de la hospitalización fue de 11 días; falleció un solo paciente. Concluimos que la necesidad de VM en RN con IRAB por VRS es de baja frecuencia (7,3 por ciento), siendo la principal causa de conexión los episodios de apnea, requiriendo, en general asistencia ventilatoria por un breve periodo

Apnea severa: signo precoz de neumonía por pneumocystis carinnii en un lactante VIH negativo / Apnea as an early sign of pneumocystis carinii pneumonia in an HIV negative infant

A few reports in the medical literature suggest an association between Pneumocystis caring and apnea in small infants. This patient, a 1 month 20 days old, HIV negative, infant girl weighing 2,000 grams was admitted to hospital after presenting a severe episode of apnea with cyanosis and bradicardia. She progressively developed bronchopneumonia by P. carinii that required prolonged mechanical ventilation with high ventilatory parameters. The clinical course of this patient illustrates that apnea can be an early sign of P. carinii infection in small infants. Early diagnosis and specific therapy might prevent morbidity and mortality and also decrease the length of hospitalization

Anillos vasculares: valor de las imágenes en 56 casos / Vascular rings: diagnostic imaging in a 56 patients series

El anillo vascular es una anomalía infrecuente de las grandes arterias y sus ramas, que comprimen la tráquea y/o el esófago produciendo estridor y/o disfagia en los niños. Analizamos retrospectivamente los pacientes con anillo vascular estudiados durante 10 años (1988-1998), correlacionando síntomas, Rx de tórax (F y P), esofagograma, endoscopia y angiografía. Utilizando base de datos Epi-6. De estos pacientes a 47 se les realizó arteriografía constatando: 20 DAA, 16 AISDur, 4 ADSlur, 3 AIA, 2 SAP y 2 DK. Se sometieron a tratamiento quirúrgico 39 pacientes. El diagnóstico de anillo vascular es efectivo en el esofagograma en un gran porcentaje de los casos, sobre todo en anillos completos. La endoscopía es útil en los pacientes sintomáticos con esofagograma normal. La clínica define la cirugía y la angiografía la anatomía puntual en los pacientes con indicación quirúrgica. La TC helicoidal con 3D y la RM podrían reemplazar en la actualidad los procedimientos endoscópicos y angiográficos en los pacientes sin cardiopatía asociada