Draft genome of Chloroflexus sp. MS-CIW-1, of the Chloroflexus sp. MS-G group from Mushroom Spring, Yellowstone National Park.

Chloroflexus sp. MS-CIW-1 was isolated from a phototrophic mat in Mushroom Spring, an alkaline hot spring in Yellowstone National Park, WY, USA. We report the draft genome of 4.8 Mb consisting of 6 contigs with 3755 protein-coding genes and a GC content of 54.45%.

Bay-Substitution of Perylene Bisimides with Bidentate Nucleophiles: The Case of Aryloxide Anions.

In this study, we delve into the regioselectivity of nucleophilic reactions involving brominated perylene bisimides (PBIs) and various bidentate aryloxide anions, previously associated with an SRN1 mechanism. We present herein a new perspective, suggesting that a single-electron-transfer aromatic nucleophilic substitution (SeT-SNAr) mechanism is a more plausible scenario. Our study reveals the favorable impact of photostimulation on reaction yields, making our method a convenient approach for accessing O-arylated PBIs.

Multimodality imaging for transcatheter tricuspid valve repair and replacement.

Transcatheter tricuspid intervention is a rapidly evolving field with multiple classes of therapeutic devices currently in development. Procedural success in tricuspid intervention is predicated on appropriate device selection for patient specific anatomy and satisfactory imaging for intra-procedural guidance. This review will outline protocols and methodology for multi-modality imaging assessment of the tricuspid valve and associated structures, with emphasis on anatomic and functional characteristics that determine suitability for each class of tricuspid intervention. Intra-procedural imaging requirements for each class of device, with design and procedural imaging guidance of specific devices, will also be addressed.

Tricuspid Leaflet Gap-Reduction Maneuvers During Transcatheter Tricuspid Valve Repair.

Transcatheter tricuspid valve edge-to-edge repair (T-TEER) has emerged as an option for treating patients with tricuspid regurgitation. Few studies have explored intraprocedural maneuvers to optimize leaflet-grasping T-TEER in order to improve technical success. This case series of 3 patients describes maneuvers that facilitated T-TEER in patients with large coaptation gaps or short leaflet lengths. (Level of Difficulty: Advanced.).

Transcatheter Tricuspid Valve Replacement With Novel Self-Expanding Valve: Secure Fixation in Insecure Anatomy.

Current transcatheter tricuspid therapies vary by design with different mechanisms of fixation, anchoring, and therapy. This is the first published report of transfemoral tricuspid valve replacement with the Intrepid device, a valve designed to anchor from annular perimeter oversizing, to treat torrential tricuspid regurgitation from leaflet impingement secondary to a ventricular septal defect occluder. (Level of Difficulty: Advanced.).

Listeriosis neonatal un desafío diagnóstico: reporte de caso y revisión de la literatura / Neonatal listeriosis a diagnostic challenge: A case report and review of the literature

Introducción: La listeriosis es una patología de baja incidencia, con síntomas leves y autolimitados en la población en general, sin embargo, la transmisión materno-fetal, puede generar cuadros graves en neonatos, manifestados como sepsis, meningitis, endocarditis, encefalitis, meningoencefalitis. El diagnóstico oportuno por clínica y datos de laboratorio en coyuntura con la terapéutica adecuada favorecen la resolución de la enfermedad. Caso clínico: Neonato prematuro tardío de 34 semanas, 6 días de edad gestacional, nació por cesárea iterativa, al nacimiento no vigoroso con líquido amniótico meconial pesado, requirió reanimación básica y avanzada. Evolución: Por los antecedentes natales se realizó estudio de infección, con reporte positivo y desarrollo en hemocultivos de Listeria Monocytogenes, diagnóstico de sepsis, meningitis y conjuntivitis, recibió antibiótico terapia intrave-nosa, completó tratamiento y presentó evolución clínica favorable. Conclusiones: En el presente caso la listeriosis de transmisión materno-neonatal tuvo una presentación grave con aspiración de líquido meconial que requirió intubación y soporte ventilatorio, el paciente desarrolló meningitis y conjuntivitis. En la placenta se presentó corionitis.

Introduction: Listeriosis is a low-incidence pathology with mild and self-limiting symptoms in the general population; however, maternal-fetal transmission can generate severe conditions in neonates, manifested as sepsis, meningitis, endocarditis, encephalitis, meningoencephalitis. Timely diagnosis by clinical and laboratory data in conjunction with adequate therapy favors the resolution of the disease. Clinical case: Late preterm neonate of 34 weeks, six days of gestational age, was born by repetitive cesarean section at non-vigorous birth with heavy meconium amniotic fluid and required basic and advanced resuscitation. Evolution: Based on the birth history, an infection study was carried out, with a favorable report and development of Listeria Monocytogenes in blood cultures, diagnosis of sepsis, meningitis, and conjunctivitis, received intravenous antibiotic therapy, completed treatment, and presented favorable clinical evolution. Conclusions: In the present case, the listeriosis of maternal-neonatal transmission had a severe presentation with the aspiration of meconium fluid that required intubation and ventilatory support; the patient developed meningitis and conjunctivitis. Chorionitis occurs in the placenta.

Severe mitral regurgitation in nonagenarians: Impact of symptomatic status, frailty and etiology on management and outcomes.

BACKGROUND: Data regarding mitral regurgitation (MR) in extremely elderly patients are limited. The aim of the present study was to assess symptomatic status, frailty, etiology and outcomes for nonagenarians with severe MR. METHODS: Single-center cohort study of patients ≥90 years of age with at least 3+ MR on echocardiography between September 2010 and August 2018. Out of a total of 11,998 patients with at least 3+ MR, 267 patients were included in the present study. RESULTS: The average age was 93.5 ± 2.6 years, and 57% were female. At baseline, 88% were symptomatic, with mean Charlson co-morbidity index of 6 ± 2 points, and mean frailty score of 2.9 ± 1.4 points. Primary MR was present in 50%, secondary in 47%, and prosthetic valve dysfunction in 3%. Among patients with primary MR, the most common etiology was mitral annular calcification (58%). In comparison, the most common etiology of secondary MR was atrial functional MR (52%). Of all, 95% were treated conservatively, and 5% underwent interventional management. Among 253 patients who had follow-up data with a median follow-up of 14 months (25th-75th interquartile range: 3-31 months), 191 patients (75%) died. Mortality trended higher in the conservative group versus the interventional group (60% vs. 22%, log-rank P = 0.063). CONCLUSIONS: Most nonagenarians with significant MR were symptomatic at presentation, had elevated Charlson co-morbidity index and frailty scores. Etiologies of MR were almost equally distributed between primary and secondary causes. The vast majority of nonagenarians with significant MR were conservatively managed.

Subjective age of acquisition norms for 1604 English words by Spanish L2 speakers of English and their relationship with lexico-semantic, affective, sociolinguistic and proficiency variables.

Psycholinguistic studies have shown that there are many variables implicated in language comprehension and production. At the lexical level, subjective age of acquisition (AoA), the estimate of the age at which a word is acquired, is key for stimuli selection in psycholinguistic studies. AoA databases in English are often used when testing a variety of phenomena in second language (L2) speakers of English. However, these have limitations, as the norms are not provided by the target population (L2 speakers of English) but by native English speakers. In this study, we asked native Spanish L2 speakers of English to provide subjective AoA ratings for 1604 English words, and investigated whether factors related to 14 lexico-semantic and affective variables, both in Spanish and English, and to the speakers' profile (i.e., sociolinguistic variables and L2 proficiency), were related to the L2 AoA ratings. We used boosted regression trees, an advanced form of regression analysis based on machine learning and boosting algorithms, to analyse the data. Our results showed that the model accounted for a relevant proportion of deviance (58.56%), with the English AoA provided by native English speakers being the strongest predictor for L2 AoA. Additionally, L2 AoA correlated with L2 reaction times. Our database is a useful tool for the research community running psycholinguistic studies in L2 speakers of English. It adds knowledge about which factors-linked to the characteristics of both the linguistic stimuli and the speakers-affect L2 subjective AoA. The database and the data can be downloaded from: https://osf.io/gr8xd/?view_only=73b01dccbedb4d7897c8d104d3d68c46 .

Cambios en la práctica de actividad física durante la pandemia por COVID-19 / Changes in Physical Activity Practice during the COVID-19 Pandemic

RESUMEN Objetivo Determinar los cambios en la práctica de actividad física durante la pandemia por COVID-19 en sujetos adultos. Métodos Estudio de corte transversal en 812 adultos de la región caribe colombiana. Se aplicó una encuesta vía telefónica, la cual registró: edad, sexo, nivel educativo y estrato socioeconómico; a su vez, se aplicó el Cuestionario de Intención hacia la actividad física de Prochaska y Marcus para medir las etapas de cambio hacia la actividad física. Se indagó sobre el tiempo sentado al día frente a pantallas como televisión, computador y celular. Las mediciones se realizaron entre los meses mayo y julio de 2020. Se realizó una regresión logística binaria para determinar la relación entre los factores individuales y la práctica de actividad física durante la pandemia. Resultados La proporción de personas que se categorizan en las tres primeras etapas de cambio aumentó de 65% en la medición antes de pandemia a 74,4% después de 4 meses de aislamiento social (p=0,0001). El promedio de horas al día en la población general frente al TV es de 2,7±2 horas; ante celulares, es de 3,8±2,8 horas, y 2,4±2,7 horas frente al computador. Las mujeres tuvieron mayor riesgo de no práctica de actividad física [OR 1,9 (IC 95% 1,4-2,7)], junto con las personas de nivel educativo bajo [OR 1,7 (IC 95% 1,2-2,4)] y las de edad mayor [OR 1,7 (IC 95% 1,3-2,4)]. Conclusión La pandemia por COVID-19 ha incrementado la inactividad física y los comportamientos sedentarios, los cuales varían según las características individuales.

ABSTRACT Objective To determine the changes in the practice of physical activity during the COVID-19 pandemic in adult subjects. Methods Cross-sectional study in 812 adults from the Colombian Caribbean region. A survey was applied by telephone that measured age, sex, educational level and socioeconomic status; likewise, the Prochaska and Marcus Physical Activity Intention Questionnaire to measure stages of change towards physical activity was applied. The time spent sitting each day in front of screens such as television, computer, and cellphone was investigated. Measurements were made throughout the months of May to July 2020. A binary logistic regression was performed to determine the relationship between individual factors and the practice of physical activity during the pandemic. Results The proportion of people who are categorized in the first three stages of change increased from 65% in the measurement before the pandemic to 74,4% after 4 months of social isolation (p=0,0001). The average hours a day in front of the TV for the general population is 2,7±2 hours; 3,8±2,8 hours in front of cellphones, and 2,4±2,7 hours in front of the computer. Women had a higher risk of not practicing physical activity [OR 1,9 (95% CI 1,4-2,7)], alongside people with a low educational level [OR 1,7 (95% CI 1,2-2,4)], and elderly people [OR 1,7 (95% CI 1,3-2,4)]. Conclusion The COVID-19 pandemic has increased physical inactivity and sedentary behaviors, which vary according to individual characteristics.

Differential Phototactic Behavior of Closely Related Cyanobacterial Isolates from Yellowstone Hot Spring Biofilms.

Phototrophic biofilms in most environments experience major changes in light levels throughout a diel cycle. Phototaxis can be a useful strategy for optimizing light exposure under these conditions, but little is known about its role in cyanobacteria from thermal springs. We examined two closely related Synechococcus isolates (Synechococcus OS-A dominates at 60 to 65°C and OS-B' at 50 to 55°C) from outflows of Octopus Spring in Yellowstone National Park. Both isolates exhibited phototaxis and photokinesis in white light, but with differences in speed and motility bias. OS-B' exhibited phototaxis toward UVA, blue, green, and red wavelengths, while OS-A primarily exhibited phototaxis toward red and green. OS-A also exhibited negative phototaxis under certain conditions. The repertoires of photoreceptors and signal transduction elements in both isolates were quite different from those characterized in other unicellular cyanobacteria. These differences in the photoresponses between OS-A and OS-B' in conjunction with in situ observations indicate that phototactic strategies may be quite versatile and finely tuned to the light and local environment. IMPORTANCE Optimizing light absorption is of paramount importance to photosynthetic organisms. Some photosynthetic microbes have evolved a sophisticated process called phototaxis to move toward or away from a light source. In many hot springs in Yellowstone National Park, cyanobacteria thrive in thick, laminated biofilms or microbial mats, where small movements can result in large changes in light exposure. We quantified the light-dependent motility behaviors in isolates representing two of the most abundant and closely related cyanobacterial species from these springs. We found that they exhibited unexpected differences in their speed, directionality, and responses to different intensities or qualities of light. An examination of their genomes revealed several variations from well-studied phototaxis-related genes. Studying these recently isolated cyanobacteria reveals that diverse phototactic strategies can exist even among close relatives in the same environment. It also provides insights into the importance of phototaxis for growth and survival in microbial biofilm communities.

Guía de tratamiento farmacológico específico de la cardiomiopatía amiloidótica por transtiretina, 2021 / Specific pharmacological treatment guide for transthyretin amyloid cardiomyopathy, 2021

Resumen Con el propósito de confeccionar una guía con la mejor evidencia disponible en el tratamiento de la amiloidosis por depósito de transtiretina (ATTR), se generó un listado de preguntas en formato PICO centradas en la efectividad y seguridad y se realizó una búsqueda en PubMed, Cochrane y Epistemokus de los artículos publicados entre 2000-2020 y se incluyeron dos estudios de extensión en relación al tafamidis. Los niveles de evidencia y los grados de recomendación se basaron en el sistema GRADE, emitiéndose 11 recomendaciones para ATTRv y ATTwt. Se consideraron los siguientes fármacos: tafamidis, diflunisal, inotersen, patisiran y doxiciclina más ácido ursodesoxicolico. El grupo de expertos consensuó que el único tratamiento que demostró reducir de la mortalidad global, mortalidad cardiovascular, internaciones cardiovasculares y la progresión de la cardiopatía con un nivel moderado de evidencia fue el tafamidis 80 mg, mientras que para la formulación tafamidis 20 mg la calidad de evidencia es baja. Para inotersen y diflunisal, se formuló una recomendación en contra del tratamiento dada la falta de evidencia de calidad respecto a su efectividad, el perfil de toxicidad y la falta de disponibilidad en el ámbito local. Con respecto al patisirán, la recomendación se focalizó en la población ATTRv. El panel de expertos consensuó que el tratamiento con doxiciclina más ácido ursodeoxicólico podría ser utilizado ante la imposibilidad de iniciar tratamiento con tafamidis, recomendación débil y calidad de evidencia muy baja.

Abstract This clinical practice guideline for treating transthyretin amyloid (ATTR) cardiomyopathy is based on the best available evidence of clinical effectiveness. The PICO format was used to generate a list of ques tions focused on the effectiveness and safety of the specific treatment of patients with ATTR cardiomyopathy. The search was conducted in PubMed, Cochrane and Epistemokus, between July-August 2020, and selected articles between 2000-2020, in English and Spanish. The level of evidence and recommendations were analyzed and classified by the GRADE system. The following drugs were included in the analysis: tafamidis, diflunisal, inotersen, patisiran y doxycycline and ursodeoxycholic acid. The expert panel had an agreement that tafamidis 80mg/daily is the only available drug with moderate evidence and weak recommendation for the reduction of total mortality, cardiovascular morbidity, heart failure hospitalization and progression of the disease in patients with ATTR cardiomyopathy and NYHA class ≤ 3. In contrast, tafamidis 20 mg/daily had low-quality evidence in this group of patients. The expert panel did not recommend inotersen, patisiran and diflunisal in patients with ATTR cardiomyopathy due to the lack of supporting evidence, local drug availability, and the potential risk of toxicity. When patients did not have access to tafamidis, the expert panel stated a weak recommendation to use doxycycline and ursodeoxycholic acid in patients with ATTR cardiomyopathy.

[Specific pharmacological treatment guide for transthyretin amyloid cardiomyopathy, 2021]. / Guía de tratamiento farmacológico específico de la cardiomiopatía amiloidótica por transtiretina, 2021.

This clinical practice guideline for treating transthyretin amyloid (ATTR) cardiomyopathy is based on the best available evidence of clinical effectiveness. The PICO format was used to generate a list of questions focused on the effectiveness and safety of the specific treatment of patients with ATTR cardiomyopathy. The search was conducted in PubMed, Cochrane and Epistemokus, between July-August 2020, and selected articles between 2000-2020, in English and Spanish. The level of evidence and recommendations were analyzed and classified by the GRADE system. The following drugs were included in the analysis: tafamidis, diflunisal, inotersen, patisiran y doxycycline and ursodeoxycholic acid. The expert panel had an agreement that tafamidis 80mg/daily is the only available drug with moderate evidence and weak recommendation for the reduction of total mortality, cardiovascular morbidity, heart failure hospitalization and progression of the disease in patients with ATTR cardiomyopathy and NYHA class = 3. In contrast, tafamidis 20 mg/daily had low-quality evidence in this group of patients. The expert panel did not recommend inotersen, patisiran and diflunisal in patients with ATTR cardiomyopathy due to the lack of supporting evidence, local drug availability, and the potential risk of toxicity. When patients did not have access to tafamidis, the expert panel stated a weak recommendation to use doxycycline and ursodeoxycholic acid in patients with ATTR cardiomyopathy.

Con el propósito de confeccionar una guía con la mejor evidencia disponible en el tratamiento de la amiloidosis por depósito de transtiretina (ATTR), se generó un listado de preguntas en formato PICO centradas en la efectividad y seguridad y se realizó una búsqueda en PubMed, Cochrane y Epistemokus de los artículos publicados entre 2000-2020 y se incluyeron dos estudios de extensión en relación al tafamidis. Los niveles de evidencia y los grados de recomendación se basaron en el sistema GRADE, emitiéndose 11 recomendaciones para ATTRv y ATTwt. Se consideraron los siguientes fármacos: tafamidis, diflunisal, inotersen, patisiran y doxiciclina más ácido ursodesoxicolico. El grupo de expertos consensuó que el único tratamiento que demostró reducir de la mortalidad global, mortalidad cardiovascular, internaciones cardiovasculares y la progresión de la cardiopatía con un nivel moderado de evidencia fue el tafamidis 80 mg, mientras que para la formulación tafamidis 20 mg la calidad de evidencia es baja. Para inotersen y diflunisal, se formuló una recomendación en contra del tratamiento dada la falta de evidencia de calidad respecto a su efectividad, el perfil de toxicidad y la falta de disponibilidad en el ámbito local. Con respecto al patisirán, la recomendación se focalizó en la población ATTRv. El panel de expertos consensuó que el tratamiento con doxiciclina más ácido ursodeoxicólico podría ser utilizado ante la imposibilidad de iniciar tratamiento con tafamidis, recomendación débil y calidad de evidencia muy baja.

A systematic review of disease related stigmatization in patients living with prostate cancer.

BACKGROUND: Prostate cancer has been shown to be susceptible to significant stigmatisation, because to a large extent it is concealable, it has potentially embarrassing sexual symptoms and has significant impact on the psychosocial functioning. METHODS: This review included studies that focused on qualitative and/or quantitative data, where the study outcome was prostate cancer and included a measure of stigmatization. Electronic databases (CINAHL, Medline, PubMed, PsycInfo, Cochrane Library, PROSPERO, and the Joanna Briggs Institute) and one database for grey literature Opengrey.eu, were screened. We used thematic analysis, with narrative synthesis to analyse these data. We assessed risk of bias in the included studies using the RoBANS. RESULTS: In total, 18 studies met review inclusion criteria, incorporating a total of 2295 participants. All studies recruited participants with prostate cancer, however four studies recruited participants with other cancers such as breast cancer and lung cancer. Of the 18 studies, 11 studies evaluated perceived or felt stigma; four studies evaluated internalised or self-stigma; three studies evaluated more than one stigma domain. DISCUSSION: We found that patients living with prostate cancer encounter stigmatisation that relate to perception, internalisation, and discrimination experiences. We also identified several significant gaps related to the understanding of prostate cancer stigmatization, which provides an opportunity for future research to address these important public health issues. REGISTRATION: This systematic review protocol is registered with PROSPERO, the international prospective register of systematic reviews in health and social care. Registration number: CRD42020177312.

On the flexibility of the sound-to-meaning mapping when listening to native and foreign-accented speech.

Extracting linguistic information from the speech signal is critical to successfully communicate with others. We usually carry out this sound-to-meaning mapping easily, but this process may be hampered under adverse listening conditions. Thus, exploring whether foreign accents might affect the sound-to-meaning mapping is particularly relevant, as interactions with these speakers are increasingly common in the globalized world. In this study, we conducted a cross-modal priming task, in which participants (N = 24) were presented with auditory primes uttered by a native or by a French foreign-accented speaker of Spanish, and with visual targets that had different degrees of relatedness to the prime: repeated, semantically related, or unrelated words. Behavioral and EEG measures were analyzed, and we found a significant relatedness effect (i.e., a processing advantage for repeated compared to related words, and for the latter compared to unrelated words). However, speakers' accents had no effect on the results. To further explore the potential effect of speakers' accent on the sound-to-meaning mapping, we conducted a second study, in which participants (N = 22) were presented with the same task, although in this case primes were uttered by the same native speaker as in the previous experiment, and by a German foreign-accented speaker with a stronger accent. We replicated the results observed in the first study. Taken together, our results show moderate evidence that speakers' accent does not affect the sound-to-meaning mapping, suggesting that this is a robust and flexible process that is not compromised by auditory variables related to speakers' characteristics.

Would You Sacrifice Yourself to Save Five Lives? Processing a Foreign Language Increases the Odds of Self-Sacrifice in Moral Dilemmas.

Foreign languages blunt emotional reactions to moral dilemmas. In this study, we aimed at clarifying whether this reduced emotional response applies to the emotions related to the self, empathy, or both. Participants were presented with moral dilemmas, written in their native or foreign language, in which they could sacrifice one man or themselves in order to save five lives (or do nothing and therefore leave five people to die). They were more willing to sacrifice themselves when processing the dilemmas in their foreign language. Also, empathy scores were reduced when responding in the foreign language, but were no reliable predictors of participants' responses to the dilemmas. These results suggest that processing a foreign language reduces emotional reactivity due to psychological and emotional self-distance.

Outcomes of contemporary imaging-guided management of sinus of Valsalva aneurysms.

BACKGROUND: Sinus of Valsalva aneurysms (SVAs) are rare. We assessed the role of multimodality imaging in guiding the contemporary management. METHODS: A single-center retrospective cohort study over a 20-year period was performed. RESULTS: Between January 1997 and June 2017, 103 patients were diagnosed with SVAs (median age: 58 years). Eighty patients presented with non-ruptured SVAs, and 23 with ruptured SVAs. Seventy-six patients underwent surgery, and 27 were conservatively managed. The median durations of follow-up were: 48 months (surgical group) vs. 37.5 months (conservative group). There was no mortality directly attributable to SVA surgery. There were no late complications in the conservative group. Transthoracic echocardiography (TTE) was the first-line imaging investigation (100.0% in surgical group vs. 92.6% in conservative group, P=0.019). Additional imaging studies included: (I) transesophageal echocardiography (TEE): 93.4% in surgical group vs. 22.2% in conservative group, P<0.001; (II) multi-detector cardiac computed tomography (MDCT): 61.8% in surgical group vs. 37.0% in conservative group, P=0.041; (III) cardiac magnetic resonance (CMR): 22.4% in surgical group vs. 14.8% in conservative group, P=0.579. At diagnosis, SVA diameters were: TTE: 4.80 cm (range, 3.30 cm); TEE: 5.40 cm (range, 4.00 cm); MDCT: 5.20 cm (range, 3.90 cm); CMR: 4.80 cm (range, 3.70 cm). CONCLUSIONS: In a 20-year cohort, proper selection for surgery and conservative management resulted in excellent outcomes for SVAs. TTE was the first-line imaging investigation for assessment of SVAs, although many patients underwent an additional imaging investigation. The contemporary outcomes of imaging-guided SVA management were excellent.

The Psychological Impact of the COVID-19 Pandemic Affected Decision-Making Processes.

A sample of 641 participants were presented with four decision-making tasks during the first stages of the COVID-19 lockdown in Spain: The dictator game, framing problems, utilitarian/deontological and altruistic/egoistic moral dilemmas. Participants also completed questionnaires on mental health status and experiences related to the COVID-19 pandemic. We used boosted regression trees (an advanced form of regression analysis based on machine learning) to model relationships between responses to the questionnaires and decision-making tasks. Results showed that the psychological impact of the COVID-19 pandemic predicted participants' responses to the framing problems and utilitarian/deontological and altruistic/egoistic moral dilemmas (but not to the dictator game). More concretely, the more psychological impact participants suffered, the more they were willing to choose the safest response in the framing problems, and the more deontological/altruistic were their responses to moral dilemmas. These results suggest that the psychological impact of the COVID-19 pandemic might prompt automatic processes.

Sleep apnea, "the Ugly Duckling of the Cinderellas" in cardiovascular prevention and rehabilitation.

Cardiovascular diseases are the leading cause of death and account for the largest share of health expenditure worldwide, mainly invested in hospital and secondary care. Prevention and rehabilitation strategies are nearly neglected, therefore "the Cinderellas," in the health-care budget. The World Health Organization has proposed cost-effective interventions to reduce the impact of cardiovascular diseases that include polydrug treatment for hypertension and diabetes, counselling, diet, exercise, and others. Obstructive sleep apnea is not even mentioned among these interventions; consequently, it could be "the Ugly Duckling of the Cinderellas." Obstructive sleep apnea (OSA) is characterized by the presence of obstructive apneas or hypopneas during sleep, accompanied by hypoxia; and it is a highly prevalent but under-diagnosed condition. Although awareness of sleep apnea has recently increased most facts about it remains ignored by many. Robust evidence suggests that OSA is associated with, or is an independent risk factor for, hypertension, cerebrovascular disease, ischemic heart disease, heart failure and arrhythmias and that its prevalence among some of these cardiovascular diseases is higher than 80%. The efficacy of continuous positive airway pressure treatment for obstructive sleep apnea has been established. If obstructive sleep apnea plays a significant role in cardiovascular diseases, then screening and timely appropriate treatment could reduce morbidity and mortality. Thus, the public health and economic impact of these conditions could be included in the "best buy" list of interventions. This narrative review discusses the relationship between OSA and cardiovascular diseases and how neglected the link is.