Cost-utility and budget impact analysis of CPAP therapy compared to no treatment in the management of moderate to severe obstructive sleep apnea in Colombia from a third-party payer perspective.

OBJECTIVES: To conduct cost-utility and budget impact analysis of providing Continuous Positive Airway Pressure (CPAP) therapy versus no treatment for moderate to severe obstructive sleep apnea (OSA) in Colombia from a third-party payer perspective. METHODS: We used a Markov model to assess the cost-utility and budget impact analysis of CPAP in patients over 40 years old with moderate to severe OSA. Data on effectiveness and utility values were obtained from published literature. A discount rate of 5% was applied for outcomes and costs. ICER was calculated and compared against the threshold estimated for Colombia, which is 86% of the GDP per capita. RESULTS: Over a lifetime horizon, the base case analysis showed the incremental cost per quality-adjusted life-years (QALYs) gained with CPAP therapy was COP$3,503,804 (USD$1,011 in 2020 prices). The budget impact analysis showed that the adoption of CPAP therapy in the target population would lead to a cumulative net budget impact of COP$411,722 million (USD$118,784,412 in, 2020 prices) over five years of time horizon. CONCLUSIONS: CPAP was cost-effective compared to no-treatment in OSA. According to the budget impact analysis, adopting this technology would require a budget allocation that is partially offset by reduced number of strokes and traffic accident events.

Study of the Ghrelin/LEAP-2 Ratio in Humans and Rats during Different Phases of Pregnancy.

The Liver-Expressed Antimicrobial Peptide 2 (LEAP-2) has emerged as an endogenous GHS-R antagonist and blunts the orexigenic action of ghrelin. This study aimed to determine the Ghrelin/LEAP-2 ratio in humans and rats during pregnancy. In humans, we conducted a nested case-control study within an observational prospective cohort. Healthy and mild preeclamptic pregnant women were studied at each trimester of gestation and three months postpartum. In addition, a group of non-pregnant women was studied into the follicular and luteal phases of the menstrual cycle. Furthermore, Ghrelin/LEAP-2 ratio was investigated in non-pregnant rats and at different periods of rat pregnancy. Human and rat serum ghrelin and LEAP-2 levels were determined using the commercially available ELISA kits. The Ghrelin/LEAP-2 ratio peak around the second trimester of gestation in healthy pregnant women (p < 0.05). Additionally, there were no statistically significant differences in Ghrelin/LEAP-2 ratio between healthy and preeclamptic pregnant women at each trimester of gestation (p > 0.05). The Ghrelin/LEAP-2 ratio in pregnant rat reached the peak around mid-gestation with a similar pattern to the human pregnancy. LEAP-2 was visualized by immunohistochemistry in human term placenta and rat placentas on days 12, 16 and 21 of pregnancy. In conclusion, this study provides the first evidence of a Ghrelin/LEAP-2 ratio peak around the half-way point of pregnancy onwards during human and rat pregnancy, and it might be associated with increased rates of weight gain during pregnancy. Thus, this study suggests that LEAP-2 and Ghrelin/LEAP-2 ratio might play an important role in maternal physiology adaptation of weight gain during pregnancy.

Maternal Fibroblast Growth Factor 21 Levels Decrease during Early Pregnancy in Normotensive Pregnant Women but Are Higher in Preeclamptic Women-A Longitudinal Study.

(1) Background: Fibroblast growth factor 21 (FGF-21) is an endocrine factor involved in glucose and lipid metabolism that exerts pleiotropic effects. The aim of this study was to investigate the serum FGF-21 profile in healthy and mild preeclamptic pregnant women at each trimester of pregnancy; (2) Methods: Serum FGF-21 levels were determined by ELISA in a nested case-control study within a longitudinal cohort study that included healthy (n = 54) and mild preeclamptic (n = 20) pregnant women, women at three months after delivery (n = 20) and eumenorrheic women during the menstrual cycle (n = 20); (3) Results: FGF-21 levels were significantly lower in the mid-luteal phase compared to the early follicular phase of the menstrual cycle in eumenorrheic women (p < 0.01). Maternal levels of FGF-21 were significantly lower in the first and second trimesters and peaked during the third trimester in healthy pregnant women (p < 0.01). Serum levels of FGF-21 in healthy pregnant were significantly lower in the first and second trimester of pregnancy compared with the follicular phase of the menstrual cycle and postpartum (p < 0.01). Serum FGF-21 levels were significantly higher in preeclamptic compared to healthy pregnant women during pregnancy (p < 0.01); (4) Conclusions: These results suggest that a peak of FGF-21 towards the end of pregnancy in healthy pregnancy and higher levels in preeclamptic women might play a critical role that contributes to protecting against the negatives effects of high concentrations of non-esterified fatty acids (NEFA) and hypertensive disorder. Furthermore, FGF-21 might play an important role in reproductive function in healthy eumenorrheic women during the menstrual cycle.

Validation of the Colombian version of the Karolinska sleepiness scale.

Introduction: Currently, daytime sleepiness is a prevalent condition worldwide. Locally validated instruments for measuring sleepiness are required. The objective of this study was to validate a version of the Karolinska sleepiness scale that was translated into the Spanish spoken in Colombia. Methods: Individuals who attended a sleep laboratory for a polysomnography study and people in the general population were included. The validation process was performed in 6 phases: translation and back translation of the original version of the scale (English), face validity (n=13), pilot test (n=20), criteria validity (n=139) by means of polysomnography and the Epworth sleepiness scale, reproducibility (n=34), and sensitivity to change (n=40). Results: Regarding its discriminant validity, the Colombian version of the Karolinska sleepiness scale is correlated with the Epworth sleepiness scale, provided that a Mann-Whitney z=2661 (p=0.0078) was obtained. The scale has an acceptable reproducibility, Spearman Rho=0.55 (p=0.0002), and sensitivity to change, as shown through a two-tailed t test (p=0.0000). Conclusions: The Karolinska Sleepiness Scale was successfully adapted to the Spanish variation spoken in Colombian and to the conditions of adult Colombians; thus, it constitutes a valid, reliable, and easy to use instrument for the assessment of patients with hypersomnia.

Effects of social isolation on sleep during the COVID-19 pandemic.

The current COVID-19 pandemic is a public health emergency that has seriously affected mental health in the general population. Both, studies on previous epidemics and those conducted during the current pandemic have reported a wide range of psychosocial consequences and multiple psychological symptoms as a result of said outbreaks, and among these problems, sleep/wake cycle alterations stand out. Publications addressing this phenomenon have consistently reported that nearly a third of people who experience social isolation develop insomnia, which, in turn, is an important predictor for mental disorders that affect people's functionality, including anxiety disorders, depression and post-traumatic stress disorder. This reflection paper aims to describe the effects that social isolation may have on sleep in the context of the current COVID-19 pandemic.

Recommendations from the Asociación Colombiana de Medicina del Sueño for the practice of sleep medicine in Colombia during the COVID-19 pandemic / Recomendaciones de la Asociación Colombiana de Medicina del Sueño para el ejercicio de la medicina del sueño en Colombia durante la pandemia por COVID-19

Abstract Measures such as frequent handwashing, mandatory use of face masks by the general population in public spaces, social and physical distancing, and mandatory confinement of most people at their homes have contributed to slowing down the spread of the new coronavirus (SARS-CoV-2), which is the source of the current COVID-19 pandemic. However, adopting some of these measures has caused delays in the diagnosis and treatment of various diseases, including sleep disorders. Therefore, it is urgent for sleep specialists and sleep centers to gradually resume activities, as long as strict biosecurity protocols aimed at reducing the risk of contagion are implemented. In this scenario, and in order to help somnologists reopen sleep centers and resume the procedures performed there, the Asociación Colombiana de Medicina del Sueño (Colombian Association of Sleep Medicine) proposes through this reflection paper several recommendations that should be considered during the reactivation process. These recommendations are based on the COVID-19 spread mitigation strategies established by the Colombian health authorities, the guidelines issued by the American Academy of Sleep Medicine, and relevant literature on this subject, which was reviewed after performing a search in the PubMed, SciELO, and Google Scholar databases using the search terms "sleep" "sleep medicine" and "COVID19".

Resumen El lavado de manos frecuente, el uso obligatorio de mascarilla por parte de la población general en sitios públicos, el distanciamiento físico y social, y el confinamiento obligatorio de la mayoría de la población en sus casas son las medidas que hasta el momento han ayudado a frenar la propagación del nuevo coronavirus (SARS-CoV-2), causante de la actual pandemia por COVID-19. Sin embargo, la adopción de algunas de estas medidas ha generado retraso en el diagnóstico y tratamiento de diferentes enfermedades, incluyendo los trastornos del sueño, por lo que es urgente que los especialistas en medicina del sueño y los centros de sueño retomen sus actividades gradualmente, siempre que se implementen estrictos protocolos de bioseguridad que mitiguen el riesgo de contagio. En este contexto, y con el fin de ayudar a los somnólogos a reabrir los centros de sueño y reanudar los procedimientos allí realizados, la Asociación Colombiana de Medicina del Sueño propone en la presente reflexión una serie de recomendaciones para tener en cuenta durante el proceso de reactivación. Estas recomendaciones se basan en las estrategias de mitigación establecidas por las autoridades sanitarias del país, las directrices de la American Academy of Sleep Medicine y la literatura disponible sobre el tema, la cual fue revisada luego de realizar una búsqueda en las bases de datos PubMed, SciELO y Google Scholar usando los términos "sleep" "sleep medicine" y "COVID19".

Mental health consequences of the COVID-19 pandemic associated with social isolation / Consecuencias de la pandemia de la COVID-19 en la salud mental asociadas al aislamiento social

Abstract The 2019 coronavirus pandemic (COVID-19) is a public health emergency of international concern, which poses a major challenge to mental health as a result of its unprecedented impact in this 21st century. Research in past epidemics has revealed a deep and wide range of psychosocial consequences at the individual and collective level. There are multiple associated psychological disturbances, ranging from isolated symptoms to complex disorders with marked impairment of functionality, such as insomnia, anxiety, depression, and post-traumatic stress disorder. Therefore, it is necessary for mental health services to develop strategies that allow them to react skillfully and provide support to health workers and the affected population so as to reduce the psychological impact as well as the development of psychiatric symptoms. The purpose of this reflection article is to show the possible consequences on the mental health of the population as a result of social isolation due to the COVID-19 pandemic.

Resumen La pandemia por coronavirus 2019 (COVID-19) es una emergencia de salud pública de preocupación internacional, con impactos sin precedentes en el siglo XXI y hoy representa un gran desafío a la salud mental. Estudios en epidemias anteriores han revelado una profunda y amplia gama de consecuencias psicosociales a nivel individual y comunitario durante los brotes. Son múltiples las alteraciones psicológicas asociadas, que van desde síntomas aislados hasta trastornos complejos, con un deterioro marcado de la funcionalidad, como insomnio, ansiedad, depresión y trastorno por estrés postraumático. En este contexto es necesario que las entidades de salud mental desarrollen estrategias que permitan reaccionar con destreza y que logren un soporte al personal de salud y a la población afectada, en aras de reducir el impacto psicológico y de los síntomas psiquiátricos. Este artículo de reflexión tiene por objetivo mostrar las posibles consecuencias en la salud mental de la población, como resultado del aislamiento social debido a la pandemia de la COVID-19.

Repercusiones psiquiátricas del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) / Psychiatric implications of obstructive sleep apnea-hypopnea syndrome (OSAHS)

Resumen La apnea del sueño es un síndrome que afecta múltiples sistemas y produce variados síntomas. En el presente artículo se revisan las enfermedades psiquiátricas más frecuentes asociadas a este y la necesidad de realizar un diagnóstico adecuado y un tratamiento interdisciplinario. La entidad que más se ha podido encontrar en los pacientes con apnea del sueño es la depresión y se piensa que se debe a la fragmentación del sueño, la cual altera la producción de neurotransmisores a nivel cerebral. La ansiedad es la segunda entidad con mayor frecuencia, quizás debido a la liberación de catecolaminas durante la noche. Existen otras sintomatologías asociadas a la apnea del sueño que deben ser revisadas y que mejorarían con un tratamiento adecuado, así como también mejoraría la calidad de vida de los pacientes, pues la atención, la concentración y la memoria incrementarían o disminuirían la irritabilidad y otros síntomas.

Abstract Sleep apnea is a syndrome that affects multiple systems and produces varied symptoms. This article reviews the most frequent psychiatric illnesses associated with this condition, as well as the need for an adequate diagnosis and an interdisciplinary treatment. The most common entity observed in patients with sleep apnea is depression, probably caused by sleep fragmentation, which alters the production of neurotransmitters in the brain. Anxiety is the second most common entity, perhaps, due to the release of catecholamines at night. Other symptoms associated with sleep apnea can be found, and should be reviewed and improved with appropriate treatment; addressing such symptoms could also improve the quality of life of patients, since attention, concentration and memory would increase or decrease irritability and other symptoms.

Evaluación del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) mediante instrumentos de medición como escalas y fórmulas matemáticas / Evaluation of obstructive sleep apnea-hypopnea syndrome (OSAHS) using measurement instruments such as scales and mathematical formulas

Resumen La psicometría del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) se puede proporcionar con el uso de variados métodos de evaluación como entrevistas clínicas, escalas, cuestionarios de sueño, autoregistros y registros psicofisiológicos. La prueba de oro para el diagnóstico de esta enfermedad sigue siendo la polisomnografía, la cual puede llegar a tener altos costos y dificultades para acceder al estudio. Debido a la alta morbimortalidad asociada a este síndrome, se requieren instrumentos que permitan la identificación rápida de individuos que puedan estar en riesgo de padecerlo. Por tales motivos, se han desarrollado herramientas que permiten detectar los pacientes en riesgo de presentar SAHOS, tales como el Cuestionario de Berlín, el STOP-Bang y la Escala de Somnolencia de Epworth. Es importante tener en cuenta los alcances y limitaciones de estas herramientas para escoger el instrumento indicado según lo que se desee evaluar.

Abstract The psychometry of obstructive sleep apnea-hypopnea syndrome (OSAHS) can be obtained through various methods of evaluation such as clinical interviews, scales, sleep questionnaires, self-reports and psychophysiological records. The gold test for the diagnosis of this disease is still polysomnography, which can be expensive and poses difficulties to access the study. Due to the high morbidity and mortality associated with this syndrome, instruments are needed to allow the rapid identification of individuals who may be at risk. In consequence, different tools have been developed to detect patients at risk, such as the Berlin Questionnaire, the STOP-Bang and the Epworth Sleepiness Scale. Considering the scope and limitations of these tools is important to choose the correct instrument depending on what needs to be evaluated.

Psicoeducación en el síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) / Psychoeducation in obstructive sleep apnea-hypopnea syndrome (OSAHS)

Resumen La psicoeducación es una alternativa complementaria a los tratamientos usuales para el paciente con apnea del sueño que permite que quien la padece aprenda a conocer su enfermedad. Se practica en el campo de la salud mental y posibilita que los pacientes afectados identifiquen su entidad nosológica y cooperen de forma participativa y activa en el tratamiento instaurado. Para tratar a los pacientes con apnea del sueño, es importante que ellos conozcan las características de la enfermedad y el tratamiento, pues esto les permite desarrollar conciencia de la enfermedad, con la que pueden alcanzar una mayor adherencia a los tratamientos. Existen varios tipos de terapia: la terapia individual, que se caracteriza por ser una ayuda que brinda el profesional de la salud mental al paciente; la terapia de pareja y la terapia familiar, que ofrecen ayuda psicológica para el manejo de la apnea del sueño y sus efectos secundarios, y la terapia de grupo, para educar en torno a la entidad y su tratamiento mediante el intercambio de experiencias positivas frente al grupo. A su vez, está la intervención de campo en el trabajo y las técnicas de desensibilización progresiva y relajación para mejorar la adherencia al uso de la terapia de presión positiva en la vía aérea (PAP).

Abstract Psychoeducation is a complementary alternative to the usual treatments for patients with sleep apnea, which allows them to learn to know their disease. It is related to the field of mental health and allows the affected patients to identify their nosological entity and to cooperate in a participatory and active way in the established treatment. In order to treat sleep apnea, that patients know the characteristics of the disease and the treatment is important since they become aware of it, thus achieving greater adherence to the treatments. There are several types of therapy: individual therapy, which is characterized as support provided by mental health professionals to the patient; couple and family therapy, which offer psychological help for the management of sleep apnea and its side effects, and group therapy, which educates about the entity and its treatment by sharing positive experiences with the group. Field intervention at work and progressive desensitization and relaxation techniques are also used to improve the adhesion to positive pressure in the airway (PAP) therapy.

Calidad de vida en síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) / Quality of life in obstructive sleep apnea-hypopnea syndrome (OSAHS)

Resumen El síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) influye en la calidad de vida de las personas que lo padecen de manera diferente. Es importante medir esta repercusión, de forma objetiva, al momento de hacer el diagnóstico y durante el tratamiento, porque puede mejorar la adherencia a este último. A partir de diferentes estudios, se han creado escalas de medición generales para las enfermedades y específicas para SAHOS, las cuales permiten evaluar diferentes dimensiones como los síntomas diurnos y nocturnos, la somnolencia diurna, las emociones y la repercusión de la enfermedad sobre las interacciones sociales de las personas y la percepción del paciente frente al tratamiento establecido.

Abstract Obstructive sleep apnea-hypopnea syndrome (OSAHS) has a direct influence on the quality of life of people who suffer from it. Objectively measuring this impact at diagnosis and during treatment is important to improve the subsequent adherence to treatment. Based on different studies, general and specific disease scales for OSAHS have been created, which allow to evaluate different dimensions such as daytime symptoms, nocturnal symptoms, daytime sleepiness, emotions, the repercussion of the disease on the social interactions of people, as well as the patient's perception of the treatment indicated.

Aspectos en la responsabilidad legal y laboral en el síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) / Legal and labor responsibility aspects related to obstructive sleep apnea-hypopnea syndrome (OSAHS)

Resumen La apnea del sueño y la somnolencia diurna excesiva (SDE) constituyen un gran riesgo para el desarrollo de actividades laborales, en especial las que se pueden considerar peligrosas y que implican responsabilidad legal; entre estas se encuentra la conducción de vehículos de transporte público, de carga y de maquinaria pesada. El trabajar por turnos y privarse de horas de sueño es también causa del aumento de accidentes laborales; este riesgo aumenta cuando los trabajadores y sus familiares no comprenden la dimensión real de este tipo de vida laboral y, por tanto, no actúan con responsabilidad respecto a su salud. Algunos autores consideran que la apnea del sueño y la SDE constituyen problemas de salud pública debido a su elevada prevalencia y a los altos costos que origina. Es importante que el Estado colombiano reglamente, por un lado, los aspectos de responsabilidad legal de los pacientes que desempeñan tareas riesgosas y están afectados por esta enfermedad y síntoma específico y, por el otro, las condiciones ocupacionales de los trabajadores que en la actualidad laboran por turnos y ven su salud afectada.

Abstract Sleep apnea and excessive daytime sleepiness (EDS) represent a major risk when developing working activities, especially those that are considered dangerous and involve legal responsibility, including handling public transport vehicles, cargo and heavy machinery. Shift work and sleep deprivation are also causes of increased work-related accidents; this risk increases when workers and their families do not understand the real dimension of this type of work life and, therefore, are not responsible for their health. Some authors think that sleep apnea and EDS are public health issues due to their high prevalence and economic burden. It is important that the Colombian State regulates, on the one hand, aspects of legal responsibility of patients who carry out hazardous tasks and are affected by this disease and specific symptoms and, on the other hand, the occupational conditions of the workers who work shifts and whose health is affected.

[Evaluation of insomnia as a risk factor for suicide]. / Evaluación del insomnio como factor de riesgo para el suicidio.

OBJECTIVE: Perform a non-systematic review of the literature to describe the relationship between insomnia and suicide and the findings of these studies. METHODS: A search was conducted in PubMed, Medline, SciELO, LILACS, and Cochrane Library OVID data combining MeSH terms: "Suicide and sleep initiation and maintenance disorders". RESULTS: Insomnia has been related to suicidal ideation, suicide attempts and suicide deaths in cross sectional studies since more than a decade. Suicide is one of the main causes of death. DISCUSSION: There are multiple risk factors for committing suicide; some are unmodifiable, such as age, male gender and Caucasian ethnicity; and others are potentially modifiable, such as symptoms of depression, substance abuse and sleep disturbances. Among these disturbances, insomnia has been proven to hold a stronger relation to suicide attempts and deaths, although nightmares have also been associated. Actually, insomnia is considered a stronger predictor of lethal suicide attempts than the presence of a suicide plan. CONCLUSIONS: Here lays the importance of why physicians must learn to detect and evaluate insomnia as a sign of alarm and a risk factor for suicide, no matter what illness the patient suffers from.

Nuevas Perspectivas en el Tratamiento del Síndrome de Apnea-Hipopnea Obstructiva del Sueño / New perspectives in the treatment of obstructive sleep apnea-hypopnea syndrome

Abstract Introduction: Obstructive sleep apnea-hypopnea syndrome (OSA) is an increasingly prevalent Received 2 February 2016 disorder in the population, which seriously compromises the quality of life of sufferers. Although continuous positive airway pressure remains the most commonly used treatment modality, its poor adhesion and relative failure have provoked several studies seeking to develop more convenient and effective alternatives for treating this condition. Objective: To review the most effective, recent and innovative strategies that scientific evidence suggests for the treatment of OSA from anatomical and physiological mechanisms involved. Materials and methods: A literature review was performed from items taken from PubMed, ScienceDirect, Springer, LILACS and PEDro databases, published between 2005 and 2015 in English. Results: OSA is an intermittent and repetitive obstruction of the upper airway during sleep, caused mainly by an imbalance in respiratory muscle synergy. For treatment, the scientific literature has recently described methods such as oral devices, oral and nasal pressure therapies, Pillar, the Night Shift, bariatric surgery and stimulation of the hypoglossal nerve. Conclusions: Although a fully effective treatment is not yet available, acombination of strategies from an interdisciplinary perspective can enhance the quality of life of patients. It is expected that in the coming years, the scientific and technological advances will allow for the implementation of a treatment protocol that is able to directly address the etiological processes to reduce their prevalence.

Introducción: El Síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) es un trastorno cada vez más prevalente en la población, que compromete seriamente la calidad de vida de quienes lo padecen. Aunque la presión positiva continua en la vía aérea es la modalidad terapéutica más utilizada, su poca adherencia y relativa insuficiencia han promovido diferentes investigaciones para desarrollar nuevas alternativas de tratamiento. Objetivo: Revisar las estrategias más recientes e innovadoras que la evidencia científica propone para el tratamiento del SAHOS con base en sus mecanismos anatómicos y fisiológicos. Materiales y métodos: Se realizó una revisión bibliográfica a partir de artículos en idioma inglés, tomados de las bases de datos PubMed, ScienceDirect, Springer, LILACS y PEDro, publicados entre 2005 y 2015. Resultados: El SAHOS es la oclusión intermitente y repetitiva de la vía aérea superior durante el sueño, causada principalmente por desbalance en la sinergia muscular respiratoria. Para su tratamiento, recientemente se han descrito modalidades como los dispositivos orales, las terapias de presión, el Pillar, el Night Shift, la cirugía bariátrica y la estimulación del nervio hipogloso. Conclusiones: Aunque aún no se cuenta con un tratamiento totalmente eficaz, la combinación de estrategias desde una perspectiva interdisciplinar puede mejorar la calidad de vida de estos pacientes. Se espera que durante los próximos anos, los avances en ciencia y tecnología permitan implementar el protocolo de tratamiento que logre abordar directamente los procesos etiológicos de la enfermedad para poder reducir su prevalencia.