[Updated recommendations for vaccination in adults with respiratory diseases. Argentine Association of Respiratory Medicine, 2023]. / Recomendaciones actualizadas para la vacunación de adultos con enfermedades respiratorias. Asociación Argentina de Medicina Respiratoria, 2023.

Adult smokers, those with comorbidities, and the elderly, are at greater risk of contracting infections and their complications. Community acquired respiratory infections due to viruses, pneumococcus and other bacteria, affect both healthy and sick adults. There are vaccines that the pulmonologist must know and prescribe. The target strains of the influenza vaccine are defined by the WHO for the Southern hemisphere considering those involved in the previous influenza season in the Northern hemisphere. Its effectiveness depends on virulence, concordance between circulating and vaccine strains, and population coverage. The anti-pneumococcal polysaccharide vaccine available since 1983 is being replaced by more effective conjugate vaccines to prevent infections related to serotypes present in them. Immunization against SARS-CoV-2 reduced the contagion, severity, and lethality of COVID-19. The acellular vaccine against Bordetella pertussis for adults is present for specific situations in the adult calendar; vaccinating them strengthens the control of childhood contagion. The double (diphtheria + tetanus), and triple (double + pertussis) bacterial vaccines, and the vaccines against measles, chickenpox, rubella, human papillomavirus, Haemophilus influenzae, meningococcus, herpes zoster, Argentine hemorrhagic fever and yellow fever, are of a more limited use. Soon we will have new vaccines such as the one recently approved by the FDA against respiratory syncytial virus. Through a consensus of experts in respiratory infections, we review the new evidence regarding the immunization of adults who consult a pulmonologist, and thus update the recommendations on vaccination made eight years ago.

Los adultos fumadores con comorbilidades, y los ancianos, corren mayor riesgo de contraer infecciones y sus complicaciones. Las infecciones respiratorias comunitarias por virus, neumococo y otras bacterias afectan tanto a adultos sanos como enfermos. Existen vacunas que el neumonólogo debe conocer y prescribir. Las cepas blanco de la vacuna contra influenza son definidas por la OMS para el hemisferio sur considerando a las implicadas en la temporada precedente de influenza en el hemisferio norte. Su efectividad depende de la virulencia, la concordancia entre las cepas circulantes y las vacunales y la cobertura de la población. La vacuna anti-neumocócica polisacárida disponible desde 1983 está siendo reemplazada por vacunas conjugadas más eficaces para prevenir infecciones relacionadas a serotipos presentes en las mismas. La inmunización contra SARS-CoV-2 redujo el contagio, la gravedad y la letalidad de COVID-19. La vacuna acelular contra Bordetella pertussis para adultos está presente para situaciones puntuales en el calendario para adultos, vacunarlos fortalece el control del contagio infantil. Las vacunas doble bacteriana (difteria + tétanos), y triple (doble + pertussis), y contra sarampión, varicela, rubeola, virus del papiloma humano, Haemophylus influenzae, meningococo, herpes zóster, fiebre hemorrágica argentina y fiebre amarilla, son de uso más limitado. Pronto contaremos con nuevas vacunas, como la recientemente aprobada por la FDA contra el virus sincicial respiratorio. Revisamos a través de un consenso de expertos en infecciones respiratorias las nuevas evidencias acerca de la inmunización de adultos que consultan al neumonólogo, y actualizamos así las recomendaciones sobre vacunación realizadas ocho años atrás.

Recomendaciones actualizadas para la vacunación de adultos con enfermedades respiratorias Asociación Argentina de Medicina Respiratoria, 2023 / Updated recommendations for vaccination in adults with respiratory diseases Argentine Association of Respiratory Medicine, 2023

Resumen Los adultos fumadores con comorbilidades, y los ancianos, corren mayor riesgo de contraer infecciones y sus complicaciones. Las infecciones respiratorias comu nitarias por virus, neumococo y otras bacterias afectan tanto a adultos sanos como enfermos. Existen vacunas que el neumonólogo debe conocer y prescribir. Las ce pas blanco de la vacuna contra influenza son definidas por la OMS para el hemisferio sur considerando a las implicadas en la temporada precedente de influenza en el hemisferio norte. Su efectividad depende de la virulencia, la concordancia entre las cepas circulantes y las vacunales y la cobertura de la población. La vacuna anti-neumocócica polisacárida disponible desde 1983 está siendo reemplazada por vacunas conjugadas más eficaces para prevenir infecciones relacionadas a sero tipos presentes en las mismas. La inmunización contra SARS-CoV-2 redujo el contagio, la gravedad y la letalidad de COVID-19. La vacuna acelular contra Bordetella pertussis para adultos está presente para situaciones puntuales en el calendario para adultos, vacunarlos fortalece el control del contagio infantil. Las vacunas doble bacte riana (difteria + tétanos), y triple (doble + pertussis), y contra sarampión, varicela, rubeola, virus del papiloma humano, Haemophylus influenzae, meningococo, herpes zóster, fiebre hemorrágica argentina y fiebre amarilla, son de uso más limitado. Pronto contaremos con nuevas vacunas, como la recientemente aprobada por la FDA contra el virus sincicial respiratorio. Revisamos a través de un consenso de expertos en infecciones respiratorias las nuevas evidencias acerca de la inmunización de adultos que consultan al neumonólogo, y actualizamos así las recomendaciones sobre vacunación realizadas ocho años atrás.

Abstract Adult smokers, those with comorbidities, and the elderly, are at greater risk of contracting infections and their complications. Community acquired respiratory infections due to viruses, pneumococcus and other bac teria, affect both healthy and sick adults. There are vac cines that the pulmonologist must know and prescribe. The target strains of the influenza vaccine are defined by the WHO for the Southern hemisphere considering those involved in the previous influenza season in the Northern hemisphere. Its effectiveness depends on virulence, concordance between circulating and vaccine strains, and population coverage. The anti-pneumococcal polysaccharide vaccine available since 1983 is being replaced by more effective conjugate vaccines to pre vent infections related to serotypes present in them. Immunization against SARS-CoV-2 reduced the conta gion, severity, and lethality of COVID-19. The acellular vaccine against Bordetella pertussis for adults is present for specific situations in the adult calendar; vaccinating them strengthens the control of childhood contagion. The double (diphtheria + tetanus), and triple (double + pertussis) bacterial vaccines, and the vaccines against measles, chickenpox, rubella, human papillomavirus, Haemophilus influenzae, meningococcus, herpes zoster, Argentine hemorrhagic fever and yellow fever, are of a more limited use. Soon we will have new vaccines such as the one recently approved by the FDA against respi ratory syncytial virus. Through a consensus of experts in respiratory infections, we review the new evidence regarding the immunization of adults who consult a pulmonologist, and thus update the recommendations on vaccination made eight years ago.

Argentine consensus recommendations for lung cancer screening programmes: a RAND/UCLA-modified Delphi study.

BACKGROUND: Lung cancer (LC) screening improves LC survival; the best screening method in terms of improving survival is low-dose CT (LDCT), outpacing chest X-ray and sputum cytology. METHODS: A consensus of experts in Argentina was carried out to review the literature and generate recommendations for LC screening programmes. A mixed-method study was used with three phases: (1) review of the literature; (2) modified Delphi consensus panel; and (3) development of the recommendations. The Evidence to Decision (EtD) framework was used to generate 13 evaluation criteria. Nineteen experts participated in four voting rounds. Consensus among participants was defined using the RAND/UCLA method. RESULTS: A total of 16 recommendations scored ≥7 points with no disagreement on any criteria. Screening for LC should be performed with LDCT annually in the population at high-risk, aged between 55 and 74 years, regardless of sex, without comorbidities with a risk of death higher than the risk of death from LC, smoking ≥30 pack-years or former smokers who quit smoking within 15 years. Screening will be considered positive when finding a solid nodule ≥6 mm in diameter (or ≥113 mm3) on baseline LDCT and 4 mm in diameter if a new nodule is identified on annual screening. A smoking cessation programme should be offered, and cardiovascular risk assessment should be performed. Institutions should have a multidisciplinary committee, have protocols for the management of symptomatic patients not included in the programme and distribute educational material. CONCLUSION: The recommendations provide a basis for minimum requirements from which local institutions can develop their own protocols adapted to their needs and resources.

Perceived stress, resilience, and stress coping in patients with drug resistant epilepsy and functional dissociative seizures.

PURPOSE: Depression and anxiety are psychiatric disorders related to chronic stress, commonly found in patients with drug-resistant epilepsy (DRE) and functional dissociative seizures (FDS). The present study compares the levels of perceived stress, resilience, and the styles of stress coping among patients with DRE (n=60), FDS (n=28), and controls (n=31). METHODS: We performed a cross-sectional study. All patients underwent Video Electroencephalography to confirm the diagnosis and completed the psychiatric assessment (SCID I and II of DSM IV) supported by several instruments validated in Spanish. RESULTS: FDS scored higher in perceived stress (p = 0.004) with lower levels of resilience compared to controls (p = 0.01). Stress coping subscales show higher scores in negative self-focus and hostility in patients with FDS compared to controls (p=0.003). Similarly, DRE patients scored higher in perceived stress (p = 0.001), and presented lower levels of resilience (p = 0.004) with higher levels of hostility compared to controls (p=0.02). However, no significant differences were found between FDS and DRE on stress coping variables. Anxiety scores and depression rates were higher in the FDS group compared to DRE (p=0.008) and higher in DRE compared to controls (p<0.05). A positive correlation between depression and perceived stress was found (r = 0.6, p=0.0001). CONCLUSIONS: Our results delineate a more detailed picture of the psychological profile of this population, emphasizing the importance of stress factors in patients with FDS and DRE. Combined intervention strategies which enhance stress coping may be appropriate to direct treatment and psychotherapy.

Factores predictivos de cesación tabáquica en adultos de Argentina: Análisis secundario de la encuesta mundial de tabaco / Who quit smoking and who wants to quit?: Secondary analysis from Global Adult Tobacco Survey in Argentina

INTRODUCCIÓN: La reducción del daño a la salud causado por el tabaco depende de la cesación. Se han descripto características sociodemográficas y personales relacionadas con el cese, pero no se cuenta con análisis en esta población. El objetivo fue evaluar los predictores de ser ex fumador o estar en una etapa favorable para dejar de fumar en la población urbana de Argentina. MÉTODOS: Análisis secundario de la Encuesta Mundial de Tabaquismo en Adultos (EMTA-GATS) empleando regresión logística multivariable. RESULTADOS: Se incluyó a 6299 sujetos (edad media: 43,3 años; hombres: 46,39%; fumadores: 23,16%). Ser ex fumador se asoció a edad (OR 1,11; IC95%: 1,02-1,20 cada 5 años), hogares en los que no se fuma (OR 2,92; IC95%: 1,78-4,78), apoyo al aumento de impuestos al tabaco (OR 2,32; IC95%: 1,52-3,56), no fumar a diario (OR 2,06; IC95%: 1,25-3,39) y ser mujer (OR 1,53; IC95%: 1,06-2,19), independientemente del nivel educativo y de ingresos. Entre los fumadores, la edad (OR 1,10; IC95%: 1,01-1,26 cada 5 años) y estar sensibilizado por advertencias sanitarias (OR 4,64; IC95%: 2,28-9,41) se asociaron a querer dejar, independientemente del género y nivel educativo. El consejo médico se asoció con la decisión de dejar de fumar (OR 6,25; IC95%: 2,91- 13,42), independientemente del nivel educativo y de ingresos. DISCUSIÓN: Implementar campañas de hogares libres de humo, advertencias sanitarias y el asesoramiento médico son estrategias útiles para contribuir a la cesación.

Outcomes of patients with non-small cell lung cancer and poor performance status treated with immune checkpoint inhibitors in the real-world setting.

BACKGROUND: Immune-checkpoint inhibitors (ICIs) are standard treatments for metastatic non-small cell lung cancer (NSCLC). Patients with poor performance status (PS) are underrepresented in clinical trials. We evaluate the efficacy and safety of ICIs in a real-world setting. METHODS: We conducted a multi-institutional retrospective study to assess clinical outcomes of NSCLC treated with ICIs. We categorized pts within two groups (PS 0-1 vs 2) and assessed clinical outcomes and safety. RESULTS: Two hundred and sixty nine patients were included, 44 patients (16.4%) had baseline PS 2 and 223 patients (82.9%) PS 0-1. The overall response rate (ORR) was 30.4%, median PFS was 7.26 months (95% CI 5.1-9.4), and median OS was 15.18 months (95% CI 9.5-20.9). Patients with a PS 2 were most likely to received ICIs in the second or later line (84.1% vs 64.6%; p = 0.01), had baseline steroids (21.4% vs 8.2%; p 0.010), lower response rate (16.7% vs 34.5%; p 0.02) and clinical benefit (35.7% vs 71%; p 0.000) compared to PS 0-1 pts. Moreover, PS ≥ 2 patients had shorter PFS, median 2.2 months (95% CI 1.3-3.1) compared to 9.9 months (95% CI 6.7-13.1] and shorter OS, 3.3 months (95% CI 2.6-4.2) versus 24.1 months (95% CI 16.1-32.1), respectively. PS was significantly associated with PFS and OS in multivariate analysis. As it was expected, immunotherapy was well tolerated with a safety profile comparable to the previous published data. CONCLUSION: Based on these retrospective results, patients with poor baseline performance status seem to have poor clinical outcomes with ICIs in the real-world setting.

Consumo de cigarrillos electrónicos en Argentina Resultados de dos encuestas nacionales / Electronic cigarette use in Argentina: Results from two national surveys

INTRODUCCIÓN: Los cigarrillos electrónicos (CE) aparecieron en 2004 y actualmente se consumen en la mayoría de los países. En Argentina, la Administración Nacional de Medicamentos, Alimentos y Tecnología Médica (ANMAT) prohibió su venta en 2011. El objetivo principal de este reporte fue informar las prevalencias de consumo actual de cigarrillos tradicionales y de CE en adultos y adolescentes de Argentina. MÉTODOS: Los datos sobre adultos se obtuvieron de la Encuesta Nacional de Factores de Riesgo de 2018 con representatividad nacional. Los datos de jóvenes provinieron de la Encuesta Mundial de Tabaco en Jóvenes de 2018, que incluyó a 1845 alumnos de escuelas públicas y privadas a nivel nacional. RESULTADOS: En adultos, la prevalencia de consumo actual de cigarrillos tradicionales fue del 22,2% y la de CE fue del 1,1%. Entre los jóvenes de 13 a 15 años, el 18,0% refirió haber consumido cigarrillos tradicionales y el 7,1%, CE en los 30 días previos a la encuesta. El 14,4% había consumido CE alguna vez en su vida. El 75% conocía los CE, y el 42% creía que eran menos dañinos que los cigarrillos tradicionales. El uso de CE se evidenció también en jóvenes que nunca habían probado un cigarrillo común. DISCUSIÓN: Dos encuestas nacionales en adultos y en jóvenes escolarizados muestran que el consumo de cigarrillos tradicionales es elevado y que, a pesar de la prohibición, el CE es consumido por jóvenes y adultos. Es necesario reforzar la fiscalización de la ley vigente y la prohibición completa de todo tipo de publicidad, promoción, patrocinio y exhibición de productos de tabaco, incluidos los CE

Prevalence and Features of Asthma in Young Adults in Urban Areas of Argentina. / Prevalencia y características clínicas del asma en adultos jóvenes en zonas urbanas de Argentina.

OBJECTIVE: To investigate the burden of asthma in a young adult population in urban areas of Argentina. DESIGN: A nationwide telephone survey in subjects aged 20-44 years was performed in urban areas in Argentina. The European Community Respiratory Health Survey questionnaire was used. Asthma was defined as an exacerbation in the last year or use of asthma medications. RESULTS: In total, 1,521 subjects responded (62.4% females, mean age 33 years), of whom 91 were classified as asthmatics (5.9%, 95% CI 4.7-7.1). Prevalence adjusted for age, sex and education level was 6.4% (95% CI 5.1-7.7). Wheezing was reported by 13.9% (95% CI 15.6-12.2) and a diagnosis of asthma by 9.5% (95% CI 8.0-11.0). Among individuals with a diagnosis of asthma (n=154), 71.3% had undergone spirometry. Among those treated (n=77), 51.9% used medications daily and 46.8% as a rescue measure. Of those reporting an exacerbation in the last year (n=60), 55% had attended an emergency department and 23% were admitted. Asthma was associated with rhinitis (OR 11.1, 95% CI 6.2-19.9) and family history (OR 3.6, 95% CI 2.3-5.5). CONCLUSION: Asthma prevalence in young adults in Argentina is similar to Europe. Although attacks and admissions were common, regular use of medications was reported by half of those treated. These results may be useful for other Latin American countries.

Efecto de las campañas y de las advertencias sanitarias de cigarrillos en la línea de atención al fumador en Argentina / Effect of Mass Media Campaigns and Health Warnings on Cigarette Packs on Smokers' Quitline in Argentina

Las líneas telefónicas de ayuda al fumador son un medio eficaz para promover la cesación. La incorporación de imágenes y frases como advertencias sanitarias junto al número de la línea en el paquete de cigarrillos se asoció a un incremento sustancial de llamadas, comparable al logrado por fuertes campañas en medios masivos.

Association Between Cigarette Smoking Prevalence and Income Level: A Systematic Review and Meta-Analysis.

INTRODUCTION: Previous evidence linked low socioeconomic status with higher smoking prevalence. Our objective was to assess the strength of this association in the world population, updating a previous work. METHODS: Systematic review and meta-analysis of observational studies. Subgroup analyses included continents, WHO regions, country mortality levels, gender, age, risk of bias, and study publication date. Independent reviewers selected studies, assessed potential bias and extracted data. We searched MEDLINE, EMBASE, CENTRAL, SOCINDEX, AFRICAN INDEX MEDICUS, and LILACS, and other sources from 1989 to 2013 reporting direct measurements of income and current cigarette smoking. RESULTS: We retrieved 13,583 articles and included 93 for meta-analysis. Median smoking prevalence was 17.8% (range 3-70%). Lower income was consistently associated with higher smoking prevalence (odds ratio [OR]: 1.45; 95% confidence interval [CI]: 1.35-1.56). This association was statistically significant in the subgroup analysis by WHO regions for the Americas (OR: 1.54; 95% CI: 1.42-1.68), South East Asia (OR: 1.53; 95% CI: 1.10-2.00), Europe (OR: 1.45; 95% CI: 1.29-1.63), and Western Pacific (OR: 1.32; 95% CI: 1.02-1.72), and in studies conducted during 1990s (OR: 1.42; 95% CI: 1.24-1.62) and 2000s (OR: 1.48; 95%CI: 1.30-1.64). Likewise, it was noted in low-mortality countries (OR: 1.48; 95% CI: 1.37-1.60) and for both genders. Prevalence was highest in the lowest income levels compared to the middle (OR: 1.69; 95% CI: 1.49-1.92), followed by the middle level compared to the highest (OR: 1.31; 95% CI: 1.20-1.43). CONCLUSIONS: Our results show that current cigarette smoking was significantly associated with lower income worldwide and across subgroups, suggesting a dose-response relationship. IMPLICATIONS: This unique updated systematic review shows a consistent inverse dose-response relationship between cigarette smoking and income level, present among most geographical areas and country characteristics. Public health measures should take into account this potential inequity and consider special efforts directed to disadvantaged populations.

Recomendaciones de vacunación en adultos con enfermedades respiratorias: Documento de la Asociación Argentina de Medicina Respiratoria para los neumonólogos / Recommendations on Vaccination for Adults with Respiratory Diseases. Document of the Argentina Association of Respiratory Medicine for Pulmonologists

El neumonólogo de adultos acostumbra a prescribir vacunas. Este documento hecho por expertos en aspectos de la especialidad que involucran vacunar a pacientes con enfermedades respiratorias, perteneciente a la Asociación Argentina de Medicina Respiratoria, resumió la información disponible proponiendo una participación activa en la vacunación contra influenza (VAG), neumococo (VAN), pertusis y zoster. El Ministerio de Salud (MSAL) en Argentina, como el CDC y su comité de consulta sobre inmunización (ACIP) en Estados Unidos, elaboran calendarios y recomendaciones para vacunación. La ACIP recomienda la VAG a mayores de 6 meses sin contraindicaciones; el MSAL a mayores de 65 años y a quienes tengan comorbilidades (incluye enfermedades respiratorias y tabaquismo) o contacto con personas vulnerables. La clásica VAN polisacárida de 23 serotipos es recomendada para adultos con riesgo de enfermedad invasiva, incluyendo a mayores de 65 años, revacunando a los inmunosuprimidos y una única vez a los mayores de 65 que hubieran sido vacunados 5 años antes o más; la ACIP recomienda dar la VAN conjugada de 13 serotipos, más inmunogénica, secuencialmente con la polisacárida de 23, en adultos con factores de riesgo y en mayores de 65 años. Sugerimos usarla en menores de 65 con comorbilidad respiratoria. El neumonólogo debe recordar al menos 2 vacunas más: dar el refuerzo decenal contra difteria y tétanos (DT) en mayores de 18, una vez con vacuna triple acelular (difteria, pertusis y tétanos) protegiendo contra pertusis y reduciendo su transmisión. El herpes zoster produce un rash cutáneo vesicular doloroso. Uno cada 2 mayores de 85 sufrirán al menos un ataque de herpes zoster. La vacuna reduce más del 50% la incidencia y más del 60% la neuralgia post herpética; el ACIP la recomienda en mayores de 60 años. Un gran número de los pacientes con afecciones pulmonares crónicas tienen esa edad.

The pulmonologist uses to prescribe vaccines to adult patients. Experts of the Argentina Association of Respiratory Medicine who are specialists in areas involving vaccination of patients with respiratory diseases prepared this document which summarizes the available information and proposes an active prescription of the infuenza, pneumococcus, pertussis and herpes zoster vaccinations. The Ministry of Health in Argentina as the CDC and its Advisory Committee on Immunization Practices (ACIP) in the USA, made recommendations on vaccination indications and schedules. The ACIP recommends influenza vaccination to persons older than 6 months of age without any contraindication. The Ministry of Health recommends this vaccination to persons over 65 years of age, to those with morbidities (including respiratory diseases and smoking habit) and to persons in contact with high risk people. The classic 23-valent polysaccharide pneumococcal vaccine is recommended for adults at risk of invasive disease, including persons over 65 years of age. Revaccination is recommended to immunosuppressed patients and persons over 65 years of age at 5-year intervals. The ACIP recommends vaccination with the 13-valent serotypes polysaccharide pneumococcal vaccine, which is more immunogenic, sequentially with the 23-valent vaccine in adults with risk factors and over 65 years of age. We suggest this practice in patients under 65 years of age with respiratory morbidities. The pulmonologist must remember at least two other vaccines: a booster vaccination every 10 years of diphtheria and tetanus vaccine to persons over 18 years of age, and once the triple acellular vaccine (diphtheria, pertussis and tetanus) to protect against pertussis and reduce transmission. Herpes zoster (shingles) causes a painful vesicular rash; 50% of persons over 85 years suffer at least one bout of herpes zoster. The vaccine reduces more than 50% incidence and more than 60% postherpetic neuralgia. This vaccine is recommended by ACIP for persons over 60 years. In this age group there are many patients with chronic lung conditions.

A multi-step pathway connecting short sleep duration to daytime somnolence, reduced attention, and poor academic performance: an exploratory cross-sectional study in teenagers.

BACKGROUND: A multi-step causality pathway connecting short sleep duration to daytime somnolence and sleepiness leading to reduced attention and poor academic performance as the final result can be envisaged. However this hypothesis has never been explored. OBJECTIVE: To explore consecutive correlations between sleep duration, daytime somnolence, attention levels, and academic performance in a sample of school-aged teenagers. METHODS: We carried out a survey assessing sleep duration and daytime somnolence using the Pediatric Daytime Sleepiness Scale (PDSS). Sleep duration variables included week-days' total sleep time, usual bedtimes, and absolute weekday to-weekend sleep time difference. Attention was assessed by d2 test and by the coding subtest from the WISC-IV scale. Academic performance was obtained from literature and math grades. Structural equation modeling was used to assess the independent relationships between these variables, while controlling for confounding effects of other variables, in one single model. Standardized regression weights (SWR) for relationships between these variables are reported. RESULTS: Study sample included 1,194 teenagers (mean age: 15 years; range: 13-17 y). Sleep duration was inversely associated with daytime somnolence (SWR = -0.36, p < 0.01) while sleepiness was negatively associated with attention (SWR = -0.13, p < 0.01). Attention scores correlated positively with academic results (SWR = 0.18, p < 0.01). Daytime somnolence correlated negatively with academic achievements (SWR = -0.16, p < 0.01). The model offered an acceptable fit according to usual measures (RMSEA = 0.0548, CFI = 0.874, NFI = 0.838). A Sobel test confirmed that short sleep duration influenced attention through daytime somnolence (p < 0.02), which in turn influenced academic achievements through reduced attention (p < 0.002). CONCLUSIONS: Poor academic achievements correlated with reduced attention, which in turn was related to daytime somnolence. Somnolence correlated with short sleep duration.

Neumonía aguda grave de la comunidad en menores de 65 años sin comorbilidades conocidas previamente: estudio multicéntrico retrospectivo / Severe community acquired pneumonia in healthy adults: a multicenter retrospective study

Objetivo: analizar las características epidemiológicas, clínicas y de estudios complementarios en pacientes jóvenes y sanos con neumonía aguda grave de la comunidad (NACG). Material y Método: evaluación retrospectiva de historias clínicas de adultos menores de 65 años, sin comorbilidades, internados con NACG entre 1998 y 2008. Resultados: se identificaron 40 pacientes (M/F = 0.48), edad promedio 37.8 ± 14.1años (16-61). El 42.5% requirió ventilación mecánica y el 57.5% inotrópicos. La PaO2/FiO2 inicial fue 203.6 ± 91.4 mmHg (50-366.7) y las anomalías de laboratorio más frecuentesincluyeron anemia, leucocitosis, hipoalbuminemia y urea y creatinina elevadas. El tratamiento antibiótico empírico consistió en ceftriaxona o ß-lactámico/inhibidor de ß-lactamasas (BL) + macrólido en el 70% de los casos. La etiología se reveló en el 50%,los patógenos y su frecuencia fueron: Streptococcus Pneumoniae, 35%; Leptospira, 15%; Hantavirus y Mycoplasma pneumoniae, 10% y Legionella pneumophila, Pneumocystisjirovecii, Histoplasma capsulatum, Klebsiella pneumoniae, Haemophilus influenzae BL (-) y Staphylococcus aureus sensible a meticilina, 5%. El 77.5% de los pacientes presentócomplicaciones, las más frecuentes fueron shock, insuficiencia respiratoria, insuficiencia renal aguda y derrame pleural. Ocho pacientes presentaron comorbilidades desconocidas,incluyendo HIV positivo, diabetes mellitus, asma, insuficiencia cardíaca e hipotiroidismo. La mortalidad fue 12.5%. Hipotensión arterial diastólica, taquicardia, requerimiento dehemodiálisis y tratamiento inadecuado se asociaron independientemente a mortalidad. Conclusiones: el 20% de los menores de 65 años con NACG, presumiblemente sanos, tenían comorbilidades. El patógeno más frecuente fue neumococo y la mortalidad se asoció a la gravedad de la sepsis e inadecuación del tratamiento.

Aims: to analyze epidemiologic, clinical and other abnormalities in healthy young adults with severe community acquired pneumonia (SCAP). Methods: retrospective analysis of clinical records of adults younger than 65 years, with SCAP and without previously known comorbidities, admitted from 1998 to 2008. Results: forty patients were included (M/F = 0.48), age 37.8 ± 14.1 years (range 16 - 61). Mechanical ventilation was used in 42.5% and vasopressors in 57.5% of patients. Initial PaO2/FIO2 ratio was 203.6 ± 91.4 mmHg (50 - 366.7); frequent laboratory abnormalities included: anemia, leukocytosis, hypoalbuminemia and high urea and creatinine levels.The empiric antimicrobial therapy was ceftriaxone or ß-lactam/ß - lactamases (BL) inhibitor plus macrolide in 70% of cases. The etiology was established in 50%; the specific pathogens were: Streptococcus pneumoniae, 35%; Leptospira, 15%; Hantavirus and Mycoplasma pneumoniae, 10%; and Legionella pneumophila, Pneumocystisjirovecii, Histoplasma capsulatum, Klebsiella pneumoniae, Haemophilus influenzae BL (-) and methicillin susceptible Staphylococcus aureus, 5%. Complications were present in 77.5% including shock, respiratory failure, acute renal failure and pleural effusion.Eight patients presented previously unknown comorbidities including HIV infection, diabetes mellitus, asthma, congestive cardiac failure and hypothyroidism. Mortality was 12.5 %. Diastolic arterial hypotension, taquichycardia, requirement of hemodialysis and inadequate therapy were significantly associated to mortality. Conclusions: 20% of young and presumably healthy adults with SCAP had comorbidities. S. pneumoniae was the commonest pathogen; mortality was associated with severity of sepsis and inadequate therapy.

Heart rate nonlinear dynamics during sudden hypoxia at 8230 m simulated altitude.

OBJECTIVE: Acute hypobaric hypoxia is associated with autonomic changes that bring a global reduction of linear heart rate variability (HRV). Although changes in nonlinear HRV can be associated with physiologic stress and are relevant predictors of fatal arrhythmias in ischemic heart disease, to what extent these components vary in sudden hypobaric hypoxia is not known. METHODS: Twelve military pilots were supplemented with increasing concentrations of oxygen during decompression to 8230 m in a hypobaric chamber. Linear and nonlinear HRV was evaluated at 8230 m altitude before, during, and after oxygen flow deprivation. Linear HRV was assessed through traditional time-domain and frequency-domain analysis. Nonlinear HRV was quantified through the short-term fractal correlation exponent alpha (alphas) and the Sample Entropy index (SampEn). RESULTS: Hypoxia was related to a decrease in linear HRV indexes at all frequency levels. A non-significant decrease in alphas (basal, 1.39 +/- 0.07; hypoxia, 1.11 +/- 0.13; recovery, 1.41 +/- 0.05; P = .054) and a significant increase in SampEn (basal, 1.07 +/- 0.11; hypoxia, 1.45 +/- 0.12; recovery, 1.43 +/- 0.09; P = .018) were detected. CONCLUSIONS: The observed pattern of diminished linear HRV and increased nonlinear HRV is similar to that seen in subjects undergoing heavy exercise or in patients with ischemic heart disease at high risk for ventricular fibrillation.

Brief review: diurnal rhythms, obesity and educational achievement in South american cultures.

Obesity causes or exacerbates a host of medical conditions, including cardiovascular, pulmonary, and endocrine diseases. In addition, there is growing evidence that obesity and sleep problems are linked in adolescents and that they are significant obstacles for learning, having a negative impact on behavior, and attainment of social competence and quality of life. The theoretical basis of this relationship is discussed. Several studies investigating the relationships between obesity, sleep disturbance, and a number of important negative outcomes are reviewed.

Cumplimiento con las guías nacionales en pacientes hospitalizados con neumonía adquirida en la comunidad: Resultados del estudio capo en Argentina / Adherence with National Guidelines in hospitalized patients with community-acquired pneumonia: Results of CAPO study in Argentina

Un comité de seis sociedades científicas en Argentina desarrolló guías para la atención de pacientes con neumonía adquirida en la comunidad (NAC). El objetivo de este estudio fue evaluar el nivel de cumplimiento con el cuidado recomendado en las guías nacionales en pacientes hospitalizados con NAC en Argentina. Usando indicadores de calidad, la atención de 436 pacientes hospitalizados en 12 centros de Argentina fue evaluada en las áreas de hospitalización, oxigenoterapia, terapia antibiótica empírica, terapia switch, alta hospitalaria y prevención. El nivel de cumplimiento fue clasificado como óptimo (>90%), intermedio (60% a 90%), y bajo (<60%). La selección de antibióticos empíricos y la administración dentro de las primeras ocho horas de admisión tuvieron una adherencia superior al 80%. Se identificó un nivel de cumplimiento bajo en las áreas del pasaje de antibióticos de la vía endovenosa a la vía oral (53%), la prevención con vacunación antineumocóccica (51%) y el ofrecimiento para dejar de fumar (29%). Usando indicadores de calidad se pueden identificar áreas específicas de atención en pacientes con NAC con un bajo nivel de cumplimiento con las guías nacionales. En Argentina se deben desarrollar inicialmente intervenciones enfocadas a mejorar el manejo del pasaje de antibióticos de la vía endovenosa a la vía oral y prevención de la NAC.

A committee of six scientific organizations from Argentina developed guidelines for the management of patients with community-acquired pneumonia (CAP).The objective of this study was to evaluate the level of adherence with the recommended care suggested by the guidelines in patients hospitalized with CAP in Argentina. Using quality indicators the management of 436 patients who were hospitalized in 12 Argentinean institutions was evaluated. The care given among the following areas was reviewed: need for hospitalization, need for oxygen therapy, empiric antibiotic therapy, switch therapy, hospital discharge, and prevention. The level of adherence was classified as optimal (>90%), intermediate (60% to 90%), and low (<60%).The selection of the empiric antibiotic therapy and the administration of antibiotics between the first 8 hours after arrival had an adherence greater to 80%. A low level of adherence was found in the areas of switch therapy (53%), prevention of CAP with pneumococcal vaccine (51%) and smoking cessation offered (29%). Using quality indicators it is possible to identify specific areas of management in patients with CAP to a low level of adherence with national guidelines. In Argentina interventions to improve switch therapy and prevention of CAP should be developed.

Snoring, witnessed sleep apnoeas and pregnancy-induced hypertension.

BACKGROUND: Snoring is common in pregnancy, but there are only a few studies that have investigated the relationship of snoring and pregnancy complications. We aimed to investigate the relationship of snoring and witnessed sleep apnoeas with pregnancy-induced hypertension. METHODS: A questionnaire was administered on the day of delivery to 456 women at the Department of Obstetrics, Hospital Donación F. Santojanni, Buenos Aires, Argentina. Pregnancy complications and blood pressure measurements were recorded from each woman's medical chart. RESULTS: Some 156 (35%) of 447 women with singleton pregnancies who answered the questionnaire, snored at some time during their pregnancy. Snoring was related to pregnancy-induced hypertension and pre-eclampsia combined, with an adjusted odds ratio of 1.82 (95% CI: 1.16-2.84; p <0.01), independent of body mass index before pregnancy, weight gain during pregnancy, neck circumference, smoking, alcohol and age. Witnessed sleep apnoeas were also related to pregnancy-induced hypertensive disease, with an adjusted odds ratio of 8.00 (95% CI: 2.71-23.55; p <0.001). Daytime sleepiness was more prevalent in snoring women. CONCLUSIONS: Snoring and witnessed sleep apnoeas are independently related to pregnancy-induced hypertensive disease.