Síndrome de platipnea-ortodesoxia como causa de disnea en un paciente con neumonía COVID-19 / Platypnea-orthodeoxia syndrome as a cause of dyspnea in a patient with covid-19 pneumonia

El síndrome de platipnea-ortodesoxia (SPO) es una entidad escasamente descrita, causada principalmente por alteraciones a nivel cardiaco y/o pulmonar. Se caracteriza por disnea e hipoxemia en bipedestación que mejora con el decúbito supino. Dada la naturaleza sutil y posicional de los síntomas, representa un reto diagnóstico, en el que se debe considerar su multicausalidad, ya que el tratamiento puede aliviar los síntomas e incluso ser potencialmente curativo. A continuación, presentamos un caso clínico de disnea persistente en un paciente con neumonía COVID-19 que debuta con síndrome de platipnea-ortodesoxia de origen cardiorrespiratorio.(AU)

Platypnea-Orthodeoxia Syndrome (SPO) is a poorly described entity, mainly caused by alterations at the cardiac and/or pulmonary level, characterized by dyspnea and hypoxemia in the upright position that improves with supine position. Because of the subtle and positional nature of the symptoms, it constitutes a diagnostic challenge and its multi-causality must be considered. The treatment can control the symptoms and even be potentially curative. We present a clinical case of persistent dyspnea in a patient with COVID-19 pneumonia which debuts with platypnea-orthodeoxia syndrome of a cardio-respiratory origin.(AU)

Migration of photoinitiators, phthalates and plasticizers from paper and cardboard materials into different simulants and foodstuffs.

The migration of photoinitiators, phthalates and plasticizers from two paper and cardboard materials into food simulants (50% and 95% EtOH and Tenax) and foodstuffs (rice, cereals and milk powder) was studied. In the case of liquid simulants migration was observed to reach the equilibrium after 60 min and depended on the material type and the physicochemical parameters of the migrants, whereas the temperature (room temperature and 60 °C) did not show significant effects. The study of migration of the compounds from a baking paper to Tenax at high temperatures (150 and 250 °C) evidenced an increment of migration when increasing temperature, except for the most volatile analytes. Finally, the migration to foodstuffs was studied using fully validated analytical protocols. Overall, the comparison of the migration rates demonstrated that Tenax was adequate for the simulation of the migration to rice and cereals, but underestimated the migration to infant milk powder, for which 95% EtOH resulted a more suitable simulant.

Target and suspect screening of substances liable to migrate from food contact paper and cardboard materials using liquid chromatography-high resolution tandem mass spectrometry.

This work describes the analysis of both target and non-target compounds in paper and cardboard materials together with the characterization of their migration to Tenax® by means of liquid chromatography coupled to both low (LC-QqQ) and high resolution tandem mass spectrometry (LC-q-Orbitrap), respectively. To this aim, an entire analytical procedure was fully developed and validated for both matrices: paper/cardboard and Tenax®. A total of 97 chemicals, including photoinitiators, phthalates, biocides, antioxidants, etc., listed by the European Regulation, were found in the materials under study together with other substances not included in this list. Moreover, the majority of annotated substances were present in the simulant, giving evidence of their migration capacity. Migration percentages of 10 photoinitiators, 4 phthalates, bisphenol A, bis-(2-ethylhexyl) adipate, acetyltributyl citrate and caprolactam to Tenax® were quantified. Despite not exceeding the established specific migration limit (SML) in any case, benzophenone, 4-phenylbenzophenone and bisphenol A concentrations in some paper and cardboard materials were very close to the SML values established by the EU legislation.

Uptake of perfluorooctanoic acid, perfluorooctane sulfonate and perfluorooctane sulfonamide by carrot and lettuce from compost amended soil.

Sewage sludge, which acts like a sink for many pollutants, including metals, pathogens and organic pollutants, that are not completely removed in waste water treatment plants (WWTPs), is applied as a nutrient rich organic fertilizer in many agricultural applications. In the present work, carrot and lettuce crops were grown in two different compost amended soils fortified with perfluorooctanoic acid (PFOA), perfluorosulfonate acid (PFOS) and perfluorosulfonamide (FOSA) and cultivated in a greenhouse. The plants were harvested and divided into root core, root peel and leaves in the case of carrots and into heart and leaves for lettuces. Concentrations for all the different compartments were determined to assess the bioconcentration factors (BCFs) and the plant distribution of the target analytes. The highest carrot BCFs for PFOA and PFOS were determined in the leaves (0.6-3.4), while lower values were calculated in the core (0.05-0.6) and the peel (0.05-1.9) compartments. However, PFOA was taken up in the translocation stream and accumulated more than PFOS in the edible part of lettuce. FOSA was totally degraded in the presence of carrot; however, a lower FOSA degradation was observed in presence of the lettuce, which was dependent on the total organic carbon (TOC) content of the soil. The higher the TOC value, the higher the FOSA degradation observed. No degradation was observed in the crop absence. In the case of the carrot experiments, different polymeric materials (polyethersulfone, PES, polyoxymethylene, and silicone rod) were tested to predict the concentration in the cultivation media. A high correlation (r(2)>0.63) was observed for the BCFs in the PES and in the carrot core and peel for PFOA and PFOS. It could be, concluded that the PES can be used as a first approach for the determination of the uptake of compounds such as PFOS and PFOA in carrot.

Fast and simple determination of perfluorinated compounds and their potential precursors in different packaging materials.

A simple and fast analytical method for the determination of fourteen perfluorinated compounds (PFCs), including three perfluoroalkylsulfonates (PFSAs), seven perfluorocarboxylic acids (PFCAs), three perfluorophosphonic acids (PFPAs) and perfluorooctanesulfonamide (PFOSA) and ten potential precursors, including four polyfluoroalkyl phosphates (PAPs), four fluorotelomer saturated acids (FTCAs) and two fluorotelomer unsaturated acids (FTUCAs) in different packaging materials was developed in the present work. In order to achieve this objective the optimization of an ultrasonic probe-assisted extraction (UPAE) method was carried out before the analysis of the target compounds by liquid-chromatography-triple quadrupole-tandem mass spectrometry (LC-QqQ-MS/MS). 7 mL of 1 % acetic acid in methanol and a 2.5-min single extraction cycle were sufficient for the extraction of all the target analytes. The optimized analytical method was validated in terms of recovery, precision and method detection limits (MDLs). Apparent recovery values after correction with the corresponding labeled standard were in the 69-103 % and 62-98 % range for samples fortified at 25 ng/g and 50 ng/g concentration levels, respectively and MDL values in the 0.6-2.2 ng/g range were obtained. The developed method was applied to the analysis of plastic (milk bottle, muffin cup, pre-cooked food wrapper and cup of coffee) and cardboard materials (microwave popcorn bag, greaseproof paper for French fries, cardboard box for pizza and cinema cardboard box for popcorn). To the best of our knowledge, this is the first method that describes the determination of fourteen PFCs and ten potential precursors in packaging materials. Moreover, 6:2 FTCA, 6:2 FTUCA and 5:3 FTCA analytes were detected for the first time in microwave popcorn bags.

Uptake of 8:2 perfluoroalkyl phosphate diester and its degradation products by carrot and lettuce from compost-amended soil.

The present work studied the uptake of 8:2 perfluoroalkyl phosphate diester (diPAP) by two different crops (lettuce and carrot) and two different amended soils. Firstly, the possible degradation of 8:2 diPAP in the absence of crop was studied and 8:2 monoPAP (monophosphate), 8:2 FTCA (saturated fluorotelomer carboxylate), 8:2 FTUCA (unsaturated fluorotelomer carboxylate), 7:3 FTCA (saturated fluorotelomer carboxylate), PFHpA (perfluoroheptanoic acid), PFHxA (perfluorohexanoic acid) and PFOA (perfluorooctanoic acid) were detected. In the presence of crops, different degradation products were detected in the soil and, while PFNA (perfluorononanoic acid), PFHpA, PFHxA, PFPeA (perfluoropentacoic acid), PFBA (perfluorobutanoic acid), 7:3 FTCA and PFOA were determined in the cultivation media when carrot was grown, PFOA was the only degradation product detected in the case of lettuce experiments. Regarding the uptake in carrot, all the degradation products except 7:3 FTCA were translocated from the soil to the carrot. Carrot core, peel and leaves bioconcentration factors, BCFs, were determined for 8:2 diPAP and its degradation products. Values lower than method detection limits for core and low BCFs in peel (0.025-0.042) and leaves (0.028-0.049) were achieved for 8:2 diPAP. Regarding to the degradation products, the higher their water solubility, the higher the plant translocation. In this sense, the lower the carbon chain length of PFCAs, the higher the BCFs determined (PFBA > PFHxA > PFHpA > PFOA > PFNA). In general, lower total BCFs were achieved when the total organic carbon of the soils increased. For lettuce experiments, 8:2 diPAP (0.04-0.18) and PFOA (0.28-1.57) were only determined in lettuce heart.

Simultaneous determination of perfluorinated compounds and their potential precursors in mussel tissue and fish muscle tissue and liver samples by liquid chromatography-electrospray-tandem mass spectrometry.

An analytical method for the simultaneous determination in fish liver and muscle tissue and mussel samples of 14 perfluorinated compounds (PFCs), including three perfluoroalkylsulfonates (PFSAs), seven perfluorocarboxylic acids (PFCAs), three perfluorophosphonic acids (PFPAs) and perfluorooctanesulfonamide (PFOSA), and 10 potential precursors, including four polyfluoroalkyl phosphates (PAPs), four fluorotelomer saturated acids (FTCAs) and two fluorotelomer unsaturated acids (FTUCAs), was developed in the present work. Different clean-up strategies by means of solid-phase extraction (SPE) using a mix-mode weak anion exchanger (WAX), reverse phase Envi-Carb or a combination of them was optimized and evaluated for the clean-up of focused ultrasonic solid-liquid (FUSLE) extracts before the analysis by liquid chromatography-triple quadrupole tandem mass spectrometry (LC-MS/MS). Mix-mode WAX coupled in-line to Envi-Carb was finally selected since it rendered the cleanest extracts and minimum matrix effect. The FUSLE-SPE-LC-MS/MS methodology was validated in terms of recovery, precision and method detection limits (MDLs). Apparent recovery values in the 65-116%, 59-119% and 67-126% range and MDLs in the 0.1-2.7 ng/g, 0.1-3.8 ng/g and 0.2-3.1ng/g range were obtained for liver, mussel and fish muscle tissue samples, respectively. The method developed was applied to the analysis of grey mullet liver (Chelon labrosus) and mussel (Mytilus galloprovincialis) samples from the Basque Coast (North of Spain) and Yellowfin tuna muscle tissue (Thunnus albacares) samples from the Indian Ocean. To the best of our knowledge this is the first method that describes the simultaneous determination of 14 PFCs and 10 potential precursors in fish liver, fish muscle tissue and mussel samples. Besides, this is the first time that 8:2 monosubstituted polyfluorodecyl phosphate (8:2 monoPAP) and 8:2 disubstituted polyfluorodecyl phosphate (8:2 diPAP) were detected in mussel and tuna samples, respectively.

Hypoxemic events in spontaneously breathing premature infants: etiologic basis.

Studies of severe hypoxemic events, defined as an arterial oxygen saturation < 80% greater than 4 s in spontaneously breathing infants, have been limited. The purpose of our study was to examine the distribution of respiratory events that lead to a fall in oximetrically measured oxygen saturation by using breathing patterns, heart rate, and validated pulse oximetry analysis. A total of 161 hypoxemic events were detected in 18 of 30 premature infants studied. Using an inductive plethysmographic based monitor, a total of 460 h of cardiorespiratory monitor recordings were analyzed. Hypoxemic events were categorized as being the direct result of apnea (duration longer than 15 s) or pauses (duration 4-14 s) with either unchanged or lower end-expiratory lung volumes compared with the preevent breaths. The breaths in the preevent period were analyzed for volume, timing, and thoracoabdominal coordination indices. Forty of the 161 events (25%) were associated with apnea of which 80% (31/40) had a mixed/obstructive basis. Ninety-four of the 161 severe hypoxemic events (58%) were associated with pauses with unchanged end-expiratory lung volume. Twenty-two of the 161 events (14%) showed pauses with lower end-expiratory lung volume. There were 5/161 events (3%) with severe hypoxemia in which no pause was observed. Comparison of the preevent periods in each category showed significant differences for only percent tidal volume from initial calibration and arterial oxygen saturation. Sixty-two percent (100/161) of severe hypoxemic events were preceded by hypopneic values of percent tidal volume. Seventy-five percent (40/161) of these hypoxemic events and their etiology would have gone undetected using respiratory monitoring from impedance pneumograms and ECGs. The varied basis for these events underscores the importance of analyzing detailed respiratory wave forms along with movement-free signal of arterial oxygen saturation and ECG, to formulate appropriate intervention strategies.

Effect of kangaroo care on sleep time for neonates.

PURPOSE: To determine the change in behavioral state and physiologic parameters due to Kangaroo Care (K Care). METHOD: A quasi-experimental design using a pretest-posttest with neonates serving as their own controls for 4 episodes of 1 hour each: Pre K Care, K Care and Post K Care. Twenty neonate-parent dyads participated. RespiTrace PT Non-invasive Monitoring system was used to record heart and respiratory rate and oxygen saturation. Behavioral state was derived from analyzing RespiTrace PT cardiorespiratory data as well as observation criteria. FINDINGS: There was a significant increase in sleep time for the neonates during K Care as compared to when they were not receiving K Care. The neonates exhibited less agitation, apnea, and bradycardia episodes and maintained stable oxygen saturation during K Care. CONCLUSION: K Care is safe even for very small neonates and is well tolerated. The stability of the preterm infants receiving K Care documents the need to incorporate it into standards of care.

A computer algorithm for differentiating valid from distorted pulse oximeter waveforms in neonates.

Current pulse oximeter technology is fraught with a significant false alarm rate. This is mainly due to motion artifacts at the sensor site which distort the pulse waveform and render the computation of SaO2 invalid. If the pulse waveform could be automatically recognized as either normal or distorted, then only valid SaO2 values would be displayed. We observed that the systolic upstroke time (Sy) of the pulse waveform has a narrow and consistent range in normal appearing pulses. The systolic upstroke time (Sy) is the time from the onset of systole to the peak of the pulse waveform. Comparison of a preset range of Sy was made against Sy obtained by computer analysis of each pulse waveform. Visual examination of 14,090 pulses was carried out to determine the sensitivity and false positive rate of the algorithm. Sensitivity of computer detection of valid pulses was 92% with a positive predictive value of 92%. When used on line for continuous recording of SaO2 in patients, this simple algorithm has the potential to decrease the false alarm rate of pulse oximeters and improve the accuracy of long-term SaO2 recordings.

Diaphragmatic flutter in three babies with bronchopulmonary dysplasia and respiratory syncytial virus bronchiolitis.

Abnormalities of respiratory control, especially apnea, have been reported previously in infants with respiratory syncytial virus (RSV) infections. This is the first report of yet another abnormality of respiratory control, diaphragmatic flutter (DF), in infants with RSV infection. The presentation of these infants did not differ from the usual clinical presentation of RSV infection. While being monitored with respiratory inductive plethysmography for occurrences of apnea known to be common in RSV infection, DF was detected. This abnormality consisted of high frequency, diaphragmatic contractions which were intermittent in nature. They lasted no more than 4 days and were not associated with change in arterial oxygen saturation or heart rate. These infants were discharged free of DF and no further episodes have been observed over a 12-month period.

Comparison of supine and prone noninvasive measurements of breathing patterns in fullterm newborns.

The current study was undertaken to ascertain whether shift from supine to prone posture alters the pattern of natural breathing in healthy fullterm newborns. Breathing patterns were measured in the supine and prone posture in 20 healthy fullterm infants using calibrated, noninvasive respiratory inductive plethysmography (RIP). The values for breathing pattern components in supine and prone postures expressed as means (+/- SD) were, respectively, tidal volume (VT), 14.1(+/- 3.2) and 18.9(+/- 4.9)mL; mean inspiratory flow 26.7(+/- 11.5) and 32.8(+/- 13.0)mL/s; and minute ventilation 232(+/- 75) and 288(+/- 96)mL/kg/min (P < 0.01). Less thoracoabdominal incoordination, expressed as the labored breathing index (LBI), occurred with shift from supine to prone posture in infants studied in the active behavioral stage, changing from 2.0(+/- 0.5) to 1.3(+/- 0.4) (P < 0.01). Placement of a facemask-pneumotachograph system increased VT measured with RIP by 26% in the supine, and 18% in the prone posture. Neither respiratory rate nor inspiratory time (Ti) changed with the postural shift. Therefore, change from supine to prone posture improved ventilation and increased respiratory drive as expressed by VT/Ti. Further, thoracoabdominal incoordination which took place during active sleep in the supine posture, lessened with change to the prone posture.

Measurement of breath amplitudes: comparison of three noninvasive respiratory monitors to integrated pneumotachograph.

Measurement of breath amplitude (BA) and similarly tidal volume (VT) in newborn infants is the standard for detection of apnea and hypopneas. The purpose of our study was to compare the accuracy for BA by three frequently utilized noninvasive respiratory monitors: respiratory inductive plethysmography (RIP), mercury in silastic strain gauges (SG), and impedance pneumography (IP). Twenty healthy full-term infants were studied in both supine and prone postures. The RC and AB gain factors for RIP were obtained using qualitative diagnostic calibration (QDC) procedure. The electrical gain of IP was set equivalent to the BA signal of a pneumotachograph (PNT). The three devices were calibrated in the supine posture and measurements were repeated in the prone posture without changing their calibration factors. Compared to PNT, postural change did not significantly alter BA measured by RIP. The accuracy of breath-to-breath BA measurement in the prone posture was worse for IP and SG compared to RIP and PNT. In contrast to SG or IP, the accuracy of BA measurement maintained was by RIP after a postural change from supine to prone in fullterm newborns.

Tidal volume measurements in newborns using respiratory inductive plethysmography.

Respiratory inductive plethysmography (RIP) is a well-accepted noninvasive technology for monitoring breathing patterns in adults. Prior attempts to calibrate this device in babies have been fraught with technical difficulties, thereby limiting applications in this population. Recently, a new method, qualitative diagnostic calibration (QDC), has been shown to provide accurate calibration of tidal volume in adults. The QDC method is based upon principles of the isovolume maneuver and carried out during natural breathing without specialized respiratory maneuvers or postural changes. We calibrated RIP with QDC in the supine posture and compared tidal volume (VT) measured with RIP to VT by a face mask-pneumotachograph (PNT) in 21 healthy full-term newborns in supine and prone postures. Eleven of the babies were calibrated during active sleep and 10 in quiet sleep. The mean VT in the supine and prone postures were 19 and 25 ml, respectively. In the supine and prone postures, weighted mean difference between RIP (VT) and PNT (VT) and 95% confidence intervals were -0.05 ml (-0.27, 0.18) and -0.32 ml (-0.08, 0.55), respectively. There was no difference in the accuracy of RIP relative to PNT calibrated during active sleep when thoracoabdominal incoordination was present or quiet sleep when it was not in either the supine or the prone postures. Therefore, in full-term infants, RIP calibrated with QDC solely in the supine posture provides clinically acceptable measurements of VT in both supine and prone postures.

Aneurysm of the right ventricular outflow tract: a complication of aorta-main pulmonary (central) shunt.

The ascending aorta-main pulmonary artery (central) polytetrafluoroethylene (PTFE) Gore-Tex shunt was introduced in 1975 by Gazzaniga and coworker. It is a widely used palliative procedure. We present a case study with an unusual late complication. An aneurysm was discovered at autopsy in a patient who was diagnosed at birth with hypoplastic right ventricle, pulmonary valve atresia, small main and branched pulmonary arteries. At 4 days of age, the patient underwent an aorta to main pulmonary artery (PTFE) Gore-Tex shunt. Subsequent echocardiogram showed dilatation of the right ventricular outflow tract. To our knowledge, this is the first reported case of right ventricular outflow tract (RVOT) aneurysm following central aortopulmonary shunt.

Serial trypsin inhibitory capacity and ceruloplasmin levels in prematures at risk for bronchopulmonary dysplasia.

Oxidant injury and release of proteolytic enzymes in prematures with respiratory distress syndrome (RDS), who are treated with ventilators and oxygen, have been postulated as possible causes of bronchopulmonary dysplasia (BPD). The premature may be at particular risk due to low levels of antiproteases, such as alpha-1-proteinase inhibitor (alpha 1PI), and antioxidants, such as ceruloplasmin (CER). Both alpha 1PI and CER deficiencies have been correlated with the severity of RDS. We studied serial alpha 1PI activity as measured by trypsin inhibitory capacity (TIC) and CER in the serum 27 prematures who required ventilator therapy for RDS. Serum TIC values for day 1 were significantly lower (0.34 vs. 0.92 mg inhibited/ml of sample) in the 13 patients who developed BPD compared to the 14 who did not. No significant differences were seen on succeeding days. No significant differences in CER were seen, although both groups had levels 33-50% of adult normals (11.3 vs 9.3 mg/dl). Other significant variables included birthweight (p less than 0.005), severity of RDS (p less than 0.03), and gestational age (p less than 0.03). One way analysis of variances demonstrated day 1 TIC to be the most significant variable (p less than 0.0001), followed by weight (p less than 0.007), severity RDS (p less than 0.04), and gestational age (p less than 0.03). CER levels were not a significant variable. A formula utilizing unstandardized canonical discriminant function including day 1 TIC, birthweight, severity of RDS, and gestational age was 100% sensitive and 85% specific in the prediction of BPD for the original study group. In an additional 25 consecutive admissions with severe RDS of whom 18 survived, the formula was 100% sensitive (6/6) and 75% specific (9/12).(ABSTRACT TRUNCATED AT 250 WORDS)

Phototherapy effect on the incidence of patent ductus arteriosus in premature infants: prevention with chest shielding.

Patent ductus arteriosus is common among premature neonates, especially those with birth weights less than 1,500 g. In vitro, room light inhibits the contraction of immature piglet's ductal rings. Because phototherapy is used frequently from the first days of life to treat jaundice in preterm neonates, we compared the occurrence of patent ductus arteriosus among premature infants exposed to this intense light source with those whose chests were shielded. Seventy-four babies with respiratory distress syndrome were randomly assigned to either a treatment group (chest shielded with aluminum foil while on phototherapy, 36 babies) or control group (no shield, 38 babies). All were on radiant warmers, received mechanical ventilation for respiratory distress syndrome, and phototherapy (Air Shields model PTU 78-1) from day 1 of life. Irradiance was maintained at greater than 4.0 microW/cm2/nm in all cases. Although both groups had similar birth weights, gestational ages, severity of respiratory distress syndrome, intravenous fluid intake, and duration of phototherapy, the incidence of patent ductus arteriosus was significantly less in the shield group (shield 11/36 v No shield 23/38; P = .009). Patent ductus arteriosus murmurs developed in shielded patients at a later date, they required less vigorous treatment (ie, indomethacin), and they had shorter hospitalizations (74 v 85 days; P less than .05). The significant reduction of patent ductus arteriosus with shielding suggests that phototherapy may play a role in the occurrence of patent ductus arteriosus in premature infants. Shielding may be a practical method to decrease this common complication should this initial observation be confirmed.

Oxidant-mediated lung disease in newborn infants.

High concentrations of oxygen are administered with increased airway pressure to most preterm neonates with respiratory distress syndrome (RDS). Among 20% to 30% of survivors a form of chronic lung disease, bronchopulmonary dysplasia (BPD), develops. Its pathogenesis may include tissue damage caused by the superoxide anion (O2-) and other free oxygen radicals. Animal experiments and other data suggested a rationale for superoxide dismutase (SOD) administration in an effort to prevent or ameliorate BPD. Our preliminary studies in 19 prematures with RDS demonstrated its safety in human newborns and permitted measurement of its plasma levels. No adverse clinical findings occurred, and laboratory parameters were unchanged. Subcutaneous administration (0.25 mg/kg) of bovine SOD led to detectable levels at 1 1/2 h (mean 0.22 microgram/ml), with a slight rise to a higher peak at 2 1/2-4 h and a plateau over the remainder of the 12-h interval. Following doses 2-5, peak levels of 0.64 microgram/ml occurred at 4-8 h. With this background, a prospective double-blind controlled study of 45 neonates (mean gestational age, 29 weeks; birth weight, 1,100 g) showed a statistically significant reduction in prevalence of clinical and X-ray signs of BPD with fewer days of continuous positive airway pressure required. The safety and pharmacokinetics of bovine SOD were confirmed.