Is Obstructive Sleep Apnea Associated with Higher Covid-19 Severity?

Objective To investigate the associations between obstructive sleep apnea (OSA) and coronavirus disease 2019 (COVID-19) severity. Methods Twelve individuals hospitalized in a Brazilian tertiary hospital diagnosed with COVID-19 by reverse transcriptase-polymerase chain reaction (RT-PCR) underwent respiratory polygraphy. Results Polygraphic records identified seven participants without obstructive sleep apnea (OSA) (OSA-) and five with OSA (OSA + ). The OSA+ group presented worse peripheral oxygen saturation (77.6% ± 7.89%) than the OSA- group (84.4% ± 2.57%) ( p = 0.041). Additionally, the OSA+ group showed greater COVID-19 severity (100%) than the OSA- group (28.57%) ( p = 0.013) and required longer oxygen therapy ( p = 0.038), but without difference in the length of hospitalization. The OSA+ group also presented higher rates of platelets ( p = 0.008) and D-dimer (1,443 ± 897) than the OSA- group (648 ± 263 ng/mL) ( p = 0.019). Conclusion Obstructive sleep apnea in individuals hospitalized due to COVID-19 was associated with higher COVID-19 severity, worse peripheral oxygen saturation, longer oxygen therapy time, and higher platelet and D-dimer rates.

Central hypersomnia and chronic insomnia: expanding the spectrum of sleep disorders in long COVID syndrome - a prospective cohort study.

INTRODUCTION: Long-onset COVID syndrome has been described in patients with COVID-19 infection with persistence of symptoms or development of sequelae beyond 4 weeks after the onset of acute symptoms, a medium- and long-term consequence of COVID-19. This syndrome can affect up to 32% of affected individuals, with symptoms of fatigue, dyspnea, chest pain, cognitive disorders, insomnia, and psychiatric disorders. The present study aimed to characterize and evaluate the prevalence of sleep symptoms in patients with long COVID syndrome. METHODOLOGY: A total of 207 patients with post-COVID symptoms were evaluated through clinical evaluation with a neurologist and specific exams in the subgroup complaining of excessive sleepiness. RESULTS: Among 189 patients included in the long COVID sample, 48 (25.3%) had sleep-related symptoms. Insomnia was reported by 42 patients (22.2%), and excessive sleepiness (ES) was reported by 6 patients (3.17%). Four patients with ES were evaluated with polysomnography and test, multiple sleep latencies test, and actigraphic data. Two patients had a diagnosis of central hypersomnia, and one had narcolepsy. A history of steroid use was related to sleep complaints (insomnia and excessive sleepiness), whereas depression was related to excessive sleepiness. We observed a high prevalence of cognitive complaints in these patients. CONCLUSION: Complaints related to sleep, such as insomnia and excessive sleepiness, seem to be part of the clinical post-acute syndrome (long COVID syndrome), composing part of its clinical spectrum, relating to some clinical data.

Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) With Extrapontine and Pulmonary Involvement: Case Report of a Rare Presentation and Review of Literature.

CLIPPERS is a rare subacute inflammatory disorder of the CNS, with a poorly understood pathogenesis and with heterogeneous clinical manifestations. Reports of extra-pontine involvement in this syndrome are rare, and as far as we know there are only two cases reported with simultaneous involvement of the CNS and pulmonary parenchyma. We report the case of a young patient with a subacute condition of cognitive dysfunction, as well as motor, sensory and balance changes. Imaging showed pontine and extrapontine brain involvement in association with multiple pulmonary nodules, characterizing a very unusual presentation of this syndrome. It is important for radiologists to be aware of that rare presentation in order to make a prompt diagnosis of this condition, enabling early treatment and avoiding permanent neurological sequelae.

Computational Investigation of the Formation of Substituted Isoindole N-Oxides through the Photo-oxidative Cyclization of 2'-Alkynylacetophenone Oximes.

Our recently published joint experiment-theory study of the photo-oxidative intramolecular cyclization of 2'-alkynylacetophenone oximes, performed in collaboration with the de Lijser group, presented the first reported formation of isoindole N-oxides. That study focused on determining a mechanistic explanation for the unexpected chemistry observed when three 2'-alkynylacetophenone oximes were photo-oxidized with 9,10-dicyanoanthracene (DCA), specifically the derivatives with a phenyl, isopropyl, or n-butyl substituent at the alkynyl group. Here, we use density functional theory to develop a broader understanding of the scope of this chemistry. In particular, we demonstrate that substituents on the alkynyl group and on the central benzene ring can significantly modulate the thermodynamic driving force for oxime radical cation generation when DCA is used as the photosensitizer. In contrast, substituents are shown to have a small impact on the chemical reactivity of the radical cation intermediates. In particular, 5-exo radical cation cyclization, which ultimately results in an isoindole N-oxide product, is always kinetically and sometimes also thermodynamically preferred over 6-endo radical cation cyclization, which would produce an isoquinoline N-oxide product. Overall, this study provides mechanistic insights into the diversity of isoindole N-oxides that can be produced through the photo-oxidative cyclization of 2'-alkynylacetophenone oximes.

Characterization of Headache in COVID-19: a Retrospective Multicenter Study.

Headache is the most common neurological symptom in COVID-19, reported in 6.5 to 34% of patients. Few studies have analyzed its characteristics, and some of them included cases without laboratory confirmation or reported only critical patients. We aimed to analyze the clinical characteristics of COVID-19 associated headache in laboratory-confirmed cases. We conducted a retrospective evaluation of patients with COVID-19 and neurological symptoms. Patients who reported headache answered an interview about its clinical characteristics. Twenty-four patients with COVID-19 associated headache completed the interview. Mean age of patients was 53.8 (standard deviation-17.44), and 14 out of 24 (58.3%) were male. The majority (75%) had no previous history of headache. Fever was documented in 19 out of the 24 patients (79.1%). Headache was predominantly bifrontal or holocranial, in pressure, during hours, worsening with cough or physical activity. COVID-19 headache tends to appear in the first days of symptoms, be either frontal or holocranial and last for days. The quality of pain in pressure and the worsening with cough or physical activity were reported in most cases. We have not found any characteristic that could differentiate COVID-19 associated headache from other causes of headache, possibly because of its multifactorial mechanism.

Analysis of pneumonitis and esophageal injury after stereotactic body radiation therapy for ultra-central lung tumors.

OBJECTIVES: SBRT has been associated with serious toxicity in ultra-central lung tumors, but little is known about the incidence and dosimetric correlates of pulmonary and esophageal complications in this setting. MATERIALS AND METHODS: We retrospectively reviewed SBRT patients whose lung tumor abutted proximal airways, or whose planning target volume overlapped esophagus. All patients received 5-15 fractions of high-dose, image-guided radiation. The primary endpoint was SBRT-related toxicity, with local control and survival as secondary endpoints. RESULTS: We included 88 patients. Nineteen patients (22 %) experienced grade ≥3 (G3+) toxicity, including 6 cases of G3+ radiation pneumonitis and 4 cases of G3+ esophageal injury. Two patients developed trachea-esophageal fistula. Overall incidence of radiation pneumonitis was 23 %. Ten patients (11.4 %) succumbed to SBRT-related complications. Multiple dosimetric parameters for lung (including mean lung dose and V20Gy) and esophagus (including maximum point dose) correlated with radiation pneumonitis and esophageal toxicity, respectively. No impact of fractionation on toxicity was seen. CONCLUSION: This analysis indicates that high rate and multiple manifestations of pulmonary and esophageal toxicity occur after SBRT for ultra-central tumors. In particular, severe radiation pneumonitis and tracheoesophageal fistula are possible. Dosimetric parameters such as mean lung dose and maximum esophageal dose are significantly correlated with toxicity. Further study is needed to optimize the safe delivery of SBRT in these patients.

Laryngeal, Tracheal, and Bronchial Disease in the Mucopolysaccharidoses: Endoscopic Study.

Mucopolysaccharidoses (MPS) are genetically determined diseases, leading to a deficiency of enzymes in the glycosaminoglycan (GAG) degradation pathway. The accumulation of GAG occurs in connective tissue in various organs and systems of the body, including the larynx, trachea, and bronchi. Respiratory symptoms are common and severe in these patients, and respiratory disease is a frequent cause of death. A cross-sectional study with flexible bronchoscopy was conducted in 30 MPS patients (6 MPS I, 8 MPS II, 2 MPS III, 3 MPS IV-A, and 11 MPS VI). Only four patients (13.33%) had a normal airway; nine (30%) had mild to moderate disease, 12 (40%) moderate to severe, and five patients (16.67%) had severe disease. Of particular interest, neuronopathic MPS II had the largest proportion of tracheostomized patients who died due to respiratory complications; in MPS IV-A, all patients had significant tracheobronchial deformity with associated tracheomalacia, despite lacking laryngeal involvement. Laryngotracheobronchial disease (LTBD) was associated to longer disease history and was significantly more severe in older patients. Longer use of enzyme replacement therapy did not prevent the progression of LTBD, although the age of therapy introduction may be a crucial factor in lower airway involvement.

Otolaryngologists and the Early Diagnosis of Mucopolysaccharidoses: A Cross-Sectional Study.

Mucopolysaccharidoses (MPS) are a group of inborn errors of metabolism with an aggressive and usually fatal course. Therefore, early treatment is essential because the involvement of head and neck structures is almost always present in MPS. Our study aimed to retrospectively assess-via a chart review and a survey of caregivers-the history of ear, nose and throat (ENT) symptoms, the number of otolaryngology visits prior to diagnosis, and whether otolaryngologists diagnosed the disease in a cohort of MPS patients followed at an academic medical center. Twenty-three patients were evaluated. Age at diagnosis ranged from 0.2 to 33.0 years (median, 3.2 years). Prior to being diagnosed with MPS, 20/23 (87%) patients presented with at least one episode of otalgia, airway disorder, sleep disturbance, speech delay or suspected hearing loss. One patient had an adenotonsillectomy with paracentesis of tympanic membranes. Ten of the 23 patients (43%) were seen by an otolaryngologist before the diagnosis of MPS, none of which had the disease suspected during these visits. Notwithstanding limitations, our results suggest that increased awareness of MPS among otolaryngologists may allow for earlier diagnosis and better management of these patients.

Acute Paracoccidioidomycosis in a 40-Year-Old Man: A Case Report and Literature Review.

Paracoccidioidomycosis (PCM) is a systemic mycosis that represents an important public health problem in Latin America due to its life-threatening character. It is considered occupational disease of agricultural workers. In this report, we present a rare and serious case of the acute form of the disease in a 40-year-old man with no history of contact with the rural environment. Diagnosis was made through cervical lymph node biopsy, and treatment was performed with antifungal drugs, which produced effective results. A literature review was conducted with discussion of clinical, pathophysiological and therapeutic aspects of PCM.

Early hematopoietic stem cell transplantation in a patient with severe mucopolysaccharidosis II: A 7 years follow-up.

Mucopolysaccharidosis type II (MPS II - Hunter syndrome) is an X-linked lysosomal storage disorder caused by a deficiency in the enzyme iduronate-2 sulfatase (I2S), leading to the accumulation of the glycosaminoglycans, affecting multiple organs and systems. Enzyme replacement therapy does not cross the blood brain barrier, limiting results in neurological forms of the disease. Another option of treatment for severe MPS, hematopoietic stem cell transplantation (HSCT) has become the treatment of choice for the severe form of MPS type I, since it can preserve neurocognition when performed early in the course of the disease. To date, only few studies have examined the long-term outcomes of HSCT in patients with MPS II. We describe the seven-year follow-up of a prenatally diagnosed MPS II boy with positive family history of severe MPS form, submitted to HSCT with umbilical cord blood cells at 70 days of age. Engraftment after 30 days revealed mixed chimerism with 79% donor cells; after 7 years engraftment remains at 80%. I2S activity 30 days post-transplant was low in plasma and normal in leukocytes and the same pattern is observed to date. At age 7 years growth charts are normal and he is very healthy, although mild signs of dysostosis multiplex are present, as well as hearing loss. The neuropsychological evaluation (Wechsler Intelligence Scale for Children - Fourth Edition - WISC-IV), disclosed an IQ of 47. Despite this low measured IQ, the patient continues to show improvements in cognitive, language and motor skills, being quite functional. We believe that HSCT is a therapeutic option for MPS II patients with the severe phenotype, as it could preserve neurocognition or even halt neurodegeneration, provided strict selection criteria are followed.

Análise de dados epidemiológicos de pacientes acompanhadas por neoplasiamamária em um hospital de Fortaleza (CE) / Epidemiological data analysis of patients accompanied by mammary cancer in a hospital in Fortaleza (CE), Brazil

Objetivo: Mediante o impacto na saúde pública e a importância da neoplasia de mama para a saúde da mulher, o objetivo deste estudo foi verificar os fatores de risco, os dados demográficos e os achados ao exame físico e aos exames complementares de uma população de pacientes em acompanhamento por câncer de mama em um hospital de Fortaleza. Métodos: Foi realizado um estudo transversal observacional, descritivo e retrospectivo de base hospitalar. Os dados foram coletados por meio de um instrumento de coleta de informação. As variáveis incluíram: idade, menarca, paridade, idade do primeiro parto, terapia hormonal, amamentação, história familiar, tabagismo, etilismo, achados ao exame físico, exames complementares de imagem e histopatológico. Foi analisada a classificação BI-RADS dos exames de imagem. Resultados: A mediana de idade foi 55 anos. Dentre os fatores de risco, a menarca variou de 9 a 18 anos de idade. 70,0% das mulheres possuíam até 4 filhos, com história de amamentação em 86,7%. O fator terapia hormonal estava presente em 20,3% (11/54), com duração entre 1 e 10 anos; o tabagismo, em 32,7% (18/55). 36,8% (25/68) apresentavam história familiar de neoplasia de mama. Analisando o resultado da primeira mamografia do acompanhamento, identificamos que 28,5% (14/49) apresentaram BI-RADS 0, e 59,2% (29/49), BI-RADS de 4 a 6. Conclusão: O impacto global do câncer de mama em mulheres é considerável e crescente em muitos países. Uma adequada caracterização das populações acometidas auxilia os profissionais de saúde, melhorando seu grau de suspeição e contribuindo para o diagnóstico precoce.

Objective: Through the impact on public health and the importance of breast cancer for women?s health, the aim of this study was to investigate the risk factors, demographic data, findings on physical examination and the findings of laboratory tests of a population of patients under treatment for breast cancer at a hospital in Fortaleza. Methods: We conducted an observational cross-sectional study, descriptive and retrospective hospitalbased. Data were collected through an instrument for collecting information. The variables included age, menarche, parity, age at first birth, hormone therapy, breastfeeding, family history, smoking, alcoholism, findings on physical examination, laboratory tests imaging and histopathology. It analyzed the classification BI-RADS of imaging. Results: The median age was 55 years. Among the risk factors menarche ranged from 9 to 18 years old. 70.0% of women had up to four children, breastfeeding history in 86.7%. Hormonal therapy factor was present in 20.3% (11/54) lasting from 1 to 10; smoking in 32.7% (18/55). 36.8% (25/68) had a family history of breast cancer. Analyzing the results of the first mammography monitoring, we found that 28.5% (14/49) showed BI-RADS 0 and 59.2% (29/49) showed BI-RADS 4?6. Conclusion: The overall impact of breast cancer in women is considerable and growing in many countries. An adequate characterization of affected populations assists healthcare professionals by improving their level of suspicion and contributing to early diagnosis.

Gastroprotective effect of alpha-pinene and its correlation with antiulcerogenic activity of essential oils obtained from Hyptis species.

BACKGROUND: Alpha-pinene (α-pinene) is a monoterpene commonly found in essential oils with gastroprotective activity obtained from diverse medicinal plants, including Hyptis species. The genus Hyptis (lamiaceae) consists of almost 400 species widespread in tropical and temperate regions of America. In the north and northeastern Brazil, some Hyptis species are used in traditional medicine to treat gastrointestinal disturbances. OBJECTIVE: The present study has investigated the gastoprotective effect of purified α-pinene in experimental gastric ulcer induced by ethanol and indomethacin in mice. MATERIALS AND METHODS: Gastric ulcers were induced in male Swiss mice (20-30 g) by oral administration of absolute ethanol or indomethacin 45 min after oral pretreatment with vehicle, standard control drugs or α-pinene (10, 30, and 100 mg/kg). One hour after the ulcerative challenges, the stomach were removed, and gastric lesions areas measured. The effects of α-pinene on the gastric juice acidity were determined by pylorus ligation model. The gastrointestinal motility and mucus depletion were determined by measuring the gastric levels of phenol red and alcian blue, respectively. Hematoxylin and eosin stained sections of gastric mucosa of the experimental groups were used for histology analysis. RESULTS: α-pinene pretreatment inhibited ethanol-induced gastric lesions, reduced volume and acidity of the gastric juice and increased gastric wall mucus (P < 0.05). Furthermore, we showed an interesting correlation between concentration of α-pinene and gastroprotective effect of Hyptis species (P Pearson = 0.98). CONCLUSION: Our data showed that the α-pinene exhibited significant antiulcerogenic activity and a great correlation between concentration of α-pinene and gastroprotective effect of Hyptis species was also observed.

Correlation between nutritional markers and appetite self-assessments in hemodialysis patients.

OBJECTIVE: Protein-energy malnutrition is among the comorbidities that most strongly affect the prognosis of patients with chronic kidney disease. Anorexia, defined as a loss of desire to eat, is one cause of such malnutrition. Tools that evaluate appetite and the correlation between appetite and nutritional parameters require further study. To evaluate the appetite status in patients from 2 hemodialysis clinics in Fortaleza, Brazil and the correlations between appetite (evaluated in the past week and in the past 4 weeks) and demographic, laboratory, and nutritional parameters. METHODS: This was a cross-sectional study of patients aged ≥18 years who had undergone dialysis for >3 months. Appetite was evaluated using the first 3 questions of the Appetite and Diet Assessment Tool (ADAT) questionnaire, which evaluate the appetite status during the past week as well as 1 question from the Kidney Disease and Quality of Life™ Short Form that assesses appetite in the past 4 weeks. The patients were divided into 3 groups according to the degree of appetite: group 1: very good and good appetite (ADAT) or not and somewhat (Kidney Disease and Quality of Life™ Short Form); group 2: fair or moderately; and group 3: poor and very poor, or very much and extremely. The nutritional parameters evaluated were body mass index (BMI), serum albumin, Geriatric Nutritional Risk Index (GNRI) and lean body mass index (lean mass in kilogram per square meter) as obtained by multifrequency bioelectrical impedance analysis. Patients with a BMI <23 kg/m(2), albumin <4 g/dL, GNRI <98, and lean body mass index below the lowest quartile were considered malnourished. The associations between appetite and nutritional variables were tested using Fisher exact test and by comparing the means of the variables in the 3 groups using the analysis of variance and Kruskal-Wallis tests. RESULTS: A total of 136 patients were included in the study with a mean age of 50.9 years and a median time on dialysis of 45 months; 57% of the patients were male. Regarding the first question on the ADAT questionnaire, 36% of patients exhibited anorexia in the past week. Furthermore, 28.7% of the population reported a lack of appetite in the last month. Moreover, 34.3% of the patients were considered malnourished according to BMI, 34.1% according to albumin, and 31.6% according to GNRI. Among the studied variables, the mean values of the following variables were different between groups 1, 2, and 3: hemoglobin (P = .0186), creatinine (P = .0392), albumin (P = .0065), GNRI (P = .0274), and lean BMI (P = .0274). CONCLUSIONS: The prevalence of a lack of appetite in hemodialysis patients in both the past week and the past month was high in the present study. The questionnaire evaluating appetite in the last 4 weeks could be used as a malnutrition screening tool in hemodialysis patients as suggested by the correlation of decreased appetite in the last month with variables that assess nutritional status such as albumin, lean body mass index, and GNRI.

Neuropatia auditiva: alerta aos pediatras / Auditory neuropathy: alert to pediatricians

OBJETIVO:Alertar os pediatras sobre a neuropatia auditiva, doença descrita recentemente e ainda desconhecida por muitos médicos. Descrever seus fatores de risco, características clínicas e diagnósticas, com a finalidade de possibilitar uma intervenção terapêutica precoce e eficaz. FONTES DE DADOS: Realizada pesquisa nas bases de dados PubMed, Lilacs e SciELO utilizando os descritores "neuropatia auditiva" e "auditory neuropathy", entre os anos de 1996 e 2010. SÍNTESE DOS DADOS: A neuropatia auditiva, também conhecida como dessincronia auditiva, descrita em 1996, caracteriza-se clinicamente pela dificuldade na compreensão das palavras, mesmo em casos de perdas auditivas leves ou moderadas. Foi relacionada a diversas neuropatias generalizadas e fatores de risco neonatais, como internação em terapia intensiva, hiperbilirrubinemia, sepse e hipóxia. Após suspeita clínica, o diagnóstico é confirmado pela presença das emissões otoacústicas associada a um potencial evocado auditivo de tronco encefálico ausente ou alterado. Sua terapêutica permanece controversa, tendo como opções a protetização auditiva, o acompanhamento fonoterápico para habilitação ou reabilitação da linguagem e, em casos de insucesso, há relatos de resultados satisfatórios com o implante coclear. CONCLUSÕES: Enfatiza-se a importância do reconhecimento pelo pediatra da neuropatia auditiva, entidade ainda pouco citada na literatura latino-americana da especialidade.

OBJECTIVE:To alert pediatricians about the auditory neuropathy, a disease that has been only recently described and is still unknown by many physicians, and to describe its risk factors, clinical and diagnostic features in order to enable an early and effective therapeutic intervention. DATA SOURCE: A literature search using terms such as "auditory neuropathy" and "neuropatia auditiva" has been conducted in the PubMed, Lilacs and SciELO databases between 1996 and 2010. DATA SYNTHESIS: Described in 1996, the auditory neuropathy, or auditory dyssynchrony is clinically characterized by a disorder in understanding words, even in patients with light or moderate hearing loss. It has been related to generalized neuropathies and neonatal risk factors, such as intensive care admission, hyperbilirubinemia, sepsis and hypoxia. After clinical suspicion, the diagnosis is confirmed by the presence of otoacoustic emissions associated with the absence of waves in auditory brainstem responses. The therapy remains controversial, with the following options: hearing aids fitting and follow-up therapy for the habilitation/rehabilitation of language. In cases of failure there are also reports of satisfactory results with cochlear implants. CONCLUSIONS: This study emphasizes the importance of the recognition of auditory neuropathy by pediatricians, which is yet an underreported problem in Latin America.