Environmental Impacts and Policy Responses to Covid-19: A View from Latin America.

COVID-19 is currently having major short run effects with possible serious long run implications for the environment and the management of natural resources in Latin America. We discuss the possible effects of the pandemic on air pollution, deforestation and other relevant environmental dimensions across the region. With contributions from environmental economists from eight countries, we give an overview of the initial and expected environmental effects of this health crisis. We discuss potential effects on environmental regulations, possible policy interventions, and an agenda for future research for those interested in the design and evaluation of environmental policies relevant for the Latin American context.

Influence of Comedication on Levetiracetam Pharmacokinetics.

BACKGROUND: To evaluate the effect of concomitant antiepileptic therapy on levetiracetam (LEV) pharmacokinetics. METHODS: A 6-year retrospective observational study. Patients were grouped according to the antiepileptic drug used as concomitant medication: group A, LEV in monotherapy; group B, LEV + enzyme-inducing antiepileptic drugs (EIAEDs); and group C, LEV + non-enzyme-inducing antiepileptic drugs (NEIAEDs). Apparent oral levetiracetam clearance (LEV CL/F) and basal serum levetiracetam concentrations (LEV C0) were compared among the different groups by analysis of variance. RESULTS: A total of 330 LEV C0 corresponding to 205 patients (56% men) were identified. The mean (±SD) of LEV CL/F in group A (n = 180), B (n = 92), and C (n = 58) was 4.41 ± 2.06 L/h, 7.23 ± 3.72 L/h, and 4.87 ± 1.65 L/h, respectively. EIAEDs increased LEV CL/F (L/h) by 64% compared with the monotherapy group and by 48% compared with the NEIAEDs group. The greatest induction in LEV CL/F, compared with the LEV monotherapy group, was observed with carbamazepine, followed by oxcarbazepine and phenobarbital, and was increased by 81%, 64%, and 44%, respectively. LEV C0 values were significantly lower in the EIAEDs group than in the monotherapy group (17.30 ± 7.77 versus 20.08 ± 9.69 mcg/mL; P = 0.038) or indeed the NEIAEDs group (17.30 ± 7.77 versus 20.49 ± 9.46 mcg/mL; P = 0.027). CONCLUSIONS: Comedication with EIAEDs increased LEV CL/F by more than 40%, whereas carbamazepine had the greatest inducing potency with LEV CL/F being 81% higher than that of the monotherapy group. These data suggest that monitoring LEV serum concentration during polytherapy with EIAEDs is indicated.

The impact of the COVID-19 pandemic on the Galapagos Islands' seafood system from consumers' perspectives.

The COVID-19 pandemic's early stages severely impacted global fisheries, particularly areas heavily reliant on imported food and tourism like the Galapagos Islands, Ecuador. To contain the spread of the virus, a full lockdown was implemented. However, the collapse of the tourism industry precipitated the worst economic crisis in the history of this multiple-use marine protected area. This paper examines the impact of the pandemic's early stages on consumption patterns and seafood security in the Galapagos from consumers' perspective, drawing on online surveys conducted during the lockdown. Our findings revealed pre-existing seafood insecurity across the archipelago, further exacerbated by the pandemic on the least-populated island. Nevertheless, the seafood system displayed moderated resilience to the pandemic's socioeconomic disruptions. A variety of adaptive responses were adopted by Galapagos residents to cope with the lockdown. Consumers modified their seafood consumption habits, while fishers adapted their harvesting and marketing strategies. Such adaptive responses were shaped by the unique socioeconomic characteristics of each inhabited island and the ability of seafood suppliers to shift from a tourism- and export-oriented to a resident- and domestic-oriented market. This transition has created novel opportunities to foster a systemic transformation of the Galapagos seafood system to enhance its resilience against future crises caused by new pandemics, climate change, or other natural and anthropogenic drivers of change.

Late-onset periodic asystolia during vagus nerve stimulation.

Cardiac changes may occasionally occur during vagus nerve stimulation (VNS) used in epileptic patients. As they can be potentially life-threatening, it is important to detect them, and this is why an intraoperative test is performed during the implantation. Few cases of asystole during this test have been described. Only one patient with late-onset bradyarrythmia caused by VNS has been reported. This patient had been implanted 2 years and 4 months before the episode. We present another case of late asystole in a patient whose VNS had been implanted 9 years before the arrhythmia onset. In our patient, each run of stimulation produced bradyarrhythmias and very often severe asystolia due to atrium-ventricular block.

Validation of the Spanish version of the Liverpool Adverse Events Profile in patients with epilepsy.

The objective of the study was to validate the Spanish version of the Liverpool Adverse Events Profile (LAEP). An observational, cross-sectional, multicenter study was carried out on patients with epilepsy treated with a stable dose of antiepileptic drugs. Patients completed the LAEP, Quality of Life in Epilepsy Inventory-31 (QOLIE-31), and Hospital Anxiety and Depression Scale (HADS). Two hundred sixty-six patients were recruited. The LAEP was completed in a short time, perceived as easy to complete, and there was no relevant information missing. Ceiling/floor effects were negligible. Internal consistency (Cronbach's alpha=0.84) and test-retest reliability (ICC=0.81) were satisfactory. LAEP scores consistently correlated with QOLIE-31 (r=0.71) and HADS (r=0.52-0.63) scores. When the LAEP was used to discriminate between patients with and without adverse events, the scores on the QOLIE and HADS corresponded. The Spanish version of the LAEP scale exhibits adequate psychometric properties, suggesting that it is an appropriate instrument to measure adverse events among Spanish-speaking patients with epilepsy.

Independent component analysis separates spikes of different origin in the EEG.

Independent component analysis (ICA) is a novel system that finds independent sources in recorded signals. Its usefulness in separating epileptiform activity of different origin has not been determined. The goal of this study was to demonstrate that ICA is useful for separating different spikes using samples of EEG of patients with focal epilepsy. Digital EEG samples from four patients with focal epilepsy were included. The patients had temporal (n = 2), centrotemporal (n = 1) or frontal spikes (n = 1). Twenty-six samples with two (or more) spikes from two different patients were created. The selection of the two spikes for each mixed EEG was performed randomly, trying to have all the different combinations and rejecting the mixture of two spikes from the same patient. Two different examiners studied the EEGs using ICA with JADE paradigm in Matlab platform, trying to separate and to identify the spikes. They agreed in the correct separation of the spikes in 24 of the 26 samples, classifying the spikes as frontal, temporal or centrotemporal, left or right sided. The demonstration of the possibility of detecting different artificially mixed spikes confirms that ICA may be useful in separating spikes or other elements in real EEGs.

Independent component analysis in the study of focal seizures.

Independent component analysis (ICA) is a novel technique that can separate statistically independent elements from complex signals. It has demonstrated its utility in separating artifacts and analyzing interictal discharges in EEG. ICA has been used recently in ictal recordings, showing the possibility of isolating the ictal activity. The goal of our study was to analyze focal seizures with ICA, decomposing the elements of the seizures to understand their genesis and propagation, and to differentiate between various types of focal seizures. We studied 26 focal seizures of temporal, frontal, or parietal origin. Only seizures with suspected focal onset were included in the study. The EEG recordings were acquired by using standard video-EEG equipment, with scalp electrodes. All the off-line analysis was carried out on a PC by means of specific software developed in the Matlab environment. ICA components were calculated with the use of the JADE (Joint Approximate Diagonalization of Eigen-matrices) algorithm. The decomposition of the seizures varied according to the EEG seizure pattern. In the seizures with focal rhythmic theta slow or sharp waves, the rhythmic activity was separated into one to five components, having an initial component with a clear concordance with the focus, whereas the others had an onset a few milliseconds later and corresponded to neighboring areas. In the 6 frontal seizures with regional rhythmic low voltage fast activity, 4 to 10 components were found, practically with a simultaneous timing, having a frontal distribution. In the three frontal seizures with a diffuse attenuation of the EEG signal, it was not possible to differentiate components of cerebral origin from the components of muscle artifact. ICA is an interesting tool to study the nature of focal seizures. The results depend on the EEG pattern. In the seizures with a clear EEG focal pattern, ICA may be useful to separate components of the ictal onset from the propagated activity.

Sleep-related laryngospasm: a video-polysomnographic recording.

We present a case of laryngospasm in a 12-year-old male who experienced sudden, nocturnal episodes of breathing difficulties and agitation. Apart from laryngospasm, the main differential diagnoses included frontal seizures, sleep-related choking syndrome, sleep asthma, sleep apnoea and REM sleep behaviour disorder. The video and the EEG recordings supported the diagnosis of laryngospasm. The pH-metry confirmed the existence of reflux. Its treatment successfully controlled the episodes. This case illustrates, with a typical video recording, this infrequent type of paroxysmal event with an important differential diagnosis.[Published with video sequences].

Independent component analysis in the distinction between focal and multifocal spikes.

Independent component analysis (ICA) is a novel method that extracts independent sources in recorded signals. One of its capabilities is to separate epileptiform activity of different origins. The goal of this study was to demonstrate that ICA is useful for differentiating focal and multifocal epilepsies. Using ICA, the authors analyzed 160 samples of patients with unifocal (temporal: 50 samples from 5 patients; frontal: 50 samples from 5 patients) or multifocal epilepsy (bitemporal: 30 samples from 3 patients; multifocal extratemporal: 30 samples from 5 patients). Each sample included at least two spikes. ICA was applied using the JADE algorithm implemented in a Matlab platform. The components were identified visually. The EEG and the isopotential map of the suspected components were reconstructed to demonstrate the nature and location of each spike. In multifocal epilepsies, the spikes were separated in distinct components in all cases. In unifocal temporal epilepsies, ICA extracted all the spikes from the same location into a single component. In the patients with unifocal frontal epilepsy, one component included all the spikes in 80% of the samples; in some of these cases, other components were responsible for small parts of the spikes, but with a close topography to the main component. The waves were separated in different components both in the unifocal and in the multifocal samples. Therefore, in epilepsies with independent foci, ICA separates the spikes of different origins into distinct components. In unifocal epilepsies, ICA tends to locate the spikes from the same area into the same component, especially in temporal epilepsies. The authors conclude that ICA might be a useful tool to distinguish between unifocal and multifocal epilepsies.

Independent component analysis as a tool to eliminate artifacts in EEG: a quantitative study.

Independent component analysis (ICA) is a novel technique that calculates independent components from mixed signals. A hypothetical clinical application is to remove artifacts in EEG. The goal of this study was to apply ICA to standard EEG recordings to eliminate well-known artifacts, thus quantifying its efficacy in an objective way. Eighty samples of recordings with spikes and evident artifacts of electrocardiogram (EKG), eye movements, 50-Hz interference, muscle, or electrode artifact were studied. ICA components were calculated using the Joint Approximate Diagonalization of Eigen-matrices (JADE) algorithm. The signal was reconstructed excluding those components related to the artifacts. A normalized correlation coefficient was used as a measure of the changes caused by the suppression of these components. ICA produced an evident clearing-up of signals in all the samples. The morphology and the topography of the spike were very similar before and after the removal of the artifacts. The correlation coefficient showed that the rest of the signal did not change significantly. Two examiners independently looked at the samples to identify the changes in the morphology and location of the discharge and the artifacts. In conclusion, ICA proved to be a useful tool to clean artifacts in short EEG samples, without having the disadvantages associated with the digital filters. The distortion of the interictal activity measured by correlation analysis was minimal.

Recognition of facial emotions and identity in patients with mesial temporal lobe and idiopathic generalized epilepsy: an eye-tracking study.

PURPOSE: To describe visual scanning pattern for facial identity recognition (FIR) and emotion recognition (FER) in patients with idiopathic generalized (IGE) and mesial temporal lobe epilepsy (MTLE). Secondary endpoint was to correlate the results with cognitive function. METHODS: Benton Facial Recognition Test (BFRT) and Ekman&Friesen series were performed for FIR and FER respectively in 23 controls, 20 IGE and 19 MTLE patients. Eye movements were recorded by a Hi-Speed eye-tracker system. Neuropsychological tools explored cognitive function. RESULTS: Correct FIR rate was 78% in controls, 70.7% in IGE and 67.4% (p=0.009) in MTLE patients. FER hits reached 82.7% in controls, 74.3% in IGE (p=0.006) and 73.4% in MTLE (p=0.002) groups. IGE patients failed in disgust (p=0.005) and MTLE ones in fear (p=0.009) and disgust (p=0.03). FER correlated with neuropsychological scores, particularly verbal fluency (r=0.542, p<0.001). Eye-tracking revealed that controls scanned faces more diffusely than IGE and MTLE patients for FIR, who tended to top facial areas. A longer scanning of the top facial area was found in the three groups for FER. Gap between top and bottom facial region fixation time decreased in MTLE patients, with more but shorter fixations in bottom facial region. However, none of these findings were statistically significant. CONCLUSION: FIR was impaired in MTLE patients, and FER in both IGE and MTLE, particularly for fear and disgust. Although not statistically significant, those with impaired FER tended to perform more diffuse eye-tracking over the faces and have cognitive dysfunction.

Aspectos clínicos de la infección por influenza en el Hospital Metropolitano de Quito, Ecuador, entre noviembre de 2017 y febrero 2018 / Clinical aspects of influenza infection at the Metropolitan Hospital of Quito, Ecuador, between November 2017 and February 2018

Introducción: la influenza es altamente contagiosa. Sus manifestaciones sintomáticas son variables; 10% presenta síntomas severos que pueden deberse a factores propios del huésped o a la cepa del virus. Objetivo: describir el perfil clínico del brote de influenza en un hospital privado de Quito-Ecuador. Materiales y métodos: estudio retrospectivo observacional en pacientes con influenza atendidos en los Servicios de Emergencia y Hospitalización del Hospital Metropolitano de Quito. Resultados: se registraron 422 casos de influenza. El síntoma más frecuente fue la tos (83%). 69,1% recibió oseltamivir, 26,5% fue tratado con oseltamivir y antibioticoterapia. 203 pacientes fueron hospitalizados (48,1%), de ellos 46,8% fueron menores de 5 años, 60% requirió aporte de oxígeno, la complicación más frecuente fue la neumonía (38,9%), 9 ingresaron a cuidados intensivos y 4 fallecieron. Conclusión: la influenza causa altas tasas de morbilidad y graves complicaciones.

Abstract: Background: Influenza is highly contagious. It presents variable clinical manifestations. 10% presents severe symptoms that can be due to factors associated with the infected individual as well as the virus strain. Objective: To describe clinical characteristics of influenza outbreak in a private hospital in Quito-Ecuador. Materials and methods: Retrospective observational study of patients with influenza who were admitted to Emergency and Hospitalization of Hospital Metropolitano of Quito. Results: 422 influenza cases were identified. The most frequent symptom was cough (83%). 69.1% was treated with oseltamivir and 26.5% with oseltamivir and antibiotics. 203 patients were hospitalized (48.1%), of which 46.8% were children less than 5 years of age. 60% required oxygen, the most frequent complication was pneumonia (38.9%). 9 patients were admitted to intensive care unit. 4 patients died. Conclusions: Influenza causes high morbidity rates and severe complications. Key words: influenza, complications, hospitalization

Clinical phenotypes within non-surgical patients with mesial temporal lobe epilepsy caused by hippocampal sclerosis based on response to antiepileptic drugs.

PURPOSE: To evaluate evolution and elucidate clinical phenotypes related to prognosis of patients with mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE-HS) treated exclusively with antiepileptic drugs (AED). METHODS: Forty-seven out of 68 MTLE-HS patients treated between January 2005 and June 2010 were retrospectively studied for demographic, clinical and outcome data. The population was divided into drug-responder and drug-resistant patients; the latter was divided, according to the duration of the seizure-free periods along their evolution, into patients with at least one seizure-free period longer than one year and those with shorter periods. Variables were compared between drug-responders vs drug-resistants and drug-resistants with long seizure-free periods vs drug-resistants without it. RESULTS: There were 7 (15%) drug-responders, 39 (83%) drug-resistants and 1 patient (2%) with an undetermined response. Eighteen (46%) drug-resistant individuals had seizure-free periods longer than one year, with mean duration of 46 months (3.8 years). Since no factor was statistically associated with long seizure-free period within drug-resistants, we can clinically distinguish two phenotypes: women with left HS and late onset of seizures, with poor prognosis, and men with right HS and earlier appearance of seizures, attaining a better outcome. Twenty out of 47 (42.5%) patients followed an intermittent pattern of epilepsy. CONCLUSIONS: Non-surgical MTLE-HS drug-resistant patients can achieve long seizure-free periods with AED, but relapses are common. Female gender, left or bilateral lesion and later onset of seizures seem to be bad prognosis factors within MTLE-HS drug-resistant patients.

[Non-convulsive status epilepticus in the 21st century: clinical characteristics, diagnosis, treatment and prognosis]. / Estado epiléptico no convulsivo en el siglo xxi: clínica, diagnóstico, tratamiento y pronóstico.

Non-convulsive status epilepticus is a significant issue for a neurologist because, despite its low prevalence, it mimics other pathologies, with therapeutics and prognostic outcomes. Diagnosis is based on clinical features, mainly mental status or impaired consciousness and electroencephalographic changes, so electroencephalogram is the first exploration we must perform with clinical suspicion. There are three clinical forms: generalized or absence status, with diffuse epileptiform discharges; focal, with epileptic discharges located in a specific brain area and may not affect consciousness; and subtle, with diffuse or local epileptic activity after a tonic-clonic seizure or convulsive status and limited or no motor activity. Treatment are benzodiazepines and antiepileptic drugs; anesthetic drugs are only recommended for patients with subtle status and in some with partial complex status. Prognosis is mainly determined by etiology and associated brain damage.

LC method for therapeutic drug monitoring of levetiracetam: evaluation of the assay performance and validation of its application in the routine area.

OBJECTIVES: An accurate and precise high-performance liquid chromatographic method using diode array detection for the determination of levetiracetam in human plasma has been developed and validated for use in pharmacokinetic studies. METHODS: A harmonized validation strategy based on the accuracy profiles was used to select the most appropriate regression model and to determine the limits of quantitation as well as the concentration range of the developed analytical procedure. On the other hand, the present paper also shows this validation approach as a suitable tool to guaranty the quality of the results obtained by the use of the analytical validated methodology for plasma levetiracetam determination in a routine setting and to ensure the risk of obtaining the future measurements outside the previously fixed acceptance limits. RESULTS: As pointed recently, the FDA, a weighted 1/x(2) quadratic regression model ranging from 0.53 to 107.00 mg/L was selected as the simplest calibration model that maximized the accuracy all over the range. Relative bias was <5%, assay imprecision was always <6% and mean extraction recovery from plasma was >90%. So, accuracy did not exceed the acceptance limits settled at + or - 20% according to the FDA or Washington conference regulatory requirements for bioanalytical methods. Internal quality control has been assessed over a 2 year time period. All controls were essentially found to provide levetiracetam concentrations within the target range according to the FDA. CONCLUSIONS: The validated analytical procedure complies with strongest regulatory standards. The validated method has a sufficiently rapid turnaround time and their results are good enough to enable the laboratory to routinely provide useful and accurate pharmacokinetic data in time to adjust patient regimens.

Indicadores de la poligrafía respiratoria y su relación con los parámetros antropométricos en obesos evaluados para cirugía bariátrica / Indicators of Respiratory Polygraphy and their Relation with Anthropometric Parameters in Obesity Patients Evaluated for Bariatric Surgery

Objetivo: Correlacionar indicadores antropométricos; índice de cintura-cadera (ICC) y diámetro sagital (DS) con IAH en candidatos a cirugía bariátrica (CB). Materiales y métodos: Se registraron el IMC, ICC y DS. Se evaluó IAH relevante (> 15 eventos/hora) mediante poligrafía respiratoria (PR) y se correlacionó con sexo, edad > de 50 años, escala de Berlín, HTA, DS ≥ 30 e ICC ≥ 1. Resultados: Fueron analizados 81 pacientes (mujeres 50/61.73%). Las medias fueron; edad: 46.32, SD: 11.53, IMC: 45.98 SD: 8.41 (rango: 35-77 kg/m²) y Epworth (ESS): 8.87, SD: 4.86. El 100% presentó alto riesgo por Berlín, ESS >10: 33.86% e HTA: 39.51%. Los indicadores poligráficos (medias) fueron; tiempo de registro: 407 minutos (SD: 110) e IAH: 20.66 (SD: 24.02). La prevalencia de IAH > 5/hora fue del 77.77%, IAH > 15/hora; 34.56% y el 21% obtuvo > 30/hora. La media del DS fue de 30.9 (SD: 4.60) y del ICC de 0.97 (SD: 0.09). Modelos de regresión para DS ≥ 30 cm (OR: 1.97 y p = 0.239) + ICC ≥ 1 (OR: 1.394 y p = 0.636) no alcanzaron significación cuando se adicionó sexo masculino (OR: 5.29 y p = 0.003). En regresión logística las variables no alcanzaron significación; DS ≥ 30 cm: OR de 1.25 (CI95%: 0.33-4.66) p = 0.739, ICC ≥ 1; OR 0.93 (SD: 0.19-4.62) p = 0.939 y muestran predictor exclusivamente al sexo masculino (OR: 4.20. CI95%: 1.21-14.5) p = 0.023. Conclusiones: La obesidad central según ICC ≥ 1 y DS ≥ 30 cm no tuvo correlación con IAH > 15/hora. Continúan siendo necesarios métodos objetivos (PR o polisomnografía) para evaluar la severidad del trastorno.

Objective: To assess correlation between anthropometric indexes; waist to hip ratio (WHI), sagital diameter (SD) and AHI obtained from home respiratory polygraphy (RP) in bariatric surgery candidates (BS). Methods: BMI, WHI and SD were recorded for BS candidates. Sleep apnea was defined as significant if AHI >15 events/hour. Variables included in the model were; sex, age greater than 50 years, Berlin questionnaire, history of hypertension (HBP), SD ≥ 30 and WHI ≥ 1. Results: Data from 81 patients were analyzed (50 women, 61.73%), age 46.32, SD 11.53, BMI 45.98 SD: 8.41 (range: 35-77 kg/m²) and ESS: 8.87 (SD: 4.86). 100% had high risk by Berlin questionnaire, 33.86% had ESS >10, and 39.51% HBP. Respiratory polygraphy data were: recording time: 407 minutes (SD: 110) and AHI: 20.66 (SD: 24.02). Prevalence of AHI > 5/hour (pathological) was 77.77%; significant AHI (> 15/hour) 34.56%, and 21% had > 30/hour. The SD was 30.9 (SD: 4.60) and WHI of 0.97 (SD: 0.09). 48.15% had a WHI ≥ 1. Logistic regression showed: DS ≥ 30 cm (OR: 1.97, p = 0.239) + WHI ≥ 1 (OR 1.394, p = 0.636) and it did not reach significance when male sex is added. Both variables included in the model did not reach statistical significance; SD ≥ 30 cm: OR of 1.25 (95% CI: 0.33-4.66) p = 0.739, ICC ≥ 1, OR 0.93 (SD: 0.19-4.62) p = 0.939. In the model, male sex was the only predictor (OR: 4.20, CI 95%: 1.21. -14.5) p = 0.023. Conclusions: Central obesity measured by WHI ≥ 1 and SD ≥ 30 cm had no significant correlation with AHI > 15/h. Objective methods (RP or polysomnography) are needed to assess the severity of the disorder before prescribing bariatric surgery.

Subthalamic role on the generation of spikes in temporal epilepsy.

SUMMARY: We report the electrophysiological findings in an unusual patient with temporal lobe epilepsy and subthalamic stimulators implanted to treat Parkinson's disease. Temporal and frontotemporal spikes were observed in the EEG. Temporal spikes spread to the STN in a 40% of cases, involving simultaneously all contacts. Frontotemporal spikes showed more frequent STN propagation (70%), shorter delays, and progressive spread from ventral to dorsal contacts than temporal spikes. These results suggest that a direct fronto-subthalamic pathway might account for the fast propagation of the frontotemporal spikes to the ventral STN.

Sleep structure in patients with periodic limb movements and obstructive sleep apnea syndrome.

Periodic limb movements (PLM) and obstructive sleep apnea syndrome (OSAS) are two frequent sleep disorders which often occur in the same patient. The goal of this study was to know the influence of the presence of PLM in the sleep architecture in patients with and without OSAS. Two hundred twenty consecutive patients (69 women and 151 men) participated in this transversal study. They were patients with clinical suspicion of dysomnia, including snoring, OSAS, and PLM. All of them underwent a full polysomnography and were interviewed using questionnaires about the sleep quality. The sleep parameters (percentage of sleep stages, rapid eye movement latency, sleep efficiency, awakenings, PLM presence, apnea-hypopnea index) were calculated and compared between groups. Descriptive statistics and nonparametric distribution techniques were used for the analysis. Patients with PLM when compared with patients with OSAS had lower sleep efficiency and less rapid eye movement percentage. The presence of PLM in patients with sleep apnea was less relevant being responsible only for an increase in the rapid eye movement latency and a decrease in the duration of the three to four sleep stages. However, the presence of OSAS was related to a better sleep efficiency (patients with PLM plus OSAS had a better sleep efficiency than patients with only PLM). PLM alters the structure of sleep. In patients with sleep apnea, the presence of PLM is less relevant.

Caso: hombre de 43 años con diagnóstico de AR y disnea de 6 meses de evolución / Case: 43-year-old man diagnosed with RA and dyspnea of 6 months of evolution

Un hombre de 42 años de edad, no fumador, fue evaluado en la consulta externa de Neumonología por tos y disnea que en los últimos seis meses había progresado hasta hacerse evidente en reposo. Aproximadamente un año antes, el paciente había notado un descenso en su tolerancia a las actividades diarias. En los últimos seis meses desarrolló disnea de esfuerzo que progresa al reposo y se acompaña de tos con expectoración hialina escasa, y sibilancias. Un mes antes de esta evaluación, el paciente había consultado a un especialista en otro centro. En la auscultación pulmonar se encontraron sibilancias 4/6 difusas, y una espirometría reveló una alteración ventilatoria obstructiva en grado muy severo. Por este motivo inició tratamiento con broncodilatadores de acción prolongada asociados a corticoides inhalados en dosis altas, así como broncodilatadores de acción corta en nebulización a demanda, pero no encontró cambios en su condición clínica

Relación entre la escala de somnolencia de Epworth y el índice de apneas e hipoapneas de la poligrafía respiratoria / Relationship between Epworth Sleepiness Scale and the Apnea/hypopnea Index in Obstructive Sleep Apnea Patients

Objetivos: Identificar el valor en la escala de Epworth (ESS) que correlaciona con un índice de apneas e hipopneas por hora de registro (IAH =15/h) de la poligrafía respiratoria (PR) en pacientes derivados por sospecha clínica de apneas e hipopneas obstructivas durante el sueño (SAHOS), y evaluar su capacidad de discriminación. Material y métodos: Estudio conducido entre enero del 2010 y marzo del 2012 (27 meses) en una cohorte de 614 pacientes referidos para exploración respiratoria del sueño. Los registros de PR (nivel III) se tomaron en domicilio una noche con técnica de auto-colocación. Se correlacionaron con datos antropométricos, del cuestionario de Berlín y la escala de somnolencia subjetiva de Epworth (ESS) y se consideró relevante un índice de apneas e hipopneas por hora de registro = 15 eventos/hora. Se ejecutó un análisis de regresión logística para factores de predicción de un IAH = 15 eventos/hora y se variaron los puntos de corte de ESS como predictor independiente. Finalmente se calculó el área bajo la curva ROC (relación sensibilidad-especificidad). Resultados: Se estudiaron 614 pacientes, 392 hombres (63.8%) y 222 mujeres con una media de edad de 54.9 años. Se definió obesidad por el IMC en el 57.7%. El cuestionario de Berlín fue de alto riesgo en 536 (87.3%) y 207 (33.7%) tuvieron ESS > 10 puntos. En 235 poligrafías respiratorias se encontró un IAH > 15/hora (38.27%). El análisis de predictores independientes en toda la población arrojó significación para sexo masculino (p = 0.0001), IMC > 30 (p = 0.0001) y edad > 50 años (p = 0.0001). En el análisis univariado, ESS > 8 obtuvo un Odds Ratio (OR) de; 1.294 (CI; 0.934-1.794), p = 0.121, ESS > 10; OR: 1.526 (CI; 1.084-2.149), p = 0.010, ESS > 11; OR: 1.610 (CI; 1.134-2.285), p = 0.008, y ESS > 12; 1.461 (CI; 0.990-2.158), p = 0.056. El análisis multivariado corregido por edad (> o 30 Kg/m2), cuestionario de Berlín de alto riesgo o diagnóstico previo de SAHOS arrojó un valor predictor de ESS > 11 con OR; 1.527 (CI; 1.042-2.238) p = 0.03. El área bajo la curva ROC obtuvo un área de 0.56 e identificó 11,11 puntos en la escala de somnolencia subjetiva de Epworth como el punto de corte con la mejor relación de sensibilidad (34.7%) y especificidad (75,1%). Conclusiones: ESS es una prueba con aceptable especificidad pero baja sensibilidad. En nuestra población de pacientes que concurren para la realización de una PR por sospecha de SAHOS, una puntuación de ESS > 11 es el valor que mejor se relaciona con un IAH = 15 por hora.

Objectives: To identify the value in the Epworth Sleepiness scale (ESS) that correlates best with an apnea/hypopnea index (AHI) greater than 15/h in the respiratory polygraphy (RP) in patients referred to a sleep clinic with suspicion of obstructive sleep apnea (OSA). Materials and Methods: This is a study conducted between January 2010 and March 2012 in a cohort of 614 patients referred for sleep evaluation. Respiratory polygraphy (level III) was performed at home with a self-electrode placement technique. Anthropometric data, Berlin questionnaire score, and ESS score were correlated with an AHI greater than 15/h. A logistic regression analysis was performed for prediction factors for AHI > 15/h, and different cut-off points for ESS were tried out as an independent predictor. Finally an area under the ROC curve was calculated. Results: 614 patients were studied, 392 males (63.8%) and 222 females with a mean age of 54.9 years. Obesity (BMI > 30) was present in 57.7%. Berlin questionnaire registered high risk in 536 cases (87.3), while 207 (33.7%) subjects had an ESS score > 10 points. In 235 RP an AHI > 15/h (38.27%) was found. The analysis for independent predictors showed significance for male gender (p = 0.0001), BMI > 30 (p = 0.0001), and age > 50 years (p = 0.0001). In a univariate analysis ESS score > 8 had an OR of 1.29 (CI 0.93-1.79), ESS score > 10 had and OR of 1.52 (CI 1.08-2.14), ESS score > 11 had an OR of 1.61 (CI 1.13-2.28), and ESS score > 12 had an OR of 1.46 (CI 0.99-2.15). The multivariate analysis including age > 50, presence of a psychiatric condition, BMI > 30, and high risk Berlin questionnaire showed that ESS > 11 had an OR of 1.53 (CI 1.04-2.24). The area under the ROC curve for ESS > 11 was 0.56, with sensitivity of 34.7% and specificity of 75.1%. Conclusions: ESS is a test with acceptable specificity and low sensitivity. In our patients evaluated with RP for suspicion of OSA, an ESS > 11 correlates best with an AHI > 15/h.