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Rationale: Obstructive sleep apnea (OSA) is associated with increased cardiovascular disease (CVD) risk. Conversely, OSA has not been shown to increase recurrent cardiovascular events in patients w...

Summary Background Despite the improvement in the prognosis of acute coronary syndrome (ACS), substantial morbidity and mortality remain. We aimed to evaluate the effect of obstructive sleep apnoea (OSA) and its treatment with continuous positive airway pressure (CPAP) on the clinical evolution of patients with ACS. Methods We designed a multicentre, open-label, parallel-group, randomised controlled trial of patients with ACS at 15 hospitals in Spain. Eligible non-sleepy patients were men and women aged 18 years and older, admitted to hospital for documented symptoms of ACS. All patients underwent respiratory polygraphy during the first 24–72 h after admission. OSA patients were randomly assigned (1:1) to CPAP treatment plus usual care (CPAP group) or usual care alone (UC group) by a computerised system available 24 h a day. A group of patients with ACS but without OSA was also included as a reference group. Because of the nature of the intervention, the trial intervention could not be masked to either investigators or patients. Patients were monitored and followed for a minimum of 1 year. Patients were examined at the time of inclusion; after 1 month, 3 months, 6 months, 12 months, 18 months, 24 months, 30 months, and 36 months; and every 12 months thereafter, if applicable, during the follow-up period. The primary endpoint was the prevalence of a composite of cardiovascular events (cardiovascular death or non-fatal events [Acute myocardial infarction, non-fatal stroke, hospital admission for heart failure, and new hospitalisations for unstable angina or transient ischaemic attack]) in patients followed up for a minimum of 1 year. The primary analysis was done according to the intention-to-treat principle. This study is registered with Clinicaltrials.gov , NCT01335087 and is now closed. Findings Between April 25, 2011, and Feb 2, 2018, a total of 2834 patients with ACS had respiratory polygraphy, of whom 2551 (90·01%) were recruited. 1264 (49·55%) patients had OSA and were randomly assigned to the CPAP group (n=633) or the UC group (n=631). 1287 (50·45%) patients did not have OSA, of whom 603 (46·85%) were randomly assigned to the reference group. Patients were followed up for a median of 3·35 years (IQR 1·50–5·31). The prevalence of cardiovascular events was similar in the CPAP and UC groups (98 events [16%] vs 108 events [17%]; hazard ratio [HR] 0·89 [95% CI 0·68–1·17]; p=0·40) during follow-up. Mean time of adherence to CPAP treatment was 2·78 h/night (SD 2·73). The prevalence of cardiovascular events was similar between patients in the reference group (90 [15%] events) and those in the UC group (102 (17%) events) during follow-up (1·01 [0·76–1·35]; p=0·93). The prevalence of cardiovascular events seem not to be related to CPAP compliance or OSA severity. 464 (74%) of 629 patients in the CPAP group had 1538 serious adverse events and 406 (65%) of 626 patients in the UC group had 1764 serious adverse events. Interpretation Among non-sleepy patients with ACS, the presence of OSA was not associated with an increased prevalence of cardiovascular events and treatment with CPAP did not significantly reduce this prevalence. Funding ResMed (Australia), Fondo de Investigacion Sanitaria (Fondo Europeo de Desarrollo Regional), the Spanish Respiratory Society, the Catalonian Cardiology Society, Esteve-Teijin, Oxigen Salud, and ALLER.

To the editor,We read with interest in this journal an article by Skralin et al. [1] on a relationship between hospital admissions and mortality in COVID-19. The findings coincide with observations...

The Mannitol test is used for the diagnosis of bronchial hyperreactivity. It is in the asthma diagnostic algorithm Aims. Make a descriptive review of the tests we had done and their usefulness. Settings and Design: Retrospective descriptive study. Methods and Material. Patients who have performed the mannitol test in the laboratory of functional respiratory tests between May 29, 2017 and December 3, 2018. Statistical analysis used. Study of frequencies in qualitative variables and measures of central tendency in quantitative. The relationships were studied with nonparametric tests: F of Fisher for qualitative variables and U of Mann-Whitney for quantitative variables. The significance was set at p≤0.05. Results. There were 54 patients, 81.5% women of 49.06 years. The most frequent adverse effect was cough that occurred in 85.4% and with a dose of 5 mg. The result was positive at 14.8%. The positives are among those older than 40 years (p = 0.04), so those who cough (p = 0.018). There are significant differences in the dose received and the fall in FEV1. There was no relationship between coughing and the positivity or negativity of the test (p=0.56), nor was there any relationship between gender and cough or positivity. Conclusions. The mannitol test is a useful test to detect hyperreactivity. The most frequent adverse effect is cough.

Objective: this study analyses long-term results of sublobar resection in daily clinical activity versus the standard procedure (lobectomy). Method: From a prospective database, patients treated with sublobar resection for NSCLC were identified (2007-2017). None of them had malignant disease in the 5 previous years nor induction treatment. Log-rank test was used to compare overall survival and disease free survival. One-to-one propensity score matching was performed for age, sex, stage, and comorbities to reduce bias selection. Results: 1214 patients were surgically treated for lung cancer in that period of time. Finally, 52 patients were included in sublobar group with following resections: pulmonary wedge 37(71.2%) cases; anatomic segmentectomy 15(28.8%) cases. Women 4(7.7%); Men 48(92.3%). Mean age: 68.6 y.o. (range 42-86). Pulmonary function test (FEV1 64.9% vs 77.3% p=0.004) and tumoral size (1.9cm vs 3.0cm p

Resumen: Introducción: El síndrome de apneas-hipopneas del sueño (SAHS) es altamente prevalente en la edad pediátrica y un problema importante de salud pública. Se pretende conocer la presentación clínica y polisomnográfica del SAHS infantil en nuestro medio. Pacientes y métodos: Estudio descriptivo retrospectivo de los estudios del sueño realizados a menores de 14 años desde 1999 hasta 2012 en la Unidad del Sueño del Complejo Hospitalario Universitario de Albacete. Se recogen edad, sexo, datos antropométricos, clínicos, indicación y variables del estudio del sueño, tratamiento y evolución. Resultados: Doscientos treinta y cuatro niños. SAHS el 71,8%: moderado 42,3% y grave 44,6%. 60,7% varones y mediana de edad 5 años; el 78% en edad preescolar o escolar. Presentaban sobrepeso/obesidad 44%, ronquidos 93,4%, apneas 84,5% y somnolencia diurna 5,4%; 23 polisomnografías y 145 poligrafías: mediana de índice de apneas-hipopneas (IAH) 10, de SatO2 mínima 84% y de índice de desaturaciones 8, y media de sueño en supino 53,65% y de eventos en supino 57,61%. El tratamiento fue medidas higiénico-dietéticas en el 29,2%, CPAP el 6% y cirugía el 42,9%. Mejoraron los ronquidos y/o apneas el 69,4% y el peso el 32,4% de los niños con sobrepeso/obesidad. Conclusiones: La mayoría de los niños estudiados tenían un IAH patológico. Casi la mitad presentaban sobrepeso/obesidad y un alto porcentaje tenía SAHS moderado-grave. El tratamiento más indicado fue la cirugía. La evolución clínica fue favorable en casi el 70%. Menos de un tercio con SAHS y sobrepeso/obesidad mejoraron el peso. Abstract: Introduction: Obstructive sleep apnoea (OSA) is highly prevalent in children and a major public health problem. An attempt is made to determine the clinical and polysomnographic presentation of paediatric OSA in our area. Patients and methods: Retrospective descriptive study of sleep tests conducted on children up to 14 years-old from 1999 to 2012 in the Sleep Unit of the University Hospital of Albacete. Age, gender, anthropometric, clinical data, indication and variables of sleep study, treatment, and outcomes were collected. Results: The study included 234 children. OSA was found in 71.8%, with 42.3% moderate and 44.6% severe. The majority were male (60.7%) and the mean age 5 was years, of whom 78% were pre-school or school age. There was overweight/obesity in 44%, with 93.4% snoring, apnoea 84.5%, and 5.4% daytime sleepiness. There were 23 polysomnographies and 145 polygraphies, with a median apnoea/hypopnoea index (AHI) of 10, Sat.O2 minimum 84%, desaturation index 8, and mean sleep supine 53.65% and supine events 57.61%. Treatment was lifestyle modifications 29.2%, CPAP 6%, and surgery 42.9%. Improved snoring and/or apnoea 69.4%, and weight 32.4% of overweight/obesity children. Conclusions: Most of the studied children had a pathological AHI. Almost half were overweight/obese, and a high percentage had moderate-severe OSA. Most frequent treatment was surgery. The clinical outcome was favourable in almost 70%. Less than a third with OSA and overweight/obesity improved weight.

Introduction: Obstructive sleep apnoea (OSA) is highly prevalent in children and a major public health problem. An attempt is made to determine the clinical and polysomnographic presentation of paediatric OSA in our area. Patients and methods: Retrospective descriptive study of sleep tests conducted on children up to 14 years old from 1999 to 2012 in the Sleep Unit of the University Hospital of Albacete. Age, gender, anthropometric, clinical data, indication and variables of sleep study, treatment, and outcomes were collected. Results: The study included 234 children. OSA was found in 71.8%, with 42.3% moderate and 44.6% severe. The majority were male (60.7%) and the mean age was 5 years, of whom 78% were pre-school or school age. There was overweight/obesity in 44%, with 93.4% snoring, apnoea 84.5%, and 5.4% daytime sleepiness. There were 23 polysomnographies and 145 polygraphies, with a median apnoea/hypopnoea index (AHI) of 10, SatO2 minimum 84%, desaturation index 8, and mean sleep supine 53.65% and supine events 57.61%. Treatment was lifestyle modifications 29.2%, CPAP 6%, and surgery 42.9%. Improved snoring and/or apnoea 69.4%, and weight 32.4% of overweight/obesity children. Conclusions: Most of the studied children had a pathological AHI. Almost half were overweight/obese, and a high percentage had moderate-severe OSA. Most frequent treatment was surgery. The clinical outcome was favourable in almost 70%. Less than a third with OSA and overweight/obesity improved weight. Resumen: Introducción: El síndrome de apneas-hipopneas del sueño (SAHS) es altamente prevalente en la edad pediátrica y un problema importante de salud pública. Se pretende conocer la presentación clínica y polisomnográfica del SAHS infantil en nuestro medio. Pacientes y métodos: Estudio descriptivo retrospectivo de los estudios del sueño realizados a menores de 14 años desde 1999 hasta 2012 en la Unidad del Sueño del Complejo Hospitalario Universitario de Albacete. Se recogen edad, sexo, datos antropométricos, clínicos, indicación y variables del estudio del sueño, tratamiento y evolución. Resultados: Doscientos treinta y cuatro niños. SAHS el 71,8%: moderado 42,3% y grave 44,6%. 60,7% varones y mediana de edad 5 años; el 78% en edad preescolar o escolar. Presentaban sobrepeso/obesidad 44%, ronquidos 93,4%, apneas 84,5% y somnolencia diurna 5,4%; 23 polisomnografías y 145 poligrafías: mediana de índice de apneas-hipopneas (IAH) 10, de SatO2 mínima 84% y de índice de desaturaciones 8, y media de sueño en supino 53,65% y de eventos en supino 57,61%. El tratamiento fue medidas higiénico-dietéticas en el 29,2%, CPAP el 6% y cirugía el 42,9%. Mejoraron los ronquidos y/o apneas el 69,4% y el peso el 32,4% de los niños con sobrepeso/obesidad. Conclusiones: La mayoría de los niños estudiados tenían un IAH patológico. Casi la mitad presentaban sobrepeso/obesidad y un alto porcentaje tenía SAHS moderado-grave. El tratamiento más indicado fue la cirugía. La evolución clínica fue favorable en casi el 70%. Menos de un tercio con SAHS y sobrepeso/obesidad mejoraron el peso.

Objective: To analyze the economic impact of vaccination of the 65-year-old cohort with the 13-valent conjugated pneumococcal vaccine (VNC13) in the Autonomous Community of Castilla-La Mancha. Methods: A dynamic transmission model based on differential equations was adapted to analyze the burden of pneumococcal disease (ND) in the 65+ year old population over 5 years, with 59% being vaccinated annually. An efficacy of VNC13 of 52.5% (CAPITA study), coverage of vaccine serotypes of 60.1% (CAPA study) and incidence of EN in the Community of 258.5 / 100,000 cases year (CMBD 2011-2015) was applied. The perspective was that of the SESCAM; costs of hospitalized EN cases according to the CBCA's CMBD (hospitalized pneumonia, € 4,675, invasive pneumonia, € 4,792, meningitis, € 11,9342, primary bacteremia, € 4,792) and cost of extra-hospital pneumonia of € 358. Results: Vaccination with VNC13 would reduce the incidence of EN by 75%, up to 324.7 cases / 100,000 accumulated in 5 years. As a c n sequence, it is expected to avoid 1,219 cases of EN; 715 hospitalized pneumonias, 437 extra-hospital pneumonias and 67 cases of invasive disease. The expected cost of vaccination in 5 years of 2.3 million euros would be fully compensated by avoiding 3.9 million euros of medical costs of illness, with a cumulative net saving of 1.4 million Euros (discount rate of 3 %). The sensitivity analysis with different scenarios was robust. Conclusion: The costs of complications from pneumococcal disease are greater than those of a VNC13 pneumococcal vaccination campaign in 65-year-old adults. Death increases in unvaccinated patients.

Restrospective analysis from a prospective database:January-2007 to September-2018, 1076 anatomical pulmonary resections were performed, of them 60(5.6%) were bronchial reconstruction for malignant disease. We analysed type of bronchial reconstruction, suture, postoperative complications, and follow-up. Results: male/female=50/10(83.3%/16.7%), mean age=60.5(range:26-79). -Sleeve lobectomy:39(65% two of them with pulmonary artery reconstruction and one with superior vena cava reconstruction), -Wedge-sleeve lobectomy:11(18.3% one of them with arterial reconstruction) -Sleeve bilobectomy:4(6.7%) -Sleeve segmentectomy:3(5%) -Lung-sparing sleeve bronchial resection:2(3.3%) -Bronchial reconstruction with autologous pericardium:1(1.7%) Right upper lobectomy: the most frequent 29(48.3%). Histology: adenocarcinoma=5 (.3%), squamous=40(66.7%) carcinoid=8(13.3%), others: 7(11.6%) Mean hospital stay:8.9days (s.d. 6.5). Induction treatment:5(8.3%), adjuvant Ch=19(31.7%), Rt=3(5.0%), Ch+Rt=7(11.7%). Non-absorbable suture=42(70.0%), absorbable=18(30.0%). Postoperative mortality:3(5.0%) Postoperative morbidity: - none:16(26.7%) - related to anastomosis:7(11.6%, two dehiscences with conservative treatment, two dehiscences with reoperation, one with diffuse mucus plugs and reintervention, two stenoses with dilatation) There were no statistically significant differences in anastomosis complications according to type of suture (p=0.14) or type of bronchial resection(p=0.47). Overal survival was lower in lymph nodes metastases(p=0.04) and squamous/adenocarcinoma vs other histology(p=0.03). Conclusions: We did not observe differences in types of surgical bronchial reconstruction.

In some patients, acute respiratory distress syndrome (ARDS) leads to life-threatening refractory hypoxemia developing. Physicians may consider hypoxemic rescue therapies in an attempt to improve oxygenation in these patients while on conventional mechanical ventilation support. Use of inhaled nitric oxide (iNO) in ARDS is one of the most widely-studied pharmacological interventions over the past two decades. Its efficacy was examined in several randomized clinical trials and has undergone meta-analyses. Although iNO treatment was associated with improved oxygenation, researchers unfortunately never demonstrated a concomitant decrease in mortality or any improved outcome. Hence the current evidence suggests that iNO should not be routinely used in patients with ARDS however may be considered as adjunct therapy to tentatively improve oxygenation while other therapies are being considered in patients with severely hypoxemic ARDS.This review focuses on the therapeutic use of iNO in adult ARDS patients. We set out some recommendations for its use as rescue therapy against refractory hypoxemia.En algunos pacientes, el síndrome de distrés respiratorio agudo (SDRA) provoca el desarrollo de una hipoxemia refractaria que compromete la vida. En este contexto pueden considerarse terapias de rescate en un intento de mejorar la oxigenación mientras los pacientes permanecen en ventilación mecánica. El uso de óxido nítrico inhalado (NOi) en el SDRA ha sido una de las terapias farmacológicas más estudiadas en las últimas dos décadas. Diversos ensayos clínicos y metaanálisis han evaluado su eficacia, y aunque se ha demostrado un aumento en la oxigenación, no se ha podido demostrar un descenso en la mortalidad o una mejora en el pronóstico. La evidencia actual sugiere que aunque el NOi no debe usarse de forma rutinaria en pacientes con SDRA, puede considerarse su uso para mejorar la oxigenación en pacientes severamente hipoxémicos.Esta revisión examina la aplicación terapéutica del NOi en pacientes adultos con SDRA. Se propone un esquema con diversas recomendaciones para su uso como terapia de rescate frente a la hipoxemia refractaria.

Heterozygous familial hypercholesterolemia affects one every 400 individuals, is caused by mutations in the LDL receptor gene and is associated with premature coronary artery disease. Nowadays, LDL cholesterol can be efficiently reduced with the new therapies to reduce blood lipids. We report a female patient who consulted in 1975, when she was 46 years old, for severe hypercholesterolemia. In 2003, a sample of leukocyte DNA was obtained and the uncommon 1705 + 1G >A mutation of the LDL receptor gene was detected. No mutations in the apolipoprotein B gene were found. The patient was treated successfully with simvastatin 80 mg/day and ezetimibe 10 mg/day and LDL cholesterol levels were reduced below 200 mg/dl