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La telangiectasia hemorrágica hereditaria (HHT), o síndrome de Rendu-Osler-Weber, se considera dentro del grupo de las enfermedades raras, pues afecta a 1 de cada 3.000 a 8.000 individuos. Tiene un patrón de herencia autosómica dominante y la mayor parte de los casos se debe a una alteración en la codificación de los genes endoglina (ENG) y activina receptor-like kinase 1 (ALK1), dando origen a los tipos 1 y 2, respectivamente. Esta alteración genética se traduce en una displasia del endotelio de la pared vascular debido a haploinsuficiencia para endoglina y se manifiesta clínicamente con epistaxis a repetición, telangiectasias mucocutáneas y malformaciones arteriovenosas (MAV) viscerales. A continuación, se presenta el caso clínico de una paciente pediátrica de 11 años de edad que se manifestó por disnea e hipoxemia severa debido a múltiples fístulas arteriovenosas pulmonares.

Hereditary hemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber syndrome, is considered among rare diseases, as it affects 1 in every 3,000 to 8,000 individuals. It follows an autosomal dominant inheritance pattern, and most cases are due to alterations in the coding of the endoglin (ENG) and activin receptor-like kinase 1 (ALK1) genes, leading to types 1 and 2, respectively. This genetic alteration results in vascular endothelial dysplasia due to haploinsufficiency for endoglin and clinically manifests with recurrent epistaxis, mucocutaneous telangiectasias, and visceral arteriovenous malformations (AVMs). Herein, we present the clinical case of an 11-year-old pediatric patient who exhibited severe dyspnea and hypoxemia due to multiple pulmonary arteriovenous fistulas.

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BACKGROUND: Damage due to respiratory viruses increases the risk of bacterial and fungal coinfections and superinfections. High rates of invasive aspergillosis are seen in severe influenza and COVID-19. This report describes CAPA cases diagnosed during the first wave in the biggest reference centre for severe COVID-19 in Mexico. OBJECTIVES: To describe the clinical, microbiological and radiological characteristics of patients with invasive pulmonary aspergillosis associated with critical COVID-19, as well as to describe the variables associated with mortality. METHODS: This retrospective study identified CAPA cases among individuals with COVID-19 and ARDS, hospitalised from 1 March 2020 to 31 March 2021. CAPA was defined according to ECMM/ISHAM consensus criteria. Prevalence was estimated. Clinical and microbiological characteristics including bacterial superinfections, antifungal susceptibility testing and outcomes were documented. RESULTS: Possible CAPA was diagnosed in 86 patients among 2080 individuals with severe COVID-19, representing 4.13% prevalence. All CAPA cases had a positive respiratory culture for Aspergillus species. Aspergillus fumigatus was the most frequent isolate (64%, n = 55/86). Seven isolates (9%, n = 7/80) were resistant to amphotericin B (A. fumigatus n = 5/55, 9%; A. niger, n = 2/7, 28%), two A. fumigatus isolates were resistant to itraconazole (3.6%, n = 2/55). Tracheal galactomannan values ranged between 1.2 and 4.05, while serum galactomannan was positive only in 11% (n = 3/26). Bacterial coinfection were documented in 46% (n = 40/86). Gram negatives were the most frequent cause (77%, n = 31/40 isolates), from which 13% (n = 4/31) were reported as multidrug-resistant bacteria. Mortality rate was 60% and worse prognosis was seen in older persons, high tracheal galactomannan index and high HbA1c level. CONCLUSIONS: One in 10 individuals with CAPA carry a resistant Aspergillus isolate and/or will be affected by a MDR bacteria. High mortality rates are seen in this population.

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OBJECTIVES: Skipping meals is linked to negative cardiometabolic health outcomes. Few studies have examined the effects of breakfast skipping after disruptive life events, like job loss. The present analyses examine whether sleep timing, duration, and continuity are associated with breakfast eating among 186 adults who recently (past 90 days) experienced involuntary unemployment from the Assessing Daily Activity Patterns Through Occupational Transitions (ADAPT) study. METHODS: We conducted both cross-sectional and 18-month longitudinal analyses to assess the relationship between actigraphic sleep after job loss and breakfast eating. RESULTS: Later sleep timing was associated with a lower percentage of days breakfast was eaten at baseline (B = -0.09, SE = 0.02, P < .001) and longitudinally over 18 months (estimate = -0.04; SE = 0.02; P < .05). No other sleep indices were associated with breakfast consumption cross-sectionally or prospectively. CONCLUSIONS: Unemployed adults with a delay in sleep timing are more likely to skip breakfast than adults with an advancement in sleep timing. Future studies are necessary to test chronobiological mechanisms by which sleep timing might impact breakfast eating. With the understanding that sleep timing is linked to breakfast eating, the advancement of sleep timing may provide a pathway for the promotion of breakfast eating, ultimately preventing cardiometabolic disease.

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The adverse events related to sodium colistimethate have had variability regarding the prevalence of nephrotoxicity, neurotoxicity, and less frequent respiratory depression. In recent years, its use has been relevant due to the increase of multidrug-resistant bacteria since it is considered the last-line drug, being its main adverse event and reason for discrepancies between authors' nephrotoxicity. The indiscriminate use of antibiotic therapy has generated multiple mechanisms of resistance, the most common being related to Colistin, the bactericidal escape effect. Based on the search criteria, no randomized clinical trials were identified showing safety and efficacy with the use of Colistin, inferring that the application of the appropriate dose is governed by expert opinion and retrospective and prospective observational studies, which confounding factors such as the severity of the patient and the predisposition to develop acute renal failure are constant. In this review, we focus on identifying the mechanism of nephrotoxicity and bacterial resistance, where much remains to be known.

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Decision simulation technology is known to augment health practitioner education and training; little is known about its use for educating lay health practitioners about cancer prevention. We report the development and evaluation of a decision simulation component of a skin cancer risk reduction electronic training (e-training) for massage therapists (MTs). Simulation facilitated tracking and analysis of MTs' selected dialog options leading to client-focused helping conversations (MT conversations intended to encourage client pro-health behavior) regarding skin cancer risk reduction. The tracking also enabled further assessment of the e-training competencies. We constructed five decision simulation cases in the DecisionSim™ online platform, mimicking MT-client encounters pertaining to skin cancer risk reduction, allowing MTs to apply training knowledge to initiate a helping conversation. We scored each simulation by tracking conversation pathways via selected dialog options (optimal, feedback required, suboptimal), analyzing total scores and real time spent on each case. MTs rated satisfaction with the simulations on a 5-point Likert scale. Eighty-one MTs completed the simulations in an average of 2.7 min. Most (91%) MTs selected feedback required or suboptimal dialog options for at least one of the five cases, often incorrectly choosing conversation statements reflecting their own feelings. The majority (86%) agreed/strongly agreed that they enjoyed the simulations (mean score 4.31); 92% found the simulations helpful to include in the training (mean score 4.36). Decision simulations integrated into e-training are useful for assessing lay practitioners' practical application of cancer risk reduction knowledge and skills and use of appropriate helping conversations.

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Sleep deficiencies amongst individuals with type 1 diabetes mellitus (T1DM) have been linked with dysregulated glycemic control and greater morbidities. Sleep extension (EXT) has been identified as a viable intervention target to improve adolescent outcomes. The intervention aims to emphasize collaborative work with families to engage in behaviors that increase the likelihood of the youth increasing their sleep duration consistently. This study will randomize up to 175 youth with T1DM and at least one caregiver to either an EXT intervention or a family routines support (FRS) consultation. It is hypothesized that the EXT condition will lead to improvements in sleep, which in turn, will contribute to improved glycemic control. The primary endpoint is improved glycemic control assessed via a continuous glucose monitor (CGM) to ascertain average glucose levels across a week, glycemic variability, and percent time in the target range at one month and HbA1c at three months. Analyses will control for co-morbid conditions, including sleep-disordered breathing and obesity. This study will provide the needed data to support addressing sleep as part of the standards of care in youth with T1DM.

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OBJECTIVE: This study prospectively examined change in waist circumference (WC) as a function of daily social rhythms and sleep in the aftermath of involuntary job loss. It was hypothesized that disrupted social rhythms and fragmented/short sleep after job loss would independently predict gains in WC over 18 months and that resiliency to WC gain would be conferred by the converse. METHODS: Eligible participants (n = 191) completed six visits that included standardized measurements of WC. At the baseline visit, participants completed the social rhythm metric and daily sleep diary and wore an actigraph on their nondominant wrist each day for a period of 2 weeks. RESULTS: When controlling for obesity and other covariates, WC trajectories decreased for individuals with more consistent social rhythms, more activities in their sdiocial rhythms, and higher sleep quality after job loss. WC trajectories did not change for individuals with lower scores on these indicators. CONCLUSIONS: The frequency and consistency of social rhythms after job loss play a key role in WC loss. These findings support the implementation of social rhythm interventions after job loss, a potentially sensitive time for the establishment of new daily routines that have an impact on metabolic health.

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The etiologic agents of central nervous system infections in HIV-infected patients comprise a broad range of opportunistic pathogens. We presented a 49-year-old male patient with HIV infection and low adherence to antiretroviral therapy. He presented with multiple cerebral abscesses, and his microbiological diagnosis approach resulted in the isolation of Nocardia beijingensis , a species rarely reported in America. Central nervous system nocardial infection in HIV-infected patients should be considered, and a diagnosis at species level is mandatory because the antibiotic susceptibility profile varies among species.

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INTRODUCCIÓN: La Organización Mundial de Salud (OMS), declaró a la COVID-19 como una pandemia. Por lo que junto a las autoridades de salud pública se adoptaron medidas para contener el brote, emitieron recomendaciones para la reorganización y ampliación progresiva de los Servicios de Salud en respuesta a la pandemia. Esto permitió visibilizar el liderazgo de las enfermeras/os, compromiso en la toma de decisiones de manera autónoma; además requirió planear, organizar, dirigir, implementar, medir y fortalecer la calidad del cuidado y la seguridad del paciente. OBJETIVO: Conocer el significado de liderazgo en la complejidad de la pandemia de la Covid 19 vivido por las enfermeras/os ecuatorianas desde la visión de las coordinadoras de enfermería. METODOLOGÍA: Fue abordada desde las nociones centrales de la fenomenología, que surge como un análisis de los fenómenos o las experiencias significativas de reflexión filosófica del pensamiento de Husserl. Las actoras claves seleccionadas dentro de los criterios de inclusión, fueron tres enfermeras de los hospitales más importantes de Ecuador. El instrumento aplicado radicó en entrevistas a profundidad. RESULTADOS: Las enfermeras/os ejercieron un liderazgo participativo fundamentados en el modelo de la teoría de la complejidad, frente a las instituciones de salud, en seis ejes fundamentales: talento humano, capacitación, trabajo en equipo, diseño normativo, condiciones de trabajo, manejo de las afecciones psicológicas y de salud. CONCLUSIONES: El estudio demostró que en el caso ecuatoriano el acercamiento teórico al liderazgo de la complejidad fue ratificado con la toma de decisiones, el empleo de herramientas e intervenciones efectivas que permitió obtener resultados positivos, crecimiento y cambio congruente con la ciencia de la complejidad. Pusieron a la vista un rol protagónico en la conducción de las unidades de salud y comunidades, demostrando capacidad, creatividad, conocimiento, actitudes positivas en la aplicación del proceso administrativo, pues respondieron de forma oportuna a circunstancias y escenarios en la pandemia.

INTRODUCTION: The World Health Organization (WHO) declared COVID-19 a pandemic. Therefore, together with the public health authorities, measures were adopted to contain the outbreak, they issued recommendations for the reorganization and progressive expansion of Health Services in response to the pandemic. This made it possible to make visible the leadership of the nurses, commitment to making autonomous decisions; It also required planning, organizing, directing, implementing, measuring and strengthening the quality of care and patient safety. OBJECTIVE: Know the meaning of leadership in the complexity of the Covid 19 pandemic experienced by Ecuadorian nurses from the perspective of the nursing coordinators. METHODOLOGY: A phenomenological notion approach was the path for this research, built as an analysis of the phenomena or the significant experiences of Husserl's though philosophical reflection. The key actors selected within the inclusion criteria were three nurses from the most important hospitals in Ecuador. The instrument applied was an in-depth interview of each of them. RESULTS: The nurses exercised participatory leadership based on the complexity theory model, compared to health institutions, in six fundamental axes: human talent, training, teamwork, regulatory design, working conditions, management of psychological and health conditions. CONCLUSIONS: The study showed that in the Ecuadorian case, the theoretical approach to complexity leadership was ratified with decision-making, the use of effective tools and interventions that allowed obtaining positive results, growth and change consistent with the science of complexity. They put out a leading role in the management of health units and communities, demonstrating capacity, creativity, knowledge, positive attitudes in the application of the administrative process, since they responded in a timely manner to circumstances and scenarios in the pandemic.

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Telehealth can provide expanded access to healthcare. The Comprehensive Patient Assessment for Using Telehealth at Home is a comprehensive approach for an intentional remote patient meeting that provides a high-quality patient encounter when using technology. In this study, we describe the perspectives of seriously ill older adults and their caregivers on the usability of the Comprehensive Patient Assessment for Using Telehealth at Home using technology to meet remotely and assess patients in their own homes. This study used qualitative description with semistructured interviews to explore participants' user experience of the telehealth visit using the Comprehensive Patient Assessment for Using Telehealth at Home. The overarching theme of participants' experiences with the Comprehensive Patient Assessment for Using Telehealth at Home intervention was of a continuum of acceptance of technology use. Participants felt that a combination of in-person and telehealth visits was ideal, and telehealth visits were appropriate for routine visits. In-person assessments would be necessary if the communication was not adequately received through remote technology. Other themes were satisfaction and detractors, usability of the technology, privacy and confidentiality, and timing of the telehealth visit. Telehealth presents new opportunities for patients to engage and connect with providers, allowing them to seek care in the comfort of their own home. In some circumstances, telehealth is appropriate but is not a permanent replacement for in-person visits.

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OBJECTIVE: Unemployment is an established risk factor for obesity. However, few studies have examined obesity-related health behavior after involuntary job loss specifically. Job loss confers a disruption in daily time structure that could lead to negative metabolic and psychological outcomes through chronobiological mechanisms. This study examines whether individuals with unstable social rhythms after involuntary job loss present with higher abdominal adiposity than individuals with more consistent social rhythms and whether this relationship varies as a function of depressive symptoms. METHODS: Cross-sectional baseline data (n = 191) from the ongoing Assessing Daily Activity Patterns in occupational Transitions (ADAPT) study were analyzed using linear regression techniques. Participants completed the Social Rhythm Metric-17 (SRM) daily over 2 weeks. They also completed the Beck Depression Inventory II (BDI-II) and participated in standardized waist circumference measurements (cm). RESULTS: A significant interaction emerged between SRM and BDI-II demonstrating that less consistent social rhythms were associated with larger waist circumference at lower levels of depressive symptoms. Additional exploratory analyses demonstrated a positive association between the number of daily activities performed alone and waist circumference when controlling for symptoms of depression. CONCLUSION: These findings are the first to demonstrate a relationship between social rhythm stability and abdominal adiposity in adults who have recently, involuntarily lost their jobs. Results highlight the moderating role of depressive symptoms on daily routine in studies of metabolic health. Future prospective analysis is necessary to examine causal pathways.

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STUDY OBJECTIVES: To evaluate predictions of moderate to severe obstructive sleep apnea (MS-OSA) by the neck circumference/height ratio (NHR) and waist circumference/height ratio (WHR) and compare to the derived STOP-Bang Questionnaire (dSBQ) prediction. METHODS: Included were 6,167 participants from the Sleep Heart Health Study baseline evaluation who completed polysomnograms and had anthropometric measurements and data to compute proxy dSBQ item answers. The sample was divided randomly into derivation (n = 2,035) and validation (n = 4,132) subsets. The derivation sample was used to estimate the NHR and WHR cut points to detect MS-OSA; the validation sample was used to evaluate sensitivity and specificity. RESULTS: Mean age was 63.1 years, and 47.2% were men for the overall sample. In the derivation sample, a cut point ≥ 0.21 for NHR yielded a sensitivity of 92.0% and a specificity of 25.0%; a cut point ≥ 0.52 for WHR yielded a sensitivity of 91.2% and a specificity of 25.0% for MS-OSA. Using the validation sample, the NHR, WHR, and dSBQ areas under the receiver operator curves were 69.8%, 65.2%, and 70.5%, respectively, for MS-OSA. There was no statistical difference with listwise comparison of the NHR and dSBQ areas under the receiver operator curves (P = .997); however, there was a significant difference between the WHR and dSBQ areas under the receiver operator curves (P = .015) for MS-OSA. CONCLUSIONS: The NHR is a viable obstructive sleep apnea screening tool comparable to the dSBQ, independent of witnessed apneas and body mass index, that can be used for different body types. CITATION: Vana KD, Silva GE, Carreon JD, Quan SF. Using anthropometric measures to screen for obstructive sleep apnea in the Sleep Heart Health Study cohort. J Clin Sleep Med. 2021;17(8):1635-1643.

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Background: The increased use of telehealth to visit patients in their home permits greater access to care, and also increases the opportunity for whole-person assessments that improve individualized care. The videoconferencing camera is a proxy for home visit provider's eyes. However, cameras limit views, thereby reducing environmental cues. The Novice to Expert Theory of skill acquisition supports the use of an intentional viewing guide to assure a comprehensive patient assessment using telehealth in the home (CPATH). This study advances the development of a CPATH framework to guide providers to be intentional when using televideo technology. Methods: A quantitative content validity approach was used to determine the validity of a priori items within domains that were in the original protocol framework. A content validity determination requires 5-10 experts to rate agreement (range 1-5) on items within domains. Our sample was composed of seven expert home health providers. More than five experts had to agree to achieve statistical significance (p < 0.05) for validity. Results: Of the 15 items in the protocol, only 8 items had significant agreement for the sample size. These items were breathing, nonverbal gesturing, positioning, oxygen, safety, and types, dosages, and administration guidance of medication. Other items were added within the existing domains of Patient Characteristics, Treatment and Equipment Functioning, Medications and Environmental Quality, with the exception of Caregivers. Conclusion: The domains triggered considerations for existing or additional items that require assessment, thereby developing the intentional guide framework that permits individualization of a telehealth home-based visit.

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BACKGROUND: The International Classification of Sleep Disorders (ICSD)-3 was developed to aid in the identification of these disorders. The core criterion A (ICSD-3A) to identify obstructive sleep apnea (OSA) requires the presentence of specific signs and symptoms. This study explores the predictive ability of the ICSD-3A for OSA as compared with objective measures of respiratory event index (REI). PARTICIPANTS: A total of 291 participants who completed a home sleep apnea test (HSAT) during the screening evaluation of the Assessing Daily Activity Patterns through occupational Transitions (ADAPT) study were included. METHODS: Participants were classified as having mild OSA (REI ≥ 5 and < 15), moderate (≥ 15 to < 30), or severe OSA (> 30). Predictive parameters identifying participants as having OSA by the ICSD-3A criteria were assessed using REI classifications as the reference standard and further compared with a subsample using the STOP-Bang questionnaire. RESULTS: The ICSD-3A had a sensitivity of 19.2% for identifying participants as having moderate to severe OSA and specificity of 84.4%. The ICSD-3A had a receiver operating characteristics (ROC) = 0.53. On the subsample of participants, the STOP-Bang questionnaire's ROC is 0.61. Results were similar when examining the classification of participants with mild compared with no OSA. CONCLUSION: In this population, the ability of the ICSD-3A in detecting moderate to severe OSA as well as mild OSA was low. The ROC for the ICSD-3 did not differ significantly from the STOP-Bang questionnaire's ROC in this research population.

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BACKGROUND: Obstructive sleep apnea (OSA) has been associated with negative occupational outcomes including absenteeism and poor work productivity. This analysis explored whether the severity of OSA was associated with multiple involuntary job loss history among recently unemployed adults. METHODS: This is a cross-sectional analysis of data from the screening visit of the Assessing Daily Activity Patterns Through Occupational Transitions study. Information was collected from 261 participants who recently involuntarily lost their jobs. Data included demographics, employment, medical history, and results from a limited channel home sleep apnea test. The respiratory event index was categorized as <5 events per hour (no-OSA), 5 to <15 (mild OSA), and ≥15 (moderate to severe OSA). Logistic regression and propensity score matching were used to identify factors associated with multiple involuntary job loss. RESULTS: A total of 44.8% of participants reported multiple involuntary job loss. Those with mild OSA had 1.85 (95%CI: 1.04, 3.28) increased odds of reporting multiple involuntary job loss as compared to participants with no OSA in the unadjusted model; while participants with moderate-to-severe OSA had 2.71 (95%CI: 1.33, 5.70) increased odds. After adjusting for age, sex, ethnicity, beginning work between 7 and 9 AM, job type, and, compensation type, the odds of involuntary job loss among participants with moderate-severe OSA were 2.46 (95%CI: 1.13, 5.52) as compared to having no OSA. CONCLUSIONS: In a sample of recently unemployed adults, having OSA significantly increased the odds of reporting previous involuntary job losses. This study suggests OSA could be a risk factor for job loss.

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