Journal of Clinical Sleep Medicine Articles in Advance

GLOBAL PRACTICE OF SLEEP MEDICINE

Sleep Societies and Sleep Training Programs in Latin America

Darwin Vizcarra-Escobar, MD

Rosario J. Fabián-Quillama, MD

Yssel S. Fernández-Gonzáles, MD

Published Online:March 2, 2020 https://doi.org/10.5664/jcsm.8422

Abstract

STUDY OBJECTIVES:

To describe and compare current information about sleep societies, training programs and requirements for certification in sleep medicine across Latin America (LA).

METHODS:

Online research was conducted from July to September 2019. Search terms and logic were established, including every region or territory in LA. Members of sleep societies were contacted to complete missing information.

RESULTS:

There are eleven sleep societies in LA included in the Latin American Federation of the Sleep Societies (FLASS). They have varied levels of available online information. Regarding training programs, Brazil offers a sleep medicine residency while Mexico includes sleep training in the neurophysiology specialty; both countries offer sleep medicine certification. Sleep societies of Colombia and Argentina have developed their own certification processes.

CONCLUSIONS:

There are remarkable differences in sleep societies consolidation, training programs, available certification, terminology, regulatory entities and requirements in LA, which may increase difficulties and obstacles for a multinational certification project.

Revista de Neuro-Psiquiatría

versión impresa ISSN 0034-8597

Resumen

VIZCARRA, Darwin R et al. Clinical Practice Guidelines: Diagnostic and Treatment of Multiple Sclerosis in Adults. Rev Neuropsiquiatr [online]. 2019, vol.82, n.4, pp.242-257. ISSN 0034-8597.  http://dx.doi.org/10.20453/rnp.v82i4.3646.

Multiple Sclerosis (MS) is a chronic disease of the central nervous system, for which there is still no definitive cure; but there is a diverse variety of therapies with the objective of modifying the course of the disease, which promotes the constant inclusion of new therapeutic strategies. Objective: The Peruvian Society of Neurology, as requested by the Peruvian Health Ministry, convened a committee of experts with the purpose of elaborating a clinical practice guideline for the diagnosis and treatment of MS. Method: Clinical practice guidelines were searched and evaluated according to the AGREE II methodology, choosing the Catalan Clinical Practice Guide as a model. The clinical questions not related to treatment were solved through a systematic review. The clinical treatment questions were assessed under the PICO format and were solved with a meta-analysis of clinical trials available until August 2017, considering the therapies approved by DIGEMID until January 2017. The final recommendations were elaborated using the modified Delphi method with a consensus of at least 80% of the members of its committee. Finally, an external revision of the manuscript was made by international experts in MS. Results: Eighteen clinical questions and twenty-one recommendations for management were developed, including therapeutic algorithms.

Palabras clave : Multiple sclerosis; practice guideline; Peru.

Review Orthostatic hypotension and REM sleep behaviour disorder: impact on clinical outcomes in α-synucleinopathies

Andrea Pilotto ,1,2 Alberto Romagnolo,3 Jasmine A Tuazon,4,5 Joaquin A Vizcarra,4 Luca Marsili,4 Maurizio Zibetti,3 Michela Rosso,6 Federico Rodriguez-Porcel,4,7 Barbara Borroni ,1 Maria Cristina Rizzetti,2 Carlo Rossi,8 Darwin Vizcarra-Escobar,9 Jennifer R Molano,10 Leonardo Lopiano,3 Roberto Ceravolo,11 Mario Masellis,12 Alberto J Espay,4 Alessandro Padovani,1 Aristide Merola 4 Movement disorders

To cite: Pilotto A, Romagnolo A, Tuazon JA, et al. J Neurol Neurosurg Psychiatry 2019;90:1257–1263. ► Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10. 1136jnnp-2019-320846).

Published by BMJ. Abstract Objective Review the effect of orthostatic hypotension (OH) and rapid-eye-movement sleep behavioural disorder (RBD) on survival, cognitive impairment and postural stability, and discuss pathogenic mechanisms involved in the association of these two common non-motor features with relevant clinical outcomes in α-synucleinopathies. Methods We searched PubMed (January 2007– February 2019) for human studies of OH and RBD evaluating cognitive impairment, postural instability, and survival in Parkinson’s disease (PD), dementia with Lewy bodies (DLB), multiple system atrophy (MSA) and pure autonomic failure (PAF). Included studies were analysed for design, key results and limitations as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results OH and RBD showed a positive association with cognitive impairment in PD and DLB, conflicting association in PAF, and no association in MSA. OH was correlated with incident falls and postural instability in PD and DLB but not in MSA. The association between RBD and postural instability was inconclusive; positive in five studies, negative in seven. OH, but not RBD, correlated with reduced survival in PD, DLB and MSA. The combination of OH and RBD was associated with cognitive impairment and more rapid progression of postural instability. Conclusions OH and RBD yielded individual and combined negative effects on disability in α-synucleinopathies, reflecting a ’malignant’ phenotype of PD with early cognitive impairment and postural instability. Underlying mechanisms may include involvement of selected brainstem cholinergic and noradrenergic nuclei. I

A case of positional central sleep apnea due to compression of the left vertebral artery on brainstemSleep Sci. 2018 Jul-Aug; 11(4): 211–214. DOI:10.5935/1984-0063.20180034

Christie Fiorella Zamora-Niño,¹ Brian Jose Villafuerte-Trisolini,¹ and Darwin Roger Vizcarra-Escobar^1,2,3

Author information Article notes Copyright and License information Disclaimer

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Abstract

Studies evaluating the association between Central Sleep Apnea (CSA) and positional sleep apnea are not commonly described and are barely understood. We report a case of a 51-year-old-male with moderate Obstructive Sleep Apnea (OSA) and severe CSA probably secondary to brainstem compression, which responded to the adoption of strict lateral body posture. The addition of Continuous Positive Airway Pressure (CPAP) optimally resolved the remaining obstructive respiratory events. We suggest including Magnetic Resonance Imaging (MRI) in the work-up plan of patients with positional CSA.

Keywords: Central Sleep Apnea, Continuous Positive Airway Pressure, Posture, Sleep-Disordered Breathing, Magnetic Resonance Imaging

INTRODUCTION

According to International Classification of Sleep Disorders Third Edition, CSA is defined as cessation in airflow of 10 or more seconds in the absence of any inspiratory effort, while positional sleep apnea is said to be present when there is a 50% reduction in the Apnea-Hypopnea Index (AHI) during non-supine sleep. The association between these conditions is poorly understood and not commonly reported¹. We reported a case of a 51-year-old male with moderate OSA and severe CSA probably due to respiratory center compression

Cyclic Alternating Pattern Associated with Catathrenia and Bruxism in a 10-Year-Old PatientJ Clin Sleep Med. 2017 Mar 15; 13(3): 511–512.

Published online 2017 Mar 15. doi: 10.5664/jcsm.6510

Brian Villafuerte-Trisolini, MD,¹ Fiorella Adrianzén-Álvarez, MD,¹ Kevin R. Duque, MD,¹ Jimmy Palacios-García, MD,^1,2,3 and Darwin Vizcarra-Escobar, MD^1,2,4

Author information Article notes Copyright and License information Disclaimer

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Abstract

Cyclic alternating pattern (CAP) is widely recognized as an expression of sleep instability in electroencephalogram activity during non-rapid eye movement sleep. We report a case with sequences of CAP followed by bruxism and catathrenia in a 10-y-old male patient with a diagnosis of attention deficit hyperactivity disorder in treatment with methylphenidate. We found CAP in 83.1% of all episodes of catathrenia, and the CAP rate was 12.8%. We propose to consider catathrenia as one of the sleep disorders that may be accompanied by CAP.

Citation:

Villafuerte-Trisolini B, Adrianzén-Álvarez F, Duque KR, Palacios-García J, Vizcarra-Escobar D. Cyclic alternating pattern associated with catathrenia and bruxism in a 10-year-old patient. J Clin Sleep Med. 2017;13(3):511–512.

Keywords: attention deficit and hyperactivity disorder, bruxism, catathrenia, cyclic alternating pattern

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INTRODUCTION

Cyclic alternating pattern (CAP) is described as periodic activity in electroencephalography in non-rapid eye movement (NREM) sleep, recognized as an expression of sleep instability. It has been associated with several sleep disorders including two of the conditions in our patient; bruxism and attention deficit hyperactivity disorder (ADHD).¹ Catathrenia, described as sleep-related expiratory groaning,² has not been previously described in association with CAP. We present a case of catathrenia, bruxism, and CAP in a 10-y-old male patient.

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REPORT OF CASE

A 10-y-old male presenting with bruxism and a vocal groaning sound like purring during his sleep, almost every night for the past 4 y, was scheduled for polysomnography. The child had a regular sleep schedule and no sleep complaints or daytime sleepiness. ADHD was diagnosed 5 y ago and treatment with methylphenidate started 2 y after diagnosis. He denied rhinitis, asthma, and gastroesophageal reflux. His physical and neurologic examinations were unremarkable.

A nighttime standard polysomnogram with video monitoring was performed (Figure 1). A certified sleep specialist reviewed the scoring, using version 2.3 of the American Academy of Sleep Medicine Manual for the Scoring of Sleep and Associated Events and identified CAP sequences manually, using the criteria proposed by Terzano et al.³ Total sleep time was 476.5 min, NREM sleep time; 398.5 min, rapid eye movement (REM) sleep time; 78.0 min, stage N1 1%, N2 49%, N3 34%, REM 16%, sleep efficiency 94%, wake after sleep onset 35 min, arousal index 21, apnea-hypopnea index 1.1, respiratory disturbance index 2, lowest oxygen saturation 95%; no snoring was detected.

Revista de Neuro-Psiquiatría

versión impresa ISSN 0034-8597

Rev Neuropsiquiatr vol.78 no.4 Lima oct. 2015

Ansiedad,síndrome de piernas inquietas y onicofagia en estudiantes de medicina.

Anxiety, restless legs syndrome and onychophagia in medical students.

Bruno Pedraz-Petrozzi^1,a, Jorge Pilco-Inga^1,a, Joaquín Vizcarra-Pasapera^1,a, Jorge Osada-Liy^1,b, Paulo Ruiz-Grosso^1,2,c, DarwinVizcarra-Escobar^3,d

¹ Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia. Lima, Perú.

² Hospital Nacional Cayetano Heredia. Lima, Perú.

³ Instituto de Medicina del Sueño Hypnos, Clínica San Felipe. Lima, Perú.

^a Estudiante de sexto año ; ^b Médico Epidemiólogo ; ^c Médico residente de Psiquiatría; ^d Médico Neurólogo.

RESUMEN

Objetivos: Describir la frecuencia de ansiedad, onicofagia y síndrome de piernas inquietas (SPI) en estudiantes de medicina y explorar la relación entre los mismos. Material y métodos: Participaron 315 estudiantes del primer al quinto año de medicina de una universidad privada de Lima. Se administraron la Escala de Ansiedad de Beck (BAI), una escala Likert para onicofagia, el Inventario de Estudios Epidemiológicos de SPI (García -Borreguero) y el Inventario de SPI (Grupo Internacional de SPI). Resultados: Se halló la frecuencia de ansiedad (61,3%), onicofagia (52,63%) ySPI(9,29%). Ser hombre es un factor protector para ansiedad (razón de prevalencia (RP) = 0,74;p = 0,001; IC 95% = 0,63 – 0,89). Existe asociación entre sintomatología ansiosa y SPI (RP =2,52; p = 0,036; IC95% = 1,06– 6); y entre sintomatología ansiosa y onicofagia (RP = 1,47; p =0,002;IC 95% = 1,15 – 1,87). La presencia de onicofagia y SPI tenía asociación con sintomatología ansiosa (RP = 5,37; p= 0,023;IC 95% = 1,26 – 22,82). No se encontró asociación significativa entre SPI y onicofagia. Conclusiones: Existe una asociación entre ansiedad y SPI; y entre ansiedad y onicofagia; pero no entre SPI y onicofagia.

PALABRAS CLAVE: Ansiedad, onicofagia, síndrome de piernas inquietas.

SUMMARY

Objectives: The present work describes the frequency of anxiety, onychophagy and restless legs syndrome (RLS) in medical students and explore the relation among these conditions. Material and methods: 315 medical students from the first to the fifth year from a private university where selected to participate. The instruments used for the study where: The Beck Anxiety Inventory, a Likert scale for onychophagy (nail biting), the Inventory of Epidemiological Studies for RLS (García – Borreguero)and the RLS Inventory (International RLS Group). Results: A frequency of anxiety (61.3%), onychophagy (52.63%) and RLS (9.29%) were found. Being male was a protective factor for anxiety (prevalence ratio (PR) = 0.74; p =0.001,95% CI = 0.63 to 0.89). There was an association between anxiety symptoms and RLS (PR = 2.52; p = 0.036, 95% CI = 1.06 – 6.00); and between anxious and onychophagy symptoms (PR = 1.47; p = 0.002, 95% CI = 1.15 -1.87). Coexistence of onychophagy and RLS were associated with anxiety symptoms (PR = 5.37; p =0.023, 95% CI = 1.26 – 22.82).There was no significant association between RLSand onychophagy. Conclusions: There is an association between anxiety and RLS, and between anxiety and onychophagy; but not between RLS and onychophagy.

KEYWORDS: Anxiety, onychophagy, restless leg syndrome, prevalence, association

NTERNATIONAL STROKE CONFERENCE MODERATED POSTER ABSTRACTS

SESSION TITLE: COMMUNITY/RISK FACTORS MODERATED POSTER TOUR II

Abstract TMP55: Polysomnographic and Sleep-related Variables Associated to Leukoaraiosis in Patients with Obstructive Sleep Apnea

Kevin R Duque ,Brian Villafuerte,Fiorella Adrianzen, Rodrigo Zamudio, Andrea Mendiola, Tito Navarro, and Darwin Vizcarra

Originally published21 Feb 2017Stroke. 2017;48:ATMP55

Abstract

Introduction: Obstructive sleep apnea (OSA) is a biological plausible risk factor for leukoaraiosis (LA). We tested the hypothesis that polysomnographic (PSG) and sleep-related variables are associated to LA in OSA patients.

Methods: Cross-sectional study in which PSG records, medical histories and brain 1.5T MRI were collected from all consecutive patients who had attended a Sleep Medicine Center between 2009-2014. LA was graded from 0 to 9 with the ’Atherosclerosis Risk In Communities’ study scale. OSA was defined by The International Classification of Sleep Disorders, 2014, and its severity categorizing according to apnea-hypopnea index (AHI, <15 mild, 15 to <30 moderate, 30 to <45 severe and ≥45 very severe). A multinomial logistic regression was performed to describe the association between OSA severity and LA (divided into 2 groups: mild-to-moderate LA and non-to-minimal LA). The covariates for all regression models were age, gender, BMI, hypertension, ischemic stroke, myocardial infarction, diabetes and pack-year of smoking.

Results: From 82 OSA patients (77% male; mean age 58±9 years, range 19-91), 54 (66%) had LA. Mild-to-moderate LA was found in 13 patients (8 mild and 5 moderate LA) and non-to-minimal LA in 69 (41 minimal and 28 non LA). Spearman’s correlation coefficient between AHI and LA grade was 0.41 (p<0.001). Furthermore, the higher OSA severity, the higher LA severity (p<0.001, for Jonckheere-Terpstra test for ordered alternatives). In the multinomial logistic regression model adjusted for cofounders, severe OSA patients had higher risk for mild or moderate LA (HR 12.8, 95% IC 1.2-141) compared to mild-to-moderate OSA patients. Additionally, self-reported habitual sleep duration from 7 to 9 hours (HR 0.36, 90% IC 0.14-0.90) and proportion of time in apnea/hypopnea over total sleep time (HR 1.04 for one unit increase, 90% IC 1.01-1.08) could be associated with the presence of LA (adjusted only for age and gender). In a multiple regression analysis with all the aforementioned variables, age (p=0.002), diabetes (p=0.003), and OSA severity (p=0.04) were predictors of the presence of LA.

Conclusion: Patients with severe OSA had higher risk for mild to moderate LA when compared to patients with mild or moderate OSA.

NEUROLOGY April 18, 2017; 88 (16 Supplement) APRIL 23, 2017

Fatigue and sleep deprivation in interns of medicine and its burden in vehicle driving (P1.051)

Brian Jose Villafuerte Trisolini, Fiorella S. Adrianzén Alvarez, Kevin R. Duque, Darwin Vizcarra Escobar, Germán Málaga Rodríguez, Etbert Pizarro Salas, Daniel Córdova Ccasa

First published April 17, 2017,

NEUROLOGY Abstract

Objective: To describe fatigue induced by extended duration work shifts (EDWS) and sleep deprivation in interns (senior medical students in Peru) and its burden on vehicle driving.

Background: Sleep deprivation and EDWS (≥24 hours) remain a hallmark practice in medical education worldwide which can affect physician wellbeing and safety.

Design/Methods: Follow-up study during 4 days in interns with shifts lasting ≥30hours. The EDWS took place on day 2. We employed actigraphs; sleep diaries; fatigue impact scale for daily use (D-FIS); psychomotor vigilance task to measure reaction time (RT) and number of lapses (NoL, RT>500ms) every 6 hours during the extended duration shift and daily at 7am.

Results: Ten participants were enrolled. Self-reported work hours per week were 83.4±7.2 hours. D-FIS score increased in day 2 (day 2: 16.6±7.3 versus day 1: 7.8±3.0, p=0.005) and RT increased in the second half of EDWS (mean RT of 7am–7pm at EDWS beginning: 341.7±44.7 versus 1am–1pm: 398.0±101.7, p=0.01). Both decreased in day 4 (5.4±4.6, p=0.005 and 330.7±58.3, p=0.01), after one night of restful sleep which lasted, in average, 154 minutes more than the night before EDWS. Out of 6 interns who drive, 4 nodded off or fell asleep while stopped in traffic and 3 while driving. Drivers who fell asleep showed higher RT (506.75 vs 364.9 ms), NoL (7.25 vs 1.25) and D-FIS score (21.5 vs 17) at the end of the night shift (at 7 am) than those who didn’t fall asleep. This study was halted when university and hospital authorities were informed of the interim analysis and extended duration shifts ceased.

Conclusions: D-FIS score and RT increase in the EDWS and return to baseline scores after one night of restful sleep. Drivers who fall asleep while driving show higher RT at the end of the EDWS than those who did not.

Study Supported by: self financed

Disclosure: Dr. Villafuerte Trisolini has nothing to disclose. Dr. Adrianzén Alvarez has nothing to disclose. Dr. Duque has nothing to disclose. Dr. Vizcarra Escobar has nothing to disclose. Dr. Málaga Rodríguez has nothing to disclose. Dr. Pizarro Salas has nothing to disclose. Dr. Córdova Ccasa has nothing to disclose.

Multiple Sclerosis Journal

Multiple sclerosis journal LACTRIMS 2018FIrst Published November 2018 Abstract

https://doi.org/10.1177/135245851879706

Health-related quality of life in a sample of patients with multiple sclerosis in Peru

Theme: Clinical Research

Theme 2: Quality of life

Christie Fiorella Zamora Niño, Sebastián Alonso Serván Lozano, Brian Villafuerte Trisolini, Kevin Ray Duque Yupanqui, Fiorella Sofía Adrianzén Álvarez, Darwin Vizcarra and Joaquín Vizcarra Pasapera

Hypnos – Instituto Del Sueño, Lima, Peru

Background: Multiple sclerosis (MS) is recognized as one of the major causes of neurological disability, thus influencing health-related quality of life (HrQOL).

Objectives: To assess HrQOL and to determine its associated variables in patients with MS.

Methods: We assessed the HrQOL of 41 patients with MS who participated in an MS-nonprofit Organization meeting. They completed the Short Form (SF)-36 questionnaire and an ad hoc questionnaire about their clinical and socio-demographic data. Then, we examined the Peruvian population-normalized scores (2012 Database) for the SF-36, and the obtained results on HrQOL were compared between MS subgroups defined by disability level, which was measured by self-reported validated Expanded Disability Status Scale (EDSS). Other variables (gender, type of treatment, number of relapses within the last year, and course of disease) were also analyzed.

Results: Fifty-four percent of participants were female, with a mean age of 45 (28–55) years, and most of them (61.5%) obtained an EDSS score of 4. The median score of the eight health-related domains of the SF-36 questionnaire was calculated as follows: physical functioning: 26.4 (0–46.7), role physical: 24.4 (15.2–54.1), bodily pain: 38.0 (25.4–44.3), general health: 39.7 (32.2–46.8), vitality: 34.0 (25.7–40.1), social functioning: 31.8 (18.6–39.9), role emotional: 34.6 (17.1–54.4), and mental health: 41.6 (19.6–45.6). All these results were significantly lower than those of the general population. Among the distinct variables evaluated across SF-36 domains, female patients and male patients with progressive forms of MS obtained lower scores in general health domain (p < 0.001). EDSS score >4 (p = 0.001) and compromise of pyramidal system (p = 0.01) were related to worse results in physical functioning domain, while patients not receiving disease-modifying therapy (p = 0.02) had worse outcomes in bodily pain domain.

Conclusion: Compared to the general population, patients with MS reported significantly lower scores in all eight domains of SF-36 HrQOL questionnaire.

NEUROLOGYApril 18, 2017; 88 (16 Supplement) APRIL 25, 2017

Analysis of clinical practice guidelines in Multiple Sclerosis using the Agree tool (P3.041)

Brian J. Villafuerte Trisolini, Kevin R. Duque, Fiorella S. Adrianzén Alvarez, Darwin Vizcarra, Rodrigo Zamudio, Cesar Caparo, Ana Cruz, Marco Huertas, Jorge Martin Gavidia Chucan, Oscar González Gamarra, Maria Meza-Vega, Victor Montalván Ayala, Nicanor Mori, Alda Rivara Castro, Edgar Rojas Huerto, Sheila Castro Suárez First published April 17, 2017,

Abstract

Objective: To assess quality of clinical practice guidelines (CPGs) for Multiple Sclerosis (MS)

Background: AGREE II is a widely used instrument designed to evaluate CPGs and therefore classify them as recommendable or not. The Peruvian committee for the development of the CPG for MS used this tool to evaluate which guidelines were most appropriate to base their recommendations on.

Design/Methods: Search was performed in Pubmed/Medline, Embase, Scopus, The Cochrane Library, Scielo, Lilacs, Hinari, Bireme, Lipecs, NGC, NHS NeLM, Guías salud de España, NICE, SIGN, UpToDate, in English and Spanish from 2010 to 2015. Keywords used for the search were: multiple sclerosis, systematic OR metanalysis, clinical trial, randomized clinical trial, pragmatic clinical trial or multicenter study. CPGs were evaluated using AGREE II by at least 2 reviewers (neurologists from the Peruvian Society of Neurology experts in MS). Intraclass correlation coefficient (ICC) was evaluated for every CPG.

Results: Twenty-one CPGs met criteria for analysis. Fifteen CPGs were evaluated by 4 reviewers, 4 CPGs were evaluated by 3 reviewers and 2 CPGs were evaluated by 2 reviewers. Mean values for each domain were: scope and purpose (75±14.1), stakeholder involvement (52.29±17.4), rigor in development (46.1±18.9), clarity and presentation (73.6±13.4), applicability (30.9±14.5) and editorial independence (62.1±26.2). ICC between reviewers was poor in 4/21 CPGs. One CPG presented slight correlation (0.01–0.20), six CPGs presented fair correlation (0.21–0.40), eight CPGs presented moderate correlation (0.41–0.60) and two CPGs presented substantial correlation (0.61–0.80). CPG of CEMCAT 2012 (6 domains >60%) and CPG of Latin America MS experts’ forum 2014 (4 domains >60%) were recommended.

Conclusions: Scope and purpose, clarity and presentation and editorial independence obtained higher scores in comparison to other domains. Agreement using AGREE II tool differed from guideline to guideline. AGREE II allows a balanced and standardized evaluation of CPG for the future development of guidelines for MS.

Journal of the Neurological Sciences

Volume 339, Issues 1–2, 15 April 2014, Pages 196-206

Management of relapsing–remitting multiple sclerosis in Latin America: Practical recommendations for treatment optimization

Author links open overlay panelJorgeCorreale^aPatricioAbad^bReginaAlvarenga^cSonizaAlves-Leon^dElizabethArmas^eJorgeBarahona^fRicardoBuzó^gTeresaCorona^hEdgardoCristianoⁱFernandoGracia^jJuan GarcíaBonitto^kMiguel AngelMacías^lArnoldoSoto^mDarwinVizcarraⁿMark S.Freedman^o

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https://doi.org/10.1016/j.jns.2014.02.017Get rights and content

Highlights

We present recommendations on treatment optimization for RR MS in Latin America.•

There is a limited window of opportunity to influence MS disease process.

Treatment modification is indicated according to changes in relapses or disability.

Treatment modification is indicated in patients with ≥ 2 new enhancing lesions.

Treatment escalation is warranted in patients with an inadequate response.

Abstract

The Latin American MS Experts’ Forum has developed practical recommendations on the initiation and optimization of disease-modifying therapies in patients with relapsing–remitting multiple sclerosis (RRMS). The recommendations reflect the unique epidemiology of MS and the clinical practice environment in Latin American countries. Treatment response may be evaluated according to changes in relapses; progression, as assessed by the Expanded Disability Status Scale and the Timed 25-foot Walk; and lesion number on magnetic resonance imaging. Follow-up assessments are recommended every six months, or annually for stable patients. Cognitive function should be evaluated in all RRMS patients at baseline and annually thereafter. These recommendations are intended to assist clinicians in Latin America in developing a rational approach to treatment selection and sequencing for their RRMS patients.

SLEEP SCIENCES Volume 8, Issue 3, November 2015, Pages 115-12

Effects of an adapted mattress in musculoskeletal pain and sleep quality in institutionalized elders Anculle Arauco Victora , Zamudio Herrera Rodrigoa , Mendiola Yamasato Andreaa , Guillen Mendoza Daniela , Pedro Jose´ Ortiz Saavedrab,c,d , Tania Tello Rodrı´guezb,c , Darwin Vizcarra-Escobara,b,n Q1 a Q2 Hypnos, Instituto del Sueño, Clínica San Felipe, Avenida Gregorio Escobedo 650, Lima 11, Peru b Faculty of medicine Universidad Peruana Cayetano Heredia, Avenida Honorio Delgado 430, Lima 31, Peru c Instituto de Gerontología de la Universidad Peruana Cayetano Heredia, Avenida Honorio Delgado 430, Lima 31, Peru d Adjunct Director of Instituto de Gerontología de la Universidad Peruana Cayetano Heredia, Avenida Honorio Delgado 430, Lima 31, Peru article info Article history: Received 9 April 2015 Received in revised form 10 August 2015 Accepted 25 August 2015 Keywords: Mattress Older adult Actigraphy abstract We aimed to evaluate the impact in sleep quality and musculoskeletal pain of a MediumFirm Mattress (MFM), and their relationship with objective sleep parameters in a group of institutionalized elders. The sample size included forty older adults with musculoskeletal pain. We did a clinical assessment at baseline and weekly trough the study period of four weeks. We employed the Pittsburgh Sleep Quality Index (PSQI) and Pain Visual Analog Scale (P-VAS). Additionally a sub-group of good sleepers, selected from PSQI baseline evaluation, were studied with actigraphy and randomized to MFM or High Firm Mattress (HFM), in two consecutive nights. We found a significant reduction of cervical, dorsal and lumbar pain. PSQI results did not change. The actigraphy evaluation found a significant shorter sleep onset latency with MFM, and a slightly better, but not statistically significant, sleep efficiency. The medium firmness mattress improved musculoskeletal pain and modified the sleep latency. & 2015 Brazilian Association of Sleep. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license

Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.70 no.10 São Paulo Oct. 2012

https://doi.org/10.1590/S0004-282X2012001000009 SPECIAL ARTICLE

Latin American algorithm for treatment of relapsing-remitting multiple sclerosis using disease-modifying agents

Algoritmo latino-americano para tratamento da esclerose múltipla remitente-recorrente utilizando drogas modificadoras da doença

Alessandro Finkelsztejn^I; Alberto Alain Gabbai^II; Yara Dadalti Fragoso^III; Adriana Carrá^IV; Miguel Angel Macías-Islas^V; Raul Arcega-Revilla^VI; Juan García-Bonitto^VII; Carlos Luis Oehninger-Gatti^VIII; Geraldine Orozco-Escobar^IX; Adriana Tarulla^X; Fernando Vergara^XI; Darwin Vizcarra^XII

^INeurologist; MSc in Epidemiology; Department of Neurology, Hospital de Clínicas de Porto Alegre; Coordinator of the Multiple Sclerosis Unit at Hospital de Clínicas de Porto Alegre, Porto Alegre RS; Professor of Neurology, Universidade de Caxias do Sul (UCS), Caxias do Sul RS, Brazil
^IINeurologist, Professor of Neurology, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo SP, Brazil
^IIINeurologist; Professor of Neurology, Universidade Metropolitana de Santos; Coordinator of the Multiple Sclerosis Reference Center DRS-IV, Santos SP, Brazil
^IVNeurologist; Multiple Sclerosis Division, Hospital Britânico, Buenos Aires BA, Argentina
^VNeurologist; Professor of Neurology, Department of Neurosciences, Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud (CUCS), Guadalajara, Mexico
^VINeurologist; Centro Medico Nacional MAC; Hospital de Especialidades del Instituto Mexicano de Seguro Social, Puebla, Mexico
^VIINeurologist; General Secretary of the Colombian Committee for Investigation and Treatment of Multiple Sclerosis (COCTRIMS); Editor of Acta Neurologica Colombiana; Neurologist at Clinica de Marly and Private Office, Bogota, Colombia
^VIIINeurologist; Associate Professor at Instituto de Neurologia, Hospital de Clínicas, Director of the Demyelinating Diseases Department at Instituto de Neurología, Hospital de Clínicas de Montevideo; Associate Professor of Neurology, Medical Faculty, Universidad de la Republica Oriental del Uruguay, Montevideo, Uruguay
^IXNeurologist, Venezuelan Society of Neurology, Working Group for the Study of Demyelinating Diseases (VECTRIMS); Coordinator of the Andes National Program of Multiple Sclerosis; Hospital Patrocinio Peñuela Ruiz, Instituto Venezolano del Seguro Social, San Cristobal, Venezuela
^XNeurologist; Department of Demyelinating Diseases, Instituto de Investigaciones Medicas Alfredo Lanari, Servicio de Neurología del Policlínico Bancario, Buenos Aires BA, Argentina
^XINeurologist; Head of the Department of Neurology, Universidad de Los Andes; Consultant Neurologist for the Clínica Alemana de Santiago, Santiago de Chile, Chile
^XIINeurologist; Associate Professor at Universidad Peruana Cayetano Heredia; Clínica San Felipe, Lima, Peru

ABSTRACT

OBJECTIVE: It is estimated that circa 50,000 individuals have relapsing-remitting multiple sclerosis in Latin America. European and North-American algorithms for the treatment of multiple sclerosis do not foresee our regional difficulties and the access of patients to treatment.
METHODS: The Latin American Multiple Sclerosis Forum is an independent and supra-institutional group of experts that has assessed the latest scientific evidence regarding efficacy and safety of disease-modifying treatments. Accesses to treatment and pharmacovigilance programs for each of the eight countries represented at the Forum were also analyzed.
RESULTS: A specific set of guidelines based upon evidence-based recommendations was designed for Latin America. Future perspectives of multiple sclerosis treatment were also discussed.
CONCLUSIONS: The present paper translated an effort from representatives of eight countries discussing a matter that cannot be adapted to our region directly from purely European and North-American guidelines for treatment.

Key words: multiple sclerosis, treatment, Latin America.

RESUMO

OBJETIVO: Estima-se que haja aproximadamente 50.000 pessoas com a forma remitente-recorrente da esclerose múltipla na América Latina. Os algoritmos de tratamento norte-americanos e europeus não levam em consideração nossas peculiaridades regionais, nem a dificuldade no acesso ao tratamento por parte dos pacientes.
MÉTODOS: O Fórum Latino-americano de Esclerose Múltipla é um grupo de especialistas independente e suprainstitucional, que avaliou as mais recentes evidências científicas sobre a eficácia e a segurança das drogas modificadoras do curso da doença. Foram avaliados também o acesso ao tratamento e os programas de farmacovigilância de cada um dos oito países representados no Fórum.
RESULTADOS: Uma lista específica de recomendações baseadas em evidências científicas foi estabelecida para a América Latina. Também foram discutidas perspectivas de futuros tratamentos para esclerose múltipla.
CONCLUSÕES: O presente estudo representou um esforço dos representantes de oito países latino-americanos em discutir um assunto que não pode ser adaptado para uso em nossa região diretamente a partir de recomendações de tratamento europeias ou norte-americanas.

Palavras-Chave: esclerose múltipla, tratamento, América Latina.

Sleep Medicine

Volume 16, Issue 8, August 2015, Pages 976-980

Original Article

Is restless legs syndrome associated with chronic mountain sickness?

Author links open overlay panelDarwinVizcarra-Escobar^abAndreaMendiola-Yamasato^aJorgeRisco-Rocca^aAlejandroMariños-Velarde^aAlanJuárez-Belaunde^aVictorAnculle-Arauco^aMaríaRivera-Chira^c

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Highlights

Limbo subjects had the highest restless legs syndrome (RLS) severity score.

Chronic mountain sickness (CMS) subjects had the lowest oxygen saturation and the highest hematocrit values.

O₂ saturation, sleep quality, and Quinghai score of >5 were associated with RLS.

RLS could be an early clinical manifestation of hypoxia at high altitudes.

High-altitude dwellers could be a good model to study the role of hypoxia in RLS.

Abstract

Background

Restless legs syndrome (RLS) and chronic mountain sickness (CMS) share physiological traits. Our objective was to explore a possible association between RLS and CMS.

Methods

We carried a cross-sectional study with male subjects living between 4100 and 4300 m above sea level. Participants underwent a clinical interview, physical examination, electrocardiographic (EKG) recording, and spirometry. We classified subjects into CMS, Limbo, and healthy high-altitude dwellers (hHAD), according to their Quinghai score and hematocrit levels. We applied the “Paradigm of questions for epidemiological studies of RLS,” The International Restless Leg Syndrome Study Group Scale, and the Pittsburgh Sleep Quality Index. Logistic regression analysis was used to determine the association between variables.

Results

Seventy-eight male subjects were included. Forty subjects were hHAD, 23 were CMS patients, and 15 participants were considered as Limbo. CMS and Limbo subjects had a higher frequency of RLS (p <0.05). Limbo subjects had the highest severity score for RLS. There were no differences in age, body mass index (BMI), or tobacco use between RLS patients and non-sufferers. In the multivariate analysis, CMS was not associated with RLS diagnosis. Oxygen saturation (p = 0.019), poor sleep quality (p <0.01), and Quinghai score of ≥6 (p = 0.026) were independently associated with RLS diagnosis.

Conclusions

Our results did not show a direct association between RLS and CMS; however, RLS was associated with reduced oxygen saturation. Hence, RLS could represent an early clinical manifestation of hypoxia, or, in CMS natural history, an early sign of maladaptation to high altitude.

J Clin Sleep Med. 2017 Mar 15; 13(3): 511–512.

Published online 2017 Mar 15. doi: 10.5664/jcsm.6510

Cyclic Alternating Pattern Associated with Catathrenia and Bruxism in a 10-Year-Old Patient

Brian Villafuerte-Trisolini, MD,¹ Fiorella Adrianzén-Álvarez, MD,¹ Kevin R. Duque, MD,¹ Jimmy Palacios-García, MD,^1,2,3 and Darwin Vizcarra-Escobar, MD^1,2,4

Go to:

Abstract Cyclic alternating pattern (CAP) is widely recognized as an expression of sleep instability in electroencephalogram activity during non-rapid eye movement sleep. We report a case with sequences of CAP followed by bruxism and catathrenia in a 10-y-old male patient with a diagnosis of attention deficit hyperactivity disorder in treatment with methylphenidate. We found CAP in 83.1% of all episodes of catathrenia, and the CAP rate was 12.8%. We propose to consider catathrenia as one of the sleep disorders that may be accompanied by CAP.

SIMPOSIO • Rev Peru Med Exp Salud Publica 33 (2) Apr-Jun 2016 • https://doi.org/10.17843/rpmesp.2016.332.2211

Salud mental en el adulto mayor: trastornos neurocognitivos mayores, afectivos y del sueño

Mental health in older adults: major neurocognitive, affective, and sleep disorders

Tania Tello-Rodríguez, Renato D Alarcón, Darwin Vizcarra-Escobar

RESUMEN

Existen numerosos factores biológicos, psicológicos y sociales con impacto más o menos prominente en la salud mental de las personas adultas mayores. Aparte de componentes derivados de los procesos normales de envejecimiento o de la coocurrencia de enfermedades médicas diversas, eventos como la muerte de un ser querido, la jubilación o la discapacidad, contribuyen significativamente a una variedad de problemas mentales o emocionales en esta fase del ciclo vital. Los problemas más frecuentes afectan las esferas neurocognitiva, afectiva y onírica. Los trastornos neurocognitivos mayores reducen el rendimiento general del paciente y generan con ello exigentes necesidades de dependencia y cuidado cercano. Los trastornos afectivos pueden acentuarse por falta de apoyo familiar y disminución marcada de interacciones sociales que pueden dar lugar a un significativo aislamiento con conducta suicida resultante. La mayor frecuencia de trastornos del sueño como insomnio, somnolencia diurna y trastornos específicos como apnea obstructiva alteran significativamente la calidad de vida de esta población.

Palabras clave:
Salud mental; Adulto mayor; Trastornos neurocognitivos; Trastornos del sueño; Depresión

ABSTRACT

Numerous biological, psychological, and social factors influence the mental health of elderly individuals to varying degrees. Apart from components related to the normal aging process and the co-occurrence of various medical conditions, events such as the death of a loved one, retirement, or disability significantly contribute to a variety of mental and emotional problems in this stage of the life cycle. The most frequent problems affect the neurocognitive, emotional, and oneiric spheres. Major neurocognitive disorders reduce one’s overall performance and, thus, increase their need for close care. Affective disorders may be exacerbated by the lack of family support and decreased social interactions, which may lead to significant isolation result in suicidal behavior. The increased frequency of sleep disorders such as insomnia and daytime sleepiness and specific disorders such as obstructive apnea significantly alter the quality of life of this population.

Key Words:
Mental Health; Elderly; Neurocognitive disorders; Sleep disorders; Depression

Cyclic alternating pattern (CAP) is widely recognized as an expression of sleep instability in electroencephalogram activity during non-rapid eye movement sleep. We report a case with sequences of CAP followed by bruxism and catathrenia in a 10-y-old male patient with a diagnosis of attention deficit hyperactivity disorder in treatment with methylphenidate. We found CAP in 83.1% of all episodes of catathrenia, and the CAP rate was 12.8%. We propose to consider catathrenia as one of the sleep disorders that may be accompanied by CAP.

Citation:

Villafuerte-Trisolini B, Adrianzén-Álvarez F, Duque KR, Palacios-García J, Vizcarra-Escobar D. Cyclic alternating pattern associated with catathrenia and bruxism in a 10-year-old patient. J Clin Sleep Med. 2017;13(3):511–512.

Keywords: attention deficit and hyperactivity disorder, bruxism, catathrenia, cyclic alternating pattern

Journal

Traffic Injury Prevention 

Volume 14, 2013 – Issue 2

Excessive Sleepiness Prevalence in Public Transportation Drivers of a Developing Country

Jorge Risco,Paulo Ruiz,Alejandro Mariños,Alan Juarez,Mariana Ramos,Frine Salmavides,Johann Vega,Hever Kruger &Darwin Vizcarra

Pages 145-149 | Received 27 Mar 2012, Accepted 07 May 2012, Accepted author version posted online: 29 May 2012, Published online:23 Jan https://doi.org/10.1080/15389588.2012.692493

Abstract

Objective: To determine the prevalence of excessive sleepiness (ES) in bus and auto-rickshaw drivers from Lima, Peru.

Methods: We conducted a cross-sectional study of Lima’s bus and auto-rickshaw drivers to estimate ES prevalence in this population. Survey sites were private transportation companies, systematically selected with a snowball approach. ES was assessed with the Spanish-validated version of the Epworth sleep questionnaire (ESQ) with a cutoff score >10. We obtained relevant demographic information.

Results: Four hundred and thirty-four bus and auto-rickshaw drivers were eligible for analysis. The overall ES prevalence was 32.7 percent (95% confidence interval [CI]: 28–37.2). ES prevalence was higher in bus drivers than in auto-rickshaw drivers, 38 percent (95% CI: 31.7–44.2) and 26.9 percent (95% CI: 20.6–33.1), respectively (P = .01). We used data from all subjects to obtain regression equations for ESQ score with several predictors. Being a bus driver, working additional nighttime hours per week, having depression or anxiety, and alcohol abuse had small but significant associations with ESQ scores.

Conclusion: ES prevalence in Lima’s public transportation drivers is in a medium range as suggested by previous regional studies.

Keywords: prevalence, disorders of excessive somnolence, motor vehicles, traffic crashes, South America, Peru

Additional information

Acknowledgment

Financial support was provided by the Peruvian Transportation and Communication Ministry.

Revista Medica Herediana

versión impresa ISSN 1018-130X

Identificación de síntomas relacionados al Síndrome de Apnea Obstructiva del sueño en historias clínicas de pacientes con eventos vasculares agudos. Identification of obstructive sleep apnea syndrome related symptoms in clinical charts of patients with an acute vascular event. VIZCARRA ESCOBAR Darwin Roger1 , KAWANO CASTILLO Jorge Fernando2 . (Rev Med Hered 2006;17:148-155)

SUMMARY Obstructive sleep apnea (OSA) main symptoms are snoring, apneas and daytime sleepiness among the most important ones. It has been demonstrated a relationship between high vascular risk and OSA. Objective: To evaluate medical search about symptoms related to OSA in patients with an acute stroke or cardiac event, who were admitted at Hospital Nacional Cayetano Heredia, in Lima, Peru, from September 2003 to September 2004. Patients and Methods: An observational retrospective study was developed recovering information in 291 clinical charts of patients who were initially diagnosed of acute stroke or cardiac event, searching questions and answers about sleep, emphasizing who took information and clinical follow up during hospitalization. Results: From 1122 evaluators, just 0.98 % of them referred ruling out sleep apnea syndrome during their evaluation of 291 patients, corresponding to 9 patients. However, 6.87 % of patients were asked about snoring during sleep, 28.52 % about somnolence and 0.68 % about apnea episodes during sleep. In only 1 opportunity was suggested to do a polysomnography in order to confirm the final diagnosis. Nobody offered any therapeutic option. Conclusions: There is not an adequate interview searching sleep apnea syndrome in patients with an acute stroke or cardiac event, in which we may expect a higher frequency of this condition. An adequate diagnosis, follow up or therapeutic advice in these patients is not achieved.. KEY WORDS: Sleep apnea, obstructive, stroke, myocardial infarction, identification

Current status of Latin American sleep societies Situação atual das sociedades de sono latinoamericanas

SLEEP SCIENCES  Summary Vol.4 Issue 1 / 2011

Mirta Averbuch¹; Sylvia Páez²; Maria Meza³; Marisa Pedemonte⁴; Ricardo Velluti⁴; Franklin Escobar²; Luciano Ribeiro⁵; Ennio Vivaldi⁶; Jorge Pezantes⁷; José Moisés⁸; Bruno Magnífico⁹; Alan Juárez⁹; Darwin Vizcarra Escobar⁹

ABSTRACT

There is scarce information on the global situation of Latin American Sleep Medicine. In the XII Congress of the Federation of Latin American Sleep Societies and the First Congress of the Peruvian Association of Sleep Medicine held in Lima, Peru, in October 2008, a meeting of representatives from different countries of Latin America was organized to implement a plan aimed to project the future. Thus, this article intended to collect information regarding sleep medicine human resources, physician and allied health professionals, educational activities, and infrastructure in selected countries of the Latin American region. Country delegates were prompted to make a presentation. These delegates brought current information to solve the following questions: Is there a national association dedicated to sleep medicine in each of their countries?; How many sleep medicine laboratories exist in their respective countries?; Is there a formal training system?; How are technologists training in each country?; What is the number of medical technologists in each individual country? and What activities related to sleep medicine are organized in each country? Participants from Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, Peru, and Uruguay described the organization of their societies, sleep study facilities, care and research in the area of sleep medicine, human resources and training events as well as their participation into education in each country. Very few countries like Argentina, Colombia, and Uruguay have health systems that cover polysomnographic studies or continuous positive airway pressure therapy. In the majority of countries, there is no formal training in sleep medicine, neither an inclusion of sleep medicine courses in medical school curricula. There is a very uneven development of sleep medicine in Latin America, with very variable availability of resources. The analysis of the region as a whole indicates a major deficiency in the practice of sleep medicine, an underserved population, and very few participation of sleep medicine in undergraduate and postgraduate medicine programs. Sleep medicine, as a field, is still young and with great development potential.

Keywords: sleep medicine specialty; societies, medical; Latin America.

RESUMO

Existem poucas informações relacionadas à situação global da Medicina do Sono Latinoamericana. No XII Congresso da Federação Latinoamericana das Sociedades de Sono e I Congresso da Sociedade Peruana de Medicina do Sono, realizados em Lima, Peru, em outubro de 2008, foi organizado um encontro com representantes de diferentes países da América Latina para implementar um plano buscando planejamento futuro. Assim, este artigo busca coletar informações relacionadas aos recursos humanos em medicina do sono, sobre os médicos e demais profissionais de saúde, atividades educacionais e infraestrutura nos países participantes. Delegados dos países participantes foram convidados a fazer apresentações individuais, com informações que respondessem às seguintes questões: Existe alguma associação dedicada à medicina do sono em seu país?; Quantos laboratórios de sono existem neste país?; Existe algum treinamento formal?; Como é o treinamento técnico em cada país?; Qual é a quantidade de médicos em cada país? e Quais atividades relacionadas à medicina do sono são organizadas em cada país? Participantes da Argentina, Bolívia, Brasil, Chile, Colômbia, Equador, México, Peru e Uruguai descreveram a organização de suas sociedades, a infraestrutura para medicina do sono, a pesquisa na área de medicina do sono, os recursos humanos e o treinamento, bem como a participação em formação e educação em cada país. Poucos países, como Argentina, Colômbia e Uruguai, possuem sistemas de saúde que cobrem exames polissonográficos ou terapia com pressão positiva e, na maioria dos países, não existe treinamento formal em medicina do sono ou inclusão desta disciplina no currículo das faculdades médicas. Há um desenvolvimento desigual da medicina do sono na América Latina, com disponibilidade de recursos bastante variável. A análise da região como um todo indica: grande deficiência na prática da medicina do sono, população mal atendida e pouca participação da medicina do sono nos cursos médicos de graduação e pós-graduação. A medicina do sono é um campo ainda novo e com grande potencial para desenvolvimento.

Palavras-chave: medicina do sono; sociedades médicas; América Latina.

Revista Medica Herediana

versión impresa ISSN 1018-130Xversión On-line ISSN 1729-214X

Rev Med Hered v.20 n.3 Lima jul. 2009

Prevalencia de Esclerosis Múltiple en Lima – Perú.

Prevalence of Multiple Sclerosis in Lima – Perú.

Vizcarra Escobar Darwin ^1,2, Kawano Castillo Jorge ^1,2,Castañeda Barba Carlos³,Chereque Gutierrez Ana ⁴, Tipismana Barbarán Martin ^1,2,5, Bernabé Ortiz Antonio ¹, Juárez Belaúnde Alan ^1,2

^{1 Facultad de Medicina Alberto Hurtado. Universidad Peruana Cayetano Heredia, Lima, Perú.}

^{2Hypnos Instituto del Sueño. Clinica San Felipe, Lima, Perú.}

^{3Clinica El Golf, Lima, Perú.}

^{4Asociacion Esclerosis Múltiple Perú. Lima, Perú.}

^{5Hospital Nacional Cayetano Heredia, Lima, Perú.}

^RESUMEN

^{La Esclerosis Múltiple (EM) es la principal enfermedad desmielinizante a nivel mundial. La epidemiología señala una mayor prevalencia de esta entidad en áreas alejadas de la línea ecuatorial. Existen algunos estudios de prevalencia en Latinoamérica, ninguno publicado en el Perú. Objetivo: Determinar la prevalencia de Esclerosis Múltiple en Lima, Perú. Material y métodos: Se utilizó el método captura recaptura para estimar la prevalencia de EM en Lima en 4 centros de pacientes con Esclerosis Múltiple de la ciudad: Hypnos Instituto del Sueño en la Clínica San Felipe, el Hospital Nacional Cayetano Heredia, la Clínica El Golf y la Asociación «Esclerosis Múltiple Perú» (ESMUP). Resultados: Se calculó la prevalencia de EM en 7,69 x 100 000 habitantes (intervalo de confianza al 95 % 7,09 a 8,30). Conclusiones: La prevalencia estimada de EM, para la ciudad de Lima, se encuentra en rango medio bajo. (Rev Med Hered 2009;20:146-150).}

^{PALABRAS CLAVE: Captura – recaptura, epidemiología, esclerosis múltiple, latinoamérica, prevalencia.} 

^SUMMARY

^{Multiple Sclerosis (ME) is the main demyelinating disease over the world. The epidemiology shows a higher prevalence of this entity in areas away from the equatorial line. There are some prevalence studies published in Latinamerica, but no previous information reported in Peru. Objetive: To determine the prevalence of ME in Lima, Peru. Material and Methods: Capture-recapture method was used to estimate the prevalence of ME in Lima, four centres of patients with ME in the city were evaluated: Hypnos Sleep Institute in «San Felipe» Clinic, Cayetano Heredia Hospital, «El Golf» Clinic and «Esclerosis Múltiple del Perú» Society (ESMUP). Results: The calculated prevalence of ME was 7.69 x 100 000 habitants (Confidence Interval at 95%: 7.09 to 8.30). Conclusions: The estimated prevalence of ME, for Lima, is about the medium low range. (Rev Med Hered 2009;20:146-150).KEY WORDS:Capture – recapture, epidemiology, multiple sclerosis, latinoamerica, prevalence.}

Esclerosis múltiple en Perú. Descripción clinicoepidemiológica de una serie de pacientes

• Autores:Darwin Vizcarra Escobar,  Cava Prado, M. Tipismana Barbarán
• Localización:Revista de neurología, ISSN 0210-0010,  41, Nº. 10, 2005, págs. 591-595
• Idioma:español
• Resumen
  • Introducción. En Perú, hasta hace algunos años se consideraba que la esclerosis múltiple (EM) era una condición inusual. Objetivo. Descripción clínica, epidemiológica, de laboratorio y control clínico de una serie de casos. Pacientes y métodos. Estudio descriptivo retrospectivo de un grupo de pacientes con diagnóstico propuesto de EM atendidos en el Hospital Nacional Cayetano Heredia y en un centro neurológico privado, entre 1993 y 2004, cuyos registros e información paraclínica se revisaron con criterios de McDonald. Resultados. Se incluyeron 55 casos (36 mujeres). El promedio de edad fue de 40 años; 27% tuvo ascendencia extranjera hasta la tercera generación. 42 casos fueron EM definida y 13 EM posible. La forma más frecuente de EM fue esclerosis múltiple remitente recurrente (49,1%). Los síntomas de inicio fueron neuritis óptica, afección motora y sensitiva; en el curso de la enfermedad aparecieron síntomas cerebelosos, acentuación de los motores y afectación de esfínteres. Se encontraron lesiones en resonancia magnética en la mitad, y un tercio de los estudios de encéfalo y médula, respectivamente. Sólo un líquido cefalorraquídeo (LCR) fue compatible con EM. La discapacidad evaluada por EDSS (Expanded Disability Status Scale) tuvo una moda de 6,5. El 30% recibió terapia inmunomoduladora. Las supervivencias a 10 y 25 años fueron 87 y 45%, respectivamente. Conclusión. Nuestra serie muestra características clinicoepidemiológicas similares a la literatura mundial, a excepción de los marcadores en LCR, inicio más frecuente con neuritis óptica y menor supervivencia. La ascendencia extranjera podría ser un factor de riesgo para EM en este grupo

odents at high

risk for the Sleep Apnea-Hypopnea Syndrome

Vizcarra—Escobar, D a,b,c ; Anculle—Arauco, V a ; Guillén—endiola—Yamasato, A a

Validation of the Peruvian versión of Berlin Questionnaire

Poster presented at WASM congress in Seoul. Chorea March 21-25, 2015 Vizcarra—Escobar, D a,b,c ; Anculle—Arauco, V a ; Guillén—Mendoza, D a ; Barbagelata—Agüero, F a ; Juarez—Belaunde, A a; Mariñoz—Velarde, A a ; Risco—Roca, J a ; Mendiola—Yamasato, A a

OBJECTIVE:The aim for our study was to develop a cross-cultural adaptation of the Peruvian version of the Berlin Questionnaire (BQ-PV).

METHODS: We made a translation of the original version by the translation retranslation method.

First, two bilingual physicians translated the 1999 version of the BQ, published by Netzer et al, to Spanish. The Spanish versions were submitted to a panel for discussion where a modi- fied version in Spanish was obtained. This modified BQ was completed by group of participants to eval- uate comprehensibility and was submitted for back- translation to two independent English-speaking natives, fluent in Spanish. A second expert panel, formed by physicians members of the Peruvian Sleep Medicine Association (APEMES), analyzed the Span- ish and the back-translated English versions of the BQ, without making substantial modifications in the Spanish version (BQ-PV). As a next step, the BQ-PV was completed by con- secutive patients scheduled for an overnight poly- somnography (PSG) in our facility, with Cadwell Easy II/III and Alice 5 systems, according to the American Academy of Sleep Medicine (AASM) re- quirements for type I studies. Patients were evaluat- ed with a structured interview. Anthropometric parameters, BQ-PV and Epworth Sleepiness Scale (ESS) were registered. According to the BQ, the patients were divided in
two groups: high risk (HR) and low risk (LR) for
sleep apnea hypopnea syndrome (SAHS). We com-
pared the means of the HR and LR groups for the
demographic data, Respiratory Disturbances Index
(RDI), Apnea – Hipopnea Index (AHI), the minimal O2 saturation and the average O2 saturation. The internal consistency was evaluat- ed by the Cronbach alpha test. Sensibility, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were calculated for each cutpoint of the RDI and AHI.

RESULTS: We included 582 patients. (Age = 49.66 ± 14.19, BMI = 28.25 ± 4.81, ESS = 9.84 ± 5.41). The internal consistency was 0.699 and 0.657 for the first and second categories respectively. The evaluation of the predictive parameters, for AHI≥ 5, shows a sensitivity of 67.3%, a specificity of 52.5%, PPV of 75.8% and NPP of 42.0%. For RDI ≥ 5, the sensitivity and the specificity were 62.1% and 78.6%, respectively, PPV was 99.2% and NPP was 4.9% respec- tively.

CONCLUSION:The BQ-PV has a moderate internal consistency. Our validated BQ shows a moderate predictive capacity for identi- fying SAHS and a great variability between AHI and RDI. One fourth of our population was over 60 years old, this group was excluded in the original article. Similar to the study by Sforza et al in subjects over 65, the BQ-PV showed some limitations in this age group, which could have influenced the overall results.

Revista Medica Herediana

versión impresa ISSN 1018-130Xversión On-line ISSN 1729-214X

Rev Med Hered v.11 n.4 Lima oct./dic. 2000

Evolución histórica de los métodos de investigación en los trastornos del sueño

Vizcarra Escobar, Darwin

Sleep Science

Volume 8, Issue 3, November 2015, Pages 115-120

Effects of an adapted mattress in musculoskeletal pain and sleep quality in institutionalized elders

Author links open overlay panelVictorAncuelle^aRodrigoZamudio^aAndreaMendiola^aDanielGuillen^aPedro JOrtiz^bcTaniaTello^bcDarwinVizcarra^ab

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Abstract

We aimed to evaluate the impact in sleep quality and musculoskeletal pain of a Medium-Firm Mattress (MFM), and their relationship with objective sleep parameters in a group of institutionalized elders. The sample size included forty older adults with musculoskeletal pain. We did a clinical assessment at baseline and weekly trough the study period of four weeks. We employed the Pittsburgh Sleep Quality Index (PSQI) and Pain Visual Analog Scale (P-VAS). Additionally a sub-group of good sleepers, selected from PSQI baseline evaluation, were studied with actigraphy and randomized to MFM or High Firm Mattress (HFM), in two consecutive nights.

We found a significant reduction of cervical, dorsal and lumbar pain. PSQI results did not change. The actigraphy evaluation found a significant shorter sleep onset latency with MFM, and a slightly better, but not statistically significant, sleep efficiency. The medium firmness mattress improved musculoskeletal pain and modified the sleep latency.

Mult Scler. 2011 Sep;17(9):1055-9. doi: 10.1177/1352458511405562. Epub 2011 May 6.

Latitudinal prevalence gradient of multiple sclerosis in Latin America.

Risco J¹, Maldonado H, Luna L, Osada J, Ruiz P, Juarez A, Vizcarra D.

Author information

Abstract

BACKGROUND:

Multiple sclerosis (MS) has a unique geographical distribution that reflects both genetic and environmental factors. Many studies have shown a positive correlation between MS frequency and latitude across both large and small geographical regions. However, scarce data have been published on the epidemiology of MS in Latin America and no study has evaluated latitudinal variation.

OBJECTIVE:

To evaluate the effect of latitude on MS prevalence in Latin America.

METHODS:

We conducted a systematic review of MS prevalence during January 2011. Prevalence rates were collected from eligible publications. The effect of latitude on prevalence was analyzed using linear regression.

RESULTS:

A total of ten studies were eligible for analysis, corresponding to six countries, spanning from Panama to Argentina. The crude prevalence of MS ranged from 0.75 to 21.5 per 100,000. We found a strong and significant association between prevalence and latitude (r(2) 0.8; p < 0.001) and determined an increase in prevalence of 0.33 per 100,000 per degree latitude.

CONCLUSION:

Our findings suggest a latitudinal prevalence gradient of MS in Latin American countries between Panama and Argentina.

PMID:21551216 DOI:10.1177/1352458511405562

Trastornos del sueño y dolor: Estudio

transversal descriptivo en un instituto de

medicina de sueño de Lima. Trastornos del sueño y dolor

Sleep disorders and pain: Cross-sectional descriptive study in a sleep institute of Lima.

Alejandro Mariños1 Rev Neuropsiquiatr 74 (3), 2011

, Jorge Kawano1, Alan Juárez2, Paulo Ruiz3, Darwin Vizcarra4

RESUMEN

Objetivo: Determinar la existencia y fuerza de asociación entre síntomas relacionados con trastornos del sueño (ronquidos, pausas respiratorias durante el sueño, somnolencia e insomnio) con presentar dolor expresado como cefalea matutina, tensión muscular y dolor muscular matutino. Material y Métodos: Estudio transversal descriptivo.

Se evaluó cuestionarios de pacientes ambulatorios de Hypnos Instituto del Sueño entre los años 1995 y 2008. Se empleó regresión logística para el análisis multivariado ajustando para edad e índice de masa corporal (IMC).

Resultados: Se analizó en total 2140 cuestionarios. El 46% de sujetos fueron varones, la edad promedio fue de 51 años y la media del IMC fue de 25,3. Se encontró una asociación significativa entre somnolencia con cefalea matutina (OR=1,5, IC95%:1,2-1,9), tensión muscular (OR=1,4, IC95%:1,1-1,8) y con dolores musculares matutinos(OR=1,5, IC95%:1,2-2,0). Del mismo modo, se encontró una asociación significativa entre insomnio con cefalea matutina (OR=1,9, IC95%:1,6-2,4), tensión muscular (OR=2,1, IC95%:1,7-2,6) y con dolores musculares matutinos (OR=1,8, IC95%:1,5-2,3).

Conclusiones: Existe en nuestra población de estudio una relación de gran intensidad

estadística entre síntomas relacionados a trastornos de sueño con cuadros de dolor.

PALABRAS CLAVE: Dolor, sueño, ronquidos, insomnio.

SUMMARY

Objectives: The aim of this study was to determine the presence and strength of association between sleep related complaints (snoring, respiratory pauses during sleep, somnolence and insomnia) with pain, assessed as morning headaches, muscle tension and morning muscular pain. Materials and methods: Descriptive cross-sectional study.

The questionnaires from outpatients treated at Hypnos Sleep Institute, between 1995 and 2008 were reviewed.

Logistic regression was performed adjusting for age and body mass index (BMI) in the multivariate analysis.

Results: In total 2140 questionnaires were assessed, 46% were males, the mean age was 51 years and the mean BMI was 25.3. A significant association was found between somnolence with morning headache (OR=1.5, IC95%:1.2-1.9), muscular tension (OR=1.4, IC95%:1.1-1.8) and with morning muscular pain (OR=1.5, IC95%:1.2-2.0). Also, 265 a significant association was found between insomnia with morning headache (OR=1.9, IC95%:1.6-2.4), muscular tension (OR=2.1, IC95%:1.7-2.6) and with morning muscular pain (OR=1.8, IC95%:1.5-2.3).

Conclusions: A strong statistical association between sleep disorders related symptoms and pain was found in the studied population

CASO CLÍNICO Insulinoma maligno A propósito de un caso

Revista Médica de la Fundación Instituto Hipólito Unanue http://www.fihu-diagnostico.org.pe/category/revista/ VOLÚMEN 52 NÚMERO 1 ENERO – MARZO 2013

1 Clìnica Stella Maris. 2 Hospital Nacional Arzobispo Loayza. 3 Universidad Peruana Cayetano Heredia. *Trabajo presentado como abstracto en el X Congreso de la Asociación Latinoamericana de Diabetes (ALAD), Noviembre 1995. Oscar Castillo (1,2), Rosa Ramos (2), Darwin Vizcarra (3), Lida Tello (2)

Resumen Introducción: El insulinoma es el tumor neuroendocrino pancreático más frecuente, la mayoría de ellos son únicos y de naturaleza benigna. Caso clínico: Varón de 38 años de edad, 7 semanas antes consultó por haber presentado en forma brusca un episodio de risa inmotivada, confusión y comportamiento bizarro, luego de 16 horas de ayuno y post ingesta alcohólica; este episodio se repite cuatro semanas después siendo de mayor intensidad. Se constata una glicemia basal de 45 mg/dl e insulina basal de 122.8 uU/ml. Tomografìa Axial Computarizada Abdominal, páncreas presenta imagen hipodensa, hipocaptadora de 3 x 4 cm localizada en la cola. Hígado muestra múltiples imágenes de diferentes tamaños que captan el contraste. Anatomía Patológica: carcinoma indiferenciado de los Islotes de Langerhans. Conclusión: Se presenta un caso poco frecuente de insulinoma maligno con metástasis hepática. Palabras clave: Insulinoma maligno, hipoglucemia.

Optimizing outcomes in multiple sclerosis: consensus guidelines for the diagnosis and treatment of multiple sclerosis in Latin America

Adriana Carra´, Miguel A´ngel Macı´as-Islas, Alberto Alan Gabbai, Jorge Correale, Carlos Bolan˜a, Eduardo Duriez Sotelo, Juan Garcı´a Bonitto, Fernando Vergara-Edwards and Darwin Vizcarra-Escobar Ther Adv Neurol Disord (2011) 4(6) 349–360 DOI: 10.1177/ 1756285611423560

Abstract: Objective: The prevalence of multiple sclerosis (MS) in Latin America varies across different studies but an intermediate risk and increased frequency of the disease have been reported in recent years. The circumstances of Latin American countries are different from those of Europe and North America, both in terms of differential diagnoses and disease management. Methods: An online survey on MS was sent to 855 neurologists in nine Latin American countries. A panel of nine experts in MS analyzed the results. Results: Diagnostic and therapeutic recommendations were outlined with special emphasis on the specific needs and circumstances of Latin America. The experts proposed guidelines for MS diagnosis, treatment, and follow up, highlighting the importance of considering endemic infectious diseases in the differential diagnoses of MS, the identification of patients at high risk of developing MS in order to maximize therapeutic opportunities, early treatment initiation, and cost-effective control of treatment efficacy, as well as global assessment of disability. Conclusions: The experts recommended that healthcare systems allocate a longer consultation time for patients with MS, which must be conducted by neurologists trained in the management of the disease. All drugs currently approved must be available in all Latin American countries and must be covered by healthcare plans. The expert panel supported the creation of a permanent forum to discuss future clinical and therapeutic recommendations that may be useful in Latin American countries. Keywords: glatiramer acetate, immunomodulators, interferon-beta, mitoxantrone, multiple sclerosis, natalizumab Introduction Multiple sclerosis (MS) is a chronic demyelinating neurological disorder that mainly affects individuals between the ages of 20 and 50 years. Approximately 85% of patients experience an initial course with relapses and remissions (relapsing-remitting multiple sclerosis, RRMS). It is estimated that some 50,000 individuals present with MS in Latin America [Luetic, 2008]. The prevalence of MS in Latin American countries ranges between 1.48 and 25/100,000 population [Dı´az et al. 2010; Cristiano et al. 2009, 2008; Melcon et al. 2008; Toro et al. 2007; Vela´zquez Quintana et al. 2003]. The available data on Latin American countries are limited, and the prevailing circumstances are different from those noted in Europe and the USA in several respects, including the lower incidence and prevalence of the disease, the differential diagnoses, and the access to diagnostic methods. In order to collect updated information, an online survey on MS was sent to general neurologists working in Latin American countries. A panel of nine MS experts of the region was convened to discuss http://tan.sagepub.com 349 T

Practical Issues Concerning the Approval and Use of Biosimilar Drugs for the Treatment of Multiple Sclerosis in Latin America

• Judith Steinberg, Yara D. Fragoso, Juan Carlos Duran Quiroz,Juan Raul García, Caroline Guerra,Virginia Rodriguez,Claudia Carcamo Rodriguez,
• Ethel Ciampi, Edgar Correa-Diaz, Miguel Macías,Nelson Novarro,
• Darwin Vizcarra, Carlos Oehninger Gatti, Geraldine Orozco &
• Adriana Carrá

Neurology and Therapy volume 8, pages207–214(2019)

Abstract

The use of biosimilar drugs for multiple sclerosis (MS) has become widespread in Latin America, with the goal of reducing costs of treatments, promoting the sustainability of healthcare systems, and improving patient access to these therapies. There is currently a need to define and comply with requirements to guarantee the efficacy, safety, and quality of these drugs. Thus, the objective of the present study was to compile up-to-date information from each Latin American country assessed on (a) approval of biosimilar drugs by regulatory agencies; (b) use of biosimilar drugs, pharmacovigilance plans, risk management; and (c) update in the knowledge on different molecules. To do so, a group of experts from Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Mexico, Panama, Peru, Uruguay, and Venezuela met to discuss the current situation regarding good practices and risks associated with the use of biosimilar drugs in their respective countries. Regulation, risk management plans, and pharmacovigilance in the whole continent must guide the strategies on the commercialization and access of biosimilar drugs and copies of complex molecules. Current regulations must be implemented for the registration of biosimilar drug products and complex molecules. It is paramount to ensure that new products follow the best quality standards at all stages beyond being safe and efficient. Uncontrolled interchangeability between original biological and biosimilar should be avoided. Latin America requires the implementation and full use of strong pharmacovigilance programs. National and multinational clinical studies are required to demonstrate the similarity in safety, efficacy, and immunogenicity profiles of complex molecules, as well as biological and biosimilar products.

Arquivos de Neuro-Psiquiatria

Arq. Neuro-Psiquiatr. vol.71 no.9A São Paulo Sept. 2013

https://doi.org/10.1590/0004-282X20130098

Multiple sclerosis in South America: month of birth in different latitudes does not seem to interfere with the prevalence or progression of the disease

Esclerose múltipla na América do Sul: mês de nascimento em diferentes latitudes não parece interferir com a prevalência ou progressão da doença

Yára Dadalti Fragoso¹Tarso Adoni²Sandra Maria Garcia de Almeida³Soniza Vieira Alves-Leon³Walter Oleschko Arruda⁴Fiorella Barbagelata-Aguero⁵Joseph Bruno Bidin Brooks¹Adriana Carra⁶Rinaldo Claudino⁷Elizabeth Regina Comini-Frota⁸Eber Castro Correa⁹Alfredo Damasceno¹⁰Benito Pereira Damasceno¹⁰Ethel Ciampi Díaz¹¹David George Elliff¹Ana Patrícia Peres Fiore¹²Clelia Maria Ribeiro Franco¹³Maria Cristina Brandao Giacomo¹⁴Sidney Gomes¹⁵Marcus Vinicius Magno Gonçalves¹⁶Anderson Kuntz Grzesiuk¹⁷Jose Luiz Inojosa¹³Damacio Ramón Kaimen-Maciel¹⁸Katia Lin⁷Josiane Lopes¹⁸Gisele Alexandre Lourenço⁴Alejandra Diana Martínez⁶Mario Oscar Melcon¹⁹Nívea de Macedo Oliveira Morales²⁰Rogério Rizo Morales²⁰Marcos Moreira²¹Shirlene Vianna Moreira²¹Celso Luis da Silva Oliveira¹Francisco Tomaz Menezes de Oliveira¹⁵João Batista Ribeiro²²Sonia Beatriz Felix Ribeiro²²Claudia Cárcamo Rodríguez¹¹Liliana Russo¹⁴Juliana Safanelli¹⁶Kirsty Deborah Shearer²⁴Fabio Siquineli²³Darwin Vizcarra-Escobar⁵

¹Department of Neurology, Universidade Metropolitana de Santos, Santos SP, Brazil;

²Department of Neurology, Hospital Sirio Libanes, São Paulo SP, Brazil;

³Department of Neurology, Universidade Federal do Rio de Janeiro, Rio de Janeiro RJ, Brazil;

⁴Department of Neurology, Universidade Federal do Parana, Curitiba PR, Brazil;

⁵HYPNOS, Clinica San Felipe, Lima, Peru;

⁶Department of Neurology, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina;

⁷Department of Neurology, Universidade Federal de Santa Catarina, Florianopolis PR, Brazil;

⁸Department of Neurology, Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil;

⁹CLINEN, Neurology and Endocrinology, Brasilia DF, Brazil;

¹⁰Department of Neurology, Universidade Estadual de Campinas, Campinas SP, Brazil;

¹¹Department of Neurology, Pontificia Universidad Católica de Chile, Santiago, Chile;

¹²Cruzada Bandeirante São Camilo Assistencia Medico Social, Santos SP, Brazil;

¹³Department of Neurology, Hospital de Clinicas, Universidade Federal de Pernambuco, Recife PE, Brazil;

¹⁴Neurology Clinic, São Paulo SP, Brazil;

¹⁵Hospital Beneficencia Portuguesa and Hospital Paulistano, São Paulo SP, Brazil;

¹⁶Department of Neurology, Universidade da Regiao de Joinville, Joinville SC, Brazil;

¹⁷Centro de Reabilitação Integral Dom Aquino Correa, Cuiaba MT, Brazil;

¹⁸Department of Neurology, Universidade Estadual de Londrina, Londrina PR, Brazil;

¹⁹Fundación para la Investigacion en Neuroepidemiología, Buenos Aires, Argentina;

²⁰Department of Neurology, Universidade Federal de Uberlandia, Uberlândia MG, Brazil;

²¹Clinical Neuroimmunology Unit, Hospital Therezinha de Jesus, FCMS Suprema, Juiz de Fora MG, Brazil;

²²Department of Neurology, Universidade Federal do Triangulo Mineiro, Uberaba MG, Brazil;

²³Institute of Medical Sciences, University of Aberdeen, Scotland, UK;

²⁴Department of Neurology, Hospital Santa Isabel, Universidade Regional de Blumenau, Blumenau SC, Brazil.

ABSTRACT

Objective

To assess whether the month of birth in different latitudes of South America might influence the presence or severity of multiple sclerosis (MS) later in life.

Methods

Neurologists in four South American countries working at MS units collected data on their patients’ month of birth, gender, age, and disease progression.

Results

Analysis of data from 1207 MS patients and 1207 control subjects did not show any significant variation in the month of birth regarding the prevalence of MS in four latitude bands (0–10; 11–20; 21–30; and 31–40 degrees). There was no relationship between the month of birth and the severity of disease in each latitude band.

Conclusion

The results from this study show that MS patients born to mothers who were pregnant at different Southern latitudes do not follow the seasonal pattern observed at high Northern latitudes.

Key words: South America; multiple sclerosis; sun exposure

Rev Med Hered 21, 2010

Frecuencia de roncopatía en mujeres durante el tercer trimestre del embarazo, en un hospital general. Snoring frequency in women during the third trimester of pregnancy in a general hospital. Renzo Figari1 , Angie Nishio2 , Pedro Saona3 , DarwinVizcarra 4 .

1 Miembro de la American Academy of Neurology. Residente del Departamento de Neurología en Henry Ford Health System, Detroit, MI, USA 2 Miembro de la American Collegues of Physicians. Residente del Departamento de Medicina Interna en Henry Ford Health System, Detroit, MI, USA. 3 Doctor en Medicina. Profesor Principal Departamento de Obstetricia y Ginecología de la Universidad Peruana Cayetano Heredia. Medico Asistente del Departamento de Obstetricia y Ginecología del Hospital Nacional Cayetano Heredia. Lima, Perú. 4 Médico Neurólogo Especialista en Medicina del Sueño. Director de Hypnos, Instituto del Sueño. Profesor Asociado de la Facultad de Medicina Alberto Hurtado de la Universidad Peruana Cayetano Heredia. Lima, Perú. 92

RESUMEN Objetivo: Determinar la frecuencia y distribución de la roncopatía durante el tercer trimestre de gestación en pacientes hospitalizadas en un hospital general.

Materiales y métodos: Estudio descriptivo y transversal, realizado entre septiembre y octubre del año 2004 en el Hospital Nacional Cayetano Heredia. Se incluyeron 295 voluntarios de 304. Se emplearon 3 encuestas: Cuestionario de Ronquidos, Escala de somnolencia de Epworth y Prueba de Calidad del Sueño. Adicionalmente se aplicó la medida morfométrica de Kushida. Resultados: La edad promedio fue de 25,9 ±1,67 años; con una edad gestacional promedio de 39,3 ±1,55 semanas. El 44,7% presentó roncopatía en el tercer trimestre y el 10,5% eran roncadoras habituales, 23,7% reportó tener somnolencia. Solo el 0,7% tuvo resultado positivo para la medida morfométrica de Kushida. Se encontró un riesgo incrementado de presentar roncopatía habitual en las pacientes mayores de 25 años. Finalmente, el 13,6% tuvo Hipertensión Inducida por la Gestación y de estas, 22,5% eran roncadoras habituales. Estas últimas con un riesgo 3 veces mayor de tener hipertensión inducida por la gestación. Conclusiones: La prevalencia de roncopatía y roncadoras habituales durante el tercer trimestre en pacientes hospitalizadas en el Hospital Nacional Cayetano Heredia es similar a la reportada en literatura internacional. El índice de Kushida no resultó aplicable en nuestra población. Existe una relación entre la presencia de roncopatía habitual e hipertensión inducida por la gestación.(Rev Med Hered 2010;21:91-96). PALABRAS CLAVE: Prevalencia, embarazo, ronquidos, apnea del sueño obstructiva, hipertensión inducida por la gestación. SUMMARY Objective: To determine the frequency and distribution of snoring during the third trimester of pregnancy in patients hospitalized in a general hospital. Material and Methods: We conducted a cross sectional and descriptive study  during September and October of 2004. 295 volunteers of a total of 304 were included. We used three validated questionnaires: Snoring questionnaire, Epworth Sleepiness Scale, Sleeping Quality Test. Additionally, we used the Kushida’s Morphometric Model. Results: The average age was 25,9 ± 1,67 years old with an average gestational age of 39,3 ± 1,55 weeks. We found 44,7% patients with snoring during the third trimester; the frequency of habitual snoring was 10,5%. 23,7% of patients reported having somnolence. Only 0,7% of patients had a positive result in the Kushida’s morphometric model. There was an increased risk of having habitual snoring in patients older than 25 years old. Finally, 13,6% had Pregnancy Induced Hypertension with a 22,5% of them having habitual snoring. Those with habitual snoring had 3 times higher risk of having pregnancy induced hypertension. Conclusions: This study found the same frequency of snoring and habitual snoring as previous studies in pregnant patients during the third trimester. The morphometric model of Kushida is not applicable to our population. There is a relation between habitual snoring and gestational hypertension. (Rev Med Hered 2010;21:91-96). KEY WORDS: Prevalence, pregnancy, snoring, sleep apnea, obstructive, hypertension pregnancy-induced

Journal

Expert Review of Neurotherapeutics 

Volume 15, 2015 – Issue 6

Biological and nonbiological complex drugs for multiple sclerosis in Latin America: regulations and risk management

Adriana Carrá,Miguel Angel Macías Islas,Adriana Tarulla,Denis Bernardi Bichuetti,Alessandro Finkelsztejn,Yara Dadalti Fragoso,Raul Árcega-Revilla,Claudia Cárcamo Rodríguez,Juan Carlos Durán,Juan García Bonitto,Rosalba León,Carlos Oehninger Gatti,Geraldine Orozco &Darwin Vizcarra Escobar

Pages 597-600 | Published online: 30 Apr 2015 https://doi.org/10.1586/14737175.2015.1042456

Abstract

Biological drugs and nonbiological complex drugs with expired patents are followed by biosimilars and follow-on drugs that are supposedly similar and comparable with the reference product in terms of quality, safety and efficacy. Unlike simple molecules that can be copied and reproduced, biosimilars and follow-on complex drugs are heterogeneous and need specific regulations from health and pharmacovigilance agencies. A panel of 14 Latin American experts on multiple sclerosis from nine different countries met to discuss the recommendations regarding biosimilars and follow-on complex drugs for treating multiple sclerosis. Specific measures relating to manufacturing, therapeutic equivalence assessment and pharmacovigilance reports need to be implemented before commercialization. Physical, chemical, biological and immunogenic characterizations of the new product need to be available before clinical trials start. The new product must maintain the same immunogenicity as the original. Automatic substitution of biological and complex drugs poses unacceptable risks to the patient.

Keywords: biosimilars, glatiramer acetate, interferon, monoclonal antibodies, multiple sclerosis

Treatment Issues in Multiple Sclerosis in Latin America Vizcarra-Escobar D.a-c · Mendiola-Yamasato A.a · Anculle-Arauco V.a · Vizcarra-Pasapera J.b · Guillen-Mendoza D.a Author affiliations Corresponding Author Keywords: Latin AmericaMultiple sclerosisSurveyTreatment

Neuroepidemiology 2015;44:66-68

https://doi.org/10.1159/000373926

Treatment issues of multiple sclerosis (MS) in Latin America (LA) have recently been addressed [1, 2] . Some particular features of the health systems, patients and medical providers are scarcely described. Moreover, LA patients are rarely included in clinical trials; therefore, data collected from key opinion leaders (KOL) from LA, although unofficial, remain as a needed source of information. In a stand-alone gathering, organized by a pharmaceutical company, in Brazil 2014, according to ‘Compliance Program Guidance for Pharmaceutical Manufacturers’ [3] , we surveyed the opinion of KOL in MS from 6 LA countries. Neurologists were selected and invited to the gathering based on their academic, research and clinical experience with MS patients and involvement as participants and speakers on regional events. A voluntary anonymous electronic survey was proposed in an interactive lecture ( table 1 ). Important definitions were given previously without further discussion on the topic to avoid biased answers. Early initiation of therapy and adherence in MS is of utmost importance. LA KOL report a fair amount of time during their patients’ DMD initiation visit, which could be a good indicator of important therapy aspects being discussed with the patient and their families. KOL were adherent to LA guidelines about the scheduled frequency of patient’s visits per year to the outpatient clinic [4] . On the other hand, most neurologists relied on selfreport when evaluating adherence. Continuous support and follow-up by a dedicated trained staff have been related to better outcomes in MS. However, MS neurologists in our region are scarce and the situation regarding MS nurses might be even wors

Only one third of KOL declared that over 80% of their patients kept the original treatment at the end of the first year. The main reason for treatment discontinuation was tolerability (injection stress, skin reactions, and injection pain), in contrast to global MS patients registered in the NARCOMS database, who discontinue treatment due to perceived lack of efficacy (no perceived benefit from the treatment, or worsening MS symptoms or disability) [6, 7] . These results could also be explained by impaired availability of DMD, because of administrative issues and interchangeability among drugs. Regarding LA Health Systems, we found a perceived improvement in treatment coverage. In 2011, experts estimated that below 35% of the LA population had access to DMDs [2] . In contrast, KOL now estimate greater proportions of their patients accessing these treatments. Nonetheless, KOL perceive that bureaucracy and corruption interfere with the availability of treatment. Our survey showed LA KOL try to offer the best treatment to their patients, sometimes balancing costs, but they agree in never using immune-suppressors instead of DMDs in order to save money. Similarly, although biosimilars may represent a cheaper treatment option, LA KOL showed a remarkable uncertainty about their safety and efficacy that can explain the divided attitudes toward their use, which brings to spotlight the urgent need of clinical trials. Fair access to DMD, issues related to adherence, health systems, the uncertainty about biosimilars, are some of the obstacles that are yet to be overcome in the treatment of patients with MS in LA. Disclaimers The views stated in this article are not an official position of the institutions or source of support. Source of Support TEVA Pharmaceutical Industries sponsored the stand-alone gathering in Brazil 2014. Disclosure of Interests Dr. Darwin Vizcarra-Escobar: Advisor for Teva and for SanofiGenzyme, he has received research grants and reimbursement for developing educational presentations from Novartis. Dr. Andrea Mendiola-Yamasato: reports no disclosures; Mr. Joaquin Vizcarra-Pasapera: reports no disclosures; Dr. Daniel Guillen-Mendoza: reports no disclosures; Dr. Victor Anculle-Arauco: rep

Quality of Life is impaired among older adults with Obstructive Sleep Apnea Hypopnea Syndrome despite disease severity

Barbagelata-Aguero, Fiorella1, Vizcarra-Escobar, Darwin2, Suarez-Peña, Mónica3, Guillén-Mendoza, Daniel1, Anculle-Arauco, Victor1

1. MD. Research fellow at Hypnos Instituto del Sueño. Lima – Peru2. MD. Director of Hypnos Instituto del Sueño – Clinica San Felipe. Universidad Peruana Cayetano Heredia. Lima – Peru3. RN. Hypnos Instituto del Sueño. Lima – Peru

Presented at the annual conference of the World Association of Sleep Medicine (WASM), September 2013, Valencia.

Introduction: It has been demostrated that Apneas and hypopneas in sleep increase with age, however there is still controversy regarding the burden of Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) and its treatment among elders.

Objective: To evaluate the effect of OSAHS in the Quality of life (QoL) of older adults compared to younger adults and normal population.

Methods: We reviewed the medical records and polysomnographies (PSG) of consecutive patients from 2007-2012. Diagnosis was made following ICSD-2 criteria and severity was set using Respiratory disturbance index (Apneas + hypopneas + RERAS)(RDI) with a cutoff of: 5 – 14 events/hour, mild; 15 – 29 events/hour, moderate; and ? 30 events/hour, severe. QoL was evaluated using the SF-36v1 questionnaire validated in our country. Excessive Daytime Sleepiness (EDS) was assessed by Epworth Scale, a score of ?10 points was considered abnormal. Antecedents, demographic information and physical findings were obtained from records.

Results: A total of 798 medical records and polysomnographies (PSG) were reviewed, 159 corresponded to older adults (?60 yo) with OSAHS. The average age was 67.93±6.95 yo; 73.6% were males, BMI was 28.18±4.70 kg/mt2, neck circumference was 41.16±4.71cm, the Epworth Scale Score was 9.16±5.23 points and the EDS were present in 32.1%. PSG showed IAH 24.67±20.35, RDI 40.47±20.94, minimum oxygen saturation 81.48±7.89%. Other comorbidities were hypertension (42.1%), diabetes mellitus (13.2%), history of stroke (4.4%), and depressive symptoms (37.1%). OSAHS severity was mild in 6.9%, moderate in 27% and severe in 66%. All the SF36v1 components showed worst scores in the OSAHS group. When comparing groups in the OSAHS patients, the older patients scored worse in the majority of components (Table 3). We did not find differences taking cutoffs according to severity range based on RDI.

Conclusions: In our population, older patients with OSAHS have a significantly worse impairment in QoL compared to general population and younger OSAHS patients. Our study would support the need to provide treatment in older patients, since their quality of life is impaired. We did not find differences in the SF36v1 scores when dividing older patients by OSAHS severity ranges, this may be explained because the RDI classification is based on the patients cardiovascular outcome; SF36v1 could be a more holistic method to detect the impairment with no strict correlation with RDI. This results could also be caused by sample size, RDI not being a good tool for older adults or, maybe being QoL Sf36v1 a sensible tool to determine impairment independently of other ways to measure severity. Finally, it could be recommend the use of QoL questionnaires as a tool for clinical decisions as to offer treatment in patients with OSAHS. Limitations of this study are the possible influence of other comorbidities in the QoL scores and should be taken in account for future studies on this matter.

Quality of Life Impairment: A reason to rethink the Importance of Upper Airway Resistance Syndrome.

Vizcarra-Escobar, Darwin1, Barbagelata-Agüero, Fiorella2, Suarez – Peña, Mónica3, Anculle-Arauco, Victor2, Guillén-Mendoza, Daniel2

1. MD. Director of Hypnos Instituto del Sueño – Clinica San Felipe. Universidad Peruana Cayetano Heredia. Lima – Peru 2. MD. Research fellow at Hypnos Instituto del Sueño. Lima – Peru3. RN. Hypnos Instituto del Sueño

For the annual conference of the World Association of Sleep Medicine (WASM), September 2013, Valencia.

Introduction: The Upper Airway Resistance Syndrome (UARS) was described by Guilleminault in 1993 to report patients that didn’t meet criteria for Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) but presented with similar symptoms, specially Excessive Daytime Sleepiness (EDS) and an abnormal breathing pattern during sleep. The diagnosis of UARS is controversial and in many cases patients are left untreated or misdiagnosed. The impact of UARS in the quality of life (QoL) haven’t been studied before in contrast with OSAHS patients in whom QoL have been reported to be impaired.

Objective: To assess the clinical and QoL differences between UARS and OSAS patients.

Materials and methods: A total of 711 consecutive patients from 2007-2012 were retrospectively evaluated using their medical records and Polysomnography (PSG). Diagnosis of UARS was made following Guilleminault definition (AHI<5+RDI>10), diagnosis of OSAHS was made according to ICSD-2 criteria. The scoring was done using the “recommended” definitions for respiratory events of the Manual for Scoring of Sleep and Associated Events of the AASM v2007. Quality of Life was evaluated by the SF36v1 questionnaire, previously validated in our country. Chi square was used for bivariate analysis between nominal variables, Student T test for continuous and nominal variables.

Results: From the 711 consecutive records, 167 (23.5%) were classified as UARS patients, 465 (65,4%) as OSAHS patients and 79 (11.1%) did not meet any of the syndromes’ diagnosis criteria.

No major differences were found between UARS and OSAHS patients in SF 36 QoL domains; with the exception of a worse score in the OSAHS group in the Physical functioning component. Regarding the clinical features, patients in the OSAHS group were older (52.81±13.56yo vs. 44.11±13.17yo p<0.001), had a higher BMI (29.25±4.65kg/m2 vs. 25.58±3.57 kg/mt2 p<0.001) and had a higher rate of high blood pressure (29.46% vs. 16.17% p<0.001). Female/male proportion was found to be 1:8 in OSAHS and 1:2 in UARS (p<0.001). No differences were found in somnolence measured by the Epworth Scale, history of Diabetes Mellitus, Stroke, depressive symptoms, or insomnia symptoms.

Conclusions: The impact in QoL, secondary to UARS or OSAHS in our patients is pretty similar, giving a strong reason for an exhaustive diagnosis protocol and an early treatment in symptomatic patients, especially since UARS represents a significant proportion of our sleep clinic patients. Special attention should be paid to clinical features such as younger age, female gender and lower BMI, where PSG must be consider as gold standard for a correct diagnosis.

Narcolepsia en el Perú: descripción De 8 casos

Revista Peruana de Neurología 2009

Vizcarra D, Kawano J.

RESUMEN
Introducción. La narcolepsia está caracterizada por la incapacidad de mantener separados los diferentes estados de la conciencia. El diagnóstico se establece con información clínica, estudio polisomnográfico (PSG) y test de latencia múltiple del sueño (TLMS). Objetivo. Describir las características clínicas y neurofisiológicas de ocho pacientes diagnosticadas de narcolepsia en Hypnos, Instituto del Sueño. Material y Métodos. De 1996 a 2005 se han realizado 860 PSG en Hypnos, Instituto del Sueño. Se definió somnolencia excesiva diurna y narcolepsia por la escala de Epworth, criterios clínicos, estudios polisomnográficos y TLMS. Resultados. Se realizaron 35 TLMS, entre las que se encontraron ocho pacientes que cumplían los criterios para narcolepsia. El 75% fue mujer, la edad promedio del diagnóstico, 28,6 años, con rangos de 5 a 60 años. La edad promedio de inicio del primer síntoma fue 14,6 años, con rangos de 2 a 40. Cinco presentaron cataplexia y parálisis del sueño; sólo uno con índice de apnea-hipopnea > de 5. En la polisomnografía nocturna los promedios en minutos para latencia del sueño fueron 8, latencia REM 53,6 minutos. El TLMS mostró un promedio en minutos para la latencia del sueño de 4.8, (1.3 – 9,5 minutos). Tres pacientes tuvieron presencia de sueño REM en todas las siestas (5/5), dos 4 episodios de sueño REM, dos pacientes 3 siestas REM y un paciente ningún episodio de REM. Conclusión: Las características clínicas y neurofisiológicas no difieren de las reportadas en la literatura, excepto el predominio del género femenino encontrado en nuestra serie. Los alertamientos nocturnos son frecuentes narcolepsia.

Frecuencia de somnolencia diurna excesiva en niños

Astorne W, Vizcarra D, Kawano J.

Revista Peruana de Neurología 2009

RESUMEN

Introducción. Los trastornos respiratorios durante el sueño son comunes en los niños y existen escasos datos acerca de esta condición en nuestro país. Materiales y Métodos. Se invitaron a participar a padres de niños entre 5 y 11 años de dos colegios privados de Lima, Perú. La información se recolectó mediante un cuestionario pediátrico validado de trastornos respiratorios durante el sueño. Resultados. Se analizaron 382 cuestionarios, 241 niños y 141 niñas. Se encontró una prevalencia de 4,71% niños con somnolencia diurna excesiva. Conclusiones. Existe una importante prevalencia de somnolencia diurna excesiva en niños de 5 a 11 años en nuestro país

Síntomas del síndrome de apnea obstructiva del sueño e hipertensión arterial

Vizcarra D, Kawano J, Tipismana M.

Sociedad Peruana de Neurología 2009

RESUMEN
Introducción. El objetivo del presente trabajo es observar frecuencias de ronquidos, apneas y somnolencia y comparar las posibles asociaciones con hipertensión arterial. Materiales y Métodos. Se analizaron cuestionarios de pacientes que acudieron a consulta ambulatoria a Hypnos, Instituto del Sueño. Se empleó un cuestionario de calidad de sueño validado para recoger datos sobre síntomas del síndrome de apnea obstructiva del sueño e hipertensión arterial. Resultados. Se analizaron 2 206 pacientes, de los que 1 015 pacientes fueron varones y 1 191, mujeres. La edad promedio fue 50,5 años. Encontramos que la presencia de ronquidos y apneas durante el sueño se asociaron estadísticamente con el hallazgo hipertensión arterial (p > 0,05). Conclusiones. Se encuentra una alta prevalencia de hipertensión arterial en pacientes con trastornos respiratorios del sueño estudiados en un centro de referencia. Existe una asociación entre los síntomas del síndrome de apnea obstructiva del sueño e hipertensión arterial

Videoelectroencefalograma en niños

Vizcarra D, Kawano J.

Revista Peruana de Neurología 2009

RESUMEN

Objetivo. Valoración de la utilidad del videoelectroencefalograma (VEEG) en niños. Materiales y Métodos. Se realiza un estudio retrospectivo descriptivo de los registros de VEEG en población pediátrica realizados en Hypnos, Instituto del Sueño, durante el período de 2004-2007. El registro fue realizado con un sistema digital Cadwell, que incluye detección automática de convulsiones y espigas. La colocación de electrodos en cuero cabelludo fue de acuerdo a sistema internacional 10 -20, con electrodos temporales anteriores cuando fue requerido. El mínimo tiempo de registro fue de una hora y el máximo 10 horas. Se incluyen VEEG convencional, polisomnografia convencional y con arreglos extendidos (electroencefalograma). Los pacientes fueron derivados por sospechas de convulsiones, conductas motoras nocturnas, parasomnias y trastornos del sueño. Veinte pacientes recibían anticonvulsivantes. Resultados. Se registran 211 VEEG desde el año 2004 hasta mayo de 2007, 93 de ellos fueron VEEG convencional, 15 polisomnografías y 103 polisomnografías con estudio de electroencefalograma ampliado. Los rangos de edades fluctuaron entre los 15 días de vida hasta los 18 años. Se encontró un 22,7% de correlación electroclínica (ictal), cuyo porcentaje aumenta a 27% cuando se suman las anormalidades electroencefalográficas sin clínica (ictal + interictal). El 55,2% (16/29) de los videos-EEGs registraron crisis parciales con focos frontales (5/16), frontotemporales derechos (4/16), temporales izquierdos (4/16), frontotemporales izquierdos (1/16), centrotemporales derechos (1/16) y centrotemporales izquierdos (1/16). Conclusiones. Primer reporte en el país de VEEG con una tasa de captura clínica electroencefalográfica de 22,7%, valor aproximado a lo reportado en la literatura.

Trastornos del Sueño y Dolor.

Dr. Vizcarra D, Dr. Kawano J, Dr. Juárez A, Lic. Caycho M, Dr. Ruiz P. – 2008

RESUMEN

Objetivo: El objetivo del estudio es determinar la relación entre ronquidos, apneas, somnolencia e insomnio con el dolor. Materiales y Métodos: Estudio transversal, se analizó cuestionarios de pacientes ambulatorios de Instituto del Sueño Hypnos (ISH), entre los años 1995 y 2008. Se utilizó regresión logística para cálculo de asociación. Resultados: Se analizaron 2205 pacientes, 1012 pacientes fueron varones. La edad promedio fue 50 años, se encontró una asociación significativa entre la presencia de somnolencia e insomnio con la presencia de cefalea matutina, tensión muscular con calambres y dolores musculares matutinos, relaciones igualmente encontradas al ser ajustadas para IMC y edad. La presencia de apneas no tuvo correlación con cefalea matutina ni dolor muscular, sino luego de asociarse ronquidos con apneas. Conclusiones: Existe en nuestra población de estudio una relación de gran intensidad estadística entre los trastornos de sueño como somnolencia e insomnio con cuadros de dolor.

Trastornos del Sueño y Dolor. Diferencias entre sexos.

Dr. Vizcarra D, Dr. Juárez A, Lic. Caycho M, Dr. Ruiz P. – 2008

RESUMEN

Objetivo: El objetivo del estudio es determinar la relación entre ronquidos, apneas, somnolencia e insomnio con el dolor en función del sexo. Materiales y Métodos: Estudio transversal, se analizaron cuestionarios de pacien tes ambulatorios de Hypnos Instituto del Sueño (HIS), entre los años 1995 y 2008. Se utilizó regresión logística para cálculo de asociación. Resultados: Se analizaron 2205 pacientes, 1012 pacientes fueron varones. La edad promedio fue 50 años, tras ajustar los valores para IMC y edad se encontró relación entre somnolencia e insomnio con cuadros de cefalea matutina y dolor muscular en hombres; y una relación entre ronquidos, apneas, somnolencia, e insomnio con todos los cuadros de dolor estudiados en el caso de mujeres. Conclusiones: No existe asociación estadística entre ronquidos y apneas con cuadros de dolor en hombres, pero sí en mujeres y con predominio de cefalea matutina. La somnolencia y el insomnio si tuvieron asociación estadística en ambos sexos, siendo la relación mas intensa en el caso de mujeres.

Impacto del CPAP en la enfermedad vascular.

Dr. Vizcarra D, Dr. Juárez A, Dr. Tipismana M, Lic. Caycho M, Dr. Ruiz P. – 2008

RESUMEN
Objetivo: El objetivo del estudio es determinar el impacto del uso de CPAP en el Desarrollo de la HTA. Materiales y Métodos: Estudio cohorte, se realizó el seguimiento de pacientes del Instituto del Sueño Hypnos (ISH) con diagnóstico de SAOS, entre los años 2005 y 2007; evaluando el desarrollo de HTA. Resultados: Se analizaron 209 pacientes con diagnóstico de SAOS, de los cuales 178 no tuvieron diagnóstico de HTA al inicio. En ellos se determino que la aparición de nuevos cuadros de HTA durante el seguimiento fue igual en el grupo de uso de CPAP versus en el de no uso. Conclusiones: El uso de CPAP no prevendría el inicio de cuadros de HTA durante el seguimiento de pacientes con diagnóstico de SAOS.

Trastornos del sueño y Parkinson.

Dr. Vizcarra D, Dr. Juárez A, Lic. Caycho M, Dr. Ruiz P – 2008

RESUMEN
Objetivo: El objetivo del estudio es determinar la relación entre la enfermedad de Parkinson y trastornos del sueño en nuestra población. Materiales y Métodos: Estudio transversal, se analizó cuestionarios de pacientes del Instituto del Sueño Hypnos (ISH), entre los años 2001 y 2006. Se utilizó regresión logística para cálculo de asociación. Resultados: Se analizaron 701 pacientes, 96 con enfermedad de Parkinson. Se encontró una asociación significativa entre la presencia de enfermedad de Parkinson e insomnio (OR=0.58 IC95= 0.35-0.98). Conclusiones: Existe en nuestra población de estudio una relación de gran intensidad estadística entre la enfermedad de Parkinson y la presencia de insomnio, a predominio tardío.

Relación entre ronquidos, Apneas e insomnio con quedarme dormido al manejar.

Dr. Vizcarra D, Dr. Juárez A, Lic. Caycho M, Dr. Ruiz P – 2008

RESUMEN
Objetivo: Determinar la relación de ronquidos, apneas, e insomnio con el quedarse dormido al manejar en una población de consulta externa de HYPNOS Instituto del Sueño y consulta ambulatoria neurológica. Métodos: Estudio transversal, se analizaron cuestionarios de pacientes ambulatorios de Hypnos Instituto del Sueño (HIS) y consulta ambulatoria neurológica, entre los años 1995 y 2006. Se utilizó regresión logística para cálculo de odds ratio. Resultados: Se analizaron 2205 pacientes, 1012 pacientes fueron varones. La edad promedio fue 50 años, se encontró una asociación entre la presencia de ronquidos (OR=2.95 IC95=1.78-4.89) y apneas (OR=3.11 IC95=1.97-4.92) con quedarse dormido al manejar una vez ajustados por edad, sexo e IMC. Conclusiones: En nuestra población Ronquidos y Apneas durante el sueño se encontraron fuertemente asociados con un mayor riesgo de quedarse dormido al manejar. No se encontró semejante relación con insomnio. Acciones preventivas en población de riesgo deben tomarse teniendo en cuenta estos hallazgos.

SLEEP KNOWLEDGE IN A SAMPLE OF LATINAMERICAN MEDICAL STUDENTS

Poster presentado para el congreso WASM 2004

Vizcarra DR,1 Delgado RN,1 Meza MS,2 Escobar F3

(1) Hypnos Instituto del Sueño. Lima Peru, (2) Laboratório de Sono Universidade de Brasília-DF Brasil, (3) Universidad Nacional Autónoma de Mexico . México, (4) Laboratorio de Neurofisiologia Clinica. Hospital San Juan de Dios Universidad Nacional de Colombia.

Introduction: Failure of adequate training or education in sleep medicine for health care professionals is main concern in the sleep medicine community.(1) Activities in medical schools show a large percentage of no structured teaching time on sleep medicine.(2) In the same way reliable instruments to measure knowledge on the topic are scarce. It has recently been published “The ASKME Survey” a reliable, consistent and discriminative test between samples with varied levels of education, experience and specialty training (3)Up to the best of our knowledge this approach has never been used to survey Latin American medical students. This report describes the findings among a sample of medical schools in two countries in Latin America using a translated version of “The ASKME survey”

Methods: A committee of Latin American’s sleep medicine experts from the “Red Latinoamericana de Educación en Medicina del Sueño” (REDLADES) were selected. All members of the committee were bilingual, some trilingual. Two translations were done, one to Spanish and the other to Portuguese. After discussion all members of the committee agreed in one final version in each language. An official translator Independently translated the original english survey to Portuguese and Spanish, and then back translated to English those versions translated by the committee. Over 90% agreement among all translated versions and english original paper was found.A group of medical students of the academic year immediately previous to internship from different universities of Brazil and

Peru were invited to participate. The questionnaire was handed out as self-administered and paper printed.

Results: The percentage of acceptance to participate was 85%. Responders were 95 medical students from three universities of Brazil and one from Peru. Results from Brazilians and Peruvians medical students, were not different in total percentage of correct answers among questions grouped by topics A second comparison was done combining the results of the original report(3) with our group of study. One-way analysis of variance among means of the results of 75 American sleep specialists, 213 American, 51 Brazilian and 44 Peruvian medical students found significant differences between sleep specialists and all medical students group, however no significant differences among medical students from different countries were reached.

Conclusions: The translated versions to Spanish and Portuguese of “The ASKME survey” could be useful for evaluating sleep knowledge in Latin American medical students. Its discriminative values might be the same as in the original English version. Although we did not find differences among results of medical students, we think bias in selection of sample and small number of participants limits more firm conclusions.

References:

(1) Rosen R, Mahowald M, Chesson A .The task force 2000 survey on medical education in sleep and sleep disorders. Sleep 1998 ;21:235-238 (2) Rosen R, Rosekind M, Rosevear C, Cole WE, Dement WC. Physicians education in sleep and sleep disorders: a national survey of U.S. medical schools. Sleep 1993; 16: 249-254 (3) Zozula R, Bodow M, Yatcilla D Development of a Brief, Self-Administered Instrument for Assessing Sleep Knowledge in Medical Education. “The ASKME Survey”. Sleep 2001;24:227-233.

Asociación entre parámetros antropométricos y puntaje epworth en polisomnografía convencional y de noche partida Rey de Castro J, Vizcarra D, Alvarez J. Revista de la Sociedad Peruana de Medicina Interna. 16 (2) 2003

RESUMEN El estudio fue prospectivo, descriptivo y transversal. La muestra estuvo constituida por pacientes con diagnóstico exclusivo de síndrome de apnea del sueño evaluados en nuestro centro entre 1997 y 2001 (total 318 estudios, total pacientes 244). Ingresaron al análisis 72 pacientes con el mismo número de pruebas: 25 fueron polisomnografiías convencionales (Grupo I) y 47 polisomnografías noche partida (Grupo II). Grupo I: Edad x 50.5 +/-14.64[20-84]años, hombres 19 (76%), Escala Somnolencia Epworth (ESE) x 10.2+/-4.24[3-20], IAH x 14.6 +/-6.56[6-31]. Grupo II: Edad x 53.57+/-14.94[33-96], hombres 41(87%), ESE x 12.27+/ 6.04[2-24], IAH x 50.95+/-18.86[27-120]. La ESE estuvo asociada a Desaturación Máxima (DmaxO2 ) en el estrato SatO2Hb<80 del Grupo I(R=0.64, p=0.048) y sólo hubo asociación IAH ESE en el estrato IAH-ESE en el estrato IAH [21-50] del Grupo II (R=0.36, p=0.042. La asociación entre estas dos variables en el Grupo II si IAH no se dividía en estratos fue: R=0.34, p=0.026, aunque el valor de R en ambas condiciones fue modesto. Por otro lado encontramos asociación entre IAH IMC(R=0.533, p=0.000), IAH- perímetro del cuello (PC) (R=0.472 , p=0.001) e IMC DmaxO2(R=-0.308, p=0.039) en el Grupo II. En el Grupo I se estableció asociación entre IAH-DmaxO2(R=-0542, P=0.009) e IMCPC (R=0.695, p=0.000). En la muestra descrita, no encontramos asociación entre parámetros polisomnográficos y somnolencia diurna calificada con Escala Epworth y hubo asociación entre variables polisomnográficas y . La escala Epworth es un instrumento valioso que enriquece los recursos empleados por el especialista en la evaluación global del paciente tanto en polisomnografía convencional como dividida.

Modificación en el uso del CPAP en pacientes con síndrome de Apnea Obstructiva del sueño (SAOS) por intervención de enfermería.

Lic. Caycho M, Dr. Juárez A, Dr. Vizcarra D.

RESUMEN

Objetivo: Evaluar los resultados del plan protocolizado de enfermería para mejoría a la adherencia del CPAP. Materiales y Métodos: Estudio descriptivo simple, se analizó el seguimiento de adherencia a CPAP tras indicación en pacientes con diagnóstico de apnea obstructiva del sueño moderada a severa del Instituto del Sueño Hypnos (ISH), entre los años 2000 y 2008 considerando la intervención de enfermería a partir del 2006. Resultados: Se analizaron 153 pacientes, 119 varones. El análisis histórico permite observar una variación positiva en porcentajes de adherencia al CPAP posterior a la intervención del plan protocolizado de enfermería a partir del 2006. Conclusiones: La intervención protocolizada de enfermería, en acompañamiento a la indicación de CPAP, en pacientes con apnea obstructiva del sueño mejora su empleo

Dolor y Sueño

REVISTA DIAGNOSTICO vol 47 numero 1. 2008

Darwin Vizcarra Escobar(1)

En el período de sueño, ese tercio de nuestras vidas, se desarrollan funciones que aún estamos en proceso de conocer. Entre las más importantes están la recuperación de energía, relajación muscular, equilibrio neurovegetativo, inmunoló-gico, metabólico y hormonal, así como un importante rol en el aprendizaje. El impacto del dolor agudo en el sueño es usualmente de corto plazo y reversible. El dolor crónico constituye una forma de aprendizaje pernicioso que genera cambios en la plasticidad neuronal y modificaciones a nivel celular, que pueden generar un círculo vicioso entre dolor y mal dormir. En el presente artículo analizaremos los aspectos más relevantes de la historia, fisiopatología, diagnóstico y tratamiento en el paciente con dolor y trastornos del sueño.

La historia del sueño y el dolor encuentra sus primeros hitos en los reportes sobre las vías sensitivas, su interacción a nivel troncal, y el comportamiento en sueño y vigilia ^(1,2), que fueron seguidos de asociaciones entre dolor somático y alteraciones electroencefalográficas en sueño conocidas como intrusión alfa en sueño de onda lenta ^(3,4). Estas descripciones se dieron casi en paralelo con el reconocimiento y consolidación de características que permiten identificar las fase de sueño REM y NO REM, así como sus subfases.

La prevalencia del dolor crónico se estima en alrede-dor de 11% ^(5,6). Entre un 50% a 90% de pacientes con dolor crónico reportan mala calidad de sueño. Las poblaciones con dolor en quienes se ha documentado problemas de sueño incluyen pacientes con cefalea, fibromialgia, síndrome de fatiga crónica, artritis reumatoide, espondilitis anquilosante, osteoartritis, síndrome del túnel carpal, lumbalgia, disfunción temporomandibular, síndrome de intestino irritable, lesiones de médula espinal y cáncer ^{(7-14 3,15-19 20)}. Se ha propuesto una relación lineal entre insomnio y dolor. Esta relación se ha reportado en una mayoría de pacientes con varios tipos de dolor musculoesquelético ^(9,10), sin embargo la influencia de comorbilidad como fatiga, ansiedad y trastornos del ánimo plantean cuestionamientos al respecto ^{(12,14,16,21-24)}. El dolor y el sueño son variables que se relacionan de forma compleja y varían en función al síndrome doloroso y con la condición comórbida, por ejemplo no se ha ha descrito relación entre un aumento en la distonia cervical dolorosa y trastorno del sueño, pero la mejoría del sueño mejora la distonía ⁽²⁵⁾. Del mismo modo se han señalado variaciones en esta relación en función a la edad y el género, siendo que el dolor crónico y el insomnio son más frecuente en mujeres y se reportan con mayor frecuencia en mayores de 55 años ^{(6, 26-28)}.

J Neuropsychiatry Clin Neurosci. 2008 Spring;20(2):240-1. doi: 10.1176/appi.neuropsych.20.2.240.

A diffuse brain injury leading to a complex neurobehavioral syndrome.

Arauco AR, Grados MA, Vizcarra D.

PMID:18451201 DOI:10.1176/jnp.2008.20.2.24

Clin Infect Dis. 2004 Oct 1;39(7):939-44. Epub 2004 Sep 1.

Clinical characteristics of patients in Peru with human T cell lymphotropic virus type 1-associated tropical spastic paraparesis.

Gotuzzo E¹, Cabrera J, Deza L, Verdonck K, Vandamme AM, Cairampoma R, Vizcarra D, Cabada M, Narvarte G, De las Casas C.

Author information

Abstract

BACKGROUND:

Human T cell lymphotropic virus type 1 (HTLV-1) is associated with tropical spastic paraparesis (TSP). Peru is an area of endemicity for HTLV-1.

METHODS:

All patients with suspected cases of TSP referred to our institute (Institute of Tropical Medicine Alexander von Humboldt, Lima, Peru) from 1989 through 2002 were interviewed and tested for HTLV-1. All patients with positive results were evaluated by an expert physician. Disease progression was defined as «rapid» if the time between TSP onset and inability to walk unaided was <2 years.

RESULTS:

Among 165 patients enrolled, the symptoms and signs most frequently found were spasticity (in 97.5% of patients), hyperreflexia (95.4%), lower limb paresthesia (90.2%), pyramidal signs (82.6%), urinary complaints (82.0%), and lumbar pain (79.0%). Rapid progression was present in 21.5% of patients; mean age at TSP onset was higher among these patients than among slow progressors (P<.001). Severe spasticity, diminished vibratory sensation, and tremor were found more frequently among rapid progressors, compared with slow progressors.

CONCLUSIONS:

HTLV-1–associated TSP is frequently diagnosed in areas of HTLV-1-endemicity. A subgroup of patients experiences rapid disease progression.

PMID:15472843 DOI:10.1086/423957

Rev Neurol. 2000 Jun 1-15;30(11):1036-40.

[Central pontine myelinolysis and pregnancy: a case report and review of literature].

[Article in Spanish]

Burneo J¹, Vizcarra D, Miranda H

Abstract

INTRODUCTION:

The ‘rapid’ correction of hyponatremia, itself a dangerous condition, is dangerous to the patient involved. There is an association between the ‘rapid’ correction of plasma sodium and the osmotic demyelination syndrome, characterized by the loss of myelin in the pontine neurons, and in extra-pontine sites such as the internal capsule, basal ganglia, cerebellum and cerebrum. Although cases of hyponatremia during pregnancy have been described, it has rarely been possible to demonstrate the condition, by imaging techniques or autopsy, showing demyelination lesions of the cerebrum. We report the case of a pregnant patient who developed this complication and had an interesting response to levodopa.

CLINICAL CASE:

A 27 year old woman had a history of progressive generalized muscle weakness for the previous six days. She had recently been discharged after receiving treatment for hyperemesis gravidarum. Imaging studies showed pontine and extrapontine myelinolysis. She was treated with levodopa which improved her extrapyramidal symptoms.

CONCLUSIONS:

Hyponatremia is the most commonly observed electrolyte disorder in the hospital population. The classical symptoms of myelinolysis are spastic quadriparesia and pseudobulbar paralysis, which reflect damage to corticospinal and corticobular paths. Serious symptomatic hyponatremia is a medical emergency which should be managed by specially trained personnel, since the treatment is as dangerous as the condition itself. More investigations are necessary to identify the precise risk factors and the mechanism by which an increase in sodium causes damage to myelin.

PMID:10904949

Cephalalgia. 1994 Oct;14(5):339-41.

Migraine, polycythemia and chronic mountain sickness.

Arregui A¹, León-Velarde F, Cabrera J, Paredes S, Vizcarra D, Umeres H.

Abstract

In the epidemiological study among 379 adult men with permanent residence at 4300 meters (14,200 feet), we found 32.2% with migraine (mostly migraine with aura), 15.2% with tension-type headache (episodic more than chronic), and 7.2% with other headaches. The frequency of migraine increased with age from 30.1% in the 20-29 year age group to 36.8% in the 50-59 year group. Episodic tension-type headaches also showed this trend. We found an age-specific increase in the frequency of high hemoglobin (Hb > 213 milligrams), low oxygen saturation (O2 saturation < 81.5%) and high chronic mountain sickness scores. Male migraineurs and those with more than two headaches per month had the highest hemoglobin levels and chronic mountain sickness scores when compared with high altitude men without headaches.

PMID:7828191 DOI:10.1046/j.1468-2982.1994.1405339.x

Arq Neuropsiquiatr. 1991 Sep;49(3):292-8.

[Non tumor intracranial expansive processes: clinico-topographical correlation].

Campos P¹, Herrera G, Valencia F, Fuentes-Dávila A, Cabrera J, Gotuzzo E, Chaparro E, Vizcarra D, Arbaiza D, Sánchez J

Abstract

Presentation of clinical-tomographic correlation in 111 cases of non tumoral intracranial expansive processes seen between 1984-1988 in the Hospital Cayetano Heredia (Lima, Peru). Emphasis is given fundamentally to: (1) the importance of establishing the organicity of partial and late epilepsy; (2) the high incidence rate of inflammatory infectious processes with CNS compromise in underdeveloping countries; (3) the necessity of making public the importance of two parasitic diseases in the differential diagnosis of non tumoral intracranial expansive processes: free living amebiasis, and toxoplasmosis (especially in association with AIDS).

PMID:1807229 DOI:10.1590/s0004-282×1991000300010

Rev Med Hered v.6 n.4 Lima oct./dic 1995

Mal de Montaña, migraña y depresión: ¿Coexistencia casual o causal? Posible rol de la hipoxia ambiental.

Chronic mountain sickness, migraine and depression: Causal or fortuitous coexistence? Possible role of hypoxic environment.

Arregui Alberto*, Cabrera Juan**, Leon Velarde Fabiola***, Vizcarra Darwin**, Umeres Hugo**, Acosta Raúl**, Paredes Samuel****.

*Laboratorio de Neurociencias. Departamento de Medicina, Universidad Peruana Cayetano Heredia. Lima, Peru.**Departamento de Medicina. Universidad Peruana Cayetano Heredia. Hospital Nacional Cayetano Heredia. Lima, Peru.***Departamento de Ciencias Fisiológicas. Universidad Peruana Cayetano Heredia. Lima, Peru.****Universidad San Antonio Abad, Cuzco, Peru

RESUMEN

Objetivo: Estudiar la posible asociación entre mal de montaña crónico, migraña y depresión. Material y métodos: Estudio epidemiológico realizado en setiembre de 1990en 379 hombres adultos con residencia permanente en la ciudad de Cerro de Pasco (4300 m.s.n.m.); se hicieron 15 preguntas asociadas a depresión y 9 preguntas asociadas al mal de montaña crónico (MMC) con las que se calcularon puntajes de depresión y del mal de montaña crónico. Los puntajes por encima de dos desviaciones estándar de la media fueron considerados como altos. Resultados: La frecuencia de migrañas fue de 48.3% entre hombres con puntajes altos de MMC y de 26.5% entre aquellos con puntajes normales (p=0.013). El 16.7% de hombres con puntaje alto de MMC tuvo puntaje alto de depresión mientras que sólo el 6.5% con puntaje normal de MMC tuvo puntaje alto de depresión (p=0.04). El riesgo de tener puntaje alto de depresión o de MMC fue más del doble entre hombres con migrañas comparados con hombres sin migrañas. La posibilidad de tener migraña o puntajes alto de MMC, fue tres veces mayor entre hombres con puntajes alto de depresión comparados con los que tuvieron puntajes de MMC más altos que aquellos sin cefaleas o con otros tipos de cefaleas. Conclusiones: Los datos muestran una coexistencia más que casual entre estas tres entidades clínicas. Se sugiere que un factor de riesgo común a las tres sea la hipoxia crónica que podría producir cambios neuroquímicos en el cerebro que explicaría, en parte, los síntomas de estos tres síndromes. Los datos también sugieren que los síntomas subjetivos que ocurren en el mal de montaña crónico son similares a los que ocurren en la depresión. (Rev Med Hered 1996; 6: 163-167).

PALABRAS CLAVE: Hipoxia, migraña, grandes alturas, mal de montaña crónico, comorbilidad.

SUMMARY

Objective: To study the association between chronic mountain sickness (CMS), migraine and depression. Material and methods: An epidemiologic study done in September 1990 among 379 adult men with permanent residence en the mining town of Cerro de Pasco (4,300 meters above the sea level), we asked 15 questions associated with depression and 9 questions usually associated with CMS. We calculated depression and CMS scores. Scores two standard deviations above the mean were considered as high scores. Results: The frequency of migraine was 48.3% among men with high CMS scores and 26.5% among those with normal scores (p=0.013). 16.7% of men with high CMS had high depression scores while among men with normal CMS scores only 6.5% had high depression scores (p=0.04). The risk of having a high depression or CMS score was highest among men with migraine when compared to men without headaches. Conversely, the risk of having migraine or a high CMS score was highest among men with high depression scores. Men with migraine with aura, the most frequent type of migraine at high altitude, had a higher frequency of high CMS scores than men with no headaches or other headache types. Conclusions: The results show a more than casual coexistence of the three clinical entities among high altitude men. A common risk factor is the environmental hypoxia which could produce neurochemical changes in the brain that may explain, in part, the symptoms of these syndromes. The data also suggest that many of the subjective symptoms seen in CMS are similar to those occurring in depression. (Rev Med Hered 1995; 6: 163-167).

KEY WORDS: Hypoxia, migraine, depression, high altitude, chronic mountain sickness, comorbidity.