IntroductionSedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV).MethodsA secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality.ResultsA total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality.ConclusionsEarly deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.

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ObjectivePolygraphy (PG) is an attractive alternative for diagnosing obstructive sleep apnea (OSA) in patients with high pre-test probability. However, several patients may not present typical symptoms. In this scenario, it is unclear the performance of PG for diagnosing OSA in non-referred populations to sleep laboratories.MethodsData from participants of the ELSA-Brasil cohort were used for this analysis. We performed an overnight home PG (Embletta GoldTM) synchronized with a wrist actigraphy (Actiwatch model 2TM). The validation strategy comprised three scorings from each participant: 1) Original scoring (PG): Routine scoring using data from the exclamation button mark to define “analysis start” and “analysis stop”; 2) Scoring using actigraphy data (PG+actigraphy): total sleep time defined by the actigraphy data; 3) Scoring using diaries (PG+diary): “analysis start” and “analysis stop” based on the diaries. Bland-Altman plots were generated to assess the agreements (Kappa) between each scoring strategy.ResultsA total of 300 participants were included in the final analysis (45% males, mean age: 48±8 years). The frequency of OSA using the PG score was 27.3%. Despite small differences in the OSA severity index, we obtained a high concordance of AHI comparing the PG vs. PG+actigraphy (Kappa: 0.95) as well as PG+diary vs. PG+actigraphy (Kappa: 0.96). No significant changes in the OSA classification (mild, moderate and severe) were observed in the 3 protocols.ConclusionUsing a pragmatic approach to address OSA at home, our results suggest that PG is a useful tool for OSA diagnosis even in subjects not referred to sleep studies.

Schistosomiasis mansoni is a fibrogenic liver disease that constitutes a major health problem in north-eastern Brazil. Although one common manifestation of the disease, periportal fibrosis (PPF), can be assessed by ultrasonography by well-trained physicians, the necessary equipment and personnel are not always readily available. Serum markers, including hyaluronic acid (HA), have been used as alternative means of measuring fibrosis. Recently serum concentrations of HA have been evaluated in 77 Brazilians (61 cases of schistosomiasis mansoni and 16 healthy controls) and compared against the ultrasound-evaluated PPF in the same subjects. The HA was measured using a non-competitive fluorescence-based assay, while the PPF was explored using a portable ultrasound scanner (SSD-500; Aloka, Tokyo) and graded, as patterns A-F, according to the World Health Organization's 'Niamey protocol'. In general, the serum concentrations of HA were found to be positively correlated with the severity of the PPF. The mean concentration of HA in the sera of the 16 controls was significantly lower than that recorded in the schistosomiasis cases who showed PPF of patterns D or E (P,0.001 for each). The cases who showed pattern-C PPF also had significantly less HA in their sera than the cases with PPF of patterns D or E (P,0.001 for each), and the cases with pattern-D fibrosis had significantly lower HA concentrations in their sera than the cases with PPF of pattern E (P,0.001).In an analysis based on a receiver-operating-characteristic (ROC) curve, an HA concentration of 20.2 mg/litre of serum was identified as a threshold that could be used to distinguish moderate cases of PPF (i.e. patterns C or D) from the more advanced cases (i.e. patterns E or F), with a sensitivity of 60% and specificity of 65%.In conclusion, it appears that serum concentrations of hyaluronic acid could be used as markers for periportal fibrosis in patients with schistosomiasis mansoni.Although the human morbidity and mortality caused by schistosomiasis mansoni have been reduced over the last 25 years by chemotherapy, the disease still represents a significant health hazard, particularly in north-eastern Brazil (Katz and Peixoto, 2000;Araú jo et al., 2007).It is believed that between 2% and 7% of humans infected with Schistosoma mansoni go on to develop hepato-splenic disease, which is associated with portal hypertension and digestive bleeding brought on by the rupture of oesophageal varices or hypertensive

Objective: To elucidate the independent associations of obstructive sleep apnea (OSA) and sleep duration (SD) as well as the potential inflammatory and metabolic mediators on carotid intima-media thickness (CIMT) in a large cohort of adults. Approach and Results: Consecutive participants from the ELSA-Brasil performed a clinical evaluation, sleep study, 1-week actigraphy for defining SD and CIMT using standard techniques. Gamma regression models were used to explore the association between OSA and SD with CIMT. Mediation analysis was performed using the mediation R package. A total of 2009 participants were included in the main analysis. As compared with no OSA (apnea-hypopnea index [AHI] <5 events/hour; n=613), patients with mild (AHI, 5–14.9; n=741), moderate (AHI, 15–29.9; n=389), and severe OSA (AHI ≥30 events/hour; n=266) presented a progressive CIMT increase (0.690 [0.610–0.790], 0.760 [0.650–0.890], 0.810 [0.700–0.940], and 0.820 [0.720–0.958] mm; P <0.001). In contrast, CIMTs were similar for those with SD <6 hours (0.760 [0.650–0.888]), 6 to 8 hours (0.750 [0.640–0.880]) and >8 hours (0.740 [0.670–0.900]). All forms of OSA were independently associated with CIMT (mild: β: 0.019, SE 0.008; P =0.022; moderate: β: 0.025, SE 0.011; P =0.022; severe OSA: β: 0.040, SE 0.013; P =0.002). Moreover, the association of AHI with CIMT was mediated by increased C-reactive protein and triglycerides ( P <0.01). SD did not interact with OSA in the association with CIMT. Conclusions: OSA is independently associated with increased CIMT in a dose-response relationship. This association is partially mediated by inflammation and dyslipidemia. In contrast, SD is not associated nor interacted with OSA to increase CIMT.