Clinical and polysomnographic predictors of suboptimal auto-adjusting CPAP titration in adult OSA patients: a single-center study.

PURPOSE: To examine potential clinical, demographic, anthropometric, and polysomnographic predictors of successful auto-adjusting continuous positive airway pressure (CPAP) titration for treatment of obstructive sleep apnea (OSA). METHODS: This cross-sectional study was conducted in adults diagnosed with moderate-to-severe OSA (baseline apnea-hypopnea index [AHI] ≥ 15.0/h), who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed®) in a sleep laboratory setting while wearing a nasal or pillow mask. Participants were then grouped into two groups: optimal CPAP titration (residual AHI < 5.0/h) or suboptimal CPAP titration (residual AHI ≥ 5.0/h). Multivariate logistic regression analysis was used to assess possible independent predictive factors for suboptimal CPAP titration. RESULTS: A total of 1222 adults consisting of 874 subjects with optimal CPAP titration (71.5%) and 348 subjects with suboptimal CPAP titration (28.5%) were evaluated. Multivariate analysis resulted in a model with an adequate calibration (Hosmer-Lemeshow chi-square-test: 7.088; p = 0.527), with male sex, higher values of baseline AHI, therapeutic pressure (95th percentile), and mask leak (95th percentile) emerging as significant and independent predictors for suboptimal CPAP titration: adjusted odds ratio (OR): 1.456 (95% confidence interval [CI] 1.076-1.971; p = 0.015), OR: 1.009 (95% CI 1.002-1.016; p = 0.013), OR: 1.281 (95% CI 1.206-1.361; p < 0.001), and 1.035 (1.026-1.043; p < 0.001), respectively. CONCLUSIONS: In a large cohort of adults undergoing auto-adjusting CPAP titration due to moderate-to-severe OSA, male sex, increased values of baseline AHI, pressure requirements, and mask leak were significant predictors for less than optimal CPAP titration.

First detection of avian metapneumovirus subtype C Eurasian lineage in a Eurasian wigeon (Mareca penelope) wintering in Northeastern Italy: an additional hint on the role of migrating birds in the viral epidemiology.

Avian metapneumovirus (aMPV) economically affects the global poultry industry causing respiratory and reproductive disorders. Considering the paucity of data on aMPV occurrence in European free-ranging avifauna, a molecular survey was conducted on wild birds of 23 species belonging to the orders Anseriformes, Charadriiformes or Passeriformes, captured alive and sampled in Northeast Italy as part of the national avian influenza virus (AIV) surveillance activities. A total of 492 oropharyngeal swabs, collected from 2007-2010, all AIV-negative, were screened from aMPV by subtype-specific qRT-PCR. An aMPV-C strain, named aMPV/C/IT/Wigeon/758/07, was found in a wintering young Eurasian wigeon (Mareca penelope) sampled in November 2007. The matrix, fusion, and attachment glycoprotein genes of the detected strain were subsequently amplified by specific independent RT-PCRs, then sequenced, and compared in a phylogenetic framework with known aMPV homologous sequences retrieved from GenBank. Close genetic relationships were found between the aMPV/C/IT/Wigeon/758/07 strain and subtype C Eurasian lineage strains isolated in the late 1990s in French domestic ducks, suggesting epidemiological links. Eurasian wigeons are medium/long-range migrant dabbling ducks that move along the Black Sea/Mediterranean flyway; our finding might, therefore, be related to migratory bridges between countries. To our knowledge, this is the first molecular evidence of the occurrence of aMPV subtype C in Italy and backdates the aMPV-C circulation to 2007. Moreover, the results suggest the susceptibility of Eurasian wigeons to aMPV. Broader investigations are needed to assess the role of wild ducks and the significance of the wildfowl/poultry interface in aMPV-C epidemiology.RESEARCH HIGHLIGHTSWild birds live-captured in Italy were tested for aMPV detection and characterization.aMPV-C Eurasian lineage was found for the first time in a wintering Eurasian wigeon.Migratory birds could be involved in the aMPV epidemiology.

Gender-related sleep duration perception in a Brazilian sleep clinic cohort.

PURPOSE: This study aims to evaluate if gender influences the sleep duration perception in adults referred for polysomnography (PSG). METHODS: A cross-sectional study was undertaken from December 2019 to January 2021. Total sleep time was objectively assessed from the overnight PSG and subjectively estimated. The sleep perception index (SPI) was defined by the ratio of subjective and objective values. Diagnosis of obstructive sleep apnea (OSA) was based on an apnea-hypopnea index ≥ 5.0/h. Insomnia was defined by the presence of one or more specific complaints: difficulty falling asleep, difficulty maintaining sleep, and/or waking up earlier than desired. The association between continuous variables and SPI was assessed by linear regression analysis. RESULTS: This study enrolled 2,004 outpatients (56% men) who were grouped into four subsamples: controls (n = 139), insomnia (n = 154), OSA (n = 912), and insomnia comorbid with OSA [COMISA] (n = 799). In women, the median SPI differed among groups and ranged from 89 to 102% (p = 0.001); while in men, it ranged from 90% to 99% (p = 0.007). However, no gender-related SPI value differences emerged within each of the subgroups: controls (p = 0.907), insomnia (p = 0.830), OSA (p = 0.070), and COMISA (p = 0.547). The presence of insomnia (ß, - 0.101, p < 0.001) or OSA (ß, - 0.082, p = 0.001), but not gender (ß, - 0.017, p = 0.612), were independent predictors of the SPI. CONCLUSION: In a clinical referral cohort, no evidence of sex dimorphism emerged for SPI irrespective of the underlying sleep diagnosis.

Nasal versus oronasal mask in patients under auto-adjusting continuous positive airway pressure titration: a real-life study.

PURPOSE: Mask type (nasal versus oronasal) can affect the optimal pressure required to correct the apnea/hypopnea index (AHI) in obstructive sleep apnea (OSA) subjects treated with CPAP. Our objective was to evaluate if mask type influenced CPAP titration outcomes in OSA patients. METHODS: A retrospective study of individuals with a baseline AHI ≥ 15.0/h, who received an auto-adjusting CPAP titrating device (S9 AutoSet ResMed®) in a sleep-lab setting. The mask type oronasal (OM) or nasal (NM) was always selected by the patients. Optimal pressure requirements, leak, and residual AHI were compared based on mask type. RESULTS: Overall, 436 patients were included: 283 with NM (64.9%) and 153 with OM (35.1%). At baseline, NM and OM cohorts had similar AHI (p = 0.160). Patients allocated to the OM cohort had a higher 95th percentile pressure, a higher 95th percentile leak, and a higher residual AHI than those with a NM: pressure requirement: 12.9 cm H2O (IQR: 10.6-15.0) versus 10.7 cm H2O (IQR: 9.2-12.3); leak: 21.6 L/min (IQR: 9.6-37.2) versus 9.6 L/min (IQR: 3.6-19.2); and residual AHI: 4.9/h (IQR: 2.4-10.2) versus 2.2/h (IQR: 1.0-4.4), respectively (p < 0.001 for all). CONCLUSIONS: CPAP mask type based on individual preferences exerts profound effects on optimal CPAP pressures and efficacy. Patients titrated with OM showed higher pressure requirements, had higher a leak, and higher residual AHI when compared to NM, which may adversely impact treatment adherence and other health outcomes.

Predicting Obstructive Sleep Apnea in Patients with Insomnia: A Comparative Study with Four Screening Instruments.

PURPOSE: Obstructive sleep apnea (OSA) and insomnia are very prevalent disorders, especially in sleep-lab setting, and insomnia may be the presenting complaint of OSA. Here, we aimed to validate No-Apnea as screening tool for OSA in patients with self-reported insomnia complaints and to compare its performance with other models. METHODS: This cross-sectional study involved evaluation of No-Apnea as well as STOP-Bang, NoSAS and Epworth Sleepiness Scale (ESS) in subjects with insomnia being evaluated with full in-lab polysomnography. Discrimination was assessed by area under the curve (AUC), while predictive parameters were calculated by contingency tables. OSA severity was classified based on the apnea/hypopnea index: ≥ 5.0/h as any OSA (OSA≥5), ≥ 15.0/h as moderate/severe OSA (OSA≥15), and ≥ 30.0/h as severe OSA (OSA≥30). RESULTS: Overall, 2591 patients with a clinical diagnosis of insomnia were included. Diagnosis of OSA≥5, OSA≥15, and OSA≥30 was of 76.3%, 53.1%, and 32.6%, respectively. At all levels of OSA severity, No-Apnea had sensitivity ranging from 84.5 to 94.1% and specificity ranging from 58.2 to 35.1%. For screening of OSA≥5, OSA≥15, and OSA≥30, discriminatory ability (AUC) of No-Apnea was: 0.790 [95% confidence interval (CI) 0.770-0.810], 0.758 (95% CI 0.740-0.777), and 0.753 (95% CI 0.734-0.772), respectively. Based on AUCs, No-Apnea, STOP-Bang, and NoSAS performed similar at all levels of OSA severity. The ESS did not present satisfactory discrimination as OSA screening model. CONCLUSIONS: In a large sample of patients with insomnia, No-Apnea, STOP-Bang, and NoSAS, but not ESS, enable satisfactory and similar discrimination at all levels of OSA severity.

Fractional Exhaled Nitric Oxide Measurements and Screening of Obstructive Sleep Apnea in a Sleep-Laboratory Setting: A Cross-Sectional Study.

PURPOSE: Obstructive sleep apnea (OSA) is a common condition characterized by repetitive collapse of the upper airways and intermittent oxygen desaturation, which may lead to airway inflammation. Here, we explored whether fractional exhaled nitric oxide (FeNO) levels provide a non-invasive screening tool of OSA. METHODS: Over a 3-month period, FeNO levels were measured in consecutive non-smoking patients referred for a sleep laboratory. All patients underwent full polysomnography. OSA severity was classified based on the apnea/hypopnea index: ≥ 5.0/h as any OSA, ≥ 15.0/h as moderate/severe OSA, and ≥ 30.0/h as severe OSA. FeNO was measured by a portable device (NIOX-MINO®; Aerocrine AB, Solna, Sweden) and expressed as parts per billion (ppb). Discrimination by area under the curve (AUC) and binary logistic regression were performed. RESULTS: A total of 229 subjects were evaluated. Mean FeNO values were similar among subjects without OSA or with OSA: 16.9 ± 10.6 ppb versus 20.2 ± 14.5 ppb, p = 0.221; respectively. FeNO was not an inclusionary parameter to predict any OSA, moderate/severe OSA, and severe OSA: odds ratio (OR) 1.023 (95% confidence interval [CI]: 0.986-1.062); OR 1.012 (95% CI: 0.991-1.034); and OR 0.999 (95% CI: 0.980-1.018), respectively. The AUC values for FeNO in the diagnosis of any OSA, moderate/severe OSA, and severe OSA showed no discriminatory properties: AUC: 0.567 (95% CI: 0.464-0.670), AUC: 0.541 (95% CI: 0.465-0.618), and AUC: 0.535 (95% CI: 0.459-0.610); respectively. CONCLUSIONS: In a sleep-lab setting, our findings suggest that FeNO measurements are inconsequential in the screening of OSA in adults.

Comparative performance of screening instruments for obstructive sleep apnea in morbidly obese patients referred to a sleep laboratory: a prospective cross-sectional study.

PURPOSE: Obstructive sleep apnea (OSA) is very common occurrence among morbidly obese patients. Our main objectives were to validate the No-Apnea, a 2-item screening tool, in morbidly obese patients and compare its performance with three other instruments: STOP-Bang questionnaire, NoSAS score, and Epworth Sleepiness Scale (ESS). METHODS: A cross-sectional analysis of morbidly obese patients (body mass index [BMI] ≥ 35.0 kg/m2) grouped into two independent samples: bariatric surgery patients (BS) and non-bariatric surgery patients (NBS). All patients underwent overnight polysomnography. Discriminatory ability was assessed by area under the curve (AUC). OSA severity was defined by apnea/hypopnea index cut-off points: ≥ 5.0/h (OSA≥5), ≥ 15.0/h (OSA≥15), and ≥ 30.0/h (OSA≥30). RESULTS: A total of 1017 subjects (40.4% in BS cohort and 59.6% in NBS cohort) were evaluated. In the BS cohort, No-Apnea had similar discrimination to STOP-Bang and NoSAS for predicting OSA≥5 (p = 0.979 and p = 0.358, respectively), OSA≥15 (p = 0.158 and p = 0.399, respectively), and OSA≥30 (p = 0.388 and p = 0.903, respectively). In the NBS cohort, No-Apnea had similar discrimination to STOP-Bang and NoSAS for predicting OSA≥5 (p = 0.528 and p = 0.428, respectively), OSA≥15 (p = 0.825 and p = 0.108, respectively), and OSA≥30 (p = 0.458 and p = 0.186, respectively). Moreover, No-Apnea performed significantly better than ESS in both BS and NBS cohorts (p < 0.001). CONCLUSIONS: No-Apnea is a useful and practical tool for screening of OSA in morbidly obese patients, with non-inferior performance to STOP-Bang questionnaire and NoSAS score.

Avian extraintestinal Escherichia coli exhibits enterotoxigenic-like activity in the in vivo rabbit ligated ileal loop assay.

Avian pathogenic Escherichia coli (APEC) strains harbor a number of virulence genes and cause extraintestinal diseases, such as septicemia, swollen-head syndrome, salpingitis, and omphalitis in poultry. APEC strains are not known to cause intestinal diseases. Herein, for the first time, it is reported that APEC strains were able to induce an enterotoxigenic-like effect in rabbit ligated ileal loops. Strain SEPT362 caused cell detachment of the intestinal villi, which also showed a flattened and wilted appearance, but the integrity of the tight junctions was maintained. Additionally, this strain did not adhere to enterocytes in vivo, although adhesin encoding genes ( fimH, csgA, lpfA2-3, and ECP) were present while other lpfA types, sfa, afa, papC, and ral genes were not. This enterotoxigenic-like activity was conserved after thermal treatment of the supernatant at 65°C but not at 100°C. Moreover, experiments based on filtering with different molecular weight cut-off (MWCO) pore sizes demonstrated that the component associated with the observed biological effect has a molecular weight >100 kDa. Blast search and polymerase chain reaction assays for known E. coli virulence factors showed that strain SEPT362 harbors the gene encoding for the toxin EAST-1 and the serine protease autotransporter (SPATE) Tsh, but is negative for genes encoding for the toxins LT-I, STh, STp, Stx1, Stx2, CNF-1, CNF-2, CDT and the SPATEs Sat, Pic, Vat, SigA, SepA, EatA, EspP, or EspC. A cloned copy of the tsh gene in E. coli K-12 was also tested and was shown to have an enterotoxic effect. These results suggest that APEC might induce fluid accumulation in the rabbit gut. The Tsh autotransporter seems to be one of the factors associated with this phenotype.

Screening for obstructive sleep apnea: comparing the American Academy of Sleep Medicine proposed criteria with the STOP-Bang, NoSAS, and GOAL instruments.

STUDY OBJECTIVES: We evaluated the performance of the 2017 American Academy of Sleep Medicine criteria (AASM2017) in screening obstructive sleep apnea (OSA) and compared them with 3 other validated instruments: NoSAS score, STOP-Bang, and GOAL questionnaires. METHODS: From July 2019 to December 2021, 4,499 adults undergoing overnight polysomnography were included. The AASM2017 instrument considers an increased high risk for moderate-to-severe OSA in the presence of excessive daytime sleepiness and at least 2 of the following 3 criteria: loud snoring; observed apnea, gasping, or choking; and hypertension. OSA severity was based on polysomnography-derived apnea-hypopnea index cutoffs: 5.0 events/h, 15.0 events/h, and 30.0 events/h. Predictive performance was evaluated by the area under the curve and contingency tables. RESULTS: When screening for any OSA severity, AASM2017 displayed a sensitivity of 31.0-40.6% and a specificity of 80.8-89.6%. For all apnea-hypopnea index thresholds, AASM2017, unlike the GOAL, STOP-Bang, and NoSAS, exhibited superior specificity but markedly lower sensitivity. GOAL, STOP-Bang, and NoSAS, but not AASM2017 criteria, emerged as an adequate screening tool for any OSA severity (all areas under the curve > 0.7) and performed significantly better than AASM2017 in predicting any OSA severity (all P < .001). For all severity OSA levels, GOAL, STOP-Bang, and NoSAS displayed similar performance when compared to each other (all P > .05). CONCLUSIONS: GOAL, STOP-Bang, and NoSAS instruments, but not AASM2017 criteria, emerge as useful OSA screening tools in a large referral single-center clinical cohort. CITATION: Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Screening for obstructive sleep apnea: comparing the American Academy of Sleep Medicine proposed criteria with the STOP-Bang, NoSAS, and GOAL instruments. J Clin Sleep Med. 2023;19(7):1239-1246.

[Bodies in balance: riverside images and everyday life in Açaí Port and on Maracujá Island, Belém (State of Pará)]. / Corpos em equilíbrio: imagens e cotidiano ribeirinho no Porto do Açaí e na Ilha do Maracujá, Belém (PA).

Based on photographic records, this paper reflects on the ebb and flow of the Maracujá Island dwellers, between the island and Belém, making use of the ways they use their bodies or 'know how to use' them, that Mauss called corporal techniques. Bodies disclosed, since they are always exposed and therefore capable of being visually and ethnographically categorized. Inspired on Certeau, the article seeks to think of the corporal tactics devised by island residents to practice the landscapes of belonging revealing peculiar body expressions in constructing their everyday experiences. Such observations do not refer to a body-object, but to a body that is the subject of culture, as Csordas says, a body that is "the existential basis of culture".

Predictive Factors for Obstructive Sleep Apnea Diagnosis in Bariatric Surgery Candidates with or Without Chronic Insomnia Complaints.

OBJECTIVE: This study aims to evaluate the frequency of insomnia complaints in bariatric patients and to assess obstructive sleep apnea (OSA) predictors according to the presence or absence of chronic insomnia. METHODS: Insomnia was defined as the presence of at least one specific symptom: difficulty falling asleep, difficulty maintaining sleep, and/or waking up earlier than expected. Diagnosis of OSA was objectively obtained from in-laboratory polysomnography. Multivariate logistic regression analysis was used to assess OSA predictors. RESULTS: This cross-sectional study contains 1,737 bariatric surgery candidates: 59.6% without insomnia and 40.4% with insomnia. OSA prevalence was similar among participants with or without insomnia either for any OSA (p = 0.168) or for moderate-to-severe OSA (p = 0.185). Patients without insomnia showed a higher prevalence of severe OSA than those with insomnia (p = 0.005). In both cohorts, five parameters were independent OSA predictors: sex, age, body mass index (BMI), neck circumference (NC), and excessive daytime sleepiness (EDS). Male sex was the most important predictor, whether in individuals without insomnia (adjusted odds ratio [OR] ranging from 4.874 to 8.369) or in those with insomnia (adjusted OR ranging from 5.672 to 12.441). CONCLUSIONS: A considerable proportion of bariatric patients report insomnia complaints. The probability of suffering from OSA was similar among bariatric candidates with or without insomnia, except for severe OSA diagnosis. Sex, age, BMI, NC, and EDS were independent predictors for OSA diagnosis irrespective of insomnia symptoms, and male sex was the main predictor for OSA in bariatric individuals with or without insomnia.

Influence of nocturnal insomnia symptoms on obstructive sleep apnea diagnosis in a clinical referral cohort.

STUDY OBJECTIVES: To assess whether nocturnal symptoms of insomnia influence the prevalence of obstructive sleep apnea (OSA) in a clinical referral cohort. METHODS: Insomnia was defined by the presence of 1 or more of the following complaints: difficulty initiating sleep, difficulty maintaining sleep, and/or early morning awakenings. OSA severity was based on an apnea-hypopnea index: ≥ 5.0 events/h (any OSA), ≥ 15.0 events/h (moderate/severe OSA), and ≥ 30 events/h (severe OSA). Multivariate logistic regression analysis was used to evaluate predictive factors for OSA diagnosis and severity. RESULTS: Overall, 12,021 outpatients referred for polysomnography were grouped into 2 cohorts: without insomnia (58.2%) and with insomnia (41.8%). Individuals without insomnia had a higher prevalence of OSA than those with insomnia (P < .001, for all OSA severity levels). The presence of insomnia was negatively associated with diagnosis of any OSA (adjusted odds ratio: 0.852; 95% confidence interval: 0.769-0.944), moderate/severe OSA (adjusted odds ratio: 0.819; 95% confidence interval: 0.751-0.892), and severe OSA (adjusted odds ratio: 0.816; 95% confidence interval: 0.746-0.892). Moreover, the number of nocturnal symptoms of insomnia was associated with a lower likelihood of OSA, even when adjusted for other confounders such as sex, age, body mass index, neck circumference, excessive daytime sleepiness, hypertension, and type 2 diabetes mellitus. CONCLUSIONS: In this present study that included a large sample of consecutive outpatients, there was an inverse relationship between the number of nocturnal symptoms of insomnia and OSA diagnosis. CITATION: Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Influence of nocturnal insomnia symptoms on obstructive sleep apnea diagnosis in a clinical referral cohort. J Clin Sleep Med. 2022;18(5):1271-1278.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing.

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Nocturnal oximetry in bariatric surgery patients referred to overnight in-lab polysomnography.

OBJECTIVE: This study aimed to evaluate nocturnal oximetry approaches in identifying obstructive sleep apnea (OSA) among bariatric surgical candidates. METHODS: This was a cross-sectional study involving adult bariatric patients who were undergoing in-lab polysomnography and who were previously screened with the GOAL questionnaire. OSA severity was established as any OSA, moderate/severe OSA, and severe OSA. Oximetry data were evaluated as oxygen saturation (average and nadir), oxygen desaturation index (ODI) at 3%, and proportion of time spent with oxygen saturation <90%. Associations between oximetry data and the apnea-hypopnea index (AHI) were assessed by Spearman correlation index (r), linear regression, logistic regression, and discrimination. RESULTS: All oximetry values were significantly correlated with the AHI among 1,178 individuals, with the ODI emerging as the better parameter (r = 0.911, p < 0.001). Using linear regression, the ODI was the only predictor of the AHI (ß = 0.952, p < 0.001). In the multivariate analysis, the ODI was the only independent parameter predicting OSA at all severity levels. In addition, the ODI exhibited excellent discrimination to predict OSA and displayed improved performance among individuals screened as being at high risk versus those at low risk with the GOAL instrument. CONCLUSIONS: The ODI emerges as a valid surrogate predictor of the AHI, particularly among those screened as being at high risk for OSA.

Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration?

STUDY OBJECTIVES: The first-choice therapy for adults with moderate/severe obstructive sleep apnea is continuous positive airway pressure (CPAP). However, studies evaluating whether the therapeutic CPAP level obtained from a titration is affected by sex are surprisingly scarce. Our main objective was to verify if sex influenced the optimal CPAP measurement obtained during a titration. METHODS: This cross-sectional study was conducted in adults diagnosed with moderate/severe obstructive sleep apnea [baseline apnea-hypopnea index (AHI) ≥ 15.0 events/h] who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed) in a sleep laboratory setting. All participants used a nasal mask during the titration. The optimal pressure, leak, and residual AHI values were registered. Multiple linear regression was used to evaluate if clinical and polysomnographic data influenced the therapeutic CPAP level setting (95th percentile pressure). RESULTS: A total of 1,006 adults were enrolled: 354 women and 652 men. There were no statistically significant sex-related differences in the CPAP requirements and leak values delineated during the titration; all P-values > .005. However, the median residual AHI was significantly higher in males vs females: 2.7 events/h vs 2.2 events/h (P = .008). Body mass index (ß: 0.292, P < .001), baseline AHI (ß: 0.167, P < .001), and age (ß: 0.065, P = .035) were independent predictors of the therapeutic CPAP level settings. CONCLUSIONS: Sex does not significantly influence the therapeutic CPAP settings. However, age, BMI, and baseline AHI emerge as independent predictors of the 95th percentile CPAP requirement during an auto-adjusting CPAP titration. CITATION: Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration? J Clin Sleep Med. 2021;17(9):1815-1820.

Prediction of obstructive sleep apnea using GOAL questionnaire in adults with or without excessive daytime sleepiness: A cross-sectional study.

OBJECTIVE: Obstructive sleep apnea (OSA) is a prevalent disorder and excessive daytime sleepiness (EDS) is a frequently associated complaint. Our objectives were (1) to evaluate the predictive performance of the GOAL questionnaire in patients with or without EDS and (2) to compare its discrimination with that of 3 other validated instruments: STOP-Bang, No-Apnea, and NoSAS. METHODS: A cross-sectional study from July 2019 to March 2020 was designed with consecutive adults undergoing full polysomnography. Participants were grouped into 2 cohorts according to the Epworth Sleepiness Scale (ESS): without EDS (ESS <11) or with EDS (ESS ≥11). Discrimination was assessed by area under the curve, while predictive parameters were calculated using contingency tables. OSA severity was classified based on apnea/hypopnea index thresholds: ≥ 5.0/h (OSA≥5), ≥ 15.0/h (OSA≥15), and ≥ 30.0/h (OSA≥30). RESULTS: Overall, 2627 patients were enrolled. In 1477 individuals without EDS, for the screening of OSA≥5, OSA≥15, and OSA≥30, GOAL showed sensitivities ranging from 79.3% to 91.5% and specificities ranging from 60.6% to 40.2%. In 1150 individuals with EDS, for the screening of OSA≥5, OSA≥15, and OSA≥30, GOAL reported sensitivities ranging from 86.2% to 94.5% and specificities ranging from 63.9% to 36.0%. In both cohorts, GOAL showed similar discrimination to STOP-Bang, No-Apnea, and NoSAS for predicting OSA≥5, OSA≥15, and OSA≥30 (all P values >.05). CONCLUSIONS: The GOAL questionnaire, a practical 4-item instrument, showed adequate predictive performance for the prediction of OSA. Moreover, its discrimination was satisfactory and non-inferior to that of STOP-Bang, No-Apnea, and NoSAS.

Phosphate Fertilization as a Modulator of Enzymatic Browning in Minimally Processed Cassava.

This study proposes to relate the increase in phosphorus (P) supply in the soil, via phosphate fertilization, to oxidative damage and protection, phenylpropanoid metabolism, and enzymatic browning in minimally processed cassava. The roots were grown with 0, 60, and 120 kg ha-1 P2O5. The roots were harvested, and the yield and P content in the root, stem, and leaves were quantified. The roots were minimally processed and stored for 12 days at 5 °C. The higher supply of P in the soil increased the P content of roots and stems but not the agro-industrial yields. Roots grown at 120 kg ha-1 P2O5 showed higher detection of hydrogen peroxide, which was accompanied by increased phenolic compounds, soluble quinones, and antioxidant capacity and increased activities of the enzymes superoxide dismutase, catalase, ascorbate peroxidase, polyphenol oxidase, and peroxidase. The present study thus demonstrates the role of phosphorus application, induction of the synthesis of phenolic compounds, and quality of fresh-cut cassava.

Early detection of SARS-CoV-2 P.1 variant in Southern Brazil and reinfection of the same patient by P.2.

Multiple variants of the Severe Acute Respiratory Syndrome coronavirus 2 virus (SARS-CoV-2) have been constantly reported across the world. The B.1.1.28 lineage has been evolving in Brazil since February 2020 and originated the P.1 variant of concern (VOC), recently named as the Gamma variant by the newly WHO nomenclature proposal, and P.2 as a variant of interest (VOI). Here we describe an early case of P.1 primary infection in Southern Brazil in late November 2020, soon after the emergence of the variant in Manaus, Northern Brazil. The same male patient was reinfected by another B.1.1.28 variant, namely P.2, in March, 2021. The genomic analysis confirmed genetically significant differences between the two viruses recovered in both infections, the P.1 lineage in the first episode and P.2 in the reinfection. Due the very early detection of P.1, we have also investigated the circulation of P.1 in the same region by differential RT-qPCR, showing that this was an isolated case of P.1 at the time of detection, and this variant has disseminated and became prominent from late January to the end of March, 2021. SARS-CoV-2 recent reports of reinfection have raised critical questions on whether and how well a first infection protects against reinfection.

Reinfection cases by closely related SARS-CoV-2 lineages in Southern Brazil.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the pandemic that started in late 2019 and still affects people's lives all over the world. Lack of protective immunity after primary infection has been involved with reported reinfection cases by SARS-CoV-2. In this study, we described two cases of reinfection caused by non-VOC (Variants of Concern) strains in southern Brazil, being one patient a healthcare worker. The four samples previously positive for SARS-CoV-2 by real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) were sequenced by a high-performance platform and the genomic analysis confirmed that lineages responsible for infections were B.1.91 and B.1.1.33 (patient 1), and B.1.1.33 and B.1.1.28 (patient 2). The interval between the two positive RT-qPCR for patients 1 and 2 was 45 and 61 days, respectively. This data shows that patients may be reinfected even by very closely related SARS-CoV-2 lineages.

Predominance of SARS-CoV-2 P.1 (Gamma) lineage inducing the recent COVID-19 wave in southern Brazil and the finding of an additional S: D614A mutation.

Recently, the highest wave of SARS-CoV-2 epidemic occurred since the beginning of the pandemic in Brazil was registered in Rio Grande do Sul (RS) State, Southern Brazil, considering the number of cases, deaths and hospitalization per day caused by COVID-19. In this study we described which lineages were circulating in the first quarter of 2021 in Southern Brazil to better understand the viral factors involved in the health crisis caused by SARS-CoV-2 in the region, searching also for possible additional SARS-CoV-2 sequence mutations. A total of 70 positive SARS-CoV-2 samples collected between January 28th, 2021 until April 23rd, 2021, were selected to sequencing. Whole genome sequencing of 70 SARS-CoV-2 samples showed a predominance of Gamma lineage (67%, 47/70), followed by P.2 lineage (27%, 19/70) and B.1.1.28 (6%, 4/70). Two Gamma lineage consensus sequences presented a new S:D614A mutation. Newly mutations could be emerging due the quick SARS-CoV-2 spreading. Thus, the greater understanding about immune protection and variants vigilance is essential to the better management of the health SARS-CoV-2 crisis.