Alan Luiz Eckeli

O presente trabalho consiste em um relato de experiências, conhecimentos e aprendizado vivenciados pela equipe de rondonistas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), que atuou no Projeto Rondon 2023: “Operação Sentinelas Avançadas”, exercendo atividades de extensão universitária no município de Alta Floresta do Oeste, em Rondônia em meados de 2023. As experiências aqui relatadas consistiram em ações sociais desempenhadas por meio de Oficinas direcionadas às comunidades da Alta Floresta do Oeste, distrito de Vila Santo Antônio, Quilombola Porto Rolim de Moura do Guaporé e Terra Indígena Rio Branco. Participaram da Operação Sentinelas Avançadas 8 alunos de graduação e 2 docentes da FMRP-USP, os quais atuaram em conjunto com a equipe da Universidade Federal de Goiás (UFG). Assim também, o grupo de trabalho obteve suporte e acompanhamento de um Subtenente do Exército Brasileiro, que ficou responsável pela segurança e logística da equipe. Os alunos de graduação da FMRP-USP eram discentes do Campus da USP em Ribeirão Preto, atuando do curso de Enfermagem, de Fisioterapia, de Terapia Ocupacional, de Informática Biomédica e de Direito. Dentre os professores participantes da USP, ambos eram médicos e docentes da FMRP-USP. A adesão das comunidades locais foi bastante satisfatória, principalmente por parte dos indígenas Aruá. O Projeto Rondon contribuiu significativamente para o crescimento pessoal e para o futuro profissional de todos os participantes, proporcionando o desenvolvimento da capacidade crítico-reflexiva de cada indivíduo.

Objective: Although hypertensive older adults require physical activity, their ability to leave the house may be limited. This study’s primary objective was to determine the effect of live-streamed tele-exercise (LSTE) on the sleep quality of hypertensive older women. Methods: This randomized controlled clinical trial included hypertensive older women aged 60 to 79 years who were receiving drug treatment, had not been diagnosed with sleep disorders, and were not taking sedatives or hypnotics. They were evaluated with the Timed Up and Go test, the 4.6 m walk test, the Pittsburgh Sleep Quality Index, and actigraphy. They were randomly assigned to a control or an LSTE group and were reassessed after 10 weeks. The LSTE group performed at least 30 exercise sessions consisting of live-streamed online sessions held twice a week and one recorded session, while the control group was monitored through a message group. Results: The mean participant age was 69.7 (SD 4.9) years. Timed Up and Go results were lower in the LSTE group (p = 0.046), and Pittsburgh Sleep Quality Index scores were reduced in both groups. According to the actigraphy results, sleep time increased in the LSTE group (from 372.4 [SD 92.7] to 428.7 [SD 67.4] min, p = 0.044) and sleep efficiency reached a value of > 85%. Conclusions: In hypertensive older women, a 10-week low-to-moderate intensity LSTE program resulted in increased total sleep time.

An Explainable Artificial Intelligence algorithm is used to generate explanations of the decisions of Machine Learning models trained to classify the severity of Obstructive Sleep Apnea based on Heart Rate Variability. First, a Random Forest classifier is used for Obstructive Sleep Apnea severity prediction and then the Local Rule-based Explanations method is applied to provide decisions interpretability. The method employs Genetic Algorithms to generate artificial examples, which are then used to train decision trees that approximate the local behavior of the black-box model. This approach enables the extraction of human-readable rules that explain individual predictions, offering valuable insights into the decision-making process of black-box models such as Random Forests. By identifying the most influential features and decision rules, our approach aims to aid medical professionals in understanding how Heart Rate Variability correlates with Obstructive Sleep Apnea severity and enhances trust in Machine Learning-driven diagnostic tools.

Benzodiazepine (BZD) receptor agonists, commonly known as Z-drugs, are non-BZD hypnotics primarily prescribed for the treatment of insomnia. Their use is recommended for no longer than four weeks to minimize the risk of adverse effects, including dependence and withdrawal. However, these guidelines are frequently disregarded, and the abuse of and dependence on Z-drugs has emerged as a growing public health concern in Brazil. The present article reviews the current evidence on Z-drug use disorder—including dependence and withdrawal—and proposes clinical guidelines for the management of discontinuation. The recommendations were developed based on a systematic review of the literature and refined using the Delphi methodology. The consensus was developed by a multidisciplinary task force, with coordination and voting led by a steering committee. An advisory committee, consisting of neurologists from the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, ABN, in Portuguese) and psychiatrists specializing in substance-use disorders, contributed to the selection and organization of the scientific literature and took part in the voting process. Key recommendations were established: 1) prior to discontinuation, a comprehensive assessment of mental status, psychiatric and sleep comorbidities, and the degree of pharmacological dependence is essential; 2) gradual tapering is advised; 3) non-pharmacological interventions, such as cognitive behavioral therapy for insomnia, are recommended, and acceptance and commitment therapy, which is optional, may be incorporated; 4) for zolpidem withdrawal, adjunctive pharmacotherapy, which is optional, may include trazodone, other antidepressants, quetiapine or other antipsychotics, alpha-2-delta (α2δ) ligands, or alternative hypnotics (such as ramelteon, zopiclone, and eszopiclone); 5) for Z-drug discontinuation, intermediate- or long-acting BZDs are recommended; and 6) short- or ultra-short-acting BZDs and immediate-release melatonin are not recommended.

In cases of dementia or major neurocognitive disorder, restless legs syndrome has not been extensively studied because the diagnosis relies on clinical assessments and self-reports from patients. Objective: The aim of this study was to investigate the association between Willis-Ekbom disease/restless legs syndrome and iron-deficiency anemia in older adults with dementia. Methods: A cross-sectional study was conducted with 70 older adults diagnosed with dementia and restless legs syndrome at a psychogeriatric clinic in the state of São Paulo, Brazil. The participants answered data collection instruments addressing sociodemographic characteristics, restless legs syndrome, neuropsychiatric symptoms, sleep quality, daytime sleepiness, and cognitive function. Creatinine, ferritin, red blood cells, hemoglobin, and hematocrit were determined by blood exams (the latter of which was collected from the patient records). Results: The sample was composed predominantly of individuals with mixed dementia (i.e., Alzheimer's disease+vascular dementia). Women accounted for 55.7% of the sample, with a mean age of 77.80±9.36 years. The prevalence of restless legs syndrome among the participants was found to be 15.7%. Individuals with this syndrome had greater frequencies of neuropsychiatric symptoms, poor sleep quality, higher BMI, and lower ferritin levels (p<0.05). Conclusion: The prevalence of restless legs syndrome among older adults with dementia was 15.7%, and individuals with this syndrome had ferritin deficiency.

Purpose Recent evidences pointed out that the prevalence of comorbidity of restless legs syndrome/Willis-Ekbom disease (RLS/WED) and obstructive sleep apnea (OSA) is around 20%. Nonetheless its association factors have not been extensively evaluated after the recent modification in diagnostic criteria. We aimed to estimate the prevalence of RLS/WED and its association factors with OSA in an adult sample. Methods This was a prospective, cross-sectional study including 490 adult patients with OSA diagnosis (apnea–hypopnea index ≥ 5 obstructive events/hour associated to clinical picture). RLS/WED diagnosis was established by the 2014 International Restless Legs Syndrome Study Group (IRLSSG) criteria established by face-to-face interview with a neurologist. Results The prevalence of RLS/WED was 18.6% (n = 91) and its diagnosis was previously established in 13.2% (n = 12/91). The mean IRLSSG severity score was 17.0 (standard deviation 6.8). RLS/WED was associated with female sex, chronic insomnia symptoms, greater anxiety, and depression severity scores, and with mild obstructive sleep apnea severity. On the other hand, severe obstructive sleep apnea was negatively associated to RLS/WED. Conclusions Despite being relatively prevalent among patients with OSA, RLS/WED is previously underrecognized in our sample. RLS/WED severity correlated with higher scores on anxiety and depression scales. Chronic insomnia symptoms were the main RLS/WED association factor.

REM sleep behavior disorder (RBD) is characterized by a loss of atonia of skeletal muscles during REM sleep, associated with acting out behaviors during dreams. Knowledge of this pathology is important to predict neurodegenerative diseases since there is a strong association of RBD with diseases caused by the deposition of alpha-synuclein in neurons (synucleinopathies), such as Parkinson's disease (PD), multiple system atrophy (MSA), and dementia with Lewy bodies (DLB). Proper diagnosis of this condition will enable the use of future neuroprotective strategies before motor and cognitive symptoms. Diagnostic assessment should begin with a detailed clinical history with the patient and bed partner or roommate and the examination of any recorded home videos. Polysomnography (PSG) is necessary to verify the loss of sleep atonia and, when documented, the behaviors during sleep. Technical recommendations for PSG acquisition and analysis are defined in the AASM Manual for the scoring of sleep and associated events, and the PSG report should describe the percentage of REM sleep epochs that meet the criteria for RWA (REM without atonia) to better distinguish patients with and without RBD. Additionally, PSG helps rule out conditions that may mimic RBD, such as obstructive sleep apnea, non-REM sleep parasomnias, nocturnal epileptic seizures, periodic limb movements, and psychiatric disorders. Treatment of RBD involves guidance on protecting the environment and avoiding injuries to the patient and bed partner/roommate. Use of medications are also reviewed in the article. The development of neuroprotective medications will be crucial for future RBD therapy.

Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P – Patient, problem, or population; I – Intervention; C – Comparison, control, or comparator; O – Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.