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Tavares CDAM, de Azevedo LCP, Rea-Neto Á, Campos NS, Amendola CP, Bergo RR, Kozesinski-Nakatani AC, David-João PG, Westphal GA, Guimarães Júnior MRR, Lobo SMA, Tavares MS, Dracoulakis MDA, de Souza GM, de Almeida GMB, Gebara OCE, Tomba PO, Albuquerque CSN, Silva MCR, Pereira AJ, Damiani LP, Corrêa TD, Serpa-Neto A, Berwanger O, Zampieri FG. Dapagliflozin in patients with critical illness: rationale and design of the DEFENDER study. Crit Care Sci 2023; 35:256-265. [PMID: 38133155 PMCID: PMC10734800 DOI: 10.5935/2965-2774.20230129-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Critical illness is a major ongoing health care burden worldwide and is associated with high mortality rates. Sodium-glucose cotransporter-2 inhibitors have consistently shown benefits in cardiovascular and renal outcomes. The effects of sodium-glucose cotransporter-2 inhibitors in acute illness have not been properly investigated. METHODS DEFENDER is an investigator-initiated, multicenter, randomized, open-label trial designed to evaluate the efficacy and safety of dapagliflozin in 500 adult participants with acute organ dysfunction who are hospitalized in the intensive care unit. Eligible participants will be randomized 1:1 to receive dapagliflozin 10mg plus standard of care for up to 14 days or standard of care alone. The primary outcome is a hierarchical composite of hospital mortality, initiation of kidney replacement therapy, and intensive care unit length of stay, up to 28 days. Safety will be strictly monitored throughout the study. CONCLUSION DEFENDER is the first study designed to investigate the use of a sodium-glucose cotransporter-2 inhibitor in general intensive care unit patients with acute organ dysfunction. It will provide relevant information on the use of drugs of this promising class in critically ill patients. CLINICALTRIALS.GOV REGISTRY NCT05558098.
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Affiliation(s)
| | | | - Álvaro Rea-Neto
- Centro de Estudos e de Pesquisas em Terapia Intensiva - Curitiba
(PR), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein - São Paulo (SP),
Brazil
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2
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da Silva BC, Cordioli RL, dos Santos BFC, Guerra JCDC, Rodrigues RDR, de Souza GM, Ashihara C, Midega TD, Campos NS, Carneiro BV, Campos FND, Guimarães HP, de Matos GFJ, de Aranda VF, Ferraz LJR, Corrêa TD. COVID-19-associated coagulopathy and acute kidney injury in critically ill patients. Einstein (Sao Paulo) 2023; 21:eAO0119. [PMID: 37729353 PMCID: PMC10501765 DOI: 10.31744/einstein_journal/2023ao0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 02/07/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVE The incidence of thrombotic events and acute kidney injury is high in critically ill patients with COVID-19. We aimed to evaluate and compare the coagulation profiles of patients with COVID-19 developing acute kidney injury versus those who did not, during their intensive care unit stay. METHODS Conventional coagulation and platelet function tests, fibrinolysis, endogenous inhibitors of coagulation tests, and rotational thromboelastometry were conducted on days 0, 1, 3, 7, and 14 following intensive care unit admission. RESULTS Out of 30 patients included, 13 (43.4%) met the criteria for acute kidney injury. Comparing both groups, patients with acute kidney injury were older: 73 (60-84) versus 54 (47-64) years, p=0.027, and had a lower baseline glomerular filtration rate: 70 (51-81) versus 93 (83-106) mL/min/1.73m2, p=0.004. On day 1, D-dimer and fibrinogen levels were elevated but similar between groups: 1780 (1319-5517) versus 1794 (726-2324) ng/mL, p=0.145 and 608 (550-700) versus 642 (469-722) g/dL, p=0.95, respectively. Rotational thromboelastometry data were also similar between groups. However, antithrombin activity and protein C levels were lower in patients who developed acute kidney injury: 82 (75-92) versus 98 (90-116), p=0.028 and 70 (52-82) versus 88 (78-101) µ/mL, p=0.038, respectively. Mean protein C levels were lower in the group with acute kidney injury across multiple time points during their stay in the intensive care unit. CONCLUSION Critically ill patients experiencing acute kidney injury exhibited lower endogenous anticoagulant levels. Further studies are needed to understand the role of natural anticoagulants in the pathophysiology of acute kidney injury within this population.
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Affiliation(s)
- Bruno Caldin da Silva
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Ricardo Luiz Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | - Roseny dos Reis Rodrigues
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Guilherme Martins de Souza
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Carolina Ashihara
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Thais Dias Midega
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Niklas Söderberg Campos
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Bárbara Vieira Carneiro
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Flávia Nunes Dias Campos
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Hélio Penna Guimarães
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Valdir Fernandes de Aranda
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Leonardo José Rolim Ferraz
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Thiago Domingos Corrêa
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Hohmann FB, Chaves RCDF, Olivato GB, de Souza GM, Galindo VB, Silva Jr M, Martino MDV, de Menezes FG, Corrêa TD. Characteristics, risk factors, and outcomes of bloodstream Candida infections in the intensive care unit: a retrospective cohort study. J Int Med Res 2023; 51:3000605221131122. [PMID: 36659829 PMCID: PMC9893083 DOI: 10.1177/03000605221131122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE The main objective was to assess the clinical characteristics, associated factors, and outcomes of patients admitted to the ICU for candidemia. The secondary objective was to examine the relationship of candidemia with the length of stay and mortality. METHODS The analysis was a retrospective single-center cohort study addressing the effect of invasive candidemia on outcomes. This study was performed in a medical-surgical ICU located in a tertiary private hospital in São Paulo, Brazil. Data was collected through the review of the hospital database. RESULTS In total, 18,442 patients were included in our study, including 22 patients with candidemia. The median age was similar in patients with and without candidemia [67 (56-84) vs. 67 (51-80)]. Most patients were male, and the proportion of men was higher among patients with candidemia (77% vs. 55.3%). The rates of renal replacement therapy (40.9% vs. 3.3%), mechanical ventilation (63.6% vs. 29.6%), and parenteral nutrition (40.9% vs. 4.8%) were higher in patients with candidemia than in those without candidemia. The mortality rate (77.3% vs. 11.9%) and length of hospital stay [42 days (23.0-78.8) vs. 8 days (5.0-17.0)] were significantly higher in patients with candidemia. CONCLUSIONS Patients with candidemia are prone to longer hospital stay and mortality. In addition, we found associations of candidemia with the use of invasive mechanical ventilation, renal replacement therapy, and parenteral nutrition.
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Affiliation(s)
- Fábio Barlem Hohmann
- Department of Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil,Fábio Barlem Hohmann, Intensive Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, 5th floor, São Paulo, Brazil, ZIP CODE: 05651-901.
| | - Renato Carneiro de Freitas Chaves
- Department of Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil,Department of Anesthesiology, Hospital Israelita Albert Einstein, São Paulo, Brazil,Takaoka Anestesia, São Paulo, Brazil
| | | | | | | | - Moacyr Silva Jr
- Department of Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil,Department of Hospital Infection Control Service, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Fernando Gatti de Menezes
- Department of Hospital Infection Control Service, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Thiago Domingos Corrêa
- Department of Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Campos PPZDA, Souza GMD, Midega T, Guimarães HP, Corrêa TD, Cordioli RL. A nationwide survey on health resources and clinical practices during the early COVID-19 pandemic in Brazil. Rev Bras Ter Intensiva 2022; 34:107-115. [PMID: 35766660 DOI: 10.5935/0103-507x.20220005-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/02/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate clinical practices and hospital resource organization during the early COVID-19 pandemic in Brazil. METHODS This was a multicenter, cross-sectional survey. An electronic questionnaire was provided to emergency department and intensive care unit physicians attending COVID-19 patients. The survey comprised four domains: characteristics of the participants, clinical practices, COVID-19 treatment protocols and hospital resource organization. RESULTS Between May and June 2020, 284 participants [median (interquartile ranges) age 39 (33 - 47) years, 56.3% men] responded to the survey; 33% were intensivists, and 9% were emergency medicine specialists. Half of the respondents worked in public hospitals. Noninvasive ventilation (89% versus 73%; p = 0.001) and highflow nasal cannula (49% versus 32%; p = 0.005) were reported to be more commonly available in private hospitals than in public hospitals. Mechanical ventilation was more commonly used in public hospitals than private hospitals (70% versus 50%; p = 0,024). In the Emergency Departments, positive endexpiratory pressure was most commonly adjusted according to SpO2, while in the intensive care units, positive end-expiratory pressure was adjusted according to the best lung compliance. In the Emergency Departments, 25% of the respondents did not know how to set positive end-expiratory pressure. Compared to private hospitals, public hospitals had a lower availability of protocols for personal protection equipment during tracheal intubation (82% versus 94%; p = 0.005), managing mechanical ventilation [64% versus 75%; p = 0.006] and weaning patients from mechanical ventilation [34% versus 54%; p = 0.002]. Finally, patients spent less time in the emergency department before being transferred to the intensive care unit in private hospitals than in public hospitals [2 (1 - 3) versus 5 (2 - 24) hours; p < 0.001]. CONCLUSION This survey revealed significant heterogeneity in the organization of hospital resources, clinical practices and treatments among physicians during the early COVID-19 pandemic in Brazil.
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Affiliation(s)
| | | | - Thais Midega
- Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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5
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Campos PPZDA, de Souza GM, Midega T, Guimarães HP, Corrêa TD, Cordioli RL. A nationwide survey on health resources and clinical practices during the early COVID-19 pandemic in Brazil. Rev Bras Ter Intensiva 2022. [PMID: 35766660 PMCID: PMC9345584 DOI: 10.5935/0103-507x.20220005-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: To evaluate clinical practices and hospital resource organization during the early COVID-19 pandemic in Brazil. Methods: This was a multicenter, cross-sectional survey. An electronic questionnaire was provided to emergency department and intensive care unit physicians attending COVID-19 patients. The survey comprised four domains: characteristics of the participants, clinical practices, COVID-19 treatment protocols and hospital resource organization. Results: Between May and June 2020, 284 participants [median (interquartile ranges) age 39 (33 - 47) years, 56.3% men] responded to the survey; 33% were intensivists, and 9% were emergency medicine specialists. Half of the respondents worked in public hospitals. Noninvasive ventilation (89% versus 73%; p = 0.001) and highflow nasal cannula (49% versus 32%; p = 0.005) were reported to be more commonly available in private hospitals than in public hospitals. Mechanical ventilation was more commonly used in public hospitals than private hospitals (70% versus 50%; p = 0,024). In the Emergency Departments, positive endexpiratory pressure was most commonly adjusted according to SpO2, while in the intensive care units, positive end-expiratory pressure was adjusted according to the best lung compliance. In the Emergency Departments, 25% of the respondents did not know how to set positive end-expiratory pressure. Compared to private hospitals, public hospitals had a lower availability of protocols for personal protection equipment during tracheal intubation (82% versus 94%; p = 0.005), managing mechanical ventilation [64% versus 75%; p = 0.006] and weaning patients from mechanical ventilation [34% versus 54%; p = 0.002]. Finally, patients spent less time in the emergency department before being transferred to the intensive care unit in private hospitals than in public hospitals [2 (1 - 3) versus 5 (2 - 24) hours; p < 0.001]. Conclusion: This survey revealed significant heterogeneity in the organization of hospital resources, clinical practices and treatments among physicians during the early COVID-19 pandemic in Brazil.
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Affiliation(s)
| | | | - Thais Midega
- Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
| | | | | | - Ricardo Luiz Cordioli
- Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
- Corresponding author: Ricardo Cordioli Hospital Israelita Albert Einstein Av. Albert Einstein, 627 - Morumbi Zip code: 05652-900 - São Paulo (SP), Brazil E-mail:
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Campos PPZDA, Souza GMD, Midega T, Guimarães HP, Corrêa TD, Cordioli RL. A nationwide survey on health resources and clinical practices during the early COVID-19 pandemic in Brazil. Rev Bras Ter Intensiva 2022. [DOI: 10.5935/0103-507x.20220005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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7
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Corrêa TD, Cordioli RL, Campos Guerra JC, Caldin da Silva B, dos Reis Rodrigues R, de Souza GM, Midega TD, Campos NS, Carneiro BV, Campos FND, Guimarães HP, de Matos GFJ, de Aranda VF, Rolim Ferraz LJ. Coagulation profile of COVID-19 patients admitted to the ICU: An exploratory study. PLoS One 2020; 15:e0243604. [PMID: 33320874 PMCID: PMC7737963 DOI: 10.1371/journal.pone.0243604] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 11/20/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Coagulation abnormalities in COVID-19 patients have not been addressed in depth. OBJECTIVE To perform a longitudinal evaluation of coagulation profile of patients admitted to the ICU with COVID-19. METHODS Conventional coagulation tests, rotational thromboelastometry (ROTEM), platelet function, fibrinolysis, antithrombin, protein C and S were measured at days 0, 1, 3, 7 and 14. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10. RESULTS Thirty patients were studied. Some conventional coagulation tests, as aPTT, PT and INR remained unchanged during the study period, while alterations on others coagulation laboratory tests were detected. Fibrinogen levels were increased in both groups. ROTEM maximum clot firmness increased in both groups from Day 0 to Day 14. Moreover, ROTEM-FIBTEM maximum clot firmness was high in both groups, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Also, D-dimer plasma levels were higher than normal reference range in both groups and free protein S plasma levels were low in both groups at baseline and increased over time, Finally, patients in group SOFA > 10 had lower plasminogen levels and Protein C than patients with SOFA <10, which may represent less fibrinolysis activity during a state of hypercoagulability. CONCLUSION COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was not only detected by ROTEM but it much more complex, where changes were observed on the fibrinolytic and endogenous anticoagulation system.
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Affiliation(s)
- Thiago Domingos Corrêa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ricardo Luiz Cordioli
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Bruno Caldin da Silva
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Thais Dias Midega
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Hélio Penna Guimarães
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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de Souza GM, Vianna FSL, Midega TD, Serpa Neto A. Probability of benefit with the use of neuromuscular blockade in patients with acute respiratory distress syndrome. J Thorac Dis 2019; 11:3676-3680. [PMID: 31656637 DOI: 10.21037/jtd.2019.09.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Thais Dias Midega
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.,Pulmonary Division, Cardio-Pulmonary Department, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
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Gronner MF, Bosi PL, Carvalho AM, Casale G, Contrera D, Pereira MA, Diogo TM, Torquato MTCG, Souza GMD, Oishi J, Leal AMO. Prevalence of metabolic syndrome and its association with educational inequalities among Brazilian adults: a population-based study. Braz J Med Biol Res 2011; 44:713-9. [PMID: 21755260 DOI: 10.1590/s0100-879x2011007500087] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 06/14/2011] [Indexed: 11/22/2022] Open
Abstract
The present study estimated the prevalence of metabolic syndrome (MS) according to the criteria established by the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII) and the International Diabetes Federation (IDF) and analyzed the contribution of social factors in an adult urban population in the Southeastern region of Brazil. The sample plan was based on multistage probability sampling according to family head income and educational level. A random sample of 1116 subjects aged 30 to 79 years was studied. Participants answered a questionnaire about socio-demographic variables and medical history. Fasting capillary glucose (FCG), total cholesterol, high-density lipoprotein cholesterol (HDL-C), and triglycerides were determined and all non-diabetic subjects were submitted to the 75-g oral glucose tolerance test. Body mass index (BMI, kg/m(2)), waist circumference and blood pressure (BP) were determined. Age- and gender-adjusted prevalence of MS was 35.9 and 43.2% according to NCEP-ATPIII and IDF criteria, respectively. Substantial agreement was found between NCEP-ATPIII and IDF definitions. Low HDL-C levels and high BP were the most prevalent MS components according to NCEP-ATPIII criteria (76.3 and 59.2%, respectively). Considering the diagnostic criteria adopted, 13.5% of the subjects had diabetes and 9.7% had FCG ≥100 mg/dL. MS prevalence was significantly associated with age, skin color, BMI, and educational level. This cross-sectional population-based study in the Southeastern region of Brazil indicates that MS is highly prevalent and associated with an important social indicator, i.e., educational level. This result suggests that in developing countries health policy planning to reduce the risk of MS, in particular, should consider improvement in education.
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Affiliation(s)
- M F Gronner
- Departamento de Medicina, Universidade Federal de São Carlos, SP, Brasil
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