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Background Hospitalizations are common among patients with idiopathic pulmonary fibrosis (IPF). We investigated the impact of hospitalizations on outcomes in patients with IPF. Methods The IPF-PRO Registry is an observational US registry that enrolled patients with IPF that was diagnosed or confirmed at the enrolling center in the previous 6 months. Associations between patient characteristics and hospitalization, and between hospitalization and mortality, were analyzed using Cox regression models. Results A total of 1002 patients with IPF were enrolled into the IPF-PRO Registry. Over a median follow-up time of 23.7 months (maximum: 67.0 months), 568 patients (56.7%) had at least one hospitalization. Of these patients, 319 (56.2%) had at least one respiratory-related hospitalization and 120 (21.1%) had at least one hospitalization with ventilatory support. Younger age (HR 0.68 [95% CI 0.55, 0.84] per 5-year increase for patients Conclusions Data from the IPF-PRO Registry demonstrate that hospitalizations are common among patients with IPF. The risk of mortality during hospitalization or within 90 days of discharge was high, particularly among patients who were hospitalized for a respiratory cause or received ventilatory support. Trial registration ClinicalTrials.gov, NCT01915511. Registered 5 August 2013, https://clinicaltrials.gov/ct2/show/NCT01915511

STUDY OBJECTIVES: The purpose of this study was to determine sleep quality and presence of sleep disorders in participants with spinal cord injury (SCI). METHODS: A web-based survey, available online from February 2011 to July 2013, using validated sleep questionnaires, advertised via the internet and locally through SCI consumer organizations in the United States, Australia, New Zealand, and Canada, was designed to evaluate sleep in adults with self-reported SCI. Demographic characteristics and medical history were obtained from participant self-report. RESULTS: In our study population, 70% of the 304 participants were male with a mean age of 45 ± 13 years. The mean duration of injury was 16 ± 12 years. Cervical injuries were reported by 49% and thoracic injuries noted in 40% of participants. Increased sleep apnea risk was noted in 31% of participants, with 66% reporting snoring. Insomnia symptoms were reported by 54% of the respondents. Almost 40% of participants ranked their sleep quality as “fairly bad” to “very bad” in the previous month, 29% reported “often” or “almost always” waking up because of pain, and 22% had difficulty falling asleep because of leg cramps. In the past year, 27% of the respondents reported daily uncomfortable leg sensations and 28% found these leg symptoms to be “moderately to extremely distressing.” CONCLUSIONS: This study increases the awareness that insomnia, sleep apnea, and poor sleep quality are common in individuals with chronic SCI; often coexisting. There is a need for increased screening for sleep problems by healthcare providers taking care of individuals living with SCI. CITATION: Shafazand S, Anderson KD, Nash MS. Sleep complaints and sleep quality in spinal cord injury: a web-based survey. J Clin Sleep Med. 2019;15(5):719–724.

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3-4-year recurring cycle of topics. These topics will be presented at the 2020 Virtual Conference. Below is the adult sleep medicine core that includes topics pertinent to sleep-disordered breathing and insomnia.

Rationale Two antifibrotic medications, nintedanib and pirfenidone, have been approved for the treatment of idiopathic pulmonary fibrosis (IPF) in the US. Few data have been published on the use of these medications in clinical practice. Objective To investigate patterns of use of antifibrotic medications in the US. Methods The IPF-PRO Registry, a multicenter US registry, has enrolled patients with IPF that was diagnosed or confirmed at the enrolling center in the past 6 months. Data from patients enrolled from 5 June 2014 to 4 March 2018 were used to determine antifibrotic medication use ("treatment") in the enrollment window and a follow-up window approximately 6 months later. Associations between patient characteristics and treatment status were tested using logistic regression. Results Overall, 551 of 782 eligible patients (70.5%) were treated in the enrollment window. Younger age, lower FVC % predicted, oxygen use with activity, worse self-rated health based on the Short Form-12 (SF-12) or St George's Respiratory Questionnaire score, referral to the enrolling center by a pulmonologist, use of lung biopsy in diagnosis, and carrying a diagnosis of IPF to the enrolling center were associated with being treated. Among 534 patients treated at enrollment who had follow-up data, 94.0% remained treated in follow-up. Better self-rated health based on the SF-12 mental component score or EuroQoL score, and not using oxygen with activity at enrollment, were associated with continuing treatment in follow-up. Among 172 patients who were untreated at enrollment and had follow-up data, 29.7% started treatment in follow-up. Lower DLco % predicted, a family history of ILD, a history of sleep apnea, and a definite diagnosis of IPF at enrollment were associated with starting treatment in follow-up. Conclusions The majority of patients in the IPF-PRO Registry were receiving an approved medication for IPF at enrollment. Treatment at enrollment was associated with greater disease severity, more compromised quality of life and the use of oxygen with activity. Clinical trial registered with ClinicalTrials.gov (NCT01915511).

There is limited information on the association between pre-treatment insomnia symptoms and dysfunctional sleep beliefs with continuous positive airway pressure (CPAP) adherence in veterans with obstructive sleep apnea (OSA). Our aims were to describe demographic and sleep characteristics of veterans with and without comorbid insomnia and determine whether pre-treatment insomnia symptoms and dysfunctional sleep beliefs predict CPAP use after 6 months of therapy. Hispanic veterans attending the Miami VA sleep clinic were recruited and completed the insomnia severity index, the dysfunctional sleep belief and attitude scale (DBAS), and other questionnaires. Participants were asked to return after 7 days and 1 and 6 months to repeat questionnaires and for objective CPAP adherence download. Hierarchical regression models were performed to determine adjusted associations of pre-treatment insomnia symptoms and DBAS sub-scores on 6-month mean daily CPAP use. Fifty-three participants completed the 6-month follow-up visit with a mean CPAP use of 3.4 ± 1.9 h. Veterans with comorbid insomnia had lower mean daily CPAP use (168 ± 125 vs 237 ± 108 min, p = 0.04) and lower percent daily CPAP use ≥ 4 h (32 ± 32 vs 51 ± 32%, p = 0.05) compared to participants without insomnia. In adjusted analyses, pre-treatment insomnia symptoms (early, late, and aggregated nocturnal symptoms) and sleep dissatisfaction were predictive of lower CPAP use at 6 months. Pre-treatment dysfunctional sleep beliefs were not associated with CPAP adherence. Pre-treatment nocturnal insomnia symptoms and sleep dissatisfaction predicted poorer 6- month CPAP use. Insomnia treatment preceding or concurrent with CPAP initiation may eliminate a barrier to regular use.

First Place Award Submission - CA147Category: Clinical ApplicationManagement of obesity after spinal cord injury: a systematic reviewMir Hatef Shojaei1, Mohammad Alavinia1, B. Catharine Craven1,21N...

Background Despite Food and Drug Administration approval of 2 new drugs for idiopathic pulmonary fibrosis (IPF), curative therapies remain elusive and mortality remains high. Preclinical and clinical data support the safety of human mesenchymal stem cells as a potential novel therapy for this fatal condition. The Allogeneic Human Cells (hMSC) in patients with Idiopathic Pulmonary Fibrosis via Intravenous Delivery (AETHER) trial was the first study designed to evaluate the safety of a single infusion of bone marrow–derived mesenchymal stem cells in patients with idiopathic pulmonary fibrosis. Methods Nine patients with mild to moderate IPF were sequentially assigned to 1 of 3 cohorts and dosed with a single IV infusion of 20, 100, or 200 × 10 6 human bone marrow–derived mesenchymal stem cells per infusion from young, unrelated, men. All baseline patient data were reviewed by a multidisciplinary study team to ensure accurate diagnosis. The primary end point was the incidence (at week 4 postinfusion) of treatment-emergent serious adverse events, defined as the composite of death, nonfatal pulmonary embolism, stroke, hospitalization for worsening dyspnea, and clinically significant laboratory test abnormalities. Safety was assessed until week 60 and additionally 28 days thereafter. Secondary efficacy end points were exploratory and measured disease progression. Results No treatment-emergent serious adverse events were reported. Two nontreatment-related deaths occurred because of progression of IPF (disease worsening and/or acute exacerbation). By 60 weeks postinfusion, there was a 3.0% mean decline in % predicted FVC and 5.4% mean decline in % predicted diffusing capacity of the lungs for carbon monoxide. Conclusions Data from this trial support the safety of a single infusion of human mesenchymal stem cells in patients with mild-moderate IPF. Trial Registry ClinicalTrials.gov; No.: NCT02013700; URL: www.clinicaltrials.gov.

Sleep disorders are prevalent in Parkinson's disease but underreported in clinical settings. The contribution of sleep disorders to health-related quality of life (HRQOL) for patients with this degenerative neurological disease are not well known.To evaluate the impact of insomnia symptoms, obstructive sleep apnea (OSA), and poor sleep quality on HRQOL in a cohort of patients with idiopathic Parkinson's disease.We enrolled a convenience sample of 66 adults seen in the University of Miami Movement Disorders Clinic between July 2011 and June 2013. Participants completed validated questionnaires to determine insomnia symptoms, OSA risk, depression, anxiety, and HRQOL. All patients underwent unattended polysomnography to confirm OSA. Results were compared for those with and without insomnia symptoms. Principal component and regression analyses were performed to evaluate determinants of HRQOL.Participants were predominately Hispanic males with mild to moderate Parkinson's disease. Insomnia symptoms were reported for 46% of the study subjects. OSA (apnea-hypopnea index, ≥5) was noted in 47%, with a mean apnea-hypopnea index of 8.3 ± 11.0. Fairly bad to very bad sleep quality was reported by 21% of the participants. Insomnia (r = 0.71; P 0.001), daytime sleepiness (r = 0.36; P = 0.003), depression symptoms (r = 0.44; P 0.001), and anxiety symptoms (r = 0.33; P = 0.006) were significant correlates of poor sleep quality. OSA, severity of Parkinson's disease, and dopaminergic therapy were not. In the principal component analysis, sleep quality was a significant component of the "psychological factor" that in turn was a significant determinant of overall HRQOL.Insomnia symptoms, OSA, and subsequent poor sleep quality are prevalent in Parkinson's disease. In this single-center, exploratory study, we found that insomnia and poor sleep quality, but not OSA, play important roles in determining overall quality of life for patients with this disease. Clinical trial registered with www.clinicaltrials.gov (NCT02034357).

Introduction While sleep disturbances and depression often co-occur, these associations are understudied among Hispanics/Latinos. We examined the associations of sleep disturbances and sleep burden with depressive symptoms among Hispanic/Latino adults in the United States. Methods We used cross-sectional data from the Hispanic Community Health Study/Study of Latinos Sueño Ancillary study (2010-2013). The study enrolled 2072 adults (ages 18-64; 51.5% females) who completed one-week wrist-actigraphy and sleep questionnaires. Sleep burden was operationalized as the total count of sleep disturbances across six domains (duration, efficiency, midpoint, variability, insomnia, sleepiness). Depressive symptoms were assessed using the Center for Epidemiological Studies Depression scale (CESD-10). We used weighted survey linear regressions to evaluate the association of sleep disturbances and sleep burden with elevated depressive symptoms (CESD≥10) in individual models adjusted for age, gender, site, heritage, nativity, education, income, and employment. Sensitivity analyses further adjusted for behavioral health risk factors and apnea-hypopnea index. Results An estimated 28.3% had elevated depressive symptoms, 8.0% had short sleep duration (9 hours), 45.2% exhibited a later sleep midpoint (≥4:00AM), 38.4% had high sleep timing variability (upper third tertile for between day sleep midpoint), 15.3% had insomnia (ISI≥10), 17.3% had excessive daytime sleepiness (ESS ≥10), 21.5% had poor sleep efficiency ( Conclusion Multiple inter-related sleep disturbances, particularly those pertaining to sleep quality and timing, are associated with depression and may be targets for future interventions aimed at improving mood among Hispanics/Latinos. Support HL127307, HL098927, HL125748

Sarcoidosis commonly affects the lung. Lung transplantation (LT) is required when there is a severe and refractory involvement. We compared post-transplant survival rates of sarcoidosis patients with chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF). We also explored whether the race and age of the donor, and double lung transplant have any effect on the survival in the post transplant setting. We analyzed 9,727 adult patients with sarcoidosis, COPD, and IPF who underwent LT worldwide between 2005–2015 based on United Network for Organ Sharing (UNOS) database. Survival rates were compared with Kaplan-Meier, and risk factors were investigated by Cox-regression analysis. 469 (5%) were transplanted because of sarcoidosis, 3,688 (38%) for COPD and 5,570 (57%) for IPF. Unadjusted survival analysis showed a better post-transplant survival rate for patients with sarcoidosis (p

Obstructive sleep apnea (OSA) is a chronic and heterogeneous disorder that leads to early mortality, stroke, and cardiovascular disease (CVD). OSA is defined by the apnea-hypopnea index, which is an index of OSA severity that combines apneas (pauses in breathing) and hypopneas (partial obstructions in breathing) associated with hypoxemia. Yet, other sleep metrics (i.e., oxygen nadir, arousal frequency), along with clinical symptoms and molecular markers could be better predictors of stroke and CVD outcomes in OSA. The recent focus on personalized medical care introduces the possibility of a unique approach to the treatment of OSA based on its phenotypes, defined by pathophysiological mechanisms and/or clinical presentation. We summarized what is known about OSA and its phenotypes, and review the literature on factors or intermediate markers that could increase stroke risk and CVD in patients with OSA. The OSA phenotypes where divided across three different domains (1) clinical symptoms (i.e., daytime sleepiness), (2) genetic/molecular markers, and (3) experimental data-driven approach (e.g., cluster analysis). Finally, we further highlight gaps in the literature framing a research agenda.

BackgroundObstructive sleep apnoea (OSA) is highly prevalent in people with spinal cord injury (SCI). Polysomnography (PSG) is the gold-standard diagnostic test for OSA, however PSG is expensive and frequently inaccessible, especially in SCI. A two-stage model, incorporating a questionnaire followed by oximetry, has been found to accurately detect moderate to severe OSA (MS-OSA) in a non-disabled primary care population. This study investigated the accuracy of the two-stage model in chronic tetraplegia using both the original model and a modified version for tetraplegia.MethodsAn existing data set of 78 people with tetraplegia was used to modify the original two-stage model. Multivariable analysis identified significant risk factors for inclusion in a new tetraplegia-specific questionnaire. Receiver operating characteristic (ROC) curve analyses of the questionnaires and oximetry established thresholds for diagnosing MS-OSA. The accuracy of both models in diagnosing MS-OSA was prospectively evaluated in 100 participants with chronic tetraplegia across four international SCI units.ResultsInjury completeness, sleepiness, self-reported snoring and apnoeas were included in the modified questionnaire, which was highly predictive of MS-OSA (ROC area under the curve 0.87 (95% CI 0.79 to 0.95)). The 3% oxygen desaturation index was also highly predictive (0.93 (0.87–0.98)). The two-stage model with modified questionnaire had a sensitivity and specificity of 83% (66–93) and 88% (75–94) in the development group, and 77% (65–87) and 81% (68–90) in the validation group. Similar results were demonstrated with the original model.ConclusionImplementation of this simple alternative to full PSG could substantially increase the detection of OSA in patients with tetraplegia and improve access to treatments.Trial registration numberResults, ACTRN12615000896572 (The Australian and New Zealand Clinical Trials Registry) and pre-results, NCT02176928 (clinicaltrials.gov).

Background Sirolimus (SIR) has been shown to stabilize the lung function in lung transplant recipients with bronchiolitis obliterans syndrome (BOS). However, there is no long-term data on the prophylactic use of SIR in lung transplant recipients. This retrospective study examines the effects of SIR in the prevention of BOS. Methods From 1999 to 2009, 24 lung transplant recipients whose maintenance immunosuppression regimen consisted of tacrolimus (Tac), mycophenolate mofetil (MMF) or azathioprine (AZA), and prednisone (Pred), were switched to Tac, SIR, and Pred at 1 year after transplantation. From these 24 patients, 5 developed side effects that necessitated the cessation of SIR within 1 year, while 19 patients tolerated long-term use of SIR. The clinical outcomes of these 19 patients (SIR group) were compared with 22 lung transplant recipients whose immunosupression regimen consisted of Tac, MMF or AZA, and Pred from the time of transplant (MMF group). Survival rates and freedom from BOS were calculated by the Kaplan-Meier method. Results The SIR group had a lower incidence of BOS and viral infection ( p = 0.05), and higher survival rates ( p = 0.004). The SIR group had lower levels of Tac and received less Pred. The incidences of acute rejection, carcinoma, hypertension, and diabetes were similar between both groups. Conclusions Results from this study suggest that conversion to SIR 1 year after lung transplantation improves survival and decreases the development of BOS. Randomized studies with higher number of patients are needed to determine the prophylactic efficacy of sirolimus in preventing the development of BOS.

There are little existing data on continuous positive airway pressure (CPAP) adherence in US Hispanic veterans with obstructive sleep apnea (OSA). Our aim was to describe determinants of 1-month adherence in a sleep clinic cohort of South Florida Hispanic veterans. Hispanic veterans referred to the Miami VA sleep clinic were recruited and completed questionnaires about sleep apnea risk, sleep quality, insomnia symptoms, sleepiness, depression/anxiety, acculturation, personality traits, and cognitions about OSA and CPAP. Individuals at risk for OSA were scheduled for baseline polysomnography (PSG), followed by in-lab CPAP titration or a trial of auto-CPAP. Participants with OSA accepting CPAP therapy were asked to return after 7 and 30 days of treatment for adherence verification and to repeat questionnaires. One hundred twenty-four participants (94 % men) were enrolled with 114 completing overnight PSG. Eighty-six out of 95 participants (91 %) with sleep apnea syndrome or moderate to severe OSA accepted CPAP treatment. Fifty-nine participants completed both follow-up visits with a mean CPAP use at 30 days of 3.6 ± 2.0 h. The only independent predictor of 7-day mean daily CPAP use was the baseline Insomnia Severity Index while the best predictor of 30-day mean daily CPAP use was the 7-day mean daily use. Our study suggests that South Florida Hispanic veterans with OSA evaluated in a sleep clinic show poor CPAP adherence. Insomnia and poor early use predicted poor adherence overall. Larger prospective studies with other race–ethnic groups are needed to determine the role of ethnicity and race in CPAP adherence among US veterans with OSA.

Study Objectives:To compare health-related quality of life (HR-QOL) across subgroups defined by sleep disturbances and ethnicity.Methods:Men (47%) and women (53%) Sleep Heart Health Study participa...

Obstructive sleep apnea (OSA) is associated with increased risks of cardiovascular disease and stroke and with elevated rates of postoperative complications (including cardiac ischemia and respiratory failure) in surgical patients. Additionally, the prevalence of OSA is higher in surgical patients than in the general population. Screening for OSA prior to surgery is recommended to identify patients at risk for postoperative complications. The presence of moderate or severe OSA calls for modified strategies of perioperative anesthesia, pain management, and postoperative monitoring to reduce the chance of OSA-associated complications.

Background This section of the guidelines is intended to provide an evidence-based approach to the preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer. Methods Current guidelines and medical literature applicable to this issue were identified by computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee. Results The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV 1 . If diffuse parenchymal lung disease is evident on radiographic studies or if there is dyspnea on exertion that is clinically out of proportion to the FEV 1 , the diffusing capacity of the lung for carbon monoxide (D lco ) should also be measured. In patients with either an FEV 1 or D lco 1 or D lco o 2 max) should be performed to further define the perioperative risk of surgery; a V˙ o 2 max of o 2 max of o 2 max of 1 of > 20% predicted, and a D lco of > 20% predicted. Conclusions A careful preoperative physiologic assessment will be useful to identify those patients who are at increased risk with standard lung cancer resection and to enable an informed decision by the patient about the appropriate therapeutic approach to treating their lung cancer. This preoperative risk assessment must be placed in the context that surgery for early-stage lung cancer is the most effective currently available treatment for this disease.

Introduction Estimating the clinical probability of mediastinal metastasis in patients with non-small cell lung cancer (NSCLC) can facilitate the selection and interpretation of staging tests. Purpose We sought to identify independent clinical predictors of mediastinal metastasis and to develop a prediction rule to estimate the pretest probability of nodal metastasis in patients with NSCLC. Methods We used data from a randomized controlled trial of selective versus routine mediastinoscopy to develop a clinical prediction model. Results Five hundred sixty-six patients were included, with a mean age of 65 ± 9 years; 31% had positive lymph nodes. Independent predictors of positive nodes included adenocarcinoma or large cell histology (OR 2.6, 95% confidence interval [CI] = 1.8–3.9), apparent metastatic disease on chest radiography (OR 2.4, 95% CI=1.2–4.7), central location of the primary tumor (OR 2.1, 95% CI=1.4–3.3), symptoms from the primary tumor (OR 1.6, 95% CI=1.1–2.4), tumor diameter ≥3.6 cm (OR 1.5, 95% CI=1.0–2.3), and age less than 65 years (OR 1.5, 95% CI=1.0–2.2). Model accuracy and calibration were good, with an area under the receiver operating characteristic curve of 0.70 (95% CI=0.66–0.75) and good agreement between observed and predicted probabilities of mediastinal metastasis. Conclusions Our prediction rule can be used to estimate the pretest probability of mediastinal metastasis in patients with NSCLC. Such estimates can facilitate clinical decision making when selecting and interpreting the results of noninvasive and invasive staging tests.

Study objectives: Patients with pulmonary arterial hypertension (PAH) often present with dyspnea and severe functional limitations, but their health-related quality of life (HRQOL) has not been studied extensively. This study describes HRQOL in a cohort of patients with PAH. Design: Cross-sectional study. Setting: A tertiary care, university hospital-based, pulmonary hypertension (PH) clinic. Participants: We studied HRQOL in 53 patients with PAH (mean age, 47 years; median duration of disease, 559 days). Eighty-three percent were women, 53% received epoprostenol, and 72% reported moderate-to-severe functional limitations with a New York Heart Association class 3 or 4 at enrollment. Measurements and results: We examined HRQOL by administering the Nottingham Health Profile, Congestive Heart Failure Questionnaire, and Hospital Anxiety and Depression Scale. We used the Visual Analog Scale and standard gamble (SG) techniques to measure preferences for current health (utilities). Compared with population norms, participants reported moderate-to-severe impairment in multiple domains of HRQOL, including physical mobility, emotional reaction, pain, energy, sleep, and social isolation. Mean SG utilities were 0.71, suggesting that, on average, participants were willing to accept a 29% risk of death in order to be cured of PH. Conclusions: PAH is a devastating condition that affects predominately young women in the prime of their life. Understanding HRQOL and preferences are important in the care and management of these patients. Compared with population norms, patients with PAH have substantial functional and emotional limitations that adversely affect their HRQOL.

Sepsis is a common cause of morbidity and death in critically ill patients, and blood culture samples are often drawn in an effort to identify a responsible pathogen. Blood culture results are usually negative, however, and even when positive are sometimes difficult to interpret. Distinguishing between true bacteremia and a false-positive blood culture result is important, but complicated by a variety of factors in the ICU. False-positive culture results are costly because they often prompt more diagnostic testing and more antibiotic prescriptions, and increase hospital length of stay. A number of factors influence the yield of blood cultures in critically ill patients, including the use of antibiotics, the volume of blood drawn, the frequency with which culture samples are drawn, and the site from which the culture samples are taken. Skin preparation techniques, handling of the cultures in the microbiology laboratory, and the type of blood culture system employed also influence blood culture yield. Attempts to identify predictors of true bacteremia in critically ill patients have been disappointing. In this review, we discuss factors that influence blood culture yield in critically ill patients, suggest ways to improve yield, and discuss true bacteremia vs false-positive blood culture results. We also discuss the costs and consequences of false-positive blood culture results, and list noninfectious causes of fever in the ICU.

Source Citation Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for obstructive sleep apnea in adults: US Preventive Services Task Force recommendation statement. JAMA. 2017;317:407-14. ...

Anthrax, a disease of great historical interest, is once again making headlines as an agent of biological warfare. Bacillus anthracis, a rod-shaped, spore-forming bacterium, primarily infects herbivores. Humans can acquire anthrax by agricultural or industrial exposure to infected animals or animal products. More recently, the potential for intentional release of anthrax spores in the environment has caused much concern. The common clinical manifestations of anthrax are cutaneous disease, pulmonary disease from inhalation of anthrax spores, and GI disease. The course of inhalational anthrax is dramatic, from the insidious onset of nonspecific influenza-like symptoms to severe dyspnea, hypotension, and hemorrhage within days of exposure. A rapid decline, culminating in septic shock, respiratory distress, and death within 24 h is not uncommon. The high mortality seen in inhalational anthrax is in part due to delays in diagnosis. Classic findings on the chest radiograph include widening of the mediastinum as well as pleural effusions. Pneumonia is less common; key pathologic manifestations include severe hemorrhagic mediastinitis, diffuse hemorrhagic lymphadenitis, and edema. Diagnosis requires a high index of suspicion. Treatment involves supportive care in an intensive care facility and high doses of penicillin. Resistance to third-generation cephalosporins has been noted. Vaccines are currently available and have been shown to be effective against aerosolized exposure in animal studies.

Poor adherence undermines the effectiveness of positive airway pressure (PAP) therapy for sleep apnea. Disparities exist in PAP adherence by race/ethnicity and neighborhood socioeconomic status (SES), but the etiology of these differences is poorly understood. We investigated whether home environmental factors contribute to PAP adherence and whether identified factors explain disparities in adherence by SES.Adult patients with sleep apnea were surveyed at clinic visits about their sleep environment. Medical records were abstracted for demographic data, sleep apnea severity, comorbidities, and objective PAP adherence. We evaluated the association between aspects of home sleep environment with PAP adherence using multivariate linear and logistic regression, and assessed effect modification by SES factors.Participants (n = 119) were diverse, with 44% nonwhite and 35% uninsured/Medicaid. After adjusting for age, sex, race/ethnicity, insurance, neighborhood SES, education, and marital status, participants who endorsed changing sleeping location once per month or more (18%, n = 21) had 77% lower odds of meeting PAP adherence criteria (4 h/night for 70% of nights) and less PAP use (median -11 d/mo, 95% confidence intervals -15.3, -6.5). Frequency of sleeping location change was the only environmental factor surveyed associated with PAP adherence.Frequent change in sleeping location is associated with reduced PAP adherence, independent of sociodemographic factors. This novel finding has implications for physician-patient dialogue. PAP portability considerations in device selection and design may modify adherence and potentially improve treatment outcomes. Prospective investigation is needed to confirm this finding and inform design of possible interventions.

Is continuous positive airway pressure (CPAP) therapy better than no therapy in reducing the incidence of hypertension or cardiovascular (CV) events in a cohort of nonsleepy patients with obstructive sleep apnea (OSA)?Randomized, controlled trial; no placebo CPAP used. ClinicalTrials.gov Identifier: NCT00127348.Randomization was performed using a computer generated list of random numbers in the coordinating center and results were mailed to participating centers in numbered opaque envelopes.Primary outcome was evaluated by individuals not involved in the study and who were blinded to patient allocation. Patients, investigators, and the statistician were not blinded.median 4 (interquartile range, 2.7-4.4) years.14 academic medical centers in Spain.725 adults (mean age 51.8 y, 14% women) who were diagnosed with OSA with apnea hypopnea index (AHI) ≥ 20 events per hour and Epworth sleepiness score (ESS) ≤ 10 were randomized. Subjects with previous CV events were excluded. However, patients with a history of hypertension were not excluded (50% of the sample were hypertensive at baseline).Patients were randomized to receive CPAP treatment or no active intervention. All participants received dietary counseling and advice about sleep hygiene.The primary outcome was the incidence of either systemic hypertension (among participants who were normotensive at baseline) or CV events (among all participants). The secondary outcome was the association between the incidence of hypertension or CV events (nonfatal myocardial infarction, nonfatal stroke, transient ischemic attack, hospitalization for unstable angina or arrhythmia, heart failure, and CV death) and the severity of OSA assessed by the AHI and oxygen saturation. The sample size was calculated assuming that the incidence of hypertension or new CV event in this population over a period of 3 years would be 10% annually; 345 patients per group were needed to detect a 60% reduction in incidence of new hypertension or CV events (90% power, 2-sided α = 0.05, assuming 10% study dropout).83% complete (only patients who received the allocated intervention were included in analysis of primary outcome).A total of 147 patients with new hypertension and 59 cardiovascular events were identified (Table). In the CPAP group, there were 68 patients with incident hypertension and 28 CV events. Of the 357 participants in the CPAP group, 127 used CPAP4 hours/night (36%). In the control group, there were 79 patients with new hypertension and 31 CV events. There was no statistically significant difference between the groups in the primary outcome. TableRisk for incident hypertension or cardiovascular eventIn adults with moderate to severe OSA and no symptoms of daytime sleepiness, CPAP therapy did not reduce incident hypertension or CV event compared with no active therapy.Instituto de Salud Carlos III (PI 04/0165) (Fondo de Investigaciones Sanitarios, Ministerio de Sanidad y Consumo, Spain), Spanish Respiratory Society (SEPAR) (Barcelona), Resmed (Bella Vista, Australia), Air Products-Carburos Metalicos (Barcelona), Respironics (Murrysville, Pennsylvania), and Breas Medical (Madrid, Spain).

There is a paucity of information on the epidemiology of sleep disorders among US Hispanics. This study describes the frequency of sleep disordered breathing (SDB) risk, insomnia complaints, poor sleep quality, and daytime somnolence in a clinical cohort of ethnically diverse US Hispanics living in South Florida.We explored the presence of sleep disorders in a cohort of Hispanics seen at primary care, pulmonary, and sleep clinics at the University of Miami and Miami Veterans Affair Medical Center. Participants completed validated questionnaires, evaluating risk of SDB, presence of insomnia symptoms, sleep quality, and daytime sleepiness. Polysomnography was completed on the majority of the sleep clinic participants.Participants (N = 282; 62% male; mean age 54 ± 15 years; mean BMI 31 ± 6 kg/m(2)) included Hispanics of Cuban, Puerto Rican, Central/South American, and Caribbean heritage. Excessive daytime sleepiness was noted by 45% of participants. Poor sleep quality was reported by 49%; 76% screened high risk for SDB, and 68% had insomnia symptoms. Sleep disorders were more commonly reported in sleep clinic participants; however, 54% of non-sleep clinic participants were high risk for SDB, 35% had insomnia complaints, 28% had poor sleep quality, and 18% reported daytime sleepiness.Sleep disorders (including SDB) are common in clinical samples of Hispanics in South Florida. These findings highlight the urgent need for linguistically relevant and culturally responsive screening, awareness and education programs in clinical sleep medicine among US Hispanics.Shafazand S; Wallace DM; Vargas SS; Del Toro Y; Dib S; Abreu AR; Ramos A; Nolan B; Baldwin CM; Fleming L. Sleep disordered breathing, insomnia symptoms, and sleep quality in a clinical cohort of US Hispanics in South Florida. J Clin Sleep Med 2012;8(5):507-514.

Background and Purpose Sleep-related falling out of bed (SFOB), with its potential for significant injury, has not been a strong focus of investigation in Parkinson's disease (PD) to date. We describe the demographic and clinical characteristics of PD patients with and without SFOB. Methods We performed a retrospective analysis of 50 consecutive PD patients, who completed an REM sleep behavior disorder screening questionnaire (RBDSQ), questionnaires to assess for RBD clinical mimickers and questions about SFOB and resulting injuries. Determination of high risk for RBD was based on an RBDSQ score of 5 or greater. Results Thirteen patients reported history of SFOB (26%). Visual hallucinations, sleep-related injury, quetiapine and amantadine use were more common in those patients reporting SFOB. Twenty-two patients (44%) fulfilled criteria for high risk for RBD, 12 of which (55%) reported SFOB. Five patients reported injuries related to SFOB. SFOB patients had higher RBDSQ scores than non-SFOB patients (8.2±3.0 vs. 3.3±2.0, p

Background There is limited data on chronic insomnia in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, in whom post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) often co-exist. Our aim was to compare sleep characteristics of three groups of OEF/OIF veterans: (1) healthy sleepers (HS), (2) those with insomnia associated with PTSD and mTBI (PTSD–mTBI), and (3) those with insomnia associated with PTSD alone. Methods Consecutive veterans with insomnia complaints (>6 months) were recruited over 6 months from the Miami VA Post Deployment clinic. Participants completed a sleep disorders clinical interview, medical history, and questionnaires about insomnia, sleepiness, pain, fatigue, depression, PTSD, and health-related quality of life. They underwent polysomnography (PSG) with 2 weeks of actigraphy (ACT) and sleep diaries. Results There were no differences in demographics or most questionnaire responses between PTSD and PTSD–mTBI groups. Subjective daytime sleepiness was significantly greater in PTSD–mTBI subjects compared with HS and PTSD participants. Significant co-morbid sleep disorders were noted in insomnia patients. PSG and ACT wake after sleep onset was significantly shorter in PTSD–mTBI subjects as compared with PTSD participants. Conclusion Insomnia patients with PTSD–mTBI were subjectively sleepier despite spending less time awake during the night than PTSD subjects, possibly as a consequence of head trauma.

Bacillus anthracis is one of a limited number of biological agents capable of causing death and disease in sufficient numbers to devastate an urban setting. In October 2001, reports of American patients with inhalational anthrax reacquainted the public with this ancient disease and introduced the harsh reality of a bioterrorist act. Cutaneous disease, gastrointestinal anthrax and inhalational disease are the known clinical manifestations of anthrax. Inhalational anthrax has an untreated mortality of nearly 100% and is the primary cause of death for an exposed and unprotected population. Vaccination affords a high degree of primary prevention and multiple effective antibiotics exist for both disease prevention and treatment. In this article, we will discuss the costs and effectiveness of prevention strategies, diagnosis, and therapy of bioterrorism related anthrax.

The current American College of Cardiology/American Heart Association (ACC/AHA) clinical guidelines for heart failure (HF), published September 20, 2005, provide a summary of the best evidence for treatment, but these recommendations are not always reflected in clinical practice.The aims of this study were to compare 6-month prescribing habits in the United States before and after the publication of updated clinical guidelines for the evaluation and management of HF and the impact of these prescribing habits on health care resource use.This retrospective, observational cohort analysis used the Humana nationwide health insurance administrative claims database that includes -3.5 million covered members from all 50 states and Puerto Rico who are enrolled in a health maintenance organization, a preferred provider organization, or a Medicare plan. The data included demographics (age, sex, type of insurance, and geographic location), medical information with up to 9 diagnostic codes per encounter, codes for procedures and medical equipment, laboratory tests, and pharmacy-dispensed medications. HF medication prescriptions and health care utilization were evaluated for 2 cohorts: those identified from claims before guideline publication (January 1, 2005-June 30, 2005) and those identified from claims after publication (October 1, 2006-March 31, 2007). Patients were eligible if they were aged ≥45 years, had 12 months of continuous enrollment (6 months before and 6 months after the index date, defined as the date of diagnosis or hospitalization for HF), and had ≥1 claim for HF. The primary outcome was the proportion of patients who received prescriptions for HF medications individually or in combination. Secondary outcomes were adherence to medication, all-cause and HF-specific hospitalizations, and emergency department and outpatient physician visits.The mean (SD) age in the before-publication cohort (n = 29,784) was 75 (11) years; in the after-publication cohort (n = 33,598), it was 74 (11) years (P0.001). Half of all patients in each cohort were female (50% [n = 14,796 and n = 16,803, respectively]); 9% (n = 2539) of the before-publication cohort and 7% (n = 2283) of the after-publication cohort were classified as having moderate to severe HF based on the baseline number of hospitalizations (P0.001). Fewer patients in the before-publication cohort received angiotensin-converting enzyme inhibitors (43% [12,811/29,784] vs 44% [14,776/33,598]; P = 0.01), β-blockers (37% [10,901/29,784] vs 41% [13,639/33,598]; P0.01), angiotensin receptor blockers (10% [3008/29,784] vs 13% [4378/33,598]; P0.01), or hydralazine (3% [865/29,784] vs 4% [1378/33,598]; P0.01). Among those with moderate to severe HF, there were no significant differences between groups in the use of combination therapy (ie, β-blockers with any combination of isosorbide dinitrate, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or hydralazine; all combinations, P = NS between cohorts), except for less use of a β-blocker with either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker among the before-publication cohort (23% [595/2539] vs38% [875/2283]; P = 0.005). Therewere significantly fewer all-cause and HF-related outpatient visits, all-cause and HF-related hospitalizations, and all-cause and HF-related emergency department visits in the after-publication cohort (all, P0.001); however, the absolute differences in the proportions of patients in each cohort who required such services were relatively small.Based on this analysis of real-world prescribing patterns, only small differences in prescribing practices were found before and after the 2005 publication of the ACC/AHA guidelines for HF treatment. Health care utilization was slightly, but significantly, reduced after publication of the guidelines.

Publisher Summary Studies of sleep in women, whether in health or disease, are affected by the distinct hormonal changes that occur throughout a woman's life cycle, including puberty, menses, pregnancy, and menopause. Differences exist not only between the sexes but within cohorts of women as they transition through these biologically determined milestones. Additionally, socioeconomic status, workplace, and familial roles influence observed gender differences. In the NSF 2007 poll, 30% of pregnant women and 42% of post-partum women reported rarely or never getting a good night's sleep, compared to 15% among all women; 25% of perimenopausal women and 30% of postmenopausal women reported getting a good night's sleep only a few nights a month or less. Not surprisingly, given their social and/or familial responsibilities, working mothers (72%) and single working women (68%) were more likely to experience sleep problems like insomnia. These sleep disturbances are not without consequences; in the NSF survey, women who experienced daytime sleepiness were more likely to report high stress (80%), drive drowsy at least once per month (27%), spend less time with friends and family (39%), be too tired for sex (33%), and be late for work (20%). Recently, studies recognize that men and women experience sleep and sleep disorders differently. They differ in the prevalence of certain sleep disorders and may have varying presentations and responses to therapies. This chapter serves to both review the existing literature on gender differences in sleep and highlight the considerable gaps in knowledge.

Source Citation Drager LF, Brunoni AR, Jenner R, et al. Effects of CPAP on body weight in patients with obstructive sleep apnoea: a meta-analysis of randomised trials. Thorax. 2014 Nov 28. [Epub ah...

The environmental mandate to eliminate the production of ozone-depleting products including chlorofluorocarbon (CFC) propellants has encouraged much needed research into improving modes of delivery of inhaled corticosteroids and enhancing drug deposition. Consequently, flunisolide CFC, an inhaled corticosteroid with a proven track record in the treatment of asthma, has been reformulated using a hydrofluoroalkane (HFA) as a propellant and is now awaiting FDA approval. Flunisolide HFA is a solution aerosol, unlike flunisolide CFC which is a suspension aerosol. As a solution aerosol, flunisolide HFA has a smaller mean particle size than flunisolide CFC. In addition, the built-in spacer included in the flunisolide HFA inhaler acts to reduce ex-actuator particle size; the smaller particle size of flunisolide HFA results in an improved deposition profile. Flunisolide HFA has substantially more lung deposition and much less oropharyngeal deposition than flunisolide CFC. Limited information is currently available on the clinical performance of flunisolide HFA. A single dose-response study has been performed in adults and in children comparing multiple doses of flunisolide HFA and flunisolide CFC. These studies indicate that flunisolide HFA is effective in controlling asthma. No unusual safety concerns have been noted, although further studies are needed to determine the long-term systemic effects of flunisolide HFA.

Gastroparesis is a serious complication of lung and heart-lung transplantation that can lead to malnutrition, gastroesophageal reflux, aspiration pneumonia and deteriorating lung function. Some patients with severe gastroparesis have symptoms that are refractory to dietary modifications and gastric promotility agents and require surgery. We describe the successful use of gastric pacing for the management of intractable gastroparesis, malnutrition and recurrent aspiration in a heart-lung allograft recipient. Lung transplant recipients with severe gastroparesis may benefit from gastric pacing.

Hypnosedative-induced complex behaviors have gained increased attention in recent years as a potential complication of benzodiazepines and benzodiazepine-receptor agonist use. Sodium oxybate (SO), the sodium salt of γ-hydroxybutyrate, an inhibitory neurotransmitter, has been associated with dose-dependent rates of somnambulism; however, there is limited information about complex motor behaviors with SO. We describe a patient with narcolepsy-cataplexy who experienced one episode of sleep-driving and at least two sleep-related eating episodes with therapeutic doses of SO.