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Background and Purpose: Although most strokes present with mild symptoms, these have been poorly represented in clinical trials. The objective of this study is to describe multidimensional outcomes, identify predictors of worse outcomes, and explore the effect of thrombolysis in this population. Methods: This prospective observational study included patients with ischemic stroke or transient ischemic attack, a baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 5, presenting within 4.5 hours from symptom onset. The primary outcome was a 90-day modified Rankin Scale score of 0 to 1; secondary outcomes included good outcomes in the Barthel Index, Stroke Impact Scale-16, and European Quality of Life. Multivariable models were created to determine predictors of outcomes and the effect of alteplase. Results: A total of 1765 participants were included from 100 Get With The Guidelines-Stroke participating hospitals (age, 65±14; 42% women; final diagnosis of ischemic stroke, 90%; transient ischemic attack, 10%; 57% received alteplase). At 90 days, 37% were disabled and 25% not independent. Worse outcomes were noted for older individuals, women, non-Hispanic Blacks and Hispanics, Medicaid recipients, smokers, those with diabetes, atrial fibrillation, prior stroke, higher baseline NIHSS, visual field defects, and extremity weakness. Similar outcomes were noted for the alteplase-treated and untreated groups. Alteplase-treated patients were younger (64±13 versus 67±1.4) with higher NIHSS (2.9±1.4 versus 1.7±1.4). After adjusting for age, sex, race/ethnicity, and baseline NIHSS, we did not identify an effect of alteplase on the primary outcome but did find an association with Stroke Impact Scale-16 in the restricted sample of baseline NIHSS score 3–5. Few symptomatic intracerebral hemorrhages were recorded ( Conclusions: A large proportion of stroke patients presenting with low NIHSS have a disabled outcome. Baseline predictors of worse outcomes are described. An effect of alteplase on outcomes was not identified in the overall cohort, but a suggestion of efficacy was noted in the NIHSS 3–5 subgroup. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02072681.

To explore the relationship of embolic particle size used in prostate artery embolisation (PAE) to patient outcomes.A systematic review of PubMed, EMBASE, and the Cochrane database was undertaken to identify all existing studies using PAE for benign prostatic hyperplasia (BPH). Inclusion criteria included prospective studies reporting baseline and 12-month International Prostate Symptom Score (IPSS) and particle size. Exclusion criteria were overlapping studies, commentaries, abstracts, and letters. Data extraction from eligible studies included the size of embolic particle, particle material, and baseline and 12-month values for the following patient outcomes: IPSS, IPSS quality of life, urinary flow rate (Q-max), prostate volume, prostate specific antigen, and post-void residual volume. A meta-regression analysis was then undertaken to examine the relationship of particle size to patient outcome measures.Six studies with a total of 687 patients were identified. Meta-regression analysis demonstrated particle size as a statistically significant (p0.001) moderator of 12-month IPSS change following PAE. No statistically significant relationships were identified with other patient outcome measures.Smaller embolic particle size is associated with a greater reduction in IPSS following PAE.

Background and Purpose: Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized. Methods: A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0–5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines–Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes. Results: Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations. Conclusions: Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT 02072681.

STUDY OBJECTIVES: Incorporating registered nurses (RN-level) into obstructive sleep apnea (OSA) management decisions has the potential to augment the workforce and improve patient access, but the appropriateness of such task-shifting in typical practice is unclear. METHODS: Our medical center piloted a nurse triage program for sleep medicine referrals. Using a sleep specialist-designed decision-making tool, nurses triaged patients referred for initial sleep studies to either home sleep apnea test (HSAT) or in-laboratory polysomnography (PSG). During the first 5 months of the program, specialists reviewed all nurse triages. We compared agreement between specialists and nurses. RESULTS: Of 280 consultations triaged by nurses, nurses deferred management decisions to sleep specialists in 6.1% (n = 17) of cases. Of the remaining 263 cases, there was 88% agreement between nurses and specialists (kappa 0.80, 95% confidence interval 0.74–0.87). In the 8.8% (n = 23) of cases where supervising specialists changed sleep study type, specialists changed from HSAT to PSG in 16 cases and from PSG to HSAT in 7. The most common indication for change in sleep study type was disagreement regarding OSA pretest probability (n = 14 of 23). Specialists changed test instructions in 3.0% (n = 8) of cases, with changes either related to the use of transcutaneous carbon dioxide monitoring (n = 4) or adaptive servo-ventilation (n = 4). CONCLUSIONS: More than 80% of sleep study triages by registered nurses in a supervised setting required no sleep specialist intervention. Future research should focus on how to integrate nurses into the sleep medicine workforce in a manner that maximizes efficiency while preserving or improving patient outcomes. CITATION: Donovan LM, Fernandes LA, Williams KM, et al. Agreement of sleep specialists with registered nurses’ sleep study orders in supervised clinical practice. J Clin Sleep Med. 2020;16(2):279–283.

Background Heavy workload in hospital transfusion services and blood centers necessitates the implementation of automated platforms. We evaluated the performance of Erytra Eflexis (Diagnostic Grifols), a recently developed midsize automated instrument for pretransfusion testing, in comparison with a US Food and Drug Administration (FDA)-cleared device (Erytra). Reproducibility and repeatability of the results were also investigated. Study design and methods Studies were conducted using the same card technology and reagents at three US sites. Tests were performed on 9174 specimens from hospital patients (55.61%) and blood donors (43.39%). Evaluations included 18,413 ABO/D/reverse typing; 9084 Rh phenotypes, 4640 K phenotypes, 2052 antibody screenings, 1232 antibody identifications, 469 direct antiglobulin tests, 612 IgG crossmatches, and 700 ABO-compatibility crossmatches. A reference blood panel was also sent to each center, for a total of 3900 replicate tests. Concordance between results with the two instruments and performance among the different centers were statistically evaluated. Results Agreement between instruments was 99.84% for 37,202 test results, with 61 discrepancies (0.16%). Percentages of positive and negative agreement were 99.82% and 99.85%, respectively. No discrepancies were observed in 12,276 tests for direct ABO/D grouping. Discrepancies were observed during antibody identification (n = 19), antibody screening (n = 15), and reverse grouping (n = 10). Investigations of the discrepancies were resolved in favor of the study instrument in 55.73% of the cases. Erytra Eflexis obtained the expected results in the reproducibility analysis. Conclusion This multicenter study demonstrates that Erytra Eflexis with its gel card technology and reagents is reliable and substantially equivalent to the FDA-cleared instrument used as the reference.

Sleep VA-ECHO (Veterans Affairs–Extension for Community Healthcare Outcomes) is a national telementorship program intended to improve knowledge about sleep disorders among non-specialty providers. The project goal was to describe the characteristics of Sleep VA-ECHO participants from primary care and their use of program-obtained knowledge in practice. Sleep VA-ECHO consisted of 10 voluntary, 75-min teleconference sessions combining didactics and case discussion. Out of 86 participants, 21 self-identified as primary care team members and completed a program evaluation. Participants self-reported their application of knowledge gained, including changes to practice as a result of program participation. These 21 participants represented 18 sites in 11 states and attended a median of 5.0 sessions. They included physicians (29%), nurse practitioners (24%), and registered nurses (24%). Nearly all participants (95%) reported using acquired knowledge to care for their own patients at least once a month; 67% shared knowledge with colleagues at least once a month. Eighty-five percent reported improved quality of sleep care for their patients, and 76% reported an expanded clinical skillset. The greatest self-reported change in practice occurred in patient education about sleep disorders (95%) and non-pharmacologic management of insomnia (81%).

Roy S Rubinfeld,1 Glenwood G Gum,2 Jonathan H Talamo,1,3 Edward C Parsons1 1CXL Ophthalmics, LLC, Encinitas, CA, USA; 2Absorption Systems California, LLC, San Diego, CA, USA; 3Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USACorrespondence: Roy S RubinfeldCXL Ophthalmics, LLC, 3131 Connecticut Avenue NW #2809, Washington DC, 20008, USATel +1 240 305-1010Email rsrubinfeld@gmail.comPurpose: To evaluate effects of sodium iodide (NaI) on riboflavin concentration in corneal stroma before and during ultraviolet A (UVA) light exposure using a novel transepithelial corneal collagen crosslinking (CXL) procedure (EpiSmart CXL system, CXL Ophthalmics, Encinitas CA).Methods: Riboflavin solutions with NaI (Ribostat, CXL Ophthalmics, Encinitas CA) and without NaI were used for CXL in rabbits using EpiSmart. A pilot study determined sufficient riboflavin loading time. Four rabbits were dosed and monitored. Riboflavin fluorescence intensity was assessed from masked slit-lamp photos. A 12 min loading time was selected. Sixteen additional rabbits received the two formulae in contralateral eyes for CXL. Riboflavin uptake was assessed at 0, 10, 15, 20, 25, and 30 min of UVA exposure using a scale for riboflavin fluorescence previously validated against stromal concentration. Post sacrifice, corneal stromal samples were analyzed for concentrations of riboflavin and riboflavin 5ʹ-phosphate.Results: Eyes dosed with NaI riboflavin had higher riboflavin grades compared to eyes dosed with the NaI-free riboflavin formulation immediately after riboflavin loading and persisting throughout UVA exposure, with significantly higher (P < 0.01 to < 0.05) riboflavin grades from 15 through 25 min of UVA exposure. Riboflavin grades decreased more slowly in eyes dosed with NaI riboflavin through 25 minutes of UVA exposure. Minor conjunctival irritation was noted with or without NaI.Conclusion: The addition of NaI to riboflavin solution is associated with increased riboflavin concentration in corneal stroma throughout a clinically relevant time course of UVA exposure. This effect may be a combination of enhanced epithelial penetration and reduced riboflavin photodegradation and should enhance intrastromal crosslinking.Keywords: corneal crosslinking, crosslinking, riboflavin, iodide, keratoconus, ectasia

STUDY OBJECTIVES: The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. The goal of this study was to assess patients’ experiences receiving sleep care by telehealth. METHODS: From June 2019 to May 2020, the authors recruited a sample of patients for semi-structured interviews, including patients who had 1 of 3 types of telehealth encounters in sleep medicine: in-clinic video, home-based video, and telephone. Two analysts coded transcripts using content analysis and identified themes that cut across patients and categories. RESULTS: The authors conducted interviews with 35 patients and identified 5 themes. (1) Improved access to care: Patients appreciated telehealth as providing access to sleep care in a timely and convenient manner. (2) Security and privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security due to avoidance of anxiety-provoking triggers (eg, crowds). Patients also noted a potential loss of privacy with telehealth. (3) Personalization of care: Patients described experiences with telehealth care that either improved or hindered their ability to communicate their needs. (4) Patient empowerment: Patients described how telehealth empowered them to manage their sleep disorders. (5) Unmet needs: Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services (eg, mask fitting). CONCLUSIONS: Patients expressed both positive and negative experiences, highlighting areas where telehealth can be further adapted. As telehealth in sleep medicine continues to evolve, the authors encourage providers to consider these aspects of the patient experience. CITATION: Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645–1651.

Understanding transmission of severe acute respiratory syndrome coronavirus 2 informs infection prevention practices. Air sampling devices were placed in patient hospital rooms for consecutive collections with and without masks. With patient mask use, no virus was detected in the room. High viral load and fewer days from symptom onset were associated with viral particulate dispersion.

Mazen M Sinjab,1,2 Roy S Rubinfeld,3,4 Kirsten Wagner,5,6 Edward C Parsons Jnr,7 Arthur B Cummings,8 Michael W Belin9 1Dr. Mazen Eye Clinic, Medcare Hospitals and Centres, Dubai, United Arab Emirates; 2Al Zahra Medical Group, Damascus, Syria; 3Department of Ophthalmology, Georgetown University Medical School/Washington Hospital Center, Washington, DC, USA; 4Re:Vision Private Practice, Rockville, MD, USA; 5Department of Ophthalmology, Medstar Georgetown University Hospital, Washington, DC, USA; 6Department of Ophthalmology, Medstar Washington Hospital Center, Washington, DC, USA; 7CXL Ophthalmics, Encinitas, CA, USA; 8Wellington Eye Clinic, Dublin, Ireland; 9Department of Ophthalmology, University of Arizona, Tucson, AZ, USACorrespondence: Roy S Rubinfeld 3131 Connecticut Ave, NW, #2809, Washington, DC, 20008, USAEmail Doctor@revisedeye.comPurpose: To assess the effectiveness of a novel treatment for patients with advanced corneal ectasia and loss of visual acuity (VA). Conductive keratoplasty (CK) is performed to improve VA followed by epithelium-on (epi-on) corneal crosslinking (CXL) to stabilize the cornea after CK.Methods: Retrospective, exploratory cohort study. Patients with keratoconus or postsurgical ectasia and best spectacle-corrected distance VA (CDVA) ≤ 20/40 were included. Conductive keratoplasty was performed (ViewPoint CK System, Refractec, Inc., Bloomington, MN); followed a day later by epi-on CXL (CXLUSA/CXLO, Bethesda, MD/CXLO Encinitas, CA). Measures included uncorrected distance visual acuity (UDVA) and CDVA, as well as refractive and tomographic measures and tomographic indices.Results: Data from 50 eyes of 45 patients were analyzed. Mean follow-up was 15.1 ± 12.2 months (range: 2 to 51). Overall, UDVA and CDVA improved postoperatively. Subjective refraction and tomographic metrics did not show consistent changes, but changes in tomographic indices were associated with treatment follow-up time. At the 1-year visit, mean UDVA significantly improved over baseline (P = 0.009) by approximately 3 lines; mean CDVA improved significantly (P = 10− 5) by approximately 2 lines. No eye lost lines of CDVA. Change in the Index of Surface Variance (ISV) was associated with treatment, and the D-Index trended over follow-up time.Conclusion: Conductive keratoplasty with a proprietary epi-on CXL treatment improved vision in patients with advanced ectasia This CK/epi-on CXL treatment offers the possibility of improved VA for patients with compromised vision due to ectasia.Keywords: conductive keratoplasty, CK, corneal crosslinking, crosslinking, keratoconus, ectasia, thermokeratoplasty

Introduction Initiating treatment with continuous positive airway pressure (CPAP) traditionally relies on in-person visits with trained therapists to provide hands-on instruction regarding CPAP usage and mask fit. To overcome geographic barriers and reduce COVID-19 transmission, health systems increasingly rely on remote set-ups of mailed equipment. Despite a strong rationale for the mailed approach, relative effectiveness is unclear. Methods Our VA medical center shifted from in-person to mailed CPAP dispensation during the COVID-19 pandemic in March 2020. Using VA administrative and wireless CPAP usage data, we assembled a cohort of patients with newly diagnosed obstructive sleep apnea (OSA) who initiated CPAP for the first time from July 2019 to August 2020. Our primary outcome was mean nightly usage over the first 90 days. We compared patients with in-person vs. mailed CPAP dispensation using generalized linear models adjusted for age, gender, race, and Charlson Comorbidity Index. Among patients with >1 hour of overall usage, we compared secondary outcomes of leak, apnea hypopnea index (AHI), and obstructive/central apnea indices. Results We identified 693 patients with newly diagnosed OSA whose CPAP was provided in-person and 296 who had CPAP mailed. Nightly usage in the first 90 days was modest in both groups (in-person: 149.7, mailed: 152.9 min/night), and we did not detect a difference in adjusted models (+7.6 min/night, 95%CI -13.6–28.8). We also did not detect a difference in 95th percentile leak (-1.2 liter/minute, 95%CI -3.3-0.9). Device-detected AHI was relatively low overall (in-person: 3.2, mailed: 4.1 events/hour), but was greater in the mailout group (+1.0/hour, 95%CI 0.2–1.7). AHI differences appeared to be driven by obstructive (+0.5/hour, 95%CI 0.2–0.8) but not central events (-0.1, 95% CI -0.2–0.4). Risk of AHI>5 was comparable between groups (in-person: 17.3%, mailed: 19.0%, OR 1.2, 95%CI 0.8–1.7). Conclusion We were able to switch from an in-person to a mail-based system of CPAP initiation without a change in CPAP adherence or mask leak. While AHI was slightly greater in the mailed group, the clinical significance of this finding is unclear. Future work will need to evaluate the impact of remote CPAP dispensation on patient-centered outcomes. Support (if any) VA Health Services Research and Development, CDA 18–187

Purpose Noninvasive ventilation (NIV) may improve survival and quality of life in Amyotrophic Lateral Sclerosis (ALS) patients. There is a surprising paucity of practical guidelines for office-based implementation and management of NIV outside of tertiary ALS centers. We saw the need for a clinical protocol to allow feasible and consistent NIV management in this patient population. Methods We created a clinical protocol for office-based initiation of NIV implemented on consecutive ALS patients referred from our regional ALS multidisciplinary clinic. The protocol provided initial empiric settings using a bilevel device in volume-assured pressure support mode. A respiratory therapist (RT) initiated NIV in an office setting and made adjustments according to patient tolerance and therapy targets outlined in the protocol. Later setting changes were performed at patient or provider request. We evaluated patient adherence and efficacy via device download at 30 days and 1 year. Results We present data from a case series of the first 14 consecutive patients initiated on NIV over a 20-month period. Our protocol underwent iterative modification based on clinical experience and patient feedback. Early challenges included the significant time and resource burden required to coordinate device downloads and patient follow-up. Early 30-day NIV adherence was variable (median 20 out of 30 days), while 1-year NIV adherence was excellent (median 27.5 out of 30 days). Conclusions Our RT-driven clinical NIV protocol was feasible but labor intensive. Achieving real-world adherence of NIV in our ALS patients required iterative protocol adjustment, significant RT provider time, and tele-based follow-up.

Background: Little is known about sleep and circadian rhythms in survivors of acute respiratory failure (ARF) after hospital discharge.Objectives: To examine sleep and rest-activity circadian rhythms in ARF survivors 3 months after hospital discharge, and to compare them with a community-dwelling population.Methods: Sleep diary, actigraphy data, and insomnia symptoms were collected in a pilot study of 14 ARF survivors. Rest-activity circadian rhythms were assessed with wrist actigraphy and sleep diary for 9 days, and were analyzed by cosinor and non-parametric circadian rhythm analysis.Results: All participants had remarkable actigraphic sleep fragmentation, 71.5% had subclinical or clinical insomnia symptoms. Compared to community-dwelling adults, this cohort had less stable rest-activity circadian rhythms (p < 0.001), and weaker circadian strength (p < 0.001).Conclusion: Insomnia and circadian disruption were common in ARF survivors. Sleep improvement and circadian rhythm regularity may be a promising approach to improve quality of life and daytime function after ARF.

We present a patient who experienced insufflation of air under the left eyelid when using continuous positive airway pressure (CPAP) via an oronasal mask. The patient had a lacrimal stent in place for many years, which was a predisposing factor for this complication. Lacrimal stents are frequently used in the treatment of epiphora (excessive tearing) secondary to obstruction of the lacrimal drainage system. In this case, we review the pathophysiology of air regurgitation into the eye with CPAP use and methods previously described to address this rare complication. We also present a novel intervention for this rare complication, the total face mask. By additionally covering the eyes, a total face mask allows equalization of pressure on both sides of the lacrimal system. With a total face mask, our patient was able to successfully use CPAP.

CITATIONPalen BN, He K, Redinger J, Parsons EC. A change of heart. J Clin Sleep Med. 2019;15(10):1543–1545.

Background People living with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD) suffer impaired quality of life due to burdensome symptoms and depression. The Advancing Symptom Alleviation with Palliative Treatment (ADAPT) trial aims to determine the effect of a multidisciplinary, team-based intervention on quality of life in people with these common diseases. Methods/design The ADAPT trial is a two-site, patient-level randomized clinical trial that examines the effectiveness of the ADAPT intervention compared to usual care on patient-reported quality of life at 6 months in veterans with CHF, COPD or ILD with poor quality of life and increased risk for hospitalization or death. The ADAPT intervention involves a multidisciplinary team—a registered nurse, social worker, palliative care specialist, and primary care provider (with access to a pulmonologist and cardiologist)—who meet weekly to make recommendations and write orders for consideration by participants’ individual primary care providers. The nurse and social worker interact with participants over six visits to identify and manage a primary bothersome symptom and complete a structured psychosocial intervention and advance care planning. The primary outcome is change in patient-reported quality of life at 6 months as measured by the Functional Assessment of Chronic Illness Therapy-General questionnaire. Secondary outcomes at 6 months include change in symptom distress, depression, anxiety, disease-specific quality of life hospitalizations, and advance care planning communication and documentation. Intervention implementation will be assessed using a mixed-methods approach including a qualitative assessment of participants’ and intervention personnel experiences and a quantitative assessment of care delivery, resources, and cost. Discussion The ADAPT trial studies an innovative intervention designed to improve quality of life for veterans with common, burdensome illnesses by targeting key underlying factors—symptoms and depression—that impair quality of life but persist despite disease-specific therapies. Leveraging the skills of affiliate health providers with physician supervision will extend the reach of palliative care and improve quality of life for those with advanced disease within routine outpatient care. The hybrid effectiveness/implementation design of the ADAPT trial will shorten the time to broader dissemination if effective and create avenues for future research. Trial registration ClinicalTrials.gov, NCT02713347. Registered March 19, 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3417-1) contains supplementary material, which is available to authorized users.

IntroductionThe COVID-19 pandemic has highlighted a need for engaging online resources to enrich psychiatry training for undergraduate medical students. Podcasting is a well-established digital communication platform utilised daily in a myriad of capacities, including education. A group of medical students were tasked with creating their own educational podcasts covering specific aspects of psychiatry.ObjectivesEach pair was set a sub-topic of psychiatry and utilised software to produce educational resources. The objective of this project was to reflect upon production as well as explore the efficacy of podcasting as a tool within undergraduate training.MethodsThe medical students conducted research and contacted experts within the field to contribute to their podcasts. The majority of the students then conducted reviews of the literature surrounding podcasting within medical education, which informed the production of their own podcasts. From this, it was discussed how this project could impact future practice, and indicated that podcasts may become crucial asynchronous learning tools in medical education.ResultsLiterature review and first-hand experience of podcast production enabled the students to appreciate the advantages of podcasting and the potential for its widespread future applications. Their wider reading revealed that podcast-using study participants outperformed or matched their peers in assessments, and overwhelmingly enjoyed using podcasts over traditional teaching methods.ConclusionsThe use of podcasting can complement traditional psychiatry training and appeal to a generation of digital natives that prefer this learning style. Podcast production is also an excellent revision method, highlighting the advantages of peer-to-peer education in both learning and increasing engagement with psychiatry.DisclosureNo significant relationships.

Primary care providers (PCPs) frequently encounter sleep complaints, especially in regions with limited specialty care access.The U.S. Department of Veterans Affairs Extension for Community Healthcare Outcomes (VA-ECHO) program (based on Project ECHO) has successfully provided rural PCP education in subspecialty areas, including hepatitis C. We describe the feasibility of an ECHO program for sleep medicine.ECHO creates a virtual learning community through video-teleconferencing, combining didactics with individualized clinical case review. We invited multidisciplinary providers to attend up to 10 stand-alone, 1-hour sessions. Invitees completed a needs assessment, which guided curriculum development. After program completion, we examined participant characteristics and self-reported changes in practice and comfort with managing sleep complaints. We surveyed participation barriers among invitees with low/no attendance.Of the 39 program participants, 38% worked in rural healthcare. Participants included nurse practitioners (26%), registered nurses (21%), and physicians (15%). Seventeen (44%) completed the summative program evaluation. Respondents anticipated practice change from the program, especially in patient education about sleep disorders (93% of respondents). Respondents reported improved comfort managing sleep complaints, especially sleep-disordered breathing, insomnia, and sleep in post-traumatic stress disorder (80% of respondents each). A follow-up survey of program invitees who attended zero to two sessions reported scheduling conflicts (62%) and lack of protected time (52%) as major participation barriers.Participants in a pilot sleep medicine VA-ECHO program report practice change and increased comfort managing common sleep complaints. Future work is needed to identify objective measures of return on investment and address participation barriers.

Introduction The prevalence of sleep-disordered breathing is increasing, and there are insufficient sleep medicine specialists to meet the clinical demand of caring for these patients. One way to meet this clinical need is to train primary care and internal medicine physicians to provide some of the care. However, trainees in these specialties often receive very little training on practical aspects of the management of obstructive sleep apnea (OSA). We developed an experiential workshop to address this need at our institution. Methods For approximately 60 internal medicine residents, we ran a 2.5-hour workshop consisting of two 20-minute didactic presentations to the whole audience and two 40-minute breakout sessions, led by eight facilitators. During the breakout sessions, the residents interacted with equipment such as positive airway pressure (PAP) devices and interfaces, reviewed sleep testing and PAP download reports, and participated in guided small-group discussions. Results We received 40 evaluation surveys with at least partial responses. Only 50% of respondents had received prior formal instruction on PAP devices. Both subjective and objective knowledge scores improved on the postworkshop questions compared to the preworkshop questions. Trainee comments were extremely positive, indicating that they enjoyed the format of the session. Discussion This curriculum provides an interactive educational session focused on practical aspects of OSA management relevant to primary care physicians and internists. It was well received and could be adapted to suit other time frames and other groups of learners.

Tuberculosis (TB) in humans is a global public health concern and the discovery of animal cases of Mycobacterium tuberculosis (Mtb) infection and disease, especially in multi-host settings, also has significant implications for public health, veterinary disease control, and conservation endeavors. This paper describes a fatal case of Mtb disease in a free-ranging African elephant (Loxodonta africana) in a high human TB burden region. Necropsy revealed extensive granulomatous pneumonia, from which Mtb was isolated and identified as a member of LAM3/F11 lineage; a common lineage found in humans in South Africa. These findings are contextualized within a framework of emerging Mtb disease in wildlife globally and highlights the importance of the One Health paradigm in addressing this anthroponotic threat to wildlife and the zoonotic implications.

Health care organizations must adopt a culture of safety and implement effective fall prevention protocols. The teach-back method is a useful strategy for health providers to determine patient understanding of information taught to maintain a safe environment and prevent falls. PURPOSEful rounding is a proactive approach to ensure that patient assessments are accurate and research supports that patients use the call light less when nurses participate in hourly rounding. This article provides the reader with evidence-based fall prevention interventions, tips for using the teach-back method, and fall prevention tools to safely care for patients of all ages. Language: en

Introduction Pulmonary equipment has become ubiquitous in clinical care. Basic device troubleshooting and mechanical manipulation skills are crucial to the practicing physician yet are frequently neglected in standard pulmonary curricula. Methods We developed a hands-on pulmonary curriculum for medical residents and students, focusing on oxygen delivery, spirometry, positive airway pressure devices, thoracostomy, and tracheostomy knowledge. The curriculum, consisting of five 1-hour sessions, offers hands-on experience with basic pulmonary equipment relevant to the ICU and/or pulmonary clinic. Each session is led by a pulmonologist or critical care facilitator and designed for a learning audience of 10–15 internal medicine trainees and medical students. More than 11 sessions have been conducted since curriculum implementation. Results Voluntary, immediate, pre- and postsession surveys assessed objective subject knowledge, perceived subject understanding, and perceived effectiveness of this hands-on format versus a conventional lecture style. A total of 52 learners returned surveys. Aggregate responses demonstrated that these sessions were typically the first formal training learners had received in these subject areas. Subject knowledge and perceived level of subject understanding both improved, and respondents reported the hands-on style of teaching was more effective than conventional lecture format. Discussion Focused on practical knowledge, this pulmonary hands-on curriculum addresses a knowledge gap for medical trainees, has been enthusiastically received by trainees, and provides a useful resource for faculty wishing to teach about these devices.

Sleep disturbance frequently affects patients with chronic obstructive pulmonary disease (COPD), and is associated with reduced quality of life and poorer outcomes. Data indicate that smokers with preserved pulmonary function have clinical symptoms similar to those meeting spirometric criteria for COPD, but little is known about the driving factors for sleep disturbance in this population of emerging interest.To compare the magnitude and correlates of sleep disturbance between smokers with preserved pulmonary function and those with airflow obstruction.Using cross-sectional data from the COPD Outcomes-Based Network for Clinical Effectiveness and Research Translation multicenter registry, we identified participants clinically identified as having COPD with a smoking history of at least 20 pack-years and either preserved pulmonary function or airflow obstruction. We quantified sleep disturbance by T-score measured in the sleep disturbance domain of the Patient-Reported Outcomes Information System questionnaire, and defined a minimum important difference as a T-score difference of two points. We performed univariate and multivariable linear regression to evaluate correlates within each group.We identified 100 smokers with preserved pulmonary function and 476 with airflow obstruction. The sleep disturbance T-score was 4.1 points greater among individuals with preserved pulmonary function (95% confidence interval [CI], 2.0-6.3). In adjusted analyses, depression symptom T-score was associated with sleep disturbance in both groups (airflow obstruction: β, 0.61 points; 95% CI, 0.27-0.94; preserved pulmonary function: β, 0.25 points; 95% CI, 0.12-0.38). Of note, lower percent predicted FEVAmong smokers with clinically identified COPD, the severity of sleep disturbance is greater among those with preserved pulmonary function compared with those with airflow obstruction. Nonrespiratory symptoms, such as depression, were associated with sleep disturbance in both groups, whereas the relationship of sleep disturbance with FEV

Background Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P < 0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P < 0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P = 0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59, 0·93 to 2·73; P = 0·091). Conclusion The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.

Highlights • A mediastinal thyroid mass discovered years after total thyroidectomy is presented. • The history, etiology, and optimal surgical approach are discussed. • The “forgotten goiter” can be safely approached through a cervical incision., Introduction A mediastinal thyroid mass discovered years after a total thyroidectomy represents an unusual and uncommon clinical situation. Few cases have been reported and controversy exists regarding the etiology of this ectopic thyroid tissue as well as the optimal surgical approach for resection. We herein describe a case of a mediastinal thyroid goiter discovered five years after a total thyroidectomy. Presentation of case A 54-year-old Hispanic female was diagnosed with a diffuse cervical goiter secondary to Hashimoto’s Thyroiditis and subsequently underwent a total thyroidectomy. Five years later the patient had a chest X-ray as part of a preoperative evaluation for an unrelated and elective surgical procedure. Significant tracheal deviation was identified. A computed tomography scan was obtained and demonstrated a well encapsulated mass in the superior mediastinum resulting in tracheal deviation and compression. This “forgotten” goiter was successfully resected utilizing a standard cervical approach and the patient recovered uneventfully. Discussion A thyroid mass within the mediastinum following a total thyroidectomy is a condition often referred to as “forgotten goiter”. Prior reported cases are few, and data is limited, with some uncertainty remaining as to the exact origin of this ectopic thyroid tissue. Possible etiologies include an incomplete removal of the thyroid gland during initial cervical thyroidectomy, or perhaps an autonomous intrathoracic goiter (AIG) – a thyroid gland located in the mediastinum, independent and with no parenchymatous or vascular connection with the cervical thyroid gland. Conclusion A trans-thoracic or sternal splitting approach is generally not required for resection of a mediastinal goiter and our experience confirms that the case of the “forgotten goiter” can be safely approached through a cervical incision as well.

Sperling LC, Cowper SE, Knopp EA. An Atlas of Hair Pathology with Clinical Correlations. Second edition. New York & London: Informa Healthcare. 2012. 216 pp. ISBN 978-184184733-7. UPC 9781841847337. $250 hardcover; $200 Kindle version.

Rationale: Poor sleep affects a majority of critically ill patients and is believed to be associated with adverse intensive care unit (ICU) outcomes such as delirium. While recent guidelines recommend sleep promotion efforts to improve delirium and other ICU outcomes, little is known about critical care providers’ beliefs regarding sleep in the ICU.Objectives: To evaluate providers’ perceptions and practices regarding sleep in the ICU.Methods: From April to July 2014, the Sleep in the ICU Survey was disseminated to ICU providers via institutional e-mail lists and four international critical care society distribution lists.Measurements and Main Results: A total of 1,223 surveys were completed by providers from 24 countries. Respondents were primarily nurses (59%) or physicians (39%). Most respondents indicated that ICU patients experienced “poor” or “very poor” sleep (75%) and that poor sleep could affect the ICU recovery process (88%). Respondents also felt that poor sleep was associated with negative ICU...

BACKGROUND: To identify patient and general practice (GP) characteristics associated with emergency (unplanned) first admissions for cancer in secondary care. METHODS: Patients who had a first-time admission with a primary diagnosis of cancer during 2007/08 to 2009/10 were identified from administrative hospital data. We modelled the associations between the odds of these admissions being unplanned and various patient and GP practice characteristics using national data sets, including the Quality and Outcomes Framework (QOF). RESULTS: There were 639,064 patients with a first-time admission for cancer, with 139,351 unplanned, from 7957 GP practices. The unplanned proportion ranged from 13.9% (patients aged 15-44 years) to 44.9% (patients aged 85 years and older, P

The purpose of this paper is to describe the resources necessary to provide competent care to persons with spinal cord injury or dysfunction (SCI/D) during their initial acute rehabilitation admission. It is not the purpose of this paper to specify standards of care. Clinical guidelines and standards of care that reflect evidence-based best practices have already been published and are available from various professional organizations.1-14 This paper will provide a brief description of the essential elements of an SCI program and the various discipline areas contributing to it, and it will refer, as appropriate for additional details, to the previously published standards of care. This paper focuses primarily on the initial inpatient rehabilitation phase of care. Although inpatient rehabilitation admissions have become shorter in duration, they are the critical first stage of the rehabilitation care continuum.

Purpose The purpose of this study was to investigate the feasibility of clot visualization in small sinus and cortical veins with contrast enhanced MRA in a cerebral venous thrombosis animal model using a blood pool contrast agent, Gadofosveset, and high spatial resolution imaging. Material and methods For induction of cerebral venous thrombosis a recently developed combined interventional and microsurgical model was used. Cerebral sinus and cortical vein thrombosis was induced in six pigs. Two further pigs died during the procedure. Standard structural, time-of-flight- and phase contrast-angiograms were followed by fast time resolved high resolution 3D MRA (4D MRA) and subsequent high spatial resolution 3D MRA in the equilibrium phase with and without addition of parallel imaging. Visualization of the clots using the different sequences was subjectively compared and contrast-to-noise ratio (CNR) was assessed. Results In the remaining six animals the procedure and MR-imaging protocol including administration of Gadofosveset was successfully completed. The 3D high resolution MRA in the equilibrium phase without the addition of parallel imaging was superior to all the other applied MR measurement techniques in terms of visualization of the clots. Only applying this sequence bridging vein thromboses were also seen as a small filling defect with a high CNR of >18. Conclusion Only the non-accelerated high spatial resolution 3D MRA in the equilibrium in conjunction with the blood pool agent Gadofosveset allows for high-contrast visualization of very small clots in the cerebral sinus and cortical veins. Statement clinical impact Detection of cortical vein thrombosis is of high clinical impact. Conventional MRI sequences often fail to visualize the clot. We could demonstrate that, in contrast to conventional sequences, with high spatial resolution 3D MRA in the equilibrium in conjunction with the blood pool agent Gadofosveset very small clots in the cerebral sinus and cortical veins could be successfully visualized. We think that with the presented approach cortical vein thrombosis might also be sufficiently visualized in patients.

Mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is the most common mitochondrial disease due to mitochondrial DNA (mtDNA) mutations. At least 15 distinct mtDNA mutations have been associated with MELAS, and about 80% of the cases are caused by the A3243G tRNA(Leu(UUR)) gene mutation. We report here a novel tRNA(Val) mutation in a 37-year-old woman with manifestations of MELAS, and compare her clinicopathological phenotype with other rare cases associated tRNA(Val) mutations.

PRX-00023, a serotonin 1A receptor agonist, was designed to provide high potency and selectivity for its target. To assess the possible therapeutic utility in anxiety, a randomized, double-blind, placebo-controlled trial was conducted in 311 subjects who met the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for generalized anxiety disorder. All subjects underwent a 1-week placebo run-in and were randomized to receive once-daily capsules containing either PRX-00023 (80 mg/d) or placebo for an additional 8 weeks. The primary outcome measure was the Hamilton Anxiety Scale (HAM-A). The Montgomery-Asberg Depression Rating Scale was used as a secondary endpoint to measure depressive symptoms. Statistical testing was performed with analysis of covariance, between baseline and week 8, with baseline values as a covariate. The anxiolytic effect of PRX-00023, compared with placebo, showed trends across all anxiolytic measures but failed to reach significance on the primary endpoint (HAM-A total score). Among the components of the HAM-A total score, the anxious mood item was significantly different from placebo in the PRX-00023-treated group (-1.015 vs -0.748; P = 0.02). The scores of the Montgomery-Asberg Depression Rating Scale were significantly improved compared with placebo at week 8 (-4.5 vs -1.6; P = 0.0094 in the last observation carried forward analysis). PRX-00023 was well tolerated; of note, there were no drug-related serious adverse events, and more patients discontinued due to adverse events in the placebo group (2.9%) than in the PRX-00023 group (1.4%). The most common adverse event was headache, observed in 15.7% and 10.9% of PRX-00023- and placebo-treated patients, respectively. Furthermore, there was no evidence of impaired sexual function, as measured by the Massachusetts General Hospital Sexual Function Scale. Collectively, these results support further clinical investigation of higher doses of PRX-00023 in anxiety and depression.

The purpose of this study was to evaluate the safety and efficacy of gadofosveset, a gadolinium-based albumin-binding MRI contrast agent, in patients with pedal arterial disease.A total of 185 adult patients with known or suspected pedal arterial disease were randomized in a group receiving 0.03 mmol/kg and a group receiving 0.05 mmol/kg of gadofosveset for MR angiography of the pedal arteries. Gadofosveset-enhanced and unenhanced time-of-flight MR angiograms were compared with conventional angiograms, the standard of reference, for the presence of vascular stenosis. All patients underwent drug safety analysis.For each of three blinded readers, the specificity (21-35%) of gadofosveset-enhanced MR angiography was a statistically significant (p0.010) improvement over that of unenhanced MR angiography in the detection of clinically significant (50%) stenosis. The sensitivities of the two techniques were similar. For all blinded readers of MR angiograms, sensitivity, specificity, and accuracy were higher with use of the 0.03-mmol/kg dose of gadofosveset than with the 0.05-mmol/kg dose. In the 0.03-mmol/kg group, 28% of patients reported a total of 50 adverse events, 96% of which were reported as mild or moderate. In the 0.05-mmol/kg group, 28% of patients reported a total of 55 adverse events, 98% of which were reported as mild or moderate. No patients died; one patient left the study because of myocardial infarction considered unrelated to the study drug.Because of markedly better efficacy than no contrast agent and a minimal and transient side-effect profile, 0.03 mmol/kg of gadofosveset was found safe and effective for MR angiography of patients with pedal arterial disease.

Background: Patients waiting for and having received lung transplantation commonly demonstrate known risk factors for sleep disordered breathing (SDB) including central sleep apnea (CSA). However, little is known is about the prevalence or clinical implications of SDB in this patient population. Methods: We report a 61 year old man who underwent uncomplicated bilateral lung transplantation. Approximately 5 weeks post-transplant, the patient developed fatigue, somnolence, and mild intermittent confusion. Extensive cardiologic and neurologic evaluations were unrevealing regarding cause of symptoms. Diagnostic polysomnogram revealed severe central sleep apnea with a periodic respiratory pattern. Results: The patient was initiated on positive airway pressure therapy during sleep with an adaptive servoventilation device which successfully treated central sleep apnea and improved daytime symptoms. A repeat diagnostic polysomnogram performed 8 months post-transplant showed resolution of central sleep apnea. Conclusion: SDB including CSA is a poorly understood occurrence in the lung transplantation patient population that warrants clinical attention and further investigation.

PURPOSE: The aim of this study was to investigate the use of a fibrin-specific contrast agent (EP-2104R, EPIX Pharmaceuticals, Lexington, Massachusetts, USA) for targeted molecular magnetic resonance (MR) imaging of human clot material removed from patients in a model of coronary thrombosis in swine. MATERIALS AND METHODS: Freshly ex vivo engineered clots from human blood and human in situ developed clots removed from patients were delivered into the coronary arteries of nine domestic swine. For MR imaging a navigator-gated, free-breathing, cardiac-triggered 3D inversion recovery black-blood gradient echo sequence was performed prior to clot delivery (baseline), after clot delivery but prior to contrast media administration, and two hours after systemic (i.v.) injection of 4 micromol/kg EP-2104R. MR images were analyzed by two investigators and the contrast-to-noise ratio and Gadolinium (Gd) concentration in the clots were assessed. RESULTS: On baseline images and prior to contrast media application no thrombi were visible. Post contrast administration all 10 coronary emboli (five ex vivo engineered clots and five human clots removed from patients) were selectively visualized as white spots with a mean contrast-to-noise ratio to the blood pool and the surrounding tissue of>12 and a mean Gd concentration of>100 microM. CONCLUSION: Molecular MR imaging using the fibrin-targeted contrast agent EP-2104R allows selective visualization of human clot material in a model of coronary thrombosis in swine.

Nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy (NFD), occurs in renal failure patients after gadolinium contrast exposure. The fibrosis of the dermis and subcutaneous septae accompanies fibrosis of other organs, including the heart, liver, lungs, and muscle. The fibrotic skin demonstrates increased dermal collagen, fibroblasts, and mucin. The mechanism by which gadolinium is associated with fibrosis is not known. We tested the hypothesis that upregulation of transglutaminases contributes to the fibrosis seen in the organs, including skin, of renal failure patients exposed to gadolinium contrast. We performed immunohistochemical studies using antibodies to transglutaminase-2, factor XIIIa, transglutaminase isopeptide, and the histiocyte marker CD68 on five archived skin biopsies of NSF. The results indicate that the dermal fibroblasts and histiocytes of NSF express transglutaminase-2, CD68, factor XIIIa, and transglutaminase isopeptide, indicating increased expression and/or activation of transglutaminases in NSF. We recommend further research into the use of transglutaminase inhibitors in the treatment and prevention of NSF.

Background and Purpose— Imaging of cerebral vein thrombosis is still challenging. Currently, diagnosis is based on CT venography and MRI including MRA and conventional digital subtraction angiography. However, especially in chronic cases, each method has shown its limitations. Newer strategies for MRI are found on molecular imaging using targeted contrast agents. The aim of this study was to prove the feasibility of a novel fibrin-targeted MR contrast agent (EP-2104R; EPIX Pharmaceuticals) for selective imaging of sinus venous thrombosis in an animal model. Methods— Thrombosis of the superior sagittal sinus with human blood was induced in 6 pigs using a combined microsurgical and interventional approach. MRI was then performed before and up to 120 minutes after injection of 4 μmol/kg body weight EP-2104R. Molecular imaging was performed with a 3-dimensional high-resolution T1-weighted gradient echo sequence. Time courses of signal-to-noise ratio and contrast-to-noise ratio were analyzed. Thrombi were then surgically removed and the Gadolinium concentration was assessed. Results— In all cases the thrombosis could be successfully induced; the complete MR protocol could be performed in 5 animals. In these cases the thrombi showed selective enhancement after injection of the molecular contrast agent. However, a continuous contrast-to-noise ratio increase was seen up to 120 minutes after contrast administration, achieving a contrast-to-noise ratio of 14.2±0.7 between clot and the blood pool. Conclusion— The novel fibrin-targeted molecular MR contrast EP-2104R allows selective and high-contrast imaging of cerebral sinus vein thrombosis in an animal model.

We cannot be certain when the next influenza pandemic will emerge, or even whether it will be caused by avian influenza (H5N1) or some unrelated virus. However, we can be certain that an influenza pandemic will occur. The United States is leading the scientific effort to contain the pandemic through vaccine studies and antiviral studies. The need for pandemic influenza preparedness is extensive and expensive. Planning entails increased development of antivirals and vaccines, effective surveillance systems not only for people, but in agriculture, effective communication systems, plans to continue essential services, identification of health care priorities, and thorough guidelines for care. Critical care nurses, as well as all health care professionals, need to consider where their personal and professional obligations meet and end. There should already be discussions of contingency plan of the institution in which they are employed and the community in which they live. Additionally, a personal plan for their families with regard to economics, safety, and optimizing personal health outcomes during such a crisis should be considered. As many have said, "It is not a matter of if, but rather of when." Although the pandemic might not be the avian flu, history has taught us that pandemics surface with little warning and can have devastating effects on human lives, and can over tax the already fragile health care system.

Acute and critical care nurses must maintain a current knowledge base for advancing science and providing direct care for patients. When an infectious process is involved, it is the practicing nurse who must be knowledgeable in treatment and prevention modalities. The integument is the body's first line of defense for invading bacteria. This barrier to bacteria is followed by inflammation and adaptive immunity, the second and third lines of defense against infectious bacteria. It is acute and critical care nurses, however, who should be the first line of defense in preventing the spread of infectious disease. Modern medicine and common sense interventions reviewed in this article are the patient's best defense to good health and wellness when used by nurses.