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Canadian surveys from spring/summer 2020 suggest the prevalence of some positive mental health (PMH) outcomes have declined compared to pre-pandemic levels. However, less is known about the state of PMH during the second wave of the COVID-19 pandemic.We compared adults' self-rated mental health (SRMH), community belonging and life satisfaction in Fall 2020 versus 2019 in the overall population and across sociodemographic characteristics using cross-sectional data from the Survey on COVID-19 and Mental Health (September-December, 2020) and the 2019 Canadian Community Health Survey. We also conducted regression analyses to examine which sociodemographic factors were associated with reporting in Fall 2020 that one's mental health was about the same or better compared to before the pandemic.Fewer adults reported high SRMH in Fall 2020 (59.95%) than in 2019 (66.71%) and fewer reported high community belonging in Fall 2020 (63.64%) than in 2019 (68.42%). Rated from 0 (very dissatisfied) to 10 (very satisfied), average life satisfaction was lower in Fall 2020 (7.19) than in 2019 (8.08). Females, those aged under 65 years, those living in a population centre, and those absent from work due to COVID-19 had lower odds of reporting that their mental health was about the same or better in Fall 2020.The PMH of adults was lower during the pandemic's second wave. However, the majority of individuals still reported high SRMH and community belonging. The findings identify certain sociodemographic groups whose mental health appears to have been more negatively impacted by the pandemic. Continued surveillance is important in ensuring mental health builds back better and stronger in Canada after the pandemic.Des enquêtes canadiennes du printemps et de l’été 2020 ont fait état d’une diminution de la prévalence de certains résultats en matière de santé mentale positive par rapport aux niveaux d’avant la pandémie. Nous en savons moins sur la santé mentale positive pendant la deuxième vague de la pandémie de COVID 19.Nous avons comparé les données de l’automne 2020 à celles de l’année 2019 en ce qui concerne la santé mentale autoévaluée, le sentiment d’appartenance à la communauté et la satisfaction à l’égard de la vie chez les adultes, pour l’ensemble de la population et en fonction de caractéristiques sociodémographiques, en utilisant les données transversales de l’Enquête sur la COVID 19 et la santé mentale (de septembre à décembre 2020) et de l’Enquête sur la santé dans les collectivités canadiennes de 2019. Nous avons également effectué des analyses de régression pour déterminer quels facteurs sociodémographiques étaient associés au fait qu’une personne déclare à l’automne 2020 que sa santé mentale était à peu près la même ou meilleure qu’avant la pandémie.Moins d’adultes ont fait état d’un niveau élevé de santé mentale autoévaluée à l’automne 2020 (59,95 %) par rapport à 2019 (66,71 %) et d’un fort sentiment d’appartenance à la communauté à l’automne 2020 (63,64 %) par rapport à 2019 (68,42 %). La satisfaction moyenne à l’égard de la vie, mesurée sur une échelle de 0 (très insatisfait) à 10 (très satisfait), était plus faible à l’automne 2020 (7,19) qu’en 2019 (8,08). Les femmes, les personnes de moins de 65 ans, la population vivant en milieu urbain et les personnes n’étant pas au travail en raison de la COVID 19 étaient moins susceptibles d’affirmer que leur santé mentale était à peu près la même voire meilleure à l’automne 2020.La santé mentale positive des adultes s’est révélée plus faible pendant la deuxième vague de la pandémie. Cependant, la majorité des individus ont tout de même fait état d’un niveau élevé de santé mentale autoévaluée et d’un fort sentiment d’appartenance à la communauté. D’après nos résultats, la pandémie semble avoir nui davantage à la santé mentale de certains groupes sociodémographiques. Il est important d’assurer une surveillance continue pour veiller à améliorer et à renforcer la santé mentale de la population canadienne après la pandémie.Fewer adults in Canada reported high self-rated mental health in Fall 2020 (59.95%) than in 2019 (66.71%). Fewer adults reported high community belonging in Fall 2020 (63.64%) than in 2019 (68.42%). Average life satisfaction was lower in Fall 2020 (7.19) than in 2019 (8.08). Being female, being under 65 years old, living in a population centre and being absent from work due to COVID-19 were associated with a lower likelihood of reporting that one’s mental health was about the same or better in Fall 2020.Moins d’adultes au Canada ont fait état d’un niveau élevé de santé mentale autoévaluée à l’automne 2020 (59,95 %) par rapport à 2019 (66,71 %). Moins d’adultes ont fait état d’un fort sentiment d’appartenance à la communauté à l’automne 2020 (63,64 %) par rapport à 2019 (68,42 %). La satisfaction moyenne à l’égard de la vie s’est révélée plus faible à l’automne 2020 (7,19) qu’en 2019 (8,08). Les femmes, les personnes de moins de 65 ans, la population vivant en milieu urbain et les personnes n’étant pas au travail en raison de la COVID 19 étaient moins susceptibles d’affirmer que leur santé mentale était à peu près la même voire meilleure à l’automne 2020.

Objectives Explore the impact transitioning from daytime to nighttime operations has on performance in U.S. Army Rangers. Methods Fifty-four male Rangers (age 26.1 ± 4.0 years) completed the Y-Balance Test (YBT), a vertical jump assessment, and a grip strength test at three time points. Baseline testing occurred while the Rangers were on daytime operations; post-test occurred after the first night into the nighttime operation training (after full night of sleep loss), and follow-up testing occurred six days later (end of nighttime training). Results On the YBT, performance was significantly worse at post-test compared to baseline during right posteromedial reach (104.1 ± 7.2 cm vs 106.5 ± 6.7 cm, p = .014), left posteromedial reach (105.4 ± 7.5 cm vs 108.5 ± 6.6 cm, p = .003), right composite score (274.8 ± 19.3 cm vs 279.7 ± 18.1 cm, p = .043), left composite score (277.9 ± 18.1 cm vs 283.3 ± 16.7 cm, p = .016), and leg asymmetry was significantly worse in the posterolateral direction (4.8 ± 4.0 cm vs 3.7 ± 3.1 cm, p = .030) and the anterior direction (5.0 ± 4.0 cm vs 3.6 ± 2.6 cm, p = .040). The average vertical jump height was significantly lower at post-test compared to baseline (20.6 ± 3.4 in vs 21.8 ± 3.0 in, p = .004). Baseline performance on YBT and vertical jump did not differ from follow-up. Conclusions Army Rangers experienced an immediate, but temporary, drop in dynamic balance and vertical jump performance when transitioning from daytime to nighttime operations. When feasible, Rangers should consider adjusting their sleep cycles prior to anticipating nighttime operations in order to maintain their performance levels. Investigating strategies that may limit impairments during this transition is warranted.

Introduction Sleep disorders’ are highly prevalent among U.S. active duty service members (ADSMs) and present well-documented challenges to military health, safety, and performance. In addition to increased need for sleep medicine services, a major barrier to effective sleep management has been a lack of alignment among patients, health providers, and economic-decision-makers. To address this gap in knowledge, the purpose of the present study was to engage diverse stakeholders vested in improving sleep disorders’ management in the military. Materials and Methods We elicited feedback from ADSMs with sleep disorders (five focus group discussion, n = 26) and primary care managers (PCMs) (11 individual semi-structured interview) in two military treatment facilities (MTFs) in the National Capitol Region, in addition to national level military and civilian administrative stakeholders (11 individual semi-structured interview) about their experiences with sleep disorders’ management in U.S. MTFs, including facilitators and barriers for reaching a definitive sleep diagnosis, convenience and effectiveness of sleep treatments, and key desired outcomes from interventions designed to address effectively sleep disorders in the U.S. military health care system (MHS). Recordings from focus groups and semi-structured interviews were transcribed verbatim and analyzed using QSR International’s NVivo 12 software using inductive thematic analysis. The study was approved by Walter Reed National Military Medical Center Department of Research Programs. Results Active duty service members with sleep disorders often fail to recognize their need for professional sleep management. Whereas PCMs identified themselves as first-line providers for sleep disorders in the military, patients lacked confidence that PCMs can make accurate diagnoses and deliver effective sleep treatments. Active duty service members cited needs for expeditious treatment, educational support and care coordination, and support for obtaining sleep treatments during deployment. Challenges that PCMs identified for effective management include insufficient time during routine care visits, delays in scheduling testing procedures, and limited number of sleep specialists. Primary care managers suggested offering evidence-based telehealth tools and enhanced care coordination between PCMs and specialists; standardized medical education, materials, and tools; patient preparation before appointments; self-administered patient education; and including behavioral sleep specialists as part of the sleep management team. For administrative stakeholders, key outcomes of enhanced sleep management included (1) improved resource allocation and cost savings, and (2) improved ADSM safety, productivity, and combat effectiveness. Conclusion Current military sleep management practices are neither satisfactory nor maximally effective. Our findings suggest that solving the military sleep problem will require sustained effort and ongoing collaboration from ADSM patients, providers, and health systems leaders. Important potential roles for telehealth and technology were identified. Future research should seek to enhance implementation of sleep management best practices to improve outcomes for patients, providers, MHS, and the military as a whole.

Based on feedback received during post-training consultation within a Prolonged Exposure (PE) implementation initiative, additional assessment training was added to help community providers identify patients who met criteria for posttraumatic stress disorder (PTSD) symptom severity and were considered appropriate for PTSD treatment. The current study investigated the rates of trauma exposure and PTSD in the community sample, as well as the percentage of individuals deemed “appropriate” for PE by community therapists. Clinicians involved in the PE Initiative administered the Post-traumatic Diagnostic Scale for DSM-5 (PDS-5) to 10,260 individuals across 13 community agencies. Clinicians were also asked to report whether patients were perceived as appropriate for PE. Consistent with our hypothesis, the rates of potential PTSD in Philadelphia community mental health (58.2% of our total sample) far exceeded national averages (8.3%). Contrary to our hypothesis, 100% of patients who scored above the clinical cutoff for PTSD were considered appropriate for PE by their community clinician. The results of this study emphasize the high prevalence of PTSD among individuals presenting for treatment to community mental health centers. Despite common misconceptions that patients are often perceived as ineligible or not appropriate for PE, 100% of patients in the PE Initiative who scored above the clinical cutoff for PTSD were considered good candidates for treatment according to their clinicians. This suggests that with sufficient training and post-training consultation, as provided in this community initiative, community clinicians may be more likely to perceive PE as an appropriate treatment option.

Peptic ulcer disease (PUD) is a common condition that is induced by acid and pepsin causing lesions in the mucosa of the duodenum and stomach. The pathogenesis of PUD is a many-sided scenario, which involves an imbalance between protective factors, such as prostaglandins, blood flow, and cell renewal, and aggressive ones, like alcohol abuse, smoking

STUDY OBJECTIVES: The aim of this study was to characterize older adult Medicare beneficiaries seen by board-certified sleep medicine providers (BCSMPs) and identify predictors of being seen by a BCSMP. METHODS: Our data source was a random 5% sample of Medicare administrative claims data (2006–2013). BCSMPs were identified using a cross-matching procedure based on national provider identifiers available within the Medicare database and assigned based on the first sleep disorder diagnosis received. Sleep disorders (insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and restless legs syndrome) were operationalized as International Classification of Disease, Ninth Revision, Clinical Modification diagnostic codes. The number of sleep disorders per beneficiary was computed and compared between BCSMPs and nonspecialists. Logistic regression was used to identify medical and demographic predictors of being seen by a BCSMP. RESULTS: A total of 57,209 beneficiaries received one or more sleep disorder diagnoses during the study period. Of these, 1,279 (2.2%) were initially diagnosed by a BCSMP. Relative to individuals seen by nonspecialists, beneficiaries treated by a BCSMP were more likely to have two or more sleep disorders (9.0% vs 24.1%, P < .001). The most common diagnosis assigned by BCSMPs was obstructive sleep apnea (70.4% of patients seen by BCSMPs were diagnosed with obstructive sleep apnea). The most common diagnosis assigned by nonspecialists was insomnia (48.2% of patients seen by nonspecialists were diagnosed with insomnia). In a fully adjusted regression model, male sex (odds ratio [OR] 1.53; 95% confidence interval [CI] 1.36, 1.72), asthma (OR 1.50; 95% CI 1.30, 1.73), and heart failure (OR 1.24; 95% CI 1.10, 1.41) were positively associated with being treated by a BCSMP. Conversely, depression (OR 0.85, 95% CI 0.73, 1.00), anxiety (OR 0.69, 95% CI .59, .82), Alzheimer and related dementias (OR 0.80, 95% CI .65, .99), and anemia (OR .88, 95% CI .78, .99) were associated with a reduced likelihood of being seen by a BCSMP. CONCLUSIONS: Relative to older adults seen by nonspecialists, those seen by BCSMPs are more medically but less psychiatrically complex and are diagnosed with a greater number of sleep disorders. These results suggest the possibility that medically complex patients are referred for specialty care, whereas psychiatrically complex patients might be seen at the nonspecialist level. Further, these results demonstrate the value of board certification in sleep medicine in caring for complex sleep patients. CITATION: Wickwire EM, Jobe SL, Parthasarathy S, et al. Which older adults receive sleep medicine specialty care? Predictors of being seen by a board-certified sleep medicine provider. J Clin Sleep Med. 2020;16(11):1909–1915.

The TNFα G308A gene polymorphism has been reported to influence performance impairment during total sleep deprivation (TSD). We investigated this effect in a randomized, double-blind, crossover lab...

High incidence of thrombotic complications was observed in patients with Acute Respiratory Distress Syndrome (ARDS) related to Coronavirus Disease 2019 (COVID-19) [1]. The pathophysiology seems related to systemic thrombophilia by hyper-immune reaction, inducing a “cytokine storm” [1].

STUDY OBJECTIVES: To examine the proportion of Medicare beneficiaries with sleep disorders who were evaluated by board-certified sleep medicine providers (BCSMPs). METHODS: Using a random 5% sample of Medicare administrative claims data (2007–2011), BCSMPs were identified by employing a novel cross-matching approach based on National Provider Identifiers available within the Medicare database. Sleep disorders were included based partially on the International Classification of Sleep Disorders, Third Edition (insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and restless legs syndrome), and operationalized as International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. The proportion of beneficiaries with each disorder who were seen by BCSMPs and nonspecialists was computed. RESULTS: Among older adult Medicare beneficiaries with sleep disorders, the most common sleep disorder was insomnia (n = 65,033), and the least common sleep disorder was narcolepsy (n = 784). Individuals with central sleep apnea (n = 1,561) were most likely to be treated by a BCSMP (63.9% of beneficiaries with central sleep apnea), and individuals diagnosed with insomnia were least likely to be treated by a BCSMP (16.4% of beneficiaries with insomnia). Most BCSMPs treated beneficiaries with obstructive sleep apnea (84.9% of BCSMPs) and insomnia (75.8% of BCSMPs). CONCLUSIONS: BCSMPs are involved in the care of a substantial proportion of Medicare beneficiaries with sleep disorders. CITATION: Wickwire EM, Albrecht JS, Dorsch JJ, et al. Practice patterns of board-certified sleep medicine providers: a national analysis among older adult Medicare beneficiaries. J Clin Sleep Med. 2020;16(5):689–694.

Many Canadians report decreased mental health during the COVID-19 pandemic, and concerns have been raised about possible increases in suicide. This study investigates the pandemic's potential impact on adults' suicide ideation.We compared self-reported suicide ideation in 2020 versus 2019 by analyzing data from the Survey on COVID-19 and Mental Health (11 September to 4 December 2020) and the 2019 Canadian Community Health Survey. Logistic regression was conducted to determine which populations were at higher risk of suicide ideation during the pandemic.The percentage of adults reporting suicide ideation since the pandemic began (2.44%) was not significantly different from the percentage reporting suicide ideation in the past 12 months in 2019 (2.73%). Significant differences in the prevalence of recent suicide ideation in 2020 versus 2019 also tended to be absent in the numerous sociodemographic groups we examined. Risk factors of reporting suicide ideation during the pandemic included being under 65 years, Canadian-born or a frontline worker; reporting pandemic-related income/job loss or loneliness/isolation; experiencing a lifetime highly stressful/traumatic event; and having lower household income and educational attainment.Evidence of changes in suicide ideation due to the pandemic were generally not observed in this research. Continued surveillance of suicide and risk/protective factors is needed to inform suicide prevention efforts.De nombreux Canadiens font état d’une détérioration de leur santé mentale depuis le début de la pandémie de COVID-19 et des inquiétudes ont été exprimées quant à une possible augmentation du nombre de suicides. Cette étude porte sur les répercussions potentielles de la pandémie sur les idées suicidaires des adultes.Nous avons comparé les idées suicidaires autodéclarées en 2020 par rapport à celles autodéclarées en 2019 en analysant les données de l’Enquête sur la COVID-19 et la santé mentale (du 11 septembre au 4 décembre 2020) et de l’Enquête sur la santé dans les collectivités canadiennes de 2019. Nous avons effectué une régression logistique pour caractériser les populations à risque plus élevé d’idées suicidaires pendant la pandémie.Le pourcentage d’adultes ayant fait état d’idées suicidaires depuis le début de la pandémie (2,44 %) n’est pas significativement différent du pourcentage d’adultes ayant fait état d’idées suicidaires dans les douze derniers mois en 2019 (2,73 %). De façon générale, il n’y avait pas non plus de différences significatives dans la prévalence d’idées suicidaires récentes en 2020 par rapport à 2019 dans les nombreux groupes sociodémographiques que nous avons examinés. Les facteurs de risque liés à la déclaration d’idées suicidaires pendant la pandémie étaient le fait d’être âgé de moins de 65 ans; d’être né au Canada; d’être un travailleur de première ligne; d’avoir déclaré une perte de revenu ou d’emploi en lien avec la pandémie; d’avoir fait état d’un sentiment de solitude ou d’isolement en lien avec la pandémie; de vivre ou d’avoir vécu une situation extrêmement stressante ou traumatisante au cours de sa vie et enfin d’avoir un revenu familial et un niveau d’études inférieurs.Dans le cadre de notre recherche, nous n’avons généralement pas observé de preuve de changements dans les idées suicidaires en raison de la pandémie. Une surveillance continue du suicide et des facteurs de risque et de protection est nécessaire pour soutenir les efforts de prévention du suicide.Recent suicide ideation was not significantly different in 2020 versus 2019 in the overall population, nor in almost every sociodemographic group examined. Some individuals were more likely than others to report contemplating suicide since the pandemic began: adults under 65 years old; Canadian-born people; frontline workers; those with a high school or lower education level and lower household income; individuals who had experienced a highly stressful/traumatic event in their lifetime; and people who lost their job/income or experienced loneliness/isolation due to the pandemic.La présence d’idées suicidaires récentes n’a pas été significativement différente en 2020 par rapport à 2019, et ce, ni dans l’ensemble de la population, ni dans quasiment tous les groupes sociodémographiques analysés. Certains individus étaient plus susceptibles que d’autres de déclarer avoir envisagé le suicide depuis le début de la pandémie : les adultes de moins de 65 ans, les natifs du Canada, les travailleurs de première ligne, les personnes ayant un niveau d’études secondaires ou inférieur et un faible revenu familial, les personnes ayant vécu une situation très stressante ou traumatisante au cours de leur vie et les personnes ayant perdu leur emploi ou leur revenu ou ayant connu la solitude ou l’isolement en raison de la pandémie.

The military lifestyle often includes continuous operations whether in training or deployed environments. These stressful environments present unique challenges for service members attempting to achieve consolidated, restorative sleep. The significant mental and physical derangements caused by degraded metabolic, cardiovascular, skeletomuscular, and cognitive health often result from insufficient sleep and/or circadian misalignment. Insufficient sleep and resulting fatigue compromises personal safety, mission success, and even national security. In the long-term, chronic insufficient sleep and circadian rhythm disorders have been associated with other sleep disorders (e.g., insomnia, obstructive sleep apnea, and parasomnias). Other physiologic and psychologic diagnoses such as post-traumatic stress disorder, cardiovascular disease, and dementia have also been associated with chronic, insufficient sleep. Increased co-morbidity and mortality are compounded by traumatic brain injury resulting from blunt trauma, blast exposure, and highly physically demanding tasks under load. We present the current state of science in human and animal models specific to service members during- and post-military career. We focus on mission requirements of night shift work, sustained operations, and rapid re-entrainment to time zones. We then propose targeted pharmacological and non-pharmacological countermeasures to optimize performance that are mission- and symptom-specific. We recognize a critical gap in research involving service members, but provide tailored interventions for military health care providers based on the large body of research in health care and public service workers.

Intraluminal contributor(s) to airflow obstruction in severe asthma are patient-specific and must be evaluated to personalize treatment. The occurrence and functional consequence of airway mucus in the presence or absence of airway eosinophils remain undetermined.The objective of this study was to understand the functional consequence of airway mucus in the presence or absence of eosinophils and to identify biomarkers of mucus-related airflow obstruction.Mucus plugs were quantified on CT scans, and their contribution to ventilation heterogeneity (using MRI ventilation defect percent [VDP]) was evaluated in 27 patients with severe asthma. Patients were dichotomized based on sputum eosinophilia such that the relationship between mucus, eosinophilia, and ventilation heterogeneity could be investigated. Fractional exhaled nitric oxide (Feno) and related cytokines in sputum were measured.Mucus plugging was present in 100% of asthma patients with sputum eosinophils and 36% of those without sputum eosinophils (P = .0006) and was correlated with MRI VDP prebronchodilator (r = 0.68; P = .0001) and postbronchodilator (r = 0.72; P .0001). In a multivariable regression, both mucus and eosinophils contributed to the prediction of postbronchodilator MRI VDP (RBoth airway eosinophils and mucus can contribute to ventilation heterogeneity in patients with severe asthma. Patients in whom mucus is the dominant cause of airway obstruction have evidence of an upregulated IL-4/IL-13 pathway that could be identified according to increased Feno level.

We aimed to compare body segment and bone lengths in glucocorticoid-treated boys with Duchenne muscular dystrophy (DMD) with healthy controls using dual-energy absorptiometry (DXA) images. Total height (Ht), sitting height (SH), leg length (LL) and bone lengths (femur, tibia) in boys with DMD and age-matched control boys were measured using DXA. Thirty boys with DMD (median age 10.0 years (6.1, 16.8)) were compared with 30 controls. SH in DMD was 3.3 cm lower (95% CI - 6.1, - 0.66; p = 0.016). LL in DMD was 7.3 cm lower (95% CI - 11.2, - 3.4; p 0.0001). SH:LL of boys with DMD was higher by 0.08 (95% CI 0.04, 0.12; p 0.0001). Femur length in DMD was 2.4 cm lower (95% CI - 4.6, - 0.12; p = 0.04), whereas tibial length in DMD was 4.8 cm lower (95% CI - 6.7, - 2.9; p 0.0001). SH:LL was not associated with duration of glucocorticoid use (SH:LL β = 0.003, 95% CI - 0.01 to 0.002, p = 0.72).Conclusion: Glucocorticoid-treated boys with DMD exhibit skeletal disproportion with relatively shorter leg length and more marked reduction of distal long bones. As glucocorticoid excess is not associated with such disproportion, our findings raise the possibility of an intrinsic disorder of growth in DMD. What is Known • Severe growth impairment and short stature are commonly observed in boys with Duchenne muscular dystrophy (DMD), especially those treated with long-term glucocorticoids (GC). • In other groups of children with chronic conditions and/or disorders of puberty, skeletal disproportion with lower spinal length has been reported. What is New • Growth impairment in GC-treated boys with DMD was associated with skeletal disproportion in relation to age, with lower limbs and distal long bones affected to a greater degree.

Introduction Insufficient sleep increases pain sensitivity in healthy individuals. Additionally, extending sleep (eg, increasing nocturnal sleep time or adding a mid-day nap) has been shown to restore pain sensitivity to baseline levels in sleep deprived/restricted individuals. Whether sleep extension can reduce pain sensitivity beyond baseline levels in non-sleep restricted/deprived individuals remains unknown. Methods In a sample of 27 healthy, pain-free, normally-sleeping individuals (17 males, mean age ∼24 yrs), we examined the impact of five nights of sleep extension on pain sensitivity. Pain threshold (elapsed time until the participant reported pain) and pain tolerance (total time the participant kept the hand submerged in the cold water) were measured using the Cold Pressor Task. Furthermore, we assessed the extent to which self-reported sleep amount in relation to the minimal subjective sleep requirement for adequate performance (sleep credit) was associated with pain sensitivity changes. Results On average individuals slept almost 2 extra hours per night. Our results indicate that sleep extension increases pain tolerance beyond baseline levels. However, sleep extension did not impact pain threshold. We also found that individuals with a smaller sleep credit (ie, those who habitually obtain less sleep than they feel they need) experienced greater increases in pain tolerance after extending sleep. Conclusions The present findings suggest that sleep extension may increase pain tolerance but not pain threshold in healthy individuals who normally sleep the recommended amount. Our findings also support the idea that sleep credit may be a strong indicator of sleep debt in the context of pain sensitivity.

Highlights • Sclerosing angiomatoid nodular transformation (SANT) is a recently recognized benign, proliferative vascular lesion affecting the spleen. • A limited number of cases are described in the worldwide literature. • Further case studies are needed to elucidate the mechanism of SANT and its possible various etiologies. • In the light of above splenectomy at now is the choice treatment both for diagnosis and treatment. • This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., Introduction SANT of the spleen is a benign lesion that does not recur after splenectomy with unknown etiology. Presentation of the case We report a case of sclerosing angiomatoid nodular transformation (SANT) of the spleen mimicking a splenic abscess in a patient with imaging studies that failed to differentiate this lesion from other splenic lesions. Discussion SANT of the spleen is a rare condition, with only less than 100 cases reported in the literature. Clinically, SANT is only a kind of described pathological diagnostic conception. As in our case, these splenic lesions are often incidental findings on imaging studies performed for other reasons. Conclusion The patient was treated with splenectomy, which has proved to be both diagnostic and therapeutic. Although histology can lead to the diagnosis of vascular tumor, immunohistochemistry is the only way to confirm the diagnosis.

Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patient factors predicted remission. Participants were 137 adults with clinically significant OCD (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≥18) despite an adequate SRI trial (≥12 weeks). Continuing their SRI, patients received 17 sessions of twice-weekly EX/RP (standard course). Patients who did not remit (Y-BOCS ≤12) received up to 8 additional sessions (extended course). Of 137 entrants, 123 completed treatment: 49 (35.8%) remitted with the standard course and another 46 (33.6%) with the extended course. Poorer patient homework adherence, more Obsessive-Compulsive Personality Disorder (OCPD) traits, and the Brain-Derived Neurotrophic Factor (BDNF) Val66MET genotype were associated with lower odds of standard course remission. Only homework adherence differentiated non-remitters from extended course remitters. Extending the EX/RP course from 17 to 25 sessions enabled many (69.3%) OCD patients on SRIs to achieve remission. Although behavioral (patient homework adherence), psychological (OCPD traits), and biological (BDNF genotype) factors influenced odds of EX/RP remission, homework adherence was the most potent patient factor overall.

An evaluation of professional practices was carried out in a cancer centre in the wake of the management of the health crisis linked to the severe acute respiratory syndrome coronavirus 2 pandemic. Hospital teams questioned the relevance of the measures adopted, internally and during home care, to manage suspected or confirmed Covid-19 patients and prevent contagion for all.

Study Objectives To describe initial insomnia-related encounters among a national sample of Medicare beneficiaries, and to identify older adults at risk for potentially inappropriate prescription insomnia medication usage. Methods Our data source was a random 5% sample of Medicare administrative claims data (2006–2013). Insomnia was operationalized as International Classification of Disease, Ninth Revision, Clinical Modification diagnostic codes. Insomnia medications included FDA-approved insomnia-related medication classes and drugs. Logistic regression was employed to identify predictors of being “prescribed only” (i.e., being prescribed an insomnia medication without a corresponding insomnia diagnosis). Results A total of N = 60 362 beneficiaries received either an insomnia diagnosis or a prescription for an insomnia medication as their first sleep-related encounter during the study period. Of these, 55.1% (n = 33 245) were prescribed only, whereas 44.9% (n = 27 117) received a concurrent insomnia diagnosis. In a fully adjusted regression model, younger age (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.98, 0.99), male sex (OR 1.15; 95% CI 1.11, 1.20), and several comorbid conditions (i.e., dementia [OR 1.21; 95% CI 1.15, 1.27] and anemia [OR 1.17; 95% CI 1.13, 1.22]) were positively associated with being prescribed only. Conversely, black individuals (OR 0.83; 95% CI 0.78, 0.89) and those of “other” race (OR 0.89; 95% CI 0.84, 0.94) were less likely to be prescribed only. Individuals who received care from a board-certified sleep medicine provider (BCSMP) were less likely to be prescribed only (OR 0.27; 95% CI 0.16, 0.46). Conclusions Fewer than half of Medicare beneficiaries prescribed insomnia medications ever received a formal sleep-related diagnosis.

Positive mental health is an essential part of youth's healthy development. For instance, positive mental health is associated with greater self-reported physical health, closer relationships and fewer conduct problems in youth. As positive mental health promotion is a public health priority, examining its potential determinants is important.We analyzed data from students in Grades 7-12 (secondary I-V in Quebec), from nine Canadian provinces, who participated in the 2016/2017 Canadian Student Tobacco, Alcohol and Drugs Survey. Psychological and social well-being (PSWB) was assessed using the Children's Intrinsic Needs Satisfaction Scale (CINSS). We conducted linear regression analyses to determine associations of sociodemographic, psychosocial and substance use variables with overall CINSS scores (n = 37 897).In general, youth in Canada reported fairly high PSWB. After adjusting for all included variables, being in a higher grade, being bullied, bullying others, reporting more behavioural problems and using cigarettes, e-cigarettes or cannabis at least once in the past 30 days were associated with lower overall CINSS scores for both male and female students. Reporting more prosocial behaviours was associated with higher overall scores for both sexes.A number of sociodemographic, psychosocial and substance use factors are associated with PSWB among youth in Canada. Prospective longitudinal and intervention studies could examine whether changes in these potential risk/protective factors are accompanied by changes in positive mental health.Une santé mentale positive est un élément essentiel du développement sain des jeunes. Par exemple, une santé mentale positive est associée à une meilleure santé physique autodéclarée, à des relations plus étroites et à moins de problèmes de comportement chez les jeunes. La promotion d’une santé mentale positive est une priorité de santé publique, il est donc important d’en examiner les facteurs déterminants potentiels.Nous avons analysé les données d’élèves de la 7e à la 12e année (1re à 5e année du secondaire au Québec) de neuf provinces canadiennes ayant participé à l’Enquête canadienne sur le tabac, l’alcool et les drogues chez les élèves de 2016­2017. Le bien­être psychologique et social a été évalué à l’aide de l’Échelle de satisfaction des besoins intrinsèques des enfants (questionnaire CINSS). Nous avons effectué des analyses de régression linéaire pour déterminer les associations des variables sociodémographiques, psychosociales et liées à la consommation de substances avec les scores globaux du questionnaire CINSS (n = 37 897).En général, les jeunes au Canada ont fait état d’un bien-être psychologique et social assez élevé. Après correction pour toutes les variables incluses, le fait d’être dans un niveau scolaire supérieur, le fait d’être victime d’intimidation, le fait d’intimider les autres, le signalement de problèmes de comportement et le fait d’avoir fumé la cigarette, vapoté ou consommé du cannabis au moins une fois au cours des 30 derniers jours sont associés à des scores globaux inférieurs au questionnaire CINSS chez les élèves des deux sexes. Le signalement de comportements prosociaux a été associé à des scores globaux élevés pour les deux sexes.Un certain nombre de facteurs sociodémographiques, psychosociaux et liés à la consommation de substances sont associés au bien-être psychologique et social chez les jeunes au Canada. Des études prospectives longitudinales et d’intervention pourraient examiner si les changements dans ces facteurs potentiels de risque et de protection se répercutent sur la santé mentale positive.This study examined correlates of psychological and social well-being (PSWB) among youth in Grades 7–12/secondary I–V in Canada. PSWB was lower for students in higher grades. Behavioural problems, being bullied and bullying others were associated with lower PSWB, while prosocial behaviours (e.g. helping, sharing) were associated with higher PSWB. Recent cigarette, e-cigarette and cannabis use were associated with lower PSWB.Cette étude a examiné les corrélats du bien-être psychologique et social chez les jeunes de la 7e à la 12e année (1re à 5e année du secondaire au Québec) au Canada. Le bien­être psychologique et social était plus faible chez les élèves des niveaux scolaires supérieurs. Les problèmes de comportement, le fait d’être intimidé et le fait d’intimider les autres étaient associés à un bien-être psychologique et social inférieur, tandis que les comportements prosociaux (p. ex. aider, partager) étaient associés à un bien-être psychologique et social supérieur. Avoir récemment fumé la cigarette, vapoté et consommé du cannabis ont été associés à un bien-être psychologique et social inférieur.

In patients with suspected dementia with Lewy bodies, the detection of the disease-associated α-synuclein in easily accessible tissues amenable to be collected using minimally invasive procedures remains a major diagnostic challenge. This approach has the potential to take advantage of modern molecular assays for the diagnosis of α–synucleinopathy and, in turn, to optimize the recruitment and selection of patients in clinical trials, using drugs directed at counteracting α-synuclein aggregation. In this study, we explored the diagnostic accuracy of α-synuclein real-time quaking-induced conversion assay by testing olfactory mucosa and CSF in patients with a clinical diagnosis of probable (n = 32) or prodromal (n = 5) dementia with Lewy bodies or mixed degenerative dementia (dementia with Lewy bodies/Alzheimer’s disease) (n = 6). Thirty-eight patients with non-α-synuclein-related neurodegenerative and non-neurodegenerative disorders, including Alzheimer’s disease (n = 10), sporadic Creutzfeldt–Jakob disease (n = 10), progressive supranuclear palsy (n = 8), corticobasal syndrome (n = 1), fronto-temporal dementia (n = 3) and other neurological conditions (n = 6) were also included, as controls. All 81 patients underwent olfactory swabbing while CSF was obtained in 48 participants. At the initial blinded screening of olfactory mucosa samples, 38 out of 81 resulted positive while CSF was positive in 19 samples out of 48 analysed. After unblinding of the results, 27 positive olfactory mucosa were assigned to patients with probable dementia with Lewy bodies, five with prodromal dementia with Lewy bodies and three to patients with mixed dementia, as opposed to three out 38 controls. Corresponding results of CSF testing disclosed 10 out 10 positive samples in patients with probable dementia with Lewy bodies and six out of six with mixed dementia, in addition to three out of 32 for controls. The accuracy among results of real-time quaking-induced conversion assays and clinical diagnoses was 86.4% in the case of olfactory mucosa and 93.8% for CSF. For the first time, we showed that α-synuclein real-time quaking-induced conversion assay detects α-synuclein aggregates in olfactory mucosa of patients with dementia with Lewy bodies and with mixed dementia. Additionally, we provided preliminary evidence that the combined testing of olfactory mucosa and CSF raised the concordance with clinical diagnosis potentially to 100%. Our results suggest that nasal swabbing might be considered as a first-line screening procedure in patients with a diagnosis of suspected dementia with Lewy bodies followed by CSF analysis, as a confirmatory test, when the result in the olfactory mucosa is incongruent with the initial clinical diagnosis., Perra et al. detected α-synuclein aggregates in olfactory mucosa and CSF samples of patients with dementia with Lewy bodies, using real-time quaking-induced conversion assay. Positivity in unpaired olfactory mucosa and CSF samples was significantly concordant with the clinical diagnosis and nearly 100% in participants in whom paired samples were tested., Graphical Abstract Graphical Abstract

Isolated REM sleep behaviour disorder (RBD) is an early-stage α-synucleinopathy in most, if not all, affected subjects. Detection of pathological α-synuclein in peripheral tissues of patients with isolated RBD may identify those progressing to Parkinson’s disease, dementia with Lewy bodies or multiple system atrophy, with the ultimate goal of testing preventive therapies. Real-time quaking-induced conversion (RT-QuIC) provided evidence of α-synuclein seeding activity in CSF and olfactory mucosa of patients with α-synucleinopathies. The aim of this study was to explore RT-QuIC detection of α-synuclein aggregates in olfactory mucosa of a large cohort of subjects with isolated RBD compared to patients with Parkinson’s disease and control subjects. This cross-sectional case-control study was performed at the Medical University of Innsbruck, Austria, the Hospital Clinic de Barcelona, Spain, and the University of Verona, Italy. Olfactory mucosa samples obtained by nasal swab in 63 patients with isolated RBD, 41 matched Parkinson’s disease patients and 59 matched control subjects were analysed by α-synuclein RT-QuIC in a blinded fashion at the University of Verona, Italy. Median age of patients with isolated RBD was 70 years, 85.7% were male. All participants were tested for smell, autonomic, cognitive and motor functions. Olfactory mucosa was α-synuclein RT-QuIC positive in 44.4% isolated RBD patients, 46.3% Parkinson’s disease patients and 10.2% control subjects. While the sensitivity for isolated RBD plus Parkinson’s disease versus controls was 45.2%, specificity was high (89.8%). Among isolated RBD patients with positive α-synuclein RT-QuIC, 78.6% had olfactory dysfunction compared to 21.4% with negative α-synuclein RT-QuIC (P

Purpose: This work is aimed at demonstrating that scraping cytology and scanning electron microscopy can successfully assist in the diagnosis of nontuberculous mycobacteria infection. For this purpose, we report the use of both these techniques in the diagnosis of cornel ulcer in a previously healthy young man. Methods: Cytological samples were achieved by scraping technique on the mucosa, both sub palpebral and temporal area of the eye tarsal conjunctiva. The obtained sample was affi xed to a sanded rectangular slide, stained with the Pappenheim method, washed in bidistilled water, treated in Giemsa solution, washed again and subsequently dried on a hot plate and observed with a microscope at various magnifi cations. Results: After a therapy based on a 500 mg clarithromycin tablet administered every 12 hours for 30 days as systemic therapy, a complete recovery of the patient from left eye infl ammation was observed and SEM cytology showed that NTM colonies had disappeared. Conclusion: Conjunctival cytology scraping and SEM technologies can be therefore exploited as new tools in diagnosis and fast identifi cation of these newly discovered mycobacteria. In fact, they have a new way for studying ocular pathology, because of the simple execution and remarkable accuracy in the diagnosis. In fact, this technique allows to gather valuable information about all pathogens expression and the cellular action involved in pathology. As a further plus, this technique provides clinicians with the opportunity to repeat the SEM cytology for monitoring patients during therapy, hence leading to evaluate the effi cacy of the pharmaceutical regimen in real time.

We applied RT-QuIC assay to detect α-synuclein aggregates in cerebrospinal fluid (CSF) of patients with suspected Creutzfeldt–Jakob disease who had a neuropathological diagnosis of dementia with Lewy bodies (DLB) (n=7), other neurodegenerative diseases with α-synuclein mixed pathology (n=20), or without Lewy-related pathology (n=49). The test had a sensitivity of 92.9% and specificity of 95.9% in distinguishing α-synucleinopathies from non-α-synucleinopathies. When performed in the CSF of patients with DLB (n=36), RT-QuIC was positive in 17/20 with probable DLB, 0/6 with possible DLB, and 0/10 with Alzheimer disease. These results indicate that RT-QuIC for α-synuclein is an accurate test for DLB diagnosis.

Background/aims Given the extent of osteoporosis in people with Duchenne muscular dystrophy treated with glucocorticoids and the limited evidence of bone-protective therapies, clinical trials are needed. We conducted surveys to obtain the opinion of young people with Duchenne muscular dystrophy, parents/guardians and neuromuscular clinicians on the feasibility of osteoporosis clinical trials in this population. Methods Online surveys were sent to three groups: (a) people with a confirmed diagnosis of Duchenne muscular dystrophy (≥14 years), (b) parents and guardians and (c) neuromuscular clinicians in the UK NorthStar Clinical Network. Surveys (a) and (b) were distributed via the UK Duchenne muscular dystrophy Registry. Results Survey respondents included 52 people with Duchenne muscular dystrophy with a median age of 17 years (range: 14, 40) and 183 parents/guardians. Fourteen out of 23 (61%) NorthStar centres responded. Of the 52 people with Duchenne muscular dystrophy, 13 (25%) were very concerned about their bone health and 21 (40%) were slightly concerned. Of the 183 parents/guardians, 75 (41%) were very concerned about their son’s bone health and 90 (49%) were slightly concerned. Fractures and quality of life were the top two main outcome measures identified by people with Duchenne muscular dystrophy. Fractures and bone density were the top two main outcome measures identified by parents/guardians and neuromuscular clinicians. Thirty percent of people with Duchenne muscular dystrophy and 40% of parents/guardians would not take part if an osteoporosis trial involved a placebo that was administered parenterally. Only 2 of the 14 NorthStar centres (14%) would enrol people with Duchenne muscular dystrophy if a parenteral placebo was used in an osteoporosis trial in Duchenne muscular dystrophy. Conclusion There is great awareness of bone health and the need for bone-protective trials among people with Duchenne muscular dystrophy and their carers. However, a proportion of people with Duchenne muscular dystrophy and parents are reluctant to participate in a placebo-controlled osteoporosis trial that included a parenteral therapy. A larger proportion of health care experts are unwilling to enrol their patients in such a trial. Our finding is relevant for the design of bone-protective studies in Duchenne muscular dystrophy.

As evidenced throughout this volume, sleep and psychiatry are deeply intertwined. Sleep and psychiatric processes share multiple biologic underpinnings, and sleep and psychiatric disorders are highly comorbid, with an additive adverse impact. Yet, much remains unknown, and much work remains to optimize treatments of sleep disorders in psychiatric populations. This chapter is to consider these issues with an eye toward the future. The chapter briefly considers sleep medicine education in psychiatry, drug development and novel compounds, consumer wearables, behavioral and complementary approaches, telehealth, and sleep health economics. The authors argue for the need to a value-based approach to sleep and psychiatry.

Isolated REM sleep behaviour disorder is an early-stage α-synucleinopathy in most, if not all, affected subjects. Detection of pathological alpha-synuclein in peripheral tissues of isolated REM sleep behaviour disorder patients may identify those progressing to Parkinson’s disease, dementia with Lewy bodies or multiple system atrophy, with the ultimate goal of testing preventive therapies. Real-Time Quaking-Induced Conversion provided evidence of α-synuclein seeding activity in cerebrospinal fluid and olfactory mucosa of patients with α-synucleinopathies. Aim of this study was to explore Real-Time Quaking-Induced Conversion detection of α-synuclein aggregates in olfactory mucosa of large cohort of subjects with isolated REM sleep behavior disorder compared to Parkinson’s disease and controls.This prospective bicentric case-control study was performed between October 2017 and December 2018 at the Medical University of Innsbruck, Austria, and the Hospital Clinic de Barcelona, Spain. Olfactory mucosa samples obtained by nasal swab in 63 patients with isolated REM sleep behavior disorder, 31 matched Parkinson’s disease patients and 59 matched controls were analysed by α-synuclein Real-Time Quaking-Induced Conversion in a blinded fashion at the University of Verona, Italy. Median age of isolated REM sleep behavior disorder patients was 70 years, 85.7% were male. All participants were tested for smell, autonomic, cognitive and motor functions.Olfactory mucosa was α-synuclein Real-Time Quaking-Induced Conversion positive in 44.4% isolated REM sleep behavior disorder patients, 41.9% Parkinson’s disease and 10.2% controls. While the sensitivity for isolated REM sleep behavior disorder plus Parkinson’s disease versus controls was 40.9%, specificity was high (89.8%). Among isolated REM sleep behavior disorder patients with positive α-synuclein Real-Time Quaking-Induced Conversion, 78.6% had olfactory dysfunction as compared to 21.4% with negative α-synuclein Real-Time Quaking-Induced Conversion, pReal-Time Quaking-Induced Conversion olfactory mucosa isolated REM sleep behavior disorder patients (pWe provide evidence that α-synuclein Real-Time Quaking-Induced Conversion assay enables the molecular detection of neuronal α-synuclein aggregates in olfactory mucosa of patients with isolated REM sleep behavior disorder and Parkinson’s disease. Although the overall sensitivity was moderate in this study, nasal swabbing is attractive as simple, non-invasive test, with a potential of use as screening test to identify subjects in the prodromal stages of α-synucleinopathies. Further studies are needed to enhance sensitivity, and better understand the temporal dynamics of α-synuclein seeding in the olfactory mucosa and spreading to other brain areas during the progression from isolated REM sleep behavior disorder to overt α-synucleinopathy.

Background. Concussions affect nearly 3 million people a year and are the leading cause of traumatic brain injury–related emergency department visits among youth. Evidence shows neuromotor regions are sensitive to concussive events and that motor symptoms may be the earliest clinical manifestations of neurodegenerative traumatic brain injuries. However, little is known about the effects repeated concussions play on motor learning. Namely, how does concussion acuity (time since injury) affect different behavioral and neurophysiological components of motor learning? Methods. Using a 3-pronged approach, we assessed (1) behavioral measures of motor learning, (2) neurophysiological measures underlying retention of motor learning known as occlusion, and (3) quantitative survey data capturing affective symptoms of each participant. Collegiate student athletes were stratified across 3 groups depending on their concussion history: (1) NonCon, no history of concussion; (2) Chronic, chronic-state of concussion (>1 year postinjury), or (3) Acute, acute state of concussion (

Background The impact of sleep disorders on active-duty soldiers’ medical readiness is not currently quantified. Patient data generated at military treatment facilities can be accessed to create research reports and thus can be used to estimate the prevalence of sleep disturbances and the role of sleep on overall health in service members. The current study aimed to quantify sleep-related health issues and their impact on health and nondeployability through the analysis of U.S. military healthcare records from fiscal year 2018 (FY2018). Methods Medical diagnosis information and deployability profiles (e-Profiles) were queried for all active-duty U.S. Army patients with a concurrent sleep disorder diagnosis receiving medical care within FY2018. Nondeployability was predicted from medical reasons for having an e-Profile (categorized as sleep, behavioral health, musculoskeletal, cardiometabolic, injury, or accident) using binomial logistic regression. Sleep e-Profiles were investigated as a moderator between other e-Profile categories and nondeployability. Results Out of 582,031 soldiers, 48.4% (n = 281,738) had a sleep-related diagnosis in their healthcare records, 9.7% (n = 56,247) of soldiers had e-Profiles, and 1.9% (n = 10,885) had a sleep e-Profile. Soldiers with sleep e-Profiles were more likely to have had a motor vehicle accident (pOR (prevalence odds ratio) =4.7, 95% CI 2.63–8.39, P ≤ 0.001) or work/duty-related injury (pOR = 1.6, 95% CI 1.32–1.94, P ≤ 0.001). The likelihood of nondeployability was greater in soldiers with a sleep e-Profile and a musculoskeletal e-Profile (pOR = 4.25, 95% CI 3.75–4.81, P ≤ 0.001) or work/duty-related injury (pOR = 2.62, 95% CI 1.63–4.21, P ≤ 0.001). Conclusion Nearly half of soldiers had a sleep disorder or sleep-related medical diagnosis in 2018, but their sleep problems are largely not profiled as limitations to medical readiness. Musculoskeletal issues and physical injury predict nondeployability, and nondeployability is more likely to occur in soldiers who have sleep e-Profiles in addition to these issues. Addressing sleep problems may prevent accidents and injuries that could render a soldier nondeployable.

Background Sleep loss negatively impacts stationary balance in a laboratory setting, but few studies have examined this link in a naturalistic environment. We tested this relationship in U.S. Army soldiers that often undergo mission-driven sleep loss and who conduct high-risk operations on precarious terrain. Methods Stationary balance was tested before and after a mission night. Results After mission-driven sleep loss, in more difficult conditions (but not easy conditions) balance was more unstable and more variable than a rested baseline condition. Furthermore, habitual sleep quality prior to sleep loss predicted the balance decrement after sleep loss. Conclusions Therefore, mission-driven sleep loss may negatively impact soldier balance, but better sleep prior to the mission may mitigate these negative effects.

Burke, TM, Lisman, PJ, Maguire, K, Skeiky, L, Choynowski, JJ, CapaldiII, VF, Wilder, JN, Brager, AJ, and Dobrosielski, DA. Examination of sleep and injury among college football athletes. J Strength Cond Res 34(3): 609-616, 2020-The purpose of this study was to characterize subjective sleep metrics in collegiate football players at the start of the season, determine the relationship between preseason subjective sleep measures and in-season objective sleep characteristics, and examine the association between subjective and objective sleep metrics and incidence of time-loss injury during the competitive season. Ninety-four Division I football players completed 5 validated sleep-related questionnaires to assess sleep quality, insomnia severity, daytime sleepiness, sleep apnea risk, and circadian preference before the start of the season. Clinical thresholds for sleep questionnaires were used to determine risk of sleep disorders. Continuous wrist actigraphy was collected throughout the season to generalize sleep behaviors. Time-loss injury incidence data were recorded and used for analysis. Results indicated that 67.4% (60 of 89) of athletes scored above clinical threshold in at least 1 questionnaire to indicate sleep disorder risk. At the start of the season, players subjectively reported an average sleep duration of 7:16 ± 1:18 hours:minutes, which was in contrast to the 6:04 ± 0:41 hours:minutes measured through actigraphy during the season. Logistic regression models adjusted for age and body mass index revealed no significant associations between injury and subjective (odds ratio [OR] = 1.00; 95% confidence interval [CI] = 0.99-1.01) and objective (OR = 1.01; 95% CI = 0.99-1.02) sleep duration or measures attained from sleep questionnaires (ORs ranged from 1.01 to 2.87). Sleep metrics (quantity and quality) were not associated with increased risk of injury in this cohort of collegiate football players.

Background and purpose The objective of this study was to assess the neurological manifestations in a series of consecutive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients, comparing their frequency with a population hospitalized in the same period for flu/respiratory symptoms, finally not related to SARS-CoV-2. Methods Patients with flu/respiratory symptoms admitted to Fondazione Policlinico Gemelli hospital from 14 March 2020 to 20 April 2020 were retrospectively enrolled. The frequency of neurological manifestations of patients with SARS-CoV-2 infection was compared with a control group. Results In all, 213 patients were found to be positive for SARS-CoV-2, after reverse transcriptase polymerase chain reaction on nasal or throat swabs, whilst 218 patients were found to be negative and were used as a control group. Regarding central nervous system manifestations, in SARS-CoV-2-positive patients a higher frequency of headache, hyposmia and encephalopathy always related to systemic conditions (fever or hypoxia) was observed. Furthermore, muscular involvement was more frequent in SARS-CoV-2 infection. Conclusions Patients with COVID-19 commonly have neurological manifestations but only hyposmia and muscle involvement seem more frequent compared with other flu diseases.

The early and accurate in vivo diagnosis of sporadic Creutzfeldt&ndash, Jakob disease (sCJD) is essential in order to differentiate CJD from treatable rapidly progressive dementias. Diagnostic investigations supportive of clinical CJD diagnosis include magnetic resonance imaging (MRI), electroencephalogram (EEG), 14-3-3 protein detection, and/or real-time quaking-induced conversion (RT-QuIC) assay positivity in the cerebrospinal fluid (CSF) or in other tissues. The total CSF tau protein concentration has also been used in a clinical setting for improving the CJD diagnostic sensitivity and specificity. We analyzed 182 CSF samples and 42 olfactory mucosa (OM) brushings from patients suspected of having sCJD with rapidly progressive dementia (RPD), in order to determine the diagnostic accuracy of 14-3-3, the total tau protein, and the RT-QuIC assay. A probable and definite sCJD diagnosis was assessed in 102 patients. The RT-QuIC assay on the CSF samples showed a 100% specificity and a 96% sensitivity, significantly higher compared with 14-3-3 (84% sensitivity and 46% specificity) and tau (85% sensitivity and 70% specificity), however, the combination of RT-QuIC testing of the CSF and OM samples resulted in 100% sensitivity and specificity, proving a significantly higher accuracy of RT-QuIC compared with the surrogate biomarkers in the diagnostic setting of patients with RPD. Moreover, we showed that CSF blood contamination or high protein levels might interfere with RT-QuIC seeding. In conclusion, we provided further evidence that the inclusion of an RT-QuIC assay of the CSF and OM in the diagnostic criteria for sCJD has radically changed the clinical approach towards the diagnosis.

Highlights • NENs are rare tumors with extremely variable behavior: they are difficult to diagnose, especially if biologically inactive. • NENs can originate from any epithelial organ and present unusual metastases. • NEN surgery is a valid treatment and a necessary tool for correct diagnosis. • NEN classification is evolving and being discussed. • Careful collection of anamnestic data and a correct analysis of patients’ symptoms can be a valuable resource., Introduction NeuroEndocrine Neoplasms (NENs) are rare and can originate from any epithelial organ. We describe a very rare case of retroperitoneal metastasis from a non-functioning neuroendocrine tumor of the ethmoid region and focus on the various issues related to NENs, from their nosological classification up to the most recent acquisitions in the diagnostic and therapeutic field. Presentation of case A woman presented with a mass in the right retroperitoneal area that infiltrated liver and kidney. The anamnestic data showed a previous undifferentiated small cell tumor of the left ethmoid-nasal-orbital region. The mass was removed surgically and the definitive histological examination revealed a non-functioning undifferentiated malignant small cell neoplasm. Discussion NENs represent a chapter of oncology whose systematization remains difficult. The lack of hormonal syndrome in Biologically Inactive Neuroendocrine Tumors (BINTs) may delay the diagnosis. Clinical manifestations relate to the size and location of the neoplasm. Small cell NeuroEndocrine Carcinoma (NEC) of the ethmoid-nose-orbital region is an extremely rare occurrence and generally the most frequent metastatic localization is represented by the larynx. Conclusion This case highlights the contradictions typical of NENs and only new scientific acquisitions in the histopathological field can help us in the future. Surgery remains the only possibility of treatment and diagnosis of large masses of inactive NENs. This is the only case in the world of metastasis from NEC of the nose-orbital region in the retroperitoneum.

The presence of obstructive sleep apnea (OSA) in ambulatory surgical patients causes significant perioperative concern; however, few data exist to guide clinicians' management decisions. The objective of this study was to measure changes in perioperative sleep parameters among an ambulatory surgery population.This study is a prospective, observational study of ambulatory patients undergoing orthopedic surgery on an extremity. Study subjects completed three unattended home sleep apnea tests: baseline before surgery, the first night after surgery (N1), and third night after surgery (N3). Anesthesia and surgical teams were blinded to study participation and patients received routine perioperative care.Two hundred three subjects were enrolled and 166 completed the baseline home sleep test. Sixty-six (40.0%) had OSA at baseline, 35 patients received a new diagnosis, and 31 patients had a previous diagnosis of OSA. Of those with a previous diagnosis, 20 (64.5%) were compliant with continuous positive airway pressure therapy. Respiratory event index and SpOAmbulatory surgery had minimal effect on sleep parameters and there was no increase in adverse events among patients with either treated or untreated OSA.Registry: ClinicalTrials.gov; Title: Evaluation of Sleep Disordered Breathing Following Ambulatory Surgery; Identifier: NCT01851798; URL: https://clinicaltrials.gov/ct2/show/study/NCT01851798.

Rationale and Objectives In patients with severe emphysema and poor quality of life, bronchoscopic lung volume reduction (BLVR) may be considered and guided based on lobar emphysema severity. In particular, x-ray computed tomography (CT) emphysema measurements are used to identify the most diseased and the second–most diseased lobes as BLVR targets. Inhaled gas magnetic resonance imaging (MRI) also provides chronic obstructive pulmonary disease (COPD) biomarkers of lobar emphysema and ventilation abnormalities. Our objective was to retrospectively evaluate CT and MRI biomarkers of lobar emphysema and ventilation in patients with COPD eligible for BLVR. We hypothesized that MRI would provide complementary biomarkers of emphysema and ventilation that help determine the most appropriate lung lobar targets for BLVR in patients with COPD. Materials and Methods We retrospectively evaluated 22 BLVR-eligible patients from the Thoracic Imaging Network of Canada cohort (diffusing capacity of the lung for carbon monoxide = 37 ± 12%predicted, forced expiratory volume in 1 second = 34 ± 7%predicted, total lung capacity = 131 ± 17%predicted, and residual volume = 216 ± 36%predicted). Lobar CT emphysema, measured using a relative area of Results In 7 of 22 patients, there were different CT and MRI predictions of the most diseased lobe. In some patients, there were large ventilation defects in lobes not targeted by CT, indicative of a poorly ventilated lung. CT and MRI classification of the most diseased and the second–most diseased lobes showed a fair-to-moderate intermethod reliability (Cohen κ = 0.40–0.59). Conclusions In this proof-of-concept retrospective analysis, quantitative MRI ventilation and CT emphysema measurements provided different BLVR targets in over 30% of the patients. The presence of large MRI ventilation defects in lobes next to CT-targeted lobes might also change the decision to proceed or to guide BLVR to a different lobar target.

PURPOSE Recent pulmonary imaging research has revealed that in patients with chronic obstructive pulmonary disease (COPD) and asthma, structural and functional abnormalities are spatially heterogeneous. This novel information may help optimize treatment in individual patients, monitor interventional efficacy, and develop new treatments. Moreover, by automating the measurement of regional biomarkers for the 19 different anatomical lung segments, there is an opportunity to embed imaging biomarkers into clinically acceptable clinical workflows and improve lung disease clinical care. Therefore, to exploit the regional structure-function information provided by thoracic imaging, and as a first step toward this goal, our objective was to develop a fully automated registration pipeline for thoracic x-ray computed tomography (CT) and inhaled gas functional magnetic resonance imaging (MRI) whole lung and segmental structure-function biomarkers. METHODS Thirty-five patients including 15 severe, poorly controlled asthmatics and 20 COPD patients [classified according to the global initiative for chronic obstructive lung disease (GOLD) criteria)] provided written informed consent to a study protocol approved by Health Canada and underwent pulmonary function tests, MRI, and CT during a single 2-hour visit. Using this diverse patient dataset, we developed and evaluated a joint deformable registration approach to simultaneously coregister CT with both 1 H and 3 He MRI by enforcing the similarity of the deformation fields from the two individual registrations. We derived a simpler model that was equivalent to the original challenging optimization problem through variational analysis and the simpler model gave rise to an efficient numerical solver that was parallelized on a graphics processing unit. The coregistered CT-3 He MRI and whole lung/segmental lung masks were used to generate whole lung and segmental 3 He MRI ventilation defect percent (VDP). To estimate fiducial localization reproducibility, a single observer manually identified 109 pairs of CT and 3 He MRI fiducials for 35 patient images on five separate occasions and determined the fiducial localization error (FLE). CT-3 He MRI registration accuracy was evaluated using the target registration error (TRE). Whole lung VDP generated using the algorithm was compared with VDP generated using a previously validated semiautomated approach and computational efficiency was evaluated using run time. RESULTS In 35 patients including 15 with severe asthma and 20 with COPD, mean forced expiratory volume in 1 s (FEV1 ) was 63±24%pred and FEV1 /forced vital capacity (FVC) was 54 ± 17%. FLE was 0.16 mm and 0.34 mm for 3 He MRI and CT, respectively. TRE was 4.5 ± 2.0 mm, 4.0 ± 1.7 mm, 4.8 ± 2.3 mm for asthma, COPD GOLD II, and GOLD III groups, respectively, with a mean of 4.4 ± 2.0 mm for the entire dataset. TRE was significantly improved for joint CT-1 H/3 He MRI registration compared with CT-1 H MRI rigid registration (P

Military medical research is critical for enhancing overall well-being and readiness of military service members. Recently, in the USA, military research budget allocation has shifted from basic research to more translational research and rapid development of fieldable products.[1][1] To meet this

Telemedicine is a novel modality of health care delivery that can improve patients' access to sleep medicine services, but little is known about telemedicine training during sleep medicine fellowship. We studied telemedicine training prevalence, use, and attitudes of program directors (PDs) and other faculty members, PDs' receptiveness to a standardized telemedicine curriculum, and whether PDs have reviewed existing American Academy of Sleep Medicine (AASM) sleep telemedicine reference materials.This was an anonymous online survey of all 86 PDs of accredited sleep medicine fellowships in the United States.Response rate was 45%. Thirteen (33.3%) of the PDs already offer telemedicine experience to their trainees, although none use a standard telemedicine curriculum. Among the 26 (66.7%) PDs not offering telemedicine experience, 38.5% plan to do so and 53.9% agree that it would benefit fellows. Most PDs (57.9%) report faculty using telemedicine now or within the next 3 years. Many PDs agree that telemedicine is technically feasible, but relatively few agree it is financially feasible (82.1% and 38%, respectively). Few PDs have reviewed both primary AASM telemedicine reference materials. Overall, 64.1% of PDs agree that a national sleep telemedicine curriculum could be useful.Although only a minority of current sleep medicine fellows are exposed to telemedicine, it is likely that most will get some exposure in the next 3 years. PDs' attitudes toward telemedicine vary significantly with respect to feasibility and importance to their programs. Nevertheless, most PDs believe a standardized sleep telemedicine training curriculum could be useful.

Introduction The bi-directional relationship between sleep and immune function is well-established. Sufficient sleep supports immune health and can increase vaccine efficacy. Conversely, sickness can disturb sleep quality, which can delay recovery and waking functioning. However, the bidirectional relationship between sleep and infectious diarrhea, the leading infectious disease threat to deployed military populations, has not been studied. We assessed the bi-directional relationship between sleep and enteric disease utilizing data from a recently-completed controlled human infection model (CHIM) with enterotoxigenic Escherichia coli (ETEC). Methods During a CHIM to assess the efficacy of an immunoprophylactic targeting ETEC (NCT03040687), we measured sleep via actigraphy over an 8-day inpatient period. Participants ingested prophylaxis 3 times/day during days -2 and -1 and ingested ETEC on day 0. The primary outcome was moderate-severe diarrhea following the ETEC challenge. We hypothesized better sleep pre-challenge would reduce risk of disease after the challenge (assessed using linear regression). We also hypothesized total sleep time (TST) and sleep efficiency (SE) after the challenge would be lower/poorer than baseline (assessed using paired t-test). Results Among 59 participants (aged 34.4±8.1yrs, 64% female), longer TST the night preceding ETEC challenge was associated with lower total diarrhea volume (B=-3.13,p=.001). SE was slightly but significantly poorer after the challenge (78 vs. 76%; t(55)=2.2,p=.03), but there was no significant change in TST, potentially due to low TST pre-challenge (316 vs. 329 minutes; p=0.12). Conclusion These results - in aggregation with previous work on sleep and vaccines - suggest military sleep regulations should be put in place to increase sleep prior to traveling to an area of responsibility with high risk for enteric disease. These minor behavioral changes could provide lasting benefits to readiness of military servicemembers. Support This work was supported by Joint Warfighter Medical Research Program (JWMRP) and the Military Operational Medicine Research Program (MOMRP). The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Army or of the US Department of Defense. This abstract has been approved for public release with unlimited distribution.

Introduction The impact of sleep disorders on active duty Soldiers’ medical readiness is clinically significant. Sleep disorders present high comorbidity with disease states directly impacting medical readiness, ranging from musculoskeletal injury (MSK-I), obesity, and drug dependence. The current study performed a risk assessment of sleep disorder comorbidity with MSK-I, obesity, and drug dependence across active duty United States Army installations. Methods Health incidences (percent active duty per installation) were queried from the Office of the Surgeon General Health of the Force (HoF) report, specifically for Fiscal Year (FY) 2017 (n = 471,000; 85.5% male, > 70% between 18 -34). Nonparametric ranked tests identified active duty Army installations at low risk (green; < 25% percentile relative to mean rank), moderate risk (amber; 25% - 50%), and high risk (red; > 75% percentile). Linear regressions determined extent of comorbidity of sleep disorders with MSK-I, obesity, and drug dependence (tobacco use and substance abuse). Results Mean rank comparisons for sleep disorders vs. injury index (p=0.499), obesity (p=0.306), tobacco use (p=0.378), and substance abuse (p=0.591) did not differ for each installation. Further, there was a high degree of co-morbidity for mean percentage of diagnosed sleep disorder with injury index (p Conclusion In general, large infantry and artillery training units located in the Southeastern United States were “in the red” for not meeting medical readiness standards. A few exceptions include Virginia-Maryland triangle, a heavily populated area. These data demonstrate strong geographical influences on health risk comorbidity in active duty Soldiers comparable to civilian sectors. Support Military Operational Medicine Research Program

When a patient is diagnosed with head and neck cancer, their oral health will likely be the last thing on their mind. Dentist Francesca Capaldi and dental nurse Catriona Arnott explain the best approach

Objective The prevalence of misuse of prescription opioids across adulthood and the associations of such misuse with symptoms of psychopathology and use of other substances were examined for an at-risk community sample of men. Method For a longitudinal study of boys (N = 206) followed to adulthood, misuse of prescription opioids was assessed on 13 occasions from ages 20-21 years to 37-38 years. Prediction of misuse was examined from prospectively assessed risk factors in 3 models: (a) parental substance use during the men's adolescence; (b) the men's own risk behaviors in adolescence-delinquent behavior, depressive symptoms, and use of tobacco, alcohol, marijuana, and opioids; and (c) within- and between-individual effects of the men's risk behaviors during adulthood. Results Opioid misuse was reported by 29% of men. After accounting for effects of age and considered individually, parent marijuana use and all of the adolescent and adult risk factors (except adolescent depressive symptoms) were significant between-individual predictors of opioid misuse. Furthermore, within-individual prediction was significant for adult delinquency and alcohol use after accounting for increases in opioid misuse with age. When risk factors were tested simultaneously, men's adult delinquency and use of marijuana and tobacco remained significant between-individual predictors, whereas no parental or adolescent risk factors remained significant in these models. Conclusion Both adolescent and adult risk factors were examined that predicted adult opioid misuse. Preventing adolescent problem behavior and using such histories to inform screening for misuse risk in adulthood may reduce the burden of the opioid crisis. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Study Objectives The purpose of the present study was to assess the extent to which sleep extension followed by sleep deprivation impacts performance on an attentional task with varying cognitive and attentional demands that influence decisions. Methods Task performance was assessed at baseline, after 1 week of sleep extension, and after 40 h of total sleep deprivation. Results One week of sleep extension resulted in improved performance, particularly for high cognitive load decisions regardless of the emotional salience of attentional distractors. Those who extended sleep the most relative to their habitual sleep duration showed the greatest improvement in general performance during sleep extension. However, a higher percentage of time spent in slow-wave sleep (SWS) on the last night of the sleep extension phase was negatively correlated with performance on more difficult high cognitive load items, possibly reflecting a relatively higher level of residual sleep need. Sleep deprivation generally resulted in impaired performance, with a nonsignificant trend toward greater performance decrements in the presence of emotionally salient distractors. Performance overall, but specifically for high cognitive load decisions, during total sleep deprivation was negatively correlated with longer sleep and higher SWS percentage during subsequent recovery sleep. Conclusions The present findings suggest two possibilities: those who performed relatively poorly during sleep deprivation were more vulnerable because (1) they utilized mental resources (i.e. accrued sleep debt) at a relatively faster rate during wakefulness, and/or (2) they failed to “pay down” pre-study sleep debt to the same extent as better-performing participants during the preceding sleep extension phase.

Background\ud \ud STAMPEDE has previously reported that the use of upfront docetaxel improved overall survival (OS) for metastatic hormone naïve prostate cancer patients starting long-term androgen deprivation therapy. We report on long-term outcomes stratified by metastatic burden for M1 patients.\ud \ud \ud \ud Methods\ud \ud We randomly allocated patients in 2 : 1 ratio to standard-of-care (SOC; control group) or SOC + docetaxel. Metastatic disease burden was categorised using retrospectively-collected baseline staging scans where available. Analysis used Cox regression models, adjusted for stratification factors, with emphasis on restricted mean survival time where hazards were non-proportional.\ud \ud \ud \ud Results\ud \ud Between 05 October 2005 and 31 March 2013, 1086 M1 patients were randomised to receive SOC (n = 724) or SOC + docetaxel (n = 362). Metastatic burden was assessable for 830/1086 (76%) patients; 362 (44%) had low and 468 (56%) high metastatic burden. Median follow-up was 78.2 months. There were 494 deaths on SOC (41% more than the previous report). There was good evidence of benefit of docetaxel over SOC on OS (HR = 0.81, 95% CI 0.69–0.95, P = 0.009) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P = 0.827). Analysis of other outcomes found evidence of benefit for docetaxel over SOC in failure-free survival (HR = 0.66, 95% CI 0.57–0.76, P 0.5 in each case). There was no evidence that docetaxel resulted in late toxicity compared with SOC: after 1 year, G3-5 toxicity was reported for 28% SOC and 27% docetaxel (in patients still on follow-up at 1 year without prior progression).\ud \ud \ud \ud Conclusions\ud \ud The clinically significant benefit in survival for upfront docetaxel persists at longer follow-up, with no evidence that benefit differed by metastatic burden. We advocate that upfront docetaxel is considered for metastatic hormone naïve prostate cancer patients regardless of metastatic burden.

Purpose To develop and assess ultrashort echo-time (UTE) magnetic resonance imaging (MRI) biomarkers of lung function in asthma patients. Materials and Methods Thirty participants including 13 healthy volunteers and 17 asthmatics provided written informed consent to UTE and pulmonary function tests in addition to hyperpolarized-noble-gas 3T MRI and computed tomography (CT) for asthmatics only. The difference in MRI signal-intensity (SI) across four lung volumes (full-expiration, functional-residual-capacity [FRC], FRC+1L, and full-inspiration) was determined on a voxel-by-voxel basis to generate dynamic proton-density (DPD) maps. MRI ventilation-defect-percent (VDP), UTE SI, and DPD values as well as CT radiodensity were determined for whole lung and individual lobes. Results Mean SI at full-expiration (P < 0.01), FRC (P < 0.05), and DPD (P < 0.01) were greater in healthy volunteers compared to asthmatics. In asthmatics, UTE SI at full-expiration and DPD were correlated with FEV1/FVC (SI r = 0.73/P = 0.002; DPD r = 0.75/P = 0.003), RV/TLC (SI r = –0.57/P = 0.02), or RV (DPD r = –0.62/P = 0.02), CT radiodensity (SI r = 0.83/P = 0.006; DPD r = 0.71/P = 0.01), and lobar VDP (SI rs = –0.33/P = 0.02; DPD rs = –0.47/P = 0.01). Conclusion In patients with asthma, UTE SI and dynamic proton-density were related to pulmonary function measurements, whole lung and lobar VDP, as well as CT radiodensity. Thus, UTE MRI biomarkers may reflect ventilation heterogeneity and/or gas-trapping in asthmatics using conventional equipment, making this approach potentially amenable for clinical use. Level of Evidence 2 J. Magn. Reson. Imaging 2016.