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Orjola Shahaj,1 Anne Meiwald,1 Krishnan Puri Sudhir,1 Rupert Gara-Adams,1 Peter Wark,2 Alexis Cazaux,3 Abelardo Elizondo Rios,4 Sergey N Avdeev,5 Elisabeth J Adams1 1Aquarius Population Health, London, UK; 2Respiratory and Sleep Medicine, John Hunter Hospital, New Castle, Australia; 3Pulmonary and Respiratory Medicine, Universidad Nacional de Cordoba, Cordoba, Argentina; 4Intensive Pneumology, Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico; 5Respiratory Medicine, Sechenov First Moscow State Medical University, Moscow, RussiaCorrespondence: Elisabeth J Adams, Aquarius Population Health, Unit 29 Tileyard Studios, London, N7 9AH, UK, Tel +44 207 993 2930, Email elisabeth.adams@aquariusph.comPurpose: Chronic obstructive pulmonary disease (COPD) poses a significant global health burden despite being largely preventable and treatable. Despite the availability of guidelines, COPD care remains suboptimal in many settings, including high-income countries (HICs) and upper-middle-income countries (UMICs), with varied approaches to diagnosis and management. This study aimed to identify common and unique barriers to COPD care across six countries (Australia, Spain, Taiwan, Argentina, Mexico, and Russia) to inform global policy initiatives for improved care.Methods: COPD care pathways were mapped for each country and supplemented with epidemiological, health-economic, and clinical data from a targeted literature review. Semi-structured interviews with 17 respiratory care clinicians were used to further validate the pathways and identify key barriers. Thematic content analysis was used to generate the themes.Results: Six themes were common in most HICs and UMICs: “Challenges in COPD diagnosis”, “Strengthening the role of primary care”, “Fragmented healthcare systems and coordination challenges”, “Inadequate management of COPD exacerbations”, “Limited access to specialized care” and, “Impact of underfinanced and overloaded healthcare systems”. One theme, “Insurance coverage and reimbursement challenges”, was more relevant for UMICs. HICs and UMICs differ in patient and healthcare provider awareness, primary care involvement, spirometry access, and availability of specialized care. Both face issues with healthcare fragmentation, guideline adherence, and COPD exacerbation management. In addition, UMICs also grapple with resource limitations and healthcare infrastructure challenges.Conclusion: Many challenges to COPD care are the same in both HICs and UMICs, underscoring the pervasive nature of these issues. While country-specific issues require customized solutions, there are untapped possibilities for implementing global respiratory strategies that support countries to manage COPD effectively. In addition to healthcare system-level initiatives, there is a crucial need for political prioritization of COPD to allocate the essential resources it requires.Keywords: COPD, barriers, qualitative research, healthcare systems, global policy

David J Stevens,1 Sarah Appleton,1 Kelsey Bickley,1 Louis Holtzhausen,2– 4 Robert Adams1,5 1Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; 2Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar; 3Section Sports Medicine, Faculty of Health Science, University of Pretoria, Pretoria, South Africa; 4Department of Exercise and Sport Science, University of the Free State, Bloemfontein, South Africa; 5Respiratory and Sleep Services, Southern Adelaide Local Health Network, Bedford Park, South Australia, AustraliaCorrespondence: David J Stevens, Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Level 2a, 5 Laffer Dve, Bedford Park, South Australia, 5041, Australia, Tel +61 7306 1816, Email david.stevens@flinders.edu.auPurpose: Little is known about sleep after a concussion, a form of mild traumatic brain injury. Given the importance of sleep for both maintaining brain health and recovery from injury, we sought to examine sleep acutely and subacutely after concussion.Methods: Athletes who experienced a sports-related concussion were invited to participate. Participants underwent overnight sleep studies within 7 days of the concussion (acute phase), and again eight-weeks after the concussion (subacute phase). Changes in sleep from both the acute and subacute phases were compared to population normative values. Additionally, changes in sleep from acute to subacute phase were analysed.Results: When compared to normative data, the acute and subacute phases of concussion showed longer total sleep time (p < 0.005) and fewer arousals (p < 0.005). The acute phase showed longer rapid eye movement sleep latency (p = 0.014). The subacute phase showed greater total sleep spent in Stage N3% (p = 0.046), increased sleep efficiency (p < 0.001), shorter sleep onset latency (p = 0.013), and reduced wake after sleep onset (p = 0.013). Compared to the acute phase, the subacute phase experienced improved sleep efficiency (p = 0.003), reduced wake after sleep onset (p = 0.02), and reduced latencies for both stage N3 sleep (p = 0.014) and rapid eye movement sleep (p = 0.006).Conclusion: This study indicated sleep during both the acute and subacute phases of SRC was characterised by longer and less disrupted sleep, along with improvements in sleep from the acute to subacute phases of SRC.Keywords: mild traumatic brain injury, somnolence, neural trauma, nocturnal activity

Bastien Lechat,1 Kelly A Loffler,1 Douglas M Wallace,2,3 Amy Reynolds,1 Sarah L Appleton,1 Hannah Scott,1 Andrew Vakulin,1,4 Nicole Lovato,1,4 Robert Adams,1,4 Danny J Eckert,1 Peter G Catcheside,1 Alexander Sweetman1,4 1Adelaide Institute for Sleep Health and FHMRI Sleep Health, Flinders University, Adelaide, South Australia, Australia; 2Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine, Miami, FL, USA; 3Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Centre, Miami, FL, USA; 4National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia, AustraliaCorrespondence: Bastien Lechat, Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute: Sleep Health, Level 2A, Mark Oliphant Building, 5 Laffer Drive, Flinders University, Bedford Park, South Australia, 5042, Australia, Email bastien.lechat@flinders.edu.auPurpose: Insomnia symptoms and sleep apnea frequently co-occur and are associated with worse sleep, daytime function, mental health and quality of life, compared to either insomnia or obstructive sleep apnea (OSA) alone. This study aimed to investigate the association of symptoms of co-morbid insomnia and sleep apnea (COMISA) with all-cause mortality.Patients and Methods: Wisconsin Sleep Cohort data were analysed to assess potential associations between COMISA symptoms and all-cause mortality. Nocturnal insomnia symptoms were defined as difficulties initiating sleep, maintaining sleep, and/or early morning awakenings “often” or “almost always”, and/or regular sedative-hypnotic medicine use. OSA was defined as an apnea-hypopnea index ≥ 5/hr sleep. Participants were classified as having neither insomnia symptoms nor OSA, insomnia symptoms alone, OSA alone, or COMISA symptoms. Associations between the four groups and all-cause mortality over 20 years of follow-up were examined via multivariable adjusted Cox regression models.Results: Among 1115 adult participants (mean ± SD age 55 ± 8 years, 53% males), 19.1% had COMISA symptoms. After controlling for sociodemographic and behavioral factors, COMISA symptoms were associated with an increased risk of all-cause mortality compared to no insomnia symptoms or OSA (HR [95% CI]; 1.71 [1.00– 2.93]). OSA alone (0.91 [0.53, 1.57]) and insomnia symptoms alone (1.04 [0.55, 1.97]) were not associated with increased mortality risk.Conclusion: Co-morbid insomnia symptoms and sleep apnea is associated with increased all-cause mortality risk. Future research should investigate mechanisms underpinning COMISA and the effectiveness of different treatment approaches to reduce mortality risk for this common condition.Keywords: sleep disordered breathing, Wisconsin Sleep Cohort, COMISA, obstructive, sleep apnea, insomnia, respiratory

Anne Meiwald,1 Rupert Gara-Adams,1 Aleix Rowlandson,1 Yixuan Ma,1 Henrik Watz,2 Masakazu Ichinose,3 Jane Scullion,4 Tom Wilkinson,5,6 Mohit Bhutani,7 Georgie Weston,1 Elisabeth J Adams1 1Aquarius Population Health, London, UK; 2Pulmonary Research Institute, LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Schleswig-Holstein, Germany; 3Academic Center, Osaki Citizen Hospital, Miyagi, Japan; 4Bush & Co, Northamptonshire, UK; 5Faculty of Medicine, Southampton University, Southampton, Hampshire, UK; 6Respiratory and Allergy, NIHR Southampton Biomedical Research Centre, Southampton, Hampshire, UK; 7Department of Medicine, University of Alberta, Edmonton, Alberta, CanadaCorrespondence: Elisabeth J Adams, Aquarius Population Health, Unit 29 Tileyard Studios, London, N7 9AH, UK, Tel +44 (0)207 993 2930, Email elisabeth.adams@aquariusph.comBackground: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. A comprehensive and detailed understanding of COPD care pathways from pre-diagnosis to acute care is required to understand the common barriers to optimal COPD care across diverse health systems.Methods: Country-specific COPD care pathways were created for four high-income countries using international recommendations and country-specific guidelines, then populated with published epidemiological, clinical, and economic data. To refine and validate the pathways, semi-structured interviews using pre-prepared discussion guides and country-specific pathway maps were held with twenty-four primary and secondary care respiratory healthcare professionals. Thematic analysis was then performed on the interview transcripts.Results: The COPD care pathway showed broad consistency across the countries. Three key themes relating to barriers in optimal COPD management were identified across the countries: journey to diagnosis, treatment, and the impact of COVID-19. Common barriers included presentation to healthcare with advanced COPD, low COPD consideration, and sub-optimal acute and chronic disease management. COVID-19 has negatively impacted disease management across the pathway but presents opportunities to retain virtual consultations. Structural factors such as insurance and short duration of appointments also impacted the diagnosis and management of COPD.Conclusion: COPD is an important public health issue that needs urgent prioritization. The use of Evidenced Care Pathways with decision-makers can facilitate evidence-based decision making on interventions and policies to improve care and outcomes for patients and reduce unnecessary resource use and associated costs for the healthcare provider/payer.Keywords: health policy, COPD management, COPD diagnosis, exacerbations, qualitative, pathway mapping

David Stevens,1 Sarah Appleton,1– 3 Andrew D Vincent,4,5 Yohannes Melaku,1 Sean Martin,3,4 Tiffany Gill,4 Catherine Hill,4,6 Andrew Vakulin,1,7 Robert Adams,1,2,8 Gary Wittert2,3,5 1Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia; 2The Health Observatory, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; 3Freemason Foundation Centre for Men’s Health, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; 4Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; 5Centre of Nutrition and Gastrointestinal Diseases, Nutrition Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; 6Rheumatology Unit, The Queen Elizabeth Hospital and the Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia; 7Sleep and Circadian Research Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; 8Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, SA, AustraliaCorrespondence: David StevensAdelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Level 2a, 5 Laffer Drive, Bedford Park, Adelaide, SA 5042, AustraliaTel +61 8 7221 8306Email david.stevens@flinders.edu.auPurpose: Reduced hand grip strength (HGS) is associated with poorer health in chronic conditions, yet there has been little research examining the association with hand grip strength and obstructive sleep apnea (OSA). Further, these studies have not examined, nor adjusted, for muscle mass. The aim of this study was to determine associations between OSA indices, HGS, muscle mass, and fat mass.Participants and Methods: A total of 613 participants (age range 41– 88, BMI 28.6 ± 4.3) from the population-based Men Androgen Inflammation Lifestyle Environment and Stress Study underwent in-home overnight polysomnography, assessment of dominant and non-dominant HGS, and dual x-ray absorptiometry to determine whole body muscle mass and fat mass. Linear models determined cross-sectional associations of polysomnographic-derived OSA indices with hand grip strength, muscle mass, and fat mass, whilst adjusting for lifestyle information (income, smoking status, diet, self-reported physical activity), blood sample derived testosterone and systemic inflammation (C-reactive protein), cardiometabolic health (cardiovascular disease, hypertension, type 2 diabetes), and depression.Results: In adjusted models, reduced dominant HGS was associated with lower oxygen nadir (unstandardised β [B] = 0.19, 95% confidence interval [CI] 0.08 to 0.29), greater time spent below 90% oxygen saturation (B = − 0.08, 95% CI − 0.14 to − 0.02), and increased apnea duration (B = − 0.3, 95% CI − 0.23 to − 0.02). By contrast, there were no associations between HGS and both AHI and REM AHI. Fat mass was consistently associated with worsening OSA indices, whereas muscle mass demonstrated no associations with any OSA index.Conclusion: Our findings suggest impairments in HGS may be related to fat infiltration of muscle, hypoxemia-induced reductions in peripheral neural innervation, or even endothelial dysfunction, which is a common outcome of hypoxemia. Longitudinal data are needed to further examine these hypotheses and establish if reduced grip strength in patients with OSA is associated with long-term adverse health outcomes.Keywords: grip strength, muscle mass, intermittent hypoxemia, myosteatosis

Sumit Mehra,1,2 Ram H Ghimire,1 Joy J Mingi,3,4 Monica Hatch,1 Himanshu Garg,1 Robert Adams,5 Subash S Heraganahally1,3 1Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia; 2Department of Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia; 3Darwin Respiratory and Sleep Health, Darwin Private Hospital, Darwin, Northern Territory, Australia; 4Department of Public Health, Charles Darwin University, Darwin, Northern Territory, Australia; 5Adelaide Institute for Sleep Health, a Flinders Centre for Research Excellence, Bedford Park, South Australia, AustraliaCorrespondence: Subash S Heraganahally Email hssubhashcmc@hotmail.comBackground: In this study, we assessed the clinical and polysomnographic (PSG) characteristics according to gender among Australian Aboriginal men and woman diagnosed to have obstructive sleep apnea (OSA).Methods: In this retrospective study, all adult Aboriginal patients over 18 years of age diagnosed to have OSA with an apnea hypopnea index (AHI) > 5/hour over a 5 year period were included.Results: Of the 337 patients (168 females and 169 males), who underwent a diagnostic PSG, 297 (88%) were diagnosed to have OSA (AHI) > 5/hour), 154/297 males (52%) and 143/297 females (48%). Amongst male and female patients with OSA, 63% and 37% were in the severe spectrum (AHI> 30/hour). The male cohort had higher stage N1 NREM sleep (P< 0.001), reduced N3 NREM sleep (P< 0.001), higher AHI severity (P< 0.001), higher NREM AHI (P< 0.001), and high arousal index (P< 0.005). REM sleep-related AHI was higher among female patients with all severity of OSA, along with severe oxygen desaturation during REM sleep. Among patients with severe OSA, the female cohort were younger (age 46 years vs 49 years, P=0.030) and had higher BMI with all severity of OSA, while males had larger neck circumference compared to females. Hypertension increased the odds of severe OSA versus the combined odds of mild and moderate OSA for both genders.Conclusion: This study highlights some important differences in the way sleep apnea manifests in Australian Aboriginal males and females and further studies are warranted to explore avenues to look for a physiological basis for these observations and targeted interventions.Keywords: aboriginal, ethnic, female, gender, male, obstructive sleep apnea