Search

There is potential to cause deterioration due to hypoxia in patients with acute exacerbation of obstructive airways disease with the indiscriminate use of aerosol bronchodilators delivered by air-driven nebulisers without supplemental oxygen. Traditionally, air-driven nebulisers have been reserved for the treatment of chronically hypoxic and hypercapnic patients with an exacerbation of chronic obstructive pulmonary disease (COPD). The purpose of this pilot study was to assess the safety of oxygen-driven nebulisers (6 L/min) in the treatment of COPD patients. Sixteen patients received bronchodilator via an oxygen-driven nebuliser for 30 minutes. No patient deteriorated clinically and in all the PaO2 rose significantly (mean baseline 43.7 ± 6.3 mmHg (± SD) post nebuliser 108.8 ± 30.4 mmHg). There was an insignificant rise in PaC02 from 59.7 ± 9.1 mmHg to 66.4 ± 15.3 mmHg and this was not important clinically. On the basis of this pilot study, we suggest that aerosol bronchodilators may be safely delivered by oxygen-driven nebulisers in chronically hypoxic and hypercapnic COPD patients. A larger scale formal trial is indicated to compare oxygen-driven versus air-driven nebulisers in COPD.

Objective: This study aimed to evaluate the accuracy of the portable SomteTM (Compumedics Limited, Melbourne, Australia) sleep data acquisition device against the current gold-standard of technician-attended, laboratory-based polysomnography (PSG) for the diagnosis of sleep disordered breathing (SDB).

Opioid use has increased rapidly in Western societies, with the major increase being in prescribed opioids, illicit or not. Opioids are commonly used for a number of clinical situations, including treatment of acute pain, trauma, cancer, and nonmalignant chronic pain and in methadone maintenance treatment (MMT) programs.1 The US Congress declared the years 2001–2010 as the Decade of Pain Control and Research (Public Law 106-386-OCT). This declaration was to address and improve the situation that clinically significant chronic pain has not been adequately managed. Of the more than 50 million Americans suffering from chronic pain, only around 40% obtain adequate relief.2 Meanwhile, illicit opioid use has increased substantially. Recent reports show that there are around 10 million heroin users in the world, with an estimated 2 to 4 million or more in Western Europe and North America alone.3,4 Methadone, a long-acting μ-opioid agonist, is recognized as the most-effective treatment for heroin addiction.5 It has been reported that short-term opioid use can cause depressed consciousness or sedation.6,7 There is conflicting evidence about tolerance to the sedative effect when opioids are used long term. Although some reports indicate that tolerance develops within a few days on a stable dose of drug and with a return of normal cognitive functioning, other studies suggest that patients continue to experience unpleasant sedative effects and cognitive impairment.6–8 Although there are a number of studies describing the sedative effects of opioids, few studies have investigated the effects of opioids on sleep architecture and the possible effects on daytime sleepiness and daytime function, even though opioids have been reported to cause disrupted sleep and abnormal sleep architecture.7,9,10 Furthermore, our previous studies have shown that central sleep apnea (CSA) occurs in approximately 30% of patients on stable MMT.11,12 The severity of CSA has been shown to correlate significantly with increased methadone blood concentration.12 Similarly, CSA is also reported in long-term users of time-release opioid analgesics, and the appearance of CSA is linked to increased opioid dose.13–15 Sleep apnea itself can cause significant daytime sleepiness and reduced daytime function.16 However, no studies to date have addressed the issue of the potential for CSA to cause these changes in subjects who use opioids on a chronic basis. Moreover, given the reported sedative effect of opioids used on a short-term basis and the significant correlation between CSA and opioid blood concentration, it would be of interest to know whether opioid blood concentration directly or indirectly affects daytime sleepiness and daytime function in patients on stable MMT. The aim of the present study was to investigate the subjective daytime sleepiness (using the Epworth Sleepiness Scale [ESS])17 and daytime function (using the Functional Outcomes of Sleep Questionnaire [FOSQ])18 of patients on stable MMT and to compare the data with those from matched control subjects. In addition, we have explored the possible mechanisms for the differences found between the patients on MMT and control subjects in particular with respect to sleep architecture, sleep disordered breathing, and opioid blood concentration.

Chronic opioid use for pain relief or as substitution therapy for illicit drug abuse is prevalent in our societies. In the US, retail distribution of methadone and oxycodone has increased by 824 and 660%, respectively, between 1997 and 2003. Mu-opioids depress respiration and deaths related to illicit and non illicit chronic opioid use are not uncommon. Since 2001 there has been an emerging literature that suggests that chronic opioid use is related to central sleep apnoea of both periodic and non-periodic breathing types, and occurs in approximately 30% of these subjects. The clinical significance of these sleep-related abnormalities are unknown. This review addresses the present knowledge of control of ventilation mechanisms during wakefulness and sleep, the effects of opioids on ventilatory control mechanisms, the sleep-disordered breathing found with chronic opioid use and a discussion regarding the future research directions in this area.

The majority of awake ventilatory control studies have shown normal or decreased ventilatory response to hypercapnia (HCVR) in obstructive sleep apnea-hypopnea syndrome (OSAHS) patients. These findings are contrary to experimental studies suggesting increased loop gain and greater breathing instability in OSAHS patients. We have investigated the relationship between central chemoreflex sensitivity tested by HCVR and obstructive sleep apnea/hypopnea index (OSAHI) in asymptomatic subjects. Twenty normal volunteers (10 men and 10 women) from the general population without physical complaints including sleep-related symptoms were included. The subjects were studied for awake ventilatory responses to hypoxia (HVR) and hypercapnia. Overnight polysomnography (PSG) was performed in two consecutive nights with the first night used as acclimatization. The subjects have an average body mass index (BMI) of 27 +/- 5 SD kg/m(2), ages of 35 +/- 9 SD years and Epworth sleepiness scale of 2.1 +/- 1.8 SD. A positive linear relationship was found between HCVR and logarithmically transformed OSAHI (r = 0.67, p = 0.001). BMI and age were not significantly correlated to HCVR or Log OSAHI. No relationship was found between HVR and Log OSAHI (r = 0.25, p = 0.29). Percentage oxygen saturation nadir during sleep was found to significantly correlate to both daytime HCVR (r = -0.60, p = 0.005) and Log OSAHI (r = -0.65, p = 0.002) and tended to correlate to HVR (r = -0.41, p = 0.07). Arousal index during sleep was not associated with either HCVR (p = 0.93) or HVR (p = 0.26). In conclusion, heightened central chemosensitivity was positively related to OSAHI in asymptomatic volunteers. We believe these findings are in keeping with the evolving theory of loop gain being a significant factor for respiratory control instability and obstructive apnea genesis. The mechanism can be applied to asymptomatic subjects with even minimal sleep-disordered breathing.

Rationale Methadone is a long-acting μ-opioid and is an effective treatment for heroin addiction. Opioids depress respiration, and patients receiving methadone maintenance treatment (MMT) have higher mortality than the general population. Few studies have investigated ventilatory responses to both hypercapnia and hypoxia in these patients. Study objectives We measured hypercapnic ventilatory response (HCVR) and hypoxic ventilatory response (HVR) and investigated possible factors associated with both in clinically stable patients receiving MMT. Design and setting Patients receiving long-term, stable doses of methadone recruited from a statewide MMT program, and normal, non-opioid-using subjects matched for age, sex, height, and body mass index were studied with HCVR and HVR. Results Fifty MMT patients and 20 normal subjects were studied, and significantly decreased HCVR and increased HVR were found in MMT patients compared to normal subjects (HCVR [mean ± SD], l.27 ± 0.61 L/min/mm Hg vs 1.64 ± 0.57 L/min/mm Hg [p = 0.01]; HVR, 2.14 ± 1.58 L/min/% arterial oxygen saturation measured by pulse oximetry [Spo 2 ] vs 1.12 ± 0.7 L/min/% Spo 2 [p = 0.008]). Respiratory rate and not tidal volume changes were the major physiologic responses contributing to both HCVR and HVR differences between the groups. Variables associated with HCVR in the MMT patients are as follows: obstructive sleep apnea/hypopnea index ( t = 5.1, p=0.00001), Paco 2 ( t = − 3.6, p=0.001), body height ( t = 2.6, p=0.01) and alveolar-arterial oxygen pressure gradient ( t = 2.5, p=0.02). Variables associated with HVR in MMT patients are body height ( t = 3.2, p=0.002) and Paco 2 ( t = − 2.8, p=0.008). Conclusions Stable long-term MMT patients have blunted central and elevated peripheral chemoreceptor responses. The mechanisms and clinical significance of these findings need further investigation.

Patients in methadone maintenance programmes (MMT) often smoke tobacco and cannabis and many have ongoing illicit drug use. There is therefore potential for these patients to have abnormal cardiorespiratory function; however, few studies address this in stable MMT patients. We assessed resting cardiorespiratory function on 50 stable MMT patients (25 males, 25 females). Forty-six MMT patients were current tobacco smokers, 19 were current cannabis users and none were currently using opioids other than prescribed methadone. We defined abnormalities of respiratory function as those results outside the 95% confidence interval of reference values for normal subjects adjusted for age, weight, height and sex. Thirty-one (62%) MMT patients had reduced carbon monoxide transfer factor (D(L)CO); 17 (34%) had elevated single breath alveolar volume (V(A)) and 43 (86%) had a reduced D(L)CO/V(A) ratio. Six patients (12%) had reduced FEV1; one (2%) had reduced FVC; and nine (18%) had an obstructive ventilatory defect. Ten (20%) patients had PaCO2 higher than 45 mmHg and 14 (28%) had alveolar to arterial oxygen gradient (A-aPO2) higher than 15 mmHg. CXR, Echocardiography and ECG showed no significant abnormalities. We conclude that stable MMT patients have abnormalities of resting respiratory function which may be due to ongoing tobacco cigarette and current or past cannabis smoking.

To evaluate the clinical utility of nasal cannula/pressure (NP) and oro-nasal thermal sensor (Th) recordings, alone and in combination for scoring respiratory events during routine diagnostic polysomnography (PSG).The use of Th devices to measure airflow during PSG is not recommended because Th are insensitive to airflow changes other then complete airflow cessation. It has been suggested that NP recording is a better measure of airflow and can also detect increased upper airway resistance during PSG.Thirty consecutive PSG's were examined using 13 standard channels including Th and NP recordings. Respiratory events were scored separately utilizing NP+Th, Th alone and NP alone in a blinded fashion using modified AASM criteria. Respiratory events were time matched to within 5 s for each of the recording methods.NP+Th detected more events than Th alone (P0.0001); NP+Th detected more events than NP alone (P0.0001) and NP alone detected more events than Th alone (P0.0001). For AHI50, NP alone and Th alone each detected 90% of matched NP+Th events. However, for AHI50, NP alone detects 54% and Th alone detects 42% (P0.005) of matched NP+Th events. For AHI50, NP alone scored 97% of matched Th alone scored respiratory events, and Th alone scored 94% of NP alone scored respiratory events (P0.05). However, for AHI50, NP alone scored 90% of matched Th alone scored respiratory events, whereas Th alone scored 62% of matched NP alone scored events (P0.0001).In severe sleep disordered breathing (AHI50), NP+Th, NP alone and Th alone have similar ability to detect respiratory events. When AHI50, NP+Th appears better for detecting respiratory events than NP or Th alone. If only one measure of airflow is used, NP detects more events than Th.

Acute respiratory tract infections (RTI) are known to worsen asthma particularly in children. There are few studies in adults assessing the incidence of RTI in patients hospitalized with acute asthma. Aim To document the incidence of RTI in adults hospitalized with acute asthma. Methods A prospective study of patients with acute asthma admitted to the Department of Respiratory Medicine, Western Hospital Footscray, over a 12-month period. A control group was studied from elective surgical inpatients. Patients were investigated with serologic tests for Chlamydia, Mycoplasma, Legionella, and influenza A and R. Nasopharyngeal aspirate (NPA) samples were cultured for influenza, respiratory syncytial virus (RSV), adenovirus, parainfluenza, rhinovirus, and herpes simplex virus. If sputum was available, it was assessed with microscopy and culture. Rlood cultures were taken if patients were febrile and all patients had a chest radiograph. Control subjects completed serologic tests and NPA. Results Seventy-nine patients (33 male and 46 female) and 54 control subjects (26 male and 28 female) were studied. Two patients were enrolled twice. Mean (±SD) age of patients was 35 ±15 years (range, 16 to 66 years), and mean age of control subjects was 37±15 years (range, 18 to 69 years). In the patient group, 29 (37%) had evidence of recent RTI of which 23 were viral. Five of the control subjects (9%) had evidence of recent RTI (p

The ultrastructure and function of nasal cilia and sperm tails were examined in 23 men with Young's syndrome and compared with data previously collected from 10 normal subjects. Quantitative electron microscopic assessment showed that sperm tails from patients with Young's syndrome contained significantly fewer central pair microtubules, radial spokes, and inner dynein arms, and their cilia contained less inner dynein arms than normal subjects. The Young's syndrome patients had normal in vitro ciliary beat frequency (11.4 +/- 0.9 Hz), and 12 of the 23 had normal nasal mucociliary clearance (15.0 +/- 5.0 minutes). However, the remaining 11 had markedly abnormal nasal mucociliary clearance in vivo. In these patients, the deficiency of ciliary inner dynein arms did not appear to affect ciliary function in vitro but may under mucus loading lead to abnormal in vivo ciliary function. The consistent abnormalities shown in cilia and sperm tails, though apparently minor, constitute a common factor in both the reproductive and respiratory tracts which may, in combination with abnormalities in the in vivo environment, lead to the features of Young's syndrome.

Self management programs have been advocated for adults who have recently been admitted to hospital or have recently attended an emergency department because of asthma. A new telephone based approach has already been trialled for the management of a number of other chronic conditions. This study sought to determine the effect of a telephone based asthma management program for adults with asthma.Adults with one or more previous admissions for asthma to either or both of two tertiary hospitals between 1 May 2001 and 30 November 2003 were invited to participate. All participants received one face-to-face session with an asthma educator. Participants were randomised to intervention (six telephone calls over 6 months) or control (usual care) groups. Measures of health care utilisation and morbidity were collected weekly for 12 months.Seventy-one adults (54 females) with a mean age of 36.2 years were recruited to the study. Twenty hospital re-admissions were recorded for the control group and one for the intervention group at 12 months. Re-admission was significantly associated with allocation to control group (p=0.05). The control group was significantly more likely to report being woken by asthma on more than half the nights of the week (p=0.03).Telephone based self management intervention results in clinically important reductions in hospital re-admission in adults previously hospitalised with asthma.

Opioid use whether acute or chronic, illicit or therapeutic is prevalent in Western societies. Opioid receptors are located in the same nuclei that are active in sleep regulation and opioid peptides are suggested to be involved in the induction and maintenance of the sleep state. mu-Opioids are the most commonly used opioids and are recognized respiratory depressants that cause abnormal awake ventilatory responses to hypercapnia and hypoxia. Abnormal sleep architecture has been reported during the process of opioids induction, maintenance and withdrawal. During induction and maintenance of opioid use there is reduction of rapid eye movement (REM) sleep and slow wave sleep. More recently, central sleep apnoea (CSA) has been reported with chronic opioid use and 30% of stable methadone maintenance treatment patients have CSA. Given these facts, it is sobering to note the paucity of human data available regarding the effects of short and long-term opioid use on sleep architecture and respiration during sleep. In this manuscript, we review the current knowledge regarding the effects of mu-opioids on sleep and respiration during sleep and suggest research pathways to advance our knowledge and to explore the possible responsible mechanisms related to these effects.

Study objectives: Methadone, a long-acting -opioid agonist, is an effective treatment for heroin addiction. Our previous data show that 6 of 10 methadone maintenance treatment (MMT) patients had central sleep apnea (CSA). This study aims to confirm these results and to investigate the pathogenesis of the CSA. Methods: Twenty-five male and 25 female MMT patients and 20 age-, sex-, and body mass index (BMI)-matched normal subjects were tested with polysomnography, blood toxicology, and ventilatory responses to hypoxia and hypercapnia. Resting cardiorespiratory tests were performed in the MMT group Results: MMT patients and normal subjects were 35 9 years old (mean SD), and BMI values were 27 6 kg/m 2 and 27 5 kg/m 2 , respectively. Thirty percent of MMT patients had a central apnea index (CAI) > 5, and 20% had a CAI > 10. All normal subjects had a CAI < 1, and no difference was found in obstructive apnea-hypopnea index between the two groups. Methadone blood concentration was the only significant variable (t 2.33, p 0.025) associated with CAI and explains 12% of the variance. Awake PaCO2, antidepressant use, reduced ventilatory response to hypercapnia, and widened awake alveolar-arterial oxygen pressure gradient together explain a further 17% of the CAI variance. Conclusions: Thirty percent of stable MMT patients have CSA, a minority of which can be explained by blood methadone concentration. Other physiologic variables may also play a role in the pathogenesis of CSA in MMT patients, and further research is indicated in this area. (CHEST 2005; 128:1348–1356)

Aims. To explore the possibility that stable MMP patients have sleep-disordered breathing (SDB) and abnormal sleep architecture defined by nocturnal sleep stages and sleep efficiency. Design. Observational. Setting. Regional Methadone Service and sleep disorders laboratory in a university affiliated hospital. Participants and measurements. Ten stable MMP patients and nine normal subjects were assessed clinically and with overnight polysomnography. Findings. There were no differences in age, sex and body mass index between the groups. The methadone dose ranged between 50 and 120 mg/day. Six patients had central apnoea index (CAI) greater than 5, four had a CAI greater than 10 and three of these exhibited periodic breathing. No normal subject had central sleep apnoea. The patients had lower sleep efficiency ( p < 0.05), less slow wave sleep ( p < 0.01), less rapid eye movement sleep ( p < 0.05) and more Stage 2 sleep ( p < 0.05) than controls. Conclusions. Stable MMP patients have more sleep architecture abnormalities than controls and a higher prevalence of central sleep apnoea. Further studies are needed to confirm these findings, to delineate the mechanisms for the abnormalities and to assess whether the SDB is related to sudden death in stable MMP patients. We recommend that MMP patients have awake and sleep respiration assessed to identify those potentially at risk.

We describe the case of a heavy marijuana and tobacco smoker who presented with progressive exertional dyspnea of 2 months' duration, and bilateral nodular lung infiltrates. Examination of the lung fields was normal, and lung function tests showed mild airflow obstruction with moderately reduced gas transfer. BAL returned green-black fluid consisting predominantly of macrophages laden with carbon pigment. Thoracoscopic lung biopsy showed miliary necrotizing granulomata with an alveolar exudate of carbon-laden macrophages within macroscopically blackened lung. The differential diagnosis of pulmonary granulomata in this patient is discussed.

Pulmonary coccidioidomycosis is a rare cause of pulmonary nodules and respiratory infection in travellers to endemic areas. An Australian tourist suffered an acute respiratory illness while on holiday in Mexico. She subsequently developed erythema nodosum and was noted to have a left pulmonary nodule on chest X-ray after return to Australia. The diagnosis of Coccidioides immitis infection was established by histology and culture of the resected lung lesion. The patient made an uneventful recovery and received one month of therapy with ketoconazole. Culture of the fungus took place under controlled Class 3 conditions. An unusual fungal infection in Australia, coccidioidomycosis poses special risks to staff of microbiology laboratories.

Young syndrome is characterized by obstructive azoospermia associated with chronic sinobronchial disease of an infectious nature, but normal sweat-gland and pancreatic function as well as normal nasal potential differences. Congenital bilateral absence of the vas deferens (CBAVD) in some patients arises from mutations within the cystic fibrosis (CF) transmembrane regulator (CFTR) gene. Because of some similarities between Young syndrome, CF, and CBAVD, we evaluated 13 patients with Young syndrome, including screening for more than 30 different mutations within the CFTR gene. The mean age of the patients was 43 yr (range, 32 to 50 yr), and all were of northern European extraction. The sweat chloride concentration was normal in all patients (mean = 29 mEq/L; range, 8 to 43 mEq/L). Most had intermittent bronchial and sinus infections, but none was chronically colonized with Staphylococcus aureus or Pseudomonas aeruginosa. The FEV1 was normal or only mildly reduced in most patients (mean = 74%; range, 48 to 100% predicted). Of 26 Young syndrome chromosomes, we identified one with the recognized CF mutation delta F508. The incidence of CFTR mutations (1 in 26) did not differ significantly from the expected carrier frequency in this population. In summary, it is unlikely that the typical Young syndrome patient has a clinical disease associated with CFTR mutation on both alleles.

Aims Recent studies have suggested an emerging link between sleep apnoea and atrial fibrillation (AF). These studies included patients with reduced left ventricular (LV) function which may cause both AF and sleep disordered breathing (SDB). We examined the prevalence of SDB in a population of patients with AF and normal LV function. Methods and results Ninety patients with paroxysmal or persistent AF and 45 controls were prospectively enrolled and matched 2:1 for age (AF 56 ± 12 years; controls 54 ± 11years) and sex. All patients had normal LV function. SDB was diagnosed using all-night portable polysomnography. Apnoea–hypopnoea index (AHI) in AF patients was higher than in controls (23.19 ± 19.26 vs. 14.66 ± 12.43, P = 0.01). The proportion with significant SDB (AHI > 15) was also greater in AF patients (62 vs. 38%, P = 0.01). After adjustment for relevant covariates, the odds ratio for the association between AF and SDB (AHI > 15) was 3.04 (95% CI 1.24–7.46, P = 0.02). The paroxysmal AF group was classified as either ‘low-frequency AF’ (≤6) or ‘high-frequency AF’ (>6) episodes in the past year. High-frequency AF was associated with a higher prevalence (75 vs. 43%, P = 0.012) and severity (mean AHI 28.08 ± 22.94 vs. 16.69 ± 15.06, P = 0.028) of SDB when compared with those with low-frequency AF. Conclusion A high prevalence of SDB is found in relatively young patients with both paroxysmal and persistent AF with normal LV function. This AF population warrants careful consideration for the presence of SDB.

The ultrastructure of normal human cilia and flagella was examined and quantitatively assessed to determine the normal variations in the structure of the axoneme. Ciliated respiratory epithelial cells and spermatozoa from 10 normal, nonsmoking male volunteers who had normal semen parameters were fixed for electron microscopy. Tannic acid and MgSO4 were included during fixation to enhance, in particular, axonemal components. In 75 axonemal cross sections per sample, the number of outer doublet and central singlet microtubules, outer and inner dynein arms, and radial spokes were recorded. Statistical analysis of the results showed a marked reduction, from the expected value of nine, in the numbers of inner dynein arms (mean +/- SE, cilia, 5.31 +/- 0.13; sperm, 5.38 +/- 0.16) and radial spokes (cilia, 4.95 +/- 0.22; sperm, 5.80 +/- 0.19). The ideal axoneme with all its structural components was seen in only 0.13% of cilia and 0.80% of sperm tails. Significantly more doublet microtubules (P less than 0.05) and less central microtubules (P less than 0.01) and radial spokes (P less than 0.01) were seen in cilia than in sperm tail axonemes. Between subjects there was little variation in the mean number of a structure seen per axoneme. However, within each sample, the variation was considerably higher, particularly for the inner and outer dynein arms and radial spokes. The doublet microtubules had significantly greater standard deviations in the sperm tails compared with the cilia (P less than 0.01), and furthermore, a significantly greater number of sperm tails compared with cilia showed the incorrect number of doublet microtubules (P less than 0.02). In one semen sample, with normal semen analysis, 20% of the sperm tails showed incorrect numbers of doublet microtubules, ranging from 12 + 2 to 5 + 2 compared with only 1.3% in cilia from this subject. This study has demonstrated that the ideal axoneme is rarely seen even in normal samples, probably because of the technical difficulties in resolution and visualization, and stresses the need for thorough documentation of axonemal ultrastructure. This work provides a normal data base for comparison with patients who have chronic respiratory disease and suspected infertility.

Subjects using opioids on a chronic basis have been reported to have a high prevalence of abnormal sleep architecture and central sleep apnea (CSA). The severity of CSA is, in part, related to blood opioid concentration. The aim of this study was to investigate subjective daytime sleepiness and daytime function in patients who are on stable methadone maintenance treatment (MMT) and to assess the possible mechanisms involving abnormal sleep architecture, CSA severity, and blood methadone concentration.Fifty patients on MMT and 20 normal control subjects matched for age and body mass index were tested using polysomnography, blood toxicology, Epworth Sleepiness Scale (ESS), Functional Outcome of Sleep Questionnaire (FOSQ), and Beck Depression Inventory (BDI).The patients receiving MMT had significantly worse daytime function, were depressed, and had increased daytime sleepiness when compared with the control subjects (FOSQ 15.47 +/- 3.19 vs 19.4 +/- 0.47, BDI 14.64 +/- 10.58 vs 2.05 +/- 2.46, ESS 7.1 +/- 5 vs 2.05 +/- 1.76; all p values0.001). Nevertheless, daytime sleepiness in the patients receiving MMT was, on average, within the normal range (ESSor = 10). Multiple regression analysis demonstrated that the severity of CSA, blood methadone concentration, and abnormalities in sleep architecture were not significant in predicting the variance of ESS or FOSQ (all p values0.05) in these patients receiving MMT. The BDI was the best predictive variable for FOSQ, explaining 16% of the variance (p = 0.004).Patients on stable MMT have, in general, normal subjective daytime sleepiness but impaired daytime function that partially relates to depression. The changes in sleep architecture, presence of CSA, and blood methadone concentrations do not significantly affect subjective daytime sleepiness and daytime function in these patients.

The authors calculated the cost of delivering telephone based asthma management compared to usual care. Self efficacy and quality of life were measured at recruitment, 6 months and 12 months. Participants were invited to comment on their experience of the telephone based intervention.The intervention was well accepted. At 12 months there was a clinically important improvement in mean quality of life in the intervention group not seen in the control group. Telephone based management costs were offset by reductions in the number of readmissions in the intervention group.Telephone based asthma management offers a well accepted, low cost yet potentially effective means of delivering asthma care.