Evaluating pharmacological treatments for excessive daytime sleepiness in obstructive sleep apnea: A comprehensive network meta-analysis and systematic review.

Obstructive sleep apnea (OSA) is associated with excessive daytime sleepiness (EDS). Pharmacotherapy offers a potential treatment approach for EDS in OSA patients. This systematic review and meta-analysis aimed to assess the efficacy and safety of pharmacological interventions for alleviating EDS in patients with OSA. Following PRISMA guidelines, we included randomized controlled trials investigating pharmacological treatments for EDS in adult OSA until August 2023. We conducted meta-analysis, subgroup, and meta-regression analyses using a random effects model. Finally, a network meta-analysis synthesized direct and indirect evidence, followed by a comprehensive safety analysis. We included 32 articles in the meta-analysis (n = 3357). Pharmacotherapy showed a significant improvement in the Epworth Sleepiness Scale (ESS) score (Mean Difference (MD) -2.73, (95 % Confidence Interval (CI) [-3.25, -2.20], p < 0.01) and Maintenance of Wakefulness Test (MWT) score (MD 6.00 (95 % CI [2.66, 9.33] p < 0.01). Solriamfetol, followed by Pitolisant and modafinil, exhibited the greatest ESS reduction, while Danavorexton, followed by Solriamfetol and MK-7288, had the strongest impact on MWT. MK-7288 had the most total adverse events (AEs), followed by Danavorexton and armodafinil. Pharmacological Interventions significantly alleviate EDS in OSA patients but with heterogeneity across medications. Treatment decisions should involve a personalized assessment of patient factors and desired outcomes.

Pneumatic stenting in the surgical candidacy assessment for cough variant expiratory central airway collapse.

Expiratory Central Airway Collapse (ECAC) is a multifactorial, underdiagnosed entity that poses unique challenges. Airway stenting is used as a predictor for successful outcomes after central airway stabilization surgery via tracheobronchoplasty (TBP). This approach may pose suboptimal performance in certain ECAC variants. We hypothesize that Continuous Positive Airway Pressure (CPAP), used as a pneumatic stent, could be a non-invasive alternative to evaluate surgical candidacy in cough-predominant ECAC presentations. We report on a 67-year-old female with a history of chronic cough and confirmed ECAC. After optimization of medical therapy without significant relief and unsuccessful stent trial. We opted to perform CPAP trial during exercise, the patient exercised on a treadmill, and CPAP was applied at two levels (9 cmH2O, 11 cmH2O). The use of CPAP was associated with resolution of cough and a decrease in exercise-related perceived exertion. Applying CPAP during exercise may be a promising alternative to stent trials to determine patients' candidacy for surgical management of cough-predominant ECAC.

Influence of medical trainee sleep pattern (chronotype) on burn-out and satisfaction with work schedules: a multicentre observational study.

BACKGROUND: Medical trainees' work schedule is designed to cover duties without consideration of differences in circadian rhythms during a 24-hour period (chronotype). OBJECTIVE: To explore chronotype variation among medical trainees and understand its association with burn-out and schedule satisfaction. METHODS: In a multicentre observational study, we conducted two surveys between 1 October 2018 and 1 April 2019. Trainees from nine centres across the USA participated. We measured burn-out using Maslach Burnout Inventory (MBI), and trainee chronotype using the Morningness-Eveningness Questionnaire (MEQ). RESULTS: 324 (32%) out of 1012 responded to our survey. Participants were 51% female and had a mean age of 30.8 years. Most participants had an intermediate MEQ type (65%). A large proportion of participants had burn-out on at least one of three tested MBI scales (62%); 5% of participants had burn-out on all three MBI scales. More participants with evening MEQ type had burn-out (66%) compared with morning MEQ type (55%), however, the results were not statically significant (p=0.294). Overall satisfaction with work shifts was 6.5 (95% CI 6.3 to 6.7), with higher satisfaction with day shift 7.7 (95% CI 7.5 to 7.9) and lowest satisfaction with overnight 24-hour call 3.5 (95% CI 3.2 to 3.9). Satisfaction was lower in trainees with burn-out 6.0 (95% CI 5.7 to 6.4), (p<0.001). In the follow-up survey, burn-out was present in at least one scale in 64% compared with 60% of respondents in the initial survey. CONCLUSION: Burn-out is prevalent among medical trainees. Improving alignment between trainee preferences may improve performance, reduce human errors and burn-out.

A comparison of 2 visual methods for classifying obstructive vs central hypopneas.

STUDY OBJECTIVES: Rules for classifying apneas as obstructive, central, or mixed are well established. Although hypopneas are given equal weight when calculating the apnea-hypopnea index, classification is not standardized. Visual methods for classifying hypopneas have been proposed by the American Academy of Sleep Medicine and by Randerath et al (Sleep. 2013;36[3]:363-368) but never compared. We evaluated the clinical suitability of the 2 visual methods for classifying hypopneas as central or obstructive. METHODS: Fifty hypopnea-containing polysomnographic segments were selected from patients with clear obstructive or clear central physiology to serve as standard obstructive or central hypopneas. These 100 hypopnea-containing polysomnographic segments were deidentified, randomized, and scored by 2 groups. We assigned 1 group to use the American Academy of Sleep Medicine criteria and the other the Randerath algorithm. After a washout period, re-randomized hypopnea-containing polysomnographic segments were scored using the alternative method. We determined the accuracy (agreement with standard), interrater (Fleiss's κ), and intrarater agreement (Cohen's κ) for obtained scores. RESULTS: Accuracy of the 2 methods was similar: 67% vs 69.3% for Randerath et al and the American Academy of Sleep Medicine, respectively. Cohen's κ was 0.01-0.75, showing that some raters scored similarly using the 2 methods, while others scored them markedly differently. Fleiss's κ for the American Academy of Sleep Medicine algorithm was 0.32 (95% confidence interval, 0.29-0.36) and for the Randerath algorithm was 0.27 (95% confidence interval, 0.23-0.30). CONCLUSIONS: More work is needed to discover a noninvasive way to accurately characterize hypopneas. Studies like ours may lay the foundation for discovering the full spectrum of physiologic consequences of obstructive sleep apnea and central sleep apnea.

Analyses of the Complexity of Patients Undergoing Attended Polysomnography in the Era of Home Sleep Apnea Tests.

STUDY OBJECTIVES: Health care complexity includes dimensions of patient comorbidity and the level of services needed to meet patient demands. Home sleep apnea tests (HSAT) are increasingly used to test medically uncomplicated patients suspected of having moderate to severe obstructive sleep apnea (OSA). Patients with significant comorbidities or other sleep disorders are not candidates for HSAT and require attended in-center polysomnography. We hypothesized that this trend would result in increasingly complex patients being studied in sleep centers. METHODS: Our study had two parts. To ascertain trends in sleep patient comorbidity, we used administrative diagnostic codes from patients undergoing polysomnography at the Mayo Clinic Center for Sleep Medicine from 2005 to June 2015 to calculate the Charlson and the Elixhauser comorbidity indices. We measured the level of services provided in two ways: (1) in a subset of patients from the past 2 months of 2015, we evaluated correlation of these morbidity indices with an internally developed Polysomnogram Clinical Index (PSGCI) rating anticipated patient care needs from 0 to 3 and (2) we measured the sleep study complexity based on polysomnography protocol design. RESULTS: In 43,780 patients studied from 2005 to June 2015, the Charlson index increased from a mean of 1.38 to 1.88 (3.1% per year, P < .001) and the mean Elixhauser index increased from 2.61 to 3.35 (2.5% per year, P < .001). Both comorbidity indices were significantly higher at the highest (Level 3) level of the PSGCI (P < .001), and sleep study complexity increased over time. CONCLUSIONS: The complexity of patients undergoing attended polysomnography has increased by 28% to 36% over the past decade as measured by validated comorbidity indices, and these indices correlate with the complexity of rendered care during polysomnography. These findings have implications for increasing requirements for staffing, monitoring capabilities, and facility design of future sleep centers. COMMENTARY: A commentary on this article appears in this issue on page 499.

Rasmussen's aneurysm: A forgotten scourge.

Rasmussen's aneurysm is an inflammatory pseudo-aneurysmal dilatation of a branch of pulmonary artery adjacent to a tuberculous cavity. Life threatening massive hemoptysis from the rupture of a Rasmussen's aneurysm is an uncommon yet life threatening complication of cavitary tuberculosis (TB). We present a case of a young woman who presented with low-grade fever and hemoptysis. Computed tomographic (CT) angiography showed biapical cavitary lesions and actively bleeding aneurysms involving pulmonary artery, which successfully underwent glue embolization.

One size does not fit all: identifying risk profiles for overweight in adolescent population subsets.

PURPOSE: The purpose of this study is to identify population subgroups of adolescents who are homogenous with respect to sociodemographic factors and potentially modifiable risk and protective factors related to overweight status in a nationally representative sample of adolescents ages 12-17. METHODS: The data used for this study are from the Centers for Disease Control and National Center for Health Statistics' National Survey of Children's Health, 2003 (NSCH). Classification and Regression Trees (CART) were used to identify population segments of adolescents based on risk and protective factors for obesity. RESULTS: In the final CART model, 12 variables remained, including: poverty level, race, gender, participation in sports, number of family meals, family educational attainment, child physical activity, participation in free lunch programs, neighborhood safety and connectedness, TV viewing time, and child age in years. Poverty level was determined to be the most variable related to weight status in this sample of adolescents. Adolescents living in households below approximately the 300% poverty level were subject to a different constellation of predictors than adolescents living in homes above the 300% poverty level. CONCLUSIONS: Our results demonstrate how risk and protective factors related to obesity emerge differently among sociodemographic subgroups and the relative importance of these risk and protective factors in relation to adolescent overweight status. Interventions that work for one population subgroup may not work for another.

Mental health problems and overweight in a nationally representative sample of adolescents: effects of race and ethnicity.

OBJECTIVES: In this study we examined the relation between mental health problems and weight in a population-based study of youth aged 12 to 17 years and whether the association between mental health problems and weight is moderated by race and ethnicity. METHODS: We used 2003 National Survey on Children's Health data. Logistic regression was used to arrive at adjusted odds ratios showing the relation between BMI and mental health problems. RESULTS: Compared with their nonoverweight counterparts, both white and Hispanic youth who were overweight were significantly more likely to report depression or anxiety, feelings of worthlessness or inferiority, behavior problems, and bullying of others. Odds ratios relating mental health problems and BMI in black subjects were not statistically significant except for physician diagnosis of depression. CONCLUSIONS: Our results suggest that, when addressing youth overweight status, mental health problems also need to be addressed. Given that the relationship between mental health problems and youth overweight differs according to race/ethnic group, public health programs that target overweight youth should be cognizant of potential comorbid mental health problems and that race/ethnicity may play a role in the relationship between mental health and overweight status.