Positive Airway Pressure in Surgical Patients with Sleep Apnea: What is the Supporting Evidence?

Obstructive sleep apnea (OSA) is prevalent amongst surgical patients and associated with an increased incidence of perioperative complications. The gold standard treatment for moderate-to-severe OSA is positive airway pressure (PAP) therapy. Practice guidelines by the American Society of Anesthesiologists and the Society of Anesthesia and Sleep Medicine have recommended preoperative screening for OSA and consideration of initiation of PAP therapy for patients with severe OSA. These guidelines, developed mainly by the consensus of experts, highlight the adverse impact of OSA on postoperative outcomes and recommend the use of postoperative PAP in surgical patients with moderate to severe OSA. Since the development of these guidelines, there has been an increase in the number of publications regarding the efficacy of PAP therapy in surgical patients with OSA. Our review provides an update on the existing literature on the efficacy of PAP therapy in surgical patients with OSA. We focus on the postoperative complications associated with OSA, potential mechanisms leading to the increased risk of postoperative adverse events, and summarize the perioperative guidelines for the management of patients with OSA, evidence supporting perioperative PAP therapy, as well as limitations to PAP therapy and alternatives. An update on the existing literature of the efficacy of PAP therapy in surgical patients with OSA is critical to assess the impact of prior guidelines, determine when and how to effectively implement PAP therapy, and target barriers to PAP adherence in the perioperative setting.

Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey.

BACKGROUND: Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine. METHODS: We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data. RESULTS: The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia. CONCLUSIONS: We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.

Lumbosacral Spinal Imaging for Patients Presenting to the Emergency Department With Nontraumatic Low Back Pain.

BACKGROUND: Choosing Wisely Canada (CWC) guidelines recommend that in the absence of clinical indicators suggestive of serious underlying pathology, physicians should not order radiological imaging for patients presenting with nonspecific low back pain (LBP). OBJECTIVE: Our aim was to determine how many patients presenting to the emergency department (ED) with nontraumatic LBP had spinal imaging before and after the release of the CWC guideline. METHODS: We conducted a retrospective medical record review for patients aged 18-70 years presenting to an academic tertiary care ED with nontraumatic LBP from April 1, 2014 to March 31, 2015 (pre-guideline) and April 1, 2017 to March 31, 2018 (post-guideline). RESULTS: One-thousand and sixty (545 pre-guideline, 515 post-guideline) patients were included. Pre-guideline, 45 patients (8.3%) had spinal imaging compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% confidence interval [CI] -2.6% to 4.0%). Of the 84 patients (7.9%) who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline compared to 11 patients (28.2%) post-guideline (Δ 19.3%; 95% CI 2.7% to 35.8%). CONCLUSIONS: CWC guidelines did not appear to alter the rate of imaging for patients presenting to the ED with nontraumatic LBP. Future clinical recommendations should consider active knowledge dissemination and education strategies to help facilitate guideline adoption.

Habitual short sleepers with pre-existing medical conditions are at higher risk of Long COVID.

STUDY OBJECTIVES: Preliminary evidence suggests that the risk of Long COVID is higher among people with pre-existing medical conditions. Based on its proven adjuvant role in immunity, habitual sleep duration may alter the risk of developing Long COVID. The objective of this study was to determine whether the odds of Long COVID are higher among those with pre-existing medical conditions, and whether the strength of this association varies by habitual sleep duration. METHODS: Using data from 13,461 respondents from 16 countries who participated in the 2021 survey-based International COVID Sleep Study II (ICOSS II), we studied the associations between habitual sleep duration, pre-existing medical conditions, and Long COVID. RESULTS: Of 2,508 individuals who had COVID-19, 61% reported at least 1 Long COVID symptom. Multivariable logistic regression analysis showed that the risk of having Long COVID was 1.8-fold higher for average-length sleepers (6-9 h/night) with pre-existing medical conditions compared with those without pre-existing medical conditions (adjusted odds ratio [aOR] 1.84 [1.18-2.90]; P = .008). The risk of Long COVID was 3-fold higher for short sleepers with pre-existing medical conditions (aOR 2.95 [1.04-8.4]; P = .043) and not significantly higher for long sleepers with pre-existing conditions (aOR 2.11 [0.93-4.77]; P = .073) compared with average-length sleepers without pre-existing conditions. CONCLUSIONS: Habitual short nighttime sleep duration exacerbated the risk of Long COVID in individuals with pre-existing conditions. Restoring nighttime sleep to average duration represents a potentially modifiable behavioral factor to lower the odds of Long COVID for at-risk patients. CITATION: Berezin L, Waseem R, Merikanto I, et al. Habitual short sleepers with pre-existing medical conditions are at higher risk of long COVID. J Clin Sleep Med. 2024;20(1):111-119.

The effectiveness of positive airway pressure therapy in reducing postoperative adverse outcomes in surgical patients with obstructive sleep apnea: A systematic review and meta-analysis.

IMPORTANCE: Obstructive sleep apnea (OSA) is prevalent in surgical patients and is associated with an increased risk of adverse perioperative events. STUDY OBJECTIVE: To determine the effectiveness of positive airway pressure (PAP) therapy in reducing the risk of postoperative complications in patients with OSA undergoing surgery. DESIGN: Systematic review and meta-analysis searching Medline and other databases from inception to October 17, 2021. The search terms included: "positive airway pressure," "surgery," "post-operative," and "obstructive sleep apnea." The inclusion criteria were: 1) adult patients with OSA undergoing surgery; (2) patients using preoperative and/or postoperative PAP; (3) at least one postoperative outcome reported; (4) control group (patients with OSA undergoing surgery without preoperative and/or postoperative PAP therapy); and (5) English language articles. PATIENTS: Twenty-seven studies included 30,514 OSA patients undergoing non-cardiac surgery and 837 OSA patients undergoing cardiac surgery. INTERVENTION: PAP therapy MAIN RESULTS: In patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a decreased risk of postoperative respiratory complications (2.3% vs 3.6%; RR: 0.72, 95% CI: 0.51-1.00, asymptotic P = 0.05) and unplanned ICU admission (0.12% vs 4.1%; RR: 0.44, 95% CI: 0.19-0.99, asymptotic P = 0.05). No significant differences were found for all-cause complications (11.6% vs 14.4%; RR: 0.89, 95% CI: 0.74-1.06, P = 0.18), postoperative cardiac and neurological complications, in-hospital length of stay, and in-hospital mortality between the two groups. In patients with OSA undergoing cardiac surgery, PAP therapy was associated with decreased postoperative cardiac complications (33.7% vs 50%; RR: 0.63, 95% CI: 0.51-0.77, P < 0.0001), and postoperative atrial fibrillation (40.1% vs 66.7%; RR: 0.59, 95% CI 0.45-0.77, P < 0.0001). CONCLUSION: In patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a 28% reduction in the risk of postoperative respiratory complications and 56% reduction in unplanned ICU admission. In patients with OSA undergoing cardiac surgery, PAP therapy decreased the risk of postoperative cardiac complications and atrial fibrillation by 37% and 41%, respectively.

Rapid cognitive assessment tools for screening of mild cognitive impairment in the preoperative setting: A systematic review and meta-analysis.

IMPORTANCE: Mild cognitive impairment (MCI) is a high-risk precursor to dementia, post-operative delirium, and prolonged hospitalization. There is a need for preoperative rapid cognitive screening tools. STUDY OBJECTIVE: To evaluate the predictive parameters of rapid MCI screening tools in different clinical settings for preoperative application. DESIGN: Systematic review and meta-analyses searching Medline, and other databases from inception to May 26, 2021. The Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines were followed for data curation and quality assessment. Title and abstract screening were conducted independently via Rayyan. Data was curated through a random-effects model and statistical analysis used R-software. SETTING: Community, memory clinic, emergency, long-term care, and in-patient settings. There were no studies in the preoperative setting. PATIENTS: Twenty-three studies with 9973 patients (≥ 60 years old) undergoing rapid MCI screening. INTERVENTION: Rapid (≤ 5 min) MCI screening tools. MEASUREMENTS: Pooled predictive parameters (sensitivity, specificity) of screening tests. MAIN RESULTS: Eighteen screening tools, compared to neuropsychological tests, were identified. The overall prevalence of MCI among the Rapid Cognitive Screen (RCS), Six-item Screener (SIS), Mini-Cog, and Clock Drawing Test (CDT) studies were 24.6%, 28.3%, 40.9%, and 20.7%, respectively. RCS has 82% sensitivity and 79% specificity in detecting MCI. SIS has 61% sensitivity and 89% specificity. Mini-Cog has 52% sensitivity and 80% specificity. CDT has 56% sensitivity and 59% specificity. Seven other index tools had high sensitivities of 97%-82% and specificities of 90%-73% but were studied only once. CONCLUSION: No rapid screening tools had been validated in the surgical population. In other populations, RCS may be a promising screening tool for MCI with stronger sensitivity and specificity than Mini-Cog, SIS, and CDT. CDT alone is ineffective for MCI detection. Further validation in the preoperative setting is required to determine the efficacy of these screening tools.

An Analysis of the #CovidPain Tweet Chat During the First Wave of the COVID-19 Pandemic in 2020.

INTRODUCTION: In March 2020, we organized two tweet chats to discuss the COVID-19 pandemic and its impact on people affected by chronic pain. The objective of this study is to evaluate the #CovidPain tweet chat activities that took place at the early stages of the COVID-19 pandemic. METHODS: We performed a quantitative analysis of the magnitude, range, engagement, and sentiment of each tweet chat. The data was extracted from Twitter and analyzed in Twitter Analytics and Symplur Signals using frequency and distributions. Then, we conducted a qualitative content analysis of the narrative tweets generated in response to the questions posted during the tweet chats. RESULTS: The two tweet chats attracted 2305 participants, which generated 4351 tweets. The participants were healthcare providers, patient advocates, researchers/academics, and caregivers. COVID-19 had both negative and positive impacts. The negative consequences of COVID-19 included the reduction of physical activity, canceled appointments and treatments, more isolation, deterioration of preexisting mental health problems, and economic consequences. The positive consequences included efficient use of telemedicine, innovative methods for self-management, and at-home interventions. CONCLUSION: Twitter and tweet chats are useful in involving a diverse group of stakeholders for taking a deep dive into the topical issues relevant to a community that might be disproportionately affected by a public health crisis.

Differential diagnosis of vitamin D-related hypercalcemia using serum vitamin D metabolite profiling.

Genetic causes of vitamin D-related hypercalcemia are known to involve mutation of 25-hydroxyvitamin D-24-hydroxylase CYP24A1 or the sodium phosphate co-transporter SLC34A1, which result in excessive 1,25-(OH)2 D hormonal action. However, at least 20% of idiopathic hypercalcemia (IH) cases remain unresolved. In this case-control study, we used precision vitamin D metabolite profiling based on liquid chromatography-tandem mass spectrometry (LC-MS/MS) of an expanded range of vitamin D metabolites to screen German and French cohorts of hypercalcemia patients, to identify patients with altered vitamin D metabolism where involvement of CYP24A1 or SLC34A1 mutation had been ruled out and who possessed normal 25-OH-D3 :24,25-(OH)2 D3 ratios. Profiles were compared to those of hypercalcemia patients with hypervitaminosis D, Williams-Beuren syndrome (WBS), CYP24A1 mutation, and normal subjects with a range of 25-OH-D levels. We observed that certain IH and WBS patients exhibited a unique profile comprising eightfold to 10-fold higher serum 23,25,26-(OH)3 D3 and 25-OH-D3 -26,23-lactone than normals, as well as very low serum 1,25-(OH)2 D3 (2-5 pg/ml) and elevated 1,24,25-(OH)3 D3 , which we interpret implies hypersensitive expression of vitamin D-dependent genes, including CYP24A1, as a general underlying mechanism of hypercalcemia in these patients. Because serum 25-OH-D3 and 24,25-(OH)2 D3 remained normal, we excluded the possibility that the aberrant profile was caused by hypervitaminosis D, but instead points to an underlying genetic cause that parallels the effect of Williams syndrome transcription factor deficiency in WBS. Furthermore, we observed normalization of serum calcium and vitamin D metabolite profiles at follow-up of an IH patient where 25-OH-D was reduced to 9 ng/ml, suggesting that symptomatic IH may depend on vitamin D nutritional status. Other hypercalcemic patients with complex conditions exhibited distinct vitamin D metabolite profiles. Our work points to the importance of serum vitamin D metabolite profiling in the differential diagnosis of vitamin D-related hypercalcemia that can rationalize expensive genetic testing, and assist healthcare providers in selecting appropriate treatment. © 2021 American Society for Bone and Mineral Research (ASBMR).

Diagnostic accuracy of subjective dyspnoea in detecting hypoxaemia among outpatients with COVID-19: a retrospective cohort study.

OBJECTIVES: The majority of patients with mild-to-moderate COVID-19 can be managed using virtual care. Dyspnoea is challenging to assess remotely, and the accuracy of subjective dyspnoea measures in capturing hypoxaemia have not been formally evaluated for COVID-19. We explored the accuracy of subjective dyspnoea in diagnosing hypoxaemia in COVID-19 patients. METHODS: This is a retrospective cohort study of consecutive outpatients with COVID-19 who met criteria for home oxygen saturation monitoring at a university-affiliated acute care hospital in Toronto, Canada from 3 April 2020 to 13 September 2020. Dyspnoea measures were treated as diagnostic tests, and we determined their sensitivity (SN), specificity (SP), negative/positive predictive value (NPV/PPV) and positive/negative likelihood ratios (+LR/-LR) for detecting hypoxaemia. In the primary analysis, hypoxaemia was defined by oxygen saturation <95%; the diagnostic accuracy of subjective dyspnoea was also assessed across a range of oxygen saturation cutoffs from 92% to 97%. RESULTS: During the study period, 89/501 (17.8%) of patients met criteria for home oxygen saturation monitoring, and of these 17/89 (19.1%) were diagnosed with hypoxaemia. The presence/absence of dyspnoea had limited accuracy for diagnosing hypoxaemia, with SN 47% (95% CI 24% to 72%), SP 80% (95% CI 68% to 88%), NPV 86% (95% CI 75% to 93%), PPV 36% (95% CI 18% to 59%), +LR 2.4 (95% CI 1.2 to 4.7) and -LR 0.7 (95% CI 0.4 to 1.1). The SN of dyspnoea was 50% (95% CI 19% to 81%) when a cut-off of <92% was used to define hypoxaemia. A modified Medical Research Council dyspnoea score >1 (SP 98%, 95% CI 88% to 100%), Roth maximal count <12 (SP 100%, 95% CI 75% to 100%) and Roth counting time <8 s (SP 93%, 95% CI 66% to 100%) had high SP that could be used to rule in hypoxaemia, but displayed low SN (≤50%). CONCLUSIONS: Subjective dyspnoea measures have inadequate accuracy for ruling out hypoxaemia in high-risk patients with COVID-19. Safe home management of patients with COVID-19 should incorporate home oxygenation saturation monitoring.