Trauma Associated Sleep Disorder: Clinical Developments 5 Years After Discovery.

PURPOSE OF REVIEW: We review recent and growing evidence that provides support for a novel parasomnia, trauma associated sleep disorder (TASD). Based on these findings, we further develop the clinical and polysomnographic (PSG) characteristics of TASD. We also address factors that precipitate TASD, develop a differential diagnosis, discuss therapy, and propose future directions for research. RECENT FINDINGS: Nightmares, classically a REM phenomenon, are prevalent and underreported, even in individuals with trauma exposure. When specifically queried, trauma-related nightmares (TRN) are frequently associated with disruptive nocturnal behaviors (DNB), consistent with TASD. Capture of DNB in the lab is rare but ambulatory monitoring reveals dynamic autonomic concomitants associated with disturbed dreaming. TRN may be reported in NREM as well as REM sleep, though associated respiratory events may confound this finding. Further, dream content is more distressing in REM. Therapy for this complex disorder likely requires addressing not only the specific TASD components of TRN and DNB but comorbid sleep disorders. TASD is a unique parasomnia developing after trauma. Trauma-exposed individuals should be specifically asked about their sleep and if they have nightmares with or without DNB. Patients who report TRN warrant in-lab PSG as part of their evaluation.

Remodeling characteristics and collagen distribution in biological scaffold materials explanted from human subjects after abdominal soft tissue reconstruction: an analysis of scaffold remodeling characteristics by patient risk factors and surgical site classifications.

OBJECTIVE: The study purpose was to evaluate the associations between patient characteristics or surgical site classifications and the histologic remodeling scores of biologic meshes biopsied from abdominal soft tissue repair sites in the first attempt to generate a multivariable risk-prediction model of nonconstructive remodeling. BACKGROUND: Host characteristics and surgical site assessments may predict remodeling degree for biologic meshes used to reinforce abdominal tissue repair sites. METHODS: Biologic meshes were biopsied from the abdominal tissue repair sites of n = 40 patients during an abdominal reexploration, stained with hematoxylin and eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell types, cell infiltration, extracellular matrix deposition, scaffold degradation, fibrous encapsulation, and neovascularization) and a mean composite score. Biopsies were stained with Sirius Red and Fast Green and analyzed to determine the collagen I:III ratio. On the basis of univariate analyses between subject clinical characteristics or surgical site classification and the histologic remodeling scores, cohort variables were selected for multivariable regression models using P ≤ 0.200. RESULTS: The model selection process for cell infiltration score yielded 2 variables: age at mesh implantation and mesh classification (C statistic = 0.989). For the mean composite score, the model selection process yielded 2 variables: age at mesh implantation and mesh classification (r = 0.449). CONCLUSIONS: These preliminary results constitute the first steps in generating a risk-prediction model that predicts the patients and clinical circumstances most likely to experience nonconstructive remodeling of abdominal tissue repair sites with biologic mesh reinforcement.

Remodeling characteristics and collagen distribution in synthetic mesh materials explanted from human subjects after abdominal wall reconstruction: an analysis of remodeling characteristics by patient risk factors and surgical site classifications.

BACKGROUND: The purpose of this study was to evaluate the associations between patient characteristics or surgical site classifications and the histologic remodeling scores of synthetic meshes biopsied from their abdominal wall repair sites in the first attempt to generate a multivariable risk prediction model of non-constructive remodeling. METHODS: Biopsies of the synthetic meshes were obtained from the abdominal wall repair sites of 51 patients during a subsequent abdominal re-exploration. Biopsies were stained with hematoxylin and eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell infiltration, cell types, extracellular matrix deposition, inflammation, fibrous encapsulation, and neovascularization) and a mean composite score (CR). Biopsies were also stained with Sirius Red and Fast Green, and analyzed to determine the collagen I:III ratio. Based on univariate analyses between subject clinical characteristics or surgical site classification and the histologic remodeling scores, cohort variables were selected for multivariable regression models using a threshold p value of ≤0.200. RESULTS: The model selection process for the extracellular matrix score yielded two variables: subject age at time of mesh implantation, and mesh classification (c-statistic = 0.842). For CR score, the model selection process yielded two variables: subject age at time of mesh implantation and mesh classification (r (2) = 0.464). The model selection process for the collagen III area yielded a model with two variables: subject body mass index at time of mesh explantation and pack-year history (r (2) = 0.244). CONCLUSION: Host characteristics and surgical site assessments may predict degree of remodeling for synthetic meshes used to reinforce abdominal wall repair sites. These preliminary results constitute the first steps in generating a risk prediction model that predicts the patients and clinical circumstances for which non-constructive remodeling of an abdominal wall repair site with synthetic mesh reinforcement is most likely to occur.

Traumatic brain injury and sleep in military and veteran populations: A literature review.

BACKGROUND: Traumatic brain injury (TBI) is a hallmark of wartime injury and is related to numerous sleep wake disorders (SWD), which persist long term in veterans. Current knowledge gaps in pathophysiology have hindered advances in diagnosis and treatment. OBJECTIVE: We reviewed TBI SWD pathophysiology, comorbidities, diagnosis and treatment that have emerged over the past two decades. METHODS: We conducted a literature review of English language publications evaluating sleep disorders (obstructive sleep apnea, insomnia, hypersomnia, parasomnias, restless legs syndrome and periodic limb movement disorder) and TBI published since 2000. We excluded studies that were not specifically evaluating TBI populations. RESULTS: Highlighted areas of interest and knowledge gaps were identified in TBI pathophysiology and mechanisms of sleep disruption, a comparison of TBI SWD and post-traumatic stress disorder SWD. The role of TBI and glymphatic biomarkers and management strategies for TBI SWD will also be discussed. CONCLUSION: Our understanding of the pathophysiologic underpinnings of TBI and sleep health, particularly at the basic science level, is limited. Developing an understanding of biomarkers, neuroimaging, and mixed-methods research in comorbid TBI SWD holds the greatest promise to advance our ability to diagnose and monitor response to therapy in this vulnerable population.

Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement.

The period of the year from spring to fall, when clocks in most parts of the United States are set one hour ahead of standard time, is called daylight saving time, and its beginning and ending dates and times are set by federal law. The human biological clock is regulated by the timing of light and darkness, which then dictates sleep and wake rhythms. In daily life, the timing of exposure to light is generally linked to the social clock. When the solar clock is misaligned with the social clock, desynchronization occurs between the internal circadian rhythm and the social clock. The yearly change between standard time and daylight saving time introduces this misalignment, which has been associated with risks to physical and mental health and safety, as well as risks to public health. In 2020, the American Academy of Sleep Medicine (AASM) published a position statement advocating for the elimination of seasonal time changes, suggesting that evidence best supports the adoption of year-round standard time. This updated statement cites new evidence and support for permanent standard time. It is the position of the AASM that the United States should eliminate seasonal time changes in favor of permanent standard time, which aligns best with human circadian biology. Evidence supports the distinct benefits of standard time for health and safety, while also underscoring the potential harms that result from seasonal time changes to and from daylight saving time. CITATION: Rishi MA, Cheng JY, Strang AR, et al. Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2024;20(1):121-125.

Traumatic Brain Injury, Sleep, and Melatonin-Intrinsic Changes with Therapeutic Potential.

Traumatic brain injury (TBI) is one of the most prevalent causes of morbidity in the United States and is associated with numerous chronic sequelae long after the point of injury. One of the most common long-term complaints in patients with TBI is sleep dysfunction. It is reported that alterations in melatonin follow TBI and may be linked with various sleep and circadian disorders directly (via cellular signaling) or indirectly (via free radicals and inflammatory signaling). Work over the past two decades has contributed to our understanding of the role of melatonin as a sleep regulator and neuroprotective anti-inflammatory agent. Although there is increasing interest in the treatment of insomnia following TBI, a lack of standardization and rigor in melatonin research has left behind a trail of non-generalizable data and ambiguous treatment recommendations. This narrative review describes the underlying biochemical properties of melatonin as they are relevant to TBI. We also discuss potential benefits and a path forward regarding the therapeutic management of TBI with melatonin treatment, including its role as a neuroprotectant, a somnogen, and a modulator of the circadian rhythm.

International Consensus Statement on Obstructive Sleep Apnea.

BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Clinical and polysomnographic features of trauma associated sleep disorder.

STUDY OBJECTIVES: Trauma associated sleep disorder is a proposed parasomnia that develops after trauma with clinical features of trauma related nightmares, disruptive nocturnal behaviors, and autonomic disturbances. The purpose of this case series is to better characterize the clinical and video-polysomnographic features of patients meeting clinical criteria for this proposed parasomnia. METHODS: Semistructured clinical interview and detailed video-polysomnography review of 40 patients. Movements and vocalizations in rapid eye movement sleep were quantified according to the rapid eye movement sleep behavior disorder severity scale. RESULTS: Patients (n = 40, 32 males) were service members and veterans with a median age of 38.9 years (range 24-57 years) who reported trauma related nightmares and disruptive nocturnal behaviors at home. On video-polysomnography, 28 (71.8%) patients had disruptive nocturnal behaviors in rapid eye movement sleep consisting of limb, head, and axial movements; vocalizations were present in 8 (20%). On the rapid eye movement sleep behavior disorder severity scale, most (n = 28, 71.8%) had a low rating but those with greater severity (n = 11, 28.2%) had a higher prevalence of posttraumatic stress disorder (P = .013) and markedly less N3 sleep (P = .002). The cohort had a high rate of insomnia (n = 35, 87.5%) and obstructive sleep apnea (n = 19, 47.5%). Most patients were treated with prazosin (n = 29, 72.5%) with concomitant behavioral health interventions (n = 25, 64.1%); 15 (51.7%) patients receiving prazosin reported improved symptomatology. CONCLUSIONS: Disruptive nocturnal behaviors can be captured on video-polysomnography during rapid eye movement sleep, although they may be less pronounced than what patients report in their habitual sleeping environment. Clinical and video-polysomnographic correlations are invaluable in assessing patients with trauma associated sleep disorder to document objective abnormalities. This case series provides a further basis for establishing trauma associated sleep disorder as a unique parasomnia. CITATION: Brock MS, Matsangas P, Creamer JL, et al. Clinical and polysomnographic features of trauma associated sleep disorder. J Clin Sleep Med. 2022;18(12):2775-2784.

The Epworth Sleepiness Scale in Service Members with Sleep Disorders.

INTRODUCTION: Excessive daytime sleepiness affects an estimated 20% of the general population. While the prevalence of sleepiness in the military is largely unknown, it is well established that short sleep duration is endemic. The reasons for this include: the demanding nature of their duties, shift work and 24-hour duty periods, deployments and exigencies of military service as well as sleep disorders. The Epworth Sleepiness Scale (ESS) is the most widely used sleep questionnaire and provides a self-assessment of daytime sleepiness. To date the clinical utility of this questionnaire in differentiating sleep disorders in military patients with sleep disorders has never been evaluated. MATERIALS AND METHODS: The primary aim of this manuscript was to assess if Epworth Sleepiness Scale (ESS) scores differed between military personnel with insomnia, obstructive sleep apnea (OSA), comorbid insomnia/obstructive sleep apnea (COMISA), and a group with neither insomnia nor obstructive sleep apnea (NISA). This study assessed the clinical utility of the ESS in differentiating sleep disorders amongst a sample (N = 488) of U.S. military personnel with insomnia (n = 92), OSA (n = 142), COMISA (n = 221), and a NISA group (n = 33) which served as the control population. RESULTS: In the present sample, 68.4% of service members reported excessive daytime sleepiness (EDS) with an ESS > 10. ESS scores differed between military personnel with COMISA (13.5 ± 4.83) and those with OSA only (11.5 ± 4.08; p < 0.001) and the NISA group (9.46 ± 4.84; p < 0.001). Also, ESS scores differed between patients with insomnia only (13.0 ± 4.84) and the NISA group (p < 0.01). CONCLUSIONS: Overall, the ESS had poor ability to differentiate sleep disorders. In military personnel, the ESS appears elevated in the most common sleep disorders, likely due to their insufficient sleep, and does not help to differentiate OSA from insomnia. Further studies are required to validate this questionnaire and determine an appropriate threshold value for abnormal sleepiness in the military population.

Nightmares in United States Military Personnel With Sleep Disturbances.

STUDY OBJECTIVES: Sleep disturbances are common in United States military personnel. Despite their exposure to combat and trauma, little is known about nightmares in this population. The purpose of this study was to describe the prevalence and associated clinical and polysomnographic characteristics of nightmares in United States military personnel with sleep disturbances. METHODS: Retrospective review of 500 active duty United States military personnel who underwent a sleep medicine evaluation and polysomnography at our sleep center. The Pittsburgh Sleep Quality Index and the Pittsburgh Sleep Quality Index-Addendum were used to characterize clinically significant nightmares. Subjective and objective sleep attributes were compared between groups. RESULTS: At least weekly nightmares were present in 31.2%; yet, only 3.9% reported nightmares as a reason for evaluation. Trauma-related nightmares occurred in 60% of those patients with nightmares. Patients with nightmares had increased sleep onset latency (SOL) and rapid eye movement (REM) sleep latency (mean SOL/REM sleep latency 16.6/145 minutes, P = .02 and P = .01 respectively) compared to those without (mean SOL/REM sleep latency 12.5/126 minutes). The comorbid disorders of depression (P ≤ .01, relative risk [RR] 3.55 [95% CI, 2.52-4.98]), anxiety (P ≤ .01, RR 2.57 [95% CI, 1.93-3.44]), posttraumatic stress disorder (P ≤ .01, RR 5.11 [95% CI, 3.43-7.62]), and insomnia (P ≤ .01, RR 1.59 [95% CI, 1.42-1.79]) were all associated with nightmares. CONCLUSIONS: Clinically significant nightmares are highly prevalent in United States military personnel with sleep disturbances. Nightmares are associated with both subjective and objective sleep disturbances and are frequently comorbid with other sleep and mental health disorders. COMMENTARY: A commentary on this article appears in this issue on page 303.

Trauma associated sleep disorder: A parasomnia induced by trauma.

Nightmares and disruptive nocturnal behaviors that develop after traumatic experiences have long been recognized as having different clinical characteristics that overlap with other established parasomnia diagnoses. The inciting experience is typically in the setting of extreme traumatic stress coupled with periods of sleep disruption and/or deprivation. The limited number of laboratory documented cases and symptomatic overlap with rapid eye movement sleep behavior disorder (RBD) and posttraumatic stress disorder (PTSD) have contributed to difficulties in identifying what is a unique parasomnia. Trauma associated sleep disorder (TSD) incorporates the inciting traumatic experience and clinical features of trauma related nightmares and disruptive nocturnal behaviors as a novel parasomnia. The aims of this theoretical review are to 1) summarize the known cases and clinical findings supporting TSD, 2) differentiate TSD from clinical disorders with which it has overlapping features, 3) propose criteria for the diagnosis of TSD, and 4) present a hypothetical neurobiological model for the pathophysiology of TSD. Hyperarousal, as opposed to neurodegenerative changes in RBD, is a component of TSD that likely contributes to overriding atonia during REM sleep and the comorbid diagnosis of insomnia. Lastly, a way forward to further establish TSD as an accepted sleep disorder is proposed.

Laparoscopic adrenalectomy for cancer.

Laparoscopic procedures are preferred by surgeons and patients alike because of decreased pain, reduced perioperative morbidity, and an earlier return to self-reliance. During the last decade, laparoscopic adrenalectomy has become the technique most commonly used for the removal of benign adrenal tumors. The indications for laparoscopy in malignant adrenal tumors remains controversial, because oncologic resections have not been reproducible compared with open techniques.

Sterile gloves: do they make a difference?

BACKGROUND: Multiple studies have demonstrated that >10(5) organisms/mL are needed to cause a wound infection. The aim of this study was to determine if there was a difference in bacterial colony-forming units (CFUs) on sterile gloves versus clean gloves in an outpatient clinical setting. METHODS: Volunteers self-gloved with pairs of clean gloves, and culture swabs were obtained from the palmar surface. Cultures were also obtained after volunteers self-donned sterile gloves and donned sterile gloves with the assistance of a surgical technician. RESULTS: Twenty-five volunteers participated. Mean growths were as follows: clean gloves, 14.08 ± 15.45 CFUs/mL (range, 0-44 CFUs/mL); self-donned sterile gloves, 1.28 ± 4.28 CFUs/mL (range, 0-20 CFUs/mL); and technician-assisted sterile gloves, 1 positive with 8 CFUs/mL. CONCLUSIONS: There was a statistically significant difference in bacterial load on clean gloves versus sterile gloves (P < .001). However, when comparing the bacterial contamination on clean gloves with that required to cause an infection, it appeared that this statistically significant difference was clinically irrelevant.