Postictal generalized EEG suppression is linked to seizure-associated respiratory dysfunction but not postictal apnea.

PURPOSE: The relationship of postictal generalized electroencephalography (EEG) suppression (PGES) with sudden unexpected death in epilepsy (SUDEP) is controversial. It has been suggested that PGES is associated with respiratory inhibition leading to SUDEP, but the relationship between PGES and respiratory depression is unknown. Respiratory rate and amplitude of airflow increase following seizures but there is persistent hypercapnia and hypoxemia. To determine whether seizures with PGES result in respiratory dysfunction, we analyzed respiratory parameters recorded during video-EEG telemetry in patients with localization-related epilepsy. METHODS: Secondarily generalized convulsive seizures (GC) with PGES on scalp EEG or bilateral postictal attenuation (BA) on intracranial recordings were compared to GC without PGES/BA. Oxygen desaturation nadir and duration, end-tidal CO(2) (ETCO(2) ), apnea duration, and duration of the seizure and of the convulsive component were compared in GC with or without PGES/BA. KEY FINDINGS: There was no significant difference between GC with (n = 30) or without PGES/BA (n = 72) for total seizure duration or duration of the convulsion. GC with PGES/BA had a mean oxygen desaturation nadir of 68.8 ± 11.8% (71.5, 43-88) (mean ± standard deviation [median, range]) that was lower (p = 0.002) than seizures without PGES/BA (76.31 ± 10.17% [79, 42-93]). The duration of desaturation was significantly longer and peak ETCO(2) higher in GC with PGES/BA. There was no difference in apnea duration. Apnea did not start during PGES/BA and did not typically extend into the postictal period in GC with or without PGES/BA. SIGNIFICANCE: PGES is not associated with postictal central apnea but is more likely related to the severity of seizure-associated intrinsic pulmonary dysfunction.

Sleepiness, fatigue, and risk of obstructive sleep apnea using the STOP-BANG questionnaire in multiple sclerosis: a pilot study.

PURPOSE: This study aims: (1) to identify patients with multiple sclerosis (MS) who are at high risk for obstructive sleep apnea (OSA) by utilizing the STOP-BANG questionnaire and (2) to evaluate the relationship between OSA risk as determined by the STOP-BANG questionnaire and self-reported sleepiness and fatigue using the Epworth Sleepiness Scale (ESS) and the Fatigue Severity Scale (FSS), respectively. METHODS: A total of 120 consecutive patients presenting to the UC Davis Neurology MS Clinic were invited to participate in an anonymous survey. The exclusion criteria were: age <18 years, indefinite MS diagnosis, or incomplete survey. RESULTS: There were 103 subjects included in our study: 42% of subjects (n = 43) met the criteria for high-risk OSA, 69% of subjects (n = 71) screened high for fatigue (FSS ≥ 4), but only 24 subjects (23%) screened high for excessive daytime sleepiness (ESS > 10). In males, 44% of the variation in ESS scores and 63% in FSS scores were explained by the STOP-BANG components. However, only 17% of the variation in ESS scores and 15% of the variation in FSS scores was explained by the STOP-BANG components in females. CONCLUSIONS: Over 40% of MS patients were identified as high risk for OSA based on the STOP-BANG questionnaire. The STOP-BANG questionnaire offers clinicians an efficient and objective tool for improving detection of OSA risk in MS patients.

Nasal trumpet as a long-term remedy for obstructive sleep apnea syndrome in a child.

We present a case of successful long-term use of nasal trumpet for severe obstructive sleep apnea syndrome in a child with cerebral palsy and complex medical issues. Obstructive sleep apnea syndrome is frequently seen in pediatric patients with cerebral palsy due to their abnormal airway tone and pulmonary vulnerability. Identifying children with cerebral palsy who are at risk for obstructive sleep apnea syndrome is important because its treatment can improve quality of life and seizure control. Although first-line treatment for obstructive sleep apnea syndrome is adenotonsillectomy, children with cerebral palsy are more likely to have residual obstructive sleep apnea syndrome postoperatively. Other options such as positive airway pressure therapy and other upper airway surgeries may pose significant challenges and tolerance issues, as in our patient. As demonstrated in our report, the low rate of complications and ease of use make nasal trumpets a potential long-term treatment option for children with obstructive sleep apnea syndrome who fail or cannot comply with the traditional treatment options.

A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures.

INTRODUCTION: Locoregional analgesia (LRA) remains underused in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF. METHODS: Noninferiority, single-center, randomized clinical trial (2017-2020) was performed. Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space), and LB involved thoracoscopic intercostal blocks of ribs 3 to 8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function score, measured daily for 5 days postoperatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality. RESULTS: Thirty-four patients were enrolled: 16 IC and 18 LB. Age, Injury Severity Score, RibScore, Blunt Pulmonary Contusion Score, and use of nonnarcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p = 0.23). There was no significant difference in Sequential Clinical Assessment of Respiratory Function score between the IC and LB groups. On postoperative days 2 to 4, narcotic requirements were less than half in the LB, as compared with the IC group; however, this difference was not statistically significant. Average wholesale price was US $605 for IC and US $434 for LB. CONCLUSION: In this noninferiority trial, LB provided at least comparable and potentially superior LRA as compared with IC among patients undergoing SSRF. LEVEL OF EVIDENCE: Therapeutic, level II.

Geoepidemiology of COPD and idiopathic pulmonary fibrosis.

Progress in improving patient outcomes and advancing therapeutics in chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF) is hampered by phenotypic heterogeneity and variable responsiveness to clinical interventions that are not fully explained by currently held disease paradigms for COPD and IPF. Although these chronic lung diseases differ in their geoepidemiology and immunopathogenesis, emerging evidence suggest that organ-specific autoimmunity may underlie subphenotypes of COPD and IPF. In particular, the links to tobacco smoking, diet, gender, and environment are explored in this review. We also highlight potential mechanisms that could guide future investigations in both laboratory and clinical settings. A paradigm shift is needed in how we think about COPD and IPF, based on geoepidemiology and a broader understanding of disease pathogenesis that may ultimately lead to new therapies and improved patient outcomes.

The Feasibility and Utility of Level III Portable Sleep Studies in the Pediatric Inpatient Setting.

STUDY OBJECTIVES: Sleep-disordered breathing (SDB) may significantly impact the course of medical illness in hospitalized children. Polysomnography (PSG) is the gold standard for establishing diagnosis of SDB, but its availability is limited. The aim of this study was to explore the feasibility and utility of level III portable sleep studies in hospitalized children with SDB. METHODS: A retrospective study was conducted at a tertiary hospital over the preceding 2 years in hospitalized children < 18 years who had undergone a level III sleep study using the Nox T3 system. The information obtained included demographic data, comorbidities, indication for admission and sleep study, time interval between the study ordered and done, adequacy of technical data from sleep study, study diagnosis, and subsequent management interventions for SDB. RESULTS: A total of 51 hospitalized children had these studies; 32 were female and mean age was 4.3 years. Approximately 90% of children had significant comorbidities, including neurological and craniofacial abnormalities. The majority (80%) of studies were conducted within 24 hours of the time requested and 92.1% studies had technically adequate data for analysis. Thirty-nine (76.5%) children were identified with SDB; all but one patient underwent therapy for SDB during that same hospitalization, including supplemental oxygen (48.7%), positive airway pressure therapy (23%), surgical intervention (38.2%) or caffeine (10.2%). Twelve percent of children had more than one intervention done. CONCLUSIONS: The level III portable sleep study is readily available, sufficient to diagnose SDB, and help to provide appropriate medical and/or surgical therapies in hospitalized children with complex medical conditions.

The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients.

BACKGROUND: Rib fracture scoring systems are limited by a lack of serial pulmonary physiologic variables. We created the Sequential Clinical Assessment of Respiratory Function (SCARF) score and hypothesized that admission, maximum, and rising scores predict adverse outcomes among critically ill rib fracture patients. METHODS: Prospective cohort study of rib fracture patients admitted to the surgical intensive care unit (ICU) at a Level I trauma center from August 2017 to June 2018. The SCARF score was developed a priori and validated using the cohort. One point was assigned for: <50% predicted, respiratory rate >20, numeric pain score ≥5, and inadequate cough. Demographics, injury patterns, analgesics, and adverse pulmonary outcomes were abstracted. Performance characteristics of the score were assessed using the receiver operator curve area under the curve. RESULTS: Three hundred forty scores were available from 100 patients. Median admission and maximum SCARF score was 2 (range 0-4). Likelihood of pneumonia (p = 0.04), high oxygen requirement (p < 0.01), and prolonged ICU length of stay (p < 0.01) were significantly associated with admission and maximum scores. The receiver operator curve area under the curve for the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. In 10 patients, the SCARF score worsened from admission to day 2; these patients demonstrated increased likelihood of pneumonia (p = 0.04) and prolonged ICU length of stay (p = 0.07). Patients who developed complications maintained a SCARF score one point higher throughout ICU stay compared with patients who did not (p = 0.04). The SCARF score was significantly associated with both narcotic (p = 0.03) and locoregional anesthesia (p = 0.03) usage. CONCLUSION: Admission, maximum, daily, and rising scores were associated with utilization of pain control therapies and development of adverse outcomes. The SCARF score may be used to guide therapies for critically ill rib fracture patients, with a proposed threshold greater than 2. LEVEL OF EVIDENCE: Prognostic study, level II.

Integrating palliative care in severe chronic obstructive lung disease.

Palliative care services for patients with chronic obstructive pulmonary disease (COPD) have been limited in most health care schemes despite the significant impact its symptoms can have on quality of life (QOL). Palliative care must be integrated to address physical and emotional distress and QOL deterioration more effectively. Multi-factorial barriers in current health care systems impede the provision of palliative care, including the lack of familiarity among health care professionals. There are sparse evidence-based studies and guidelines for clinicians to better recognize the need for palliative care in COPD patients compared to the large experience and resources available to cancer patients and hospice care. The multidisciplinary approach of palliative care should help COPD patients navigate through the continuum of chronic disease management. Highest QOL, not necessarily the highest physiologic goals, with relief of physical and emotional suffering, are most important to patients. Hospice care, the last phase of palliative care, can be offered to COPD patients when their goal of care has changed from life-prolonging therapies to comfort treatment. We suggest a scheme for identifying COPD patients for palliative care and for delivering simultaneous disease-directed care to help patients live life to the fullest. Pulmonary rehabilitation offers the best venue for incorporating palliative care. We review the need for, barriers to, and key activities for integrating palliative care into the current health care management of patients living with COPD.

A double-blind, randomized controlled trial of gabapentin vs. placebo for acute pain management in critically ill patients with rib fractures.

INTRODUCTION: Achieving adequate pain control for rib fractures remains challenging; prescription of alternatives to narcotics is imperative to curtail the current opioid epidemic. Although gabapentin has shown promise following elective thoracic procedures, its efficacy in patients with rib fractures remains unstudied. We hypothesized that gabapentin, as compared to placebo, would both improve acute pain control and decrease narcotic use among critically ill patients with rib fractures. MATERIALS AND METHODS: Adult patients admitted to the trauma surgery service from November 2016 - November 2017 at an urban, Level I trauma center with one or more rib fractures were randomized to either gabapentin 300 mg thrice daily or placebo for one month following their injury. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings during the index admission, as well as and one-month quality of life survey data were abstracted. RESULTS: Forty patients were randomized. The groups were well matched with respect to age, gender, prior narcotic use, tobacco use, and prior respiratory disease. Although the median RibScore did not differ between groups, the gabapentin group had a higher median number of ribs fractured as compared to the placebo group (7 vs. 5, respectively). Degree of pulmonary contusion and injury severity score were similar between groups. Use of loco-regional anesthetic modalities did not differ between groups. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings were similar between both groups. No benefit was observed when adding gabapentin to a multi-modal analgesic regimen for rib fractures. There were no instances of pneumonia, respiratory failure, or mortality in either group. Hospital and intensive care unit length of stay were similar between groups. Both overall and chest-specific quality of life was equivalent between groups at one month follow-up. CONCLUSIONS: In this group of critically ill patients with rib fractures, gabapentin did not improve acute outcomes for up to one month of treatment.

Differential Pulmonary Rehabilitation Outcomes in Patients With and Without COPD: ROLE OF GENDER.

PURPOSE: Individuals with all forms of pulmonary disease are referred for pulmonary rehabilitation. This study examines pulmonary rehabilitation outcomes between individuals with chronic obstructive lung disease (COPD) and non-COPD disease and the impact of gender. METHODS: This is a retrospective study at a tertiary center. The primary endpoint was the difference in 6-min walk test distance. Secondary measurements included treadmill and NuStep minutes; biceps curls and front arm raises load; quality of life measured by the St George's Respiratory Questionnaire; and University of California San Diego-Shortness of Breath Questionnaire (UCSD-SOBQ) scores. RESULTS: Eighty patients were included: 38 men (23 COPD, 15 non-COPD) and 42 women (31 COPD, 11 non-COPD). There was a statistically significant improvement in 6-min walk test distances pre- to post-pulmonary rehabilitation for all participants, P = .0003. Although both the COPD and non-COPD groups demonstrated overall improvement (P < .0004 and P = .02, respectively), subgroup analysis showed no statistically significant change in the non-COPD group when divided by gender. There was a significant statistical improvement in lower and upper extremity strength in all participants. Only women with COPD showed a statistically significant improvement with respect to overall quality of life as measured by St. George's Respiratory Questionnaire (P = .01). Women showed significant improvement in their depression score, as well as a trend toward improvement in the University of California San Diego-Shortness of Breath Questionnaire, while only men with COPD showed any improvement in their sleep quality measured by the Pittsburgh Sleep Quality Index. CONCLUSIONS: Pulmonary rehabilitation results in different but improved outcomes regardless of gender or disease state.

Sleep in critically ill chemically paralyzed patients requiring mechanical ventilation.

OBJECTIVE: To determine sleep characteristics in patients receiving mechanical ventilation who require a neuromuscular blocking agent (NMBA). DESIGN: Observational study. SETTING: Adult medical ICU at a university hospital. PARTICIPANTS: Eighteen patients with respiratory failure requiring mechanical ventilation were classified into three groups based on medication regimen determined a priori: intermittent sedation (IS), continuous sedation (CS), or CS and an NMBA. MEASUREMENTS: Twenty-four-hour polysomnography was performed to determine sleep architecture and fragmentation. Measurement of severity of illness, laboratory indexes, patient-care interventions, and drug dosage were compared between groups, and the effects on sleep staging and fragmentation were analyzed. Sleep stages were scored manually using criteria of Rechtschaffen and Kales, as well as by a modified 50-muV voltage criteria for scoring delta activity. RESULTS: All patients demonstrated abnormal sleep architecture. In each group of patients, the total sleep time (TST) was > 10 h. There was no statistical difference in the delta activity between the two scoring methods; delta activity was increased in all groups: 32.9%, 49.6%, and 43.7% in the IS, CS, and CS/NMBA groups, respectively. Patients receiving NMBAs spent 22% of the sleep period awake. Rapid eye movement sleep could not be detected in the patients receiving NMBAs and was reduced in the other two groups (3.5%). TST, sleep stage, or arousal/awakening index were not statistically correlated with either severity of illness, clinical laboratory indexes, drug dosage, patient-care interventions, or mode of mechanical ventilation. CONCLUSION: TST during a 24-h period is not reduced in patients requiring mechanical ventilation. Delta activity is increased and may reflect age, drug, or a contributing metabolic process. The effect of wakefulness in patients receiving chemical paralysis on recovery and weaning from mechanical ventilation, and overall clinical outcome is unknown.

Interstitial lung disease associated with epidermal growth factor receptor tyrosine kinase inhibitor therapy in non-small-cell lung carcinoma.

Interstitial lung disease is a rare but serious complication of epidermal growth factor receptor tyrosine kinase inhibitor therapy. Although our understanding of this phenomenon remains incomplete, recently there have been significant insights made into the mechanisms of injury, incidence, risk factors, and its clinical manifestations. Japanese patients appear to be at a higher risk (1.6%-3.5%) than patients in the rest of the world (0.3%), and other risk factors, such as coincident interstitial lung disease, concurrent chemotherapy, previous radiation, preexisting pulmonary fibrosis, and male sex, have been identified. In the majority of cases, the histopathology, the acute and often dramatic clinical presentation, and the radiographic findings resemble acute respiratory distress syndrome. Aside from immediate cessation of the offending agent, the treatment is largely supportive, although corticosteroids appear to be of benefit. The mortality remains high at approximately 30%-50%. We present a review of the incidence, risk factors, clinical manifestations, diagnosis, management, and outcome of this disorder.

Inadequate Sedation During Therapeutic Paralysis: Use of Bispectral Index in Critically Ill Patients.

BACKGROUND: Patients receiving therapeutic paralysis may experience inadequate sedation due to intrinsic limitations of behavioral sedation assessment. Bispectral index (BIS™) provides an objective measure of sedation; however, the role of BIS™ is not well defined in intensive care unit (ICU) patients on neuromuscular blocking agents (NMBA). OBJECTIVE: The aim of this study was to delineate the relationship between BIS™ and level of sedation for critically ill patients during therapeutic paralysis. METHODS: This was a retrospective observational study conducted in ICU patients receiving continuous infusion NMBA and BIS™ monitoring. The primary endpoint was the correlation of BIS™ <60 during therapeutic paralysis with a Richmond Agitation Sedation Score (RASS) of -4 to -5 (i.e., deep or unarousable sedation) at the time of emergence from therapeutic paralysis. RESULTS: Thirty-one patients were included in the analysis. Three of these patients (9.6 %) were inadequately sedated upon emergence from paralysis; that is, restless or agitated (RASS +1 to +2). We did not observe a correlation between BIS™ and RASS upon emergence from paralysis (r = 0.27, p = 0.14). The sensitivity of BIS™ <60 in predicting deep sedation (RASS -5 to -4) was 100 % (95 % confidence interval [CI] 0-100) with a positive predictive value of 35.7 %. The sensitivity and positive predictive value of BIS™ <60 in predicting light sedation or deeper (RASS -5 to -2) was 92.9 % (95 %CI 83.3-100) and 92.9 %, respectively. CONCLUSION: These results suggest that 1 in 10 critically ill patients receiving therapeutic paralysis may be inadequately sedated. BIS™ monitoring may serve as a useful adjunctive measure of sedation in critically ill patients receiving therapeutic paralysis.

Pulmonary edema following generalized tonic clonic seizures is directly associated with seizure duration.

PURPOSE: Postictal pulmonary edema (PPE) is almost invariably present in human and animal cases of sudden unexpected death in epilepsy (SUDEP) coming to autopsy. PPE may be a contributing factor in SUDEP. The incidence of postictal PPE is unknown. We retrospectively investigated PPE following generalized tonic clonic seizures (GTCS) in the epilepsy monitoring unit. METHODS: Chest X-Rays (CXR) following each GTCS were obtained in 24 consecutive patients. Relationship of CXR abnormality to seizure duration, ictal/postictal oxygen desaturation (SpO2), apnea and presence of postictal generalized EEG suppression (PGES) was investigated using logistic regression. RESULTS: Eleven of 24 patients had CXR abnormalities following a GTCS. In these 11 patients, 22 CXR were obtained and abnormalities were present in 15 CXR. Abnormalities included PPE in 7 patients, of which 2 also had focal infiltrates. In 4 patients focal infiltrates were present without PPE. There was no significant difference in mean time to CXR (225 min) following GTCS in the abnormal CXR group versus the normal group of patients (196 min). Mean preceding seizure duration was longer (p=0.002) in GTCS with abnormal CXR (259.7 sec) versus GTCS with normal CXR (101.2 sec). Odds-ratio for CXR abnormality was 20.46 (p=0.006) with seizure duration greater than 100 sec versus less than 100 sec. On multivariable analysis, only the seizure duration was a significant predictor of CXR abnormality (p=0.015). CONCLUSIONS: Radiographic abnormalities are not uncommon following GTCS. The presence of CXR abnormality is significantly associated with the duration of the preceding GTCS. Severe, untreated PPE may be relevant to the pathophysiology of SUDEP.

Severe upper airway obstruction during sleep.

Few disorders may manifest with predominantly sleep-related obstructive breathing. Obstructive sleep apnea (OSA) is a common disorder, varies in severity and is associated with significant cardiovascular and neurocognitive morbidity. It is estimated that between 8 and 18 million people in the United States have at least mild OSA. Although the exact mechanism of OSA is not well-delineated, multiple factors contribute to the development of upper airway obstruction and include anatomic, mechanical, neurologic, and inflammatory changes in the pharynx. OSA may occur concomitantly with asthma. Approximately 74% of asthmatics experience nocturnal symptoms of airflow obstruction secondary to reactive airways disease. Similar cytokine, chemokine, and histologic changes are seen in both disorders. Sleep deprivation, chronic upper airway edema, and inflammation associated with OSA may further exacerbate nocturnal asthma symptoms. Allergic rhinitis may contribute to both OSA and asthma. Continuous positive airway pressure (CPAP) is the gold standard treatment for OSA. Treatment with CPAP therapy has also been shown to improve both daytime and nighttime peak expiratory flow rates in patients with concomitant OSA and asthma. It is important for allergists to be aware of how OSA may complicate diagnosis and treatment of asthma and allergic rhinitis. A thorough sleep history and high clinical suspicion for OSA is indicated, particularly in asthma patients who are refractory to standard medication treatments.

Sleep is associated with the metabolic syndrome in a multi-ethnic cohort of midlife women: the SWAN Sleep Study.

STUDY OBJECTIVES: We evaluated associations among subjective and objective measures of sleep and the metabolic syndrome in a multi-ethnic sample of midlife women. DESIGN: Cross-sectional study. SETTING: Participants' homes. PARTICIPANTS: Caucasian (n = 158), African American (n = 125), and Chinese women (n = 57); mean age = 51 years. Age range = 46-57 years. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Metabolic syndrome was measured in the clinic and sleep quality was assessed by self-report. Indices of sleep duration, continuity/fragmentation, depth, and sleep disordered breathing were assessed by in-home polysomnography (PSG). Covariates included sociodemographics, menopausal status, use of medications that affect sleep, and self-reported health complaints and health behaviors known to influence metabolic syndrome risk. Logistic regression was used to test the hypothesis that the metabolic syndrome would be associated with increased subjective sleep complaints and PSG-assessed sleep disturbances. In univariate analyses, the metabolic syndrome was associated with decreased sleep duration and efficiency and increased NREM beta power and apnea-hypopnea index (AHI). After covariate adjustment, sleep efficiency (odds ratio [OR] = 2.06, 95% confidence interval [CI]: 1.08-3.93), NREM beta power (OR = 2.09, 95% CI: 1.09-3.98), and AHI (OR = 1.86, 95% CI: 1.40-2.48) remained significantly associated with the metabolic syndrome (odds ratio values are expressed in standard deviation units). These relationships did not differ by race. CONCLUSIONS: Objective indices of sleep continuity, depth, and sleep disordered breathing are significant correlates of the metabolic syndrome in midlife women, independent of race, menopausal status and other factors that might otherwise account for these relationships.

Evaluation of the association of menopausal status with delta and beta EEG activity during sleep.

STUDY OBJECTIVES: Women report increasing sleep difficulties during menopause, but polysomnographic measures do not detect sleep disturbances. We examined whether two spectral analysis sleep measures, delta and beta power, were related to menopausal status. DESIGN: The Study of Women's Health Across the Nation (SWAN) Sleep Study compared cross-sectionally spectral sleep measures in women in different stages of menopause. SETTING: Sleep EEG was recorded in the participants' homes with ambulatory recorders. PARTICIPANTS: A multi-ethnic cohort of premenopausal and early perimenopausal (n = 189), late perimenopausal (n = 73), and postmenopausal (n = 59) women. MEASUREMENTS: EEG power in the delta and beta frequency bands was calculated for all night NREM and all night REM sleep. Physical, medical, psychological, and socioeconomic data were collected from questionnaires and diaries. RESULTS: Beta EEG power in NREM and REM sleep in late perimenopausal and postmenopausal women exceeded that in pre- and early perimenopausal women. Neither all night delta power nor the trend in delta power across the night differed by menopausal status. In a multivariate model that controlled for the physical, demographic, behavioral, psychological, and health-related changes that accompany menopause, beta power in both NREM and REM sleep EEG was significantly related to menopausal status. The frequency of hot flashes explained part but not all of the relation of beta power to menopausal status. CONCLUSIONS: Elevated beta EEG power in late perimenopausal and postmenopausal women provides an objective measure of disturbed sleep quality in these women. Elevated beta EEG activity suggests that arousal level during sleep is higher in these women.

Sleep in the ICU: potential mechanisms and clinical implications.

Patients in the ICU are known to have severely disrupted sleep with disturbed circadian pattern, decreased nocturnal sleep time, abnormally increased stages 1 and 2 sleep, and reduced or absent deep sleep. Recent data reveal that a subpopulation of critically ill patients manifests unique EEG sleep patterns. The etiology of sleep disruption in the ICU includes the inherent nature of the environment, medications, ventilator-patient interaction, and the effect of acute illness. How sleep disruption contributes to outcomes in critically ill patients, such as recovery time and weaning from mechanical ventilation, is unknown. This article reviews the literature describing sleep in ICU patients, including recent investigations in patients who require mechanical ventilation, factors that affect sleep in critically ill patients, and the potential mechanisms and clinical implications of disturbed sleep in the ICU setting with directions to consider for future investigations.

Sleep in hospitalized medical patients, part 2: behavioral and pharmacological management of sleep disturbances.

BACKGROUND: As described in Part 1 of this article, multiple factors lead to disrupted sleep in hospitalized medical patients. Recognizing and addressing these factors can help clinicians more effectively manage patients' sleep complaints. METHODS: A PubMed search was conducted by cross-referencing the terms "sleep deprivation," "insomnia," and "sleep"; "hospitalized," "acutely ill," and "critically ill"; and "medication," "drugs," "hypnotics," "benzodiazepines," and "sedatives." The search was limited to English-language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search. RESULTS: Few articles addressed the topic of the assessment and management of sleep problems in hospitalized medical patients. In Part 2, we propose an evaluation and treatment algorithm that includes recommendations regarding the use of nonpharmacologic and pharmacologic therapies as clinicians consider relevant clinical data. The algorithm is accompanied by 5 tables that include pertinent and practical information to assist clinicians as they manage their inpatients' sleep complaints. CONCLUSIONS: Assessment of a sleep complaint should include a review of factors that could exacerbate patients' sleep. The treatment could then focus on ameliorating these factors, and the judicious use of nonpharmacologic strategies and psychopharmacologic agents.