A mobile, web-based system can improve positive airway pressure adherence.

SleepMapper is a mobile, web-based system that allows patients to self-monitor their positive airway pressure therapy, and provides feedback and education in real time. In addition to the usual, comprehensive support provided at our clinic, we gave the SleepMapper to 30 patients initiating positive airway pressure. They were compared with patients initiating positive airway pressure at our clinic without SleepMapper (controls) to determine whether SleepMapper affected adherence. A total of 61 patients had polysomnographic and adherence data analysed, 30 were given SleepMapper and 31 received our standard of care. The two groups were well matched at baseline to include no significant differences in age, apnea-hypopnea index, percentage receiving split-night polysomnographs and starting pressures. Patients in the control group received significantly more non-benzodiazepine sedative hypnotics the night of their polysomnography and during positive airway pressure initiation. At 11 weeks, patients in the SleepMapper group had a greater percentage of nights with any use (78.0 ± 22.0 versus 55.5 ± 24.0%; P < 0.001) and >4 h positive airway pressure use (78.0 ± 22.0 versus 55.5 ± 24.0%; P = 0.02). There was a trend toward more patients in the SleepMapper group achieving >4 h of use for at least 70% of nights [9/30 (30%) versus 3/31 (9.7%); P = 0.06]. In multivariate linear regression, the SleepMapper remained significantly associated with percentage of nights >4 h positive airway pressure use (ß coefficient = 0.18; P = 0.02). Added to our usual, comprehensive programme to maximize positive airway pressure adherence in new users, the SleepMapper was independently associated with an 18% increase in nights >4 h of use.

Lung function abnormalities among service members returning from Iraq or Afghanistan with respiratory complaints.

BACKGROUND: Service members deploying to Afghanistan (OEF) and Iraq (OIF) often return with respiratory symptoms. We sought to determine prevalence of lung function abnormalities following OEF/OIF. METHODS: We identified OEF/OIF patients who had unexplained respiratory symptoms evaluated using lung function testing. Lung function data were summarized and analyzed for associations with demographic and deployment characteristics. RESULTS: We found 267 patients with unexplained cough or dyspnea, lung function testing and a history of OEF/OIF deployment. All patients had basic spirometry performed and 82 had diffusion capacity for carbon dioxide (DLCO) measured. The median (IQR) number of deployments and total days deployed were 1 (1-2) and 352.0 (209-583), respectively. There were 83 (36.6%) patients with abnormal spirometry, 53 (63.9%) of whom had an abnormal FEV1/FVC. Only one (1.2%) patient had an abnormal DLCO adjusted for alveolar volume. Of 104 patients who had post bronchodilator (BD) testing performed, six (5.8%) had a positive response by ATS criteria. We found no relationships between lung function and time in theater, deployment location, deployment frequency, or land based-deployment. Dyspnea and enlisted rank were associated with tobacco use and lower FEV1, and cough was associated with total number of deployments. CONCLUSIONS: Service members with respiratory complaints following OEF/OIF have a high prevalence of abnormalities on spirometry. Tobacco use, enlisted rank and total number of deployments were associated with symptoms or spirometric abnormalities.

Validation of the International Medical Prevention Registry on Venous Thromboembolism Bleeding Risk Score.

BACKGROUND: Recent guidelines recommend assessing medical inpatients for bleeding risk prior to providing chemical prophylaxis for VTE. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score (BRS) was derived from a well-defined population of medical inpatients but it has not been validated externally. We sought to externally validate the IMPROVE BRS. METHODS: We prospectively collected characteristics on admission and VTE prophylaxis data each hospital day for all patients admitted for a medical illness to the Walter Reed Army Medical Center over an 18-month period. We calculated the IMPROVE BRS for each patient using admission data and reviewed medical records to identify bleeding events. RESULTS: From September 2009 through March 2011, 1,668 inpatients met the IMPROVE inclusion criteria. Bleeding events occurred during 45 separate admissions (2.7%); 31 events (1.9%) were major and 14 (0.8%) were nonmajor but clinically relevant. Two hundred fifty-six patients (20.7%) had an IMPROVE BRS ≥ 7.0. Kaplan-Meier curves showed a higher cumulative incidence of major (P = .02) and clinically important (major plus clinically relevant nonmajor) (P = .06) bleeding within 14 days in patients with an IMPROVE BRS ≥ 7.0. An IMPROVE BRS ≥ 7.0 was associated with major bleeding in Cox-regression analysis adjusted for administration of chemical prophylaxis (OR, 2.6; 95% CI, 1.1-5.9; P = .03); there was a trend toward a significant association with clinically important bleeding (OR, 1.9; 95% CI, 0.9-3.7; P = .07). CONCLUSIONS: The IMPROVE BRS calculated at admission predicts major bleeding in medical inpatients. This model may help assess the relative risks of bleeding and VTE before chemoprophylaxis is administered.

Venous thromboembolism prophylaxis for patients receiving regional anesthesia following injury in Iraq and Afghanistan.

BACKGROUND: Soldiers with combat-related traumatic injury are at high risk for venous thromboembolism (VTE) and often require regional anesthesia (RA) for pain control. We evaluated whether the recommended reduction in chemoprophylaxis in the presence of RA increases VTE rates. METHODS: We collected data each hospital day for all soldiers admitted to the Walter Reed Army Medical Center following injury in Iraq or Afghanistan. We analyzed thromboprophylaxis and RA rates and assessed risk factors for VTE. We separated outcomes by whether RA was central neuraxial (cNAB) or peripheral blockade. RESULTS: Among 1,259 patients, 323 received RA for a median of 12 days (5-27 days). Those with RA were younger and more likely to have been injured in combat or by an improvised explosive device. They also received more packed red blood cell transfusions and had longer admissions. Patients with RA spent a greater percentage of days on enoxaparin 40 mg daily compared with those without RA (34.4% vs. 22.0%, p < 0.001) and more hospital days without any chemoprophylaxis (2.0 [1.0-6.0] vs. 1.0 [0.0-3.0], p < 0.001). Patients with cNAB were less likely to be placed on enoxaparin 30 mg twice daily. Patients with RA in place had mechanical prophylaxis ordered at the same rate as those without RA. Neither the presence of any RA nor cNAB specifically was associated with an increased risk for VTE. No bleeding or neurologic complications occurred in those receiving RA. CONCLUSION: Despite changes to chemoprophylaxis, soldiers wounded in combat who receive RA are not at increased risk for VTE. LEVEL OF EVIDENCE: Therapeutic study, level III.

Thromboprophylaxis and VTE rates in soldiers wounded in Operation Enduring Freedom and Operation Iraqi Freedom.

OBJECTIVES: US soldiers suffer catastrophic injuries during combat. We sought to define risk factors and rates for VTE in this population. METHODS: We gathered data each hospital day on all patients injured in Afghanistan or Iraq who were admitted to the Walter Reed Army Medical Center (WRAMC). We analyzed prophylaxis rates and efficacy and identified risk factors for VTE. RESULTS: We recorded data on 506 combat casualties directly admitted to WRAMC after medical air evacuation. The average injury severity score for the group was 18.4 ± 11.7, and the most common reason for air evacuation was injury by improvised explosive device (65%). As part of the initial resuscitation, patients received 4.7 ± 9.0 and 4.00 ± 7.8 units of packed RBCs and fresh frozen plasma, respectively, and 42 patients received factor VIIa. Forty-six patients (9.1%) were given a diagnosis of VTE prior to discharge, 18 (3.6%) during air evacuation, and 28 (5.5%) during the hospital stay. In Cox regression analysis, administration of 1 unit of packed RBCs was associated with a hazard ratio (HR) of 1.04 (95% CI, 1.02-1.07; P = .002), and enoxaparin, 30 mg bid, administered subcutaneously for the majority of hospital days was associated with a HR of 0.31 (95% CI, 0.11-0.86; P = .02) for VTE during the hospitalization. CONCLUSIONS: Patients who suffer traumatic injuries in combat overseas are at high risk for VTE during evacuation and recovery. Those with large resuscitations are at particularly high risk, and low-molecular-weight heparin is associated with a decrease in VTE.