Comorbid insomnia symptoms predict lower 6-month adherence to CPAP in US veterans with obstructive sleep apnea.

PURPOSE: There is limited information on the association between pre-treatment insomnia symptoms and dysfunctional sleep beliefs with continuous positive airway pressure (CPAP) adherence in veterans with obstructive sleep apnea (OSA). Our aims were to describe demographic and sleep characteristics of veterans with and without comorbid insomnia and determine whether pre-treatment insomnia symptoms and dysfunctional sleep beliefs predict CPAP use after 6 months of therapy. METHODS: Hispanic veterans attending the Miami VA sleep clinic were recruited and completed the insomnia severity index, the dysfunctional sleep belief and attitude scale (DBAS), and other questionnaires. Participants were asked to return after 7 days and 1 and 6 months to repeat questionnaires and for objective CPAP adherence download. Hierarchical regression models were performed to determine adjusted associations of pre-treatment insomnia symptoms and DBAS sub-scores on 6-month mean daily CPAP use. RESULTS: Fifty-three participants completed the 6-month follow-up visit with a mean CPAP use of 3.4 ± 1.9 h. Veterans with comorbid insomnia had lower mean daily CPAP use (168 ± 125 vs 237 ± 108 min, p = 0.04) and lower percent daily CPAP use ≥ 4 h (32 ± 32 vs 51 ± 32%, p = 0.05) compared to participants without insomnia. In adjusted analyses, pre-treatment insomnia symptoms (early, late, and aggregated nocturnal symptoms) and sleep dissatisfaction were predictive of lower CPAP use at 6 months. Pre-treatment dysfunctional sleep beliefs were not associated with CPAP adherence. CONCLUSIONS: Pre-treatment nocturnal insomnia symptoms and sleep dissatisfaction predicted poorer 6- month CPAP use. Insomnia treatment preceding or concurrent with CPAP initiation may eliminate a barrier to regular use.

Determinants of continuous positive airway pressure adherence in a sleep clinic cohort of South Florida Hispanic veterans.

PURPOSE: There are little existing data on continuous positive airway pressure (CPAP) adherence in US Hispanic veterans with obstructive sleep apnea (OSA). Our aim was to describe determinants of 1-month adherence in a sleep clinic cohort of South Florida Hispanic veterans. METHODS: Hispanic veterans referred to the Miami VA sleep clinic were recruited and completed questionnaires about sleep apnea risk, sleep quality, insomnia symptoms, sleepiness, depression/anxiety, acculturation, personality traits, and cognitions about OSA and CPAP. Individuals at risk for OSA were scheduled for baseline polysomnography (PSG), followed by in-lab CPAP titration or a trial of auto-CPAP. Participants with OSA accepting CPAP therapy were asked to return after 7 and 30 days of treatment for adherence verification and to repeat questionnaires. RESULTS: One hundred twenty-four participants (94 % men) were enrolled with 114 completing overnight PSG. Eighty-six out of 95 participants (91 %) with sleep apnea syndrome or moderate to severe OSA accepted CPAP treatment. Fifty-nine participants completed both follow-up visits with a mean CPAP use at 30 days of 3.6 ± 2.0 h. The only independent predictor of 7-day mean daily CPAP use was the baseline Insomnia Severity Index while the best predictor of 30-day mean daily CPAP use was the 7-day mean daily use. CONCLUSIONS: Our study suggests that South Florida Hispanic veterans with OSA evaluated in a sleep clinic show poor CPAP adherence. Insomnia and poor early use predicted poor adherence overall. Larger prospective studies with other race-ethnic groups are needed to determine the role of ethnicity and race in CPAP adherence among US veterans with OSA.

Inhalational anthrax: epidemiology, diagnosis, and management.

Anthrax, a disease of great historical interest, is once again making headlines as an agent of biological warfare. Bacillus anthracis, a rod-shaped, spore-forming bacterium, primarily infects herbivores. Humans can acquire anthrax by agricultural or industrial exposure to infected animals or animal products. More recently, the potential for intentional release of anthrax spores in the environment has caused much concern. The common clinical manifestations of anthrax are cutaneous disease, pulmonary disease from inhalation of anthrax spores, and GI disease. The course of inhalational anthrax is dramatic, from the insidious onset of nonspecific influenza-like symptoms to severe dyspnea, hypotension, and hemorrhage within days of exposure. A rapid decline, culminating in septic shock, respiratory distress, and death within 24 h is not uncommon. The high mortality seen in inhalational anthrax is in part due to delays in diagnosis. Classic findings on the chest radiograph include widening of the mediastinum as well as pleural effusions. Pneumonia is less common; key pathologic manifestations include severe hemorrhagic mediastinitis, diffuse hemorrhagic lymphadenitis, and edema. Diagnosis requires a high index of suspicion. Treatment involves supportive care in an intensive care facility and high doses of penicillin. Resistance to third-generation cephalosporins has been noted. Vaccines are currently available and have been shown to be effective against aerosolized exposure in animal studies.

Improved quality of life among patients completing a pulmonary rehabilitation program: one center's early experience.

INTRODUCTION: The conclusion of previous investigations that pulmonary rehabilitation (PR) is an effective intervention for the management of chronic lung disease may not be generalizable to PR programs with limited experience delivering this complex, interdisciplinary service. OBJECTIVE: Determine whether PR is effective for the first group of patients treated in a newly formed interdisciplinary PR program. METHODS: We conducted a longitudinal analysis of changes in health-related quality of life and 6-minute walk test for the first group of patients completing our newly formed 8-week outpatient PR program. We studied 6 men, age 65-77 years, with stable severe chronic obstructive pulmonary disease. Patients completed the Chronic Respiratory Disease Questionnaire immediately before and 1 year after participation in our PR program. RESULTS: Four patients completed the PR 6-minute walk test both before and after the program. We found improvement in all Chronic Respiratory Disease Questionnaire domains at follow-up (mean +/- SD before and after): dyspnea 1.67 +/- 0.82 vs 4.92 +/- 0.49; emotional function 2.33 +/- 0.82 vs 5.50 +/- 0.55; fatigue 2.00 +/- 0.63 vs 5.00 +/- 0.63; feeling of mastery over disease 1.83 +/- 0.41 vs 5.83 +/- 1.17. The interval improvements in all health-related quality of life domains were statistically significant (p < 0.02 for all comparisons). There was a trend toward improvement in exercise tolerance: 231 +/- 213 ft before PR vs 353 +/- 66 ft at the 1-year follow-up (p = 0.2). CONCLUSIONS: PR can result in sustained improvement in the quality of life of patients with severe chronic obstructive pulmonary disease, even when this complex, interdisciplinary service is delivered by a newly formed and inexperienced PR program.

Sleep-related falling out of bed in Parkinson's disease.

BACKGROUND AND PURPOSE: Sleep-related falling out of bed (SFOB), with its potential for significant injury, has not been a strong focus of investigation in Parkinson's disease (PD) to date. We describe the demographic and clinical characteristics of PD patients with and without SFOB. METHODS: We performed a retrospective analysis of 50 consecutive PD patients, who completed an REM sleep behavior disorder screening questionnaire (RBDSQ), questionnaires to assess for RBD clinical mimickers and questions about SFOB and resulting injuries. Determination of high risk for RBD was based on an RBDSQ score of 5 or greater. RESULTS: Thirteen patients reported history of SFOB (26%). Visual hallucinations, sleep-related injury, quetiapine and amantadine use were more common in those patients reporting SFOB. Twenty-two patients (44%) fulfilled criteria for high risk for RBD, 12 of which (55%) reported SFOB. Five patients reported injuries related to SFOB. SFOB patients had higher RBDSQ scores than non-SFOB patients (8.2±3.0 vs. 3.3±2.0, p<0.01). For every one unit increase in RBDSQ score, the likelihood of SFOB increased two-fold (OR 2.4, 95% CI 1.3-4.2, p<0.003). CONCLUSIONS: SFOB may be a clinical marker of RBD in PD and should prompt confirmatory polysomnography and pharmacologic treatment to avoid imminent injury. Larger prospective studies are needed to identify risk factors for initial and recurrent SFOB in PD.

Insomnia characteristics and clinical correlates in Operation Enduring Freedom/Operation Iraqi Freedom veterans with post-traumatic stress disorder and mild traumatic brain injury: an exploratory study.

BACKGROUND: There is limited data on chronic insomnia in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, in whom post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) often co-exist. Our aim was to compare sleep characteristics of three groups of OEF/OIF veterans: (1) healthy sleepers (HS), (2) those with insomnia associated with PTSD and mTBI (PTSD-mTBI), and (3) those with insomnia associated with PTSD alone. METHODS: Consecutive veterans with insomnia complaints (> 6 months) were recruited over 6 months from the Miami VA Post Deployment clinic. Participants completed a sleep disorders clinical interview, medical history, and questionnaires about insomnia, sleepiness, pain, fatigue, depression, PTSD, and health-related quality of life. They underwent polysomnography (PSG) with 2 weeks of actigraphy (ACT) and sleep diaries. RESULTS: There were no differences in demographics or most questionnaire responses between PTSD and PTSD-mTBI groups. Subjective daytime sleepiness was significantly greater in PTSD-mTBI subjects compared with HS and PTSD participants. Significant co-morbid sleep disorders were noted in insomnia patients. PSG and ACT wake after sleep onset was significantly shorter in PTSD-mTBI subjects as compared with PTSD participants. CONCLUSION: Insomnia patients with PTSD-mTBI were subjectively sleepier despite spending less time awake during the night than PTSD subjects, possibly as a consequence of head trauma.