Assessment of Sleep Quality among Medical Students During the Covid- 19 Pandemic

Objective: To assess the sleep quality among medical students, comparing their sleep cycles during physical and online studies along with other factors associated with sleep patterns. Study Design: Cross-sectional Questionnaire based survey Place and Duration of Study: Department of Community Medicine, HITEC Institute of Medical Sciences Taxila from 1st January 2020 to 31st March 2020 Methodology: One hundred and forty seven students were surveyed in a time period of 1 month. The questionnaire included PSQI Pittsburgh Sleep Quality Index and other clinically validated questions. Students with known sleeping disorders were excluded from this survey. Result(s): There were 81 (55.1%) females and 65 (44.2%) males with mean age 20+/-1.4 years. Out of these 94(63.9%) were classified as "Poor Sleepers" and only 53 (36.1%) were "Good Sleepers". Poor sleep quality was associated with female gender (p<0.05), day-scholar residence status (p<0.054), excessive time required to sleep (p<0.00), excessive screen time usage (p<0.007), increased hours of study (p<0.089), experiencing trouble while driving, eating and socializing (p<0.002), lack of enthusiasm (p<0.000), unsatisfactory daily activities (p<0.000) and poor daytime alertness levels (p<0.360). 104 (70.7%) were aware of the effects of melatonin on sleep, only 51 (34.7%) admitted to have used coffee to stay awake at night. 98 (66.7%) subjects were pre-exam workers, 95 (64.6%) admitted not being able to wake up easily in the morning. Conclusion(s): The students and hostelites that used less screen time slept better. Excessive daytime tiredness was also a result of poor sleeping habits. Students who studied for longer periods of time and had difficulty waking up in the morning slept poorly. Poor sleepers also find it difficult to interact and are often unambitious about performing their daily menial tasks, as well as displeased with their daily activities. As a matter of fact, we deduce that sleep quality has unanticipated consequences for medical students' social and mental health.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.

Systematic Reviews of Different Types of Drug Delivery in the Treatment and Prevention of Oral and Dental and Cardiorespiratory Diseases in Patients and Animals Involved in the Disease

This study has systematically investigated the types of drug delivery in the treatment and prevention of oral and dental and cardiorespiratory diseases in patients and animals involved in the disease. Early recognition of risk factors and primary prevention significantly reduces complications and mortality in chronic heart diseases. Lifestyle modification with diet, exercise and smoking cessation is very important to reduce cardiovascular risk factors. In the first days of the disease, when the patient has mild symptoms and has not yet developed respiratory symptoms, you can start treatment with painkillers for headache, sore throat and body pain, along with taking antitussive medicine and vitamin D and C although scientifically the effect of vitamin C. It is not proven, but considering that we still do not have extensive studies on this disease, it seems that taking vitamins may help the patient. Sometimes, some patients themselves start treatment with azithromycin, while this antibiotic has an effect on antibacterial infections and has no effect on the disease of Covid-19. Favipiravir treatment should be started in high-risk outpatients with corona. Of course, along with treatment with favipiravir and similar antiviral effects, it can be effective in the treatment of corona. Famotidine and melatonin, which help improve sleep and are said to have antiviral effects. Of course, melatonin medicine should be taken at around 11 to 12 at night. Because it affects the sleep and wake cycle. Montelukast along with fexofenadine, can have antiviral effects for covid-19 patients. Since the beginning of the Corona pandemic, the world has emphasized on the monthly consumption of vitamin D, but if you do not have a monthly intake, use 1000 milligrams daily or up to 50 thousand units every week and after some time continue to consume vitamin D on a monthly basis. It is also recommended to take vitamin C and magnesium, and it is better for patients to eat foods rich in protein, potassium, and dairy products.

Sleep disturbances in craniopharyngioma: a challenging diagnosis

Introduction: The hypothalamus plays a crucial role in regulating vital functions and circadian rhythms. Both the tumor involving the hypothalamic area and its treatment can lead to hypothalamic dysfunction, resulting in disturbances in sleep-wake patterns, sleep fragmentation, and increased daytime sleepiness. We describe two patients with craniopharyngioma who came to our attention due to the occurrence of episodes characterized by psychomotor slowing and afinalistic limb movements, temporal and spatial disorientation, psychomotor agitation, and oneiric stupor like episodes diagnosed as severe sleep disturbances. Case reports: Patient 1 is a 19-year-old male diagnosed with surgically treated craniopharyngioma. Subsequently, episodes of psychomotor slowing, afinalistic movements of the upper limbs diagnosed as seizures in another neurological center appeared;antiepileptic treatment was started without improvement. At the first examination in our center, excessive daytime sleepiness (EDS), fragmented nighttime sleep, episodes characterized by bimanual automatic gestures occurring during drowsy state, hypnagogic hallucinations, and sudden loss of muscle tone while awake were recognized. Actigraphy demonstrated irregular bedtimes, frequent nocturnal activity, and inappropriate daytime rest episodes. The Epworth Sleepiness Scale (ESS) showed subjective EDS (ESS=19). At PSG, hypersomnolence, severe sleep-related breathing disorder (SRBD), and no interictal and ictal seizure abnormalities were found. A BiPAP NIV was started, and antiepileptic therapy was discontinued. In the following months, PSG revealed marked improvement in SRBD and 1 SOREMP, and the MSLT a mean SOL of 6 min and 10 sec and 3 SOREMPs. These data allowed the diagnosis of secondary narcolepsy, and treatment with pitolisant was initiated with clinical improvement and reduced daytime sleepiness (ESS=9). Patient 2 is a 12-year-old male, surgically treated for craniopharyngioma at the age of 4 years, who developed episodes of myoclonic jerks, temporal and spatial disorientation, and psychomotor agitation during the lockdown period for COVID-19 emergency. Surmising paroxysmal epileptic episodes, the patient was hospitalized. The anamnestic data collection revealed a sleep-wake rhythm dysregulation, fragmented nighttime sleep, EDS, oneiric stupor-like episodes during which the patient performed simple automatic gestures mimicking daily-life activity, and severe impairment of alertness. The Long-term video-EEG, including polygraphic measurements, showed destruction of the wake-NREM sleep-REM sleep boundaries, episodes of undetermined state of vigilance, and concurrence of elements typical of different sleep stages. Moreover, a severe SRBD (AHI 19/h) has been observed. The MRI showed a volumetric increase in the post-surgical interpeduncular fossa and right paramedian cysts. Therefore, a multifactorial therapeutic plan including sleep hygiene and slow-release melatonin was started with improvement in nighttime sleep, but EDS persisted. Surgical treatment of cyst fenestration improved sleep-wake rhythm and behavior;BiPAP NIV was initiated with very poor adherence. Discussion: We aim to focus on sleep disorders as a possible complication of tumors involving the hypothalamic region. Our cases highlight that the clinical manifestation of these dysfunctions can be challenging to diagnose and can lead to misdiagnosis and inappropriate treatment that can harm patients' health and the quality of life of patients and their families. Conclusion: These findings support the need to incorporate comprehensive sleep assessment in survivors from childhood brain tumors involving the suprasellar/hypothalamic region.

How does Austria sleep? Sleeping habits and sleep problems before and during Corona

In the talk I discuss the sleeping habits and sleep problems before and during the Corona pandemic. An alarming increase in sleep problems from 6-year-old primary school children to adolescents and older adults is shown. Half of the interviewed adult Austrians (N=968) sleep less than 7 hours and only 31% classify themselves as "good sleepers". Changes due to the Corona pandemic and lockdown measures are also found across different cultural groups (Austria/Germany, Brazil, Greece, Cuba, Ukraine) and show, on the one hand, a high level of anxiety due to the pandemic (78% of respondents). In addition, in non-system-relevant jobs we see a consistent later going to bed and an extension of sleep times on working days (13 min daily), which in total lead to a reduced "social jetlag". People in system-relevant jobs also go to bed later and get up later, but show no increase in sleep time on weekdays and even a reduction in sleep time on days off (cf. Florea et al., 2021);overall, they also show a reduction in social jetlag, albeit to a lesser extent. We find cultural differences only of a general nature in the sense that people in Greece and Ukraine go to bed and get up later than the other cultural groups studied. Among children and adolescents (N= 2,232), we find 74.8% less physical activity during the Corona pandemic, 44.2% less exposure to daylight and 85% a strong increase in smartphone/tablet use during the pandemic or lock-downs. In addition, a shift of the sleep-wake rhythm to later times (for 94%) & more bedtime, and yet a subjective deterioration in sleep quality is also evident in that data. An alarming number of 33.3-45.3% depending on the age group now even subjectively report sleep problems during the pandemic (cf. Bothe et al., in preparation).

Novel Agents for Treatment of Delirium: A Proposal for a Multimodal Approach

Background: Delirium, a syndrome characterized by impairment in attention and consciousness, commonly occurs in hospital setting and is associated with higher mortality and poor long-term outcomes. With precise etiology of delirium yet to be elucidated, our current understanding describes delirium as a state of multifactorial global brain dysfunction occurring in susceptible elderly and critically ill patients. (Maldonado, 2008) To treat such a multimodal disorder, we propose investigating two novel multimodal pharmacological approaches: Granulocyte-macrophage colony stimulating factor (GM-CSF) inhibitors and pro-cholinergic muscarinic-receptor agonists. Discussion: Neuroinflammation is a focus of inquiry in a number of neuropsychiatric diseases. Unlike individual cytokine (TNF, IL-6) inhibitors, GM-CSF inhibitors combat the entire inflammatory cascade implicated in delirium: blunting the cytokine response (IL-1, IL-6, TNF) to reduce inflammation, limiting chemotaxis (IL-8 inhibition), reducing cell degradation (H2O2, MMPs), and dulling the T- and B-cell response. (Patel, 2021) GC-CSF inhibitors (otilimab and TMJ2) have already been shown to be effective in and approved for the treatment of inflammatory conditions, such as Rheumatoid Arthritis, and have been effective in treatment of inflammatory processes of COVID-19. (Patel, 2021) Given the role of the neuroinflammatory cascade in delirium, we propose investigating the GM-CSF inhibitors to treat delirium. Acetylcholine dysregulation (‘anticholinergic surge’), on the other hand, has long been implicated in delirium and studies suggest some efficacy of acetylcholinesterase inhibitors in treatment of delirium. Novel schizophrenia treatment studies combine xanomeline, a M-receptor agonist, with trospium, a peripheral anticholinergic, to create a net-positive pro-cholinergic state in the brain while minimizing systemic side-effects. (Brannan, 2020) In addition to treating schizophrenia and cognitive impairment, this combination (KarXT), may be useful in reversing the anti-cholinergic state of the delirious brain. Currently in Phase III clinical trials, KarXT should be considered a viable candidate for delirium treatment, once FDA-approved. Conclusions: Pharmacological approaches to delirium have been limited to managing behavioral dysregulation and sleep-wake cycle disturbances. Presently, we are looking at two potential additional approaches to delirium treatment. One is limited to cholinergic circuitry and aims to restore AcH balance via direct M-receptor agonism. The other, based on Systems Integration Failure Hypothesis, addresses the entire inflammatory cascade via GM-CSF inhibition. As agents from both classes are either approved or are close to FDA-approval, we should consider them as candidates for delirium management. References: 1. Maldonado, J, Kapinos, G. (2008). Pathoetiological Model of Delirium, Critical care clinics. 24. 789-856, ix. 10.1016/j.ccc.2008.06.004. 2. Brannan, S, Sawchak, S, et al.(2020). Efficacy and Safety of Xanomeline, a M1/M4 Receptor Preferencing Agonist, Plus Trospium, a Peripheral Muscarinic Antagonist, in Schizophrenia. Biological Psychiatry, 87(9), S169. doi: 10.1016/j.biopsych.2020.02.446 3. Patel, S, Saxena, B., Mehta, P. (2021). Recent updates in the clinical trials of therapeutic monoclonal antibodies targeting cytokine storm for the management of COVID-19. Heliyon, 7(2), e06158. doi: 10.1016/j.heliyon.2021.e06158

P.0435 Psychological impact of COVID-19 pandemic in patients with Alzheimer's disease: a comprehensive review

Background and Aims: The ongoing coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus (SARS-CoV)-2 is having unprecedented effects in healthcare systems, economies and society [1]. Although the respiratory tract is the primary target of SARS-CoV-2, emerging evidence suggests that the virus may also invade the central nervous system (CNS), leading to numerous neurological issues [2]. In particular, people with Alzheimer's disease (AD) are vulnerable group at risk of contracting COVID-19 and present more severe forms and worse outcomes. Social isolation measures (e.g., visitation bans, stay-at-home orders, and lockdowns in care facilities), which are necessary for controlling the spread of SARS-CoV-2 and reducing thus the disease transmission, could cause an imbalance in the lifestyle and mental health, increasing the risk of hospitalization and mortality for people suffering from AD [3]. This situation can cause a wide range of psychological and clinical problems, such as agitation, anxiety, irritability, delirium, aggressiveness, depression and sleep disorders that may contribute to the acceleration of neurodegenerative processes. Given the high prevalence of AD individuals affected by COVID-19, the present review provides an updated overview on published literature on the psychological impact of COVID-19 pandemic in patients affected by AD. Methods: A literature search was conducted in accordance with the PRISMA guidelines. PubMed database in English language was searched for publications before 6st April 2021 using the keywords: “Alzheimer's disease” AND “COVID-19” AND “psychology”. Reviews, clinical studies and meta-analyses were also included with no geographic limitations. All fields were selected and no other filters were applied. Results: A total number of 83 published manuscripts were included (67 research articles, 14 reviews, 1 clinical study and 1 meta-analysis). As expected, the majority of AD patients were women. Interestingly, a general function and cognitive decline has been often observed in demented subjects, leading to an impaired performance in activities of daily living. In regard with the most frequently reported behavioral symptoms related to social distancing, AD patients presented increased mood, sadness, apathy, agitation, hallucinations, anxiety, irritability, sleep disorders such as insomnia or sleep-wake cycle alterations. In addition, these symptoms were greater in patients affected by moderate or severe AD. Conclusions: Current literature reported an increased burden of behavioral symptoms in the majority of AD patients, suggesting a complex and bidirectional relationship with COVID-19. These symptoms were probably triggered by deprivation or reduced social contact, loneliness during the lockdowns, decreased daily activities, lack of physical contact with family members. In turn, an impaired cognitive performances may exacerbate mental health concerns in these patients, which may accelerate the neurodegeneration in AD patients. Therefore, during and after the pandemic, implementation of caregiver support, the presence of skilled nursing home staff or the implementation of new technology solutions are essential to maintain social interaction and to provide adequate support to people suffering from AD. No conflict of interest