Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study.

STUDY OBJECTIVES: Reduced sleep duration and work hour variability contribute to medical error and physician burnout. This study assesses the relationships between physician performance, burnout, and the dimensions of sleep beyond hours slept. METHODS: This was an ancillary analysis of 3 years of data from an international prospective cohort study: the Intern Health Study. Actigraphy data from 3,654 intern physicians capturing sleep timing, regularity, efficiency, and duration were used individually and combined as a composite sleep health index to measure the association of multidimensional sleep patterns on self-reported medical errors and burnout. RESULTS: From 2017-2019, interns' work hours decreased by 4 hours per week and total sleep time also decreased (6.7 to 5.99 hours), and sleep efficiency, timing, and regularity all worsened (all P < .05). In the 21.2% of participants who committed an error, there was no difference in sleep duration, timing, or regularity. Lower sleep efficiency was associated with higher odds of committing an error (P = .003) and higher burnout scores (P < .001). Although overall sleep quality was poor in the entire cohort, interns in the lowest quintile of sleep duration, regularity, and efficiency had higher burnout scores than those in the best quintile. CONCLUSIONS: Sleep efficiency, not duration, was associated with increased self-reported medical errors and burnout in intern physicians. Overall sleep quality and duration worsened despite fewer hours worked. Future studies on physician burnout should measure all aspects of sleep health. CITATION: Hassinger AB, Velez C, Wang J, Mador MJ, Wilding GE, Mishra A. Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study. J Clin Sleep Med. 2024;20(2):221-227.

Racial disparity in sleep apnea-related mortality in the United States.

BACKGROUND: Sleep apnea is one of the most common sleep disorders in the United States (US). Although the prevalence, risk factors, and clinical presentations of sleep apnea vary by racial groups, the racial disparity in sleep apnea-related mortality remains unclear. METHODS: Sleep apnea-related mortality for 1999-2019 was obtained from the National Center for Health Statistics provided by the Centers for Disease Control and Prevention. We examined the mortality trends for sleep apnea using Joinpoint regression analysis and compared the associated outcomes and multiple causes of death between Blacks and Whites. RESULTS: For 1999-2019, sleep apnea was documented as the underlying cause of death in 17,053 decedents, with 2593 Blacks and 14,127 Whites. The overall age-adjusted mortality rates in all population, Blacks, and Whites were 2.5, 3.5, and 2.4 per 1,000,000 population, respectively (P < 0.001). Both Blacks and Whites had the highest mortality rates in the Midwest and the lowest in the Northeast. Despite the flattened mortality trend in the last decade overall, Black males had a continuous mortality increase over the study period (Annual Percentage Change 2.7%, 95% CI: 1.2-4.2). For both genders of sleep apnea decedents, Blacks were more likely to have multiple cause of death of Cardiac Arrest, Hypertension, Obesity, and Chronic Renal Failure, but Arrhythmia was more common in Whites (P < 0.05). CONCLUSIONS: There is a significant racial disparity in sleep apnea-related mortality in the US. The uptrend in mortality in Black males and associated outcomes related to cardiovascular disease should raise concerns specifically in Blacks with sleep apnea.

Longer Duration of Palliative Care in Patients With COPD Is Associated With Death Outside the Hospital.

Background: Patients with advanced chronic obstructive pulmonary disease (COPD) have a significant symptom burden despite maximal medical therapy, yet few are referred for concomitant palliative care. Objective: To evaluate the utilization and impact of palliative care on the location of death and to identify clinical variables associated with palliative care contact. Design: Retrospective chart review from 2010 to 2016 at the VA Western New York Healthcare System using ICD-9/10 diagnosis of COPD. Palliative care contact was identified by Z51.5 or stop code 353. Results: Only 0.5% to 2% of living patients received palliative care, increasing abruptly at death (6%). Lower diffusion capacity for carbon monoxide (DLCO) (greater emphysema) was associated with palliative care contact, independent of comorbid disease burden or age. Initial outpatient contact was associated with a longer duration of palliative care (P = .003) and death in a home-like setting. Outpatient palliative care was associated with more severe airflow obstruction (forced expiratory volume in 1 second, percent predicted [FEV1%]), whereas greater disease exacerbation frequency was associated with inpatient contact. COPD patients not referred to palliative care had a greater comorbid disease burden, similar FEV1%, fewer disease exacerbations, and a greater DLCO. Conclusion: Few patients with COPD received palliative care, similar to national trends. Initial outpatient palliative contact had the longest duration of care and death in the preferred home environment. The extent of emphysema (DLCO reduction) and more frequent disease exacerbations identified in patients were more likely to receive palliative care. Our study begins to define the benefits of palliative care in advanced COPD and confirms underutilization in the years before death, where a prolonged impact on the quality of life may be realized.

Effects of Preoperative Breathing Exercise on Postoperative Outcomes for Patients With Lung Cancer Undergoing Curative Intent Lung Resection: A Meta-analysis.

OBJECTIVE: To determine the benefits of preoperative breathing exercises on hospital length of stay (LOS), pneumonia, postoperative pulmonary complications (PPC), 6-minute walk distance (6MWD), forced expiratory volume in 1 second (FEV1), and health-related quality of life (HRQOL) in patients undergoing surgical lung cancer resection. DATA SOURCES: PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials were comprehensively searched from inception to March 2021. STUDY SELECTION: Only studies including preoperative inspiratory muscle training (IMT) and/or breathing exercises compared with a nontraining control group were included. The meta-analysis was done using Cochrane software for multiple variables including LOS, pneumonia, PPC, 6MWD, FEV1, mortality, and HRQOL. DATA EXTRACTION: Two authors extracted the data of the selected studies. The primary outcomes were LOS and PPC. DATA SYNTHESIS: A total of 10 studies were included in this meta-analysis, 8 of which had both IMT and aerobic exercise. Pooled data for patients who performed preoperative breathing exercises, compared with controls, demonstrated a decrease in LOS with a pooled mean difference of -3.44 days (95% confidence interval [CI], -4.14 to -2.75; P<.01). Subgroup analysis also demonstrated that LOS was further reduced when breathing exercises were combined with aerobic exercise (χ2, 4.85; P=.03). Preoperative breathing exercises reduce pneumonia and PPCs with an odds ratio of 0.37 (95% CI, 0.18-0.75; P<.01) and 0.37 (95% CI, 0.21-0.65; P<.01), respectively. An increase in 6MWD of 20.2 meters was noted in those performing breathing exercises (95% CI, 9.12-31.21; P<.01). No significant differences were noted in FEV1, mortality, or HRQOL. CONCLUSIONS: Preoperative breathing exercises reduced LOS, PPC, and pneumonia and potentially improved 6MWD in patients undergoing surgical lung cancer resection. Breathing exercises in combination with aerobic exercise yielded greater reductions in LOS. Randomized controlled trials are needed to test the feasibility of introducing a preoperative breathing exercise program in this patient population.

A Retrospective Observational Study of Domiciliary Oxygen Usage in a Subset of Veterans.

BACKGROUND: Long-term oxygen therapy (LTOT) delivered continuously is known to decrease mortality in patients with COPD and who are hypoxemic; however, supportive data for LTOT use in patients without COPD is lacking. In addition, many patients may be prescribed LTOT without a definitive etiology for hypoxemia. First, we investigated the diagnoses for which oxygen was prescribed to a sample of veterans and whether each diagnosis was supported by confirmatory testing. Second, we looked at the proportion of subjects who were prescribed non-continuous therapy. METHODS: We retrospectively studied subjects prescribed domiciliary oxygen at the Veterans Administration Western New York Healthcare System. The subjects who met inclusion criteria were identified by using a computerized patient record system; data were collected on subject characteristics, oxygen prescription information, diagnosis for hypoxia, and diagnostic workup. Descriptive data were presented as mean ± SD and median (range). Statistical analysis was performed by using the chi-square test and an unpaired t test. RESULTS: A total of 494 subjects were included: 96.8% men, mean ± SD ages 74.2 ± 10.8 y. Most of the subjects were prescribed oxygen as out-patients (68.5%). A total of 335 (67.8%) were prescribed oxygen for continuous therapy, 72 (14.1%) for nocturnal therapy, 50 (10.1%) for exertion, and 30 (6.1%) for both exertion and nocturnal use. At 3 months, 19.6% of the initial cohort had oxygen discontinued. In those subjects with oxygen continued at 3 months, COPD was the most common diagnosis (63.6%), of which 76.1% had pulmonary function tests (PFTs), with 85.7% showing obstruction on spirometry. CONCLUSIONS: Results of our study showed a 99.4% adherence to Medicare criteria for domiciliary oxygen prescription. Also, 30.3% of the subjects were prescribed LTOT for exertional or nocturnal desaturation or both. Repeated testing at 3 months identified subjects who no longer required oxygen. COPD was the most common etiology for domiciliary oxygen. A small proportion of the subjects (6.9%) were prescribed oxygen without underlying etiology for hypoxia. Exertional and/or nocturnal oxygen prescription was common, and further research to elucidate its utility is clearly warranted.

Anti-interleukin (IL)-5 as a steroid-sparing agent in chronic eosinophilic pneumonia.

Introduction: Anti-interleukin (IL)-5 therapy is a novel drug class clinically effective in patients with diverse eosinophil-related disorders such as allergic eosinophilic asthma, eosinophilic granulomatosis with polyangiitis (EGPA), nasal polyposis, eosinophilic COPD, and other non-pulmonary disorders such as eosinophilic esophagitis. Chronic eosinophilic pneumonia (CEP) is a steroid responsive disorder, however, relapses are common following corticosteroid tapering. Case Study: We present the case of a 42-year-old woman with steroid-dependent relapsing CEP successfully treated with anti-IL-5 antibody. Results: Treatment with anti-IL-5 antibody resulted in remission with the ability to taper off the steroids, and no recurrence of the disease for 6 months. Conclusion: Our case report supports the potential use of anti-IL-5 therapy for remission of patients with CEP with recurrent relapses. Whether, it would also be an effective initial therapy might also be an area that deserves future investigation.

Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea with Schizophrenia.

INTRODUCTION: To determine the 1-year and 3-year adherence rates with Positive Airway Pressure (PAP) therapy in patients with schizophrenia compared to matched controls. METHODS: A case-control retrospective analysis was performed in a Veterans Affairs hospital. All symptomatic patients with schizophrenia ever started on PAP therapy between 2007 and 2015 were compared with controls matched for severity of sleep apnea based on AHI, BMI, and age at the time of diagnosis. RESULTS: Total number of subjects in both groups was 39. Mean AHI among cases and controls was 27.63 ± 22.16 and 33.59 ± 44.04 (p = 0.32), mean BMI was 34.91 ± 5.87 and 33.92 ± 5.21 (p = 0.43), and mean age at diagnosis was 53.6 ± 11.75 and 55.97 ± 11.92 (p = 0.36), respectively. There was no statistically significant difference in PAP use between patients with schizophrenia and controls at 1-year (percent days device use > 4 h-36.43% ± 31.41 vs. 49.09% ± 38.76; p = 0.17) and 3-year (percent days device use > 4 h-42.43 ± 35.50 vs. 60.53 ± 38.56; p = 0.089) visits CONCLUSIONS: PAP adherence and usage is not significantly different among patients with schizophrenia compared to matched controls. Therefore, schizophrenia does not appear to influence CPAP compliance.

Omalizumab versus Mepolizumab as add-on therapy in asthma patients not well controlled on at least an inhaled corticosteroid: A network meta-analysis.

OBJECTIVE: The purpose of this study is to examine the comparative efficacy of Omalizumab (OMA) and Mepolizumab (Mepo) in the treatment of severe asthma by performing a network meta-analysis. METHOD: Data Sources: A systematic review of the literature was performed through four databases from their inception to February 2016. STUDY SELECTIONS: Randomized control trials and cohort studies were considered if they addressed the individual efficacy of OMA and Mepo in the treatment of asthma that was not well controlled on inhaled corticosteroids (ICSs) with or without other agents. RESULTS: OMA was significantly better than Mepo in improving the Asthma Quality of Life Questionnaire with a mean difference of 0.38 and a confidence interval of (0.21-0.55), p < 0.0001, without reaching the minimal clinically important difference of 0.5. No significant difference was seen in Asthma Control Questionnaire, forced expiratory volume in second 1 (FEV1), and Peak Expiratory Flow Rate (PEFR) improvement from baseline. Both medications were successful in reducing the calculated annualized rates of asthma exacerbations (AEs) vs placebo by approximately 50%. The heterogeneity score for the different comparisons were elevated except for the PEFR. CONCLUSION: When compared indirectly via a network meta-analysis, the efficacy of OMA and Mepo was similar in the treatment of asthma that was not well controlled on at least high-dose ICS. The high heterogeneity observed and the different selection criteria for the use of the two drugs do not permit us to make any definitive recommendations for the preferential use of OMA vs Mepo in the patient populations studied. However, the current data do not suggest any major differences in efficacy.

The Influence of Body Composition on Pulmonary Rehabilitation Outcomes in Chronic Obstructive Pulmonary Disease Patients.

INTRODUCTION: Alterations in body composition are commonly present in chronic obstructive pulmonary disease (COPD). The hypothesis of this study is that COPD patients would achieve clinical benefits after pulmonary rehabilitation (PR) independent of muscle mass depletion or body weight. METHODS: We conducted a retrospective cohort study using single-frequency bioelectrical impedance analysis (BIA) for assessment of fat-free mass (FFM) depletion (muscle depletion). Patients were stratified into three categories based on (1) obesity BMI ≥ 30 kg/m2, (2) non-obesity BMI < 30 kg/m2, and (3) combined cachexia (BMI < 21 kg/m2 and FFM index < 16 kg/m2) and muscle atrophy (BMI ≥ 21 kg/m2 and FFMI < 16 kg/m2). PR outcomes were defined as the improvement in exercise capacity (maximal exercise capacity, 6-min walk, constant workload cycle exercise duration) and quality of life determined by Chronic Respiratory Questionnaire after PR. RESULTS: We studied 72 patients with available FFM measured by BIA. Patients were predominantly elderly man (N = 71; 98%), with a mean age of 72 years with COPD GOLD stage I-IV. The groups were balanced in terms of age, comorbidities, baseline FEV1, exercise capacity, and quality of life. The absolute changes in patients with muscle depletion or obesity compared to those without muscle depletion or obesity were not statistically different as was the percentage of patients reaching the minimal clinically important difference (MCID) after PR. CONCLUSION: A comprehensive PR program in COPD patients improved exercise tolerance and quality of life independent of muscle mass depletion or obesity. Similarly, muscle depletion or obesity had no effect on the percentage of patients achieving the MCID for measures of quality of life and exercise tolerance after PR.

Incidental Finding of Bronchopulmonary Sequestration in a 64-Year-Old Female.

BACKGROUND: Bronchopulmonary sequestration is a congenital abnormality of the primitive foregut. In adults, the typical age at presentation is 20-25 years. CASE REPORT: A 64-year-old female was referred for evaluation of an 8 × 6-cm right lower lobe cystic lesion. Her medical history was significant for recurrent right lower lobe pneumonia requiring multiple hospitalizations. Her physical examination was significant for crackles at the right lung base. Computed tomography (CT) of the chest with contrast showed cystic changes with thickened septation of the medial segment of the right lower lobe lacking distinct visceral pleura and with arterial supply from the anomalous branch of the thoracic aorta arising near the celiac trunk. Pulmonary angiography confirmed the diagnosis of intralobar pulmonary sequestration. The patient underwent celiac endovascular coil embolization of the anomalous artery to lessen the risk of hemorrhage prior to video-assisted thoracoscopic surgery (VATS) resection of the right lower lobe. She recovered well and was discharged home 1 week after VATS lobectomy. Follow-up CT of the chest 2 months later showed normal postsurgical changes related to right lower lobe lobectomy. The patient remained asymptomatic and resumed her daily activities. CONCLUSION: Pulmonary sequestration can present with recurrent pneumonia in late adulthood. Physicians must review any previous imaging studies of the chest to identify the structural abnormality and be cognizant of differential diagnoses such as infected cystic bronchiectasis, bronchogenic cyst, congenital diaphragmatic hernia, or cystic adenomatoid malformation that can occur in conjunction with bronchopulmonary sequestration. Pulmonary angiogram is the gold standard to confirm the diagnosis of bronchopulmonary sequestration. Surgical resection is the standard of care.

Endobronchial hamartoma; a rare structural cause of chronic cough.

Pulmonary hamartomas are rare benign tumors consisting of multiple mesenchymal cell lines like cartilage, bone and fat. We discuss an interesting case of a 53-year-old male patient, who was referred to our clinic for persistent cough. Chest X-ray revealed a left suprahilar density associated with plate like atelectasis, which on chest CT was found to be a densely calcified nodule, causing narrowing of the left upper lobe (LUL) bronchus with calcified bilateral hilar lymph nodes. A bronchoscopy revealed a smooth endobronchial mass with calcification, which was removed. Histopathology revealed pulmonary hamartoma.

Endobronchial lipoma causing progressive dyspnea.

We describe a 63-year-old male who presented with progressive exertional dyspnea, post-obstructive pneumonia and chest CT findings of an endobronchial lesion. Bronchoscopy revealed an endobronchial lipoma, which was resected using snare electrocautery. Complete resolution of the patient's symptoms was noted following bronchoscopic resection.

Comorbidities in Patients With Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation Outcomes.

PURPOSE: The objective of this study was to evaluate the impact of comorbidities as potential predictors of the response to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). METHODS: The study included 165 patients with COPD with exercise limitations. Comorbidity was classified as cardiac, metabolic, orthopedic, behavioral health problems, or other diseases. Number of comorbidities was grouped as 0, 1, or ≥2. Outcomes were defined as improvement in exercise capacity (maximal exercise capacity, 6-minute walk test, and constant workload cycle exercise duration) and quality of life (Chronic Respiratory Questionnaire). We assessed the effect of comorbidities on improvement in outcomes and the impact of the number of comorbidities on the percentage of patients reaching the minimal clinically important difference for each outcome. RESULTS: Most patients (n = 160; 96%) were elderly males (mean age 70 years) with COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages II to IV. Sixty-four percent of patients had at least 1 comorbidity. The ≥2 comorbidity group (n = 29) had a higher modified Charlson index and more patients required continuous supplemental oxygen. Absolute differences in dyspnea scores in patients with cardiac disease and orthopedic problems compared with those without these comorbidities were 2.6 ± 0.87; 95% CI 0.89 to 4.32; p = .003, and -3.25 ± 1.23; 95% CI -5.69 to -0.82; p = .009, respectively. Comorbidities had no significant effect on other exercise outcomes or quality of life. CONCLUSION: Patients with cardiac disease experienced greater improvement in the dyspnea score compared with patients with no cardiac disease, whereas patients with orthopedic problems had a smaller but also clinically significant improvement in dyspnea after pulmonary rehabilitation.

Continuous Positive Airway Pressure Adherence In Patients with Obstructive Sleep Apnea & Symptomatic BPH.

Purpose To determine the short-term and long-term adherence rates with continuous positive airway pressure (CPAP) therapy in sleep apnea patients with benign prostatic hyperplasia (BPH) compared to matched controls. Methods A case-control retrospective analysis was performed in a veterans affairs hospital. All symptomatic patients with BPH (n = 107) ever started on CPAP therapy between 2006 and 2012 were compared with controls matched for severity of sleep apnea (AHI). Adherence measures were obtained at the third and twelfth month visits. The cases included symptomatic BPH patients on active medical therapy. Diuretic use among cases and controls, and severity of nocturia among the cases were also analyzed. Results The mean AHI among cases and controls was 35.6 ± 27.3 and 35.5 ± 31 (p = 0.96). The population was male and predominantly Caucasian. There was no statistically significant difference in percent days CPAP device use ≥4 h. between symptomatic BPH patients and controls at 3-month (51.6 ± 38 vs. 47.2 ± 36; p = 0.43) and 1-year (64 ± 40.5 vs. 64.7 ± 31.3; p = 0.90) visits. The use of diuretics in the cases and controls, and the severity of nocturia in the cases did not influence adherence with CPAP therapy. Conclusions BPH or diuretic use did not affect adherence with CPAP therapy in obstructive sleep apnea. Severity of nocturia did not have any influence on adherence among the cases. BPH, regardless of the severity of nocturia, and diuretic use does not influence CPAP adherence in patients with OSA.