An assessment of a sleep aid and sleep promotion practices in hospitalized medical patients.

BACKGROUND: Half of patients admitted to medicine units report sleep disruption, which increases the risk of sleep deprivation. Non-pharmacological interventions are the first step to improving sleep. However, utilization of sleep aids continues to be prevalent. Limited data are available on sleep aid prescribing practices across transitions of care. OBJECTIVES: The aim of this study was to describe the current practices for assessing sleep and prescribing pharmacologic agents to promote sleep in the adult medicine population. METHODS: This study was designed as a single-center, retrospective, observational cohort study of all patients discharged by the general medicine teams over a 3-month period (September 2019- November 2019). Prior to admission, inpatient and discharge prescriptions for sleep aids were recorded, and documentation of sleep assessments and non-pharmacological interventions were evaluated. RESULTS: Of 754 patients included, 211 (28%) were prescribed a sleep aid while inpatient. During hospitalization, 124 (16%) patients had at least one documented sleep assessment, and only 22 (3%) were ordered the institutional non-pharmacological sleep promotion order set. The most prescribed sleep aid in inpatients was melatonin (50%), as well as prior to admission (35%) and at discharge (25%). Overall, the relative reduction in sleep aid prescriptions between admission and discharge was 67%. CONCLUSION: Inpatient sleep aid prescribing is common in medical patients. Despite this, sleep assessments and the standard of care of non-pharmacological interventions are rarely utilized. Future efforts should focus on implementation of strategies to make sleep assessments and non-pharmacological sleep promotion routine and consistent in the inpatient setting.

Associations Between Coronary Artery Calcium Score and Exacerbation Risk in BLOCK-COPD.

Introduction: In 2019, the Beta-Blockers for the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease study (BLOCK-COPD) evaluated the effect of metoprolol on exacerbation risk and mortality in a COPD population without indications for beta-blocker use. We hypothesized that an imaging metric of coronary artery disease (CAD), the coronary artery calcium (CAC) score, would predict exacerbation risk and identify a differential response to metoprolol treatment. Methods: The study population includes participants in the BLOCK-COPD study from multiple study sites. Participants underwent clinically indicated thoracic computed tomography (CT) scans ± 12 months from enrollment. The Weston scoring system quantified CAC. Adjusted Cox proportional hazards models evaluated for associations between CAC and time to exacerbation. Results: Data is included for 109 participants. The mean CAC score was 5.1±3.7, and 92 participants (84%) had CAC scores greater than 0. Over a median (interquartile range) follow-up time of 350 (280 to 352) days, there were 61 mild exacerbations and 19 severe/very severe exacerbations. No associations were found between exacerbations of any severity and CAC>0 or total CAC. Associations were observed between total CAC and CAC>0 in the left circumflex (LCx) and time to exacerbation of any severity (adjusted hazard ratio [aHR]=1.39, confidence interval [CI]: 1.08-1.79, p=0.01) and (aHR=1.96, 95% CI: 1.04-3.70, p=0.04), respectively. Conclusions: CAD is a prevalent comorbidity in COPD accounting for significant mortality. Our study confirms the high prevalence of CAD using the CAC score; however, we did not discover an association between CAC and exacerbation risk. We did find novel associations between CAC in the LCx and exacerbation risk which warrant further investigation in larger cohorts.

Successful Treatment of Respiratory Failure in a Patient with Prader-Willi Syndrome with Noninvasive Ventilation with AVAPS.

Prader-Willi syndrome (PWS) is the most prevalent syndromic form of obesity, which starts during early childhood in the setting of hyperphagia. Due to the development of obesity, there is a high prevalence of obstructive sleep apnea (OSA) among these patients. This case report presents a patient with PWS with morbid obesity, severe OSA, and obesity hypoventilation syndrome admitted to the hospital for hypoxemic and hypercapnic respiratory failure. Noninvasive ventilation (NIV) with average volume-assured pressure support, a newer NIV modality, was used successfully to treat this patient, achieving major clinical and gas exchange improvement both during the hospitalization and long term after discharge.

The COVID-19 pandemic and sleep medicine: a look back and a look ahead.

The coronavirus disease 2019 (COVID-19) pandemic is a reminder that global infectious disease outbreaks are not new and they have the potential to cause catastrophic morbidity and mortality, disrupt health care delivery, demand critical decision making in the absence of scientific certainty, interrupt trainee education, inflict economic damage, and cause a spike in demand for health care services that exceeds societal capacity. In this article, we look back at how the sleep medicine community adapted to challenges imposed by the COVID-19 pandemic. To mitigate viral transmission perhaps the single most effective and efficient adaptation was the rapid adoption of telemedicine. Many additional strategies were taken up virtually overnight, including more home sleep apnea testing, reconsideration of potential risks of positive airway pressure therapy, a reduction or cessation of laboratory services, and deployment of workers to provide frontline care to infected patients. During some periods, critical shortages in essential personal protective equipment, respiratory assist devices, and even oxygen added to logistical challenges, which were exacerbated by persistent financial threats and insufficient staffing. Through ongoing innovation, resiliency, and adaptability, breakthroughs were made in assigning staff responsibilities and designing workflows, using clinical spaces, obtaining legislative support, and achieving professional society collaboration and guidance so that the missions of providing health care, teaching, and academic pursuits could continue. Here we summarize what we have learned through these critical months and highlight key adaptations that deserve to be embraced as we move forward. CITATION: Khosla S, Beam E, Berneking M, et al. The COVID-19 pandemic and sleep medicine: a look back and a look ahead. J Clin Sleep Med. 2022;18(8):2045-2050.

Population Decline in COPD Admissions During the COVID-19 Pandemic Associated with Lower Burden of Community Respiratory Viral Infections.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has led to widespread implementation of public health measures, such as stay-at-home orders, social distancing, and masking mandates. In addition to decreasing spread of severe acute respiratory syndrome coronavirus 2, these measures also impact the transmission of seasonal viral pathogens, which are common triggers of chronic obstructive pulmonary disease (COPD) exacerbations. Whether reduced viral prevalence mediates reduction in COPD exacerbation rates is unknown. METHODS: We performed retrospective analysis of data from a large, multicenter health care system to assess admission trends associated with community viral prevalence and with initiation of COVID-19 pandemic control measures. We applied difference-in-differences analysis to compare season-matched weekly frequency of hospital admissions for COPD prior to and after implementation of public health measures for COVID-19. Community viral prevalence was estimated using regional Centers for Disease Control and Prevention test positivity data and correlated to COPD admissions. RESULTS: Data involving 4422 COPD admissions demonstrated a season-matched 53% decline in COPD admissions during the COVID-19 pandemic, which correlated to community viral burden (r = 0.73; 95% confidence interval, 0.67-0.78) and represented a 36% greater decline over admission frequencies observed in other medical conditions less affected by respiratory viral infections (incidence rate ratio 0.64; 95% confidence interval, 0.57-0.71, P < .001). The post-COVID-19 decline in COPD admissions was most pronounced in patients with fewer comorbidities and without recurrent admissions. CONCLUSION: The implementation of public health measures during the COVID-19 pandemic was associated with decreased COPD admissions. These changes are plausibly explained by reduced prevalence of seasonal respiratory viruses.

Quantifying heterogeneity of physical and mental health-related quality of life in chronic obstructive pulmonary disease patients in the United States.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a heterogenous condition. This study aims to quantify the heterogeneity of Health-related Quality of Life (HRQoL), and identify subgroups with the lowest HRQoL, in COPD patients in the United States (US). Methods Data from 2008-2015 Medical Expenditure Panel Survey were used to examine the heterogeneity of HRQoL between different COPD subgroups using mixed-effects modeling and G-computation. The Physical Composite Summary (PCS) and Mental Composite Summary (MCS) scores from the Short-Form-12 questionnaire were utilized. We also compared the heterogeneity of HRQoL in our COPD cohort against that in a matched non-COPD cohort. Results The final sample consisted of 1,866 (weighted = 19,952,143) COPD patients with a mean age of 63.2 years (Standard error (SE):0.38), mean MCS score of 46.84 (SE:0.35), and mean PCS score of 35.65 (SE:0.32). The adjusted MCS and PCS scores ranged from 36.19 to 53.06, and from 25.52 to 48.27, respectively, for COPD subgroups. COPD patients had statistically significantly lower MCS and PCS scores by 4.61, and 5.86 points, respectively, compared to the matched non-COPD cohort, and MCS scores showed a wider variability in the COPD cohort. Conclusion Our study quantifies substantial heterogeneity of HRQoL in COPD in the US and provides evidence for prioritizing COPD subgroups with the lowest HRQoL for targeted interventions.

Lymphoproliferative disorder in a lung transplant recipient.

Post-transplantation lymphoproliferative disorder (PTLD) is uncommon following solid organ transplantation. We present a case of PTLD presenting as hematochezia and abdominal pain in a 66-year-old man, who had undergone bilateral lung transplantation with alemtuzumab induction 7 months prior to presentation. The transplant serologic status was "high-risk" for the presence of both Epstein-Barr virus (EBV) serologies in the donor and negative serologies in the recipient. Biopsies taken during colonoscopy stained strongly positive for EBV-encoded RNA. Mediastinal lymph node biopsies also showed atypical, EBV-positive lymphohistiocytic infiltration with focal necrosis. The patient's hospital course was complicated by treatment side effects, most notably bowel perforation following rituximab. In this case report the topic of PTLD is reviewed and consideration is given to whether alemtuzumab induction may have contributed to the patient's development of PTLD.

A Guide to Management of Sleepiness in ESKD.

Daytime sleepiness, also known as hypersomnolence, is common among patients receiving maintenance dialysis and following successful kidney transplantation. Sleepiness may be secondary to medical comorbid conditions, medication side effect, insufficient sleep syndrome, and sleep-disordered breathing or the result of a primary central disorder of hypersomnolence, such as narcolepsy. Unrecognized and untreated sleep disorders are associated with substantial morbidity and mortality among patients with end-stage kidney disease. Effective management of hypersomnolence can improve quality of life in patients with kidney disease. This review focuses on the principal causes of sleepiness in patients with end-stage kidney disease. Awareness of these disorders by treating nephrologists is crucial. This review provides a systematic approach to guide providers through the recognition, early diagnosis, and treatment of hypersomnolence, which is commonly encountered in this patient population. Areas of future research are also suggested.

Seasonal and Regional Variations in Chronic Obstructive Pulmonary Disease Exacerbation Rates in Adults without Cardiovascular Risk Factors.

RATIONALE: Colder temperatures have been shown to increase hospitalization and mortality rates in adults with chronic obstructive pulmonary disease (COPD) and cardiac disease. Seasonal influences on exacerbation rates in adults with severe COPD but without significant cardiovascular disease are unclear. In addition, regional variations in COPD exacerbations in North America have not yet been explored. OBJECTIVES: In this study, we sought to determine the seasonal and regional variability in exacerbation rates in those with COPD but without significant cardiovascular risk factors. METHODS: We studied adults without cardiovascular risk factors from STATCOPE (Simvastatin in the Prevention of COPD Exacerbations) and placebo arm of MACRO (Azithromycin for the Prevention of Exacerbations of COPD) studies. Forty-five study sites were divided into climate regions in Canada and the United States; seasons were defined as winter, spring, summer, and fall. The primary outcome was the rate of COPD exacerbation. Secondary outcomes included time to first exacerbation, severity of exacerbations, all-cause mortality, and antibiotic and steroid use. RESULTS: We analyzed 1,175 subjects with a mean age of 63.3 ± 8.6 years, forced expiratory volume in 1 second of 41.5 ± 17.1% predicted, and 53.6 ± 29.4 pack-years of smoking history. The COPD exacerbation rate was higher in winter (0.13 exacerbations/person-month) than in spring, summer, and fall (0.11, 0.079, and 0.10 exacerbations/person-month, respectively) (P < 0.001). Summer had the highest proportion of severe exacerbations (40.5%) compared with spring, fall, and winter (32.6%, 34.7%, and 33.1%, respectively) (P = 0.004). Mortality was highest in spring and winter (34% and 30%, respectively). There was significant regional variability in the time to first exacerbation, with the Southeast and West having longer median times to first exacerbation (350 and 342 d, respectively, compared with 184 d in other regions) (P < 0.001). CONCLUSIONS: Significant seasonal and regional variability exist in the rate and severity of exacerbations and overall mortality in adults with COPD without cardiovascular disease.

Statins in the treatment of COPD and asthma-where do we stand?

Asthma and chronic obstructive pulmonary disease (COPD) are the two most prevalent obstructive lung diseases that account for tremendous morbidity and mortality throughout the world. These diseases have strong inflammatory components, with multiple prior studies showing elevated levels of various inflammatory markers and cells in those with COPD and asthma. Therefore, efforts to target inflammation in management of these diseases are of great interest. Statins, which define a class of drugs that are HMG-CoA inhibitors, are used to decrease cholesterol levels and have also been described to have many pleotropic effects that include anti-inflammatory and anti-oxidative properties. These properties have led to multiple studies looking at the potential use of statins in decreasing inflammation in many diseases, including COPD and asthma. This review aims to address the current evidence behind the potential use of statins in the treatment of asthma and COPD.

Daily Peak Expiratory Flow Rate and Disease Instability in Chronic Obstructive Pulmonary Disease.

Rationale: Chronic obstructive pulmonary disease, (COPD) is a major cause of morbidity and mortality in the United States. Peak expiratory flow rate (PEFR) monitoring could provide a daily objective measurement of lung function in COPD patients at home. We hypothesized that individuals with greater variability in daily PEFR would signal an unstable patient population with worse outcomes. Methods: This was a retrospective analysis of prospectively collected data using an electronic diary to record daily PEFR and symptoms in severe and very severe COPD patients. Rates of PEFR change were used to characterize patients into stable and unstable groups determined by the distribution of slopes. Exacerbation-free days, time to first hospitalization, hospitalization rate, length of hospitalization, and all-cause mortality were assessed. Results: A total of 104 severe and very severe COPD patients met entry criteria, and were observed for 37,702 patient-days. There were no significant differences in baseline symptoms, demographics, forced expiratory volume in 1 second (FEV1) or comorbidities between stable versus unstable groups. The unstable group had 34.7 less exacerbation-free days and significantly shorter 6 minute walk distances (6MWD) (227.1 versus 270.7 meters, p=0.031), shorter time to first hospitalization (163 versus 286 days, p=0.017), more frequent hospitalizations (2.6 versus 1.7 per year, p=0.032) and higher all-cause mortality (10.8 versus 5.1%, p= 0.04). Conclusion: Patients with severe to very severe COPD with greater changes in PEFR have shorter 6MWD, reduced time to first hospitalization, more frequent hospitalizations, and higher all-cause mortality despite similar demographic, spirometric and comorbid parameters at baseline. Daily peak flow monitoring can be a useful tool in identifying COPD patients predisposed to worse outcomes.