Ineffective CPAP Treatment After Effective CPAP Titration.

CASE PRESENTATION: A 67-year-old woman was evaluated for snoring, frequent awakenings, excessive sleepiness, nocturia, headaches, witnessed apneas, and choking and gasping from sleep. Medical history included OSA, hypertension, type 2 diabetes, depression in remission, and mild intermittent asthma. Epworth sleepiness scale score was 22 (abnormal is ≥10, maximum score is 24; increasing scores represent increasing sleepiness). She had been prescribed CPAP therapy. She reported initial nasal mask discomfort (ResMed AirFit N20 nasal mask), which improved with change to an oronasal mask. Patient used nightly, with acceptable tolerance. Sleep onset and wake times remained consistent, with an average total sleep time of 7 hours. She denied alcohol intake, sedative medication use, or changes in weight.

Implementing primary palliative care best practices in critical care with the Care and Communication Bundle.

BACKGROUND: Clinician-family communication is a central component of medical decision-making in the intensive care unit (ICU) and the quality of this communication has a direct impact on decisions made regarding care for patients who are critically ill. AIM: The purpose of the project was to emphasise the need for quality improvement in the medical ICU at the University of Florida Health Hospital in regard to communication between the patients, families and providers. METHOD: Interventions included development of a more systemic approach to primary palliative care by using the nationally recognised and published Care and Communication Bundle tool. The Bundle is a standardised clinical pathway of palliative care best practices. RESULTS: During the project period, staff satisfaction/engagement increased from tier 3 to tier 1 level, the medical ICU length of stay decreased from 4.97 days in fiscal year (FY) 2016 to 4.22 days in FY2017. Moreover, the number of patients discharged directly to hospice increased from 21 in FY2016 to 42 in FY2017, representing a 100% increase. Additionally, palliative care consults decreased in the medical ICU (FY2016=108, FY2017=82), as a result of an increase in daily primary palliative care interventions. The findings demonstrate an improvement in outcome measures during the project.

Circadian Rhythm Sleep-Wake Phase Disorders.

This article reviews delayed and advanced sleep-wake phase disorders. Diagnostic procedures include a clinical interview to verify the misalignment of the major nocturnal sleep episode relative to the desired and social-normed timing of sleep, a 3-month or greater duration of the sleep-wake disturbance, and at least a week of sleep diary data consistent with the sleep timing complaint. Treatment options include gradual, daily shifting of the sleep schedule (chronotherapy); shifting circadian phase with properly timed light exposure (phototherapy); or melatonin administration. Future directions are discussed to conclude the article.

Effect of melphalan 140 mg/m(2) vs 200 mg/m(2) on toxicities and outcomes in multiple myeloma patients undergoing single autologous stem cell transplantation-a single center experience.

Although melphalan at a dose of 140 mg/m(2) (MEL140) is an acceptable conditioning regimen for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) patients, very few studies compared it to the most commonly used dose of 200 mg/m(2) (MEL200). A retrospective review of records of MM patients (2001-2010) identified 33 patients who received MEL140 and 96 patients who received MEL200. As expected, significantly higher percentage of patients in the MEL140 arm were >65 years or had cardiac ejection fraction <50%, had Karnofsky score <80, or had creatinine >2 at the time of ASCT (P≤.01). There were no significant differences in incidence of treatment related mortality and morbidity. At a median follow-up of 74 months from ASCT, there were no significant differences in relapse free survival (RFS) and overall survival (OS) between the two groups. Similar proportion had myeloma status improve to ≥VGPR at 3 months post-ASCT. Usage of post-ASCT maintenance was similar. In multivariate cox proportional hazards model, only disease status of ≥VGPR at the time of ASCT significantly improved RFS (P=.024), but not OS (P=.104). In conclusion, MM patients who received MEL140 had similar long-term outcomes to MEL200 patients despite their older age and co-morbidities.