Treatment of sleep disturbance following stroke and traumatic brain injury: a systematic review of conservative interventions.

PURPOSE: Sleep disorders are common following stroke and traumatic brain injury. We present a systematic review of the literature investigating conservative interventions to improve sleep in these populations. MATERIALS AND METHODS: The PRISMA statement was used. Embase, PubMed, and the Cochrane library were searched for all experimental studies published prior to 28th March 2020 that assessed conservative interventions to improve the sleep or sleep disorders of adults with a history of stroke or traumatic brain injury (TBI). Two authors reviewed publications of interest and risk of bias assessments were performed using the Cochrane Risk of Bias Tool or the Methodological Index for Non-Randomised Studies instrument. RESULTS: Twenty-three publications were included in this systematic review. Meta-analyses were not performed due to study heterogeneity. Psychotherapy-based approaches might be useful for sleep disturbance after TBI and acupuncture may help improve insomnia or sleep disturbance following stroke or TBI, respectively. The evidence was less clear for morning bright light therapy and exercise. Limitations included a single author performing primary searches, only English publications, the reporting of secondary outcome measures, and sleep disorder diagnoses. CONCLUSIONS: Some conservative interventions might be useful for improving sleep disturbance or disorders in these populations, but further research is required.IMPLICATIONS FOR REHABILITATIONSleep disturbance is common following stroke and traumatic brain injury, with insomnia and obstructive sleep apnoea being the most frequently diagnosed sleep disorders.Psychotherapy-based approaches might be useful for sleep disturbance after TBI and acupuncture may help improve insomnia or sleep disturbance following stroke or TBI, respectively.Morning bright light therapy appeared to be more beneficial for fatigue rather than sleep disturbance after TBI, and the evidence for exercise was less clear.

Diagnostic accuracy of whole-body MRI versus standard imaging pathways for metastatic disease in newly diagnosed non-small-cell lung cancer: the prospective Streamline L trial.

BACKGROUND: Whole-body magnetic resonance imaging (WB-MRI) could be an alternative to multi-modality staging of non-small-cell lung cancer (NSCLC), but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in NSCLC. METHODS: The Streamline L trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed NSCLC that was potentially radically treatable on diagnostic chest CT (defined as stage IIIb or less). Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or histologies other than NSCLC. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs) and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN50436483, and is complete. FINDINGS: Between Feb 26, 2013, and Sept 5, 2016, 976 patients were screened for eligibility. 353 patients were recruited, 187 of whom completed the trial; 52 (28%) had metastasis at baseline. Pathway sensitivity was 50% (95% CI 37-63) for WB-MRI and 54% (41-67) for standard pathways, a difference of 4% (-7 to 15, p=0·73). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (93% [88-96]) and standard pathways (95% [91-98], p=0·45). Agreement with the multidisciplinary team's final treatment decision was 98% for WB-MRI and 99% for the standard pathway. Time to complete staging was shorter for WB-MRI (13 days [12-14]) than for the standard pathway (19 days [17-21]); a 6-day (4-8) difference. The number of tests required was similar WB-MRI (one [1-1]) and standard pathways (one [1-2]). Mean per-patient costs were £317 (273-361) for WBI-MRI and £620 (574-666) for standard pathways. INTERPRETATION: WB-MRI staging pathways have similar accuracy to standard pathways, and reduce the staging time and costs. FUNDING: UK National Institute for Health Research.

Hamman-Rich syndrome.

INTRODUCTION: Acute interstitial pneumonia is a rare but important diagnosis, associated with a high mortality rate and important to identify early. CASE PRESENTATION: A 76 year-old individual presented to hospital with a two-week history of shortness of breath, fevers and a non-productive cough. Treatment initially was for lower respiratory tract infection but returned to hospital three days later as her shortness of breath and peripheral oedema was worsening despite diuretic treatment. Arterial blood gas showed Type 1 Respiratory Failure (p02 was only 10 kPa on 4 L per minute of oxygen). A computed tomography pulmonary angiography (CTPA) was performed to rule out a pulmonary embolism (PE), which showed multifocal diffuse areas of consolidations bilaterally involving all lobes. Bronchoalveolar lavage cellular analysis was also done. The patient was treated as nonspecific interstitial pneumonia. This case study highlights this rare condition presenting similarly to common pulmonary conditions. DISCUSSION: The disease is often preceded by a flu-like prodromal illness lasting one to two weeks prior to presentation. Acute respiratory failure develops in previously healthy individuals without pre-existing lung disease. Diagnosis is also supported by high-resolution computed tomography (HRCT). The effects of high flow ventilation in patients with idiopathic pulmonary fibrosis are associated with improvement in respiratory parameters, improving the efficiency of breathing. CONCLUSION: Acute interstitial pneumonitis can be a difficult diagnosis, associated with a high mortality rate up to 60%. It is also difficult to treat; however supportive treatment with high flow oxygen therapy along with pulsatile high dose Corticosteroids can aid recovery.