Contemporary Concise Review 2022: Sleep.

COVID-19 AND SLEEP: The COVID-19 pandemic is associated with an increase in insomnia and impaired sleep quality Health care workers are particularly susceptible and improved with cognitive behavioural therapy for insomnia (CBT-I) Long COVID has significant effects on sleep OSA impacts on the severity of acute COVID-19 illness OBSTRUCTIVE SLEEP APNOEA: Large trials of clinically representative patients confirm the cardiovascular benefits of CPAP treatment in OSA CPAP may improve long-term cognitive outcomes in OSA, but further research is needed Racial disparities in OSA prevalence and mortality risk are becoming evident Periodic evaluation of OSA risk in pregnancy is important as timing may be key for intervention to prevent or treat cardiovascular risk factors INSOMNIA: Comorbid insomnia and obstructive sleep apnoea (COMISA) can frequently co-exist and the combined negative effects of both may be deleterious, particularly to cardiovascular health There is evidence for effectiveness with novel orexin receptor antagonists.

The Melbourne epidemic thunderstorm asthma event 2016: a 5-year longitudinal study.

Background: In 2016, Melbourne was struck by the world's largest and most devastating epidemic thunderstorm asthma (ETSA) episode. While affected individuals displayed worsened short-term asthma control, little is known about their longer-term natural history, nor about interventions that restore control. Objective: We assessed the asthma symptomatology and related behaviours of ETSA-affected individuals through a single-centre prospective 5-year longitudinal study. We embedded an open-label observational trial investigating the role of grass pollen sublingual tablet (Oralair) allergen immunotherapy in improving asthma and allergic rhinitis symptoms. Methods: Allergic rhinitis symptom severity, frequency of asthma symptoms and inhaled corticosteroid usage were assessed via questionnaire yearly. In 2018, a subgroup of participants was enrolled in an observational study of Oralair treatment compared to control. The active group received Oralair from 2019 to 2021; both groups were followed-up for 5 years. Subgroup analyses were performed for participants with complete datasets, and who completed the trial per-protocol. Results: Year-on-year data across 5 years was available for 30 participants. The rate of persistent asthma symptoms declined from 37% to 7% in 2016 to 2021. Only 10%-27% of participants reported being completely asymptomatic in any given year. The inhaled preventer prescription rate was 67%, with only 35% being adherent. Twenty-seven participants with available data completed the Oralair trial per-protocol. No significant difference was noted between control and active groups for allergic rhinitis symptoms or asthma control, although the Oralair group saw a significant improvement in asthma control comparing 2019 with 2021. Conclusion: This is the longest documented follow-up of ETSA-affected individuals. Five years following sentinel event, there was progressive reduction but some persistence in asthma symptoms. Oralair allergen immunotherapy did not further improve allergic rhinitis or asthma symptoms compared to control, but there were no further ETSA events to test a protective effect during the study period.

Effect of shift work on frontline doctors' mood and sleep during the COVID-19 pandemic.

Purpose: Shift work has detrimental effects on healthcare workers, which may be further compounded by frontline work during the COVID-19 pandemic. We postulated that sleep would worsen and distress would increase during COVID-ward service. Methods: Doctors (n = 18) were recruited from a tertiary centre during the second wave of the COVID-19 pandemic in Melbourne, Australia. Participants had been rostered ON to consecutive 7 day or night shifts and a week OFF over a fortnight. 9 worked on COVID wards managing positive/suspected COVID patients, and 9 were allocated to general MEDICAL wards. Participants wore wrist actigraphy, and completed the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Kessler Psychological Distress Scale (K10) at baseline and the end of each week. Results: Both the COVID and MEDICAL groups spent less time in bed and had reduced total sleep time during their week ON shift compared to week OFF shift. The COVID group had worse sleep quality (PSQI Δ + 1.0, 6.8 vs 5.8, p = 0.036), daytime sleepiness (ESS Δ + 2.6, 8 vs 5.4, p = 0.014) and greater distress (K10 Δ + 1.7, 17 vs 15.3, p = 0.002) during their week ON compared to BASELINE. Conclusion: During the COVID-19 pandemic shift workers had poorer sleep during their week ON. Those working on COVID wards had greater distress during their week ON than those working on general MEDICAL wards. It is important to recognise the potential for sleep deficits and greater distress in medical workers during the pandemic.

Barriers to sleep in acute hospital settings.

OBJECTIVE: This study aimed to examine the environmental and operational factors that disrupt sleep in the acute, non-ICU hospital setting. DESIGN, SETTING AND PARTICIPANTS: This was a prospective study of adult patients admitted to an acute tertiary hospital ward (shared versus single room) and sleep laboratory (single room conducive to sleep). MAIN OUTCOME MEASURES: This study measured ambient light (lux) and sound (dB), number of operational interruptions, and questionnaires assessing sleep and mental health. RESULTS: Sixty patients were enrolled, 20 in a double bedroom located close to the nursing station ('shared ward'), 20 in a single bedroom located distant to the nursing station ('single ward') and 20 attending the sleep laboratory for overnight polysomnography ('sleep laboratory'). Sleep was disturbed in 45% of patients in the shared and single ward groups (Pittsburgh Sleep Quality Index > 5). Light levels were appropriately low across all 3 locations. Sound levels (significant effect of room F(1.38) = 6.452, p = 0.015) and operational interruptions (shared ward 5.6 ± 2.5, single ward 6.2 ± 2.9, sleep laboratory 2.7 ± 2.1 per night, p < 0.05 wards compared to sleep laboratory) were higher in the shared and single ward group compared to the sleep laboratory but not compared to each other. Noise was rated as the greatest environmental disturbance by 70% of ward patients compared to 10% in the sleep laboratory. CONCLUSION: Higher noise levels and frequent operational interruptions are potential barriers to sleep and recovery on an acute medical ward which are not ameliorated by being in a single bedroom located distant to the nursing station.

Psychoactive drug and medication use among patients referred to a tertiary sleep laboratory population.

Psychoactive drugs including alcohol, caffeine, and prescription medications are commonly consumed to alter sleep/wake states, however the prevalence and impact of these drugs among populations seeking assessment from sleep physicians are unknown. We investigated the prevalence of commonly used drugs (alcohol and caffeine), and medications in a population (N=120; 50 females and 70 males) attending a tertiary sleep clinic for diagnostic polysomnography (PSG) assessment. In addition to objective sleep assessment, participants completed questionnaires assessing sleep quality (Pittsburgh Sleep Quality Index, PSQI), daytime sleepiness (Epworth Sleepiness Scale, ESS), depression and anxiety (Hospital Anxiety and Depression Scale, HADS), alcohol use (Alcohol Use Disorders Identification Test, AUDIT), caffeine and medication use, as well as their experience of adverse events (motor vehicle accidents and near-miss crashes). Caffeine was consumed by 90% of the population and was associated with a reduction in excessive sleepiness symptomology; while high AUDIT scores were associated with increased near-miss crashes. Polypharmacy was common, with a greater number of medications associated with poorer sleep quality, and changes in sleep architecture. This study maps commonly used drugs in those attending a tertiary sleep clinic, and demonstrates associations between drug use and sleep outcomes assessed objectively and subjectively.

Natural history of asthma symptoms after epidemic thunderstorm asthma: a 3-year longitudinal study.

BACKGROUND: The world's most catastrophic epidemic thunderstorm asthma event (ETSA) affected Melbourne in 2016. Little is known about the natural history of individuals affected by such extreme events. OBJECTIVE: In this single center prospective 3-year longitudinal study, symptomatology and behaviors of individuals affected by ETSA were assessed. METHODS: Standardized telephone questionnaire was used to evaluate frequency of asthma symptoms, inhaled corticosteroid preventer use, asthma action plan ownership, and healthcare utilization. Questionnaires were administered at 12, 24, and 36 months after 2016 ETSA. Subgroup analyses of the 'current', 'past', 'possible,' and 'no asthma' subgroups were also conducted. RESULTS: Two hundred and eight, 164, and 112 completed questionnaires were analyzed in 2017, 2018, and 2019, respectively. Seventy to eighty five percent of respondents reported ongoing asthma symptoms in any given year, of which 20%-28% experienced weekly symptoms. Nearly 50% of respondents were prescribed preventers, with approximately 45% adherent at least 5 days a week. Less than 40% had an asthma action plan and 15%-20% sought urgent medical attention for asthma over the follow-up period. Among 106 individuals with 3 consecutive years of completed questionnaires, those with no prior doctor diagnosis of asthma were significantly more likely to be asymptomatic on follow-up than those with a prior doctor diagnosis of asthma (p = 0.02). Subgroup analyses suggest that large proportions of respondents with 'past' and 'no asthma' continue to remain symptomatic throughout the 36-month period. CONCLUSION: In individuals affected by ETSA, we found evidence of ongoing loss of asthma control in those with previously well controlled asthma, and the persistence of symptoms suggestive of asthma in those with no history or symptoms suggestive of prior asthma, even after 36 months from initial ETSA. Low rates of inhaler adherence and asthma action plan ownership may contribute to increased morbidity and mortality from future ETSA events. Further research is required to confirm these findings.

Clinician and patient barriers to the recognition of insomnia in family practice: a narrative summary of reported literature analysed using the theoretical domains framework.

BACKGROUND: Insomnia is a common sleep complaint, with 10% of adults in the general population experiencing insomnia disorder, defined as lasting longer than three months in DSM-5. Up to 50% of patients attending family practice experience insomnia, however despite this, symptoms of insomnia are not often screened for, or discussed within this setting. We aimed to examine barriers to the assessment and diagnosis of insomnia in family practice from both the clinician and patient perspective. METHODS: The present article identified research that has examined barriers to assessing insomnia from the clinician's and the client's perspectives following MEDLINE and Google Scholar searches, and then classified these barriers using the theoretical domains framework. RESULTS: The most common barriers from the clinician's perspective were related to Knowledge, Skills, and the Environmental Context. From the patient perspective, barriers identified included their Beliefs about the consequences of Insomnia, Social Influences, and Behavioural Regulation of Symptoms. CONCLUSIONS: Utilising this theoretical framework, we discuss options for bridging the gap between the identification and subsequent management of insomnia within the family practice setting. To assist clinicians and those in community health care to overcome the Knowledge and Skills barriers identified, this article provides existing relevant clinical criteria that can be utilised to make a valid diagnosis of insomnia.

An epidemic of thunderstorm asthma in Melbourne 2016: asthma, rhinitis, and other previous allergies.

BACKGROUND: On 21st November 2016, Melbourne experienced an epidemic of 'thunderstorm asthma.' Although previously described in the literature, risk factors and natural history remain incompletely understood. OBJECTIVE: Our aim was to follow up those presenting to the 3 Emergency Departments (EDs) in our health service during the epidemic, and assess their history for previous asthma, rhinitis, and allergies. METHODS: ED notes of all respiratory presentations within 48 hours of the thunderstorm event were reviewed and patients with acute asthma included. A standardised questionnaire was devised encompassing asthma diagnosis, undiagnosed asthma symptoms and rhinitis severity. Patients were contacted by phone within 30 days of the event. RESULTS: Three hundred forty-four patients were identified overall; 263 patients were contactable and completed a phone or mail questionnaire. The mean age was 32.7 ± 19.2 years (range, 6 months-87 years; 25% < 18 years) with 58% male sex. A previous diagnosis of asthma was present in 42% (n = 111), and there was no previous asthma diagnosis in 58% (n = 152). Of those who had no asthma diagnosis 53% had probable undiagnosed asthma. Overall, rhinitis prevalence was 88%, of which 72% were moderate or severe (Allergic Rhinitis and its Impact on Asthma guidelines) and 51% (n = 133) reported a history of grass pollen allergy. CONCLUSION: Our data highlights the importance of atopy and rhinitis as risk factors for epidemic thunderstorm asthma. Better identification of undiagnosed asthma, and implementing treatment of asthma and rhinitis may be important.

The impact of nocturnal oxygen desaturation on quality of life in cystic fibrosis.

BACKGROUND: Nocturnal oxyhaemoglobin desaturation is common in cystic fibrosis (CF) but the effect on quality of life (QoL) remains unknown. METHODS: Sixty stable CF outpatients with mean age 31±8 years (mean±1 SD), BMI 20.8±3.2 kg/m(2) and FEV(1) 42±13% predicted had arterial blood gas sampling, lung function testing, overnight pulse oximetry and completed the CF QoL questionnaire, Epworth Sleepiness Scale and Medical Research Council dyspnoea scale. RESULTS: 11 (18%) of the CF patients were 'desaturators,' (SpO(2)<90% for ≥30% recording time on overnight oximetry). Desaturators had greater difficulty performing their treatments (39±22 vs 61±26, p<0.01) and more exertional dyspnoea (3.2±0.8 vs 2.0±0.9, p<0.001) than non-desaturators after controlling for the effects of FEV(1), awake PaO(2) and PaCO(2) (adjusted p-values <0.01 and 0.04 respectively). CONCLUSIONS: Nocturnal oxyhaemoglobin desaturation is associated with impaired QoL, independent of the effects of lung function and awake gas exchange, in stable CF outpatients with moderate to severe lung disease.

The syndrome of inappropriate anti-diuretic hormone secretion concurrent with an acute exacerbation of cystic fibrosis.

Acute exacerbations of cystic fibrosis (CF) can be associated with dehydration, hyponatraemia and hypochloraemia. The syndrome of inappropriate anti-diuretic hormone secretion (SIADH) has also been described in CF patients in the setting of hyponatraemia, but may be under-recognised. Diagnosing SIADH has therapeutic implications as it necessitates fluid and water restriction rather than fluid resuscitation. We report the case of an acute pulmonary exacerbation of CF in which features of SIADH are demonstrated.