Management of Sleep-Disordered Breathing in a Spinal Cord Injury Rehabilitation Center: Model of Care Adaptation and Implementation.

Background: Obstructive sleep apnea (OSA) is highly prevalent and poorly managed in spinal cord injury (SCI). Alternative management models are urgently needed to improve access to care. We previously described the unique models of three SCI rehabilitation centers that independently manage uncomplicated OSA. Objectives: The primary objective was to adapt and implement a similar rehabilitation-led model of managing OSA in an SCI rehabilitation center in Australia. Secondary objectives were to identify the local barriers to implementation and develop and deliver tailored interventions to address them. Methods: A clinical advisory group comprised of rehabilitation clinicians, external respiratory clinicians, and researchers adapted and developed the care model. A theory-informed needs analysis was performed to identify local barriers to implementation. Tailored behavior change interventions were developed to address the barriers and prepare the center for implementation. Results: Pathways for ambulatory assessments and treatments were developed, which included referral for specialist respiratory management of complicated cases. Roles were allocated to the team of rehabilitation doctors, physiotherapists, and nurses. The team initially lacked sufficient knowledge, skills, and confidence to deliver the OSA care model. To address this, comprehensive education and training were provided. Diagnostic and treatment equipment were acquired. The OSA care model was implemented in July 2022. Conclusion: This is the first time a rehabilitation-led model of managing OSA has been implemented in an SCI rehabilitation center in Australia. We describe a theory-informed method of adapting the model of care, assessing the barriers, and delivering interventions to overcome them. Results of the mixed-methods evaluation will be reported separately.

Electrophysiological trajectories of concussion recovery: From acute to prolonged stages in late teenagers.

PURPOSE: Numerous studies have reported electrophysiological differences between concussed and non-concussed groups, but few studies have systematically explored recovery trajectories from acute concussion to symptom recovery and the transition from acute concussion to prolonged phases. Questions remain about recovery prognosis and the extent to which symptom resolution coincides with injury resolution. This study therefore investigated the electrophysiological differences in recoveries between simple and complex concussion. METHODS: Student athletes with acute concussion from a previous study (19(2) years old) were tracked from pre-injury baseline, 24-48 hours after concussion, and through in-season recovery. The electroencephalography (EEG) with P300 evoked response trajectories from this acute study were compared to an age-matched population of 71 patients (18(2) years old) with prolonged post-concussive symptoms (PPCS), 61 (SD 31) days after concussion. RESULTS: Acute, return-to-play, and PPCS groups all experienced a significant deficit in P300 amplitude compared to the pre-injury baseline group. The PPCS group, however, had significantly different EEG spectral and coherence patterns from every other group. CONCLUSION: These data suggest that while the evoked response potentials deficits of simple concussion may persist in more prolonged stages, there are certain EEG measures unique to PPCS. These metrics are readily accessible to clinicians and may provide useful parameters to help predict trajectories, characterize injury (phenotype), and track the course of injury.

Left Ventricular Support for Unprotected Left Main Coronary Artery Interventions (The Dayton Heart and Vascular Impella Registry).

Background: Coronary artery bypass grafting is the standard of care for patients with obstructive left main (LM) coronary disease. In poor surgical candidates, high-risk percutaneous coronary artery intervention (PCI) is an alternative. Methods: We investigated a retrospective cohort of patients who underwent LM PCI from January 2010 to March 2014 (n = 89). Obstructive LM disease was defined as 50% angiographic obstruction of luminal flow, and the primary endpoint was inhospital mortality. Ventricular assist device (VAD) was defined as the use of either intra-aortic balloon pump (IABP) or Impella 2.5 devices before, during, or following PCI. Results: A total of 89 patients with LM PCI were divided into those with (n = 39) and without (n = 50) VAD support. The former group was further divided into those with support from either Impella 2.5 (n = 28) or IABP (n = 11). Age, race, and gender did not differ between patients who received unassisted LM-PCI from those with VAD support (P = 0.142, 1.0, and 0.776, respectively). The angiographic stenosis of atherosclerotic lesions in LM, proximal left anterior descending artery, and other native/surgical coronary vessels was similar between the groups. The duration of hospitalization was significantly longer for patients with VAD support compared to those without (7.19 ± 6.89 vs. 2.78 ± 3.39, P < 0.001). The incidence of cardiogenic shock and inhospital mortality was significantly higher in the VAD group (P = 0.009 and 0.001, respectively). Overall, inhospital mortality was 9% (8/89). The IABP and Impella 2.5 groups had mortality proportions of 46% (5/11) and 11% (3/28), respectively; P = 0.028. For all patients, inhospital mortality was higher for those with versus without cardiogenic shock (56% or 5/9 vs. 4% or 3/80; P < 0.001), and for those with versus without left ventricular systolic function <40% (17% vs. 2%;P < 0.025). Conclusion: In a selected group of patients with LM disease, unsupported PCI appears to be a feasible and safe procedure. In high-risk patients, the use of Impella 2.5 appears to be superior to IABP in LM PCI resulting in favorable short-term outcomes.

A putative link between pertussis and new onset of gastroesophageal reflux an observational study.

Background: Pertussis is an infectious disease of the respiratory tract with a changing epidemiology. An increasing incidence has been found in the adult population with recurrent infections possibly related to changes in the current vaccine. Is there an association between pertussis infection, refractory cough and atypical gastro-oesophageal reflux (GORD)? Does this magnify and compound respiratory complications? Methods: Observational study which compares post-pertussis (n=103) with non-pertussis patients (n=105) with established GORD. Patients were assessed for laryngopharyngeal reflux and aspiration of refluxate by a novel scintigraphic study. Results: Both groups showed severe GORD in association with high rates of laryngopharyngeal reflux (LPR) and pulmonary aspiration and lung disease. High rates of hiatus hernia and clinical diagnosis of "atypical" asthma showed correlations with pulmonary aspiration. Conclusions: A high level of new onset LPR and lung aspiration has been shown in patients with chronic cough after recent pertussis infection by a novel scintigraphic technique with fused hybrid x-ray computed tomography (SPECT/CT).

Effectiveness of a patient-centred sleep study report in the management of obstructive sleep apnoea.

PURPOSE: Obstructive sleep apnoea (OSA) is a common condition with a range of short- and long-term health implications. Providing patient-centred care is a key principle to ensure patients are well informed and empowered to participate in clinical decision making. This study aimed to develop a patient-centred sleep study report for patients with obstructive sleep apnoea and to determine whether or not its implementation led to improved patient understanding of their disease. METHODS: The study was performed in two phases. The first phase utilised the Delphi-survey technique to develop and critically appraise a patient-centred sleep study report (PCSR) for patients with OSA, to accurately and simply convey key components of the patient's diagnosis and management. The second phase was a prospective, randomised controlled trial to assess the effect of the PCSR on patient knowledge, self-efficacy, and understanding as measured through validated patient questionnaires. RESULTS: The PCSR was developed on key concepts deemed to be important by the surveyed physicians, senior sleep scientists and patients. This included ensuring the results were customised, highlighting the patient's apnoea-hypopnea index, oxygen desaturation index and arousal index and limiting technical information to a few key pieces. Patients randomised to receive the PCSR had improved understanding and perceived patient-physician interaction compared to those randomised to standard care. CONCLUSION: The development and implementation of the PCSR was feasible and improved patient understanding and perceived patient-physician interaction in patients with moderate to severe OSA. Whether or not use of the PCSR will translate to improved compliance with therapy will require further evaluation.

A transformational change in scintigraphic gastroesophageal reflux studies: A comparison with historic techniques.

BACKGROUND: The inclusion of scintigraphy in the diagnostic algorithm for gastroesophageal reflux is controversial due to variability in methodology and reporting. A novel scintigraphic reflux study has been developed and validated against the current standards for the diagnosis of gastroesophageal reflux disease (GORD). OBJECTIVE: To compare a new scintigraphic reflux test against historic techniques and standardised diagnostic reference tests for gastroesophageal reflux disease. METHODS: Paired scintigraphic studies were conducted in seventeen patients. All patients underwent at least one other standardised diagnostic reflux test such as 24- hour oesophageal impedance/ pH, and oesophageal manometry, barium swallow, gastroscopy or the Peptest. Patients inadvertently presented at sites B for scintigraphic reflux testing rather than at Site A which was part of an approved study. The findings from sites B did not correlate with clinical symptoms and other diagnostic reference tests from GORD. These studies were then repeated at Site A with approval from the patients. A second reflux study was performed at site A, utilising a novel technique with the capability of assessing oesophageal and extra-oesophageal disease. RESULTS: The Site A technique shows good concordance with the reference diagnostic tests with an accuracy of 82.4% and kappa of 0.64 (SE: 0.16, p = 0.00). Site B had an overall accuracy of 47.1% and kappa of 0.066 (SE: 0.068, p = 0.45). CONCLUSION: The Site A technique shows higher accuracy than either site B or the historic reflux techniques. It has characteristics that make it an effective screening tool for assessment of local oesophageal disease and its extraoesophageal manifestations.

Fungal Pneumonia in The Immunocompetent Host: A Possible Statistical Connection Between Allergic Fungal Sinusitis with Polyposis and Recurrent Pulmonary Infection Detected by Gastroesophageal Reflux Disease Scintigraphy.

OBJECTIVES: Fungal pneumonia in the immune competent host is a rarity with few reported cases in the literature. We present a series of 7 cases of recurrent fungal pneumonia in association with allergic fungal rhinosinusitis and gastroesophageal reflux disease (GERD). We hypothesised that recurrent infection may have been transported from the infected paranasal sinuses into the lung by GERD as the process was terminated by surgical fundoplication in 2 of these patients. METHODS: Patients were recruited into the study if they were immune competent and had recurrent fungal pneumonia and GERD. Allergic fungal rhinosinusitis was proven by biopsy. GERD was investigated by a scintigraphic test that assessed local oesophageal disease, lung aspiration and head and neck involvement with a hybrid gamma camera and X-ray computed tomography. RESULTS: All patients were shown to have GERD with 5/7 showing paranasal sinus contamination and 7/7 showing laryngopharyngeal involvement and 6/7 lung aspiration. One patient had characteristics strongly predictive of aspiration. Fundoplication led to cessation of fungal lung infection in two patients. CONCLUSION: Recurrent fungal pneumonia in the immune competent host should raise the possibility of re-infection from the paranasal sinuses, especially in patients with GERD.

In-clinic event related potentials after sports concussion: A 4-year study.

PURPOSE: Electrophysiological event-related potentials (ERP's) have been reported to change after concussion. The objective of this study is to use a simple 2-tone auditory P300 ERP in routine clinical settings to measure changes from baseline after concussion and to determine if these changes persist at return to play when other standard measures have normalized. METHODS: Three-hundred sixty-four (364) student athletes, aged 17-23 years, participating in contact sports were tracked over consecutive years. In this blinded study P300, plus physical reaction times and Trail Making tests, were collected alongside standard clinical evaluations. Changes in these measures after concussion were compared to clinical outcomes over various stages of post-injury recovery. RESULTS: Concussed players experienced significant reaction time and/or P300 amplitude changes compared to pre-concussion baseline measurements (p< 0.005). P300 changes persisted in 38% of the players after standard measures, including reaction times, had cleared. Many of those players slow to normalize were part of the sub-concussive symptom group and/or appeared more prone to repeat concussions. CONCLUSION: These data suggest significant P300 amplitude changes after concussion that are quantifiable and consistent. These changes often normalized slower than other standard assessments. More data are needed to determine if slow normalization relates to sub-concussive or repeated events.

Simultaneous tonsillectomy and nasal surgery in adult obstructive sleep apnea: a pilot study.

OBJECTIVE: Although adenotonsillectomy is the accepted treatment for obstructive sleep apnea (OSA) in the pediatric population, tonsillectomy has not been widely adopted in adults, and its success in this group has not been well reported. Despite the lack of current evidence, there may be an important role for tonsillectomy in selected adult cases, and further study is required. This is a pilot study from a larger group of subjects currently enrolled and awaiting surgery and repeat polysomnography. STUDY DESIGN: Retrospective series with chart review. SETTING: Tertiary referral teaching hospitals. SUBJECTS AND METHODS: Thirteen consecutive eligible subjects with tonsillar hypertrophy and OSA were identified after treatment. These patients had undergone pre- and postoperative polysomnography for assessment of the severity of sleep-disordered breathing. Post hoc analysis of key parameters was performed by Wilcoxon signed rank and paired t tests. Tonsillectomy was performed on all subjects, using the diathermy dissection technique. Nasal surgery was performed simultaneously in 11 subjects for symptomatic nasal blockage unresponsive to medical treatment. RESULTS: There was a statistically significant improvement in the severity of OSA after surgery. The total Respiratory Disturbance Index (RDI) was significantly decreased from median values of 31.7 to 5.5 (P = .0002). The RDI in rapid eye movement and non-rapid eye movement sleep and the arousal index were also significantly decreased. CONCLUSION: In selected adult subjects, tonsillectomy with intercurrent nasal surgery should be considered an effective treatment for OSA and may reduce the requirement for continuous positive airway pressure, oral appliances, or further therapeutic intervention.

Sniff nasal inspiratory pressure and sleep disordered breathing in childhood neuromuscular disorders.

The ease of sniff nasal inspiratory pressure testing may extend application of respiratory muscle assessment to younger and cognitively-impaired children. We sought to quantify sniff nasal inspiratory pressure in childhood neuromuscular disorders, and to correlate this measure with conventional pulmonary function tests and overnight polysomnography. Thirty children (mean 9.7 ± 3.8 years, range 4.3-16.5 years) with diagnosed neuromuscular disorders (Duchenne muscular dystrophy, spinal muscular atrophy, Becker muscular dystrophy, congenital myopathy, facioscapulohumeral muscular dystrophy, myotonic dystrophy, multi-minicore disease) underwent assessment. Thirty-seven percent displayed cognitive impairment. Those with neuromuscular disorders were then compared with 32 volunteer age- and gender-matched controls (mean 10.9 ± 2.9 years, range 6.6-17.2 years) with normal respiratory function. Twenty-three children with neuromuscular disorders also underwent overnight polysomnography. Children with neuromuscular disorders demonstrated significantly impaired sniff nasal inspiratory pressure, maximal inspiratory pressure, FEV(1) and FVC (p<0.05). A positive correlation was identified between daytime sniff nasal inspiratory pressure and maximal inspiratory pressure (r=0.58), FEV(1) (r=0.55) and FVC (r=0.46), though not with polysomnography variables (respiratory disturbance index, nadir SpO(2), peak CO(2)). Moderate prevalence of nocturnal hypoxia was observed, and 32% of children demonstrated sleep disordered breathing. Sniff nasal inspiratory pressure assessment was well tolerated, representing a promising surrogate measure for assessment of respiratory function in childhood neuromuscular disorders.

Liraglutide: a once-daily human glucagon-like peptide-1 analogue for type 2 diabetes mellitus.

PURPOSE: The pharmacology, pharmacokinetics, efficacy, safety, dosage and administration, adverse effects, and place in therapy of liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, are reviewed. SUMMARY: Liraglutide, the first once-daily human GLP-1 analogue, retains 97% homology with the endogenous hormone and shares its glucose-dependent glucose-lowering action but has a considerably longer half-life that supports once-daily dosing. After promising Phase II study results, the Liraglutide Effect and Action in Diabetes (LEAD) Phase III clinical development program, involving more than 4000 patients worldwide, investigated the efficacy and tolerability of liraglutide 1.2 or 1.8 mg daily (n = 2735) as monotherapy and in combination with various oral antidiabetic drugs. The LEAD studies yielded encouraging results indicating that patients receiving liraglutide could expect to attain glycosylated hemoglobin reductions of about 1-1.5% and fasting plasma glucose reductions of 15-43 mg/dL. Loss of body weight was consistent throughout the studies: when using liraglutide 1.8 mg as monotherapy, patients lost a mean of 2.5 kg over a 52-week period. Accompanying reductions in some cardiovascular risk endpoints, such as systolic blood pressure, were also observed. By virtue of its glucose-dependent mode of action, liraglutide was generally well tolerated in clinical trials, with only very rare episodes of major hypoglycemia reported. The most frequently observed adverse effects were gastrointestinal, with 10-40% of patients experiencing an episode of nausea, which was often mild or moderate in severity and transient in nature. CONCLUSION: Liraglutide is efficacious and well tolerated in patients with type 2 diabetes and has been found to reduce weight and blood pressure.

The utility of the AusEd driving simulator in the clinical assessment of driver fatigue.

Several driving simulators have been developed which range in complexity from PC based driving tasks to advanced "real world" simulators. The AusEd driving simulator is a PC based task, which was designed to be conducive to and test for driver fatigue. This paper describes the AusEd driving simulator in detail, including the technical requirements, hardware, screen and file outputs, and analysis software. Some aspects of the test are standardized, while others can be modified to suit the experimental situation. The AusEd driving simulator is sensitive to performance decrement from driver fatigue in the laboratory setting, potentially making it useful as a laboratory or office based test for driver fatigue risk management. However, more research is still needed to correlate laboratory based simulator performance with real world driving performance and outcomes.

Low-resolution electromagnetic tomography neurofeedback.

Through continuous feedback of the electroencephalogram (EEG) humans can learn how to shape their brain electrical activity in a desired direction. The technique is known as EEG biofeedback, or neurofeedback, and has been used since the late 1960s in research and clinical applications. A major limitation of neurofeedback relates to the limited information provided by a single or small number of electrodes placed on the scalp. We establish a method for extracting and feeding back intracranial current density and we carry out an experimental study to ascertain the ability of the participants to drive their own EEG power in a desired direction. To derive current density within the brain volume, we used the low-resolution electromagnetic tomography (LORETA). Six undergraduate students (three males, three females) underwent tomographic neurofeedback (based on 19 electrodes placed according to the 10-20 system) to enhance the current density power ratio between the frequency bands beta (16-20 Hz) and alpha (8-10 Hz). According to LORETA modeling, the region of interest corresponded to the Anterior Cingulate (cognitive division). The protocol was designed to improve the performance of the subjects on the dimension of sustained attention. Two hypotheses were tested: 1) that the beta/alpha current density power ratio increased over sessions and 2) that by the end of the training subjects acquired the ability of increasing that ratio at will. Both hypotheses received substantial experimental support in this study. This is the first application of an EEG inverse solution to neurofeedback. Possible applications of the technique include the treatment of epileptic foci, the rehabilitation of specific brain regions damaged as a consequence of traumatic brain injury and, in general, the training of any spatial specific cortical electrical activity. These findings may also have relevant consequences for the development of brain-computer interfaces.

Hippocampal area metabolites relate to severity and cognitive function in obstructive sleep apnea.

BACKGROUND AND PURPOSE: Obstructive sleep apnea (OSA) is associated with intermittent hypoxia and cognitive decrements. As the hippocampus is particularly susceptible to hypoxia, we hypothesized that it may show biochemical abnormalities, and they may relate to apnea severity. PATIENTS AND METHODS: Eight males with OSA and five age-matched controls underwent neurocognitive testing before and after polysomnography and proton magnetic resonance spectra were obtained from the left hippocampal area of all subjects. RESULTS: In the left hippocampal area, N-acetyl-containing/creatine-containing compounds was significantly increased in OSA (P=0.04). Inspection of these compounds with respect to the water resonance indicated that this was most likely due to a decrease in creatine-containing compounds rather than any change in N-acetyl-containing compounds. Lower levels of hippocampal creatine-containing compounds were correlated with worse OSA severity and neurocognitive performance. CONCLUSIONS: We suggest the changes in creatine levels in the hippocampal area represent adjustments to brain bioenergetics, similar to those seen in ischemic preconditioning, and may reflect the different susceptibility of these tissues to hypoxic damage in OSA.

Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers.

Sleep-disordered breathing and excessive sleepiness may be more common in commercial vehicle drivers than in the general population. The relative importance of factors causing excessive sleepiness and accidents in this population remains unclear. We measured the prevalence of excessive sleepiness and sleep-disordered breathing and assessed accident risk factors in 2,342 respondents to a questionnaire distributed to a random sample of 3,268 Australian commercial vehicle drivers and another 161 drivers among 244 invited to undergo polysomnography. More than half (59.6%) of drivers had sleep-disordered breathing and 15.8% had obstructive sleep apnea syndrome. Twenty-four percent of drivers had excessive sleepiness. Increasing sleepiness was related to an increased accident risk. The sleepiest 5% of drivers on the Epworth Sleepiness Scale and Functional Outcomes of Sleep Questionnaire had an increased risk of an accident (odds ratio [OR] 1.91, p = 0.02 and OR 2.23, p < 0.01, respectively) and multiple accidents (OR 2.67, p < 0.01 and OR 2.39, p = 0.01), adjusted for established risk factors. There was an increased accident risk with narcotic analgesic use (OR 2.40, p < 0.01) and antihistamine use (OR 3.44, p = 0.04). Chronic excessive sleepiness and sleep-disordered breathing are common in Australian commercial vehicle drivers. Accident risk was related to increasing chronic sleepiness and antihistamine and narcotic analgesic use.

Treadmill ambulation with partial body weight support for the treatment of low back and leg pain.

STUDY DESIGN: A single-subject experimental design using an A-B-A treatment protocol. OBJECTIVE: To determine whether walking on a treadmill with partial body weight support (PBWS) would be an effective adjunct treatment method to standard care for decreasing pain and increasing function in patients suffering from low back and leg pain. BACKGROUND: Mechanical low back pain (LBP) is commonly aggravated by activities that increase axial loading in the spine, such as sitting, standing, and walking. Patients with mechanical LBP usually describe relief with positions that unload the spine. One traction technique now being used in clinics to unload the spine is the PBWS system. The use of endurance exercise has also been found to be a consistent predictor of better outcomes in patients with LBP. Thus treatment that combines spinal unloading using PBWS and endurance exercise may be an effective intervention for patients with low back and leg pain. METHODS AND MEASURES: Eleven subjects participated in this study using an A-B-A design. Phase A was defined as the baseline condition and phase B was intervention with PBWS provided by a mechanical unloading system. The Roland-Morris Questionnaire (RMQ) and Visual Analog Scale (VAS) were utilized to collect data on functional status and perceived pain, respectively. Visual Analysis and 2 standard deviation band method (2SDBM) were used to analyze the data. RESULTS: Pain scores between baseline and PBWS treatment phases were significantly improved for 3 out of the 6 subjects who completed the study. RMQ baseline and treatment scores revealed that 5 out of 6 subjects had significant functional improvements in the PBWS treatment phase. CONCLUSION: The results suggest that ambulation with PBWS combined with the standard level of care for this population holds sufficient promise for pain relief and functional improvement to justify testing its efficacy in larger groups of subjects with these complaints.