Characteristics, therapies, and outcomes of In-Hospital vs Out-of-Hospital cardiac arrest in patients presenting to cardiac intensive care units: From the critical care Cardiology trials network (CCCTN).

BACKGROUND: Cardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA. METHODS: The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA. RESULTS: We analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p < 0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p < 0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p < 0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p < 0.001) and in-hospital mortality (36.1% vs 44.1%, p < 0.001). CONCLUSION: Despite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.

Early Compared With Delayed Physician Rounds on Patient Satisfaction of Postpartum Women: A Randomized Controlled Trial.

OBJECTIVE: To investigate whether delayed timing of physician rounds improves patient satisfaction for postpartum women. METHODS: Women were randomized to early (5-7 AM) or delayed (8-10 AM) physician rounding. Women with stillbirth, high-risk pregnancy, or complications precluding delayed rounding were excluded. At discharge, women completed a modified Hospital Consumer Assessment of Healthcare Providers and Systems survey. The primary outcome was rating of the hospital. Secondary outcomes included patient assessment of patient-physician communication, various hospital experiences, and timing of maternal and neonatal discharge. We estimated that 74 women were needed to detect a 20% difference in rating of the hospital (0-10 score) between groups (assumption P=.05, power 90%). Given limited information on primary outcome, an a priori plan was in place to conduct the study for 2 months. RESULTS: One hundred fifty-two women were randomized (n=76 early rounding; n=76 delayed rounding). More women had a cesarean delivery in the early compared with the delayed rounding group (47.4% compared with 22.4%). Median rating of the hospital was higher in the delayed as compared with the early rounding group (9.0 [7.0-9.0] compared with 7.0 [6.0-8.0]; P<.01). Median scores regarding physician communication and perception of hospital experiences were higher in the delayed compared with the early group (8.0 [7.0-9.0] compared with 6.0 [5.0-7.0]; P<.001). Adjustment for delivery mode did not alter results (P<.01). No differences in timing of maternal (P=.47) or neonatal hospital discharge (P=.35) were observed. CONCLUSION: Postpartum women receiving delayed physician rounding were more satisfied with their hospital experience and patient-physician communication without prolonging maternal or neonatal discharge. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02432573.

Pediatric Insomnia.

Insomnia in children is complex and frequently multifactorial. This review discusses the major categories of insomnia as well as common causes. The consequences of insomnia, including issues with mood, behavior, and cognition, are discussed. Sleep disorders are much more prevalent in certain pediatric populations, such as children with autism spectrum disorders. The evaluation of insomnia in children includes a focused history and examination and occasionally actigraphy or polysomnography. Behavioral and pharmacological therapies are discussed, as are future directions for research and clinical practice.

Reverse sleep state misperception.

A 71-year-old woman with a 3-year history of excessive daytime sleepiness and an increased need for sleep did not feel restored upon awakening and had daytime fatigue despite a full night's sleep. She was evaluated with polysomnography (PSG). She significantly underestimated her sleep latency and awake time after sleep onset. The following morning, she stated that she had slept all night, when in fact she had extremely poor sleep efficiency and prolonged sleep latency. Another PSG and a two-week long actigraphy confirmed her misperception. Therefore, she perceived physiologic wakefulness, by PSG and actiraphy criteria, as subjective sleep, in direct contrast to 'conventional' sleep state misperception, in which patients usually present with a complaint of insomnia but have normal sleep quality and duration by PSG criteria. This patient may have a previously undescribed variation of sleep state misperception that the authors have tentatively named 'reverse' sleep state misperception.

The relationship of sleep disturbances and fatigue in multiple sclerosis.

BACKGROUND: Fatigue is experienced by most patients with multiple sclerosis (MS) and often is profoundly debilitating. No large-scale studies to our knowledge have examined circadian rhythm abnormalities in MS patients or the relationship of fatigue to circadian rhythms. OBJECTIVE: To determine if patients with MS and fatigue have sleep disturbances or circadian rhythm abnormalities associated with fatigue. DESIGN: Case-control study. SETTING: Washington University School of Medicine, St Louis, Mo. PATIENTS: Fifteen patients with MS and fatigue were compared with 15 patients with MS without fatigue and 15 age- and sex-matched, healthy controls. MAIN OUTCOME MEASURES: Sleep disturbances and circadian rhythm abnormalities were quantitated by actigraphy, fatigue by the Fatigue Descriptive Scale, and excessive sleepiness by the Epworth Sleepiness scale (ESS). RESULTS: Of the 15 fatigued patients with MS, 2 had delayed sleep phase, 10 had disrupted sleep, and 3 had normal sleep. One of the 15 nonfatigued MS patients had irregular sleep cycles, 2 others had disrupted sleep, and 12 had normal sleep. All 15 of the healthy controls had normal sleep. Nine patients with MS and fatigue scored 10 or higher on the ESS, suggesting excessive daytime sleepiness. Only 2 patients with MS without fatigue scored higher than 10 on the ESS. None of the healthy controls were fatigued, and 14 were not excessively sleepy. A relationship was found between fatigue and abnormal sleep cycles or disrupted sleep (Fisher exact test, P =.003). There was also a relationship between subjective excessive daytime sleepiness and fatigue in MS patients (P =.02). CONCLUSION: There is a significant correlation between fatigue in MS patients and disrupted sleep or abnormal sleep cycles.