Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial.

BACKGROUND: Adherence to short-term continuous positive airway pressure (CPAP) may predict long-term use. Unfortunately, initial CPAP intolerance may lead to poor adherence or abandonment of therapy. OBJECTIVE: To determine whether a short course of eszopiclone at the onset of therapy improves long-term CPAP adherence more than placebo in adults with obstructive sleep apnea. DESIGN: Parallel randomized, placebo-controlled trial from March 2007 to December 2008. Randomization, maintained and concealed centrally by pharmacy personnel, was computer-generated using fixed blocks of 10. Referring physicians, investigators, and patients were blinded to the treatment assignment until after the final data were collected. (ClinicalTrials.gov registration number: NCT00612157). SETTING: Academic sleep disorder center. PATIENTS: 160 adults (mean age, 45.7 years [SD, 7.3]; mean apnea-hypopnea index, 36.9 events/h [SD, 23]) with newly diagnosed obstructive sleep apnea initiating CPAP. INTERVENTION: Eszopiclone, 3 mg (n = 76), or matching placebo (n = 78) for the first 14 nights of CPAP. MEASUREMENTS: Use of CPAP was measured weekly for 24 weeks. Adherence to CPAP (primary outcome) and the rate of CPAP discontinuation and improvements in symptoms (secondary outcomes) were compared. Follow-up at 1, 3, and 6 months was completed by 150, 136, and 120 patients, respectively. RESULTS: Patients in the eszopiclone group used CPAP for 20.8% more nights (95% CI, 7.2% to 34.4%; P = 0.003), 1.3 more hours per night for all nights (CI, 0.4 to 2.2 hours; P = 0.005), and 1.1 more hours per night of CPAP use (CI, 0.2 to 2.1 hours; P = 0.019). The hazard ratio for discontinuation of CPAP was 1.90 (CI, 1.1 to 3.4; P = 0.033) times higher in the placebo group. Side effects were reported in 7.1% of patients and did not differ between groups. LIMITATIONS: Patients had severe obstructive sleep apnea treated at a specialized sleep center with frequent follow-up; results may not be generalizable to different settings. Patients' tolerance to CPAP and their reasons for discontinuation were not assessed. CONCLUSION: Compared with placebo, a short course of eszopiclone during the first 2 weeks of CPAP improved adherence and led to fewer patients discontinuing therapy.

The prevalence and impact of respiratory symptoms in asthmatics and nonasthmatics during deployment.

OBJECTIVE: The purpose of this study was to compare the prevalence, severity, and impact of respiratory symptoms in asthmatics and nonasthmatics during Operation Enduring Freedom and Operation Iraqi Freedom. METHODS: A survey was given to 1,250 active duty soldiers and Department of Defense contractors returning from Operation Enduring Freedom/Operation Iraqi Freedom. Subjects were asked about demographics, smoking habits, respiratory symptoms, and impact on job performance before and during deployment. Patients with a history of asthma were asked method of diagnosis, current symptoms, and asthma therapy. RESULTS: A total of 1,193 subjects returned the completed questionnaire (95% response rate). Mean age of respondents was 38 +/- 11 years, 83% (n = 977) were male, and 31% (n = 375) were past or present smokers. Sixty-one subjects (5%) reported a previous diagnosis of asthma. Both asthmatics and nonasthmatics had increased respiratory symptoms of wheezing, cough, sputum production, chest pain/tightness, and allergy symptoms during deployment compared to predeployment (p < 0.05 for all). When compared to nonasthmatics, asthmatic subjects reported more wheezing, sputum production, and chest pain/tightness during deployment (p < 0.0001, 0.05, 0.05 respectively), had more difficulty with military duties (p < 0.05), and were more likely to seek medical attention and receive duty restrictions (p < 0.0001). Twenty-six percent (n = 16) of asthmatics reported poor baseline symptom control, and this group had significantly increased symptoms, functional limitations, and health care utilization when compared to asthmatics who were symptom-controlled at baseline. CONCLUSIONS: Respiratory symptoms were common among both asthmatics and nonasthmatics during deployment. Differences in symptoms and health care utilization in this group of asthmatics were primarily due to subjects with poor baseline control.

Bacteria recovered from patients admitted to a deployed U.S. military hospital in Baghdad, Iraq.

The predominant bacteria and antimicrobial susceptibilities were surveyed from a deployed, military, tertiary care facility in Baghdad, Iraq, serving U.S. troops, coalition forces, and Iraqis, from August 2003 through July 2004. We included cultures of blood, wounds, sputum, and urine, for a total of 908 cultures; 176 of these were obtained from U.S. troops. The bacteria most commonly isolated from U.S. troops were coagulase-negative staphylococci, accounting for 34% of isolates, Staphylococcus aureus (26%), and streptococcal species (11%). The 732 cultures obtained from the predominantly Iraqi population were Klebsiella pneumoniae (13%), Acinetobacter baumannii (11%), and Pseudomonas aeruginosa (10%); coagulase-negative staphylococci represented 21% of these isolates. These differences in prevalence were all statistically significant, when compared in chi2 analyses (p < 0.05). Antimicrobial susceptibility testing demonstrated broad resistance among the Gram-negative and Gram-positive bacteria.

Bacteriology of war wounds at the time of injury.

Bacterial contamination of war wounds occurs either at the time of injury or during the course of therapy. Characterization of the bacteria recovered at the time of initial trauma could influence the selection of empiric antimicrobial agents used to prevent infection. In the spring of 2004, U.S. military casualties who presented to the 31st Combat Support Hospital in Baghdad, Iraq, with acute traumatic injuries resulting in open wounds underwent aerobic culture of their wounds to identify the bacteria colonizing the wounds. Forty-nine casualties with 61 separate wounds were evaluated. Wounds were located predominantly in the upper and lower extremities and were primarily from improvised explosive devices or mortars. Thirty wounds (49%) had bacteria recovered on culture, with 40 bacteria identified. Eighteen casualties (20 wounds) had undergone field medical therapy (irrigation and/or antimicrobial treatment); six of these had nine bacterial isolates on culture. Of the 41 wounds from 31 patients who had received no previous therapy, 24 grew 31 bacteria. Gram-positive bacteria (93%), mostly skin-commensal bacteria, were the predominant organisms identified. Only three Gram-negative bacteria were detected, none of which were characterized as broadly resistant to antimicrobial agents. The only resistant bacteria recovered were two isolates of methicillin-resistant Staphylococcus aureus (MRSA). Our assessment of war wound bacterioly soon after injury reveals a predominance of Gram-positive organisms of low virulence and pathogenicity. The presence of MRSA in wounds likely reflects the increasing incidence of community-acquired MRSA bacteria. These data suggest that the use of broad-spectrum antibiotics with efficacy against more resistant, Gram-negative bacteria, such as Pseudomonas aeruginosa and Acinetobacter spp., is unnecessary in early wound management.

Medical problems of detainees after the conclusion of major ground combat during Operation Iraqi Freedom.

After the conclusion of major ground combat operations during Operation Iraqi Freedom, the focus of the mission changed, although intense armed conflict continued. Included in this mission was management of security detainees, including provision of their medical care. We retrospectively reviewed the admission records identified at a short-term holding facility over 2 months and diagnoses of detainees admitted to a combat support hospital over 4 months as a health care service utilization statistics review. Six thousand six hundred thirty-one detainee encounters occurred at the short-term facility with approximately 45% of detainees reporting medical problems during each daily evaluation. Most frequent complaints were neurological (11%), gastrointestinal (10%), and respiratory (8%). Two hundred nineteen detainees' admission diagnoses were retrospectively reviewed from the combat support hospital, 98 (45%) due to gunshot or fragmentary injuries and 121 (55%) to other medical problems. Medical problems included cardiac (29%), gastrointestinal (17%), neurological (14%), musculoskeletal (11%), and pulmonary (6%) disease. Medical problems not traditionally dealt with in a combat theater, including management of transplant recipients, patients with cardiac valve replacement, and cancer patient, were also seen.

Inhalational exposure to nerve agents.

The respiratory system plays a major role in the pathogenesis of nerve agent toxicity. It is the major route of entry and absorption of nerve agent vapor, and respiratory failure is the most common cause of death follow-ing exposure. Respiratory symptoms are mediated by chemical irritation,muscarinic and nicotinic receptor overstimulation, and central nervous system effects. Recent attacks have demonstrated that most patients with an isolated vapor exposure developed respiratory symptoms almost immediately. Most patients had only mild and transient respiratory effects, and those that did develop significant respiratory compromise did so rapidly. These observations have significant ramifications on triage of patients in a mass-casualty situation, because patients with mild-to-moderate exposure to nerve agent vapor alone do not require decontamination and are less likely to develop progressive symptoms following initial antidote therapy. Limited data do not demonstrate significant long-term respiratory effects following nerve agent exposure and treatment. Provisions for effective respiratory protection against nerve agents is a vital consideration in any emergency preparedness or health care response plan against a chemical attack.