Narcolepsy type 1 comorbid with myasthenia gravis: possible immunological link.

Narcolepsy type 1 (NT1) has a probable autoimmune pathophysiology. Myasthenia gravis (MG) is an auto-antibody-mediated neuromuscular junction disorder. In the case report below we describe 2 women who were diagnosed with NT1 at ages 33 and 46 years, respectively. Both have seronegative MG and, although the MG was diagnosed earlier than the NT1, the symptoms of both conditions in both women started simultaneously. We discuss the potential mechanism linking these 2 conditions and the possibility of early detection of NT1 in patients with MG. CITATION: El Sammak S, Cipriani V, Sahni A, Attarian H. Narcolepsy type 1 comorbid with myasthenia gravis: possible immunological link. J Clin Sleep Med. 2022;18(7):1889-1890.

Autonomic dysfunction in idiopathic hypersomnia: an overlooked association and potential management.

There is a small yet robust body of literature regarding autonomic dysfunction in idiopathic hypersomnia as well as sleep disturbances in postural orthostatic tachycardia syndrome. This review aims at summarizing the current literature and highlighting gaps in the current knowledge. This article additionally presents the personal experience of one of the authors at the sleep center. CITATION: Adra N, Reddy M, Attarian H, Sahni AS. Autonomic dysfunction in idiopathic hypersomnia: an overlooked association and potential management. J Clin Sleep Med. 2022;18(3):963-965.

Association of continuous positive airway pressure adherence with complications in patients with type 2 diabetes and obstructive sleep apnea.

STUDY OBJECTIVES: To explore the association of continuous positive airway pressure (CPAP) adherence with clinical outcomes in patients with type 2 diabetes and obstructive sleep apnea in a real-world setting. METHODS: This was a retrospective study of patients with type 2 diabetes diagnosed with obstructive sleep apnea between 2010 and 2017. CPAP adherence (usage for ≥ 4 h/night for ≥ 70% of nights) was determined from the first CPAP report following the polysomnography. Data including estimated glomerular filtration rate, hemoglobin A1c, systolic and diastolic blood pressure, lipid panel, and incident cardiovascular/peripheral vascular/cerebrovascular events were extracted from medical records. Mixed-effects linear regression modeling of longitudinal repeated measures within patients was utilized for continuous outcomes, and logistic regression modeling was used for binary outcomes. Models were controlled for age, sex, body mass index, medications, and baseline levels of outcomes. RESULTS: Of the 1,295 patients, 260 (20.7%) were CPAP adherent, 318 (24.5%) were CPAP nonadherent, and 717 (55.3%) had insufficient data. The follow-up period was, on average, 2.5 (1.7) years. Compared to those who were CPAP nonadherent, those who were adherent had a significantly lower systolic blood pressure (ß = -1.95 mm Hg, P = .001) and diastolic blood pressure (ß = -2.33 mm Hg, P < .0001). Among the patients who were CPAP adherent, a 17% greater CPAP adherence was associated with a 2 mm Hg lower systolic blood pressure. Lipids, hemoglobin A1c, estimated glomerular filtration rate, and incident cardiovascular/peripheral vascular/cerebrovascular events were not different between the 2 groups. CONCLUSIONS: Achieving CPAP adherence in patients with type 2 diabetes and obstructive sleep apnea was associated with significantly lower blood pressure. Greater CPAP use within patients who were adherent was associated with lower systolic blood pressure. CITATION: Sheth U, Monson RS, Prasad B, et al. Association of continuous positive airway pressure adherence with complications in patients with type 2 diabetes and obstructive sleep apnea. J Clin Sleep Med. 2021;17(8):1563-1569.

Deep learning model to predict the need for mechanical ventilation using chest X-ray images in hospitalised patients with COVID-19.

OBJECTIVES: There exists a wide gap in the availability of mechanical ventilator devices and their acute need in the context of the COVID-19 pandemic. An initial triaging method that accurately identifies the need for mechanical ventilation in hospitalised patients with COVID-19 is needed. We aimed to investigate if a potentially deteriorating clinical course in hospitalised patients with COVID-19 can be detected using all X-ray images taken during hospitalisation. METHODS: We exploited the well-established DenseNet121 deep learning architecture for this purpose on 663 X-ray images acquired from 528 hospitalised patients with COVID-19. Two Pulmonary and Critical Care experts blindly and independently evaluated the same X-ray images for the purpose of validation. RESULTS: We found that our deep learning model predicted the need for mechanical ventilation with a high accuracy, sensitivity and specificity (90.06%, 86.34% and 84.38%, respectively). This prediction was done approximately 3 days ahead of the actual intubation event. Our model also outperformed two Pulmonary and Critical Care experts who evaluated the same X-ray images and provided an incremental accuracy of 7.24%-13.25%. CONCLUSIONS: Our deep learning model accurately predicted the need for mechanical ventilation early during hospitalisation of patients with COVID-19. Until effective preventive or treatment measures become widely available for patients with COVID-19, prognostic stratification as provided by our model is likely to be highly valuable.

Effects of Cannabinoids on Sleep and their Therapeutic Potential for Sleep Disorders.

The recent trend for legalization of medicinal cannabis and cannabinoid-containing products, together with their soporific effects, has led to a surge of interest of their potential therapeutic role in the management of some common sleep disorders, such as insomnia, sleep disordered breathing, and restless legs syndrome, and less common disorders such as narcolepsy and parasomnias. Although much of the pre-clinical and clinical data were derived from studies with relatively small sample sizes and limited by biases in assessment, and in clinical trials lack of allocation concealment, as a whole, the results indicate a potential therapeutic role for cannabinoids in the management of some sleep disorders. Clinical trials are underway for insomnia and obstructive sleep apnea management, but there remains a substantial need for rigorous large multi-center studies to assess the dose, efficacy, and safety of the various types of cannabinoids on sleep disorders. This review aims to summarize the modulatory effects of cannabinoids on sleep physiology and provide a critical evaluation of the research on their potential therapeutic benefit in various sleep disorders.

Extubating to Noninvasive Ventilation: Noninvasive Ventilation from Intensive Care Unit to Home.

Weaning to noninvasive ventilation in intensive care unit and bridging the patients to home with respiratory support is evolving as the technology of noninvasive ventilation is improving. In patients with chronic obstructive pulmonary disease exacerbation, timing of initiation of noninvasive ventilation is the key, as persistently hypercapnic patients show benefits. High-intensity pressure support seems to do better in comparison to low-intensity pressure support. In patients with obesity and hypercapnia, obesity hypoventilation cannot be ruled out especially in an inpatient setting, and it is crucial that these patients are discharged with noninvasive ventilation.

Impact of traumatic brain injury on sleep: an overview.

Traumatic brain injury (TBI) is a global health problem that affects millions of civilians, athletes, and military personnel yearly. Sleeping disorders are one of the underrecognized sequalae even though they affect 46% of individuals with TBI. After a mild TBI, 29% of patients have insomnia, 25% have sleep apnea, 28% have hypersomnia, and 4% have narcolepsy. The type of sleep disturbance may also vary according to the number of TBIs sustained. Diffuse axonal injury within the sleep regulation system, disruption of hormones involved in sleep, and insults to the hypothalamus, brain stem, and reticular activating system are some of the proposed theories for the pathophysiology of sleep disorders after TBI. Genetic and anatomical factors also come to play in the development and severity of these sleeping disorders. Untreated sleep disturbances following TBI can lead to serious consequences with respect to an individual's cognitive functioning. Initial management focuses on conservative measures with progression to more aggressive options if necessary. Future research should attempt to establish the effectiveness of the treatments currently used, as well as identify manageable co-existing factors that could be exacerbating sleep disorders.

Management Of Excessive Sleepiness In Patients With Narcolepsy And OSA: Current Challenges And Future Prospects.

Excessive daytime sleepiness (EDS) can be caused by insufficient sleep but is also a manifestation of medical or sleep disorders and a side effect of medications. It impacts quality of life and creates safety concerns in the home, at work, and on the roads. Screening questionnaires can be used to estimate EDS, but further evaluation is necessary. EDS is a common symptom of both narcolepsy and obstructive sleep apnea (OSA). Polysomnography and multiple sleep latency testing are used to diagnose these disorders. However, isolating the primary etiology of EDS can be challenging and may be multifactorial. Untreated OSA can show polysomnographic findings that are similar to narcolepsy. The effects of sleep deprivation and certain medications can also affect the polysomnographic results. These challenges can lead to misdiagnosis. In addition, narcolepsy and OSA can occur as comorbid disorders. If EDS persists despite adequate treatment for either disorder, a comorbid diagnosis should be sought. Thus, despite advances in clinical practice, appropriate management of these patients can be challenging. This review is focused on EDS due to OSA and narcolepsy and addresses some of the challenges with managing this patient population.

Sleep disorders in traumatic brain injury.

BACKGROUND: Sleep disorders play a significant role in the care of those with Traumatic Brain Injury (TBI). OBJECTIVE: To provide a literature review on the interaction of sleep and circadian processes on those with TBI. METHODS: A literature review was conducted on PubMed using the following key words and their combination: "Sleep Apnea", "Traumatic Brain Injury", "Circadian", "Parasomnia", "Insomnia", "Hypersomnia", "Narcolepsy", and "Restless Legs". We review the spectrum of traumatic brain injury associated sleep disorders and discuss clinical approaches to diagnosis and treatment. RESULTS: Disordered sleep and wakefulness after TBI is common. Sleep disruption contributes to morbidity, such as the development of neurocognitive and neurobehavioral deficits, and prolongs the recovery phase after injury. Early recognition and correction of these problems may limit the secondary effects of traumatic brain injury and improve neuro recovery/patient outcomes. CONCLUSIONS: A more focused approach to sleep health is appropriate when caring for those with TBI.

Respiratory Care in Neuromuscular Diseases.

Caring for patients with neuromuscular disease (NMD) is challenging. Respiratory care is of the utmost importance because it is a major determinant of quality of life and survival. Noninvasive ventilation (NIV) is one of the few modalities that has shown survival benefit in the NMD patient population. Newer modes with smart technologies are being developed to assist in better ventilation. Some noninvasive methods have shown success in the management of sialorrhea, which is of paramount importance in the initiation of NIV. This review will summarize the management of respiratory symptomatology in patients with NMD with recent advances made in NIV.

Effect of arterial puncture on ventilation.

BACKGROUND: Clinicians frequently assume that during arterial puncture for measuring arterial blood gases patients hyperventilate from pain and anxiety. This assumption leads clinicians to falsely interpret a PaCO2 and pH near the upper limit of normal as a chronic respiratory acidosis corrected by an acute respiratory alkalosis. OBJECTIVE: Determine if participants hyperventilate during arterial puncture from pain and anxiety. METHODS: We recruited participants from a pulmonary function laboratory referred for arterial blood gas measurement. We excluded those with heart failure and included those with any respiratory condition (COPD, asthma, sleep apnea). We measured end tidal PCO2 (PETCO2), respiratory rate, and heart rate 15 min before topical anesthesia, during anesthesia, during arterial puncture, and 15 min later. We assessed generalized anxiety before and measured pain during and after arterial puncture. RESULTS: 24 participants were recruited (age: 54 ± 12 years; men: 54%). PaCO2 was 41 ± 5 mmHg. One had acute respiratory alkalosis. Respiratory rate increased from (19 ± 6 breaths per minute (bpm)) before to a maximum (21 ± 6 bpm) during arterial puncture (p = 0.001). Heart rate was stable throughout. The lowest PETCO2 during the procedure (35 ± 5) was similar to PETCO2 before the procedure (p = 0.1). The change in PETCO2 and respiratory rate did not correlate with pain, anxiety, or lung function. CONCLUSION: Respiratory rate increased slightly during arterial puncture without any change in PETCO2. Hence, acid-base status must be interpreted without the assumption of procedure induced hyperventilation.

Therapeutic hypothermia at an urban public hospital: Development, implementation, experience and outcomes.

BACKGROUND: Therapeutic hypothermia (TH) improves the outcome of comatose patients suffering an out-of-hospital sudden cardiac arrest (SCA) with shockable rhythm and return of spontaneous circulation (ROSC). Evidence supporting its use in other circumstances is weak and the adoption of TH remains limited. OBJECTIVE: Describe the development and implementation of a TH program at an urban public hospital and report outcomes of out-of-hospital and in-hospital SCA and important quality measures. METHODS: The protocol was developed at 464-bed urban public hospital. We assembled historical and prospective samples of patients suffering an SCA. We measured the neurologic outcome of patients at the time of hospital discharge who underwent TH after SCA. We compared outcomes and important quality measures (duration of arrest, time to cooling, and time to target temperature) to existing literature. We determined reasons for not using TH in patients with in-hospital SCA. RESULTS: We described the development of our TH program and the challenges we faced implementing it. Of 45 patients treated with TH after SCA, 23 (51%) survived to discharge, 14 (31%) with good neurologic outcomes. In comparison to historical controls, TH did not improve outcome of in-hospital SCA. SCA from a shockable rhythm was associated with the best outcome. The time from return of spontaneous circulation to initiation of TH was consistently within 8 h. CONCLUSIONS: Despite logistical and financial constraints, we were able to rapidly implement a TH program with quality and outcomes similar to published data. TH did not improve outcomes for patients with an in-hospital SCA.