bluuebunny/crossref_metadata_2025 huggingface dataset:
786 Trait Extraversion is Associated with Increased Suicidal Ideation During Total Sleep Deprivation and Insomnia
Authors: Killgore William , Capaldi Vincent , Grandner Michael , Kamimori Gary
Published: May 2021

Introduction

It is known that sleep disturbance is associated with increased suicidal thinking, and completed suicides are most common during the late night/early morning hours, but no studies have examined the role of trait-like individual differences in vulnerability to suicidal ideation during sleep deprivation or insomnia. In two separate studies, we examined whether the trait of extraversion is predictive of changes in suicidal thinking following two nights of sleep deprivation and among individuals meeting criteria for insomnia.

Methods

Study 1: Twenty-five healthy military personnel (20 males), ages 20–35 completed the NEO-PI-R Extraversion scale and the Suicidal Ideation (SUI) scale of the Personality Assessment Inventory (PAI). Participants completed 77 hours of continuous sleep deprivation. After 56 hours of sleep deprivation, participants completed the SUI scale a second time. Study 2: 1,011 adults aged 18–79 (470 males) were divided into two groups based on the clinical threshold (≥15) on the Insomnia Severity Index (ISI) and completed measures of extraversion and depression, including the suicide item of the Patient Health Questionnaire-9 (PHQ9).

Results

Study 1: After controlling for caffeine group and changes in PAI Depression, Extraversion scores were used to predict changes in SUI scores using stepwise multiple linear regression. Higher Extraversion was significantly associated with increased non-clinical suicidal ideation following sleep loss, β=.463, partial r=.512, p=.013. Study 2: After controlling for depression, extraversion was more strongly correlated with greater suicidal ideation, particularly for those meeting criteria for insomnia, β=.340, partial r=.387, p<.0000001, compared to those below the threshold, β=.185, partial r=.218, p<.0000001.

Conclusion

Higher trait extraversion was associated with increased vulnerability to suicidal ideation between rested baseline and total sleep deprivation, and was associated with greater suicidal ideation among those meeting criteria for clinically severe insomnia. These findings point to a potential trait-like vulnerability factor that may further our understanding of sleep disruption in the phenomenology of suicide.

Support (if any):
801 Obstructive Sleep Apnea Symptoms Predict Cognitive Function Following Mild Traumatic Brain Injury
Authors: Le Andrew , Dailey Natalie , Grandner Michael , Killgore William
Published: May 2021

Introduction

Sleep disturbances are commonly reported following mild traumatic brain injury (mTBI). Specifically, one of these disturbances is obstructive sleep apnea (OSA), which involves repeated episodes of reduced upper-airway flow during sleep. When compared to the general population, OSA is reported at a much higher rate among the mTBI population. However, little research has investigated the relationship between OSA and cognitive performance among the mTBI population. We predicted that in those who suffered a mTBI, symptoms of sleep apnea would be predictive lower cognitive processing.

Methods

We collected data from 37 healthy controls (Mean age = 24.3 □ 5.8) and 145 participants with mTBI (Mean age = 24.3 □ 6.8), ranging from 2 weeks to 12 months post-injury. Participants completed the Pittsburg Sleep Quality Index (PSQI) including questions indicative of OSA, such as “cannot breathe comfortably” and “cough or snore loudly” during sleep. We calculated the PSQI Sleep Disturbance (PSQI-SD) composite score, which ranged from 0 to 2. Participants completed the Automated Neuropsychological Assessment Metrics (ANAM4), a novel computer-based assessment, to measure reaction time (RT).

Results

When comparing the percentage of participants in each group endorsing sleep disturbances on the PSQI-SD, we found a significant difference in the proportion of individuals scoring a 2 on PSQI-SD between the groups (□2(2) = 13.55, p = .001). In healthy controls, 8% scored 0, 89% scored 1, and 3% scored 2 on the PSQI-SD. In contrast, following mTBI, 1.4% scored 0, 72.4% scored 1, and 26.2% scored 2 on the PSQI-SD. Furthermore, PSQI-SD significantly predicted RT (□ = .18, p = .03) in the mTBI group, a relationship not observed in the control group (□ = .30, p = .07).

Conclusion

mTBI increases the incidence of sleep disturbances and symptoms related to OSA. Furthermore, sleep disturbances and OSA-related symptoms were predictive of cognitive performance in individuals who sustained a mTBI, but not healthy controls. Increases in PSQI-SD scores were associated with increased RT, indicating greater deficits in cognitive function, specifically reaction time. These data provide evidence that higher severity in respiratory symptoms relating to sleep apnea hinders cognitive processing, particularly for individuals who have suffered a mTBI.

Support (if any):
818 A Ghost from the Past: Unmasked Insomnia Affecting Hypoglossal Nerve Stimulation Therapy Adherence
Authors: Stuewe Elena , Grover Aarti , Ostrow Peter , Schumaker Greg , Oster Joel , Zacharias Rajesh
Published: May 2021

Introduction

Hypoglossal nerve stimulation (HNS) is an efficacious option for treating moderate to severe obstructive sleep apnea (OSA). However, there is sparse evidence regarding tolerance and adherence to HNS therapy in patients with a diagnosis of insomnia.

Report of case(s)

A 57-year-old man with well-controlled depression presented for evaluation for HNS therapy. He had been diagnosed with moderate OSA with an apnea-hypopnea index of 22/hour, intolerant of continuous positive airway pressure and mandibular advancement device. He underwent uvulopalatopharyngoplasty without significant improvement. At the time of initial evaluation, he denied history of insomnia and prior sleep aid use. He subsequently underwent successful HNS device implantation and activation. One week after HNS initiation, the patient reported new symptoms of significant difficulty with sleep onset and inability to fall back asleep, which was worse than his untreated OSA symptoms. Device interrogation did not reveal any hardware problems. Adjustments to start delay, pause time and device configuration with awake endoscopy did not improve tolerance. Subsequently, the patient disclosed a remote history of insomnia, which was treated with multiple hypnotics in addition to cognitive-behavioral therapy for insomnia (CBTi) and had resolved. He was diagnosed with recurrent chronic insomnia, for which eszopiclone was initiated without significant improvement. He eventually agreed to CBTi, with partial improvement in device tolerance and improvement in insomnia symptoms.

Conclusion

This case highlights that HNS therapy adherence can be affected by prior history of, or a current diagnosis of insomnia. Our patient had a predisposition for insomnia that was well controlled prior to HNS therapy initiation. The onset of recurrent insomnia with HNS activation suggests that HNS was a precipitating factor for his now chronic insomnia. Although there is insufficient evidence to suggest whether history of insomnia should affect the decision to initiate HNS therapy, this case illustrates the importance of screening for insomnia at pre-implant evaluation. Our center is now routinely screening for a history of insomnia to identify patients who may benefit from treatment prior to HNS implantation. Larger studies are needed to explore a possible relationship between insomnia and HNS adherence.

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820 An Unusual Case of Post-Traumatic Brain Injury Kleine-Levin Syndrome with Anti-GAD-65 Autoantibodies
Authors: Tse Caroline , Mignot Emmanuel , Lim Miranda
Published: May 2021

Introduction

Kleine-Levin Syndrome (KLS) is a rare clinical syndrome, and is precipitated by traumatic brain injury (TBI) in 9% of cases. An autoimmune component to KLS has previously been suggested. Autoantibody profiles in KLS are diverse and its overlap with autoimmune encephalitis is still not well described or understood. Here, a case of KLS in a patient with autoimmune diabetes with very high levels of serum autoimmune GAD-65 antibodies is presented.

Report of case(s)

A 36-year-old male Veteran with a history of alpha-thalassemia minor, prior history of insomnia with nightly sleep of 6 hours, prior history of mild OSA with AHI of 5.8 on PSG in 2018, sustained a mild TBI on 11/13/2019 after a 50-pound box fell on his head. CT head and cervical spine were normal. One week later, he developed recurrent episodes of hypersomnia, sleeping up to 80 hours continuously, waking briefly only to urinate or eat, with hyperphagia, irritability, and derealization present during episodes. One month after the TBI, he was diagnosed with Latent Autoimmune Diabetes in Adults (LADA) after blood glucose was found to be elevated at 566. Serum GAD-65 antibody level was very elevated at 10,594 U/mL (ref range: 0–5 U/mL), hemoglobin a1c was 7.7%, and insulin was started. Six months later, he was evaluated in the VA Sleep Clinic for continued hypersomnia, despite controlled diabetes. Neurological examination, MRI brain, and sleep-deprived EEG were normal. Cerebrospinal fluid testing was normal, with the exception of a CSF autoimmune encephalitis panel with a positive GAD-65 titer of 0.24 nmol/L (range <0.02 nmol/L) – non-diagnostic for autoimmune encephalitis. HLA-DQ1B status is pending.

Conclusion

Autoimmunity is an emerging topic of clinical significance in KLS. GAD-65 serum antibodies have both endocrine and neurologic significance, with high levels seen in autoimmune diabetes, encephalitis, stiff-person syndrome, and cerebellar ataxia. An autoantibody panel can be considered in patients with KLS, as the presence of autoimmune encephalitis may support the use of immunotherapy.

Support (if any)

Portland VA Research Foundation to Dr. Lim. The contents do not represent the views of the United States Government.
824 Case Series on the Use of Volume Assured Pressure Support in Patients with Chronic Pulmonary Disease and Progressive Hypercapnia
Authors: LeMaster William , Jun Dale , De Cruz Sharon , Zeidler Michelle , Saggar Rajan
Published: May 2021

Introduction

Chronic hypercapnia results from destruction of lung parenchyma which occurs in chronic lung diseases including interstitial lung disease (ILD), bronchiectasis, and chronic lung transplant rejection. Many patients with these diseases will experience progressive respiratory failure eventually requiring consideration of transplantation or re-transplantation. Due to physiologic changes in sleep including reduction in tidal volume, worsening air tapping, and REM atonia, hypoventilation can be exacerbated during the sleeping hours. We present four patients who were prescribed nocturnal Volume Assured Pressure Support VAPS for their progressive hypercapnia.

Report of case(s)

Subject 1 is a 72 year old female with severe bronchiectasis and restrictive lung disease due to TB pneumonia at a young age. Subject 2 is a 45 year old male with history of pulmonary cavitation due to extensive TB disease when he was younger. Subject 3 is a 45-year-old woman with rheumatoid arthritis related ILD with associated pulmonary arterial hypertension. Subject 4 is a 74 year old patient with a bilateral lung transplant for IPF complicated by bronchiolitis obliterans syndrome who presented with progressive dyspnea and hypercapnia. Despite optimal therapy, all of these patients were admitted for hypercapnic and hypoxemic respiratory failure requiring treatment with BPAP then transitioned to nocturnal VAPS on discharge. For all patients, dyspnea and pCO2 improved as outpatients although all patients did eventually experience an exacerbation of their lung disease requiring repeat admission.

Conclusion

Due to the physiologic changes that occur with sleep, patients with severe lung disease may experience worsening CO2 retention while sleeping. There is little data assessing the use of chronic nocturnal non-invasive ventilation (NIV) to treat the hypercapnia of chronic lung diseases other than chronic obstructive pulmonary disease, extra-thoracic restriction, and neuromuscular disease. In this case series, nocturnal VAPS stabilized and/or reduced pCO2 in patients with pulmonary parenchymal disease of various etiologies. Additional studies are needed to assess long term effects of VAPS in these patients, including exacerbations, symptoms, and overall mortality.

Support (if any):
826 Central Sleep Apnea associated with Sodium Oxybate– A Case Series
Authors: Rath Subhendu , Binns Lizabeth , Kaplish Neeraj
Published: May 2021

Introduction

Sodium oxybate (SO) is indicated to treat cataplexy and excessive daytime sleepiness (EDS) in patients with narcolepsy. Only a handful of cases have been reported of new-onset Central Sleep Apnea (CSA) in the setting of SO use. We present 3 patients who developed CSA in the setting of use of SO.

Report of case(s)

Patient 1: A 25-y/o man presented with hypersomnolence. His diagnostic polysomnogram (PSG) showed moderate Obstructive Sleep Apnea (OSA), and he was placed on Continuous Positive Airway Pressure (CPAP) therapy. Due to persistent hypersomnia in the setting of effectively treated OSA, he had a Multiple Sleep Latency Test (MSLT), which revealed pathological sleepiness with a mean latency of 3.8 minutes with a sleep-onset REM on the overnight polysomnogram. SO was started for clinical diagnosis of Narcolepsy after he failed other stimulant medications. Hypersomnolence improved though data from his PAP device, home sleep studies, re-titration studies performed when he was on SO demonstrated CSA following 1st or 2nd dose of SO. Patient 2: A 17-y/o man was diagnosed to have Narcolepsy with Cataplexy, based on PSG followed by MSLT. 20 years later, he was diagnosed with OSA based on a PSG and was treated with CPAP. A few years later, he was started on SO for fragmented sleep and EDS. A home sleep study performed when he was on SO, revealed CSA. Later, an in-lab titration study showed CSA with Cheyne-Stokes respiration (CSR), treated with Adaptive Servo-Ventilation (ASV) therapy. Patient 3: A 15-y/o man initially presented after several cataplectic episodes and was diagnosed with Narcolepsy with Cataplexy. His initial PSG showed no evidence of sleep-disordered breathing. A few years later, for persistent cataplectic events, he was started on SO with improvement in the episodes’ frequency. Several years later, a baseline PSG demonstrated OSA and CSA, with frequent CSA events soon after taking SO. The CPAP titration study, performed following the PSG, also revealed frequent CSA following the second dose of SO.

Conclusion

Close monitoring is warranted with SO use, given some narcolepsy patients’ predisposition to develop CSA. Follow-up studies are needed to address the pathogenesis and management strategies.

Support (if any)

None
828 Challenges of artifact in Polysomnography-An LVAD Story
Authors: Koothirezhi Rupa , Anne Pratibha , Okorie Ugorji , Ho Minh Tam , Monceaux Brittany , Liendo Cesar , Chernyshev Oleg
Published: May 2021

Introduction

Congestive heart failure and sleep-disordered breathing frequently coexist. Many of these patients are referred for polysomnography(PSG). Left ventricular assist device (LVAD) is increasingly used as a destination therapy or as a bridge to transplant. This can lead to artifacts in EEG and EKG. The artifact can mask pathological waves or over-reading of pathology. We present a case report of a patient who underwent a PSG on LVAD.

Report of case(s)

Sixty-six-year old male with severe heart failure with reduced ejection fraction (EF) of 15 % presented with snoring and witnessed apnea. The patient was diagnosed with predominant central sleep apnea (92%) but never initiated BPAP/ST due to an unstable heart. He was placed on LVAD (HeartMate III LVAD, oscillatory speed of 5300 rpm/83.3Hz) as the heart status deteriorated. Repeat polysomnography was done for persistent snoring but improved witnessed apneas revealed a newly appearing artifact. EEG showed a diffuse low amplitude,6–7 Hz frequency waves, and a regularly appearing high voltage sharp-peaked wave. The morphology of alpha wave, K wave, spindles, and delta waves could not be appreciated and hence was unable to perform sleep staging. EKG had electrical artifacts. All troubleshooting maneuvers were unsuccessful in eliminating artifacts. The artifact is generated by the impeller rotational speed of LVAD that ranges from 2400 rpm to 10,00 rpm(oscillation frequencies of 40 Hz to 166.7 Hertz,1Hz == 60 rpm). The device’s artificial pulse causes additional minor peaks. EEG artifact can be improved by moving the amplifier away from the heart and repositioning the patient. Adjusting the low-frequency filter can affect the nasal pressure tracing, delta waves, and stage 3 recognition. Reducing the high-frequency filter frequency by 10 from the LVAD oscillation frequency improves the EKG signal. But this may cut off the frequency component of pathologies like left ventricular hypertrophy.

Conclusion

The LVAD has been increasingly used in the United States. It is important to improve awareness regarding the artifacts among sleep techs and physicians. Unresolved artifacts may lead to missing serious pathologies in EEG and EKG and also can lead to misreading the waves as pathological leading to unnecessary treatment.

Support (if any)

An image of EEG and EKG
830 Combined Phototherapy and Melatonin for treatment of Circadian Rhythm Disorder in a Patient with Cornelia de Lange Syndrome
Authors: Emanuel Hina , Revana Amee , Te Tue , Kaplan Kevin
Published: May 2021

Introduction

Cornelia de Lange syndrome (CdLS) is a rare genetic disorder characterized by variable physical, cognitive, and behavioral characteristics. Sleep disturbances have been frequently reported in CdLS including insomnia, sleep-disordered breathing, intrinsic sleep disorders, and circadian rhythm disorders (CRDs). The characterization and prevalence of CRDs in CdLS remain ill- defined. We report a case of a 13-year-old female with CdLS presenting with advanced sleep wake phase disorder (ASWPD).

Report of case(s)

A 13-year-old female with a past medical history of CdLS, developmental delay, bilateral cleft palate status post repair presents with inability to fall asleep at night and excessive daytime sleepiness.(EDS) Her sleep history consists of going to bed at 4 pm with no delayed sleep onset. She wakes at 2:30 am which has occurred since infancy. Mother reports the patient will remain awake from 2:30 am until she goes to school at 7:30 am. History is consistent with EDS and sleeping during the day while at school. Total sleep time of approximately 11–12 hours was reported in 24-hour period. History of obstructive sleep apnea, parasomnias, insomnia, restless leg syndrome, and psychotropic medications were not reported. Patient was treated with timed low dose melatonin therapy 0.5 mg at 4 pm and bright light therapy using 10,000 lux for 30 minutes at 7 am and 4 pm. Dim lights starting at 7:30 pm with structured scheduled sleep hygiene ensuring consistent bedtime at 9:30 pm. A consistent wake time at 7 am and no naps during the day was recommended. Follow up visits report successful response to therapy with attainment of desired sleep wake rhythm (bedtime at 9:30 pm and wake time at 7 am) and resolution of sleepiness during the day. Our patient was able to be weaned off of melatonin and light therapy and her circadian rhythm remained entrained.

Conclusion

Patients with disorder such as CdLS are at risk for circadian rhythm disorders. Our patient responded well to treatment with combined timed phototherapy and low dose melatonin therapy. Better knowledge and characterization of typology of CRDs in CdLS patients could permit a more specific therapeutic approach to sleep disorders in this population.

Support (if any)

None
837 Narcolepsy in a toddler
Authors: Sekhon Anupamjeet , Prero Moshe , Ross Kristie , Ibrahim Sally
Published: May 2021

Introduction

Narcolepsy is a central disorder of hypersomnia with a bimodal peak incidence at ages 15 and 35. Onset in early childhood has been reported, but rarely under the age of 5. We present a case of Narcolepsy Type 1 in a 2.5-year-old with dropping spells.

Report of case(s)

A 2.5-year-old African American healthy male presented with acute onset sudden drops, unsteady gait, and staring spells. These episodes lasted a few seconds, occurred multiple times a day, and were associated with eye fluttering and dysarthric speech. History was notable for increased daytime sleep/sleep attacks, disrupted nocturnal sleep with confusional arousals, nightmares and sleepwalking, weight gain and mood instability with aggressive behavior. No preceding head injury or illness. Physical examination demonstrated frequent atonic episodes with loss of deep tendon reflexes. A clinical suspicion of myoclonic/atonic epilepsy prompted video- electroencephalogram (EEG) which showed frequent bursts of generalized intermittent slowing representative of NREM 1 sleep lasting several seconds. Magnetic resonance imaging of the brain and infectious workup was unremarkable. Cerebrospinal fluid (CSF) Orexin was <50 pg/mL. While 76–98% of patients with narcolepsy type-1 have HLADQB1*06:02, our patient tested negative. Due to lack of MSLT validity at this age, only diagnostic PSG was performed which showed REM without atonia and sleep fragmentation. Prior to sleep onset, cataplexy was observed in the patient while laughing, though EMG tone was relatively preserved during this episode. We had limited treatment options considering lack of FDA approved medications for ages less than 7. A helmet was prescribed to prevent head injury. Methylphenidate 5mg/day improved sleepiness and slightly stabilized mood. For cataplexy, neither Fluoxetine nor Imipramine helped. His mother disapproved further medication trials. Continuing methylphenidate, the family was referred to behavior psychology for support, coping with the diagnosis and behavioral changes.

Conclusion

This case demonstrates an unusual presentation of Narcolepsy Type 1 in a toddler initially thought to have epilepsy. Video-EEG and low CSF orexin led to the diagnosis. His age, severity of cataplexy, mood changes, and parental concerns made treatment challenging. Furthermore, this case highlights the importance of early recognition of Narcolepsy in young children to provide appropriate treatment during critical developmental stages.

Support (if any):
839 Not Your Everyday Daytime Sleepiness: Two Peas in a Pod
Authors: Stuewe Elena , Ostrow Peter , Grover Aarti , Schumaker Greg , Oster Joel , Zacharias Rajesh
Published: May 2021

Introduction

Obstructive sleep apnea (OSA) and narcolepsy are both causes of excessive daytime sleepiness (EDS). OSA is a more prevalent diagnosis, but it can coexist with narcolepsy and confound diagnosis. We present a case of a delayed diagnosis of type 2 narcolepsy in a patient with known OSA.

Report of case(s)

A 31-year-old man with depression treated with sertraline and prior history of severe OSA diagnosed at an outside facility presented to our clinic for residual excessive daytime sleepiness. He demonstrated adequate adherence to continuous positive airway pressure (CPAP) of 13 cmH2O over a period of one year, good sleep hygiene and adequate sleep duration. He reported vivid dreams and sleep paralysis in the past, but none recently. There was no history of a delayed sleep phase. He denied hypnagogic or hypnopompic hallucinations or cataplexy. An in-lab polysomnogram (PSG) followed by multiple sleep latency test (MSLT) was ordered for further evaluation. Sertraline was held 2 weeks prior to the study. Overnight PSG on CPAP showed adequate treatment of OSA on CPAP pressures of 13–16 cmH2O. MSLT showed 3/5 sleep-onset rapid eye movement periods with a mean sleep latency of 5.8 minutes. A diagnosis of coexisting type 2 narcolepsy was made. Treatment was initiated with modafinil; however, his symptoms of EDS persisted and he was changed to methylphenidate with subsequent improvement.

Conclusion

The case above highlights the importance of maintaining a broad differential when investigating the etiology of EDS. In particular, patients with narcolepsy often experience a significant delay between onset of symptoms and receiving a diagnosis. Diagnosis can be confounded by a lack of classic symptoms and/or the presence of another sleep-related breathing disorder, as in the patient above. Residual EDS can be seen in patients with adequately treated OSA. There is sparse data regarding the co-prevalence of narcolepsy as the etiology of residual EDS in adequately treated OSA. Patients should still be screened for symptoms suggestive of narcolepsy. Persistence of EDS symptoms in young adults with adequately treated OSA should raise suspicion for another sleep-related disorder and merits further investigation.

Support (if any):
864 New-onset Obstructive Sleep Apnea Diagnosis in a COVID-positive Patient
Authors: Nguyen Nobel , Mebust Kimberly
Published: May 2021

Introduction

Risk factors for the mortality of COVID-19, such as cardiovascular and lung disease, are commonly seen in patients with obstructive sleep apnea (OSA). Patients with OSA experience approximately 8-fold greater risk for COVID-19 infection compared to a similar age population. Among patients with COVID-19 infection, OSA was associated with an increased risk of hospitalization and approximately doubled the risk of developing respiratory failure. However, there is little information on whether COVID-19 can directly develop OSA. To the best of our knowledge, we describe the first case-presentation of a positive COVID-19 patient who developed sudden-onset OSA.

Report of case(s)

NL is a 47-year-old female who complains of new-onset snoring, excessive daytime sleepiness, and witnessed apnea events after testing positive for COVID-19 seven months prior after developing mild symptoms. Her ESS score is 12/24, neck circumference is 14.75 cm, BMI is 27.9, and Mallampati II. She has no pertinent PMH and is not a tobacco user. In regards to her sleep, she has no symptoms of restless legs, narcolepsy, or periodic limb movements. She denies any physical disturbances, psychiatric conditions, environmental factors, or medical issues that might affect her sleep. There is no family history of sleep apnea, snoring, or other sleeping disorders. The patient's presentation at the initial sleep visit prompted a home sleep study. Results of her home sleep study revealed 131 total number of sleep-related respiratory events, with an apnea-hypopnea index of 11.9 per hour. Mean oxygen saturation was 94% and the minimum oxygen saturation was 83%. Total estimated sleep time was 7 hours, 59 mins, and sleep quality and duration were deemed adequate. The results from NL's sleep study gave the final diagnosis of mild OSA.

Conclusion

Besides having a slightly overweight BMI, NL had relatively few risk factors for developing OSA (no family history, no comorbidities, and normal physical exam findings). The link between the virus and the development of OSA in healthy individuals is not readily apparent. We recommend sleep studies for healthy patients who develop OSA like-symptoms after being infected with COVID-19 to prevent unwanted health risks associated with OSA.

Support (if any):
A Novel Teaching Strategy in Nursing Pharmacology: Learning Using Cognitive Load Theory
Authors: Mauldin Betsy
Published: May 2021

Nursing pharmacology is a complex and content-dense course that is often difficult for educators and students. Cognitive load theory explains why utilizing slide decks for instruction overloads the working memory and impedes processing information into long-term memory. An instructional design change in a baccalaureate nursing pharmacology course provided an example of understanding the impact of cognitive load theory. The Pharmacology Phamily Project is a multimodal, multiphase assignment in which students created a case study video about a unique medication and presented it via discussion board for peer feedback and learning. Student investment improved over traditional past semesters, and student-to-instructor feedback was positive.
Providing Mentorship and Support for ADN-BSN Students Enrolled in a Partnership Model
Authors: Johnson M. Deonne , Kumm Sharon
Published: May 2021

In response to the Institute of Medicine Future of Nursing report goal to increase the proportion of baccalaureate degree nurses to 80 percent, a plan known as the “Partnership Model” was implemented to allow students accepted into community college programs to enroll concurrently in university courses. The plan enabled students to complete a cost-effective baccalaureate degree and associate degree in nursing simultaneously. All 66 students participating in spring 2019 were encouraged to complete a survey to evaluate support and stressors associated with the program. Results from 54 respondents were used to improve the Partnership Model experience.
The Psychological Impact of COVID-19 Outbreak on Nurses Working in Iran
Authors: Kamran Aziz , Malekpour Azim , Naeim Mahdi
Published: May 2021

The psychosocial consequences of the coronavirus pandemic is serious for health professionals including nurses because of a higher level of exposure. Nurses often face huge psychological pressure as a result of workload, long hours, and working in a high-risk environment. This study aimed to assess the associated factors of anxiety, depression, and stress among nurses working in Iran. The research method is library type which was done during 2 months by using valid scientific sources and books. More than two-thirds, more than half, and nearly one-fifth of the nurses had anxiety, depression, and stress, respectively. Unavailability of a guideline, fear of infecting family, and having chronic diseases increase the risk of developing anxiety. Nurses who did not have a guideline, received negative feedback from families, had a history of mental disorders, and chronic diseases have a higher odds of depression. Working in the night shift, lack of training, fear of infecting family, negative feedback from families, presence of confirmed/suspected cases in the family, and having chronic diseases increases the risk of developing stress.
Progression of Tibia Fracture Healing Using RUST: Are Early Radiographs Helpful?
Authors: Wojahn Robert D. , Bechtold Daniel , Abraamyan Torgom , Spraggs-Hughes Amanda , Gardner Michael J. , Ricci William M. , McAndrew Christopher M.
Published: May 2021

Objectives:

To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early postoperative radiographs.

Design:

Retrospective case series.

Setting:

Urban academic Level 1 trauma center.

Patients/Participants:

Three hundred three patients with acute tibial shaft fractures underwent intramedullary nailing between 2006 and 2013, met inclusion criteria, and had at least 3 months of radiographic follow-up.

Intervention:

Baseline demographic, injury, and surgical data were recorded for each patient. Each set of postoperative radiographs were scored using RUST and evaluated for implant failure.

Main Outcome Measurements:

Postoperative time distribution for each RUST score, RUST score distribution for 4 common follow-up time points, and the presence and timing of implant failure.

Results:

The fifth percentile and median times, respectively, for reaching “any radiographic healing” (RUST = 5) was 4.0 weeks and 8.4 weeks, “radiographically healed” (RUST = 9) was 12.1 and 20.9 weeks, and “healed and remodeled” (RUST = 12) was 23.5 weeks and 47.7 weeks. At 6 weeks, 84% of radiographs were scored as RUST ≤ 6 (2 or fewer cortices with callus). No implant failure occurred within the first 8 weeks after surgery, and the indication for all 7 reoperations within this period was apparent on physical examination or immediate postoperative radiographs.

Conclusions:

The median time to radiographic union (RUST = 9) after tibial nailing was approximately 20 weeks, and little radiographic healing occurred within the first 8 weeks after surgery. Routine radiographs in this period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection.

Level of Evidence:

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Extracorporeal Cytokine Adsorption Therapy As a Preventive Measure in Cardiac Surgery and As a Therapeutic Add-On Treatment in Sepsis: An Updated Systematic Review of Comparative Efficacy and Safety*
Authors: Goetz Gregor , Hawlik Katharina , Wild Claudia
Published: May 2021

OBJECTIVES:

Evaluating whether there is a clinical benefit of using extracorporeal cytokine adsorption therapy in two indications.

DESIGN:

Systematic review.

SETTING:

Search on four databases, Medline, Embase, The Cochrane Library, and the European Network for Health Technology Assessment planned and ongoing projects database.

PATIENTS:

Patients with sepsis/septic shock; patients undergoing cardiac surgery

INTERVENTIONS:

Cytokine adsorption.

MEASUREMENTS AND MAIN RESULTS:

Randomized controlled trials and prospective studies with concurrent control were eligible for the evidence synthesis. The quality of the individual studies and the strength of the available evidence were assessed using the Cochrane risk of bias tool and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. For the preventive treatment of extracorporeal cytokine adsorption therapy in patients undergoing cardiac surgery, we found very low-quality inconclusive evidence for mortality (five randomized controlled trials, n = 163), length of stay in the ICU (five randomized controlled trials, n = 163), and length of hospitalization (three randomized controlled trials, n = 101). Very low-quality inconclusive evidence was found for (serious) adverse events (four randomized controlled trials, n = 148). For the therapeutic treatment of extracorporeal cytokine adsorption therapy in patients with sepsis/septic shock, we found very low-quality inconclusive evidence for mortality up to 60-day follow-up (two randomized controlled trials, n = 117), organ function (two randomized controlled trials, n = 117) and length of stay in the ICU (one randomized controlled trial, n = 20). Very low-quality inconclusive evidence was found for (serious) adverse events (two randomized controlled trials, n = 117).

CONCLUSIONS:

Given the available evidence, the efficacy and safety of extracorporeal cytokine adsorption therapy in combination with standard care in the investigated indications was not established. We strongly recommend considering well-powered studies with patient-relevant endpoints instead of investing further research funds on studies that may not shed light on the clinical benefit of extracorporeal cytokine adsorption therapy.
Application of Full-Spectrum Rapid Clinical Genome Sequencing Improves Diagnostic Rate and Clinical Outcomes in Critically Ill Infants in the China Neonatal Genomes Project*
Authors: Wu Bingbing , Kang Wenqing , Wang Yingyuan , Zhuang Deyi , Chen Liping , Li Long , Su Yajie , Pan Xinnian , Wei Qiufen , Tang Zezhong , Li Yangfang , Gao Jin , Cheng Rui , Zhou Wei , Wang Zhangxing , Qiu Gang , Wang Jian , Yang Lin , Zhang Ping , Zhao Xuemei , Wang Yao , Gan Mingyu , Li Gang , Liu Renchao , Ni Qi , Xiao Feifan , Yan Kai , Cao Yun , Lu Guoping , Lu Yulan , Wang Huijun , Zhou Wenhao
Published: May 2021

OBJECTIVES:

To determine the diagnostic and clinical utility of trio-rapid genome sequencing in critically ill infants.

DESIGN:

In this prospective study, samples from critically ill infants were analyzed using both proband-only clinical exome sequencing and trio-rapid genome sequencing (proband and biological parents). The study occurred between April 2019 and December 2019.

SETTING:

Thirteen member hospitals of the China Neonatal Genomes Project spanning 10 provinces were involved.

PARTICIPANTS:

Critically ill infants (n = 202), from birth up until 13 months of life were enrolled based on eligibility criteria (e.g., CNS anomaly, complex congenital heart disease, evidence of metabolic disease, recurrent severe infection, suspected immune deficiency, and multiple malformations).

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Of the 202 participants, neuromuscular (45%), respiratory (22%), and immunologic/infectious (18%) were the most commonly observed phenotypes. The diagnostic yield of trio-rapid genome sequencing was higher than that of proband-only clinical exome sequencing (36.6% [95% CI, 30.1–43.7%] vs 20.3% [95% CI, 15.1–26.6%], respectively; p = 0.0004), and the average turnaround time for trio-rapid genome sequencing (median: 7 d) was faster than that of proband-only clinical exome sequencing (median: 20 d) (p < 2.2 × 10–16). The metagenomic analysis identified pathogenic or likely pathogenic microbes in six infants with symptoms of sepsis, and these results guided the antibiotic treatment strategy. Sixteen infants (21.6%) experienced a change in clinical management following trio-rapid genome sequencing diagnosis, and 24 infants (32.4%) were referred to a new subspecialist.

CONCLUSIONS:

Trio-rapid genome sequencing provided higher diagnostic yield in a shorter period of time in this cohort of critically ill infants compared with proband-only clinical exome sequencing. Precise and fast molecular diagnosis can alter medical management and positively impact patient outcomes.
Duration of Hyperoxia and Neurologic Outcomes in Patients Undergoing Extracorporeal Membrane Oxygenation
Authors: Al-Kawaz Mais N. , Canner Joseph , Caturegli Giorgio , Kannapadi Nivedha , Balucani Clotilde , Shelley Leah , Kim Bo Soo , Choi Chun Woo , Geocadin Romergryko G. , Whitman Glenn , Cho Sung-Min
Published: May 2021

OBJECTIVES:

To evaluate the impact of duration of hyperoxia on neurologic outcome and mortality in patients undergoing venoarterial extracorporeal membrane oxygenation.

DESIGN:

A retrospective analysis of venoarterial extracorporeal membrane oxygenation patients admitted to the Johns Hopkins Hospital. The primary outcome was neurologic function at discharge defined by modified Rankin Scale, with a score of 0–3 defined as a good neurologic outcome, and a score of 4–6 defined as a poor neurologic outcome. Multivariable logistic regression analysis was performed to evaluate the association between hyperoxia and neurologic outcomes.

SETTING:

The Johns Hopkins Hospital Cardiovascular ICU and Cardiac Critical Care Unit.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

We measured first and maximum Pao
2 values, area under the curve per minute over the first 24 hours, and duration of mild, moderate, and severe hyperoxia. Of 132 patients on venoarterial extracorporeal membrane oxygenation, 127 (96.5%) were exposed to mild hyperoxia in the first 24 hours. Poor neurologic outcomes were observed in 105 patients (79.6%) (102 with vs 3 without hyperoxia; p = 0.14). Patients with poor neurologic outcomes had longer exposure to mild (19.1 vs 15.2 hr; p = 0.01), moderate (14.6 vs 9.2 hr; p = 0.003), and severe hyperoxia (9.1 vs 4.0 hr; p = 0.003). In a multivariable analysis, patients with worse neurologic outcome experienced longer durations of mild (adjusted odds ratio, 1.10; 95% CI, 1.01–1.19; p = 0.02), moderate (adjusted odds ratio, 1.12; 95% CI, 1.04–1.22; p = 0.002), and severe (adjusted odds ratio, 1.19; 95% CI, 1.06–1.35; p = 0.003) hyperoxia. Additionally, duration of severe hyperoxia was independently associated with inhospital mortality (adjusted odds ratio, 1.18; 95% CI, 1.08–1.29; p < 0.001).

CONCLUSIONS:

In patients undergoing venoarterial extracorporeal membrane oxygenation, duration and severity of early hyperoxia were independently associated with poor neurologic outcomes at discharge and mortality.
Plasma Ferritin as Marker of Macrophage Activation-Like Syndrome in Critically Ill Patients With Community-Acquired Pneumonia
Authors: Brands Xanthe , de Vries Floris M. C. , Uhel Fabrice , Haak Bastiaan W. , Peters-Sengers Hessel , Schuurman Alex R. , van Engelen Tjitske S. R. , Lutter René , Cremer Olaf L. , Bonten Marc J. , Schultz Marcus J. , Scicluna Brendon P. , van der Poll Tom
Published: May 2021

OBJECTIVES:

Plasma ferritin levels above 4,420 ng/mL have been proposed as a diagnostic marker for macrophage activation-like syndrome in sepsis and used for selection of sepsis patients for anti-inflammatory therapy. We here sought to determine the frequency, presentation, outcome, and host response aberrations of macrophage activation-like syndrome, as defined by admission ferritin levels above 4,420 ng/mL, in critically ill patients with community-acquired pneumonia.

DESIGN:

A prospective observational cohort study.

SETTING:

ICUs in two tertiary hospitals in the Netherlands.

PATIENTS:

One hundred fifty-three patients admitted with community-acquired pneumonia.

MEASUREMENTS AND MAIN RESULTS:

Patients were stratified in community-acquired pneumonia–macrophage activation-like syndrome (n = 15; 9.8%) and community-acquired pneumonia–control groups (n = 138; 90.2%) based on an admission plasma ferritin level above or below 4,420 ng/mL, respectively. Community-acquired pneumonia–macrophage activation-like syndrome patients presented with a higher disease severity and had a higher ICU mortality (46.7% vs 12.3% in community-acquired pneumonia–controls; p = 0.002). Twenty-three plasma biomarkers indicative of dysregulation of key host response pathways implicated in sepsis pathogenesis (systemic inflammation, cytokine responses, endothelial cell activation, and barrier function, coagulation activation) were more disturbed in community-acquired pneumonia–macrophage activation-like syndrome patients. Hematologic malignancies were overrepresented in community-acquired pneumonia–macrophage activation-like syndrome patients (33.3% vs 5.1% in community-acquired pneumonia–controls; p = 0.001). In a subgroup analysis excluding patients with hematologic malignancies (n = 141), differences in mortality were not present anymore, but the exaggerated host response abnormalities in community-acquired pneumonia–macrophage activation-like syndrome patients remained.

CONCLUSIONS:

Macrophage activation-like syndrome in critically ill patients with community-acquired pneumonia occurs more often in patients with hematologic malignancies and is associated with deregulation of multiple host response pathways.
Nurse Cognition, Decision Support, and Barcode Medication Administration
Authors: Sloss Elizabeth Ann , Jones Terry L.
Published: May 2021

This article synthesizes theoretical perspectives related to nurse cognition. We present a conceptual model that can be used by multiple stakeholders to study and contemplate how nurses use clinical decision support systems, and specifically, Barcode-Assisted Medication Administration, to make decisions during the delivery of care. Theoretical perspectives integrated into the model include dual process theory, the Cognitive Continuum Theory, human factors engineering, and the Recognition-Primed Decision model. The resulting framework illustrates the process of nurse cognition during Barcode-Assisted Medication Administration. Additionally, the model includes individual or human and environmental factors that may influence nurse cognition and decision making. It is important to consider the influence of individual, human, and environmental factors on the process of nurse cognition and decision making. Specifically, it is necessary to explore the impact of heuristics and biases on clinician decision making, particularly related to the development of alarm and alert fatigue. Aided by the proposed framework, stakeholders may begin to identify heuristics and cognitive biases that influence the decision of clinicians to accept or override a clinical decision support system alert and whether heuristics and biases are associated with inappropriate alert override.
Single-stage Latissimus Dorsi Breast Reconstruction Using Spectrum Devices: Outcomes and Technique
Authors: Boudreau Colton , Boehm Kaitlin S. , MacDonald Aevan , Williams Jason
Published: May 2021

Background:

Latissimus dorsi (LD) flap is a workhorse flap in breast reconstruction. Despite many advantages, the primary criticism of this flap is the requirement of a second surgery to exchange expansion devices for permanent implants. This study reports a single-stage reconstruction and outcomes wherein Spectrum devices (Mentor, Irving, TX), which serve as expanders and permanent implants, are used, and expansion ports are removed under local anesthetic.

Methods:

A retrospective chart review of all patients undergoing LD flap reconstruction with Spectrum device by a single surgeon at a single center during a 10-year period was performed. All patients, unilateral/bilateral, immediate/delayed were included. Details of implants, surgical procedure(s), and follow-up visits were assessed for patient outcomes.

Results:

In total, 41 patients and 56 breasts were included. Of the total patients, 58.5% retained the Spectrum device and had the expansion port removed under local anesthetic. An estimated 6 major complications occurred (14.6%), requiring return to the operating room: 3 patients required a capsulectomy, 1 a capsulotomy/implant repositioning, one had loss of implant (infection), and 1 had venous congestion of the flap. Eleven minor complications occurred (26.8%): 5 seromas (3 at the breast site, 2 at the donor site), 3 delayed wound healings (2 at donor site, 1 at breast site), 1 mastectomy flap necrosis, 2 infections (1 at each breast site, 1 at donor site).

Conclusions:

This study provides details of a single-stage LD flap with Spectrum device breast reconstruction that can be considered when performing an LD reconstruction. This technique is efficient and safe with comparable complication profile.
Multimodal Neurocognitive Screening of Military Personnel With a History of Mild Traumatic Brain Injury Using the Bethesda Eye & Attention Measure
Authors: Ettenhofer Mark L. , Hungerford Lars D. , Agtarap Stephanie
Published: May 2021

Objective:

To evaluate a neurocognitive eye tracking task, the Bethesda Eye & Attention Measure (BEAM), for use in cognitive screening of patients with a history of mild traumatic brain injury (TBI).

Setting:

US military TBI rehabilitation clinic.

Design/Participants:

Cross-sectional study of 191 military personnel receiving outpatient services related to history of mild TBI. Main measures: BEAM; neuropsychological screening measures of attention, processing speed, executive function, and memory.

Results:

Medium effect sizes were found for partial correlations (controlling for age) between key BEAM metrics and neuropsychological screening tests. Linear regression analyses demonstrated that BEAM saccadic eye movements and manual (button press) metrics each provided complementary value in measurement of cognitive performance, above and beyond effects of demographic factors and clinical characteristics.

Conclusion:

This study provides initial support for the use of BEAM neurocognitive eye tracking in cognitive screening of adults with a history of mild TBI. BEAM saccadic metrics appear to be particularly well-suited for the assessment of visual attention. Study findings also highlight opportunities for greater cognitive sensitivity or testing efficiency that may be missed by tests measuring only one response modality at a time.