Reduction in fall risk markers following CPAP treatment of obstructive sleep apnoea in people over 65 years.

OBJECTIVES: Falls in older people can lead to serious injury and significant societal health and financial burden. Obstructive sleep apnoea (OSA) is associated with impaired gait/balance and may increase fall risk, yet few studies examined whether treating OSA reduces fall risk. This study examined the effect of continuous positive airway pressure (CPAP) on fall risk markers in people over 65yrs diagnosed with OSA. DESIGN: Single arm intervention study. SETTING: University and tertiary care CPAP clinic. PARTICIPANTS: Individuals over 65 years diagnosed with OSA and recommended CPAP. INTERVENTION: 3-6 months CPAP therapy. MEASUREMENTS: 28 participants had a physiological profile assessment (PPA) at baseline and following 3-6 months of CPAP. The PPA examines visual contrast sensitivity, lower limb proprioception, knee extension strength, reaction time and postural sway to generate a fall risk score (FRS). t-tests were used to determine difference between pre- and post-treatment FRS. Regression was used to examine the associations between CPAP use and daytime sleepiness with FRS. RESULTS: CPAP significantly reduced the FRS ([Mean ± SD] 0.59 ± 1.0 vs 0.04 ± 1.1, p = 0.016), contrast sensitivity and lower limb proprioception (P < 0.05). Increased CPAP use was associated with improvement in FRS in unadjusted analysis (ß = -0.213, 95%CI -0.371 to -0.056, p = 0.01). Reduction in Epworth sleepiness score was associated with a reduction in FRS in unadjusted (p = 0.023) and adjusted analysis (adjusted for AHI p = 0.027 or O2Nadir p = 0.015). CONCLUSIONS: CPAP may reduce fall risk in people over 65yrs, possibly related to better CPAP adherence and reduced daytime sleepiness. Future controlled trials and mechanistic studies are needed to elucidate how CPAP may reduce fall risk.

Increase in the Number and Duration of Sleep Episodes During Class After Reopening of Schools Following Closure due to COVID-19.

Sleep is important for the well-being of school-aged children. Almost all schools in Hyogo prefecture in Japan were closed from April 7 to May 31, 2020, owing to the coronavirus disease 2019 pandemic. The pandemic restrictions resulted in the disruption of the sleep routines of children. The number of children who experienced sleepiness in class after school closure increased. The number of children who visited our hospital 1 year before and after the closure was 208 (11.73 ± 3.24 years of age) and 155 (11.45 ± 3.30 years), respectively. The number of chief complaints of sleep-related symptoms at the first visits showed no significant difference between the two time periods. The percentage of patients who slept during class increased (but not significantly) after the school closure. However, the mean number and duration of sleep episodes during class significantly increased from 0.31 ± 0.76 to 1.04 ± 1.14 episodes/day and from 15.8 ± 38.6 to 45.7 ± 46.9 min/day (each P < 0.001) before and after school closure, respectively. The total number of patients in our hospital with the primary central disorders of hypersomnolence, i.e., narcolepsy, idiopathic hypersomnia, and Kleine-Levin syndrome, and the number of patients with insufficient sleep syndrome after the school closure significantly increased compared with those before closure (P = 0.034 and 0.048, respectively). School closure was associated with an increased incidence of sleeping during class; therefore, maintaining a stable daily routine for children with sleep disorders could have an alleviating effect.

Central hypersomnia and chronic insomnia: expanding the spectrum of sleep disorders in long COVID syndrome - a prospective cohort study.

INTRODUCTION: Long-onset COVID syndrome has been described in patients with COVID-19 infection with persistence of symptoms or development of sequelae beyond 4 weeks after the onset of acute symptoms, a medium- and long-term consequence of COVID-19. This syndrome can affect up to 32% of affected individuals, with symptoms of fatigue, dyspnea, chest pain, cognitive disorders, insomnia, and psychiatric disorders. The present study aimed to characterize and evaluate the prevalence of sleep symptoms in patients with long COVID syndrome. METHODOLOGY: A total of 207 patients with post-COVID symptoms were evaluated through clinical evaluation with a neurologist and specific exams in the subgroup complaining of excessive sleepiness. RESULTS: Among 189 patients included in the long COVID sample, 48 (25.3%) had sleep-related symptoms. Insomnia was reported by 42 patients (22.2%), and excessive sleepiness (ES) was reported by 6 patients (3.17%). Four patients with ES were evaluated with polysomnography and test, multiple sleep latencies test, and actigraphic data. Two patients had a diagnosis of central hypersomnia, and one had narcolepsy. A history of steroid use was related to sleep complaints (insomnia and excessive sleepiness), whereas depression was related to excessive sleepiness. We observed a high prevalence of cognitive complaints in these patients. CONCLUSION: Complaints related to sleep, such as insomnia and excessive sleepiness, seem to be part of the clinical post-acute syndrome (long COVID syndrome), composing part of its clinical spectrum, relating to some clinical data.

Functional and microstructural brain abnormalities, fatigue, and cognitive dysfunction after mild COVID-19 (preprint)

Background: Little is known about the underpinning mechanisms of neurological dysfunction in post-COVID syndrome. Methods: We conducted a cross-sectional study of 87 consecutive subjects after a mild infection, with a median of 54 days after diagnosis of COVID-19. We performed structured interviews, neurological examinations, 3T-MRI scans, and neuropsychological assessments. The MRI study included white matter investigation with diffusion tensor images (DTI) and functional connectivity with resting-state functional MRI (RS-fMRI). Results: Subjects self-reported headaches (40%) and memory difficulties (33%). The quantitative analyses confirmed symptoms of fatigue (68% of participants), excessive somnolence (35%), symptoms of anxiety (29%), impaired cognitive flexibility (40%), and language dysfunction (33%). Besides, we observed a correlation between DTI fractional anisotropy (FA) and abnormal attention and cognitive flexibility in the Trail Making Test part B. Elevated levels of fatigue and somnolence associated with higher connectivity of the posterior cingulate cortex (PCC) in the RS-fMRI study of the default mode network. While higher connectivity of the PCC with bilateral angular gyri was associated with higher fatigue levels, the elevated levels of somnolence correlated with higher connectivity between the PCC and both the left thalamus and putamen. Conclusions: COVID-19 is associated with long-term neuropsychiatric symptoms and cerebral functional and microstructural alterations.

Adolescent mobile phone addiction during the COVID-19 pandemic predicts subsequent suicide risk: a two-wave longitudinal study.

Both the rate of mobile phone addiction and suicidality among adolescents have increased during the pandemic lockdown. However, the relationship between mobile phone addiction and suicide risk and the underlying psychological mechanisms remains unknown. This study examined the associations between mobile phone addiction in adolescents during the first month of lockdown and the suicide risk in the subsequent five months. A two-wave short-term longitudinal web-based survey was conducted on 1609 senior high school students (mean age = 16.53 years, SD = 0.97 years; 63.5% female). At Time 1 (T1), the severity of mobile phone addiction and basic demographic information was collected from Feb 24 to 28, 2020 in Sichuan Province, China (at the pandemic's peak). Five months later, between July 11 and July 23 (Time 2, T2), mobile phone addiction, daytime sleepiness, depression, and suicidality were measured within the past five months. The regression analysis revealed that mobile phone addiction during quarantine directly predicted suicidality within the next five months, even after controlling for the effect of depression and daytime sleepiness. Meanwhile, mobile phone addiction at T1 also indirectly predicted suicidality at T2, with depression and daytime sleepiness mediating this association. Programs targeting improvement of daytime sleepiness and depressive symptoms may be particularly effective in reducing suicide risk among adolescents with mobile phone addiction.

Changes in Sleep Pattern During the COVID-19 Lockdown in Patients With Narcolepsy, Idiopathic Hypersomnia, and Restless Legs Syndrome.

BACKGROUND AND OBJECTIVES: To explore the first coronavirus disease 2019 (COVID-19) lockdown effect on sleep symptoms in patients with narcolepsy, idiopathic hypersomnia (IH), and restless legs syndrome (RLS). METHODS: Between March and May 2020, a sample of adult patients regularly followed up in a Reference Hospital Sleep Unit (299 with narcolepsy, 260 with IH, and 254 with RLS) was offered an online survey assessing their sleep-wake habits, daily activities, medication intake, and validated scales: International RLS Study Group questionnaire, Narcolepsy Severity Scale (NSS), IH Severity Scale (IHSS), Epworth Sleepiness Scale (ESS), Insomnia Severity Index, Beck Depression Inventory-II, and European Quality of Life (QoL) scale. The survey was proposed once, and the questions were answered for the prelockdown (recall of the month before the confinement) and the lockdown (time of study) periods. RESULTS: Overall, 331 patients completed the survey (response rate 40.7%): 102 with narcolepsy, 81 with IH, and 148 with RLS. All patients reported later bedtimes, with reduced differences for time in bed (TIB) and total sleep time (TST) over 24 hours between weekdays and weekends. Patients with narcolepsy spent more TIB and increased TST overnight, with more daytime napping. They had more awakenings, higher ESS scores, lower QoL, and no NSS changes. Patients with IH also increased their TIB, TST overnight and 24 hours on weekdays. Nocturnal sleep latency and the number of awakenings increased but with no change in ESS, QoL, and IHSS scores. Patients with RLS reported longer nocturnal sleep latency, more awakenings, more naps, decreased TIB, and TST overnight. RLS severity increased while QoL decreased. A significant portion of patients reported disease worsening during the lockdown (narcolepsy: 39.4%, IH: 43.6%, and RLS: 32.8%), and some patients stopped or lowered their medication (narcolepsy: 22.5%, IH: 28%, and RLS: 9.5%). DISCUSSION: During the lockdown, all patients reported later bedtimes; those with narcolepsy and IH extended their sleep duration unlike patients with RLS. These changes were often associated with negative consequences on QoL. In the current context of recurrent COVID-19 waves, the recent development of teleconsultations should enable physicians to monitor patients with chronic sleep disorders more closely and to recommend optimized sleep schedules and duration, in order to prevent psychological problems and improve their QoL.

Long-term functioning status of COVID-19 survivors: a prospective observational evaluation of a cohort of patients surviving hospitalisation.

OBJECTIVES: The study investigated the long-term functional status of hospitalised COVID-19 survivors to explore and document their functional situation. DESIGN: This prospective observational study assessed 801 COVID-19 survivors at 3-11 months after hospital discharge. It analyses participants' sociodemographic background, COVID-19 clinical manifestations, and clinical and functional evaluations. SETTING: Tertiary-level university hospital in São Paulo, Brazil. PARTICIPANTS: Study participants are COVID-19 survivors admitted to hospital care for at least 24 hours to treat acute SARS-CoV-2 infection. OUTCOME MEASURES: Epworth Sleepiness Scale, EuroQoL-5 Dimensions-5 Levels, Functional Assessment of Chronic Illness Therapy-Fatigue, Functional Independence Measure, Functional Oral Intake Scale, Handgrip Strength, Insomnia Severity Index, Medical Research Council (MRC) Dyspnea Scale, MRC sum score, Modified Borg Dyspnea Scale, pain Visual Analogue Scale, Post-COVID-19 Functional Status, Timed Up and Go, WHO Disability Assessment Schedule 2.0, 1-Minute Sit to Stand Test. RESULTS: Many participants required invasive mechanical ventilation (41.57%, 333 of 801). Mean age was 55.35±14.58 years. With a mean of 6.56 (SD: 1.58; 95% CI: 6.45 to 6.67) months after hospital discharge, 70.86% (567 of 800) reported limited daily activities, which were severe in 5.62% (45 of 800). They also reported pain and discomfort (64.50%, 516 of 800), breathlessness (64.66%, 514 of 795), and anxiety and depression (57.27%, 457 of 798). Daytime sleepiness and insomnia evaluations showed subthreshold results. Most (92.85%, 727 of 783) participants reported unrestricted oral intake. Data indicated no generalised fatigue (mean score: 39.18, SD: 9.77; 95% CI: 38.50 to 39.86). Assessments showed poor handgrip strength (52.20%, 379 of 726) and abnormal Timed Up and Go results (mean 13.07 s, SD: 6.49). The invasive mechanical ventilation group seemed to have a better handgrip strength however. We found no clear trends of change in their functional status during months passed since hospital discharge. CONCLUSIONS: Muscle weakness, pain, anxiety, depression, breathlessness, reduced mobility, insomnia and daytime sleepiness were the most prevalent long-term conditions identified among previously hospitalised COVID-19 survivors.

Autoimmune conditions following mRNA (BNT162b2) and inactivated (CoronaVac) COVID-19 vaccination: a descriptive cohort study among 1.1 million vaccinated people in Hong Kong (preprint)

Background Concerns regarding the autoimmune safety of COVID-19 vaccines may negatively impact vaccine uptake. We aimed to describe the incidence of autoimmune conditions following BNT162b2 and CoronaVac vaccination and compare these with age-standardized incidence rates in non-vaccinated individuals. Methods This is a descriptive cohort study conducted in public healthcare service settings. Territory-wide longitudinal electronic medical records of Hong Kong Hospital Authority users (≥16 years) were linked with COVID-19 vaccination records between February 23, 2021 and June 30, 2021. We classified participants into first/second dose BNT162b2 groups, first/second dose CoronaVac groups and non-vaccinated individuals for incidence comparison. The study outcomes include hospitalized autoimmune diseases (16 types of immune-mediated diseases across six body systems) within 28 days after first and second dose of vaccination. Age-standardized incidence rate ratios (IRRs) with exact 95% confidence intervals (CIs) were estimated using Poisson distribution. Results This study included around 3.9 million Hong Kong residents, of which 1,122,793 received at least one dose of vaccine (BNT162b2: 579,998; CoronaVac: 542,795), and 721,588 completed two doses (BNT162b2: 388,881; CoronaVac: 332,707). Within 28 days following vaccination, cumulative incidences for all autoimmune conditions were below 9 per 100,000 persons, for both vaccines and both doses. None of the age-standardized incidence rates were significantly higher than the non-vaccinated individuals, except for an observed increased incidence of hypersomnia following the first dose of BNT162b2 (standardized IRR: 1.47; 95% CI: 1.10–1.94). Conclusions Autoimmune conditions requiring hospital care are rare following mRNA and inactivated virus COVID-19 vaccination with similar incidence to non-vaccinated individuals. The association between first dose BNT162b2 vaccination and immune-related sleeping disorders requires further research. Population-based robust safety surveillance is essential to detect rare and unexpected vaccine safety events. Funding Research Grant from the Food and Health Bureau, the Government of the Hong Kong Special Administrative Region (Ref. No. COVID19F01).

Sleep Disorder During the Third Wave of COVID-19 Pandemic among Malaysian Adults (preprint)

Background: The outbreak of coronavirus posits deleterious consequences on global healthcare system while affecting human life in every aspect. Despite various measures undertaken to limit the socio-economic effect of coronavirus, various challenges remain pervasive, and one such challenge is mental health, particularly sleep disorders. Therefore, this study examines the prevalence and determinants of sleep disorders among Malaysian adults. Methods: : An online survey was conducted from 11 January to May 2021. Structured questionnaire link using Google form was sent to the adults through E-mail in Malaysia. The study utilized Holland Sleep Disorder Questionnaire (HSDQ) to screen out the various sleep disorders, namely; Insomnia, Parasomnia, Circadian Rhythm Sleep Disorder (CRSD), Hypersomnia, Restless Legs Syndrome (RLS/PLMD), and Sleep-disordered Breathing (SDB). Percentage distribution and logistic regression analysis were used as study tools. Results: : Around 70% of the surveyed population had one or another sleep disorder. One-third reported RLS/PLMD (34.8%) and CRSD (33.9%). More than one-fourth of the adults reported Insomnia (29.7%) and Hypersomnia (25.8%). Increased risk of sleep disorders was found to be associated with being unemployed (OR=2.4, C.I.=1.17-4.89). The risk of insomnia and hypersomnia was higher among female adults (OR=1.6, C.I.=1.11-2.3) and unemployed adults (OR=2.4, C.I.=1.23-5.04), respectively. Conclusion: Immediate interventions to prevent aggravation of sleep disorders should be promoted. It is recommended to bring forth psychiatric and psychological support to those suffering from various sleep disorders in the ongoing coronavirus pandemic. Government shall impart counselling through various online channels consisting of psychologists and sleep experts to improve the quality of sleep.

Current Update on Clinically Relevant Sleep Issues in Parkinson's Disease: A Narrative Review.

Sleep disturbances are among the common nonmotor symptoms in patients with Parkinson's disease (PD). Sleep can be disrupted by nocturnal motor and nonmotor symptoms and other comorbid sleep disorders. Rapid eye movement sleep behavior disorder (RBD) causes sleep-related injury, has important clinical implications as a harbinger of PD and predicts a progressive clinical phenotype. Restless legs syndrome (RLS) and its related symptoms can impair sleep initiation. Excessive daytime sleepiness (EDS) is a refractory problem affecting patients' daytime activities. In particular, during the COVID-19 era, special attention should be paid to monitoring sleep problems, as infection-prevention procedures for COVID-19 can affect patients' motor symptoms, psychiatric symptoms and sleep. Therefore, screening for and managing sleep problems is important in clinical practice, and the maintenance of good sleep conditions may improve the quality of life of PD patients. This narrative review focused on the literature published in the past 10 years, providing a current update of various sleep disturbances in PD patients and their management, including RBD, RLS, EDS, sleep apnea and circadian abnormalities.

Functional and microstructural brain abnormalities, fatigue, and cognitive dysfunction after mild COVID-19 (preprint)

Although post-acute cognitive dysfunction and neuroimaging abnormalities have been reported after hospital discharge in patients recovered from COVID-19, little is known about persistent, long-term alterations in people without hospitalization. We conducted a cross-sectional study of 87 non-hospitalized recovered individuals 54 days after the laboratory confirmation of COVID-19. We performed structured interviews, neurological examination, 3T-MRI scans with diffusion tensor images (DTI) and functional resting-state images (fMRI). Also, we investigated fatigue, anxiety, depression, somnolence, language, memory, and cognitive flexibility, using validated instruments. Individuals self-reported a high frequency of headache (40%) and memory difficulties (33%). The quantitative analyses confirmed symptoms of fatigue (68%), excessive somnolence (35%), anxiety (29%), impaired cognitive flexibility (40%) and language impairment (33%). There were widespread cerebral white matter alterations (mainly characterized by increased fractional anisotropy), which correlated with abnormal attention and cognitive flexibility. The resting-state fMRI networks analysis showed severely disrupted brain hyperconnectivity and loss of resting-state networks specificity.

Symptom- and prevention based testing of COVID-19 in nursing home residents: Symptoms and mortality, a retrospective cohort study (preprint)

Background: Nursing homes (NH) residents with COVID-19 can either be tested because of presence of core symptoms (fever, cough, dyspnea) (S-based) or because of transmission prevention (TP-based). We described the clinical presentation and course of COVID-19 in NH residents who were tested either because of presence of core symptoms (S-based) or because of transmission prevention (TP-based).Methods:. XXX (XXX), is a 1185-bed NH. All NH residents who underwent SARS-CoV-2 RT-PCR testing between March 16, 2020 and May 31, 2020 were included (n = 380) in this retrospective cohort study. Clinical symptoms, temperature and oxygen saturation were extracted from medical records, 7 days before testing up to 14 days after testing.Results: SARS-CoV-2 was confirmed in 81 (21%) residents. Of these 81, 36 (44%) residents were tested S-based and 45 (56%) residents were tested TP-based. Yet, CT-values did not differ between the groups. In the 7 days prior to the test the most common symptoms in both groups were: falling (32%), somnolence (25%) and fatigue (21%). Two days before the test, we observed a stronger decrease in oxygen saturation and an increase in temperature for the S-based group compared to the T-based group that remained up to 10 days after testing. Residents with in the S-based group were 2.5 times more likely to decease within 30 days than residents in the TP-based group (HR, 2.56; 95% 1.3 to 5.2). Even though, 73% of the T-based group did eventually developed core symptoms.Conclusions: Many NH residents with a positive PCR did not have core symptoms when tested but had other signs/symptoms in the week before the positive test. Testing policies should therefore be adjusted to prevent transmission. Daily measures of temperature and oxygen saturation can contribute to earlier detection.

Symptom based and transmission-prevention based testing in long-term care facilities: Symptomatology, clinical course and mortality for residents with COVID-19 (preprint)

Objectives: Initially, for preventing COVID-19 transmission in long-term care facilities (LTCF) primarily rely on presence of core symptoms (fever, cough, dyspnea), but LTCF residents may also show an atypical course of a SARS-CoV-2 infection. We described the clinical presentation and course of COVID-19 in LTCF residents who were tested either because of presence of core symptoms (S-based) or because of transmission prevention (TP-based) Design: Retrospective cohort study. Setting and participants: Amsta (Amsterdam, The Netherlands), is a 1185-bed LTCF. All LTCF residents who underwent SARS-CoV-2 RT-PCR testing between March 16, 2020 and May 31, 2020 were included (n = 380). Measures: Clinical symptoms, temperature and oxygen saturation were extracted from medical records, 7 days before testing up to 14 days after testing. Results: SARS-CoV-2 was confirmed in 81 (21%) residents. Of these 81, 36 (44%) residents were tested S-based and 45 (56%) residents were tested TP-based. Yet, CT-values did not differ between the groups. In the 7 days prior to the test the most common symptoms in both groups were: falling (32%), somnolence (25%) and fatigue (21%). Two days before the test, we observed a stronger decrease in oxygen saturation and an increase in temperature for the S-based group compared to the T-based group that remained up to 10 days after testing. Residents with in the S-based group were 2.5 times more likely to decease within 30 days than residents in the TP-based group (HR, 2.56; 95% 1.3 to 5.2). Even though, 73% of the T-based group did eventually developed core symptoms. Conclusion and implications: Many LTCF residents with a positive PCR did not have core symptoms when tested but had other signs/symptoms in the week before the positive test. Testing policies should therefore be adjusted to prevent transmission. Daily measures of temperature and oxygen saturation can contribute to earlier detection.

Case of COVID-19 in a 5-week-old baby.

On 31 December 2019, the first case of COVID-19, was reported in Wuhan. A public health emergency of international concern was declared on 30 January 2020 and the first case in Scotland, on 2 March. The effect of COVID-19 appears to be less in the paediatric population and there are fewer cases reported in the literature in comparison to the adult population. Here, we report a case of a previously well 5-week-old infant who presented with fever and increased sleepiness. There was no known contact with any unwell individuals. COVID-19 was identified through a septic screen work up. The infant's course was uneventful and she has made a full recovery. This case highlights the need to have a low index of suspicion in the diagnosis of COVID-19 and the need to be vigilant in use of personal protective equipment, even in paediatric patients with subtle symptoms.

COVID-19 associated meningoencephalitis complicated with intracranial hemorrhage. A case report. (preprint)

Introduction: The Coronavirus pandemic that started in December 2019 is mainly related to clinical pictures consistent with respiratory symptoms; nevertheless, reports about neurological complications have recently appeared in the medical literature.The case: we describe a case of a 36 years old Coronavirus-positive patient that was admitted on emergency basis; his clinical presentation included neurological symptoms such as drowsiness and mild confusion. Imaging revealed findings consistent with meningoencephalitis complicated by intracerebral hematoma and subdural hematoma. The latter was surgically evacuated after it became chronic and evidence of Coronavirus was found in the fluid.  Conclusion: our experience confirms that neurological complications might be a likely event in COVID-19. Although uncommon, the possible occurrence of meningoencephalitis should be kept in mind by physicians involved in the management of COVID-19 patients. Early recognition of brain involvement may provide better prognosis, preventing evolution into intracerebral hemorrhagic events.