Impact of Hemodialysis on Sleep Disorders in Patients With End-Stage Renal Disease in a Tertiary Care Academic Hospital.

INTRODUCTION: Although hemodialysis (HD) has prolonged the survival of patients with end-stage renal disease (ESRD), it has also adversely affected the sleep and emotional state of these patients. We evaluated the impact of HD on sleep duration, quality, and other sleep-related disorders. METHODS: We recruited consecutive adult patients visiting our tertiary care dialysis unit. We included only ESRD patients who had an estimated glomerular filtration rate (eGFR) of <15 mL/min/1.73m2. We excluded patients with unrelated comorbidities or on medications that could affect sleep. Basic demographic information, anthropometric data, and appropriate lab investigations were obtained. Objective information related to their sleep duration and quality was asked using a predefined proforma. Subjective sleep scores were obtained by using the Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), and insomnia severity index (ISI). For comparison, the patients were divided into HD and conservative treatment (CT) groups based on their treatment modality. The baseline characteristics of the patients were noted. The Shapiro-Wilk test was used to test normality. Correlations were obtained by using Student's t-test for parameters that were normally distributed and the Mann-Whitney-Wilcoxon test for those that were not. RESULTS: Of the 56 patients we studied, 59% were males. The average age and body mass index (BMI) were 45.7 years and 20.98 kg/m2, respectively. Overall, 41% of patients were assigned to the HD group, and the remaining to the CT group. The CT group had fewer comorbidities compared to the HD group. The average sleep duration was similar in both groups (HD: 6.64 hours, CT: 6.49 hours). There was a weak-to-moderate positive correlation between the sleep scores. Overall, one-half of the patients had excessive daytime sleepiness (EDS) (46.43%) and insomnia (48.21%), and two-thirds of them were poor sleepers (66.07%). Symptoms suggestive of sleep-disordered breathing (SDB) were seen in 25% of patients, restless legs syndrome (RLS) in 19.64% of patients, and periodic limb movement disorder (PLMD) in 44.64% of patients. Patients undergoing HD had poorer sleep quality compared to the CT group (p=0.038). The odds of developing poor sleep were 3.6 times higher in the HD group. CONCLUSION: This cross-sectional study focuses on the quantification of objective and subjective deterioration of sleep quality in ESRD patients on HD. The prevalence of EDS (63.64%), insomnia (51.52%), and poor sleep quality (84.84%) in the HD group was more than the previously reported values. The PSQI, ESS, and ISI scores were higher in HD patients, indicating poorer sleep quality. Our study highlights the underestimation of sleep disorders in HD patients in underserved areas. The results warrant a meticulous evaluation of the same by a keen nephrologist, followed by referral to sleep providers where necessary.

Image-Based Communication for Strengthening Patient Health Education in Rural and Underserved Settings.

Effective communication is the cornerstone of efficient patient care. It is vital to obtain a thorough history, build the patient's trust, and ensure compliance to treatment. Image-based communication (IBC) using comic-like strips is better than the conventional verbal and written modes, as it is inexpensive, less human resource dependent, and diversity agnostic. Strips based on local and socioculturally relevant issues and characters grab readers' attention, are relatable and entertaining, and utilize a storyline that invigorates thinking. The medical advice delivered by an ideal IBC strip is easy to comprehend, has a better recall, and promotes patient adherence. With an idea that IBC strips can serve as a vital supportive tool in underserved and overburdened clinics, we have described the nuances of adapting them into the existing physician-patient experience. We utilize a prototype IBC of an elderly woman helping a family whose child developed acute fever, possibly malaria. Various elements of an IBC strip, namely, panels, gutters, background, characters, bubbles, captions, and visual effects, are illustrated, and their variations are described later. Once designed, an IBC strip must be critically evaluated for the accuracy of the educational message, and errors, if any, must be corrected. The images are then subjected to a series of local field tests to ensure that they serve their purpose and have the desired cultural competence. Once ready, IBC strips can be posted in public spaces and outside clinics or distributed to healthcare workers or patients. Here, they serve as educational and health literacy tools. The strips can significantly reduce caregiver-patient interaction time and improve the quality of communication, especially when patients are illiterate or understand a different language. It is easier to develop rapport and partnership with a patient when the communication is presented through a pictorial tool. An IBC strip can be used to train grassroot workers, who subsequently train patients, thereby serving a dual purpose. To obtain tangible clinical and epidemiologic benefits from IBC strips, rigorous evidence building and standardization are a crucial long-term goal.

Withania somnifera as an Adjunctive Treatment for Refractory Restless Legs Syndrome in Parkinson's Disease: A Case Report.

Non-motor symptoms of Parkinson's disease (PD), such as insomnia and restless legs syndrome (RLS), tend to worsen and become refractory as neurodegeneration progresses. We report the case of a 72-year-old female with a six-year history of PD and two-and-half-year history of insomnia and refractory RLS. We added a neuroprotective agent, Withania somnifera, to the existing treatment regimen for her insomnia. Besides the partial remission of her insomnia and motor symptoms of PD, there was a complete reversal of the RLS symptoms. Withania somnifera has been shown to improve PD symptoms by preventing oxidative damage of the nigrostriatal dopaminergic neurons and improving dopamine levels in the midbrain and corpus striatum. Our case provides the first-time evidence where Withania somnifera added for insomnia caused a complete remission of refractory RLS, possibly due to its anti-apoptotic and pro-dopaminergic actions. Withania somnifera could prove beneficial in cases where the disease advances but further addition of dopamine agonists for refractory RLS is not possible due to the risk of dopamine augmentation.

Antiplatelet Agents in Sepsis-Putting it all together: A Call to Action.

How to cite this article: Tiwari NR, Chaudhari KS, Sharma R, Haas KP, Sharma VR. Antiplatelet Agents in Sepsis-Putting it all together: A Call to Action. Indian J Crit Care Med 2020;24(6):483-484.

Effect of Sudarshan Kriya Yoga (SKY) on daytime and situational sleep propensity in novice practitioners: a prospective cohort study.

OBJECTIVES: Hectic, late-night lifestyle has reduced 90 min sleep in 20% adults resulting in insomnia and excessive daytime sleepiness (EDS). We assess the scope of Sudarshan Kriya Yoga (SKY), a 4-component, breathing process in reducing EDS, generally and situationally. METHODS: This is a prospective, controlled study involving randomized subjects without any sleep-wake cycle anomalies and prior experience in SKY. Subjects (n=52) performed 30 min of SKY for 6 days/week for 8 weeks, while controls (n=53) performed sitting activity and Suryanamaskar for 4-weeks each. Epworth Sleepiness Scale (ESS) was used to measure EDS at 0, 4, and 8 weeks. RESULTS: SKY group showed significant ESS score improvements between 0-4 weeks and 4-8 weeks of 1.22 (p=0.0001) and 1.66 (p=0.001) respectively. Controls however failed to improve with score differences of 0.02 (p=0.892) and 0.02 (p=0.8212) respectively. SKY group showed significant ESS score improvement over controls at 4-weeks (difference=1.74; p=0.013) and 8-weeks (difference eight; p=0.0001). Improvement was most for obese people and those sitting in a halted car. CONCLUSIONS: Improvement in subjects' nighttime sleep and daytime wakefulness in SKY practitioners can be attributed to polyvagal theory. Increased heart rate variability (HRV) alterations and sympathetic hyperarousal in chronic insomnia; and cholinergic and GABAergic dysregulation in anxiety disorders are countered by regulated vagal nerve stimulation post SKY. Our study establishes effectivity of SKY in reducing EDS (total and situational), provides a clinical correlation for prior polysomnographic evidence and paves way for larger trials directed towards SKY prescriptions for insomnia.

Sjögren Syndrome without Focal Lymphocytic Infiltration of the Salivary Glands.

OBJECTIVE: Primary Sjögren syndrome (SS) is characterized by a focal lymphocytic infiltrate in exocrine glands. We describe patients who lacked this key feature. METHODS: We evaluated patients with sicca in a comprehensive clinic at which medical, dental, and ophthalmological examinations were performed. All subjects underwent a minor salivary gland biopsy with focus score calculation. Extraglandular manifestations were also determined. We categorized subjects as high, intermediate, or low in terms of expression of interferon (IFN)-regulated genes. RESULTS: About 20% (51 of 229, 22%) of those classified as having primary SS had a focus score of zero. Compared to those with anti-Ro positivity and a focus score > 1.0, the patients with focus score of zero (who by classification criteria must be anti-Ro-positive) were statistically less likely to have anti-La (or SSB) and elevated immunoglobulin, as well as less severe corneal staining. The focus score zero patients were less likely to have elevated expression of IFN-regulated genes in peripheral blood mononuclear cells than anti-Ro-positive SS patients with a focal salivary infiltrate. CONCLUSION: There are only a few clinical differences between patients with primary SS with focus score zero and those with both anti-Ro and a focus score > 1.0. The small subset of focus score zero patients tested did not have elevated expression of IFN-regulated genes, but did have systemic disease. Thus, extraglandular manifestations are perhaps more related to the presence of anti-Ro than increased IFN. This may have relevance to pathogenesis of SS.

Rare X Chromosome Abnormalities in Systemic Lupus Erythematosus and Sjögren's Syndrome.

OBJECTIVE: Sjögren's syndrome (SS) and systemic lupus erythematosus (SLE) are related by clinical and serologic manifestations as well as genetic risks. Both diseases are more commonly found in women than in men, at a ratio of ~10 to 1. Common X chromosome aneuploidies, 47,XXY and 47,XXX, are enriched among men and women, respectively, in either disease, suggesting a dose effect on the X chromosome. METHODS: We examined cohorts of SS and SLE patients by constructing intensity plots of X chromosome single-nucleotide polymorphism alleles, along with determining the karyotype of selected patients. RESULTS: Among ~2,500 women with SLE, we found 3 patients with a triple mosaic, consisting of 45,X/46,XX/47,XXX. Among ~2,100 women with SS, 1 patient had 45,X/46,XX/47,XXX, with a triplication of the distal p arm of the X chromosome in the 47,XXX cells. Neither the triple mosaic nor the partial triplication was found among the controls. In another SS cohort, we found a mother/daughter pair with partial triplication of this same region of the X chromosome. The triple mosaic occurs in ~1 in 25,000-50,000 live female births, while partial triplications are even rarer. CONCLUSION: Very rare X chromosome abnormalities are present among patients with either SS or SLE and may inform the location of a gene(s) that mediates an X dose effect, as well as critical cell types in which such an effect is operative.

Neurocognitive Effect of Nootropic Drug Brahmi (Bacopa monnieri) in Alzheimer's Disease.

Alzheimer's disease (AD) is a progressive neurodegenerative disease of the elderly. The rapid increase in its incidence has necessitated development of newer drugs. Ayurvedic herbal medications are increasingly researched due to their biosafety profile and usefulness in cognitive impairment. In this article, we critically reviewed one such Medhya Rasayana (nootropic drug) Brahmi-derived from extract of Bacopa monnieri (EBm). Studies have shown that EBm promotes free radical scavenger mechanisms and protects cells in prefrontal cortex, hippocampus, and striatum against cytotoxicity and DNA damage implicated in AD. It also reduces lipoxygenase activity reducing lipid peroxidation, increases glutathione peroxidase and chelates iron. Administration of EBm was seen to protect the cholinergic neurons and reduce anticholinesterase activity comparable to donepezil, rivastigmine, and galantamine. It also reduces hippocampal ß-amyloid deposition and stress-induced hippocampal damage. The neuroprotective effect of EBm is also due to nitric oxide-mediated cerebral vasodilation. EBm improved the total memory score and maximum improvement was seen in logical memory and paired associate learning in humans and reversed phenytoin-induced memory impairment in experimental model. EBm has not shown any serious clinical, neurological, hematological complications, or vital organs damage in experimental studies. Rats showed marked reduction in fertility; however, libido was unaffected. There is no experimental evidence of genotoxicity or teratogenesis by use of EBm. Mild nausea and gastrointestinal upset are seen in humans. Brahmi promises to be a novel agent in AD; however, further human trials are recommended to verify the efficacy and rule out any side effects as evidenced by the experimental models.