Treatment of sleep disturbance following stroke and traumatic brain injury: a systematic review of conservative interventions.

PURPOSE: Sleep disorders are common following stroke and traumatic brain injury. We present a systematic review of the literature investigating conservative interventions to improve sleep in these populations. MATERIALS AND METHODS: The PRISMA statement was used. Embase, PubMed, and the Cochrane library were searched for all experimental studies published prior to 28th March 2020 that assessed conservative interventions to improve the sleep or sleep disorders of adults with a history of stroke or traumatic brain injury (TBI). Two authors reviewed publications of interest and risk of bias assessments were performed using the Cochrane Risk of Bias Tool or the Methodological Index for Non-Randomised Studies instrument. RESULTS: Twenty-three publications were included in this systematic review. Meta-analyses were not performed due to study heterogeneity. Psychotherapy-based approaches might be useful for sleep disturbance after TBI and acupuncture may help improve insomnia or sleep disturbance following stroke or TBI, respectively. The evidence was less clear for morning bright light therapy and exercise. Limitations included a single author performing primary searches, only English publications, the reporting of secondary outcome measures, and sleep disorder diagnoses. CONCLUSIONS: Some conservative interventions might be useful for improving sleep disturbance or disorders in these populations, but further research is required.IMPLICATIONS FOR REHABILITATIONSleep disturbance is common following stroke and traumatic brain injury, with insomnia and obstructive sleep apnoea being the most frequently diagnosed sleep disorders.Psychotherapy-based approaches might be useful for sleep disturbance after TBI and acupuncture may help improve insomnia or sleep disturbance following stroke or TBI, respectively.Morning bright light therapy appeared to be more beneficial for fatigue rather than sleep disturbance after TBI, and the evidence for exercise was less clear.

Hamman-Rich syndrome.

INTRODUCTION: Acute interstitial pneumonia is a rare but important diagnosis, associated with a high mortality rate and important to identify early. CASE PRESENTATION: A 76 year-old individual presented to hospital with a two-week history of shortness of breath, fevers and a non-productive cough. Treatment initially was for lower respiratory tract infection but returned to hospital three days later as her shortness of breath and peripheral oedema was worsening despite diuretic treatment. Arterial blood gas showed Type 1 Respiratory Failure (p02 was only 10 kPa on 4 L per minute of oxygen). A computed tomography pulmonary angiography (CTPA) was performed to rule out a pulmonary embolism (PE), which showed multifocal diffuse areas of consolidations bilaterally involving all lobes. Bronchoalveolar lavage cellular analysis was also done. The patient was treated as nonspecific interstitial pneumonia. This case study highlights this rare condition presenting similarly to common pulmonary conditions. DISCUSSION: The disease is often preceded by a flu-like prodromal illness lasting one to two weeks prior to presentation. Acute respiratory failure develops in previously healthy individuals without pre-existing lung disease. Diagnosis is also supported by high-resolution computed tomography (HRCT). The effects of high flow ventilation in patients with idiopathic pulmonary fibrosis are associated with improvement in respiratory parameters, improving the efficiency of breathing. CONCLUSION: Acute interstitial pneumonitis can be a difficult diagnosis, associated with a high mortality rate up to 60%. It is also difficult to treat; however supportive treatment with high flow oxygen therapy along with pulsatile high dose Corticosteroids can aid recovery.

Can Screening Tools for Obstructive Sleep Apnea Predict Postoperative Complications? A Systematic Review of the Literature.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a common, underdiagnosed condition that is associated with significant morbidity and mortality in the perioperative setting. Increasing evidence suggests that the utility of preoperative screening tools may go beyond identification of OSA, to the prediction of perioperative complications. The primary objective of this study was to systematically review the literature on all studies assessing whether high risk scores on the STOP-Bang questionnaire, American Society of Anesthesiologists (ASA) checklist, and the Berlin Questionnaire (BQ) are associated with higher rates of postoperative complications. METHODS: A systematic review of English language records was performed using Medline, EMBASE, and PsychInfo with additional studies identified by manual search through reference lists. Only studies that evaluated the ability of the STOP-Bang, the BQ, and ASA checklist to predict postoperative complications in adults were included. RESULTS: Twelve studies were included in the final review. Eight studies looked at STOP-Bang, 3 at the Berlin Questionnaire, and 2 at the ASA Checklist. Significant differences across study characteristics prevented a meta-analysis and the studies were evaluated qualitatively. CONCLUSIONS: The ASA checklist, Berlin Questionnaire, and STOP-Bang questionnaire may be able to risk stratify patients for perioperative and postoperative complications. Further research is required, with a particular focus on specific surgery types and adjustment of potentially confounding factors in the analysis.

Successful use of blood pleurodesis to resolve an iatrogenic persistent pneumothorax in a patient with pulmonary tuberculosis.

A Somali patient with previous tuberculosis presented clinically unwell with features consistent with a right-sided pleural effusion. Subsequent investigations confirmed a community-acquired pneumonia and relapse of pulmonary tuberculosis, with a drug resistant strain isolated. The patient developed a large left-sided iatrogenic pneumothorax, which recurred and failed to resolve despite the successful insertion of both Seldinger and surgical chest drains, and the patient remained clinically unstable on the intensive care unit. A blood pleurodesis was successfully used to provide resolution of this patient's previously persistent pneumothorax, which has resulted in stabilisation of the patient and no further pneumothoraces have occurred subsequently. The authors therefore highlight the use of a blood pleurodesis as a little used technique that may provide a valuable tool to other clinicians in similar cases.

Diagnostic predictors of obesity-hypoventilation syndrome in patients suspected of having sleep disordered breathing.

INTRODUCTION: Obesity-hypoventilation syndrome (OHS) is associated with significant morbidity and mortality and requires measurement of arterial pCO2 for diagnosis. OBJECTIVE: To determine diagnostic predictors of OHS among obese patients with suspected obstructive sleep apnea/hypopnea syndrome (OSAHS). METHODS: Retrospective analysis of data on 525 sleep clinic patients (mean age 51.4 ± 12.7 years; 65.7% males; mean BMI 34.5 ± 8.1). All patients had sleep studies, and arterialized capillary blood gases (CBG) were measured in obese subjects (BMI > 30 kg/m2). RESULTS: Of 525 patients, 65.5% were obese, 37.2% were morbidly obese (BMI > 40 kg/m2); 52.3% had confirmed OSAHS. Hypercapnia (pCO2 > 6 kPa or 45 mm Hg) was present in 20.6% obese and 22.1% OSAHS patients. Analysis of OHS predictors showed significant correlations between pCO2 and BMI, FEV1, FVC, AHI, mean and minimum nocturnal SpO2, sleep time with SpO2 < 90%, pO2, and calculated HCO3 from the CBG. PO2 and HCO3 were independent predictors of OHS, explaining 27.7% of pCO2 variance (p < 0.0001). A calculated HCO3 cutoff > 27 mmol/L had 85.7% sensitivity and 89.5% specificity for diagnosis of OHS, with 68.1% positive and 95.9% negative predictive value. CONCLUSION: We confirmed a high prevalence of OHS in obese OSAHS patients (22.1%) and high calculated HCO3 level (> 27 mmol/L) to be a sensitive and specific predictor for the diagnosis of OHS.