A systematic review on adherence to continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in individuals with mild cognitive impairment and Alzheimer's disease dementia

Obstructive sleep apnoea (OSA) is highly prevalent in mild cognitive impairment (MCI) and Alzheimer's disease (AD). The gold standard treatment for OSA is continuous positive airway pressure (CPAP). Long-term, well-powered efficacy trials are required to understand whether CPAP could slow cognitive decline in individuals with MCI/AD, but its tolerability in this group remains uncertain. The present review investigates CPAP adherence among individuals with OSA and MCI/AD. Electronic searches were performed on 8 databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Six independent studies and four secondary analyses included 278 unique participants (mean age = 72.1 years). In five of the retained studies, around half of participants (45% N = 85 MCI, 56% N = 22 AD) were adherent to CPAP, where ≥4 h use per night was considered adherent. Three of the retained studies also reported average CPAP use to range between 3.2 and 6.3 h/night. CPAP adherence in individuals with MCI and AD is low, albeit similar to the general elderly population. Reporting adherence in future studies as both average duration as well as using a binary cut-off would improve our understanding of the optimum CPAP use in dementia clinical trials and care.

COVID-19-related changes in outpatient CPAP setup pathways for OSA are linked with decreased 30-day CPAP usage

The COVID-19 pandemic changed continuous positive airway pressure (CPAP) setup pathways. We evaluated patients commenced on CPAP in 2019 (prepandemic) and 2020 (post-first UK wave). Face-to-face (F2F) setup numbers, with CPAP turned on, decreased from 613 patients (98.9%) in 2019, to 6 (1.1%) in 2020. In 2020, setups were F2F without CPAP turned on (403 (71.1%)), or remote (158 (27.9%)). Prepandemic median CPAP usage at first follow-up was 5.4 (2.7-6.9) hours/night and fell by 0.9 hours/night (95% CI 0.5 to 1.2, p<0.0001) in 2020. We found clinically relevant reductions in CPAP usage with pathway changes post-COVID-19.

ARTP statement on pulmonary function testing 2020

The Association for Respiratory Technology & Physiology (ARTP) last produced a statement on the performance of lung function testing in 1994. At that time the focus was on a practical statement for people working in lung function laboratories. Since that time there have been many technological advances and alterations to best practice in the measurement and interpretation of lung function assessments. In light of these advances an update was warranted. ARTP, therefore, have provided within this document, where available, the most up-to-date and evidence-based recommendations for the most common lung function assessments performed in laboratories across the UK. These recommendations set out the requirements and considerations that need to be made in terms of environmental and patient factors that may influence both the performance and interpretation of lung function tests. They also incorporate procedures to ensure quality assured diagnostic investigations that include those associated with equipment, the healthcare professional conducting the assessments and the results achieved by the subject. Each section aims to outline the common parameters provided for each investigation, a brief principle behind the measurements (where applicable), and suggested acceptability and reproducibility criteria.

2017 ERS/ATS standards for single-breath carbon monoxide uptake in the lung

This document provides an update to the European Respiratory Society (ERS)/American Thoracic Society (ATS) technical standards for single-breath carbon monoxide uptake in the lung that was last updated in 2005. Although both D_LCO (diffusing capacity) and T_LCO (transfer factor) are valid terms to describe the uptake of carbon monoxide in the lung, the term D_LCO is used in this document. A joint taskforce appointed by the ERS and ATS reviewed the recent literature on the measurement of D_LCO and surveyed the current technical capabilities of instrumentation being manufactured around the world. The recommendations in this document represent the consensus of the taskforce members in regard to the evidence available for various aspects of D_LCO measurement. Furthermore, it reflects the expert opinion of the taskforce members on areas in which peer-reviewed evidence was either not available or was incomplete. The major changes in these technical standards relate to D_LCO measurement with systems using rapidly responding gas analysers for carbon monoxide and the tracer gas, which are now the most common type of D_LCO instrumentation being manufactured. Technical improvements and the increased capability afforded by these new systems permit enhanced measurement of D_LCO and the opportunity to include other optional measures of lung function.

Executive Summary: 2017 ERS/ATS standards for single-breath carbon monoxide uptake in the lung

This document summarises an update to the European Respiratory Society (ERS)/American Thoracic Society (ATS) technical standards for single-breath carbon monoxide uptake in the lung that was last updated in 2005. The full standards are also available online as https://doi.org/10.1183/13993003.00016-2016 The major changes in these technical standards relate to D_LCO measurement with systems using rapidly responding gas analysers for carbon monoxide and the tracer gas, which are now the most common type of D_LCO instrumentation being manufactured. Technical improvements and the increased capability afforded by these new systems permit enhanced measurement of D_LCO and the opportunity to include other optional measures of lung function.

The effect of neoadjuvant chemotherapy and chemoradiotherapy on exercise capacity and outcome following upper gastrointestinal cancer surgery: an observational cohort study

Background

In 2014 approximately 21,200 patients were diagnosed with oesophageal and gastric cancer in England and Wales, of whom 37 % underwent planned curative treatments. Potentially curative surgical resection is associated with significant morbidity and mortality. For operable locally advanced disease, neoadjuvant chemotherapy (NAC) improves survival over surgery alone. However, NAC carries the risk of toxicity and is associated with a decrease in physical fitness, which may in turn influence subsequent clinical outcome. Lower levels of physical fitness are associated with worse outcome following major surgery in general and Upper Gastrointestinal Surgery (UGI) surgery in particular. Cardiopulmonary exercise testing (CPET) provides an objective assessment of physical fitness. The aim of this study is to test the hypothesis that NAC prior to upper gastrointestinal cancer surgery is associated with a decrease in physical fitness and that the magnitude of the change in physical fitness will predict mortality 1 year following surgery.

Methods

This study is a multi-centre, prospective, blinded, observational cohort study of participants with oesophageal and gastric cancer scheduled for neoadjuvant cancer treatment (chemo- and chemoradiotherapy) and surgery. The primary endpoints are physical fitness (oxygen uptake at lactate threshold measured using CPET) and 1-year mortality following surgery; secondary endpoints include post-operative morbidity (Post-Operative Morbidity Survey (POMS)) 5 days after surgery and patient related quality of life (EQ-5D-5 L).

Discussion

The principal benefits of this study, if the underlying hypothesis is correct, will be to facilitate better selection of treatments (e.g. NAC, Surgery) in patients with oesophageal or gastric cancer. It may also be possible to develop new treatments to reduce the effects of neoadjuvant cancer treatment on physical fitness. These results will contribute to the design of a large, multi-centre trial to determine whether an in-hospital exercise-training programme that increases physical fitness leads to improved overall survival.

Trial registration

ClinicalTrials.gov NCT01325883 - 29^th March 2011.

Correlation between perceived asthma control and thoraco-abdominal asynchrony in primary care patients diagnosed with asthma

OBJECTIVE

Thoraco-abdominal asynchrony (TAA), the discordant movement of the abdomen and thorax, may impact upon health-related variables. Here, we investigated the extent to which TAA is associated with health-related variables, particularly perceived asthma control and quality of life.

METHODS

Ambulatory respiratory data from 43 patients diagnosed with asthma and 43 healthy age and sex-matched controls were recorded over 4 hours. Phase relation (Ph Rel Total), the percentage of time that the effects of rib cage (RC) and diaphragmatic movement result in opposite effects on intra-thoracic volume, quantified TAA. Subjects completed the Mini Asthma Quality of Life Questionnaire (AQLQ), Asthma Control Questionnaire (ACQ), Nijmegen questionnaire (NQ), Hospital Anxiety and Depression Scale (HADS), Spielberger State-Trait Anxiety Inventory (STAI), and General Health Perception (GHP) subscale of the short form 36 questionnaire'. Capnography profiling, breath-hold time (BHT), and standard spirometry were performed.

RESULTS

The time in asynchrony was significantly greater in the asthma than in the healthy control group (Ph Rel Total = 14% (interquartile range (IQR) 8.5-20.7%) versus 10.4% (IQR 7.1-14.5%), p = .012). In patients with asthma, Ph Rel Total was weakly associated with poorer ACQ scores (r = 0.33, p = .03), and in the healthy control group with GHP (r = 0.319, p = .037). Post-hoc exploratory analysis revealed a moderate relationship in the female asthma subgroup between Ph Rel Total and AQLQ (r = -0.56, p = .003).

CONCLUSIONS

TAA may be associated with decreased perceived asthma control. In healthy individuals, asynchrony may be associated with low perception of general health. Further studies are required to investigate if the reduction of TAA improves these health-related variables.

A validation of the 7.5% CO2 model of GAD using paroxetine and lorazepam in healthy volunteers

The inhalation of 7.5% carbon dioxide (CO2) in healthy subjects produces an increase in blood pressure and heart rate, and increased feelings of anxiety, fear and tension (Bailey et al. 2005). As this state is similar to that of general anxiety rather than panic, we further validated this by examining the effects of anxiolytic medication. Two separate studies in healthy volunteers are described; study one is a double-blind, placebo-controlled study of a single dose of 2 mg lorazepam and study two describes the effects of 21 days of treatment with paroxetine. Gas challenges were air and 7.5% CO2 inhaled for 20 minutes, delivered on day 0 (before treatment) and day 21 (after treatment) in the paroxetine study. Subjective effects were measured using visual analogue scales and questionnaires. When compared with placebo, lorazepam 2 mg significantly reduced peak CO2-induced subjective fear, feelings of wanting to leave, tension and worry. In the paroxetine study, when compared with day 0, day 21 showed a significantly attenuated peak CO2-induced nervousness and a trend for reduced ratings of anxiety, fear, feel like leaving, tense and worried. In these studies we have shown that this CO2 model of anxiety is sensitive to lorazepam and to a lesser extent paroxetine. This gives support to its utility as an experimental model of general anxiety disorder in healthy volunteers.

General practice critical incident reviews of patient suicides: benefits, barriers, costs, and family participation

AIM

To explore the feasibility of holding critical incident reviews (CIRs) after patient suicides in general practice and their ability to change practice.

METHODS

Thirteen practices were invited to conduct a facilitated CIR on 18 current patient suicides. Next of kin views were sought. All staff attending a CIR were interviewed after the review.

RESULTS

Ten practices reviewed 12 deaths. Twenty six staff attended reviews; all were interviewed. Next of kin contributed to six reviews; only one criticised care. Changes following the reviews included steps to improve internal communication and bereavement support to set up internal CIRs and review prescribing policies. Communications between practices and other agencies were clarified.

CONCLUSION

Practices were willing to hold CIRs and appreciated the potential positive value but need reassurance that they will not be blamed for suicides, and that the cost in time and resources will be recognised.

Acute carbon dioxide exposure in healthy adults: evaluation of a novel means of investigating the stress response

Acute hypercapnia was studied to assess its potential as a noninvasive and simple test for evoking neuroendocrine, cardiovascular and psychological responses to stress in man. A single breath of four concentrations of carbon dioxide (CO(2)), 5%, 25%, 35% and 50%, was administered to nine healthy volunteers in a randomized, single-blind fashion. Although no adverse effects occurred, most subjects were unable to take a full inspired vital capacity breath of 50% CO(2). In response to the remaining exposures, subjective and somatic symptoms of anxiety increased in a dose-dependent manner. Unlike 5% and 25% CO(2), 35% CO(2) stimulated significant adrenocorticotropic hormone and noradrenaline release at 2 min and cortisol and prolactin release at 15 min following inhalation. This same dose also provoked a significant bradycardia that was followed by an acute pressor response. No significant habituation of psychological, hypothalamic-pituitary-adrenal (HPA) or cardiovascular responses following 35% CO(2) was seen when this dose was repeated after 1 week. A single breath of 35% CO(2) safely and reliably produced sympathetic and HPA axis activation and should prove a useful addition to currently available laboratory tests of the human stress response.

Striatal recruitment during an implicit sequence learning task as measured by functional magnetic resonance imaging

Prior research has repeatedly implicated the striatum in implicit sequence learning; however, imaging findings have been inconclusive with respect to the sub-territories and laterality involved. Using functional magnetic resonance imaging (fMRI), we studied brain activation profiles associated with performance of the serial reaction time task (SRT) in 10 normal right-handed males. Behavioral results indicate that significant implicit learning occurred, uncontaminated by significant explicit knowledge. Concatenated fMRI data from the entire cohort revealed significant right-lateralized activation in both the caudate and putamen. Analysis of fMRI data from individual subjects showed inter-individual variability as to the precise territories involved, including right as well as left caudate and putamen. Interestingly, all seven subjects who manifested robust learning effects exhibited significant activation within the putamen. Moreover, among those seven subjects, the magnitude of signal intensity change within the putamen correlated significantly with the magnitude of reaction time advantage achieved. These findings demonstrate right-sided striatal activation across subjects during implicit sequence learning, but also highlight interindividual variability with respect to the laterality and striatal subterritories involved. In particular, results from individual subjects suggest that, during the SRT, the reaction time advantage garnered via implicit sequence learning might be predominantly associated with activity within the putamen.

Hidden on the ward: the abuse of children in hospitals

Hidden on the ward: the abuse of children in hospitals While there have been a small number of high profile cases of the abuse of children by hospital staff, there has been relatively little attention paid to the child protection issues for children staying in hospitals. Drawing on a conceptual framework from work on institutional abuse, we identify three types of abuse: physical and sexual abuse; programme abuse; and system abuse. Physical and sexual abuse can be perpetrated by medical professionals and hospital workers, it can be perpetrated by other children, or it can be perpetrated by the child's own parent(s). Research evidence from the United States of America (USA) suggests that the rate of abuse in hospitals is higher than in the family home. Programme abuse occurs when treatment and care falls below normally accepted standards. Recently, a tragic case of programme abuse concerned the unacceptably high death rate of babies undergoing heart surgery at Bristol Royal Infirmary. System abuse is the most difficult to define but concerns the way in which child health services fail to meet the needs of children. Recent reports have highlighted inadequate services for children and young people, lack of priority given to children's services, and geographical inequalities in the provision of services. Three crucial aspects in safeguarding children from abuse are highlighted: listening to children; the selection support and training of staff; and external systems of inspection, monitoring and standards. The recent British government agenda which has placed quality at the centre of National Health Service (NHS) developments are discussed. Only by addressing the abuse of children in hospital openly and honestly will effective child protection be possible.

Oral midazolam premedication and postoperative behaviour in children

We examined the effect of oral midazolam premedication on postoperative behaviour. Seventy children (ASA Physical Status 1 and 2; aged 1-10 yrs) were assigned randomly in a prospective, blinded fashion to receive either midazolam 0.5 mg.kg-1 (maximum 10 mg) or placebo. Behaviour assessments were made prior to medication, during induction of anaesthesia and 15 min following arrival to recovery room. The baseline behavioural evaluation scores were not significantly different. The children receiving midazolam cried significantly less during induction (P < or = 0.02). At one week follow-up, eight of 35 subjects receiving placebo had experienced adverse behaviour changes (nightmares, night terrors, food rejection, anxiety, negativism); 19 of 35 of the midazolam group experienced these changes (P < or = 0.02). At four week follow-up, most behaviour changes had resolved. Children given preoperative oral midazolam were less likely to cry and fight while being anaesthetized, and preoperative sedation was associated with increased incidence of adverse postoperative behaviour changes.

Probing striatal function in obsessive-compulsive disorder: a PET study of implicit sequence learning

Positron emission tomography was employed to contrast the brain activation pattern in patients with obsessive-compulsive disorder (OCD) to that of matched control subjects while they performed an implicit learning task. Although patients and control subjects evidenced comparable learning, imaging data from control subjects indicated bilateral inferior striatal activation, whereas OCD patients did not activate right or left inferior striatum and instead showed bilateral medial temporal activation. The findings further implicate corticostriatal dysfunction in obsessive-compulsive disorder. Furthermore, when OCD patients are confronted with stimuli that call for recruitment of corticostriatal systems, they instead appear to access brain regions normally associated with explicit (conscious) information processing.

Sesamol as an inhibitor of growth and lipid metabolism in Mucor circinelloides via its action on malic enzyme

Sesamol, a nonoil component of sesame seed oil, inhibited growth, fatty acid synthesis, and desaturation by Mucor circinelloides in vivo. Although sesamol also inhibited the growth of other fungi and yeasts, its effect on the lipid metabolism of M. circinelloides was exceptional. An enzymological study demonstrated that sesamol affected lipid synthesis primarily by the inhibition of malic enzyme activity, thereby limiting the NADPH supply for fatty acid synthesis and desaturation. Sesamol itself had no inhibitory effect on malic enzyme activity in vitro. A metabolite of sesamol is therefore probably responsible for the in vivo effects of sesamol on lipid metabolism.

Effects of fat content, weight, and acceptability of the meal on postlunch changes in mood, performance, and cardiovascular function

This study examined the effects of fat content and meal size on postlunch changes in mood, performance, and cardiovascular function. Forty-six subjects (20 males, 26 females) were tested before and after lunch. Subjects were assigned to one of the following lunch conditions: a) low fat (23 g), large meal (860 g); b) low fat (18 g), small meal (600 g); c) high fat (84 g), large meal (840 g); d) high fat (79 g), small meal (530 g). The results showed only small effects of fat composition and meal size, with no cardiovascular effects being observed and no evidence of fat content or the weight of the meal influencing performance of logical reasoning or cognitive vigilance tasks. A few effects of meal type were significant in the mood data, but given the large number of analyses conducted, these could represent chance effects. Results from two selective attention tasks showed that subjects given the high-fat meals responded more slowly but more accurately, which differs from the effects of carbohydrate, protein, and calorie content reported in earlier papers. Weight of the meal influenced the degree of distraction from near and far distractors and also the accuracy of responses to central and peripheral targets. However, both the effects of fat and meal size were modified by task parameters, and further research is required before firm conclusions can be drawn about the functional importance of the influences of nutrient content and meal size on performance. The high-fat and large meals were rated as more acceptable than the low-fat and small meals.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of breakfast and caffeine on cognitive performance, mood and cardiovascular functioning

Two experiments examined the effect of breakfast (1.89 MJ) and caffeine (4 mg/kg) on cognitive performance, mood and cardiovascular functioning. In the first experiment, breakfast had no effect on performance of sustained attention tasks, but it increased pulse rate and influenced mood. The mood effects after breakfast differed between a cooked breakfast and a cereal/toast breakfast. In contrast to the effects of breakfast, this relatively high dose of caffeine improved performance of the sustained attention tasks, increased blood pressure and increased mental alertness. In the second experiment, effects of a breakfast and caffeine on mood and cardiovascular functions confirmed the results of the first study. The breakfast improved performance on free recall and recognition memory tasks, had no effect on a semantic memory task and impaired the accuracy of performing a logical reasoning task. In contrast to this, caffeine improved performance on the semantic memory, logical reasoning, free recall and recognition memory tasks. Overall, these results show that breakfast can improve performance in some but not all cognitive tasks and that these changes are very different from those observed after lunch, and those produced by caffeine.

Desaturation of polyunsaturated fatty acids in Mucor circinelloides and the involvement of a novel membrane-bound malic enzyme

1. The component fatty acids of the endogenous phospholipids of microsomal preparations of Mucor, when shaken at 30 degrees C, increased in both chain length and in degree of unsaturation. The net effect was the production of gamma-linolenic acid which, over 2 h, increased from 17% to 32% of total fatty acids present. No further significant changes occurred after this time. 2. The major site for desaturation/elongation reactions was at the sn-2 position of PtdIns. PtdCho and PtdEtn were not implicated. 3. Of numerous metabolites and cofactors added to the microsomes, only malate could prolong the elongation/desaturation reactions for up to 6 h. This effect was shown to be due to a membrane-associated malic enzyme [malate dehydrogenase (decarboxylating) NADP+] with the NADPH produced being used in fatty-acid desaturation. 4. Kinetic analysis of cytosolic and microsomal enzymes [both in 0.1% (mass/vol.) Chaps] could not distinguish between them. However, when the microsomal malic enzyme was dialysed to remove Chaps, it lost 90% of activity, although the cytosolic malic enzyme lost only 20% activity. 5. The structural analogue of malate, tartronic acid, which is an inhibitor of malic enzyme, also inhibited the malate-induced stimulation of fatty-acyl group desaturation and elongation in the microsomal membranes. 6. It is concluded that two distinct malic enzymes exist, one soluble and one membrane bound, with similar active sites. Both have different roles in the production of NADPH, for lipid metabolism. The former will produce NADPH for fatty-acid biosynthesis whilst the latter produces NADPH for fatty-acid desaturation.

Lipids of selected molds grown for production of n-3 and n-6 polyunsaturated fatty acids

The lipid classes and component fatty acids of seven fungi were examined. Three marine fungi, Thraustochytrium aureum, Thraustochytrium roseum and Schizochytrium aggregatum (grown at 30, 25 and 25 degrees C, respectively), produced less than 10% lipid but contained docosahexaenoic acid (DHA) up to 30% and eicosapentaenoic acid (EPA) up to 11% of the total fatty acids. Mortierella alpinapeyron produced 38% oil containing solely n-6 polyunsaturated fatty acids (PUFA) with arachidonic acid (AA) at 11% of the total fatty acids. Conidiobolus nanodes and Entomorphthora exitalis produced 25% oil and contained both n-3 and n-6 PUFA, with AA at 16% and 18%, respectively. Saprolegnia parasitica produced 10% oil and contained AA and EPA, respectively, at 19% and 18%. The triacylglycerol fraction always represented the major component at between 44% and 68% of the total lipid. Each fungus, except T. aureum, had the greatest degree of fatty acid unsaturation in the phospholipid fraction. The triacylglycerol fraction of T. aureum was the most unsaturated with DHA representing 29% (w/w) of all fatty acids present. The presence of the enzyme ATP:citrate lyase correlated with the ability of molds to accumulate more than 10% (w/w) lipid when the fungi were grown in nitrogen-limiting media. In those molds that failed to accumulate more than 10% lipid, the enzyme was absent.

Binding of thiopental in neonatal serum

Protein binding of thiopental was studied in 21 samples of neonatal serum (from placental blood) and compared with protein binding in ten healthy volunteers. These infants ranged between 32 and 43 weeks of gestational age (mean, 37.7 weeks) and the adult age range was from 27 to 54 years (mean, 35.4 years). Because the unbound fraction of the drug is responsible for its pharmacologic effect, a marked difference in the protein binding between neonates and adults may be relevant to the clinician. Blood obtained from freshly delivered placentas or from adult volunteers was allowed to clot and the serum separated from the sample. A portion of the serum was sent for protein and bilirubin analysis and the remainder retained for study. This latter serum was combined with four concentrations of thiopental. These specimens were then ultrafiltered and the amount of thiopental in the ultrafiltrate (unbound) compared with the prefiltered amount (total), as measured by reverse-phase high-performance liquid chromatography. The binding studies were repeated at pH 7.2, 7.4, and 7.6 in both the adult and neonatal serum. Total protein and albumin are significantly less in neonatal serum, whereas bilirubin (total and direct) is significantly higher in neonatal serum than in adult serum (P less than 0.01). Neonatal serum was associated with significantly more unbound thiopental than adult serum at all levels of pH studied (P less than 0.005). Increasing the pH resulted in less free drug in both groups, but this reached statistical significance only in the adult group (P less than 0.025). Drug concentration had no effect on binding in the range examined.(ABSTRACT TRUNCATED AT 250 WORDS)