1
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Thomas CL, Capaldi VF, Collen JF. Breathing new life into PTSD-related sleep disorders! J Clin Sleep Med 2024; 20:335-336. [PMID: 38156417 PMCID: PMC11019207 DOI: 10.5664/jcsm.11008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 12/28/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Connie L. Thomas
- Walter Reed Army Institute of Research, Silver Spring, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
- Uniformed Services University, Bethesda, Maryland
| | - Vincent F. Capaldi
- Walter Reed Army Institute of Research, Silver Spring, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
- Uniformed Services University, Bethesda, Maryland
| | - Jacob F. Collen
- Walter Reed National Military Medical Center, Bethesda, Maryland
- Uniformed Services University, Bethesda, Maryland
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2
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Thomas CL, Carr K, Yang F, Fleisher S, Um P, Clemens B, McNutt R, Balkin T, Collen JF. From trenches to technology: a narrative review of sleep medicine in the military. J Clin Sleep Med 2024. [PMID: 38420974 DOI: 10.5664/jcsm.11088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Diagnoses of military-relevant sleep disorders have increased substantially since the terrorist attacks of 9-11. The cause of this increase appears to be complicated and multifactorial, with military and civilian populations clearly differing with respect to both the nature and distribution of sleep disorders diagnoses. In part, these differences may be attributable to the fact that a majority of service members (SMs) are chronically sleep restricted - an unavoidable consequence of continuous and sustained military operations that 'set the stage' for development of specific sleep disorders. The purpose of this narrative review is to describe the military relevance of several common sleep disorders, assess the extent to which these disorders currently constitute a burden on the military healthcare system, and suggest strategies to alleviate that burden. The military healthcare system does not have enough sleep providers to address the immediate and long-term consequences of sleep disorders in military personnel. Digital technologies and education packages can be leveraged to improve access to care.
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Affiliation(s)
- Connie L Thomas
- Walter Reed Army Institute of Research, Silver Spring, MD
- Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University, Bethesda, MD
| | - Kyle Carr
- Uniformed Services University, Bethesda, MD
| | - Felix Yang
- Uniformed Services University, Bethesda, MD
| | | | - Paul Um
- Uniformed Services University, Bethesda, MD
| | | | - Ryan McNutt
- Womack Army Medical Center, Fort Liberty, NC
| | - Thomas Balkin
- Walter Reed Army Institute of Research, Silver Spring, MD
| | - Jacob F Collen
- Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University, Bethesda, MD
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3
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Stekl EK, Collen JF. No time to waste! Acute sleep interventions after trauma. J Clin Sleep Med 2022; 18:2091-2092. [PMID: 36047783 PMCID: PMC9435324 DOI: 10.5664/jcsm.10204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Emily K. Stekl
- Sleep Research Center, Behavioral Biology Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Jacob F. Collen
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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4
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Adornetti JP, Wade CE, Deeley MK, Verceles AC, Collen JF, Capaldi VF, Williams SG, Assefa SZ, Wilckens K, Chen S, Wickwire EM. Remote clinical research operations during COVID-19: lessons learned and recommendations. Sleep 2022; 45:6608292. [DOI: 10.1093/sleep/zsac124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Julianna P Adornetti
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Christine E Wade
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Maura K Deeley
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Avelino C Verceles
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Jacob F Collen
- Department of Medicine, Uniformed Services University of the Health Sciences , Bethesda, MD , USA
| | - Vincent F Capaldi
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research , Silver Spring, MD , USA
| | - Scott G Williams
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research , Silver Spring, MD , USA
| | - Samson Z Assefa
- Sleep Disorders Center, Fort Belvoir Community Hospital , Ft Belvoir , VA , USA
| | - Kristine Wilckens
- Department of Psychiatry, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Shuo Chen
- Department of Psychiatry, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Emerson M Wickwire
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine , Baltimore, MD , USA
- Department of Psychiatry, University of Maryland School of Medicine , Baltimore, MD , USA
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5
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Moores LK, Tritschler T, Brosnahan S, Carrier M, Collen JF, Doerschug K, Holley AB, Iaccarino J, Jimenez D, LeGal G, Rali P, Wells P. Thromboprophylaxis in Patients With COVID-19: A Brief Update to the CHEST Guideline and Expert Panel Report. Chest 2022; 162:213-225. [PMID: 35167861 PMCID: PMC8839802 DOI: 10.1016/j.chest.2022.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients hospitalized with COVID-19 often exhibit markers of a hypercoagulable state and have an increased incidence of VTE. In response, CHEST issued rapid clinical guidance regarding prevention of VTE. Over the past 18 months the quality of the evidence has improved. We thus sought to incorporate this evidence and update our recommendations as necessary. STUDY DESIGN AND METHODS This update focuses on the optimal approach to thromboprophylaxis in hospitalized patients. The original questions were used to guide the search, using MEDLINE via PubMed. Eight randomized controlled trials and one observational study were included. Meta-analysis, using a random effects model, was performed. The panel created summaries using the GRADE Evidence-to-Decision framework. Updated guidance statements were drafted, and a modified Delphi approach was used to obtain consensus. RESULTS We provide separate guidance statements for VTE prevention for hospitalized patients with acute (moderate) illness and critically ill patients in the ICU. However, we divided each original question and resulting recommendation into two questions: standard prophylaxis vs therapeutic (or escalated dose) prophylaxis and standard prophylaxis vs intermediate dose prophylaxis. This led to a change in one recommendation, and an upgrading of three additional recommendations based upon higher quality evidence. CONCLUSIONS Advances in care for patients with COVID-19 have improved overall outcomes. Despite this, rates of VTE in these patients remain elevated. Critically ill patients should receive standard thromboprophylaxis for VTE, and moderately ill patients with a low bleeding risk might benefit from therapeutic heparin. We see no role for intermediate dose thromboprophylaxis in either setting.
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Affiliation(s)
- Lisa K Moores
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Shari Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University Langone Health System, New York, NY
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jacob F Collen
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD; Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Kevin Doerschug
- Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, IA
| | - Aaron B Holley
- Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jonathan Iaccarino
- American College of Chest Physicians, Glenview, IL; The Pulmonary Center, Boston University School of Medicine, Boston, MA
| | - David Jimenez
- Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Gregoire LeGal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Philip Wells
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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6
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Holley AB, McMahon MJ, Warren WA, Collen JF, Sherner JH, Zeman JE, Morris MJ. Response. Chest 2022; 161:e253-e254. [PMID: 35396066 DOI: 10.1016/j.chest.2021.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Aaron B Holley
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD.
| | | | | | | | | | - Joseph E Zeman
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD
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7
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Haynes ZA, Stewart IJ, Poltavskiy EA, Holley AB, Janak JC, Howard JT, Watrous J, Walker LE, Wickwire EM, Werner K, Zarzabal LA, Sim A, Gundlapalli A, Collen JF. Obstructive sleep apnea among survivors of combat-related traumatic injury: a retrospective cohort study. J Clin Sleep Med 2022; 18:171-179. [PMID: 34270410 PMCID: PMC8807913 DOI: 10.5664/jcsm.9530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea is prevalent among military members despite fewer traditional risk factors. We sought to determine the incidence and longitudinal predictors of obstructive sleep apnea in a large population of survivors of combat-related traumatic injury and a matched control group. METHODS Retrospective cohort study of military service members deployed to conflict zones from 2002-2016 with longitudinal follow-up in the Veterans Affairs and Military Health Systems. Two cohorts of service members were developed: (1) those who sustained combat injuries and (2) matched, uninjured participants. RESULTS 17,570 service members were retrospectively analyzed for a median of 8.4 years. After adjustment, traumatic brain injury (hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.20-1.60), posttraumatic stress disorder (HR 1.24, 95% CI 1.05-1.46), depression (HR 1.52, 95% CI 1.30-1.79), anxiety (HR 1.40, 95% CI 1.21-1.62), insomnia (HR 1.71, 95% CI 1.44-2.02), and obesity (HR 2.40, 95% CI 2.09-2.74) were associated with development of obstructive sleep apnea. While combat injury was associated with obstructive sleep apnea in the univariate analysis (HR 1.25, 95% CI 1.17-1.33), the direction of this association was reversed in the multivariable model (HR 0.74, 95% CI 0.65-0.84). In a nested analysis, this was determined to be due to the effect of mental health diagnoses. CONCLUSIONS The incidence of obstructive sleep apnea is higher among injured service members (29.1 per 1,000 person-years) compared to uninjured service members (23.9 per 1,000 person-years). This association appears to be driven by traumatic brain injury and the long-term mental health sequelae of injury. CITATION Haynes ZA, Stewart IJ, Poltavskiy EA, et al. Obstructive sleep apnea among survivors of combat-related traumatic injury: a retrospective cohort study. J Clin Sleep Med. 2022;18(1):171-179.
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Affiliation(s)
- Zachary A. Haynes
- Walter Reed National Military Medical Center, Bethesda, Maryland,Address correspondence to: Zachary A. Haynes, MD, Captain, Medical Corps, US Army, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889; ,
| | - Ian J. Stewart
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Aaron B. Holley
- Walter Reed National Military Medical Center, Bethesda, Maryland,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | | | | | - Lauren E. Walker
- David Grant USAF Medical Center, Travis Air Force Base, California
| | | | - Kent Werner
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Alan Sim
- Defense Health Agency/J6, Randolph Air Force Base, Texas
| | | | - Jacob F. Collen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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8
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Thomas CL, Collen JF. Burnt out: how to help firefighters help themselves. J Clin Sleep Med 2022; 18:9-10. [PMID: 34398743 PMCID: PMC8807893 DOI: 10.5664/jcsm.9604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Connie L. Thomas
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland;,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jacob F. Collen
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland;,Uniformed Services University of the Health Sciences, Bethesda, Maryland,Address correspondence to: Jacob F. Collen, MD, Uniformed Services University of the Health Sciences, Department of Internal Medicine, 4301 Jones Bridge Road, Bethesda, MD 20814; Tel: (703) 966-1598;
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9
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McMahon MJ, Holley AB, Warren WA, Collen JF, Sherner JH, Zeman JE, Morris MJ. Posttraumatic Stress Disorder Is Associated With a Decrease in Anaerobic Threshold, Oxygen Pulse, and Maximal Oxygen Uptake. Chest 2021; 160:1017-1025. [PMID: 33844979 DOI: 10.1016/j.chest.2021.03.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) has been linked to respiratory symptoms and functional limitations, but the mechanisms leading to this association are poorly defined. RESEARCH QUESTION What is the relationship between PTSD, lung function, and the cardiopulmonary response to exercise in combat veterans presenting with chronic respiratory symptoms? STUDY DESIGN AND METHODS This study prospectively enrolled military service members with respiratory symptoms following deployment to southwest Asia. All participants underwent a comprehensive evaluation that included pulmonary function testing and cardiopulmonary exercise testing. Pulmonary function test variables and cardiopulmonary response to exercise were compared in subjects with and without PTSD by using multivariable linear regression to adjust for confounders. RESULTS A total of 303 participants were included (PTSD, n = 70; non-PTSD, n = 233). Those with PTSD had a greater frequency of current respiratory symptoms. There were no differences in measures for airway disease or lung volumes, but patients with PTSD had a reduction in diffusing capacity that was eliminated following adjustment for differences in hemoglobin levels. Participants with PTSD had a lower anaerobic threshold (23.9 vs 26.4 cc/kg per minute; P = .004), peak oxygen pulse (19.7 vs 18.5 cc/beat; P = .03), and peak oxygen uptake (34.5 vs 38.8 cc/kg per minute; P < .001). No significant difference was observed in gas exchange, respiratory reserve, or effort at peak exercise between participants with and without PTSD. INTERPRETATION A diagnosis of PTSD was associated with a reduced anaerobic threshold, oxygen pulse, and peak oxygen uptake. This objective reduction in cardiopulmonary work is independent of baseline lung function, was not associated with abnormalities in gas exchange or respiratory reserve, and may be related to deconditioning.
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Affiliation(s)
- Michael J McMahon
- Tripler Army Medical Center, Walter Reed National Military Medical Center, Bethesda, MD
| | - Aaron B Holley
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, MD.
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10
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Holley AB, Collen JF, Morris MJ. Expected Disability From Isolated Small Airway Disease. Mil Med 2021; 186:203-204. [PMID: 33693807 DOI: 10.1093/milmed/usab096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aaron B Holley
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Jacob F Collen
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Michael J Morris
- Pulmonary and Critical Care Medicine, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
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Abstract
STUDY OBJECTIVES The aim of this study was to determine the impact of serious parental injury on adolescent sleep disorder diagnoses, outpatient care, and medication use. METHODS U.S. military personnel who sustained a serious injury and were parents of adolescents aged 10-18 years were identified. Included adolescents were enrolled in the Military Health System for 2 years before their parent's injury and 2 years after the injury. We used logistic regression clustered by adolescents to compare the odds of having a sleep diagnosis and negative binomial regression analysis clustered by adolescents to compare outpatient sleep disorder visits and sleep medication days before and after parental injury. RESULTS There were 96,318 parents seriously injured during 2004-2014 who had 117,577 children aged 10-18 years in 2002-2016. Approximately 2% of adolescents had a sleep disorder diagnosis, both before and after their parent's injury or illness. Outpatient sleep disorder visits increased 36% after a parent's injury (incidence rate ratio 1.36 [1.24-1.50]), with a twofold increase in insomnia visits (incidence rate ratio 2.35 [2.08-2.64]). Increases in sleep visits were most pronounced in adolescents of parents with traumatic brain injury, comorbid traumatic brain injury and posttraumatic stress disorder, battle injury, and those who were medically discharged from the military. The number of adolescents using sleep medications increased, but sleep medication days did not increase. CONCLUSIONS Adolescents in our study used more outpatient medical care for sleep disorders; sleep medication use increased after parental injury. Sleep disorders should be considered in the care of adolescents with injured parents.
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Affiliation(s)
- Saira Ahmed
- Division of Adolescent Medicine, Department of Pediatrics, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
| | | | - Apryl Susi
- Department of Pediatrics, Uniformed Services University, Bethesda, Maryland
| | - Brian D Robertson
- Department of Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jacob F Collen
- Department of Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Medicine, Uniformed Services University, Bethesda, Maryland
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12
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Abstract
NONE Sexsomnias are unconscious sexual behaviors during sleep (parasomnias) that are garnering more attention as they become increasingly evident in forensic cases. Presentations of sexsomnia in active duty service members are seldom described, and often evaluation is clouded by intoxication with substances such as alcohol, sleep deprivation, untreated sleep disturbances, or criminal behavior masquerading as a medical disorder. We present a case of a 40-year-old male soldier evaluated in our sleep clinic for multiple episodes of sleep masturbation occurring over a period of 2 years. The patient was concerned about his suitability for deployment to a combat zone and participation in field training exercises (both require sleeping in groups in an open environment). Video polysomnography confirmed moderate obstructive sleep apnea, and the patient showed improvement with continuous positive airway pressure therapy. The authors also discuss the relevance of this case compared with previously reported sexsomnia cases and expand on parasomnia topics that are more common in military populations.
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Affiliation(s)
- David S Kim
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Brian E Foster
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jasmine A Scott
- F. Edward Herbert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Meagan M Rizzo
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jacob F Collen
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Rodolfo Soca
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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13
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Wappel SR, Scharf SM, Cohen L, Collen JF, Robertson BD, Wickwire EM, Diaz-Abad M. Improving sleep medicine education among health professions trainees. J Clin Sleep Med 2021; 17:2461-2466. [PMID: 34170221 DOI: 10.5664/jcsm.9456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Despite increasing recognition of its importance, sleep medicine education remains limited during medical training. We sought to assess the baseline knowledge of a group of health professions trainees and to determine whether an educational sleep medicine "boot camp" led to improvement in sleep medicine knowledge. METHODS Participants attended a two-day introduction to sleep medicine course designed for new sleep medicine fellows in July 2017 and 2018. Participants completed two validated sleep knowledge questionnaires (The Assessment of Sleep Knowledge in Medical Education [ASMKE] and The Dartmouth Sleep Knowledge and Attitude Survey [Dartmouth]) prior to and at the conclusion of the course. RESULTS A total of 21 health professions trainees including 14 sleep medicine fellows completed both pre- and post-surveys. Baseline ASKME score was 21.4 ± 3.4 out of 30 (71.4% ± 11.4%) and baseline Dartmouth score was 16.1 ± 2.4 out of 24 (67.3% ± 9.9%). There was no difference in baseline scores between sleep medicine fellows and other health professions trainees. There was a statistically significant improvement in ASKME (2.9 ± 2.1 points, p=0.004) and Dartmouth (2.5 ± 3.0 points, p=0.001) scores among all participants after the course, without a difference in degree of improvement among sleep medicine fellows compared to other health professions trainees. CONCLUSIONS Our findings suggest that baseline sleep medicine knowledge is higher than previously reported among health professions trainees. An educational sleep medicine boot camp improved knowledge even in a group of learners with high baseline knowledge and interest in sleep medicine, including new sleep medicine fellows.
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Affiliation(s)
- Stephanie R Wappel
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Steven M Scharf
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Larry Cohen
- Department of General Dentistry, University of Maryland School of Dentistry, Baltimore, Maryland
| | - Jacob F Collen
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Brian D Robertson
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Emerson M Wickwire
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Montserrat Diaz-Abad
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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14
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Haynes ZA, Collen JF, Poltavskiy EA, Walker LE, Janak J, Howard JT, Werner JK, Wickwire EM, Holley AB, Zarzabal LA, Sim A, Gundlapalli A, Stewart IJ. Risk factors of persistent insomnia among survivors of traumatic injury: a retrospective cohort study. J Clin Sleep Med 2021; 17:1831-1840. [PMID: 33928909 DOI: 10.5664/jcsm.9276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Insomnia is a diagnosis with broad health and economic implications that has been increasingly recognized in military service members. This trend was concurrent with an increase in traumatic wartime injuries. Accordingly, we sought to determine longitudinal predictors of persistent insomnia in combat veterans who sustained traumatic injuries. METHODS Retrospective cohort study of service members deployed to conflict zones from 2002-2016, with longitudinal follow-up in the Veterans Affairs and Military Health Systems. Two cohorts were derived: 1) service members who sustained traumatic injuries and 2) an age, sex, and service component matched cohort of uninjured service members who deployed to a combat zone. Insomnia was defined using International Classification of Diseases Ninth Revision or International Classification of Diseases Tenth Revision Clinical Modification codes. RESULTS The final population of 17,374 service members was followed from date of injury (or date of matched participant's injury) for a median of 8.4 (IQR 5.3-10.7) years. Service members with traumatic injury were at significantly greater risk of developing insomnia than uninjured service members (HR=1.43, 95% CI 1.30-1.58) after adjustment. Traumatic brain injury (TBI) was associated with insomnia when compared to patients without TBI in the multivariable model: mild/unclassified TBI (HR=2.07, 95% CI 1.82-2.35), moderate/severe/penetrating TBI (HR=2.43, 95% CI 2.06-2.86). Additionally, burn injury (HR=1.95, 95% CI 1.47-2.59) and amputation (HR=1.61, 95% CI 1.26-2.06) significantly increased the risk of a diagnosis. CONCLUSIONS Traumatic injuries significantly predicted a diagnosis of insomnia after controlling for mental health disorders. Our findings strongly suggest the need for long-term surveillance of sleep disorders in trauma survivors.
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Affiliation(s)
| | - Jacob F Collen
- Walter Reed National Military Medical Center, Bethesda, MD.,Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | | | | | | | - J Kent Werner
- Walter Reed National Military Medical Center, Bethesda, MD.,Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Aaron B Holley
- Walter Reed National Military Medical Center, Bethesda, MD.,Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Alan Sim
- Defense Health Agency/J6, San Antonio, TX
| | - Adi Gundlapalli
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT
| | - Ian J Stewart
- Uniformed Services University of the Health Sciences, Bethesda, MD
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15
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Affiliation(s)
- Subodh Arora
- Sleep Disorders Center, Wilford Hall Ambulatory Surgical Center, San Antonio, Texas
| | - Jacob F Collen
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
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16
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Doty TJ, Collen JF. Buzzed before bedtime: hidden harms of late day caffeine consumption. J Clin Sleep Med 2021; 16:23-24. [PMID: 33054955 DOI: 10.5664/jcsm.8890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Tracy Jill Doty
- Sleep Research Center, Behavioral Biology Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Jacob F Collen
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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17
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Affiliation(s)
- Jacob F Collen
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Emerson M Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland.,Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vincent Capaldi
- Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed Army Institute of Research, Silver Spring, Maryland
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18
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Moores LK, Tritschler T, Brosnahan S, Carrier M, Collen JF, Doerschug K, Holley AB, Jimenez D, Le Gal G, Rali P, Wells P. Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019: CHEST Guideline and Expert Panel Report. Chest 2020; 158:1143-1163. [PMID: 32502594 PMCID: PMC7265858 DOI: 10.1016/j.chest.2020.05.559] [Citation(s) in RCA: 438] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Emerging evidence shows that severe coronavirus disease 2019 (COVID-19) can be complicated by a significant coagulopathy, that likely manifests in the form of both microthrombosis and VTE. This recognition has led to the urgent need for practical guidance regarding prevention, diagnosis, and treatment of VTE. METHODS A group of approved panelists developed key clinical questions by using the PICO (Population, Intervention, Comparator, Outcome) format that addressed urgent clinical questions regarding the prevention, diagnosis, and treatment of VTE in patients with COVID-19. MEDLINE (via PubMed or Ovid), Embase, and Cochrane Controlled Register of Trials were systematically searched for relevant literature, and references were screened for inclusion. Validated evaluation tools were used to grade the level of evidence to support each recommendation. When evidence did not exist, guidance was developed based on consensus using the modified Delphi process. RESULTS The systematic review and critical analysis of the literature based on 13 Population, Intervention, Comparator, Outcome questions resulted in 22 statements. Very little evidence exists in the COVID-19 population. The panel thus used expert consensus and existing evidence-based guidelines to craft the guidance statements. CONCLUSIONS The evidence on the optimal strategies to prevent, diagnose, and treat VTE in patients with COVID-19 is sparse but rapidly evolving.
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Affiliation(s)
- Lisa K Moores
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Shari Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University Langone Health System, New York, NY
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jacob F Collen
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD; Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Kevin Doerschug
- Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, IA
| | - Aaron B Holley
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD; Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - David Jimenez
- Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Gregoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Philip Wells
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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19
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Kim DS, Foster BE, Collen JF, Eliasson AH. 1034 Should We Recommend More Sleep To Prevent Obesity? Sleep 2020. [DOI: 10.1093/sleep/zsaa056.1030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
According to the 2015-2016 National Health and Nutrition Examination Survey (NHANES), the national adult obesity rate was 40% with the incidence of adult obesity having increased by 70% over the last 30 years. Paralleling the obesity epidemic have been worsening sleep deprivation and eroding sleep quality. We analyzed data from a Cardiovascular Health Registry to explore a link between total sleep time and obesity.
Methods
Registry participants underwent anthropometrics and completed validated questionnaires assessing health behaviors and symptoms including total sleep time (TST), Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI), Perceived Stress Scale (PSS), and exercise time. Differences between subjects with sufficient (≥7 hours) and insufficient (<7 hours) sleep were analyzed using T-tests.
Results
Registry participants (n=630) had mean age 55.3±9.9 years (45% men, 391W, 182B, 26H, 12A, 19O). The subgroup with sufficient sleep (n=261, 48% men), had mean BMI 29.3±5.6 while the subgroup with insufficient sleep (n=369, 44% men) had mean BMI of 30.5±5.3, p=0.008. The insufficient sleep group was noted to be sleepier (ESS 9.7±4.9 vs 7.4±4.6, p<0.001), more fatigued (FSS 4.9±2.3 vs 3.5±2.4, p<0.001) and have worse sleep quality (PSQI 8.6±3.7 vs 4.7±2.8, p<0.001). Insufficient sleepers also perceived greater stress levels (PSS 22.2±8.4 vs 18.9±6.2, p<0.001), and showed a trend toward less exercise per week (143±134 vs 163±106 minutes, p=0.13).
Conclusion
Participants with insufficient sleep were significantly more overweight on average and were more symptomatic for insufficient sleep. While current approaches to weight management focus largely on diet and physical activity, the data from this study suggest that insufficient sleep should also be considered as a risk factor for obesity and should be incorporated into management plans for obesity.
Support
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Affiliation(s)
- D S Kim
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - B E Foster
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, MD
| | - J F Collen
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, MD
| | - A H Eliasson
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, MD
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20
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Foster BE, Collen JF, Eliasson AH. 1050 Sleep, The Missing Domain For Cardiovascular Health? Sleep 2020. [DOI: 10.1093/sleep/zsaa056.1046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
In developed countries, cardiovascular disease (CVD) is the leading cause of death. Identification and mitigation of CVD risk factors has been the chief strategy for prevention of CVD. To this end, the American Heart Association (AHA) and American College of Cardiology (ACC) suggest metrics of ideal cardiovascular (CV) health in seven domains and have published guidelines encouraging use of the “Simple Seven” to improve CV health. Sleep is notably absent from the Simple Seven despite substantial epidemiological evidence of its importance for CV health. We sought to measure the correlation of sleep parameters with CVD risk estimate by Framingham risk score (FRS).
Methods
Subjects prospectively enrolled in a CV Health Registry provided data for FRS, the seven domains of the “Simple Seven” including blood pressure, physical activity, total cholesterol, diet, weight, smoking, and glucose level, and completed validated questionnaires: Pittsburgh Sleep Quality Index (PSQI) and Berlin Questionnaire (BQ) for sleep apnea. Pearson correlations were analyzed between FRS and the “Simple Seven” as well as for the sleep questionnaires for comparison.
Results
Among the 646 subjects (mean age 55.4 ±9.9y, 43% men, 399W, 190B, 26H, 12A, 19other), FRS correlated substantially with blood glucose (R=0.398, p<0.00001), moderately with blood pressure (R=0.220, p<0.00001), and mildly with weight (r=0.145, p-0.0002) and physical activity (R=0.110, p=0.01). A negative (paradoxical) correlation was identified between total cholesterol and diet when compared to FRS. In comparison, FRS did correlate mildly with BQ (R=0.114, p=0.0002) and PSQI (r=-0.103, p=0.009).
Conclusion
This study suggests that sleep parameters, specifically BQ and PSQI, may contribute to risk assessment of CVD while also offering actionable information for improving CV health.
Support
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Affiliation(s)
- B E Foster
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University, Bethesda, MD
| | - J F Collen
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University, Bethesda, MD
| | - A H Eliasson
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University, Bethesda, MD
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21
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Kim DS, Foster BE, Rizzo MM, Collen JF, Soca R. 1225 Sexsomnia: A Case of Sleep Masturbation And Sleeping In An Open Work Environment. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Sleep sex or sexsomnia is classified in the International Classification of Sleep Disorders as a non-rapid eye movement (NREM) parasomnia. The overall prevalence is unknown but several conditions such as obstructive sleep apnea (OSA), shift work, and/or insufficient sleep have been reported as factors affecting the frequency of NREM parasomnias. Parasomnias, with sexsomnias in particular, can cause significant emotional distress to patients and their families. We present a case of co-morbid sexsomnia and OSA in a patient serving in the military that had the complicating factor of sleeping in open quarters.
Report of Case
A 40-year-old male in active duty military without significant past medical history or medication use presented to clinic with a two year history of disruptive sleep masturbation reported by wife. Patient’s wife reported no instances of attempted sexual intercourse. The patient had no recollection of the episodes. The frequency and nature of the episodes were causing personal and marital distress. Patient was also concerned about work responsibilities, since he was periodically required to sleep in open environments. After initial clinic evaluation, patient underwent a video polysomnography (vPSG) with an extended EEG montage. No parasomnia activity was captured on vPSG but patient was diagnosed with moderate OSA. He was started on continuous positive airway pressure (CPAP) therapy, resulting in decreased number of episodes with relapses corresponding to nights without CPAP usage.
Conclusion
Sexsomnia cases require careful history taking and evaluation. The nature of the episodes and the sleep environment of the patient must be examined for any medico-legal ramification as there are court precedents of sexual assault charges made in sexsomnia-related cases. The military environment is unique with group-sleeping conditions, often in austere environments. If sexsomnia were to be misinterpreted as indecent exposure, under the military code of conduct, this could have significant career implications.
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Affiliation(s)
- David S Kim
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Brian E Foster
- Sleep Medicine Center, Walter Reed National Military Medical Center, Bethesda, MD
| | - Meagan M Rizzo
- Sleep Medicine Center, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Jacob F Collen
- Sleep Medicine Center, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Rodolfo Soca
- Sleep Medicine Center, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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22
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Holley AB, Mabe DL, Hunninghake JC, Collen JF, Walter RJ, Sherner JH, Huprikar NA, Morris MJ. Isolated Small Airway Dysfunction and Ventilatory Response to Cardiopulmonary Exercise Testing. Respir Care 2020; 65:1488-1495. [PMID: 32234772 DOI: 10.4187/respcare.07424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The effect of isolated small airway dysfunction (SAD) on exercise remains incompletely characterized. We sought to quantify the relationship between isolated SAD, identified with lung testing, and the respiratory response to exercise. METHODS We conducted a prospective evaluation of service members with new-onset dyspnea. All subjects underwent plethysmography, diffusing capacity of the lung for carbon monoxide (DLCO), impulse oscillometry, high-resolution computed tomography (HRCT), and cardiopulmonary exercise testing (CPET). In subjects with normal basic spirometry, DLCO, and HRCT, SAD measures were analyzed for associations with ventilatory parameters at submaximal exercise and at maximal exercise during CPET. RESULTS We enrolled 121 subjects with normal basic spirometry (ie, FEV1, FVC, and FEV1/FVC), DLCO, and HRCT. Mean age and body mass index were 37.4 ± 8.8 y and 28.4 ± 3.8 kg/m2, respectively, and 110 (90.9%) subjects were male. The prevalence of SAD varied from 2.5% to 28.8% depending on whether FEV3/FVC, FEF25-75%, residual volume/total lung capacity, and R5-R20 were used to identify SAD. Agreement on abnormal SAD across tests was poor (kappa = -0.03 to 0.07). R5-R20 abnormalities were related to higher minute ventilation ([Formula: see text]) and higher [Formula: see text]/maximum voluntary ventilation (MVV) during submaximal exercise and to lower [Formula: see text] during maximal exercise. After adjustment for differences at baseline, there remained a trend toward a relationship between R5-R20 and an elevated [Formula: see text]/MVV during submaximal exercise (β = 0.04, 95% CI -0.01 to 0.09, P = .10), but there was no significant association with [Formula: see text] during submaximal exercise or with [Formula: see text] during maximal exercise. No other SAD measures showed a relationship with ventilatory parameters. CONCLUSIONS In 121 subjects with normal basic spirometry, DLCO, and HRCT, we found poor agreement across tests used to detect SAD. Among young, healthy service members with postdeployment dyspnea, SAD as identified by lung function testing does not predict changes in the ventilatory response to exercise.
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Affiliation(s)
- Aaron B Holley
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - Donovan L Mabe
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John C Hunninghake
- Pulmonary/Critical Care Medicine Service, Brooke Army Medical Center, San Antonio, Texas
| | - Jacob F Collen
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Robert J Walter
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John H Sherner
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Nikhil A Huprikar
- Department of Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Michael J Morris
- Pulmonary/Critical Care Medicine Service, Brooke Army Medical Center, San Antonio, Texas
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23
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Kancherla BS, Upender R, Collen JF, Rishi MA, Sullivan SS, Ahmed O, Berneking M, Flynn-Evans EE, Peters BR, Gurubhagavatula I. What is the role of sleep in physician burnout? J Clin Sleep Med 2020; 16:807-810. [PMID: 32108567 DOI: 10.5664/jcsm.8412] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
None The occurrence of physician burnout is widespread among clinicians and academic faculty, who report indicators such as low quality of life and poor work-life balance. Chronic insufficient sleep, whether due to extended work hours, circadian misalignment, or unrecognized sleep disorders, is a critically important risk factor for burnout that is overlooked and under-studied, and interventions to promote healthy sleep may reduce burnout susceptibility among attending physicians. While strategies to reduce burnout among resident and attending physicians have been under-evaluated, evidence suggests a need to address burnout at both individual and organizational levels. Solutions have been offered that are applicable to many stakeholders, including employers; payers; licensing and certification boards; state and federal regulatory agencies; and physicians and researchers. As more studies are undertaken to evaluate how these approaches impact burnout, two questions need to be addressed: (1) What is the role of sleep in the crisis of burnout, specifically among attendings, who are particularly under-studied? (2) Is restoration of healthy sleep the fundamental mechanism by which burnout interventions work? It is essential for key stakeholders to consider the role of sleep, sleepiness, and sleep disorders in order to optimize any efforts to mitigate the present crisis in physician burnout, particularly among attending physicians, an understudied group.
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Affiliation(s)
- Binal S Kancherla
- Department of Pediatrics, Division of Pediatric Pulmonology, Texas Children's Hospital - Baylor College of Medicine, Houston, Texas
| | - Raghu Upender
- Department of Neurology, Division of Sleep Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Jacob F Collen
- Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Muhammad Adeel Rishi
- Department of Pulmonology, Critical Care and Sleep Medicine, Mayo Clinic, Eau Claire, Wisconsin
| | | | - Omer Ahmed
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York
| | | | - Erin E Flynn-Evans
- Fatigue Countermeasures Laboratory, Human Systems Integration Division, NASA Ames Research Center, Moffett Field, California
| | - Brandon R Peters
- Sleep Disorders Center, Virginia Mason Medical Center, Seattle, Washington
| | - Indira Gurubhagavatula
- Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
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24
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Kancherla BS, Upender R, Collen JF, Rishi MA, Sullivan SS, Ahmed O, Berneking M, Flynn-Evans EE, Peters BR, Abbasi-Feinberg F, Aurora RN, Carden KA, Kirsch DB, Kristo DA, Malhotra RK, Martin JL, Olson EJ, Ramar K, Rosen CL, Rowley JA, Shelgikar AV, Gurubhagavatula I. Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement. J Clin Sleep Med 2020; 16:803-805. [PMID: 32108570 DOI: 10.5664/jcsm.8408] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
None Physician burnout is a serious and growing threat to the medical profession and may undermine efforts to maintain a sufficient physician workforce to care for the growing and aging patient population in the United States. Burnout involves a host of complex underlying associations and potential for risk. While prevalence is unknown, recent estimates of physician burnout are quite high, approaching 50% or more, with midcareer physicians at highest risk. Sleep deprivation due to shift-work schedules, high workload, long hours, sleep interruptions, and insufficient recovery sleep have been implicated in the genesis and perpetuation of burnout. Maladaptive attitudes regarding sleep and endurance also may increase the risk for sleep deprivation among attending physicians. While duty-hour restrictions have been instituted to protect sleep opportunity among trainees, virtually no such effort has been made for attending physicians who have completed their training or practicing physicians in nonacademic settings. It is the position of the American Academy of Sleep Medicine that a critical need exists to evaluate the roles of sleep disruption, sleep deprivation, and circadian misalignment in physician well-being and burnout. Such evaluation may pave the way for the development of effective countermeasures that promote healthy sleep, with the goal of reducing burnout and its negative impacts such as a shrinking physician workforce, poor physician health and functional outcomes, lower quality of care, and compromised patient safety.
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Affiliation(s)
- Binal S Kancherla
- Department of Pediatrics, Division of Pediatric Pulmonology, Texas Children's Hospital - Baylor College of Medicine, Houston, Texas
| | - Raghu Upender
- Department of Neurology, Division of Sleep Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Jacob F Collen
- Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Muhammad Adeel Rishi
- Department of Pulmonology, Critical Care and Sleep Medicine, Mayo Clinic, Eau Claire, Wisconsin
| | | | - Omer Ahmed
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York
| | | | - Erin E Flynn-Evans
- Fatigue Countermeasures Laboratory, Human Systems Integration Division, NASA Ames Research Center, Moffett Field, California
| | - Brandon R Peters
- Sleep Disorders Center, Virginia Mason Medical Center, Seattle, Washington
| | | | - R Nisha Aurora
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kelly A Carden
- Saint Thomas Medical Partners - Sleep Specialists, Nashville, Tennessee
| | | | | | - Raman K Malhotra
- Sleep Medicine Center, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer L Martin
- Veteran Affairs Greater Los Angeles Healthcare System, North Hills, California.,David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Eric J Olson
- Division of Pulmonary and Critical Care Medicine, Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kannan Ramar
- Division of Pulmonary and Critical Care Medicine, Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | - Carol L Rosen
- Department of Pediatrics, Case Western Reserve University, University Hospitals - Cleveland Medical Center, Cleveland, Ohio
| | | | - Anita V Shelgikar
- University of Michigan Sleep Disorders Center, University of Michigan, Ann Arbor, Michigan
| | - Indira Gurubhagavatula
- Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
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25
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Holley AB, Boose WD, Perkins M, Sheikh KL, Solomon NP, Dietsch AM, Vossoughi J, Johnson AT, Collen JF. A Rapid, Handheld Device to Assess Respiratory Resistance: Clinical and Normative Evidence. Mil Med 2019; 183:e370-e377. [PMID: 29425367 DOI: 10.1093/milmed/usx224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/30/2017] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Following reports of respiratory symptoms among service members returning from deployment to South West Asia (SWA), an expert panel recommended pre-deployment spirometry be used to assess disease burden. Unfortunately, testing with spirometry is high cost and time-consuming. The airflow perturbation device (APD) is a handheld monitor that rapidly measures respiratory resistance (APD-Rr) and has promising but limited clinical data. Its speed and portability make it ideally suited for large volume pre-deployment screening. We conducted a pilot study to assess APD performance characteristics and develop normative values. MATERIALS AND METHODS We prospectively enrolled subjects and derived reference equations for the APD from those without respiratory symptoms, pulmonary disease, or tobacco exposure. APD testing was conducted by medical technicians who received a 10-min in-service on its use. A subset of subjects performed spirometry and impulse oscillometry (iOS), administered by trained respiratory therapists. APD measures were compared with spirometry and iOS. RESULTS The total study population included 199 subjects (55.8% males, body mass index 27.7 ± 6.0 kg/m2, age 49.9 ± 18.7 yr). Across the three APD trials, mean inspiratory (APD-Ri), expiratory (APD-Re), and average (APD-Ravg) resistances were 3.30 ± 1.0, 3.69 ± 1.2, and 3.50 ± 1.1 cm H2O/L/s. Reference equations were derived from 142 clinically normal volunteers. Height, weight, and body mass index were independently associated with APD-Ri, APD-Re, and APD-Ravg and were combined with age and gender in linear regression models. APD-Ri, APD-Re, and APD-Ravg were significantly inversely correlated with FEV1 (r = -0.39 to -0.42), FVC (r = -0.37 to -0.40), and FEF25-75 (r = -0.31 to -0.35) and positively correlated with R5 (r = 0.61-0.62), R20 (r = 0.50-0.52), X5 (r = -0.57 to -0.59), and FRES (r = 0.42-0.43). Bland-Altman plots showed that the APD-Rr closely approximates iOS when resistance is normal. CONCLUSION Rapid testing was achieved with minimal training required, and reference equations were constructed. APD-Rr correlated moderately with iOS and weakly with spirometry. More testing is required to determine whether the APD has value for pre- and post-deployment respiratory assessment.
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Affiliation(s)
- Aaron B Holley
- Pulmonary/Sleep and Critical Care Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Dr, San Antonio, TX
| | | | | | - Karen L Sheikh
- Respira Medical, Inc. 09 Pinnacle Drive, Suite R, Linthicum, MD
| | - Nancy P Solomon
- Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD
| | | | - Jafar Vossoughi
- Engineering and Scientific Research Associates, 2330 Jeong H. Kim Engineering Building, College Park, MD
| | - Arthur T Johnson
- Fischell Department of Bioengineering University of Maryland, College Park, 2330 Jeong H. Kim Engineering Building College Park, MD
| | - Jacob F Collen
- Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD
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26
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Robertson BD, Lerner BS, Collen JF, Smith PR. The Effects of Transgender Hormone Therapy on Sleep and Breathing: A Case Series. J Clin Sleep Med 2019; 15:1529-1533. [PMID: 31596219 PMCID: PMC6778344 DOI: 10.5664/jcsm.7992] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 12/29/2022]
Abstract
None The effect of hormone therapy on sleep-disordered breathing in transgender patients has not been described. We present three cases of patients undergoing gender reassignment and treated with hormone replacement. The first case was a transgender woman (assigned male at birth) with a prolonged history of severe obstructive sleep apnea (OSA) that resolved following initiation of female sex hormones. The second and third cases both address transgender males (assigned female at birth) in whom OSA developed following initiation of male sex hormones (with pretreatment polysomnography documenting absence of OSA). The growing interest in transgender health warrants further evaluation of the effects of related therapies on sleep and sleep-disordered breathing.
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Affiliation(s)
- Brian D. Robertson
- Walter Reed National Military Medical Center-Bethesda, Bethesda, Maryland
| | - Brian S. Lerner
- Walter Reed National Military Medical Center-Bethesda, Bethesda, Maryland
| | - Jacob F. Collen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Patrick R. Smith
- Walter Reed National Military Medical Center-Bethesda, Bethesda, Maryland
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27
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Collen JF, Holley AB, Moores LK. Response. Chest 2019; 154:735. [PMID: 30195370 DOI: 10.1016/j.chest.2018.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Jacob F Collen
- Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Aaron B Holley
- Pulmonary, Critical Care and Sleep Medicine Service, San Antonio Military Medical Center, San Antonio, TX
| | - Lisa K Moores
- Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD; Office for Student Affairs, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD.
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28
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Abstract
CITATION Collen JF, York CM. Wrist wearables: more questions than answers? J Clin Sleep Med. 2019;15(8):1077-1078.
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Affiliation(s)
- Jacob F. Collen
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Carla M. York
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland
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Flynn-Evans EE, Ahmed O, Berneking M, Collen JF, Kancherla BS, Peters BR, Rishi MA, Sullivan SS, Upender R, Gurubhagavatula I. Industrial Regulation of Fatigue: Lessons Learned From Aviation. J Clin Sleep Med 2019; 15:537-538. [PMID: 30952229 DOI: 10.5664/jcsm.7704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 03/20/2019] [Indexed: 11/13/2022]
Affiliation(s)
- Erin E Flynn-Evans
- Fatigue Countermeasures Laboratory, Human Systems Integration Division, NASA Ames Research Center, Moffett Field, California
| | - Omer Ahmed
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York
| | | | - Jacob F Collen
- Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Binal S Kancherla
- Department of Pediatrics, Division of Pediatric Pulmonology, Texas Children's Hospital - Baylor College of Medicine, Houston, Texas
| | - Brandon R Peters
- Sleep Disorders Center, Virginia Mason Medical Center, Seattle, Washington
| | - Muhammad Adeel Rishi
- Department of Pulmonology, Critical Care and Sleep Medicine, Mayo Clinic, Eau Claire, Wisconsin
| | - Shannon S Sullivan
- Division of Sleep Medicine, Stanford University, Redwood City, California
| | - Raghu Upender
- Department of Neurology, Division of Sleep Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Indira Gurubhagavatula
- Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Rizzo MM, Holley AB, Terry S, Robertson B, Collen JF. 0645 REM without Atonia In Combat Veterans With PTSD And Co-morbid OSA. Sleep 2019. [DOI: 10.1093/sleep/zsz067.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Meagan M Rizzo
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Aaron B Holley
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Seth Terry
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brian Robertson
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jacob F Collen
- Walter Reed National Military Medical Center, Bethesda, MD, USA
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Werner JK, Collen JF. 0391 Mindfulness Based Stress Reduction as a Treatment for Chronic Insomnia in Traumatic Brain Injury Patients. Sleep 2019. [DOI: 10.1093/sleep/zsz067.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Kent Werner
- Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Jacob F Collen
- Uniformed Services University of Health Sciences, Bethesda, MD, USA
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Rizzo M, Robertson B, Collen JF. Distinct Disorder? Or Mash Up of Several? J Clin Sleep Med 2019; 15:181-182. [PMID: 30736890 DOI: 10.5664/jcsm.7610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/04/2019] [Indexed: 11/13/2022]
Affiliation(s)
- Meagan Rizzo
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Brian Robertson
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jacob F Collen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Affiliation(s)
- Scott G Williams
- Directorate for Medicine, Fort Belvoir Community Hospital, Fort Belvoir, Virginia.,Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jacob F Collen
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Christopher J Lettieri
- Directorate for Medicine, Fort Belvoir Community Hospital, Fort Belvoir, Virginia.,Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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Collen JF, Williams SG, Lettieri CJ. Doomed to Repeat History: The Burden of Trauma-Related Nightmares in Military Personnel. J Clin Sleep Med 2018; 14:303-305. [PMID: 29458710 DOI: 10.5664/jcsm.6964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/02/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Jacob F Collen
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Moores LK, Holley AB, Collen JF. Working With a Mentor: Effective Strategies During Fellowship and Early Career. Chest 2018; 153:799-804. [PMID: 29477494 DOI: 10.1016/j.chest.2018.02.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/22/2018] [Accepted: 02/15/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Lisa K Moores
- Office for Student Affairs, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD; Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD.
| | - Aaron B Holley
- Pulmonary, Critical Care and Sleep Medicine Service, San Antonio Military Medical Center, San Antonio, TX
| | - Jacob F Collen
- Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
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Lettieri CJ, Collen JF, Williams SG. Challenges in the Management of Sleep Apnea and PTSD: Is the Low Arousal Threshold an Unrealized Target? J Clin Sleep Med 2017; 13:845-846. [PMID: 28416046 DOI: 10.5664/jcsm.6640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 03/26/2017] [Indexed: 11/13/2022]
Affiliation(s)
- Christopher J Lettieri
- Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jacob F Collen
- Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Scott G Williams
- Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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Williams SG, Collen JF, Lettieri CJ. The Continued Search for Optimal Therapy in Patients With OSA and PTSD. J Clin Sleep Med 2017; 13:849. [PMID: 28502285 DOI: 10.5664/jcsm.6644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 11/13/2022]
Affiliation(s)
- Scott G Williams
- Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jacob F Collen
- Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Christopher J Lettieri
- Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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Slowik JM, Costan-Toth1 C, Terry S, Butler G, Sheikh K, Shaha D, Robertson B, Collen JF, Williams SG, Golden D, Andrada T, Holley A. 0547 THE IMPACT OF SEDATIVE HYPNOTIC MEDICATION ON COMPLIANCE IN PATIENTS WITH PTSD AND OSA WHO ARE TREATED WITH CPAP THERAPY. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Hostler DC, Marx ES, Moores LK, Petteys SK, Hostler JM, Mitchell JD, Holley PR, Collen JF, Foster BE, Holley AB. Validation of the International Medical Prevention Registry on Venous Thromboembolism Bleeding Risk Score. Chest 2016; 149:372-9. [PMID: 26867833 DOI: 10.1378/chest.14-2842] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 05/03/2015] [Accepted: 06/25/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Recent guidelines recommend assessing medical inpatients for bleeding risk prior to providing chemical prophylaxis for VTE. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score (BRS) was derived from a well-defined population of medical inpatients but it has not been validated externally. We sought to externally validate the IMPROVE BRS. METHODS We prospectively collected characteristics on admission and VTE prophylaxis data each hospital day for all patients admitted for a medical illness to the Walter Reed Army Medical Center over an 18-month period. We calculated the IMPROVE BRS for each patient using admission data and reviewed medical records to identify bleeding events. RESULTS From September 2009 through March 2011, 1,668 inpatients met the IMPROVE inclusion criteria. Bleeding events occurred during 45 separate admissions (2.7%); 31 events (1.9%) were major and 14 (0.8%) were nonmajor but clinically relevant. Two hundred fifty-six patients (20.7%) had an IMPROVE BRS ≥ 7.0. Kaplan-Meier curves showed a higher cumulative incidence of major (P = .02) and clinically important (major plus clinically relevant nonmajor) (P = .06) bleeding within 14 days in patients with an IMPROVE BRS ≥ 7.0. An IMPROVE BRS ≥ 7.0 was associated with major bleeding in Cox-regression analysis adjusted for administration of chemical prophylaxis (OR, 2.6; 95% CI, 1.1-5.9; P = .03); there was a trend toward a significant association with clinically important bleeding (OR, 1.9; 95% CI, 0.9-3.7; P = .07). CONCLUSIONS The IMPROVE BRS calculated at admission predicts major bleeding in medical inpatients. This model may help assess the relative risks of bleeding and VTE before chemoprophylaxis is administered.
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Affiliation(s)
- David C Hostler
- Department of Pulmonary and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Elizabeth S Marx
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD
| | - Lisa K Moores
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Sarah K Petteys
- Department of Pulmonary and Critical Care Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jordanna Mae Hostler
- Department of Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Joshua D Mitchell
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Paul R Holley
- Department of Informatics, US Army Medical Research Institute of Infectious Diseases, Frederick, MD
| | - Jacob F Collen
- Department of Pulmonary and Critical Care Medicine, San Antonio Military Medical Center, San Antonio, TX
| | - Brian E Foster
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Aaron B Holley
- Department of Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD.
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Lettieri CJ, Williams SG, Collen JF. OSA Syndrome and Posttraumatic Stress Disorder: Clinical Outcomes and Impact of Positive Airway Pressure Therapy. Chest 2016; 149:483-490. [PMID: 26291560 DOI: 10.1378/chest.15-0693] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We sought to determine the impact of OSA syndrome (OSAS) on symptoms and quality of life (QoL) among patients with posttraumatic stress disorder (PTSD). In addition, we assessed adherence and response to positive airway pressure (PAP) therapy in this population. METHODS This was a case-controlled observational cohort study at the Sleep Disorders Center of an academic military medical center. Two hundred consecutive patients with PTSD underwent sleep evaluations. Patients with PTSD with and without OSAS were compared with 50 consecutive age-matched patients with OSAS without PTSD and 50 age-matched normal control subjects. Polysomnographic data, sleep-related symptoms and QoL measures, and objective PAP usage were obtained. RESULTS Among patients with PTSD, more than one-half (56.6%) received a diagnosis of OSAS. Patients with PTSD and OSAS had lower QoL and more somnolence compared with the other groups. Patients with PTSD demonstrated significantly lower adherence and response to PAP therapy. Resolution of sleepiness occurred in 82% of patients with OSAS alone, compared with 62.5% of PAP-adherent and 21.4% of nonadherent patients with PTSD and OSAS (P < .001). Similarly, posttreatment Functional Outcomes of Sleep Questionnaire ≥ 17.9 was achieved in 72% of patients with OSAS, compared with only 56.3% of patients with PTSD and OSA who were PAP adherent and 26.2% who were nonadherent (P < .03). CONCLUSIONS In patients with PTSD, comorbid OSAS is associated with worsened symptoms, QoL, and adherence and response to PAP. Given the negative impact on outcomes, the possibility of OSAS should be considered carefully in patients with PTSD. Close follow-up is needed to optimize PAP adherence and efficacy in this at-risk population.
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Affiliation(s)
- Christopher J Lettieri
- Department of Medicine, Uniformed Services University, Bethesda, MD; Department of Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Scott G Williams
- Department of Medicine, Uniformed Services University, Bethesda, MD; Department of Pulmonary, Critical Care, and Sleep Medicine, Womack Army Medical Center, Fort Bragg, NC
| | - Jacob F Collen
- Department of Medicine, Uniformed Services University, Bethesda, MD; Department of Pulmonary, Critical Care, and Sleep Medicine, Brooke Army Medical Center, Fort Sam Houston, TX.
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Mysliwiec V, Matsangas P, Gill J, Baxter T, O'Reilly B, Collen JF, Roth BJ. A Comparative Analysis of Sleep Disordered Breathing in Active Duty Service Members with and without Combat-Related Posttraumatic Stress Disorder. J Clin Sleep Med 2015; 11:1393-401. [PMID: 26156954 DOI: 10.5664/jcsm.5272] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/29/2015] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) are frequently co-occurring illnesses. The purpose of this study was to determine whether comorbid PTSD/OSA is associated with increased PTSD symptoms or decreased OSA severity compared to PTSD or OSA alone in recently deployed Active Duty Service Members (ADSM). METHODS Cross-sectional observational study of ADSM who returned from combat within 24 months. Participants underwent an attended diagnostic polysomnogram and were assessed for PTSD, depression, combat exposure severity, sleepiness, and sleep quality with validated clinical instruments. RESULTS Our study included 109 military personnel who returned from a combat deployment within 24 months with a mean age of 34.3 ± 8.23 and BMI of 30.8 ± 3.99. Twenty-four participants had PTSD/OSA, 68 had OSA, and 17 had PTSD. Mean PTSD Checklist- Military Version (PCL-M) scores were 62.0 ± 8.95, 60.5 ± 4.73, and 32.5 ± 8.95 in PTSD/OSA, PTSD, and OSA, respectively. The mean AHI was 16.9 ± 15.0, 18.9 ± 17.0, and 1.73 ± 1.3 for those with PTSD/OSA, OSA, and PTSD. PTSD symptoms and OSA severity in military personnel with comorbid PTSD/OSA were not significantly different from those with PTSD or OSA alone. On multivariate analysis, BMI was a significant predictor of OSA (OR, 1.21; 95% CI, 1.04-1.44) and age trended towards significance. Depression, but not OSA severity, was associated with PTSD symptoms. CONCLUSIONS Following recent combat exposure, comorbid PTSD/OSA is not associated with increased PTSD symptoms or decreased severity of OSA. Early evaluation after traumatic exposure for comorbid OSA is indicated in PTSD patients with sleep complaints given the high co-occurrence and adverse clinical implications.
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Affiliation(s)
| | | | - Jessica Gill
- National Institutes of Health National Institute of Nursing Research, Bethesda, MD
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Rawlins FA, Collen JF, Morris MJ. Management of Asthma in the Military. Fed Pract 2015; 32:6S-12S. [PMID: 30766098 PMCID: PMC6375480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This article examines the evaluation and management of asthma based on current guidelines, advances in therapy, and the challenges of managing asthma in today's military.
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Affiliation(s)
- Frederic A Rawlins
- , , and are all affiliated with the Pulmonary/Critical Care Service, Department of Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Jacob F Collen
- , , and are all affiliated with the Pulmonary/Critical Care Service, Department of Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Michael J Morris
- , , and are all affiliated with the Pulmonary/Critical Care Service, Department of Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
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Abstract
OBJECTIVES Environmental exposures during military deployments to Iraq and Afghanistan may lead to higher rates of respiratory complaints and diagnoses. This study investigates whether there is a relationship between rates of asthma diagnosis and severity associated with military deployment. METHODS Retrospective review of active duty Army personnel underwent fitness for duty evaluation (Medical Evaluation Board) for asthma. The electronic medical record was reviewed for onset of diagnosis (pre- or post-deployment), disease severity, screening spirometry, bronchodilator response and bronchoprovocation testing. We compared patients with and without a history of combat deployment to Operations Iraqi Freedom/Enduring Freedom. RESULTS Four hundred consecutive Army personnel with a clinical diagnosis of asthma were evaluated. Equal numbers of patients had deployed (48.5%) versus never deployed (51.5%). Of those who deployed, 98 (24.5%) were diagnosed post-deployment. The diagnosis of asthma was objectively confirmed in 74.8% of patients by obstructive screening spirometry, bronchodilator response, and/or methacholine challenge testing. There were no significant differences in spirometry between deployers and non-deployers or based on pre- and post-deployment diagnosis. Similarly, asthma severity classification did not differ between deployed and non-deployed service members, or by pre- and post-deployment diagnosis status. CONCLUSIONS Among active duty military personnel with career limiting asthma, there is no significant relationship between rates of diagnosis or severity based on history of deployment to Southwest Asia.
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Affiliation(s)
- Sally P DelVecchio
- Pulmonary/Critical Care Service, Womack Army Medical Center , Fort Bragg, NC , USA
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Holley AB, Petteys S, Mitchell JD, Holley PR, Collen JF. Thromboprophylaxis and VTE rates in soldiers wounded in Operation Enduring Freedom and Operation Iraqi Freedom. Chest 2014; 144:966-973. [PMID: 23539197 DOI: 10.1378/chest.12-2879] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES US soldiers suffer catastrophic injuries during combat. We sought to define risk factors and rates for VTE in this population. METHODS We gathered data each hospital day on all patients injured in Afghanistan or Iraq who were admitted to the Walter Reed Army Medical Center (WRAMC). We analyzed prophylaxis rates and efficacy and identified risk factors for VTE. RESULTS We recorded data on 506 combat casualties directly admitted to WRAMC after medical air evacuation. The average injury severity score for the group was 18.4 ± 11.7, and the most common reason for air evacuation was injury by improvised explosive device (65%). As part of the initial resuscitation, patients received 4.7 ± 9.0 and 4.00 ± 7.8 units of packed RBCs and fresh frozen plasma, respectively, and 42 patients received factor VIIa. Forty-six patients (9.1%) were given a diagnosis of VTE prior to discharge, 18 (3.6%) during air evacuation, and 28 (5.5%) during the hospital stay. In Cox regression analysis, administration of 1 unit of packed RBCs was associated with a hazard ratio (HR) of 1.04 (95% CI, 1.02-1.07; P = .002), and enoxaparin, 30 mg bid, administered subcutaneously for the majority of hospital days was associated with a HR of 0.31 (95% CI, 0.11-0.86; P = .02) for VTE during the hospitalization. CONCLUSIONS Patients who suffer traumatic injuries in combat overseas are at high risk for VTE during evacuation and recovery. Those with large resuscitations are at particularly high risk, and low-molecular-weight heparin is associated with a decrease in VTE.
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Affiliation(s)
- Aaron B Holley
- Department of Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD.
| | - Sarah Petteys
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Joshua D Mitchell
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD
| | - Paul R Holley
- Department of Informatics, US Army Medical Research Institute of Infectious Diseases, Frederick, MD
| | - Jacob F Collen
- Department of Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD
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Holley AB, Petteys S, Mitchell JD, Holley PR, Collen JF. Response. Chest 2014; 145:195-6. [DOI: 10.1378/chest.13-2329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Collen JF, Lettieri CJ, Hoffman M. The impact of posttraumatic stress disorder on CPAP adherence in patients with obstructive sleep apnea. J Clin Sleep Med 2012; 8:667-72. [PMID: 23243400 DOI: 10.5664/jcsm.2260] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a common comorbid condition in patients with posttraumatic stress disorder (PTSD); insufficiently treated OSA may adversely impact outcomes. Sleep fragmentation and insomnia are common in PTSD and may impair CPAP adherence. We sought to determine the impact of combat-related PTSD on CPAP adherence in soldiers. METHODS Retrospective case-control study. Objective measures of CPAP use were compared between OSA patients with and without PTSD. Groups were matched for age, BMI, and apnea-hypopnea index (AHI). RESULTS We included 90 patients (45 Control, 45 PTSD). Among the cohort, mean age was 39.9 ± 11.2, mean BMI 27.9 ± 8.0, mean ESS 13.6 ± 5.7, and mean AHI 28.2 ± 22.4. There was a trend towards a higher rate of comorbid insomnia among patients with PTSD (25.8% vs. 11.1%, p = 0.10). PTSD was associated with significantly less use of CPAP. Specifically, CPAP was used on 61.4% ± 22.2% of nights in PTSD patients compared with 76.8% ± 16.4% in patients without PTSD (p = 0.001). Mean nightly use of CPAP was 3.4 ± 1.2 h in the PTSD group compared with 4.7 ± 2.2 h among controls (p < 0.001). Regular use of CPAP (> 4 h per night for > 70% of nights) was also lower among PTSD patients (25.2% vs. 58.3%, p = 0.01). CONCLUSION Among soldiers with OSA, comorbid PTSD was associated with significantly decreased CPAP adherence. Given the potential for adverse clinical outcomes, resolution of poor sleep quality should be prioritized in the treatment of PTSD and potential barriers to CPAP adherence should be overcome in patients with comorbid OSA.
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Affiliation(s)
- Jacob F Collen
- Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.
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Mitchell JD, Collen JF, Petteys S, Holley AB. A simple reminder system improves venous thromboembolism prophylaxis rates and reduces thrombotic events for hospitalized patients1. J Thromb Haemost 2012; 10:236-43. [PMID: 22188121 DOI: 10.1111/j.1538-7836.2011.04599.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Compliance with venous thromboembolism (VTE) prophylaxis is poor. OBJECTIVES We sought to determine whether a simple electronic reminder applicable to all hospitalized patients would increase prophylaxis rates and reduce VTE rates. METHODS An electronic reminder was added to the electronic medical record admission note used by all services in our hospital. Prophylaxis, VTE and bleeding rates before and after implementation were compared. Data were analyzed with sas version 9.1. RESULTS Among all adult medical and surgical patients admitted to our hospital during the time periods studied, 42.8% (1236/2888) before and 60.0% (1410/2350) after the reminder was added received appropriate prophylaxis as per American College of Chest Physicians (ACCP) guidelines (P < 0.001). The difference reached significance for both medical (51.0% vs. 68.9%; P < 0.001) and surgical (48.0% vs. 61.0%; P < 0.001) services. Fewer patients were diagnosed with VTE after our reminder was added (1.1% vs. 0.3%; P = 0.001), and there was a trend towards fewer bleeds (1.1% vs. 0.6%; P = 0.09). The presence of the reminder was an independent predictor for prophylaxis being given (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.70-2.18; P < 0.001), and was independently associated with a decreased risk for VTE (OR 0.30, 95% CI 0.14-0.64; P = 0.003) after adjustment for other VTE risk factors. CONCLUSION Adding an electronic reminder to the admission note improved prophylaxis rates and reduced VTE rates across services. The system is easily reproducible and applicable to other facilities. The improvement obtained was modest, so additional measures will probably be needed to optimize prophylaxis rates.
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Affiliation(s)
- J D Mitchell
- Department of Internal Medicine, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, USA
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Petteys S, Mitchell J, Collen JF, Cazares K, Holley AB. Implementation of an Electronic Reminder Improves Venous Thromboembolism Prophylaxis Rates According to ACCP Guidelines. Chest 2010. [DOI: 10.1378/chest.10796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Greer J, Holley AB, Barnes S, Lukes Y, Morris E, Collen JF, Lettieri CJ. Gene Methylation in Bronchoalveolar Lavage Fluid From Patients With Cancer, Inflammatory Lung Disease, and Tobacco Exposure. Chest 2010. [DOI: 10.1378/chest.10838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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