Effect of Trazodone on Upper Airway Resistance in Chronic Spinal Cord Injury

Background: Spinal cord injury (SCI) is a known risk factor for sleep-disordered breathing. While device-based therapies such as CPAP are beneficial in these individuals, adherence to these treatments is often low; consequently, pharmacotherapies for sleep-disordered breathing in patients with SCI are in high demand. Trazodone is an atypical antidepressant with a complex mechanism of action, including alpha adrenergic agonist activity and inhibition of serotonin reuptake. Serotonin (5-HT) is a known modulator of respiratory circuitry, which has been shown to influence the ventilatory drive. Trazodone is commonly prescribed as a sleep aid, but its impact on breathing during sleep is still unclear. Methods: We randomized 9 participants with chronic spinal cord injury and sleep-disordered breathing to receive either placebo or trazodone 100 mg for seven days. On day 7, participants underwent polysomnography with a supraglottic pressure catheter to determine upper airway pressure. Participants then underwent a 1-week washout period before crossing over to the other medication and repeating the same protocol. Parameters of interest included apnea-hypopnea index (AHI), obstructive apnea index (OAI), central apnea index (CAI), oxyhemoglobin desaturation index (ODI), and upper airway resistance (RUA). Results: 7 participants completed polysomnography on both medications, 5 of which had adequate data to calculate RUA. Trazodone did not result in significant improvement in AHI (47.86±24.27 on placebo vs 28.73±28.79 on trazodone, p=0.10), OAI (9.29±9.48 vs 2.86±3.39, p=0.13), CAI (1.14±1.46 vs 1.71±3.30, p=0.52), ODI (25.00±28.39 vs 19.44±33.61, p=0.34), or RUA (2.47±0.92 vs 8.98±11.02, p=0.23). Conclusion: Based on our preliminary data in a small number of subjects, trazodone is not effective in treating sleep-disordered breathing in individuals with spinal cord injury. Due to the limited sample size, our data may not accurately represent the clinical utility of trazodone, and further study in a larger number of patients is warranted

Sleep and Function in Patients with Multiple Sclerosis

Introduction: Fatigue is a core symptom of Multiple Sclerosis (MS) and impairs function and quality of life in this patient population. Studies show that sleep-disordered breathing is also common in persons with MS and may exacerbate fatigue symptoms. Within a larger study of patients with spinal cord injuries and disorders, we evaluated the relationships among sleep-disordered breathing (SDB) severity, sleep quality, and functional outcomes in patients with MS. Our objective was to examine the impact of SDB severity on the severity of fatigue and functional impairment in this population. Methods: Twenty-five subjects (average age=57(11), min=35, max=79; 80% male; average AHI=27(20) min=3, max=70; and 67% with AHI \u3e 15) 24 completed in-laboratory polysomnography (PSG) to measure apnea-hypopnea index (AHI) and sleep efficiency (SE) and questionnaires about sleep and function including: Craig Handicap Assessment and Reporting Technique (CHART), Insomnia Severity Index (ISI), Pittsburg Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Flinders Fatigue Scale (FFS), PHQ-9 depression scale (excluding sleep item), Generalized Anxiety Disorder-7 (GAD-7), Brief Pain Inventory (BPI) and World Health Organization Quality of Life . Relationships between sleep measures (AHI and SE from PSG, ISI and PSQI) and measure of daytime function (ESS, FSS, SCIM III-SR, PHQ-9, GAD-7, and WHOQOL) were assessed by bivariate correlation. Results: At the baseline study visit, we assessed participant’s daytime sleepiness, fatigue, sleep quality, depression and anxiety. The mean scores on questionnaires are as follows: ESS was 8.0(5.6), ISI was 11.5(6.7), PSQI was 9.3(4.4), FFS was 17.3(8.7), BPI severity was 3.4 (3.12), BPI interference was 3.5 (3.5), PHQ-9 was 7.3(5.8). There were significant relationships between ISI and FSS (r=0.78, p=0.000), PSQI and FFS (r=0.68, p=0.001), as well as ISI and WHOQOL(r=-0.64 p=0.001). In terms of relationships between daytime and nighttime measurements: total AHI had a weak positive correlation with CHART physical independence (r=-0.49, p=0.016), Sleep efficiency has a weak positive correlation with quality of life (r=0.43, p=0.042) and sleep efficiency is weakly inversely correlated with fatigue (r=-0.45, p=0.041). Conclusion: Our data suggests that there is a strong association between the severity of insomnia and the severity of fatigue and depression in MS patients, a moderately strong correlation between reported sleep disturbances as fatigue, and a moderate association between severity of insomnia and reported quality of life. Although twenty-three out of twenty-four subjects in this study have SDB, severity of SDB had a weaker correlation with daytime measures such as fatigue, quality of life, and physical independence. Given that fatigue and depression are common among MS patients and negatively impact quality of life, treatment of insomnia and lessening of sleep disturbances through sleep hygiene and/or SDB treatment may improve patient outcomes

Communication Training in Adult and Pediatric Critical Care Medicine. A Systematic Review

Background: Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. Objective: To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. Methods: We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. Results: The 23 publications meeting inclusion criteria fell into the following study classifications: intervention (n = 15), cross-sectional survey (n = 5), and instrument validation (n = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Conclusion: Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention.Background: Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. Objective: To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. Methods: We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. Results: The 23 publications meeting inclusion criteria fell into the following study classifications: intervention (n = 15), cross-sectional survey (n = 5), and instrument validation (n = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Conclusion: Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention

Relationship between Posttraumatic Stress Disorder and Sleep Disturbances in Syrian Refugees in the United States

Background Posttraumatic stress disorder (PTSD) is associated with disturbed sleep. However, the impact of sleep disturbances and PTSD symptomology in refugee populations is not well known. This study examined how PTSD-related sleep symptoms and overall sleep quality were impacted by previous and current traumatic and stressful experiences. Methods Adult Syrian refugees living in Southeast Michigan were assessed via scheduled in-home interviews. Overall sleep quality was measured using the Pittsburgh Sleep Quality Index. PTSD-related sleep disturbances were measured using the Pittsburgh Sleep Quality Index Addendum. The presence of PTSD symptomatology was assessed via self-report using the Posttraumatic Stress Disorder Checklist. The Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-5 screened for prior traumatic events experienced and the Postmigration Living Difficulties Questionnaire was assessed for postmigration stressors. Correlational analysis was conducted between overall sleep quality, PTSD symptom severity, and previous trauma experienced. A stepwise linear regression analysis was conducted to examine the role of overall sleep quality, PTSD-specific sleep disturbances, current living difficulties, and the number of preimmigration traumatic events directly experienced or witnessed due to the presence of overall PTSD symptomology. Results A total of 53 adults completed the study. PTSD-disturbed sleep was found to be positively associated with overall poor sleep quality (r = 0.42, p < 0.01), PTSD symptomology (r = 0.65, p < 0.01), and current living difficulties (r = 0.37, p < 0.05). The PTSD-related sleep disturbances (B = 0.66, p < 0.01) and postmigration living difficulties (B = 0.44, p < 0.01) were found to be the strongest predictors of PTSD symptoms. Conclusion Disturbed sleep is strongly associated with current stressful experiences and PTSD symptomology among Syrian refugees

Sleep-Disordered Breathing and Spinal Cord Injury: A State-of-the-Art Review.

Individuals living with spinal cord injury or disease (SCI/D) are at increased risk for sleep-disordered breathing (SDB), with a prevalence that is three- to fourfold higher than the general population. The main features of SDB, including intermittent hypoxemia and sleep fragmentation, have been linked to adverse cardiovascular outcomes including nocturnal hypertension in patients with SCI/D. The relationship between SDB and SCI/D may be multifactorial in nature given that level and completeness of injury can affect central control of respiration and upper airway collapsibility differently, promoting central and/or obstructive types of SDB. Despite the strong association between SDB and SCI/D,&nbsp;access to diagnosis and management remains limited. This review explores the&nbsp;role of SCI/D in the pathogenesis of SDB, poor sleep quality, the barriers in diagnosing and managing SDB in SCI/D, and the alternative approaches and future directions in the treatment of SDB, such as novel pharmacologic and nonpharmacologic treatments

Impact Of Spinal Cord Injury On Sleep: Current Perspectives.

Sleep disorders are commonly encountered in people living with spinal cord injury (SCI). Primary sleep disorders such as sleep-disordered breathing (SDB), sleep-related movement disorders, circadian rhythm sleep-wake disorders, and insomnia disorder are common conditions after SCI but remain under-recognized, underdiagnosed and therefore remain untreated for a majority of patients. Sleep disturbances in people living with SCI are associated with significant impairments of daytime function and quality of life. Previous reviews have described findings related mainly to SDB but have not examined the relationship between other sleep disorders and SCI. This narrative review examines various sleep abnormalities and related functional and physical impairments in people living with SCI. It discusses new evidence pertaining to management, highlights existing limitations in the literature and recommends future directions for research

Feasibility of oropharyngeal and respiratory muscle training in individuals with OSA and spinal cord injury or disease: A pilot study.

OBJECTIVES: To examine the feasibility of individuals with spinal cord injury or disease (SCI/D) to perform combined oropharyngeal and respiratory muscle training (RMT) and determine its impact on their respiratory function. METHODS: A prospective study at a single Veterans Affairs (VA) Medical Center. Inclusion criteria included: 1) Veterans with chronic SCI/D (&gt;6 months postinjury and American Spinal Injury Association (ASIA) classification A-D) and 2) evidence of OSA by apnea-hypopnea index (AHI ≥5 events/h). Eligible participants were randomly assigned to either an experimental (exercise) group that involved performing daily inspiratory, expiratory (using POWERbreathe and Expiratory Muscle Strength Trainer 150 devices, respectively), and tongue strengthening exercises or a control (sham) group that involved using a sham device, for a 3-month period. Spirometry, maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP), polysomnography, and sleep questionnaires were assessed at baseline and at 3 months. RESULTS: Twenty-four individuals were randomized (12 participants in each arm). A total of eight (67%) participants completed the exercise arm, and ten (83%) participants completed the sham arm. MIP was significantly increased (p &lt; 0.05) in the exercise group compared with the baseline. CONCLUSIONS: Combined oropharyngeal and RMT are feasible for individuals with SCI/D. Future studies are needed to determine the clinical efficacy of these respiratory muscle exercises